MatthewAddison
Registered
By that logic her rebreather was set up correctly because she wore it in front of another rebreather diver.
Logic is face-palming right now.
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Fatality at Jersey Island
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By that logic her rebreather was set up correctly because she wore it in front of another rebreather diver.
Logic is face-palming right now.
...........
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Dr. Lecter
Contributor
Whether or not she "passed" a 5 minute pre-breathe is irrelevant. None of the checks used were designed to stand alone, and having not checked (at a minimum) the one-way flow before doing the pre-breathe would render the pre-breathe less useful than planned.
If the goal of the pre-breathe was to catch each and every possible permutation of gross incompetence prior to the pre-breathe, it'd probably be 20
ing minutes and exactly nobody would do it. Gian and some mouth-breathing public official can point to the unit "passing" one check all they want, it doesn't change the fact that nobody is trained or supposed to rely on that one test alone, and it's very length is dependent upon it being used in connection with a whole series of other procedures and checks. If you do, don't whine when death comes knocking because of something that doing all of the basic checks would have caught. This was a tragedy, but the unit itself seems to have played a very minor role in it.
What I would very much like to know is how the Hell a freshly trained CCR diver could possibly have been so complacent. I think it's safe to say that most of us were not trained to just take a built unit, give it a pre-breathe, and drop...so why would someone with her OC experience and recent CCR training do so?
If the goal of the pre-breathe was to catch each and every possible permutation of gross incompetence prior to the pre-breathe, it'd probably be 20
ing minutes and exactly nobody would do it. Gian and some mouth-breathing public official can point to the unit "passing" one check all they want, it doesn't change the fact that nobody is trained or supposed to rely on that one test alone, and it's very length is dependent upon it being used in connection with a whole series of other procedures and checks. If you do, don't whine when death comes knocking because of something that doing all of the basic checks would have caught. This was a tragedy, but the unit itself seems to have played a very minor role in it.What I would very much like to know is how the Hell a freshly trained CCR diver could possibly have been so complacent. I think it's safe to say that most of us were not trained to just take a built unit, give it a pre-breathe, and drop...so why would someone with her OC experience and recent CCR training do so?
if she did the pre breath all she dive was load up on co2 ,
you have made your point , lest,s move on
you keep going on about how this lady was at the top of her game work wise and also a dive instuctor / professional ,
yet she she put the breather togeather like a red sea noddy , you must have seen them BC facing one way and the reg s facing the other way , .
im with you on it should be keyed , so you cant fook it up , and its v sad she did fook it up , she found a new way to kill your self ,
it will get fixed , and we all will move on ,
when i was firsy looking at getting a breather , the one thing that pushed me toeards the YBOD was all the deaths , it seemed to me that , thay had found all the ways to kill your self with that unit , and with that info , i could / maybe keep my self safe as i know what not to do ,
funny how each of us see thingds , you had your pronlems on the ybod , then went for a meg ,
i work with tools , you work with your smarts ,
i dont like to point the finger at my tool if i dont do a good job
i work with what i have, no sue some one , lol
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There has been some valuable discussion in this thread. Unfortunately a lot of it is corrupted by bickering, name calling and blame-storming.
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gianaameri
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To answer the specific question and specific comments above:
The rebreather is rather permanently secured to the diver. It is very important that the counterlungs, wherever they are positioned, they stay very close to the body (technically the "Lung Centroid") or WOB can go well above the tested and safe limits, and cause CO2 retention (i.e. pass out and drown without warning due to hypercapnia as in this sad fatality). So, there is lots of straps, buckles...
In short, when the buddy you would be tethered to passes out, and loses the mouthpiece, the rebreather would flood.
A rebreather has an internal volume of maybe 10 - 15 liters. This fills with water, and the buddy suddenly becomes negatively buoyant (a lot negatively buoyant).
So, you are attached to a weight. You cannot remove the rebreather easily or quickly from the buddy because it is designed to stay put and tight (no quick release as a weight belt).
If the buddy is semi-conscious or struggles, that raises the risk for you even further.
Tethering can do good, but also has the potential for a dual fatality.
It is somewhat safer in our application, to be good buddies and stay at arm's lenght and be vigilant, and for each rebreather diver in the buddy team do like the French military do and wear a Draeger Crown Strap.
Then, as explained earlier, if you can get hold and control your buddy, you will need some means to remove him/her from the rebreather loop poisoning him/her, and give fresh gas - and that is where the BOV comes in.
You can see how actually the Crown Strap sits on the diver at minute 1:47 here:
https://www.youtube.com/watch?v=j4VcSduUJbY#t=108
I train with these people and they are some of the finest divers and they have top instructors (they are between Russia and Germany, a rock and a hard place).
The BOV instead you (especially useful for gobfish1) can see and hear its safety use described here at about minute 04:57 and 06:20:
CCR Explorer Brett Hemphill and his modified KISS Classic on Vimeo
So, not so much tethering, but a Crown Strap and a BOV could have helped to prevent this fatality (and good training from qualified ex-military instructors rather than the average rebreather instructor could have helped too - strict adherence to protocol and good knowledge of what actually works and does not and how to teach).
Hope this helps and may save lives in the future. Lessons to be learned from THIS fatality.
---------- Post added December 8th, 2014 at 05:09 AM ----------
I agree with most of your good points.
If there are two or more ways to do something, and one of those ways can result in a catastrophe, then someone will do it, and she did it.
At some point in the future we may 'agree to disagree.' But, meantime, let us hold fast the essentials from the Coroner and HSL investigation (I quote):
The rebreather equipment in question was a Hollis Prism 2 Rebreather.
The main findings of the inspection of the equipment were:
- The rebreather did not comply with clause 5.1 of BS EN 14143: 2013 or BS EN 14143: 2003, which states:
- 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.
- Two of the oxygen sensors were labelled “Do not use after Nov 2013”.
- The log book from the dive computer indicated that the diver appears to have stopped moving after 3.00 minutes into the dive.
In addition, from the evidence heard at inquest:
- The pre-breather checks carried out on land by Mrs Smith were for 5 minutes (believed to be manufacturers recommended time) and this would have been insufficient time for the build-up of CO2 to be recognised by Mrs Smith. 10 minutes might have been more appropriate.
- There are three oxygen sensors on this equipment, but no CO2 sensors. Some form of CO2 sensor might be appropriate.
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.
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I can't understand "the cover for the scrubber bucket and head were missing". Does anyone know what part of the rebreather is being addressed?
darushin
Contributor
Either she wasn't using a list or if she was this was suicide period.
- The inhale counter lung was positioned to the divers right hand side, instead of the left hand side.
- The exhale counter lung was positioned to the divers 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
Again, covered in the List. Second in this configuration the unit should be unbreathable. If she did do a pre-breathe, she wouldn't have been able to exhale or inhale or doing so would have resulted damn near impossible WOB. She should have also passed out from CO2 due to not being able to inhale or exhale.
- Two of the oxygen sensors were labelled Do not use after Nov 2013.
Again, covered in training. Never use sensor that are over 1 yr old.
- There are three oxygen sensors on this equipment, but no CO2 sensors. Some form of CO2 sensor might be appropriate
At the end of the day had she used a list (which training dictates as mandatory), she would be alive. To have this many things wrong either the instructor should be blamed or this should be viewed as a intentional act.
Daru
MatthewAddison
Registered
The report states the victim aspirated on her own stomach contents. In other words, she threw up into her DSV shortly after eating and then choked on the contents. Had there been ANY hope of self rescue, a crown strap would have hindered the attempt in this instance. I am not against crown straps, (what we used to loving refer to as "suicide straps"), but they are not the be-all-end-all in rebreather safety some unseasoned divers purport them to be. In this situation and in catastrophic flooding situations they can make matters worse, not better. Not to mention that some people, myself included, find them uncomfortable and irritating as hell over the course of a few hours dive.
Furthermore, a BOV does no good if the person who it is attached to is incapable of operating it. Given the careless manner in which the system was put together and no operational checks performed, I have well-founded doubts if a BOV would not have been plumbed into the O2, or plumbed into nothing at all. So much about this accident beggars belief that there is not a single doubt that can be dismissed as irrational or "over the top".
Remember, there were two Prism 2 divers standing together on that ramp doing their "pre-breathe checks" (one on a system not possible to do any actual "checks" and pass) and neither diver questioned why one divers' manual O2 add was on the inside right, and the other divers manual O2 add was on the outside left, ADV on one being on the right and the other on the left? All the aforementioned valves are supposed to be operated and verified during a proper pre-breathe check.
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