AIDA SAFETY COMMITTEE
AIDA國際自由潛水協會安全委員會
嚴重事故報告 - 意潛自由潛水俱樂部
撰寫人- Jonathan Sunnex, AIDA 安全委員會主席- 星期二 ，2018年5月15日
AIDA安全委員會 - 嚴重事故報告
Brief
介紹
It is the objective of AIDA International and the AIDA Safety Committee to educate and assist our members by providing feedback whenever there is a serious or unusual incident. We greatly appreciate the co-operation of all involved, for together we will continue to grow our sport and improve the safety for all.
當有嚴重事故或者不尋常的事故發生時，AIDA國際自由潛水發展協會和AIDA安全委員會有責任向事故相關方進行教育和協助。我們感謝各方積極參與了這次調查，為了我們的運動能夠往更安全的方向去發展。
I have made the following observations, provided analysis and recommendations based on the information provided to me in the report sent by the Onefreedive Club and the surface video provided.
在意潛自由潛水俱樂部提供嚴重事故報告及水面錄像之後，通過分析和觀察我們撰寫了這份報告。
We would like to see the sport of freediving continue its growth in the safety way possible. The recommendations deal directly with the issues that will arise with the safety of individuals and the public image of the sport within China and internationally.
我們希望自由潛水運動繼續朝著安全的方向去發展，我所提供的這些建議直接面向該次事故中出現的個人安全問題及中國自由潛水在世界範圍內的形象。
Details
事故細節
日期：2018年2月23日
下潛時間：8:10 am
地點：菲律賓薄荷 Relax Divers Resort
預報成績: 68m 恆重無蹼 (挑戰新國家紀錄）
運動員: 朱霖 / Costa Zhu
首席安全員: 孟濤 / Meng Tao
第二和第三安全員: Gui Gui, Yan Xiaosen
事故類型：運動員嚴重昏厥事故（20米深度）, 及首席安全員昏厥事故
洋流: 輕度水面洋流但底盤附近稍強
能見度：20米
The Primary safety divers leaves the surface 1 min 45 sec after the OT, BEFORE the turn is announced.
首席安全員在OT後1分45秒下潛，也就是賽事工作人員在宣告運動員轉身的時間之前。
Turn announced at 1 min 50, 5 sec after the first safety departs the surface.
運動員在1分50秒轉身，也就是首席安全員離開水面5秒之後。
There does not appear to be a depth sounder in use to aid in tracking the divers progress.
在賽事中沒有使用聲吶來追蹤運動員的下潛深度。
The Second safety leaves the surface at 2 min 05 sec after OT, 20 sec after the first safety and 15 sec after the turn.
第二安全員在2分05秒離開水面，也就是首席安全員下潛水後的20秒及運動員轉身後的15秒。
Third safety leaves at 2 min 15 after OT, 10 seconds after second safety.
第三安全員在2分15秒後離開水面，也就是第二安全員下潛10秒後。
The divers surface together approximately 3 min 8 seconds after OT.
在OT後的3分08秒後，所有潛水員一同出水。
The primary safety diver arrives to the surface in a hypoxic condition and looses consciousness approximately 4 seconds after surfacing.
首席安全員在到達水面後處於極端缺氧的狀況並於4秒之後昏厥。
The loss of consciousness of the safety diver is detected by the surface safety in green within the first second of its occurrence and within 5 seconds has him on his back and airways clear of the water.
首席安全員昏厥過後，在水面穿綠色衣服的安全員在5秒之內進行了救援並將首席安全員的氣道脫離水面。
As this is happening Coach Enzo takes over the rescue response of the athlete, with BTT and rescue breathes delivered to a satisfactory level.
當該事故發生之後，運動員的教練Enzo對運動員進行了標準的BTT和人工呼吸操作。
First rescue breathe delivered approximately 12-13 seconds after surfacing and four delivered in total. The athlete regains consciousness 39 seconds after surfacing which is classed as a 『Serious Black out』 as per the AIDA BO policy.
人工呼吸在運動員出水後12-13秒做了第一次，總共做了4次。運動員在出水39秒後恢復意識，根據AIDA BO的標準，該BO視作為「嚴重昏厥」。
The second and third safety appear disorientated and do not provide adequate assistance in either BO.
第二和第三安全員不知所措，對運動員和首席安全員的昏厥沒有任何的作為。
During the duration of the video, the athlete does not receive oxygen.
在賽事方提供的水面視頻中，運動員沒有得到純氧的醫療救助。
Updated
事故細節更新
The underwater images shows that the primary safety diver did not receive assistance below the water from the other safety divers.
水下影像顯示首席安全員未從第二和第三安全員那獲得任何協助。
The arm position of the safety diver during the rescue was lower than ideal, the arms not being extended to their full capacity, which increases the drag/decreases streamlining making it more difficult for the rescuer.
進行救援的首席安全員在實施救援時手臂過於彎曲，未充分伸展開以對昏厥運動員提供足夠的支持，這造成了水下極大的阻力，使得救援進行的異常困難。
Analysis
事故分析
Based on what I can see in this video, in my opinion the Primary safety diver left the surface too soon. I can see that there are some waves and current that could affect the detection and announcement of the divers turn so if this is the case then I can also understand if the safety diver has based his departure on the announced dive time alone. However, a safety diver needs to take into account what is ACTUALLY happening during a dive vs what has been predicted by the diver with his/her announcement and apply judgement.
根據我從視頻中所觀察到的來看，首席安全員離開水面的時間過早。我可以看到水面有一定的浪和洋流可能會影響到賽事工作人員通知下潛的運動員觸底轉身的時間，所以我可以理解首席安全員根據運動員下潛的時間進行了判斷。但是作為一名賽事的安全員，其必須能夠極為清晰地掌控下潛過程中實際發生的所有事情而不是僅僅基於運動員在賽前的預報時間。
The athlete must ascend 38m without fins and the safety diver must descend 30m with fins for them to meet at the designated depth of -30m. The safety diver/s should take into account the likely speed of each diver(athlete and safety). A diver with fins is likely to move slightly faster than one who does not have fins, hence the recommended departure AFTER the turn.
運動員必須在無蹼的狀態下升水38米方能夠與必須下潛到30米深的首席安全員於水下匯合。安全員必須能夠清楚地算出每個運動員和其他安全員大概的下潛速度。也要知道穿戴腳蹼的運動員比不穿戴腳蹼的運動員的速度要稍快，所以我們強烈建議在運動員轉身後首席安全員再進行下潛。
For the level of competition/dives being attempted at this event a safety diver should be capable of performing safety divers of this time frame and longer. Waiting for an athlete that is behind their AP and on the verge of BO is a stressful situation for any safety diver but one that they should be prepared for. Specific training drills can be used to help safety divers train for undesired circumstances.
對於這個級別的賽事和國家紀錄挑戰的下潛，一個安全員應該具備相應的素質以應對可能出現的狀況。因為在預判深度進行等待及救援出現昏厥的狀況勢必會造成心理壓力，但是其應該為這些情況早有所準備。在賽前進行這類事故的必要演練對於對於應對特殊情況有著極大的幫助。
Steps should be taken in improving the safety diver training so that each safety diver knows his position and role during a rescue and so that they can work instinctively and as a team in stressful situations.
賽事方必須採取措施來對安全員的救援訓練進行改進，每個安全員應該清楚地知道自己的位置在哪裡，他們每一個人在一次救援中處於什麼樣子的角色中，這樣才能在緊急的情況中將團隊的力量發揮出來。
Improved arm/hand position should be rehearsed by the safety teams to improve the streamlining during a rescue. This is especially important for 『deep』 rescues where an athlete must be brought up from a considerable depth.
安全員團隊必須改進在救援過程中手臂和手的姿勢以使得救援期間保持高效並有效減少水阻。在深度救援中這一點尤為的重要。
The report gives the impression that only 『solo』 rescues are practiced and rehearsed, with only one safety diver actively bringing an unconscious person to the surface. We recommend that 『team』 rescues are practiced with two persons actively pushing the athlete to the surface at one time, one covering the mouth and pushing upwards, the other pushing against the hips, waist or under the arms.
在賽事方提供的報告中，賽事方僅僅在賽前演練了單獨的救援。我們要求演練內容為至少有兩名安全員協同的情況下將運動員帶回水面，其中一名按住嘴部並將運動員向水面推進，另一名安全員向上拖住運動員的臀部、腰部或者是腋下。
Recommendations
建議
I commend both AIDA China and OneFreedive Club for their co-operation during this investigation. Moving forward I would like to see the following course of actions take place in order for OneFreedive club to continue with it’s proposed competition.
我命令在未來類似的情況下，意潛自由潛水俱樂部必須積極配合AIDA中國的調查。我必須看到意潛自由潛水俱樂部在切實採取如下整改措施的情況之下，才將考慮是否批覆未來該俱樂部舉辦的其他比賽。
The use of a depth sounder MUST BE EMPLOYED at the next OneFreediving event. This will enable real time feedback of the athletes progress below the surface and will enable the safety divers to better time their departure and not to be left hanging for excessive times. I can recommend the Garmin 5D, which is the same device we use at Blue Element events. Please carry out the necessary checks and tests prior to using it in your event. It is advised to use it during any official and deep trainings.
必須在所有賽事中使用聲吶探測儀。該儀器的使用可以確保運動員的深度能夠在水面得到實時監控，這樣安全員便可以更好的知道出發的時間，不至於在深度進行停留等待。我建議Garmin 5D型號，這是我們在Blue Elements賽事中所使用的。請在賽事開始前進行檢查和測試。我們建議在任何比賽以及進行深度訓練的時候均使用聲吶。
Further training MUST be carried out by ALL members of the safety. (See Safety diver rescue drills, performance requirements below). Rescue drills MUST be performed in front of and signed off by the event judge and the form should be returned to AIDA International along with the other event paperwork(Performances results, Incident Summary, Serious incident reports(if required), etc). Please heed the advise included in this report where I have described hand/arm positions, team rescues, etc.
所有的安全員必須重新進行進行培訓。（請參照安全員救援練習，並按照要求執行）。救援演練必須在賽事裁判的觀察下完成，賽事裁判必須籤署一個表格表示救援是合格的並將該表格返回到AIDA國際自由潛水協會，連同其它文件（比賽結果記錄表，事故總結，嚴重事故報告等）請參照我在該報告中提及的關於改變手及手臂的救援動作標準，團隊救援的操作等。
It is important to note that ALL PERSONS who dive within the competition zone need to be accounted for after every dive. Incidents such as this though less common are far from unheard of. I have personally witnessed event photographers suffering LMC’s/ BO’s upon reaching the surface. Chief of Safeties/Head judges MUST remind safety divers and other crew members to be diligent at all times.
必須著重強調的是，所有比賽區域內下潛的人員必須得到照顧。有些事故可能很少見而且聞所未聞。但我親眼見到過賽事攝影師的SAMBA和昏厥。首席安全員和首席裁判必須提醒所有安全員和其他成員保持專注。
As soon as practicable, the persons who suffered the BO should be given oxygen to aid in their recovery, baring in mind SOONER IS BETTER. Please ensure that persons receive oxygen in a more timely manner.
任何人昏厥甦醒之後，必須提供純氧以供恢復使用，必須銘記，越早越好。請確保相關人及時得到純氧。
Compliance with AIDA China and AIDA International is important to ensure the safety of all divers and to protect the public image of the sport. Please maintain communications to notify us that the requested steps have been completed. Thank you again for the co-operation and best of luck with your upcoming event and 2018 season. We look forward to hearing from you.
服從AIDA中國及AIDA國際自由潛水協會對於確保所有潛水員的安全及保護自由潛水運動的形象是極為重要的。請確保溝通的順暢並及時通知AIDA中國及AIDA國際自由潛水協會，俱樂部是否合規並按照要求執行了所有的安全操作。感謝你們的合作並祝願你們2018將來的活動好運。我期待你的回覆。
Sincerely
Jonathan Sunnex
AIDA國際自由潛水協會安全委員會委員