Fatality on Mk VI in Portugal - April 2013

[gianaameri]

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

I am not sure the interlock is the best solution, but sure, that is a step toward engineering a product to take into account of Human Factors.

Well done Hollis!

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

All my statements are informed (although my communication skills are informal).

 

[cathal]

Here are the automatic system tests for the MK VI taken from the users manual:
Test 1: Confirms the main data logger is functional
• Tests 2–9: verify the ROM, RAM and EEPROM function in all four processors
• Test 14: Confirms the battery data logger is functional
• Test 15: Confirms the firmware version is consistent across all four processors
• Test 16: Confirms the power consumption calculations are functioning properly
• Tests 17–20: Confirm the power-draw of the backlight, solenoid valves, and alarms
are correct
• Test 22: Vibrator current test
• Tests 24-27: Solenoid current test
• Test 29: Speaker current test
• Tests 30-31: Cylinder HP sensor validation
• Tests 34-35: PO2 sensor validation HW test
• Test 38: Depth/temperature sensor validation
• Test 40: Decompression status verification
• Test 43: Mouthpiece OC test
• Tests 44-45: Sufficient oxygen and diluent to go diving test
• Test 48: Sufficient battery power to go diving test
• Test 49: Positive pressure loop test (PPLT)
• Test 50: Mouthpiece CC test
• Test 53: O2 calibration test
• Test 54: Open Circuit regulator test
• Test 55: Service interval test

No sign of a test for whether there is a cartridge in situ or not.
For a machine that is manufactured for the mass market why can we not expect a fatality rate comparable to civilian aviation fatality rates which I believe are currently one every 6,000,000 flight hours? This is what is accepted by society (socially accepted level of risk) and governments today. From studying the reports from these forums the current fatality rate for rebreathers has a long way to go.

 

[GLOC]

No sign of a test for whether there is a cartridge in situ or not.
For a machine that is manufactured for the mass market why can we not expect a fatality rate comparable to civilian aviation fatality rates which I believe are currently one every 6,000,000 flight hours? This is what is accepted by society (socially accepted level of risk) and governments today. From studying the reports from these forums the current fatality rate for rebreathers has a long way to go.

This has been covered to high level of detail in this thread http://www.ccrexplorers.com/showthread.php?t=15298

Cost, time and requirements. Rather than detract from this thread, if you want to talk about general safety requirements comparing them to High Reliability Organisations, continue the discussion there. Have a read before posting straight away please to prevent the same ground being gone over.

Regards

 

[wedivebc]

Here are the automatic system tests for the MK VI taken from the users manual:
Test 1: Confirms the main data logger is functional
***8226; Tests 2***8211;9: verify the ROM, RAM and EEPROM function in all four processors
***8226; Test 14: Confirms the battery data logger is functional
***8226; Test 15: Confirms the firmware version is consistent across all four processors
***8226; Test 16: Confirms the power consumption calculations are functioning properly
***8226; Tests 17***8211;20: Confirm the power-draw of the backlight, solenoid valves, and alarms
are correct
***8226; Test 22: Vibrator current test
***8226; Tests 24-27: Solenoid current test
***8226; Test 29: Speaker current test
***8226; Tests 30-31: Cylinder HP sensor validation
***8226; Tests 34-35: PO2 sensor validation HW test
***8226; Test 38: Depth/temperature sensor validation
***8226; Test 40: Decompression status verification
***8226; Test 43: Mouthpiece OC test
***8226; Tests 44-45: Sufficient oxygen and diluent to go diving test
***8226; Test 48: Sufficient battery power to go diving test
***8226; Test 49: Positive pressure loop test (PPLT)
***8226; Test 50: Mouthpiece CC test
***8226; Test 53: O2 calibration test
***8226; Test 54: Open Circuit regulator test
***8226; Test 55: Service interval test

No sign of a test for whether there is a cartridge in situ or not.
For a machine that is manufactured for the mass market why can we not expect a fatality rate comparable to civilian aviation fatality rates which I believe are currently one every 6,000,000 flight hours? This is what is accepted by society (socially accepted level of risk) and governments today. From studying the reports from these forums the current fatality rate for rebreathers has a long way to go.

I can confirm from personal experience the MKVI does not test for the presence of a scrubber. In fact during training I did a predive with one intentionally left out to prove it to myself and it passed all predive checks without it.

The Hollis Explorer T version may be provided with a packable scrubber which could be installed empty. It may also be provided without an optional CO2 monitor but in that case the starting sequence will require a 5 minute prebreath which will either alert the diver due to lack of change on the temp stick or by the massive migrain he will suffer for breathing without a CO2 scrubber.

 

[GLOC]

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

There is nothing in the manual which says it gives any warning about scrubber installation or scrubber usage.

All my statements are informed (although my communication skills are informal).

If you make a statement that says assuming Mk VI does something, why not look it up and provide a definitive answer? If you said, assuming a [generic brand] CCR does something fine...that is what I am on about.

Regards

 

[gianaameri]

There is nothing in the manual which says it gives any warning about scrubber installation or scrubber usage.


If you make a statement that says assuming Mk VI does something, why not look it up and provide a definitive answer? If you said, assuming a [generic brand] CCR does something fine...that is what I am on about.

Regards

I was asked an hypothetical question which I quote just below.

And if you ignore the warning?

Checked the manual and saw no sign of a scrubber IN test.

So, I answered the question hypothetically using the word "assuming."

Furthermore, I do not trust literature, on rebreathers in particular.

I prefer to rely on Operatives (i.e. practicioners) and first-hand knowledge.

Rebreathers are repeatedly alleged to meet EN14143:2003, but no disclosure is ever made that they do not meet Clause 5.13.1 of EN14143:2003 - that is they lack Functional Safety (and Functional Safety requires Human Factors to be taken into account).

So, any document you locate on the internet about rebreathers, some of which you have posted links, are "hypothetical" - not necessarily real.

If you check the APOC Manual (allegedly SIL 3),there is no scrubber IN test.

Merely a transparent window to show the scrubber is inserted.

Of course there is the iCCR end-tidal CO2 Monitor which should cover from a scrubber OUT risk (i.e. to SIL 3), but then again, that I consider "hypothetical."

I am a practitioner, not an academician.

 

[psmedo]

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

thanks

 

[GLOC]

Chill...last 2 posts removed as add nothing to the discussion nor the premise of just culture and safety engineering.

As I said above, look at thread about Failure Rate Metrics if you want to discuss that in general.

Bear in mind that true Safety Management Systems are still evolving in very well invested environments such as medicine and aviation. Sport diving is worth almost nothing in monetary terms and therefore will not attract substantial investment (unfortunately)

Regards

 

[psmedo]

GLOC,

IMHO Poseidon shall at LEAST knowing this latent condition of possible active failure and this accident promote imediatly for the REC market the use of "Exterior Warning Labels" containing an appropriate signal word accompanied by a safety alert symbol, that advises diver of the hazard and written in BIG black letters against an orange background clearly VISIBLE on the CCR

The message panel should be legible from a minimum safe viewing distance.
Finally, the panel should contain a safety pictorial that rapidly conveys information about the nature and consequences of the hazard - DEATH...

KISS

Just my 2 cents, if i was a MK VI owner you bet i would do it right away...at the cost of saving my life one day for 2 bucks price...

 

[GLOC]

Agreed. That would be a very cost effective measure to identify the risk to the user, but depending on what the words say (which are already likely to exist in the manual) this idea isn't likely to be popular with training and delivery organisations (dive centres) who are in the marketing game

Regards

 

[Mr Walker]

GLOC,

IMHO Poseidon shall at LEAST knowing this latent condition of possible active failure and this accident promote imediatly for the REC market the use of "Exterior Warning Labels" containing an appropriate signal word accompanied by a safety alert symbol, that advises diver of the hazard and written in BIG black letters against an orange background clearly VISIBLE on the CCR

The message panel should be legible from a minimum safe viewing distance.
Finally, the panel should contain a safety pictorial that rapidly conveys information about the nature and consequences of the hazard - DEATH...

KISS

Just my 2 cents, if i was a MK VI owner you bet i would do it right away...at the cost of saving my life one day for 2 bucks price...

Where in the Poseidon manual or in the training does Poseidon imply the possibility to take the Disco for a safe dive without a srubber?

/nils

 

[Bmwgsboy]

GLOC,

IMHO Poseidon shall at LEAST knowing this latent condition of possible active failure and this accident promote imediatly for the REC market the use of "Exterior Warning Labels" containing an appropriate signal word accompanied by a safety alert symbol, that advises diver of the hazard and written in BIG black letters against an orange background clearly VISIBLE on the CCR

The message panel should be legible from a minimum safe viewing distance.
Finally, the panel should contain a safety pictorial that rapidly conveys information about the nature and consequences of the hazard - DEATH...

KISS

Just my 2 cents, if i was a MK VI owner you bet i would do it right away...at the cost of saving my life one day for 2 bucks price...

If the deceased person doesn't open the unit to check for a scrubber what good do warning labels do??i have had warning labels on all my breather and never really paid any mind to them. I like the idea of not being abel to close the head without the scrubber( but then again what if you install scrubber without any sorb?? In Portugal a pack of cigarettes have a huge warning label that reads
SMOKING KILLS. People still smoke.

 

[psmedo]

See after all you are able to understand the objective of warning labels. Great. They do not avoid or tuern impossile the events but ALERT and inform of consequences.

Those warnings are imposed worldwide by the HSEof each coutry therefore you find them in professional tools, equipments, factories, constrution yards etc..and airplanes. Did you know that in Europe it´s not allowed the plane to take off before the safety briefing to passangers is finished ? And do you pay attention to it ?

RGDS

 

[Bmwgsboy]

See after all you are able to understand the objective of warning labels. Great. They do not avoid or tuern impossile the events but ALERT and inform of consequences.

Those warnings are imposed worldwide by the HSEof each coutry therefore you find them in professional tools, equipments, factories, constrution yards etc..and airplanes. Did you know that in Europe it´s not allowed the plane to take off before the safety briefing to passangers is finished ? And do you pay attention to it ?

RGDS

I fly a lot ( twice something 3 times a month) I see your point but IMHO
It's useless. How many people are sitting in a airplane and just not paying any mind to the safety briefing (including pilots and staff )IMHO its just a cover your own ass.We do them all the time in my line of work and more than once a year someone dies for something so simple.People are going to do whatever they want,no matter how many warning labels you put up. I still can't believe how crazy it is to forget a scrubber. I wish he was hear to discuss this topic. RIP Jorge.

 

[DSix36]

I remember when Hollis first came out with the Explorer. It had the safety feature that would not let you dive it without a scrubber. My first thought was that this was an actual bit of genius and all RB should have this. Next I thought about how stupid I would have to be in order to leave out the scrubber and figured this feature was completely unneeded. Finally I thought about some of the other stupid things I have done and once again think the design is indeed a good one.
.





If you want to know how I really feel then this link is for you:

MY PERSONAL THOUGHTS AND IDEAS

Don't blame me if you don't like what you see!

 

[psmedo]

This happened in march 2013...

Striking similarities...

Durban - A Joburg holidaymaker died during a deep-sea dive off eMkhomazi on the South Coast on Thursday.

The man, believed to be in his mid-20s, was a member of the Twin Palms Dive Club in Gauteng and was with a group visiting the Blue Vision Dive Centre, in eMkhomazi, for the weekend.

Dive centre owner Carol Oosthuizen said she was “shocked” by the man’s death. She suspected the diver had a heart attack under water during the recreational dive.

“We do not believe the cause of death was dive-related,” she said, “But we will know for sure only once the post-mortem is complete.” Netcare911 spokesman Chris Botha said the man was 27m under water when he lost consciousness.

“A rescue diver was with him at the time. He saw what happened and brought the man to the surface,” said Botha. The man was placed on a boat and CPR was administered on the way to the launch site.

When paramedics arrived they took over. “But the man was declared dead at the beach,” said Botha. Oosthuizen said the man had been an experienced diver.“

He was a recreational diver, a deep sea diver and a rescue diver,” she said

 

[GLOC]

This happened in march 2013...

Striking similarities...

Unfortunately the bits that you highlighted could be common for a whole bunch of fatalities.

From the Poseidon attachment

The investigation is ongoing and Poseidon has only taken part of the log-files and
verbal testimonials so far. We will disclose any findings WHEN we are allowed to by
authorities and insurance companies. At this point we have not been privy to the autopsy
report and we do not even know what was the cause of death.

At RF3.0 Martin Parker and David Concannon discussed some of the challenges faced when trying to get evidence to complete an investigation.

I've answered the timeliness question in the other thread (Durban Mk VI) which you just posted in. However, I am pretty sure that if the canister had been left out, then it would have made it into the initial press release from Poseidon.

Regards

 

[gianaameri]

However, I am pretty sure that if the canister had been left out, then it would have made it into the initial press release from Poseidon.

Is there a Poseidon Press release on the Portugal accident?

 

[GLOC]

Is there a Poseidon Press release on the Portugal accident?

I haven't seen one but I was referring to the Durban incident where they mentioned that they had downloaded the 'black box' data.

Regards

 

[JONT]

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.

No, this isnt a memorial, this is about information with the hope of prevention, a non existent scrubber speaks volumes........and its something a 5 minute pre breathe would detect, so again another example of diver error.

Whats enraging about this situation is that this death should have never occurred and stupidity doesn't come close to describing what happened.

Some times the truth isnt pretty but we need to know it none the less.