(Photos by Jill Heinerth courtesy of Dam Builder Productions)
Last August I wrote an article about the death of Carlos Fonseca. He was a dynamic diver and someone whom I was just getting to know as a friend. He died while diving in a cave called "The Devil's System" at Ginnie Springs in North Central Florida. According to a report put out by Dive Ontario, Carlos' buddies stated that he clipped on a stage bottle (extra gas carried by technical divers) marked O2 (pure oxygen) and when it was pointed out that the gas was inappropriate for the depth of the dive (oxygen poisons you below 30 feet), Carlos allegedly dismissed the concern and stated he knew the tank was filled with air. The report goes on to state that the team entered the cave and went upstream about 400 feet. Carlos began to have seizures. His team managed to extract him and he was rushed to hospital where he died. Allegedly a local instructor tested Carlos' stage bottle and found it had 98% O2.
Of course if that's true then clearly Carlos was breathing a toxic mixture and it was only a matter of time before he succumbed to oxygen toxicity. But is all that true?
Entering the Devil's Ear
I went looking for the facts. I waited until the Medical Examiner had completed his report and I ordered a copy. The bottom line -- Carlos Fonseca was a healthy person without any physical problems who died as a result of drowning. Not many answers there so I kept looking.
I called the Gilchrist County Sheriff's office and asked to speak with the investigator who handled the case. Eventually I spoke with Det. Ken Philips. He was most helpful. But when I asked him exactly what his investigation consisted of, it really didn't amount to a great deal. He said he essentially relied on the Medical Examiner's report and some interviews done by Lt. Troy Davis. He said Davis had spoken with dive instructor Michael O'Leary at the scene and taken his word about the testing of the tank. Now I have a huge regard for Michael O'Leary. I consider it a privilege that I took my first Cavern course from him. But this was a police investigation. Surely basic police procedure dictates that they do their own forensic work. By not having their own people test that tank, from an legal stand point, they lost the ability to say for certain what the content of the tank really was. There's more.
I asked Det. Philips whether his department had checked any of Carlos' equipment, ruled out any other cause of death. They had not. Once again they merely spoke to a few witnesses and left it at that. Incomplete police work by any standard. Intentional negligence? Probably not. According to Tampa Bay based criminal lawyer Timothy Fitzgerald, lack of resources is probably more to the point. "Dade County would have a dive team and they would be able to look at the equipment." Gilchrist Country, according to Fitzgerald probably wouldn't spend money on resources for what looked like an accident. Why bother to bring in a forensic team unless foul play was suspected?
Fair enough, but what does all this mean? Well it means that we'll never be able to say for sure what happened to Carlos Fonseca. We may think we know, but we will never be able to certain. That's bad news for Cave Diving.
Inside the Devil's cave system
That sport uses a system called "accident analysis" to raise standards of safety. The theory is that if you keep analysing why accidents happen, then you can prevent them from happing in the future. I'm a huge fan of the concept. But for that system to work, the analysis has to be based on proven facts or it becomes flawed analysis. Regrettably whatever we might have gained from the incident with Carlos, we've now lost.
Exiting the Devil's system
What we got instead was "Sound and Fury." Shortly after Carlos died, on line dive forums lite up. Some of what was discussed was valuable in terms of re-examining basic cave diving safety issues. But much of what was said was petty and mean. Many took advantage of the forum discussion to heap derision on Carlos -- almost as if they had some small minded desire to settle verbal scores. It wasn't a pretty sight.
I made the mistake of suggesting that waiting for all the facts to come in might be a better course of action before conclusions were drawn. That had the effect of turning me into another target. I was mocked for my relative lack of cave diving experience (I make no apologies for the fact that I'm just learning.) My profession as a journalist was called into question. Numerous people suggested I had no business raising any of the issues I spoke about. Essentially I was derided because I had the temerity to ask questions about whether what everyone assumed--that Carlos made a careless error -- was correct.
Inside the Devil's system
To my way of thinking that means we've lost twice as a result of this episode. We've lost a dynamic member of the diving community, Carlos. What's more, by refusing to truly examine the facts of the accident, we've lost a potential lesson for the future. One that might have saved other divers lives.