Double Fatality in June 2014 (UK) - Inquest and Media Reports

GLOC

GLOC

real name: Gareth Lock!
Following the inquest yesterday and public domain media reports, I have just uploaded a number of media and mailing list outputs to DISMS (www.divingincidents.org) which concerned a double fatality in the UK last June (2014).

The two fatalities were not directly linked, one fatality due to Oxygen Toxicity and the subsequent one effecting one of the rescuing divers.

There are numerous lessons to be learned from this incident, especially when it comes to maintenance of kit, operating equipment beyond recognised best practice dates, bad luck, task loading...

I know there are some who were directly involved in this who are putting a more detailed study together and I hope to work with them, but in the meantime, luck isn't something that should be included in the dive plan...

https://www.divingincidents.org/incidents/121 with the specific media reports listed at the bottom of the page.

Regards
 
Gareth, did anyone examine the Megalodon the same way the Inspiration was examined? Was one of the cells in that unit really 4 years old, another 3yrs, and the youngest cell 19 months old?
 
GLOC said:
There are numerous lessons to be learned from this incident, especially when it comes to maintenance of kit, operating equipment beyond recognised best practice dates, bad luck, task loading...
Click to expand...

The one that I found most worrisome is someone doing Trimix dives that can't handle a loss of diluent. Out of all of the skills required to pass a Trimix rebreather course I would rate that as one of the easiest ones. Makes you wonder if the skill was just that out of practice, if it was never mastered or taught or if some psychological stress made something that should be simple difficult enough that it was ultimately fatal.


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Dropping through the water column with no dil, f**k all to breathe, it does kind of make all the calmly swap from the loop to a reg drills seem like bollocks. Whenever I've needed to bail (really needed to bail) the time pressure was massive. Bailing out is an easy drill but in reality I've found it one of the hardest things I've had to do without a bov. With a bov it's a non event, without a bov, no gas, lung squeeze, descending... I understand why he blew the loop with anything.

The things I take away from this:

- bailout training is not realistic. Said this for years. How you get round it I dont know because simulating those kind of stress levels is dangerous in itself. Use a bov maybe.

- all the heroes that say a little bit of oxygen wont kill you at depth...

- the human/machine interface is poor


As for the cells... you cant practice not being stupid.
 
Very sad story, again.

Without knowing for certain what role overaged cells played in this tragic accident I was struck with one thought.

What if the chip in the cells was to tell the rebreather its date of manufacture on startup, and the rebreather was to demand this info from the cells. If the rebreather don't recieve a date or if the age is calculated to be > 18 months the RB will tell you No Dive and shut down.
I don't think this would be more expensive or difficult to achieve than other recent developments with a bling/safety factor close to stupid.

Just a thought.

/nils
 
Because it is unnecessary or proportionate.

Keeping track of cells isnt hard. You dont forget a cell is 4 years old. You'll simply displace the stupidity somewhere else.

It was not a failing of cells, kit or skills. Diving 4 year old cells is deliberately pushing your unit. Fix the attitude, not the equipment.
 
No, I don't agee. If traing can't weed out stupidity or change attitude perhaps it's worth a try to make the equipment enforce that change. It should be simple and affordable enough. And if the diver isn't allowed by the machine to be stupid with cells it doesn't necessarily mean that he will look for other new places to be stupid instead.
When it comes to development in rebreathers it seems to me that focus is rarely on improving the weakest point - cells. I can see a need for change in attitude here, both with manufacturers and users. Making new divecomputers smaller with bright OLED displays, HUD's NERD's HUS's etc is all very fine. But it's not fixing our biggest problem.

/nils
 
Affordable? How many rebreathers are there in the field? 20,000? 50,000? Who knows. So they have to be retrofitted to make a difference. It needs a new connector to the cell. It needs 2 versions of the cell to be manufactured for all the people with good sense not to "upgrade". It will probably mean manufacturers phasing out dateless cells because making 2 types will not be cost effective. Which means people holding on to old "good" cells longer than they have to, using shit alternatives and pushing the dates.

Oh look... guess how this discussion came around...

Naive nonsense.
 
I think you're barking up the wrong tree Nils. It just adds complexity to a part that needs to be uber reliable/simple.

Whatever happened to Arne sieber's work on printable oxygen cells?
 
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Your just looking for problems where there are none. Sticking yor head in the sand.

It doesn't need a new connector. The rebreather sends a spike to the this new type of cell. The spike reaches the circuitboard in the cell where it serves as a kick in the the head prompting for the cell to transmit it's date of manufacture. With or without this spike the cell will function as any old cell in any old rebreather. Newer rebreathers will require cells to give up there date, older rebreathers won't. The No Dive restriction will be in the SW in the rebreather not in the the cell. This is not naive nore nonsense. Unless of course you think that cells (and how we treat them) are fine as they are and in no need if development. Now that is naive for real. You are talking nonsense.

/nils
 
Whatever. Assume the technology is available tomorrow to every new rebreather sold and available for retrofit. Assume maybe 10% of people at best will retrofit their units. Assume just 10000 units in use on the planet. That's 8000 new units that are going to need to be sold plus 1000 retrofits before there is an even split between date enabled and non date enabled units. For a minor problem by a handful of stupid people.

You think that's a realistic response? Fair enough. Back to the grassy knoll for me then.

Utter nonsense.
 
Personally I think you can spend a lot of time throwing technology at a problem......or you can change the mindset/culture. the mindset has a bigger overall impact and is more within the control of the diver.
 
ebt said:
Personally I think you can spend a lot of time throwing technology at a problem......or you can change the mindset/culture. the mindset has a bigger overall impact and is more within the control of the diver.
Click to expand...
I agree, but changing technology appears to be easier because it has more immediate results and is more 'tangible'.

Culture takes time to change, and as a consequence there will be lost lives until it becomes more acceptable to identify issues with someone else's configuration/currency/attitude and 'protect' them from themselves. However, there are those out there who think that they know better and don't want to be protected. It has been discussed before, but the communication of issues such as these is a two-way street - people need to be able to ask questions in a manner which is not confrontational and at the same time, those on the receiving end need to be accommodating of those who appear to be concerned.

Those who have validated a bad decision and got away with it, are unlikely to reverse that decision until something catastrophic happens and unfortunately that is sometimes too late.

Regards
 
I actually meant the divers attitude....
Assuming the kit may be faulty and checking/diving it accordingly. A lot of folks seem to think the problems can be resolved by technology, I always assume the technology just changes risk...and sometimes adds new ones...
 
ebt said:
I actually meant the divers attitude....
Assuming the kit may be faulty and checking/diving it accordingly. A lot of folks seem to think the problems can be resolved by technology, I always assume the technology just changes risk...and sometimes adds new ones...
Click to expand...
The only realistic thing you can change is attitude. No matter how much you want to change technology it's like wishing the sky was green. You can go on about cells that know how old they are, lockouts on controllers, etc forever. It's always the same whenever there is an incident, people come up with a wish list of technology changes. Nothing wrong with it other than it is mental masturbation. We are where we are with technology, you might think nuclear powered rebreathers will solve all problems but until they get invented in the future it is a fantasy.

Attitude exists. Current rebreather technology exists. They need to be made to work together.
 
ebt said:
I actually meant the divers attitude....
Assuming the kit may be faulty and checking/diving it accordingly. A lot of folks seem to think the problems can be resolved by technology, I always assume the technology just changes risk...and sometimes adds new ones...
Click to expand...
But the diver's (individual) attitude is influenced by the culture around them. I see a number of conflicting cultures at the moment:

1. Those who have learned the hard way and modified their behaviours because things went wrong.
2. Those who have developed over time and nothing has gone wrong, their behaviours aren't necessarily aligned with #1's behaviours because things haven't gone wrong and they are taking (potentially) unacceptable risks.
3. Those who have been taught by #2 instructors and influenced by commercial drivers where the 'sausage machine' rules apply and risks are not necessarily clearly articulated. They eventually become #2 divers.
4. Those who have come with experience from other domains (aviation, nuclear, medicine, rail etc) and modified their behaviours to be more like #1 but without having to learn from mistakes themselves.

Technology can help resolve some issues, but unfortunately even with the best attitudes, that technology can fail and so behaviour has to be consistent. Individual behaviour is easily corrupted (we drift) which is why organisations try to use redundant human checking when there is a risk of a single failure point at the human level.

Regards
 
I hope that proven and tested Solid State Sensors Cells System made for moisture environments becomes a thing of the future. This technology along with (1) up to date analog sensor would seem to make some sense. The combination of these (two) technologies combined would be a safer step forward as new technology makes further advancements in CCR developments.

Best regards,
Chett
 
ebt said:
Personally I think you can spend a lot of time throwing technology at a problem......or you can change the mindset/culture. the mindset has a bigger overall impact and is more within the control of the diver.
Click to expand...

True, whats most scary is the assumption that the technology thrown will make it safe I have yet to see any add-on tech that significantly improves safety, gag straps, BOV's and HUD's are all great additions but the majority of stuff is total garbage.

A cultural shift would help but you will always encounter morons, CCR is just not suitable for all- the sooner manufacturers realised this and kill off "recreational" CCR's the better IMO.
 
Mr Walker said:
Very sad story, again.

Without knowing for certain what role overaged cells played in this tragic accident I was struck with one thought.

What if the chip in the cells was to tell the rebreather its date of manufacture on startup, and the rebreather was to demand this info from the cells. If the rebreather don't recieve a date or if the age is calculated to be > 18 months the RB will tell you No Dive and shut down.
I don't think this would be more expensive or difficult to achieve than other recent developments with a bling/safety factor close to stupid.

Just a thought.

/nils
Click to expand...

All you have to do is change the date in your computer and the "out of date" micro chipped cell becomes a "still good by date" sensor. People are responsible for their own actions. Darwinism at work, people will always find a way to "get around" the useless chip added. Don't dive with old cells. Anybody who does so is rolling the dice.
 
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