Fatality at Jersey Island

[flots am]

Custom chips can be pretty economical when you can amortize the cost over tens of millions of $39 printer cartridges, it might not work so well at the scale for rebreathers. This is even more true when you realize that a large part of the reason they paid to create the custom chip in an inkjet cartridges was to ensure the manufacturer has a monopoly on supplying inkjet cartridges for their printers.

There are more then a handful of people killed every year because a highly trained and licensed nurse or physician attached a normal saline IV to a drain line or a feeding tube to an IV due to a momentary loss of attention. So this isn't exactly an isolated issue. Ideally it would be the case that you couldn't possibly assemble it wrong, but I strongly suspect it's harder to do this than it seems. Building a dozen different custom connectors that are totally reliable under 100 meters of sea water is probably not a trivial undertaking for someone who sells the number of units that even the top rebreather manufacturers sell. And I suspect the average buyer would rather have a connector that would absolutely work rather then one that they couldn't connect wrong, but will occasionally result in the rebreather flooding at a really inconvenient moment.

People make mistakes. This is absolutely guaranteed. If you do something long enough, you're going to screw up.

If you're willing to use a product that waits patiently for you to screw up so it can kill you, I guess that's your call. The current generation of devices do not currently meet my usability or safety standards, so I won't be using one and would never recommend one to a friend.

OTOH, if someone goes in with their eyes open, knows it could easily kill them, and uses it anyway, I guess "You pays your money and you takes your chances."


flots

 

[victorzamora]

if someone goes in with their eyes open, knows it could easily kill them, and uses it anyway, I guess "You pays your money and you takes your chances."

Everyone goes into everything knowing something could kill them. If they don't know it, they were ignorant and should've been better informed. Period. Everything in life can kill you, some things more cleverly than others. If you engage in a hobby/sport/activity, you do so full-and-well knowing it can kill you. OC can kill you and there are plenty of ways OC gear can fail in a way that ends poorly. There was a recent "high profile" Scubaboarder that passed away on OC gear despite HIGH levels of skill and training and experience. Nobody came on here saying that BCD's should be programmed to rocket you to the surface if they believe you're overweighted or running low on gas.

The fatality in Jersey was a tragedy, truly. I mourn the loss of any diver, no matter the reason. But this person, of full mental faculties, made the adult decision to engage in this activity, knowing full and well the associated risks. This person was properly certified to do the dive she expired during. There is no good reason why the dive didn't go off successfully. There was a chain of poor decisions and poor execution being made from the get go.

My point is that she went into this "with [her] eyes open, knew it could easily kill her, and used it anyway".....she paid her money and took her chances. It was her mistakes that caused the chain of events to unfold the way they did, period....not the fault of the rebreather.

 

[gianaameri]

Everyone goes into everything knowing something could kill them. If they don't know it, they were ignorant and should've been better informed. Period. Everything in life can kill you, some things more cleverly than others. If you engage in a hobby/sport/activity, you do so full-and-well knowing it can kill you. OC can kill you and there are plenty of ways OC gear can fail in a way that ends poorly. There was a recent "high profile" Scubaboarder that passed away on OC gear despite HIGH levels of skill and training and experience. Nobody came on here saying that BCD's should be programmed to rocket you to the surface if they believe you're overweighted or running low on gas.

The fatality in Jersey was a tragedy, truly. I mourn the loss of any diver, no matter the reason. But this person, of full mental faculties, made the adult decision to engage in this activity, knowing full and well the associated risks. This person was properly certified to do the dive she expired during. There is no good reason why the dive didn't go off successfully. There was a chain of poor decisions and poor execution being made from the get go.

My point is that she went into this "with [her] eyes open, knew it could easily kill her, and used it anyway".....she paid her money and took her chances. It was her mistakes that caused the chain of events to unfold the way they did, period....not the fault of the rebreather.

Nope, rebreathers are marketed as safe, for everybody, certified to this and that, tested, meeting EN14143 - well guess what - it is not entirely true (never was, and maybe never will).

If she were told this rebreather DOES NOT meet EN14143 and it will kill you eventually without warning because of your inevitable ability as a human to make errors or because of "something else," she would have been more properly warned.

 

[Edward3c]

Nope, rebreathers are marketed as safe, for everybody, certified to this and that, tested, meeting EN14143 - well guess what - it is not entirely true (never was, and maybe never will).

If she were told this rebreather DOES NOT meet EN14143 and it will kill you eventually without warning because of your inevitable ability as a human to make errors or because of "something else," she would have been more properly warned.

From what I understand units only meet the EN Standard on the day there sold by the manufacturer. Most units in use no longer meet the Standard as users modify or attach other components, like in-line valves. I would doubt many second hand units are EN compliant.

 

[Dr. Lecter]

Nope, rebreathers are marketed as safe, for everybody . . .

Yeah, not so much. From the manual (among numerous other warnings about how potentially unsafe the unit can be):

WARNING: The importance of working with checklistswhen setting up your PRISM 2 cannot be overstated! If
you have not set-up your PRISM 2 using the checklists, DO
NOT dive the rebreather.

And:

PRISM 2 Operational Checklist:
This is the checklist you will use to test all assembled components of the
rebreather to make sure they are functioning properly as a whole prior to
entering the water. You will complete these steps after assembly, or if a
piece of the functioning rebreather has been disassembled at any time.
This is the most critical part of the entire set up process, since a nonfunctional
rebreather will always become evident at some point as you
go through the operational checks. Do not dive the rebreather if it has not
passed every step of this checklist.

(emphasis mine)

 

[gianaameri]

From what I understand units only meet the EN Standard on the day there sold by the manufacturer. Most units in use no longer meet the Standard as users modify or attach other components, like in-line valves. I would doubt many second hand units are EN compliant.

Well, YES modified rebreathers no longer meet the original test. There are many reasons why users modify rebreathers, but this is a separate topic.

The deceased did not modify her rebreather (she assembled it incorrectly) and based on what HSL and the Coroner found and HIGHwing kindly demonstrated here the rebreather did not meet EN14143.

The specific EN14143 Clause it failed to meet was not disclosed to her or to anyone to this date by Hollis, unless I have missed the Safety Notice.

Having said that, most rebreathers probably do not meet some EN14143 Clause (generally back-mounted ones all fail the EN14143 hydrostatic imbalance test), so none really meet EN14143 (we are just not told).

The real issue is if because of that failure to meet a specific EN14143 clause, then someone has an accident.

---------- Post added December 18th, 2014 at 04:18 PM ----------

...Do not dive the rebreather if it has not
passed every step of this checklist...

I'd like to know if she skipped the entire check-list altogether, or if she just made a mistake following the checklist and in error ticked a test as PASS when it was supposed to be a FAIL.

The mandatory 5 minute pre-breathe she did in accordance to manufacturer and training agency standard, but that did not pick-up either her gross and unforgivable assembly error.

 

[Dr. Lecter]

I'd like to know if she skipped the entire check-list altogether, or if she just made a mistake following the checklist and in error ticked a test as PASS when it was supposed to be a FAIL.

The mandatory 5 minute pre-breathe she did in accordance to manufacturer and training agency standard, but that did not pick-up either her gross and unforgivable assembly error.

You're hilarious. In what universe does someone unthinkingly tick boxes on the checklist after the unit fails to pass a test that same person just performed, and then blithely go on their merry way because HEY, EVERYTHING IS MARKED PASS?

We've been over the pre-breathe thing already, but I'll say it again: doing it by itself is not any kind of catch-all test. Only when performed in connection with all other checks is a 5 minute pre-breathe relevant. Use the system or don't, but don't claim that your picking and choosing what to test somehow invalidates the one test you decided to perform.

 

[gianaameri]

You're hilarious. In what universe does someone unthinkingly tick boxes on the checklist after the unit fails to pass a test that same person just performed, and then blithely go on their merry way because HEY, EVERYTHING IS MARKED PASS?

People make all sorts of mistakes. A check on a check-list does not mean that in actual fact the unit passed the test.

A check-list is a tool. It will not prevent someone assembling the unit incorrectly, if it can be assembled incorrectly.

What will prevent someone assembling the unit incorrectly is if the unit is designed such that it cannot be assembled incorrectly.

A square peg will not fit in a round hole, check-list or no check-list.

 

[Dr. Lecter]

People make all sorts of mistakes. A check on a check-list does not mean that in actual fact the unit passed the test.

The check on the list is not important: the performance of the check and knowledge of whether it was a pass or a fail is what matters. If the diver did a stereo check, the loop would have failed miserably because there'd be no one way flow misassembled as it was. At that point, where she marked the paper is irrelevant: she's been alerted to the problem and must act on that alert.

Above you whined that a diver who ignores a HUD or other active alarm on the unit screaming at them they've screwed up is at fault rather than the unit's design. Guess what, same thing here.

A check-list is a tool. It will not prevent someone assembling the unit incorrectly, if it can be assembled incorrectly.

The checklist under discussion follows, not precedes, the misassembly in question. Had it been done, the misassembly would have been detected. End of discussion as to fault.

 

[victorzamora]

Nope, rebreathers are marketed as safe, for everybody

Everybody diving a rebreather knows that they're out to kill you. Period. Everybody that has ever even mostly considered buying or getting trained on a rebreather knows that it's out to kill you. Most manuals make it painfully clear. Period.

meeting EN14143 - well guess what - it is not entirely true (never was, and maybe never will).

It did, in fact, meet EN14143. According to the manufacturer and independent qualifier.

If she were told this rebreather DOES NOT meet EN14143 and it will kill you eventually without warning because of your inevitable ability as a human to make errors or because of "something else," she would have been more properly warned.

Like I said, anybody diving a rebreather is smart enough and informed enough to know that they can kill you at any time. Your job as a CC diver is to enjoy your dive while fighting off your untimely demise.

Having said that, most rebreathers probably do not meet some EN14143 Clause (generally back-mounted ones all fail the EN14143 hydrostatic imbalance test), so none really meet EN14143 (we are just not told).

No product would EVER meet CE standards if they were expected to be 100% foolproof. Period.

The real issue is if because of that failure to meet a specific EN14143 clause, then someone has an accident.

No. Period. The real issue is that there was a fatality due to a long list of poor and negligent decisions.

I'd like to know if she skipped the entire check-list altogether, or if she just made a mistake following the checklist and in error ticked a test as PASS when it was supposed to be a FAIL.

Either way, the checklist (and therefore assembly) was not accomplished and the fault was 100% on the operator.