Functional Safety, Human Factors and General Safety Discussion (Moved from Mk VI)

[hoffi]

In many of these incidents there seems to be a electronic warning device that should have helped. However in truth most of the divers died on units with a plethora of buzzers and flashing lights which either failed or did noting to save them.

ATB

Mark

In addition.

My subjective observation, there are still quite a few folks using mCCR with lowest level of electronics, cells + PO2meter, no HUD etc... f.e. can be found among cavedivers diving hardcore longrange sh**, sumpjumpers...sure can be found among wreckdivers too.

People being less vocal in social media these days but they still do exist.

The discussion KISS/mCCR vs. eCCR mono / double handsets + HUD has become silent a bit, on the boards at least the general picture seems ruled by electronic packages of higher levels.

mCCR with continuous bleed looks being a bit out of fashion, FWIW UTD has stopped being vocal about their radical passive/manual approach... how many UTD xCCR-divers have died within the past three years? Not a fan of UTD due to AGs Amway-style but I'm interested to hear how things go after some years of xCCR being in the field.

Yes, good training will cover manual operation BUT the time AFTER the course is more relevant and this is the time when the majority of the divers die.

Trend of today seems to: " I'll buy eCCR, I can do everything with it out of the box, superdeep, manual ops, SCR...most versatile " ... but how many people actually use that versatility and do not fall into lazy reliance to let the controller do the work after the course too often.

The general picture sound all to well and selfreflective...but does this reflect the reality in the field?
Much of it may be just wishful thinking.

However,
for people being new to the scene it IMHO makes sense to scan beyond that general trendy picture.

I'll stick to another subjective observation of mine, I don't see KISS-divers getting overly "darwinized".

Again,
all very subjective and m2c of course.


Hoffi

 

[Randy Thornton]

To make this work there should be a generic CCR training course free of industry / manufacturors bias, followed by a cross over course to the unit of choice.

No doubt the manufacturors cours will gloss over issues they think they have covered with electronics (which is exactly what i think they do now) but hopfulley the generic CCR course can realy focus on key issues.

ATB

Mark

Mark, this is an interesting concept and one that I happen to fully agree with by the way.

As Paul mentioned above, for all practical purposes, most "technical CCR MOD 1 courses" function as you have outlined. (This is not to be confused with the new recreational CCR courses that are currently being flogged in the industry) For example, TDI has a nice generic CCR manual written by Kevin Gurr. It covers basic CCR diving knowledge from a broad spectrum point of view. It is non-unit specific and deals primarily with general fundamental physics, physiology, and core principals of CCR diving. The initial classroom lectures utilize a powerpoint presentation that gives an overview of the generic manual and allows the instructor to delve deeply into various general CCR related topics as needed. The hope is that the student can gain a basic understanding of rudimentary CCR principals and knowledge.

In addition to this general overview of CCR principals and concepts, this first course will also introduce the student to unit specific procedures and functionality. This portion of the course will utilize the manufacturer's unit specific manual and will go through set up, maintenance, operational, and procedural items that are unique to that specific unit. For the student that is new to CCR diving, the TDI combination of generic (or general) CCR knowledge combined with unit specific training is the core of the first level CCR training. The actual in water skills are a combination of general CCR procedures as well as a focus on unique procedural nuances for each specific unit. This level of training usually requires a minimum of 5 days and usually involves about 40 hours if all goes well.

For a diver that is looking to crossover to an additional unit, a shorter educational/training path is available. Because the diver has already completed and hopefully mastered the initial CCR generic training, a cross over course focuses on unique unit specific knowledge, procedures and skills with less focus on general CCR knowledge unless of course the instructor feels that the student needs some remedial general CCR knowledge/training. (Unfortunately, the remedial training is needed quite often due to the fact that the student has either forgotten initial training items or received crap training to start with!) The cross over course takes a minimum of 3 days with usually about 24 hours classroom, pool and open water again with the focus on unit specific items.

Because I spend a lot of my time as an Instructor Trainer teaching and evaluating CCR Instructors, one of my pet peeves is the general lack of preparation and general knowledge of instructor candidates. CCR instructors are expected to have not only significant general CCR knowledge and skill but also to have complete and full understanding and mastery of the specific unit they are teaching. I can't emphasize enough the importance of unit specific training and mastery. IMHO, it's the little details that can kill you! The little gotchas that make the difference. The instructor and the student need to understand every quirk and potential failure point and mode that each individual unit has and how to deal with them. (IMHO, every unit out there has them!)

In depth general CCR training in conjunction with quality unit specific training is absolutely necessary in order to improve the overall safety of our industry. Combine this with manufacturers continually striving to improve the reliability and functionality of their units and increased pressure within the diving community to follow simple rules like using checklists, swapping out O2 cells with regularity and not taking shortcuts, and we are really on to something!

IMHO, we currently have the tools to improve the overall safety of our CCR diving community. We now just need to develop the discipline as individual divers, training organizations and manufacturers to stay the course and require/demand quality and consistency at every level of training, manufacturing and diving! Anything less, will ultimately bite us in the butt as an industry and diving community.

Warm regards,
Randy
TDI CCR Instructor Trainer
TDI Training Advisory Panel Member

 

[AD_Ward9]

Also - in the interests of full disclosure for those members who do not know the history - Alex Deas was discredited as a Subject Matter Expert in a British court of law by the judge presiding over the very case he was supposed to be providing evidence to an an expert witness. There is also a conflict of interest with his association with DeepLife / the Apocalypse rebreather.

Alex Deas - Why we have a hard time believing his claims

Your first statement is untrue, and as you plan returning to the UK, you may need to be more careful with truth before you slander people.

The second is a link slanderous site created and mounted by a US lawyer to try and discredit expert witnesses on the other side of his case - something that is illegal to do in the UK, and unethical everywhere. Apparently, it is legal in the USA where it is done, but let us see how the judge views his methods in the next trial that comes up.

Why don't you stick to the facts instead of trying to mask them by slandering people? I declared all conflicts of interests. There is a point to be debated here, and when it does not go in a way that suits your agenda, you attack the people. This is not a new strategy.

I wrote up the whole strategy why technical people such as myself are abused for promoting Functional Safety in an investment paper on the middle of the DL group web site home page: all can can see what is going on, where we stand, and again all conflicts of interest are declared. Link is: http://www.deeplife.co.uk/Avoiding_Pitfalls_in_Acquisitions_of_Safety_Product_Companies.pdf

Alex

 

[paulraymaekers]

...., and when it does not go in a way that suits your agenda, you attack the people. This is not a new strategy.


Alex

yup, sadly that is what is happening...

we even can't just say anything correctly on a public forum, with the risk of beiing slandered in a next 'newsletter'

sad, and shamefull!

 

[AD_Ward9]

yup, sadly that is what is happening...

we even can't just say anything correctly on a public forum, with the risk of beiing slandered in a next 'newsletter'

sad, and shamefull!

You can't afford to say things unless you are prepared to be quoted! That is a different thing.

Back to the topic of this thread:

Years ago we had a device which closed off the scrubber cap when a scrubber is not fitted. We dropped it as the ALVBOV was developed. However, reading the facts of this accident, we are reconsidering it: it would have to be simplified, but this is not the first accident to have occurred where no scrubber was fitted.

The device we had was a bit complicated, involving a spring loaded cap under the flow cone, so when one put in a scrubber it was pushed down opening the gas path, and no scrubber meant no gas path.

The complication was the thing pushed out the flow cone from time to time. That was fixed by welding the flow cone in, but then the spring assembly was unserviceable.

Given this is at least the third accident where no scrubber was fitted, then we will revisit this. If we get something more reliable than the small risk it addresses, all current users will get it for free.

Actions on how to avoid repeat accidents is what this thread should be about. I would not have thought it very difficult to produce devices that shut off the gas path when the scrubber is not fitted. We had another device for when the O2 was not flowing ... purely mechanical, again replaced by the ALVBOV and relies on electronics, and worse, an electro-mechanical actuator.

Alex

 

[paulraymaekers]

...
The second is a link slanderous site created and mounted by a US lawyer to try and discredit expert witnesses on the other side of his case - something that is illegal to do in the UK, and unethical everywhere.
...
Alex

yup, shamefull, illegal?.... but absolutely unethical!!!

... who created 'silent dying' ? the website that slanders all the expert witnesses of the 'other other' side...?

... and that praises a certain mr AD as the only thruthfull, honest witness...

.. and that was created long before the mentioned US site?...

 

[paulraymaekers]

The fact that you and your associates have lobbied to have Functional Safety removed from the prEN14143:2013 draft, simply destroys credibility in the system.

Alex

lobbying... who lobbied to have the 61508 in the standard.....?

Dr Alex Deas (witness for Barrett)

Dr. Deas' qualifications are BSc Hons (Electronics and Computing), MSc (Microelectronics), PhD (Electronics, Mathematics and Computing), FIEE (now FIET), CEng. He is on the 61508 Association Committee in the UK dealing with the implementation of the EN61508 standard to computing devices....

 

[GLOC]

Ok....can we please keep this on topic. I know that there are personal, professional and commercial issues at play here but that doesn't help anyone.

Alex, how does such a system work if you don't put scrubber material into the canister? In addition, surely with the CO2 system you have been developing, you would alarm and auto-bail a diver when excessive CO2 was detected in the system, and therefore don't need this. Or is this for those who have purchased a system without ALBOV? In that case, why wasn't this system in place before releasing the O2 units?

Regards



Sent from my iPad using Tapatalk HD

 

[paulraymaekers]

Ok....can we please keep this on topic. I know that there are personal, professional and commercial issues at play here but that doesn't help anyone.

you're probably right, I just wanted to point out that people should not do to other people, what they don't want to happen to themself

 

[Chris Brown]

Your first statement is untrue, and as you plan returning to the UK, you may need to be more careful with truth before you slander people.

The second is a link slanderous site created and mounted by a US lawyer to try and discredit expert witnesses on the other side of his case - something that is illegal to do in the UK, and unethical everywhere. Apparently, it is legal in the USA where it is done, but let us see how the judge views his methods in the next trial that comes up.

Why don't you stick to the facts instead of trying to mask them by slandering people? I declared all conflicts of interests. There is a point to be debated here, and when it does not go in a way that suits your agenda, you attack the people. This is not a new strategy.

I wrote up the whole strategy why technical people such as myself are abused for promoting Functional Safety in an investment paper on the middle of the DL group web site home page: all can can see what is going on, where we stand, and again all conflicts of interest are declared. Link is: http://www.deeplife.co.uk/Avoiding_Pitfalls_in_Acquisitions_of_Safety_Product_Companies.pdf

Alex

Anyone who read my post can see that it wasnt a personal attack. I was stating FACT for the benefit of the members. One link I posted has the actual court document transcripts. Hardly made up in an effort to 'attack' you.

Plus, the Mods would have removed my post or warned me if I had breached the TOS in posting the links.

FACT - You were discredited as an expert by a judge in a court of law.

Slander is verbal, so I think you probably meant to threaten me with litigation for libel. Given that my written comments are factual, I dont think that would be advisable as it would likely be unsuccessful.

Im already in the UK, so no problems there either. If you like we could meet up and discuss your issues with everyone else's designs. As long as you promise not to put my classic lid in the dishwasher

 

[Mr fish]

what,s the difference between 120k a year and 180k a year ,

:abducted:






will According to a judge its a red heads p60 , :haha:


ps
Chris you have mail :chuckle::flame:

 

[Chris Brown]

For those who arent in UK and may not know what a P60 is:

P60 - Wikipedia, the free encyclopedia

Its a document that a judge could use to identify fraudulent claims of income for example

 

[Mr fish]

fraudulent claims ,

Would that be like telling pork pie,s to get some sort of advantage.

No cant be , who would do a thing like that ,, A scoundrel maybe :moon:

 

[Mike Ferguson]

I followed the link in post 186 to the deep life document and came across the bit below.

When salesman Nick designed your rebreather electronics and software, how were you to know he had never been trained as an engineer or programmer, never worked as an engineer before, had never been trained in Functional Safety, and was in fact thoroughly incompetent? What does a rebreather
manufacturer do, when he finds out that the man that provided his electronics and software had a dark problem for which “mistakes” in rebreather design provide the perfect alibi!

It got me thinking. Hypothetically speaking what would you do if you were producing systems like rebreathers that are used in harsh environments and rely on sound mechanical design (flow analysis, stress analysis, materials selection, etc) and production engineering techniques for their performance and reliability; and you discover that your chief designer was trained in eletctronics and computing and had never been educated as a mechanical engineer and has had no training in systems engineering or production engineering?

or vice versa he has never been trained as an electronics engineer and taught himself coding?

would it matter? in our new litigous age where it seems everyone is running scared of parasitic laywers (one of my best friends is a laywer but I'll still say it) should all rebreathers be designed by teams of specialists with years of training and experience in their own disciplines? In which case will the bar be raised ever higher for new entrants into the market?

is the day of the pioneering amateur inventor coming to a close as far as production rebreathers are concerned?

 

[Mr fish]

:thumbsup:Yes read that one ,

Just made me laugh , Recognising the Dogs,
said guy speaks with some experience on the flogging of dogs , 10 years worth maybe, :hail:


educated mechanical engineer,s , ( i read of one engineer way back in 2003 said he had a few co2 cell,s and would / could knock up a working unit for a breather in a week , lol true ) still knocking that one up . 2013
Its a shame that same well educated engineers, even after doing a course on how to dive a breather,
could not calibrate his unit , and yet said engineer was told time and time again he was doing it wrong , but no he would have none of that , full post post on rbw , top stuff from are man the ccr guru ,

The father of orphans and defender of widows lol this will be the same guy that was telling other ccr manufacturers how to get round being sued by having lot,s of straw men / LTD Companies , even bragging how he has lots of starw men working for him and his trust fund,

the above info wont be in the link on post 186,
but i do have a file almost as fat as a well known head with red hair ,:cheers:

And please remember , You can't afford to say things unless you are prepared to be quoted! (that go,s for redheads as well i hope )


PS
Mike , what do you make of this from the link on post 186

is he saying MP has been trying to kill him , :cuckoo: tell me im wrong ,:trophy:

(why not kill the expert
Get him to dive one of the units with that
special code or scrubber and get him underwater.
this sounds crazy, but it has been done.) errrrrrrrrrrrrr i never came up with the word crazy lol

White Paper: Avoiding Investment Pitfalls in Safety
About the Author: Ret Ard PhD, FIET, C.Eng,
.
OP
sorry for going OT but i don,t have a BS web page to post on and then put in my link , SORRY
maybe ill go crazy one day and set one up , That,s if MP don,t kill me first ,:haha::haha::haha::


Ad iv told you once be4 how to stop your dog from humping your leg , Reminder for you ,
http://www.google.co.uk/url?sa=t&rc...GNsLxgklg1WKc-M1g&sig2=Y1iLNSJnt5u_C0ZLZQSvkQ :thumbsup:

much faster than reading it your latest 14 page,s of tripe
all way,s happy to be of help ,

 

[Mark Chase]

I fully agree, but in my opinion that's what is on the market now!

the first full course a user takes, is a general rebreather course, plus a unit specific part, for the unit he trains on

then for a new unit, there are cross over courses...

so what's the difference ?

btw.... unless I'm mistaking.... in many other posts you were against the mandatory cross over course when going to a new unit....

The present Mod1 Mod2/3 courses are manufacturor designed so the course tends to work to the perceived design strengths of he unit being taught.

I feel a generic "how to dive and survive on a CCR" course would be able to ignore manufacturor bias and focus on generic key safety areas.

The last part of the course could be unit specific a bit like a cross over course to the unit you baught which can then be dived bassed on the knowladge of CCR you have.

So its all Mod1 just in two parts.



Personaly Id like a new cross over level course option added to the list which would be a one day kit familurisation course showing how to strip asemble cleen and service the unit and running through the menue / control system.

For those that need it or want it, the instructor can offer an extended get wet version of the course with drills and skills refreshers.


ATB

Mark

 

[AD_Ward9]

Alex, how does such a system work if you don't put scrubber material into the canister? In addition, surely with the CO2 system you have been developing, you would alarm and auto-bail a diver when excessive CO2 was detected in the system, and therefore don't need this. Or is this for those who have purchased a system without ALBOV? In that case, why wasn't this system in place before releasing the O2 units?

On how it works, it was simply a sprung plate under the flow cones. Without a scrubber inserted the plate is up against the flow cone, so it is impossible to breathe from the loop. The plate was plastic with a TPU covering, so it shut off the flow entirely. Put a scrubber in, the centre rod of the EAC presses down on the centering pin, and pushed the plate away from the flow cone the correct distance, making the loop open.

A very very simple mechanism. It was considered as part of three things that could be done to mitigate the risk of divers diving without a scrubber fitted.

The sprung plate is less reliable than the window in the scrubber in the Apoc, in that the moving section could jam and could trap debris. That was the only reason it was not adopted in the production model of the Apocs, and why the only mechanical mitigation of this risk is a black/white scrubber fitted indication window, fitted to the Apocs, Incursion military and commercial rebreathers.

This decision was taken in the context that the CO2 sensor is on all the electronic versions of these rebreather (military, commercial, and that unit still on the shelf the iCCR). If we had not had the CO2 sensor, we would have far more likely fitted the scrubber close off cap, and done the extra engineering to deal with the issues of where sand migrates to, etc.

The iCCR has a different release mechanism in the ALVBOV than the other versions of the unit, and that release mechanism has been a prime problem in terms of reliability across extremes of temperature, hence its delays. Meanwhile OSEL has shipped a fair number of basic Apocs, and there is another batch being finished off for "OEMs" who use third party PPO2 indicators and no CO2 sensor, hence my comment that the lesson should be that we revisit the question of fitting a mechanical loop shut off.

Almost every rebreather I have used could have a loop shutoff operating mechanically if the scrubber is not fitted. The Functional Safety work we did conclude that all rebreathers should have a means to alert the diver if there is no scrubber. There is a big spectrum of "means", from the scrubber fitted indicator window, to mechanical shutoffs, to CO2 sensors, to CO2 sensors combined with shutoffs.

If we do re-introduce the mechanical loop shutoff, it won't be just for new units: it will be offered free of charge to all Apoc users as per its lifetime free-upgrade guarantee on all safety related matters. It is compatible with the ALVBOV, though the electronic version of the ALVBOV does a better job overall than the mechanical scrubber shutoff because the ALVBOV in the iCCR version is part of a system that looks at downstream CO2, which catches far more than just divers who forget to fit a scrubber.

At a very basic level, would fitting a scrubber fitted indicator window have avoided this accident? Such a window costs pennies. In any regime where checklists are used, that window is sufficient to prevent a dive on a rebreather without a scrubber. Any manufacturer can fit such a window, and most can do it easily.

Alex

 

[AD_Ward9]

lobbying... who lobbied to have the 61508 in the standard.....?

Dr Alex Deas (witness for Barrett)

Dr. Deas' qualifications are BSc Hons (Electronics and Computing), MSc (Microelectronics), PhD (Electronics, Mathematics and Computing), FIEE (now FIET), CEng. He is on the 61508 Association Committee in the UK dealing with the implementation of the EN61508 standard to computing devices....

61508 is a requirement in the EN 14143:2003 standard. I had no involvement whatsoever in writing that. Obviously some clever people thought that Functional Safety was important even back then.

Also, as you joined the CEN SC7 committee in 2009 to urge them to remove the 61508 requirement, you would know that the spokesmen from countries such Norway and Holland are very opposed to removing 61508 (these being public views they have expressed outside the committee meeting so I can refer to them without breaking confidentiality).

The UK even did a public consultation, where different experts commented on how essential 61508 was to EN 14143:2003, only to have all of their feedback dismissed by the UK at CEN in seconds without any discussion of their Functional Safety points. At that point I resigned from the Swiss CEN SC7 team as I don't want to be involved in this whitewash. There are more important things to life than money.

You refer to the Barrett case. Why not add 30 other hypoxia cases, none of which would have occurred had the rebreather conformed to IEC EN 61508? How hard is it to switch the rebreather on and inject gas if the PPO2 is below 0.16atm? How hard is it to employ real engineers to design circuits so they don't hang instead of allowing amateur salesmen to do it? How hard is it to fit rechargeable batteries that do not suffer battery bounce? How hard is it to include a brown out circuit and a watchdog timer and test them to ensure they actually work? How hard is it to ensure there are no non-life support modes in a rebreather controller's software (i.e. nowhere for the program to get stuck in, where it stops injecting O2 or stops updating the PPO2 display). How hard is it to remove or disable the Power Off button? These things are not rocket science but elementary.

You were discredited as an expert by a judge in a court of law.

This is not true - your original reference was to the Bromsgrove case. The HSE's first "expert" in that case turned out to be a totally unqualified technician and he found for the manufacturer, as did another expert who was not present but worked for the manufacturer. The HSE read my report, were alarmed and so put much more senior people on the case. To the HSE's credit, they then came to court, contradicted outright and directly their own technician, and reported to the court that the rebreather did in fact hang. They also reported that they had observed it hang when it fell over on their desk. Their undoing came when the HSE tried to reproduce that at the inquest. The coroner noted there was no unanimous view of the two groups of experts (the HSE senior staff and I on one one side of this argument, and the technician and a person who was a contractor to the manufacturer on the other side), so recorded an open verdict. You need to be accurate with your facts.

On the Barrett case, does anyone really believe Concannon's suggestion that a diver with new Diversorb dies in 6 minutes from hypercapnia just because he used Draeger Divesorb, which in tests last longer than 797? The highest medical officer in the US Navy gave evidence it was hypoxia, it was obvious even from the manufacturer's faulty simulation it was hypoxia. So if someone suggests that nonsense such as hypercapnia, say it here and I can contact the widow in the case, and subject to her agreement, publish the whole report minus just the autopsy photos. Let's stop the whitewash, look at the facts, and get some improvements here, otherwise the Rec rebreather initiatives are going to be short term, and there IS responsibility to those widows for those who stand in the way of these simple safety improvements.

Alex

 

[paulraymaekers]

Also, as you joined the CE committee to urge them to remove the 61508 requirement, ....Alex

false and misleading statement: try to post without these types of ... then we can have a correct discussion

I joined the committee to have mCCR incorporated into the standard, that was my work (ask anyone from the committee...

functional safety is not removed from the new standard, just the pure requirement that EN61508 had to be fullfilled.

 

[AD_Ward9]

functional safety is not removed from the new standard, just the pure requirement that EN61508 had to be fullfilled.

So you voted to have EN 61508 removed from EN 14143:2003?

Yes or No?

As you know, I know the answer, so please keep to the truth.

You have had absolutely zero functional safety training. You have never had any functional safety audit. You voted down the comments of five experts who DID have that training, DID have that experience, including those stating that compliance with EN 61508 was ESSENTIAL to EN 14143.

In the new proposed standard there is NO requirement that EN 61508 be met at ANY SIL level. All requirements for any audit by anyone trained in Functional Safety are removed. Instead there is a whitewash appendix. Again, let's stop the whitewash.

Rather than spiral into a pit, rise to this:
Tell us please, what you are doing to improve the Functional Safety of your products.

What improvement are you considering in response to this accident? What mitigations have you taken already?

Alex