Fatality on Mk VI in Portugal - April 2013

psmedo

psmedo

Member
An experient recreatonal diver was found death at shallow depth (?) by other divers participating in the same diving today. Accident occured near the city of Setubal in Portugal about 90 km from the capital Lisbon Details are still emerging but accoding some well informed souces a preliminary inspection to the CCR envolved concluded that the scrubber cartridhge was not found in the machine. If so, the top event is a CO2 hit caused by HUMAN ERROR.Possible escalation factors, the absence of a sofware alarm in the MK VI (recreational CCR) for scrubber (system part missing) not been inserted into the CCR...marketing factors on safety assurance....

It´s worring that a CCR marketing moto is ABSOLUTE SAFETY....

Reality unfortunately shows a diferent side of the coin...

Rgds
 
psmedo said:
An experient recreatonal diver was found death at shallow depth (?) by other divers participating in the same diving today. Accident occured near the city of Setubal in Portugal about 90 km from the capital Lisbon Details are still emerging but accoding some well informed souces a preliminary inspection to the CCR envolved concluded that the scrubber cartridhge was not found in the machine. If so, the top event is a CO2 hit caused by HUMAN ERROR.Possible escalation factors, the absence of a sofware alarm in the MK VI (recreational CCR) for scrubber (system part missing) not been inserted into the CCR...marketing factors on safety assurance....

It´s worring that a CCR marketing moto is ABSOLUTE SAFETY....

Reality unfortunately shows a diferent side of the coin...

Rgds
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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.
 
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 agree that we should have respect for the dead, and the friends and relatives who may stumble on our posts, but at the same time we should not be screamish about making comments and observations.

If he did leave his scrubber out that represents a serious flaw in his preparation that others can learn from, and will spark debates and ideas which may ultimately save another divers life down the line. Telling people to shut-up out of respect will not save anyone.

RIP, and comiserations to any friends or family reading this post.
 
Agree with Iain. It's a sad time for all those involved and my thoughts are with them.

But as a community we need to share this information rather than hide it. It is exactly these learnings which have moved our training, hardware and standards forwards.
 
One more in support of discussing the issues. Sadly, safety procedures are written with the blood of those who passed away but it is what it is.

D

Sent from my GT-I9300 using Tapatalk 2
 
This is a continual problem when trying to learn from incidents, and the more I look into this in my studies, the harder it is to stop hindsight bias from influencing what I (we) think happened.

I would ask, as one of the Mods on here and someone keen to develop a Just Culture within sport diving, that if you are going to talk about this specific incident and what the diver 'actually' did, then you talk from a position of knowledge - first hand, not here-say.

However, there is nothing to stop you from talking about either hypothetical situations using this equipment (Mk VI), or near-misses which you have encountered personally. We learn from making mistakes, but unless you have the facts, you can't talk from a position of authority about this specific incident.

Regards


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Reguardless of the incident, if the unit dosent have some failsafe for a missing scrubber its a serious design flaw on a suposedly recreational unit that capable of being dived by people with little understanding of CCR.

ATB

Mark
 
GLOC said:
This is a continual problem when trying to learn from incidents, and the more I look into this in my studies, the harder it is to stop hindsight bias from influencing what I (we) think happened.

I would ask, as one of the Mods on here and someone keen to develop a Just Culture within sport diving, that if you are going to talk about this specific incident and what the diver 'actually' did, then you talk from a position of knowledge - first hand, not here-say.

However, there is nothing to stop you from talking about either hypothetical situations using this equipment (Mk VI), or near-misses which you have encountered personally. We learn from making mistakes, but unless you have the facts, you can't talk from a position of authority about this specific incident.

Regards


Sent from my iPad using Tapatalk HD
Click to expand...

G, is there a way where we divers can consent or request that should anything ever happened to us whilst diving the information/fact in respect of the incient can be released to a "governed"/licenced/ priviledged organisation like Cognitas.

Should anythig ever happen to me I would like to know that people can learn from my mistakes….

Greg
 
Perhaps this is something that can happen to all of us with DAN membership. From studying behavioural physcology it's a must thats its made opt out though.
 
humpbackdiving said:
G, is there a way where we divers can consent or request that should anything ever happened to us whilst diving the information/fact in respect of the incient can be released to a "governed"/licenced/ priviledged organisation like Cognitas.

Should anythig ever happen to me I would like to know that people can learn from my mistakes***8230;.

Greg
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Speak to your family is all I can say as it is normally them that limit access to information. Coroners do not consider research organisations as 'interested parties'

Regards
 
Mark Chase said:
Reguardless of the incident, if the unit dosent have some failsafe for a missing scrubber its a serious design flaw on a suposedly recreational unit that capable of being dived by people with little understanding of CCR.

ATB

Mark
Click to expand...

When I did my rebreather courses it was on a "recreational unit that capable of being dived by people with little understanding of CCR."

We are recreational divers and at some point we were all "people with little understanding of CCR."

Even now despite rebreathers having been around for some time there is a lot yet to be learned about this technology and the man/machine interaction.

I forgot to put the scrubber in once in my unit.

It was during a course.

The instructor was there while I prepared my unit.

There were only two of us and not a huge crowd.

I packed the car, we were ready to go, and I give a last look in the garage to make sure nothing was left behind, and I see my dutifully packed scrubber resting on the table in the garage.

That scared me.

We are all recreational divers (irrespective of the level of training) and we have all been at some point grossly ignorant about the risk of rebreathers and to some extent - to the extent that we are only given partial information about the tested performance of our unit - we are and we will continue to be ignorant of the true risks we take.

"Tec Diving" is just an expression of recreational diving, and both "Tec" units and "Rec" units should be designed with the same level of safety in mind.

We have good standards for that, but regretfully they are not fully implemented, and, standards do precisely require to take into account Human Factors when systems (i.e. the rebreather), procedures (i.e. Situational Awareness), and Controls are designed and put in place.

R.I.P.
 
I am also a true believer in the "learning from our mistakes" moto but I also think that information should be put out with clarity, exactitude and without manufacturer/equipment bias.
I believe this is the only way we can really learn something useful.
I know it is dificult for some people but we should try to avoid getting sidetracked by the "my rig is better than yours" mentality.
I did not know the diver personally but have a few friends that did, information is still scarce at the moment but the OP's info regarding the cause might be correct (missing scrubber cartridge).
The reasons that lead to the unfortunate mistake are still fuzzy but might be related with surface task loading (apparently the victim had been very busy this last few years struggling to open a dive center near Lisbon and the accident happened on the first official outing).
At the moment the information we have is, I believe, based on earsay.
Regards to all and safe diving
 
gianaameri said:
When I did my rebreather courses it was on a "recreational unit that capable of being dived by people with little understanding of CCR."

We are recreational divers and at some point we were all "people with little understanding of CCR."

Even now despite rebreathers having been around for some time there is a lot yet to be learned about this technology and the man/machine interaction.

I forgot to put the scrubber in once in my unit.

It was during a course.

The instructor was there while I prepared my unit.

There were only two of us and not a huge crowd.

I packed the car, we were ready to go, and I give a last look in the garage to make sure nothing was left behind, and I see my dutifully packed scrubber resting on the table in the garage.

That scared me.

We are all recreational divers (irrespective of the level of training) and we have all been at some point grossly ignorant about the risk of rebreathers and to some extent - to the extent that we are only given partial information about the tested performance of our unit - we are and we will continue to be ignorant of the true risks we take.

"Tec Diving" is just an expression of recreational diving, and both "Tec" units and "Rec" units should be designed with the same level of safety in mind.

We have good standards for that, but regretfully they are not fully implemented, and, standards do precisely require to take into account Human Factors when systems (i.e. the rebreather), procedures (i.e. Situational Awareness), and Controls are designed and put in place.

R.I.P.
Click to expand...



A full on CCR course should teach the diver everything he needs to know about diving a CCR to Mod1 depths.

Including obviously asembly of the unit and pre breath.

A recreational unit is more "try dive" in nature and Id have thaught that along with its solinoid tests, cell checks, dill check and 02 checks it would have a basic sensor or dead mans switch to ensure the bloody scrubber was in place.


Personaly id notice if my 02 was off or the solinoid wasent fireing but once asembled no way can i be sure wether or not my scrubber is in / attached QED to me its a primary safety issue on a truley recreational unit.


As for leaving the scrubber out on the course??? I'd have the instructor sacked. That just should not be possable.


We were taught to methodicly take the unit apart and lay out each component in order of refitting. Once the units reasembled I'd like to hope id notice a scrubber laying on the bench.


I have done try dives for non CCR divers on my rigs. I have let them fill scrubbers asemble the rig etc. but stood over them every step of the way.

ATB

Mark
 
Mark Chase said:
As for leaving the scrubber out on the course??? I'd have the instructor sacked. That just should not be possable.
Click to expand...

It was my fault, not the instructors' fault.

After completing the checklist I took the scrubber out for some reason now I can't remember and forgot to put it back in.

Human Factor!

Situational Awareness saved me.
 
Mark Chase said:
We were taught to methodicly take the unit apart and lay out each component in order of refitting. Once the units reasembled I'd like to hope id notice a scrubber laying on the bench.
Mark
Click to expand...

On reflection, pre-packed scrubber cartridges just scare me! It would be easy to be in a hurry and just forget to put it in place. The mess of packing your own is always an event that is hard to forget! There is the mess, the de-dusting, etc.

Safe Diving
 
Knock on wood I'll never have that problem.

I never close the unit if the scrubber isn't attached to the head. No if's or but's

Sent from my GT-I9300 using Tapatalk 2
 
Iain3 said:
I agree that we should have respect for the dead, and the friends and relatives who may stumble on our posts, but at the same time we should not be screamish about making comments and observations.

If he did leave his scrubber out that represents a serious flaw in his preparation that others can learn from, and will spark debates and ideas which may ultimately save another divers life down the line. Telling people to shut-up out of respect will not save anyone.

RIP, and comiserations to any friends or family reading this post.
Click to expand...


If he did leave his scrubber out that represents a serious flaw in his preparation that others can learn from, and will spark debates and ideas which may ultimately save another divers life down the line. Telling people to shut-up out of respect will not save anyone.
I agreed but if that the case, were was the checklist??
Then again last week I went thru my checklist and checked my bailout. At my my bubble check I realized it was off. Which left me thinking why did I check the pressure then shut it off before diving the unit?Very simple fix(turned it on), but if your task loading can turnout to be difficult.it seems to be not the case here but I Just don't believe in speculating,
 
Iain3 said:
I agree that we should have respect for the dead, and the friends and relatives who may stumble on our posts, but at the same time we should not be screamish about making comments and observations.

If he did leave his scrubber out that represents a serious flaw in his preparation that others can learn from, and will spark debates and ideas which may ultimately save another divers life down the line. Telling people to shut-up out of respect will not save anyone.

RIP, and comiserations to any friends or family reading this post.
Click to expand...



I agreed but if that the case, were was the checklist??
Then again last week I went thru my checklist and checked my bailout. At my my bubble check I realized it was off. Which left me thinking why did I check the pressure then shut it off before diving the unit?Very simple fix(turned it on), but if your task loading can turnout to be difficult.it seems to be not the case here but I Just don't believe in speculating,
 
Seems like either a co2 active monitor or a temp based alerting system could have provided the diver with some important data here...although a checklist is pretty low fidelity and available now.
It sure would be great to have active monitoring of most common or deadly elements in the breathing gas (o2,n,he,co2,co...)
 
Things like this are always so sad since they are 100% preventable.

It's obvious that things like this can be reduced with checklists.

I have to say that the starting point is with the instructors and how they make things "easy" to follow.

Here are two that have always stuck with me and a shout out to each of them.. Not that they invented this stuff but their teaching made an impression on me.

Andrew Driver was my original YBOD Classic Instructor - One of the take away from him that stuck with me was that when you go to breakdown/set up your rig, put EVERYTHING in the YBOD case. That way if you get finished and there's something left, you have a Darwin moment and say WTF and fix it. We also had a bunch of reminders taped to the inside of the case. Since moving over to the HH, I do the same thing but with a box.

Martin Robson was my CCR Cave Instructor - One take away from him was predive checking things of "2" starting at the top of the diver and working your way down... Lights, Valves, Inflation etc.... you get the point....

I am not saying that this solves everything by any ways or means but.... we are loosing good people due to "simple" things and that is very very sad...

Let's not try to say that we need cars to automatically turn the vehicle left to avoid the accident and then complain that it was not fast enough responding when an accident happens. Let's make sure they know how to drive before we put them behind the wheel...

Dive Safe...

Mark
 
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