@oya,
seriously, until it becomes an ingrained habit, it's quite easy to allow your DSV to leave your mouth without turning it off. That's the entire point of training: to create great habits. That's also the point of gaining experience before you take another step like trimix or hypoxic trimix. We don't know how many hours he had on a rEvo. Rumor has it that this was a borrowed unit and not even his own, so he probably didn't have that many hours. It's why many of us believe that he went too far, too fast.
Now, if you're telling me that anyone who makes any mistakes ever on their rebreather should not be diving on one, then I'm going to cry "hypocrite" and ask you to stop diving yours. Unless, of course, you're claiming to have never ever made a mistake on your rebreather and are also suggesting that fatigue can not be a factor in making simple mistakes. That's the depth of foolishness to not make allowances as your limits, cognitive and otherwise, are compromised by any number of factors including cold, depth, distractions and yes, even fatigue. Just because a dive can be done on paper, doesn't mean it should be attempted. Ask Doc Deep, oh wait: he died too. A diver's got to know and honor their limitations. I'm a very cautious diver and I credit that cautiousness to having never been bent or injured on a dive going on now 48 years since first breathing underwater. It's not from having never made a mistake either. Humans stop making mistakes right when they die. For me it's been a matter of good training with a lot of experience thrown in to make that training useful. A good diver makes very few mistakes. A great diver knows how to identify and rectify each and every one before it becomes an incident.