Fatality at Jersey Island

[shoredivr]

Well that takes it to another level completely.

 

[gianaameri]

Someone else assembled her rebreather?

/threadclosed

Yup...

This is the first I hear of this.

But if I read it on the internet, then it must be true.

We have no evidence anyone assembled her rebreather other than hearsay by HIGHwing now.

 

[Wookie]

Highwing, I know you've been in touch with folks who desperately want the blame to go to something other than the rebreather and the manufacturers adherence to the CE standard. Is there any possibility that the folks who gave you this information are in error, or are being disingenuous, or really want this thread to go away? To make a bold statement like "someone else assembled her unit" is, in fact, bold. Has anyone actually seen the coroner's report, which Gian led us to believe that the only findings are that the rebreather didn't meet the CE standard, then find out that that point is kind of moot is a lot to swallow here.

---------- Post added December 3rd, 2014 at 12:04 PM ----------

You're pretty smart. You'll figure out exactly what happened.

I assume her husband did the assembly? Do we know if her (their, presumably) instructor was the third diver in the team?

 

[gianaameri]

Highwing, I know you've been in touch with folks who desperately want the blame to go to something other than the rebreather and the manufacturers adherence to the CE standard. Is there any possibility that the folks who gave you this information are in error, or are being disingenuous, or really want this thread to go away? To make a bold statement like "someone else assembled her unit" is, in fact, bold. Has anyone actually seen the coroner's report, which Gian led us to believe that the only findings are that the rebreather didn't meet the CE standard, then find out that that point is kind of moot is a lot to swallow here.

It is not the only finding. Here is the list (posted elsewhere on the net). The list is not complete and I am aware there to be more.

However, NO, never heard the rebreather was assembled by someone else.

Even then, the rebreather is defective or non-compliant.

Assembly by someone else only introduces another variable to the chain of errors, while exculpating the deceased of "incorrect assembly."

The list as published on the net elsewhere by someone else:

"It was so a Hollis.

It was sitting at the Health and Safety Laboratory Buxton Derby SK19 9JN ring them telephone number +44 1298 218000

SNIP

• The rebreather had been put together such that the gas would not circulate in the required loop and CO2 would not be removed from the inhaled gas.
• The inhale counter lung was positioned to the diver’s right hand side, instead of the left hand side.
• The exhale counter lung was positioned to the diver’s left hand side, instead of the right hand side.
• The one way inhale valve that should be positioned on the inhale side of the mouthpiece, to ensure the gas circulated the loop, was found butted against the one way exhale valve of the mouthpiece stopping any gas passing into the exhale counter lung on the diver’s right hand side.
• The unit was flooded with fluid.
• The cover for the scrubber bucket and head were missing, apart from a small piece attached to the fitting above the battery housing.
• Two of the three oxygen sensors were reading 0.18 and 0.16 partial pressure of oxygen (ppO2) when exposed to air (0.21 ppO2), and when put into a 100% oxygen atmosphere (1.00ppO2) gave a reading of 0.80 oxygen. The third indicated 0.00 oxygen in air and 0.28 in 100% oxygen. Images received with the equipment taken by the Jersey Police indicate that the sensors appeared to be working correctly at the time of the incident. The subsequent reduction in oxygen sensor readings was due to the sensors being contaminated by the fluid within the rebreather damaging the oxygen sensors.

In UK terms this would be labelled as an accidental death, possibly misadventure, however, inquests in Jersey have narrative verdicts. The verdict in this case for Mrs Jillian Smith (age 41 years and 7 months) was as follows:*
“That she died in the afternoon of Saturday 15th March 2014 at St Catherine’s Slipway, St. Martin, [Jersey] after having been found unconscious in the sea during an underwater dive at St Catherine’s Breakwater; the cause of death was asphyxia caused by obstruction of the airways by inhalation of gastric contents due to unconsciousness by hypercapnia; this occurred after failure of the incorrectly assembled ‘rebreather’ diving equipment that she was using whilst underwater during her dive.”
The inquest was informed that the manufacturer, Hollis, has now modified the mouthpiece assembly and re-issued it.
SNIP"

 

[HIGHwing]

So as is established... I was playing with my P2 last night trying to assemble it in weird and impossible ways. The more I messed with it the more puzzled I became. How could this happen? A trained CCR diver would have noticed the hoses just don't line up because the diver would just be too familiar with the gear post training. The diver who wouldn't notice is someone who is NOT diving that personal rig.

Why isn't a lawsuit filed? Then it hit me. I just about shouted an expletive aloud. No way she built her rig.

A couple phone calls later and a sad voice on the phone confirmed my suspicion to my satisfaction.

So let's go with this, I believe it to be fact that she did NOT build her own rig on the morning of the fateful dive.

 

[Wookie]

It is not the only finding. Here is the list (posted elsewhere on the net). The list is not complete and I am aware there to be more.

However, NO, never heard the rebreather was assembled by someone else.

Even then, the rebreather is defective or non-compliant.

Assembly by someone else only introduces another variable to the chain of errors, while exculpating the deceased of "incorrect assembly."

The list as published on the net elsewhere by someone else:

"It was so a Hollis.

It was sitting at the Health and Safety Laboratory Buxton Derby SK19 9JN ring them telephone number +44 1298 218000

SNIP

• The rebreather had been put together such that the gas would not circulate in the required loop and CO2 would not be removed from the inhaled gas.
• The inhale counter lung was positioned to the diver’s right hand side, instead of the left hand side.
• The exhale counter lung was positioned to the diver’s left hand side, instead of the right hand side.
• The one way inhale valve that should be positioned on the inhale side of the mouthpiece, to ensure the gas circulated the loop, was found butted against the one way exhale valve of the mouthpiece stopping any gas passing into the exhale counter lung on the diver’s right hand side.
• The unit was flooded with fluid.
• The cover for the scrubber bucket and head were missing, apart from a small piece attached to the fitting above the battery housing.
• Two of the three oxygen sensors were reading 0.18 and 0.16 partial pressure of oxygen (ppO2) when exposed to air (0.21 ppO2), and when put into a 100% oxygen atmosphere (1.00ppO2) gave a reading of 0.80 oxygen. The third indicated 0.00 oxygen in air and 0.28 in 100% oxygen. Images received with the equipment taken by the Jersey Police indicate that the sensors appeared to be working correctly at the time of the incident. The subsequent reduction in oxygen sensor readings was due to the sensors being contaminated by the fluid within the rebreather damaging the oxygen sensors.

In UK terms this would be labelled as an accidental death, possibly misadventure, however, inquests in Jersey have narrative verdicts. The verdict in this case for Mrs Jillian Smith (age 41 years and 7 months) was as follows:*
“That she died in the afternoon of Saturday 15th March 2014 at St Catherine’s Slipway, St. Martin, [Jersey] after having been found unconscious in the sea during an underwater dive at St Catherine’s Breakwater; the cause of death was asphyxia caused by obstruction of the airways by inhalation of gastric contents due to unconsciousness by hypercapnia; this occurred after failure of the incorrectly assembled ‘rebreather’ diving equipment that she was using whilst underwater during her dive.”
The inquest was informed that the manufacturer, Hollis, has now modified the mouthpiece assembly and re-issued it.
SNIP"

All of those other subsequent findings stem from the rebreather being assembled incorrectly. Flooded cells not reading correctly, unit flooded, The missing cover all resulted from putting the unit together wrong.

 

[descent]

... I believe it to be fact that she did NOT build her own rig on the morning of the fateful dive.

An accidental misassembly would be unbelievably tragic.

What you're suggesting is like something out of Macbeth.

 

[Douglas Ward]

No Change.

The rebreather isn't defective or non-compliant and shouldn't be recalled or a Safety Notice issued with a fix being offered by Hollis to all owners/users.

Lesson Take Away: 1) Assemble and Maintain your own gear 2) Follow Your Training 3) Do your checklist 4) Double Check your assembly 5) Don't dive unless your are 110% confident everything is right.

 

[gianaameri]

All of those other subsequent findings stem from the rebreather being assembled incorrectly. Flooded cells not reading correctly, unit flooded, The missing cover all resulted from putting the unit together wrong.

More like that the user passed out and drowned and then the rebreather flooded.

However, if somebody else assembled it, it would be interesting to know if there is any corroboration from an official source.

Omisson could help if he can get the full Coroner and HSL report.

At the moment all we have is voices heard by HIGHwing in respect of this third-party assembler.

It would be interesting to hear from HIGHwing if these voices said anything about the third-party assembler being qualified or not.

Imagine if he/she were an Hollis instructor who assembled the rebreather for her like that.

Speculation by HIGHwing aside, the fact remains the unit was defective or non-compliant and the user made a chain of mistakes while pre-breathe done in accordance with manufacturer and training standards and requirements and present two other buddy rebreather divers did not prevent the accident from happening.

---------- Post added December 3rd, 2014 at 12:35 PM ----------

Lesson Take Away: 1) Assemble and Maintain your own gear 2) Follow Your Training 3) Do your checklist 4) Double Check your assembly 5) Don't dive unless your are 110% confident everything is right.

6) Don't make mistakes...

 

[HIGHwing]

You have very binary thinking. I'll probably enrage you, and subject everyone to miles of posts, quotes, and links, but...

I don't think the rebreather, as presented, performs other than designed. The victim in this case was diving a collection of parts each working on their own. What she had intended to dive was a life support system. Beginning with the assembly checklist through the decision to dive - the rebreather exhibited a fail on all of the checklists, threads would have been exposed on the DSV, the chest straps wouldn't have worked, and the lungs would have breathed in sync. I don't believe she got the feedback of the O2 MAV and Dil ADV hoses, which may have saved her life - who knows.

I will agree the P2 could have reasonable and likely very cost effective modifications (not improvements per say) that could prevent this specific error in the future. I also think this should be tempered with the knowledge at least four checklists caught the error, the assembly provided approximatley four opportunities to catch the problem, and I believe she just didn't have enough experience to spot the problem - on a fully assembled machine.

If I were teaching the P2. I would consider improperly assembling the unit in this way and make my student remedy the problem pointing out all the things that just don't look right and fail a checklist in this condition. I do agree it is possible for this to happen again, but it seems like everytime the CCR manufacturer's builds a more idiot-proof machine...