Fatality at WKP

[Thalassamania]

I don't think that's what Rick was saying, remember ... he was a Naval aviator, that changes your perspective concerning changes in the SOP.

 

[Rick Murchison]

Keeping the O2 sensor is not a protocol for a possible screw up. It's a sanity check. Just like my dive computer is a sanity check. I don't fly my computer on decompression dives. I plan my dives and dive my plans. But I also use a dive computer as verification that all is well. Same goes for SPGs. When I look at SPGs I'm only verifying the gas volume left, not checking to see what it is. Applying that same thought process, I should get rid of my SPGs because they breed complacency.

Not at all. But insisting that you follow the gas switch protocol when you're making a bottle switch between bottles of the same gas when bottles of the same gas are all that you have aboard and you know that it is *impossible* to be switching gasses is a recipe for holding that procedure in contempt, to become complacent about it, and to transfer that complacency to the rest of your diving. In other words, insisting on a procedure where you *know* it serves no purpose isn't being "extra safe" - it's just wasting time and energy and if you know it's just wasting time and energy you're setting yourself up for the bad habit of "let's just skip that." There are certainly grey areas... as Lynne alluded to in her "environment of similar bottles of different gasses" and if it's grey then it's an area for a procedure that eliminates the grey. But once eliminated, it's eliminated.

Rick

 

[Dive-aholic]

You have me confused. Are we discussing the ppO2 display on SCRs or are we discussing bottle switch when all the cylinders we have are the same gas?

 

[Blackwood]

You have me confused. Are we discussing the ppO2 display on SCRs or are we discussing bottle switch when all the cylinders we have are the same gas?

Both.

 

[SuPrBuGmAn]

I think there's something to be said about a standard procedure, regardless of whether or not that procedure would apply to that specific dive. I think I'm going to handle all gas switches now(aside from sidemount bottles) with a bit more care, regardless of whether or not I think its possible for a mixup to occur. I think if I consider exeptions, complacency may find its way in eventually.

Thats what I took away from this accident.

 

[Rick Murchison]

You have me confused. Are we discussing the ppO2 display on SCRs or are we discussing bottle switch when all the cylinders we have are the same gas?

I'm not addressing any particular specific beyond using a specific to illustrate a philosophy of safety procedure development and implementation; that is, how to evolve the best protocols to assure an outcome. On every dive. (A protocol is a set of procedures followed to achieve a specific objective/outcome - like assuring we're breathing a safe gas... where bottle and gas switches and ppO₂ monitoring all may apply, depending on the circumstances)
Given that the protocol we develop assures the outcome we desire, (that is, it's foolproof!) I think we can all agree that:
(1) A simple procedure is preferable to a complicated one.
(2) The further upstream you can push a protocol the better. (The earlier you can eliminate a risk the better)
(3) A protocol should be distilled to the fewest procedural steps possible.
That's not to say that good habits should be abandoned. For example, checking the mix on every bottle you breathe during the switch to that bottle is a 'good habit'... It just doesn't need to be part of the switch protocol when all the bottles you have are the same mix. That's vastly different from cylinder pressure checking, simply because the mix in a bottle doesn't change in the water (CCR's an entirely different animal here), but pressure changes for both normal and extra-normal reasons.
but I'm drifting...
In this mishap, what I'm reading is that in the WKPP, because the environment includes dropped pick-up bottles of various mixes, the protocol calls for a formal double check of MOD at every gas switch, whether it's supposed to be a "single gas on board" situation or not. Certainly adherence to that protocol would have prevented this tragedy. As for the bottle drop protocol, and whether any changes are warranted there, I'm still not clear... I know that my own bottle drop protocol was not what it needs to be and will be from now on.
Rick

 

[LiteHedded]

it's cool that people are thinking about MOD stickers but perhaps we can move the sales pitches elsewhere

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A ScubaBoard Staff Message...

Done.
A&I Mod

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[Thalassamania]

I didn't see that as a sales pitch but as a suggestion to how to easily solve a problem.

 

[TSandM]

I think if a thread about a fatality due to not noticing you are breathing a gas with the wrong MOD, ends in people ordering stickers that make it easier to see your MOD, that's actually a very good outcome for that thread. (Changed procedures would be good, too.)

 

[cerich]

it's cool that people are thinking about MOD stickers but perhaps we can move the sales pitches elsewhere

wasn't meant as a sales pitch, it was an observation i have made as a tech instructor for 17 years regarding gas and what I do because of that observation. the fact that I now have my opwn brand and put the logo on the decals is not relevant to the discussion

sorry if it came across that way.