Fatality on Mk VI in Portugal - April 2013

From a risk elimination perspective would it not have been best to start with having a simple engineering control in the the ccr whereby it is not possible to operate the unit without the scrubber in place (eliminate the risk first) as an example of this, the diver would not able to breathe from the loop without the scrubber in the unit?

Also I stand to be corrected but I thought this particular unit had a built in fail safe against this specific situation i.e. leaving out the scrubber.

R.I.P

Condolences to family and friends

Cathal
 
Bmwgsboy said:
Once again please have some respect for the family, and stop posting on every forum the death of a fellow Ccr diver without knowing all the facts.
Question 1 were you there?
Q 2 did you help in the recovery??
Q3 are you a trained professional on the MK v1??
Tem um pouco de respeito pela família do mergulhador.
Click to expand...

I do not understand your point of vue. PLS explain in what sense a cloud of SIIELNCE is a safer and more ethic approach to any accident ? Or in what extend it respects the divers´s family or will help preventig other similar occurences ?

To save time and talk here there´s something called JUST CULTURE it exists in aviation for decades. Have you eard about it ? If not you should try to know about it. It helps to open some horizons...


Now the facts;

Victim;
Male aged 42, married with two kids. Had about 40 hours on the MK VI. Certified as OWSI in OC.

A Dive Center owner and manager and was going with three customers to do the second service performed to customers from his Dive Center (it had opeened the previous weekend).

Was using a borrowed MK VI CCR (was expecting his machine tobe delivered from factory). Some witness refer the victim as been very tiered due to a lot of work related with the dive center bussiness on the previous days to the accident including a night without any sleep.

When deleivered the machine, he was asked if he had scrubber cartriges to put onto the CCR, to witch victim replyed yes, he had he did not need any supply of those.

Dive site environment;
Bottom depth 10/12 meters, god visibility, no current. God wether no strong winds, dive in the morning.


The dive;
Victim was trying to moor the boat on a sandy bottom. As it was getting difficult to get the anchor "stucked" and in order to "check" if it was fixed on botom victim entered the water equiped with the CCR to do a quick survey on the bottom. If all was well it was supused to resurface and descend together with all the others In spite of trying to go down he could´t due to excessive bouyancy, and requested 1 piece of 2 kgs to add to his weight belt. Still not achiving negative bouyancy another 2 kgs was added to the weight. Then he went down. About 8 minuts passed away and in the boat the other divers decided to go and check what was delaying the Instructor. They found him laying on bottom out of the loop nothing in mouth. Body was recovered and CPR performed at no avail.

The CCR examination;
Machine was with several alarms onging and in CCR mode. Loop was not flooded. When scrubber cover was remouved to check a complete scrubber flood,scrubber cartridge was found to be missing.


R.I.P my friend
 
cathal said:
From a risk elimination perspective would it not have been best to start with having a simple engineering control in the the ccr whereby it is not possible to operate the unit without the scrubber in place (eliminate the risk first) as an example of this, the diver would not able to breathe from the loop without the scrubber in the unit?

Also I stand to be corrected but I thought this particular unit had a built in fail safe against this specific situation i.e. leaving out the scrubber.

R.I.P

Condolences to family and friends

Cathal
Click to expand...


You´ve made my point...

RGDS
 
psmedo said:
I do not understand your point of vue. PLS explain in what sense a cloud of SIIELNCE is a safer and more ethic approach to any accident ? Or in what extend it respects the divers´s family or will help preventig other similar occurences ?

To save time and talk here there´s something called JUST CULTURE it exists in aviation for decades. Have you eard about it ? If not you should try to know about it. It helps to open some horizons...


Now the facts;

Victim;
Male aged 42, married with two kids. Had about 40 hours on the MK VI. Certified as OWSI in OC.

A Dive Center owner and manager and was going with three customers to do the second service performed to customers from his Dive Center (it had opeened the previous weekend).

Was using a borrowed MK VI CCR (was expecting his machine tobe delivered from factory). Some witness refer the victim as been very tiered due to a lot of work related with the dive center bussiness on the previous days to the accident including a night without any sleep.

When deleivered the machine, he was asked if he had scrubber cartriges to put onto the CCR, to witch victim replyed yes, he had he did not need any supply of those.

Dive site environment;
Bottom depth 10/12 meters, god visibility, no current. God wether no strong winds, dive in the morning.


The dive;
Victim was trying to moor the boat on a sandy bottom. As it was getting difficult to get the anchor "stucked" and in order to "check" if it was fixed on botom victim entered the water equiped with the CCR to do a quick survey on the bottom. If all was well it was supused to resurface and descend together with all the others In spite of trying to go down he could´t due to excessive bouyancy, and requested 1 piece of 2 kgs to add to his weight belt. Still not achiving negative bouyancy another 2 kgs was added to the weight. Then he went down. About 8 minuts passed away and in the boat the other divers decided to go and check what was delaying the Instructor. They found him laying on bottom out of the loop nothing in mouth. Body was recovered and CPR performed at no avail.

The CCR examination;
Machine was with several alarms onging and in CCR mode. Loop was not flooded. When scrubber cover was remouved to check a complete scrubber flood,scrubber cartridge was found to be missing.


R.I.P my friend
Click to expand...

How can it be reconciled being "out of the loop" and "loop was not flooded" ?

He closed the loop, bailed-out on BOV, and then passed away (i.e. lost consciousness and drowned)?
 
Finally some "facts", thank you for that! Now we can analyze and learn something (maybe...).
When diving, whether it is OC or CC, we have protocols and we should follow them. Check lists are paramount, AFAIK every manufacturer has one and when we take our MOD 1 we are taught to follow them thoroughly, right?
If we don't who's to blame, the manufacturer? the instructor?
Are we not intelligent beings? Marketing is marketing, nothing is 100% safe or foolproof.
If we take our rebreather cylinders to the filling station and the guy makes a mistake and, let us say, fills our diluent cylinder with 100% o2 and we go diving without noticing it, who's to blame? Do we not know we always have to analyze our gasses?
Unfortunately we seem to only wake up when someone dies (and unfortunately this wake up call seems not to last long).
Safe diving to all.
 
gianaameri said:
How can it be reconciled being "out of the loop" and "loop was not flooded" ?

He closed the loop, bailed-out on BOV, and then passed away (i.e. lost consciousness and drowned)?
Click to expand...

CCR wasn´t in BO mode. If diver BO and then returned to the loop is something only a more insidius investigation on the machine black box can reveal. All i know is that water wasn´t present in the scrubber canister area, as it occurs if a complete flooding situation happens.

This IMHO is another wake up call to the teaching AGENCIES regarding HUMAN FACTOS absence from ALL diving CCR syllabus...either "Tek" or "Rec"

Just my 2 cents
 
psmedo said:
CCR wasn***180;t in BO mode. If diver BO and then returned to the loop is something only a more insidius investigation on the machine black box can reveal. All i know is that water wasn***180;t present in the scrubber canister area, as it occurs if a complete flooding situation happens.

This IMHO is another wake up call to the teaching AGENCIES regarding HUMAN FACTOS absence from ALL diving CCR syllabus...either "Tek" or "Rec"

Just my 2 cents
Click to expand...

So, it appears he passed out in shallow water, unable to self-rescue, shortly after the beginning of the dive, likely due to CO2.




Sent from my HTC Desire C using Tapatalk 2
 
First, condolences to the family..

Secondly - I'd like to relate a personal story, which illustrates the difficulty with any human activity involving danger:

My Dad was a incredibly competent Electrician, specializing in Industrial work, machines and high voltages. Dad was a real pro - used to lecture me constantly on grounding, safety, etc... Had his own shop, and was in such demand, he had to hire people like crazy to keep up - even though all his customers wanted "Bill" to do the work.

One day, back in August of 1998, my Mom was bugging my Dad to take her to the mall, but he had a customer who needed a "quick job" - Dad promised my Mom he'd be right back, and hopped in his truck to go do the simple job of hooking up some piece of machinery for a good customer.

But since he was in a hurry (I'm guessing), he didn't bother to lock-out / tag-out the breaker or breaker box feeding the circuit he was going to be working on. Someone switched the breaker back "on" just before Dad was cutting into a high voltage line - and like that - poof, he was gone...

I'm telling this story because it informs us that even the most experienced, most dedicated, most conscientious of us can make a mistake - even what others would consider a "stupid" mistake (or series of them), and wind up paying for it (I often wonder what I'd say to my Dad about his screw-up - he'd probably be pretty embarrassed, but give me shit for even bringing it up...).

It's just human nature. You can train, you can teach, you can lecture, you can try to engineer-around potential mistakes, but people still find a way to screw up - even the best and brightest, like my Dad...

So when one of us makes a mistake, it's good to remember that.

Kevin.
 
I can relate to this incident, especially the overworked tired dive shop owner bit.

Doing dive charter / trip related activity such as setting a hook whilst on CCR is risky, especially of you have under 100 hours experience.

If the events described are correct, then it looks like the victim skipped his prebreathe. He would have known there was no scrubber in the unit after 3-5 minutes breathing off the loop.

- failed build
- failed checklist
- failed to abort the dive / bailout presumably due to incapacitation from C02

very sad. RIP
 
At first when I saw the Explorer rebreather had a spring mechanism that didn't allow you to breathe off of it when there was no scrubber I kind of laughed to myself. I thought someone who forgets that shouldn't be diving. But then I realized I m sure I have made plenty mistake equally as bad. How many of us have made mistakes and caught ourselves thinking wow that would of been bad had I dived it like that?

I am a supporter for trying to improve design (Especially in recreational units), trying to improve training, trying to improve a positive attitude of using checklists, trying to improve knowledge and respect for the things that can go wrong.

Sadly even with all of this people will make tragic mistakes.
My condolences.
 
heyydude said:
It's just human nature. You can train, you can teach, you can lecture, you can try to engineer-around potential mistakes, but people still find a way to screw up.

So when one of us makes a mistake, it's good to remember that.

Kevin.
Click to expand...
The part in red should be seared into every diver's consciousness. And maybe inside and out of their dive tub.

I feel I am seeing a ground swell of thought that is trying to make rebreathers fool-proof. Kevin just reminded us of an old saying, but it does go further: even great people, those technically excellent, gifted, aware, etc. etc. can and do make mistakes. Momentary, for sure, but still they are mistakes. I can do it in my profession, despite every effort and no one gets hurt (well, not too much). It isn't the same for many other professions and activities. It certainly is not something one wants to make in any underwater activity.

The sad part is that at times such a mistake in diving may carry a very high price.

cheers

Andy
 
Andy Del said:
The part in red should be seared into every diver's consciousness. And maybe inside and out of their dive tub.

I feel I am seeing a ground swell of thought that is trying to make rebreathers fool-proof. Kevin just reminded us of an old saying, but it does go further: even great people, those technically excellent, gifted, aware, etc. etc. can and do make mistakes. Momentary, for sure, but still they are mistakes. I can do it in my profession, despite every effort and no one gets hurt (well, not too much). It isn't the same for many other professions and activities. It certainly is not something one wants to make in any underwater activity.

The sad part is that at times such a mistake in diving may carry a very high price.

cheers

Andy
Click to expand...

Price we do not have to pay.

We are human. Our attention is fragmentary. We get excited. We get stupid.

Of course, you can't make adventure safe, for then it's not adventure, but equipment which kills you without warning (this is what happened here) in the hands of civilians for recreational activities can be designed taking into account Human Factors.

It is actually a requirement of the current rebreather standard, but it is ignored.

Imagine a car which would kill you every time you forgot the keys on your desk, or a mobile phone which would kill you if you forgot it in the car.

The car and the mobile do not need special features to deal with those mistakes (we make tons of little mistakes all the times), but where the machine is not a car or a mobile, but it is a rebreather in civilian use for recreational purposes, the rebreather ought to be designed taking into account Human Factors.

Sent from my HTC Desire C using Tapatalk 2
 
Last edited:
Imagine a car which would kill you if you forgot to install brake pads, or ignored the dash display that warned you about that.

There's nothing wrong with improving CCR safety, but perhaps some people are better suited to getting the bus instead.
 
ebt said:
Imagine a car which would kill you if you forgot to install brake pads, or ignored the dash display that warned you about that.

There's nothing wrong with improving CCR safety, but perhaps some people just need to take the train instead ;-)
Click to expand...

Does the MKVI display warn you that you forgot to install the scrubber before you pass-out and drown?

It may very well do, just asking, I have never dived the unit.

It is very well conceived, with 4 (I think) independent processors, performing dedicated functions, communicating over a network, but it looks like that for a civilian rebreather to be used for recreational purposes it has room for improvements.

Don't get me wrong - it is clearly human error.

However, rather than scream "Human Factor" and do nothing about it, it is one of those Human Factors which the current rebreather standard requires to be taken into account when designing a rebreather.

If the rebreather could not kill you without warning, of course, scrubber in or out would make little difference (i.e. it would be one of the many inconsequential mistakes we make all the times in ordinary life, but it is not inconsequential when using a rebreather).
 
As has already been pointed out everybody makes mistakes at some point, no matter how concientious they think they are. anybody who thinks they don't ever make a mistake is fooling themselves. Some mistakes don't really matter and some do, some you catch, some you don't. you only need to not catch one mistake that really matters and your screwed.

I'm a great believer in people taking responsibility for their own continued existence but sometimes just a little bit of engineering out of potential issues can help avoid life threatening situations from developing. I've spent most of my life trying to find engineering solutions that minimise ways for people to kill themselves, sometimes it's just not possible and you have to live with it and have operating procedures to try to manage the risk, but if you can find an engineering solution that minimises the risk then you should.

If I was designing a unit from scratch I'd be trying my hardest to make it as idiotproof as I could without compromising performance. Warnings are all very well but preventing someone from breathing off a rebreather that isn't mechanically complete is a better solution. Mechanically preventing someone diving with a used scrubber would be hard but I wouldn't have thought it difficult to work in a valve that seals the loop, or install an interlock to prevent the unit being assembled if the scrubber isn't installed properly to stop people breathing from a loop with no cartridge in place. This particular potential failure mode seems fairly common amongst many rebreathers.

Prototypes and cottage industry rebreathers are one thing, but production units aimed at a mass market and built by conpanies that claim to be experts in the field and have ISO standards in place should undergo proper design reviews and FMECA's to highlight potential life threatening issues and, if possible, implement engineering solutions to prevent such occurrences.

Rather than just keep saying it's operator error these sort of incidents should be a wake up call to the industry. Intelligent, experienced divers dying for stupid reasons because somebody didn't put in place an appropriate engineering solution isn't really acceptable.

mike
 
Robert Månsson said:
And if you ignore the warning?
Click to expand...

My car if I forget to close the boot or do not close the boot properly (or a kid does not shut the door properly) gives me a warning.

The dashboard is designed very intelligently with lots of warning lights, but they are all OFF and do not clutter my vision or give rise to confusion.

A warning light coming ON is clearly visible in such well designed and conceived Human Interface system designed to reduce the Human Error of missing the warning (if a warning light comes ON, it is hard to miss).

So,

a. on the assumption the MKVI Display/HUD gives you a warning (visual and audible and vibrating) that you forgot to install the scrubber and
b. the MKVI Human Interface is NOT cluttered with information where the warning could be missed

then, if the diver ignores the warning, it is User Error number 2.

The first human error was to forget to insert the scrubber pre-dive.

The second human error would be to fail to notice and/or take action after the MKVI issues a warning.

The above assumes the absence of stress.

Add stress, and we see less, hear less, and miss important cues from the environment.

It is not uncommon for person under stress to become so focused in the task at hand (i.e. landing a plane on an aircraft carrier) that they see what they expect to see and miss all warnings as if they never happened.

They are just not perceived.

Add stress, and we get fear.

If fear is used to "focus," fear enhances our ability to deal with stress.

Otherwise, we start tearing around or trashing through the brush... unable to perform correct tasks despite best training... even remove the regulator and drown (if we have difficulty breathing as in a CO2 hit it is an instinctive reaction to clear the mouth from whatever you have in the mouth to breathe).

So, the answer to your question is complex.

BUT, it all starts with the equipment being properly designed to take into account of Human Factors.

THEN, you need to understand and be trained in Situational Awareness (not trained in "Human Factors").

The training methodology is key to foster Situational Awareness (you won't get it by reading a book, watching a video, listening to a lecture... it requires a special type of training method).

Far too easy to dismiss any accident due to Human Factor.

There will often always be a Human Error to blame or a "violation" (i.e. "the pilot did not sleep enough the night before"), when that is just one of the many factors at play.
 
Last edited:
Gian,

Rather than making assumptions about what a piece of equipment is configured with or without, look it up and then make informed statements.

http://www.poseidon.com/sites/all/files/mkvi_user_manual_2.4.pdf

Equipment design evolves which is probably why the Hollis Explorer has a physical interlock which prevents the unit from being used without a canister being in place.

I cannot find the formal specifications for what constitutes an 'R' unit and 'T' unit. This is the best I can find at the moment but not sure how up-to-date it it.

http://www.kiwidiver.com/Downloads/Unit_Register_announcement_v22.pdf

which says that you should not be able to operate the unit without a canister present or if you can a warning is provided. I have heard of a Mk VI being used in the Red Sea without a canister so this isn't likely to be the first time that this has happened. However, I also know that a military unit has been used without scrubber material present and the diver passed out on the surface just before descending the shot. That happens with robust processes and procedures in place.

Safety management hierarchy rules.

1st: Engineering primary control - making something in such a way that it cannot possibly go wrong, e.g. physical interlocks.

2nd: Procedural primary control - drills and strict adherance to them

3rd: Engineering secondary control - limiting just how wrong something can go, e.g. a redundant buoyancy device

4th: Procedural secondary control - emergency drills, to be carried out in the event of a problem

There are costs applied to each of those controls, but you need to understand how many things can go wrong and have to ignore your own knowledge when constructing failure; people can do very 'clever' things when they are circumventing processes and procedures. This is where Alex and APOC have gone.

Regards
 
Last edited:
You must log in or register to reply here.
Back
Top