Fatality at Jersey Island

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There's a black plastic cover that attaches to a bolt at the top of the frame over the unit. Except for maybe protecting the scrubber canister from scratches if you bang into a cave or wreck ceiling, I've never seen the point in it and leave mine in the closet.

Okay, so I'm clearly a shot of caffeine short today. Right, the cover. /facepalm I use my cover in caves and accept the scratches because otherwise the top center latch on the scrubber canister comes open in the tight spaces. Can't say it makes every dive though. :)
 
Could smaller rope or net material slip under the cover and present an entanglement hazard?

If you were trying to escape an entanglement without ditching the rebreather, how much force would it take to snap the cover in half?
 
I use my cover in caves and accept the scratches because otherwise the top center latch on the scrubber canister comes open in the tight spaces. Can't say it makes every dive though. :)

That's a good point. I might have to reconsider using it when I do my cave cross-over.
 
That's a good point. I might have to reconsider using it when I do my cave cross-over.
It happens so often, that I might suggest the cover is required equipment for overhead environments. FYI - The bucket does not leak if one of the fancy latches opens. But it gives me enough pause to just put the cover on. It also helps with, "Hey Mister Cave Diver Dude, What rebreather is that???". I wouldn't normally mind the question, but it breaks up my pre-cave dive trance a bit. :D
 
This is of some debate. There are studies that have shown by the time CO2 sensors respond to a breakthrough you have little to no time to respond before reaching debilitating and deadly levels.
In this case, it appear it wasn't a breakthrough, it was likely a slow and steady rise because they had cleverly bypassed the scrubber. So a CO2 sensor should have been useful.
 
In this case, it appear it wasn't a breakthrough, it was likely a slow and steady rise because they had cleverly bypassed the scrubber. So a CO2 sensor should have been useful.

Depending on the location of the CO2 sensor they may have "cleverly bypassed" the CO2 sensor... Not trying to be a jerk but I don't see that as helping in this case.


Sent from my iPhone using Tapatalk
 
Here's the response from the coroner:

Dear Counselor Halloran:

Thank you for your further enquiries received on 3 December 2014.

Unfortunately, under the law pertaining to inquests in Jersey, the Deputy Viscount (as coroner) is not in a position to release reports or statements to you. As the inquest has now concluded, he is not able to discuss the evidence further, nor to be addressed on the facts of the case. By law, the purpose of the inquest is to find the answers to four factual questions, being who the deceased was, where, when and how she died. The law specifically prohibits any finding of blame or liability. These matters would be dealt with by separate court action.

However, as mentioned in previous correspondence, the Deputy Viscount has written to various authorities including Hollis UK and the Trading Standards Department Devon and Somerset with the findings of the inquest and the inspection of the equipment by the Health and Safety Laboratory, England. It is hoped that this will stimulate appropriate action to prevent further fatalities of a similar nature.

With very kind regards

Sheila
Sheila Pierce
Corporate Services Officer
Viscount's Department | Morier House | Halkett Place | St Helier | JE1 1DD | Tel: +44(0)1534 441402 | fax: +44(0)1534 441499 | email: s.pierce@gov.je


From: dhalloran@halloranlaw.org [mailto:dhalloran@halloranlaw.org]
Sent: 13 December 2014 06:54
To: Sheila Pierce
Subject: Follow up Coroner inquiry

Ms. Pierce,

Will you be responding to my follow up inquiry sent two weeks ago?

Dan Halloran, Esq.


On Dec 2, 2014, at 6:03 AM, Sheila Pierce <S.Pierce@gov.je> wrote:

Counselor Halloran

The Deputy Viscount has asked me to reply as follows:

The rebreather equipment in question was a Hollis Prism 2 Rebreather.

The Deputy Viscount has written to various authorities including the manufacturer and the Trading Standards Department Devon and Somerset. This will outline the findings of the inquest and the inspection of the equipment by the Health and Safety Laboratory, England.

The main findings of the inspection of the equipment were:

It appears the rebreather did not comply with clause 5.1 of BS EN 14143: 2013 or BS EN 14143: 2003.
The rebreather had been put together such that the gas would not circulate in the required loop and CO2 would not be removed from the inhaled gas.
The inhale counter lung was positioned to the diver’s right hand side, instead of the left hand side.
The exhale counter lung was positioned to the diver’s left hand side, instead of the right hand side.
The one way inhale valve that should be positioned on the inhale side of the mouthpiece, to ensure the gas circulated the loop, was found butted against the one way exhale valve of the mouthpiece stopping any gas passing into the exhale counter lung on the diver’s right hand side.
The unit was flooded with fluid.
The cover for the scrubber bucket and head were missing, apart from a small piece attached to the fitting above the battery housing.
Two of the three oxygen sensors were reading 0.18 and 0.16 partial pressure of oxygen (ppO2) when exposed to air (0.21 ppO2), and when put into a 100% oxygen atmosphere (1.00ppO2) gave a reading of 0.80 oxygen. The third indicated 0.00 oxygen in air and 0.28 in 100% oxygen.
Two of the oxygen sensors were labelled “Do not use after Nov 2013”.
The log book from the dive computer indicated that the diver appears to have stopped moving after 3.00 minutes into the dive.

In addition, from the evidence heard at inquest:

The pre-breather checks carried out on land by Mrs Smith were for 5 minutes (believed to be manufacturers recommended time) and this would have been insufficient time for the build-up of CO2 to be recognised by Mrs Smith. 10 minutes might have been more appropriate.
There are three oxygen sensors on this equipment, but no CO2 sensors. Some form of CO2 sensor might be appropriate.

In UK terms this would be labelled as an accidental death, possibly misadventure, however, inquests in Jersey have narrative verdicts. The verdict in this case for Mrs Jillian Smith (age 41 years and 7 months) was as follows:

“That she died in the afternoon of Saturday 15th March 2014 at St Catherine’s Slipway, St. Martin, [Jersey] after having been found unconscious in the sea during an underwater dive at St Catherine’s Breakwater; the cause of death was asphyxia caused by obstruction of the airways by inhalation of gastric contents due to unconsciousness by hypercapnia; this occurred after failure of the incorrectly assembled ‘rebreather’ diving equipment that she was using whilst underwater during her dive.”

The inquest was informed that the manufacturer, Hollis, has now modified the mouthpiece assembly and re-issued it.

For your information, the coroner on the Island of Jersey has the title of Deputy Viscount.

Kind regards
Sheila
Sheila Pierce
Corporate Services Officer
Viscount's Department | Morier House | Halkett Place | St Helier | JE1 1DD | Tel: +44(0)1534 441402 | fax: +44(0)1534 441499 | email: s.pierce@gov.je




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---------- Post added December 15th, 2014 at 03:40 PM ----------

Essentially they will not release lab reports or explain the basis of any conclusions reached. They indicated no one has been charged (manufacturer or instructor) but they did not know if it was a new or used unit. The report could not identify the cause precedent- (ie hypercapnia, oxygen toxicity, hypoxia, etc)- which precipitated the drowning.

So really.... They were no help. Bat least we know where the regurgitated snippets that were posted came from...
 
Here's the response from the coroner:
However, as mentioned in previous correspondence, the Deputy Viscount has written to various authorities including Hollis UK and the Trading Standards Department Devon and Somerset with the findings of the inquest and the inspection of the equipment by the Health and Safety Laboratory, England. It is hoped that this will stimulate appropriate action to prevent further fatalities of a similar nature.

Did the Safety Notice come out yet?
 
Depending on the location of the CO2 sensor they may have "cleverly bypassed" the CO2 sensor... Not trying to be a jerk but I don't see that as helping in this case.


Sent from my iPhone using Tapatalk

The best place to put a CO2 sensor would, IMHO, after the scrubber on the inhale side. My understanding was the re-breathed air in question was not getting to the inhale side but was moving back-and-forth between the deceased's lungs and the exhale counterlung. It would make no sense, IMHO, to put a CO2 sensor where you KNOW there will/should be CO2 flowing....right?

So, I believe, a CO2 sensor would've done precisely zero. Right?
 
https://www.shearwater.com/products/teric/

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