Ron Akeson 4/17/2014

[Jeff Pack]

Well, since his friends finally posted some details of this dive accident on our local board, it was time to write up an incident report.

2 Divers (Jeff Pack and Jeff Gerritsen) were talking their mod2/3 IANTD Normoxic and CCR Trimmix courses from Ron Akeson of Adventures Down Under.

Ron is the guy I took my Mod1 course with, and I looked forward a year later to take my mod 2/3 course with him. We'd (Jeff and I) been actively tec diving the previous year, with each of us around 150 hours+ on our Megs. We'd decided to finally get actually certified.

The accident occured Thursday 4/17/2014.

We had already completed our confined water, skills, etc the prior monday. Tuesday we also did some addition skills and OW dives. We called the day early, Ron had a cell flare to 2.0 on the dive, the weather turned abit, so we called any further dives. We were set to start the beginning of our 130/160/200/250/300 foot class dives Wednesday, but Ron called it off not feeling well. As I look back upon this now, I wonder if he really had the flu, or actually toxed monday, just not enough to seize. So Wednesday was canceled, and we rescheduled to Thursday to start our class dives.

The plan was to dive the Mukilteo Boat Ramp area, an area used by tec instructors, because you can easily reach 300ft very quickly.

The dive plan was to swim out to the pilings, decend to 130ft, and return back, light deco out, and do some skills as well.

Unknown to me at the time (but mydive buddy was aware) Ron decided to move the what he thought was a faulty cell, from position 3 > 1 on his Meg. I was under the impression that was the bad cell, but as we learned later, it was actually the only good one, and 2 bad cells voted it out.(Both current limited)

The dive went as planned, descended in horrible visiblity(less than 5ft) to 20ft where we met up at the pilings and proceeded downslope to 130ft. We accumulated around 5m of deco, and proceeded back up slope.

Ron was to my right, Jeff Gerritsen to my left.

At around 80ft Ron signaled me with his light. I had Ron to my right about 5 feet. I look over, and he had his BO reg is his mouth. While was looking at him, he spit it out.

At first I was thinking this was some instructor trick, and we were goign to practice donate BO regs. So I grabbed my BO reg, and handed it to him. He wouldnt accept it.

Now I was kinda pissed, cuz it wasnt funny, so I grabbed him, threw him under me, and tried to force him the reg, which he wouldnt accept. Now I was really pissed, and this wasnt funny.

Then I saw his eyes. Theres a look. If you've seen it before, you'll always recognize it and never forget it. That was the look. At this point Jeff Gerritsen was also trying to force a reg, or even purge feed some air. Wasnt any help. At that point we decided we need to get him to the surface.

There was no need for both us to go up with him, and no need to (even with a small deco obligation) to have 2 bent divers. So I brought Ron to the surface, Jeff Gerritsen stayed behind to deco out.

We were about 100 yards from shore, 2 divers in full tec gear, and I can tell you it was one hell of a workout to get to shore. I managed to haul him about 4 feet from shore, and get a passerby to call the paramedics. I was physically spent, and with 150 pounds of gear on, plus him, I couldnt get him any closer to shore.

Around this time, Jeff Gerritsen had finished deco, and was doffing his gear to drag Ron the last few feet to shore and perform CPR. About then the paramedics showed up. We gave them all the info from above (excepting anything about a tox, flu, or equipment stuff).

At this point I called posted a 911 message to Joshua Smith an MDS team member about the accident. I managed to contact Matt Spiro, whom I knew as a close friend to Josh, to help get a message to Josh and his fellow MDS team members. Jeff and I stayed behind and Ron was moved to the hospital.

While talking with his daugher on the phone, her passing info to the hospital folks, we realized it was AFU, and loaded up rons equipment and headed to the hospital only to find when I spoke with ER folks, much of the info we passed to the paramedics was not passed onto the ER personnel. Not even his name was accurately passed on.

We recounted most of the above to Josh, Rob, Paul, and sorry I dont recall the other persons name.

Some things I learned from this accident.

Be religious about cell maintenance, age, and an O2 spike(s) during the dive. I still struggle to this day how Ron, a very experienced Meg diver, could have missed no O2 spike test, the solenoid firing to often, and what had to have been a loop that was getting quite full and needing venting.

Dont count on first responders to accurately pass on dive accident info to ER personnel.

Its one hell of a workout to pull a fully loaded tec diver 100 yards, and almost to shore. I'm thankful to be quite physically fit, but there's only so much you can do with a RB on, BO tanks, etc. I was physically spent and on all fours for awhile before I had the strength to even get up and doff my gear. If you tec dive, you need to strive to be physically fit. I strongly believe that.

Later I spoke with the head of the paramedics regarding some flaws in this event, and I understand some changes have taken place. Specifically to have one person responsible for gathering information and making sure its passed to ER personnel.

To this date, neither Jeff or I have moved forward to finish our courses. But we still actively tec dive every weekend. But after ever dive day, I call my spouse and tell her "I've cheated death yet another day". I say it jokingly, but in reality I also say it with reverence to Rons untimely passing.

The diving world lost a great man that day.

 

[Peter L]

My deep condolences, these things leave a shadow over all who are associated with them, I am still in the same place.
My lesson from this and my own is that there is no such thing as a cell flare, it takes actual O2 to spike a cell such that you have to trust the highest cell always.
The odds of a poor calibration being at fault are lower than the real deal such that you can't ignore it.

 

[Bruce Partridge]

I have known Ron and dived rebreathers with him for well over ten years. It is very sad that I have to ask this question:

What were the dates of the O2 cells?

Bruce

 

[Jeff Pack]

That would be a question of his MDS mates, they did the unit analysis. I heard second hand information, but wish not to say anything I dont directly know.

 

[uwxplorer]

Thanks for sharing this report and my condolences to all involved.

I feel directly concerned by your lessons, as I am of a school where the necessity of a 20 m O2 cell check was forgotten after the first few dives. I am not even mentioning checking them with a diluent flush at depth. I will start relearning and practicing those skills starting next dive.

If I may add, this accident reinforces the validity of a redundant pO2 readout as offered in the rEvo. Or the importance of constant cell validation as implemented in the Poseidon units (never dove them besides in the pool, so I can't speak of experience about its reliability).

As a naive question to controller designers, wouldn't it be possible to warn the user of an inordinate amount of O2 injections (compared to "usual" dive statistics?). It wouldn't use much memory to store the time and duration of solenoid "open" states and compare them to the expected number of durations, assuming some reasonable dive and physiological parameters. Mind you, I am not suggesting automated intervention, but a simple warning that something is possibly at odds with expectations, the user being the ultimate decider of whether this is normal considering the circumstances of the dive or indeed testing the cells' linearity might be a good idea (or changing the connected gas information if that is the cause of the disagreement).

 

[Randy Thornton]

Jeff,

Thank you for you post. It is very unfortunate that it takes these types of tragic events to "wake up" the community at times. I hope that we can glean enough from this terrible tragedy to help us be more diligent in our protocols and practices. I'm sorry you and your dive buddy had to live through this type of experience.

Warm regards,
Randy

 

[Mark Chase]

I have known Ron and dived rebreathers with him for well over ten years. It is very sad that I have to ask this question:

What were the dates of the O2 cells?

Bruce

Its very sad I have to say this yet again but what f##g diferance does it make

Brand spanking new cells fail too. I dont know how old his cells were but are you saying if they were within age tolerance this incident is somehow OK?

Or are you saying if the cells are too old this incident should be ignored as its the cells fault?

The death was caused by not managing a cell error properly. Some thing thats sadly lacking in CCR training I feel

The age of the cell at point of failure has no relevance aside from highlighting the same complacancy that stoped the diver from doing full and proper manual cell checks when the initial reading occured

And can somone explain to me on what planet a cell failes high for any considerable length of time? Yes they can run hot just before they burn out, but not for very long.

Please dont detract from the real issue here with referance to cell age.

ATB

Mark

 

[Jeff Pack]

Date of cells is just a data point in the story, not a reason or justification...

FYI: On the shore, the cells read .79/.91/1.02 I dont recall the SP after I flipped it to manual Cell 1 was voted out.

 

[heyydude]

Thanks for sharing this report and my condolences to all involved.

I feel directly concerned by your lessons, as I am of a school where the necessity of a 20 m O2 cell check was forgotten after the first few dives. I am not even mentioning checking them with a diluent flush at depth. I will start relearning and practicing those skills starting next dive.

If I may add, this accident reinforces the validity of a redundant pO2 readout as offered in the rEvo. Or the importance of constant cell validation as implemented in the Poseidon units (never dove them besides in the pool, so I can't speak of experience about its reliability).

As a naive question to controller designers, wouldn't it be possible to warn the user of an inordinate amount of O2 injections (compared to "usual" dive statistics?). It wouldn't use much memory to store the time and duration of solenoid "open" states and compare them to the expected number of durations, assuming some reasonable dive and physiological parameters. Mind you, I am not suggesting automated intervention, but a simple warning that something is possibly at odds with expectations, the user being the ultimate decider of whether this is normal considering the circumstances of the dive or indeed testing the cells' linearity might be a good idea (or changing the connected gas information if that is the cause of the disagreement).

The problem is with a system like you describe above, you'd need additional parameters for the computer to make a judgement - each of which adds more complexity (read: potential for failure) to the system. If the ppO2 is low, you could technically calculate the bolus of O2 needed for raising the ppO2 to Set-Point (something the Hammerhead does against depth) - but what about the Interstage Pressure being low? To know that, you'd have to use some sort of pressure transducer (either HP or LP in the delivery line) to determine if you have flow, and if so, what the bolus of O2 would be. Further, what if there is an O2 Leak someplace in the LP system? Do you err on the side of delivering too little O2?

For every engineering "solution" there represents a ton of additional failure points. For every diver error, there represents a ton of additional "automation" that could be added. Eventually, you reach a system which has so many failure points that diving becomes almost impossible, or dangerous in ways that we cannot yet contemplate...

Flushing the loop - or using the "PO2" command in the Hammerhead (for instance) is a great way to verify your O2 sensors while diving. Products like "The Remobulator" allow you to verify your sensors from the safety of your bench in the garage. All these tools can and should be used by all divers.

My condolences to the family - it is a terrible tragedy that none of us ever want to see. If the circumstances indicated by Jeff in his post are true, it is all the more frustrating that we've engineered Solutions for these matters that were not utilized by others.

Kevin Juergensen
Juergensen Marine, Inc.

 

[uwxplorer]

This is why my question was about implementing a warning, not an automated reaction. I agree that the latter would be impractical.

A gag strap could have helped prevent this tragedy, I suppose...

 

[Mark Chase]

The problem is with a system like you describe above, you'd need additional parameters for the computer to make a judgement - each of which adds more complexity (read: potential for failure) to the system. If the ppO2 is low, you could technically calculate the bolus of O2 needed for raising the ppO2 to Set-Point (something the Hammerhead does against depth) - but what about the Interstage Pressure being low? To know that, you'd have to use some sort of pressure transducer (either HP or LP in the delivery line) to determine if you have flow, and if so, what the bolus of O2 would be. Further, what if there is an O2 Leak someplace in the LP system? Do you err on the side of delivering too little O2?

For every engineering "solution" there represents a ton of additional failure points. For every diver error, there represents a ton of additional "automation" that could be added. Eventually, you reach a system which has so many failure points that diving becomes almost impossible, or dangerous in ways that we cannot yet contemplate...

Flushing the loop - or using the "PO2" command in the Hammerhead (for instance) is a great way to verify your O2 sensors while diving. Products like "The Remobulator" allow you to verify your sensors from the safety of your bench in the garage. All these tools can and should be used by all divers.

My condolences to the family - it is a terrible tragedy that none of us ever want to see. If the circumstances indicated by Jeff in his post are true, it is all the more frustrating that we've engineered Solutions for these matters that were not utilized by others.

Kevin Juergensen
Juergensen Marine, Inc.

Do we need engenearing to solve this?

And would it realy have helped?


A manual dill flush cell confirmation is easy to do and would show which cells were acurate within a reasnoble tolerance

On the Sheerwater you have a PP02 on Dill at your current depth display which is helpfull but I can work it out in my head easy enough or use a multi level slate

And an auto dill flush could display that all cells were capabul of reading accuratly at 0.9pp02, but its the subsiquent re-aquuireing of set point and spikeing beyound that shows if cells are current limited.

ATB

Mark

 

[Bruce Partridge]

Its very sad I have to say this yet again but what f##g diferance does it make

Brand spanking new cells fail too. I dont know how old his cells were but are you saying if they were within age tolerance this incident is somehow OK?

ATB

Mark

I certainly didn't say that this is OK, and I don't think it is OK. Those are your words.

The reason I ask is because there have now been three fatalities in the last few years with exactly the same root cause. All of them would presumably have been avoided if there weren't two expired cells in the system.

That doesn't mean that you should abandon all other mitigations. What I am suggesting is that if there are several mitigations available, why not do all of them. There is no doubt, in my experience, that cells that are within 18 months of manufacture date tend to fail less.

I don't think running all of your cells until they die, and then depending on your skills to detect the failure is a way to enhance safety.

There is a second lesson here too I think. We aren't doing a good enough job of communicating our knowledge. There was a presentation at OzTek 2013 that described this (assumed) failure mode in detail. Two divers probably died from the same failure.

By all means use the advanced skills that I know you have, but let's not encourage people to abandon the simple mitigations that are available.

Bruce

 

[Mark Chase]

I certainly didn't say that this is OK, and I don't think it is OK. Those are your words.

The reason I ask is because there have now been three fatalities in the last few years with exactly the same root cause. All of them would presumably have been avoided if there weren't two expired cells in the system.

That doesn't mean that you should abandon all other mitigations. What I am suggesting is that if there are several mitigations available, why not do all of them. There is no doubt, in my experience, that cells that are within 18 months of manufacture date tend to fail less.

I don't think running all of your cells until they die, and then depending on your skills to detect the failure is a way to enhance safety.

There is a second lesson here too I think. We aren't doing a good enough job of communicating our knowledge. There was a presentation at OzTek 2013 that described this (assumed) failure mode in detail. Two divers probably died from the same failure.

By all means use the advanced skills that I know you have, but let's not encourage people to abandon the simple mitigations that are available.

Bruce

Bruce

This is not an advanced skill, this is Mod1 level stuff. I fail to see how anyone can dive a CCR without this very basic understanding of how to check cells

Non of these incidents would have been avoided by new cells if the new cells had failed

I have had considerably more failures with new cells than I have with old cells. That is to say, I have only ever had one cell fail that was outside its normal working peramiters in terms of packaging and use by dates and that was in the great cell famin when good cells were just not available

Then after the great cell famin caused by the Ginger one we suffered the APD cell fiasco where the vast majority of the brand new cells comming to my diving circle of friends were failing within a few dives.

I personaly replace my cells every year. My current cells were fitted last July

I DO NOT do this as a safety precaution. I dont consider new cells any safer than old ones (infact I have a healthy distrust of any new cell) I do it to minimise the risk of missing a dive due to a cell error.

ALL cells can fail, its how we deal with a cell error that seporates out the incident being a minor iritation or a fatel error


The attitude tawards this incident in so far as writing them off because of the use of old cells, just breeds complacency.

The sugestion is, My cells are in date QED I dont need to do cell checks???

I sometimes check my cells because they are working too well. If its all 1.3 every time I look down I start to get nervous and pop a bit of 02 in jut to see them jump up a bit.

Please dont sugest I am banging my drum for guru status by promoting "advanced skills????"

Personaly I dont consider a 1 second press of the 02 button to see if the cells move up a bit, to be beyound the abuility of a week 1 CCR diver

I admit its a little more chalanging to put your unit on low set pont, flush it with dill and compare the depth/pp02 for known dill on your computer (or slate) with the readings you have on you CCR, but hardly rocket science

I was taught to carry a slate with dill pp02s on so on a dive id have a PP02 for dill at 5m incriments for that dill. I had a laminated set on my Inspo Classic handsets

So lets say I use 18/45 dill on 30-50m diving (as i do)

I have a slate which says

18/45

30 0.72
35 0.81
40 0.90
45 0.10
50 1.08
55 1.17


Then I have another slate for 13/65

55 0.85
60 0.91
65 0.98
70 1.04
75 1.10

I dont need a slate for 10/70 as its the same PP02 as depth in ATMs so 70 to 100m is a doddle as it is for 10/50


I cant see anything too chalanging about this


ATB

MArk

 

[Jeff Pack]

What I learned from this incident, and I guess overall I agree with Mark, is that there are in dive procedures one can do to verify cells arent current limited. Doesnt matter if your cells are new or old.

Myself, I spike the cells to at least 1.5 several times during the dive. I also watch for any lags between cells as a warning. If any cells starts acting wacky, its off to the cell checker later.

 

[Michael Thornton]

Jeff
Thank you for sharing. I am truly sorry you had to experience this first hand. I have never had to drag someone on the surface in full kit as you described in a real life scenario. It has always been in training. Looking back do you think it would have been any faster and or easier to remove the equipment (yours and or his) before or during the swim back?
A few years ago we had to do this as a drill as part of my instructor trainer evaluation. I was the only one who chose to remove the equipment (both mine and the diver who was simulating LOC). I did the drill much faster and smoother than my classmates (IMHO). Granted we were in single tank set ups but I think I would try the same if I was in my CCR. I would be interested in your opinion since you have actually done this in real life.


Sent from my iPhone using Tapatalk

 

[Randy Thornton]

I totally agree with your thoughts here Bruce.

I certainly didn't say that this is OK, and I don't think it is OK. Those are your words.

The reason I ask is because there have now been three fatalities in the last few years with exactly the same root cause. All of them would presumably have been avoided if there weren't two expired cells in the system.

That doesn't mean that you should abandon all other mitigations. What I am suggesting is that if there are several mitigations available, why not do all of them. There is no doubt, in my experience, that cells that are within 18 months of manufacture date tend to fail less.

I don't think running all of your cells until they die, and then depending on your skills to detect the failure is a way to enhance safety.

There is a second lesson here too I think. We aren't doing a good enough job of communicating our knowledge. There was a presentation at OzTek 2013 that described this (assumed) failure mode in detail. Two divers probably died from the same failure.

By all means use the advanced skills that I know you have, but let's not encourage people to abandon the simple mitigations that are available.

Bruce

 

[Bruce Partridge]

Bruce

this is not an advanced skill, this is Mod1 level stuff. I fail to see how anyone can dive a CCR without this very basic understanding of how to check cells

ATB

MArk

Mark,

Yet we have at least two cases of instructors, while teaching a course, dying because they incorrectly diagnosed a cell problem. I suspect that Ron is the the third.

The fact that you don't see it that way doesn't make it false.

By all means verify your cells. On the other hand, I think it would be reckless to try to convince people that their skills will always protect them. The field of safety systems has evolved to specifically address the fact that humans are inherently fallible, and that we should protect them with layers of mitigation where possible.

The sugestion is, My cells are in date QED I dont need to do cell checks???

ATB

MArk

Again, I am not saying that. Those are your words.

Bruce

 

[Garth]

Just like people remember where they were when the twin towers in NYC were attacked, I will always remember reading the post about the cell failure on Facebook then reading the post days later about the tragedy.

I'm not joking. This case affected me. I think about it a lot particularly every time I analyze my cells.

So sorry you had to go through this Jeff and thank you for sharing this on here. It really goes to show that even some of the best divers out there can suffer an incident if not situationally aware of danger.

Garth


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[Jeff Pack]

Jeff
Thank you for sharing. I am truly sorry you had to experience this first hand. I have never had to drag someone on the surface in full kit as you described in a real life scenario. It has always been in training. Looking back do you think it would have been any faster and or easier to remove the equipment (yours and or his) before or during the swim back?
A few years ago we had to do this as a drill as part of my instructor trainer evaluation. I was the only one who chose to remove the equipment (both mine and the diver who was simulating LOC). I did the drill much faster and smoother than my classmates (IMHO). Granted we were in single tank set ups but I think I would try the same if I was in my CCR. I would be interested in your opinion since you have actually done this in real life.


Sent from my iPhone using Tapatalk

An interesting question. Getting out of a rebreather and twin 80's, canister light and heater packs, drysuit connections (heater and inflator), in the water, while trying to manage a down diver. I dont think it'd be possible.

 

[Mark Chase]

Mark,

Yet we have at least two cases of instructors, while teaching a course, dying because they incorrectly diagnosed a cell problem. I suspect that Ron is the the third.

The fact that you don't see it that way doesn't make it false.

By all means verify your cells. On the other hand, I think it would be reckless to try to convince people that their skills will always protect them. The field of safety systems has evolved to specifically address the fact that humans are inherently fallible, and that we should protect them with layers of mitigation where possible.


Bruce

This is where we are poles apart.

I think it reckless to relly on low budget automated safety systems IE ones without millions of pounds worth of R&D and development testing, just like the CCRs we ALL dive today are

There is a 100% sure way to manualy test cells function against a known diluient during a dive and it can even be done on a Inspo Classic

You put forward "instructors" as if they were somehow above diving badly. I have dived with several instructors and they all to a man take the piss underwater

Manual cell checks are not taught properly on any CCR training sylabus i have came across, so why should you beleive instructors teaching said courses are doing it themselves.

Instructors are just divers who thaught it would be fun to teach or decided to try and make a living at it. Many are crap divers. Many dont have a lot of experiance, many take the piss due to overconfidance. Most drink the cool ade for the unit they dive and were instrucotr tained on and dont think outside the box. (no pun intended)

Again, I am not saying that. Those are your words.

Your implying it even if you dont realise you are

Manual safety checks on cells would have saved this divers life, there is no doubt about it. The error would have been discovered on the previos survived dive.

New cells would not have helped in any way because when they fail (and they do fail) they fail just like old cells and often worse as its less predictable so whilst the failure rate of new cells may be lower (i dispute this) it would just have delayed the enevitable untill one day a new cell failed.

Aside from Posidons rather dodgy (IMHO) claim to do mid dive cell testing I don't see any other currently available systems out there.

Presure testing cells dry is a dive saver but would never replace mid dive cell checks. Cells work right up till the point they dont and on a 3 hour dive in high humidity conditions thats very likley to be underwater.

ATB

Mark