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Diving Accident / Incident Report Form

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Diving Accident / Incident Report Form DIVING ACCIDENT / INCIDENT REPORT FORM NOTE: FAU Scientific Divers shall use this form to report diving related accidents, injuries, and incidents including; near-drowning, decompression sickness, gas embolism, lung overexpansion, or injuries that require hospitalization as well as any incidents that compromised diver safety or might result in later hospitalization, therapy, or litigation. FAU Dive Logs for all dives related to the accident / incident must also be submitted with this report. Contact the FAU Dive Safety Officer at 561-297-3129 with questions about whether or not to report an incident. GENERAL INFORMATION ABOUT THE ACCIDENT/ INCIDENT VICTIM DIVER NAME: DATE & TIME OF INCIDENT: DIVE LOCATION: DIVING CERTIFICATION LEVEL: CERTIFICATION DEPTH: Scientific Diver Diver-In-Training Temporary Diver CURRENT MEDICATIONS: CURRENT HEALTH PROBLEMS: If the diver is not anFAU-certified diver, complete this section. FAU-certified divers skip to the next section. AGE: SEX: (M/F) DIVER’S AGENCY OR ORGANIZATION: AGENCY OR ORGANIZATION DSO NAME & TELEPHONE #: # YEARS DIVING: TOTAL # DIVES: # DIVES LAST 6 MONTHS: PREVIOUS DIVE INCIDENTS & DATES: DESCRIPTION OF THE ACCIDENT / INCIDENT: Please describe accident / incident in detail. Include ANY factor which you believe may have contributed to, or minimized the accident / incident. If more than one accident / incident occurred please fill out a separate form. Use extra paper if necessary. What could have been done to prevent this accident / incident? Did the accident / incident cause harm: Diver’s qualification: (may circle >1) Yes No Not known Diving student …… DS Open water ……...OW Advanced diver…….AD Divemaster ……...DM Specify : Dive instructor ….. DI Untrained …… .. UT Professional ……... PD Technical diver…...TD Not known …….. NK CDAA .. Cavern CA Other………………… .. Sinkhole SI Did the accident / incident occur in training: ..Cave CV Yes No Not known .. Penetrat. PN Specify : Contributing Factors (Check all that apply): Inadequate knowledge Poor physical fitness Unfamiliar diving environment/conditions Feeling unwell Unfamiliar diving equipment Error in judgement Inexperience in diving Poor communication Poor dive planning Malfunction of equipment Insufficient training in diving Failure to understand equipment Failure to check Lack of servicing of equipment Lack of a buddy check Poor servicing of equipment Haste Lack of post dive equipment maintenance Inattention Inadequate supervision of diver Fatigue Sea sickness Anxiety Poor technique Recent illness Recreational drug/alcohol/hangover pre dive Did the accident / incident involve any of the following (Circle all that apply): Low air situation ………… LA Problem at deco stop ……. DE Out of air situation ………... OA Poor buddy pairing ………. BP Rapid ascent …………….. RA Poor buddy response ………… BR Unable to slow rapid ascent ... US Loss buddy contact …………. BC Out of air ascent ………….. OR Marine animal ………………….. MA Buddy breathing …………. BB Equalization problem descent … ED Octopus breathing ………. OB Equalization problem ascent … EA Pony bottle breathing …… PB Equipment ……………………… EP Multiple ascents …………. AA Poor visibility/silting ……………… PV Buoyancy problem ………. BP Strong current ………………… SC Problem on ascent ………. PA Flying <24hrs after diving ….. FL Problem at safety stop ….. SS Altitude >300ms after diving .. AL Deco stop missed ………. DS Panic …………………………… PC Not detected by buddy check … ND Anchor retrieval …………….. AR Nausea, vomiting U/W ……… NV Entanglement/trapped/guideline.. ET First Aid: st No O2 available / limited O2 supply Lack of trained 1 aid assistance O2 ran out Lack of first aid supplies O2 used inappropriately Poor first aid Gas Supply Gas supply in use during dive: Air Nitrox Mixed gas O2 No/poor analysis predive Confusion gas mix during dive Air consumption greater than usual this dive: Yes No Equipment involved in the accident / incident (Check all that apply): Hired Borrowed New Misuse Essential equipment lacking Equipment forgotten Torch Mask Depth gauge Mouthpiece Surface signal device BCD Dive computer Scooter Dive Flag Fins Regulator Reel or line Alterative air supply Snorkel Watch/Timer Shot/safety line Weight belt Wet suit Camera/trophy bag Gloves Weights Dry suit Rebreather Climbing equipment Ankle weights Lyrca suit Exit ladder Other Tank/cylinder Knife Boat Specify______________ Compressor/ Hookah Contents gauge Surface buoy Regulator and Gas Supply (Check all that apply): nd Low to out of air Inaccurate contents gauge Free flowing 2 stage Unable to locate alternative nd Contents not analysed prior Unable to read contents Octopus 2 stage air supply to dive or incorrectly gauge problem Air used frequently to Air not turned on Contents gauge hose 'O' ring problem maintain buoyancy Air not turned on fully rupture/leak Regulator breathing Tape on pillar valve st Air turned on then off prior Hose rupture/leak resistance increased 1 stage attached incorrectly to dive Pillar valve problem Unable to purge 2nd stage Separation regulator parts Air supply turned off 1st stage malfunction Pony bottle problem Swivel problem inappropriately 2nd stage malfunction 'Octopus' reg snagged Didn’t check contents gauge regularly Miscellaneous Equipment (Check all that apply): Weights and weight belts: Buoyancy Jacket (BCD): Inflated restricted breathing Overweight Underweight Unfamiliar with its use Unable to deflate Unable to release Spontaneously inflated BCD air cylinder problem Didn't know how to release Inflation device failed Unable to inflate Quick release jammed Inflator hose leaked Unable to inflate due to low air Tongue overlap stopped release Inflation device not connected Provided inadequate buoyancy Snagged during release Incorrect inflator hose Confusion deflate/inflate buttons Weight belt /weights dropped Didn’t know how to inflate BCD Buddy couldn’t deflate vest Snagged causing release Didn’t know how to deflate vest Buddy couldn’t inflate vest BCD integrated weight problem Inflator/octopus combination Leaked Incorrect size Wet / dry suit: Uncomfortable problem Other Tight - restricted breathing Dump valve malfunction Specify : Changed buoyancy Uncomfortable Mask Dive computer Depth gauge Flooding/dislodged caused panic Not used Inaccurate Not used Inaccurate Flooding/dislodged no panic Stopped working Unable to read Strap broke Forgot to activate it Maxm depth indicator problem Unable to clear Unable to read/layout confusing Confusion units used Clearing caused panic Battery problems Tank/cylinder Dive tables Fins Out of test Faulty Not used Misread Strap broke Lost Changed buoyancy Unable to understand Caused cramp Incorrect size Not secured in backpack Size change between dives Tank Configuration Used: SINGLE TANK TWIN TANKS SLING TANKS OR STAGES Yes Independent back mounted Yes No Not known Independent side mounted Manifolded ( isolator problem) One Two Not known Configuration not Not known known Configuration and contents if known: Report Prepared By: _____________________ _____________________________ _________________________ Signature Printed Name Date .
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