Fatality at Jersey Island

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Following the checklist is good, but making your own (well in advance, in a nice, safe, controlled environment of your own) is better so long as you don't mess it up. Religiously following a list is most likely to happen when it works with how you do things. Thus, build checklists are especially good for customization: I have a binder full of copies of one that is written for how I like to do things, ordered and grouped as I would build the unit if I were just going from memory. Because of that flow, I actually go through the build using the list, reading and doing and verifying and checking off/recording values.
 
What? If you breath out it goes somewhere in a counterlung and then into a scrubber. If the mushroom valves were both installed in same direction the air was going through the scrubber.

What you are suggesting is that one or both mushroom valves were not installed at all. Do you have that knowledge?

I dive a rebreather and understand the gas flow of a standard rebreather. Breathing in and out of a balloon suggests that either the mushroom valves were not installed, or the scrubber wasn't installed... Otherwise the scrubber is in play. If both mashroom valves are oriented in opposite directions you either can't breath in or you cant breathe out.

If an o ring was omitted fine then yes the scrubber may be bypassed but if the direction of flow is switched there is no reason why the scrubber wouldn't work...

Garth



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---------- Post added December 3rd, 2014 at 07:48 PM ----------



Did you not read my BOv comment. Are you denying that people have actually bailout out and survived a CO2 hit?

It's possible although not ideal to have a CO2 hit at all obviously.

A lot of these comments seem like they are coming from people who don't dive rebreathers... Just sayin.

Garth


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---------- Post added December 3rd, 2014 at 07:53 PM ----------



You have a lot of Rebreathers listed in your profile but do you actually dive Rebreathers frequently or are you teaching often?

I'm not convinced this was a primary CO2 hit as opposed to a flooded rebreather event with building CO2.

Everyone has an opinion. No one has to like mine... :)

Breathing in a balloon... Not good for your health...


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1. My understanding is that the one-way valves were properly oriented, but butted one against the other all on one side of the DSV. This means there would be no flow through that side of the DSV and hose. I may be wrong though, and she may as well have reversed one of the two one-way valves from its standard position, but I do not think so (in either case the rebreather would be dangerous to use). A person closely connected to the design/manufacturing is a good friend of mine and I am not sure he was involved in putting a one-way valve in the hose when all other rebreather manufacturers DON'T do that (all other manufacturers put the one-way valves in the DSV itself so that including by user error they cannot be butted one against the other as in the HP2). He won't like me saying this, but in hindsight it may have not been such a good idea.

2. I survived a full-fledged CO2 hit by bailing out to BOV before it hit. I was very lucky I bailed out when I did when I felt a sensation of "being in the wrong place, at the wrong time" with no other symptoms. Had I done that 3 breaths later I believe I would have been unconscious and drowned and be dead. BOV is essential for me, although the odds of surviving CO2 poisoning, submerged, while diving a rebreather are miniscule. CO2 is narcotic and causes psychosis (will post a link to the study when I find it).

3. CO2 sensors in rebreathers on the inhale side work very well. I developed one for my rebreather and then gave all my testing for free to a young entrepreneur who turned it into a product called NOTCO2. I have not tried it, but if it works as good as the one I had put together as a homebuilder, it is very good (for the inhale side to detect CO2 in the inhale counterlung).

"The system was developed for a personal need, I wanted to buy a rebreather but I did not trust the filter. I am a Informatic Engineer, I have performed studies with large mathematical content, so I can not conceive the uncertainty of an independent variable such as CO2 which in this case could take values unknown to me for dozens of reasons, including: a filter badly compacted, an assembly error of the machine and the like. Thus was born the system NotCO2. At first I tried so many different sensors, each had its own peculiarities and its flaws, but the intersection was common to all the moisture sensitivity. One day, reading between the various forums, I noticed that Gian Ameri - a diver rebreatherista - had carried out tests with a sensor Dynament with amazing results, so I decided to buy one and start new experiments. To date, no sensor gave results identical to the one used." (source: http://www.notco2.com/index.php/progetto ).

On a separate note, if somebody has a Hollis Prism 2, and they have the time, it would be interesting to assemble it incorrectly like the deceased did, create positive pressure in it by filling it up with air, and then ducking the DSV in a bucket of water to see if there are any visible bubbles.

If there are bubbles, it beggars belief how the two rebreather buddies failed to see the deceased DSV bubbling either side at the 6 meter bubble check. I know the deceased stopped moving after 3 minutes into the dive, which means it is possible they became separated before they were able to do a buddy bubble check, but possibly not either.
 
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if your not moving gas round the loop ,
id also think that the o2 in the head / round the cells is not getting much use , cell,s would read say 1.3 , but id say what s in the one bag/lung would be less . my thinking is if the c02 had not got her lack of o2 may well be up on the list , as well ,

just thinking ,
 
if your not moving gas round the loop ,
id also think that the o2 in the head / round the cells is not getting much use , cell,s would read say 1.3 , but id say what s in the one bag/lung would be less . my thinking is if the c02 had not got her lack of o2 may well be up on the list , as well ,

just thinking ,

Maybe... but O2 moles move quickly, especially if disturbed, while CO2 moles take time to be absorbed by the scrubber.
 
Maybe... but O2 moles move quickly, especially if disturbed, while CO2 moles take time to be absorbed by the scrubber.

yes with you on at , and both , low o2 and co2 make you fall asleep . / slow in responding .
 
yes with you on at , and both , low o2 and co2 make you fall asleep . / slow in responding .

Low O2 and HIGH CO2 make you fall asleep (and there is no "happy ending" because high CO2 causes unpleasant and horrible psychosis, still looking for the link to the research).

For the uninitiated:

CO2: The rebreather incident

PCO2: The Dark Matter of Rebreather Diving | DIVER magazine

DO WATCH THIS: http://www.hse.gov.uk/diving/video/hse_diving_shell.swf

The crazy thing is that all these rebreather gurus could not find a solution, but I did in my garage long ago.

In any event, that is not enough.

Poor equipment and poor systems, procedures, and control inevitably lead to fatalities. The whole thing is f-up at the moment as exemplified by this fatality which demonstrates a whole chain of errors from design and manufacturing, to certification, to training, and to use and prior product delivery.

It don't get more f-up than this (take it from the guy who has two high power rifles recalled in the U.S., but not in the U.K.).
 
If there are bubbles, it beggars belief how the two rebreather buddies failed to see the deceased DSV bubbling either side at the 6 meter bubble check. I know the deceased stopped moving after 3 minutes into the dive, which means it is possible they became separated before they were able to do a buddy bubble check, but possibly not either.

Given how the unit was put together and the multiple checks that were ignored, what makes you think they would have done a bubble check?
 
Hmmm... what are we going to do with all the dead rebreather instructors...

Nice theory, but it does not hold.

Jillian Smith made a mistake just the same as the other ladies I mentioned (and me) can make a mistake.

Plus, Jillian Smith did not have the experience the other ladies have.

she made several mistakes , one of them we can pin on the unit makers , all the other mistakes were down to the diver and team members ,

we all make mistakes , iv made a few , but none that would kill me outright , my ybod is a simple thing . dont need to remember much ,

tell me this , do you not do a suck and blow down your dsv hose,s be4 you plug them in to the tee,s , the flipper valves and the big scrubber O-RING are 3 of the things i know will kill me , so i test them and make sure i dont leave O-RING out or spacer ,
scrubber Packed , that side of the deal is done , move on to the next killer ,

rebreather instructors...what to do with them . lol best we start a new thread m8,

iv been around a long time seem half the uk nstuctors when they were still noddy diving , they would come to dotty to get a few stunt dives in
looks good on the CV ,
 
tell me this , do you not do a suck and blow down your dsv hose,s be4 you plug them in to the tee,s ,

No, I do it differently, because that is wrong, although it is thought as the golden standard.

This could also be another potential cause for which Jillian Smith missed that one test (wrong method of testing the one-way valves, although it is being taught as best practice).
 
I'd like to take this is a bit different direction--the fact that contact was lost with the victim diver during the dive. We have been concentrating on the rebreather itself, and not on all the other aspects of this accident. The lost contact kept assistance from occurring in a timely manner, as described at the very beginning of this thread. In accident analysis, all aspects must be examined, so what about the lost contact?

Years ago, when I was diving in limited visibility with my buddy off the Oregon coast, we used a "buddy line" to keep us together. The buddy line was a four-foot ,1/4 inch diameter nylon line, with brass snap links on the end and attached to a belt harness which had parachute "D" rings sewn into each side of the belt. That led to my buddy and I being together and not separated when we were rolled by a very large wave. We ended up on the surface together after being rolled, dumped our weight belts, and spent about 3 hours awaiting pickup by the U.S. Coast Guard.

What would have been the outcome had these divers been linked together with buddy lines in that limited visibility? Would this have been a fatality, or simply an incident because they had constant communication with each other and could thereby assist one another when the emergency occurred with the rebreather?

SeaRat
 

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