October 2016 Eagles Nest Tragedy, Revisited

THE EAGLES NEST TRAGEDY REVISITED

As promised back in October the NSSCDS would report on the October 15th Eagles Nest accident as best it could within the context of established protocols. This should by no means be construed as an accident analysis, but rather a summation of known facts, most of which are already in the public domain as part of an effort to learn from this accident.

What we know is that two men perished in Eagles Nest Cave on the aforementioned date. They were diving JJ Rebreathers, both of which were functioning properly. Their equipment consisted of 3 scooters; one as a backup and two as primaries. Open circuit bailout gasses were of the appropriate mixes and their volume was more than adequate. They formulated a plan. They had a surface support diver ready to assist. They did everything right.

Below are facts as reported by Charlie Roberson, one of the IUCRR (International Underwater Cave Rescue and Recovery) divers. Please note that this information was posted by Charlie on an internet forum. Some of his report is paraphrase here, some is verbatim, but this is an accurate depiction of what they found.

Chris Rittenmeyer and Patrick Peacock initiated a dive at Eagles Nest Cave at approximately 2:00 PM on Saturday October 15, 2016.  On the day prior they had “set up” the cave with the appropriate decompression gasses and bailout bottles which were distributed along their planned route in the event of a CCR failure. For those readers who are not familiar with CCR protocols, the normal procedure is to remain on the rebreather for the duration of the dive, including decompression. Adequate open circuit gasses are “staged” as “bailouts” in the event of a CCR failure.

Each diver was equipped with a JJ Closed Circuit Rebreather (JJ-CCR), two Faber 95 cu. ft. bottles in a side mount configuration, an AL80 safety bottle and a scooter. The team also towed a third scooter as a backup. It should also be noted that both divers were trained as Full Cave, Trimix, CCR and DPV (scooter) divers.  Both men also had years of ocean and cave diving experience.  

A third diver remained as surface support. The plan was for the surface support diver to affirm they were on deco and OK at a predetermined time. When they failed to show up at that time diver 3 checked back every 30 minutes until they were several hours past due and at around 6:00 PM he placed a call to Cave Country Dive Shop and spoke with Jon Bernot, who immediately loaded his vehicle and began the drive to Eagles Nest. While enroute Jon called around and activated a response team of qualified and available personnel.

At this juncture it should be noted that whenever an accident of this nature occurs it is considered a crime scene by the authorities. IUCRR divers are trained to gather and preserve evidence on behalf of the police agency in charge of the investigation. By prior agreement, any information gathered belongs to that agency and can only be disseminated by them or with their permission. That is why it typically takes a long time before any “facts” are released.

The first Search Team consisted of Jon Bernot and Charlie Roberson. They got underway at approximately 11:00 PM and planned to do a search of the upstream passage. According to the surface support diver 3, that was their intended dive plan.  Upon entry they inspected the decompression habitat and observed three bottles marked “O2” at twenty feet. Four 50% or 70 foot bottles were staged at 70 feet. They also noticed two bottles marked 120 (gas they contain is safe to breathe at 120 feet) staged at 120 feet. Both divers noticed that the 120 bottles were staged on the downstream side of the line but decided to search upstream because that was what the surface support diver told them the plan was. After doing a thorough search of the upstream tunnels the team returned to the entrance room and proceeded to search the downstream tunnel up to and including the Lockwood Tunnel, all to no avail. The first team surfaced at around 3:30 A.M.

The second search team, consisting of Ted McCoy and AJ Gonzales got underway at around 3:45 AM to continue the downstream search. They immediately found the two decedents on the exit side of the Pit.

At this juncture the second team fully documented the scene for about 45 minutes (as previously stated this is a crime scene until law enforcement states otherwise). The following observations were made:

  1. Diver one was wearing his CCR but his bailouts were not in place. One empty 95 cu. ft. cylinder was beside him and attached to his rig via a QC6 Swagelok Hi Flow Quick Disconnect fitting. A long hose was attached to that cylinder and deployed.
  2. His loop was open and out of his mouth and the hose on the inhale side was crushed.
  3. He had 300 psig of onboard O2 but his onboard diluent bottle was empty.
  4. A 13 cu. ft. inflation bottle had gas remaining in it.
  5. He had no primary light head and his backup lights were not deployed.
  6. There was one scooter next to him but it was unclipped and turned off.
  7. Diver two was wearing only a drysuit, mask and fins. He was positively buoyant with a backup light clipped off and dangling from his pocket. No other bottles were nearby.
  8. A full AL80 was staged just on the exit side of the Pit restriction but was not easily seen if exiting. The missing primary light head with an e/o cord was also found there. Another full AL80 stage was found just downstream of the jump to the Lockwood Tunnel next to another teams full safety bottle.
  9. Two of the four 95 cu. ft. bailouts the divers carried side mounted (two each) were found on the downstream side of the Pit restriction. Both were empty.
  10. On Sunday afternoon recovery team one, consisting of Eric Deister and Colt Smith, brought both bodies to the top of the Ballroom and recovery team two, consisting of Ken Sallot and one other diver brought them to the surface.
  11. On Monday, October 17, 2016 a gear recovery team consisting of Jon Bernot and James Draker was dispatched to search for and recover any gear left in the cave. Two scooters, diver 2’s rebreather and a 95 cu. ft. bailout were located at the end of the gold line outside the restriction leading into Revelation Space. The CCR loop was closed and appeared to be fully operational. All gear was removed and turned over to law enforcement as evidence and for analysis.

Below is a drawing of the revelation Space restriction made by Don Six.                        

                                                

The computers logged 36 hour dives which were outside the parameters of the Shearwater Software. Because of that special factory modifications were necessary in order to download the profiles. They indicated the divers most likely entered and exited this restriction twice but never passed through it. As the above illustration shows, the restriction is small and extremely silty. It appears that the divers began their exit at approximately 61 minutes. One of the computers also showed a ppO2 spike at approximately 83 minutes. This agrees with the finding that the diver with the rebreather had an empty diluent bottle but 300 psig left in his O2 bottle.

A timeline constructed from the computer data with the help of Ken Sallot indicates the divers arrived at their destination at 43 minutes into the dive. They entered the restriction at about 49 minutes and exited at about 52 minutes. A second try began at about 58 minutes and ended at 61 minutes, which is when the CCR was abandoned. This can also be interpreted as one diver got through the restriction and waited for his buddy to come through. When he did not appear he attempted to exit the restriction and got into trouble. Both men arrived in the vicinity of the pit restriction at approximately 85 minutes into their dive, which is where they were found.  

Staged gasses were analyzed and were found to be consistent with their labeling. They were 100% O2, 50% O2, balance N2, 21/35/44 Trimix (O2, He and N2 content).

It was previously noted that diver one had no primary light head and his backup lights were not deployed. The light head was found in the clay in the vicinity of the pit. It had been connected to the battery pack via an E/O connector.  

What actually occurred is anyone’s guess. We know that one of the divers had to remove his gear for reasons we can only speculate on and that the divers stayed together. For reasons unknown they abandoned a functional rebreather and a full 95 cu. ft. bailout bottle in the vicinity of the exit side of the restriction. Equipment recovery divers reported that the area was silty 48 – 72 hours later.

By virtue of having no equipment for “ballast” diver 2 had to be buoyant because of the drysuit. This would make his exit very difficult. Three empty 95 cu. ft. bailouts would bear this out. Diver ones’ on board diluent was empty and his long hose was deployed indicating there was probably an air share, at least at some point. The bailout bottle was also plumbed into the loop via a QC6 connector so it is possible that it was a contributing factor in the emptying of Diver 1’s on board diluent. It would also be logical to attribute the loss of diluent to wing inflation caused by buoyancy issues.

WHAT IS THE LESSON LEARNED HERE?

First and foremost we need to understand that sometimes bad things happen to good people for no apparent reason. These men did everything right. They set up the cave the day before. They had all of the correct bailout / safety gasses. They had top quality equipment and the training to go with it. So what went wrong? Obviously we will never know for sure but we need to realize that there is a very fine line between a mission that is successful and one that is not. Some days we are just “off our game”. Learn to recognize those days and don’t push it. Sometimes that little voice inside our heads says “don’t do that”. Learn to listen to it. The psychologists call it “rapid cognition”. It is when you arrive at a conclusion with no logical explanation.

Try to dive with more experienced divers. Learn from them and build up a well of experience you can draw from when that inevitable bad day happens; and know that it eventually will happen. Understand that you can do everything right and still have a bad day.

Never engage in “goal oriented” dives. When you do that the goal trumps everything and good judgment sometimes goes out the window.

We have tried to outline the facts here with no speculation. It is up to you, the reader, to glean what you can from this and use it to enhance your own safety. For me the take away is to expect the unexpected.

On behalf of The NSSCDS, the IUCRR and our respective members, I extend our heartfelt condolences to the surviving families. The close knit and small cave diving community feels your grief. Both men were “one of ours”.

Respectfully,

Joe Citelli
Chairman, NSSCDS

NSS-CDS Forum Thread:
https://nsscds.org/community/threads/eagles-nest-double-fatality.677/

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