Fatality at Jersey Island

[gianaameri]

WT? If true, this incident has officially gone off into bizzaro land. Can you source the info or is it something you cannot yet disclose?

On the one hand, diving a fully assembled CCR that you didn't build is up there on the list of what I'd call insane: among other reasons, you cannot do the stereo check, which confirms the hearts of your one-way gas flow are actually working right, with the loop assembled on the unit. On the other hand, it would make this much, much more tragic than it already is...if someone else has to kick themselves for what happened.

If you were a novice rebreather diver and your instructor assembled it and were told this was O.K., would it still be insane to dive it?

Misplaced trust maybe, but not insane.

---------- Post added December 3rd, 2014 at 02:49 PM ----------

Husband and Wife purchase P2s and inital training. They complete the class together allegedly achieving certification.

This is pure speculation at this stage.

We do not know that, although it is possible.

Let me repeat what we know which at the moment has been made public (but there is more):

"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"

 

[tomfcrist]

In my mind, the only way she misses the mountain of cues available to her is if she didn't build the rig and didn't have all the information in the first place.

Either way it point to the cause of the incident being her actions(or inactions) vice the rebreather itself.

---------- Post added December 3rd, 2014 at 02:53 PM ----------

If you were a novice rebreather diver and your instructor assembled it and were told this was O.K., would it still be insane to dive it?

Misplaced trust maybe, but not insane.

Still user error or a training error, which makes HER the proximate cause of her own accident.

 

[gianaameri]

If you were a novice rebreather diver and your instructor assembled it and were told this was O.K., would it still be insane to dive it?

Misplaced trust maybe, but not insane.

Still user error or a training error, which makes HER the proximate cause of her own accident.

No, because the instructor owes a Duty of Care to the student and is in a position of trust.

However, we do not know if an instructor or any other third-party assembled Jillian Smith rebreather.

At the moment, it is pure fantasy on the part of HIGHwing.

 

[HIGHwing]

At the moment, it is pure fantasy on the part of HIGHwing.

You've presented an equal amount of facts proving your assumption she built the rebreather herself. Your confidence relies on the fact that normally in a succesful CCR dive, the diver builds the unit.

 

[gianaameri]

You've presented an equal amount of information proving she built the rebreather.

Sure, maybe the UFOs built-it.

We have no evidence that a third-party assembled her rebreather and the Coroner and HSL as far as we know did not release any such info.

Are you saying somebody actually told you a third-party built her rebreather and it is a reliable source who would know this as a fact?

 

[tomfcrist]

Originally Posted by gianaameri
If you were a novice rebreather diver and your instructor assembled it and were told this was O.K., would it still be insane to dive it?



Misplaced trust maybe, but not insane.



No, because the instructor owes a Duty of Care to the student and is in a position of trust.

However, we do not know if an instructor or any other third-party assembled Jillian Smith rebreather.

At the moment, it is pure fantasy on the part of HIGHwing.

First of all, she wasn't taking a class during this dive.....there is no professional duty of care involved...unless she got poor training, and if she cant follow and verify a written checklist, she got really poor training. Being an instructor herself, she should have known that rebreathers are high risk units...therefore if she didn't understand the checklist during training...she should have asked. (Instructor would be the Proximate cause).

Lets assume she assembled her own unit.....She didn't do it the way she was trained. (She is the Proximate Cause) If the unit had been assembled that way during training, she would have died during training.

Lets now assume someone else assembled her unit.....She didn't follow the checklist and find the failed stereo check.(She is the Proximate Cause)

Regardless of HighWing's theory of who assembled the unit.....The failure chain starts and ends with her actions/inactions....Not the fact that it is physically possible to wrongly assemble the unit itself(which if properly assembled works just fine).

 

[gianaameri]

First of all, she wasn't taking a class during this dive.....there is no professional duty of care involved...unless she got poor training, and if she cant follow and verify a written checklist, she got really poor training. Being an instructor herself, she should have known that rebreathers are high risk units...therefore if she didn't understand the checklist during training...she should have asked. (Instructor would be the Proximate cause).

Lets assume she assembled her own unit.....She didn't do it the way she was trained. (She is the Proximate Cause) If the unit had been assembled that way during training, she would have died during training.

Lets now assume someone else assembled her unit.....She didn't follow the checklist and find the failed stereo check.(She is the Proximate Cause)

Regardless of HighWing's theory of who assembled the unit.....The failure chain starts and ends with her actions/inactions....Not the fact that it is physically possible to wrongly assemble the unit itself(which if properly assembled works just fine).

We all agree the unit was assembled incorrectly and as much has been ascertained by the inquest.

We also know that because of that the unit has been found non-compliant to a specific EN14143 Clause.

It takes both occurrences to have a fatality.

If one of the two were removed, then no fatality would have occurred.

 

[Omisson]

Hey Giann, did you forget to mention this:

The incident occurred March 2014-

- the oxygen sensors were labelled “Do not use after Nov 2013"- and gave inaccurate readings of 0.0, 0.16, and 0.18 when exposed to air, 0.21.

Or was that just an oversight on your part to sell the story?

 

[Dr. Lecter]

If you were a novice rebreather diver and your instructor assembled it and were told this was O.K., would it still be insane to dive it?

Misplaced trust maybe, but not insane.

Still insane. Novice or not, if you're certified you build your own unit before you dive it. Period. If you're still in training (she wasn't), I'll allow it's a different question.

 

[tomfcrist]

We all agree the unit was assembled incorrectly and as much has been ascertained by the inquest.

We also know that because of that the unit has been found non-compliant to a specific EN14143 Clause.

It takes both occurrences to have a fatality.

If one of the two were removed, then no fatality would have occurred.

For gods sake man, do you not think that she had the major role in this? Is she not responsible and accountable for her own actions?

Placing the blame on the equipment manufacturer is like saying that BMW is responsible for me wrecking my car because they created a vehicle that could go over 160mph and marketed it in a country where the fastest speed limit is 80mph. It makes no sense.

Here is a compromise for you. Agree to this.

Jillian was responsible for the correct assembly and operation of her rebreather. She had a tragic accident because she failed to assemble/operate her CCR properly. Hollis can make modifications in the future to prevent this particular accident from happening again.

^^^^If you argue against that, then you are just too dense to acknowledge reality.