Fatality at Jersey Island

[gianaameri]

Not at all. I am saying, somewhere,.... Training, attention to details & common sense has to play a roll. As I have heard before, "you can idiot- proof things all you want, God will always create the better idiot to get around it".

Yeah, but the equipment in this case was neither idiot-proof nor did it meet the basic standard of safety which the industry chose to give itself.

Training was adhered do - and TWO rebreather buddies failed to spot any problem with someone who built her rebreather backwards and was wearing it in front of them while breathing CO2 from a single of the two rebreather counterlungs (the other counterlung non-functioning) and the scrubber NOT removing CO2.

The dive was to 14 meters (not 140 meters) and Open Water (no cave, no deco).

Gee, don't you see there is a problem with manufacturing and training?

 

[gianaameri]

It's no more or less acceptable than any other logical consequence of one's own actions. Step off a curb in right in front of a bus and physics takes over - whether it's "acceptable" or not is irrelevant, because we need both busses and curbs. It's up to us to look before we step, and in this case someone chose to go diving on a CCR after training without doing any looking. It's very sad, but it's not a problem with the CCR's design.

Subway or Underground example then.

Easy to fall under one - but the newer ones have access doors both on train and platform.

What is acceptable in Sierra Leone now, may not be acceptable in the EU, and what was acceptable in the UK in the Middle Ages, may not be acceptable now.

What is acceptable now in our application is the safety standard which the rebreather industry gave itself - and it was not met according to the Coroner and HSL.

So, let me add to the failure by manufacturing and training, also the failure by Supervision:

1. The Notified Body who certified the unit and gave it a PASS on its check-list.
2. The Authorities who are supposed to supervise Notified Bodies and Manufacturers.

BUT Yes, the user was at fault big time in this case.

---------- Post added November 29th, 2014 at 01:20 PM ----------

As to your checklist point, note that there are some relevant sections you skipped over:

We do not know if she skipped over the check-list or that if assembled the way she did the unit would pass or fail pos. or neg. pressure tests.

The information I have say nothing as to check-list.

BUT any rebreather diver that does not do a pos. and neg. check pre-dive is skipping a very important check (I do those tests and don't use a check-list).

We do not know if she did or skipped pos. and neg. test from the information available.

 

[Dr. Lecter]

We do not know if she skipped over the check-list or that if assembled the way she did the unit would pass or fail pos. or neg. pressure tests.

The information I have say nothing as to check-list.

BUT any rebreather diver that does not do a pos. and neg. check pre-dive is skipping a very important check (I do it and don't use a check-list).

We do not know if she did it or skipped it from the information available.

We know from someone who actually dives a P2 that the unit will fail both positive and negative checks if misassembled as your information claims was the case here. We also know from what you yourself said about this victim's inhale and exhale valves that the unit could not have passed a stereo check. All three of those checks are in the P2 manual's build list and check lists, and discussed at length in the manual as well. Thus, we do know at least three checks that could have caught the problems must have either been skipped or done very incorrectly.

It is possible that isn't the diver's fault - maybe she had really bad training. I don't know. But I do know that based on what you've posted and what we know about the P2's design, the unit would have failed positive, negative, and stereo checks if they were correctly done. That's not the fault of the P2 or its checklists.

 

[gianaameri]

We know from someone who actually dives a P2 that the unit will fail both positive and negative checks if misassembled as your information claims was the case here. We also know from what you yourself said about this victim's inhale and exhale valves that the unit could not have passed a stereo check. All three of those checks are in the P2 manual's build list and check lists, and discussed at length in the manual as well. Thus, we do know at least three checks that could have caught the problems must have either been skipped or done very incorrectly.

It is possible that isn't the diver's fault - maybe she had really bad training. I don't know. But I do know that based on what you've posted and what we know about the P2's design, the unit would have failed positive, negative, and stereo checks if they were correctly done. That's not the fault of the P2 or its checklists.

I don't know the unit and the one-way valves are placed in the hoses and not the DSV/BOV as in all other units I know.

I also don't know exactly what she did and did not do.

It would have to be replicated on her unit and then see if it pass or fail the prescribed manufacturer tests in the check-list.

What we know is that if the unit was designed such that it could not be incorrectly assembled, then we would not be having this discussion now (and maybe she would be alive barring her making some other fatal mistake).

 

[tstormdiver]

Yeah, but the equipment in this case was neither idiot-proof nor did it meet the basic standard of safety which the industry chose to give itself.

Training was adhered do - and TWO rebreather buddies failed to spot any problem with someone who built her rebreather backwards and was wearing it in front of them while breathing CO2 from a single of the two rebreather counterlungs (the other counterlung non-functioning) and the scrubber NOT removing CO2.

The dive was to 14 meters (not 140 meters) and Open Water (no cave, no deco).

Gee, don't you see there is a problem with manufacturing and training?

Issues with the diver's Training &/ or attention to detail, yes... Manufacturing, not so much. When you think of it, it's sad that, the other divers did not notice the counterlungs being reversed, if they too are at all familiar with the unit- once again... attention to detail & the training to know the details. The differences in the lungs are night & day. Only 1 lung has an OPV (drysuit style) in the center & the manual O2 addition valve on the side, the other has the ADV/ manual valve in the center. If the lungs looked even remotely like each other, I would side with you. It does not take a genius to see the differences. If manufacturing is really the problem, then why am I & all other Hollis Prism2 divers not already 6 ft under? I will stick to my guns with it being vastly more an issue of training, attention to detail & common sense, in that order.

---------- Post added November 29th, 2014 at 12:53 PM ----------

I don't know the unit and the one-way valves are placed in the hoses and not the DSV/BOV as in all other units I know.

The 1 way valves are placed- 1, on the end of the inhale hose going into the DSV. The other 1 way valve is on the end of the DSV going into the Exhalation hose. The 1 way valves in the BOV are factory installed (& not easy to get out) directionally with keyed threads for the hoses, with the regulator part purge & exhaust valves to show what is front/ back & up/ down.

 

[gianaameri]

If manufacturing is really the problem, then why am I & all other Hollis Prism2 divers not already 6 ft under? I will stick to my guns with it being vastly more an issue of training, attention to detail & common sense, in that order.

Manufacturing, or rather design, is the problem identified by the Coroner and HSL.

You (I understand you are a HP2 diver) ain't dead because you did not make the same mistake she did, which was preventable if the unit had been designed such that it cannot be assembled incorrectly.

My rebreather can be assembled incorrectly (the one-way valve on my Golem BOV and POS7 Gen2 BOV can be reversed, the latter the key having being re-machined to use it on the Meg which has a different flow direction from the POS7...)... and I ain't dead yet either.

However, according to the manufacturers' standard for these PADI Type Rebreathers for the PADI Type Training for the PADI Type divers, this is not allowed (not allowed for any diver generally).

 

[tstormdiver]

However, according to the standard for these PADI Type Rebreathers for the PADI Type Training for the PADI Type divers, this is not allowed (not allowed for any diver generally).

It is a Tech style rebreather (& advertised as such)... Not a "PADI Style"( I assume you mean strictly recreational style). Yes, it can be used for recreational diving, same as your Meg can, but it can also for technical level dives without any modifications. The Prism2 can be either manually or electronically controlled. If that is the case,.. then your Meg & all other such rebreathers are also a "PADI style" rebreathers.

 

[gianaameri]

It is a Tech style rebreather (& advertised as such)... Not a "PADI Style"( I assume you mean strictly recreational style). Yes, it can be used for recreational diving, same as your Meg can, but it can also for technical level dives without any modifications. The Prism2 can be either manually or electronically controlled. If that is the case,.. then your Meg & all other such rebreathers are also a "PADI style" rebreathers.

To be a PADI Type rebreather you gotta be in the PADI list of accepted rebreathers.

HP2 is.

My Meg is so modified that not even Leon would recognise it!

 

[Dr. Lecter]

Dive boats and liveaboards are not currently required by their insurance carriers to employ safety personnel who hold the (imaginary) occupational certification of "Rebreather Rigger".

If there are enough high-profile accidents, it would be reasonable to expect carriers to try to force larger operations to adopt some safety regs that are less "Wild West" and more "Nanny State". It has happened before.

The idea of diving a unit that has been "rigged" by someone else is so alien to most people I know who dive rebreathers, that I don't think we'll ever see anything even approaching that. Most of us get grouchy about other people even casually touching fully assembled units--as between not doing the dives I do, or doing them on a CCR built by someone else, I would find another hobby.

Again, we come back to which risk does the diver prioritize the avoidance of: the risk of their own human error, or, the risk of problems from an external source (be it an over-engineered rebreather designed to avoid any potential for human error, or an expert who built your unit for you). Most of us, I think, would prefer to be cursing our own foolishness as we expire, rather than someone else's. YMMV, of course.

 

[Omisson]

Then just ask the Coroner like I did.

---------- Post added November 29th, 2014 at 03:55 AM ----------



I think she had a scary amount of CO2 possibly producing near instant incapacitation on descent accompanied with overwhelming psychosis.

See: http://ocw.tufts.edu/data/33/508776.pdf .

Because O2 was added to a fixed volume, but CO2 was not being removed, I think she may have had to vent out some (not a lot) excess counterlung volume during the pre-breathe.

Good news Giann.... I took your advice.

I sent a formal enquiry to the Viscounts office which they acknowledged receipt of - sent it referencing being a former public safety official, a scuba instructor and current attorney to see what the parameters are. I asked for any investigative data and lab testing. Also there inclusions and whether Hollis was charged with any violations of EU law.

As soon as I get the response I'll post it here so EVERYONE can see it first hand.

Looking forward to it.