Rebreather Discussion from Brockville Incident

[gianaameri]

Ok, I get it - you don't like rebreathers aka boxes of death. But you're way ahead of yourself in terms of what may have caused this incident

A&I forum is supposed to be for analysing the incident (currently, there is nothing to analyse), not getting on your soapbox

BTW I don't dive a RB so it's not like I care either way, and as stated previously I agree there is no reason to remove RB from the title, but that's a long way from saying that the equipment was "involved" in this event

I love rebreathers and use them, but to use it effectively you need to understand in full its limitations.

You will never be able to establish a rebreather being the cause of a fatality and it is far from my intention to suggest that in this case or any other situation the rebreather has caused the fatality.

However, whenever a rebreather was in use when a fatality occurred, the make, model, year of manufacture is extremely useful and relevant information (certainly no reason to omit from an accident analysis the fact that a rebreather was in use and which one together with as many other potentially useful details as possible).

I hope someone will now post the information pertaining to the unit used, if this is known.

 

[Hatul]

In spite of what's been said, when a rebreather diver become unresponsive at depth the number one suspect is you know what.

 

[doctormike]

I think that the accidents and incidents threads are very important, because by speculating and discussing what we know about an accident, we often will highlight weaknesses in our own protocols and training, and we can improve our diving practices.


Whenever an accident is reported, almost nothing is ever known about the specifics, unless someone who was very closely involved is willing to post. And even in such cases, even a buddy or rescuer may not know the exact events that happened to the victim leading up to the accident. Occasionally, we are told to "wait for the final report" before jumping to conclusions, but this isn't a court of law, and our discussions are for our own learning purposes, not to establish liability. Also, with rare exceptions, we are never going to have access to the "final report" of the investigative authorities.


As far as family members reading the threads, that's a good case for not gratuitously bashing the deceased without grounds, but if that is going to be such an overriding concern, then we shouldn't have an A&I forum at all. And that would be a shame, because I think that it's helpful.


All that having been said, I don't think that it's wrong to discuss the specifics of the equipment involved in this case. CCR really is different from OC in fundamental ways, and CCRs do vary from unit to unit far more than does OC gear. I'm not saying that no one should ever use a rebreather, but anyone who does needs to understand that there is a lot of technology keeping your blood oxygen and CO2 levels in the zones that support life.


Sure, it could have been a heart attack, but that is a last resort diagnosis of exclusion with a diving fatality, and one that we should only consider if there is real autopsy evidence for that (supported by clinical information).


Looking at gianaameri's profile, I doubt that he (she?) just doesn't like rebreathers, and is just jumping to conclusions. His comments seem thoughtful and backed by some real experience.

 

[Doppler]

In spite of what's been said, when a rebreather diver become unresponsive at depth the number one suspect is you know what.

No, I don't know what. Please be specific.

 

[Chris Brown Tech]

No, I don't know what. Please be specific.

You beat me to it Steve!

Ive found recently that after being optimistic post RF3 and thinking that we had reached a new dawn on understanding rebreather fatalities, its now like we have stepped back 5 years on these internet forums.

The same old school myths abound despite the manufacturers, instructors and training agencies seemingly agreeing that we the diver are to blame for the rebreather fatality count.

The same old school thinking is being applied in manually maintaining po2 and keeping an eye on those gauges and distrusting any electronics. Im still hearing the old mantra "my rebreather is trying to kill me, its my job to stop it"

Yet, nearly 10 years later we haven't seen any clear evidence of any of the mainstream commercially available rebreathers killing anyone due to a design flaw.

Condolences to the family. Lets hope the investigation is done properly as Steve mentioned and I hope the family can get some information as to the cause of death.

 

[dreamdive]

First: My condolences to the family and friends.

I know this is not a discussion on CCR being the bringers of death, however, can we suspend the speculations and stop blaming CCR and any model until the end of the investigation.

"We have more than 288 recorded fatalities to date whilst using a rebreather which is an extremely dangerous and insidious tool for diving (you pass out without warning and then drown, buddy generally unable to help fast enough, autopsy unable to determine cause of death since we all die of hypoxia and a bit of hypercapnia)."

Who is we?
How many OC fatalities do you have?

Diving multiple rebreathers, I disagree that it is "extremely dangerous and insidious tool for diving". And since you feel this way, why "I love rebreathers and use them, ...."



​

 

[doctormike]

I'm not sure why I'm participating in this discussion at all, since there are people here with far more experience than my test flights on a rEvo and an Inspiration a few years ago. But it seems like there must be some middle ground between the assumption that CCR technology is no different than any other OC regulator, and the assumption that anyone diving a rebreather has a death wish. I have great respect for rebreather divers, but it doesn't help to dismiss any discussion of their possible role in fatalities, if for no other reason than to make CCR safer in the future.

It's not that there are specific design flaws that are lethal - there may be in some cases, especially with non-mainstream gear, but I wouldn't know that. It's that diving a rebreather seems (correct me if I'm wrong) to require far more attention to complex procedures, continuous O2 monitoring, and pre-flight checklists than does OC diving, so given the fact that these are used by human beings, there is an opportunity for accidents that just isn't present in OC. That doesn't mean that they shouldn't be used, but it doesn't help to minimize this issue when discussing accidents. Even if every CCR death was proven to be operator error rather than an actual device failure due to a design flaw, that doesn't mean that the equipment wasn't a contributory factor, because it makes an operator error more likely to happen.

Any form of diving involves an assessment of risk, steps to minimize that risk, and ultimately an acceptance of some level of risk. Rebreather diving is no different than cave diving, wreck diving, technical diving or even shallow Caribbean reef diving in that respect. But I have been at a quarry when a diver keeled over standing up in 4 feet of water breathing from the loop. I know that the equipment manufacturer was recently dismissed from Wes Skiles' widow's lawsuit, but the fact remains that one of the most experienced rebreather divers in the world died at age 53 after ascending from a 75 foot dive, with no evidence of a massive MI or other medical explanation.

And finally, I took this picture a few years ago of a friend's dive gear. If the manufacturer actually embosses that message into the case, that means something to me...

 

[Doppler]

I know that the equipment manufacturer was recently dismissed from Wes Skiles' widow's lawsuit, but the fact remains that one of the most experienced rebreather divers in the world died at age 53 after ascending from a 75 foot dive, with no evidence of a massive MI or other medical explanation...

The point surely is that in a number of forums and seminars over the years, the consensus among dive industry pros working on and with rebreathers has been:
Use a Checklist
Dive within your certification level (unit specific)
Carry off-board bailout

I no longer have to send Happy Birthday cards to two friends for failing to follow that last guideline... and several because they ignored one or both of the first two.

SIMPLE pieces of advice but they opted not to follow them and now are dead. Is that the rebreather's fault? I don't think so, do you?

 

[doctormike]

The point surely is that in a number of forums and seminars over the years, the consensus among dive industry pros working on and with rebreathers has been:
Use a Checklist
Dive within your certification level (unit specific)
Carry off-board bailout

I no longer have to sent Happy Birthday cards to two friends for failing to follow that last guideline... and several because they ignored one or both of the first two.

SIMPLE pieces of advice but they opted not to follow them and now are dead. Is that the rebreather's fault? I don't think so, do you?

"Fault" is a loaded word, but as I said in my post, to imply that the technical complexity of rebreathers plays no contributing role in facilitating operator error is wrong.

So in answer to your question, I would say yes, the decision to dive CCR was probably a contributing factor (based on the limited information that you provided). I say this respectfully, as you are far more experienced a diver than me. But there is evidence to support this.

I'm sorry for your loss of your two friends. I hope that you don't see this discussion as disrespectful to their memory, but rather a way for people to improve safety in the future. For what it's worth, the (young) person who owned the rebreather in my photo above is also gone. Very sad.

 

[Doppler]

"Fault" is a loaded word, but as I said in my post, to imply that the technical complexity of rebreathers plays no contributing role in facilitating operator error is wrong.

I believe we are talking at cross purposes. There is no question that rebreathers are more complex than say OC. The point of my post was to mention that there are some simple "best practices" that the rebreather community has endorsed to help alleviate operator error.

So in answer to your question, I would say yes, the decision to dive CCR was probably a contributing factor (based on the limited information that you provided).

And the rebreathers made that decision? I do not follow the logic. Sorry.

I say this respectfully, as you are far more experienced a diver than me. But there is evidence to support this.

And I appreciate that but my experience as a diver is immaterial. It's my experience deconstructing incidents of injury and death in a high-risk activity that have a little, but not much, bearing here.

I'm sorry for your loss of your two friends. I hope that you don't see this discussion as disrespectful to their memory, but rather a way for people to improve safety in the future. For what it's worth, the (young) person who owned the rebreather in my photo above is also gone. Very sad.

THANKS but their deaths... more than two sadly... have to be used as an object lesson for those of us that continue to dive and teach on rebreathers. Not to do so would be, in my opinion, disrespectful.