The assembly error was hers to make, but we've now learned it wasn't her error. The person who put her rebreather together didn't notice the mistake and she apparently didn't have enough experience with the machine to discover it through her application of the checklists. Having a 3rd party assemble your rebreather is something I can't even wrap my head around. But, in this case is exactly what actually happened.
Fatality at Jersey Island
- Thread starter DandyDon
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gianaameri
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Maybe the instructor is dead or will be soon. We don't know that either.
Jilliam Smith was a Dive Instructor herself, and a Hyperbaric Center Emergency Medic, and a well known and respected qualified financial professional in the Jersey financial industry - dead on rebreather.
Somebody else mentioned Ron Akeson - a top notch instructor (Instructor Trainer blablablablabla...) - dead on rebreather (see http://divenewsnetwork.com/index.ph...s/2460-ron-akeson-1957-2014-mission-well-done ).
My instructor (Jordi Mateo pictured in my Avatar with me and two other instructors) and top notch guy and diver and cave diver - dead on rebreather.
Instructors are not immune from human error and if training is wrong (i.e. a too short/inadequate pre-breathe) and they learn the wrong thing and they teach the wrong thing - they die on rebreather from training as well (despite doing everything "right" in accordance to manufacturer and industry standard).
Okay, I have now read through this whole thread. It is apparent that some who read my previous post did not go to the links and read through them, as the different types of analyses available were spelled out pretty completely in those links.
One further observation, and that has to do with the pre-breathing of the rebreather. It appears from the outside (again, I am not a rebreather diver, and do not plan to become one), that you are trying to induce hypercapnia in order to determine whether the unit is actually scrubbing the CO2 from the system. As you know, CO2 is odorless, colorless and tasteless, so what you are trying to determine is from the physiological parameters of hypercapnia.
Years ago, I found out the hard way not to use my body senses to determine the nature of a hazard. We were flying HH-53 Super Jolly Green Giant helicopters when the incident occurred (read the link to determine what happened). In my training as an industrial hygienist we use instruments to determine the presence or absence of toxic chemicals. Carbon dioxide is one of those chemicals, and there are test methods and instrumentation to test for CO2.
If CO2 is one of the main ways of killing a diver using a rebreather, why is this sensor not included in the rebreather's instrumentation, just as oxygen is sensed? Why is the diver the "test dummy" for every dive? Why are there no "bells, whistles, or warning devices" built into the system to say to the diver, and his/her buddy, that his scrubber is either not working or used up? This is the twenty-first century, isn't it?
SeaRat
John C. Ratliff, CSP, CIH, MSPH
One further observation, and that has to do with the pre-breathing of the rebreather. It appears from the outside (again, I am not a rebreather diver, and do not plan to become one), that you are trying to induce hypercapnia in order to determine whether the unit is actually scrubbing the CO2 from the system. As you know, CO2 is odorless, colorless and tasteless, so what you are trying to determine is from the physiological parameters of hypercapnia.
Note the "mild symptoms...might include" not only headache, but also "confusion and lethargy." So you try to induce hypercapnia in yourself to determine whether the unit is functioning by pre-breathing for five or ten minutes, and then when potentially in a state of "confusion and lethargy" you are to determine whether the loop works? Are you pinning your hopes on the headache portion of the symptoms, but neglecting the potential for confusion in this required test? And note the "...elevation of arterial blood pressure and a propensity toward arrhythmias (heart beat abnormalities).
Years ago, I found out the hard way not to use my body senses to determine the nature of a hazard. We were flying HH-53 Super Jolly Green Giant helicopters when the incident occurred (read the link to determine what happened). In my training as an industrial hygienist we use instruments to determine the presence or absence of toxic chemicals. Carbon dioxide is one of those chemicals, and there are test methods and instrumentation to test for CO2.
If CO2 is one of the main ways of killing a diver using a rebreather, why is this sensor not included in the rebreather's instrumentation, just as oxygen is sensed? Why is the diver the "test dummy" for every dive? Why are there no "bells, whistles, or warning devices" built into the system to say to the diver, and his/her buddy, that his scrubber is either not working or used up? This is the twenty-first century, isn't it?
SeaRat
John C. Ratliff, CSP, CIH, MSPH
gianaameri
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Priceless. Simply brilliant!
Douglas Ward
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This is a great point. No one but the diver themselves diving the equipment should ever assemble their gear.
If she had assembled her own gear maybe her training would have been adequate and she would still be here
Lesson Take Away: 1) Assemble and Maintain your own gear 2) Follow Your Training 3) Do your checklist 4) Double Check your assembly 5) Don't dive unless your are 110% confident everything is right
It is a good point to make.
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descent
Contributor
Good Lord! I do not even let anyone touch my OC technical equipment & cringe when anyone messes with my recreational OC equipment, let alone my rebreather:shocked2:. I was taught from the very beginning of my technical training that I am the only one responsible for my equipment. My instructor/ service tech will not touch my unit, without me being right there & usually directly involved.
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