Fatality on Mk VI in Portugal - April 2013

I would not even remotely dream of going diving Solo with a rebreather in Open Water for a 10 - 12 meter dive (let alone not check the scrubber was in).




How many on here do dive solo? How many on here dive with OC divers that have no idea about a rebreather. To me that is a solo dive.
 
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The problem is Gian, people more often than not get away with it and this is what perpetuates the 'lack of risk' perception that people have.

I know an advanced trimix diver about 4 years ago who did a try-dive on a Mk VI with no training, no reading of the manual, and who watched the start up procedure with wonder as none of the codes on the paddle meant sense as it inflated, deflated and beeped away. This dive was also his first dive on a CCR so didn't quite know what to expect although he was bright enough to take a bailout bottle with him and a very attentive and competent buddy on the 10m/30mins bimble they did. The diver had very little confidence in CCR units as a whole and knew that CCRs could kill him relatively quickly and without notice. He had a concern that the majority of divers who this unit (and other 'recreational' units) were being marketed at wouldn't know how to use a bailout even though he was carrying one and was competent in stage usage.

The try-dive was being run by a member of the dive centre but it was not an instructional dive and no liability forms had been signed. Indeed, the guy who owned the Mk VI didn't dive with the diver and so safety cover was left to the buddy. Liability will be an interesting point to consider.

The diver was the 2nd diver to use the unit that day and so the Dil and O2 had been partially. At the turn point the buzzer went off but the diver didn't really notice and looked at the paddle at the symbols being displayed and couldn't really make too much sense of them so bailed out and then carried out the return dive on off-board OC.

The dive ended without further incident but the diver was left wondering what the market was for this unit and how easily it could be 'mis-used' at dive centres when try-dives will be taking place, especially in areas where the safety management is a little lax. This issue was raised by the diver on a number of occasions at RF3.0 where the question of standards maintenance was covered.

That diver was me and I still don't understand how the business model can be supported and safety maintained. Any system has failures because we cannot afford to engineer them out. Despite having the mindset of military aircrew, a relatively intelligent guy, relatively experienced technical diver, GUE Tech 2 trained, I still put myself in 'harm's way' because the 'system' allowed me to; I was part of that system. However, I believe I understood the majority of the risks I was taking and my two mitigations were taking bailout and an attentive buddy, another Tech 2 diver.

Did I break a whole bunch of 'rules'? Yes. Did I violate the warning in the manual which says get training otherwise this unit may kill you? Yes. Did I even read the manual? No!! This was a 'trust me dive' in the real sense of the term. I won't be the last, and I won't be the last who 'gets away with it' and thinks that I am bullet proof. However, the difference is I know that I am not bullet proof and will mitigate what risks I know that are out there. I cannot get rid of them without stopping diving.

Those instructors who have a positive attitude to safety and safety management systems will provide good knowledge and experience to their students, ensuring that they really understand what is required of them and how to mitigate the problems they can face. However, there are a number of instructors and IT/CDs who aren't in this group and they are the ones who will likely cause major problems for the industry when rebreathers start to make an impact on recreational diving.

Regards

Sent from my iPad using Tapatalk HD
 
Poseidon just release a report on this event. Unfortunately insted of alerting in order to prevent other "copy case" scenario, the disclosed informtion brings nothing new to what has been discussed here. :juggle:
 

Attachments

And until they have completed their investigations and reached a formal conclusion, then saying anything would be same as something incorrect.

Notwithstanding this, they could say that the canister was not present and that everyone should ensure that they follow their instruction and training (which you should be doing anyway!) to make sure that it is present and that you complete your pre-breathe.

Regards
 
psmedo said:
Poseidon just release a report on this event. Unfortunately insted of alerting in order to prevent other "copy case" scenario, the disclosed informtion brings nothing new to what has been discussed here. :juggle:
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No, they haven't released a report. The following is taken from the link you provided:
"As in all cases where Poseidon equipment is involved in incidents/accidents, we will strive to publicize
as much information about what caused the accident, when we are allowed to do so by involved
authorities and persons, but prior to that we will/can not release any information."

When they are allowed to and have enough information as to what caused the accident, I'm sure they will release a proper report, they have done so in the past. You just have to be a little bit patient.
 
psmedo said:
Poseidon just release a report on this event. Unfortunately insted of alerting in order to prevent other "copy case" scenario, the disclosed informtion brings nothing new to what has been discussed here. :juggle:
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What are you looking for ? According to you, you already know the answer to your questions(regarding the deceased). He forgot the scrubber now please stop with the MK trashing. Just for the record I don't dive that unit.
 
Bmwgsboy said:
What are you looking for ? According to you, you already know the answer to your questions(regarding the deceased). He forgot the scrubber now please stop with the MK trashing. Just for the record I don't dive that unit.
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Have your eard about the 5 WHY´S ?? I´m sure you haven´t if so you would understand my point of vue. Do you think for a second that an investigation of this nature goes into the very deep roots os this event ? If so i can only say that you´ve a very naife carachter...


READ AND MEDITATE
There was an elephant and a mosquito who were very great friends. The elephant always use to visit mosquito's house every Friday for sleepovers.

One day the elephant said "dear mosquito, every Friday I sleep in your house. Please come and sleep in my house this Friday."

Thus on Friday when the mosquito arrived at the elephant's house, he was warmly welcomed by the elephant's wife. They had a wonderful dinner and when it came time to sleep there were only two beds, so the elephant and the mosquito slept in one bed, and elephant's wife slept in the other.

In the morning a very sad thing happenned! Yes you are right. The mosquito is dead. The cause for the death... Guess it.

Maybe you are right.

The cause is that the elephant's wife has accidently lit a mosquito killer coil.
 

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Psmedo,

I am not sure what you are looking for either. There is a set process to follow and it will likely involve the Portuguese equivalent of the HSE as the deceased was 'at work' and will also involve the authorities working on behalf of the family and Poseidon to find out what went wrong.

Until the case has finished in a Coroners inquest (or the equivalent in Portugal) no information, unless it is of immediate safety concern (think aviation comparison - ground the fleet a la Dreamliner batteries) will be made public.

If, as is suspected, that the reason why the diver died was because they left canister out and they had a hypercapnic event which may have caused a cardiac arrest, then the reason for this is because they did not follow their training. There is nothing more that Poseidon can do right now to change the system. Would they do a system recall?

The problem with the diving fatality investigations is that there is no single process to follow and no higher level authority to demand that certain things are done. Sport diving is way down there (at the global level) when it comes to investment in safety management systems and we need to be aware of this. If you want more, then you will need to pay a premium accordingly, but I am not sure that the majority of the community think the same way. As such, we have to make do with the current limited reporting we do have and provide feedback to the community through whatever medium we have.

The 5 Whys is a good way of looking at things, but unless someone does that level of investigation, how are you going to get the answers you are looking for?

Regards
 
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GLOC said:
Psmedo,

There is a set process to follow and it will likely involve the Portuguese equivalent of the HSE as the deceased was 'at work' and will also involve the authorities working on behalf of the family and Poseidon to find out what went wrong.

If, as is suspected, that the reason why the diver died was because they left canister out and they had a hypercapnic event which may have caused a cardiac arrest, then the reason for this is because they did not follow their training. There is nothing more that Poseidon can do right now to change the system. Would they do a system recall?

The problem with the diving fatality investigations is that there is no single process to follow and no higher level authority to demand that certain things are done. Sport diving is way down there (at the global level) when it comes to investment in safety management systems and we need to be aware of this. If you want more, then you will need to pay a premium accordingly, but I am not sure that the majority of the community think the same way. As such, we have to make do with the current limited reporting we do have and provide feedback to the community through whatever medium we have.

The 5 Whys is a good way of looking at things, but unless someone does that level of investigation, how are you going to get the answers you are looking for?

Regards
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GLOC;

I´m bailing out now...

The HSE rules do not apply to REC diving activities here cause there´s a specific law for recreational diving and this was not a fatalitie involving a client, Therefore IMHO we have a recreational diver doing a recreational diving activitie, that decided to do a solo dive (forbiden in the new portuguese law) to check the boat anchor and died.

As no HSE investigation will be done the authorities will focus IMHO in the "technical issues", (equipment and procedures)...

And to go even just a little bit deeper..what about the investigators experience and qualifications...GIGO got it ???

Answer; PILOT ERROR

It was like that in the aviation accident investigation until the 90´s when the new "systems approach" of multiple factors begun to be considered. Latent conditions will remain. Human memory ios the most falible of all safety barriers.

BO now.:wave2:

3 - Trainning ? Human and social inteactions ? Pshycological factors ?
 
I understand your frustrations, as they are the same frustrations in the UK. Even the Coroner's Inquest that people say will provide the answers about 'why' the incident occurred don't, as that is not the job of the Coroner - they are there to determine cause of cause of death and the reports are only available to interested parties. Unless you are at the inquest and can copy down everything that is said, you won't get access to the reports. Furthermore unless a party will pay for the Health and Safety Lab investigation of the equipment, it won't happen.

Human memory fails, especially after traumatic events (read 'The Invisible Gorilla' for examples of that) and therefore the account of what happened changes/varies as time goes on. Anyone involved in an incident should write down everything there and then without speaking to anyone else and keep it safe. That is likely to be the most reliable version of the event from that person's perspective.

A genuine question. What is your proposal and how would it be funded? There certainly isn't the interest in the UK unless liability is being sought. Unfortunately.

Regards
 
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Hello Psmedo,

There is another way forward, PADI. They have the commercial muscle to drive change as nothing depresses sales revenue like a dead punter.

Poseidon could get away with one death; but when the second occurs, they will be forced to install active warning/ interlock system to better warn or prevent diving without a scrubber in the unit or risk losing their precious Type R rating.

I'd be very surprised if Poseidon were not already looking at how to improve its unit on this issue or even had a solution awaiting implementation (for a cost).

Regards,
Tony
 
Tony,

I don't have the formal definition of Type R, but this is one which have found

1. The unit should be of robust design and engineered so that it cannot be assembled incorrectly and/or has systems for identifying incorrect assembly and function.
2. The unit will not operate without a scrubber canister present or will warn* the diver.

* Warnings must be very apparent and not likely to be missed by the diver. A vibrating mouthpiece alarm is ideal, coupled with a visual alarm in the diver’s line of sight and/or an audible alarm. A secondary warning located on the unit’s back, discernable to other divers, is highly desirable.

Regards
 
GLOC said:
...engineered so that it cannot be assembled incorrectly and/or has systems for identifying incorrect assembly and function.
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This ^ is Impossible.


Anything you try to engineer out can always be bypassed with stupidity, error or cunning, divers will always try to bodge a dive despite the danger, it seems inherent in Divers DNA (something for the next study Gloc?)

You could put 100sensors in and someone will work out how to fool them- wanna test the electronics on my Unamed future CCR with multiple scrubber sensors, just drop a can of warm baked beans in that fits the scrubber, gives off heat and CO2 long enough to boot through calibration- Job done :big:

Oh quick- better go diving, hmm, Tomato sauce flavoured scrubber, lovely- oh sh*t......

You can't have 100% user proof, current units are maybe 75-80%, 90-95% maybe attainable but there will always be a sizable room for error while you have so much user intervention to maintain, service and recharge units between dives, with CCR you cannot escape those replenishment and cleaning jobs and the errors they will introduce.

Fixing the units to 100% impossible.
Fixing the Divers, Very Very Difficult but we could do better IMO and stopping dumbing down CCR so it can be flogged to anyone would be the first step.
 
Ben, I know that...which is why I think the comment the other day about the four areas of concern should be addressed in parallel (and linked) and not treated as separate entities.

Part of my studies will be to look at why people make the mistakes they do and will require feedback from both users and instructors. I am very interested in why what is on paper isn't necessarily delivered as it should be because there is a massive gap in the knowledge in this area. Requires people to be honest with themselves first though...

Regards
 
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Ben Field said:
This ^ is Impossible.


Anything you try to engineer out can always be bypassed with stupidity, error or cunning, divers will always try to bodge a dive despite the danger, it seems inherent in Divers DNA (something for the next study Gloc?)

You could put 100sensors in and someone will work out how to fool them- wanna test the electronics on my Unamed future CCR with multiple scrubber sensors, just drop a can of warm baked beans in that fits the scrubber, gives off heat and CO2 long enough to boot through calibration- Job done :big:
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There is however a difference between errors caused by missing something (or even stupidity) and deliberately bypassing safety features. It should be possible to engineer out the former. Someone deliberately trying to bypass safety features probably deserves to be a Darwin Award winner - however even there it would be useful to understand why someone would want to bypass safety features.
 
MeRodent said:
Someone deliberately trying to bypass safety features probably deserves to be a Darwin Award winner - however even there it would be useful to understand why someone would want to bypass safety features.
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Something that stops you diving without a canister would take serious suicidal tendencies, but what about alarms or protocols to stop you getting into the water without a complete system check being done, or where the system 'fails' but you 'know better'? (Sometimes the system fails but it is serviceable and so the user loses confidence in the system)

http://www.ccrexplorers.com/showpost.php?p=146569&postcount=208 (Functional Safety thread, post 208) onwards shows examples of people 'breaking the rules' and still going diving, and the potential reasons for this. Madness, until you are in that situation...

Regards
 
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