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

[Pedro Burrito]

This was published by Cognitas Incident Research & Management - https://cognitasresearch.wordpress....le-cell-failure-human-factors-inquest-report/

The inquest report - https://cognitasresearch.files.word...the-inquest-into-the-death-of-philip-gray.pdf

 

[descent]

Now that's a thorough report.

No updated manual yet.

---------- Post added May 5th, 2015 at 08:52 PM ----------

I take that back.

Page 11 of the 2014 version of the Inspo manual describes the warnings that cannot be suppressed.

 

[Yarbrough]

Wow, just wow.... this report shows how complacency and over confidence can effect any of us. Small mistakes made early in the planning stage of the dive compounded with the unfriendly environment led to a tragic outcome, even with experience and what seems to be the correct reaction on the part of the victim. With no real CCR experience here, can anyone tell me aside from not aborting early in the dive and correcting the problems then, was anything else done wrong?

 

[KevinNM]

Other then not replacing his oxygen sensors two years earlier and not completing the pre-dive checklist?

 

[FiddlerOnTheRoof]

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

 

[Yarbrough]

Other then not replacing his oxygen sensors two years earlier and not completing the pre-dive checklist?

Right, both of which were crazy, but were probably caused by comfort and complacency, who knows how many times these same short cuts were taken with no ill effects. Checklists are so important in this sport, and not allowing yourself to get comfortable... ever.

So, I just realized that we may not know how many times, but we know that for two years at least one of the shortcuts was taken.

 

[FiddlerOnTheRoof]

If you are going to do it, do it right! This sport is not one that you can slack off, get lazy about following procedures, routinely checking equipment, etc... Taking shortcuts and neglecting your equipment WILL eventually lead to a bad situation to say the least.

I for one never leave for tomorrow what needs to be done today. Even with "little" things like washing your gear down with fresh water after diving. Believe me I see many divers who get home after a dive somewhere and leave their saltwater drenched equipment in the garage for a few days before washing it! I don't care if I get home tired, exhausted at 3AM... First thing I do is wash it all down and hang to dry.

When it comes to oxygen sensors I know they can be expensive for some, but if you can't keep up with maintenance why do it? It's not worth the risk. Go back to using OC and it will be safer.

 

[iamrushman]

either way....sad news....

 

[bilsant]

was Wood unharmed? Ballzy move.

Amazingly detailed report.

 

[dreamdive]

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

That's like saying "I don't need to check my gas!" as he was not taking care of his gear i.e. sensors and check list!

Quit blaming the rebreather, although I am surprised that Mr. Gian has not chimed in, yet. Mind you, on the very latest OC death, CCR would have been a live safer. And as distasteful as this is to point out, I am.

You can die OC by being complacent, you can die driving a car by being complacent......complacency kills, not the type of diving.