STEPHEN KEENAN ACCIDENT REPORT

Published: 11/6/2017

INTRODUCTION
On Saturday the 22nd of July, Alessia Zecchini, the current AIDA world record holder in constant weight, crossed the Arch in Dahab's Blue Hole. The general organization was carried out by Stephen Keenan, AIDA safety officer and co-owner of DAHAB FREEDIVERS freediving center.
A team of eight people accompanied Stephen Keenan for the organization of this dive, under his supervision and three additional scuba divers were involved, to capture the crossing on camera, but were not a part of the team in charge of safety.
The weather was sunny, the water temperature was 27°C on the surface with no thermocline. There was some wind and waves on the surface and a very mild current. The visibility was 20m in the depths down to -25m, then visibility was 30-35m from -25m depth and deeper.
Stephen himself crossed the Arch in 2016. Moreover, he previously organized two other crossings of the Arch. Finally, he took part in several other crossings of the Arch as a safety diver.
Alessia Zecchini trained in Dahab for 3 weeks before attempting this dive. She was training in the Blue Hole, coached by Stephen. She was in excellent shape both physically and mentally, doing dives in training in FIM and CNF that were close to the current women's world records. In the days preceding the Arch dive, for example, she made a -90m FIM dive and new PB of -69m in CNF. Both times with a very short and extremely clear surface protocol.
The day before the Arch dive, on the 21st of July, she did a test dive in the Light House bay in Dahab, in order to get the best estimate of the total time of her dive through the Arch. This FIM test dive was limited to -45m due to the maximum depth of the bay but allowed to accurately extrapolate the time of her FIM descent to -52m. She also did a test dive of 30m DNF in the bay, at 15m depth, to estimate the time it would take her to swim through the Arch.
Alessia’s predicted crossing of the Arch reads as follows: descent to -52m in FIM in 1'05'', DNF crossing through the Arch in 35'', ascent in FIM from -55m in 1'05''. Total dive time estimated: 2'40'' - 2'50''.
On the evening of the 21st of July, a general briefing was organized to set-up the dive plan. The athlete and all members of the safety were present.
On the morning of the 22nd of July, the entire team went to the Blue Hole. A second, more specific briefing, was organized before the setup was put in place, this time also explaining the dive plan to the technical divers. Stephen specified twice in a row to Alessia that she was to stay on the right side of the arch when crossing, to avoid any collision with the tech-divers who would be positioned on the left side of the arch and allow them to film her properly. Stephen also explained to Alessia that the exit of the arch is not clearly defined but that he would be there waiting to guide her.
The official top was delayed from 11:00 to 11:20 to allow for a calm environment whilst setting up the equipment.

TEAM COMPOSITION
The athlete
Stephen Keenan: organizer, AIDA instructor trainer, AIDA safety officer, safety 1 (outside BH)
SAFETY_A: AIDA instructor, safety 2 (outside BH)
SAFETY_B: SSI level 3, safety 3 (outside BH)
SAFETY_C: AIDA instructor and lifeguard, safety 1 (inside BH)
SAFETY_D: AIDA level 4, safety 2 (inside BH)
SAFETY_E: AIDA instructor, communication on surface and dive logistics
SAFETY_F: AIDA level 4, in charge of keeping buoy 2 in position (outside BH)
SAFETY_G: AIDA level 4, responsible for in-water oxygen, buoy 3 (outside BH)
SAFETY_H: emergency on-shore logistics
Only for photo / video capture, not part of safety team:
SCUBADIVER_A: scuba-diver, video 2
SCUBADIVER_B: scuba-diver, video 1
SCUBADIVER_C: scuba-diver, photographer

IN-WATER EQUIPMENT
Buoy 1 was attached inside the Blue Hole, 5m in front of the reef, on a fixed perpendicular surface line, providing constant positioning. Line set at: -52m. Buoy 2 was outside Blue Hole, in front and in the middle of the Arch exit, and kept in position at all times by SAFETY_F, who was specially briefed by Stephen. Line set at: -55m. Buoy 3 carried a tank of 100% O2 and was kept close to Buoy 2 at all times by SAFETY_G.
A variable weight sandbag weighing ~ 9kg while in water was attached to Buoy 2. Stephen would use it to go down to -55m, to do the first safety and meet Alessia upon her exit of the Arch. There was a second variable weight sandbag attached under the oxygen buoy (Buoy 3), as backup.
Note about sandbag VWT safety: Stephen used this sandbag system for more than 25 safety dives at a depth of around -50m, usually for safeties of -100+m freedivers. He knew the system very well. Reaching -50m takes around 40sec.
Marine scooters are at the moment illegal to import in Egypt. Stephen was still looking for a way to import a couple.

ON-SHORE EQUIPMENT
At Aqua Marina restaurant in front of the Blue Hole, 20m away from the water exit, was a medical safety kit, including free-flow oxygen and ambu-bag. There was also a second 100% O2 tank as back-up safety. Note there was no AED or suction device on shore.
ALESSIA'S AND STEVE'S EQUIPMENT
Alessia was wearing a 1.5mm one-piece suit with no hood. She had no weights. She was wearing an Aqualung Sphera mask. Stephen was wearing a 3mm suit (high-waist pants and hooded jacket) and no weights for his VWT safety dive. He was wearing an Aqualung Micro-mask and carbon bi-fins.
NOTE ABOUT THE ARCH
The exit is not symmetrical due to its organic shape. The width at -55m depth is about 10-15m. It is known to be a bit tricky for freedivers or tech-divers to orientate themselves and to know if they are already outside or still inside the Arch. The light is usually quite homogenous in the exit area, giving no specific information to the eye that one might be exiting the Arch. On many freediving Arch attempts, very few freedivers spotted the dive line immediately upon exiting. Many got slightly disoriented, but thankfully without any incident. That is one of the main reasons why Stephen decided to do a VWT dive down to the bottom and wait there for Alessia's exit, to optimize her level of safety and be ready to guide her to the ascent dive line if necessary.

DIVE PLAN IN THEORY
Alessia would go down to -52m in FIM, in around 1’00-1’05, then cross the Arch in DNF for about 25-30m in 30-35'’, swimming on the right side then moving slowly to the middle of the exit in about 10'', where the ascent line was located. There, she would meet Steve and ascend from -55m in FIM in 1’00-1’05''. Total planned dive time: 2’40''-2’50''.
When Alessia would start her FIM descent inside the Blue Hole, SAFETY_E would send a signal on the surface to Buoy2. SAFETY_A would then start a 40'' countdown, giving another OT (we call it OT2) to Stephen for his deep VWT safety (OT2 = OT+40'').
Stephen was supposed to start his safety 40'' after Alessia started her FIM dive, so that he would arrive at -55m at 1’20’’ (40'' + 40'', time it takes to go down to -55m in VWT), while Alessia would be arriving to the exit.
Stephen would wait for Alessia at the bottom weight at -55m. If needed, he would swim a few meters to meet her and guide her to the ascent rope, as Alessia was supposed to appear on the right side of the arch and swim horizontally to the middle, to the line, before starting her FIM ascent.
Once both were at the ascent line ready to start the ascent, Stephen would pull 2 times on the line, so that on the safety waiting on the surface, SAFETY_A, would know that everything is going according to plan and could start the descent as second safety down to -25m. SAFETY_A was in charge of watching Alessia during the final 25m of her ascent.
SAFETY_B would be doing safety 3, after SAFETY_A and was in charge of watching Stephen during the final part of his ascent.
One tech-diver would be recording the dive at entrance at -55m depth. A second tech-diver recording at the exit at 55m. Both would be on the left side of the Arch, to avoid any collision with Alessia. A third scuba-diver would be on the exit side at -40m depth, shooting pictures of the ascent.

DIVE_REALITY
Alessia started her dive at OT + 5’’. For clarity, for the rest of the report on the actual dive, we will consider Alessia's actual start of the dive as the new OT. In the first stage, everything went as planned, Alessia entered the Arch at OT+1’05’’, exactly as expected. Inside the Blue Hole, SAFETY_C followed her down to -35m, watched her entering the Arch and sent confirmation by hand signal to SAFETY_D, located at -15m depth. SAFETY_D relayed the ok sign to SAFETY_E, who was on the surface inside Blue Hole.
On the surface, the OK signal was given from SAFETY_E to Stephen, across the Arch, as soon as Alessia started her FIM dive. Once he got the signal relayed by SAFETY_D, SAFETY_E then sent another OK signal across the Arch to SAFETY_B at buoy 2 that all is going on as planned and Alessia had now entered the Arch.

Outside the Blue Hole, on Buoy 2, at the last minute Stephen asked SAFETY_A to postpone his own OT2 by 10 seconds without explanation (planned 40'' after Alessia's OT, bringing it to 50’’ after Alessia's OT). As soon as they got the OK sign from SAFETY_E that Alessia had started her FIM descent, SAFETY_A started the 50'' countdown for Stephen. At OT+50’’ Stephen got his top to start his VWT dive but it seems it took him few seconds more to start his dive (maybe few extra packing and eventually few seconds more to release his softbag). The dive computers show he actually started his dive 60'' after Alessia start. So, at this point Steve was 20'' late on the plan. It took Stephen 40'' to reach -54m (OT + 1’40’’).
Alessia crossed the Arch a little faster than predicted (25-30'' instead of 30-35''), on the right side of the reef wall, at a distance of 2-3m from the wall. Once she arrived at the exit of the arch (OT + 1’30’’), and as Steve was not there, she thought she was still inside the arch and continued following the reef wall, keeping it on her right hand side. She became disorientated, not realizing that she was turning slowly while following the reef wall and ending with a 90° angle from exit, and swimming away from the ascent line.
Steve reached the bottom at OT +1’40’’ instead of the planned OT+1’20’’. Alessia was already +-15/20m away from him, swimming in the opposite direction (she exited the arch right side at OT +1’30’’ and had swam already 10’’ with a speed of +- 1 m/s).
In the original plan Stephen would have been there 20 seconds earlier (OT +1’20’’) waiting for Alessia once she exited the arch or arriving at approximately the same time. Alessia would have spotted Steve by eye contact and/or through his strong grouper sound (Steve can do it very well at this depth). She would then have swum the +-10m from the right side of the arch to the ascent line in the middle to meet Steve. The line was positioned exactly in the middle of the arch as planned (the video shows this very clearly).
Meanwhile at the surface: SAFETY_A was waiting for the signal of two pulls on the rope from Stephen, to start her descent as second safety. At the expected time, there was no signal. SAFETY_A waited a bit longer thinking Alessia can be slower than expected and Steve was waiting for her down there. After a brief moment still without signal, she decided to start her SAFETY_Dive anyway. She dove down to -25m but could see the line all the way down to the bottom weight. There was no sign of Alessia or Steve in any direction. At this moment, it can be supposed that both Steve and Alessia were around 50m away from SAFETY_A and out of sight. SAFETY_A signaled to SAFETY_B on the surface that things had gone wrong and started her ascent. Just after SAFETY_A surfaced SAFETY_B went for another dive to -20m. During SAFETY_B's dive SAFETY_A was trying to spot Alessia and Steve on the surface in a 360° perimeter. There was nothing on the surface except for a group of snorkelers around 40-50m away in the direction of the saddle (see map below) of the blue hole.

Back underwater: Steve arrived +- 20'' late at the bottom (OT + 1’40’’), spotted Alessia 15/20m away, and started sprinting straight towards her, horizontally, with a speed of around 2m/s. He reached her after a super heavy dynamic sprint of +- 28’’. The video ends at this point. From here, the information for the remainder of the dive is based on SCUBADIVER_C's testimony and pictures, and also based on Alessia's and Stephen's dive computers.

Stephen finally reached Alessia and showed himself in front of her, by passing under her. By then they were around +-50m from the line, on the right side of the arch exit, a few meters from the reef wall and at a depth of -40m. Time was OT +2’08’’ (Stephen OT2 +1’08’’). Stephen positioned himself in front of Alessia and they started to ascend facing each other. For the first 10-15m Alessia came up swimming by herself. At a depth of around -30m Stephen held her by the hips. As she had no fins on, Stephen finned hard to help her ascend. On one of the pictures Alessia also appeared to be kicking with her legs.
It can be supposed, looking at Stephen's computer dive profile, that Stephen almost made it to the surface. Both Alessia and Stephen have similar ascent graph curves from -40m. We could suppose that Stephen blacked out between -10m and the surface. If Stephen blacked out at -10m he would still have ascended with a speed of +-1m/s, being positively buoyant (and wearing no weights for his VWT dive).
Once SCUBADIVER_C saw things going wrong from her position at -35m depth, she decided to come up straight away. Arriving at -5m she saw Stephen face down, unconscious on the surface. Alessia was a few meters away above her. SCUBADIVER_C decided to surface directly without her planned safety stop. She surfaced close to Alessia. Alessia was conscious but unaware of her surroundings and vacant in the eyes. She looked paralyzed. SCUBADIVER_C shook Alessia while screaming at her. Alessia «woke up». They both looked at Stephen and Alessia turned Stephen onto his back and started screaming for help. At the same moment SAFETY_C was arriving on the scene. Stephen and Alessia had been spotted by the other SAFETY_Divers once SCUBADIVER_C screamed for help. Alessia and Stephen actually surfaced extremely far from buoy 2 (a distance of minimum 58m up to 70m).

 

Timewise we can suppose:
- Official top Alessia 11:20’05”
- Official top Stephan +- 11:21’05”
- Alessia and Stephen surfaced at 11:22'52'' (confirmed by computers)
- SCUBADIVER_C emerged close to Alessia at +- 11:24'15''
- They were spotted by SAFETY_C at +- 11:24'30''
- SAFETY_E, SAFETY_Diver, started to take care of Stephen with rescue breaths at 11:25’00'', approximately four minutes after Stephens initial descent.

SAFETY_E and SAFETY_C were the first safety divers to arrive at the spot where Stephen and Alessia and later on SCUBADIVER_C surfaced. At that moment Stephen had already been turned on his back by Alessia.
SAFETY_E started giving rescue breaths first as soon as he got there, followed by SAFETY_C. This group towed Steve from the point of surfacing towards the exit. They were met on the way by SAFETY_A and SAFETY_B, who had spotted people calling for help from their position on buoy 2, and started straight away pushing the buoy 3 with oxygen tank towards them. They met just before reaching the surface line crossing the Blue Hole. There, Stephen was placed into an upright position with the aid of a buoy, SAFETY_E held his head whilst SAFETY_A delivered rescue breaths, breathing in pure oxygen before delivering the breath. After this unsuccessful attempt, that training buoy was untied to help bring Stephen back to the shore while SAFETY_E continued holding him and SAFETY_A gave him rescue breaths. Yellowish white foam was still coming out of Stephen's mouth abundantly but at no stage was there any signs of blood or pinkish red fluids to give any indication of lung barotrauma. Once arriving at the Blue Hole entrance Stephen had to be towed the rest of the way without any floatation device.
SAFETY_C, SAFETY_E and a bystander carried Stephen, placed him on his back on the ground(roadway) near the entry/exit point and started CPR immediately. A pick up taxi arrived 4-5 minutes afterwards (as cars are not allowed to stay close to Blue Hole entrance they need to be parked a few hundred meters away). No AED was available at Blue Hole but the oxygen tank was brought. Stephen’s wetsuit top was cut open. CPR was continued, breathing in pure oxygen before giving each rescue breath, until the pick-up taxi arrived.
Stephen was lifted onto the back of the pick up taxi by SAFETY_E, SAFETY_C and SAFETY_B and shortly transferred to an arriving ambulance. Despite all efforts to revive Stephen he was pronounced dead shortly after arrival at Dahab Hospital.

Summary of the key moments:

- Official top Alessia 11:20’05”
- Official top Stephan +- 11:21’05”
- Alessia and Stephen surfaced at 11:22'52'' (confirmed by computers)
- SCUBADIVER_C emerged close to Alessia at +- 11:24'15''
- They were spotted by SAFETY_C at +- 11:24'30''
- SAFETY_E, SAFETY_Diver, started to take care of Stephen with rescue breaths at 11:25’00'', approximately four minutes after Stephens initial descent.
- Oxygen assisted rescue breaths were first delivered between an estimated one-two minutes later at, now within the Blue hole at +- 11:26’30”
- Steve was removed from the water at approximately +- 11:30’00”. CPR was initiated immediately. Oxygen assisted breathes continued.
- Pick up taxi arrives, transports Stephen, SAFETY_C, SAFETY_E and SAFETY_B’ to meet ambulance +- 11:35’00”.
- Ambulance arrives at Dahab Hospital at +- 12:05’00”. CPR was continued until the ambulance reached the hospital.

TESTIMONY OF THE ATHLETE

“I think every day about Stephen and what happened that day, I tried to remember more as possible and understand that I could have done more.
When I started to swim in the arch, I looked forward to me only one time and I saw the videomaker on the left. I continued to swim on the right, I fell that I was negative and I had to swim more quickly. When arrived to the end I didn’t see the line and I continued to follow the arch and after to swim to the surface. After some seconds, Stephen appeared in front of me and I thought that we went the line then. I started to swim in CNF and after, I don’t know how many meters, he took my hands and helped me to come out and I swam only with the legs. After, he left one hand and maybe that is the moment the he had the blackout… but I didn’t understand nothing, also when we arrived to the surface. I don’t know why, but I was motionless, I didn’t see nobody and I couldn’t to do nothing. When the photograph came out to the surface and called me I woke up and turned Steve, removed the mask and called help. But it was too much late.”

CONCLUSIONS
The dive was well organized and shows the following points:
- Sea conditions were a bit windy and wavy, and a mild current was occurring but not having any effect on the dive. We could say that the conditions were close to an average day, Dahab being in a very windy area.
- There was a decent amount of people dedicated to safety and dive logistics (8 in total excluding scuba-divers).
- Briefings were done properly.
- A prior test dive was done on the previous day to estimate the total dive.
- Stephen's experience in general safety, in emergency procedures, and in VWT deep safety dives to -50m+ was excellent.
- His knowledge of the arch topology itself was good but he eventually underestimated the possibility for the athlete to get disoriented. - The fitness level of Alessia was excellent and he was expecting her to do this dive very easily without complication.
For us the accident happened unfortunately due to the first factor:
Stephen decided at the last minute to postpone his own OT by 10'' and took few seconds more to start his dive. He was finally 15/20’’ late at the bottom and Alessia then could not spot him upon exiting the arch as he was supposed to be there already.
Then the following elements made the chain of catastrophes go on:

Alessia got disoriented and kept going on the right side and didn’t realize she was out of the arch and turning in the wrong direction. This disorientation can be explained by the topology of the exit and by the fact that she got the following information from Stephen on both briefings:
- « Knowing when you really exit is not always clear »
- « Stay on the right side of the reef wall to avoid any tech-diver »
- « You will see me down there when you exit »
Then they started ascending already around 40/50m away from the line and we suppose with an angle due to the absence of vertical line. So, they emerged at a minimum 58m away buts most likely around 70m from the exit buoy (buoy 2). This unusual distance made them hard to spot, furthermore because they also emerged behind a large group of snorkelers. Alessia was in no condition to be, nor expected to be, a 'safety' for Stephen. She was hypoxic by witness account of Scuba Diver C. Stephen had assisted her to the surface by witness account Scuba Diver A and dive profile. She had to discover that he was in trouble through her own fog of confusion and hypoxia. The other Safety's, Scuba Divers and Alessia acted and did what they could once the situation was recognized.
Stephen was face down. After repositioning him, rescuers (safety E, safety A) report yellow fluid and water coming out of his mouth that probably indicates salt water in his lungs. By definition, this is called 'wet drowning’. “Apnoea” eventually exceeds breaking point and causes hyperventilation, causing aspiration and a variable degree of laryngospasm. This leads to hypoxia, loss of consciousness and eventually cardiac arrest. The yellow fluid is 'exudate' from fluid shifts in the pulmonary vessels filling the alveoli with fluid.
We do agree that the level of safety have been higher with a few extra modifications: another deep diver making a safety at -35m between Stephen and SAFETY_A to keep visual contact, some flashing lights at the bottom weight of ascent line, Stephen as first safety with a marine scooter, possibly a line crossing the arch between the two bottom weights, having a doctor present onsite. The presence of a doctor onshore could have changed the fatal end. So, would have maybe the presence of a more experienced paramedic in the ambulance.
We can suppose that Stephen never thought about this extreme situation (him being late and Alessia being disoriented) and felt in control of the dive. The dive time is short but the nature of the dive, a hang with a 25-30’’ sprint combined with a 50m ascent helping another person to surface under stress is enough for even a very good freediver to blackout.
Given that this was the first dive of the arch for Alessia, choosing the FIM-CNF-FIM protocol is subject to discussion: without fins and in case she could not find the rope for her FIM ascent, without Stephen to guide her, diving became risky.
Due to Stephen's experience in general we do conclude that the entire organization of the dive showed a decent level of preparation even if after this accident we do think the general organization of a dive like the arch should be brought to another higher safety level in the future.
Lastly, for us, the person in charge of organisation and analyzing the potential risks was Stephen. Alessia was under his responsibility and she had total confidence in him.

We have attempted to find the most detailed information possible to understand the errors that occurred on the day of the accident. Not only so that the doctors and the freediving community can apply better safety protocols, but also for all those people who from all over the world and who loved Steve as much as we do, followed the event in the distance and respected family and friends in such difficult times, understanding that an accident report requires time, research and tranquility so that conclusions can be drawn as close to reality as possible.
Wet drowning has an 85% fatality rate. We think Stephen would want us to be resilient and make the changes we need to make after this event. It is about making sense of the unexpected, collective mindfulness, and enacting changes after a tragedy like this.
Right now, all freedive instructors based long-term in Dahab are discussing chipping in for a fully-stocked SAFETY BOX, including AED, suction device, and of course Oxy, that will be kept at all times at the Blue Hole at the Aquamarina restaurant. And a specialist doctor/paramedic will come to provide regular training to people on how to use them, for free. It is being discussed as we speak and will hopefully be implemented in the near future.

Amorgos, 11th October 2017 // Miguel Lozano and Pascal Berger