Fatality at Jersey Island

[rongoodman]

Every diver makes mistakes.

I dive a Prism 2 too, and to call installing the counterlungs backwards, and then not noticing it at multiple points in several required checks, goes far beyond a "mistake". Among other things, it meant that she couldn't have checked the OPV and manual diluent or O2 addition during the pre-breath check.

 

[Dr. Lecter]

Tammy, could you help me out and point to the evidence or analysis that shows this for a fact? My understanding is that most rebreather fatalities have insufficient detail about the root cause to form a conclusion, which would point to a rather critical flaw in your proof.
If you haven't already perhaps it's worth emailing the Jersey coroner and reading in full what he says, as this incident appears to be one of the known exceptions to your statement....

Kindly provide an explanation for how diving a unit that had been built in such a way that it would have failed a positive check, a negative check, and/or a stereo check...is not operator error. Bonus points if you include manage to work in a reference to a vaporware CCR model, or link me to some super-helpful PDFs. I'll go get some popcorn.

 

[uwxplorer]

There may be more in the BSAC Incident Report (had not time to find it, but please Google it and post link for those who have the time).

http://www.bsac.com/core/core_picker/download.asp?id=26137&filetitle=Diving+Incident+Report+2014

Case 14/036

Page 6:

"March 2014 14/036
The information received indicates that the casualty entered with water at a shallow site, accompanied by two other divers. All three were using rebreathers. The casualty had recently completed her rebreather training. Diving to a maximum depth of 14m, the group quickly became separated in low visibility, and all but the casualty surfaced. They realised the casualty was missing, and conducted a search. The casualty was located and was brought to the surface unconscious. CPR was commenced but the emergency services declared her deceased at the scene."

Edit: just realized that gianaameri had modified his post to include the above quote. The whole BSAC document is worth a peek though, as it includes short calls and incidents.

 

[Brad_Horn]

Kindly provide an explanation for how diving a unit that had been built in such a way that it would have failed a positive check, a negative check, and/or a stereo check...is not operator error.

Because apparently it could be 'correctly' built and dived that way! It would appear as far as any operator is concerned that the "The Prism 2 rebreather has completed 3rd party testing to the EU standard 14143 and met all acceptance criteria." Prism 2 TEK
and thus the following is not possible.....!

The main findings of the inspection of the equipment were: The rebreather did not comply with clause 5.1 of BS EN 14143: 2013 or BS EN 14143: 2003, which states:
“It shall not be possible to assemble or combine the components or parts in such a way that it can affect the safe operation and safe use of the apparatus, e.g. by incorrect connection of the hoses to the breathing circuit.”
1) 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.
2) The inhale counter lung was positioned to the diver’s right hand side, instead of the left hand side.
3) The exhale counter lung was positioned to the diver’s left hand side, instead of the right hand side.
4) 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.

Not doing pre-dive checks to verify the safe operation of any rebreather would appear to be a totally separate (and additional) training/checklist/reinforcement issue, but I can't see how any operator of any rebreather can be considered at fault or in error for something that is theoretically not possible (or if possible, then not a problem) in the first place!!!

 

[Wookie]

Well, I am glad to find myself incorrect, and happy to learn of a more prudent approach than I had ever heard of before.

I hope other operations are able to follow your example.

Sadly, they were Willis, and that's a whole other thread.

---------- Post added November 30th, 2014 at 08:04 AM ----------

They made a mistake.

We all make mistakes and when they are inconsequential we don't even notice them and we think we are "cool" and go on with our life.

Do that with a rebreather, and you still think you are cool, but you pass out and drown as exemplified in this case.

That is why we need equipment which is designed to protect (as far as reasonably practical) the ordinary person from his/her ordinary mistakes, and we also need systems, procedures, and controls to further mitigate the risk.

Military rebreathers which cost 10 times more and are used in an environment with strict adherence to system, procedures, and controls result in nil fatality rates.

There is a study from the French which shows this. When I'll find it, I'll post it.

We have too many unnecessary fatalities because equipment is poor and system, procedures, and controls (training and what follows) is poor.

Is not that the case in this fatality?

Not in my opinion. This is clearly a case of operator error. There were multiple checks and balances built into the system that would have caught the error had the operator adhered to the standards of the training she was said to have received when being checked out on the unit. She had to have worked hard to make the components fit incorrectly. She had to have completely failed to do a minimum pre-dive check of the unit before getting in the water and becoming unresponsive almost immediately. As a dive instructor on Open Circuit, I would have expected her to to at least step back and take an overall look at her scuba unit before putting it on, as I do every time I dive just to see if it looks right.

This is a tragedy, but not only because a young woman died, it is a tragedy because someone would attempt to use a truly senseless death to promote the idea that folks breathing underwater (a completely foreign and inhospitable environment for land dwelling mammals) could be made inherently safe. The coroner has it wrong, as any following lawsuit will show. This is a case of death by misadventure, and the majority of the misadventure falls on the young woman's shoulders, with perhaps some blame going to her instructor. You can't blame the rebreather manufacturer for the ability to assemble the unit incorrectly if the most basic pre-dive check would have discovered the mistake, if performed.

 

[rongoodman]

They made a mistake.

In either case, they didn't make "a mistake". They made multiple errors, one on top of the other, probably a dozen in case of the rebreather diver, depending on how you count. Catching just one would have allowed her to survive. That mindset is to me more interesting than whether the Prism 2 should have different threads on the countering hoses.

 

[gianaameri]

The coroner has it wrong, as any following lawsuit will show. This is a case of death by misadventure, and the majority of the misadventure falls on the young woman's shoulders, with perhaps some blame going to her instructor. You can't blame the rebreather manufacturer for the ability to assemble the unit incorrectly if the most basic pre-dive check would have discovered the mistake, if performed.

My understanding is that the Coroner would agree with you that this is a case of "death by misadventure."

Where there is a clear disagreement between the Coroner and HSL with you is as to the quality of the equipment. The equipment has been shown to be non-compliant with manufacturers set safety standards applicable in the whole of the EU.

Now, if this afternoon you take on a diver on your boat with one of the at least 8 defective or non-compliant (to the aforementioned standard in this thread) HP2s possibly in circulation, and he/she dies, sure you, the manufacturer, the retailer, the instructor... might get away with it for all the good reasons you give.

This is rather common with rebreathers, custom and practice.

---------- Post added November 30th, 2014 at 09:05 AM ----------

In either case, they didn't make "a mistake". They made multiple errors, one on top of the other, probably a dozen in case of the rebreather diver, depending on how you count. Catching just one would have allowed her to survive. That mindset is to me more interesting than whether the Prism 2 should have different threads on the countering hoses.

That is normal. People do not make just one mistake, they make multiple ones.

The outcome though should be that they can laugh about their mistakes, rather than mourn because of their mistakes.

It is not always possible, but as far as reasonably practicable, good equipment and sound system, procedures, and controls have shown to be invaluable in decreasing fatalities and accidents.

In this video ( http://www.rebreathermallorca.com/video/scubaboard/f.up.mp4 ) I said "Perfect" and "O.K." - but then I f-up (got out the wrong side of the car) and while I laugh about it and get told off I f-up even more.

Yet, we are all still laughing about it no harm done because the equipment was good and the activity was designed to be carried out in safety - taking into account the possible human errors and possible equipment failures (and there were many potential deadly ones) which can happen.

No one has to die because one makes a silly mistake - at least such occurrence (death/injury...) should be mitigated as far as reasonably possible.

 

[gianaameri]

Gianaameri do you have any affiliation with OSEL?

No, I am just a diver.

---------- Post added November 30th, 2014 at 02:12 PM ----------

Yes, I'm now bored, and I'd rather argue with Omission anyway. He makes coherent sense when he argues.

Let's wait for Omisson to come up with the Coroner and HSL Lab report since there seems no more new facts to discuss.

---------- Post added November 30th, 2014 at 03:39 PM ----------

They made a mistake.

We all make mistakes and when they are inconsequential we don't even notice them and we think we are "cool" and go on with our life.

Do that with a rebreather, and you still think you are cool, but you pass out and drown as exemplified in this case.

That is why we need equipment which is designed to protect (as far as reasonably practical) the ordinary person from his/her ordinary mistakes, and we also need systems, procedures, and controls to further mitigate the risk.

Military rebreathers which cost 10 times more and are used in an environment with strict adherence to system, procedures, and controls result in nil fatality rates.

There is a study from the French which shows this. When I'll find it, I'll post it.

We have too many unnecessary fatalities because equipment is poor and system, procedures, and controls (training and what follows) is poor.

Is not that the case in this fatality?

Here is the study I was referring to stating:

1. Conclusion: Gas toxicities are frequently encountered by French military divers using rebreathers, but the very low incidence of fatalities over 30 years can be explained by the strict application of safety diving procedures.
2. ...the diving procedures imposed by military regulations (mouthpiece strap, buddy team with link, and diving instructor with open circuit to lend assistance if necessary during training) have greatly limited life-threatening complications, ie, drowning, which are too often recorded in recreational technical diving.
3. Three fatalities were ultimately reported; these concerned 2 CS students using the OXYGERS 57 who were unable to return to the surface, caught under a barge, during an attack swim and another accident in which an MCD was trapped in a deep wreck with no visibility during a dive using a MIXGERS apparatus. CNS oxygen toxicity for the CS and insufficient gas associated with panic for the last decedent were identified as the disabling agents in post-mortem investigations.

http://publications.amsus.org/doi/pdf/10.7205/MILMED-D-10-00420

 

[boulderjohn]

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A ScubaBoard Staff Message...

Please remember that this thread is about a specific incident about the unfortunate death of a specific person. Please take the debate about generic rebreather design philosophy to the rebreather forum. This is not the place for that debate.

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[gianaameri]

The deceased (if I am not confusing one person for another) was a qualified professional:

Jill Smith
"Jill Smith joined the team in 2009 is a diving instructor, Emergency Medic Technician, works in the finance industry and a very proactive member of the team."

http://www.jerseyhyperbaric.org.uk/7.html

---------- Post added December 2nd, 2014 at 06:19 AM ----------

I have taken the time yesterday to go through the HP2 manual (current version) which has detailed pictures of the equipment (breathing hoses, one-way valves...) and list procedures.

All this may not be the same as for the equipment used by the deceased because we know that Hollis has since the incident made modification to the equipment breathing loop (no Safety Notice, Recall, public announcement).

We know this from another piece of information posted on the web stating:

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

It would seem that based on the latest manual and version of the breathing loop as represented in this latest manual, on the assumption that it could still be assembled incorrectly (which should not be the case since it appears Hollis re-issued the breathing loop addressing the issue), that checking the breathing loop for flow direction ("stereo check") before assembling/connecting it to the counterlungs should show the problem (i.e. fail the test).

Checking the breathing loop for flow direction after assembling the breathing loop to the counterlungs may miss the problem.

Again, we do not really know if this applies to the deceased equipment because its design has been since modified by the manufacturer.