Report to the Minister of Justice and Solicitor General Public Fatality Inquiry

Transcription

1 Report to the Minister of Justice and Solicitor General Public Fatality Inquiry Fatality Inquiries Act WHEREAS a Public Inquiry was held at the Court House in the Town of Stony Plain, in the Province of Alberta, (City, Town or Village) (Name of City, Town, Village) on the 3 rd day of June, 2013, (and by adjournment year on the 4 th and 5 th days of June, 2013 ), year before Charles D. Gardner, a Provincial Court Judge, into the death of Tyler Theodore Manchester 20 (Name in Full) (Age) of Site 3, R.R. 1, Calahoo, Alberta and the following findings were made: (Residence) Date and Time of Death: Place: August 7, 2011 at 9:54 A.M. Lac Beauvert, Jasper, Alberta Medical Cause of Death: ( cause of death means the medical cause of death according to the International Statistical Classification of Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose and published by the World Health Organization The Fatality Inquiries Act, Section 1(d)). Air embolism as a consequence of a rapid ascent from depths while scuba diving Manner of Death: ( manner of death means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable or undeterminable The Fatality Inquiries Act, Section 1(h)). Accidental

2 Report Page 2 of 8 Circumstances under which Death occurred: In the spring of 2011 Mr. Russell Manchester and his two sons Tyler, then age 20, and younger son Matthew, made a family decision to take up the sport of scuba diving. The genesis for their decision was Matthew s involvement in a youth group affiliated with the Alberta Fish and Game Association, a group which Tyler, when younger, had also been involved in. The group s interest in scuba diving was as a result in its interest in environmental preservation and the desire to further that by having the young people get involved in lake clean-up. Matthew began scuba training with the youth group and his father and brother decided to join him. The youth group undertook research and determined that Northwest Scuba in Edmonton, a diving equipment supply and training establishment had a good reputation and as a result the group members, including Matthew, began a training program. For training purposes Northwest Scuba is an authorized affiliate of an international scuba diving training organization called PADI (Professional Association of Diving Instructors), which is a private dive instructor accreditation organization. Due to scheduling constraints Mr. Manchester and Tyler, after Matthew took his initial training with the group, took part in classroom training and pool dives on their own and then joined the group for what is styled open water training at Narrows Lake Conservation Camp. Leading up to that open water training and in accord with PADI diver training course requirements, father and sons attended lectures at the dive shop, received and reviewed written and audio-visual training DVDs, undertook self-testing and completed written testing at the dive shop. They were also tested in the learned diving techniques in a swimming pool setting. The training included all aspects of scuba diving techniques and diver safety protocols.

3 Report Page 3 of 8 Mr. Manchester, Matthew and Tyler were all successful in the various testing phases leading to the open water dives at Narrow Lakes. There was no indication in that process that Tyler was experiencing any difficulty with any aspect of the training. All three were successful in achieving, again according to PADI standards and as certified by the Northwest Scuba instructor, their open water certification. In that certification process the deepest dive which had been undertaken was approximately 18 feet. Mr. Manchester s understanding was that this certification level limited them to dives of no more than 30 feet. At a point in time after receiving the open water accreditation and when Mr. Manchester attended at Northwest Scuba to reserve (for rental purposes) diving equipment for he and his sons so that they could undertake some recreational practice diving, it was suggested by a Northwest Scuba employee that they undertake the next level of certification which was styled Advanced Open Water. This involved taking a further course and then taking part in two days of open water which involved training in three dive specialties: 1) peak performance buoyancy; 2) a night dive; and, 3) a deep dive. The preparation for this certification, accordingly to the PADI training protocol, did not involve any classroom lectures and training, but there were written and audio visual materials to be reviewed. The three undertook a review of that material and it was then arranged that the course would be taken in Jasper, Alberta at Lake Edith on Saturday, August 6 th, 2011 and on Sunday, August 7 th, 2011 at Lac Beauvert, a popular diving location because of its depth. With instructors and a class, the Manchesters took part in two dives at Lake Edith on Saturday morning, a night dive at Lac Beauvert on Saturday evening and then the deep dive on Sunday

4 Report Page 4 of 8 morning at Lac Beauvert. Until that deep dive all dives took place without incident. These training dives were conducted under the supervision of Northwest Scuba dive instructor Andrew Wheeler, assisted by a Northwest Scuba dive master Christina Wendel and dive master trainees Grey Molendyke and Whitney Reynolds. On the Sunday deep dive, the first three participated in the dive with the students and Ms. Reynolds remained out of the water for what was described as shore support. It was when this deep dive had reached its maximum depth of 65 feet that events went wrong eventually leading to Tyler Manchester s death, not from drowning, as one unfamiliar with scuba diving might wrongly conclude, but from an air embolism akin to a heart attack caused by an excessively rapid ascent from such a depth. At that 65 foot depth the dive instructor, Andrew Wheeler, turned to his group of students and the dive masters assisting him and gave the symbol which divers are trained to understand as meaning is everything OK. This inquiry was made just as he was about to lead the group on a gradual ascent to the surface. All, including Tyler, gave the appropriate sign to indicate that everything was indeed OK. However, soon, perhaps 30 seconds later, dive master Christina Wendel noticed that one student, Tyler, after he had given the OK sign was signaling that he had a problem. As a result Ms. Wendel went to him, gave the sign to ask if he was OK, and from a shake of his head received an indication that he was not. She, again through signals, asked if he wanted to ascend and received his indication that he did. The dive plan for the group called for a gradual angular ascent following the lake bottom toward the shore and that is how the group proceeded. Ms. Wendel, given Tyler s indication and what

5 Report Page 5 of 8 she perceived as some panic in his expression, elected to assist in an ascent going straight up. Again at 65 feet this must be undertaken slowly to avoid what is commonly call the bends. The bends, also known as decompression sickness (DCS) or Caisson disease occurs in scuba divers or high altitude or aerospace events when dissolved gases (mainly nitrogen) come out of solution in bubbles and can affect just about any body area including joints, lung, heart, skin and brain. Decompression sickness (DCS) is caused by the formation of bubbles of gas that occur with changes in pressure during scuba diving. It is also experienced in commercial divers who breathe heliox (a special mixture of oxygen and helium), and astronauts and aviators that experience rapid changes in pressure from sea level. In addition to air tanks and associated breathing apparatus and to maintain appropriate buoyancy in the water to be thus able to regulate their depth in the water and their rate of descent and ascent, standard scuba diver equipment includes weights and a buoyancy control devise (BCD), a part of which is a low pressure regulator. This device, at the diver s control, inflates and deflates the BCD from the air tank thus affecting buoyancy and thereby descent or ascent. I will point out as well at this point in my Report that divers from their first exposure to scuba diving training have drilled into them the importance of constant breathing from their air source. They are taught not to hold their breath. As Tyler and Ms. Wendel were ascending, he indicated something to her which she took to mean that he wished to breathe off of her alternate air source which is a second mouthpiece used in the event of difficulty with the primary source. She was reluctant to allow this as students sometimes erroneously believe that something is wrong with their air source when they are nervous and not breathing as trained. As Tyler, in her view seemed to be panicking, she felt it appropriate to make him feel better and get him to the surface. However, as they headed up she felt they were doing so at an unsafe rate so she let her air out of her

6 Report Page 6 of 8 BCD but noticed that Tyler, in a panic, was inflating his BCD to increase the rate of ascent to get to the surface faster. She then concluded, based on her observations of him, that he must have realized his error in that regard and he let air out, but too much, which caused him to drop straight to the bottom. It was then of course necessary to ascend again, and this time there was a concern that Ms. Wendel s air supply was running out as both were breathing from it, and Tyler was breathing heavily as was she due to the strain of bringing the two of them to the surface a second time. In that process she was also attempting to disengage Tyler from his weight belt to increase his buoyancy. They did surface but were struggling she with his equipment, his own air supply being in free flow, that is bubbling into the water and she was holding him and kicking to keep them both above the surface and calling for help. Ms. Wendel then lost her grip on him and Tyler again descended to the bottom and once her alternate air supply pulled from his mouth he was without an air supply. Subsequent examination of his equipment revealed that his air tank at some point in time became empty. Notwithstanding that her own supply of air was extremely low she descended and attempted to locate Tyler but was unsuccessful. Her cries for help at the surface were heeded by other divers in the area and Andrew Wheeler who dove down and eventually located Tyler. He was brought to the surface unconscious and was immediately transported to the Seton General Hospital in Jasper where he was pronounced dead at 9:54 A.M.. A subsequent scuba dive expert examination of the equipment used by Tyler on August 7, 2011 revealed that it was operating as it should that is to say there is no evidence to point to equipment

7 Report Page 7 of 8 malfunction as in any way contributing to Tyler s death. From the evidence placed before me at the Inquiry I believe that Tyler Manchester s death is a consequence of his panic and failure to follow breathing and depth ascent procedures in accordance with his training as an open water diver. Nothing in Tyler s behavior either on the day in question nor in the manner in which he participated in his scuba diver training, testing or earlier dives gave any indication to his father, his instructors or his dive companions on previous dives indicating that he was in any way fearful or apprehensive about participating in a deep water dive. On the day previous he had been briefly behaving in a manner which led his father to believe that he was not taking the instruction seriously enough. But his father spoke to him and he responded appropriately. There was nothing in his behavior which would have led to a concern that he might react as he did. Clearly all three Manchesters were new to the sport and had completed only a few open water dives prior to the deep dive on August 7, However, based upon the PADI training protocols they had accomplished all that was necessary in their training and testing to undertake such a dive under supervision. Mr. Manchester s and Mathew s successful completion of the deep water dive are indicators of that. Recommendations for the prevention of similar deaths: At the Inquiry I heard extensive evidence concerning the PADI training program and the manner in which Northwest Scuba became accredited through PADI to deliver its scuba training programs. In addition, I have received and reviewed all of the PADI written and audio visual training and testing material that formed the training undergone by the Manchesters. I say without hesitation that it is

8 Report Page 8 of 8 comprehensive. At the Inquiry I learned that, with the exception of the Province of Quebec, no Canadian province regulates the scuba diving industry. It was argued at the Inquiry by counsel for the Manchester family that an industry which is inherently dangerous should be subject to strict government oversight. Because of the inherent dangers of scuba diving, those who take part in it, whether by way of providing equipment or providing diver training services, take responsibility for the lives of those with whom they deal. One would expect that such an industry given that responsibility would take that responsibility very seriously. From the evidence provided at the Inquiry it is apparent that the dive community does in fact take that responsibility very seriously. There is nothing in what I have learned about the PADI training program or the manner in which it was delivered by Northwest Scuba which leads me to conclude that any government controlled form of regulation or supervision would have led to a safer environment which might have prevented Tyler s death. Tyler s death was an unfortunate accident and I am unable to make any recommendation(s) which I feel would prevent similar deaths from occurring. DATED October 30, 2015 at Stony Plain, Alberta. Charles D. Gardner Charles D. Gardner A Judge of the Provincial Court of Alberta