Inspiration inquest Nic Gotto

[Lisa3]

Cork City Coroner, Dr Myra Cullinane, last week recorded an open verdict at the conclusion of the inquest into the death of Nic Gotto, Union Hall, County Cork, who died in July 1998 whilst using the Buddy Inspiration Rebreather. The coroners court heard that Nic and some friends were due to dive to the Kowloon Bridge wreck, just a few miles south of Glandore harbour in County Cork, when the tradgy happened. Nic and his buddy entered the water as normal and proceeded to the bow of the wreck at 9m. All was well at thisstage, Nic was seen to have looked at his handsets and then signalled Ok to his buddy. He indicated a direction for the dive to continue and lead the way with his buddy following behind. The visibility was very poor that day and Nic's buddy lost sight of him for a few minutes only able to follow by using Nic's torch beam for direction. Within a few minutes the buddy came upon Nic lying on his back with his mouthpiece out and having what appeared to be a convulsion. His buddy immediately realised that Nic was in trouble and attempt to rescue him. In the rescue attempt Nic's buddy lost his own mouthpiece and weight belt and started to ascend. He made it to the 9m mark and managed to alert another pair of divers that Nic was in trouble. One of the other divers quickly found Nic and assisted him to the surface where he was taken onboard the boat and CPR was administered for 45 minutes after which time the Air Sea Rescue helicopter winched him on board and flew him to hospital where he was pronounced dead on arrival. The court heard that Nic's rebreather was dropped during his rescue and was not recovered for some days. On inspection the Buddy Inspiration Rebreather was found to be in good working order and no alterations had been made to the kit. There was a reading on both guages. Both handsets, when opened, were found to be cracked and full of seawater. Nic had been seen to be having difficulties calibrating his equipment prior to getting on the boat. On the boat prior to the dive, Nic dismantled and cleaned and re assembled his equipment, breathed from the unit and prepared to enter the water. It was noted that no alarm was heard at anytime before, during and after Nic was brought to the surface. Mr Hogan, the pathologist at Cork University Hospital, said that Nic had suffered drowning after a metabolic event had occurred leading to him losing consciousness, he said that it might have Hyperoxia or Hycapnia. It was recorded that Nic had completed approx. 10 dives on the equipment. As no one had witnessed Nic changing the scrubber canister the manufactures, AP Valves, did make a submission that it might have been Hypercapnia that lead to Nic's demise. Nic's widow Rachel was able to tell the court that of two 20kg drums of sofnalime at her house over half of one is gone. The coroner seemed satisfied that this suggested that Nic had replaced the scruba contents. At the end of three days the Jury were directed to return one of three possible verdicts, accidental death, death by misadventure and open verdict. They returned the latter.
During questioning, a witness who initially reported that Nic told her the scrubber could last 10 hours, confirmed this 10 hours could well have related to the O2 cylinder duration and not the scrubber.

My condolencies to Rachel, Nic's wife, and his three daughters, two who are teenagers and one little girl who has never seen her father.

As for reports of natural causes there is no evidense to suport this. In one case the buddy was above the user on the shot line, looked back and he was gone. This has been sugested as natural causes - there is no evidense either for or againsed as the diver was never recovered.
In the case of Gerant, is symptoms were confusion on the shot line and chest pain. He was also fighting +ve bouyancy. Possibly due to O2 addition? This chest pain delayed entry in to chamber for 5 hours after missed decompression. Chest pain is also a symptom of hyperoxia due to lung damage. He did die of a heart attack 20 minutes after entering the post, but take a look at medical literature and you will see hyperoxia can lead to heart attack.

 

[madmole]

Nics cracked handsets is a new one on me, this wasn't reported by Martin Parker or Nics Buddies on the dive, or by those who examined the unit afterwards. The report into the scrubber use is also wrong, the figures are 8 hours. neither APD nor Martin were allowed to make ANY representations to the court. I take it this is a newspapaer cutting and we know how accurate they are

This is the note Martin posted the other day

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Last week we attended the 2nd day of the Nic Gotto inquest.

Nic died at the end of July 1998 while diving the wreck of the Kowloon Bridge in Southern Ireland.

The jury weren't given sufficient information to decide between high O2 or high CO2 so they recorded an open verdict. Cause of death was "by a metabolic event", changed from the pathologist's original statement of Death by Drowning. Neither an expert diving pathologist nor I were allowed to give evidence. Quite why we weren't given the opportunity to prove it was CO2 I don't know. I guess the Coroner didn't want to see the controversial stuff argued or settled in her Court, she just needed to know who died, when, where and how and that's what she did.

I have no doubt that it was high CO2. I have to keep most of the proof of that to myself for now, but it is a matter of public record that Nic told a witness prior to the dive that the Calcium Hydroxide was good for 10 hours but he'd only used it for 8 ! The witness had a PhD in Chemistry.

The handset was checked at 9m and Nic continued. At no time were buzzers heard or bubbles seen. Nic moved ahead of his buddy and was out of his sight in the poor vis. for only 15 secs or so but was found by his buddy in approx. 24m of water, already on his back, mouthpiece out, arms shaking at his chest, eyes wide. He was unable to bring him to the surface, due to Nic being heavy. The time frame is 3 to 4 mins from leaving the surface. Nic was recovered later by another diver. The kit was jettisoned during the dive and was recovered 9 days later.

With this open verdict I'm afraid we are in for the usual critical press, one newspaper in Ireland stated that "the Buddy Inspiration is believed to have killed 15 other divers"

Bottom line: Take care of the CO2 issue before you get in the water:

- change your scrubber regularly, ensure the O ring is in place and well lubricated, ensure the spacer and scrubber side wall is free of dents and scratches, ensure the mouthpiece valves are working properly.

The CO2 duration is not just a 3 hour limit regardless of the type of dive. Once the scrubber time reaches 2hrs 20 mins you should be shallower than 20m, when the scrubber reaches 50 mins you should be shallower than 50m.

Your CO2 production is independent of depth but with DERA testing it is proven that depth has a great effect on reducing the scrubber life. Please bear in mind that the Inspiration's scrubber is one of the most efficient, if not the most efficient DERA have seen in cold water (that is it makes most use of the Calcium Hydroxide). This reduction in performance at depth is not due to poor design but is common to all rebreathers, the increase in gas density is going to apply to them as well as us- I guess the other manufacturers don't warn about the limitations because they haven't done the quantified CO2 tests that we have done?



Martin Parker

Managing Director

Ambient Pressure Diving

Manufacturers of the Inspiration Closed Circuit Rebreather Water-ma-Trout Industrial Estate, Helston, Cornwall, TR13 OLW, UK.

Tel: 01326 563834, Fax: 01326 573605.

Website: www.ambientpressurediving.com

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Controversial as many would say the arm shaking was a symptom of an O-tox, but most don't realise that convulsions are also a documented feature of hypercapnia. As the alarms didn't sound (and they are loud!!) a hypercapnia event seems unlikely, coupled with overuse of the scrubber then hypercapnia seems the most likely cause. The scrubber is rated at 3 hours max. Also, Same ocean buddy diving claims another victim. Buddy diving means you are within arms reach or very good visual contact, not 1 min behind!!!!!

The hansets will flood if the loop floods badly, they are air spaced linked to the loop by design

As for Garret, that was a cardiac arrest. The equipment was examined immediatley afterwards and was fully functional. Claudia Milz his fiance and buddy for that dive has talked to me personally about this incident and she has access to all facts. She is convinced it was a cardiac arrest and this fits in with everything she saw on the ascent.

I dont see what point you are making. Both of these cases just serve to show that the unit was not at fault.

Full public details of ALL the fatalities on the unit are available on my site

 

[caveseeker7]

madmole once bubbled...
Full public details of ALL the fatalities on the unit are available on my site

And thanks so much for that, Madmole. It's important to analyze and learn from those accidents. Too bad that there is no central place for other unit's accidents.

From what I hear on the web, there has been a fatality with the Halcyon SCR.
Do you, or anybody, know more about that?

And Lisa3, what is your source?

 

[Lisa3]

My source is that I was at the inquest, 18 Feb and 4th March.

The cracked handsets are shocking, but only seen when the black casing is pulled back.

The witness originally said Nic had told her the scrubber unit had a duration of 10 hours and he had used it for only eight. She then admitted that Nic may not have been refering to the scrubber, but to the oxygen cylinder or some other part of the unit. She was not sure.
Nic had purchased two 20kg tubs at sofnolime. Aprox 12kg was missing from one of them, about 4 fills. Nic had done about 10 dives, the coroner was happy that Nic had changed the scrubber.

Do bear in mind that Martin Parker is the manufacturer. If he admits liability or does not defend his product he will not sell many more and may leave himsef open to legal action.

 

[madmole]

Yep, I'm more than aware Martin has an axe to grind

It's interesting to hear the handsets were cracked. This does happen and was more common in the past when the hoses were longer and it was possible to stand the unit on the handsets (the hoses were shortened when it was worked out this was happening)

If the handsets were cracked they could malfunction. If this was to happen Nic would have probably been aware of the problem if he was monitoring them. Problem is Nic had made a VERY bad descision to dive with NO bailout fitted, so he had no option but to rely on these handsets. Commenest problem with cracked handsets was not that they malfunctioned but that they allowed the loop to flood. Again Nic had no way of recovering from this situation.

If the handsets were shorting they probably would not allow the solenoid to fire (cant generate the required current as it shorts) so hyperoxia is even more unlikely

I dont think we will ever know the full truth of this incident. Whatever the cause we can all learn some really good leasons from it. Its just a real shame that Nic paid the ultimate price

a) Allways carry bailout
b) Buddy diving is when your buddy is next to you and in sight, not 15 seconds away

 

[Lisa3]

Nic did not have side slung bailout but he had a regulator on his diluent bottle. This gave him acsess to 3l of air, on a non deco 24m dive. The cracked handsets were recognised by Dave Crockford when he inspected the unit. This then lead him to re-check Paul Haydon's unit where he found those handsets were cracked too, and evidence of sea water ingress ( salt crystals aparent).


It takes a lot of research to find the medical back ground to certain symptoms and occurences. Speak to any anaesthatist and they will tell you that although it is not totally unknown, convulsions due to CO2 are not common.

The are natural systems within the body which recognise the level of CO2 being inhailed, the body has no natural way of recognising high or low O2. It is the level of CO2 which induces us to breath, and increases our desire to breath when CO2 levels go up. This is the reason that some medical grades of O2 contain a small level of CO2, in fact, lack of the CO2 effect can cause medical problems of death with people suffering certain medical conditions.

It was also recognised in the inquest that there was no data available as to what can hapen when the handsets do flood.

 

[madmole]

I was told by Martin that Nic had no regulators fitted and no way or breathing from the on board diluent

I am very aware of what happens when one breaths CO2 and CO. I was a paramedic for 12 years. I have personally seen 2 CO2 fits it that time (gas posioning due to duff water heaters). I have never seen an O2 fit. must admit that none of this was diving related but they do happen. I am probably much more aware than most people about CO2 retainers and those that need high O2 levels to exist. We see a lot of them in the back of the Ambulance. Not any on dive boats

Also No mention of a cracked handset was made at Paul Haydons Inquest, The Coroner's verdict was accidental death caused by hypoxia following leakage of the on-board O2. Which was found to be partially unscrewed (inside the inspiration cover so it couldn't have been knocked) and the O2 cylinder empty. DDRC did the unit autompsy with Martin Parker as a witness). Paul could not bail to his Trimix as his bail out regulators diagphram was missing!!! and it looked like he made no attempt to come off the loop. His spare off board O2 was not switched on. It is very feasable that if his handsets were cracked (not mention in inquest) that the low O2 buzzer may not have sounded (or he didn't hear it) and he failed to notice the falling O2 or the falling contents guage. Again Solo diving claimed another victim

 

[Lisa3]

If you are a medic then here is something else Martin Parker will not tell you. Paul's pose mortem showed glial and neuronal changes due to a hypoxic event ( quoted as acute
hypoxia but in a medical context hypoxia would only be termed as chronic when going on for weeks eg in bronchitis, emplasaema etc). The pathologist stated that he had seen these changes in people who had suffered a hypoxic event hours or days before death. Continued perfusion of blood to the brain is needed for these changes to take place, so if death follows immediately after hypoxia then these changes do not appear.

Also bear in mind that if Paul was unconsious on the sea bed with the unit feeding him O2 at the level it beleives it should, unless the unit is turned off or the diver dies and so stops metabolising the O2 in the loop then the unit will continue to feed O2 until the cylinder is exhausted - reputedly 10 hours at normal rates of metabolism according to AP Valves. This - obviously, leads to an empty cylinder.


The cracks in Paul Haydon's handsets were not noticed until after the initial inspection. The cylinder was partially loose but remember it is the gas pressure within the cylinder which keeps the o ring pushed in place and gas tight. AP reccomend that this is not overtightened.

If there was no internal pressure at depth under water then there would have been water leakege in to the the cylinder. There was not.

Once the unit was brought on board the police RIB - he was recovered two days later, there was a two hour bumpy RIB journey followed by a road journey back to the police station. If the contact had been loose then this would possibly be agravated by the vibration of the journey.

Paul Haydon had made no attempt to use his bail out. The reg was still bungied along the cylinder Paul also had a regulator bungied around his neck. Dave Crockford also stated that it was not unusable.

 

[madmole]

Not quite with you on a couple of these Lisa3 can you explain more. I'm always keen to dig a little deeper in these incidents and to find out the stuff that hasn't been made public yet

Paul's pose mortem showed glial and neuronal changes due to a hypoxic event ...........The pathologist stated that he had seen these changes in people who had suffered a hypoxic event hours or days before death. Continued perfusion of blood to the brain is needed for these changes to take place, so if death follows immediately after hypoxia then these changes do not appear.

But these changes were seen acording to your first statement. So are you saying that Paul had hypoxia on an earlier dive and not on this dive, or that Paul remained alive for some time after becomming incapacitated?

Also bear in mind that if Paul was unconsious on the sea bed with the unit feeding him O2 at the level it beleives it should, unless the unit is turned off or the diver dies and so stops metabolising the O2 in the loop then the unit will continue to feed O2 until the cylinder is exhausted - reputedly 10 hours at normal rates of metabolism according to AP Valves. This - obviously, leads to an empty cylinder

True if Paul remained unconscious and breathing for 10 hours after his event, But The valve would not have come loose afterwards. There is a nasty problem on the old seeman sub first stages in that you HAVE to do them up very tightly before pressursinsing or they do leak. I have first hand experiance of this (as do many other owners). Paul would not have been the first person to dump his O2 during the dive. The tightness you have to do the first stages up to prevent leaks is very high, they are a real pain to undo most times.

He he had stopped breathing and the loop was still intact, then the O2 would have remained in the Cylinder (assuming no loop leaks) as it was not being consumed and there was no need for injection

Handsets were inpected by DDRC at the request of the coroner with Martin Parker in attendance as a witness. No cracks were seen at this time (and they were checked for). The daiphram was missing from the off board bail out regulator so it was not viable. I've emailed Martin to check this was so and to query the cracked handsets. They one thing that was noticed in the report that the coroner didn't pick up on was that 2 of Pauls 3 cells were severely current limited and probably would have miscalibrated and certainly could not react to a high PPO2. Pauls lack of training (2 days) and then diving to 70m+ with 10 hours on the unit was also a contributing factor

As I've said many times before and probably will again, the real cause of death here is SOLO diving. We will probably never be 100% sure of what happened on these dives, but whatever unfortunate event took place its obvious that the deceased could not deal with it and may have been unconscious before being aware he had a problem. You carry redundancy of most critical things while diving, why not a spare brain and body (the most important bits if you ask me) in the form of a buddy

I'd love to know where your sources are AM and maybe we can have a chat at some time about any other info you have. I want all the theories on my site and would be happy to post your information. I think both of us want the truth known to the masses

 

[Lisa3]

Paul's pose mortem showed glial and neuronal changes due to a hypoxic event ...........The pathologist stated that he had seen these changes in people who had suffered a hypoxic event hours or days before death. Continued perfusion of blood to the brain is needed for these changes to take place, so if death follows immediately after hypoxia then these changes do not appear.

But these changes were seen acording to your first statement. So are you saying that Paul had hypoxia on an earlier dive and not on this dive, or that Paul remained alive for some time after becomming incapacitated?

This was Paul's first dive for 2 weeks. You hit the nail on the head with your second point. Martin Parker was aware of this because of the pathologist's evidence. On the second day of the inquest he even attempted to admit a graph which was about 10 fold out on its figures ( this was pointed out and he withdrew the graph but the dammage had been done), trying to show that the unit could sustain a diver for 45 minutes with no oxygen addition.

Also bear in mind that if Paul was unconsious on the sea bed with the unit feeding him O2 at the level it beleives it should, unless the unit is turned off or the diver dies and so stops metabolising the O2 in the loop then the unit will continue to feed O2 until the cylinder is exhausted - reputedly 10 hours at normal rates of metabolism according to AP Valves. This - obviously, leads to an empty cylinder

True if Paul remained unconscious and breathing for 10 hours after his event, But The valve would not have come loose afterwards. There is a nasty problem on the old seeman sub first stages in that you HAVE to do them up very tightly before pressursinsing or they do leak. I have first hand experiance of this (as do many other owners). Paul would not have been the first person to dump his O2 during the dive. The tightness you have to do the first stages up to prevent leaks is very high, they are a real pain to undo most times.

Paul was meticulous with his preparation and was observed going through this prior to the dive. Especially after all the problems he had had with the unit. It is rather unlikely that he could dump 3l x 200bar O2 15 minutes in to a dive without being engufed in bubbles.

He he had stopped breathing and the loop was still intact, then the O2 would have remained in the Cylinder (assuming no loop leaks) as it was not being consumed and there was no need for injection

Handsets were inpected by DDRC at the request of the coroner with Martin Parker in attendance as a witness. No cracks were seen at this time (and they were checked for). The daiphram was missing from the off board bail out regulator so it was not viable. I've emailed Martin to check this was so and to query the cracked handsets. They one thing that was noticed in the report that the coroner didn't pick up on was that 2 of Pauls 3 cells were severely current limited and probably would have miscalibrated and certainly could not react to a high PPO2. Pauls lack of training (2 days) and then diving to 70m+ with 10 hours on the unit was also a contributing factor

Dave Crockford has reported seeing salt christals in the handsets. Paul had a regulator bungied around his nech. The one with the missing diaphragm was on his side slund bailout which remained in its ceepers. Paul had done a 5 day modual I instruction course with Dave Thompson and a second unofficial ( before it was formal) trimix course (a week in Scapa Flow with John Thornton before the official course was finalised. He had done around 20 rebreather dives, 5 on trimix totalling about 14 hours. His final dive was to 65m. Martin Parker was well aware of the level of trimix diving being performed, these were all being openly discussed on the Inspiration list, amongst about 10 divers. He had never warned the users of any danger of using the unit with trimix. - Perhaps Martin is confusing Paul with someone else, there are so many.
Martin Parker never mentioned the cells during the inquest. Paul had had a number of problems with his original unit, which was eventually replaced. He had only had his replacement for a few weeks, is it not rather poor for him to have been supplied cells in this condition? At the time of his death I cannot recall I saw any warning to divers to check the current generation of the cells, just to replace them after - something like a year.


As I've said many times before and probably will again, the real cause of death here is SOLO diving. We will probably never be 100% sure of what happened on these dives, but whatever unfortunate event took place its obvious that the deceased could not deal with it and may have been unconscious before being aware he had a problem. You carry redundancy of most critical things while diving, why not a spare brain and body (the most important bits if you ask me) in the form of a buddy

I agree, if some of these divers had a buddy they may still be alive, Paul would. But the buddy must know what to do. Both Ian Swift's and Nic Gotto's buddy's attempted to lift them during a fit. Ian was sent to the surface and suffered baratrauma and died. Nic's mouthpiece was out when he was found fitting so there was probably little hope by the time the fit had subsided. He also suffered baratrauma. It is vital that anyone buddying a rebreather diver knoes how to react if a problem occurs.

I'd love to know where your sources are AM and maybe we can have a chat at some time about any other info you have. I want all the theories on my site and would be happy to post your information. I think both of us want the truth known to the masses

My sources are many and close to the families. I cannot count the hours I have spent looking for the answer. I am more than happy to tell you all I know and make your web page as accurate as possible.

Lisa.