2018 Rebreather fatality - Stoney Cove

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DandyDon

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Old news not previously posted here, under new light. It sounds like the Instructor got off easy...

Atechnical diving instructor has been sentenced to 50 hours’ unpaid work after a Health and Safety Executive (HSE) investigation found he was responsible for ‘multiple failings’ leading to his student’s death during a training dive at Stoney Cove in Leicester, UK, in 2018.

Technical diving instructor, Lance Palmer, was conducting an entry-level Technical Diving International (TDI) Closed Circuit Rebreather Course with experienced recreational diver and father-of-two Roger Clarke, 55, when the fatal incident occurred.

During the inquest it was revealed that Palmer had serviced Clarke’s rebreather before the dive, which expert testimony found was carried out with ‘significant failings’.

In addition to poor maintenance of the rebreather, the course standards mandate a maximum depth for the dive of 30m; however, Palmer – who had a safety diver with him – took Clarke to Stoney Cove’s ‘sump’, an area with a maximum depth of 35m and known for its poor visibility.

While in the sump, Clarke’s rebreather issued a number of alarms, requiring him to bail out onto his backup cylinder. However, he became unconscious and, following a failed attempt by Palmer and his safety diver to return Clarke to the surface, all three divers remained at 35m for 3 minutes, during which time it was shown that Clarke had not been using any breathing apparatus.

By the time Palmer and his safety diver had brought Clarke to the surface, he had drowned.

The HSE investigation ruled that Palmer was responsible for not adequately maintaining and checking his student’s breathing apparatus; failing to remain in close enough proximity to monitor his student, which meant he did not notice the audible and visual alarms sounding on the breathing apparatus; contravening TDI rules for exceeding maximum diving depths on repeat dives, and failing to have an adequately qualified rescue diver in the water with him and the student.

In his conclusion, Ivan Cartwright, area coroner for Leicester City and South Leicestershire, found that errors and omissions by the instructor and safety diver ‘significantly increased the risks associated with the dive and may have caused, or contributed, to Mr Clarke’s death.’ Lance Palmer was ordered to undertake 50 hours unpaid work and costs of £3,085.

In a family impact statement, Clarke’s widow, Angela, said that her husband’s death has left her with a fear of water.

‘From the day I lost Roger to this day I cannot get into water, not even a bath and I can’t put my face into a shower,’ she said. ‘He was my world. We had a good lifestyle. We had everything. I lost my world and reason to live and all I wanted to do was curl up and die and to be with my husband.

‘I have only one regret in my life – not being with my husband when he died.’

Speaking after the case HSE Inspector Richard Martins said: ‘Technical diving is a high-risk activity where student divers are totally reliant on their instructors.

‘This was a tragic and wholly avoidable incident caused by the failure of Lance Palmer to plan, manage and conduct his diving training in accordance with the law and his training agency’s rules.’
 
Any specifics about the 'significant failings' in servicing the rebreather?

I can’t find any actual information on this event (rebreather brand, rebreather age, how long the alarms were going off), or really any information other than this site has had many fatalities, mostly training related it would seem from a quick google search.

Hard to pass judgement “of the judgement” without any of the details.

I’m no lawyer but it sounds like the instructor took a plea deal and plead guilty to have reduced charges.
 
https://www.shearwater.com/products/peregrine/

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