Rebreather NSS/CDS report from death at Peacock earlier this year.

[DOBY]

I'm not sure if it is still true or not, but the only commonality between ALL CCR fatalities (as of a couple years ago) was a lack of written checklist used.

I got to call shrimp on “the only commonality between ALL CCR fatalities (as of a couple years ago) was a lack of written checklist used.”

 

[kensuf]

Thanks to the IUCRR, whoever the Meg diver was conducting the inspection, and to all first responders and fellow divers involved. This report reads like a real robust and heroic response from the dive community in Florida. Condolences to this person's son, family, and friends for such a tragedy. 20 years of experience on a CCR is notable and really underscores the need for continued vigilance throughout our CCR diving careers.

The IUCRR was not involved with the writing of the report or the incident analysis. The work was conducted by the NSS-CDS Accident Analysis Committee, they deserve the credit for their work. I am not a member of that committee.

 

[sea_ledford]

I got to call shrimp on “the only commonality between ALL CCR fatalities (as of a couple years ago) was a lack of written checklist used.”

Yeah, I wish I had a reference as it is pretty unbelievable. But I have heard it at several in person presentations. It also might not be all that unbelievable if only 15% (completely made up stat) of CCR divers use a checklist.

Did just find this reference here: Staying Alive on Rebreathers: It Really Is All About Set-Up
I think I've also heard the same from Neal Pollock, and maybe Garreth Locke.

"Concannon, a speaker at Rebreather Forum 3.0 and a well-known attorney whose law firm has strong practice in sports and recreation law, sees the issue as a cultural one.

“I am certain that the fix does not require a redesign by mainstream manufacturers or changes in the training [curriculum] offered by established agencies: it’s much more straightforward than that. I believe we need to change the attitude of the average diver preparing for a CCR dive, and this change includes the use of a pre-dive checklist.”
During his law practice and work as advocate for several dive-industry clients (including CCR manufacturer AP Diving and training agency TDI), Concannon has investigated dozens of fatalities. “Striking in its absence in 100 percent of the cases I have seen that involved a rebreather is a physical checklist; no sign of one on the diver’s person, in his kit, on his rebreather.”

This, Concannon says, indicates a “cultural short-coming.”"

But if it is 100% or 90%, it doesn't matter. We need to use written checklists to prevent this type of incident. And we need to make it the cultural standard.

 

[crofrog]

20 years of experience on a CCR is notable and really underscores the need for continued vigilance throughout our CCR diving careers.

20 years of experience doesn’t mean anything.

Proficiency and currency matter much more.

 

[missionmtb]

The IUCRR was not involved with the writing of the report or the incident analysis. The work was conducted by the NSS-CDS Accident Analysis Committee, they deserve the credit for their work. I am not a member of that committee.

Thanks @kensuf for the correction and to the NSS-CDS AAC for their work.

 

[Dsix36]

I would like to see every manufacturer give a waterproof predive checklist with their units. I know some of them do. I have used them in the past but found almost all of them too complicated and gave up on them. I created my own that is both simplified and flows better for me. since the creation of my own, I have had 2 minor issues that caused me to add 2 more items. It has been many years and nothing else has been added. I would be great if the culture around RBs would not only accept checklists (which I think every single diver does) but to also promote their use to others without chastising.

 

[DOBY]

Yeah, I wish I had a reference as it is pretty unbelievable. But I have heard it at several in person presentations. It also might not be all that unbelievable if only 15% (completely made up stat) of CCR divers use a checklist.

Did just find this reference here: Staying Alive on Rebreathers: It Really Is All About Set-Up
I think I've also heard the same from Neal Pollock, and maybe Garreth Locke.

"Concannon, a speaker at Rebreather Forum 3.0 and a well-known attorney whose law firm has strong practice in sports and recreation law, sees the issue as a cultural one.

“I am certain that the fix does not require a redesign by mainstream manufacturers or changes in the training [curriculum] offered by established agencies: it’s much more straightforward than that. I believe we need to change the attitude of the average diver preparing for a CCR dive, and this change includes the use of a pre-dive checklist.”
During his law practice and work as advocate for several dive-industry clients (including CCR manufacturer AP Diving and training agency TDI), Concannon has investigated dozens of fatalities. “Striking in its absence in 100 percent of the cases I have seen that involved a rebreather is a physical checklist; no sign of one on the diver’s person, in his kit, on his rebreather.”

This, Concannon says, indicates a “cultural short-coming.”"

But if it is 100% or 90%, it doesn't matter. We need to use written checklists to prevent this type of incident. And we need to make it the cultural standard.

Yes, check lists are important. I never said they weren’t necessarily or not an important pre-dive step. A checklist might have prevented the Roaring River fatality (or not if the deceased actually intended to use the gases he did - which is a very high probability). Just that the belief using a checklist guarantees nothing can go wrong is a crock of ****. Keep hearing “no deceased CCR diver has ever been found with a checklist.” Well…..no deceased diver has ever been found with an aardvark. So should we all have an aardvark with us while we kit up???

Three recent CCR cave fatalities had nothing to do with not using a checklist - Twin Caves, Jackson Blue, and the one beyond the Henkel at Ginnie. You could also add more such as the last Eagle’s Nest double fatality. The use, or not, of a checklist had absolutely no bearing on these accidents. Yes use a checklist. But it’s not that simple.

 

[DOBY]

I would like to see every manufacturer give a waterproof predive checklist with their units. I know some of them do. I have used them in the past but found almost all of them too complicated and gave up on them. I created my own that is both simplified and flows better for me. since the creation of my own, I have had 2 minor issues that caused me to add 2 more items. It has been many years and nothing else has been added. I would be great if the culture around RBs would not only accept checklists (which I think every single diver does) but to also promote their use to others without chastising.

Dsix36 hit the nail on the head. A lot of CCR divers soon give up on a check list that’s too complicated. Especially if it’s a long pre-dive check list sitting in a boat in drysuit in 90 dedree temps and rolling waves. Plus there’s a difference between a long build check list and a short pre-dive check list. Capt. Brian if Black Dog charters on Lake Huron would run through a short, very realistic CCR checklist before each diver would space in. Wish I had kept a copy of it.

 

[crofrog]

Dsix36 hit the hail on the head. A lot of CCR divers soon give up on a check list that’s too complicated. Especially if it’s a long pre-dive check list sitting in a boat in drysuit in 90 dedree temps and rolling waves. Plus there’s a difference between a long build check list and a short pre-dive check list. Capt. Brian if Black Dog charters on Lake Huron would run through a short, very realistic CCR checklist before each diver would space in. Wish I had kept a copy of it.

There is a big difference between a check-list and a do-list. This is all stuff that was learned in aviation over many years, but not enough of the concepts are being carried over.

 

[Underwater Tourist]

What a checklist should and shouldn’t be: