Fatality at Jersey Island

[rongoodman]

It was the design of the Hollis Prism 2 which did not prevent the user from reversing the breathing loop, something which by design was easily preventable at little to no increase in unit production cost (much more expensive to deal with the consequences now of a fatality and possibly the costs and the reputational consequences of a product recall or lack thereof).

The cause of this accident was the diver ignoring her training and multiple checks specified by Hollis before diving the unit. Had the lungs been impossible to reverse, I think it have only been a matter of time before she found some other ingenious way to injure or kill herself.

 

[wedivebc]

The cause of this accident was the diver ignoring her training and multiple checks specified by Hollis before diving the unit. Had the lungs been impossible to reverse, I think it have only been a matter of time before she found some other ingenious way to injure or kill herself.

I could assemble a P2 with the CLs on backwards without any serious consequence. I cannot put two mushroom valves on the same side without suffering a likely fatal CO2 hit. Even a CO2 sensor would not have prevented this accident because unless the gas is flowing through the loop it will not read elevated CO2.
The O2 sensors likely have no effect on the outcome of this accident. The unit was flooded which likely killed the O2 sensors.
The smoking gun is the mushroom valve mixup and nothing else.

 

[Dr. Lecter]

The smoking gun is the mushroom valve mixup and nothing else.

And there are whole sections in the P2 manual about the importance of a stereo check, which would have without any doubt at all caught that mixup...to say nothing of the fact that all training also discusses the importance of checking to confirm one way flow.

If the diver was somehow inadequately trained on that point, then we have a something of an explanation (I wouldn't say training substitutes for reading and understanding the manual any more than the manual substitutes for training, but we'll let that slide for now)...but there's no evidence of that of which I'm aware.

 

[HIGHwing]

It is purely speculation at this stage that the husband had set-up the deceased rebreather.

My point is, you do have to look at it from the perspective of the newly certified user (the deceased was), including a married couple (they were married), being sold a finished and certified product (not a homebuilt or prototype) in the way which is marketed nowadays (i.e. a "Hollis" product, Hollis being synonymous with quality and integrity and not the garden shed rebreather companies we were accustomed to in the early days).

My point is you're down way too small of a rabbit hole. As they say, you can't see the forest for the trees.

You need to step away from the hardware fittings, step off the dive boat and ask yourself, "How did this accident *really* happen? What did it take for all the pieces to come together before the loop went in her mouth?

This was the first dive after certification on their P2s.
It's 100% clear to me this accident didn't happen in the water; she was essentially just waiting to die when she jumped in the water. The accident happened while her husband was assembling her rebreather. But, Why? The husband was also fresh out of class and certainly knew how to assemble a P2. The more you think about the mistake with a P2 in front of you, you'll realize the less cues he had to work from versus the primary user of the machine. That doesn't explain WHY he didn't sequentially complete the checklist, but it does explain WHY the user was unable to complete the stereo check - because the unit was assembled for her. It explains the human factors reason WHY neither individual noticed the incorrect assembly and failed tests.

I want to know WHY this happened and WHAT are the human and environment factors that allowed it?

You want to know WHO thought it was a good idea that part A can possibly be connected to part C. Honestly, I cared two weeks ago, but we're well beyond that now. We get it already. The installed base of P2 divers and Instructors are well aware of this potential improper assembly procedure and Hollis is offering the updated DSV to affected units - as specified by the coroner's report you've posted about a dozen times.

Part A going into Part C is interesting, but it doesn't explain WHY it happened, the sequence of events necessary, or procedures that need to be reviewed and studied for changed to prevent similar accidents.

 

[C Dub]

Husband assembled it?

Ugh. Damm. Really bummed to hear that.

 

[Dr. Lecter]

Husband assembled it?

Ugh. Damm. Really bummed to hear that.

As far as I can tell, that's still conjecture. It also doesn't make much more sense than the victim doing it, given that they're both fresh off Mod 1 and all that it drills into CCR divers. Indeed, even if he was prone to being reckless, one could argue it's less likely the husband would have been so caviler with his wife's unit versus his own.

 

[victorzamora]

I do not think a COMPLETELY compliant rebreather exist that she could have used, so it is highly hypothetical.

So....no rebreathers are fully compliant with the EN certs? So all other rebreathers are just deathtraps waiting to strike? I don't get your premise. You're saying they should be COMPLETELY impossible to screw up because EN says so....but that's impossible to achieve. There's no logical consistency.

My point is that a sufficiently determined fool can ruin ANY "foolproof" system given enough time. Checks, tests, and training are what keep you from dying on every dive.

 

[gianaameri]

You're saying they should be COMPLETELY impossible to screw up because EN says so....but that's impossible to achieve.

I am not saying the words you are trying to put in my mouth.

It is impossible to achieve anything which cannot be screwed up by a human (WE AGREE!).

What I am saying is that in life-support applications it is desirable to reduce the risk to the user to as low as reasonably practicable.

In the specifics of this case, to stay on focus, it was assembly error which brought about the fatality, and simple and low cost design features could have prevented it (i.e. measure considered to be reasonable and practicable which were instead not implemented in the original design).

---------- Post added December 17th, 2014 at 03:58 AM ----------

I want to know WHY this happened and WHAT are the human and environment factors that allowed it?

I might get threatened again with a lawsuit, but consumer attitude (husband and wife post-purchase behaviour in this case) towards a product and its use is a consequence of marketing and training.

---------- Post added December 17th, 2014 at 03:59 AM ----------

The accident happened while her husband was assembling her rebreather.

Speculative at this point.

---------- Post added December 17th, 2014 at 04:01 AM ----------

The installed base of P2 divers and Instructors are well aware of this potential improper assembly procedure and Hollis is offering the updated DSV to affected units - as specified by the coroner's report you've posted about a dozen times.

The Coroner report did NOT state what you purport to be happening.

Where is the Safety Notice to users and instructors you appear to be quoting from?

 

[Neoteric James]

I just found out I can assemble my car without the brakes on it. I was curios if this is covered by the EN whatever that keeps being posted. Damn it will drive too, I better go on over to the car forums and post 20 pages of nonsense and opinion so maybe I can turn off some people from even following a section on a forum.

I doubt my point will be heeded, and my off topic post likely to be deleted, but seriously, there is not a damn thing to learn from this anymore, just nonsense and the demand for hand holding.

 

[flots am]

Part A going into Part C is interesting, but it doesn't explain WHY it happened, the sequence of events necessary, or procedures that need to be reviewed and studied for changed to prevent similar accidents.

Why is this even possible?

It's not a novel problem, and is exactly why you can't put an HP hose on an LP port anymore.

flots.