Diver dead on the Andrea Doria

[Ayisha]

Correct me if I am wrong, but in my little time in the ccr world we don't know what causes most of the ccr deaths. The reports, if they are ever released, do not clearly define a cause of death.

We do know what causes most of the rb deaths and the results are released. Almost all of the rb deaths that have occurred in the last 6 or so years have been attributed to operator error. Every one that I can think of off the top of my head was attritubed to operator error.

It's the oc deaths that we do not always get answers for...

 

[down4fun]

We do know what causes most of the rb deaths and the results are released. Almost all of the rb deaths that have occurred in the last 6 or so years have been attributed to operator error. Every one that I can think of off the top of my head was attritubed to operator error.

It's the oc deaths that we do not always get answers for...

really? wes skiles? the diver on the arundo last year? these last two?

 

[Thalassamania]

You've hit the $64,000 question. The CCR makers would say it's pilot error, the grieving friends and worshipers will blame it on the CCR manufacturer.

The problem I'd like to point out, and I say this as a moderately experienced MK15 user, is that being a really good CCR tech is a damn near full time job. If you add a little diving on top of that ... there's not much of the day left over for family, friends, personal maintenance, a job, etc. Perhaps that's the result of my luck (good/bad?) in falling into enough M15 parts to build one and I might have a different view if I were wedded to a more civilian unit ... but from what I've seen, they're all a bit of trouble and fuss.

 

[cerich]

the real pilot community (the one that flies aircraft) had a interesting problem with the advent of widespread IFR flights. Pilots kept on crashing and buying the farm, all "pilot error". Anyhow the forerunner to the FAA did some serious investigating and felt that part of the problem was a lack of standardization. They developed the "standard T" instrument layout and the accident rate had a DRAMATIC improvement.

So, yes it was pilot error but it was often created by crappy instrument placement.

My point being this, right now most ccr divers are willing to accept less than reliable oxygen measurement and far from reliable CO2 measurement in a high WOB unit as being part of the "compromise" to enjoy the benefits of CCR in technical diving (a real benefit only realized however if you also accept poor or convoluted bailout gas management "plans", which is OK if you are OK with being dead if the unit fails. In submarines we used to joke that the escape tower was only for the peace of mind of moms and wives, in a real disaster they wouldn't save us.. 90% of what I see for bailout planning seems to be in that vein...but I digress)

IMHO, the idea that we can compromise on these items is the killer that is unspoken. It creates a dive with too many "baked in" problems already, leaving zero room for real life to intrude. Can you dive a CCR and survive? Of course, but as of now we have "eyes bigger than our stomachs" and we need to be more forthcoming on the real dangers. Right now in the zeal we see them glossed over or dismissed and a whole community of CCR divers that have "been doing just fine, thank you" coupled with the normal "that can't happen to me" with a dash of "they don't know what they don't know" thrown in for measure.

CCR deaths rates are unacceptable. It's far past time that members of the community address this so we can fix it!

We do know what causes most of the rb deaths and the results are released. Almost all of the rb deaths that have occurred in the last 6 or so years have been attributed to operator error. Every one that I can think of off the top of my head was attritubed to operator error.

It's the oc deaths that we do not always get answers for...

 

[gsk3]

We do know what causes most of the rb deaths and the results are released. Almost all of the rb deaths that have occurred in the last 6 or so years have been attributed to operator error. Every one that I can think of off the top of my head was attritubed to operator error.

When "old age" was made inadmissible as a cause of death, longevity improved.

When "pilot error" was made less acceptable as a cause of crash, plane safety improved.

Where "the resident messed up" has been made unacceptable as an explanation of a mistake, patient safety improved.

When "operator error" is made unacceptable as a cause of RB death, RB safety will improve.


If you constantly blame it on the individual, you'll never see the flaw in the system that put the individual in that place to begin with.

 

[kwinter]

We do know what causes most of the rb deaths and the results are released. Almost all of the rb deaths that have occurred in the last 6 or so years have been attributed to operator error. Every one that I can think of off the top of my head was attritubed to operator error.

It's the oc deaths that we do not always get answers for...

I don't know where you're getting this crap. I've known 6 rebreather divers that have died in the last 2+ years, and there is only a good cause known for one of them. Whenever the cause isn't known, it gets listed as "drowning" and published as "diver error".

 

[Ayisha]

I don't know where you're getting this crap. I've known 6 rebreather divers that have died in the last 2+ years, and there is only a good cause known for one of them. Whenever the cause isn't known, it gets listed as "drowning" and published as "diver error".

So if you know that they get published as "diver error", then you know where the "crap" that most rb deaths are attributed to operator error is gotten from.

It seems clear that there is a systemic problem that needs to be dealt with in the manufacturing, training, expectations and standards areas in rb use, especially as rb's are becoming more and more widespread and attainable.

 

[Thalassamania]

Rebreathers should not be that hard, it was one thing back in the days of analog control circuits, but today ... there just should not be the problems that there seem to be. One of the current problems, I feel, is the way in which safety analyses are done. In the old days everyone did Failure Modes and Effects Analyses (FMEA). Attempts had been made in many fields at conducting what are known as Probabilistic Risk Assessments (PRA).

The story is told, perhaps apocryphally, that early in the Apollo project the question was asked about the probability of successfully sending astronauts to the moon and returning them safely to Earth. A risk, or reliability, calculation of some sort was performed and the result was a very low success probability value. So disappointing was this result that NASA became discouraged from further performing quantitative analyses of risk or reliability until after the Challenger mishap in 1986. Instead, NASA decided to rely on the Failure Modes and Effects Analysis (FMEA) method for system safety assessments. To date, FMEA continues to be required by NASA in all its safety related projects.

But there are some real advantages to PRA, but that is a rather specialized area of expertise and hiring a team of PRA experts and training them up on first diving and then rebreathers before turning them loose on the problem(s) would be prohibitive in terms of cost. So we are left with FEMA for diving and PRA has really only advanced in the Nuclear Energy industry and post-Challenger NASA.

 

[D_B]

Interesting discussion

maybe this question belongs in another forum, but ... has technology advanced to the point a better RB design is possible right now ? and would that be in the area of system monitoring, or automatic controls, or both?
... are there any RB designs that are heading that way ?

 

[padiscubapro]

IMHO the problem is not that rebreathers are not reliable enough its just the opposite they are TOO reliable.. If the units were expected to fail often divers would not take it for granted that a failure is a low probability event and become complacent. Rebreathers allow the diver to do dives they wouldn't even attempt on oc and without the proper training, experience and constant practice even an event that shouldn't be more than just an inconvenience could become a serious situation.

I have been diving and teaching CCRs longer than most, and to this day I still take the attitude that the damn machine is going to try and kill me on every dive.. This way I am mentally ready for anything that can happen... if I'm out of the water for even just a few weeks.. I do a skills practice dive to make sure I'm ready once again... I do alot of gear testing and know I don't need a 100% functioning unit to stay alive if a diver is not comfortable being on the unit with something not working right then they shouldn't be diving a CCR. Bailing to OC shouldn't be their crutch..

One day I might end up being discussed but I'm pretty sure it's going to be something medically related out of my control rather than the equipment failing or me screwing up.