Chris Brown
Official CAMRA ale tester
Gulf Stream = 5knts
Accident in Finland
- Thread starter Igor
- Start date
Gulf Stream = 5knts
plazma
Just add ice & water
Google "Jyrki Sariola Ojamo" and you get some stories in Finnish.
Suomen Tivolin johtaja menehtyi sukellusturmassa saamiinsa vammoihin | Kotimaan uutiset | Iltalehti.fi
Jyrki was a great guy and diver. He traveled across the country with his amusement park and dived with local divers. I used to dive with him every summer when he arrived to my town.
I feel I have learned many things about all accident discussions even if the case in hand has been still unclear. All the comments and opininions gives something to think about.
In both JJ cases there has been discussoion that CPR was not successfull perhaps as the whole body has become too hypoxic after some minutes of breathing of hypoxic gas. Would be interesting to get an experts opinion about that.
In the earlier case there was effective O2 treatment few minutes after unconsciousness but still no success.
Jukka
In both JJ cases there has been discussoion that CPR was not successfull perhaps as the whole body has become too hypoxic after some minutes of breathing of hypoxic gas. Would be interesting to get an experts opinion about that.
In the earlier case there was effective O2 treatment few minutes after unconsciousness but still no success.
Jukka
Igor
Ingemar Lundgren
Some more info on the accident. Keep in mind that this might not be accurate. A friend have herd the following.
The guys had planned a deep dive, 130-140 meters (not unusual depth to them). So very little oxygen in the diluent.
The sun was shining very brighly, so it`s likely he didn`t see the HUD, while concentraining to attach the multiple bailout tanks just below the surface.
Why he went hypoxic, I don`t know and don`t even want to speculate. The authorities have the unit for checking.
The guys had planned a deep dive, 130-140 meters (not unusual depth to them). So very little oxygen in the diluent.
The sun was shining very brighly, so it`s likely he didn`t see the HUD, while concentraining to attach the multiple bailout tanks just below the surface.
Why he went hypoxic, I don`t know and don`t even want to speculate. The authorities have the unit for checking.
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gianaameri
gian @ gian.ameri.name
Two fatalities of JJ divers in two years in Finland. And what - how many JJ divers we have currently in Finland? 20-30 or so, that makes scary percentages.
Makes me think that either the product is not so safe or there is definitely something wrong or missing in the training? It cannot be both or just the other. Don't want to point fingers but saying out loud what some people in the Finnish diving community are thinking.
Sorry for the loss of another fellow Finn.
I do not think there is anything unit specific anywhere.
If you combine the three risks:
1. Equipment Risk: a Probability of Failure on Demand greater than 1 in 10,000 + complexity of the equipment (to include higher WOB and CO2 elimination issues)
2. Human Factors Risk: every diver makes mistake
3. Task Risk: Diving is per se risky
then it is only to be expected that there will be significant fatalities.
To reduce the fatalities, then you have to reduce and mitigate each of the 3 risks individually as much as reasonably practicable.
BUT, when people go hypoxic AT THE SURFACE it is clearly more of a Risk 1 and Risk 2 problem, than a Risk 3 problem, and to me it shows that current systems, procedures, and controls are inadequate and have to be improved taking into account the 3 risks and their interaction.
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Dave Sutton
Banned
It's terrible to lose a diver.... and this has already been a bad month for it...
But, as we should say: :"Nothing is ever wasted, it can always be used to teach the surviors, if they will only listen to the message", so let us try:
Just a few thoughts:
Most importantly: Following the procedure of a 5 minute "all systems running" on deck pre-breathe with the solenoid bringing up the loop from 0.21 to 0.70 would reduce the number of RB mishaps by a huge percentage. This is not about the scrubber: It's about your 02 addition sytem.
The MOST important part of the statement above might be hidden, so let me clarify further:
During the prebreathe you MUST allow the solenoid to raise the PP02 to your low setpoint. You must SEE this occuring,. You do NOT want to have raised the PP02 high before the pre-breathe with the manual 02 add valve.
Sit down on the box, strap into the rig, look at the displays, and go from 0.19 to 0.70 on your handset. SIT THERE and watch the rig come up to 0.7. If it does... your system is working and the 02 is on. KIf not you have a real problem. This is the US Navy Mark-16 procedure, it's the Meg procedure, and ought to be THE eCCR procedure. My guess is that this would have prevented the case that we are discussing, based on the very slight information offered. It's just an educated guess.
The following is just a segue, taken from the above but not an observation on the JJ, but merely on diver habit patterns: I have spent the last three days with Leon, and we were discussing hybrids, etc.. and his view on them (which I share) is that they actually reduce safety: Divers get used to tuning theor 02 OFF, which allows them a chance to forget to turn it back ON.
Dave
.
But, as we should say: :"Nothing is ever wasted, it can always be used to teach the surviors, if they will only listen to the message", so let us try:
Just a few thoughts:
Most importantly: Following the procedure of a 5 minute "all systems running" on deck pre-breathe with the solenoid bringing up the loop from 0.21 to 0.70 would reduce the number of RB mishaps by a huge percentage. This is not about the scrubber: It's about your 02 addition sytem.
The MOST important part of the statement above might be hidden, so let me clarify further:
During the prebreathe you MUST allow the solenoid to raise the PP02 to your low setpoint. You must SEE this occuring,. You do NOT want to have raised the PP02 high before the pre-breathe with the manual 02 add valve.
Sit down on the box, strap into the rig, look at the displays, and go from 0.19 to 0.70 on your handset. SIT THERE and watch the rig come up to 0.7. If it does... your system is working and the 02 is on. KIf not you have a real problem. This is the US Navy Mark-16 procedure, it's the Meg procedure, and ought to be THE eCCR procedure. My guess is that this would have prevented the case that we are discussing, based on the very slight information offered. It's just an educated guess.
The following is just a segue, taken from the above but not an observation on the JJ, but merely on diver habit patterns: I have spent the last three days with Leon, and we were discussing hybrids, etc.. and his view on them (which I share) is that they actually reduce safety: Divers get used to tuning theor 02 OFF, which allows them a chance to forget to turn it back ON.
Dave
.
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Mike Ferguson
WTF is that?
I don't know what caused the hypoxic loop here but I very nearly went the same way and think that all rebreathers should give you the alarm equivalent of a kick in the nuts if ppO2 has dropped below 0.4 and you haven't noticed yet. Increasing the number of red flashes in a HUD that you can't really see in bright light, and you're used to always seeing flashing red to tell you the ppO2 is below 1.0, or silently changing a handset display doesn't really cut it for me.
A low ppO2 alarm should not be something that informs you it is out of the ordinary but gets your full attention by being REALLY OUT OF THE ORDINARY AND ATTENTION GRABBING AND ANNOYING.
Meanwhile I intend to start diving the pure O2 above 6m routine, advocated by some other members, on every dive rather than rely on noticing the number of HUD flashes or trying to look at a handset while swimming hard to the shot and arranging stages, etc.
quick clarification. Dave's right. I was thinking push up the O2 after watching the ppO2 rise and stabilise.
mike
A low ppO2 alarm should not be something that informs you it is out of the ordinary but gets your full attention by being REALLY OUT OF THE ORDINARY AND ATTENTION GRABBING AND ANNOYING.
Meanwhile I intend to start diving the pure O2 above 6m routine, advocated by some other members, on every dive rather than rely on noticing the number of HUD flashes or trying to look at a handset while swimming hard to the shot and arranging stages, etc.
quick clarification. Dave's right. I was thinking push up the O2 after watching the ppO2 rise and stabilise.
mike
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Dave Sutton
Banned
Dead right, Mike:
Here's the formal Meg procedure, which I advocate for everything:
"First Golden Rule of how not to die near the surface":
On deck, you MUST MUST MUST MUST MUST let the system raise the PP02 from 0.19 (Shearwater) 0.20 (Meg) or whatever LOWER THAN SETPOINT PP02 IS IN THE BAG to 0.7 ON THE BOX DURING THE PREBREATHE. This validates the 02 bottle is on, solenoid working, etc...
You really do not need to add more manually at that point. If you have "optimal loop volume" you cannot breathe it down low enough to go hypoxic with a breathable volume, and by staying at 0.7 you CONTINUOUSLY validate the system as you do the balance of your work near the surface. 0.7 v/s "pure 02 above 6 meters" also reduces PP02 spike on descent.
"Second golden rule of how not to die near the surface":
The ADV MUST BE ISOLATED UNTIL YOU GET TO 6 METERS. This preculdes ANY possibility of anything other than that nice rich gas being in the loop while you swim, snap on stages, etc. Need more lung volume to get to 6 meters? ADD OXYGEN.
At 6 meters it's isolator for ADV open, bubble check done (ASP for Meg divers), and off you go.
On the bottom it is ADV OFF, and it ought to STAY OFF until you are descending at 6 meters on the next dive, or need to flush.
Mike, Methinks these 2 simple procedures would have caught your sparkly-eyes incident, and likely many more. I can count several dead friends for whom this would have prevented their loss.
JJ Guys: Add an Isolator to your ADV. It might mean your life one day. Freeflowing ADV with hypoxic gas is just as likely a cause for this accident as 02 bottle not turned on.
rEvo guys: You cannot isolate your ADV (unless you talk to me and I talk you thru a workaround, which can be done with some Omniswivel parts)). For that reason I no longer support their use with hypoxic mix as-sold.
A freeflowing ADV near the surface should not be a path to death.
Dave
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I really like those procedures for the Meg I don't dive an eCCR and they address some of my concerns. I still fall into "the spike on the steering wheel" philosophy of the mCCR.
What about never having a gas that will not support life plumbed to unit/bov?
I have some reservations about "automated" checklists--I think they become too long and cumbersome and lead some people to start "cheating" them--and then what is the point. If you can't be bothered to make sure your unit doesn't kill you when it tries, chances are it trying to hold your hand more probably won't help.
And again without speculating about this specific incident, I try to be aware that my unit is trying to kill me, especially shallow, I try to plan specifically my dive from water entry to 20 feet.
In my opinion, training should absolutely include simulated mishaps like turning off tank valves. If you can think of how to do this safely, you shouldn't be training people to dive--again in my opinion. During my CCR training there was even a simulated assault with an edged weapon...
Lastly in my opinion, learning from someones fatal mistake, and perhaps not dieing is truly a fitting way to memorialize/remember them.
Stay safe everyone.
What about never having a gas that will not support life plumbed to unit/bov?
I have some reservations about "automated" checklists--I think they become too long and cumbersome and lead some people to start "cheating" them--and then what is the point. If you can't be bothered to make sure your unit doesn't kill you when it tries, chances are it trying to hold your hand more probably won't help.
And again without speculating about this specific incident, I try to be aware that my unit is trying to kill me, especially shallow, I try to plan specifically my dive from water entry to 20 feet.
In my opinion, training should absolutely include simulated mishaps like turning off tank valves. If you can think of how to do this safely, you shouldn't be training people to dive--again in my opinion. During my CCR training there was even a simulated assault with an edged weapon...
Lastly in my opinion, learning from someones fatal mistake, and perhaps not dieing is truly a fitting way to memorialize/remember them.
Stay safe everyone.
gianaameri
gian @ gian.ameri.name
With that procedure, it would be very easy to forget (Human Factor) the ADV in the "wrong" position, and it is downhill (bad) from there because you would assume it is isolated, when it is not.
Fireman, I assume by "automated checklists" you are referring to checklists that are found in the electronics and must be validated to move on to the next item?
I have to disagree with you on this one. IMHO, someone who can't be bothered to follow an electronic checklist is probably not going to be disciplined enough to follow a memorized checklist or follow a checklist that is based on an acronym etc. As has been discussed many many times on this forum and others, checklists have been proven to save lives in other safety critical fields, including medical, aviation, military, etc. etc. Simply relying on experience, muscle memory or whatever else you would like to call it is not sufficient. I would think that all of the dead very experienced CCR divers and instructors would validate this point.
I would think that if we can somehow make the checklist part of the electronics, it would make it that much easier not to skip over the process because it would eliminate the "I left my checklist at home" excuse from the equation.
We all rationalize from time to time and try to take the easy most expedient route to get in the water and not hold up the rest of the team. This is human nature. What we are trying to do as a community is develop the discipline to take the steps to ensure that we never jump in the water without having 100% knowledge that all of the CCR's safety critical systems are currently functional right at that moment, including the seemingly simplest of tasks, that of turning on our tanks. (By the way, I am absolutely not saying that is what happened in this accident, because I have no idea what actually caused the hypoxic event)
Hopefully these types of horrible accidents will serve as a wake up call to myself and the CCR community at large that we MUST become more disciplined and consistent in our standards and procedures. This is obviously not unique to one brand of CCR, one training agency or instructor's students.
Chris Brown
Official CAMRA ale tester
Totally agree. It also takes out the macho factor (that some divers, not all, suffer from)of not wanting to be seen fussing over your unit like a beginner at the dock.
I know a few divers have sold their sentinels as they find it annoying to go through the electronic checks 2 or 3 times prior to diving. (If you leave the unit alone for 5 minutes, it will shut itself off, requiring another run through the checks prior to jump.) However I find it quite refreshing, especially when I have students. It makes me slow down and focus on my unit and not get distracted by my students needs. Yes, I know there are people on RBW that berate me for making ANY mistakes (theres one guy who thinks you should be beaten for leaving your DSV open on the surface by mistake) but I am human and I dont believe anyone that claims they havent made one
I also dont like the .19 or similar low set points. I dont see the need for them. On my inspo / evo's Im at at least 70% 02 on the surface and never see anything much below that. I check my solenoid is working and my 02 is switched on by turning it to high setpoint and watching it go up to 1.0ish. Whats the difference? Why do you need to see it go from below low set point to low? Why not low to higher?
Michael Thornton
Rebreather Enthusiast
Totally agree. It also takes out the macho factor (that some divers, not all, suffer from)of not wanting to be seen fussing over your unit like a beginner at the dock.
I know a few divers have sold their sentinels as they find it annoying to go through the electronic checks 2 or 3 times prior to diving. (If you leave the unit alone for 5 minutes, it will shut itself off, requiring another run through the checks prior to jump.) However I find it quite refreshing, especially when I have students. It makes me slow down and focus on my unit and not get distracted by my students needs. Yes, I know there are people on RBW that berate me for making ANY mistakes (theres one guy who thinks you should be beaten for leaving your DSV open on the surface by mistake) but I am human and I dont believe anyone that claims they havent made one
I also dont like the .19 or similar low set points. I dont see the need for them. On my inspo / evo's Im at at least 70% 02 on the surface and never see anything much below that. I check my solenoid is working and my 02 is switched on by turning it to high setpoint and watching it go up to 1.0ish. Whats the difference? Why do you need to see it go from below low set point to low? Why not low to higher?
Chris
You make a good point. As long as you can hear the unit hold a set point. Meaning solenoid is firing I think it is ok. Plus I feel 5 mins should e spent at one set point on the pre breathe otherwise you need to vent from the loop and would not notice as easily a CO2 problem.
The only time I disagree about a set point lower than .7 is at very high altitude it is difficult for the breather to maintain a .7 on the surface. But that depends on the unit.
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divingabe
Member
Totally agree. It also takes out the macho factor (that some divers, not all, suffer from)of not wanting to be seen fussing over your unit like a beginner at the dock.
I know a few divers have sold their sentinels as they find it annoying to go through the electronic checks 2 or 3 times prior to diving. (If you leave the unit alone for 5 minutes, it will shut itself off, requiring another run through the checks prior to jump.) However I find it quite refreshing, especially when I have students. It makes me slow down and focus on my unit and not get distracted by my students needs. Yes, I know there are people on RBW that berate me for making ANY mistakes (theres one guy who thinks you should be beaten for leaving your DSV open on the surface by mistake) but I am human and I dont believe anyone that claims they havent made one
I also dont like the .19 or similar low set points. I dont see the need for them. On my inspo / evo's Im at at least 70% 02 on the surface and never see anything much below that. I check my solenoid is working and my 02 is switched on by turning it to high setpoint and watching it go up to 1.0ish. Whats the difference? Why do you need to see it go from below low set point to low? Why not low to higher?
I believe that the point of going from very low set point .2 let say to 1.0 is not only to make sure the electronics and solenoid are working properly, but it is a way of making sure the O2 bottle is on and not have been charged and turned off for whatever reason.
And I agree we all at some point make mistakes and are presently thankfull that they have been just that a mistake not a life extinguishing event.
So please lets all be more vigilant about following our predive safety procedures.
Gabe
Michael Thornton
Rebreather Enthusiast
Makes sense. For me I just find it easier to physically touch the valves for my check and look at the SPGs. If they drop while the solenoid fires or while you hit the MAV then it was charged and turned off.
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As a rEvo-mCCR diver these are my protocols:
Light it up. Kit up. Mask on, loop in mouth, blow PPO over 0.5. rEvoDreams go green <- this is important!
Signal RDY to splash, and if sun is shining, keep take reading from HUD shadowing with your hand. I have sometimes (but very seldomly let it drop just below 0.5), and mentally kick myself when it happens - hey just tellign it as it is.
Splash down, in current and fight down the shot line, I never stop at 6m.
At bottom close ADV-isolator (Yes Dave, my rusty screws are still holding up just fine). And it comes naturally that it has to be closed when ascending, for deco and all.
Now getting to the surface and onto the boat with isolated loop, have in one instace "saved" my bacon. Sun was shining, waves was rolling, unfamiliar ladder and after climbing, just at the top, I could not breathe. I had simply burned off the O2 until the loopvolume had shrunk, I had no free hands since it was rollign so hard. I just left my self fall back into the drink, and added O2, and did another try.
In that case, heavily workign, in the sun, clinging on for dear life you HAVE to be on an isolated loop of pure O2!
Igor
Ingemar Lundgren
Regarding the 0,19 set point. I am not to excited about that idea as it may introduce another thing you might forget.
As soon as you get on your loop and start pre breathing your Po2 will drop to around 0.4 Po2 (if it was at 0,7) or so and the solonoid will then add gas to get back to 0,7. You will then see that the solonoid works and you check that it maintains it during the rest of the pre breath. I also test the ADV and flush down the loop to 0,4 or so and that gives me another check that the solonoid raises the po2 up to 0,7 again. That seems enough to me anyway.
There might be enough o2 in the hoses even if the valve is turned off to raise the po2 to 0,7 and maintain it for a while masking a turned off valve. In my pre breath routine i check the manual o2 add valve is working and at the same time check o2 pressure gauge. A closed valve would be identified right away.
I have 5 critical control points (CCP) that i check during pre breath.
There are many ways of doing it. The most important thing is that we actually follow a procedure. And always follow it. The day you gonna die is gonna be when something unexpected happens like the DIN o - ring on your 02 fist stage leaks. You get pissed off and angry, climb aboard, fix the o ring, get stressed and even more pissed off, jump in to the water again and forget to turn that valve on and as you already did a pre dive check before the first time you jumped you ignore it. On top of that the boat have drifted away and you have to swim long and hard to the shot, bright sun light and you don´t notice your HUD. It is situations like this that we need procedures for. My two cents.
P.S. I have also herd that the mine they where diving in was not allowed to dive in. That may have made the divers enter the water in a hurry and just maybe (speculation) might have made them less thorough in their pre dive check routine.
As soon as you get on your loop and start pre breathing your Po2 will drop to around 0.4 Po2 (if it was at 0,7) or so and the solonoid will then add gas to get back to 0,7. You will then see that the solonoid works and you check that it maintains it during the rest of the pre breath. I also test the ADV and flush down the loop to 0,4 or so and that gives me another check that the solonoid raises the po2 up to 0,7 again. That seems enough to me anyway.
There might be enough o2 in the hoses even if the valve is turned off to raise the po2 to 0,7 and maintain it for a while masking a turned off valve. In my pre breath routine i check the manual o2 add valve is working and at the same time check o2 pressure gauge. A closed valve would be identified right away.
I have 5 critical control points (CCP) that i check during pre breath.
There are many ways of doing it. The most important thing is that we actually follow a procedure. And always follow it. The day you gonna die is gonna be when something unexpected happens like the DIN o - ring on your 02 fist stage leaks. You get pissed off and angry, climb aboard, fix the o ring, get stressed and even more pissed off, jump in to the water again and forget to turn that valve on and as you already did a pre dive check before the first time you jumped you ignore it. On top of that the boat have drifted away and you have to swim long and hard to the shot, bright sun light and you don´t notice your HUD. It is situations like this that we need procedures for. My two cents.
P.S. I have also herd that the mine they where diving in was not allowed to dive in. That may have made the divers enter the water in a hurry and just maybe (speculation) might have made them less thorough in their pre dive check routine.
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Very good point Igor. This is precisely why many people use a "survival check list" or a short "ultimate pre-dive check list" that deals with just the most important issues to keep you alive. Turning on your O2 would definitely be high on the list! (or confirming that your O2 is on after getting out of the water)
Chris Brown
Official CAMRA ale tester
Some great points being made here. Doesnt it just prove that each unit is different so therefore get unit specific training and that its not really about how you do it, but more about making sure you do it in the first place. consistently and routinely!
Michael Thornton
Rebreather Enthusiast
And train to become a thinking diver that can make or adapt his safety protocols fit all types of diving you do.
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