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207 of the Rebreather Fatal Accidents to 7th October 2010
Context
Each one of the accidents listed overleaf was a personal tragedy for a diver, his family and friends. The list includes many exceptional
people that were enjoying life to the full, enriching us in the process: a Nobel Prize-winner, leading underwater explorers, photographers that
created NatGeo documentaries for the masses, and above all decent, kind and gentle people who were the breadwinners and emotional
cornerstones for their families. The majority were cut off in their prime (average Decadent age is 44 and around 97% of the Decadents are
male). hundreds of deaths, most of which appear to be easily avoidable, rebreather accidents are treated with indifference. Until Deep Life
Despite
invested the effort to compile this list, no manufacturer or training agency had catalogued them: an essential step to avoid the lessons from
these accidents being repeated - experience is a hard teacher, but the wise learn from the experience of others. A few courageous widows
attempted to compile lists to show the scale of this slaughter. Divermole in the UK made a good start on a list for one of the most dangerous
rebreathers at the time. Manufacturer's accident data on their own rebreathers has been for the most part, sporadic, incomplete and in
some cases, heavily biased either to avoid liability or due to lack of knowledge of Functional Safety methods.
Some manufacturers have vehemently opposed publication of this data, attacking those who dare to stand up to question them, in a manner
reminiscent of the tobacco industry in the 1970s. The US legal counsel of one manufacturer has gone as far as creating a web site to
slander the Expert Witness whom they fear most, and solicited negative articles in journals they advertise in: blatant attempts to discredit the
witness and to silence others. Other witnesses have received legal threats, and many live under commercial pressure to keep silent.
Some web forum with connections to manufacturers fostered a cabal that orchestrated attacks on individuals highlighting safety, by selective
site moderation. The ethics of the industry are at the level where at least one rebreather widow and her infant daughter had their home, bank
accounts and family wages attached by the manufacturer of the rebreather that killed their breadwinner even though the amount recoverable
is most unlikely to cover the legal cost involved in the attachment. It is a good sign that two of the newest sport rebreather companies are
taking a very limited to approach, in which there is a desire forrecord: most Health the exception rather than the rule in the sports rebreather
Denial is not different those manufacturers that have a poor integrity, but this is and Safety agencies have abrogated their responsibilities,
pretending that nobody uses sports rebreathers for work - not the instructors, diver masters etc. No action is taken against companies
touting fraudulent rebreather certifications, nor against bodies who issue CE certifications for equipment that does not come close to meeting
the Harmonised standard. In re-audits, equipment has been presented that is very different from that involved in the relevant accidents. All
but five of the national standards bodies responsible for diver safety in Europe have put commercial interests ahead of safety by pressing for
all Functional Safety requirements to be removed from rebreather standards while retaining expensive non-safety related tests that are
barriers to new entrants trying to bring safer equipment to the market. Divers too deny the hazard, particularly the less experienced. As
compilers of this list, we long for the time when this list stops having accidents added to it that would have been prevented had certified
Functional Safety processes been applied: to achieve that, those with responsibility for dive safety need to achieve competency in Functional
Safety, seek
Overall Analysis out the data and apply the lessons that it contains. Our mission is to catalogue that data.
1. The fatal accident risk of non-decompression diving is around 1 fatality in 9500 diver-years in North America and Europe (from DAN and
BSAC annual reports). This list can be divided into accidents that do not involve the rebreather, and those that do. The rate of non-
rebreather related accidents in this list is much higher than for diving in general at around 1 in 950 diver-years, based on the best available
diver population data, and the average rate of rebreather related accidents is between 1 in 100 diver-years. For reference, the highest risk
activity that is considered socially acceptable is that of a woman giving birth in a developed country: this carries a 1 in 10,000 fatality risk to
the woman. Using that metric, the rebreathers in this list, used in the manner they are, are around 100 times more risky than socially
accepted high risk activities, and Technical Diving is ten times more risky. This list is incomplete, so the risks may be up to twice that quoted
here. Rebreather divers appear to use a rebreather sold to them for an average of 2.5 years: the most popular rebreather is involved in one
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2. What these statistics mean is that equipment is a factor in around 90% of rebreather accidents, using the same methods for statistical
analysis as DAN. The average rebreather Decadent is slightly younger than the average Open Circuit decadent (44 compared to 48), is
involved in a much deeper dive (60m compared to 24m for O.C.), and is much more likely to be in an overhead environment. The higher risk
profile of the rebreather diver accounts for around a tenth of the accidents listed, based on the accident rate of fatalities that do not have a
3. All risk or trigger involving are for diver-years for the period 1998 to 2006. It is not known how diver-years compares with risk per dive:
root causerates quoted above the rebreather.
many Open Circuit instructors do huge numbers of dives, but the DAN figure of up to 900,000 divers in the USA and Canada includes many
who do only a couple of dives a year. Few rebreather divers do anything close to the number of dives as Open Circuit instructors in popular
resorts, and there are many rebreather divers whose diving activity is almost dormant.
4. No rebreather manufacturer in this list here has applied any recognised Functional Safety standard. Virtually all oppose those standards.
Furthermore, until this list was compiled accidents were analysed by persons with no Functional Safety training whatsoever. This present
analysis concludes that 80% to 90% of these accidents would likely never have occurred had Functional Safety been applied. The situation
is that one of the most popular rebreather electronics and software was developed by a lone salesman without any engineering training, and
rebreather development projects have been led by sales people without anything but the minimum statutory school education. Thousands of
those rebreathers have been sold. It is hardly surprising therefore that many deaths occur: ignorance of Functional Safety appears to be the
biggest killer - see Kruger & Denning, "Unskilled and Unaware of it: How Difficulties in Recognising One's Own Incompetence Lead to
Inflated Self-Assessments", Journal of Personality and Social Psychology 1999, Vol 77, No. 6, pp 1121-1134. The opposition by
manufacturers to efforts to apply recognised Functional Safety standards to rebreathers is damning, as is the indifference of the community
Method
Accidents are classified by most probable cause, using rebreather fault trees developed in a certified IEC 61508 process to determine Root
Cause analysis (identifying Root Cause, Trigger, Disabling Agent, Cause of Death). Observations and comments are in a separate column
to the facts reported.
Definitions
Human Error is assigned when the root cause of the accident is due to the diver choosing to dive a piece of equipment known to be
malfunctioning or has wilfully ignored an instruction or essential dive procedure that led to the root cause.
General Diving Hazard is assigned where an accident would have occurred even if the diver had been on open circuit.
Rebreather Issue is assigned where the root cause was due to using a rebreather instead of open circuit. Where possible, these are further
If the root cause of an accident would have been identified by a HAZOP and it is within ALARP to mitigate the fault then it classified as a
Rebreather Design Fault.
If the accident would not have happened if the equipment had met EN14143 then it is also classified as a Rebreather Design Fault,
regardless of which year the equipment was introduced.
All accidents resulting in hypoxia are classified as Rebreather Design Fault unless the diver has been reckless, such as wilfully ignored
instructions or missed basic training or ignored alarms when tanks have been switched off on the surface: in those events the accident is
If the root a Human error.
classified as cause was due to the diver exceeding the known performance envelope of the rebreather then it is classified as Exceeded
Performance Envelope / Human error
Heart Attack , is indicated where the best information available states the cause is a heart attack: an autopsy result is given precedence
over a coroner report, which is given precedence over medical paramedics at accident scene, and finally witnesses. There is an excessive
number of heart attacks on this list, and it has been postulated that some of these may be due to high CO2 instead.
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Experience levels are: Trainee 1000 hours or > 10 years of rebreather diving. These levels are specific to rebreathers - experience on Open Circuit is not
considered.
Accuracy
1. Extensive audit and analysis of this data has been carried out. A separate file contains the source information from one of those
analyses: see the Combined Analysis on this web site. The data that follows is published in Excel format, so you can sort the data, check it,
review it, and analyse it to publish your own conclusions. We strive for accuracy, despite the chaos that often surrounds a fatal accident,
with conflicting interests reporting data. The method of Root Cause Analysis is the same as that used by DAN accident researchers. Fault
Tree Analysis provides the highest degree of rigour, using what information is available from witnesses. However, there is one big error we
2. After this list was attacked by a manufacturer claiming accidents on their missing from this list.
must declare: this list is not comprehensive - there are rebreather accidentsunit did not happen, we took the exceptional step of publishing
the names of each Decadent (almost all were known for that manufacturer's rebreather), and provide a public web link per accident so
anyone can start the process of tracing the data themselves. Several parties have audited this list, searching for error, and the difference
between this list and their audits has been 2 to 3%: the list is accurate for statistical purposes - most of that the audit difference is due to data
simply not being available to the auditor in a brief web search. The latest event in this saga is that in the autumn of 2010, after 10 years of
opposition that manufacturer released indirectly their summaries of the accidents involving their equipment. The very good accuracy of this
list when checked against that block of new data surprised even the compilers and editors of this list: an internet forum claiming to be
creating a definitive database of accident facts has based their data on this list - complete with typos removed 6 months ago, indicating again
3. Please advise all errors to accidents@balticinstitute.ru indicating clearly the confidentiality or otherwise of the date: i.e. what is public,
what is not, what is regarded as sub-judicae in the country where the accident occurred.
Note on special provision to protect manufacturer's reputation from effect of small sample sizes:
New rebreathers tend to have a small population size, but random accidents can still occur. When a rebreather has its first accident in
circumstances where it is obvious the accident would have occurred even if the diver were on Open Circuit then the Rebreather type will be
stated as "Not related to accident" to avoid risks being extrapolated unfairly from this data. When a second accident on the same type of
rebreather occurs, the rebreather type will be stated for all accidents on that unit, so the community can track accidents using Open Circuit
accident rates for comparison. At this time, there are no accidents where the rebreather identity has been withheld under this fairness
provision .
Other Exclusions:
1. Military accidents and commercial diving accidents are not included on this list, unless the diver was using sports diving equipment.
2. This list is not by any means comprehensive. Many rebreather accidents are not reported as rebreather accidents, but simply as a diving fatality.
There are many accidents that have not been verified by traceable evidence that it was definitely a rebreather accident, so those accidents are NOT
on this list. In addition accidents in 3rd world countries, and on dive charters, are usually covered up: there is poor reporting of these even back in
the diver's home country from accidents that have been tracked. For example, in the Seychelles the loss of 14 divers in a single event did not even
make the local papers, nor any papers back home indicating it was diving related (the dive boat sank). Other accidents occur in the UK, Europe and
the USA where there are unconfirmed reports of the diver using a rebreather but until a DAN report or BSAC report is published with circumstances
that match the known details, or a corroborating source confirming the diver was on a rebreather, then the accident is not included on this list. For
example, in the UK in 2009 there were 3 accidents confirmed to be fatal dive accidents, informal reports of the diver being on a rebreather, but no
definite confirmation during 2009 that the rebreather the diver took on the boat in each case was used on the fatal dive. Added to this, rebreather
specific internet forums that rely on advertising revenue are now suppressing new accident reports while focusing on old accidents already on this
list, even where the new accidents are from credible and verified sources: essentially, the industry in general is covering up the truth and vigorously
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3. One sports accident is excluded because after the diver was formally pronounced dead, he came around. Numerous accidents are excluded
where the diver lost consciousness in the water and was rescued then resuscitated. The definition of a fatal accident used for this list, is an event
arising from a rebreather dive that results in at least one person becoming clinically dead permanently. There are very many rebreather accidents
that have resulted in the long terms disablement of the diver, none of which are on this list. There is one accident where the diver has been missing
underwater for several days: when the accident was first reported, the decision was made to wait three days in the hope the diver is rescued, but
there was no rescue so after 3 days it went onto this list; it has been withdrawn as it is understood there are still hopes to find the diver, which we
Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
207 03/10/2010 Eric Establie Dual: EDO 04 Unknown Solo cave dive 52/87 Dragonnière Guru 52
modified as Gaud, France
mccr and EDO
04 pSCR
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Root Case Disabling Injury Key information received on accident
General diving hazard / Entrapment 3rd Oct The French Cave Rescue was alerted of the late return of a diver from a dive
Entrapment team of cavers who were exploring the Dragonnière Gaud near the town Labastide de
Virac, Ardeche. He was gone for a dive with dual rebreathers with dual scooters. A
reconnaissance dive to the landing was carried by his teammates at around 19:30,
without success.
6th Oct the British diving team found at 780 meters from the entrance a closure of the
cave by a clogging of gravel resulting from a ground shift or slide.
One of Deceased‟s DPV „s was found trapped in the direction of the exit. Rescuers
believed that the diver, after trying unsuccessfully to dig to cross this narrow passage,
has deliberately left his DPV visible at this place to indicate that he could not clear the
obstacle.
11 Oct Deceased was found dead by the British sidemount divers at a distance of
about 900-950m from the basin inlet trap. It was a low point in this gallery at a depth of-
70m.
Water temp was 12‟C with poor visibility once silt was disturbed.
Analysis of Deceased's computer shows that he died 5 hours 20 minutes after the start
of his dive. It shows he did reach an air surface beyond the restriction and then
returned to it, where he spent about 2 hours trying to get through.
The French press also reports that one of the two British divers (they don't say which)
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Divers equipment other then dive computer not yet
recovered. Appears to be land slide trapping the diver as
the sole cause.
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An external reference confirming that
accident occurred
http://translate.googleusercontent.com/translate_c?hl
=en&sl=fr&u=http://ssf.ffspeleo.fr/index.php%3Foptio
n%3Dcom_content%26view%3Darticle%26id%3D42
3:2010-10-03-dragonniere-de-gaud-ardeche-
07%26catid%3D39:encours%26Itemid%3D83&prev=
/search%3Fq%3Dplongeescout%26hl%3Den%26clie
nt%3Dfirefox-
a%26hs%3D1JQ%26rls%3Dorg.mozilla:en-
US:official&rurl=translate.google.com.au&usg=ALkJr
hi8T2SZjG5yvjQuFfM_6wdjLWhpqA
http://www.rebreatherworld.com/rebreather-accidents-
incidents/35477-dragonniere-rescue-eric-establie-
6.html#post339169
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
206 9/10/2010 Rob Lower Inspiration Classic APD Classic Solo dive 75 USA, Hawaii Expert 29
(2010)
205 7/31/2010 Yasuko Fiasco KISS Classic Jetsam Buddy dive then solo 35 USA, NJ, Arundo Expert 28
Okada mCCR Wreck
204 7/25/2010 Ziga Dobrajc Voyager SCR Unknown Try dive 4 Italy, Miramare Trainee 31
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Root Case Disabling Injury Key information received on accident
Human Error / DCS Gas Embolism Daily diving to 75m to 100m. Collecting fish professionally for sale to the aquarium
trade, in this case Masked Angel Fish, a rare species. Despite mild DCS symptoms
from a dive the previous day, to > 90m depth, Deceased dived to 75m without a viable
dive computer: Deceased had his dive computer fail a few days prior to the accident,
and it is reported that the replacement computer either did not support a fixed PPO2 or
was not available - conflicting reports received. Replacement computer would not
have his very high tissue compartment loadings in any case. Deceased surfaced from
the 75m deep dive suffering DCS symptoms which became worse on the boat.
Deceased was flown to a chamber from Kauai. Recompressed because he had the
bends and a seizure. Deceased stopped breathing in the chamber and they couldn‟t
resuscitate him after an hour. Reported Cerebral Embolism. Deceased had been
advised that his dive practices were extremely hazardous. Deceased chose to dive
when he knew he did not have adequate decompression data, and was already
suffering from DCS, when from his training he would have known he should seek
Scant data Scant data Scant data. Deceased used the KISS when she passed cave diver training in 2009:
http://www.scubafi.com/scubafi/Trip_Reports/Entries/2009/12/7_Team_Olsen_goes_ca
ve_diving.html so would be at least expert level on the KISS. CO2 scrubber status
unknown at this time.
Rebreather design fault Hypoxia Twelve Slovenian and Trieste Scientific Divers with two instructors were conducting
/ Training issue rebreather try-dives in shallow water off Miramare over a 4 day period, as part of a
sales effort to sell Voyager rebreathers to the Slovenian National Institute of Biology,
Marine Station Piran. The first diver, a Slovenian Tech Staff Member, was seen by one
of the instructors, Marco Panico who is also a policeman, floating face down in front of
the Ducal Bath, near the Castle, at 11:20am, at a point where the depth is only 4
meters. The diver was recovered to the shore, CPR was applied during transport to
Grignano harbour where an EMS team was present. The diver was then taken to
Cattinara hospital where the diver was put on life support for 4 days. Scans showed no
signs of brain activity so was declared clinically dead following scans to search for
brain activity. Later on during the day the first diver had his fatal accident, another
Slovenian diver was noticed missing and his body found 4 hours later: that is there
were two separate fatalities with the same dive group in one day: see below.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
The Deceased was ignoring the most basic rules of diving, Training should Add decompression computation
apparently believing he was immortal. Any replacement emphasise that doing functions to eCCRs.
computer would not have the correct loadings unless the another deep dive is not
diver took a rest for several days, which he did not. Diver treatment for DCS, but
left behind his wife and young daughter, and was well likely to make matters far
regarded as a nice guy. Legislation being introduced to worse. Also, if a diver can
ban tropical fish collection from January may have placed feel offgasing, it is
some pressure on the diver to collect before the ban because of large bubbles
comes into place: see that trigger DCS: using a
http://www.westhawaiitoday.com/articles/2010/08/05/local/l feeling instead of a dive
ocal01.txt Classified as a solo dive, because the buddy computer will result in a
was at 18m and the Deceased was at 75m, both of whom serious accident, probably
were trying to catch fish. Deco practice was outside that sooner rather than later.
supported by any dive training agency, hence Human Error
Tribute on
http://mikesdivelog.blogspot.com/2010/08/farewell-fi.html
This particular accident appears to be a combination of Voyager was identified in the stats
poor equipment design, poor supervision and inadequate analysis from this list as being by far
training. Dives are described as 'try dives" but are more the most dangerous rebreather in the
like "test dives" using experienced divers who are market. The Voyager is massively
unfamiliar with rebreathers. over-represented on this list, and the
over-representation has a probability
of more than 99.95% of being
statistically significant. Manufacturer
claims to have sold over 900
rebreathers, which would alter the
stats, but this figure of 900
rebreathers is contradicted by dive
shop surveys and ludicrous. See
below.
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An external reference confirming that
accident occurred
http://reefbuilders.com/2010/09/11/rare-fish-collector-
rob-dies-diverelated-injuries
http://mikesdivelog.blogspot.com/2010/08/farewell-
fi.html
See immediately below
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
203 7/25/2010 Samos Alajbegovic Voyager SCR Unknown Try dive 7 Italy, Miramare Trainee 41
202 7/21/2010 Wes Skiles O2ptima HH Buddy Dive 23 USA, Florida, Guru 52
Marathon
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Root Case Disabling Injury Key information received on accident
Rebreather design fault Hypoxia Connected with accident above.
/ Training issue A dozen divers accompanied by two instructors from NUET (North Underwater
Explorer Team). Dived in wetsuits in a series of organised try dives in Miramare, over a
four day period from 23rd to 25th July 2010, in shallow waters with objective of
photography and test the quality of the rebreather.
The first accident on 25th July at 11:20am was a factor in the organisers failing to
realise that a second Slovenian try diver, a biologist, did not emerge along with the rest
of the group. Around thirty people including the Dive Master, firefighters, police and
marine police team searched the length and breadth of the seabed of the Reserve for
about four hours. The Deceased was found around 15:00 hours, laying at a depth of
seven metres, about forty meters from the Sphinx of the Park of Miramare.
Coroner Fuliani Denny reported no external injuries. Medics on site appear unfamiliar
with diving accidents let alone rebreathers: "From a doctor - said Fuliani - it is plausible
that there has been a gas embolism. Hypothesis compatible with deposits found in the
counterlungs. Less probable is cardiac illness, especially as the two divers felt ill a few
minutes apart." - a body at 7m for four hours will offgas heavily when recovered. Also
Doctor Fulvio Costantinides and his radiologist doctor Fabio Cavalli performed a 3D
Scant data Scant data Reported to have died during a photographic shoot for National Geographic on ultra
fast photography. "Diving off the Boynton Inlet ( between West Palm Beach and Boca
Raton ) on a private boat with two other divers. They were probably on the third reef but
not confirmed, in 77 feet of water, run time at recovery was 103 minutes. Deceased
signaled he was going up for more film after an hour of diving filming Goliath Groupers,
one other diver went up shortly thereafter and didn't find Deceased on the surface,
went back down and found him laying on the reef 25 minutes later. Taken to a local
hospital in Palm Beach County, DOA. For the prior three days plus the day of the
accident, Deceased was using a borrowed Dive Rite O2ptima. Prior to this four days of
diving, Deceased is reported to have never dived an O2ptima and he was not formally
trained on the O2ptima, but this is not confirmed because the Deceased has a feature
page on the Dive-rite site as an apparent sponsored O2ptima user.
The O2ptima was not fitted with any on board bailout system (although normally
supplied with one) and he was not carrying any off board bailout. The accident
occurred sometime in the last thirty minutes of the run time (so approximately 73
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Investigating coroner is Fuliani Denny. Rebreather diving The Voyager was sold on the basis of
organised by NUET Company (Underwater Explorer North a false CE cert from an incompetent
Team) & attached info reflects that this is a rebreather Notified Body in Trieste who is not
sales setup. Not clear if the accident was caused by accredited under the PPE Directive:
hypoxia or hypercapnia - low probability of underlying S.T.E.A.M. ss Sicurezza Tecnologia
medical causes. Waiting on Coroner's report. Based on Energia Ambiente c Mare Divisione
the book http://www.blurb.com/bookstore/detail/1197355 Mare. It is not known if RINA have
they use Voyager rebreathers {Rhib also appears to match certified it subsequently: in reality,
with the one doing the body recovery in one of the none of the Voyager rebreathers
Scubaboard post links}. The reports indicate less than come close to meeting EN 14143,
competent examination of the rebreather, and medical neither do they meet the PPE
ignorance of the main hazards of the rebreather. Directive.
Subsequently they let the manufacturer examine the
equipment and funnily enough nothing was wrong with it!
Application of the fault tree concludes hypoxia for the first
accident, and either hypercapnia or hypoxia for the
second.
One of the best underwater photographers, with extensive
cave diving experience: he became a certified cave diver
at age 16! See
http://www.gainesville.com/article/20100418/MAGAZINE01
/100419415?p=1&tc=pg and
http://ngm.nationalgeographic.com/2010/08/bahamas-
caves/skiles-photography and tributes on
http://www.caves.org/committee/salons/Skiles_Tribute.htm
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An external reference confirming that
accident occurred
http://translate.google.com.au/translate?hl=en&sl=it&
u=http://www.informatrieste.eu/blog/blog.php%3Fid%
3D6961&ei=lGlNTITPHpDIvQPpjpC7Cg&sa=X&oi=tr
anslate&ct=result&resnum=10&ved=0CEwQ7gEwC
Q&prev=/search%3Fq%3DNUET%2Brebreather%26
hl%3Den%26client%3Dfirefox-
a%26hs%3Dx0L%26sa%3DX%26rls%3Dorg.mozilla:
en-US:official%26nfpr%3D1
http://www.cavediver.net/forum/showthread.php/1396
2-Wes-Skiles-accident-analysis
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
201 7/17/2010 Tony Pratley Dolphin modified Unknown Buddy dive 37 Australia, Scant data 49
to be mCCR Queenscliff, SS
Rotamahana
wreck
200 6/27/2010 Leszek Nowak Inspiration Vision APD Vision Extreme Diving 20m => fall later 40mètres => 0m ==> 6mètres ==> end
surfaces. Deceased had a Meg and Inspo (Inspiration instructor) fitted with a Polish
Nemo Solutions BOV: not clear which was in use on the day of the accident.
Rebreather issue Hypercapnia or hypoxia Deceased died after getting into difficulty during his ascent from the wreck of the
Chrisoula K, in the Abu Nuhas area. Deceased was using his own Buddy Inspiration
Classic closed-circuit rebreather, was reported to have been underwater for 45 minutes
before losing consciousness at a depth of 10m while in the company of other divers.
Resuscitation attempts started in the water and continued on the dive boat, but
Deceased did not regain consciousness and was later pronounced dead.
His equipment has been sent to a tester "approved by its manufacturer".
Rebreather issue Hypoxia Body found floating on the surface 15 minutes after a boat dive near the shore.
Deceased was the divemaster.
Rebreather issue / Hyperoxia Deceased found unconscious on surface. Unconfirmed report diver bailed out from
Human error rebreather onto 54% Nitrox at 42m after rebreather failure.
Page 38 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Asian forum appears to have divers competing for the
maximum depth on a rebreather. There is assumed to be a
beat other divers depth attempt, as the depth with the
accident in April running from the same port is too
coincidental.
As above, double fatality.
Var is visited by 20,000 divers a year. 2 accidents there in
2009.
Most plausible cause hyperoxia. Human error in not Questions have been
having appropriate bail out if report is correct. However, raised with regard to the
as the chain started with a rebreather failure, that is the adequacy of the diver
root cause. Both hypoxia and hypercapnia on a rebreather training that the
can lead to subsequent inappropriate actions. manufacturer supports.
Page 39 of 210
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An external reference confirming that
accident occurred
Governmental source
Governmental source
http://translate.google.com.au/translatehl=en&sl=fr&u
=http://pscausette.plongeesout.com/viewtopic.php%3
Ff%3D2%26t%3D1332&ei=U2q1S5zXLs2TkAW106
CRDQ&sa=X&oi=translate&ct=result&resnum=8&ve
d=0CCAQ7gEwBw&prev=/search%3Fq%3Dstephan
e%2Bhavard%26hl%3Den%26client%3Dfirefox-
a%26hs%3D2Ct%26rls%3Dorg.mozilla:en-
US:official
http://translate.google.com.au/translate?u=http%3A%
2F%2Fwww.ninjadivers.dk%2F&sl=da&tl=en&hl=&ie
=UTF-8
http://www.philstar.com/Article.aspx?articleId=52690
6&publicationSubCategoryId=107
Page 40 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
189 11/14/2009 Timothy Evolution Vision APD Vision Buddy dive 25 USA, Key West, Experienced 51
Teagarden Oriskany Wreck
188 11/13/2009 Richard McCoy Jr Sentinel VR Buddy dive 27 USA, Key West, Experienced 51
Vandenburg
Wreck
187 11/5/2009 Stewart Wright Inspiration Vision APD Vision Solo Diving 70 UK, Cumbria, Scant data 39
Wastwater
186 11/3/2009 Jim Woodall Evolution APD Vision Cave Diving 72 USA, Eagle's Experienced 39
Nest cave
Page 41 of 210
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Root Case Disabling Injury Key information received on accident
Scant data Scant data Autopsy describes Deceased as having a good picture of health. Police investigation
is focusing on equipment.
Underlying Hypercapnia / heart attack Deceased had been down about 95 feet with two instructors, just after noon, when he
illness/Rebreather issue reportedly began having trouble. The instructors began helping Deceased, but he
stopped breathing about 25 feet from the surface. Visibility on the site was reported to
be approximately 40 feet with a mild to moderate current running southeast. There is
no indication at this point as to whether or not the rebreather technology malfunctioned
and this was clearly a non-penetration dive conducted on one of the main decks
outside of the wreck. The accident occurred from the vessel M.V. Spree. By all
accounts available at this time, both the supervising team in the water and the vessel‟s
crew responded effectively and made every effort to assist the injured diver.
Scant data Scant data Scant data. Stewybear on forums.
Rebreather issue Hypercapnia Two divers both on rebreathers with 18/30 mix, were exiting a 1000' penetration
upstream when the Deceased showed signs of agitation in the Super Room area while
exiting...the surviving diver offered his bailout gas three times, was rejected three
times, then the Deceased went comatose on the bottom. The Deceased's AL80 BOB
had 1000 or so psi in it, indicating that he may have been on it a while, trying to solve
his issues (with PPO2 of 1.8). They were swimming, not scootering, and the Deceased
was apparently a large man, so towing via swim was not an option for the survivor.
Divers reported to have dove downstream to John's Pocket the day before, with
scrubbers packed several days before in Kentucky, then drove to Orlando, then to the
Nest.
Page 42 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Moderate current at 95ft, followed by events described,
results in the classification using the Fault Tree. More firm
data would be useful in determining which cause was the
trigger.
Page 43 of 210
1cd741fb-406a-44d0-a1ff-d2e0ca24226e.xls
An external reference confirming that
accident occurred
http://seaduction.com/scuba-diving/vandenberg-
death-rebreather/
http://www.yorkshire-divers.com/forums/incident-
reports/99283-death-diver-wass-water-5-nov-2009-
yd-member-stewybear-9.html
Page 44 of 210
1cd741fb-406a-44d0-a1ff-d2e0ca24226e.xls
Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
185 10/27/2009 Dr. Marcus Lim Megalodon ISC Buddy dive 25 Malaysia, Pulau Unknown 37
Aur
184 10/21/2009 Andy Letourneau Inspiration Classic APD Classic Solo dive Scant data British Columbia, Guru 46
Port Hardy
183 9/23/2009 Jerry Gunderson Unknown O2- Unknown Solo dive 8 USA, Florida, Guru 75
CCR Deerfield Beach
182 8/5/2009 Colin Bell Inspiration with HH Buddy dive 55 UK, Hartlepool Experienced 52
HH electronics
181 8/2/2009 Dean Repola Inspiration APD Scant data Scant data USA, NJ Guru 48
Page 45 of 210
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Root Case Disabling Injury Key information received on accident
Scant data Scant Data Friends of the Singapore National Eye Centre specialist who died in a diving accident
on Saturday said he was feeling well before the accident.
One of the divers who tried to resuscitate Dr Marcus Lim recounted the tragedy.
On Saturday, Deceased was diving near a shipwreck in the South China Sea. He was
honing his skills in preparation for a diving expedition to Antarctica in 2010.
A friend of the Deceased who was there said Dr Lim, who was feeling well before the
dive and went down with a group of three others under calm sea conditions,
experienced some difficulties after 23 minutes underwater. Deceased was brought to
the surface and lost consciousness.
Jay Siak, dive buddy of Deceased, said: “CPR was commenced, and the boat set sail
for the nearest hospital which is Mersing Hospital. But despite four hours of CPR, we
could not revive him.
Scant data Scant data Scant data. Equipment recovered and being checked by Canadian Navy.
Underlying Illness Heart attack or Hyperoxia Deceased was collecting golf balls from the lake using an oxygen rebreather. Found
dead in the centre of the lake at the Deer Creek Country Club in Deerfield Beach,
Florida. Used Grace Sodasorb. Unconfirmed report of mild heart attack in the water a
few years earlier. Diver used high O2 tox limits.
Scant data Hypoxia Scant data. Diver made rapid ascent from deco stop. Diver found unconscious on
surface.
Experienced diver although initial reports state he was not trained on rebreather.
Reported to have bought unit 2nd hand two weeks earlier. Modified frame and larger
cylinders not relevant to accident.
Scant data Scant Data Scant data. Body not recovered.
Page 46 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Dr Lim was passionate about photography and he was
able to combine this with his love of diving to stunning
effect.
Sudden LOC on ascent results in most plausible cause
being hypoxia on a rebreather.
Page 47 of 210
1cd741fb-406a-44d0-a1ff-d2e0ca24226e.xls
An external reference confirming that
accident occurred
http://www.bigbluetech.net/big-blue-tech-
news/2009/11/01/rebreather-diver-fatality/
http://www.scubaboard.com/forums/accidents-
incidents/305257-golf-ball-diver-dies.
http://www.cdnn.info/news/safety/s090809b.html
http://www.vancouverite.com/2009/10/08/oregon-
man-dies-in-b-c-diving-accident/
Page 48 of 210
1cd741fb-406a-44d0-a1ff-d2e0ca24226e.xls
Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
180 25/06/2009 Phil. J. Patz Highly modified HH Solo Shore Dive 90 USA, Lake Experienced 48
BMI BMR500, Michigan
with a reversed
loop, water trap,
switchable adv
for diluent or O2,
HH Elecs . No
HUD. BMR500
DSV.
179 23/06/2009 Bob Lenham Inspiration APD Buddy dive 60 UK, English Expert 61
Channel, Empire
Javelin
178 12/06/2009 Claudio Menchin Inspiration Vision APD Vision Solo Diving 13 Italy, Porto Santo Unknown 39
Stefano
Page 49 of 210
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Root Case Disabling Injury Key information received on accident
Rebreather design fault Hypercapnia Known data: Solo shore dive. Deceased known to use 10/90 mix for these dives which
is hypoxic on the surface instead of 16/84 which could have been used and would have
provided a breathable gas on the surface. Rebreather was based on a BMI500 or
BMR500 but heavily modified. Comments made that modifications may have included
mCCR functionality. The Deceased bought overhauled HH handsets meant for an
Inspiration and patched them into his rig using R10Ds. The cells would have had a
maximum readable ppO2 of about 1.15 to 1.20 because their output is double the
normal level, unless an additional load resistor is added. The handsets did not check
cell type or range automatically.
Scant data Scant Buddy lost track of Deceased when surfacing.
Rebreather issue Hypoxia Porto Santo Stefano: An experienced scuba diver, 39 years old, dived in the waters of
the Islet Argentarola at 15.30, telling two friends who accompanied him on a raft, he
would end the dive at around 18:30 . At 19:00, the two companions, seeing that he was
late and initiated the search and rescue procedures, contacting the Coast Guard patrol
boat 868, which began immediately to search for the missing diver, while the Fire
Department divers of the Nucleus of Grosseto and volunteers to local diving centers
have carried out an initial survey dive. At 22:00 the search was suspended because of
darkness. It was resumed the next day under the coordination of Coast Guard
operations room in Porto Santo Stefano, attended with three Coast Guard vessels in
Porto Santo Stefano (CP 2087, 868 and 803) and the Fire Department, with divers
from Grosseto, Florence, Livorno and Romand a AB 412 helicopter froim Arezzo. At
15:20, the Rome Fire Department found the body of the diver at a depth of
approximately 13 meters at the entrance of the cave on the south wall Isolotto
Argentarola, with no lifesigns evident. The magistrate on duty, Dr. Rossi has ordered
the investigative findings of the case, including seizure of the rebreather and autopsy to
determine the possible cause of death. Hypoxia reported. Manufacturer reports
Page 50 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Observations: Neither the original rebreather nor any
modifications had had any formal testing to determine the
functional limits. The modified rebreather was not even
characterised in its basic operation. BMR500 was
advertised as having 6 hour scrubber life at any depth
when in fact at 90m the scrubber life would be around 15
minutes based on tests using similar scrubber geometry
and load: BMR500 has an axial sub 2kg scrubber design
developed from an attempt to produce a cheaper civilian
Mk15/15.5 clone using concepts seen in the Biopak 240
(Biopak 240 was not engineered nor designed for diving).
Channelling is a significant risk, but the scrubber life is the
primary risk with this design. Given the very poor scrubber
design, depth profile and water temperature, hypercapnia
is the most plausible cause, rather than hyperoxia.
There are some reports of this model having a logging Logs are critical in understanding
issue with PPO2 recording. The other evidence points to accidents, so should be to
hypoxia. As the logs may not be entirely trustworthy, most recognised Functional Safety
probable cause is hypoxia. standards rather than some amateur
standard.
Page 51 of 210
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An external reference confirming that
accident occurred
http://www.wqad.com/news/sns-ap-wi--
diverdies,0,888623.story and
http://www.rebreatherworld.com/decompression-and-
gas-choices/22065-heliox-dil-s-what-have-you.html
http://www.timesonline.co.uk/tol/news/uk/article65662
66.ece and
http://www.rebreatherworld.com/members/bob-
lenham.html
http://translate.googleusercontent.com/translate_c?hl
=en&sl=it&tl=en&u=http://www.marescoop.com/ftopic
t-
1881.html%26sid%3D1b344f268d522aec7158719a1
02827aa&rurl=translate.google.com.au&usg=ALkJrhj
mqQ5cwEoNFVUyETfwG231nhqqRg
Page 52 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
177 24/05/2009 Carl Spencer Ouroboros VR Group Trimix Dive 100 Greece, Britannic Guru 37
176 18/05/2009 Paul Blanchette Jr Megalodon, pre ISC Solo diving 30 USA, MA Guru 50
2006
175 13/05/2009 Gene White Copis Meg ISC Copis Solo diving 0/35/35 USA, N.J. Expert 42
mCCR mCCR Bargegat Inlet
174 05/05/2009 Dewayne Smith Inspiration Modified by APD Buddy dive 20 USA, Key Largo Expert 36
for saturation
use
Page 53 of 210
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Root Case Disabling Injury Key information received on accident
Rebreather Hyperoxia Diver was reported as having been seen in difficulty on the bow of the Britannic.
failure/human error Report that rebreather flooded, in which case, diver's CNS clock would be reduced due
to CO2. Diver ascended and at 50m was offered O.C gas from one of the Deceased's
bottles by another diver. The bottle was not marked, but contained 50% deco gas,
hence MOD is 22m. Deceased then suffered a seizure and made a very fast ascent,
blowing all stops. Diver died of Pulmonary barotrauma / AGE / Explosive DCS.
Convulsions make the most probable cause of the disabling injury was CNS due to the
diver being susceptible to CNS from the high CO2 and then being given a deco gas
with a 22m MOD gas at 50msw. The origin of the accident is reported to be a flooded
rebreather, but accident progressed to the next level when diver was given the wrong
gas by another diver.
Rebreather Hypoxia Diver recovered several days after going missing. Indirect report from a person
failure/human error involved with the recovery, that the Oxygen cylinder valve on the CCR was turned off.
A person on the boat reported that he had a leak on that side and was messing around
with the regulator prior to entry, apparently fixed the leak, but failed to turn the gas back
on. No explanation for lack of alarms.
Rebreather fault / Hypoxia / hyperoxia Diver found at depth of 125fsw unconscious, after recovery, failed to revive. Witnesses
Human error said White lost consciousness as he was resurfacing and sank down. Mouthpiece
bitten through.
Rebreather design fault Hypoxia Diver found unconscious on sea floor. "Shepard said Tuesday‟s dive was going as
planned when Deceased signaled to his two fellow divers, dubbed aquanauts, that he
was headed back to Aquarius. A few minutes later he was found unconscious on the
ocean bottom.
Shepard said divers, who are all trained as first responders, carried him to Aquarius
and began performing basic first aid and CPR. A Navy doctor soon dove down from
the surface to assist, but it was too late. Deceased was pronounced dead at 3:25 p.m.
Unsafe software modification to rebreather (trying to use a sports product for sat
diving), caused eCCR controller to shut off underwater while being dived. Predive
check not done. Diver task loaded. Diver was having a bad day: previous dive had
problems with O-ring spacer not installed on scrubber and had less than ideal
monitoring of handsets. Diver did not notice there were no lights on HUD.
Page 54 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Expedition management allowed an unmarked cylinder on Unmarked cylinder in the
a mixed gas dive. water on a mixed gas
dive. Diver was not
carrying sufficient bail out.
As it is a pre-2006 Meg, investigators should consider
carefully all scrubber bypass faults as a routine, as well all
other potential faults as accident rate on pre-2006 units are
excessive.
Manufacturer subsequently issued a Warning "Inadvertent
Handset Operation by Underwater Hydraulic Equipment,
Oct 2009" which states clearly the equipment has got
states in which it does not support life, and these can be
entered into underwater (i.e. it is not a TTA architecture,
and has major errors in its electronics and software in
allowing this). It is understood that these events are
connected: that the accident was caused by the equipment
switching out of a life support mode underwater due to
vibration on the buttons.
Page 55 of 210
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An external reference confirming that
accident occurred
Confidential communication and news reports such
as
http://www.lastingtribute.co.uk/tribute/spencer/30845
62
http://coastguardnews.com/coast-guard-searching-
for-missing-diver-7/2009/05/18/
http://coastguardnews.com/coast-guard-aircrew-
medevacs-1-near-barnegat-nj/2009/05/16/#more-
10206
Jeff Godfrey offers a presentation entitled 'The
Evolution and Future of Rebreathers in Scientific
Diving' at the 2010 Northeast Rebreather &
Advanced Diving Technology Workshop, and
manufacturer's safety notice. See also 30m point on
http://www.youtube.com/watch%3Fv%3DVRLsvdlFke
M
Page 56 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
173 26/04/2009 Paul Leyland a.k.a. Inspiration APD Classic Solo diving 4.5 UK, Brixham Expert 51
"Odin" Classic, age (2000)
2000
172 28/03/2009 David Auteza KISS Classic Jetsam Cave Diving 68 France, Le Guru but KISS 31
mCCR Ressel novice
Page 57 of 210
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Root Case Disabling Injury Key information received on accident
Rebreather design fault Hypoxia Shore diving at Brixham and Deceased dived on his Classic with another diver
on a Classic and a trainee, shallow dive and for less than an hour. On returning to the
shore the trainee had dropped some equipment and Deceased returned to the water to
retrieve it - he was in the water for a short period of time (5-10 minutes) at a depth of
4.5m and surfaced unconscious, was recovered and resuscitated, and flown to
Derriford Hospital in Plymouth, but lost his life around 10.30pm. Inspiration was
manufactured in 2000 and while the head had been back to the manufacturer, it
appears to have the original handsets. Manufacturer raised various spurious issues at
inquest, such as reference to strain on solenoid wires, whilst failing to disclose the very
serious design defects in pre-2001 Inspiration handsets, namely they are liable to
hang, where the PPO2 displayed on the handsets appears to be normal, there are no
alarms, but the PPO2 is falling because the solenoid is not driven by the processor -
this usually occurs on water entry giving a 6 to 7 minute dive time for an average sized
diver swimming gently. Surprisingly, the manufacturer's report also makes no mention
of replacing any battery compartment: if it is the original, then it will compound the
handset issue.
Rebreather design fault WOB induced respiratory Two divers went in the cave "Ressel". One diver on trimix, second diver (Deceased) on
/ Human error spasm or CO2 retention air dil using a KISS acquired 10 days earlier. It was not a team: they didn't plan
anything together. Diver on trimix planned a 1000m penetration dive with trimix diluent,
the KISS diver on air did not have a plan other than a test dive in
the first shallow part of the cave. However, the second diver just followed the first
diver, even in the deep part. At 1080m from entrance, they made a U turn, but, on the
way back, they made a navigation error and missed the junction. Instead of going to
the exit, they went in another deep gallery. After 200m, at a depth of 68m, they realized
the mistake. At this moment the second diver is reported to have suddenly "went back
like crazy" and his buddy never saw him again. The first diver on trimix found the
junction and went to the exit gallery.
Deceased had again missed again the junction and took again the wrong gallery (the
first gallery they went in). Deceased was found dead at almost 1100m (the place where
they made the first U-turn), hood and mask ripped off.
All cylinders were empty on recovery (The oxygen cylinder being empty is as expected
with an mCCR).
Page 58 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Inquest was informal yet nobody disclosed to the Coroner
that there is a fundamental design defect in the Inspiration
handsets made in year 2000 causing them to hang
unpredictably from battery bounce, resulting in death from
hypoxia after 6 to 7 minutes. This matches the known
facts perfectly. It is not known whether it was a pre-Aug
2000 or post Aug handset pair. Both are liable to cause
hypoxia, but the earlier is MUCH more likely - a very
dangerous design by non-engineers. Manufacturer issued
a letter which covered up these matters. No functional
safety inspection of the rebreather took place. A lot of
emphasis put on this being a solo dive by the Coroner, but
it was only to 4.5m for under ten minutes: few buddies stay
that close so the solo dive aspect is a Red Herring further
obscuring the truth.
Well known diver. Fireman by profession. Narcosis a Diver untrained on the A very experienced diver in the USA
major element, which can lead to panic, but CO2 retention rebreather. Dive on air. on the same profile found the WOB
would have been very high at this depth, on air, with high so high on the KISS at that depth, it
workload. caused respiratory spasm. The WOB
Respiratory spasm is the most plausible cause using the on the KISS is around 6 times the CE
fault tree method, with second being WOB induced CO2 safe limit, and over 10 times the
retention (not accounting for unconsciousness at 50m), the NEDU limit at that depth.
third most plausible being scrubber breakthrough (not
accounting for unconsciousness at 50m), other fault tree
branches that cannot be eliminated at this stage include
oxygen insufficiency for dive duration - dive computer data
is needed.
Page 59 of 210
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An external reference confirming that
accident occurred
http://www.yorkshire-divers.com/forums/closed-
circuit-rebreathers/129020-coroners-report-inspo-
classic-death-14-09-10-a.html#post1517521
http://efps.ffspeleo.fr/analyse_des_accidents.html
Page 60 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
171 18/03/2009 Bruce (surname Inspiration APD Solo diving Pak 1 Wreck, Guru 40+
unknown) Thailand
170 24/01/2009 Arie Mazor Evolution APD Vision Buddy dive Israel, Eilat (Red Novice 57
Sea)
169 16/11/2008 Andreas Rudolph Sentinel VR Quarry Diving 17 Germany, Guru 39
Löbejün
Steinbruch
Page 61 of 210
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Root Case Disabling Injury Key information received on accident
Scant data Scant data The Deceased was reported to be a diving instructor working with Royal Thai Navy
divers but was using a sport rebreather. Initial reports was that it was the diving
instructor but further investigation indicated Deceased was not the instructor for that
group at that time but was a contractor on recreational equipment.
The group had been conducting training dives on the "Pak 1" wreck, using the the
Royal Thai Navy landing ship HTMS Mun Klang (782) as their base of operation. Series
of training dives have been conducted on the "Pak 1" since March 5th, 2009.
Deceased was using an Inspiration CCR, which is not a military rebreather but a sports
rebreather. On March 18th, the Deceased had completed a dive (on CCR) and
returned to the water (surface interval unknown) with a video camera intending on
filming the training session and parts of the wreck itself.
Shortly afterwards, the Deceased was seen to stop moving (some report indicated that
the video camera was dropped and the Deceased was found unconscious near the
wreck) and his fellow divers immediately began to bring him up to the surface (ascent
rate unknown). A helicopter was called for emergency evacuation but the Deceased
died shortly after being brought back aboard HTMS Mun Klang and his body was
Human Error / DCS DCS Civilian accident, 3 divers, 2 surfaced, Deceased did not. Deceased had suffered
polio in early life but had completed a professional diving course just 6 weeks earlier
and was believed fit to dive. Dive download shows this was the diver's 12th dive on
this rebreather. This was his first dive (with this rebreather) to 50m.
Diver conducted pre-breathe. Ascended from deepest part of dive 50m to 43m,
reaching 43m at 41 mins. Diver then ascended at 29m/min. The diver remained on
surface for 25 secs, descended to 1.26m for 10 secs and was then again on the
surface for 10 secs before sinking, no longer breathing from the rebreather.
PO2 was within life support limits at all times. Scrubber activity was normal.
Scant data Pulmonary barotrauma Scant data. Deceased found on surface, after diving inside Boiler 1 in quarry dive (of
(Burst Lung). 3). Pulmonary barotrauma (Burst Lung). Ascent was very fast, followed by diver
sinking, also quickly.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Deceased is not Bruce Konife (nor connected with him). Based on units submission for RN
consideration, the rebreather in
question does not meet the
standards required of a rebreather for
naval use.
Accident apparently being covered up in Israel initially: Emphasise the need to
information exceptionally hard to obtain, whereas for other build up gradually to
dive accidents in Israel it is obtained easily. Information deeper dives, with
eventually released to the RBW list (assumed from guidance of at least 50
manufacturer). The profile is very long at this depth, and hours and extended
diver would likely be suffering DCS from such a direct duration qualified, before
ascent. The scrubber duration is questionable: the very exceeding 40m depth.
warm water means it is unlikely to be the cause of the
accident though. This is a deep dive for an inexperienced
diver.
German distributor for the Sentinel. The Sentinel has only
got a single counterlung, so it would not have reverse
oxygen flow even in a very fast ascent.
Page 63 of 210
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An external reference confirming that
accident occurred
http://www.rebreatherworld.com/rebreather-accidents-
incidents/25633-fatality
http://www.rebreatherworld.com/rebreather-accidents-
incidents/24477-missing-diver.html#post237540
http://www.taucher.net/unfall/Toedlicher_TU_am_16.
11._im_Steinbruch_Loebejuen_tu479.html
http://www.rebreatherworld.com/rebreather-accidents-
incidents/23268-fatality-near-berlin-germany.html
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
168 10/11/2008 Kevin Bailey O2ptima HH Wreck Diving 68 New Zealand Expert 63
167 28/09/2008 John Maneely Inspiration APD Classic Solo Cave Diving 26 France, Source Guru 32
Classic de Doubs
166 19/09/2008 Richard Mork, Megalodon ISC Apecs Cave Diving 35 USA, Jackson Experienced 38
a.k.a. eCCR (Modified Blue Cave
"Packetsniffer" displays), dived
with known
faulty solenoid
165 12/09/2008 Eric Sterck Megalodon ISC Buddy dive 40 France, Expert 40
Cavalaire, Rubis
WWII Sub Wreck
164 10/09/2008 Jan Otys Habenero SCR Unknown Buddy dive 90 Croatia, Cavtat. Experienced
163 28/07/2008 Terry DeWolf O2ptimaFX HH Solo Diving c70 USA, Andrea Expert 38
Doria
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Root Case Disabling Injury Key information received on accident
Rebreather issue / Hypoxia / hyperoxia Diver recovered by trawler. Diver on trimix. Reported to have only 1% O2 in a trimix
Equipment issue (not intended to have 18% O2. Divers were decompressing at 15m, line dropped, and
rebreather) Deceased disappeared from sight.
Human error Drowning/asphyxia Diver passes the restriction of -52m with rebreather on his back then descends to -57.
The make up gas is trimix (40% helium). Diver carried a bottle of 11L air in case of
failure of the rebreather. On return, Deceased was stuck in the restriction and tried to
squeeze through several times: this restriction is harder to pass on the way back than
the way in. Diver chose to take off the rebreather, and use the breathing air cylinder to
pass the restriction. Unbalanced (his ballast was mostly on the rebreather), under the
influence of stress and narcosis, he rose to the top of the pit with the bottle in his hand.
He lost control of his buoyancy, and its only source of gas. His body was found at -25 in
the pit, stuck under an overhang, drysuit hyper-expanded, bottle 1m below him.
Human error / Hyperoxia Diver suffered a classic CNS type event in a cave dive. Sensors were 18 months old
Rebreather issue and the fact that at least one had ceiling faults is reported to be known to the diver - in
fact all three had faults. Diver appears to have been aware of a rebreather failure.
Also oxygen injector failure, known to diver: diver was switching off injector using a
flow stop device manually.
Including the injector fault, and cell faults, rebreather had 6 different known faults, but
diver still used it.
Rebreather issue Hyperoxia Poss solenoid stuck open, 8 minutes into the dive, confirmed CNS convulsion,
drowning. O2 tank had been shut down by the time the Deceased was recovered.
Strong current and divers swimming very hard. Deceased was an Inspo instructor.
Underlying Illness / Heart attack, during a Heart attack started at 90msw, diver ascended, blacked out at 6msw. .
Rebreather design fault period of hypercapnia
Human error/Equipment Drowning/asphyxia Diver had little experience of deep cold water diving and attempted to dive the Andrea
issue (not rebreather) Doria. Diver's BCD dump got tangled. Diver made uncontrolled descent. Gas to suit
was turned off. Diver shrink-wrapped by suit. Diver did not drop weights. Diver did not
use redundant BCD. Incident happened faster on rebreather as Deceased would be
unable to breathe.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
If diver was on high O2 mix, for deco, this would lead to
most probable cause of hypoxia, if diver was on trimix
mixture, it would lead to hyperoxia. Investigation underway
and more detailed and better information likely to be
published.
If a rebreather is to be removable
during a dive, this needs to be
considered as part of the diving
system.
NEDU Report published. Coroners report published.
Known to accident investigators prior, but confidential
information now released publically allowed the updating
detail in the description on left.
Diver was warned about his lack of maintenance, hence
conclusion from the information available is human error
led to rebreather issue.
For the team, J-J Bolanz
At 90msw WOB is extremely high on this rebreather, post
mortem would not have known about links between
retained CO2 and rebreather diving
Page 67 of 210
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An external reference confirming that
accident occurred
http://www.stuff.co.nz/timaru-
herald/news/3314086/Fatal-dive-was-plagued-by-
faults
Inquest reported first on
http://www.cdnn.info/news/safety/s090501a.html and
Detail from team on http://www.swiss-cave-
diving.ch/PDF-dateien/Unfall_Doubs_28092008.pdf
http://www.cavediver.net/forum/showthread.php?t=85
53
http://www.rebreatherworld.com/megalodon-
rebreather/21550-the-rubis-
cavalaire.html#post209176
http://www.finnsub.cz/garibaldi/eng/index.php
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
162 28/07/2008 Unknown O2ptima HH Buddy dive 35 North Carolina, Experienced
Canadian male Atlantic Ocean
161 26/07/2008 Viccica Linen (or Inspiration APD Vision Buddy dive 120 Italy, Cornino Guru 37
Lino Vercicia) Vision
160 13/07/2008 Craig Whitehouse Prism Topaz SM Buddy dive 60+ Canada, Experienced 53
Tobermory
159 01/07/2008 Jayne Bloom Megalodon ISC Apecs Buddy dive 60/0 Truk lagoon Experienced
eCCR
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Root Case Disabling Injury Key information received on accident
Exceeded Performance Hypercapnia from spent Diving U-Boat. Divers buddy reported that they were on deco at about 50 feet when
Envelope / Human error scrubber the Deceased went to bailout, ascended 20 or so feet, re-descended, then bolted to the
surface where he became unresponsive.
Diver pronounced dead on the boat. May be heart attack: awaiting autopsy information.
Scrubber spent.
Exceeded Performance Hypercapnia Wreck dive off Sarecono Tip. Diver surfaced on open circuit from 123m dive. Seen to
Envelope be in some pain on video during ascent, didn‟t accept help from support divers, swam
to surface, missing decompression, asked for O2 and went unconscious shortly after.
On board diluent = HeOx10 – empty. Inspiration Vision download confirms reports.
Bailout cylinders = HeOx 12 and HeOx 18.
Human error AGE/Cardiac Apparently DCS, possibly cardiac. Dived without bailout on a wall, to depths of
60msw+
Human error AGE According to Keep (deceased's fiancee), Deceased resurfaced from a rebreather
decompression dive to a maximum depth of 57 meters (187 ft) and returned to the dive
boat where she suddenly lost her vision and became very weak.
Despite receiving oxygen onboard the dive boat, Deceased soon lost consciousness
and her condition worsened during the long 40-minute trip back to Blue Lagoon Resort,
where the New Frontier Diving holiday package group had checked in two days before.
After the boat finally reached the resort and with a critically ill diver in need of
immediate emergency medical care, dive trip leaders Keep and Bishop are reported to
have made a fatal mistake that delayed treatment for nearly an hour and a half and
stemmed directly from their lack of emergency preparedness, their complete ignorance
about how things work in Chuuk (and many other small and remote dive destinations)
and their failure to acknowledge that Bloom was severely injured and required more
than a quick "patch-up" at the local chamber before resuming their dream holiday
diving the wrecks of Truk Lagoon.
Instead of rushing Bloom to the local hospital where she could first be stablized while
doctors organized the island's emergency response hyperbaric medical team and a
recompression table appropriate for Bloom's dive profile, Keep and Bishop wasted
more precious time by taking her to the local hyperbaric chamber unaware that there
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Symptoms fit with hypercapnia.
Deceased died in front of his wife and child. Diver ignoring
safety divers points towards hypercapnia, as does the
empty on board make-up gas. At 123m the duration of this
scrubber is very short. Once on the surface, after missing
such a large amount of decompression, the diver would
suffer explosive DCS.
Leigh Bishop and Jeff Keep heavily criticised by inquest Importance of dive
judge. Fatality was a direct result of poor organisation, and planning in remote
interestingly, nobody on the trip checked the emergency locations should be
details. Large differences in accounts of witnesses, in emphasised.
particular whether the ascent was normal or not: divers say
it was normal, but examination of dive computer indicated
11 breaches of deco ceilings, but it is not clear from
reports whether that is relevant (1ft above a 60ft ceiling
momentarily, or touching the 3m ceiling in swell is
common).
Page 71 of 210
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An external reference confirming that
accident occurred
http://www.rebreatherworld.com/rebreather-accidents-
incidents/20725-north-carolina-O2ptima-
fatality.html#post201005
http://melomane-news.blogspot.com/2008/07/trapani-
immersione-fatale.html
http://www.scubaboard.com/forums/accidents-
incidents/243067-diving-accident-tobermory-past-
weekend-4.html
Further information on CDNN link
http://www.cdnn.info/news/safety/s100306.html but
see also http://www.deepimage.co.uk/cdnn.htm
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
158 27/06/2008 Lawrence Crom KISS Classic Jetsam Buddy dive 30 / 70 Canada, St Experienced 45
mCCR Wreck of
Lawrence
Seaway, Roy A.
Jodrey
157 02/06/2008 Kenneth Farrow Inspiration APD Buddy dive 0 Orkney, Westray Guru 61
156 20/05/2008 Bill Prince Inspiration APD Buddy dive ?/0 USA, Wisconsin, Trainee on RBs,
Wazi Reservoir Experienced diver
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Root Case Disabling Injury Key information received on accident
Rebreather design fault Heart attack during a Deceased completed dive on wreck (wreck is 165 - 240 fsw). Deceased was on the
/ Exceeded period of hypercapnia way to the surface and stopped at 100' deco stop. He went into some kind of distress
Performance Envelope from WOB. as reported by his buddy. Deceased bailed out to OC and went right to the surface
with 30+ minutes of deco obligation. Surface saw Deceased immediately, conscious,
but not talking. Divers reached him and within 90 seconds brought him to boat. While
towing Deceased to boat, the Deceased lost consciousness and the team was
intercepted by the Coast Guard (their station is right next to the wreck). Deceased was
taken immediately to a hospital on the bank of the river and was in medical care within
minutes. Deceased never regained consciousness. Apparent heart attack. Autopsy
result not obtained yet: Heart attack and AGE is expected.
Underlying Illness / Heart attack during a Deceased died from heart attack, completing a dive and exiting onto rocks with heavy
Rebreather design fault period of hypercapnia exertion. BSAC Incident 08/080 states a group of divers planned a dive on a wreck
which was positioned close to the shoreline. There was breaking swell above the wreck
so the plan was for the divers to descend to the seabed about 35m from the shore at a
depth of 26m and then to swim underwater to the wreck. They planned to return
by the same route. One trio and three pairs of divers entered the water to conduct the
dive. The first pair returned to the boat as planned and shortly afterwards a second
pair, who were using rebreathers, surfaced above the wreck in the swell. These divers
then started to swim out of the rough water towards the boat. One of the pair made it to
the boat but the other turned round in the rough water and swam to rocks by the shore
and climbed onto them; once out of the water he was seen to sit down on a rock ledge.
In order to assist this diver back to the boat a member of the party snorkelled to him
and planned to help him swim with the now changed water current through the rocks
into clear water where they would be recovered by the boat. The snorkel diver reached
the shore and discovered that the diver who had climbed on the rocks had died. He
Underlying Illness / Heart attack during a Surfaced on bail out because he felt bad. Reported to have died on shore, not in the
Rebreather design fault period of hypercapnia. water. From information available at this juncture, heart attack seems to have started
during dive, then progressed. Diver was involved in heavy effort in leaving surf/rocks.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
WOB is much higher than safe limits, hence design fault
classification.
Very heavy exertion by the Decadent. Due to age of
Decadent, it is likely there was underlying cardiac health
issues. Use of rebreather even on the surface, would
increase the breathing resistance considerably, leading to
a degree of hypercapnia.
Page 75 of 210
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An external reference confirming that
accident occurred
First reported by Swampdiver, by PM on RBW
Orkney news and BSAC report
GS is getting details. RB is instructor.
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
155 04/04/2008 Steven Ottewell Megalodon ISC Apecs Buddy dive 42 Scapa Flow, Experienced 38
eCCR Mark Graff
154 16/03/2008 Mike Riopel O2ptima HH Buddy dive 20 Florida, Pompano OC, Expert, RB
Bch Expert but on
Rebreather Trainee
153 11/03/2008 Mark Fyvie Megalodon ISC Cave Diving 32 Devil's system, Experienced on RB,
Ginnie Springs, New cave diver
152 01/02/2008 Scant data RB80 Clone (SF- Unknown Red Sea
1)
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Root Case Disabling Injury Key information received on accident
Rebreather design fault Hypoxia Deceased had LOC, the PFD on the rebreather was flashing red. Deceased lost
during attempted rescue, and recovered 7 weeks later. BSAC Incident 08/057 reports
that "Two divers conducted full buddy checks and then entered the water to descend a
shotline to a wreck. One of the pair was using a rebreather with air as the diluent; the
other was using open circuit air. They exchanged 'OK' signals as they descended. At
about 35m they could see the light of other divers below them on the wreck. They
exchanged 'OK' signals again but immediately afterwards the rebreather diver began to
signal rapidly with his left hand. The buddy moved to help him. The rebreather diver
was now sinking quickly. The buddy followed after him and they arrived on the seabed
at 42m. The rebreather diver was motionless, face down on the bottom. The buddy was
suffering from nitrogen narcosis but he attempted a diluent flush on the unconscious
diver's rebreather, he also attempted to inflate his suit. He noticed that the head up
display on the rebreather was flashing red. The buddy tried to lift the unconscious diver
from the seabed. He tried a number of times but lost his grip and made a buoyant
ascent to the surface. His dive duration was 9 min. He was recovered into the boat and
Human error Hypoxia the Coastguard to bealerted. An extensiveon underwater. Diver did conducted and an
Tanks reported was off. Alarms went off air and sea search was not bail out.
Human error Drowning/asphyxia Extreme cave dive. Diver appears to have taken off the rebreather to get through a
restriction using side-slung O.C. On returning to the rebreather an hour later, it was
flooded and out of gas probably because water got into the O2 cells causing the
injector to fire, burping the OPV and letting in water in the process. Diver used
available gas to purge rebreather, when he was 50ft of a staged emergency bottles,
and used all his gas to do so. Silt out, 3,300ft into cave, diver did not simply abandon
RB and go for the stage bottles until it was too late.
Scant data Scant data Only data is unverified report from http://www.rebreatherworld.com/rebreather-
accidents-incidents/17555-rb80-clone-accident.html#post170603
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Flashing Red means hypoxia. Buddy checks means there
was enough gas and cylinders were on. Is this one of the
Meg controllers with the potting performed using hot glue?
One of these controllers was sectioned and found to have
considerable water ingress and corrosion: the potting is not
to a professional standard on the samples inspected. In
any case, where there is sufficient power, and there is
enough oxygen, when the disabling agent is hypoxia then
the fault tree indicates most probable cause is a design
fault.
Diver reported to be Dolphin SCR instructor. Probable that
diver surfaced from 1st dive, isolated cylinders then did not
do pre-dive checklist on unit for 2nd dive.
Training example of why If a rebreather is to be removable
divers should not take off during a dive, this needs to be
rebreathers underwater, considered as part of the diving
or leave them if they are system and formally validated with
their sole means of return. unmanned testing of the rebreather
prior to human trials.
Ensure designs are highly flood
resistant. OPVs should be double
valved so as not to let in water when
they burp. Flood warning would likely
mitigate risk, but only if diver is
wearing the unit.
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An external reference confirming that
accident occurred
BSAC incident 08/057
First reported by RBW Blomman. Details then started
to fill in. Note Gregg Stanton is aware of data but
unable to disclose for legal reasons.
http://www.nsscds.org/phpBB2/viewtopic.php?t=337
&sid=d377b98c612eced9400
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
151 27/11/2007 Allan Greisen Inspiration APD Buddy dive 30/59/0 Red Sea Experienced 42
(Vision) on
Buddy who
suffered a
sudden LOC,
Diver on
Inspiration died
as a result of
rescue
150 04/11/2007 Laurent Rossignol Voyager Unknown Buddy dive 80 France, wreck Experienced 41
Henkel
Mediterranean
149 29/10/2007 Jean-Jacques Voyager Unknown Cave Diving 86/152/150 Greece, Lilly cave Guru, Experienced 67
Bolanz RB, thousands of
dives on O.C.
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Root Case Disabling Injury Key information received on accident
Rebreather issue Hypercapnia of buddy Accident started when the Deceased's buddy suffered a sudden LOC on an
caused Explosive DCS in Inspiration Vision during a dive to 59msw for 15mins, followed by an ascent to 30msw
Deceased in 5 mnutes. LOC occurred at 30msw. Profile showed increased ascent speed from
30m while Deceased brought his unconscious buddy (Inspo Vision diver) to the
surface. Profile also indicated that the unconscious buddy was still breathing and the
Rebreather kept injecting O2 as normal, hence hypercapnia but questions over the
accuracy of log on the Vision.
The buddy regained consciousness on the surface, Deceased told him to remain on
O2 on the loop to prepare for the DCS hit they where about to take. Deceased again
lost consciousness shortly after that. The buddy had trouble calling for help while he
was working on Deceased at the same time. Waves and current caused a delay before
a small RIB came to their rescue.
Rebreather design fault Hypoxia 20mins into a wreck dive at 80 m, sudden LOC, most probable reason is hypoxia.
Scant data Scant data Cave diving. Reports suggest Deceased had some alerts while diving passive SCR.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Deceased knew the risk he took in the rescue, counselling
the buddy on this when he returned to consciousness on
the surface: he gave his life to rescue another diver in his
care. Deceased is reported to have started to put his mark
on the Danish diving scene by 1998. He is reported to
have been an extremely helpful person; when his friends
or customers were in a tight spot, he would put himself or
his finances on the line to make things right again. Wreck
diving was his passion, but he was a adventurer in many
other fields, always up for the challenge.
The root cause is the sudden LOC of the Deceased's
buddy, but in the fatal accident to the Deceased, the
disabling agent was explosive DCS, and the cause of
death would be arterial embolism.
Buddy suffered severe DCS in trying to save the
Deceased, paraplegic after accident. Girlfriend of
Deceased had to manage situation on surface.
Deceased was one of the mythical cave divers and
speleologists who made astonishing dives and discoveries
back in the 1980s, mainly in Europe. He was also the
former president of the Cave Diving Commission of the
International Union of Speleology and of the Swiss Cave
Diving Rescue Team. Being already in his mid-60s, he
moved from OC to SCR and later to CCR and continued to
dive in resurgence and multi-sump caves for the sake of
exploration.
Page 83 of 210
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An external reference confirming that
accident occurred
Confidential communication
http://www.rebreatherworld.com/rebreather-accidents-
incidents/15150-jean-jacques-bolanz.html
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
148 27/10/2007 Sven Paepke Inspiration APD Classic Buddy dive 40/125 Australia, Expert 42
Bermagui
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Root Case Disabling Injury Key information received on accident
Rebreather issue/Gas Hypercapnia/respiratory/N Deceased used his onboard cylinder filled with air as dil/inflation on shallow dives but
switch issue arcosis on deeper dives, disconnected his dil hose and plugged it into his offboard dil cylinder.
It appears that he forgot to disconnect the onboard air from his ADV and connect it to
his offboard dil cylinder. This resulted in descent on air diluent.
He may have realised his mistake at 60m when he asked his buddy to plug the
connector from his offboard dil cylinder into the manual dil button. His buddy assumed
at the time that he was having a problem with his ADV as this had occurred on a
previous dive. Deceased gave the
OK sign to his buddy twice and they continued the descent.
At about 90m Deceased became unconscious with his hand still on the shot line, but
had lost his mouthpiece. Buddy then had trouble keeping his buddy on the line as he
become negatively buoyant as his rebreather flooded. Buddy tried forcing an OC reg
into Deceased's mouth unsuccessfully because Deceased's jaw as clenched shut. The
buddy tried adding gas Deceased's wing and drysuit but neither system worked.
Deceased and buddy all dropped to the bottom in 125m and Buddy removed
Deceased's weight belt but he remained negatively buoyant. Due to a strong current
and dragging shot line other divers were unable to recover Deceased's body on day of
acident.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Most plausible cause is nitrogen narcosis due to breathing Use a FFM or mouthpiece restraining
air diluent between 60m and 90m caused Deceased to Training Lessons: strap to prevent rebreathers flooding
become unconscious. 1. Dive the rebreather with if the diver becomes unconscious.
the correct gas onboard
so that mistakes with Correct gas's and buddy training is
connectors or switch required for deep dives
blocks cannot be made.
2. Re-institute the old The fitment of a Helium content gas
buddy check. Buddy monitor would have advised the diver
wasn't aware of that he was still breathing Air diluent
Deceased's on descent
configuration before the
dive. This may have
picked up the mistake.
3. Use a FFM or
mouthpiece restraining
strap to prevent
rebreathers flooding
if the diver becomes
unconscious.
Page 87 of 210
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An external reference confirming that
accident occurred
http://www.rebreatherworld.com/rebreather-accidents-
incidents/15088-fatal-diving-
accident.html#post146374
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
147 02/10/2007 Michael Hanrahan Inspiration APD Buddy dive 63 Ireland Experienced 46
146 25/08/2007 Unknown German Submatix Unknown - - Norway, Bergen - -
diver
145 19/08/2007 Lee Shortt O2ptima HH Buddy dive 0 USA, Florida Experienced 38
144 31/07/2007 Wayne Hernandez Dolphin Unknown Solo Diving 3 USA, Seattle Expert 43
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Root Case Disabling Injury Key information received on accident
Exceeded Performance Hypercapnia The dive team was filming the U-boat when the diver got into difficulties. Reported to
Envelope/Human error: be a CO2 hit on ascent.
Deceased was seen 30 minutes after descent onto the submarine at 63m doing heavy
work: this is well beyond the scrubber duration for the Inspiration at that depth
(commonly quoted Inspiration durations are a dive profile with only 20minutes spent at
40m), then worked up the shot line, pulling its 50lb load because it had become
snagged on the wreck. The Deceased was seen repeatedly looking at the handset
readings, taking his mouthpiece out, blowing some bubbles then putting it back in. The
buddy saw the deceased fall past him and land on the submarine on his back. They
made efforts to recover the diver, but without success. The Deceased's body was
secured to the submarine, and recovered the next day.
Rebreather was beeping before diver got into water (usually a cell issue), so diver
should not have started this dive, hence also a human issue. Recent (2010)
information on this cell issue confirms an earlier report that The diver fitted non-factory
approved oxygen cells. Reports the unit would not allow calibration, reporting "Cells
Out of range, No Dive. The dive was recorded on three video cameras including one
carried by this diver. The unit was beeping continuously before and during the entire
dive and was recorded on all three cameras. The dive team was filming the U-boat
when the diver got into difficulties. At around 45 mins the diver swam back to the
shotline and said to his buddy - not too clearly "I'm f***ed, I've got to go up" (sound
Scant data Scant data recorded on two video cameras) and then the diver sank back to the wreck facing
Scant data
Human error AGE Deceased is reported to have been trying to outdo his buddy in depth, on air. Result
was DCS. Diver died 6 hours after surfacing.
General diving hazard Drowning/asphyxia Tangled in a buoy line, including caught on equipment. Rebreather involved no more
prone to entanglement than open circuit.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Removing the mouthpiece repeatedly, and feeling as if out
of air, are classic CO2 symptoms. It was concluded this
was a classic a CO2 hit from the first reports that arrived,
hence hypercapnia. It is a rebreather issue but this
accident was listed as "Exceeding Performance Envelope"
from the outset, as dive profile was beyond the
Inspiration's scrubber duration at 63m. Human error
added as a secondary conclusion due to the rebreather not
being fully functional before the dive, and the dive plan
was too long at 63m for this apparatus. Drowning is the
end product of most diving accidents, rather than root
cause.
Scant data RB should check gas is on, and give
clearer alarms
Note: Rebreather is relevant as it enables the community
to track risk level relative to Open Circuit. This accident
would have happened even if the diver was on Open
Circuit.
Minimise entanglement points on
CCR.
Ensure crown strap fitted with
sufficient OC gas immediately
available.
Page 91 of 210
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An external reference confirming that
accident occurred
http://www.inishowennews.com/06MichaelHanrahan
0626.htm
http://www.rebreatherworld.com/rebreather-accidents-
incidents/13906-death-submatix-diver-norway.html
http://www.rebreatherworld.com/rebreather-accidents-
incidents/13717-oriskany-accident-3.html
http://www.rebreatherworld.com/rebreather-accidents-
incidents/13386-diver-death-seattle.html
http://seattletimes.nwsource.com/html/localnews/200
3817861_webdiver02.html
Page 92 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
143 29/07/2007 Pc Paul Jackson Inspiration, APD Vision Solo Diving 30/54/80 Ireland, Donegal Expert 49
Vision
142 14/07/2007 Dominique Submatix Unknown Solo Diving 3 France - -
Chauvin
141 26/05/2007 Claude Lau Inspiration: APD Vision Buddy dive 32 England, Dorset Novice -
Vision
Page 93 of 210
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Root Case Disabling Injury Key information received on accident
Rebreather design fault Drowning/asphyxia Unknown problem with the rebreather caused diver to bail out onto BOV where there
/ rebreather issue was a flow shut-off fitted (that was closed).
Accident occurred when Deceased was checking the shotline, solo. Wreck was at
80msw. Diver halted descent at 3 mins at 53m and then started to ascend, as he had
advised buddies he would be, this being his first dive in some while. It seems he lead
them to believe that he hadn't dived for 5 months, where in fact the rebreather log
showed it was 10 - he may have had an O.C. dive 5 months previously. At 11 mins,
38m, the diver went off the loop. At 12 mins 52 secs at 42m the diver sank. No sign of
life after that. Came to rest at 13 mins 52 secs at 75m. Deepest previous dive in
download is to 58m.
Underlying illness Heart attack Heart attack in swimming pool. State of scrubber unknown.
Human issue Drowning/asphyxia Wreck diving. See also BSAC report May 2007, 07/065. Inquest report. Manufacturer's
analysis released. Two rebreather divers entered the water and commenced their dive
down a shotline to a wreck. They conducted a bubble check at 6m and exchanged OK
signals at 20m. They reached the top of the wreck at 32m. One of the pair indicated
that all was not well. The dive leader signalled that they should ascend and they started
to do so. 2m into the ascent the troubled diver became agitated, closed and removed
his rebreather mouthpiece and placed his bail out regulator into his mouth. He then
spat this regulator out and began to panic. His buddy placed the regulator back into his
mouth and attempted to purge it; he discovered that it was not turned on. He turned the
cylinder on and attempted to put the regulator into the diver's mouth, but the diver was
not able to take the regulator and he fell unconscious. The pair had sunk to the bottom
at a depth of 35m. The buddy dropped the casualty's weightbelt and inflated both their
jackets. They made a buoyant ascent to the surface. Their total dive time was 6 min. At
the surface the casualty was not breathing. The buddy called for help and tried to give
rescue breaths. This was difficult to do because of their inflated BCDs and side
mounted gas cylinders, Their boat reached them quickly but they could not get the
casualty back into the boat. His rebreather was removed and he was held by the boat.
The Coastguard was alerted and 5 min later a helicopter arrived. After some difficulty
the casualty was airlifted to hospital where he died three days later. The buddy was
airlifted to a recompression chamber for precautionary treatment. The Decadent had
Page 94 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
As bail out was so shortly after entering the water, it points Flow stops should not be Bail out valves should not have any
to an electronic problem. Not clear at all otherwise why used. stable state other than on the loop or
diver would bail out at 38m. on open circuit.
Another problem was that the Golem bail-out valve was in
an intermediate position (not on, not off), and having a flow
stop in the shut position. Cause of LOC was probably
asphyxia.
PPO2 risk alarm needed. Auto-loop
shut-off even on mCCR would have
avoided accident. Better PPO2
alarms: voice, sound?
Cause of bail out event unknown. It could be something Manufacturer should Manufacturer should publish in
as simple as the diver testing the bail out drill. provide instructors with rebreather manual maximum length
mandatory guidance for of scrubber storage between use.
students based on Manufacturer should provide a
independently audited recommended maximum storage life
testing of the maximum of scrubber in a rebreather based on
duration of scrubber over fully traceable testing. Rebreathers
multiple dives and should be fitted with CO2 monitoring
maximum storage lifespan by manufacturers or warnings issued
between dives based on about the hazards of exceeding the
worse case scenarios. published maximum scrubber
Training for buddy checks duration between use with data
on rebreather should published by the manufacturer. BOV
emphasis that all bailout is should be mandatory on all
to be verified as rebreathers sold with a published
operational during the pre- minimum OC performance exceeding
dive checks and included the EN250 requirements
during bubble check
verification at 6m.
Page 95 of 210
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An external reference confirming that
accident occurred
http://news.bbc.co.uk/1/hi/northern_ireland/6922993.
stm http://www.cdnn.info/news/safety/s070730a.html
http://www.taucher.net/unfall/TU_Norwegen_an_der_
Seattle_itu514.html
http://www.harrowtimes.co.uk/news/localnews/displa
y.var.1468514.0.diving_death_tragedy.php
Page 96 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
140 13/05/2007 Emanuel Ajimati Home Build Unknown Solo Diving 50 UK, Swithland Intermediate -
(Manny) Woods
139 09/05/2007 Roberto Delaide Inspiration APD Solo Diving 0 / 109 Italy, Garda Lake Expert -
138 29/04/2007 Tomohiko Megalodon ISC Apecs Buddy dive 30? Japan, Numazu, Expert 46
Tsuruoka eCCR Shizuoka
Prefecture
137 07/04/2007 Mario Inspiration APD Buddy dive 90 / 70 Switzerland, Lake Advanced trimix 43
Wohlgehaben Neuenburg, diver. RB
Abyss intermediate.
Page 97 of 210
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Root Case Disabling Injury Key information received on accident
Rebreather design fault Hypoxia Diving in a quarry. See also BSAC report May 2007, 07/064. Rebreather diver
entered the water ahead of his two buddies and dived to place a decompression
cylinder on a shotline. He resurfaced and spoke to a fourth diver who was preparing to
enter the water. Although they had planned to dive together, when the two buddies
entered the water the first diver had already left the surface again. They continued their
dive and, several minutes later, they saw the torchlight of the first diver. They found him
lying on the bottom at a depth of 50m; he was unconscious, his mouthpiece was out of
his mouth and he was tangled in some branches and other debris. They freed him and
sent him to the surface. They started their ascent and met the fourth diver coming
down. The fourth diver returned to the surface and found the casualty on his back with
his mask off, he recovered him to the side, removed him from the water and started
resuscitation procedures. 10 min later the casualty's two buddies surfaced and
contacted the emergency services. The casualty was taken to hospital where he was
declared dead. Decadent was diving with a rebreather that he had built himself.
Rebreather issue Hypercapnia, caustic Diver LOC after surfacing at end of solo dive to 109m. Used Amsorb: a low flow 2lpm
cocktail anaesthesia absorbent which has no catalyst (NaOH).
Underlying Illness Heart attack Believed to be a heart attack associated with hard smoking
Exceeded Performance Hypercapnia, AGE Diving with buddy. Problem at depth, likely caused by hypercapnia, emergency ascent
Envelope / Human error due to stress and panic. . A later report in Octopus magazine states the diver bailed
out to OC at 80m, his regulator froze, he then breathed from his buddy‟s stage – at
20m he bolted for the surface. Buddy returned to 50m to continue deco, Diver climbed
on to the boat and told others he was okay. He died 15 mins later, torn alveoli and
AGE.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Report was that scrubber was spent: it had not been Shut off breathing loop automatically
characterised. if it cannot be breathed from.
Hypercapnia within minutes at the start of the dive seems If a crown strap was fitted diver may
odd even if he was using a Ray scrubber (unless Drager not have drowned due to loss of
Ray sized scrubber & medical sorb - both sorb & scrubber DSV.
unknowns though)?. Some scrubbers can break through
very quickly at 50m. A hung controller or blocked/off
oxygen feed leading to Hypoxia on descent also fits the
description of the dive., or any PPO2 control issue
because after the first ascent the PPO2 would be low if
there was anyPPO2 sensing or control issue at all. Home
rebreather designers are often unaware of how sensitive
O2 cell placement is, and how moisture can very easily
lead to a total block of all sensors simultaneousl;y.
Amsorb is completely unsuitable for rebreathers. Diver Emphasis not to use Design the scrubber so medical sorb
would have pushed the duration of even the recommended medical sorb in cannot be used.
sorb on this dive. Conclusion is hypercapnia due to use of rebreathers.
an unsuitable absorbant. Manufacturer subsequently
tested Amsorb and put out a warning notice to all users
about its unsuitability.
The fast ascent was most likely due to hypercapnia. At Diver was too deep too
this dive profile and water temperature, the scrubber fast on the rebreather.
duration even with 797 would be very short indeed. Diver Manuals should provide
was not using 797: probably Draegersorb, which has a constant depth durations
similar performance (or slightly better, in many for scrubbers.
rebreathers).
Page 99 of 210
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An external reference confirming that
accident occurred
http://www.rebreatherworld.com/memorial-
forum/11865-diver-dies-quarry-2.html
http://www.rebreatherworld.com/rebreather-accidents-
incidents/11796-roberto-delaide-fatality.html
Confidential communication and inquest reports
Confidential communication and inquest reports
Page 100 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
136 11/03/2007 Paula Blackemore Evolution APD Vision Buddy dive 73 UK, Dorothea Experienced 43
quarry
135 04/03/2007 Rob Sherratt Inspiration, APD Vision Group Trimix Dive 62 / 75 /92 UK, Cornwall Expert -
Vision Quarry
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Root Case Disabling Injury Key information received on accident
Rebreather fault / Drowning/asphyxia The Deceased was having a problem with her rebreather, and was pulling on the shot
General diving hazard. buoy when trying to address the rebreather problem. Both divers had difficulty clearing
their ears during descent. A valve diaphragm had ruptured in a regulator, but not clear
if this is the rebreather or a bail out device. The permanent shot buoy then flooded and
came down on the diver pair, entangling one of the divers.
The buddy lost sight of the Deceased so descended a trail of bubbles and reached
40m (131ft) below the surface where the Deceased was going to a ridge in a desperate
attempt to stop her descent. The rope to the buoy was tangled around her left leg.
Buddy tried to remove rope but could not. Equipment inspection and download
revealed the unit had been modified with a stainless backplate and attached weights
that impinged on the wing BC, to the extent that the wing could only inflate to
approx.1/3 of it's volume ( it is unknown what role if any this had on the incident but for
sure the wing was not capable of lifting her from depth). It was also clear that the diver
had too much lead by a considerable degree. The ADV had a flow-stop valve which
Exceeded Performance Hypercapnia Lost consciousness soon after surfacing from fast ascent from 62m in 92m depth.
Envelope Diver was on new rebreather, and manufacturer suggests it is possible the fast ascent
was due to the dry suit exhaust being blocked. Some differences with BSAC 2007
report March 07/026, which states:An instructor and two trainees were engaged in a
trimix training course. The instructor was using a rebreather and the students were
using open circuit equipment. They dived to a maximum depth of 75m. The two
students started their ascent and the instructor remained at depth some time longer.
The two students were conducting their first stop when they saw the instructor making
a rapid ascent up the shotline. They offered him an alternative gas source but he
refused this, inflated his BCD and rose directly to the surface missing all stops. The
emergency services were alerted and the diver was taken to hospital where he was
declared dead.""
Page 102 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Poor buoyancy control, caused by diver carrying far too Divers should not fit shut Bail out device should not free flow,
much lead, constraining the fairly limited buoyancy device off valves to bail out so diver does not need to fit a shut off
fitted to the rebreather by her modifications. Flow stops devices. Bouyancy device.
on bail out valve noted, causing the bail out device to training is needed by
implode. many divers. Personal
view of some of the panel,
is that a diver should be
able carry out an Open
circuit dive without any
buoyancy control device,
before moving onto
advanced dives.
Expert diver, so uncontrolled fast ascent from BCD or suit Manuals should contain Integrated bail out needed. The
valve failure unlikely. BSAC report does NOT support the constant depth duration of the scrubber at constant
diagnosis apparently from manufacturer that his drysuit scrubber durations, as the depths should be stated in the
inflator jammed, because the BSAC report states clearly "dive profile to depth X" manual.
that the diver inflated his BCD and refused on OC reg on can be highly misleading.
passing his students on ascent! Rather the BSAC report Trimix instructors need to
would appear to support the original KNOW the maximum
hypercapniaconclusion based on his remaining at depth performance envelope of
but then suddenly needing to surface for fresh air despite their rebreather through
blowing off a fatal amount of decompression stops. This publication of
particular model has a very short duration at 92m, but the independently audited
manual states only a "dive profile" to 40m and in that empirical data by the
profile it is understood that breakthrough starts after just 20 rebreathers manufacturer
minutes. at constant depth.
O2 control issue implicated by manufacturer, but
hypercapnia should not be excluded as behaviour
suggests it is far more likely to be involved, and 19 mins in
cold water at 92m is beyond the scrubber endurance for
this rebreather. Cause of death probably DCS (AGE.
Inquest was late 2008.
Page 103 of 210
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An external reference confirming that
accident occurred
http://www.cdnn.info/news/safety/s070718a.html
http://www.rebreatherworld.com/rebreather-accidents-
incidents/10431-rob-sherratt-fatality.html
Page 104 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
134 04/03/2007 Miss Andrea RB80 clone (AH- Unknown Group dive 10-15/55 Switzerland Novice on RB, OC 34
Zepperitz 1) Instructor, Trimix
diver
133 07/02/2007 Andrea Lui Azimuth Trimix Unknown Solo dive 40 Italy, Carda Lake Experienced -
132 29/01/2007 Fernando Moreno Voyager Unknown Solo Diving 6 Spain Trainee -
131 01/01/2007 Willem Botha Draeger Ray Unknown Solo Diving 6 South Africa, Intermediate -
Hermanus
130 10/12/2006 Marco Voyager Unknown Buddy dive 9/43 Italy, Lago albano Experienced 48
Campolungo di
castelgandolfoo
(Lake Albano)
129 06/11/2006 Alessandro Dodi Azimuth Trimix Unknown Training dive 14 Italy, Lake Como Trainee on RBs, 48
Experienced diver
128 07/10/2006 Robert Crawford Prism Topaz SM Buddy dive 0 USA, San Mateo, Expert 65
CA
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Root Case Disabling Injury Key information received on accident
Exceeded Performance Hypercapnia, AGE Experience level 12 hours, 10 dives on RB. Diver spent about 20' at 50m and then
Envelope / Human error ascended directly to the surface from 12m: total dive time was an hour. . Diver had
bailed out when found. There is information that it was a training dive, but it was a
couple of dives after training. Dive buddy did a search at depth (9m to 21m) for several
minutes, but did not ascend due to rest decompression obligation of 25'-30'. Diver
was female.
VR3 data only.
Scant data Scant data Only short message on RBW forum.
Rebreather Scant data Scant data. First check dive. Spain.
issue/human error
Human error / Pulmonary barotrauma When body was found, a dry suit hose was disconnected. Medical conclusion:
Equipment issue (not (Burst Lung). Pulmonary barotrauma (Burst Lung).
rebreather)
Rebreather design fault Hypoxia Deceased had a problem with the dry suit and signalled to his dive partners that he
would abort the dive and so did his ascent alone. The buddy divers then surfaced a few
minutes later and didn't see the Deceased (he had signalled to them that he would
surface alone), so they dived again, following the underwater path which had been
installed for dive training exercises in the lake, and found Deceased quietly asleep on
the bottom at 9m a few minutes later.
Rebreather Scant data Rebreather issue/human error while on a rebreather course. Report of use of different
issue/human error SCR flow to standard.
Rebreather design Hypoxia Diver was on surface and instantly lost consciousness and sank down.
fault/human error
Page 106 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Most probable cause is hypercapnia either from scrubber
or WOB: no report of convulsions for hyperoxia
Possible reason for drysuit hose being disconnected is that
he noticed that nitrox was running low quickly from a leak
or that his dry suit's inflator mechanism stuck open.
Cause of death appears to be hypoxia (from sudden LOC),
but hypercapnia can't be ruled out on the information
available.
Note that though the diver was a cave diver, this was not a
cave accident: the Italian cave diving organisation states
there were no fatal cave diving accidents in Italy in 2005
and certainly not in Lake Albano, because the "lago albano
di castelgandolfo" (this is its true name) is a sleeping
volcano crater and therefore has no limestone or
sandstone caves.
Believed to be hypoxia, possibly blocked injection valve or
tanks off. If latter it would be user error.
Page 107 of 210
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An external reference confirming that
accident occurred
http://www.rebreatherworld.com/rebreather-accidents-
incidents/10500-rebreather-death-switzerland.html
http://www.rebreatherworld.com/rebreather-accidents-
incidents/9936-new-rebreather-death-italy.html
Confidential communication
Confidential communication
See report (from RBW Wookie) at
*http://www.ilmessaggero.it/view.php?data=2006121
1&ediz=11_METROPOLIT&npag=48&file=A_3417.x
ml&type=STANDARD
http://www.rebreatherworld.com/rebreather-accidents-
incidents/8469-alessandro-dodi.html
http://www.cdnn.info/news/safety/s070718a.html
http://www.cdnn.info/news/safety/s061109a.html
Page 108 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
127 17/09/2006 Harry Inspiration APD Solo Diving 5 USA, Los Experienced 46
Khachatoorian Angeles
126 27/08/2006 Jere Thorne Inspiration APD fitted but Buddy dive 15 USA, Louise Pit, Experienced 45?
not used? MN
125 16/08/2006 Mahatma Robles Inspiration APD Solo Diving 30 USA, San Pedro, Experienced 40
(Ghandi) Olympic wreck
124 16/08/2006 Stale Tveitane Megalodon ISC Cave Diving 75 / 110 Norway, Plura Experienced 37
cave
123 14/08/2006 Ivzor Buna Home build SCR Unknown Cave Diving 88 Bosnia, Blagai Expert -
Page 109 of 210
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Root Case Disabling Injury Key information received on accident
Rebreather issue Hypercapnia The diver surfaced after a 30 mins dive, signalled for help and then slipped below the
surface before anyone reached him. The rebreather was reported to be in alarm mode,
due to a high level of oxygen in the breathing loop, but on the surface this is not
credible. Information released in 2010, apparently by manufacturer, adds to this
"Download shows: 3rd dive of the day. Diver trying to use high setpoint in the shallows
and was suffering buoyancy control issues. Rapid ascent (87m/min from 14m) after 34
mins dive time, reached surface and sank back, unit flooded. "
Human error Hypoxia Planned to be a short dive and diver was brought to a surface after a sudden LOC.
Resuscitation was started but appeared to be fruitless. Diver attempted to use the
rebreather as an SCR due to having no working cells or electronics.
Rebreather design fault Hypoxia Rebreather either failed on entry to the water, or was not switched on. Diver seen
swimming in a wreck several minutes into the dive, at around 20msw. Deceased
recovered a day later, no dive log from which the precise cause of the accident can be
determined. Cylinders reported off, handsets off, handsets did not switch on
automatically to warn of falling PPO2.
Human error / Insufficient make up gas / This accident has several conflicting reports. Deceased had not been diving for about
Rebreather fault hypoxia 6 months, and did a very extended cold water cave dive with an open circuit diver who
knew the cave. Deceased had never been in the cave prior to this dive. The dive had
many changes in depth and Deceased ran out of onboard diluent 1200m into the cave
at a depth of 110m, he was attempting to plug in his offboard dil, and had stuck himself
to the ceiling (apparently trying to get enough volume to breathe from), the cap on the
offboard gas add valve (a dry suit valve on the exhale CL) was being held on by
pressure, he had not plugged in the offboard gas at the surface and the differential
pressure was preventing him from pulling the protective cap at depth. When the CCR
was recovered, it still had a breathable atmosphere, but constricted loop volume (report
is inconsistent: the volume would expand on recovery). The HUD was still active two
days later at the recovery, however the primary battery was flat. Buddy assisted but
had to leave deceased at 75m due to shortage of O.C. gas.
Scant data Scant data Exploration dive with Dual Rebreathers (type unknown - SCR likely), dual 10L cylinders
with 20/30 Trimix
Body found at 88m
Both rebreather loops found closed with nearly empty cylinders
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
It is assumed the Rebreather was flooding: loss of CO2 levels should not rocket if the
buoyancy, and alarms. Explosive DCS (in the form of a rebreather is flooding.
pulmonary barotrauma) or hypercapnia, or both.
Manufacturer seems to concur, but concludes likely
pulmonary barotrauma: the OPV on the rebreather should
protect from that. If rebreather was flooding, the CO2 level
would be very high, so hypercapnia concluded. Buoyancy
issues should not exist at 14m from a high set point.
Hypoxia. Diver may have been using the rebreather as a
KISS style mCCR, in which case it is the Deceased that
did the design.
There is no explanation why the diver did not move to bail
out, and the buddy did not offer bail out gas because he
was unfamiliar with the rig: hypoxia of the Deceased was
stated.
There is no explanation of why there would be insufficient
loop volume: the diver ascended to the ceiling - this
increases loop volume, unless there is no oxygen supply
(supporting the hypoxia report).
Assumed from remaining pressure in gas cylinders that
SCR was passive addition design.
Page 111 of 210
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An external reference confirming that
accident occurred
http://www.divester.com/2006/09/20/another-
rebreather-death-in-los-angeles/
http://www.rebreatherworld.com/memorial-
forum/6634-memory-jere-thorne.html
http://scubageek.thedeepstop.com/2006/08/18/rebre
ather-diver-fatality-in-los-angeles/
http://www.cdnn.info/news/safety/s060816a.html
From www.plongeesout.com / Accidents/Bosnia
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
122 27/07/2006 Grzegorz “Banan” Inspiration APD Solo Diving / Wreck 36 Poland, Darlowo Guru 42
Dominik Diving (Baltic Sea)
121 10/07/2006 David Bright Inspiration APD Solo Diving 80 USA, Montauk. Expert 40
Andrea Doria
120 14/06/2006 Fred Leroy Inspiration APD Buddy dive 6 Belgium, Intermediate
Zilvermeer
(Silverlake)
119 04/06/2006 Massimiliano Voyager Unknown Cave Diving 44 Italy, Tuscany, Intermediate 28
Valsecchi Pollaccia Cave
118 04/06/2006 Maksim Sobolev Evolution APD Vision Buddy dive 90 Black Sea Intermediate
Page 113 of 210
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Root Case Disabling Injury Key information received on accident
Rebreather design fault Hypoxia Reports of a sudden LOC. Body not recovered. Unconfirmed information suggesting
'he was testing new absorbent' at approximately 40 meters. Dominik was diving
modified 'Inspo', the same that he just took to 210 meters, at the wreck of Yolanda in
Egypt.
Scant data AGE Uncontrolled ascent. Explosive DCS. Otherwise scant data
Rebreather design fault Hypoxia Sudden LOC in shallow depth indicates hypoxia.
Rebreather fault / Drowning/asphyxia Diver from Gigi Casati's team. Diver had bailed out off the rebreather, and was caught
Human error in a narrow passage when a counterlung swelled up, and was not able to reach a bail-
out bottle. Reason for bail out unknown and assumed to be a rebreather fault.
Following account written by JJ Bolanz (himself Deceased from a cave accident on a
RB in 29th Oct 2007).
"Deceased, 28 years old, who had been diving with us for 6-7 years, had a fatal
accident, on Sunday, 4th June during a diving of preparation in Pollaccia, in Tuscany.
Deceased was found wedged in a corner, heading out of the cave in a restriction
120m from the entrance, at a depth of 44m. The Deceased had bailed out off the
rebreather.
Diver was found with 10 bars of trimix in a 7 litre O.C. bail out cylinder, and a one 9
litres cylinder still closed with 220 bars. Another bottle was 10 m in front of him and a
stage bottle was placed 25 m behind him. Deceased had tense hands reaching forward
but the 9-litre bottle he was carrying with him was unreachable due to the confined
space. The CO2 absorbent, examined after its recovery, 12 hours after its death,
shows that lime in practice still changed colour."
Exceeded Performance Heart attack during a Seen to go unconscious when reaching the shotline. Download data eliminated
Envelope period of hypercapnia Hyperoxia and Hypoxia. Diver went unconscious at c. 19mins, sent to surface by his
buddy. No temp-stik fitted so scrubber data not available. Doctors pronounced heart
attack. First and 2nd dives to 4.5m totalling 64 mins then one dive to 55m then the next
dive to 103m. He died on dive No 2.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
The Rebreather was an old Inspiration, with no backlight
handsets, that is prone to hang on battery bounce.
Sudden LOC points to hypoxia caused by a hang.
Rebreather should have been recalled long ago. The
Diver was a technical OC instructor but an intermediate on
rebreathers. Too similar to multiple previous accidents: no
adequate response to these hypoxia accidents by
manufacturer.
Cave team's hypothesis is that as the 7 litre trimix O.C.
cylinder emptied, breathing became difficult. They think
that he had a physical problem which prevented him from
opening its second bottle. The diluent feed on the RB had
free flowed caused the counterlung to swell, fixing the
diver in the cave restriction. " I was ending my landing in 6
m when Deceased crossed me, starting his diving. After
the exchange of the usual signs, I noted that his progress
which was perfectly normal. Luigi arrived at the source
some minutes after my exit. It is Roberto, diving 30-40
minutes after Massimiliano, who found him dead in the
étroiture. The Italian spéléo assistance took out the body
during the night of Sunday to Monday."
Diver profiles exceed known scrubber endurance. Dive Log shows extreme
Appears to be hypercapnia inducing a heart attack. dives done too soon
Page 115 of 210
1cd741fb-406a-44d0-a1ff-d2e0ca24226e.xls
An external reference confirming that
accident occurred
http://www.wielkiblekit.pl/nurkowanie?more=1669496
688
http://www.rebreatherworld.com/memorial-
forum/5780-david-bright-researcher-dies-after-
andrea.html
Confidential communication and inquest reports
http://www.rebreatherworld.com/rebreather-accidents-
incidents/5268-fatality-italy-more.html
Confidential communication and inquest reports
Page 116 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
117 01/06/2006 Lothar Kaiser Inspiration APD Buddy dive 62 Croatia Experienced
116 01/06/2006 Lena Bitzern Inspiration APD Buddy dive 62 Croatia Experienced
115 14/05/2006 Dave Williams Megalodon ISC Apecs Buddy dive 24 England, -
eCCR Littlehampton
114 22/04/2006 Rob Davie Inspiration APD Buddy dive 15 Egypt Expert -
Page 117 of 210
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Root Case Disabling Injury Key information received on accident
Human error Hypoxia MOD3 training dive. Two deaths, two hospitalised. unconventional training operation at
depth involving semi-closed ascent from depth with the handsets switched off, resulting
in two deaths and two hospitalised out of a party of four. Decadent had a LOC at 30m
from hypoxia.
Gas contamination also a factor.
Human error Hypoxia MOD3 training dive. Two deaths, two hospitalised. unconventional training operation at
depth resulting in two deaths and two hospitalised out of a party of four. Gas
contamination also a factor. Decadent panicked on seeing another diver go
unconscious at 30m. All four divers ascended rapidly.
Rebreather issue Hypoxia? Shirala wreck off Littlehampton UK. Diver was found unconscious at the surface.
Rebreather Hypercapnia: WOB/CO2 Possible cause is foreign object placed inside DSV or incorrectly assembled DSV
issue/human error: retention increasing WOB considerably, causing hypercapnia. Diver bailed to OC before ascent.
Found dead on surface. Diver switched to O.C. at around 20m, and released his
weight belt. He was seen swimming on the surface towards the recovery boat then lost
consciousness.
Page 118 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Crazy training protocol, involving switching the handsets Incompetent instructor: Electronic rebreather controllers
off: this information was withheld from the public list until needs to be better training should meet IEC 61508: if they did, it
published elsewhere due to concern over legal risk if it and policing of instructors. would not allow the rebreather to be
turned out to be wrong. It is now confirmed. Rebreather switched off underwater.
should not allow a non-life support mode underwater: this
is a design fault, but given the danger of the exercise, the
problem is small compared to the error of the instructor.
See above. Inadequate safety planning for a deep dive Incompetent instructor: As above.
with trainees. It is surprising the students all agreed to do
this exercise.
Sudden LOC, so points to hypoxia. Meg of this build date Electronic rebreather controllers
is known to have problems with O2 control, scrubber should meet IEC 61508.
bypass fault and electronic encapsulation is also Rebreathers must switch on
inadequate: these issues should be explored by examiner, automatically. Auto-shut off valve
as well as generic faults (cylinders off, Rebreather off etc). needed.
Divers should not modify Gross incompetence in design of
manufacturer's equipment electronic portion of rebreather, with
in any way without many single points of failure.
contacting factory. Manufacturer does not have any
annual service requirement for
rebreather itself, and did not do a
recall for battery housing
improvement.
Page 119 of 210
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An external reference confirming that
accident occurred
Confidential communication and inquest reports
Confidential communication and inquest reports
Confidential communication and inquest reports
http://www.scubabrucie.com/dive/2007/01/25/rebreat
her-fatalities/
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
113 17/04/2006 Soeren Konstet Inspiration APD Buddy dive 55 Germany, - -
Hemmoor
112 16/04/2006 Mike Bromsgrove Inspiration APD Solo Diving 1/11/conf Isle of Man Advanced Trimix, -
hundreds of RB
hours
111 04/04/2006 Fred Evans Megalodon ISC Apecs Buddy dive then solo 50 Thailand, China Expert
eCCR Sea, Unidentified
wreck close to
the Tottorri Maru
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Root Case Disabling Injury Key information received on accident
Human error / Drowning/asphyxia Diver experienced stress and surfaced. He ditched his equipment but it was strapped
Rebreather design fault on to his wrist by the torch cable. Weights were on the rebreather, which pulled him
/ Rebreather issue down. Following the reports containing the above date, the following data emerged:
"Unit bought 2nd hand, oxygen cells 3 years old (exceeding manufacturer's
recommendation by 50%), this was the 2nd dive of the day, shortly after completing
training course. Air diluent, so Narcosis may have been a factor, Diver got a cell
warning. He bailed out to his 7 litre side mount and emptied if in short order, remaining
on the bottom. He then went onto his buddy's 7 litre and all three ascended quickly.
They ditched their equipment for some unknown reason ( they said as per training).
Deceased sank. Found later still attached to the rebreather by torch cable. Diver not a
registered owner."
Rebreather design fault Hypoxia Deceased was a large man, very experienced rebreather diver. Deceased had a very
short profile, with the dive of just 1.5 minutes, before the diver went from a depth of
10.5m to the surface rapidly, lost consciousness, then sank. Investigation concluded
due to battery bounce and related software bug, manufacturer claims rebreather was
not on (rebreather involved has a design fault in not switching on automatically). O2
cells were definitely working properly for the dive profile.
Human Hyperoxia Deceased was diving Meg serial number 65, Buddy was diving Meg serial number 69.
error/Rebreather issue The Meg 65 was sold in January 2006 to Deceased by Soo Seng Khoo in Singapore
(now deceased from rebreather accident on 9th May 2010). Deceased was an
experienced KISS diver before moving to the Meg. The cells fitted to Meg 65 at the
time of the accident were from April 2004 have numbers 299416 D4, 299347 D4 and
299381 D4 and these cells are still fitted to the rebreather (they were not lost as was
suggested by a person challenging the events reported here). One cell had failed
before the dive and was not replaced because no replacement was available at short
notice. Deceased was almost deaf in one ear and had reduced hearing on the other
but the rebreather was not fitted with any audible alarms so this would not have
affected the accident other than the diver's ability to hear the solenoid or injector.
The Meg was standard other than both the first stages had been changed to Oceanics
to improve hose routing, and the backplate had been changed. Deceased and Buddy
began the dive together. The shot was off the wreck and had to be dragged across the
seabed at 50m and tied into the wreck. After that the divers separated as planned to
explore the wreck individually. 35 mins into a 45-50m dive Deceased was seen having
a convulsion. An OC diver tried to assist Deceased as he was convulsing by placing
Page 122 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
New information did not add anything new, other than the Very similar to another Cells should be tested by the
root issue was the rebreather not testing and rejecting its accident. Divers should be rebreather and rejected if showing
cells, and the diver did not replace the cells as directed in trained never to remove characteristics of old cells.
the user manual. RBs in the water unless
both the rebreather and
the diver are secured to
the surface. Cell change
should be emphasised.
Inquest concluded Open Verdict. Case went no further
due to manufacturer's history of claiming against plaintiffs.
The compilers of this database have been contacted by a IEC 61508 audit of another
person who claims to have known the Deceased but has rebreather emphasised the need to
not examined the equipment. That person claimed errors test O2 cells automatically, including
in this listing. This was followed up in detail including during the dive. The use of manual
checks with eye witnesses, and Craig Challen: the dive O2 injectors running from
buddy and the person currently holding the rebreather. compensated regulators is known to
The original listing was found to be materially correct: be hazardous, and this hazard was
Deceased was effectively deaf, cells were old (just present on this equipment.
entering their third year) and one was faulty. Given the
information on the cells, the fact that the diver was seen to
convulse, the rig was tested immediately after the dive on
the boat and both manual injector and solenoid was
working normally, the conclusion is Hyperoxia due to a
ceiling fault on two cells and a faulty third cell likely fully
expired (all, as concluded originally). Due to deafness,
Deceased would not have heard the solenoid firing
excessively.
Page 123 of 210
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An external reference confirming that
accident occurred
http://www.rebreatherworld.com/rebreather-accidents-
incidents/4425-hemmoor-accident-report.html
Full accident investigation with all evidence available
http://www.rebreatherworld.com/memorial-
forum/4111-fred-evans.html
Page 124 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
110 01/04/2006 Ken Woodward Inspiration APD Solo Diving - England - -
109 01/04/2006 Unknown Inspiration APD Buddy dive 12 England Novice -
108 25/02/2006 Lewis Gavin Inspiration APD Buddy dive 0 Australia, Sydney Experienced
107 01/01/2006 Jackie Smith BMR500 Unknown Solo Diving 28 USA, Lake Expert about
Norman Quarry 40
106 23/12/2005 Harvey L. Harris Dolphin Unknown Solo diving, Pool 3 USA, Washington Experienced 51
Page 125 of 210
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Root Case Disabling Injury Key information received on accident
Rebreather design fault Hypoxia BSAC Incident report 06/080. Diver was found motionless on the seabed. A rebreather
diver conducted a solo dive. Another diver from the same party found him motionless
on the seabed. He brought him to the surface and he was recovered into the boat. The
Coastguard was alerted and resuscitation techniques were applied. A lifeboat was
launched to assist. The boat returned to the shore where the casualty was declared
dead.
Rebreather design fault Hypoxia / AGE Two divers entered the water to conduct a drift dive in a maximum depth of 12m. One
/ Human error of the pair was using a rebreather with air as the diluent, the other diver was using
open circuit nitrox 32. Initially the rebreather diver had difficulties leaving the surface. At
the bottom he held onto a rock and his buddy had to swim against the current to get to
him. As previously agreed, the open circuit diver deployed a delayed SMB. As she
deployed the buoy it jammed momentarily and she rose slightly. She watched the buoy
ascend and then realised that her buddy was not there. She believed that he had
started the drift and she moved with the current for 15 min. She then surfaced, making
a 3 min safety stop at 6m. Surface conditions were rough and initially she couldn't see
the boat. She was recovered into the boat and reported the separation. The missing
rebreather diver was then seen floating on his back at the surface. Two divers entered
the water. They found that the diver was unconscious. He was recovered into the boat
and oxygen assisted resuscitation techniques were applied. The Coastguard was
alerted. He was airlifted to hospital but was declared dead on arrival BSAC Incident
Rebreather design fault Hypoxia Deceased was the last on the mermaid line (right behind his buddy) when the group
was going into the water. No dive was done.
Deceased disappeared from the ocean surface. Deceased was breathing from
rebreather on surface. The diver appears to have lost consciousness from hypoxia.
Older model of the rebreather.
Rebreather design fault Hypoxia / Heart attack or Diver found on surface unconscious. The equipment was well checked before diving
/ Underlying illness stroke. and the diver reported to have been one of the best trained and experienced.
Suggestion has been made publicly that the variable flow valve did not provide enough
gas when surfacing, resulting in hypoxia: this was an experimental / very low volume
production device that was depth compensating: this was on
www.gorilladiving.com/ocv2info.htm
Human error Hypoxia due to O2 Ran out of make up gas while using an SCR rebreather. Cause of death is Asphyxia,
exhausted and drowning
Page 126 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
If the diver had taken a Auto-loop shut off required. Should
buddy, it is likely this not be possible to switch off
accident may not have Rebreather underwater, so
had fatal outcome. Rebreather will always ensure
adequate PPO2.
Diver clearly had a rapid ascent from 12m. Conclusion of Functional safety procedures would
hypoxia reached by elimination simply by following the fault have eliminated hypoxia as the cause
tree. From 12m, DCS eliminated as a causal factor. Baro- had they been applied in this design.
trauma (AGE) unlikely from 12m, as rebreather fitted with Rebreather buoyancy control should
CE exhaust valve with pressure not exceeding 40mbar, but be simplified. Automatic switch to
can't be ruled out. No contact with other hard objects. All low PPO2 set point at shallow depths
WOB, hypercapnia and hyperoxia branches in the fault would be beneficial.
tree eliminated, though diver was probably not running
minimum loop (hence buoyancy issue) or may have had
leaky inflator. Not known if diver had switched to the low
set point (if not, more likely to be buoyancy problems on
ascent). No gas pressure issues reported. Sudden LOC
and ascent conditions, points to hypoxia.
Battery bounce is most likely cause, or failure of rebreather Auto-loop shut off required. Should
either to be switched on or to auto-on (classed as a design not be possible to switch off
fault using IEC 61508 processes). Rebreather underwater, so
Rebreather will always ensure
adequate PPO2.
Unknown if this was the same mCCR variable oxygen flow
system as fitted to Phil Patz's BMR500.
Page 127 of 210
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An external reference confirming that
accident occurred
http://www.bsac.com/page/807/fatalities.htm
http://www.bsac.com/page/807/fatalities.htm
http://www.rebreatherworld.com/memorial-
forum/3686-lewis-gavin.html?
http://www.rebreatherworld.com/rebreather-accidents-
incidents/2746-just-read-another-board-about-
diver.html
http://www.cdnn.info/news/safety/s051227.html
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
105 01/12/2005 Billy O'Connor Inspiration APD Buddy dive 50 Ireland, Co. Experienced 49
Wexford
104 24/11/2005 Zack Jones Megalodon ISC Apecs Buddy dive 60 USA, Florida Expert 30
eCCR
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Root Case Disabling Injury Key information received on accident
Rebreather issue Hypoxia/hyperoxia Deceased was on a deco stop at 8m after a 50m dive. Dive was a search for a trawler
following missing fishermen. Deceased's buddy said it was a relaxed dive with no
problems. Buddy was above him on line - he looked down and Deceased was gone.
Body was recovered a week later at bottom of shot.
Rebreather design Hypoxia / Hypercapnia Seven minutes after descending, Jones and his designated dive buddy, Richard
fault/Human error Hartley, were at a depth of 194 feet. They exchanged "OK" hand signals and separated
to explore. Jones, was the only diver using a rebreather. On the bottom, Jones and
buddy Richard Hartley parted ways in a common but unsafe move. Hartley told the
medical examiner's office that they split off so Jones could spearfish without risk of
skewering his friend. Some time later, another diver, Catherine Baldwin, saw that
Jones had speared what looked like a 50-pound grouper. Jones caught the biggest
grouper of his life. His father, David Jones, says that the two had speared ten- and 20-
pounders on their fishing trips but not a 50-pounder. Jones' adrenaline probably went
through the roof as he wrestled with the monster and subdued it. And it's possible that
those exertions put Jones into danger. Breathing faster, Jones might have been
dragged deeper by the fish, and that may have affected the level of oxygen in his loop.
His fight with the fish might also have taken his mind off his rebreather's heads-up
display, a warning device that flashes green, then yellow and finally red directly into a
diver's eyes. Jones' Megalodon was found after the dive to have a 1.3PPo2 setpoint
programmed. Removing the fish from the shaft of his spear gun, Jones looked
satisfied with his catch But a few minutes later, something was wrong. For some
reason, nearly 200 feet down, Jones decided to bail off his loop. Hartley spotted Jones
hovering at about 160 feet, the fish gone, and Jones looked listless, like he was staring
at the coral. Hartley banged his knife against his tank, trying to get Jones' attention, but
there was no response. Then Jones began to sink so Hartley swam down to him and
reached for Jones' buoyancy compensator. Hartley inflated it, and Jones rose in an
explosive uncontrolled ascent.
Bozanic found a powder caked on the interior surfaces of the oxygen cell housing that
could have been soda lime, residual cleaning solution, or even salt. The powder was
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Sudden event points to hypoxia, though could be CNS as Awareness that CNS Active WOB monitoring needed.
clock was high and scrubber may have started to fail. limits need proper WOB should not exceed
margins, and that high EN14143:2003 limits.
CO2 causes limits to
reduce dramatically.
The following factors were considered. Weight pockets should not be on the
1. At 200ft on a rebreather with a PPO2 of 1.3, the PPO2 rebreather for SCUBA units. Added
could drop to 1.1 with that controller. This is unlikely to by user.
cause nitrogen blackout.
2. There is a fault on the generation of Megs that was
used, whereby scrubber bypass can occur at depth via the
water dump. This would create hypercapnia. The scrubber
duration is very short indeed on the Meg at this depth in
cold water, with high exertion rates even though the water
was warm.
3. The work of breathing would be high, adding to the
hypercapnia background.
4. The diver was in good health, and reported to be
careful.
5. The O2 cylinder was empty. This is very surprising for
the dive and recovery profile. The diver bailed off the loop
realising it was not breathable. Reviewing all the data, the
diver is likely to have noticed the PPO2 was wrong (if the
cylinder was empty on recover, then it could be either very
high emptying the cylinder, or very low).
6. The powder is a red herring. The Meg does not have a
crown strap, or retainer, so when the diver has a LOC then
the rebreather floods. If the rebreather leaked water, the
diver would not have got to 200ft.
Conclusion from the information known is that the diver
Page 131 of 210
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An external reference confirming that
accident occurred
Confidential communication and inquest reports
http://www.divernet.com/cgi-
bin/articles.pl?id=2501&sc=1&ac=d
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
103 21/11/2005 Penny Glover Evolution APD Vision Buddy dive 77 France, La Londe Guru 41
Les Maures
102 21/11/2005 Jacques Filippi Inspiration APD Buddy dive 77 France, La Londe Expert -
Les Maures
101 01/11/2005 Unknown Inspiration APD France, Becon
les Granites
100 01/11/2005 Unknown Inspiration APD France, Becon
les Granites
99 11/10/2005 G. Mamoulas Inspiration APD Solo Diving 60 Greece, Cape - 35
Krios, Crete
98 06/10/2005 Paul Theriault Megalodon ISC - 56 USA, Florida
Keys
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Root Case Disabling Injury Key information received on accident
Equipment issue / Hypercapnia following Two divers were missed on 21st November 2005 and bodies found only at beginning of
Exceeded Performance hyperoxia problem with January 2006. Investigation and dive download suggest buddy was on open circuit
Envelope / human error buddy during the ascent and deco from 77m dive. Penny had his empty stages. Deco is
nearly finished when Penny descends at normal rate. Lead to believe by investigative
team that she descended after buddy. PO2 spikes because she started descent with
1.3, she flushes manually and continues descent. It spikes again, so she adds a little
diluent but then she goes open circuit for 5 minutes on the bottom where there appears
to be attempts to ascend. After that she returns to the rebreather loop. After 3 mins
there is a final small ascent at the peak of that ascent the mouthpiece comes out.
Found on her knees facing buddy. Appears to be a brave but unsuccessful rescue
attempt.
Equipment issue / Hyperoxia following bail Two divers were missed on 21st November 2005 and bodies found only at beginning of
Exceeded Performance out January 2006. See above. Diver appears to have bailed out to open circuit for some
Envelope / human error reason at bottom of 77m dive, then sank towards the end of last deco stop.
Scant data Scant data. Report of double fatality, equipment, month and location and that is all. It was first
thought that this accident was a duplicate report of the accident on 11th Jan in the
same year (as that is what the date looks like in American date order), but the report
came from France and was clear that it was in November, as a dual accident which
that in January is not.
Scant data Scant data. Report of double fatality, equipment, month and location and that is all.
Exceeded Performance Hypercapnia from spent Diver used expired scrubber while spearfishing.
Envelope / Human error scrubber
Scant data Scant data. Scant data.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Awareness that CNS
limits need proper
margins, and that high
CO2 causes limits to
reduce dramatically.
May be simply a buoyancy problem but suggested is CNS Awareness that CNS Gross incompetence in design of
hit from high O2 in the trainee diver - possibly exacerbated limits need proper electronic portion of rebreather, with
by hypercapnia, and other diver died in the attempted margins, and that high many single points of failure.
rescue. CO2 causes limits to Manufacturer does not have any
reduce dramatically. annual service requirement for
rebreather itself, and did not do a
recall for battery housing
improvement.
Electronic rebreather controllers
should meet IEC 61508. Tank
contents monitoring linked to auto-
shut off valve would probably have
avoided this accident.
Scant data.
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An external reference confirming that
accident occurred
http://www.cdnn.info/news/safety/s060106.html
http://www.cdnn.info/news/safety/s060106.html
Confidential communication
Confidential communication
Confidential communication and inquest reports
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
97 25/09/2005 Roland Schoen RB80 Clone Unknown Solo Diving 15 / 5 Switzerland, OC Instr., TMX 38
(Schön) (Habanero) Zugersee (Lake diver, Cave diver.
of Zug). RB first dive.
96 22/09/2005 Nigel Peter Lees Inspiration APD Solo Diving 15 New Zealand, Experienced 48
Ship Cove
95 17/09/2005 Tom Storm Inspiration APD Solo Diving 15/?/0 Sweden, West Experienced
Coast
94 01/09/2005 Unknown diver Inspiration Buddy dive 6 / 46 / 46 UK Experienced
93 28/08/2005 Dmitry Satyukov Azimuth Unknown Solo Diving 26 USA, New Experienced 33
Jersey, Bald
Eagle wreck
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Root Case Disabling Injury Key information received on accident
Human error Hypoxia Reports: 1/2hour less introduction to the unit. 1/13 ratio. 21/35 as dil gas: insufficient
O2 in diluent.
Divers separated at depth on purpose. Due to no (limited) RB experience, not enough
flushing of the RB during ascent. Death due to hypoxia. Diver had previously
completed a Dolphin course, but is reported not to have done any dives on the Dolphin
afterwards.
Rebreather design fault Hypoxia Handsets appeared not to be on. Make-up-gas cylinder was empty. Wing may have
caused a problem with breathing hoses, but unlikely.
Rebreather design fault Hypoxia While preparing for a shallow advanced Nitrox dive that he was instructing. JB
suggests that Deceased didn't look at the handsets since his hands were occupied with
linelaying, and controller failed. Pre-backlit version of the Inspo, that was prone to
hang.
Scant data Scant data. Report of BSAC 05/214. A rebreather diver completed an 80 min dive to 46m including
the following stops; 2 min at 35m, 2 min at 28m, 2 min at 19m, 5 min at 9m and 25 min
at 6m. During the ascent he felt sick and had to switch to his bail out regulator so that
he could be sick underwater. He got water in his mask and he swallowed this water. He
requested help to get back in the boat and was sick again. He drank some tea and
vomited again. He complained of feeling unwell. He sat down and breathed enriched
air from his rebreather. He then became incoherent and collapsed. The Coastguard
was alerted and the diver was placed on oxygen. The diver was airlifted to hospital
where he died four days later."
Training issues Scant data Deceased was a diver from Brooklyn and had a FFM. Deceased was among a group of
divers who took the 42 ft dive boat Karen 10 miles off Gerritsen Beach around noon.
Divers on the Kare, were allotted an hour and a half to dive, but Satyukov didn't surface
along with the others. The boat's skipper called the Coast Guard. In response to the
distress call, the dive boat Jeanne II, pulled the hook from the wreck they were diving
and joined the Karen for the search of the body. A mate from the Jeanne found the
body floating face up. He tried to put air in the BC but failed. Either there was no air left
or the LP hose was not connected properly. He tied a lift bag to the body and shot him
up. Rescuers found Satyukov dead underwater face up about 30 minutes later, at 2
p.m. Body recovered with lift-bag.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
LOC from hypoxia while ascending from trial dive, oxygen Need to flush SCRs
content in loop too low at end of dive in shallow waters. during ascent needs to be
reinforced.
Investigators may not be aware of the capacity for the Provide adequate margin for CNC
equipment to turn off after being switched on. In any case, clock. Provide CO2 monitoring.
lack of automatic switch on is a fundamental safety design Simple switch to count down to zero,
fault: equipment does not comply with any Functional and disable loop, that resets when
Safety standard without it. scrubber fitted.
Provide adequate margin for CNC
clock. Provide CO2 monitoring.
Simple switch to count down to zero,
and disable loop, that resets when
scrubber fitted.
The captain of the Jeanne II mentioned that in the past,
this same diver dove with him using a rebreather and
showed no knowledge whatsoever on it. He then banned
the guy from diving in his boat with a RB. A very interesting
note is the fact that the deceased's rebreather instructor
was the fellow that died in 4' of water in a pool a few
months previous to this fatality. The Bald Eagle is a broken
up wreck lying on 85 fsw about 15 miles of the NJ coast.
Viz is usually decent.
Page 139 of 210
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An external reference confirming that
accident occurred
http://www.scubabrucie.com/dive/2007/01/25/rebreat
her-fatalities/
http://dcyccr.blogspot.com/2007/01/news-article-
about-nigel-lees-inquest.html
Confidential communication and inquest reports
http://www.bsac.com/page/260/fatalities.htm
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
92 21/08/2005 Gerry Tychansky Megalodon ISC Buddy dive 4 Canada, Experienced 43
Hamilton, Ontario
91 09/07/2005 Takahara Yoharu Inspiration APD Solo Diving 50 Japan, Ida beach, Experienced 38
Numazu
90 05/07/2005 Manolis Efthinakis Inspiration APD Buddy dive 32 Greece - -
89 17/06/2005 Keith Morris Megalodon ISC Solo Diving 69 Channel Islands, Experienced, OC 66
Guernsey Trimix diver
88 05/06/2005 Nicholas Jackson Inspiration APD Trimix 60 UK -
87 01/06/2005 Unknown diver Inspiration Group Diving 68 UK Experienced
86 07/05/2005 David Rampersad Azimuth Unknown Solo Diving 3 USA, PA Experienced 38
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Root Case Disabling Injury Key information received on accident
Underlying Illness / Heart attack during a Underlying Illness: heart attack.
Rebreather design fault period of hypercapnia
Rebreather Hypercapnia: WOB/CO2 Diver didn't carry bailout and communication system had broken.
issue/human error: retention Savage current.
Exceeded Performance Hypercapnia from spent Diver reported to be using expired scrubber. Diver died while filming under water pipe.
Envelope / Human error scrubber
Scant data Scant data. 20 miles north west of Guernsey (SHEARWATER). Instructor trainer.
Exceeded Performance Hypercapnia Only report of BSAC 05/102. A group of four divers dived on a wreck at a maximum
Envelope depth of 60m, all using rebreathers with trimix. Although in the water together they
conducted their dives separately. After 60 min, one diver was seen by another to be
recovering a porthole. The porthole was later found at the surface under the diver's
lifting bag. Three divers surfaced having completed over 150 min decompression on a
trapeze. The diver who had been seen with the porthole did not surface and the alarm
was raised when he was 15 min overdue. A search was initiated involving two lifeboats,
two helicopters, a warship and other vessels. The missing diver was not found.
Rebreather design fault Hypoxia Only report of BSAC 05/135. A diver conducted a dive on a wreck to a maximum depth
of 68m using a rebreather. He dived alone although others from his party were in the
water at the same time. He was last seen hovering motionless above the wreck. He
failed to surface and an extensive search involving aircraft was made. His body has not
been recovered.
Human error Hypoxia In school swimming pool. Report of diver using air instead of nitrox in this SCR
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Not ruled out hypercapnia induced because equipment Provide adequate margin for CNC
had possibility of scrubber bypass fault. clock. Provide CO2 monitoring.
Simple switch to count down to zero,
and disable loop, that resets when
scrubber fitted.
CO2 sensor required. Simple switch
to count down to zero when scrubber
fitted. WOB should not exceed
EN14143:2003 limits.
The accident seems to be classic case of hypercapnia.
Heavy exertion, deep dive (scrubber endurance is not
good at this depth and from the decompression of 150
minutes, was exceeded considerably).
Sudden LOC in a buddy dive suggests hypoxia as most There are many accidents
probable cause. There is a paucity of data in this accident. where one diver sees
A range of other conclusions is possible, but hovering another hovering
motionless suggests a very sudden LOC hence hypoxia. motionless and does
Divers observing the motionless diver did nothing nothing, surprisingly.
apparently: compassion and care did not seem to come Perhaps divers may need
naturally to them. to be trained to assist
immediately when they
see a motionless person
underwater.
Auto-shut off valve would have
avoided accident.
Page 143 of 210
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An external reference confirming that
accident occurred
http://www.rebreatherworld.com/rebreather-accidents-
incidents/1322-meg-fatality.html#post55985
http://www.rebreatherworld.com/rebreather-accidents-
incidents/1206-inspiration-accidents.html
http://www.rebreatherworld.com/rebreather-accidents-
incidents/1206-inspiration-accidents.html
http://www.rebreatherworld.com/memorial-
forum/2243-keith-morris.html
http://www.bsac.com/page/260/fatalities.htm
http://www.bsac.com/page/260/fatalities.htm
Confidential communication and inquest reports
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
85 01/05/2005 Unknown diver Inspiration Buddy dive - UK -
84 01/05/2005 Unknown diver Inspiration Buddy dive - UK -
83 12/04/2005 Alain Colas Dolphin Unknown Buddy dive 15 France, Fabregas Experienced 46
near Toulon
82 06/04/2005 Wlodzimierz Inspiration APD Cave Solo Diving 105 France, Saint Guru
Szymanowski Andeol
(Wlodek)
81 01/04/2005 French Diver Inspiration APD Training dive 11 Switzerland, Trainee 41
Neuenburger
See.
80 25/03/2005 Bernd Heiko Inspiration, APD Vision Solo Diving 56.7 Austria, Weyregg Novice 46
Schultz Vision am Attersee
79 09/03/2005 Brendan Megalodon ISC Apecs Ice Diving 16 USA, Bethlehem Trainee
McGuiness eCCR PA
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Root Case Disabling Injury Key information received on accident
Scant data Scant data. Dual fatality. Only report of BSAC 05/095. Three divers conducted a dive in a quarry.
They exchanged signals to ascend. One of the three became separated, surfaced, got
out of the water and waited for his buddies to surface. Two sets of bubbles were seen
but these turned out to be a different pair of divers. Later two rebreather divers found
the two missing divers apparently lifeless at a depth of 34m. They were unable to lift
the divers so they marked their location with delayed SMBs. The divers were recovered
and resuscitation techniques were applied. They were taken to hospital where death
was confirmed
Scant data Scant data. Dual fatality. Quarry dive. Only report of BSAC 05/095. See above.
Human error / Hypoxia Fabregas near Toulon in France 14' into the dive. The diver was taking pictures and
Rebreather design fault was found with the rebreather tank empty.
Human error Human error: Narcosis. Extreme cave diving in Bourg Saint Andeol, France. The rescue diver who found
Deceased at -105 point, stated that the vr3 showed tx 10/70 but that the diluent
connected was air ! Diver was carrying 10/53 trimix, but not connected to rebreather.
Underlying Hypercapnia cold induced, Diver rushed from 11m to the surface and then drowned. Hypercapnia.
illness/Rebreather issue cause of death heart http://www.taucher.net/unfall/unfallShow.html?unfallNummer=336 reports 4th dive with
attack RB under supervision of a RB Instructor. Dive intended to be to 25msw and a dive
time of max of 45` without exercises. After 35 mins the diver shot to the surface from
a depth of approx. 11m for unexplainable reasons. After a further 12 minutes,
Deceased was found the unconscious at a depth of approx. 3m.
Rebreather AGE Equipment failure leading to uncontrolled ascent from 37m. May be underlying illness,
issue/Equipment as diver vomited before drowning. This was the first dive following the course. Air
issue/underlying make-up-gas.
illness/human error
Exceeded Performance Hypercapnia from flapper (SHEARWATER) Ice diving - very cold water and sub zero air.
Envelope valve failure
Page 146 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
The Deceased was a speleologist but not a cave diver, the Auto-shut off valve would have
incident occurred while diving and making some shots of avoided accident. Rebreathers need
sealife - this was not a cave dive. active tank content monitors.
Most plausible cause is that diver did not realise his gas
was running low and inadequate monitoring.
Use of air as the make-up-gas would cause considerable Better buddy checks in He sensor required on trimix units.
narcosis at this depth (worse than on air at 105m), giving expedition dives. This is not a complex addition.
rise to risk of nitrogen blackout.
Behaviour points to a hypercapnia problem. Autopsy found CO2 sensor required. Simple switch
heart attack. to count down to zero when scrubber
fitted. WOB should not exceed
EN14143:2003 limits.
Deep and solo dive for very inexperienced rebreather Guidance at the time was
diver: his first dive after the training course other than a 2m that divers should not
weight check. exceed the depth limit of
the course until they have
built up 50 hours.
Most plausible cause of several Rebreather issues is Rebreathers are not Sensing of mushroom valve and
hypercapnia due to WOB from sticking inhale counterlungs suitable for diving in water WOB would have reduced the risk of
or mushroom. Hypercapnia from scrubber not being warm less than 4C without this accident occurring. WOB should
enough at start of dive should not be ruled out. counterlung heating. not exceed EN14143:2003 limits.
Page 147 of 210
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An external reference confirming that
accident occurred
http://www.bsac.com/page/260/fatalities.htm
http://www.bsac.com/page/260/fatalities.htm
http://www.plongeesout.com/causette/affiche.php?m
essage=5446&session_id=
http://www.plongeesout.com/causette/affiche.php?m
essage=5302&session_id=
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
http://www.rebreatherworld.com/rebreather-accidents-
incidents/14619-comprehensive-list-all-accidents-
3.html
Page 148 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
78 05/03/2005 Radek K Dolphin Unknown Ice Diving 9 Poland, Quarry Trainee 31
Jaworzno
Szczakowa
77 01/11/2005 Patrice Morelec Inspiration APD Buddy dive France, Becon
les Granites
76 09/01/2005 Nick Flemming Inspiration APD Solo Diving 46 UK Expert -
Page 149 of 210
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Root Case Disabling Injury Key information received on accident
Exceeded Performance Hypercapnia from spent Training dive. Polish diver. Scrubber exhausted. A report of caustic cocktail inhaled by
Envelope / Human error scrubber diver. Initial report of witnesses was heart attack, but cause was scrubber failure. For
reference intiial report translated from Polish is "During diver training on SCR Draeger
Dolphin during the ascent phase after about 20 minutes of immersio at, the depth of
about 8-9 meters distance from the pontoon (a steel platform anchored at coast) about
10 meters), one of the divers had an accident - the loss of consciousness, emergence
to the surface and send down to the bottom.
Partner alone was not able to pull Deceased to the surface, emerged and called
support - in mere minutes with the second diver, who immediately went down again
dressed equipment on the bottom and pulled the victim to the pontoon. Immediately
wciągnęliśmy it onto a pontoon and after noting the absence of respiratory and cardiac
resuscitation began.
Summoned in the meantime, rescue ambulance arrived within minutes and its crew
continued CPR. According to the team reanimacyjnego likely cause of death was a
heart attack.
The victim was an experienced diver (200 dives, the degree of normoxic trimix), after
taking equipment was found that the gas cylinders was - in the main cylinder
Rebreather - nitrox EAN54, in bail out - air, in addition to the equipment had stage 8l
cylinder with air - not used. This was the second dive that day the victim on the same
hardware - the previous time about 30 minutes break with a three hour break.
Can I just add in order to bring issues that immediately prior to an emergency situation,
the partners exchanged among themselves, "okejki.
Rebreather design fault Hypoxia. Diver's training was unclear. Rebreather was the original old model that was prone to
hand, bought third hand. Diver found on the 2nd dive of the day with the handsets off.
Scant data Scant data Diver completed an 80 minute dive including deco stops. Felt unwell during ascent.
Changed to O.C. Flooded mask. Vomited at surface. Died 4 days later in hospital.
Report of hypoxia, but does not fit other data.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
When the rebreather hangs, divers usually switch the Electronic rebreather controllers
handsets off and back on again. From the profile, the should meet IEC 61508.
handsets were on at the start of the dive. Therefore this
accident is put down to the extremely high risk of this
particular model of the Inspiration (pre Aug 2000), of
hanging, reseting, jumping to inappropriate code etc.
This report on the RBW list matches most of an
uncooberated report for the deceased, but with some
discrepancies. This list had held it back, but it is believed
the RBW data comes from APD. Interestingly, the name
has been withheld, as this list has stated for several years
that we are looking for data on Nicholas Flemming's
accident.
Page 151 of 210
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An external reference confirming that
accident occurred
Confidential communication
Accident on new RBW list matched uncooberated
reports.
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
75 08/01/2005 David Shaw MK15.5 HH Solo Diving 271 S. Africa, Expert 50
Boesmansgat
74 01/01/2005 Unknown Inspiration APD - New Zealand
73 01/08/2004 Unknown diver Unknown Unknown Buddy Dive - UK Novice -
72 27/08/2004 Earl Peterson Inspiration APD Solo Diving 25/50 USA, Lake Mead, Untrained -
Nevada
71 27/07/2004 Luigi Longo Voyager Unknown Solo Diving 14 Italy, Marano Trainee 34
70 24/07/2004 Kikuchi Ayamura Inspiration APD Solo Diving - Japan, Okinawa Experienced 35
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Root Case Disabling Injury Key information received on accident
Exceeded Performance Hypercapnia: WOB/CO2 Presentation by Simon Mitchell at DAN Tech Conference
Envelope / Human error retention
Scant data Scant data. Scant details
General diving hazard Drowning A diver entered the water for his second dive of the day. He was using a rebreather. In
the water he appeared to be very negatively buoyant and he called for assistance. His
buddy offered his alternative air source but the troubled diver did not take it. The buddy
had his mask knocked off and his regulator knocked from his mouth. The troubled diver
sank quickly. There was a 2 knot current. The buddy refitted his equipment and dived
down to try to locate the missing diver. He was not successful. The Coastguard was
alerted and an unsuccessful air and sea search was conducted. His body was found,
washed ashore, twelve days later.
Rebreather issue Hyperoxia due to The diver was very overweight and had medical issues on at least two previous
hypercapnia occasions.
Rebreather design fault Hypoxia Reported as a rebreather fault resulting in hypoxia. Dive was a try dive organised by
Geomar Controls.
Rebreather design fault Hypercapnia: WOB/CO2 Equipment malfunction: there was information about several breakdowns of the CCR
retention before the accident. Body was not found. Most plausible cause is high WOB due to
savage current. WOB of this equipment was more double the EN14143 safety limit.
Page 154 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Hypercapnia on extremely deep dive. Caused by CO2 sensor required. Simple switch
increased WOB from addition to equipment by diver and to count down to zero when scrubber
misassembly. fitted. WOB should not exceed
EN14143:2003 limits.
Scant details
BSAC 04/256 Report only. Buoyancy provisions on rebreathers
should make the rebreather diveable
in a shorty without other weight.
Buoyancy available from wing needs
sufficient lift for the flooded
rebreather, and a diver using steel
cylinders with steel bail outs.
It looks as if diver took an O2 hit and then shot to surface Ensure equipment complies with IEC
and had an embolism. O2 hit probably caused by 61508
hypercapnia.
Deceased was an only son, ultra fit, naval diver in Foreign False certifications and false claims
Legion and then tried out the Voyager. The judicial inquiry for the Voyager mean that any
did not use any competent expert, and the case was regulations or standards
covered up. The Voyager is hugely over-represented in improvements are likely to be
this list. Equipment was supplied by Nicola Donda, ignored: active enforcement is
Trieste, who later organised the event that became the necessary across the EU, including
Slovenian double fatality in July 2010. Italy.
Diver was a medical doctor. Mother a concert piano Divers should be taught Active WOB measurement required.
soloist. Devastating effect on the family concerned. the WOB limits, and what Ensure WOB is within EN14143:2003
they mean. limit.
Page 155 of 210
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An external reference confirming that
accident occurred
Extensive expert review and discussion on internet.
Video of fatal dive on Youtube.
Confidential communication
BSAC Report Only
From accident investigator and investigator hired by
Park Service
http://translate.google.com/translate?hl=en&ie=UTF-
8&sl=it&tl=en&u=http://ricerca.gelocal.it/ilpiccolo/arch
ivio/ilpiccolo/2010/07/31/NZ_13_SPAL.html&rurl=tran
slate.google.com.au
http://eco.ac/ckc/new/nippon/accident-list.html
Page 156 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
69 29/06/2004 Johnny van der Draeger FGG 3 Unknown Buddy dive 15/54 South Africa, Expert -
Walt Sodwana
68 24/05/2004 Eddie Girvan Inspiration APD Buddy dive 50 UK, Chepstow Experienced 44
67 01/05/2004 Wiktor Bolek Inspiration APD Classic Solo Diving 6 Germany, Expert -
Wildeshutz
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Root Case Disabling Injury Key information received on accident
Rebreather issue Hypercapnia or hypoxia Apparent sudden loss of consciousness underwater. Suggested heart attack.
Rebreather design fault Hypoxia Buddy described how had found Deceased unconscious, with his rebreather handsets -
which control the addition of oxygen into the breathing loop - not fully switched on.
BSAC report 04/172 contains following further information: ""hree divers using
rebreathers prepared to make a dive to a maximum depth of 60m. One of them waited
in the water for the others to finish kitting up as he was warm. They then swam 20m to
a shotline and began their descent. They descended the line one behind the other, with
the diver who had waited in the water last. They checked each other twice during the
descent. The first two divers arrived at the bottom of the shotline at a depth of 50m.
They changed the settings of their rebreathers and one attached a strobe to the
shotline. They looked up for the third diver but he was not there. They checked around
and they made an ascent to the surface. The missing diver was not at the surface.
They raised the alarm and one of the divers re-descended to search for the missing
diver. He found the missing diver on the bottom. His rebreather hand sets were found
to be part way through the set up sequence. The casualty had his mouth piece in place
Underlying Illness / Hypoxia but autopsy Diver made short dive with his buddy on 6m where they separated: the buddy went
Rebreather fault / reported Heart attack deeper (because he had different aim for this dive) and victim has turn back to the
Human error surface to take some more O2 stages and settle them on 6m. Diver had been found on
surface unconscious. In medical report as a cause was given heart attack but there
were also some suspicions that diver did not open O2 valve, so he had hypoxia,
without alarms
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Much more likely hypercapnia or hypoxia: latter from using Gas less than 99% O2 O2 cells should be calibrated in air,
gas that is not pure O2. cannot be used in not on pure O2. Checks needed to
rebreathers. This ensure the O2 is really pure O2.
message is not getting
through. Some divers are
still using 92% O2 gas,
ignorant that the 8%
remaining has a lot of
argon and collects in their
breathing loop.
Cause of not being in dive mode is almost certainly may Electronic rebreather controllers
have had problem and switched Rebreather off, but should comply with IEC 61508. In
software bug prevents restart, battery bounce, cracked this case the equipment did not
handsets, any of numerous electronic components, or comply as it had many single points
simply known software faults with this version of of failure.
rebreather.
Rebreather not in dive mode and did not go into dive mode
automatically when in use: this is a fundamental design
mistake that would have been avoided had Functional
Safety design procedures been used.
Coroner was not aware of the problems with this
Rebreather leading to a highly questionable verdict. The
Coroner was misled by the failure to disclose this key fact
about this particular rebreather model and age.
Deceased did not have BI buzzer (Deceased had
disconnect buzzer some time before for deep dives), that
is why Deceased did not hear signals when PPO2 was
getting lower
Page 159 of 210
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An external reference confirming that
accident occurred
Confidential communication and inquest reports
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
http://gnj.org.pl/artykuly/wiktor.php
Page 160 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
66 24/04/2004 Peter 'Crusty' Inspiration APD Classic Solo Diving, Wreck 50 Australia, Sydney Experienced -
McDowell penetration
65 01/04/2004 Richard Diamond Prism Topaz SM Solo Diving 0 Thailand Experienced 40s
64 09/03/2004 Deane Brown Dolphin Unknown Buddy dive 16 Philippines, Expert -
Olongapo, Subic
Bay.
63 07/03/2004 Luca "El Inspiration APD Classic Solo Diving 20 France, Cote Experienced -
Bombarolo" Torelli d'Azur
Page 161 of 210
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Root Case Disabling Injury Key information received on accident
Human error Human error: Removed During a wreck penetration diver had removed the rebreather to go through small hole
rebreather and snagged, leaving the equipment out of reach. Witness report on file.
Underlying Illness / Heart attack, during a A diver jumped in for his morning dive and came back to the surface quickly,
Rebreather fault period of hypercapnia unconscious and died shortly thereafter. Plausible causes are hypercapnia, hypoxia.
No report of Rebreather flood. The cause was reported to be a massive heart attack,
but this was an exceptionally fit individual, who ran every day. Those who knew
Deceased discount the heart attack theory.
Underlying Illness / Heart attack, during a The diver was an instructor and was making a training dive with a student. At the
Rebreather design fault period of hypercapnia bottom the student lost visual contact with instructor and ascended. The instructor was
found at the bottom after about an hour. An autopsy came to conclusion that the cause
of death was a massive heart attack but coroner would be unaware of hypercapnia
risk. Scrubber exhausted, so likely to have high PPCO2 on exhale, hence diver
suffering from hypercapnia.
Rebreather design fault: Hypoxia Most plausible cause is a modification that failed as it was being tested, but data too
possibly a modification scant to conclude. Rebreather was modified to be a KISS style unit, in which case the
that failed as it was Inspiration controllers would have acted as PPO2 monitors. Solo diving testing a new
being tested. feature.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Not an equipment failure but may be a training failure Directors of one agency Rebreather needs to be designed for
because agencies are training divers to do this procedure. are known to teach their removal underwater and this
recreational students to functionality neesds to be part of
Divers are not aware that a RB will usually float up, and not remove their RBs in a diving system with a breathable gas
sink like tanks, and also off the diver the rebreather cannot pool. source available to diver at all times.
be breathed due to the hydrostatic pressure. There is also
the problem that the RB usually carries some of the diver's
weight, so if it does sink then the diver floats upwards.
Details known to JB and reported. Buddy was also a
Prism diver, who checked Deceased's Rebreather after
accident, but found no cause: no scrubber testing carried
out. SMI did not have an opportunity to examine
equipment. Heart attack conclusion is purely from medics
on board the vessel, not post mortem. Suspected link
between hypercapnia and heart attack may not have been
known to investigators.
CO2 sensor required. Simple switch
to count down to zero when scrubber
fitted. WOB should not exceed
EN14143:2003 limits.
Solo diving on rebreathers
is much more hazardous
than on Open Circuit.
Divers should not modify
eCCRs.
Page 163 of 210
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An external reference confirming that
accident occurred
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
http://sportsnetwork.talk-about-
network.com/Subic_Bay_Incident-006773-2469.html
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
http://www.rebreatherworld.com/rebreather-accidents-
incidents/14619-comprehensive-list-all-
accidents.html
Page 164 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
62 01/03/2004 Lothe Kaiser Inspiration APD Classic Buddy dive 20/5 Norway, Håkøy, Experienced 26
Tirptitz wreck
61 01/01/2004 Alessandro Voyager Unknown - 10 Italy, Maggiore - -
Brusatori Lake
60 12/12/2003 Steven Alan Megalodon ISC Apecs Buddy dive - USA, Bonne
Russell eCCR Terre Mine, MN
59 26/10/2003 Clemens Inspiration ISC Apecs Solo Diving 17 Egypt - -
Neuenhaus eCCR
58 23/08/2003 Wolfgang Lutz RB80 Clone Unknown Solo Diving 3 Germany Novice
(EDO04)
57 24/04/2003 Dan Meyers Azimuth Unknown Buddy dive 3 USA, Willow Experienced 40
Springs Quarry,
Richland, PA
56 24/04/2003 Deki Aboitiz Dolphin Unknown Buddy dive 30 Philippines Trainee
55 06/02/2003 Tomas Rosenfeldt Inspiration APD Classic Solo Diving 100 Hawaii, Kona Conflicting reports -
54 01/01/2003 Unknown diver Fieno Unknown -
Page 165 of 210
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Root Case Disabling Injury Key information received on accident
Rebreather design fault Hypercapnia In 2004 diving team had to do a series of dives to map the wreck on the Tirpitz, but in
March at Cap Martin after being at a depth of 20 meters, diver made a stop at 5 (five)
meters deep for about ten minutes and suddenly rose to the surface without meaning
and there remained until found (data collected by the wrist computer),
Deceased was engaged in from physical sports 22 years of age, 'myocardial there'
enter.
Scant data Scant data Scant data
Rebreather Scant data
issue/human error:
Rebreather design fault Scant data Scant data but strong similarity with other accidents, hence classification.
Rebreather design fault Hypercapnia from no Coroner ordered a recall of the equipment. Novice diver on RB. Diver used RB80
(Prosecutor's office scrubber Clone, i.e. EDO04. Accident happened at 3m, ascending from his 4th dive on the unit.
ordered a recall) Sudden LOC due to hypoxia, though indicator was hypercapnia. Public prosecutor
put out an order for immediate recall of the equipment as the deaths are due to a
design fault (faulty mushroom valve material and spider).
Rebreather design fault Hypoxia Quarry diving. Diver was relaxing at the bottom of the entry platform and his mates
found him unresponsive. His equipment had gone to low-flow and he passed out and
drowned.
Human error Hypoxia, Narcosis Ascending after reef dive. Deceased was left alone, and found tangled with the reef
hook at 60m. He had not yet been certified on the Rebreather and was still in training.
JB has detailed report.
Scant data Scant data Scant data. Body was not found. A known fact is that the Kona Aggressor boat was
used for diving. Aggressor fleet conceals dive accident information. Witness report
received by DL.
Scant data Scant data. Scant data.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Scant data
Bonne Terre mine - there are multiple reports of it being a
dangerous and badly run dive facility.
Simple switch needed to detect
scrubber replacement, and
countdown timer. CO2 monitor
needed.
Here are some pictures of the faulty part: Solo diving on rebreathers Negligence in equipment design:
http://www.unterwasser.de/aktuell/Newsdetail/d453783a- is much more hazardous failure to test the part to EN14143.
00d1-4bd3-be65-2a5989fbc165/ than on Open Circuit
and here
http://www.getoese.de/tauchen/themen/archiv2003/kreisla
ufgeraet.htm
There are other factors which 'helped' the accident to
happen:
- solo
PPO2 display required. Auto-loop
shut off required.
Scant data. Body was not found. A known fact is that the
Kona Aggressor boat was used for diving. Aggressor fleet
conceals dive accident information. Witness report
received by DL.
Scant data.
Page 167 of 210
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An external reference confirming that
accident occurred
Public information is from page 5, top post of
http://translate.googleusercontent.com/translate_c?hl
=en&sl=it&tl=en&u=http://www.marescoop.com/ftopic-
1881-days0-orderasc-
60.html%26sid%3D13118a1e497c5631205b9faece3
772d2&rurl=translate.google.com.au&usg=ALkJrhg8
dMApwPS2Tgg-ugzFibWwjsaMVg
Confidential communication and inquest reports
http://www.rebreatherworld.com/rebreather-accidents-
incidents/14619-comprehensive-list-all-accidents-
3.html
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
Confidential communication and inquest reports
Confidential communication and
http://www.smokeysdiversden.com/diver_dan/dan1.h
tml#
http://raven.utc.edu/cgi-
bin/WA.EXE?A2=ind0306&L=SCUBA-SE&P=19767
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
Confidential communication and inquest reports
Page 168 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
53 10/08/2002 Carlton Lee Draeger Ray Unknown Solo Diving 17 Singapore
52 06/08/2002 Unknown diver Unknown Buddy dive - Croatia, Island of - -
Mljet
51 03/08/2002 Robert Barrett Inspiration APD Classic Solo Diving 14 USA, Bainbridge, RB Expert, Inspo 32
PA Experienced. O.C.
trimix instructor.
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Root Case Disabling Injury Key information received on accident
Underlying Illness / Heart attack during heavy Heavy current, and heavy person (weighed 300lbs), found with 1 fin missing.
Rebreather design fault work and hypercapnia Coroner's report was heart attack.
Scant data Scant data Scant data
Rebreather design fault Hypoxia Witnesses describe Barrett as the best diver they had ever seen. Full investigation
carried out. Mr. Barrett was teaching an 18 year old student to use a Dolphin
rebreather on 3rd August 2002, accompanied by two other divers on open circuit. Mr.
Barrett was using an Inspiration rebreather to build up his hours: he had done 65 to 70
hours but the US Distributor appears to have required 100 hours before Mr. Barrett
could be an instructor on the unit. All four divers had completed a shallow dive in the
morning, two hours earlier: Mr. Barrett‟s dive computer showed these as a series of six
shallow dives. The Inspiration rebreather was in the same state as it left the factory for
all material purposes. It had been manufactured less than 2 months previously though
he received his Inspiration training in the first week of March 2002. The Inspiration was
a 2002 model of the APD Inspiration rebreather.
It was a hot day: 90F to 95F. The back of the Inspiration would have been off during
part of the day.
The divers were wearing dry suits. They had to carry their equipment for between 3
and 5 minutes from the kit up area to the point where they entered the water. Mr.
Barrett‟s equipment weighed around 130lbs. During this walk he would have been
stressed with the heat, wearing a dry suit.
The dive profile was a short surface swim and then a dive to 4.5m, pause on a
platform, then to 11m, and after three minutes ascent back to 4.5m, ending in sudden
LOC after 6.5 minutes total dive time.
Mr. Barrett was breathing from the rebreather before he passed out. References to a
regulator by the diver who carried out the recovery mean the rebreather mouthpiece:
the regulator was stowed and the tank with the regulator was full.
The witness reports do not indicate any stress or loss of mental reasoning, or odd
behaviour before Mr. Barrett left the other divers. Mr. Barrett left the other divers not
more than one or two minutes before the accident: it may have been only 30 seconds.
He left for reasonable cause: the visibility was low and Mr Barrett wanted to find a
feature underwater – in poor visibility this would have enabled Mr. Barrett to keep his
trio together. Almost immediately after leaving the group Mr. Barrett swam towards the
surface: this might be that he recognized his rebreather had malfunctioned but with his
Page 170 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Most likely cause of several is hypercapnia: diver over- WOB monitoring required. WOB
breathed the Rebreather in the heavy current, which given should not exceed EN14143:2003
the Deceased's general coronary health, triggered a heart limits.
attack.
Reported by witness.
Extensive information reviewed. It is clear from Mr. An experienced Draeger Electronic rebreather controllers
Barrett‟s profile that he suffered a sudden loss of diver, so would not be should meet IEC 61508. Equipment
consciousness due to hypoxia. The was also the opinion of used to look at his involved did not comply in any shape
medical experts. Master handset battery failure when slave handset. This was not or form, with many single points of
was sitting in "Dive Now?" mode after battery bounce. given enough emphasis in failure. Equipment liable reset into
Cause is almost certainly sudden failure of master battery training. modes which did not support life, and
after battery bounce on slave. Counsel for manufacturer can hang.
has suggested four alternative causes, but these are
plainly contradicted by validated facts (e.g. they claim the
diver died due to using the wrong sorb - the diver fitted
new Draegersorb, which is generally better sorb than 797
in independent tests).
Hypoxia fault modes were reproduced in examination of
the equipment and tied in perfectly with formal modellng of
the accident: there is no doubt at all the diver died from
hypoxia. However, jury of 8 decided that manufacturer
was not legally culpable for accident. Diver had not looked
at his handsets for a 6 minute period, and the
manufacturer advises the diver to look at the handsets
every minute, and continuously on ascent: the Deceased
failed to do that.
Ethics by manufacturer and their legal counsel on this
were very poor, slandering main witnesses on internet, in
print and privately in heavy concerted campaign, and used
countersuits on widow, expert witness, legal counsel of
plaintiff etc which has had the effect of putting relatives in
other hypoxia cases from prosecuting their respective
claims.
This model of the Inspiration is much improved on Nick
Hester's first attempt (pre Aug 2000 Inspirations), which
Page 171 of 210
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An external reference confirming that
accident occurred
Confidential communication and inquest reports
Confidential communication and inquest reports
Full accident investigation with all evidence available
Page 172 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
50 18/05/2002 Michel Guerin CCR1000 (MK- Unknown Semi-solo 6 Canada, Expert 42
15) Tobermory,
Ontario.
49 11/05/2002 Unknown Spanish Inspiration APD Classic Buddy dive 4 -
diver
48 06/05/2002 Dean Livesey Inspiration APD Classic Buddy dive 4 Channel Islands, - -
Sark
47 01/05/2002 Unknown diver Unknown - 0/60/- UK - -
46 01/01/2002 Unknown male Dolphin Unknown Solo Diving 60 Norway, Askøy, Novice 40
Bergen.
45 01/01/2002 Unknown diver Fieno Unknown - -
44 01/11/2001 Bernard Gonon Inspiration APD Classic Buddy dive 100 France Experienced 55
43 16/09/2001 Eric Reichardt Cis-Lunar Mk5P Cis-Lunar Solo Diving 90 USA, Florida Experienced 42
42 01/08/2001 Adriano Busato Azimuth Unknown Buddy dive 3 Italy, Garda Lake Trainee -
41 01/07/2001 Unknown Unknown Buddy dive 15 UK - -
40 01/07/2001 Mick Brennan Inspiration APD Classic Solo Diving 110 - 120 Wales, Holyhead Expert on Trimix -
O.C., Intermediate
on RB
39 23/06/2001 Garrett Weinberg Inspiration APD Classic Buddy dive 30, JB comments USA, Mukilteo, Expert -
may be 90m WA
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Root Case Disabling Injury Key information received on accident
Rebreather design fault Hypoxia. Witness report.
/ Human error
Rebreather design fault Hypoxia. During ascent diver LOC at 4 m and drowned.
Rebreather design fault Hypoxia Diver entered water after calibrating his Rebreather twice for unknown reason.
Appeared unconscious at 4 m in head down position.
Scant data Scant data. Only report of BSAC 02/112. Diver was seen to surface and then sink back down. He
did not resurface and body was not found.
Rebreather Scant data First dive after course. Points to a training problem, depth is body recovery depth.
issue/human error
Scant data Scant data. Scant data.
Rebreather design fault Hypoxia Appears to be an early model of that Rebreather which is prone to hang.
Marine life: Bull shark. Marine life: Bull shark The diver was attacked by a shark during a wreck dive and then drowned. Diver
haemorrhaged before drowning. The shark attack was confirmed by autopsy report.
The wreck was known to be the home of a 13ft Bull Shark.
Rebreather issue Hypoxia. Training dive first time: during the 3 m safety stop Deceased stopped breathing.
General diving hazard Entanglement Only report of BSAC 01/237. One of the pair became tangled in SMB line. The diver
was not found.
Rebreather design fault Hypoxia Master handset hung, with pre-backlit handsets that were very prone to hang. RB
bought second hand. Training was spread out, as no proper structure at the time.
Deceased would have been qualified automatically for trimix (MOD 3) because he had
extensive O.C. trimix experience and certs, and more than 50 hours on the rebreather
in the 7 months since purchase. BSAC report 01/218.
General Diving Hazard / AGE JB: Reports dry suit inflator caused uncontrolled ascent from 90m to surface, he got to
Rebreather issue / surface, reported to those on shore that he needed help, was taken to emergency
Inappropriate medical room instead of to a chamber. Deceased was suffering pulmonary DCS but was
response treated as if it was a heat attack.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Diver could have turned off the electronics or the O2 bottle Auto-shut off valve would have
on the surface and forgotten to turn them on in the water. avoided accident.
Hypoxia.
Most plausible cause, hypoxia. This is understood to Electronic rebreather controllers
another one of the pre-Aug 2000 models that has a strong should meet IEC 61508.
tendancy to hang.
Hypoxia. Appears to be due to an electronic failure, but Electronic rebreather controllers
scant information. Was this one of the pre-Aug 2000 should meet IEC 61508.
designs?
Review of instructor
standards
Scant data.
Electronic rebreather controllers
should meet IEC 61508.
Not far from a popular shark feeding site.
Data points to an Rebreather design
fault.
Need to carry line cutters
as standard equipment
Two witness reports. Rumour that Deceased was Electronic rebreather controllers
untrained or had few hours Rebreather is false. Inquest should meet IEC 61508. Incompetent
had vital information withheld. A cover up seems to have electronic design was most probable
occurred. cause of this accident.
Frustrating accident, where a DCS was treated as if the
diver was having a heart attack, despite pleas by diver to
the contrary. Incompetent medical personnel.
Page 175 of 210
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An external reference confirming that
accident occurred
http://www.aquanaute.com/listes/aquatek/msg00311.
html
Confidential communication and inquest reports
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
http://www.bsac.com/uploads/documents/Diving_Saf
ety/incidents/the_2002_report.pdf
http://www.rebreatherworld.com/rebreather-accidents-
incidents/
Confidential communication and inquest reports
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
http://www.scubaboard.com/forums/86091-
post8.html
http://216.239.59.104/search?q=cache:gHm85BLPw
HwJ:www.nwdesigns.com/rbarchive/2003/1121.html.
gz+Fieno+fatality&hl=en&ct=clnk&cd=3
http://www.bsac.com/uploads/documents/Diving_Saf
ety/incidents/the_2001_report.pdf
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
Claudia Milz (dive partner, and also Fiancee),
reported to Jeff Bozanic
Page 176 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
38 06/06/2001 Ghassem Geissary CCR2000 Unknown Buddy dive - France Experienced -
37 01/06/2001 Unknown Unknown Solo Diving 35 UK Experienced -
36 24/05/2001 Jan Magnus Inspiration APD Classic Solo Diving 25 Norway -
Soerboe
36 12/05/2001 Steve Hughes Inspiration APD Classic Buddy dive 50 England Novice -
35 07/01/2001 Hans Schneider Inspiration APD Classic Solo dive 110 England Intermediate or -
Experienced
34 01/01/2001 Stefano Sbizzera Azimuth or - - Sardinia, Italy - -
CCR2000
conflicting
reports
33 27/11/2000 Dennis Harding Halcyon "Fridge" Unknown Buddy dive 70 South Africa, Expert -
(Halcyon PVR- Jesser Canyon,
BASC) Sodwana Bay
32 09/08/2000 Ron Fuller FROG Unknown Solo Diving 17 USA, La Jolla Experienced 51
Shores, CA
Page 177 of 210
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Root Case Disabling Injury Key information received on accident
Human error Hypoxia Diver started the dive with a malfunctioning unit. He had no PPO2 display. The system
would not have maintained a PPO2 of .7. Witness report.
Scant data Hyperoxia due to Only report of BSAC 01/186. An instructor was teaching on a rebreather course. He
hypercapnia dived and is reported to have suffered an oxygen toxicity convulsion as he made his
ascent.
Rebreather design fault Hypoxia Diver was found floating on the surface after 1.5 hours.
Human error / Scant data. BSAC Incident report 01/155. The missing diver was not found. Rebreather was prone
Rebreather design fault to hang. Novice diver at trimix depths.
Scant data Scant data. Rebreather was prone to hang. It is not known how deep the diver planned to dive:
the body was recovered four weeks after the dive in a depth of 110m to 120m, but may
have been swept there. Air make-up-gas was connected, indicating the dive was
planned to be shallow.
Scant data Scant data Scant data
Rebreather design fault Hypercapnia: WOB/CO2 Suggested that diver suffered from a CO2 problem caused by WOB, when swimming
retention very hard to overcome current, with "Fridge" on his back. Coroner's verdict: Dennis
died as a result of Severe Decompression Illness. Underlying cause was hypercapnia.
Detail analysis report:
http://www.nwdesigns.com/rebreathers/Nuggets/Halcyon/DennisHardingAbridgedRepo
rt.htm and witness report.
Rebreather Scant data Unsatisfactory investigation. It is reported that diver had made some modifications to
issue/human error. his rebreather but whether these are relevant is not known. Victim is reported to have
been
appeared to be overweighed and never ditched his weight belt.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Witness report. PPO2 display required. Auto-loop
shut off required.
Awareness that CNS Provide adequate margin for CNC
limits need proper clock. Provide CO2 monitoring.
margins, and that high Simple switch to count down to zero,
CO2 causes limits to and disable loop, that resets when
reduce dramatically. scrubber fitted. WOB should not
exceed EN14143:2003 limits.
Classification and cause is based on the being a non-
backlit model of Inspiration that was prone to hang,
Electronic rebreather controllers
should meet IEC 61508.
Scant data, but this is the model of the Inspiration that was Electronic rebreather controllers
prone to hang. should meet IEC 61508.
Scant data
WOB of Rebreather is well above accepted safety limits. Active WOB measurement required.
WOB should not exceed
EN14143:2003 limits.
Page 179 of 210
1cd741fb-406a-44d0-a1ff-d2e0ca24226e.xls
An external reference confirming that
accident occurred
http://216.239.59.104/search?q=cache:dL6d7CjN2xo
J:www.diveoz.com.au/OLD_FORUMS_GONE/lm.asp
%3Fid%3D4083%26pp%3D1
http://www.bsac.com/uploads/documents/Diving_Saf
ety/incidents/the_2001_report.pdf
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
RBW accident list, tied up with an unverified accident
on this date.
Confidential communication and inquest reports
http://www.rebreatherworld.com/rebreather-accidents-
incidents/14619-comprehensive-list-all-accidents-
2.html
http://www.nwdesigns.com/rbarchive/2000/3963.html
.gz
Page 180 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
31 06/08/2000 Andy Wilde Inspiration APD Classic Buddy dive 6 England, Experienced -
Plymouth
30 13/06/2000 Ian Swift Inspiration APD Classic Buddy dive 48 UK, Salsette, Expert 41
Portland
29 01/06/2000 Dr Max Hahn Inspiration APD Classic Buddy dive 43 Germany, Bigge- Expert 70
See
Page 181 of 210
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Root Case Disabling Injury Key information received on accident
Rebreather issue Hypercapnia from spent Very deep dive as part of a team practicing for a 172m dive. Diver spat out the
scrubber mouthpiece and rushed to surface during 6m stop after 2 hours 45 minutes.
Information on maximum scrubber durations may not have been applied correctly.
Body was not recovered. Diver is reported to use a 1.4 bar setpoint and 1.6 bar on
deco. BSAC report 00/179.
Rebreather design fault Hyperoxia Diver tried but failed to bail out before convulsing at 43msw. Rebreather had gone
back to APD 5 times due to equipment faults, but in any case the Rebreather should
not have had old cells in it. May be BSAC report 00/134?
Exceeded Performance Hypercapnia, followed Scrubber was exhausted. Diver closed tank valves during ascent. Most plausible
Envelope / Human error during a period of by cause is hypercapnia, followed possibly by hypoxia as accident progressed. Heart
/ Underlying medical hypoxia as accident disease indicated in autopsy.
progressed.
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
This was a deep dive. Same version of Inspiration with Divers should be Provide adequate margin for CNC
faulty handset design as killed Paul Haydon, but due to the extremely careful on clock. Provide CO2 monitoring.
phase of the dive when this occurred, cause of death more rebreather scrubber Simple switch to count down to zero,
likely to be simply Hypercapnia or CNS. The diver did endurance where a profile and disable loop, that resets when
exceed CNS limits, but the level of O2 exposure is very is given rather than scrubber fitted. Always provide
unlikely to have caused an issue. The Inspiration scrubber constant depth. The constant depth scrubber endurance
duration at a constant 40m depth under CE conditions is former is almost figures, not just profiles with very
not disclosed: a profile is used because after 20 minutes marketing data, the latter short times to a given depth.
signs of breakthrough can be observed. This mix of is what the diver must
"profile" and a reference to 40m depth, can cause divers to keep within, as there is an
believe the scrubber duration is better than it is. infinite nuber of possible
profiles. Awareness that
CNS limits need proper
margins, and that high
CO2 causes limits to
reduce dramatically.
Rebreather was designed with gross incompetence in not Equipment had grossly incompetent
having any brown out, and no watchdog. Equipment would safety design with no brown-out or
jump to other modes due to random values being in watchdog. Force annual service
unused memory. May have been exacerbated by an O2 intervals by a handset countdown,
cell fault but unlikely. then disable unit. Factory service
should replace cells.
Deceased was the Chairman of the European Standards Simple switch needed to detect
committee that defined rebreather safety standards. scrubber replacement requirement,
and countdown timer. CO2 monitor
needed.
Page 183 of 210
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An external reference confirming that
accident occurred
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
Page 184 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
28 07/08/1999 Peter Osborne Cis-Lunar Mk5P Cis-Lunar Surface 0 England, Isle of - 44
Wight
27 26/06/1999 Maarten van der Inspiration APD Classic Solo Diving 27 Holland, Freisan - 36
Weerdt Islands,
Schiermonnikoog
26 25/05/1999 Harry Norman Inspiration APD Classic Semi Solo 54 South Coast UK, Advanced OC mix -
Railing Portland diver
25 15/02/1999 Henry Kendall Cis-Lunar Mk5 Cis-Lunar Solo Diving 3 Florida, Wakulla, Expert 72
SpringsState
Park
24 01/11/1998 Unknown diver Dolphin Unknown USA, Annacapa Untrained Novice 39
Island, CA
23 13/09/1998 Keith Milburn Inspiration APD Classic Solo Diving 4 Northern Ireland, Experienced 44
Ardglass
Page 185 of 210
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Root Case Disabling Injury Key information received on accident
Rebreather design fault Hypoxia. Rebreather was turned off: Rebreather does not turn on automatically.
Rebreather design fault Hypoxia Rebreather did not switch on automatically and was prone to hang, as it suffered from
battery bounce and had no brown-out circuit. Equipment had same gross faults as that
in the accident of 23/5/98
General diving hazard Pulmonary barotrauma Argon suit inflator jammed open. Not rebreather related. Pulmonary barotrauma (Burst
(Burst Lung). Lung)
Rebreather design fault Hypoxia Accident described in Wakulla 2 Expedition Statement by Dr. Bill Stone 18th February
1999, suggested this was a heart attack during a period of hypercapnia. However, J.
Caruso's Medical Examiner's Perspectives, DAN 2010 Fatality Workshop, showing
cause was not natural but due to a gas switch block being in the "External source"
position (intended for use with surface supplied gas), but as a SCUBA configured
rebreather this position was one where the rebreather could not provide oxygen, and
this lead to hypoxia. There was no interlock on the switch block to prevent this position
being used without gas being connected, and no one-way valves that is normal for
surface supplied rebreathers to avoid this type of accident. There was a red flashing
Low Oxygen light on the Cis Lunar, which Deceased either ignored or did not see.
Deceased found unconscious on the bottom after 7 minutes.
Scant data AGE Night dive. Scant data.
Human error Hypoxia. O2 Switched off. User did not do a pre-dive breathe on this second dive. Hypoxia.
Page 186 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Failing to turn a Rebreather on is such an obvious risk, Auto-turn on required.
especially as previous accidents had occurred, and its
mitigation is so trivial, that any accidents with equipment
not turned on has to be treated as a fundamental design
error rather than a human failing. If it is not very apparent
a Rebreather is not turned on, then people will make the
mistake of not turning it on when it is needed.
Suggestion that Rebreather was not switched on or in dive Gross incompetence in equipment
mode, is likely false, since divers were not separated until design in this model of the unit,
90s into the dive. This is the same type of Rebreather as causing it to hang. Electronic
rebreathers should meet EN14143.
Use of dry suits.
Diver won the Nobel prize for Physics in 1990. The
reference to other surface supplied rebreathers, refers to
more modern equipment, but one-way valves were put into
that equipment from the outset as a result of running a
HAZOP: a basic safety technique that was widely known at
the time the Cis Lunar was developed.
Equipment should check the O2 is on if there is electronics Needs auto-switch-on as an absolute
to do so, or failing that, provide clearer alarms so the minimum, and auto-shut-off valve.
accident can be averted. Another example where auto- Tank contents sensors need to be
switch on is a manifest requirement. part of rebreather monitoring.
Page 187 of 210
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An external reference confirming that
accident occurred
http://wrolf.net/Cautionary.html
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
Pages from Feb 15 till the 17 were removed.
http://www.usdct.org/Updates-Feb/feb18.htm
J. Bozanic has extensive information as Deceased
treated at his hyperbaric facility
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
22 24/07/1998 Nic Gotto Inspiration APD Classic Semi Solo 24 Ireland, Experienced 49
Castletownshend,
Co Cork
21 01/07/1998 Andrey Rodjkov IDA Unknown Ice Diving - North Pole, Experienced -
Expedition
20 20/06/1998 Bob Forster Inspiration APD Classic - 15 England, -
Windtown
19 27/05/1998 Wesley Gradin Dolphin Unknown Solo Diving 20 USA, Friday Experienced 45
Harbor, WA
18 23/05/1998 Paul Haydon Inspiration APD Classic Solo Diving, Trimix 73 England, Devon, Intermediate or
MV Afric Experienced
17 09/05/1998 Unknown diver Atlantis Unknown Solo Diving Australia ?
Page 189 of 210
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Root Case Disabling Injury Key information received on accident
Rebreather issue Hypercapnia or hyperoxia Scrubber was probably exhausted. Diver used scrubbers for a multiple of their safe
under conditions of duration due to lack of information on safe limit and insufficient testing.
hypercapnia.
Exceeded Performance Inhale counterlung or the Based on tests on similar equipment, the most plausible cause is inhale counterlung or
Envelope inhale mushroom valve the inhale mushroom valve stuck together due to icing.
stuck together due to icing
Human error / Drowning Drowning Stress on the rebreather led to diver dumping the equipment. Diver drowned because
he attached a torch to the rebreather. All the divers in the group had dumped their
equipment, which normally floats. Diver's equipment carried his weights.
Rebreather issue / Hypercapnia: WOB/CO2 Very heavy current, loss of consciousness and drowning. Diver also had task loading
Human issue retention, and hyperoxia and further exertion due to shooting video. Diver was using Nitrox 86 and is reported
not to have analysed it prior to the dive.
Rebreather design fault Hypoxia Diver passed out from hypoxia 14 minutes into the dive. O2 tank was empty on
recovery, but probably from a leak. and during the dive the tank was full. Rebreather
was examined by DDRC, found to have cracked handsets and manufacturer advised
of this failure. Cracked handset can cause the Rebreather to fail to inject gas, however
most likely cause in this case was not the cracked handsets but battery bounce. This
is a very suspicious death, as the manufacturer claims the diver survived 14 minutes
without any oxygen available for the rebreather. This particular model was very prone
to battery bounce.
Rebreather issue Hypercapnia, Water in Rebreather issue: Hypercapnia, Water in scrubber?
scrubber?
Page 190 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
It was suggested that the diver was heavily overweighted, Awareness of scrubber CO2 sensor required. Simple switch
having an expensive camera in one hand and tools in the life to count down to zero when scrubber
other. He may not have wanted to jettison his equipment, fitted.
so reacted to hypercapnia poorly.
The diver was ice diving at the North Pole as part of an Awareness of the effects CL heaters required for dives in water
expedition. A video caught the whole dive, lasting just 8 of extreme cold on under 4C.
minutes. rebreathers.
Awareness of effects of
dumping equipment in the
water.
Nitrox 86 was reported to used with a low flow rate, Awareness of WOB limits Need method to monitor WOB
however, emptying the counterlung would cause pulses of for depth and work rates. actively. WOB should be less than
this gas though that would occur when the PPO2 was Diver must use the correct EN14143:2003 limits. PPO2 monitor
lowered by metabolism and the constant leak rate, so the gas in an SCR and it must should be fitted to all SCRs.
FO2 in the loop would be around 45 to 50%. This PPO2 be analysed before the
at 20m is high but unlikely to be quite high enough for an dive.
O2 tox on its own. However, when the diver has an
elevated blood CO2 level due to WOB, then the tox limits
reduce. Question is which killed the diver: both were
factors. Rebreather issue concluded due to there being no
PPO2 alarm, and the WOB being a factor, the latter
triggering the O2 issue.
In pre Sept 2000 versions of the Inspiration there was no Gross incompetence in design of
watchdog timer, no working brown out circuit, and electronic portion of rebreather, with
Rebreather was liable to suffer battery bounce: the many single points of failure. The
handsets would hang as a result. This happened model of Inspiration involved was
frequently. Deas notified manufacturer in April 2000, with prone to hang.
report and recommendations in June 2000. Brown out
circuit added, but no recall was made, power system and
software still unsafe.
CO2 monitor, auto-loop shut off and
flood detection required.
Page 191 of 210
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An external reference confirming that
accident occurred
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
http://www.videodive.com/films/arktika.php
http://www.btinternet.com/~madmole/DiverMole/DMD
anger.htm
http://www.nwdesigns.com/rebreathers/users/Paul/B
odyCount.htm#Homebuilts
Confidential communication and detailed
examination of the handsets of the type involved.
Inquest report. Full data from inquest.
K. Kramer, 1998, R-Files
Page 192 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
16 04/04/1998 Unknown diver Dolphin Unknown Scant data 29 New Guinea -
15 01/01/1998 CDBA Scant data 6m Canada
14 01/01/1997 Unknown diver MK 16 Unknown Scant data - USA -
13 01/06/1994 Ian Rolland Cis Lunar Mk4 Cis-Lunar Cave diving 3 Mexico, San Experienced 29
Augustin, Huautla
Cave System
12 01/01/1992 Unknown diver Unknown Scant data - Australia Scant data -
11 01/01/1989 Unknown diver Atlantis Unknown Scant data - Hawaii
10 01/01/1984 Unknown diver Unknown Scant data - Australia Scant data -
9 01/01/1982 Unknown diver Unknown Scant data - Australia Scant data -
8 01/01/1979 Unknown diver LAR III? Solo Diving 0 - - -
7 01/01/1971 Unknown diver Electrolung Electrolung Buddy dive - - - -
EX19
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Root Case Disabling Injury Key information received on accident
Human error Hyperoxia from use of Gas was not analysed before the dive: it was Nitrox 86. Diver failed to follow clearly set
wrong mix. down procedures.
Rebreather design Hypoxia from clogged Poor maintenance allowed mass flow controller to become clogged. Also poor mass
fault/human error mass flow controller. flow controller design, inadequate monitoring and alarms
Scant data Scant data Scant data
Underlying illness / LOC diabetic Diver was a diabetic, and forgot to bring his chocolate on that dive. Diver passed out as
Human error a result.
Scant data Scant data The only reason the accident is known is that it is in the 2010 DAN Fatality presentation
by J. Lippmann.
Underlying Illness / Heart attack from From Dr. Jeff Bozanic's list.
Rebreather design fault hypercapnia: WOB
caused CO2 retention
Scant data Scant data The only reason the accident is known is that it is in the 2010 DAN Fatality presentation
by J. Lippmann.
Scant data Scant data The only reason the accident is known is that it is in the 2010 DAN Fatality presentation
by J. Lippmann.
Human error Hypoxia The diver died of hypoxia after failing to flush his counterlung on this O2 rebreather
Scant data Scant data. Scant data.
Page 194 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Diver used a gas other than air, and failed to analyse it Training agencies already PPO2 monitor required on all
when he bought it/mixed it, and also when he went to use emphasise need to rebreathers.
it. analyse gas, but many
users not aware of the
effect of using less than
pure O2 (argon, and N2
needed to be flushed out).
Poor equipment design: use a multi-
orifice valve, use PPO2 monitoring,
use auto-loop shut off valves.
Scant data
Full cave diving investigation carried out. First Cis-Lunar Expeditions need buddy
accident. Close friend of Bill Stone, diving as a group. checklists for divers, just
as regular divers use
checklists. If diver
requires medication
during dive, it should be
on the checklist.
Probably not an Atlantis (too early). Perhaps date is out?
Even O2 rebreathers require PPO2
monitors, and should have auto-loop
shut off valves.
Scant data.
Page 195 of 210
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An external reference confirming that
accident occurred
http://www.nwdesigns.com/rebreathers/users/Paul/B
odyCount.htm#Homebuilts
Sharron Readey, as reported to J. Bozanic
Confidential communication
"Beyond the Deep", W. Stone and B. Ende, ISBN 0-
446-52709-2 and
www.cdnn.info/news/article/a041206.html
2010 DAN Fatality presentation by J. Lippmann
J. Bozanic collation of diver fatality data for DAN
2010 DAN Fatality presentation by J. Lippmann
2010 DAN Fatality presentation by J. Lippmann
J. Bozanic collation of diver fatality data for DAN
http://www.nwdesigns.com/rebreathers/users/Paul/B
odyCount.htm
Page 196 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
6 01/01/1970 Unknown diver Electrolung Electrolung Buddy dive - - - -
EX19
5 17/02/1969 Berry L. Cannon Mark IX sCCR Buddy dive 203 USA, San Experienced 33
Clemente Island,
CA
4 01/01/1969 Unknown diver Electrolung Electrolung - 70 Caman Islands - -
EX19
3 03/11/1962 E J "Jack" Waddon Homemade Cave Diving 3 UK, Mineries Experienced 30
rebreather Pool, Somerset
2 28/01/1951 John WWII O2 CCR Solo Diving 3m S. Australia, Port Training 33
Noarlunga
Page 197 of 210
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Root Case Disabling Injury Key information received on accident
Rebreather design fault Hypoxia The diver forgot to turn on the solenoid power switch after calibrating the unit, and the
/ Human error Rebreather did not have any automatic switch on, e.g. wet switches or PPO2 drop auto-
on trigger.
Sabotage Hypercapnia from missing No absorbent (baralyme) in rebreather. Rebreather prepped by technician, not checked
scrubber by diver. Died of CO2 toxicity - hypercapnia. Diver worked for the Sealab III project for
US Navy. Some evidence that the problem may have been intentional, i.e. someone
attempting to sabotage the project (other related incidents at the same time), which if
true would make this a murder.
Rebreather design fault Hyperoxia Diver mistakenly valving-in pure O2.
/ Human error
Rebreather fault Hypoxia, though cause of Died of pulmonary oedema, most probably caused by hypoxia while training with
death was pulmonary experimental equipment, due to error in adjusting flow regulator. Diver was also
oedema suffering from hypercapnia. No line connection was made to surface and the diver was
unable to readily ditch weights and regain surface. Diver was unconscious in water for
an hour, due to use of full face mask was resuscitated but died an hour later in
hospital.
Human error/Thermal Hyperoxia due to CNS fit from hyperoxia caused by hyercapnia in cold diver, Full Face Mask (FFM),
balance hypercapnia and cold. seizure at the surface, line tended, 1st dive (training dive), hypothermic (inadequate
exposure suit).
Page 198 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
The power drain of logic at the time this equipment was Poor equipment design. There should
made, was many orders of magnitude higher than that just have been no such switch.
5 years later. This would have meant that the obvious risk Equipment needs auto-on feature.
identification may not have been able to mitigated as it
would in the 1980s onwards, when wet contacts or
pressure actuated turn on became almost universal on
dive computers.
The frequency of similar incidents in the same facility Provide means for divers to check
suggests strongly that this was not a simple procedural the scrubber is fitted in an assembled
error. Accident included in sports list as it is not military, unit. Also identified as an issue at a
nor is it umbilical diving, and accident can occur to sports HAZID meeting in Bergen in 2007 for
divers. commercial divers and solution
proposed was to add a scrubber
viewing window to the scrubber
canisters.
Awareness of problem Remove manual O2 valve: diver
that some rebreathers should inject make-up-gas instead.
have left to right flow,
instead of more normal
right to left.
Experimental divers Weights must be able to be ditched
require continuous easily, and not move to entrap diver
monitoring. upside down. Divers should not be
required to adjust flow regulators.
Hypercapnia strongly predisposes a diver to hyperoxic Awareness that CNS Provide adequate margin for CNC
seizures, reducing the CNS clock considerably. limits need proper clock. Provide CO2 monitoring, a
margins, and that high simple switch to count down to zero,
CO2 causes limits to and a disable loop that resets when
reduce dramatically. scrubber fitted. WOB and dead
space should not exceed
EN14143:2003 limits.
Page 199 of 210
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An external reference confirming that
accident occurred
http://www.nwdesigns.com/rebreathers/Nuggets/Bod
yCount.htm#EX19
Bunton WJ, 2000, Death of an Aquanaut, Best
Publishing Corp., 69 pages
Confidential communication
The Darkness Beckons, M J Farr, 2nd Edition,
Diadem Books, 1991 and Caving Diving Accidents
1948 to 1978
http://www.cavedivinggroup.org.uk/Articles/BCDA.pdf
J. Bozanic, Report by Peter Horne, Australia: Book
"Diving fatalities of Western Australia"
Page 200 of 210
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Electronics
fitted to Depth of
Type of dive
Deceased's Rebreather rebreather for accident
№ Date (Solo, Group, Location Experience Age
Name involved PPo2 (/deepest/planne
Cave etc.)
Monitoring or d ) (m)
Control
1 09/04/1949 James Gordon WWII O2 CCR Cave Diving 5 UK, Wookey Hole Novice on -
Ingram-Marriott Cave, Somerset rebreathers.
Experienced open
water diver but no
cave diving
experience.
Pink background: basic information needs verification
Sand background: might be a duplicate
Blue background: needs confirmation of equipment type
Page 201 of 210
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Root Case Disabling Injury Key information received on accident
Rebreather Hypoxia due to O2 LOC from hypoxia while returning through known sump. Ran out of oxygen due to
issue/Human error exhausted faulty pressure gauge on rebreather oxygen supply and failed to locate reserve
cylinder, which was not adequately attached to equipment.
Page 202 of 210
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Comments or Discussion in arriving at most
Training implications Design implications
plausible cause, addition to use of the Fault Tree
Page 203 of 210
1cd741fb-406a-44d0-a1ff-d2e0ca24226e.xls
An external reference confirming that
accident occurred
The Darkness Beckons, M J Farr, 2nd Edition,
Diadem Books, 1991; A Glimmering in Darkness, F
G Balcombe, Cave Diving Group, 2007 and more
detail in Cave Diving Accidents 1948 to 1978
http://www.cavedivinggroup.org.uk/Articles/BCDA.pdf
Page 204 of 210
Classification Analysis
Percentage of
Frequency Root case
known causes
5 4% General diving
hazard
13 11% Exceeded
performance
envelope
18 15% Human error
6 5% Human
error/Rebreather
fault
3 3% Non rebreather
equipment
1 1% Marine life
29 25% Rebreather design
fault
27 23% Rebreather issue
1 1% Sabotage
11 9% Heart attack
4 3% Other underlying
illness
Scant data 32
Total ignoring Scant Data cases 118 100%
Total number of cases analysed 150
Number of cases out of the total 21
expected from a perfect EN61508
compliant design, based on
Accident Classification
Root Cause Analysis
Percentage of
Frequency Root cause
known causes
9 7% AGE
9 7% CNS
9 7% Drowning/aspyxia
1 1% Entanglement
13 10% Heart attack
2 2% Other human error
29 23% Hypercapnia
50 39% Hypoxia
1 1% Caustic cocktail
1 1% Marine life
1 1% Underlying medical,
other than cardiac
and PFO
2 2%Pulmonary barotrauma
Total ignoring Scant Data cases 127
Number of cases out of the total 27
expected from a perfect EN61508
compliant design, based on
Accident Root Cause
Number concluded
applying Pareto
principle
6
17
5 6
1 14 17
23
8
23
34
4
1 8
37
37 14
34
1
14
5
Number concluded 1
applying Pareto 1 1
principle
11 2 11
11
11 11
1
15 11
2
34 59
59 15
1
1
1
2
34
2
General diving hazard
Exceeded performance
envelope
Human error
Human error/Rebreather fault
Non rebreather equipment
23 Marine life
Rebreather design fault
Rebreather issue
4
Sabotage
Heart attack
Other underlying illness
AGE
CNS
Drowning/aspyxia
Entanglement
Heart attack
11
1 Other human error
15 Hypercapnia
Hypoxia
2
Caustic cocktail
Marine life
Underlying medical, other than
cardiac and PFO
Underlying medical, other than
cardiac and PFO
Pulmonary barotrauma