Inquest into the death of Philip Andrew Gray - Death 9 February 2013

[GLOC]

Abdullah,

Hindsight is a great thing because you can look back at the things that you wished you had done differently but at the time, they might not have been as obvious as they should have been.

Did you read the blog article which was also linked? Did you watch the video? Human fallibility is a real problem, especially when it comes to monitoring life support equipment.

There is also a known phenomenon called 'Normalisation of Deviation' whereby the operator or organisation drifts from the norm in small increments and each time that deviation occurs and nothing goes wrong, then the poor decision is validated. Then deviation starts from that new norm. When the accident happens, you only see the deviation from the original baseline to the accident, rather than the small incremental steps. Look up how the Challenger disaster occurred.

Also something to bear in mind, at the time getting hold of reliable cells for AP units wasn't easy and sometimes it is 'better the devil you know' influenced by your natural biases, than get hold of cells which didn't have a strong record in terms of reliability. When you are earning money, there is an increased pressure to undertake the task which would be contrary to 'normal' operations.

I recently posted this blog elsewhere and got the following comment (paraphrased and cleaned up from the OP).

The most telling thing, well to me anyway is the coroner would not confirm due to a lack of actual evidence that the diver opted not to calibrate the unit before the dive because it was suggested that he new he had a high chance of it not calibrating with the net result of cancelling what for him was an instructing/earning dive. I have actually considered doing just this a couple years ago when having issues with AP14 cells ! I had a set ( under 1 year old ) working at home but was not confident they would calibrate again the following day just before the dive.

I remember making a conscious decision not to calibrate unit as I was sure the cells would crap out. It was a dive I had wanted to do for years with cost time etc etc all factored in. I actually walked away from the unit to consider the plan and only decided to calibrate when I asked around at how many spare cells on the boat, I had run out! In the end I did Calibrate on the boat and they did work! But the point is I considered not doing it.

The thing to take away from this, we ALL make mistakes and that detailed reports are essential if we are to try and improve performance and safety. We also need to be aware that in a number of situations the only person who really knows why they made those decisions is no longer with us and therefore to negatively judge without knowing the whole background or context does not help the community come forward when they have made honest mistakes (or violations) so that others can learn from them.

Regards

Gareth

Cognitas Incident Research and Management
DISMS | Home

 

[KevinNM]

If he had, he'd probably still be alive. I understand his reluctance to do so--it's usually a waste of O2 because you've usually checked your cells recently anyway, and then you waste time and dill flushing it back down so you can drop at any kind of reasonable speed--but if you're diving 40 month-old cells (nobody should), you should be extra careful about that step.

I've read that this isn't terribly trustworthy, cells tend to work better here then then will as the dive continues. If they don't work here then you know you have a big problem, but if they do they may still not be good. Apparently doing an O2 flush at the end of the dive is a much better sanity check on the cells, though it's only useful for you next dive. But yeah, when you are already cutting every corner, that was not a good time to skip that test.

 

[Dr. Lecter]

I've read that this isn't terribly trustworthy, cells tend to work better here then then will as the dive continues. If they don't work here then you know you have a big problem, but if they do they may still not be good. Apparently doing an O2 flush at the end of the dive is a much better sanity check on the cells, though it's only useful for you next dive. But yeah, when you are already cutting every corner, that was not a good time to skip that test.

Both checks are a good idea - checking the cells' linearity regularly with a pressure pot is much better, though.

 

[dreamdive]

I have yet to meet a CCR diver that sticks to all defined specification across the CCR spectrum.

Come visit us in Ft. Lauderdale and you will meet not just one but a whole bunch - but please also define "across the CCR spectrum"

 

[boulderjohn]

I recently posted this blog elsewhere and got the following comment (paraphrased and cleaned up from the OP).

The most telling thing, well to me anyway is the coroner would not confirm due to a lack of actual evidence that the diver opted not to calibrate the unit before the dive because it was suggested that he new he had a high chance of it not calibrating with the net result of cancelling what for him was an instructing/earning dive. I have actually considered doing just this a couple years ago when having issues with AP14 cells ! I had a set ( under 1 year old ) working at home but was not confident they would calibrate again the following day just before the dive.

I remember making a conscious decision not to calibrate unit as I was sure the cells would crap out. It was a dive I had wanted to do for years with cost time etc etc all factored in. I actually walked away from the unit to consider the plan and only decided to calibrate when I asked around at how many spare cells on the boat, I had run out! In the end I did Calibrate on the boat and they did work! But the point is I considered not doing it.

I am not a rebreather diver, but I have had similar thoughts on certain occasions in the past. Due to some unusual circumstances, I am fairly frequently in a position where I am instructing classes far from local conditions. Both the students and I have traveled far for the occasion, and a lot of money has been spent. I have sometimes found myself to be in less than the best of health when we are ready to do a dive. Calling the dives because of my health would create a significant rescheduling problem and the loss of lots of money for everyone. I will admit that I have done some dives with those students that I would have called had I been juat diving for fun. In each case, I asked myself if I were creating a real danger for either myself or the students by doing the dive, and I decided that even in the worst case scenario, things would be OK. I just had to put up with what amounted to discomfort.

I can see how the pressure to perform for students who are really counting on you can potentially drive you to take risks that you would not otherwise take.

 

[Abdullah]

Abdullah,

Hindsight is a great thing because you can look back at the things that you wished you had done differently but at the time, they might not have been as obvious as they should have been.

Did you read the blog article which was also linked? Did you watch the video? Human fallibility is a real problem, especially when it comes to monitoring life support equipment.

There is also a known phenomenon called 'Normalisation of Deviation' whereby the operator or organisation drifts from the norm in small increments and each time that deviation occurs and nothing goes wrong, then the poor decision is validated. Then deviation starts from that new norm. When the accident happens, you only see the deviation from the original baseline to the accident, rather than the small incremental steps. Look up how the Challenger disaster occurred.

Also something to bear in mind, at the time getting hold of reliable cells for AP units wasn't easy and sometimes it is 'better the devil you know' influenced by your natural biases, than get hold of cells which didn't have a strong record in terms of reliability. When you are earning money, there is an increased pressure to undertake the task which would be contrary to 'normal' operations.

I recently posted this blog elsewhere and got the following comment (paraphrased and cleaned up from the OP).



The thing to take away from this, we ALL make mistakes and that detailed reports are essential if we are to try and improve performance and safety. We also need to be aware that in a number of situations the only person who really knows why they made those decisions is no longer with us and therefore to negatively judge without knowing the whole background or context does not help the community come forward when they have made honest mistakes (or violations) so that others can learn from them.

Regards

Gareth

Cognitas Incident Research and Management
DISMS | Home

According to the official report (I really don't care about the blogs or vidoes as they aren't evidence in the coroners report), he intentionally dove out of spec devices, and he failed to comply with process controls intended to identify equipment problems that could cause a fatality. If he were a recreational CC diver, I might buy normalization of deviance, but he was not, he was a rebreather instructor working hand in hand with written standards and protocols, supposedly setting a positive example of how to do things right.

A basic hierarchy of hazard mitigation (Avoidance, Engineering Controls, Administrative Controls, PPE) works to control human fallibility. But the participants need to be disciplined in compliance with the controls laid out in the hierarchy. In this case an individual who teaches the hierarchy of controls to rebreather students himself failed to comply with the controls he is supposed to be demonstrating.

 

[GLOC]

I agree, the point I was making is that there are reasons why people make mistakes and those reasons are not immediately apparent to those external to the event.

I teach Crew Resource Management in the Oil industry, a high reliability (or should be) industry and yet these experts still make mistakes even when controls are in place. Normalisation of Deviance occurs in all walks of life, look at NASA and Challenger, look at BP and Deepwater Horizon, look at diving instructors with no external QA/QC in place...

From your terms you appear to understand the principles of safety (or risk management) but that doesn't mean others share the same views. The Dunning Kruger effect doesn't just impact those who don't know any better (they don't know what they don't know), but also those who have considerable knowledge judging others as to why they made mistakes which are contrary to their own knowledge and practice.

Did the guy break the 'rules' by using out of date cells and not following protocols to manage that, yes. Did that breaking of the 'rules' work for a while, yes. Did it finally catch him out? Yes! However, to truly improve safety, we need to understand why they decided to follow that incorrect behaviour. Just saying 'following best practice' is not enough if those 'rules' aren't working (reliable cells not necessarily available due to Teledyne pulling out of the market).

Regards

 

[Peter69_56]

I am not a rebreather diver, but I have had similar thoughts on certain occasions in the past. Due to some unusual circumstances, I am fairly frequently in a position where I am instructing classes far from local conditions. Both the students and I have traveled far for the occasion, and a lot of money has been spent. I have sometimes found myself to be in less than the best of health when we are ready to do a dive. Calling the dives because of my health would create a significant rescheduling problem and the loss of lots of money for everyone. I will admit that I have done some dives with those students that I would have called had I been juat diving for fun. In each case, I asked myself if I were creating a real danger for either myself or the students by doing the dive, and I decided that even in the worst case scenario, things would be OK. I just had to put up with what amounted to discomfort.

I can see how the pressure to perform for students who are really counting on you can potentially drive you to take risks that you would not otherwise take.

My instructor died because of this philosophy. We were due to do our Decompression Procedures course after her returned from Indonesia. He was clearly not well and I told him to get better then we could complete the course. He refused and we did the course. He deteriorated during the period of the course.

We booked in for the Extended Range Course but he was so unwell he cancelled and then went into hospital. Within a few days he was dead. He had been bitten by a mosquito or some such bug in Indonesia. This gave him flu symptoms which he ignored. He became so spaced out at the end of our course, he had a minor traffic accident in front of us. He was of the personality that he would continue on to meet his obligations regardless of his own struggles.

Had he gone to hospital earlier, he could have been given a large dose of antibiotics which would have killed the larvae in his blood stream. Instead he ignored it and they overloaded all his organs and he dies of a heart attack as his heart couldn't cope.

It was so sad and an unnecessary death. before he died he apologised to his wife, as he had realised he could have prevented his demise and knew he was dying.

Dive safe and make sure you are here for tomorrows dive, not just the one for today.

 

[wgw04024]

You guys can keep your CCRs as for myself I'll stick to my al80s and steel 100s!

Diddo! I don't take short cuts in this sport, but I do know how much I like doing extra work and prepping for things. The CCR route would probably be one that would go beyond what I was really willing to keep up with on a regular and routine basis. For that reason, knowing my personality, I would never touch one. I was my gear after use, check it all pre dive numerous times, and have it serviced regularly. That's about the limit to what I want to do.

 

[chris.evans]

In situations where oxygen tox has a higher risk, has anyone used something like the Manta Bite? Is it uncomfortable? I have been thinking about getting one and trying it. It also says that you can relax your jaw and it lessens jaw fatigue.

Any CCR people seen these mouthpieces on regs? It would be interesting to read about data as to whether this has helped or not.