Fiona Sharp death in Bonaire

[hroark2112]

so given the analysis of ccr related deaths what % are machine breakdown versus human error

If only it were that simple.

So many factors go into it. Is there a problem with the unit? Did the diver know about it and still dive? Did the problem arise underwater? What caused the problem - was it diver error in the build or was it a mechanical failure that was unforeseeable? Did the electronics function properly to warn the diver of the problem? Did the warnings go unseen/unheeded? What was the outcome of the failure - did it cause hypercapnia (which causes confusion and a definite slowing of reaction time) or did it cause hyperoxia (which can cause unrecoverable convulsions leading to drowning) or did it cause hypoxia (which can cause dizziness and the inability to act)? Did someone choose the wrong gas to inject? Was the scrubber packed improperly? Were the oxygen sensors current limited? Were they properly calibrated? Were they too old? Was the oxygen turned off? Was the diluent a hypoxic mix and breathed too shallow?

I've experienced hypoxia and had to be saved. I never want to experience that again! Had I not been brought back to life, would my death have been considered an equipment failure? Possibly, as it was not giving me oxygen. Would that have been 100% accurate? No, because it was a known issue and I chose to splash. So does that make it a human error? Definitely. But if I had not been brought back, how would we have known?

Blaming the technology, the manufacturer, the individual unit, or blaming the diver is seldom the whole story. It's kind of like asking a couple going through a divorce what the cause of the divorce is. Rarely is it just one issue. Terrible analogy maybe, especially given that I am in the middle of that myself, but painfully accurate. That is why there is no way to come up with that magical number assigning blame. The ones who know all the answers can not contribute to the discussion.

 

[John the Pom]

so given the analysis of ccr related deaths what % are machine breakdown versus human error

I think if you study many different types of accident investigation you find that there is nearly always a cascade of failures, and frequently a history of things going wrong that foreshadowed the final disaster. It is often difficult to attribute a single cause. That's why the better companies place such emphasis on developing a 'safety culture', rather than just focussing on, say, enforcement of safety procedures.

 

[Mark Gebhard]

I would like to shed some light on this event as a certified tech trimix rebreather diver who has many dives in the vicinity where Fiona was found.
1. It is possible to reach 300’ depth and deeper approximately 200-300 yards from the location where her body was found. The bottom of the reef is approximately 100 to 130’ and slopes out away from the reef toward Kline. Opinion: It is NOT possible for this is to be an accident where something went wrong and she ended up at 300’ as indicated in prior discussion. I doubt it is a spur of the moment type decision.
2. A dive to 300 feet would require an ADVANCED TRIMIX certification for the brand of rebreather used in is dive. No one has mentioned her level of certification, this should be no big secret if others are to learn something. Without speculating, everyone should be aware of the risks and hazards of diving beyond their certification level as it is often a contributing cause of a fatality.

3. Fiona was SOLO diving. It doesn’t take speculation to conclude this type of diving has its own risks and hazards.
Opinion 1: The average diver should not be diving in the extended range or to depths exceeding 200 feet without a buddy. I am sure some of the ELITE full cave divers will want to argue the point.
Opinion 2: this accident was preventable if a good tech buddy who is familiar with her unit was present and paying attention.

4. No one has commented on the scrubber and the duration of use. I would use a new scrubber cartridge or replace the loose fill before embarking on this type of dive to help prevention of hypercapnia. Even if the scrubber is new, the issue of WOB (work of breathing) can come into play for the physical exertion for the distance to swim out and back where 300 feet is accessible. Even if this became the underlying problem, a good buddy could have recognized it within a minute and brought her to the surface. Time is not your friend when it comes to resuscitation.

5. Without seeming to be a butthole, let’s state the obvious, it goes BEYOND reason to make a dive to a depth of 300 feet with a rebreather or open circuit with the configuration reported; i.e. gases reported and the size of bailout and the gases listed in the bailout, especially in light of this being a SOLO dive. This brings into question the level of training and certification for Fiona. You don’t have to be a rocket scientist to learn something here.

6. Everyone who is rebreather certified should be aware of the level of discipline and the level of detail required to setup, maintain and follow pre-dive procedures via a checklist. No one has mentioned review of this material which should be available and may provide insights and lessons to be learned.

7. I agree there are many possibilities as to the exact cause. Not ruling out a medical condition, one of which is a fatal heart attack, a good buddy will be challenged to over come this type of event. Even if this is the cause, all the content in this message applies to preventing a fatality.

 

[hroark2112]

No disrespect intended Mark, but you not knowing the diver and her certification & skill levels should have precluded you from making this your first post on Scubaboard.

 

[Mark Gebhard]

Dear Tech Instructor hroark:
1. Thanks for your insightful comment. I don’t appreciate people that take the time to attack the commentator and not the issue.
2. I was at Bonaire for tech week, the week before the incident. More than one of my friends who are rebreather tech instructors were still on the island during the incident. Unlike others here who hide under a carpet of secrecy, some for good reason and others because their judgement is clouded by friendships. It has been almost a year, and I have spent hours reading the comments here, most of which are speculation and little facts provided.
3. If this forum is about learning and helping the dive community to be safe, my review is spot on with facts and probing questions that would be useful in the analysis.
4. If this forum is solely about protecting the reputation of arguably a pillar and respected member of the dive community, at the expense of all the other divers safety, then please let me know.
5. If you can not respond with facts, such as Fiona was an advanced trimix rebreather diver and can provide a reasonable explanation for her willful disregard for her actions, you should not respond. If you don’t have details of the autopsy or the dive computer, you need not respond.
6. Conclusion: You may not have intended to be disrespectful, but you certainly are not only to my post but to the entire dive community which deserves to have answers which just might save another life. If you can not embrace this ideology, you should not be a dive professional.

 

[hroark2112]

Noted. I’ll mail all my cards back immediately!!

 

[lermontov]

Dear Tech Instructor hroark:
1. Thanks for your insightful comment. I don’t appreciate people that take the time to attack the commentator and not the issue.
2. I was at Bonaire for tech week, the week before the incident. More than one of my friends who are rebreather tech instructors were still on the island during the incident. Unlike others here who hide under a carpet of secrecy, some for good reason and others because their judgement is clouded by friendships. It has been almost a year, and I have spent hours reading the comments here, most of which are speculation and little facts provided.
3. If this forum is about learning and helping the dive community to be safe, my review is spot on with facts and probing questions that would be useful in the analysis.
4. If this forum is solely about protecting the reputation of arguably a pillar and respected member of the dive community, at the expense of all the other divers safety, then please let me know.
5. If you can not respond with facts, such as Fiona was an advanced trimix rebreather diver and can provide a reasonable explanation for her willful disregard for her actions, you should not respond. If you don’t have details of the autopsy or the dive computer, you need not respond.
6. Conclusion: You may not have intended to be disrespectful, but you certainly are not only to my post but to the entire dive community which deserves to have answers which just might save another life. If you can not embrace this ideology, you should not be a dive professional.

at this stage maybe those that have the verified facts can list them- not a buddy was there facts or I was told she was this or that facts

 

[tursiops]

LOL. I was there. I was the last person to see her alive. I reported on my information in this thread.
I have no desire to reiterate them for Mark Gebhard's education....they probably will not fit his narrative.
Others have also reported facts.
More is known than is in this thread, but you'd have to go to Bonaire and talk to the right people over a beer (or 2 or 3) to get the info.
No one here has the "right" to know anything....especially if you ask with an attitude.

 

[The Chairman]

No one here has the "right" to know anything.

I'm sorry, but I find this lamentable. It's like the scene where Jack Nicholson screams "You can't handle the truth!" Rly? Aren't we a bit past this? People want to know, not just because they just want to but because this kind of thing is unsettling. When an experienced rebreather diver dies (or a caver, or a tech diver), it causes all of us to pause and consider why. The whole point of accident analysis is to learn from the mistakes of others. Why not? Why let their death be in vain? @Uncle Pug told us that IF he died on Scuba, he wanted us to dissect his death. Many of us, myself included, echoed that very sentiment. If I die on Scuba, on a rebreather, in a cave or where ever, PLEASE LEARN FROM MY MISTAKE(s). I'll be beyond caring what you think of me and it would mean a lot if you know anything about my death that you post it right here on ScubaBoard. Make me look stupid for breaking protocols. TEACH people what not to do, Expose my hubris. It's OK, you have my written permission. Oh, don't get me wrong: I'm not in the same league with Fiona. Still, I'm begging you to MAKE MY DEATH HELP OTHERS. Tell people how I effed up.

I didn't know Fiona well, but it's my opinion that she doesn't care about her reputation any longer. In fact, I bet she would nod her head in agreement that we should be told as much as possible so others can learn from her mistakes. For Fiona's sake: come clean with all the information.

 

[NothingClever]

Dear Tech Instructor hroark:
1. Thanks for your insightful comment. I don’t appreciate people that take the time to attack the commentator and not the issue.
2. I was at Bonaire for tech week, the week before the incident. More than one of my friends who are rebreather tech instructors were still on the island during the incident. Unlike others here who hide under a carpet of secrecy, some for good reason and others because their judgement is clouded by friendships. It has been almost a year, and I have spent hours reading the comments here, most of which are speculation and little facts provided.
3. If this forum is about learning and helping the dive community to be safe, my review is spot on with facts and probing questions that would be useful in the analysis.
4. If this forum is solely about protecting the reputation of arguably a pillar and respected member of the dive community, at the expense of all the other divers safety, then please let me know.
5. If you can not respond with facts, such as Fiona was an advanced trimix rebreather diver and can provide a reasonable explanation for her willful disregard for her actions, you should not respond. If you don’t have details of the autopsy or the dive computer, you need not respond.
6. Conclusion: You may not have intended to be disrespectful, but you certainly are not only to my post but to the entire dive community which deserves to have answers which just might save another life. If you can not embrace this ideology, you should not be a dive professional.

Awkward first and second post, mate. I think your communication style here and prescriptive guidance about who can and cannot respond undermine the better part of your intentions. Maybe I’m being harsh but anytime a diver front loads an initial conversation with their certifications, I tend to think they’re compensating. The dive leaders I like to listen to just flip on the fog lights and move everyone forward with salient content and useful insight. I totally get the speculative nonsense and wild conjecture in this thread (OK, a lot of threads) is maddening but I’m not sure your efforts improved anything or really flipped on the fog lights so late in the conversation.