Fatality at Jersey Island

[gianaameri]

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?

First time I read it on the net.

There is more though, as you should know by now.

---------- Post added December 3rd, 2014 at 03:24 PM ----------

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.

Reality:

“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.”

 

[Omisson]

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.

No Hollis can't fix stupid. the oxygen sensors were expired and should have been changed by the operator - and the unit never should have been in the water in March 2014 with O2 sensors that expired Nov 2013.

 

[tomfcrist]

No Hollis can't fix stupid. the oxygen sensors were expired and should have been changed by the operator - and the unit never should have been in the water in March 2014 with O2 sensors that expired Nov 2013.

Anyone with common sense can see what the root cause of this was...

Others though, they are the kind of folks that blame spoons for making them fat.

 

[gianaameri]

No Hollis can't fix stupid. the oxygen sensors were expired and should have been changed by the operator - and the unit never should have been in the water in March 2014 with O2 sensors that expired Nov 2013.

True, and how did that happen?

Please also consider:

• 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.

 

[Omisson]

True, and how did that happen?

Please also consider:

• 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.

First thing I was told about diving rebreather was to check the oxygen sensors to make sure a) they worked and b) they were in service date.

She did not do this.

She died.

Not a surprise.

---------- Post added December 3rd, 2014 at 03:40 PM ----------

True, and how did that happen?

Please also consider:

• 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.

"Sensors appeared to be working at the time of the incident" .... but that's PURE speculation.

What isn't speculation was that the sensors were clearly labeled that they were expired and clearly marked as such.

Why didn't you bother to mention that to everyone?

 

[HIGHwing]

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?

Yup...

I wish I could sit with you in front of a P2 and build it with you. I think having the parts in your hands would modify some of your opinions. Ultimately, and sadly, Tom C. is correct. Jill is the proximate cause of this accident, but that doesn't make it any less unfortunate. It doesn't help the CCR image, and it doesn't help the industry.

 

[gianaameri]

First thing I was told about diving rebreather was to check the oxygen sensors to make sure a) they worked and b) they were in service date.

She did not do this.

She died.

Not a surprise.

---------- Post added December 3rd, 2014 at 03:40 PM ----------



"Sensors appeared to be working at the time of the incident" .... but that's PURE speculation.

What isn't speculation was that the sensors were clearly labeled that they were expired and clearly marked as such.

Why didn't you bother to mention that to everyone?

There are some things I know which I do not mention, but will gladly comment on things I know which others post on the net.

So, how did out-dated sensors made it into her rebreather?

She is an OC Dive Instructor and Hyperbaric Chamber Emergency Personnel and trained Hollis Rebreather diver - just finished her course!!!

How in the hell out-dated sensors are in her rebreather (although the inquest has concluded O2 sensors did not contribute to the fatality)?

There is some really bad stuff going on in terms of systems, procedures, and controls, and if what HIGhwing is saying is true, that somebody else assembled her rebreather, it gets even more crazy.

 

[John C. Ratliff]

A Safety Notice is a step in the right direction.

The product would remain non-conformant to the required standard for Hollis to sell the product in the EU - that is Hollis loses a big market.

Hollis or its U.S. Distributor (say DivegearExpress, one of the best) would be able to sell it to an individual from the U.S., such individual becoming the "Importer," but then the individual would not be able to on-sell it to another EU person.

It is commercially limiting, to say the least.

For the 2 pence or 3 cents it costs to roll-out a fix, they should be working on a solution, from a commercial perspective, which actually makes the rebreather safer or in any event better.

---------- Post added December 3rd, 2014 at 01:15 PM ----------



Thing is, the rebreather can still be dangerously assembled and if used liked that (i.e. by human error blablablablablabla...) kill again.

Not exactly sure the fix is good enough.

Maybe it is, maybe it is not.

I cannot be the judge of that.

Guess HIGHwing can issue a Certificate to attest the unit satisfies the requirements of EN14143 as published/attested by him on Scubaboard and it is good do go!

In order to "certify" a piece of equipment as meeting a standard, especially the EU standards, you must use a Nationally Recognized Testing Laboratory, or NRTL. These are third party testing labs, and they issue a report citing deficiencies, or else certify compliance, to the standard in question. OSHA maintains a Complete List of NRTLs on their website. When I was involved in product safety for the ALTA Pattern Generation Machine, we used TUV Rheinland of North America, Inc. (TUV). It is important to have this done by a third party with the resources to do it correctly.

SeaRat

 

[Omisson]

There are some things I know which I do not mention, but will gladly comment on things I know which others post on the net.

So, how did out-dated sensors made it into her rebreather?

She is an OC Dive Instructor and Hyperbaric Chamber Emergency Personnel and trained Hollis Rebreather diver - just finished her course!!!

How in the hell out-dated sensors are in her rebreather (although the inquest has concluded O2 sensors did not contribute to the fatality)?

There is some really bad stuff going on in terms of systems, procedures, and controls, and if what HIGhwing is saying is true, that somebody else assembled her rebreather, it gets even more crazy.

No you did not mention it because we all would know the fatality could have been caused by this fact alone AND it proves the negligence on her part was profound.

Every rebreather guideline calls for checking oxygen sensors to be current before diving. She either didn't check or ignored they were expired.

Either way... Her fault.

 

[gianaameri]

Every rebreather guideline calls for checking oxygen sensors to be current before diving. She either didn't check or ignored they were expired.

Who put them in there?