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Incident Report: Lost in a Cave

How could four experienced divers get lost in a cave? Human nature got in the way. Human factors pundit Gareth Lock analyzes the factors that led to this “Oh S***” moment and how they might apply to your diving; they are much more common than you think.

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by Gareth Lock

Header photo by Kirill Egorov

A team of four divers, all of whom were at least full cave trained, were exploring a cave system in Croatia. The team had already laid a significant amount of line the previous year, and the plan for this dive was to fix and extend the current line and conduct some basic surveying. They also planned to use a novel camera mount to produce 360-degree imagery using multiple GoPro cameras mounted on a special “selfie stick.” Although the maximum depth was 100 ft/30 m, given the length of dive, they would use twin 18s (18 liter tanks) and a stage and scooters. The cave had a small amount of flow but nothing major.

The dive started as planned, and after 30 minutes or so, the divers reached the end of the line and saw the final tie-off from the previous survey and exploration teams. The lead diver pointed to one of the other three to tie in the exploration reel so that they would be ready to explore once the rest of the team had sorted out the camera gear. Due to the complicated nature of the camera and lighting rig, it had been stowed during the long transit to this point. Assuming that the line was being tied in, the other three busied themselves with sorting out the video gear. This process took them approximately three to five minutes to complete.

Once the video rig was ready to go, the lead diver signalled to the team that they would start exploring the cave and shooting video. At this point, the leader noticed that the main reel, which should have been tied in, was still clipped to the first diver’s harness! And because there was a small amount of flow in the cave, and most of the the team had been fixated on sorting out the video rig, they had drifted from the end of the line and were now in the cave without a fixed line to the surface.

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They were now 40 minutes into the dive, 100 ft/30 m deep, and had no idea which way was out. Not a great place to be! The lead diver then started lost line protocols, and it took them 15 minutes before they found the end of the line to tie in to and start their exit.

Analysis  

As with many incidents, it is easy to join the dots and see why the team ended up in the predicament they did. Hindsight affords us a vision that says “it was obvious it would end up like this.” In this particular case, we can easily surmise that the team members were task- focused, they lost” situational awareness, were complacent, made assumptions, and didn’t close their communication loops. However, all of these negative actions regularly happen on other dives but usually don’t result in negative consequences. That is to say that errors are typically only recognized after something goes wrong!

Many times, we don’t even see errors because we aren’t looking for them; plus they don’t create a negative outcome. If we don’t go looking for near misses by reviewing the situation (e.g., by using a structured debrief), we won’t see how the process had errors or violations within it. Consequently, it is the error-producing conditions we need to focus on, not the (positive or negative) outcome. Losing the line is an outcome; why the divers’ attention was pointed at something perceived to be more important or relevant is where we should be looking if we are to improve safety and performance.

In addition to just noticing the outcome, we are hard-wired to focus on the severity of the outcome. The more the severity increases, the more harshly we judge those involved. For example, would our feelings about this event be the same if the team were working in open water and they didn’t remember to tie in and could ascend straight to the surface? And how about if someone had died because they couldn’t find the original tie-off?

So why did this happen? In this case, the task was novel and challenging and was taking a large percentage of the mental capacity of the divers. The diver who was supposed to tie in was likely more interested in the camera, the lighting rig, and the team rather than the primary task of tying in. Although the tying-in task was important, research on brain activity has shown that when not actively directing one’s attention, humans shift focus between four key categories of information: dangerous, interesting, pleasurable, and important (DIPI). In this example, the camera task/rig was interesting (novel activity, part of a project that was pushing the survey) and pleasurable (surveying new cave, shooting 360 video); consequently, “important” and “dangerous” disappeared down the list of things that were considered worthy of the divers’ attention.

Diver Lauren Fanning in Ginnie Springs. Photo by Kirill Egorov.

The lighting team would be focused on configuring their rig, thereby reducing their peripheral vision. Being in a cave with bright lights and being mid-water would reduce it further. Peripheral vision is used to detect movement, and this might explain why they missed drifting further into the cave, and so the danger was missed. Even if they had noticed the movement, the working mental model would have been that the first diver had tied in the line, and there was no cause for concern when they saw that first diver again.

Assumptions and miscommunication are commonplace in modern life. In fact, assumptions are essential to operate at the pace we do, since we are unable to consciously process the vast amounts of information that we receive through our sensory systems. In addition to assumptions, a critical instruction was passed (i.e., tie in the line), but the communications loop was not completed. The leader should have ensured that the tie-in had started before the team began working on the video rig.

Applying these Lessons to Your Diving  

The Limitations of Situational Awareness. If we don’t want to be distracted at the wrong or critical time, we need to understand how our attention system works. We have a finite capacity in our working memory, shown to be seven +/- two elements of information at any one time. Note that this is “elements” and not “pieces” of information, a critical distinction when it comes to improving situational awareness and mental capacity.

As we become more skilled at an activity, we start to chunk information together (e.g., when we first start to dive, we have to actively think about the sequence of activities to stabilize at a stop). These might be: look at the computer/timer, note that we are 3-5 ft/1-2 m below the stop depth, reach back and grab the OPV dump cord (or inflator hose), pull the cord (press the deflate button), monitor how much gas leaves the wing (or the time the button is pressed/cord pulled), and watch the computer to see where we are. Unfortunately, we often don’t get it right, either stopping too soon or too late, and then start to oscillate around the stop depth.

However, when we are more experienced, the activity of arriving at a stop combines all these actions into one “element” that we don’t actively think about, and we get it right the first time. This means we have more capacity to see what else is going on around us and to anticipate what might happen next. The same goes for other technical skills that need to be developed.

Definition of Error. Divers have a vested interest in making sure that they make a decision that ensures that they (or someone else) doesn’t die or get injured. As such, if a diver knows with 100% certainty what the outcome is going to be, and it is a negative outcome, they won’t execute that decision. Errors happen all the time, but not every error ends up as an incident or accident. If we want to improve our safety, we need to invest time to review what we’ve just done and not just the outcome. Ultimately, we need to understand how it made sense for those involved.  

Like incident reports? Read another

Header photo by Kirill Egorov.

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Gareth Lock is an OC and CCR technical diver with the personal goal of improving divingsafety and diver performance by enhancing the knowledge, skills, and attitudes towards human factors in diving. Although based in the UK, he runs training and development courses across the globe as well as via his online portal https://www.thehumandiver.com.He is the Director of Risk Management for GUE and has been involved with the organization since 2006 when he completed his Fundamentals class.

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Cave

Karen van den Oever Continues to Push the Depth at Bushmansgat: Her New Record—246m

Karen van den Oever recently broke her own world cave diving depth record by a little more than 10m/33 ft at Bushmansgat cave in South Africa. The S.African cave diver conducted the 8 hour 14 min high-altitude dive on open circuit scuba, breathing trimix 4/90 bottom mix, and suffered mild High Pressure Nervous Syndrome (HPNS). Here former world depth record holder, Nuno Gomes who was van den Oever’s cave instructor, offers the details of her record setting dive along with a short history of the women’s depth records.

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By Nuno Gomes. Images courtesy of Karen van den Ever.

Karen van den Oever and her husband Francois Bain

Karen van den Oever, from Johannesburg, South Africa, has dived to a depth of 246.65 m/809 ft. This is equivalent to a dive to a depth of 296 m/971 ft when corrected for an altitude of 1550 m/5,085 ft above sea level. The dive was conducted on October 27, 2022, in Bushmansgat cave, South Africa, and is a new women’s world record cave dive. Karen bettered her own previous world record to a depth of 236.04m/770 ft  (283 m/924 ft correcting for altitude), also accomplished at Bushmansgat cave in 2021.

I actually felt really good after the dive, a little tired but overall, quite good. I felt much better after this dive than the previous one. I’m happy that the dive went well, just thinking about what comes next. I have no definite plans going forward, we are looking into diving some of the caves in Namibia and also exploring some of the caves not yet dived in Zambia but no concrete plans yet.”—Karen van den Oever

Karen and Theo van Eeden, with the signed tag.

Women have been making record deep dives for quite some time. Back in 1981, one of the first deep diving records was made by Sheck Exley’s wife, Mary Ellen Eckhoff (USA). She used a dive propulsion vehicle (DPV) to travel into Wakulla Springs cave, as well as staged tanks for decompression purposes. Mary Ellen dived on open circuit, together with Paul DeLoach and John Zumrick, and they reached a distance of 363 m/1192 ft and a depth of 80 m/260 ft, which was a major dive at the time.

In 1996, Dr. Ann Kristovich (USA), a friend of Jim Bowden, considerably extended the record, reaching a depth of 167 m/548 ft on open circuit at Zacaton cave, Mexico. Ann’s world record dive would remain in place for a long time.

It was not until the year 2000 that another woman, Claudia Serpierri (Italy), would beat the previous record, but this time in the sea (Mediterranean Sea). Claudia would reach a depth of 211 m/692 ft on open circuit, diving from a support ship. This dive remains the deepest sea dive by a woman to date.

Toward the end of 2001, Verna van Schaik (South Africa), was ready to challenge the women’s record. First, she did her deepest dive by reaching a depth of  186 m/610 ft  (223 m/732 ft correcting for altitude), on open circuit, at Bushmansgat cave in South Africa. This was not enough for her, and during her next expedition on October 25, 2004, Verna would go back to Bushmansgat cave to become the first South African woman to get her name in the Guinness Book of World Records by reaching a depth of  221 m/725 ft  (265 m/870 ft altitude corrected), on open circuit. Her deep support diver was the late Dave Shaw (Australia), on closed circuit, who died of respiratory insufficiency at a sub-250 m dive at Bushmansgat in 2005.

View of the surface pool of Boesmansgat cave.

Following Verna van Schaik’s dive at Bushmansgat cave, two women divers died trying to break her record, as follows: 

In May 2010, French diver Brigitte Lenoir, died in Dahab, Egypt during a dive in the Red Sea. The accident took place at 147 m/482 ft while ascending from a 200 m/656 ft, on closed circuit. Her body was recovered with an ROV. 

In September 2017, Bulgarian technical diving instructor trainer, Teodora Balabanova, died attempting a dive to 231 m/754 ft, on open circuit, while her husband, Mihail Balabanov, suffered from decompression sickness. 

Karen van den Oever is a science graduate from the University of Witwatersrand in Johannesburg, South Africa, where she currently resides. Like Verna van Schaik, who now resides in New Zealand, she is a CMAS diving instructor, and also a former member of the University of the Witwatersrand Underwater Club. 

Her original cave, trimix and blending training was with me. I also trained her husband Francois Bain. 

Unstoppable Karen van den Oever

Karen had previously dived to 201 m/660 ft (241 m/792 ft altitude corrected) on open circuit in Bushmansgat cave in South Africa’s Northern Cape province on February 27, 2020. That dive’s total dive time was 7 hours and 21 minutes. On March 26, 2021, Karen dove to 236.04 m/770 ft (283 m/924 ft), on open circuit, at Bushmansgat cave, using a bottom gas of trimix 6/85. The total dive time was 7 hours and 18 minutes. That dive is the current deep diving Guinness World Record (women).

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Karen’s new world record dive, done on October 27, 2022, was made to a depth of 246.65 m/809 ft (296 m/971 ft), in Bushmansgat cave. The dive was done on open circuit, using a bottom gas of trimix 4/90, and with a total dive time of 8 hours and 14 minutes. The dive would not have been possible without a large team of support divers. 

Karen’s dive computer. Actual depth from rope measurements by independent witnesses was 246.56m/809 ft.

Peter Reid was at 209 m/686 ft (251 m/823 ft); this was his personal deepest dive on closed circuit, and his total dive time was 6 hours and 20 minutes. Don Hauman did deep support at 110 m/361 ft (132 m/433 ft). Her husband Francois provided shallow support and surface support, together with the other team members.

Karen’s support team.

Karen’s Total Narcotic Depth (TND) was 48.06 m/158 ft; the Equivalent Narcotic Depth (END) considering nitrogen only was 9.49 m/31.14 ft, and her maximum Partial Pressure of Oxygen (PO2) was 1.03 Atm. Gradient factors: 40/75.

There were no serious incidents during the dive except that Karen suffered some mild High Pressure Nervous Syndrome (HPNS), which ultimately did not prevent her from going any deeper. Karen had some difficulties recovering the evidence tag from her maximum depth because of the tremors that she was experiencing as a result of the HPNS, but in the end she turned the dive mainly because she ran out of bottom time. 

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Dive Deeper

InDEPTH: South African Cave Diver Karen van den Oever Sets New Women’s Deep Cave Diving Record

InDEPTH: Diving Beyond 250 Meters: The Deepest Cave Dives Today Compared to the Nineties

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InDEPTH: Opinion: Don’t Break That Record

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Nuno Gomes is a professional civil engineer, a CMAS technical diving instructor and a commercial diver. He was born in Lisbon, but his family relocated to South Africa during his youth. He now lives permanently in New York with his family. He has dived all over the world.

He used SCUBA (open circuit) to dive to a depth of 321.81 meters (1,056 feet), inclusive of rope stretch, in the Red Sea off the coast of Egypt near Dahab, in June 2005. The total dive time was 12 hours and 20 minutes. The descent took 14 minutes with two minutes spent at the bottom.

He also used SCUBA (open circuit) to dive to 282.6 meters (927 feet) in the Bushmansgat cave, in South Africa, in 1996. The cave is located at an altitude of 1,550 meters (5,086 feet) above sea level, which resulted in a decompression schedule for an equivalent sea level dive to a depth of 339 meters (1,112 feet) in order to prevent decompression sickness. The total dive time was 12 hours and 15 minutes with four minutes spent at the bottom of the cave.

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