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Diver Rebreather Fatalities Database Extract d9081ce0

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217 of the Rebreather Fatal Accidents to 31st January 2011
Filename datecode is reassigned on publication to 100725 to allow static hyperlinking to this doc, without redirections.


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).
      Despite hundreds of deaths, most of which appear to be easily avoidable, rebreather accidents are treated with indifference. Until Deep Life 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 try to 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 smear 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 income 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 different approach, in
      which there is a desire for integrity, but this is the exception rather than the rule in the sports rebreather industry.
      Denial is not limited to those manufacturers that have a poor record: most Health 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 out the data and apply the lessons that it contains. Our
      mission is to catalogue that data.
Overall Analysis
      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 1 in 100 diver-
      years, which is much higher than for diving in general at around 1 in 950 diver-years, based on the best available diver population data. 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 alone 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 fatal accident for at least one in every 34 sold.
      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 root cause or trigger involving the rebreather.
      3. All risk rates quoted above are for diver-years for the period 1998 to 2006. It is not known how diver-years compares with risk per dive: 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 to these deaths: we can murder by an action, or
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 subdivided as below:
        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 classified as a Human error.
        If the root 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.
      Experience levels are: Trainee < 6 hours, Novice < 20 hours, Intermediate < 50 hours, Experienced < 100 hours, Expert < 1000 hours, Guru > 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 must declare: this list is not comprehensive - there are rebreather accidents missing from this list.
      2. After this list was attacked by a manufacturer claiming accidents on their unit 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 the accuracy in which it is secretely regarded by its
      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.
      4. The fault tree method produces statistically accurate data, but should not be confused with a conclusion of certain cause that may be developed using a full
      accident analysis with formal modelling.
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 opposing those are who try to uncover it. Our assessment is that overall, this list probably covers



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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.

                                                                      Electronics
                                                                        fitted to
                                                                                                                  Depth of accident
                                                  Rebreather         rebreather for      Type of dive (Solo,                                                                                     Root Case using fault     Disabling Injury using                                                                                                                  Comments or Discussion in arriving at most plausible cause,                                                                                                     An external reference confirming that accident
           Date          Deceased's Name                                                                         (/deepest/planned           Location              Experience           Age                                                            Key information received on accident                                                                                                                                    Training implications                           Design implications
                                                   involved               PPo2           Group, Cave etc.)                                                                                       tree method               fault tree method                                                                                                                       addition to use of the Fault Tree.                                                                                                                                                 occurred
                                                                                                                       ) (m)
                                                                     Monitoring or
                                                                        Control
217      01/01/11       Mike Firth             A wing                     N/A                Group Diving              On surface       Cocos                          Guru              50s     Poor equipment cleaning   Infection by Aspergillus    Diver took just a couple of breaths from a wing (rebreathing the wing gas in the process). Two             See key information, from excellent article in Divernet by Steve            Emphasise the importance of      Use materials that are easy to clean, include   www.divernet.com/other_diving_topics/medical_health/68
                                               (rebreathing, 2                                                                                                                                                             fumigatus                   breaths from a wing, resulted in Mike Firth losing 70% of his lungs from Aspergillus fumigatus fungi       Weinman referenced on right. Debated whether to include this                equipment cleaning, and          clear cleaning instructions in all user         2407/think_twice_before_breathing_off_a_bag.html and
                                               breaths)                                                                                                                                                                                                infection, requiring oxygen                                                                                accident in this list, and it was decided to include it on the grounds      consequences of failing to       manuals, publicise risks of failure to clean    then
                                                                                                                                                                                                                                                                                                                                                                  that 1) the diver became infected by rebreathing from the wing, 2)          clean counterlungs and wings.    equipment. Note the hard plastic parts          www.diveoz.com.au/discussion_forums/topic.asp?TOPIC_
                                                                                                                                                                                                                                                                                                                                                                  the hazard that killed the diver is much more acute on a rebreather         Recommend daily washing,         were infected. Recommend Virkon and             ID=24651, both with capture dates of 13th February 2011 and
                                                                                                                                                                                                                                                       metres, and                                                                                                than on O.C. equipment, 3) due to the risk being acute, all                 and at least weekly use of       provide Virkon as stocked item to all users     UK HSE Information Sheet 12, Cleaning of Diving
                                                                                                                                                                                                                                                                                                                                                                  rebreather divers should be aware of this accident to avoid repeating       Virkon rather than Milton. In    (Virkon S is for animal use, and import into    Equipment, www.hse.gov.uk/pubs/dvis12.pdf.
                                                                                                                                                                                                                                                       detailed account of the accident. Diver lived for 30 months after incident, before dying from factors      it - i.e. publication can provide material safety benefits for rebreather   particular, show correct         the USA is restricted even though it is made
                                                                                                                                                                                                                                                       caused by that accident, hence diver fatality, and root cause is rebreathing a wing. Part that carried the divers.                                                                     cleaning procedure that does     in the USA, because it is classed as a
                                                                                                                                                                                                                                                       infective organisms was the hard plastic and the hoses, surprisingly, not the wing.                                                                                                    not involve breathing from the   pharmecutical product: Virkon is
                                                                                                                                                                                                                                                                                                                                                                                                                                              apparatus being cleaned.         chemically identical). Include failure mode
216      31/01/11       Bill Bowden            O2ptima                     HH                Cave Diving                    -           USA, Eagle's Nest             Expert                     Scant data                DCS                         Diver died 31/01/2011 in hospital from Decompression Injuries following a dive at Eagles Nest.                                                                                                                          in all diving FMECAs.
                                                                                                                                        cave                                                                                                           References to the diver getting back into diving on an Optima in October give a short time frame from
                                                                                                                                                                                                                                                       basic CCR diver to deep cave. Scant data currently: cave community investigate accidents well                                                                                                                                                                           See threads listed under key facts
                                                                                                                                                                                                                                                       generally, so further information is expected in due course. Threads below archived:
                                                                                                                                                                                                                                                       General threads:
                                                                                                                                                                                                                                                       http://www.floridadiversforum.com/vb3/showthread.php?p=21158
                                                                                                                                                                                                                                                       http://www.cavediver.net/forum/showthread.php/15519-Eagle-s-Nest
                                                                                                                                                                                                                                                       http://www.scubaboard.com/forums/passings/368864-rest-peace-bill-bowden.html                                Fault trees for why he became bent on a CCR dive connect to
                                                                                                                                                                                                                                                       http://www.cavediver.net/forum/showthread.php/15517-Bill-Bowden-Deltona-Florida-RIP                         medical, training and controller subtrees. Insufficient data to prune
                                                                                                                                                                                                                                                       Optima reference Post:                                                                                      further at this time.
                                                                                                                                                                                                                                                       http://www.scubaboard.com/forums/5713518-post3.html
                                                                                                                                                                                                                                                       Scene post about ambulance, diver was alert and clear headed:
                                                                                                                                                                                                                                                       http://www.cavediver.net/forum/showthread.php/15517-Bill-Bowden-Deltona-Florida-
                                                                                                                                                                                                                                                       RIP?p=135509&viewfull=1#post135509
                                                                                                                                                                                                                                                       Post referencing recent timeframe of his open heart surgery I.e last year
                                                                                                                                                                                                                                                       http://www.cavediver.net/forum/showthread.php/15517-Bill-Bowden-Deltona-Florida-
                                                                                                                                                                                                                                                       RIP?p=135379&viewfull=1#post13
215      27/12/10       Rob McKelvey           Inspiration            APD Classic            Cave Diving                    -           South Africa: Badgat          Expert             43      Scant data                Scant data                  Death is widely reported to be a rebreather accident. Type of rebreather based on this image (dated         See death notice reference.
                                                                                                                                        / Komati Springs                                                                                               25 Nov 2010)
                                                                                                                                                                                                                                                       http://2.bp.blogspot.com/_XdfQgOGGvpc/TO615MWnR2I/AAAAAAAAC0c/fgCKjjPgeY0/s16                                                                                                                                                                                           Death notice
                                                                                                                                                                                                                                                       00/148828_449581237100_601277100_5906714_542265_n.jpg from                                                                                                                                                                                                              http://www.wegotads.co.za/class_ad.cmp?products_id=353
                                                                                                                                                                                                                                                       http://www.dahabdiverstechnical.blogspot.com as Deceased is diving an Inspo Classic deep only a                                                                                                                                                                         948&sfid=1
                                                                                                                                                                                                                                                       month prior to the report of his death.


214      21/11/10       Richard Bufton (Aka    Poseidon Mk6          Poseidon Mk6              Try dive                    3            UK, Lancashire                Novice             62      Scant data                Scant data                  Deceased was conducting a try dive on the Poseidon Mk6 at 9:30am, as the first dive on a try dive  Included here for the present so it is not lost. It may be removed                                                                                                   http://www.bbc.co.uk/news/uk-wales-north-west-wales-
                        Diversgold on YD)                                                                                                                                                                                                              event when he became ill and was taken to hospital where he subsequently died. Diver was qualified following review of more detailed reports, as the diver appears to be                                                                                                11820435
                                                                                                                                                                                                                                                       as BSAC 1st class, UK diver 4 star, commercial and sat diver had over 40 years O.C. experience,    swimming on the surface following the dive.                                                                                                                          http://www.yorkshire-divers.com/forums/surface-
                                                                                                                                                                                                                                                       10,000 dives on O.C., having worked to 170m. Reported to have died while swimming on the surface                                                                                                                                                                        interval/138000-rip-diversgold-richard-bufton-saturday-20-
                                                                                                                                                                                                                                                       immediately after the dive, not breathing from the rebreather.                                                                                                                                                                                                          nov-2010-a.html
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               http://www.yorkshire-divers.com/forums/tek-talk/124951-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               tek-dive-north-2010-a.html
213     30/10/2010      Pompeo Maurizio        Inspiration              Unknown               Group dive                   70           Italy, Punta Licosa          Unknown             33      Scant data                Scant data                  Diving about 6 miles off Punta Licosa. One of a group of divers on a rebreather who experienced      Scant data.                                                                                                                                                        http://www.marescoop.com/ftopicp-30603.html#30603 .
                                                                                                                                                                                                                                                       difficulties was Pompeo Maurizio of 33 years, residing in Terracina, Latina. A call came in at 13.00
                                                                                                                                                                                                                                                       Harbour Agropoli by phone 1530 by people who were in the boat advising they had a diver in distress,
                                                                                                                                                                                                                                                       following a fast ascent from about 70 meters deep. Men patrol the immediate CP855, led by
                                                                                                                                                                                                                                                       Lieutenant Vascello Vincenzo Zagarola, after medical staff on board also came on the spot. .
                                                                                                                                                                                                                                                       Unfortunately, the medical staff on site could only confirm his death. The corpse of Pompeo was
                                                                                                                                                                                                                                                       returned to the port of Agropoli and then transported to the hospital in the town for autopsy.



212     23/10/2010      Marian Walter          Evolution or                 -                 Group dive                   96           Italy, Lake Garda              Guru              55      Scant data                Scant data                  About 600 meters from the entrance of the port of Castelletto di Brenzone, Marian Walter, died while        Deceased left behind his wife and a 6 year old child. Report of                                                                                             http://clic.larena.it/GiornaleOnLine/Arena/stampa_articol
                                               Inspiration                                                                                                                                                                                             he was taking pictures of the wreck, "Diana."                                                               clinging to rope, feeling unwell, points to hypercapnia or underlying                                                                                       o.php?id_articolo=1721320&pagina=24
                                                                                                                                                                                                                                                       The wreck built in 1919 in in 90 to 100m depth is currently the focus of a restoration project by the       illness, but a wide range of possibilities are plausible from the fault
                                                                                                                                                                                                                                                       local authority, the Superintendence of Cultural Heritage and monuments in the Veneto region. And           tree with the witness reports. It is likely relevant that victim became
                                                                                                                                                                                                                                                       the authority had commissioned a team of expert service to this sub composed of nine people, coming         very heavy: rebreather flooding likely, which may be the cause of the
                                                                                                                                                                                                                                                       mostly from Lombardy.                                                                                       hypercapnia. Persons suffering from heart disease (likely due to age)
                                                                                                                                                                                                                                                       For reasons that are still under investigation by the police, around 13 Mariani began to gesticulate        may be stressed by hypercapnia at lower levels than young fit divers.
                                                                                                                                                                                                                                                       with dive buddies about 5 minutes into the dive.                                                            Scant data, but using fault tree is pointing towards a flood leading to
                                                                                                                                                                                                                                                       "He brought the index and middle finger to the right temple," said John Fiacca, 37, "when we were 96        hypercapnia: will hold off assignment of root cause for the present in
                                                                                                                                                                                                                                                       meters deep, and made it the nod in conventional If you feel unwell. I immediately approached and           case better data becomes available shortly. It was understood the BC
                                                                                                                                                                                                                                                       started to help in the ascent, clinging to the rope that, since our boat was anchored on the lake bottom.   was 18kg lift, but constrained and may have provided insufficient lift
                                                                                                                                                                                                                                                       "                                                                                                           once the rebreather buoyancy was lost by flooding.
                                                                                                                                                                                                                                                       After traveling a few meters, however, Mariani said to have "started to lose consciousness because they
                                                                                                                                                                                                                                                       no longer responded to my stimuli," said still weak. The other two companions were approached and,
                                                                                                                                                                                                                                                       while doing the Fiacca went back and provided the necessary decompression stops, others have
                                                                                                                                                                                                                                                       sought to support the partner in trouble dragging it to the surface.
                                                                                                                                                                                                                                                       "Unfortunately, at that point Mariani was clearly unconscious and very heavy. After more metres
                                                                                                                                                                                                                                                       comrades had let go ", remaining helpless to watch as the body was fell inexorably towards the bottom.
                                                                                                                                                                                                                                                       "An attempt to activate the BC to try to raise victom again but victim sank. Recovery of the body used
                                                                                                                                                                                                                                                       an ROV. Among the five people on board the boat to support the expedition was Edward Pavia,
                                                                                                                                                                                                                                                       responsible for dive safety and famous around the world to have done service on prestigious relics
211     03/10/2010      Eric Establie          Dual: EDO 04             Unknown              Solo cave dive              52/87          Dragonnière Gaud,              Guru              52      General diving hazard /   Entrapment                  3rd Octthe ' Britannic ', and officials of alerted of the late return Veneto, Francesco Dossola. cavers
                                                                                                                                                                                                                                                       such as The French Cave Rescue was the Superintendence of of a diver from a dive team of                 Divers equipment other then dive computer not yet recovered.                                                                                                   http://translate.googleusercontent.com/translate_c?hl=en&
                                               modified as mccr                                                                         France                                                   Entrapment                                            who were exploring the Dragonnière Gaud near the town Labastide de Virac, Ardeche. He was gone Appears to be land slide trapping the diver as the sole cause.                                                                                                           sl=fr&u=http://ssf.ffspeleo.fr/index.php%3Foption%3Dcom
                                               and EDO 04 pSCR                                                                                                                                                                                         for a dive with dual rebreathers with dual scooters. A reconnaissance dive to the landing was carried by                                                                                                                                                                _content%26view%3Darticle%26id%3D423:2010-10-03-
                                                                                                                                                                                                                                                       his teammates at around 19:30, without success.                                                                                                                                                                                                                         dragonniere-de-gaud-ardeche-
                                                                                                                                                                                                                                                       6th Oct the British diving team found at 780 meters from the entrance a closure of the cave by a                                                                                                                                                                        07%26catid%3D39:encours%26Itemid%3D83&prev=/searc
                                                                                                                                                                                                                                                       clogging of gravel resulting from a shift of the ground.                                                                                                                                                                                                                h%3Fq%3Dplongeescout%26hl%3Den%26client%3Dfirefox-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               a%26hs%3D1JQ%26rls%3Dorg.mozilla:en-
                                                                                                                                                                                                                                                       after trying unsuccessfully to dig to cross this narrow passage, has deliberately left his DPV visible at                                                                                                                                                               US:official&rurl=translate.google.com.au&usg=ALkJrhi8T2S
                                                                                                                                                                                                                                                       this place to indicate that he could not clear the obstacle.                                                                                                                                                                                                            ZjG5yvjQuFfM_6wdjLWhpqA
                                                                                                                                                                                                                                                       11 Oct Eric Establie 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.                                                                                                                                                                                        http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               incidents/35477-dragonniere-rescue-eric-establie-
                                                                                                                                                                                                                                                       Update: analysis of Eric's computer shows that he died 5 hours 20 minutes after the start of his dive. It                                                                                                                                                               6.html#post339169
                                                                                                                                                                                                                                                       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) was treated for
                                                                                                                                                                                                                                                       a limb-pain DCI episode in Marseilles.
                                                                                                                                                                                                                                                       Note: This fatality was originally published 3 days after this diver was reported missing, then
210     29/09/2010      Dr. James Archibald    Unknown                  Unknown               Group dive                   70           Truk lagoon                  Unknown             55      DCS                       Pulmonary DCS               Obituary notice and comments confirmed it to be a rebreather accident. Dive was reported to be off          Historically it has been known that the Aggressor fleet cover up any       Training should emphasise                                                        http://www.inmemoriam.ca/view-announcement-207060-dr-
                        McNamara                                                                                                                                                                                                                       an Aggressor fleet vessel. A researcher from Duke University, Diver Medicine, reported the following        fatalities that occur on their vessels. The compilers of list question     need to take breaks every few                                                    james-archibald-mcnamara.html
                                                                                                                                                                                                                                                       information from interviews with two divers who were on the boat: "The diver was running 1.4 ATA,           the right of a commercial concern to hush up someone else's death.         days, when doing                                                                 apparently same person as
                                                                                                                                                                                                                                                       diving around 130-140 (ft) which would put his EAD shallower than his actual depth. Deep, but not           The report shows the trend for divers wanting to learn so they avoid       decompression diving.                                                            http://www.chgd.umich.edu/faculty/mcnamara.html
                                                                                                                                                                                                                                                       excessively so. He did have some extended bottom times and did at least two decompression dives             following suit. The Aggressor fleet policy covers up mistakes,
                                                                                                                                                                                                                                                       per day. One of the divers I spoke with was thinking that he had pulmonary O2 toxicity, but from the        accidents and lessons. It is fortunate that in this case, witnesses were
                                                                                                                                                                                                                                                       description, the symptoms sounded more like pulmonary DCS to me. He had cutis marmorata (red                able to speak to a person interested in recording dive data. One
                                                                                                                                                                                                                                                       mottling of the skin), which is often accompanied by more severe DCS symptoms. The diver was also           note, in the analysis, is if there is CO2 retention (diver was of above
                                                                                                                                                                                                                                                       significantly overweight.                                                                                   average weight, dives were deep, extended duration means that on
                                                                                                                                                                                                                                                       There's a temptation, when you're in an exotic, once-in-a-lifetime place, to take full advantage of the     many rebreathers the dives were longer than the rated scrubber
                                                                                                                                                                                                                                                       time you're there and maximize your dives. We recommend an "off-gassing" day halfway through a              duration - most manufacturers still quote "profiles" for scrubber
                                                                                                                                                                                                                                                       week-long trip, especially when it involves long, deep dives. Go do an easy hike, snorkel, whatever,        endurance where the bottom time is very short) then this CO2
                                                                                                                                                                                                                                                       but don't breathe compressed air. This will significantly reduce the risk of DCS. Following                 would sensitise the diver to CNS toxicity, but no CO2 effect is
                                                                                                                                                                                                                                                       publication of this information by the Duke researcher, "Seacobra" posted, "I have also spoken with         recorded relating to pulmonary O2 toxicity. Therefore the Duke
                                                                                                                                                                                                                                                       folks that were there that day and from what I was told his dives on that fateful day were more like        researcher's assessment in this case is the same as the fault tree
                                                                                                                                                                                                                                                       209fsw max depth with a run time of 127 minutes, 4 hour SIT followed by 166fsw max depth with 112           assessment.




                                                                                                                                                                                                                                                                          Page 2 of 20
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                                                               Electronics
                                                                 fitted to
                                                                                                       Depth of accident
                                          Rebreather          rebreather for   Type of dive (Solo,                                                                Root Case using fault       Disabling Injury using                                                                                                                     Comments or Discussion in arriving at most plausible cause,                                                                                                  An external reference confirming that accident
       Date        Deceased's Name                                                                    (/deepest/planned       Location        Experience    Age                                                         Key information received on accident                                                                                                                                         Training implications                         Design implications
                                           involved                PPo2        Group, Cave etc.)                                                                  tree method                 fault tree method                                                                                                                          addition to use of the Fault Tree.                                                                                                                                              occurred
                                                                                                            ) (m)
                                                              Monitoring or
                                                                 Control
209   9/10/2010   Rob Lower             Inspiration Classic    APD Classic          Solo dive                 75             USA, Hawaii        Expert      29    Human Error / DCS           Gas Embolism              Daily diving to 75m to 100m. Collecting fish professionally for sale to the aquarium trade, in this case The Deceased was ignoring the most basic rules of diving, apparently             Training should emphasise         Add decompression computation functions http://reefbuilders.com/2010/09/11/rare-fish-collector-rob-
                                                                 (2010)                                                                                                                                                 Masked Angel Fish, a rare species. Despite mild DCS symptoms from a dive the previous day, to >          believing he was immortal. Any replacement computer would not                    that doing another deep dive to eCCRs.                                    dies-diverelated-injuries
                                                                                                                                                                                                                        90m depth, Deceased dived to 75m without a viable dive computer: Deceased had his dive computer          have the correct loadings unless the diver took a rest for several days,         is not treatment for DCS, but
                                                                                                                                                                                                                        fail a few days prior to the accident, and it is reported that the replacement computer either did not   which he did not. Diver left behind his wife and young daughter,                 likely to make matters far
                                                                                                                                                                                                                        support a fixed PPO2 or was not available - conflicting reports received. Replacement computer           and was well regarded as a nice guy. Legislation being introduced to             worse. Also, if a diver can feel
                                                                                                                                                                                                                        would not have his very high tissue compartment loadings in any case. Deceased surfaced from the         ban tropical fish collection from January may have placed some                   offgasing, it is because of large
                                                                                                                                                                                                                        75m deep dive suffering DCS symptoms which became worse on the boat. Deceased was flown to a             pressure on the diver to collect before the ban comes into place: see            bubbles that trigger DCS:
                                                                                                                                                                                                                        chamber from Kauai. Recompressed because he had the bends and a seizure. Deceased stopped                http://www.westhawaiitoday.com/articles/2010/08/05/local/local                   using a feeling instead of a dive
                                                                                                                                                                                                                                                                                                                                 01.txt Classified as a solo dive, because the buddy was at 18m and               computer will result in a
                                                                                                                                                                                                                        Embolism. Deceased had been earned that his dive practices were extremely hazardous. Deceased the Deceased was at 75m, both of whom were trying to catch fish.                            serious accident, probably
                                                                                                                                                                                                                        chose to dive when he knew he did not have adequate decompression data, and was already suffering Deco practice was outside that supported by any dive training                           sooner rather than later.
                                                                                                                                                                                                                        from DCS, when from his training he would have known he should seek treatment and stay out of the agency, hence Human Error is concluded as primary cause, with
                                                                                                                                                                                                                        water. Deceased is reported to have claimed he could "feel the nitrogen coming out of him", so did not DCS as secondary.
208   7/31/2010   Yasuko Fiasco Okada     KISS Classic            Jetsam       Buddy dive then solo           35           USA, NJ, Arundo      Expert      28    Scant data                  Scant data                Scant data. Deceased used the KISS when she passed cave diver training in 2009:                          Tribute on http://mikesdivelog.blogspot.com/2010/08/farewell-                                                                                                    http://mikesdivelog.blogspot.com/2010/08/farewell-fi.html
                                            mCCR                                                                               Wreck                                                                                    http://www.scubafi.com/scubafi/Trip_Reports/Entries/2009/12/7_Team_Olsen_goes_cave_div fi.html
                                                                                                                                                                                                                        ing.html so would be at least expert level on the KISS. CO2 scrubber status unknown at this time.
207   7/25/2010   Ziga Dobrajc            Voyager SCR           Unknown              Try dive                 4             Italy, Miramare     Trainee     31    Rebreather design fault /   Hypoxia                   Twelve Slovenian and Trieste Scientific Divers with two instructors were conducting rebreather try- This particular accident appears to be a combination of poor                                                           Voyager was identified in the stats analysis http://www.scubaboard.com/forums/5674998-post6.html
                                                                                                                                                                  Training issue                                        dives in shallow water off Miramare over a 4 day period, as part of a sales effort to sell Voyager       equipment design, poor supervision and inadequate training. Dives                                                 from this list as being by far the most
                                                                                                                                                                                                                        rebreathers to the Slovenian National Institute of Biology, Marine Station Piran. The first diver, a     are described as 'try dives" but are more like "test dives" using                                                 dangerous rebreather in the market. The
                                                                                                                                                                                                                        Slovenian Tech Staff Member, was seen by one of the instructors, Marco Panico who is also a              experienced divers who are unfamiliar with rebreathers.                                                           Voyager is massively over-represented on
                                                                                                                                                                                                                        policeman, floating face down in front of the Ducal Bath, near the Castle, at 11:20am, at a point where                                                                                                                    this list, and the over-representation has a
                                                                                                                                                                                                                        the depth is only 4 meters. The diver was recovered to the shore, CPR was applied during transport                                                                                                                         probability of more than 99.95% of being
                                                                                                                                                                                                                        to Grignano harbour where an EMS team was present. The diver was then taken to Cattinara hospital                                                                                                                          statistically significant. Manufacturer claims
                                                                                                                                                                                                                        where the diver was put on life support for 4 days. Scans showed no signs of brain activity so was                                                                                                                         to have sold over 900 rebreathers, which
                                                                                                                                                                                                                        declared clinically dead following scans to search for brain activity. Later on during the day the first                                                                                                                   would alter the stats, but this figure of 900
                                                                                                                                                                                                                        diver had his fatal accident, another Slovenian diver was noticed missing and his body found 4 hours                                                                                                                       rebreathers is contradicted by dive shop
                                                                                                                                                                                                                        later: that is there were two separate fatalities with the same dive group in one day: see below.                                                                                                                          surveys and ludicrous. See below.
206   7/25/2010   Samos Alajbegovic       Voyager SCR           Unknown              Try dive                 7             Italy, Miramare     Trainee     41    Rebreather design fault /   Hypoxia                   Connected with accident above.                                                                                   Damir Podnar, an experienced diver and instructor, member of a                                            The Voyager was sold on the basis of a false   http://translate.google.com.au/translate?hl=en&sl=it&u=htt
                                                                                                                                                                  Training issue                                        A dozen divers accompanied by two instructors from NUET (North Underwater Explorer Team).                        group of experts that examined the equipment after the accident                                           CE cert from an incompetent Notified           p://www.informatrieste.eu/blog/blog.php%3Fid%3D6961&
                                                                                                                                                                                                                        Dived in wetsuits in a series of organised try dives in Miramare, over a four day period from 23rd to            presented the following information at the Marine Biological Station                                      Body in Trieste who is not accredited under    ei=lGlNTITPHpDIvQPpjpC7Cg&sa=X&oi=translate&ct=re
                                                                                                                                                                                                                        25th July 2010, in shallow waters with objective of photography and test the quality of the rebreather.          in Piran in January 2011.                                                                                 the PPE Directive: S.T.E.A.M. ss Sicurezza     sult&resnum=10&ved=0CEwQ7gEwCQ&prev=/search%3F
                                                                                                                                                                                                                        The first accident on 25th July at 11:20am was a factor in the organisers failing to realise that a second       "The confiscated and sealed equipment was thouroghly examined in                                          Tecnologia Energia Ambiente c Mare             q%3DNUET%2Brebreather%26hl%3Den%26client%3Dfiref
                                                                                                                                                                                                                        Slovenian try diver, a biologist, did not emerge along with the rest of the group. Around thirty people          August, the whole procedure was videotaped and properly                                                   Divisione Mare. It is not known if RINA        ox-a%26hs%3Dx0L%26sa%3DX%26rls%3Dorg.mozilla:en-
                                                                                                                                                                                                                        including the Dive Master, firefighters, police and marine police team searched the length and breadth           documented so there can be no doubts about the findings. On one of                                        have certified it subsequently: in reality,    US:official%26nfpr%3D1 and see
                                                                                                                                                                                                                        of the seabed of the Reserve for about four hours. The Deceased was found around 15:00 hours,                    the rigs we found out that the hose from the doser {This is the                                           none of the Voyager rebreathers come close     http://www.scubaboard.com/forums/5674998-post6.html
                                                                                                                                                                                                                        laying at a depth of seven metres, about forty meters from the Sphinx of the Park of Miramare.                   oxygen dosing unit} to the counterlung was missing. This means that                                       to meeting EN 14143, neither do they meet
                                                                                                                                                                                                                        Coroner Fuliani Denny reported no external injuries. Medics on site appear unfamiliar with diving                the counterlung wasn't getting the correct mixture. On the second rig                                     the PPE Directive.
                                                                                                                                                                                                                        accidents let alone rebreathers: "From a doctor - said Fuliani - it is plausible that there has been a gas       a seal on the first stage (on the rebreather) was so worn out that air
                                                                                                                                                                                                                        embolism. Hypothesis compatible with deposits found in the counterlungs. Less probable is cardiac                was leaking from the system. Beside these two technical errors we
                                                                                                                                                                                                                        illness, especially as the two divers felt ill a few minutes apart." - a body at 7m for four hours will offgas   discovered several smaller ones; for example, the tanks weren't
                                                                                                                                                                                                                        heavily when recovered. Also Doctor Fulvio Costantinides and his radiologist doctor Fabio Cavalli                tested, even though older tanks are supposed to be tested every two
                                                                                                                                                                                                                        performed a 3D scan to eliminate medical causes. Criminal investigation is underway. Lucia Baldovin              years. This goes to show how unprofessionally the owner
                                                                                                                                                                                                                        will give the task to examine bottles, scrubber, corrugated hoses and regulator to some diving                   maintained the equipment." said Damir Podnar, who's convinced
                                                                                                                                                                                                                        specialists which will be named by the Harbour-office: this then became the manufacturer. The                    that the accident should not have happened despite the
                                                                                                                                                                                                                                                                                                                                         catastrophically badly maintained equipmnent, because both
                                                                                                                                                                                                                        cylinder with the breathing gas, i.e. it was an SCR. The content of the cylinders is not known at this           students should have had instructors with them, which should have
                                                                                                                                                                                                                        time.                                                                                                            noticed problems within a minute of occurrence.
                                                                                                                                                                                                                                                                                                                                         Because of technical errors both divers breathed unsuitable air
                                                                                                                                                                                                                                                                                                                                         mixture, oxygen content dropped from the mandatory {?} 30% to
205   7/21/2010   Wes Skiles                O2ptima                HH              Buddy Dive                 23             USA, Florida,       Guru       52    Rebreather issue            Hypoxia                   Reported to have died during a photographic shoot for National Geographic on ultra fast                          One of the best underwater photographers, with extensive cave                                                                                            http://www.cavediver.net/forum/showthread.php/13962-
                                                                                                                              Marathon                                                                                  photography. "Diving off the Boynton Inlet ( between West Palm Beach and Boca Raton ) on a                       diving experience: he became a certified cave diver at age 16! See                                                                                       Wes-Skiles-accident-analysis
                                                                                                                                                                                                                        private boat with two other divers. They were probably on the third reef but not confirmed, in 77 feet           http://www.gainesville.com/article/20100418/MAGAZINE01/10
                                                                                                                                                                                                                        of water, run time at recovery was 103 minutes. Deceased signaled he was going up for more film after            0419415?p=1&tc=pg and
                                                                                                                                                                                                                        an hour of diving filming Goliath Groupers, one other diver went up shortly thereafter and didn't find           http://ngm.nationalgeographic.com/2010/08/bahamas-
                                                                                                                                                                                                                        Deceased on the surface, went back down and found him laying on the reef 25 minutes later. Taken to              caves/skiles-photography and tributes on
                                                                                                                                                                                                                        a local hospital in Palm Beach County, DOA. For the prior three days plus the day of the accident,               http://www.caves.org/committee/salons/Skiles_Tribute.htm An
                                                                                                                                                                                                                        Deceased was using a borrowed Dive Rite O2ptima. Prior to this four days of diving, Deceased is                  autopsy found no indication of any causal health issue. Rebreather
                                                                                                                                                                                                                        reported to have never dived an O2ptima and he was not formally trained on the O2ptima, but this is              was operable after the accident. The temporary nature of the cause,
                                                                                                                                                                                                                        not confirmed because the Deceased has a feature page on the Dive-rite site as an apparent sponsored             leaving no signs, points strongly to an hypoxia fault.
                                                                                                                                                                                                                        O2ptima user.
                                                                                                                                                                                                                        The O2ptima was not fitted with any on board bailout system (although normally supplied with one)
204   7/17/2010   Tony Pratley          Dolphin modified        Unknown            Buddy dive                 37               Australia,      Scant data   49    Rebreather issue            Scant data                and he was not carrying anyto get intobailout. The accident occurred 40m, becoming agitated, then
                                                                                                                                                                                                                        Scant data. Diver reported off board difficulties during ascent from sometime in the last thirty       News reports just after the accident give the name of the town the                                                                                                 http://www.geelongadvertiser.com.au/article/2010/07/19/
                                          to be mCCR                                                                        Queenscliff, SS                                                                             sinking down again. Recovered quickly by three buddies, but pronounced dead on-shore. Buddies          diver is from rather than his correct name shown here.                                                                                                             192801_news.html
                                                                                                                           Rotamahana wreck                                                                             being treated for DCS. News reports suggested heart attack or equipment issue. Conflicting report
                                                                                                                                                                                                                        that the diver was found unconscious on the sea bed and brought to the surface by the three buddies.
203   6/27/2010   Leszek Nowak          Inspiration Vision      APD Vision       Extreme Diving             < 103           Poland, Hancza       Guru        -    Rebreather issue / Human    Hypercapnia               Instructor died while conducting an Advanced Trimix course, while attempting to rescue a student.      At this depth, scrubber endurance on this model is very short                      Training agencies need to        Manufacturers may quote scrubber
                                                                                                                                                                  error                                                                                                                                                        indeed, and if the instructor was exerting a lot of effort, as is likely,          emphasise that rebreathers       durations with profiles, but as so much of
                                                                                                                                                                                                                                                                                                                               then CO2 breakthrough would occur rapidly. Some users do not                       that quote scrubber life as a    the diving here is a depths and durations
                                                                                                                                                                                                                                                                                                                               realise that this manufacturer quotes scrubber durations as a                      profile, have a CE scrubber      that are well beyond those profiles, then
                                                                                                                                                                                                                                                                                                                               "profile", in which very little of the deeper profiles is actually at the          duration at constant depth       constant depth scrubber durations should
                                                                                                                                                                                                                                                                                                                               maximum depth of the profile.                                                      which is not far off the short   also be quoted.
                                                                                                                                                                                                                                                                                                                                                                                                                  bottom time in these profiles.
202   5/15/2010   Brigitte Lenoir          Megalodon          ISC Apecs eCCR     Extreme Diving            147 / 200        Dahab, Red Sea       Guru       40    Rebreather design fault     Hyperoxia                 During ascent from 200 meters, the solenoid injecting oxygen into the rebreather loop failed stuck               Primary reports indicate it is due to the solenoid sticking on, but a                                     Design fault because no auto-shut off on the http://www.20min.ch/ro/news/romandie/story/La-
                                                                                                                                                                                                                        open. At 147 meters, following the massive injection of O2, the hyperoxic conditions caused the                  person has challenged this report on this list pointing out the manual                                    O2, leaving a single point of failure in the Valaisanne-Brigitte-Lenoir-est-d-c-d-e-17035648
                                                                                                                                                                                                                        Deceased to lose consciousness. Reported by Morier. The Deceased was with Barnabas Pascal, a                     O2 injector will also inject a very large amount of gas when used at                                      E/EP/PS.
                                                                                                                                                                                                                        world record holder for deep diving, who was unable to save her.                                                 depth and may stick on. Diver had been diving rebreathers since
                                                                                                                                                                                                                        The body was recovered a month later by ROV, but the equipment was not for reasons unknown (it                   2006. Deceased had multiple issues with her Meg the previous
                                                                                                                                                                                                                        may not have been found, or considered important after such a long time in the water).                           month on a 160m? dive
                                                                                                                                                                                                                                                                                                                                         http://translate.google.co.uk/translate?hl=en&sl=fr&u=http://ww
                                                                                                                                                                                                                                                                                                                                         w.plongeur.com/magazine/2010/04/12/brigitte-lenoir-recycleur-
                                                                                                                                                                                                                                                                                                                                         record-feminin-suisse-mondial-plongee-ccr-160m-225m-
                                                                                                                                                                                                                                                                                                                                         4/&ei=VGXwS4_3DIyRsAa63-
                                                                                                                                                                                                                                                                                                                                         C8Bg&sa=X&oi=translate&ct=result&resnum=7&ved=0CDEQ7g
                                                                                                                                                                                                                                                                                                                                         EwBg&prev=/search%3Fq%3DBrigitte%2BLenoir%26hl%3Den%2
                                                                                                                                                                                                                                                                                                                                         6client%3Dfirefox-a%26hs%3DNn6%26rls%3Dorg.mozilla:en-
                                                                                                                                                                                                                                                                                                                                         US:official.
201   5/9/2010    Khoo Soo Seng            Megalodon          ISC Apecs eCCR       Buddy dive                 64           Indonesia, Seven      Guru       68    Heart attack                Heart attack              Deceased bailed and got to the surface and was brought onto the dive boat where he showed signs of               Deceased was one of the first sports rebreather divers. Mr Khoo was                                                                                      RBW report by "Dr Mike", friend of Deceased.
                                                                                                                             Skies Wreck                                                                                having breathing difficulties. Deceased was an extremely experienced diver.                                      well-known as a pioneer and veteran of the diving industry. He was a
                                                                                                                                                                                                                                                                                                                                         former president of the Singapore Underwater Federation. Since the
                                                                                                                                                                                                                        Mr Khoo Soo Seng, 68, is reported to have suffered a heart attack while on a recreational dive at the            late 1970s, he had been promoting ecological awareness and
                                                                                                                                                                                                                        Seven Skies wreck - a popular dive site off Pulau Aur on Malaysia's east coast.                                  educational programmes for divers here and in the region. Depth
                                                                                                                                                                                                                        Deceased lost consciousness while surfacing from his dive and was surfaced by his dive buddy.                    needs confirmation, as CO2 profile for stats purposes depends on
                                                                                                                                                                                                                        He was resuscitated on the dive boat. His breathing and pulse resumed for a while but eventually                 depth.
                                                                                                                                                                                                                        faded away. Mr Khoo was declared dead at Mersing Hospital.




                                                                                                                                                                                                                                            Page 3 of 20
                                                                                                                                                                                                                                      d9081ce0-7e95-44ed-9e81-0fdd6fd43e58.xls




                                                               Electronics
                                                                 fitted to
                                                                                                           Depth of accident
                                          Rebreather          rebreather for     Type of dive (Solo,                                                                          Root Case using fault      Disabling Injury using                                                                                                                  Comments or Discussion in arriving at most plausible cause,                                                                                                  An external reference confirming that accident
        Date        Deceased's Name                                                                       (/deepest/planned        Location            Experience       Age                                                            Key information received on accident                                                                                                                                  Training implications                            Design implications
                                           involved                PPo2          Group, Cave etc.)                                                                            tree method                fault tree method                                                                                                                       addition to use of the Fault Tree.                                                                                                                                              occurred
                                                                                                                ) (m)
                                                              Monitoring or
                                                                 Control
200   5/8/2010     Unknown male             Poseidon             Cis-Lunar       Solo dive, effectively         4 / 10         Norway, Nauntes,        Experienced       33   Human error                Hypoxia                       Buddy reports that "the diver had completed his first dive, and went for a second dive. There were two The diver made a serious error in not bailing out when the                   Experience level of the diver is   First FS Observation: publishing the          http://www.bt.no/nyheter/lokalt/I-sorg-etter-
                                            Discovery                                                                             Øygarden                                                                                             predive start up attempts made, that both failed due to insufficient battery power. However, the diver rebreather indicated alarms, and was also in error for not completing        not known, but is understood       analysis is very good FS practice, and        dykkerulykken-1082118.html and ninjadivers.dk
                                                                                                                                                                                                                                       was doing an Instructor course, so would have been experienced on the unit. The Diver KNEW the pre-dive checks. The Diver KNEW the battery was low and should                       to be at very low end of the       Poseidon have led in this.
                                                                                                                                                                                                                                       battery level was low. Diver relied on automatic startup to begin the dive. Buddies reported him lost not have dived as a result. Diver also chose to dive solo, a known            scale. Diver did not dive with     Second FS Observation: Battery Low is a
                                                                                                                                                                                                                                       after one hour. Just after the found the diver unconscious at 4 meters depth. They did CPR, but no life extremely high risk activity on a rebreather. However, as well as the       a Buddy.                           hazard intrinsic to electronically controlled
                                                                                                                                                                                                                                       signs. Term Buddy is used in "same ocean": dive was effectively solo. Report that the diver was         human errors in this accident, a secondary issue is that alarm                                                 rebreathers: it can be expected to occur
                                                                                                                                                                                                                                       untrained and not fit for diving. Detailed investigation report issued by Poseidon, Document IR-2010- annunciation is questionable mitigation for a single point failure                                               frequently in FS terms. The failure results
                                                                                                                                                                                                                                       05-31-1 by J. Nilsson, "The unit was started using the Emergency startup procedure, without a           (power loss), so following a Functional Safety analysis then a                                                 in the solenoid injecting oxygen being off:
                                                                                                                                                                                                                                       successful pre dive check, i.e. the unit has automatically gone in to Dive Mode, as the depth indicated secondary issue is the Functional safety issues noted on the right - as                                        leading to hypoxia. Therefore mitigation is
                                                                                                                                                                                                                                       by the on board depth gauge was greater then zero meters. At this point, the unit starts all on board   the equipment is EN 14143 certified it should not have Functional                                              required. Alarm annunciation is not
                                                                                                                                                                                                                                                                                                                                               Safety faults, so a higher bar is used and a Rebreather Design Fault                                           mitigation. Crown straps with a constant
                                                                                                                                                                                                                                       was not aborted.                                                                                        could be recorded - it is overwhelmed though by the diver choosing                                             O2 bleed, auto-bail out, variable flow
                                                                                                                                                                                                                                       During the dive, as long as there was power in the battery, the unit maintained a correct PO2 level in to dive with a flat battery.                                                                                    injectors rather solenoids, procedural
                                                                                                                                                                                                                                       the breathing loop. Non essential systems were shut down to preserve battery power, which was used                                                                                                                     reinforcement in the PPO2 checks are all
                                                                                                                                                                                                                                       to maintain life support functions for as long as possible.                                                                                                                                                            mitigating features that are within ALARP.
                                                                                                                                                                                                                                       Approximately 20 minutes in to the dive, at 4 meters depth, the battery runs out of power, so the                                                                                                                      Normally off solenoids do not meet
                                                                                                                                                                                                                                       injector solenoid is off, data logging stops. The DV switch of the mouthpiece was set in Closed                                                                                                                        Functional Safety standards when used for
                                                                                                                                                                                                                                       Circuit (CC) mode when the diver was found. No attempts to switch to Open Circuit (OC) were                                                                                                                            the sole source of O2. However, Poseidon
                                                                                                                                                                                                                                       recorded on the log file. The unit was equipped with an Octopus connected to the Diluent 1 st stage.                                                                                                                   have followed common industry practice,
                                                                                                                                                                                                                                       The unit had adequate amounts of Oxygen (69 bar) and Diluent gas (176 bar). " Concluded from logs                                                                                                                      so the FS implications of this accident
                                                                                                                                                                                                                                       that diver entered water without checks relying on auto-on feature, then battery failed. Single battery                                                                                                                affects most eCCR manufacturers.
                                                                                                                                                                                                                                       failure resulted in hypoxia, leading to death. Diver left behind a wife and two children.
199   4/13/2010    Wallace Leung           Megalodon          ISC Apecs eCCR         Buddy dive                  150           Philippines, Puerto    Intermediate or     -   Human error / Rebreather   Scant Data                    Deceased ordered Meg 26th November 2009. Deceased is reported observed by another diver in              Deceased dived with Apecs eCCR Meg with factory fitted                      Whilst diver appears to have                                                  http://hkdiver.com/viewtopic.php?f=17&t=36202
                                                               controller with                                                       Galera             Experienced           issue                                                    water at 80m ascending from 150m with DSV removed and then falling in water column.                     Liquivision X1. Appears from published imagery to not have dived            been a KISS instructor, he
                                                               Liquivision X1                                                                                                                                                                                                                                                                  with an aftermarket BOV installed nor sufficient OC bailout for a           only appears to have ordered
                                                                PPo2 display                                                                                                                                                                                                                                                                   150m dive. Performance of Deceased's rebreather beyond 100m may             his eCCR Meg in November
                                                                                                                                                                                                                                                                                                                                               be a factor.                                                                2009 which is a short time
                                                                                                                                                                                                                                                                                                                                                                                                                           period to be attempting
                                                                                                                                                                                                                                                                                                                                                                                                                           extreme diving outside the
                                                                                                                                                                                                                                                                                                                                                                                                                           manufacturer's guidelines for
                                                                                                                                                                                                                                                                                                                                                                                                                           the rebreather used.
198   3/1/2010     Unknown Korean           Unknown                 ISC              Buddy dive                  150           Philippines, Puerto    Intermediate or     -   Scant data                 Scant Data                    Two Korean rebreather divers took a boat out from Puerto Galleria with a single boatman, and threw a Asian forum appears to have divers competing for the maximum                                                                                                 Governmental source
                   diver                                                                                                             Galera             Experienced                                                                    line down to 150m, descended and never surfaced. Boatman waited until late evening but divers did depth on a rebreather. There is assumed to be a beat other divers
                                                                                                                                                                                                                                       not return. Neither bodies nor equipment recovered.                                                  depth attempt, as the depth with the accident in April running from
                                                                                                                                                                                                                                                                                                                                            the same port is too coincidental.
197   3/1/2010     Unknown Korean           Unknown                 ISC              Buddy dive                  150           Philippines, Puerto    Intermediate or     -   Scant data                 Scant Data                    Two Korean rebreather divers took a boat out from Puerto Galleria with a single boatman, and threw a As above, double fatality.                                                                                                                                   Governmental source
                   diver                                                                                                             Galera             Experienced                                                                    line down to 150m, descended and never surfaced. Boatman waited until late evening but divers did
                                                                                                                                                                                                                                       not return. Neither bodies nor equipment recovered.
196   2/21/2010    Stéphane Havard        Megalodon or                               Buddy dive                  75            France, Calaliere Le       Guru           49   Rebreather issue           Hypoxia                       Deceased lost consciousness near the surface just after ascending. Fatal Dive profile was apparently Var is visited by 20,000 divers a year. 2 accidents there in 2009.                                                                                           http://translate.google.com.au/translatehl=en&sl=fr&u=http
                   (Not the RBW            Inspiration                                                                             Lavandou                                                                                            78mètres => 20m => fall later 40mètres => 0m ==> 6mètres ==> end surfaces. Deceased had a Meg                                                                                                                                                                     ://pscausette.plongeesout.com/viewtopic.php%3Ff%3D2%2
                   Stephane, and name                                                                                                                                                                                                  and Inspo (Inspiration instructor) fitted with a Polish Nemo Solutions BOV: not clear which was in                                                                                                                                                                6t%3D1332&ei=U2q1S5zXLs2TkAW106CRDQ&sa=X&oi
                   in French is male)                                                                                                                                                                                                  use on the day of the accident.                                                                                                                                                                                                                                   =translate&ct=result&resnum=8&ved=0CCAQ7gEwBw&pr
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         ev=/search%3Fq%3Dstephane%2Bhavard%26hl%3Den%26
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         client%3Dfirefox-a%26hs%3D2Ct%26rls%3Dorg.mozilla:en-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         US:official
195   1/21/2010    David Allseybrook    Inspiration Classic     APD Classic          Buddy dive                  10              Egypt, Red Sea        Experienced       43   Rebreather issue           Hypercapnia or hypoxia        Deceased died after getting into difficulty during his ascent from the wreck of the Chrisoula K, in the                                                                                                                                                           http://translate.google.com.au/translate?u=http%3A%2F%2
                                                                                                                                                                                                                                       Abu Nuhas area. Deceased was using his own Buddy Inspiration Classic closed-circuit rebreather,                                                                                                                                                                   Fwww.ninjadivers.dk%2F&sl=da&tl=en&hl=&ie=UTF-8
                                                                                                                                                                                                                                       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".
194   11/24/2009   Eok Soo Kim             Inspiration             APD               Buddy dive                  110              Philippines,         Experienced            Rebreather issue           Hypoxia                       Body found floating on the surface 15 minutes after a boat dive near the shore. Deceased was the                                                                                                                                                                  http://www.philstar.com/Article.aspx?articleId=526906&pu
                                                                                                                                  Panagsama,                                                                                           divemaster. A post in 2010 onto a forum reporting a profile for a South Korean diver, Sung Gi Baek                                                                                                                                                                blicationSubCategoryId=107
                                                                                                                                   Moalboal                                                                                            for 24th Nov 2009, http://www.rebreatherworld.com/rebreather-accidents-incidents/35648-sudden-
                                                                                                                                                                                                                                       blow-up-and-iwr.html seems too coincidental to be a different accident. It is assumed this is the same
                                                                                                                                                                                                                                       dive, in which case the victim was recovered to the surface by the buddy, who was Sung Gi Baek, then
                                                                                                                                                                                                                                       recovered to the boat.
193   11/20/2009   Nakis                     Voyager             Unknown             Buddy dive                  46             Cypress, Larnaca       Intermediate     Scant Rebreather issue / Human   Hyperoxia                     Deceased found unconscious on surface. Unconfirmed report diver bailed out from rebreather onto           Most plausible cause hyperoxia. Human error in not having                 Questions have been raised
                                                                                                                                                                         data error                                                    54% Nitrox at 42m after rebreather failure.                                                               appropriate bail out if report is correct. However, as the chain          with regard to the adequacy of
                                                                                                                                                                                                                                                                                                                                                 started with a rebreather failure, that is the root cause. Both hypoxia   the diver training that the
                                                                                                                                                                                                                                                                                                                                                 and hypercapnia on a rebreather can lead to subsequent                    manufacturer supports.
                                                                                                                                                                                                                                                                                                                                                 inappropriate actions.
192   11/14/2009   Timothy Teagarden    Evolution Vision        APD Vision            Buddy dive                 25             USA, Key West,         Experienced       51   Scant data                 Scant data                    Autopsy describes Deceased as having a good picture of health. Police investigation is focusing on
                                                                                                                                Oriskany Wreck                                                                                         equipment.
191   11/13/2009   Richard McCoy Jr          Sentinel               VR                Buddy dive                 27             USA, Key West,           Trainee         51   Underlying                 Hypercapnia / heart attack    Deceased had been down about 95 feet with two instructors, just after noon, when he reportedly        Moderate current at 95ft, followed by events described, results in the                                                                                      http://seaduction.com/scuba-diving/vandenberg-death-
                                                                                                                               Vandenburg Wreck                               illness/Rebreather issue                                 began having trouble. The instructors began helping Deceased, but he stopped breathing about 25       classification using the Fault Tree. More firm data would be useful in                                                                                      rebreather/
                                                                                                                                                                                                                                       feet from the surface. Visibility on the site was reported to be approximately 40 feet with a mild to determining which cause was the trigger.
                                                                                                                                                                                                                                       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

                                                                                                                                                                                                                                       effectively and made every effort to assist the injured diver.
190   11/5/2009    Stewart Wright       Inspiration Vision      APD Vision           Solo Diving                 70              UK, Cumbria,           Scant data       39   Scant data                 Scant data                    Scant data. Stewybear on forums.                                                                                                                                                                                                                                  http://www.yorkshire-divers.com/forums/incident-
                                                                                                                                  Wastwater                                                                                                                                                                                                                                                                                                                                                              reports/99283-death-diver-wass-water-5-nov-2009-yd-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         member-stewybear-9.html
189   11/3/2009    Jim Woodall              Evolution           APD Vision           Cave Diving                 72            USA, Eagle's Nest       Experienced       39   Rebreather issue           Hypercapnia                   Two divers both on rebreathers with 18/30 mix, were exiting a 1000' penetration upstream when the
                                                                                                                                     cave                                                                                              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.
188   10/27/2009   Dr. Marcus Lim          Megalodon                ISC               Buddy dive                 25            Malaysia, Pulau Aur      Unknown          37   Scant data                 Scant Data                    Friends of the Singapore National Eye Centre specialist who died in a diving accident on Saturday         Dr Lim was passionate about photography and he was able to                                                                                              http://www.bigbluetech.net/big-blue-tech-
                                                                                                                                                                                                                                       said he was feeling well before the accident.                                                             combine this with his love of diving to stunning effect.                                                                                                news/2009/11/01/rebreather-diver-fatality/
                                                                                                                                                                                                                                       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.

                                                                                                                                                                                                                                       hospital which is Mersing Hospital. But despite four hours of CPR, we could not revive him.
187   10/21/2009   Andy Letourneau      Inspiration Classic     APD Classic            Solo dive              Scant data       British Columbia,          Guru           46   Rebreather design fault    Hypoxia                       Scant data. Equipment recovered and being checked by Canadian Navy. Autopsy confirmed that                Very experienced diver. M Boule reported that "Andy was a lifetime
                                                                                                                                  Port Hardy                                                                                           diver did not drown and has no sign of traumatic injury.                                                  Oregonian. He and his wife, Meegan, had just bought their dream
                                                                                                                                                                                                                                                                                                                                                 home in Colton. He was 46. Andy was a generous man, a kind man.
                                                                                                                                                                                                                                                                                                                                                 He helped a lot of people."
186   9/23/2009    Jerry Gunderson       Unknown O2-             Unknown               Solo dive                  8              USA, Florida,            Guru           75   Underlying Illness         Heart attack or Hyperoxia     Deceased was collecting golf balls from the lake using an oxygen rebreather. Found dead in the centre                                                                                                                                                             http://www.scubaboard.com/forums/accidents-
                                            CCR                                                                                 Deerfield Beach                                                                                        of the lake at the Deer Creek Country Club in Deerfield Beach, Florida. Used Grace Sodasorb.                                                                                                                                                                      incidents/305257-golf-ball-diver-dies.
                                                                                                                                                                                                                                       Unconfirmed report of mild heart attack in the water a few years earlier. Diver used high O2 tox
185   8/5/2009     Colin Bell            Inspiration with           HH                Buddy dive                 55              UK, Hartlepool        Experienced       52   Scant data                 Hypoxia                       limits.data. Diver made rapid ascent from deco stop. Diver found unconscious on surface.
                                                                                                                                                                                                                                       Scant                                                                                                 Sudden LOC on ascent results in most plausible cause being hypoxia                                                                                          http://www.cdnn.info/news/safety/s090809b.html
                                         HH electronics                                                                                                                                                                                Experienced diver although initial reports state he was not trained on rebreather. Reported to have   on a rebreather.
                                                                                                                                                                                                                                       bought unit 2nd hand two weeks earlier. Modified frame and larger cylinders not relevant to accident.
184   8/2/2009     Dean Repola             Inspiration             APD                Scant data              Scant data            USA, NJ               Guru           48   Scant data                 Scant Data                    Scant data. Body not recovered.                                                                                                                                                                                                                                   http://www.vancouverite.com/2009/10/08/oregon-man-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         dies-in-b-c-diving-accident/




                                                                                                                                                                                                                                                          Page 4 of 20
                                                                                                                                                                                                                                             d9081ce0-7e95-44ed-9e81-0fdd6fd43e58.xls




                                                                 Electronics
                                                                   fitted to
                                                                                                            Depth of accident
                                            Rebreather          rebreather for       Type of dive (Solo,                                                                           Root Case using fault       Disabling Injury using                                                                                                                      Comments or Discussion in arriving at most plausible cause,                                                                                               An external reference confirming that accident
        Date        Deceased's Name                                                                        (/deepest/planned        Location              Experience         Age                                                              Key information received on accident                                                                                                                                     Training implications                         Design implications
                                             involved                PPo2            Group, Cave etc.)                                                                             tree method                 fault tree method                                                                                                                           addition to use of the Fault Tree.                                                                                                                                           occurred
                                                                                                                 ) (m)
                                                                Monitoring or
                                                                   Control
183   25/06/2009   Phil. J. Patz          Highly modified             HH               Solo Shore Dive            90                USA, Lake             Experienced        48    Rebreather design fault     Hypercapnia                    Known data: Solo shore dive. Deceased known to use 10/90 mix for these dives which is hypoxic on             Observations: Neither the original rebreather nor any modifications                                                                                   http://www.wqad.com/news/sns-ap-wi--
                                           BMI BMR500,                                                                              Michigan                                                                                                  the surface instead of 16/84 which could have been used and would have provided a breathable gas on          had had any formal testing to determine the functional limits. The                                                                                    diverdies,0,888623.story and
                                           with a reversed                                                                                                                                                                                    the surface. Rebreather was based on a BMI500 or BMR500 but heavily modified. Comments made                  modified rebreather was not even characterised in its basic                                                                                           http://www.rebreatherworld.com/decompression-and-gas-
                                          loop, water trap,                                                                                                                                                                                   that modifications may have included mCCR functionality. The Deceased bought overhauled HH                   operation. BMR500 was advertised as having 6 hour scrubber life at                                                                                    choices/22065-heliox-dil-s-what-have-you.html
                                         switchable adv for                                                                                                                                                                                   handsets meant for an Inspiration and patched them into his rig using R10Ds. The cells would have            any depth when in fact at 90m the scrubber life would be around 15
                                         diluent or O2, HH                                                                                                                                                                                    had a maximum readable ppO2 of about 1.15 to 1.20 because their output is double the normal level,           minutes based on tests using similar scrubber geometry and load:
                                          Elecs. No HUD.                                                                                                                                                                                      unless an additional load resistor is added. The handsets did not check cell type or range                   BMR500 has an axial sub 2kg scrubber design developed from an
                                           BMR500 DSV.                                                                                                                                                                                        automatically.                                                                                               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.
182   23/06/2009   Bob Lenham                Inspiration              APD                Buddy dive               60               UK, English              Expert           61    Scant data                  Scant                          Buddy lost track of Deceased when surfacing.                                                                                                                                                                                                                         http://www.timesonline.co.uk/tol/news/uk/article6566266.
                                                                                                                                Channel, Empire                                                                                                                                                                                                                                                                                                                                                                    ece and http://www.rebreatherworld.com/members/bob-
                                                                                                                                       Javelin                                                                                                                                                                                                                                                                                                                                                                     lenham.html
181   12/06/2009   Claudio Menchin       Inspiration Vision        APD Vision            Solo Diving              13            Italy, Porto Santo         Unknown           39    Rebreather issue            Hypoxia                        Porto Santo Stefano: An experienced scuba diver, 39 years old, dived in the waters of the Islet              There are some reports of this model having a logging issue with                                          Logs are critical in understanding accidents,
                                                                                                                                      Stefano                                                                                                 Argentarola at 15.30, telling two friends who accompanied him on a raft, he would end the dive at            PPO2 recording. The other evidence points to hypoxia. As the logs                                         so should be to recognised Functional         http://translate.googleusercontent.com/translate_c?hl=en&
                                                                                                                                                                                                                                              around 18:30 . At 19:00, the two companions, seeing that he was late and initiated the search and            may not be entirely trustworthy, most probable cause is hypoxia.                                          Safety standards rather than some amateur sl=it&tl=en&u=http://www.marescoop.com/ftopict-
                                                                                                                                                                                                                                              rescue procedures, contacting the Coast Guard patrol boat 868, which began immediately to search                                                                                                                       standard.                                     1881.html%26sid%3D1b344f268d522aec7158719a102827aa
                                                                                                                                                                                                                                              for the missing diver, while the Fire Department divers of the Nucleus of Grosseto and volunteers to                                                                                                                                                                 &rurl=translate.google.com.au&usg=ALkJrhjmqQ5cwEoNF
                                                                                                                                                                                                                                              local diving centers have carried out an initial survey dive. At 22:00 the search was suspended because                                                                                                                                                              VUyETfwG231nhqqRg
                                                                                                                                                                                                                                              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 download shows the diver surfaced and was on the surface
                                                                                                                                                                                                                                              Diver was reported as havingunconscious. difficulty on the bow of the Britannic. Report that
                                                                                                                                                                                                                                              for some minutes, then sank been seen in
180   24/05/2009   Carl Spencer              Ouroboros                 VR             Group Trimix Dive           100           Greece, Britannic            Guru            37    Rebreather failure/human    Hyperoxia                                                                                                                           Expedition management allowed an unmarked cylinder on a mixed                     Unmarked cylinder in the                                                    Confidential communication and news reports such as
                                                                                                                                                                                   error                                                      rebreather flooded, in which case, diver's CNS clock would be reduced due to CO2. Diver ascended gas dive.                                                                             water on a mixed gas dive.                                                  http://www.lastingtribute.co.uk/tribute/spencer/3084562
                                                                                                                                                                                                                                              and at 50m was offered O.C gas from one of the Deceased's bottles by another diver. The bottle was                                                                                     Diver was not carrying
                                                                                                                                                                                                                                              not marked, but contained 50% deco gas, hence MOD is 22m. Deceased then suffered a seizure and                                                                                         sufficient bail out.
                                                                                                                                                                                                                                              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.
179   18/05/2009   Paul Blanchette Jr     Megalodon, pre              ISC                Solo diving              30                USA, MA                  Guru            50    Rebreather failure/human    Hypoxia                        Diver recovered several days after going missing. Indirect report from a person involved with the       As it is a pre-2006 Meg, investigators should consider carefully all                                                                                       http://coastguardnews.com/coast-guard-searching-for-
                                              2006                                                                                                                                 error                                                      recovery, that the Oxygen cylinder valve on the CCR was turned off. A person on the boat reported       scrubber bypass faults as a routine, as well all other potential faults as                                                                                 missing-diver-7/2009/05/18/
                                                                                                                                                                                                                                              that he had a leak on that side and was messing around with the regulator prior to entry, apparently    accident rate on pre-2006 units are excessive.
                                                                                                                                                                                                                                              fixed the leak, but failed to turn the gas back on. No explanation for lack of alarms.
178   13/05/2009   Gene White            Copis Meg mCCR ISC Copis mCCR                   Solo diving            0/35/35         USA, N.J. Bargegat          Expert           42    Rebreather fault / Human    Hypoxia / hyperoxia            Diver found at depth of 125fsw unconscious, after recovery, failed to revive. Witnesses said White lost                                                                                                                                                            http://coastguardnews.com/coast-guard-aircrew-medevacs-1-
                                                                                                                                      Inlet                                        error                                                      consciousness as he was resurfacing and sank down. Mouthpiece bitten through.                                                                                                                                                                                      near-barnegat-nj/2009/05/16/#more-10206
177   05/05/2009   Dewayne Smith             Inspiration        Modified by APD          Buddy dive               20             USA, Key Largo             Expert           36    Rebreather design fault     Hypoxia                                                                                                                                Manufacturer subsequently issued a Warning "Inadvertent Handset                                                                                            Jeff Godfrey offers a presentation entitled 'The Evolution and
                                                                for saturation use                                                                                                                                                            Deceased signaled to his two fellow divers, dubbed aquanauts, that he was headed back to Aquarius. Operation by Underwater Hydraulic Equipment, Oct 2009" which                                                                                                    Future of Rebreathers in Scientific Diving' at the 2010
                                                                                                                                                                                                                                              A few minutes later he was found unconscious on the ocean bottom.                                       states clearly the equipment has got states in which it does not                                                                                           Northeast Rebreather & Advanced Diving Technology
                                                                                                                                                                                                                                              Shepard said divers, who are all trained as first responders, carried him to Aquarius and began         support life, and these can be entered into underwater (i.e. it is not a                                                                                   Workshop, and manufacturer's safety notice. See also 30m
                                                                                                                                                                                                                                              performing basic first aid and CPR. A Navy doctor soon dove down from the surface to assist, but it TTA architecture, and has major errors in its electronics and                                                                                                  point on
                                                                                                                                                                                                                                              was too late. Deceased was pronounced dead at 3:25 p.m.                                                 software in allowing this). It is understood that these events are                                                                                         http://www.youtube.com/watch%3Fv%3DVRLsvdlFkeM
                                                                                                                                                                                                                                              Unsafe software modification to rebreather (trying to use a sports product for sat diving), caused      connected: that the accident was caused by the equipment switching
                                                                                                                                                                                                                                              eCCR controller to shut off underwater while being dived. Predive check not done. Diver task            out of a life support mode underwater due to vibration on the
                                                                                                                                                                                                                                              loaded. Diver was having a bad day: previous dive had problems with O-ring spacer not installed on      buttons.
                                                                                                                                                                                                                                              scrubber and had less than ideal monitoring of handsets. Diver did not notice there were no lights on
176   26/04/2009   Paul Leyland a.k.a.   Inspiration Classic,     APD Classic            Solo diving              4.5             UK, Brixham               Expert           51    Rebreather design fault     Hypoxia                        HUD.
                                                                                                                                                                                                                                              Shore diving at Brixham and Deceased dived on his Classic with another diver                            Inquest was informal yet nobody disclosed to the Coroner that there                                                                                        http://www.yorkshire-divers.com/forums/closed-circuit-
                   "Odin"                     age 2000              (2000)                                                                                                                                                                    on a Classic and a trainee, shallow dive and for less than an hour. On returning to the shore the            is a fundamental design defect in the Inspiration handsets made in                                                                                    rebreathers/129020-coroners-report-inspo-classic-death-14-
                                                                                                                                                                                                                                              trainee had dropped some equipment and Deceased returned to the water to retrieve it - he was in the         year 2000 causing them to hang unpredictably from battery bounce,                                                                                     09-10-a.html#post1517521
                                                                                                                                                                                                                                              water for a short period of time (5-10 minutes) at a depth of 4.5m and surfaced unconscious, was             resulting in death from hypoxia after 6 to 7 minutes. This matches
                                                                                                                                                                                                                                              recovered and resuscitated, and flown to Derriford Hospital in Plymouth, but lost his life around            the known facts perfectly. It is not known whether it was a pre-Aug
                                                                                                                                                                                                                                              10.30pm. Inspiration was manufactured in 2000 and while the head had been back to the                        2000 or post Aug handset pair. Both are liable to cause hypoxia, but
                                                                                                                                                                                                                                              manufacturer, it appears to have the original handsets. Manufacturer raised various spurious issues at       the earlier is MUCH more likely - a very dangerous design by non-
                                                                                                                                                                                                                                              inquest, such as reference to strain on solenoid wires, whilst failing to disclose the very serious design   engineers. Manufacturer issued a letter which covered up these
                                                                                                                                                                                                                                              defects in pre-2001 Inspiration handsets, namely they are liable to hang, where the PPO2 displayed on        matters. No functional safety inspection of the rebreather took
                                                                                                                                                                                                                                              the handsets appears to be normal, there are no alarms, but the PPO2 is falling because the solenoid is      place. A lot of emphasis put on this being a solo dive by the Coroner,
                                                                                                                                                                                                                                              not driven by the processor - this usually occurs on water entry giving a 6 to 7 minute dive time for an     but it was only to 4.5m for under ten minutes: few buddies stay that
                                                                                                                                                                                                                                              average sized diver swimming gently. Surprisingly, the manufacturer's report also makes no mention           close so the solo dive aspect is a Red Herring further obscuring the
                                                                                                                                                                                                                                              of replacing any battery compartment: if it is the original, then it will compound the handset issue.        truth.



175   28/03/2009   David Auteza             KISS Classic             Jetsam              Cave Diving              68            France, Le Ressel     Guru but KISS novice   31    Rebreather design fault /   WOB induced respiratory        Two divers went in the cave "Ressel". One diver on trimix, second diver (Deceased) on air dil using a        Well known diver. Fireman by profession. Narcosis a major            Diver untrained on the                A very experienced diver in the USA on the http://efps.ffspeleo.fr/analyse_des_accidents.html
                                              mCCR                                                                                                                                 Human error                 spasm or CO2 retention         KISS acquired 10 days earlier. It was not a team: they didn't plan anything together. Diver on trimix        element, which can lead to panic, but CO2 retention would have       rebreather. Dive on air.             same profile found the WOB so high on the
                                                                                                                                                                                                                                              planned a 1000m penetration dive with trimix diluent, the KISS diver on air did not have a plan other        been very high at this depth, on air, with high workload.                                                 KISS at that depth, it caused respiratory
                                                                                                                                                                                                                                              than a test dive in                                                                                          Respiratory spasm is the most plausible cause using the fault tree                                        spasm. The WOB on the KISS is around 6
                                                                                                                                                                                                                                              the first shallow part of the cave. However, the second diver just followed the first diver, even in the     method, with second being WOB induced CO2 retention (not                                                  times the CE safe limit, and over 10 times
                                                                                                                                                                                                                                              deep part. At 1080m from entrance, they made a U turn, but, on the way back, they made a navigation          accounting for unconsciousness at 50m), the third most plausible                                          the NEDU limit at that depth.
                                                                                                                                                                                                                                              error and missed the junction. Instead of going to the exit, they went in another deep gallery. After        being scrubber breakthrough (not accounting for unconsciousness
                                                                                                                                                                                                                                              200m, at a depth of 68m, they realized the mistake. At this moment the second diver is reported to           at 50m), other fault tree branches that cannot be eliminated at this
                                                                                                                                                                                                                                              have suddenly "went back like crazy" and his buddy never saw him again. The first diver on trimix            stage include oxygen insufficiency for dive duration - dive computer
                                                                                                                                                                                                                                              found the junction and went to the exit gallery.                                                             data is needed.
                                                                                                                                                                                                                                              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).
174   18/03/2009   Bruce (surname            Inspiration              APD                Solo diving                              Pak 1 Wreck,               Guru            40+   Scant data                  Scant data                     The Deceased was reported to be a diving instructor working with Royal Thai Navy divers but was           Deceased is not Bruce Konife (nor connected with him).                                                       Based on units submission for RN            http://www.rebreatherworld.com/rebreather-accidents-
                   unknown)                                                                                                         Thailand                                                                                                  using a sport rebreather. Initial reports was that it was the diving instructor but further investigation                                                                                                              consideration, the rebreather in question   incidents/25633-fatality
                                                                                                                                                                                                                                              indicated Deceased was not the instructor for that group at that time but was a contractor on                                                                                                                          does not meet the standards required of a
                                                                                                                                                                                                                                              recreational equipment.                                                                                                                                                                                                rebreather for naval use.
                                                                                                                                                                                                                                              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
173   24/01/2009   Arie Mazor                Evolution            APD Vision             Buddy dive                              Israel, Eilat (Red         Novice           57    Human Error / DCS           DCS                            Klang and his body was returned to shore by the landing ship.
                                                                                                                                                                                                                                               Civilian accident, 3 divers, 2 surfaced, Deceased did not. Deceased had suffered polio in early life but Accident apparently being covered up in Israel initially: information        Emphasise the need to build                                                   http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                                        Sea)                                                                                                  had completed a professional diving course just 6 weeks earlier and was believed fit to dive. Dive        exceptionally hard to obtain, whereas for other dive accidents in            up gradually to deeper dives,                                                     incidents/24477-missing-diver.html#post237540
                                                                                                                                                                                                                                              download shows this was the diver's 12th dive on this rebreather. This was his first dive (with this      Israel it is obtained easily. Information eventually released to the         with guidance of at least 50
                                                                                                                                                                                                                                              rebreather) to 50m.                                                                                       RBW list (assumed from manufacturer). The profile is very long at            hours and extended duration
                                                                                                                                                                                                                                              Diver conducted pre-breathe. Ascended from deepest part of dive 50m to 43m, reaching 43m at 41            this depth, and diver would likely be suffering DCS from such a              qualified, before exceeding
                                                                                                                                                                                                                                              mins. Diver then ascended at 29m/min. The diver remained on surface for 25 secs, descended to             direct ascent. The scrubber duration is questionable: the very warm          40m depth.
                                                                                                                                                                                                                                              1.26m for 10 secs and was then again on the surface for 10 secs before sinking, no longer breathing       water means it is unlikely to be the cause of the accident though.
                                                                                                                                                                                                                                              from the rebreather.                                                                                      This is a deep dive for an inexperienced diver.
                                                                                                                                                                                                                                              PO2 was within life support limits at all times. Scrubber activity was normal.
172   16/11/2008   Andreas Rudolph            Sentinel                 VR               Quarry Diving             17            Germany, Löbejün             Guru            39    Scant data                  Pulmonary barotrauma (Burst Scant data. Deceased found on surface, after diving inside Boiler 1 in quarry dive (of 3). Pulmonary            German distributor for the Sentinel. The Sentinel has only got a
                                                                                                                                   Steinbruch                                                                  Lung).                      barotrauma (Burst Lung). Ascent was very fast, followed by diver sinking, also quickly.                         single counterlung, so it would not have reverse oxygen flow even in                                                                                  http://www.taucher.net/unfall/Toedlicher_TU_am_16.11.
                                                                                                                                                                                                                                                                                                                                                           a very fast ascent.                                                                                                                                   _im_Steinbruch_Loebejuen_tu479.html
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 incidents/23268-fatality-near-berlin-germany.html




                                                                                                                                                                                                                                                                 Page 5 of 20
                                                                                                                                                                                                                                           d9081ce0-7e95-44ed-9e81-0fdd6fd43e58.xls




                                                                 Electronics
                                                                   fitted to
                                                                                                           Depth of accident
                                             Rebreather         rebreather for      Type of dive (Solo,                                                                        Root Case using fault       Disabling Injury using                                                                                                                       Comments or Discussion in arriving at most plausible cause,                                                                                                        An external reference confirming that accident
        Date        Deceased's Name                                                                       (/deepest/planned        Location            Experience        Age                                                                Key information received on accident                                                                                                                                    Training implications                              Design implications
                                              involved               PPo2           Group, Cave etc.)                                                                          tree method                 fault tree method                                                                                                                            addition to use of the Fault Tree.                                                                                                                                                    occurred
                                                                                                                ) (m)
                                                                Monitoring or
                                                                   Control
171   10/11/2008   Kevin Bailey               O2ptima                 HH               Wreck Diving               68              New Zealand             Expert         63    Rebreather issue            Hyperoxia / Hypercapnia          Mr Bailey was the owner and manager of a Blenheim dive shop and an industry veteran who had been            The decent would be on a high O2 loop, making hyperoxia the most                                                                                               http://www.stuff.co.nz/timaru-herald/news/3314086/Fatal-
                                                                                                                                                                                                                                            diving recreationally since the late 1960's and professionally since 1988. Dive was on trimix. Divers       plausible cause following the fault tree. Hypoxia unlikley on descent.                                                                                         dive-was-plagued-by-faults
                                                                                                                                                                                                                                            were decompressing at 15m after ascending then descending to recover a dropped bell, the line               The divers descended to recover a bell and this extra workload on
                                                                                                                                                                                                                                            dropped, and deceased disappeared from sight. Mr Bailey and his rebreather were recovered later by a        the Optima with its high WOB means that the heartattack prognosis
                                                                                                                                                                                                                                            trawler. Initial investigation reports were of low O2 in the divers cylinders, but this was proven not to   also remains a plausible factor.
                                                                                                                                                                                                                                            be by coroner due to cylinders flooding prior to recovery and sitting 3 months before accident
                                                                                                                                                                                                                                            investigation verified the contents.""

170   28/09/2008   John Maneely           Inspiration Classic     APD Classic         Solo Cave Diving            26            France, Source de         Guru           32    Human error                 Drowning/asphyxia                Diver passes the restriction of -52m with rebreather on his back then descends to -57. The make up                                                                                                                         If a rebreather is to be removable during a     Inquest reported first on
                                                                                                                                     Doubs                                                                                                  gas is trimix (40% helium). Diver carried a bottle of 11L air in case of failure of the rebreather. On                                                                                                                     dive, this needs to be considered as part of    http://www.cdnn.info/news/safety/s090501a.html and
                                                                                                                                                                                                                                            return, Deceased was stuck in the restriction and tried to squeeze through several times: this                                                                                                                             the diving system.                              Detail from team on http://www.swiss-cave-diving.ch/PDF-
                                                                                                                                                                                                                                            restriction is harder to pass on the way back than the way in. Diver chose to take off the rebreather,                                                                                                                                                                     dateien/Unfall_Doubs_28092008.pdf
                                                                                                                                                                                                                                            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.
169   19/09/2008   Richard Mork, a.k.a.      Megalodon          ISC Apecs eCCR          Cave Diving               35           USA, Jackson Blue       Experienced       38    Human error / Rebreather    Hyperoxia                        Diver suffered a classic CNS type event in a cave dive. Sensors were 18 months old and the fact that at     NEDU Report published. Coroners report published. Known to                                                                                                     http://www.cavediver.net/forum/showthread.php?t=8553
                   "Packetsniffer"                                  (Modified                                                        Cave                                      issue                                                        least one had ceiling faults is reported to be known to the diver - in fact all three had faults. Diver     accident investigators prior, but confidential information now
                                                                 displays), dived                                                                                                                                                           appears to have been aware of a rebreather failure. Also oxygen injector failure, known to diver: diver     released publically allowed the updating detail in the description on
                                                                with known faulty                                                                                                                                                           was switching off injector using a flow stop device manually.                                               left.
                                                                     solenoid
                                                                                                                                                                                                                                            Including the injector fault, and cell faults, rebreather had 6 different known faults, but diver still used Diver was warned about his lack of maintenance, hence conclusion
                                                                                                                                                                                                                                            it.                                                                                                          from the information available is human error led to rebreather issue.

168   12/09/2008   Eric Sterck               Megalodon                ISC               Buddy dive                40            France, Cavalaire,        Expert         40    Rebreather issue            Hyperoxia                        Poss solenoid stuck open, 8 minutes into the dive, confirmed CNS convulsion, drowning. O2 tank              For the team, J-J Bolanz                                                                                                                                       http://www.rebreatherworld.com/megalodon-
                                                                                                                                Rubis WWII Sub                                                                                              had been shut down by the time the Deceased was recovered. Strong current and divers swimming                                                                                                                                                                              rebreather/21550-the-rubis-cavalaire.html#post209176
                                                                                                                                     Wreck                                                                                                  very hard. Deceased was an Inspo instructor.
167   10/09/2008   Jan Otys                Habenero SCR            Unknown              Buddy dive                90             Croatia, Cavtat.      Experienced             Underlying Illness /        Heart attack, during a period    Heart attack started at 90msw, diver ascended, blacked out at 6msw. .                                       At 90msw WOB is extremely high on this rebreather, post mortem                                                                                                 http://www.finnsub.cz/garibaldi/eng/index.php
                                                                                                                                                                               Rebreather design fault     of hypercapnia                                                                                                                               would not have known about links between retained CO2 and
                                                                                                                                                                                                                                                                                                                                                        rebreather diving
166   29/07/2008   Unknown male               Unknown                                   Buddy dive                40             North Carolina,       Experienced       63    Underlying Illness /        Heart attack                     A dive boat arrived at the Aelous wreck site and came upon two divers some distance from the two            Detailed consideration of whether reports may be the same accident                                                                                             Carteret County Paper and
                                                                                                                                 Atlantic Ocean                                Rebreather fault                                             dive boats already on location. Divers were recovered, one diver was unconscious and unresponsive.          as reported on 28th July 2008 and concluded it is not a duplicate. As                                                                                          http://www.wrecksite.eu/wreck.aspx?14829 and
                                                                                                                                                                                                                                            EMT divers on board performed CPR for 1.5 hours. Pronounced dead on arrival. Diver known to                 EMT divers appear to conclude it was a heart attack, until Carteret                                                                                            http://www.nc-
                                                                                                                                                                                                                                            have prior medical issues. May be heart attack: awaiting autopsy information.                               County make available autopsy findings, this seems the only cause                                                                                              wreckdiving.com/WRECKS/AEOLUS/AEOLUS.HTML
                                                                                                                                                                                                                                                                                                                                                        indicated.
165   28/07/2008   Terry DeWolf              O2ptimaFX                HH                Solo Diving            3/80/70         USA, Andrea Doria          Expert         38    Human error/Equipment       Asphyxia                         Diver became a certified Technical cave diver, Wreck diver and 100m CCR diver the previous year.            With a dry suit that is not pressure compensated, the suit squeeze is     US boat practice of disvowing        Excess of pull dumps appears to be a
                                                                                                                                                                               issue (not rebreather)                                       Attempted to dive the Andrea Doria. Reported to have little deep cold wreck experience. Diver's             sufficient at 70m for complete disablement of the diver. Diver was        responsibility, such that divers     hazard, as are excessive cord lengths on pull
                                                                                                                                                                                                                                            BCD dump reportedly got tangled. Diver made uncontrolled descent. Gas to suit was reported to be            probably unconscious before the flood, hence disabling injury is          without buddy checks jump            dumps. For reference, DL FMECA on a
                                                                                                                                                                                                                                            turned off. Diver shrink-wrapped by suit because suit was not equalised. Diver did not break the seal       asphyxia though cause of death would be drowning because diver            off the boat, is a major factor in   wing design for a rebreather concluded
                                                                                                                                                                                                                                            on the suit (flood suit). Diver did not drop weights. Diver did not use redundant side of BCD. Diver        would inhale water in his last breaths while unconscious.                 this accident.                       optimum number of pull dumps is just one
                                                                                                                                                                                                                                            hit sea bottom hard enough to crack rebreather and rebreather flooded. Diver was using an OMS                                                                                                                              (on opposite side to inflator/deflator, for
                                                                                                                                                                                                                                            dual wing on an Optima: the wing is not designed for the rebreather. Diver found unconscious on                                                                                                                            hand access).
                                                                                                                                                                                                                                            back on sea floor later that day.
164   28/07/2008   Unknown Canadian           O2ptima                 HH                Buddy dive                35             North Carolina,       Experienced             Exceeded Performance        Hypercapnia from spent           Diving U-Boat. Divers buddy reported that they were on deco at about 50 feet when the Deceased              Symptoms fit with hypercapnia.                                                                                                                                 http://www.rebreatherworld.com/rebreather-accidents-
                   male                                                                                                          Atlantic Ocean                                Envelope / Human error      scrubber                         went to bailout, ascended 20 or so feet, re-descended, then bolted to the surface where he became                                                                                                                                                                          incidents/20725-north-carolina-O2ptima-
                                                                                                                                                                                                                                            unresponsive.                                                                                                                                                                                                                                                              fatality.html#post201005
                                                                                                                                                                                                                                            Diver pronounced dead on the boat. May be heart attack: awaiting autopsy information. Scrubber
                                                                                                                                                                                                                                            spent.
163   26/07/2008   Viccica Linen (or      Inspiration Vision      APD Vision            Buddy dive               120             Italy, Cornino           Guru           37    Exceeded Performance        Hypercapnia                      Wreck dive off Sarecono Tip. Diver surfaced on open circuit from 123m dive. Seen to be in some              Deceased died in front of his wife and child. Diver ignoring safety                                                                                            http://melomane-news.blogspot.com/2008/07/trapani-
                   Lino Vercicia)                                                                                                                                              Envelope                                                                                                                                                                 divers points towards hypercapnia, as does the empty on board make-                                                                                            immersione-fatale.html
                                                                                                                                                                                                                                                                                                                                                        up gas. At 123m the duration of this scrubber is very short. Once on
                                                                                                                                                                                                                                            empty. Inspiration Vision download confirms reports. Bailout cylinders = HeOx 12 and HeOx 18.               the surface, after missing such a large amount of decompression, the
                                                                                                                                                                                                                                                                                                                                                        diver would suffer explosive DCS.
162   13/07/2008   Craig Whitehouse          Prism Topaz              SM                Buddy dive               60+           Canada, Tobermory       Experienced       53    Human error                 AGE/Cardiac                      Apparently DCS, possibly cardiac. Dived without bailout on a wall, to depths of 60msw+                                                                                                                                                                                     http://www.scubaboard.com/forums/accidents-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       incidents/243067-diving-accident-tobermory-past-weekend-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       4.html
161   01/07/2008   Jayne Bloom               Megalodon          ISC Apecs eCCR          Buddy dive               60/0             Truk lagoon          Experienced             Human error                 AGE                              According to Keep (deceased's fiancee), Deceased resurfaced from a rebreather decompression dive         Leigh Bishop and Jeff Keep heavily criticised by inquest judge.       Importance of dive planning in                                                              Further information on CDNN link
                                                                                                                                                                                                                                            to a maximum depth of 57 meters (187 ft) and returned to the dive boat where she suddenly lost her       Fatality was a direct result of poor organisation, and interestingly, remote locations should be                                                                  http://www.cdnn.info/news/safety/s100306.html but see
                                                                                                                                                                                                                                            vision and became very weak.                                                                             nobody on the trip checked the emergency details. Large differences emphasised.                                                                                   also http://www.deepimage.co.uk/cdnn.htm
                                                                                                                                                                                                                                                                                                                                                     in accounts of witnesses, in particular whether the ascent was normal
                                                                                                                                                                                                                                            Despite receiving oxygen onboard the dive boat, Deceased soon lost consciousness and her condition or not: divers say it was normal, but examination of dive computer
                                                                                                                                                                                                                                            worsened during the long 40-minute trip back to Blue Lagoon Resort, where the New Frontier Diving indicated 11 breaches of deco ceilings, but it is not clear from reports
                                                                                                                                                                                                                                            holiday package group had checked in two days before.                                                    whether that is relevant (1ft above a 60ft ceiling momentarily, or
                                                                                                                                                                                                                                                                                                                                                     touching the 3m ceiling in swell is common).
                                                                                                                                                                                                                                            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 was no one there to operate the facility.
160   27/06/2008   Lawrence Crom             KISS Classic            Jetsam             Buddy dive              30 / 70        Canada, St Wreck of     Experienced       45    Rebreather design fault /   Heart attack during a period of Deceased completed dive on wreck (wreck is 165 - 240 fsw). Deceased was on the way to the surface WOB is much higher than safe limits, hence design fault                                                                                                                   First reported by Swampdiver, by PM on RBW
                                               mCCR                                                                             Lawrence Seaway,                               Exceeded Performance        hypercapnia from WOB.           and stopped at 100' deco stop. He went into some kind of distress as reported by his buddy.          classification.
                                                                                                                                  Roy A. Jodrey                                Envelope                                                    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.
159   02/06/2008   Kenneth Farrow            Inspiration              APD               Buddy dive                0             Orkney, Westray           Guru           61    Underlying Illness /        Heart attack during a period of Deceased died from heart attack, completing a dive and exiting onto rocks with heavy exertion. BSAC          Very heavy exertion by the Decadent. Due to age of Decadent, it is                                                                                             Orkney news and BSAC report
                                                                                                                                                                               Rebreather design fault     hypercapnia                     Incident 08/080 states a group of divers planned a dive on a wreck which was positioned close to the         likely there was underlying cardiac health issues. Use of rebreather
                                                                                                                                                                                                                                           shoreline. There was breaking swell above the wreck so the plan was for the divers to descend to the         even on the surface, would increase the breathing resistance
                                                                                                                                                                                                                                           seabed about 35m from the shore at a depth of 26m and then to swim underwater to the wreck. They             considerably, leading to a degree of hypercapnia.
                                                                                                                                                                                                                                           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
158   20/05/2008   Bill Prince               Inspiration              APD               Buddy dive               ?/0            USA, Wisconsin,       Trainee on RBs,          Underlying Illness /        Heart attack during a period of Surfaced onwould bebecause he by the boat. The snorkel diver reached the shorethe water. Fromthat
                                                                                                                                                                                                                                           where they bail out recovered felt bad. Reported to have died on shore, not in and discovered                                                                                                                                                                               GS is getting details. RB is instructor.
                                                                                                                                 Wazi Reservoir      Experienced diver         Rebreather design fault     hypercapnia.                     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.
157   04/04/2008   Steven Ottewell           Megalodon          ISC Apecs eCCR          Buddy dive                42            Scapa Flow, Mark       Experienced       38    Rebreather design fault     Hypoxia                          Deceased had LOC, the PFD on the rebreather was flashing red. Deceased lost during attempted                Flashing Red means hypoxia. Buddy checks means there was                                                                                                       BSAC incident 08/057
                                                                                                                                      Graff                                                                                                 rescue, and recovered 7 weeks later. BSAC Incident 08/057 reports that "Two divers conducted full           enough gas and cylinders were on. Is this one of the Meg controllers
                                                                                                                                                                                                                                            buddy checks and then entered the water to descend a shotline to a wreck. One of the pair was using a       with the potting performed using hot glue? One of these controllers
                                                                                                                                                                                                                                            rebreather with air as the diluent; the other was using open circuit air. They exchanged 'OK' signals as    was sectioned and found to have considerable water ingress and
                                                                                                                                                                                                                                            they descended. At about 35m they could see the light of other divers below them on the wreck. They         corrosion: the potting is not to a professional standard on the
                                                                                                                                                                                                                                            exchanged 'OK' signals again but immediately afterwards the rebreather diver began to signal rapidly        samples inspected. In any case, where there is sufficient power, and
                                                                                                                                                                                                                                            with his left hand. The buddy moved to help him. The rebreather diver was now sinking quickly. The          there is enough oxygen, when the disabling agent is hypoxia then the
                                                                                                                                                                                                                                            buddy followed after him and they arrived on the seabed at 42m. The rebreather diver was motionless,        fault tree indicates most probable cause is a design fault.
                                                                                                                                                                                                                                            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 the Coastguard was alerted. An extensive
                                                                                                                                                                                                                                            air and sea search was conducted and an ROV was used to search around the wreck but the missing




                                                                                                                                                                                                                                                               Page 6 of 20
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                                                                Electronics
                                                                  fitted to
                                                                                                       Depth of accident
                                            Rebreather         rebreather for   Type of dive (Solo,                                                                            Root Case using fault       Disabling Injury using                                                                                                                      Comments or Discussion in arriving at most plausible cause,                                                                                                      An external reference confirming that accident
        Date        Deceased's Name                                                                   (/deepest/planned        Location              Experience          Age                                                               Key information received on accident                                                                                                                                    Training implications                            Design implications
                                             involved               PPo2        Group, Cave etc.)                                                                              tree method                 fault tree method                                                                                                                           addition to use of the Fault Tree.                                                                                                                                                  occurred
                                                                                                            ) (m)
                                                               Monitoring or
                                                                  Control
156   16/03/2008   Mike Riopel               O2ptima                HH              Buddy dive               20            Florida, Pompano      OC, Expert, RB Expert         Human error                 Hypoxia                         Tanks reported to be off. Alarms went off on underwater. Diver did not bail out.                            Diver reported to be Dolphin SCR instructor. Probable that diver                                                                                           First reported by RBW Blomman. Details then started to fill
                                                                                                                                  Bch              but on Rebreather                                                                                                                                                                                   surfaced from 1st dive, isolated cylinders then did not do pre-dive                                                                                        in. Note Gregg Stanton is aware of data but unable to disclose
                                                                                                                                                        Trainee                                                                                                                                                                                        checklist on unit for 2nd dive.                                                                                                                            for legal reasons.
155   11/03/2008   Mark Fyvie               Megalodon               ISC             Cave Diving              32             Devil's system,       Experienced on RB,           Human error                 Drowning/asphyxia               Extreme cave dive. Diver appears to have taken off the rebreather to get through a restriction using                                                                                 Training example of why             If a rebreather is to be removable during a http://www.nsscds.org/phpBB2/viewtopic.php?t=337&sid=
                                                                                                                            Ginnie Springs,         New cave diver                                                                         side-slung O.C. On returning to the rebreather an hour later, it was flooded and out of gas probably                                                                                 divers should not take off          dive, this needs to be considered as part of d377b98c612eced9400
                                                                                                                                                                                                                                           because water got into the O2 cells causing the injector to fire, burping the OPV and letting in water in                                                                            rebreathers underwater, or          the diving system and formally validated
                                                                                                                                                                                                                                           the process. Diver used available gas to purge rebreather, when he was 50ft of a staged emergency                                                                                    leave them if they are their sole   with unmanned testing of the rebreather
                                                                                                                                                                                                                                           bottles, and used all his gas to do so. Silt out, 3,300ft into cave, diver did not simply abandon RB and                                                                             means of return.                    prior to human trials.
                                                                                                                                                                                                                                           go for the stage bottles until it was too late.                                                                                                                                                                          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.
154   01/02/2008   Scant data             RB80 Clone (SF-        Unknown                                                        Red Sea                                        Scant data                  Scant data                  Only data is unverified report from http://www.rebreatherworld.com/rebreather-accidents-
                                                  1)                                                                                                                                                                                   incidents/17555-rb80-clone-accident.html#post170603
153   27/11/2007   Allan Greisen             Inspiration           APD              Buddy dive             30/59/0              Red Sea              Experienced         42    Rebreather issue            Hypercapnia of buddy caused Accident started when the Deceased's buddy suffered a sudden LOC on an Inspiration Vision during                Deceased knew the risk he took in the rescue, counselling the buddy
                                         (Vision) on Buddy                                                                                                                                                 Explosive DCS in Deceased   a dive to 59msw for 15mins, followed by an ascent to 30msw in 5 mnutes. LOC occurred at 30msw.                  on this when he returned to consciousness on the surface: he gave
                                           who suffered a                                                                                                                                                                              Profile showed increased ascent speed from 30m while Deceased brought his unconscious buddy                     his life to rescue another diver in his care. Deceased is reported to
                                            sudden LOC,                                                                                                                                                                                (Inspo Vision diver) to the surface. Profile also indicated that the unconscious buddy was still                have started to put his mark on the Danish diving scene by 1998. He
                                              Diver on                                                                                                                                                                                 breathing and the Rebreather kept injecting O2 as normal, hence hypercapnia but questions over the              is reported to have been an extremely helpful person; when his
                                         Inspiration died as                                                                                                                                                                           accuracy of log on the Vision.                                                                                  friends or customers were in a tight spot, he would put himself or his
                                          a result of rescue                                                                                                                                                                           The buddy regained consciousness on the surface, Deceased told him to remain on O2 on the loop to               finances on the line to make things right again. Wreck diving was his
                                                                                                                                                                                                                                       prepare for the DCS hit they where about to take. Deceased again lost consciousness shortly after that.         passion, but he was a adventurer in many other fields, always up for
                                                                                                                                                                                                                                       The buddy had trouble calling for help while he was working on Deceased at the same time. Waves                 the challenge.
                                                                                                                                                                                                                                       and current caused a delay before a small RIB came to their rescue.
                                                                                                                                                                                                                                                                                                                                                       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.


152   04/11/2007   Laurent Rossignol          Voyager            Unknown            Buddy dive               80              France, wreck           Experienced         41    Rebreather design fault     Hypoxia                         20mins into a wreck dive at 80 m, sudden LOC, most probable reason is hypoxia.                              Buddy suffered severe DCS in trying to save the Deceased,                                                                                                    Confidential communication
                                                                                                                                Henkel                                                                                                                                                                                                                 paraplegic after accident. Girlfriend of Deceased had to manage
                                                                                                                             Mediterranean                                                                                                                                                                                                             situation on surface.
151   29/10/2007   Jean-Jacques Bolanz        Voyager            Unknown            Cave Diving          86/152/150         Greece, Lilly cave   Guru, Experienced RB,   67    Scant data                  Scant data                      Cave diving. Reports suggest Deceased had some alerts while diving passive SCR.                             Deceased was one of the mythical cave divers and speleologists who                                                                                           http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                                                 thousands of dives on                                                                                                                                                                                 made astonishing dives and discoveries back in the 1980s, mainly in                                                                                          incidents/15150-jean-jacques-bolanz.html
                                                                                                                                                         O.C.                                                                                                                                                                                          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.
150   27/10/2007   Sven Paepke              Inspiration         APD Classic         Buddy dive             40/125          Australia, Bermagui          Expert           42    Rebreather issue/Gas        Hypercapnia/respiratory/Nar Deceased used his onboard cylinder filled with air as dil/inflation on shallow dives but on deeper       Most plausible cause is nitrogen narcosis due to breathing air diluent                                              Use a FFM or mouthpiece restraining strap http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                                                                               switch issue                cosis                       dives, disconnected his dil hose and plugged it into his offboard dil cylinder. It appears that he forgotbetween 60m and 90m caused Deceased to become unconscious.             Training Lessons:                            to prevent rebreathers flooding           incidents/15088-fatal-diving-accident.html#post146374
                                                                                                                                                                                                                                       to disconnect the onboard air from his ADV and connect it to his offboard dil cylinder. This resulted                                                                           1. Dive the rebreather with the              if the diver becomes unconscious.
                                                                                                                                                                                                                                       in descent on air diluent.                                                                                                                                                      correct gas onboard so that
                                                                                                                                                                                                                                                                                                                                                                                                                       mistakes with                                Correct gas's and buddy training is required
                                                                                                                                                                                                                                           He may have realised his mistake at 60m when he asked his buddy to plug the connector from his                                                                              connectors or switch blocks                  for deep dives
                                                                                                                                                                                                                                           offboard dil cylinder into the manual dil button. His buddy assumed at the time that he was having a                                                                        cannot be made.
                                                                                                                                                                                                                                           problem with his ADV as this had occurred on a previous dive. Deceased gave the                                                                                             2. Re-institute the old buddy                The fitment of a Helium content gas
                                                                                                                                                                                                                                           OK sign to his buddy twice and they continued the descent.                                                                                                                  check. Buddy wasn't aware of                 monitor would have advised the diver that
                                                                                                                                                                                                                                           At about 90m Deceased became unconscious with his hand still on the shot line, but had lost his                                                                             Deceased's                                   he was still breathing Air diluent on descent
                                                                                                                                                                                                                                           mouthpiece. Buddy then had trouble keeping his buddy on the line as he become negatively buoyant                                                                            configuration before the dive.
                                                                                                                                                                                                                                           as his rebreather flooded. Buddy tried forcing an OC reg into Deceased's mouth unsuccessfully                                                                               This may have picked up the
                                                                                                                                                                                                                                           because Deceased's jaw as clenched shut. The buddy tried adding gas Deceased's wing and drysuit but                                                                         mistake.
                                                                                                                                                                                                                                           neither system worked. Deceased and buddy all dropped to the bottom in 125m and Buddy removed                                                                               3. Use a FFM or mouthpiece
                                                                                                                                                                                                                                           Deceased's weight belt but he remained negatively buoyant. Due to a strong current and dragging shot                                                                        restraining strap to prevent
                                                                                                                                                                                                                                           line other divers were unable to recover Deceased's body on day of acident.                                                                                                 rebreathers flooding
                                                                                                                                                                                                                                                                                                                                                                                                                       if the diver becomes
                                                                                                                                                                                                                                                                                                                                                                                                                       unconscious.
149   02/10/2007   Michael Hanrahan         Inspiration            APD              Buddy dive               63                  Ireland             Experienced         46    Exceeded Performance        Hypercapnia                     The dive team was filming the U-boat when the diver got into difficulties. Reported to be a CO2 hit         Removing the mouthpiece repeatedly, and feeling as if out of air, are                                                                                        http://www.inishowennews.com/06MichaelHanrahan0626.
                                                                                                                                                                               Envelope/Human error:                                       on ascent.                                                                                                  classic CO2 symptoms. It was concluded this was a classic a CO2 hit                                                                                          htm
                                                                                                                                                                                                                                           Deceased was seen 30 minutes after descent onto the submarine at 63m doing heavy work: this is well         from the first reports that arrived, hence hypercapnia. It is a
                                                                                                                                                                                                                                           beyond the scrubber duration for the Inspiration at that depth (commonly quoted Inspiration                 rebreather issue but this accident was listed as "Exceeding
                                                                                                                                                                                                                                           durations are a dive profile with only 20minutes spent at 40m), then worked up the shot line, pulling       Performance Envelope" from the outset, as dive profile was beyond
                                                                                                                                                                                                                                           its 50lb load because it had become snagged on the wreck. The Deceased was seen repeatedly looking          the Inspiration's scrubber duration at 63m. Human error added as a
                                                                                                                                                                                                                                           at the handset readings, taking his mouthpiece out, blowing some bubbles then putting it back in.           secondary conclusion due to the rebreather not being fully functional
                                                                                                                                                                                                                                           The buddy saw the deceased fall past him and land on the submarine on his back. They made efforts           before the dive, and the dive plan was too long at 63m for this
                                                                                                                                                                                                                                           to recover the diver, but without success. The Deceased's body was secured to the submarine, and            apparatus. Drowning is the end product of most diving accidents,
                                                                                                                                                                                                                                           recovered the next day.                                                                                     rather than root cause.
                                                                                                                                                                                                                                           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 recorded on two video cameras) and then the
                                                                                                                                                                                                                                           diver sank back to the wreck facing upwards, continuously taking his mouthpiece out and replacing it,
148   25/08/2007   Unknown German            Submatix            Unknown                 -                    -             Norway, Bergen                 -              -    Scant data                  Scant data                      Scant data                                                                                                  Scant data                                                                                                   RB should check gas is on, and give clearer     http://www.rebreatherworld.com/rebreather-accidents-
                   diver                                                                                                                                                                                                                                                                                                                                                                                                                                            alarms                                          incidents/13906-death-submatix-diver-norway.html
147   19/08/2007   Lee Shortt                O2ptima                HH              Buddy dive                0               USA, Florida           Experienced         38    Human error                 AGE                             Deceased is reported to have been trying to outdo his buddy in depth, on air. Result was DCS. Diver         Note: Rebreather is relevant as it enables the community to track                                                                                            http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                                                                                                                                           died 6 hours after surfacing.                                                                               risk level relative to Open Circuit. This accident would have                                                                                                incidents/13717-oriskany-accident-3.html
                                                                                                                                                                                                                                                                                                                                                       happened even if the diver was on Open Circuit.
146   31/07/2007   Wayne Hernandez            Dolphin            Unknown            Solo Diving               3               USA, Seattle              Expert           43    General diving hazard       Drowning/asphyxia               Tangled in a buoy line, including caught on equipment. Rebreather involved no more prone to                                                                                                                              Minimise entanglement points on CCR.            http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                                                                                                                                           entanglement than open circuit.                                                                                                                                                                                                                                          incidents/13386-diver-death-seattle.html
                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Ensure crown strap fitted with sufficient       http://seattletimes.nwsource.com/html/localnews/2003817
                                                                                                                                                                                                                                                                                                                                                                                                                                                                    OC gas immediately available.                   861_webdiver02.html
145   29/07/2007   Pc Paul Jackson       Inspiration, Vision    APD Vision          Solo Diving           30/54/80          Ireland, Donegal            Expert           49    Rebreather design fault /   Drowning/asphyxia               Unknown problem with the rebreather caused diver to bail out onto BOV where there was a flow shut-          As bail out was so shortly after entering the water, it points to an   Flow stops should not be              Bail out valves should not have any stable      http://news.bbc.co.uk/1/hi/northern_ireland/6922993.stm
                                                                                                                                                                               rebreather issue                                            off fitted (that was closed).                                                                               electronic problem. Not clear at all otherwise why diver would bail used.                                    state other than on the loop or on open         http://www.cdnn.info/news/safety/s070730a.html
                                                                                                                                                                                                                                           Accident occurred when Deceased was checking the shotline, solo. Wreck was at 80msw. Diver                  out at 38m.                                                                                                  circuit.
                                                                                                                                                                                                                                           halted descent at 3 mins at 53m and then started to ascend, as he had advised buddies he would be,          Another problem was that the Golem bail-out valve was in an
                                                                                                                                                                                                                                           this being his first dive in some while. It seems he lead them to believe that he hadn't dived for 5        intermediate position (not on, not off), and having a flow stop in the
                                                                                                                                                                                                                                           months, where in fact the rebreather log showed it was 10 - he may have had an O.C. dive 5 months           shut position. Cause of LOC was probably asphyxia.
                                                                                                                                                                                                                                           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
144   22/07/2007   Van A. Losh               Unknown                                Solo Diving               4            USA, Ohio, Putnam         Experienced         60    Scant data                  Scant data.                     58m.
                                                                                                                                                                                                                                           Sources at the scene report that the diver had some problems underwater. The team surfaced                  3rd accident in the quarry in as many months.                                                                                                                http://www.ncdivers.com/phpBB2/viewtopic.php?f=40&t=
                                                                                                                            County, Gilboa                                                                                                 everything "was fine". The diver told the rest of the team to go on with their dive and he would go back                                                                                                                                                                 3958
                                                                                                                                Quarry                                                                                                     to shore. There were five individuals diving together as a group," said Lt. Tim Meyer of the Putnam
                                                                                                                                                                                                                                           County Sheriff's Office. "(Losh) resurfaced, they watched him resurface, and they continued to dive.
                                                                                                                                                                                                                                           When they came back from their dive, they found their friend was right by the dock there, floating in
                                                                                                                                                                                                                                           the water." . A former student apparently said Van frequently dove a rebreather.

143   14/07/2007   Dominique Chauvin         Submatix            Unknown            Solo Diving               3                  France                    -              -    Underlying illness          Heart attack                    Heart attack in swimming pool. State of scrubber unknown.                                                                                                                                                                PPO2 risk alarm needed. Auto-loop shut-         http://www.taucher.net/unfall/TU_Norwegen_an_der_Se
                                                                                                                                                                                                                                                                                                                                                                                                                                                                    off even on mCCR would have avoided             attle_itu514.html
                                                                                                                                                                                                                                                                                                                                                                                                                                                                    accident. Better PPO2 alarms: voice,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                    sound?




                                                                                                                                                                                                                                                              Page 7 of 20
                                                                                                                                                                                                                                                     d9081ce0-7e95-44ed-9e81-0fdd6fd43e58.xls




                                                                 Electronics
                                                                   fitted to
                                                                                                           Depth of accident
                                            Rebreather          rebreather for      Type of dive (Solo,                                                                                 Root Case using fault        Disabling Injury using                                                                                                                         Comments or Discussion in arriving at most plausible cause,                                                                                                    An external reference confirming that accident
        Date        Deceased's Name                                                                       (/deepest/planned         Location                Experience            Age                                                                 Key information received on accident                                                                                                                                      Training implications                            Design implications
                                             involved                PPo2           Group, Cave etc.)                                                                                   tree method                  fault tree method                                                                                                                              addition to use of the Fault Tree.                                                                                                                                                occurred
                                                                                                                ) (m)
                                                                Monitoring or
                                                                   Control
142   26/05/2007   Claude Lau            Inspiration: Vision      APD Vision            Buddy dive                32            England, Dorset                Novice              -    Human issue                  Drowning/asphyxia                Wreck diving. See also BSAC report May 2007, 07/065. Inquest report. Manufacturer's analysis                  Cause of bail out event unknown. It could be something as simple as Manufacturer should provide              Manufacturer should publish in rebreather http://www.harrowtimes.co.uk/news/localnews/display.var.
                                                                                                                                                                                                                                                      released. Two rebreather divers entered the water and commenced their dive down a shotline to a               the diver testing the bail out drill.                               instructors with mandatory               manual maximum length of scrubber           1468514.0.diving_death_tragedy.php
                                                                                                                                                                                                                                                      wreck. They conducted a bubble check at 6m and exchanged OK signals at 20m. They reached the top                                                                                  guidance for students based              storage between use. Manufacturer should
                                                                                                                                                                                                                                                      of the wreck at 32m. One of the pair indicated that all was not well. The dive leader signalled that they                                                                         on independently audited                 provide a recommended maximum storage
                                                                                                                                                                                                                                                      should ascend and they started to do so. 2m into the ascent the troubled diver became agitated, closed                                                                            testing of the maximum                   life of scrubber in a rebreather based on
                                                                                                                                                                                                                                                      and removed his rebreather mouthpiece and placed his bail out regulator into his mouth. He then spat                                                                              duration of scrubber over                fully traceable testing. Rebreathers should
                                                                                                                                                                                                                                                      this regulator out and began to panic. His buddy placed the regulator back into his mouth and                                                                                     multiple dives and maximum               be fitted with CO2 monitoring by
                                                                                                                                                                                                                                                      attempted to purge it; he discovered that it was not turned on. He turned the cylinder on and                                                                                     storage lifespan between dives           manufacturers or warnings issued about the
                                                                                                                                                                                                                                                      attempted to put the regulator into the diver's mouth, but the diver was not able to take the regulator                                                                           based on worse case scenarios.           hazards of exceeding the published
                                                                                                                                                                                                                                                      and he fell unconscious. The pair had sunk to the bottom at a depth of 35m. The buddy dropped the                                                                                 Training for buddy checks on             maximum scrubber duration between use
                                                                                                                                                                                                                                                      casualty's weightbelt and inflated both their jackets. They made a buoyant ascent to the surface. Their                                                                           rebreather should emphasis               with data published by the manufacturer.
                                                                                                                                                                                                                                                      total dive time was 6 min. At the surface the casualty was not breathing. The buddy called for help and                                                                           that all bailout is to be verified       BOV should be mandatory on all
                                                                                                                                                                                                                                                      tried to give rescue breaths. This was difficult to do because of their inflated BCDs and side mounted                                                                            as operational during the pre-           rebreathers sold with a published minimum
                                                                                                                                                                                                                                                      gas cylinders, Their boat reached them quickly but they could not get the casualty back into the boat.                                                                            dive checks and included                 OC performance exceeding the EN250
                                                                                                                                                                                                                                                      His rebreather was removed and he was held by the boat. The Coastguard was alerted and 5 min later                                                                                during bubble check                      requirements
                                                                                                                                                                                                                                                      a helicopter arrived. After some difficulty the casualty was airlifted to hospital where he died three days                                                                       verification at 6m.
                                                                                                                                                                                                                                                      later. The buddy was airlifted to a recompression chamber for precautionary treatment. The Decadent
141   13/05/2007   Emanuel Ajimati          Home Build             Unknown              Solo Diving               50             UK, Swithland              Intermediate           -    Rebreather design fault      Hypoxia                          Diving in a quarry. See also BSAC report May 2007, 07/064. Rebreather diver entered the water                 Report was that scrubber was spent: it had not been characterised.                                           Shut off breathing loop automatically if it   http://www.rebreatherworld.com/memorial-forum/11865-
                   (Manny)                                                                                                         Woods                                                                                                              ahead of his two buddies and dived to place a decompression cylinder on a shotline. He resurfaced             Hypercapnia within minutes at the start of the dive seems odd even                                           cannot be breathed from.                      diver-dies-quarry-2.html
                                                                                                                                                                                                                                                      and spoke to a fourth diver who was preparing to enter the water. Although they had planned to dive           if he was using a Ray scrubber (unless Drager Ray sized scrubber &                                           If a crown strap was fitted diver may not
                                                                                                                                                                                                                                                      together, when the two buddies entered the water the first diver had already left the surface again.          medical sorb - both sorb & scrubber unknowns though)?. Some                                                  have drowned due to loss of DSV.
                                                                                                                                                                                                                                                      They continued their dive and, several minutes later, they saw the torchlight of the first diver. They        scrubbers can break through very quickly at 50m. A hung controller
                                                                                                                                                                                                                                                      found him lying on the bottom at a depth of 50m; he was unconscious, his mouthpiece was out of his            or blocked/off oxygen feed leading to Hypoxia on descent also fits
                                                                                                                                                                                                                                                      mouth and he was tangled in some branches and other debris. They freed him and sent him to the                the description of the dive., or any PPO2 control issue because after
                                                                                                                                                                                                                                                      surface. They started their ascent and met the fourth diver coming down. The fourth diver returned to         the first ascent the PPO2 would be low if there was anyPPO2 sensing
                                                                                                                                                                                                                                                      the surface and found the casualty on his back with his mask off, he recovered him to the side,               or control issue at all. Home rebreather designers are often unaware
                                                                                                                                                                                                                                                      removed him from the water and started resuscitation procedures. 10 min later the casualty's two              of how sensitive O2 cell placement is, and how moisture can very
                                                                                                                                                                                                                                                      buddies surfaced and contacted the emergency services. The casualty was taken to hospital where he            easily lead to a total block of all sensors simultaneousl;y.
                                                                                                                                                                                                                                                      was declared dead. Decadent was diving with a rebreather that he had built himself.



140   09/05/2007   Roberto Delaide          Inspiration              APD                Solo Diving             0 / 109         Italy, Garda Lake              Expert              -    Rebreather issue             Hypercapnia, caustic cocktail    Diver LOC after surfacing at end of solo dive to 109m. Used Amsorb: a low flow 2lpm anaesthesia               Amsorb is completely unsuitable for rebreathers. Diver would have         Emphasis not to use medical        Design the scrubber so medical sorb cannot http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                                                                                                                                                      absorbent which has no catalyst (NaOH).                                                                       pushed the duration of even the recommended sorb on this dive.            sorb in rebreathers.               be used.                                   incidents/11796-roberto-delaide-fatality.html
                                                                                                                                                                                                                                                                                                                                                                    Conclusion is hypercapnia due to use of an unsuitable absorbant.
                                                                                                                                                                                                                                                                                                                                                                    Manufacturer subsequently tested Amsorb and put out a warning
                                                                                                                                                                                                                                                                                                                                                                    notice to all users about its unsuitability.
139   29/04/2007   Tomohiko Tsuruoka        Megalodon          ISC Apecs eCCR           Buddy dive               30?             Japan, Numazu,          Expert                   46    Underlying Illness           Heart attack                     Believed to be a heart attack associated with hard smoking                                                                                                                                                                                                               Confidential communication and inquest reports
                                                                                                                               Shizuoka Prefecture
138   07/04/2007   Mario Wohlgehaben        Inspiration              APD                Buddy dive              90 / 70         Switzerland, Lake Advanced trimix diver.          43    Exceeded Performance         Hypercapnia, AGE                 Diving with buddy. Problem at depth, likely caused by hypercapnia, emergency ascent due to stress       The fast ascent was most likely due to hypercapnia. At this dive                Diver was too deep too fast on                                                   Confidential communication and inquest reports
                                                                                                                                Neuenburg, Abyss    RB intermediate.                    Envelope / Human error                                        and panic. . A later report in Octopus magazine states the diver bailed out to OC at 80m, his regulator profile and water temperature, the scrubber duration even with 797              the rebreather. Manuals
                                                                                                                                                                                                                                                                                                                                                              would be very short indeed. Diver was not using 797: probably                   should provide constant depth
                                                                                                                                                                                                                                                      50m to continue deco, Diver climbed on to the boat and told others he was okay. He died 15 mins         Draegersorb, which has a similar performance (or slightly better, in            durations for scrubbers.
                                                                                                                                                                                                                                                      later, torn alveoli and AGE.                                                                            many rebreathers).

137   11/03/2007   Paula Blackemore          Evolution            APD Vision            Buddy dive                73             UK, Dorothea               Experienced           43    Rebreather fault / General   Drowning/asphyxia                The Deceased was having a problem with her rebreather, and was pulling on the shot buoy when                  Poor buoyancy control, caused by diver carrying far too much lead,        Divers should not fit shut off Bail out device should not free flow, so          http://www.cdnn.info/news/safety/s070718a.html
                                                                                                                                    quarry                                              diving hazard.                                                trying to address the rebreather problem. Both divers had difficulty clearing their ears during descent.      constraining the fairly limited buoyancy device fitted to the             valves to bail out devices.     diver does not need to fit a shut off device.
                                                                                                                                                                                                                                                      A valve diaphragm had ruptured in a regulator, but not clear if this is the rebreather or a bail out          rebreather by her modifications. Flow stops on bail out valve noted,      Bouyancy training is needed
                                                                                                                                                                                                                                                      device. The permanent shot buoy then flooded and came down on the diver pair, entangling one of               causing the bail out device to implode.                                   by many divers. Personal view
                                                                                                                                                                                                                                                      the divers.                                                                                                                                                                             of some of the panel, is that a
                                                                                                                                                                                                                                                      The buddy lost sight of the Deceased so descended a trail of bubbles and reached 40m (131ft) below                                                                                      diver should be able carry out
                                                                                                                                                                                                                                                      the surface where the Deceased was going to a ridge in a desperate attempt to stop her descent. The                                                                                     an Open circuit dive without
                                                                                                                                                                                                                                                      rope to the buoy was tangled around her left leg. Buddy tried to remove rope but could not.                                                                                             any buoyancy control device,
                                                                                                                                                                                                                                                      Equipment inspection and download revealed the unit had been modified with a stainless backplate                                                                                        before moving onto advanced
                                                                                                                                                                                                                                                      and attached weights that impinged on the wing BC, to the extent that the wing could only inflate to                                                                                    dives.
                                                                                                                                                                                                                                                      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
136   04/03/2007   Rob Sherratt          Inspiration, Vision      APD Vision        Group Trimix Dive         62 / 75 /92         UK, Cornwall                 Expert              -    Exceeded Performance         Hypercapnia                      considerable degree. The ADV had a flow-stop valve which was still in the depth. Diver and so she
                                                                                                                                                                                                                                                      Lost consciousness soon after surfacing from fast ascent from 62m in 92m closed positionwas on new            Expert diver, so uncontrolled fast ascent from BCD or suit valve          Manuals should contain the      Integrated bail out needed. The duration of http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                                    Quarry                                              Envelope                                                      rebreather, and manufacturer suggests it is possible the fast ascent was due to the dry suit exhaust          failure unlikely. BSAC report does NOT support diagnosis                  constant depth scrubber         the scrubber at constant depths should be incidents/10431-rob-sherratt-fatality.html
                                                                                                                                                                                                                                                      being blocked. Some differences with BSAC 2007 report March 07/026, which states:An instructor                apparently from manufacturer that his drysuit inflator jammed,            durations, as the "dive profile stated in the manual.
                                                                                                                                                                                                                                                      and two trainees were engaged in a trimix training course. The instructor was using a rebreather and          because the BSAC report states clearly that the diver inflated his        to depth X" can be highly
                                                                                                                                                                                                                                                      the students were using open circuit equipment. They dived to a maximum depth of 75m. The two                 BCD and refused on OC reg on passing his students on ascent!              misleading. Trimix instructors
                                                                                                                                                                                                                                                      students started their ascent and the instructor remained at depth some time longer. The two students         Rather the BSAC report would appear to support the original               need to KNOW the maximum
                                                                                                                                                                                                                                                      were conducting their first stop when they saw the instructor making a rapid ascent up the shotline.          hypercapniaconclusion based on his remaining at depth but then            performance envelope of their
                                                                                                                                                                                                                                                      They offered him an alternative gas source but he refused this, inflated his BCD and rose directly to         suddenly needing to surface for fresh air despite blowing off a fatal     rebreather through
                                                                                                                                                                                                                                                      the surface missing all stops. The emergency services were alerted and the diver was taken to hospital        amount of decompression stops. This particular model has a very           publication of independently
                                                                                                                                                                                                                                                      where he was declared dead.""                                                                                 short duration at 92m, but the manual states only a "dive profile" to     audited empirical data by the
                                                                                                                                                                                                                                                                                                                                                                    40m and in that profile it is understood that breakthrough starts after   rebreathers manufacturer at
                                                                                                                                                                                                                                                                                                                                                                    just 20 minutes.                                                          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.
135   04/03/2007   Miss Andrea           RB80 clone (AH-           Unknown              Group dive             10-15/55            Switzerland           Novice on RB, OC         34    Exceeded Performance         Hypercapnia, AGE                 Experience level 12 hours, 10 dives on RB. Diver spent about 20' at 50m and then ascended directly to Most probable cause is hypercapnia either from scrubber or WOB:                                                                                                    http://www.rebreatherworld.com/rebreather-accidents-
                   Zepperitz                    1)                                                                                                     Instructor, Trimix diver         Envelope / Human error                                        the surface from 12m: total dive time was an hour. . Diver had bailed out when found. There is         no report of convulsions for hyperoxia                                                                                                                            incidents/10500-rebreather-death-switzerland.html
                                                                                                                                                                                                                                                      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.
134   07/02/2007   Andrea Lui             Azimuth Trimix           Unknown               Solo dive                40            Italy, Carda Lake           Experienced            -    Scant data                   Scant data                       Only short message on RBW forum.                                                                                                                                                                                                                                         http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               incidents/9936-new-rebreather-death-italy.html
133   29/01/2007   Fernando Moreno            Voyager              Unknown              Solo Diving               6                   Spain                    Trainee             -    Rebreather issue/human       Scant data                       Scant data. First check dive. Spain.                                                                                                                                                                                                                                     Confidential communication
                                                                                                                                                                                        error
132   01/01/2007   Willem Botha             Draeger Ray            Unknown              Solo Diving               6               South Africa,             Intermediate           -    Human error / Equipment      Pulmonary barotrauma (Burst When body was found, a dry suit hose was disconnected. Medical conclusion: Pulmonary barotrauma Possible reason for drysuit hose being disconnected is that he                                                                                                                Confidential communication
                                                                                                                                   Hermanus                                             issue (not rebreather)       Lung).                      (Burst Lung).                                                                                           noticed that nitrox was running low quickly from a leak or that his
                                                                                                                                                                                                                                                                                                                                                         dry suit's inflator mechanism stuck open.
131   10/12/2006   Marco Campolungo           Voyager              Unknown              Buddy dive               9/43          Italy, Lago albano di        Experienced           48    Rebreather design fault      Hypoxia                     Deceased had a problem with the dry suit and signalled to his dive partners that he would abort the     Cause of death appears to be hypoxia (from sudden LOC), but                                                                                                           See report (from RBW Wookie) at
                                                                                                                                  castelgandolfoo                                                                                                dive and so did his ascent alone. The buddy divers then surfaced a few minutes later and didn't see the hypercapnia can't be ruled out on the information available.                                                                                                          *http://www.ilmessaggero.it/view.php?data=20061211&edi
                                                                                                                                  (Lake Albano)                                                                                                  Deceased (he had signalled to them that he would surface alone), so they dived again, following the                                                                                                                                                                           z=11_METROPOLIT&npag=48&file=A_3417.xml&type=S
                                                                                                                                                                                                                                                 underwater path which had been installed for dive training exercises in the lake, and found Deceased Note that though the diver was a cave diver, this was not a cave                                                                                                         TANDARD
                                                                                                                                                                                                                                                 quietly asleep on the bottom at 9m a few minutes later.                                                 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.
130   06/11/2006   Alessandro Dodi        Azimuth Trimix           Unknown             Training dive              14            Italy, Lake Como          Trainee on RBs,         48    Rebreather issue/human       Hypoxia due to cylinder off      Student died from hypoxia while on a rebreather course because the O2 cylinder valve was turned off. Alarms should have picked this up, as should have competent                        Instructor liable if O2 cylinder                                                 http://www.marescoop.com/ftopicp-30195.html#30195 and
                                                                                                                                                         Experienced diver              error                                                         Instructor found to be responsible and received suspended sentence of one year in prison.            instructor.                                                                        is off during a training dive.                                                   http://www.marescoop.com/ftopicp-30204.html#30204

129   07/10/2006   Robert Crawford          Prism Topaz               SM                Buddy dive                0             USA, San Mateo,                Expert             65    Rebreather design            Hypoxia                          Diver was on surface and instantly lost consciousness and sank down.                                          Believed to be hypoxia, possibly blocked injection valve or tanks off.                                                                                     http://www.cdnn.info/news/safety/s070718a.html
                                                                                                                                      CA                                                fault/human error                                                                                                                                                           If latter it would be user error.                                                                                                                          http://www.cdnn.info/news/safety/s061109a.html
128   17/09/2006   Harry Khachatoorian      Inspiration              APD                Solo Diving               5             USA, Los Angeles            Experienced           46    Rebreather issue             Hypercapnia                      The diver surfaced after a 30 mins dive, signalled for help and then slipped below the surface before          It is assumed the Rebreather was flooding: loss of buoyancy, and                                            CO2 levels should not rocket if the           http://www.divester.com/2006/09/20/another-rebreather-
                                                                                                                                                                                                                                                      anyone reached him. The rebreather was reported to be in alarm mode, due to a high level of oxygen            alarms. Explosive DCS (in the form of a pulmonary barotrauma) or                                             rebreather is flooding.                       death-in-los-angeles/
                                                                                                                                                                                                                                                      in the breathing loop, but on the surface this is not credible. Information released in 2010, apparently      hypercapnia, or both. Manufacturer seems to concur, but concludes
                                                                                                                                                                                                                                                      by manufacturer, adds to this "Download shows: 3rd dive of the day. Diver trying to use high setpoint         likely pulmonary barotrauma: the OPV on the rebreather should
                                                                                                                                                                                                                                                      in the shallows and was suffering buoyancy control issues. Rapid ascent (87m/min from 14m) after 34           protect from that. If rebreather was flooding, the CO2 level would
                                                                                                                                                                                                                                                      mins dive time, reached surface and sank back, unit flooded. "                                                be very high, so hypercapnia concluded. Buoyancy issues should
                                                                                                                                                                                                                                                                                                                                                                    not exist at 14m from a high set point.
127   27/08/2006   Jere Thorne              Inspiration        APD fitted but not       Buddy dive                15            USA, Louise Pit,            Experienced           45?   Human error                  Hypoxia                          Planned to be a short dive and diver was brought to a surface after a sudden LOC. Resuscitation was Hypoxia. Diver may have been using the rebreather as a KISS style                                                                                                    http://www.rebreatherworld.com/memorial-forum/6634-
                                                                     used?                                                           MN                                                                                                               started but appeared to be fruitless. Diver attempted to use the rebreather as an SCR due to having   mCCR, in which case it is the Deceased that did the design.                                                                                                        memory-jere-thorne.html
                                                                                                                                                                                                                                                      no working cells or electronics.
126   16/08/2006   Mahatma Robles           Inspiration              APD                Solo Diving               30            USA, San Pedro,             Experienced           40    Rebreather design fault      Hypoxia                          Rebreather either failed on entry to the water, or was not switched on. Diver seen swimming in a                                                                                                                                                                         http://scubageek.thedeepstop.com/2006/08/18/rebreather-
                   (Ghandi)                                                                                                     Olympic wreck                                                                                                         wreck several minutes into the dive, at around 20msw. Deceased recovered a day later, no dive log                                                                                                                                                                        diver-fatality-in-los-angeles/
                                                                                                                                                                                                                                                      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.




                                                                                                                                                                                                                                                                         Page 8 of 20
                                                                                                                                                                                                                                d9081ce0-7e95-44ed-9e81-0fdd6fd43e58.xls




                                                        Electronics
                                                          fitted to
                                                                                                Depth of accident
                                       Rebreather      rebreather for   Type of dive (Solo,                                                                           Root Case using fault       Disabling Injury using                                                                                                                        Comments or Discussion in arriving at most plausible cause,                                                                                               An external reference confirming that accident
        Date        Deceased's Name                                                            (/deepest/planned        Location             Experience         Age                                                               Key information received on accident                                                                                                                                      Training implications                         Design implications
                                        involved            PPo2        Group, Cave etc.)                                                                             tree method                 fault tree method                                                                                                                             addition to use of the Fault Tree.                                                                                                                                           occurred
                                                                                                     ) (m)
                                                       Monitoring or
                                                          Control
125   16/08/2006   Stale Tveitane       Megalodon           ISC             Cave Diving             75 / 110        Norway, Plura cave       Experienced        37    Human error / Rebreather    Insufficient make up gas /      This accident has several conflicting reports. Deceased had not been diving for about 6 months, and           There is no explanation why the diver did not move to bail out, and                                                                                   http://www.cdnn.info/news/safety/s060816a.html
                                                                                                                                                                      fault                       hypoxia                         did a very extended cold water cave dive with an open circuit diver who knew the cave. Deceased had           the buddy did not offer bail out gas because he was unfamiliar with
                                                                                                                                                                                                                                  never been in the cave prior to this dive. The dive had many changes in depth and Deceased ran out            the rig: hypoxia of the Deceased was stated.
                                                                                                                                                                                                                                  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       There is no explanation of why there would be insufficient loop
                                                                                                                                                                                                                                  cap on the offboard gas add valve (a dry suit valve on the exhale CL) was being held on by pressure, he       volume: the diver ascended to the ceiling - this increases loop
                                                                                                                                                                                                                                  had not plugged in the offboard gas at the surface and the differential pressure was preventing him           volume, unless there is no oxygen supply (supporting the hypoxia
                                                                                                                                                                                                                                  from pulling the protective cap at depth. When the CCR was recovered, it still had a breathable               report).
                                                                                                                                                                                                                                  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.
124   14/08/2006   Ivzor Buna         Home build SCR     Unknown            Cave Diving               88              Bosnia, Blagai           Expert            -    Scant data                  Scant data                      Exploration dive with Dual Rebreathers (type unknown - SCR likely), dual 10L cylinders with 20/30             Assumed from remaining pressure in gas cylinders that SCR was                                                                                         From www.plongeesout.com / Accidents/Bosnia
                                                                                                                                                                                                                                  Trimix                                                                                                        passive addition design.
                                                                                                                                                                                                                                  Body found at 88m
                                                                                                                                                                                                                                  Both rebreather loops found closed with nearly empty cylinders
123   27/07/2006                        Inspiration        APD          Solo Diving / Wreck           36            Poland, Darlowo             Guru            42    Rebreather design fault     Hypoxia                         Reports of a sudden LOC. Body not recovered. Unconfirmed information suggesting 'he was testing                The Rebreather was an old Inspiration, with no backlight handsets,                                                                                   http://www.wielkiblekit.pl/nurkowanie?more=1669496688
                   Dominik                                                    Diving                                  (Baltic Sea)                                                                                                new absorbent' at approximately 40 meters. Dominik was diving modified 'Inspo', the same that he              that is prone to hang on battery bounce. Sudden LOC points to
                                                                                                                                                                                                                                  just took to 210 meters, at the wreck of Yolanda in Egypt.                                                    hypoxia caused by a hang. Rebreather should have been recalled
122   10/07/2006   David Bright         Inspiration        APD              Solo Diving               80             USA, Montauk.             Expert           40    Scant data                  AGE                             Uncontrolled ascent. Explosive DCS. Otherwise scant data                                                      long ago. The testing new absorbent is a ploy that was used by the                                                                                    http://www.rebreatherworld.com/memorial-forum/5780-
                                                                                                                      Andrea Doria                                                                                                                                                                                                                                                                                                                                                                    david-bright-researcher-dies-after-andrea.html
121   14/06/2006   Fred Leroy           Inspiration        APD              Buddy dive                 6                 Belgium,            Intermediate             Rebreather design fault     Hypoxia                         Sudden LOC in shallow depth indicates hypoxia.                                                                Diver was a technical OC instructor but an intermediate on                                                                                            Confidential communication and inquest reports
                                                                                                                       Zilvermeer                                                                                                                                                                                                               rebreathers. Too similar to multiple previous accidents: no
                                                                                                                       (Silverlake)                                                                                                                                                                                                             adequate response to these hypoxia accidents by manufacturer.
120   04/06/2006   Massimiliano          Voyager         Unknown            Cave Diving               44             Italy, Tuscany,         Intermediate       28    Rebreather fault / Human    Drowning/asphyxia               Diver from Gigi Casati's team. Diver had bailed out off the rebreather, and was caught in a narrow            Cave team's hypothesis is that as the 7 litre trimix O.C. cylinder                                                                                    http://www.rebreatherworld.com/rebreather-accidents-
                   Valsecchi                                                                                         Pollaccia Cave                                   error                                                       passage when a counterlung swelled up, and was not able to reach a bail-out bottle. Reason for bail out emptied, breathing became difficult. They think that he had a                                                                                               incidents/5268-fatality-italy-more.html
                                                                                                                                                                                                                                  unknown and assumed to be a rebreather fault. Following account written by JJ Bolanz (himself                 physical problem which prevented him from opening its second
                                                                                                                                                                                                                                  Deceased from a cave accident on a RB in 29th Oct 2007).                                                      bottle. The diluent feed on the RB had free flowed caused the
                                                                                                                                                                                                                                  "Deceased, 28 years old, who had been diving with us for 6-7 years, had a fatal accident, on Sunday, 4th counterlung to swell, fixing the diver in the cave restriction. " I was
                                                                                                                                                                                                                                  June during a diving of preparation in Pollaccia, in Tuscany. Deceased was found wedged in a corner, ending my landing in 6 m when Deceased crossed me, starting his
                                                                                                                                                                                                                                  heading out of the cave in a restriction 120m from the entrance, at a depth of 44m. The Deceased had diving. After the exchange of the usual signs, I noted that his progress
                                                                                                                                                                                                                                  bailed out off the rebreather.                                                                                which was perfectly normal. Luigi arrived at the source some
                                                                                                                                                                                                                                  Diver was found with 10 bars of trimix in a 7 litre O.C. bail out cylinder, and a one 9 litres cylinder still minutes after my exit. It is Roberto, diving 30-40 minutes after
                                                                                                                                                                                                                                  closed with 220 bars. Another bottle was 10 m in front of him and a stage bottle was placed 25 m              Massimiliano, who found him dead in the étroiture. The Italian
                                                                                                                                                                                                                                  behind him. Deceased had tense hands reaching forward but the 9-litre bottle he was carrying with             spéléo assistance took out the body during the night of Sunday to
                                                                                                                                                                                                                                  him was unreachable due to the confined space. The CO2 absorbent, examined after its recovery, 12 Monday."
                                                                                                                                                                                                                                  hours after its death, shows that lime in practice still changed colour."
119   04/06/2006   Maksim Sobolev       Evolution        APD Vision         Buddy dive                90                Black Sea            Intermediate             Exceeded Performance        Heart attack during a period of Seen to go unconscious when reaching the shotline. Download data eliminated Hyperoxia and                     Diver profiles exceed known scrubber endurance. Appears to be              Dive Log shows extreme dives                                               Confidential communication and inquest reports
                                                                                                                                                                      Envelope                    hypercapnia                     Hypoxia. Diver went unconscious at c. 19mins, sent to surface by his buddy. No temp-stik fitted so            hypercapnia inducing a heart attack.                                       done too soon
                                                                                                                                                                                                                                  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.
118   01/06/2006   Lothar Kaiser        Inspiration        APD              Buddy dive                62                 Croatia             Experienced              Human error                 Hypoxia                         MOD3 training dive. Two deaths, two hospitalised. unconventional training operation at depth                  Crazy training protocol, involving switching the handsets off: this        Incompetent instructor: needs Electronic rebreather controllers should     Confidential communication and inquest reports
                                                                                                                                                                                                                                  involving semi-closed ascent from depth with the handsets switched off, resulting in two deaths and           information was withheld from the public list until published              to be better training and     meet IEC 61508: if they did, it would not
                                                                                                                                                                                                                                  two hospitalised out of a party of four. Decadent had a LOC at 30m from hypoxia.                              elsewhere due to concern over legal risk if it turned out to be wrong.     policing of instructors.      allow the rebreather to be switched off
                                                                                                                                                                                                                                  Gas contamination also a factor.                                                                              It is now confirmed. Rebreather should not allow a non-life support                                      underwater.
                                                                                                                                                                                                                                                                                                                                                mode underwater: this is a design fault, but given the danger of the
                                                                                                                                                                                                                                                                                                                                                exercise, the problem is small compared to the error of the
117   01/06/2006   Lena Bitzern         Inspiration        APD              Buddy dive                62                 Croatia             Experienced              Human error                 Hypoxia                         MOD3 training dive. Two deaths, two hospitalised. unconventional training operation at depth                  instructor. Inadequate safety planning for a deep dive with trainees.
                                                                                                                                                                                                                                                                                                                                                See above.                                                                 Incompetent instructor:        As above.                                   Confidential communication and inquest reports
                                                                                                                                                                                                                                  resulting in two deaths and two hospitalised out of a party of four. Gas contamination also a factor.         It is surprising the students all agreed to do this exercise.
                                                                                                                                                                                                                                  Decadent panicked on seeing another diver go unconscious at 30m. All four divers ascended rapidly.
116   14/05/2006   Dave Williams        Megalodon      ISC Apecs eCCR       Buddy dive                24                 England,                 -                   Rebreather issue            Hypoxia?                        Shirala wreck off Littlehampton UK. Diver was found unconscious at the surface.                               Sudden LOC, so points to hypoxia. Meg of this build date is known                                         Electronic rebreather controllers should Confidential communication and inquest reports
                                                                                                                      Littlehampton                                                                                                                                                                                                             to have problems with O2 control, scrubber bypass fault and                                               meet IEC 61508. Rebreathers must switch
                                                                                                                                                                                                                                                                                                                                                electronic encapsulation is also inadequate: these issues should be                                       on automatically. Auto-shut off valve
                                                                                                                                                                                                                                                                                                                                                explored by examiner, as well as generic faults (cylinders off,                                           needed.
                                                                                                                                                                                                                                                                                                                                                Rebreather off etc).
115   22/04/2006   Rob Davie            Inspiration        APD              Buddy dive                15                  Egypt                Expert            -    Rebreather issue/human      Hypercapnia: WOB/CO2            Possible cause is foreign object placed inside DSV or incorrectly assembled DSV increasing WOB                                                                                           Divers should not modify       Gross incompetence in design of electronic http://www.scubabrucie.com/dive/2007/01/25/rebreather-
                                                                                                                                                                      error:                      retention                       considerably, causing hypercapnia. Diver bailed to OC before ascent. Found dead on surface. Diver                                                                                        manufacturer's equipment in    portion of rebreather, with many single        fatalities/
                                                                                                                                                                                                                                  switched to O.C. at around 20m, and released his weight belt. He was seen swimming on the surface                                                                                        any way without contacting     points of failure. Manufacturer does not
                                                                                                                                                                                                                                  towards the recovery boat then lost consciousness.                                                                                                                                       factory.                       have any annual service requirement for
                                                                                                                                                                                                                                                                                                                                                                                                                                                          rebreather itself, and did not do a recall for
                                                                                                                                                                                                                                                                                                                                                                                                                                                          battery housing improvement.
114   17/04/2006   Soeren Konstet       Inspiration        APD              Buddy dive                55                Germany,                  -              -    Human error / Rebreather    Drowning/asphyxia               Diver experienced stress and surfaced. He ditched his equipment but it was strapped on to his wrist           New information did not add anything new, other than the root              Very similar to another      Cells should be tested by the rebreather and http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                        Hemmoor                                       design fault / Rebreather                                   by the torch cable. Weights were on the rebreather, which pulled him down. Following the reports              issue was the rebreather not testing and rejecting its cells, and the      accident. Divers should be   rejected if showing characteristics of old   incidents/4425-hemmoor-accident-report.html
                                                                                                                                                                      issue                                                       containing the above date, the following data emerged: "Unit bought 2nd hand, oxygen cells 3 years            diver did not replace the cells as directed in the user manual.            trained never to remove RBs cells.
                                                                                                                                                                                                                                  old (exceeding manufacturer's recommendation by 50%), this was the 2nd dive of the day, shortly                                                                                          in the water unless both the
                                                                                                                                                                                                                                  after completing training course. Air diluent, so Narcosis may have been a factor, Diver got a cell                                                                                      rebreather and the diver are
                                                                                                                                                                                                                                  warning. He bailed out to his 7 litre side mount and emptied if in short order, remaining on the                                                                                         secured to the surface. Cell
                                                                                                                                                                                                                                  bottom. He then went onto his buddy's 7 litre and all three ascended quickly. They ditched their                                                                                         change should be emphasised.
                                                                                                                                                                                                                                  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."
113   16/04/2006   Mike Bromsgrove      Inspiration        APD              Solo Diving            1/11/conf           Isle of Man         Advanced Trimix,      -    Rebreather design fault     Hypoxia                         Deceased was a large man, very experienced rebreather diver. Deceased had a very short profile, with          Inquest concluded Open Verdict. Case went no further due to                                                                                           Full accident investigation with all evidence available
                                                                                                                                         hundreds of RB hours                                                                     the dive of just 1.5 minutes, before the diver went from a depth of 10.5m to the surface rapidly, lost        manufacturer's history of claiming against plaintiffs.
                                                                                                                                                                                                                                  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.
112   04/04/2006   Fred Evans           Megalodon      ISC Apecs eCCR   Buddy dive then solo          50            Thailand, China            Expert                 Human error/Rebreather      Hyperoxia                       Deceased was diving Meg serial number 65, Buddy was diving Meg serial number 69. The Meg 65 was               The compilers of this database have been contacted by a person who                                        IEC 61508 audit of another rebreather       http://www.rebreatherworld.com/memorial-forum/4111-
                                                                                                                    Sea, Unidentified                                 issue                                                       sold in January 2006 to Deceased by Soo Seng Khoo in Singapore (now deceased from rebreather                  claims to have known the Deceased but has not examined the                                                emphasised the need to test O2 cells        fred-evans.html
                                                                                                                    wreck close to the                                                                                            accident on 9th May 2010). Deceased was an experienced KISS diver before moving to the Meg. The               equipment. That person claimed errors in this listing. This was                                           automatically, including during the dive.
                                                                                                                     Tottorri Maru                                                                                                cells fitted to Meg 65 at the time of the accident were from April 2004 have numbers 299416 D4,               followed up in detail including checks with eye witnesses, and Craig                                      The use of manual O2 injectors running
                                                                                                                                                                                                                                  299347 D4 and 299381 D4 and these cells are still fitted to the rebreather (they were not lost as was         Challen: the dive buddy and the person currently holding the                                              from compensated regulators is known to
                                                                                                                                                                                                                                  suggested by a person challenging the events reported here). One cell had failed before the dive and          rebreather. The original listing was found to be materially correct:                                      be hazardous, and this hazard was present
                                                                                                                                                                                                                                  was not replaced because no replacement was available at short notice. Deceased was almost deaf in            Deceased was effectively deaf, cells were old (just entering their third                                  on this equipment.
                                                                                                                                                                                                                                  one ear and had reduced hearing on the other but the rebreather was not fitted with any audible               year) and one was faulty. Given the information on the cells, the fact
                                                                                                                                                                                                                                  alarms so this would not have affected the accident other than the diver's ability to hear the solenoid or    that the diver was seen to convulse, the rig was tested immediately
                                                                                                                                                                                                                                  injector. The Meg was standard other than both the first stages had been changed to Oceanics to               after the dive on the boat and both manual injector and solenoid was
                                                                                                                                                                                                                                  improve hose routing, and the backplate had been changed. Deceased and Buddy began the dive                   working normally, the conclusion is Hyperoxia due to a ceiling fault
                                                                                                                                                                                                                                  together. The shot was off the wreck and had to be dragged across the seabed at 50m and tied into the         on two cells and a faulty third cell likely fully expired (all, as
                                                                                                                                                                                                                                  wreck. After that the divers separated as planned to explore the wreck individually. 35 mins into a 45-       concluded originally). Due to deafness, Deceased would not have
                                                                                                                                                                                                                                  50m dive Deceased was seen having a convulsion. An OC diver tried to assist Deceased as he was                heard the solenoid firing excessively.
                                                                                                                                                                                                                                  convulsing by placing and purging a regulator in his mouth. He kept trying to get Deceased breathing
                                                                                                                                                                                                                                  through his long hose. Despite his own deco obligation he used up all his back gas purging his long
111   01/04/2006   Ken Woodward         Inspiration        APD              Solo Diving                -                 England                  -              -    Rebreather design fault     Hypoxia                         BSAC Incident report 06/080. Diver was found motionless on the seabed. A rebreather diver                                                                                                If the diver had taken a buddy, Auto-loop shut off required. Should not be http://www.bsac.com/page/807/fatalities.htm
                                                                                                                                                                                                                                  conducted a solo dive. Another diver from the same party found him motionless on the seabed. He                                                                                          it is likely this accident may  possible to switch off Rebreather
                                                                                                                                                                                                                                  brought him to the surface and he was recovered into the boat. The Coastguard was alerted and                                                                                            not have had fatal outcome.     underwater, so Rebreather will always
                                                                                                                                                                                                                                  resuscitation techniques were applied. A lifeboat was launched to assist. The boat returned to the                                                                                                                       ensure adequate PPO2.
                                                                                                                                                                                                                                  shore where the casualty was declared dead.
110   01/04/2006   Unknown              Inspiration        APD              Buddy dive                12                 England               Novice            -    Rebreather design fault /   Hypoxia / AGE                   Two divers entered the water to conduct a drift dive in a maximum depth of 12m. One of the pair was           Diver clearly had a rapid ascent from 12m. Conclusion of hypoxia                                          Functional safety procedures would have     http://www.bsac.com/page/807/fatalities.htm
                                                                                                                                                                      Human error                                                 using a rebreather with air as the diluent, the other diver was using open circuit nitrox 32. Initially the   reached by elimination simply by following the fault tree. From 12m,                                      eliminated hypoxia as the cause had they
                                                                                                                                                                                                                                  rebreather diver had difficulties leaving the surface. At the bottom he held onto a rock and his buddy        DCS eliminated as a causal factor. Baro-trauma (AGE) unlikely from                                        been applied in this design. Rebreather
                                                                                                                                                                                                                                  had to swim against the current to get to him. As previously agreed, the open circuit diver deployed a        12m, as rebreather fitted with CE exhaust valve with pressure not                                         buoyancy control should be simplified.
                                                                                                                                                                                                                                  delayed SMB. As she deployed the buoy it jammed momentarily and she rose slightly. She watched                exceeding 40mbar, but can't be ruled out. No contact with other                                           Automatic switch to low PPO2 set point at
                                                                                                                                                                                                                                  the buoy ascend and then realised that her buddy was not there. She believed that he had started the          hard objects. All WOB, hypercapnia and hyperoxia branches in the                                          shallow depths would be beneficial.
                                                                                                                                                                                                                                  drift and she moved with the current for 15 min. She then surfaced, making a 3 min safety stop at 6m.         fault tree eliminated, though diver was probably not running
                                                                                                                                                                                                                                  Surface conditions were rough and initially she couldn't see the boat. She was recovered into the boat        minimum loop (hence buoyancy issue) or may have had leaky
                                                                                                                                                                                                                                  and reported the separation. The missing rebreather diver was then seen floating on his back at the           inflator. Not known if diver had switched to the low set point (if not,
                                                                                                                                                                                                                                  surface. Two divers entered the water. They found that the diver was unconscious. He was recovered            more likely to be buoyancy problems on ascent). No gas pressure
                                                                                                                                                                                                                                  into the boat and oxygen assisted resuscitation techniques were applied. The Coastguard was alerted.          issues reported. Sudden LOC and ascent conditions, points to
                                                                                                                                                                                                                                  He was airlifted to hospital but was declared dead on arrival BSAC Incident report 06/079                     hypoxia.
109   25/02/2006   Lewis Gavin          Inspiration        APD              Buddy dive                 0            Australia, Sydney        Experienced              Rebreather design fault     Hypoxia                         Deceased was the last on the mermaid line (right behind his buddy) when the group was going into              Battery bounce is most likely cause, or failure of rebreather either to                                   Auto-loop shut off required. Should not be http://www.rebreatherworld.com/memorial-forum/3686-
                                                                                                                                                                                                                                  the water. No dive was done.                                                                                  be switched on or to auto-on (classed as a design fault using IEC                                         possible to switch off Rebreather          lewis-gavin.html?
                                                                                                                                                                                                                                  Deceased disappeared from the ocean surface. Deceased was breathing from rebreather on surface.               61508 processes).                                                                                         underwater, so Rebreather will always
                                                                                                                                                                                                                                  The diver appears to have lost consciousness from hypoxia. Older model of the rebreather.                                                                                                                               ensure adequate PPO2.




                                                                                                                                                                                                                                                     Page 9 of 20
                                                                                                                                                                                                                                 d9081ce0-7e95-44ed-9e81-0fdd6fd43e58.xls




                                                       Electronics
                                                         fitted to
                                                                                              Depth of accident
                                        Rebreather    rebreather for   Type of dive (Solo,                                                                             Root Case using fault      Disabling Injury using                                                                                                                        Comments or Discussion in arriving at most plausible cause,                                                                                                   An external reference confirming that accident
        Date        Deceased's Name                                                          (/deepest/planned        Location              Experience          Age                                                                Key information received on accident                                                                                                                                     Training implications                            Design implications
                                         involved          PPo2        Group, Cave etc.)                                                                               tree method                fault tree method                                                                                                                             addition to use of the Fault Tree.                                                                                                                                               occurred
                                                                                                   ) (m)
                                                      Monitoring or
                                                         Control
108   01/01/2006   Jackie Smith          BMR500         Unknown            Solo Diving               28           USA, Lake Norman             Expert           about Rebreather design fault /   Hypoxia / Heart attack or   Diver found on surface unconscious. The equipment was well checked before diving and the diver                    Unknown if this was the same mCCR variable oxygen flow system as                                                                                          http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                       Quarry                                     40 Underlying illness           stroke.                     reported to have been one of the best trained and experienced. Suggestion has been made publicly                  fitted to Phil Patz's BMR500.                                                                                                                             incidents/2746-just-read-another-board-about-diver.html
                                                                                                                                                                                                                              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
107   23/12/2005   Harvey L. Harris      Dolphin        Unknown          Solo diving, Pool           3            USA, Washington           Experienced          51    Human error                Hypoxia due to O2 exhausted Ran out of make up gas while using an SCR rebreather. Cause of death is Asphyxia, and drowning                                                                                                                                                                              http://www.cdnn.info/news/safety/s051227.html
106   01/12/2005   Billy O'Connor       Inspiration       APD              Buddy dive                50             Ireland, Co.            Experienced          49    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            Sudden event points to hypoxia, though could be CNS as clock was       Awareness that CNS limits     Active WOB monitoring needed. WOB                    Confidential communication and inquest reports
                                                                                                                      Wexford                                                                                                 fishermen. Deceased's buddy said it was a relaxed dive with no problems. Buddy was above him on                   high and scrubber may have started to fail.                            need proper margins, and that should not exceed EN14143:2003 limits.
                                                                                                                                                                                                                              line - he looked down and Deceased was gone. Body was recovered a week later at bottom of shot.                                                                                          high CO2 causes limits to
                                                                                                                                                                                                                                                                                                                                                                                                                       reduce dramatically.
105   24/11/2005   Zack Jones           Megalodon     ISC Apecs eCCR       Buddy dive                60              USA, Florida              Expert            30    Rebreather design          Hypoxia / Hypercapnia            Seven minutes after descending, Jones and his designated dive buddy, Richard Hartley, were at a              The following factors were considered.                                                               Weight pockets should not be on the                  http://www.divernet.com/cgi-
                                                                                                                                                                       fault/Human error                                           depth of 194 feet. They exchanged "OK" hand signals and separated to explore. Jones, was the only            1. At 200ft on a rebreather with a PPO2 of 1.3, the PPO2 could drop                                  rebreather for SCUBA units. Added by                 bin/articles.pl?id=2501&sc=1&ac=d
                                                                                                                                                                                                                                   diver using a rebreather. On the bottom, Jones and buddy Richard Hartley parted ways in a common             to 1.1 with that controller. This is unlikely to cause nitrogen                                      user.
                                                                                                                                                                                                                                   but unsafe move. Hartley told the medical examiner's office that they split off so Jones could spearfish     blackout.
                                                                                                                                                                                                                                   without risk of skewering his friend. Some time later, another diver, Catherine Baldwin, saw that            2. There is a fault on the generation of Megs that was used, whereby
                                                                                                                                                                                                                                   Jones had speared what looked like a 50-pound grouper. Jones caught the biggest grouper of his life.         scrubber bypass can occur at depth via the water dump. This would
                                                                                                                                                                                                                                   His father, David Jones, says that the two had speared ten- and 20-pounders on their fishing trips but       create hypercapnia. The scrubber duration is very short indeed on
                                                                                                                                                                                                                                   not a 50-pounder. Jones' adrenaline probably went through the roof as he wrestled with the monster           the Meg at this depth in cold water, with high exertion rates even
                                                                                                                                                                                                                                   and subdued it. And it's possible that those exertions put Jones into danger. Breathing faster, Jones        though the water was warm.
                                                                                                                                                                                                                                   might have been dragged deeper by the fish, and that may have affected the level of oxygen in his loop.      3. The work of breathing would be high, adding to the hypercapnia
                                                                                                                                                                                                                                   His fight with the fish might also have taken his mind off his rebreather's heads-up display, a warning      background.
                                                                                                                                                                                                                                   device that flashes green, then yellow and finally red directly into a diver's eyes. Jones' Megalodon was    4. The diver was in good health, and reported to be careful.
                                                                                                                                                                                                                                   found after the dive to have a 1.3PPo2 setpoint programmed. Removing the fish from the shaft of his          5. The O2 cylinder was empty. This is very surprising for the dive
                                                                                                                                                                                                                                   spear gun, Jones looked satisfied with his catch But a few minutes later, something was wrong. For           and recovery profile. The diver bailed off the loop realising it was
                                                                                                                                                                                                                                   some reason, nearly 200 feet down, Jones decided to bail off his loop. Hartley spotted Jones hovering        not breathable. Reviewing all the data, the diver is likely to have
                                                                                                                                                                                                                                   at about 160 feet, the fish gone, and Jones looked listless, like he was staring at the coral. Hartley       noticed the PPO2 was wrong (if the cylinder was empty on recover,
                                                                                                                                                                                                                                   banged his knife against his tank, trying to get Jones' attention, but there was no response. Then Jones     then it could be either very high emptying the cylinder, or very low).
                                                                                                                                                                                                                                   began to sink so Hartley swam down to him and reached for Jones' buoyancy compensator. Hartley               6. The powder is a red herring. The Meg does not have a crown
                                                                                                                                                                                                                                   inflated it, and Jones rose in an explosive uncontrolled ascent.                                             strap, or retainer, so when the diver has a LOC then the rebreather
                                                                                                                                                                                                                                   Bozanic found a powder caked on the interior surfaces of the oxygen cell housing that could have been        floods. If the rebreather leaked water, the diver would not have got
                                                                                                                                                                                                                                   soda lime, residual cleaning solution, or even salt. The powder was swabbed and stored at the medical        to 200ft.
104   21/11/2005   Penny Glover          Evolution      APD Vision         Buddy dive                77            France, La Londe             Guru             41    Equipment issue /          Hypercapnia following            Two divers were missed on 21st November 2005 and bodies found only at beginning of January 2006.                                                                                    Awareness that CNS limits                                                          http://www.cdnn.info/news/safety/s060106.html
                                                                                                                      Les Maures                                       Exceeded Performance       hyperoxia problem with           Investigation and dive download suggest buddy was on open circuit during the ascent and deco from                                                                                   need proper margins, and that
                                                                                                                                                                       Envelope / human error     buddy                            77m dive. Penny had his empty stages. Deco is nearly finished when Penny descends at normal rate.                                                                                   high CO2 causes limits to
                                                                                                                                                                                                                                   Lead to believe by investigative team that she descended after buddy. PO2 spikes because she started                                                                                reduce dramatically.
                                                                                                                                                                                                                                   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.
103   21/11/2005   Jacques Filippi      Inspiration       APD              Buddy dive                77            France, La Londe            Expert             -    Equipment issue /          Hyperoxia following bail out     Two divers were missed on 21st November 2005 and bodies found only at beginning of January 2006. May be simply a buoyancy problem but suggested is CNS hit from                          Awareness that CNS limits        Gross incompetence in design of electronic http://www.cdnn.info/news/safety/s060106.html
                                                                                                                      Les Maures                                       Exceeded Performance                                        See above. Diver appears to have bailed out to open circuit for some reason at bottom of 77m dive, high O2 in the trainee diver - possibly exacerbated by hypercapnia,                   need proper margins, and that    portion of rebreather, with many single
                                                                                                                                                                       Envelope / human error                                      then sank towards the end of last deco stop.                                                       and other diver died in the attempted rescue.                                         high CO2 causes limits to        points of failure. Manufacturer does not
                                                                                                                                                                                                                                                                                                                                                                                                                            reduce dramatically.             have any annual service requirement for
                                                                                                                                                                                                                                                                                                                                                                                                                                                             rebreather itself, and did not do a recall for
                                                                                                                                                                                                                                                                                                                                                                                                                                                             battery housing improvement.
102   01/11/2005   Unknown              Inspiration       APD                                                      France, Becon les                                   Scant data                 Scant data.                      Report of double fatality, equipment, month and location and that is all. It was first thought that this                                                                                                                                                               Confidential communication
                                                                                                                       Granites                                                                                                    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.
101   01/11/2005   Unknown              Inspiration       APD                                                      France, Becon les                                   Scant data                 Scant data.                      Report of double fatality, equipment, month and location and that is all.                                                                                                                                                                                              Confidential communication
                                                                                                                       Granites
100   11/10/2005   G. Mamoulas          Inspiration       APD              Solo Diving               60           Greece, Cape Krios,             -              35    Exceeded Performance       Hypercapnia from spent           Diver used expired scrubber while spearfishing.                                                                                                                                                                           Electronic rebreather controllers should
                                                                                                                        Crete                                          Envelope / Human error     scrubber                                                                                                                                                                                                                                                   meet IEC 61508. Tank contents
                                                                                                                                                                                                                                                                                                                                                                                                                                                             monitoring linked to auto-shut off valve
                                                                                                                                                                                                                                                                                                                                                                                                                                                             would probably have avoided this accident.
99    06/10/2005   Paul Theriault       Megalodon         ISC                   -                   56            USA, Florida Keys                                    Scant data                 Scant data.                      Scant data.                                                                                               Scant data.                                                                                                                                                  Confidential communication and inquest reports
98    25/09/2005   Roland Schoen        RB80 Clone      Unknown            Solo Diving             15 / 5           Switzerland,        OC Instr., TMX diver,    38    Human error                Hypoxia                          Reports: 1/2hour less introduction to the unit. 1/13 ratio. 21/35 as dil gas: insufficient O2 in diluent. LOC from hypoxia while ascending from trial dive, oxygen content               Need to flush SCRs during                                                     http://www.scubabrucie.com/dive/2007/01/25/rebreather-
                   (Schön)              (Habanero)                                                                Zugersee (Lake of      Cave diver. RB first                                                                      Divers separated at depth on purpose. Due to no (limited) RB experience, not enough flushing of the in loop too low at end of dive in shallow waters.                                    ascent needs to be reinforced.                                                fatalities/
                                                                                                                       Zug).                    dive.                                                                              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.

97    22/09/2005   Nigel Peter Lees     Inspiration       APD              Solo Diving               15           New Zealand, Ship         Experienced          48    Rebreather design fault    Hypoxia                          Handsets appeared not to be on. Make-up-gas cylinder was empty. Wing may have caused a                        Investigators may not be aware of the capacity for the equipment to                                         Provide adequate margin for CNC clock.     http://dcyccr.blogspot.com/2007/01/news-article-about-
                                                                                                                       Cove                                                                                                        problem with breathing hoses, but unlikely.                                                                  turn off after being switched on. In any case, lack of automatic switch                                      Provide CO2 monitoring. Simple switch to nigel-lees-inquest.html
                                                                                                                                                                                                                                                                                                                                                on is a fundamental safety design fault: equipment does not comply                                           count down to zero, and disable loop, that
                                                                                                                                                                                                                                                                                                                                                with any Functional Safety standard without it.                                                              resets when scrubber fitted.
96    17/09/2005   Tom Storm            Inspiration       APD              Solo Diving             15/?/0           Sweden, West            Experienced                Rebreather design fault    Hypoxia                          While preparing for a shallow advanced Nitrox dive that he was instructing. JB suggests that Deceased                                                                                                                                                                Confidential communication and inquest reports
                                                                                                                       Coast                                                                                                       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.
95    01/09/2005   Unknown diver        Inspiration                        Buddy dive            6 / 46 / 46             UK                 Experienced                Scant data                 Scant data.                      Report of BSAC 05/214. A rebreather diver completed an 80 min dive to 46m including the following                                                                                                                         Provide adequate margin for CNC clock.     http://www.bsac.com/page/260/fatalities.htm
                                                                                                                                                                                                                                   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                                                                                                                       Provide CO2 monitoring. Simple switch to
                                                                                                                                                                                                                                   felt sick and had to switch to his bail out regulator so that he could be sick underwater. He got water in                                                                                                                count down to zero, and disable loop, that
                                                                                                                                                                                                                                   his mask and he swallowed this water. He requested help to get back in the boat and was sick again.                                                                                                                       resets when scrubber fitted.
                                                                                                                                                                                                                                   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."

94    28/08/2005   Dmitry Satyukov       Azimuth        Unknown            Solo Diving               26            USA, New Jersey,         Experienced          33    Training issues            Scant data                      Deceased was a diver from Brooklyn and had a FFM. Deceased was among a group of divers who took               The captain of the Jeanne II mentioned that in the past, this same
                                                                                                                   Bald Eagle wreck                                                                                               the 42 ft dive boat Karen 10 miles off Gerritsen Beach around noon. Divers on the Kare, were allotted         diver dove with him using a rebreather and showed no knowledge
                                                                                                                                                                                                                                  an hour and a half to dive, but Satyukov didn't surface along with the others. The boat's skipper called      whatsoever on it. He then banned the guy from diving in his boat
                                                                                                                                                                                                                                  the Coast Guard. In response to the distress call, the dive boat Jeanne II, pulled the hook from the          with a RB. A very interesting note is the fact that the deceased's
                                                                                                                                                                                                                                  wreck they were diving and joined the Karen for the search of the body. A mate from the Jeanne                rebreather instructor was the fellow that died in 4' of water in a pool a
                                                                                                                                                                                                                                  found the body floating face up. He tried to put air in the BC but failed. Either there was no air left or    few months previous to this fatality. The Bald Eagle is a broken up
                                                                                                                                                                                                                                  the LP hose was not connected properly. He tied a lift bag to the body and shot him up. Rescuers              wreck lying on 85 fsw about 15 miles of the NJ coast. Viz is usually
                                                                                                                                                                                                                                  found Satyukov dead underwater face up about 30 minutes later, at 2 p.m. Body recovered with lift-            decent.
93    21/08/2005   Gerry Tychansky      Megalodon          ISC             Buddy dive                4            Canada, Hamilton,         Experienced          43    Underlying Illness /                                       bag.
                                                                                                                                                                                                  Heart attack during a period of Underlying Illness: heart attack.                                                                             Not ruled out hypercapnia induced because equipment had                                                      Provide adequate margin for CNC clock.     http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                      Ontario                                          Rebreather design fault    hypercapnia                                                                                                                                   possibility of scrubber bypass fault.                                                                        Provide CO2 monitoring. Simple switch to incidents/1322-meg-fatality.html#post55985
                                                                                                                                                                                                                                                                                                                                                                                                                                                             count down to zero, and disable loop, that
                                                                                                                                                                                                                                                                                                                                                                                                                                                             resets when scrubber fitted.
92    09/07/2005   Takahara Yoharu      Inspiration       APD              Solo Diving               50            Japan, Ida beach,        Experienced          38    Rebreather issue/human     Hypercapnia: WOB/CO2             Diver didn't carry bailout and communication system had broken.                                                                                                                                                                                                      http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                       Numazu                                          error:                     retention                        Savage current.                                                                                                                                                                                                                                                      incidents/1206-inspiration-accidents.html
91    05/07/2005   Manolis Efthinakis   Inspiration       APD              Buddy dive                32                Greece                     -               -    Exceeded Performance       Hypercapnia from spent           Diver reported to be using expired scrubber. Diver died while filming under water pipe.                                                                                                                                   CO2 sensor required. Simple switch to      http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                                                                       Envelope / Human error     scrubber                                                                                                                                                                                                                                                   count down to zero when scrubber fitted. incidents/1206-inspiration-accidents.html
                                                                                                                                                                                                                                                                                                                                                                                                                                                             WOB should not exceed EN14143:2003
                                                                                                                                                                                                                                                                                                                                                                                                                                                             limits.
90    17/06/2005   Keith Morris         Megalodon          ISC             Solo Diving               69            Channel Islands,       Experienced, OC        66    Scant data                 Scant data.                      20 miles north west of Guernsey (SHEARWATER). Instructor trainer.                                                                                                                                                                                                    http://www.rebreatherworld.com/memorial-forum/2243-
                                                                                                                     Guernsey               Trimix diver                                                                                                                                                                                                                                                                                                                                                keith-morris.html
89    05/06/2005   Nicholas Jackson     Inspiration       APD                Trimix                  60                 UK                       -                     Exceeded Performance       Hypercapnia                      Only report of BSAC 05/102. A group of four divers dived on a wreck at a maximum depth of 60m, all           The accident seems to be classic case of hypercapnia. Heavy                                                                                             http://www.bsac.com/page/260/fatalities.htm
                                                                                                                                                                       Envelope                                                    using rebreathers with trimix. Although in the water together they conducted their dives separately.         exertion, deep dive (scrubber endurance is not good at this depth
                                                                                                                                                                                                                                   After 60 min, one diver was seen by another to be recovering a porthole. The porthole was later found        and from the decompression of 150 minutes, was exceeded
                                                                                                                                                                                                                                   at the surface under the diver's lifting bag. Three divers surfaced having completed over 150 min            considerably).
                                                                                                                                                                                                                                   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.
88    01/06/2005   Unknown diver        Inspiration                       Group Diving               68                  UK                 Experienced                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              Sudden LOC in a buddy dive suggests hypoxia as most probable                There are many accidents                                                      http://www.bsac.com/page/260/fatalities.htm
                                                                                                                                                                                                                                   a rebreather. He dived alone although others from his party were in the water at the same time. He was       cause. There is a paucity of data in this accident. A range of other        where one diver sees another
                                                                                                                                                                                                                                   last seen hovering motionless above the wreck. He failed to surface and an extensive search involving        conclusions is possible, but hovering motionless suggests a very            hovering motionless and does
                                                                                                                                                                                                                                   aircraft was made. His body has not been recovered.                                                          sudden LOC hence hypoxia. Divers observing the motionless diver             nothing, surprisingly. Perhaps
                                                                                                                                                                                                                                                                                                                                                did nothing apparently: compassion and care did not seem to come            divers may need to be trained
                                                                                                                                                                                                                                                                                                                                                naturally to them.                                                          to assist immediately when
                                                                                                                                                                                                                                                                                                                                                                                                                            they see a motionless person
                                                                                                                                                                                                                                                                                                                                                                                                                            underwater.




                                                                                                                                                                                                                                                     Page 10 of 20
                                                                                                                                                                                                                            d9081ce0-7e95-44ed-9e81-0fdd6fd43e58.xls




                                                               Electronics
                                                                 fitted to
                                                                                                      Depth of accident
                                          Rebreather          rebreather for   Type of dive (Solo,                                                                 Root Case using fault      Disabling Injury using                                                                                                                      Comments or Discussion in arriving at most plausible cause,                                                                                                     An external reference confirming that accident
       Date        Deceased's Name                                                                   (/deepest/planned        Location         Experience    Age                                                             Key information received on accident                                                                                                                                     Training implications                           Design implications
                                           involved                PPo2        Group, Cave etc.)                                                                   tree method                fault tree method                                                                                                                           addition to use of the Fault Tree.                                                                                                                                                 occurred
                                                                                                           ) (m)
                                                              Monitoring or
                                                                 Control
87   07/05/2005   David Rampersad            Azimuth            Unknown            Solo Diving               3                 USA, PA         Experienced   38    Human error                Hypoxia                        In school swimming pool. Report of diver using air instead of nitrox in this SCR. Rampersad, who             The report of diver using air instead of nitrox is yet to be confirmed.                                     Auto-shut off valve would have avoided          http://www.nydailynews.com/archives/ny_local/2005/05/
                                                                                                                                                                                                                             had more than a decade of experience in diving, was a certified instructor for the Scuba Network dive        It is noted that rebreather was known to have a problem, but if air is                                      accident.                                       10/2005-05-10_dive_gear_checked_in_pool_de.html
                                                                                                                                                                                                                             shop in Carle Place.                                                                                         used, then that would make any fault meaningless: it would have
                                                                                                                                                                                                                             Three other dive instructors from the shop were teaching a class Saturday at the Chaminade pool,             killed the diver anyway. Circumstances show clearly the disabling
                                                                                                                                                                                                                             which Scuba Network leases from the Catholic school, when Rampersad showed up about 1:30 p.m.                agent was hypoxia.
                                                                                                                                                                                                                             "He was not scheduled to instruct that day," Laursen said. "But he told one of the other instructors that
                                                                                                                                                                                                                             he was having problems with the rebreather and wanted to test it out."
                                                                                                                                                                                                                             Rampersad, who was married and lived in Richmond Hill, Queens, entered the shallow end of the
                                                                                                                                                                                                                             pool while the diving class trained in the deep end.
                                                                                                                                                                                                                             About 15 minutes later, an instructor spotted Rampersad unconscious in about 4 feet of water, his
                                                                                                                                                                                                                             mouthpiece out of his mouth, Laursen said.
                                                                                                                                                                                                                             He was rushed by ambulance to a local hospital, where he was pronounced dead at 2:59 p.m.



86   01/05/2005   Unknown diver            Inspiration                             Buddy dive                -                   UK                 -              Scant data                 Scant data.                    Dual fatality. Only report of BSAC 05/095. Three divers conducted a dive in a quarry. They                                                                                                                                                                               http://www.bsac.com/page/260/fatalities.htm
                                                                                                                                                                                                                             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
85   01/05/2005   Unknown diver            Inspiration                             Buddy dive                -                   UK                 -              Scant data                 Scant data.                    Dual fatality. Quarry dive. Only report of BSAC 05/095. See above.                                                                                                                                                                                                       http://www.bsac.com/page/260/fatalities.htm
84   12/04/2005   Alain Colas               Dolphin             Unknown            Buddy dive               15             France, Fabregas    Experienced   46    Human error / Rebreather   Hypoxia                        Fabregas near Toulon in France 14' into the dive. The diver was taking pictures and was found with           The Deceased was a speleologist but not a cave diver, the incident                                          Auto-shut off valve would have avoided          http://www.plongeesout.com/causette/affiche.php?message
                                                                                                                             near Toulon                           design fault                                              the rebreather tank empty.                                                                                   occurred while diving and making some shots of sealife - this was not                                       accident. Rebreathers need active tank          =5446&session_id=
                                                                                                                                                                                                                                                                                                                                          a cave dive.                                                                                                content monitors.

                                                                                                                                                                                                                                                                                                                                          Most plausible cause is that diver did not realise his gas was running
                                                                                                                                                                                                                                                                                                                                          low and inadequate monitoring.
83   06/04/2005   Wlodzimierz              Inspiration            APD           Cave Solo Diving            105              France, Saint        Guru             Human error                Human error: Narcosis.         Extreme cave diving in Bourg Saint Andeol, France. The rescue diver who found Deceased at -105               Use of air as the make-up-gas would cause considerable narcosis at Better buddy checks in                   He sensor required on trimix units. This is     http://www.plongeesout.com/causette/affiche.php?message
                  Szymanowski                                                                                                   Andeol                                                                                       point, stated that the vr3 showed tx 10/70 but that the diluent connected was air ! Diver was carrying       this depth (worse than on air at 105m), giving rise to risk of nitrogen expedition dives.                   not a complex addition.                         =5302&session_id=
                  (Wlodek)                                                                                                                                                                                                   10/53 trimix, but not connected to rebreather.                                                               blackout.
82   01/04/2005   French Diver             Inspiration            APD             Training dive             11              Switzerland,         Trainee     41    Underlying                 Hypercapnia cold induced,      Diver rushed from 11m to the surface and then drowned. Hypercapnia.                                          Behaviour points to a hypercapnia problem. Autopsy found heart                                              CO2 sensor required. Simple switch to           http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                          Neuenburger See.                         illness/Rebreather issue   cause of death heart attack    http://www.taucher.net/unfall/unfallShow.html?unfallNummer=336 reports 4th dive with RB under                attack.                                                                                                     count down to zero when scrubber fitted.        nger.htm
                                                                                                                                                                                                                             supervision of a RB Instructor. Dive intended to be to 25msw and a dive time of max of 45` without                                                                                                                       WOB should not exceed EN14143:2003
                                                                                                                                                                                                                             exercises. After 35 mins the diver shot to the surface from a depth of approx. 11m for unexplainable                                                                                                                     limits.
                                                                                                                                                                                                                             reasons. After a further 12 minutes, Deceased was found the unconscious at a depth of approx. 3m.

81   25/03/2005   Bernd Heiko Schultz   Inspiration, Vision     APD Vision         Solo Diving              56.7           Austria, Weyregg      Novice      46    Rebreather                 AGE                            Equipment failure leading to uncontrolled ascent from 37m. May be underlying illness, as diver                Deep and solo dive for very inexperienced rebreather diver: his first Guidance at the time was that                                                        http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                             am Attersee                           issue/Equipment                                           vomited before drowning. This was the first dive following the course. Air make-up-gas.                      dive after the training course other than a 2m weight check.           divers should not exceed the                                                         nger.htm
                                                                                                                                                                   issue/underlying                                                                                                                                                                                                                              depth limit of the course until
                                                                                                                                                                   illness/human error                                                                                                                                                                                                                           they have built up 50 hours.
80   09/03/2005   Brendan McGuiness        Megalodon          ISC Apecs eCCR       Ice Diving               16            USA, Bethlehem PA      Trainee           Exceeded Performance       Hypercapnia from flapper       (SHEARWATER) Ice diving - very cold water and sub zero air.                                                  Most plausible cause of several Rebreather issues is hypercapnia due Rebreathers are not suitable           Sensing of mushroom valve and WOB            http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                                                                   Envelope                   valve failure                                                                                                                               to WOB from sticking inhale counterlungs or mushroom.                  for diving in water less than 4C     would have reduced the risk of this accident incidents/14619-comprehensive-list-all-accidents-3.html
                                                                                                                                                                                                                                                                                                                                          Hypercapnia from scrubber not being warm enough at start of dive without counterlung heating.               occurring. WOB should not exceed
                                                                                                                                                                                                                                                                                                                                          should not be ruled out.                                                                                    EN14143:2003 limits.
79   05/03/2005   Radek K                    Dolphin            Unknown             Ice Diving               9              Poland, Quarry       Trainee     31    Exceeded Performance       Hypercapnia from spent         Training dive. Polish diver. Scrubber exhausted. A report of caustic cocktail inhaled by diver. Initial                                                                                                                                                               Confidential communication
                                                                                                                               Jaworzno                            Envelope / Human error     scrubber                       report of witnesses was heart attack, but cause was scrubber failure. For reference intiial report
                                                                                                                              Szczakowa                                                                                      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

                                                                                                                                                                                                                             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.
78   01/11/2005   Patrice Morelec          Inspiration            APD              Buddy dive                              France, Becon les                       Rebreather design fault    Hypoxia.                       Diver's training was unclear. Rebreather was the original old model that was prone to hand, bought     When the rebreather hangs, divers usually switch the handsets off                                                 Electronic rebreather controllers should
                                                                                                                               Granites                                                                                      third hand. Diver found on the 2nd dive of the day with the handsets off.                              and back on again. From the profile, the handsets were on at the                                                  meet IEC 61508.
                                                                                                                                                                                                                                                                                                                                    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.
77   09/01/2005   Nick Flemming            Inspiration            APD              Solo Diving              46                   UK              Expert       -    Scant data                 Scant data                     Diver completed an 80 minute dive including deco stops. Felt unwell during ascent. Changed to O.C. This report on the RBW list matches most of an uncooberated                                                                                                           Accident on new RBW list matched uncooberated reports.
                                                                                                                                                                                                                             Flooded mask. Vomited at surface. Died 4 days later in hospital. Report of hypoxia, but does not fit report for the deceased, but with some discrepancies. This list had
                                                                                                                                                                                                                             other data.                                                                                          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.
76   08/01/2005   David Shaw                 MK15.5                HH              Solo Diving              271               S. Africa,         Expert      50    Exceeded Performance       Hypercapnia: WOB/CO2           Presentation by Simon Mitchell at DAN Tech Conference                                                        Hypercapnia on extremely deep dive. Caused by increased WOB                                                 CO2 sensor required. Simple switch to           Extensive expert review and discussion on internet. Video of
                                                                                                                             Boesmansgat                           Envelope / Human error     retention                                                                                                                                   from addition to equipment by diver and misassembly.                                                        count down to zero when scrubber fitted.        fatal dive on Youtube.
                                                                                                                                                                                                                                                                                                                                                                                                                                                      WOB should not exceed EN14143:2003
                                                                                                                                                                                                                                                                                                                                                                                                                                                      limits.
75   01/01/2005   Unknown                  Inspiration            APD                  -                                    New Zealand                            Scant data                 Scant data.                    Scant details                                                                                           Scant details                                                                                                                                                Confidential communication
74   01/08/2004   Unknown diver             Unknown             Unknown            Buddy Dive                -                 UK                Novice       -    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    BSAC 04/256 Report only.                                                                                         Buoyancy provisions on rebreathers should BSAC Report Only
                                                                                                                                                                                                                             appeared to be very negatively buoyant and he called for assistance. His buddy offered his alternative                                                                                                                   make the rebreather diveable in a shorty
                                                                                                                                                                                                                             air source but the troubled diver did not take it. The buddy had his mask knocked off and his regulator                                                                                                                  without other weight. Buoyancy available
                                                                                                                                                                                                                             knocked from his mouth. The troubled diver sank quickly. There was a 2 knot current. The buddy                                                                                                                           from wing needs sufficient lift for the
                                                                                                                                                                                                                             refitted his equipment and dived down to try to locate the missing diver. He was not successful. The                                                                                                                     flooded rebreather, and a diver using steel
                                                                                                                                                                                                                             Coastguard was alerted and an unsuccessful air and sea search was conducted. His body was found,                                                                                                                         cylinders with steel bail outs.
                                                                                                                                                                                                                             washed ashore, twelve days later.
73   27/08/2004   Earl Peterson            Inspiration            APD              Solo Diving             25/50           USA, Lake Mead,      Untrained     -    Rebreather issue           Hyperoxia due to hypercapnia The diver was very overweight and had medical issues on at least two previous occasions.                       It looks as if diver took an O2 hit and then shot to surface and had an                                     Ensure equipment complies with IEC              From accident investigator and investigator hired by Park
                                                                                                                               Nevada                                                                                                                                                                                                     embolism. O2 hit probably caused by hypercapnia.                                                            61508                                           Service
72   27/07/2004   Luigi Longo                Voyager            Unknown            Solo Diving              14              Italy, Marano        Trainee     34    Rebreather design fault    Hypoxia                        Reported as a rebreather fault resulting in hypoxia. Dive was a try dive organised by Geomar                 Deceased was an only son, ultra fit, naval diver in Foreign Legion and                                      False certifications and false claims for the   http://translate.google.com/translate?hl=en&ie=UTF-
                                                                                                                                                                                                                             Controls.                                                                                                    then tried out the Voyager. The judicial inquiry did not use any                                            Voyager mean that any regulations or            8&sl=it&tl=en&u=http://ricerca.gelocal.it/ilpiccolo/archivi
                                                                                                                                                                                                                                                                                                                                          competent expert, and the case was covered up. The Voyager is                                               standards improvements are likely to be         o/ilpiccolo/2010/07/31/NZ_13_SPAL.html&rurl=translate
                                                                                                                                                                                                                                                                                                                                          hugely over-represented in this list. Equipment was supplied by                                             ignored: active enforcement is necessary        .google.com.au
                                                                                                                                                                                                                                                                                                                                          Nicola Donda, Trieste, who later organised the event that became                                            across the EU, including Italy.
                                                                                                                                                                                                                                                                                                                                          the Slovenian double fatality in July 2010.
71   24/07/2004   Kikuchi Ayamura          Inspiration            APD              Solo Diving               -             Japan, Okinawa      Experienced   35    Rebreather design fault    Hypercapnia: WOB/CO2           Equipment malfunction: there was information about several breakdowns of the CCR before the                  Diver was a medical doctor. Mother a concert piano soloist.               Divers should be taught the       Active WOB measurement required.             http://eco.ac/ckc/new/nippon/accident-list.html
                                                                                                                                                                                              retention                      accident. Body was not found. Most plausible cause is high WOB due to savage current. WOB of this            Devastating effect on the family concerned.                               WOB limits, and what they         Ensure WOB is within EN14143:2003
                                                                                                                                                                                                                             equipment was more double the EN14143 safety limit.                                                                                                                                    mean.                             limit.
70   29/06/2004   Johnny van der Walt    Draeger FGG 3          Unknown            Buddy dive              15/54             South Africa,       Expert       -    Rebreather issue           Hypercapnia or hypoxia         Apparent sudden loss of consciousness underwater. Suggested heart attack.                                    Much more likely hypercapnia or hypoxia: latter from using gas that       Gas less than 99% O2 cannot       O2 cells should be calibrated in air, not on Confidential communication and inquest reports
                                                                                                                               Sodwana                                                                                                                                                                                                    is not pure O2.                                                           be used in rebreathers. This      pure O2. Checks needed to ensure the O2
                                                                                                                                                                                                                                                                                                                                                                                                                    message is not getting            is really pure O2.
                                                                                                                                                                                                                                                                                                                                                                                                                    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.




                                                                                                                                                                                                                                               Page 11 of 20
                                                                                                                                                                                                                                    d9081ce0-7e95-44ed-9e81-0fdd6fd43e58.xls



                                                         Electronics
                                                           fitted to
                                                                                                Depth of accident
                                          Rebreather    rebreather for   Type of dive (Solo,                                                                           Root Case using fault        Disabling Injury using                                                                                                                        Comments or Discussion in arriving at most plausible cause,                                                                                                   An external reference confirming that accident
       Date        Deceased's Name                                                             (/deepest/planned        Location              Experience         Age                                                                 Key information received on accident                                                                                                                                     Training implications                           Design implications
                                           involved          PPo2        Group, Cave etc.)                                                                             tree method                  fault tree method                                                                                                                             addition to use of the Fault Tree.                                                                                                                                               occurred
                                                                                                     ) (m)
                                                        Monitoring or
                                                           Control
69   24/05/2004   Eddie Girvan            Inspiration       APD              Buddy dive               50              UK, Chepstow            Experienced        44    Rebreather design fault      Hypoxia                      Buddy described how had found Deceased unconscious, with his rebreather handsets - which control                 Cause of not being in dive mode is almost certainly may have had                                            Electronic rebreather controllers should      http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                                                                                                                                 the addition of oxygen into the breathing loop - not fully switched on. BSAC report 04/172 contains              problem and switched Rebreather off, but software bug prevents                                              comply with IEC 61508. In this case the       nger.htm
                                                                                                                                                                                                                                 following further information: ""hree divers using rebreathers prepared to make a dive to a maximum              restart, battery bounce, cracked handsets, any of numerous                                                  equipment did not comply as it had many
                                                                                                                                                                                                                                 depth of 60m. One of them waited in the water for the others to finish kitting up as he was warm. They           electronic components, or simply known software faults with this                                            single points of failure.
                                                                                                                                                                                                                                 then swam 20m to a shotline and began their descent. They descended the line one behind the other,               version of rebreather.
                                                                                                                                                                                                                                 with the diver who had waited in the water last. They checked each other twice during the descent.               Rebreather not in dive mode and did not go into dive mode
                                                                                                                                                                                                                                 The first two divers arrived at the bottom of the shotline at a depth of 50m. They changed the settings          automatically when in use: this is a fundamental design mistake that
                                                                                                                                                                                                                                 of their rebreathers and one attached a strobe to the shotline. They looked up for the third diver but           would have been avoided had Functional Safety design procedures
                                                                                                                                                                                                                                 he was not there. They checked around and they made an ascent to the surface. The missing diver was              been used.
                                                                                                                                                                                                                                 not at the surface. They raised the alarm and one of the divers re-descended to search for the missing           Coroner was not aware of the problems with this Rebreather leading
                                                                                                                                                                                                                                 diver. He found the missing diver on the bottom. His rebreather hand sets were found to be part way              to a highly questionable verdict. The Coroner was misled by the
                                                                                                                                                                                                                                 through the set up sequence. The casualty had his mouth piece in place and the rescuing diver                    failure to disclose this key fact about this particular rebreather model
                                                                                                                                                                                                                                 completed the rebreather set up sequence and then brought the casualty to the surface. Both divers               and age.
68   01/05/2004   Wiktor Bolek            Inspiration    APD Classic         Solo Diving               6                Germany,                 Expert           -    Underlying Illness /         Hypoxia but autopsy reported Diver made the casualty to ahis buddyand 6m where theyto recover him from the water. Resuscitation
                                                                                                                                                                                                                                 then towed short dive with pontoon on others helped separated: the buddy went deeper (because                    Deceased did not have BI buzzer (Deceased had disconnect buzzer                                                                                           http://gnj.org.pl/artykuly/wiktor.php
                                                                                                                        Wildeshutz                                     Rebreather fault / Human     Heart attack                 he had different aim for this dive) and victim has turn back to the surface to take some more O2 stages          some time before for deep dives), that is why Deceased did not hear
                                                                                                                                                                       error                                                     and settle them on 6m. Diver had been found on surface unconscious. In medical report as a cause was             signals when PPO2 was getting lower
                                                                                                                                                                                                                                 given heart attack but there were also some suspicions that diver did not open O2 valve, so he had
                                                                                                                                                                                                                                 hypoxia, without alarms
67   24/04/2004   Peter 'Crusty'          Inspiration    APD Classic     Solo Diving, Wreck           50             Australia, Sydney        Experienced         -    Human error                  Human error: Removed         During a wreck penetration diver had removed the rebreather to go through small hole and snagged,                Not an equipment failure but may be a training failure because          Directors of one agency are         Rebreather needs to be designed for             http://www.btinternet.com/~madmole/DiverMole/DMDa
                  McDowell                                                   penetration                                                                                                            rebreather                   leaving the equipment out of reach. Witness report on file.                                                      agencies are training divers to do this procedure.                      known to teach their                removal underwater and this functionality nger.htm
                                                                                                                                                                                                                                                                                                                                                                                                                          recreational students to            neesds to be part of diving system with a
                                                                                                                                                                                                                                                                                                                                                  Divers are not aware that a RB will usually float up, and not sink like remove their RBs in a pool.         breathable gas source available to diver at all
                                                                                                                                                                                                                                                                                                                                                  tanks, and also off the diver the rebreather cannot be breathed due to                                      times.
                                                                                                                                                                                                                                                                                                                                                  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.
66   01/04/2004   Richard Diamond         Prism Topaz        SM              Solo Diving               0                 Thailand             Experienced        40s   Underlying Illness /         Heart attack, during a period    A diver jumped in for his morning dive and came back to the surface quickly, unconscious and died            Details known to JB and reported. Buddy was also a Prism diver,                                                                                           http://sportsnetwork.talk-about-
                                                                                                                                                                       Rebreather fault             of hypercapnia                   shortly thereafter. Plausible causes are hypercapnia, hypoxia. No report of Rebreather flood. The            who checked Deceased's Rebreather after accident, but found no                                                                                            network.com/Subic_Bay_Incident-006773-2469.html
                                                                                                                                                                                                                                     cause was reported to be a massive heart attack, but this was an exceptionally fit individual, who ran       cause: no scrubber testing carried out. SMI did not have an
                                                                                                                                                                                                                                     every day. Those who knew Deceased discount the heart attack theory.                                         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.
65   09/03/2004   Deane Brown              Dolphin        Unknown            Buddy dive               16               Philippines,              Expert           -    Underlying Illness /         Heart attack, during a period    The diver was an instructor and was making a training dive with a student. At the bottom the student                                                                                                                     CO2 sensor required. Simple switch to         http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                     Olongapo, Subic                                   Rebreather design fault      of hypercapnia                   lost visual contact with instructor and ascended. The instructor was found at the bottom after about an                                                                                                                  count down to zero when scrubber fitted.      nger.htm
                                                                                                                           Bay.                                                                                                      hour. An autopsy came to conclusion that the cause of death was a massive heart attack but coroner                                                                                                                       WOB should not exceed EN14143:2003
                                                                                                                                                                                                                                     would be unaware of hypercapnia risk. Scrubber exhausted, so likely to have high PPCO2 on exhale,                                                                                                                        limits.
                                                                                                                                                                                                                                     hence diver suffering from hypercapnia.
64   07/03/2004   Luca "El Bombarolo"     Inspiration    APD Classic         Solo Diving              20            France, Cote d'Azur       Experienced         -    Rebreather design fault:       Hypoxia                        Most plausible cause is a modification that failed as it was being tested, but data too scant to conclude.                                                                              Solo diving on rebreathers is                                                  http://www.rebreatherworld.com/rebreather-accidents-
                  Torelli                                                                                                                                              possibly a modification that                                  Rebreather was modified to be a KISS style unit, in which case the Inspiration controllers would have                                                                                   much more hazardous than on                                                    incidents/14619-comprehensive-list-all-accidents.html
                                                                                                                                                                       failed as it was being tested.                                acted as PPO2 monitors. Solo diving testing a new feature.                                                                                                                              Open Circuit. Divers should
                                                                                                                                                                                                                                                                                                                                                                                                                             not modify eCCRs.
63   01/03/2004   Lothe Kaiser            Inspiration    APD Classic         Buddy dive              20/5            Norway, Håkøy,           Experienced        26    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                                                                                                                                                                   Public information is from page 5, top post of
                                                                                                                      Tirptitz wreck                                                                                                 Martin after being at a depth of 20 meters, diver made a stop at 5 (five) meters deep for about ten                                                                                                                                                                    http://translate.googleusercontent.com/translate_c?hl=en&
                                                                                                                                                                                                                                     minutes and suddenly rose to the surface without meaning and there remained until found (data                                                                                                                                                                          sl=it&tl=en&u=http://www.marescoop.com/ftopic-1881-
                                                                                                                                                                                                                                     collected by the wrist computer),                                                                                                                                                                                                                                      days0-orderasc-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            60.html%26sid%3D13118a1e497c5631205b9faece3772d2&r
                                                                                                                                                                                                                                     Deceased was engaged in from physical sports 22 years of age, 'myocardial there' enter.                                                                                                                                                                                url=translate.google.com.au&usg=ALkJrhg8dMApwPS2Tgg-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            ugzFibWwjsaMVg
62   01/01/2004   Alessandro Brusatori     Voyager         Unknown               -                    10            Italy, Maggiore Lake            -             -    Scant data                   Scant data                       Scant data                                                                                                   Scant data                                                                                                                                          Confidential communication and inquest reports
61   12/12/2003   Steven Alan Russell     Megalodon     ISC Apecs eCCR       Buddy dive                -             USA, Bonne Terre                                  Rebreather issue/human       Scant data                                                                                                                                    Bonne Terre mine - there are multiple reports of it being a                                                                                         http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                          Mine, MN                                     error:                                                                                                                                                                     dangerous and badly run dive facility.                                                                                                              incidents/14619-comprehensive-list-all-accidents-3.html
60   26/10/2003   Clemens Neuenhaus       Inspiration   ISC Apecs eCCR       Solo Diving              17                    Egypt                   -             -    Rebreather design fault      Scant data                       Scant data but strong similarity with other accidents, hence classification.                                                                                                                                          Simple switch needed to detect scrubber    http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                                                                                                                                                                                                                                                                                                                                                           replacement, and countdown timer. CO2 nger.htm
                                                                                                                                                                                                                                                                                                                                                                                                                                                           monitor needed.
59   23/08/2003   Wolfgang Lutz           RB80 Clone      Unknown            Solo Diving               3                 Germany                Novice                 Rebreather design fault      Hypercapnia from no              Coroner ordered a recall of the equipment. Novice diver on RB. Diver used RB80 Clone, i.e. EDO04.            Here are some pictures of the faulty part:                                 Solo diving on rebreathers is Negligence in equipment design: failure to Confidential communication and inquest reports
                                           (EDO04)                                                                                                                     (Prosecutor's office ordered scrubber                         Accident happened at 3m, ascending from his 4th dive on the unit. Sudden LOC due to hypoxia,                 http://www.unterwasser.de/aktuell/Newsdetail/d453783a-00d1-                much more hazardous than on test the part to EN14143.
                                                                                                                                                                       a recall)                                                     though indicator was hypercapnia. Public prosecutor put out an order for immediate recall of the             4bd3-be65-2a5989fbc165/                                                    Open Circuit
                                                                                                                                                                                                                                     equipment as the deaths are due to a design fault (faulty mushroom valve material and spider).               and here
                                                                                                                                                                                                                                                                                                                                                  http://www.getoese.de/tauchen/themen/archiv2003/kreislaufgera
                                                                                                                                                                                                                                                                                                                                                  et.htm
                                                                                                                                                                                                                                                                                                                                                  There are other factors which 'helped' the accident to happen:
                                                                                                                                                                                                                                                                                                                                                  - solo
58   24/04/2003   Dan Meyers               Azimuth        Unknown            Buddy dive                3               USA, Willow            Experienced        40    Rebreather design fault      Hypoxia                          Quarry diving. Diver was relaxing at the bottom of the entry platform and his mates found him                                                                                                                            PPO2 display required. Auto-loop shut off     Confidential communication and
                                                                                                                      Springs Quarry,                                                                                                unresponsive. His equipment had gone to low-flow and he passed out and drowned.                                                                                                                                          required.                                     http://www.smokeysdiversden.com/diver_dan/dan1.html#
                                                                                                                       Richland, PA
57   24/04/2003   Deki Aboitiz             Dolphin        Unknown            Buddy dive               30                Philippines             Trainee                Human error                  Hypoxia, Narcosis                Ascending after reef dive. Deceased was left alone, and found tangled with the reef hook at 60m. He                                                                                                                                                                    http://raven.utc.edu/cgi-
                                                                                                                                                                                                                                     had not yet been certified on the Rebreather and was still in training. JB has detailed report.                                                                                                                                                                        bin/WA.EXE?A2=ind0306&L=SCUBA-SE&P=19767
56   06/02/2003   Tomas Rosenfeldt        Inspiration    APD Classic         Solo Diving              100              Hawaii, Kona        Conflicting reports    -    Scant data                   Scant data                       Scant data. Body was not found. A known fact is that the Kona Aggressor boat was used for diving.            Scant data. Body was not found. A known fact is that the Kona                                                                                             http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                                                                                                                                     Aggressor fleet conceals dive accident information. Witness report received by DL.                           Aggressor boat was used for diving. Aggressor fleet conceals dive                                                                                         nger.htm
                                                                                                                                                                                                                                                                                                                                                  accident information. Witness report received by DL.
55   01/01/2003   Unknown diver             Fieno         Unknown                 -                                                                                    Scant data                   Scant data.                      Scant data.                                                                                                  Scant data.                                                                                                                                               Confidential communication and inquest reports
54   10/08/2002   Carlton Lee             Draeger Ray      None              Solo Diving              17                Singapore                                      Underlying Illness /         Heart attack during heavy        Heavy current, and heavy person (weighed 300lbs), found with 1 fin missing. Coroner's report was             Most likely cause of several is hypercapnia: diver over-breathed the                                        WOB monitoring required. WOB should           Confidential communication and inquest reports
                                                                                                                                                                       Rebreather design fault      work and hypercapnia             heart attack.                                                                                                Rebreather in the heavy current, which given the Deceased's general                                         not exceed EN14143:2003 limits.
                                                                                                                                                                                                                                                                                                                                                  coronary health, triggered a heart attack.
53   06/08/2002   Unknown diver            Unknown                           Buddy dive                -             Croatia, Island of             -             -    Scant data                   Scant data                       Scant data                                                                                                   Reported by witness.                                                                                                                                      Confidential communication and inquest reports
                                                                                                                          Mljet
52   03/08/2002   Robert Barrett          Inspiration    APD Classic         Solo Diving              14             USA, Bainbridge,       RB Expert, Inspo     32    Rebreather design fault      Hypoxia                          Witnesses describe Barrett as the best diver they had ever seen. Full investigation carried out. Mr.                                                                                     An experienced Draeger          Electronic rebreather controllers should     Full accident investigation with all evidence available
                                                                                                                            PA             Experienced. O.C.                                                                         Barrett was teaching an 18 year old student to use a Dolphin rebreather on 3rd August 2002,             that he suffered a sudden loss of consciousness due to hypoxia. The             diver, so would not be used to   meet IEC 61508. Equipment involved did
                                                                                                                                            trimix instructor.                                                                       accompanied by two other divers on open circuit. Mr. Barrett was using an Inspiration rebreather to     was also the opinion of medical experts. Master handset battery                 look at his handset. This was    not comply in any shape or form, with many
                                                                                                                                                                                                                                     build up his hours: he had done 65 to 70 hours but the US Distributor appears to have required 100      failure when slave was sitting in "Dive Now?" mode after battery                not given enough emphasis in     single points of failure. Equipment liable
                                                                                                                                                                                                                                     hours before Mr. Barrett could be an instructor on the unit. All four divers had completed a shallow    bounce. Cause is almost certainly sudden failure of master battery              training.                        reset into modes which did not support life,
                                                                                                                                                                                                                                                                                                                                             after battery bounce on slave. Counsel for manufacturer has                                                      and can hang.
                                                                                                                                                                                                                                     shallow dives. The Inspiration rebreather was in the same state as it left the factory for all material suggested four alternative causes, but these are plainly contradicted
                                                                                                                                                                                                                                     purposes. It had been manufactured less than 2 months previously though he received his Inspiration by validated facts (e.g. they claim the diver died due to using the
                                                                                                                                                                                                                                     training in the first week of March 2002. The Inspiration was a 2002 model of the APD Inspiration       wrong sorb - the diver fitted new Draegersorb, which is generally
                                                                                                                                                                                                                                     rebreather.                                                                                             better sorb than 797 in independent tests).
                                                                                                                                                                                                                                     It was a hot day: 90F to 95F. The back of the Inspiration would have been off during part of the day.   Hypoxia fault modes were reproduced in examination of the
                                                                                                                                                                                                                                     The divers were wearing dry suits. They had to carry their equipment for between 3 and 5 minutes        equipment and tied in perfectly with formal modellng of the
                                                                                                                                                                                                                                                                                                                                             accident: there is no doubt at all the diver died from hypoxia.
                                                                                                                                                                                                                                     around 130lbs. During this walk he would have been stressed with the heat, wearing a dry suit.          However, jury of 8 decided that manufacturer was not legally
                                                                                                                                                                                                                                     The dive profile was a short surface swim and then a dive to 4.5m, pause on a platform, then to 11m,    culpable for accident. Diver had not looked at his handsets for a 6
                                                                                                                                                                                                                                     and after three minutes ascent back to 4.5m, ending in sudden LOC after 6.5 minutes total dive time. minute period, and the manufacturer advises the diver to look at the
                                                                                                                                                                                                                                     Mr. Barrett was breathing from the rebreather before he passed out. References to a regulator by the handsets every minute, and continuously on ascent: the Deceased
                                                                                                                                                                                                                                     diver who carried out the recovery mean the rebreather mouthpiece: the regulator was stowed and the failed to do that.
                                                                                                                                                                                                                                     tank with the regulator was full.                                                                        Ethics by manufacturer and their legal counsel on this were very
                                                                                                                                                                                                                                     The witness reports do not indicate any stress or loss of mental reasoning, or odd behaviour before     poor, slandering main witnesses on internet, in print and privately in
                                                                                                                                                                                                                                     Mr. Barrett left the other divers. Mr. Barrett left the other divers not more than one or two minutes   heavy concerted campaign, and used countersuits on widow, expert
                                                                                                                                                                                                                                     before the accident: it may have been only 30 seconds. He left for reasonable cause: the visibility was witness, legal counsel of plaintiff etc which has had the effect of
                                                                                                                                                                                                                                                                                                                                             putting relatives in other hypoxia cases from prosecuting their
                                                                                                                                                                                                                                     Mr. Barrett to keep his trio together. Almost immediately after leaving the group Mr. Barrett swam      respective claims.
                                                                                                                                                                                                                                     towards the surface: this might be that he recognized his rebreather had malfunctioned but with his     This model of the Inspiration is much improved on Nick Hester's
                                                                                                                                                                                                                                     training he would more likely bail out. He probably simply ascended to find where he was. Signs of      first attempt (pre Aug 2000 Inspirations), which were little more
                                                                                                                                                                                                                                     battery bounce on battery contacts, but batteries removed by manufacturer's representative. Diver       than slaughter machines that would hang, reset or jump to random
51   18/05/2002   Michel Guerin          CCR1000 (MK-     Unknown             Semi-solo                6                Canada,                  Expert          42    Rebreather design fault /    Hypoxia.                          Witness report.                                                                                        Diver could have turned off the electronics or the O2 bottle on the                                              Auto-shut off valve would have avoided        http://www.aquanaute.com/listes/aquatek/msg00311.html
                                             15)                                                                       Tobermory,                                      Human error                                                                                                                                                           surface and forgotten to turn them on in the water. Hypoxia.                                                     accident.
                                                                                                                        Ontario.
50   11/05/2002   Unknown Spanish         Inspiration    APD Classic         Buddy dive                4                   -                                           Rebreather design fault      Hypoxia.                         During ascent diver LOC at 4 m and drowned.                                                         Most plausible cause, hypoxia. This is understood to another one of                                                  Electronic rebreather controllers should      Confidential communication and inquest reports
                  diver                                                                                                                                                                                                                                                                                                                  the pre-Aug 2000 models that has a strong tendancy to hang.                                                          meet IEC 61508.
49   06/05/2002   Dean Livesey            Inspiration    APD Classic         Buddy dive                4             Channel Islands,               -             -    Rebreather design fault      Hypoxia                          Diver entered water after calibrating his Rebreather twice for unknown reason. Appeared unconscious Hypoxia. Appears to be due to an electronic failure, but scant                                                       Electronic rebreather controllers should      http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                         Sark                                                                                                        at 4 m in head down position.                                                                       information. Was this one of the pre-Aug 2000 designs?                                                               meet IEC 61508.                               nger.htm
48   01/05/2002   Unknown diver            Unknown                                -                  0/60/-               UK                        -             -    Scant data                   Scant data.                      Only report of BSAC 02/112. Diver was seen to surface and then sink back down. He did not                                                                                                                                                                              http://www.bsac.com/uploads/documents/Diving_Safety/i
                                                                                                                                                                                                                                     resurface and body was not found.                                                                                                                                                                                                                                      ncidents/the_2002_report.pdf
47   01/01/2002   Unknown male             Dolphin        Unknown            Solo Diving              60             Norway, Askøy,             Novice           40    Rebreather issue/human       Scant data                       First dive after course. Points to a training problem, depth is body recovery depth.                                                                                    Review of instructor standards                                                                 http://www.rebreatherworld.com/rebreather-accidents-
                                                                                                                        Bergen.                                        error                                                                                                                                                                                                                                                                                                                                incidents/



                                                                                                                                                                                                                                                       Page 12 of 20
                                                                                                                                                                                                                                        d9081ce0-7e95-44ed-9e81-0fdd6fd43e58.xls




                                                              Electronics
                                                                fitted to
                                                                                                     Depth of accident
                                         Rebreather          rebreather for   Type of dive (Solo,                                                                              Root Case using fault      Disabling Injury using                                                                                                                 Comments or Discussion in arriving at most plausible cause,                                                                                                   An external reference confirming that accident
       Date        Deceased's Name                                                                  (/deepest/planned        Location               Experience           Age                                                             Key information received on accident                                                                                                                                Training implications                           Design implications
                                          involved                PPo2        Group, Cave etc.)                                                                                tree method                fault tree method                                                                                                                      addition to use of the Fault Tree.                                                                                                                                               occurred
                                                                                                          ) (m)
                                                             Monitoring or
                                                                Control
46   01/01/2002   Unknown diver             Fieno              Unknown                -                     -                                                                  Scant data                 Scant data.                    Scant data.                                                                                             Scant data.                                                                                                                                               Confidential communication and inquest reports
45   01/11/2001   Bernard Gonon           Inspiration         APD Classic         Buddy dive               100                 France                Experienced         55    Rebreather design fault    Hypoxia                        Appears to be an early model of that Rebreather which is prone to hang.                                                                                                                                             Electronic rebreather controllers should      http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                                                                                                                                                                                                                                                                                                                                                             meet IEC 61508.                               nger.htm
44   16/09/2001   Eric Reichardt       Cis-Lunar Mk5P          Cis-Lunar          Solo Diving               90              USA, Florida             Experienced         42    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 Not far from a popular shark feeding site.                                                                                                                      http://www.scubaboard.com/forums/86091-post8.html
                                                                                                                                                                                                                                         drowning. The shark attack was confirmed by autopsy report. The wreck was known to be the home
                                                                                                                                                                                                                                         of a 13ft Bull Shark.
43   01/08/2001   Adriano Busato           Azimuth             Unknown            Buddy dive                3             Italy, Garda Lake            Trainee            -    Rebreather issue           Hypoxia.                       Training dive first time: during the 3 m safety stop Deceased stopped breathing.                                                                                                                                    Data points to an Rebreather design fault.    http://216.239.59.104/search?q=cache:gHm85BLPwHwJ:w
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           ww.nwdesigns.com/rbarchive/2003/1121.html.gz+Fieno+fat
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           ality&hl=en&ct=clnk&cd=3
42   01/07/2001   Unknown                  Unknown                                Buddy dive                15                   UK                       -               -    General diving hazard      Entanglement                   Only report of BSAC 01/237. One of the pair became tangled in SMB line. The diver was not found.                                                                                  Need to carry line cutters as                                                   http://www.bsac.com/uploads/documents/Diving_Safety/i
                                                                                                                                                                                                                                                                                                                                                                                                                           standard equipment                                                              ncidents/the_2001_report.pdf
41   01/07/2001   Mick Brennan            Inspiration         APD Classic         Solo Diving            110 - 120        Wales, Holyhead       Expert on Trimix O.C.,    -    Rebreather design fault    Hypoxia                        Master handset hung, with pre-backlit handsets that were very prone to hang. RB bought second           Two witness reports. Rumour that Deceased was untrained or had                                              Electronic rebreather controllers should      http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                                                 Intermediate on RB                                                                      hand. Training was spread out, as no proper structure at the time. Deceased would have been             few hours Rebreather is false. Inquest had vital information                                                meet IEC 61508. Incompetent electronic        nger.htm
                                                                                                                                                                                                                                         qualified automatically for trimix (MOD 3) because he had extensive O.C. trimix experience and          withheld. A cover up seems to have occurred.                                                                design was most probable cause of this
                                                                                                                                                                                                                                         certs, and more than 50 hours on the rebreather in the 7 months since purchase. BSAC report                                                                                                                         accident.
40   23/06/2001   Garrett Weinberg        Inspiration         APD Classic         Buddy dive        30, JB comments may USA, Mukilteo, WA              Expert             -    General Diving Hazard /    AGE                            01/218.
                                                                                                                                                                                                                                         JB: Reports dry suit inflator caused uncontrolled ascent from 90m to surface, he got to surface,        Frustrating accident, where a DCS was treated as if the diver was                                                                                         Claudia Milz (dive partner, and also Fiancee), reported to Jeff
                                                                                                            be 90m                                                             Rebreather issue /                                        reported to those on shore that he needed help, was taken to emergency room instead of to a             having a heart attack, despite pleas by diver to the contrary.                                                                                            Bozanic
                                                                                                                                                                               Inappropriate medical                                     chamber. Deceased was suffering pulmonary DCS but was treated as if it was a heat attack.               Incompetent medical personnel.
                                                                                                                                                                               response
39   06/06/2001   Ghassem Geissary         CCR2000             Unknown            Buddy dive                 -                 France                Experienced          -    Human error                Hypoxia                        Diver started the dive with a malfunctioning unit. He had no PPO2 display. The system would not         Witness report.                                                                                                                                    http://216.239.59.104/search?q=cache:dL6d7CjN2xoJ:www
                                                                                                                                                                                                                                                                                                                                                                                                                                                             PPO2 display required. Auto-loop shut off
                                                                                                                                                                                                                                         have maintained a PPO2 of .7. Witness report.                                                                                                                                                                       required.                              .diveoz.com.au/OLD_FORUMS_GONE/lm.asp%3Fid%3
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    D4083%26pp%3D1
38   01/06/2001   Unknown                  Unknown                                Solo Diving               35                   UK                  Experienced          -    Scant data                 Hyperoxia due to hypercapnia Only report of BSAC 01/186. An instructor was teaching on a rebreather course. He dived and is                                                                                      Awareness that CNS limits     Provide adequate margin for CNC clock.     http://www.bsac.com/uploads/documents/Diving_Safety/i
                                                                                                                                                                                                                                       reported to have suffered an oxygen toxicity convulsion as he made his ascent.                                                                                                      need proper margins, and that Provide CO2 monitoring. Simple switch to ncidents/the_2001_report.pdf
                                                                                                                                                                                                                                                                                                                                                                                                                           high CO2 causes limits to     count down to zero, and disable loop, that
                                                                                                                                                                                                                                                                                                                                                                                                                           reduce dramatically.          resets when scrubber fitted. WOB should
                                                                                                                                                                                                                                                                                                                                                                                                                                                         not exceed EN14143:2003 limits.
37   24/05/2001   Jan Magnus Soerboe      Inspiration         APD Classic         Solo Diving               25                 Norway                     -                    Rebreather design fault    Hypoxia                        Diver was found floating on the surface after 1.5 hours.                                                Classification and cause is based on the being a non-backlit model of                                                                                     http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                                                                                                                                                                                                                                                 Inspiration that was prone to hang,                                                                                                                       nger.htm
37   12/05/2001   Steve Hughes            Inspiration         APD Classic         Buddy dive                50                England                  Novice             -    Human error / Rebreather   Scant data.                     BSAC Incident report 01/155. The missing diver was not found. Rebreather was prone to hang.                                                                                                                        Electronic rebreather controllers should      http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                                                                               design fault                                              Novice diver at trimix depths.                                                                                                                                                                                      meet IEC 61508.                               nger.htm
36   07/01/2001   Hans Schneider          Inspiration         APD Classic          Solo dive               110                England              Intermediate or        -    Scant data                 Scant data.                     Rebreather was prone to hang. It is not known how deep the diver planned to dive: the body was         Scant data, but this is the model of the Inspiration that was prone to                                      Electronic rebreather controllers should      RBW accident list, tied up with an unverified accident on this
                                                                                                                                                     Experienced                                                                         recovered four weeks after the dive in a depth of 110m to 120m, but may have been swept there. Air      hang.                                                                                                       meet IEC 61508.                               date.
                                                                                                                                                                                                                                         make-up-gas was connected, indicating the dive was planned to be shallow.
35   01/01/2001   Stefano Sbizzera        Azimuth or                                   -                     -              Sardinia, Italy               -               -    Scant data                 Scant data                     Scant data                                                                                              Scant data                                                                                                                                                Confidential communication and inquest reports
                                           CCR2000
                                       conflicting reports
34   27/11/2000   Dennis Harding        Halcyon "Fridge"       Unknown            Buddy dive                70           South Africa, Jesser          Expert             -    Rebreather design fault    Hypercapnia: WOB/CO2           Suggested that diver suffered from a CO2 problem caused by WOB, when swimming very hard to              WOB of Rebreather is well above accepted safety limits.                                                     Active WOB measurement required. WOB http://www.rebreatherworld.com/rebreather-accidents-
                                        (Halcyon PVR-                                                                     Canyon, Sodwana                                                                 retention                      overcome current, with "Fridge" on his back. Coroner's verdict: Dennis died as a result of Severe                                                                                                                   should not exceed EN14143:2003 limits. incidents/14619-comprehensive-list-all-accidents-2.html
                                             BASC)                                                                              Bay                                                                                                      Decompression Illness. Underlying cause was hypercapnia. Detail analysis report:
                                                                                                                                                                                                                                         http://www.nwdesigns.com/rebreathers/Nuggets/Halcyon/DennisHardingAbridgedReport.htm
                                                                                                                                                                                                                                         and witness report.
33   09/08/2000   Ron Fuller                 FROG              Unknown            Solo Diving               17              USA, La Jolla            Experienced         51    Rebreather issue/human     Scant data                     Unsatisfactory investigation. It is reported that diver had made some modifications to his rebreather                                                                                                                                                             http://www.nwdesigns.com/rbarchive/2000/3963.html.gz
                                                                                                                             Shores, CA                                        error.                                                    but whether these are relevant is not known. Victim is reported to have been
                                                                                                                                                                                                                                         appeared to be overweighed and never ditched his weight belt.
32   06/08/2000   Andy Wilde              Inspiration         APD Classic         Buddy dive                6            England, Plymouth           Experienced          -    Rebreather issue           Hypercapnia from spent         Very deep dive as part of a team practicing for a 172m dive. Diver spat out the mouthpiece and          This was a deep dive. Same version of Inspiration with faulty             Divers should be extremely        Provide adequate margin for CNC clock.     http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                                                                                                          scrubber                       rushed to surface during 6m stop after 2 hours 45 minutes. Information on maximum scrubber              handset design as killed Paul Haydon, but due to the phase of the         careful on rebreather scrubber    Provide CO2 monitoring. Simple switch to nger.htm
                                                                                                                                                                                                                                         durations may not have been applied correctly. Body was not recovered. Diver is reported to use a 1.4   dive when this occurred, cause of death more likely to be simply          endurance where a profile is      count down to zero, and disable loop, that
                                                                                                                                                                                                                                         bar setpoint and 1.6 bar on deco. BSAC report 00/179.                                                   Hypercapnia or CNS. The diver did exceed CNS limits, but the              given rather than constant        resets when scrubber fitted. Always
                                                                                                                                                                                                                                                                                                                                                 level of O2 exposure is very unlikely to have caused an issue. The        depth. The former is almost       provide constant depth scrubber endurance
                                                                                                                                                                                                                                                                                                                                                 Inspiration scrubber duration at a constant 40m depth under CE            marketing data, the latter is     figures, not just profiles with very short
                                                                                                                                                                                                                                                                                                                                                 conditions is not disclosed: a profile is used because after 20 minutes   what the diver must keep          times to a given depth.
                                                                                                                                                                                                                                                                                                                                                 signs of breakthrough can be observed. This mix of "profile" and a        within, as there is an infinite
                                                                                                                                                                                                                                                                                                                                                 reference to 40m depth, can cause divers to believe the scrubber          nuber of possible profiles.
                                                                                                                                                                                                                                                                                                                                                 duration is better than it is.                                            Awareness that CNS limits
                                                                                                                                                                                                                                                                                                                                                                                                                           need proper margins, and that
                                                                                                                                                                                                                                                                                                                                                                                                                           high CO2 causes limits to
                                                                                                                                                                                                                                                                                                                                                                                                                           reduce dramatically.
31   13/06/2000   Ian Swift               Inspiration         APD Classic         Buddy dive                48              UK, Salsette,              Expert            41    Rebreather design fault    Hyperoxia                       Diver tried but failed to bail out before convulsing at 43msw. Rebreather had gone back to APD 5      Rebreather was designed with gross incompetence in not having any                                            Equipment had grossly incompetent safety      http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                             Portland                                                                                                    times due to equipment faults, but in any case the Rebreather should not have had old cells in it. May brown out, and no watchdog. Equipment would jump to other                                                    design with no brown-out or watchdog.         nger.htm
                                                                                                                                                                                                                                         be BSAC report 00/134?                                                                                 modes due to random values being in unused memory. May have                                                  Force annual service intervals by a handset
                                                                                                                                                                                                                                                                                                                                                been exacerbated by an O2 cell fault but unlikely.                                                           countdown, then disable unit. Factory
                                                                                                                                                                                                                                                                                                                                                                                                                                                             service should replace cells.
30   01/06/2000   Dr Max Hahn             Inspiration         APD Classic         Buddy dive                43           Germany, Bigge-See            Expert            70    Exceeded Performance       Hypercapnia, followed during Scrubber was exhausted. Diver closed tank valves during ascent. Most plausible cause is hypercapnia, Deceased was the Chairman of the European Standards committee                                                    Simple switch needed to detect scrubber       http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                                                                               Envelope / Human error /   a period of by hypoxia as    followed possibly by hypoxia as accident progressed. Heart disease indicated in autopsy.             that defined rebreather safety standards.                                                                        replacement requirement, and countdown        nger.htm
                                                                                                                                                                               Underlying medical         accident progressed.                                                                                                                                                                                                                               timer. CO2 monitor needed.

29   07/08/1999   Peter Osborne        Cis-Lunar Mk5P          Cis-Lunar            Surface                 0              England, Isle of               -              44    Rebreather design fault    Hypoxia.                        Rebreather was turned off: Rebreather does not turn on automatically.                                  Failing to turn a Rebreather on is such an obvious risk, especially as                                      Auto-turn on required.                        http://wrolf.net/Cautionary.html
                                                                                                                               Wight                                                                                                                                                                                                             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.
28   26/06/1999   Maarten van der         Inspiration         APD Classic         Solo Diving               27             Holland, Freisan               -              36    Rebreather design fault    Hypoxia                        Rebreather did not switch on automatically and was prone to hang, as it suffered from battery bounce    Suggestion that Rebreather was not switched on or in dive mode, is                                          Gross incompetence in equipment design http://www.btinternet.com/~madmole/DiverMole/DMDa
                  Weerdt                                                                                                       Islands,                                                                                                  and had no brown-out circuit. Equipment had same gross faults as that in the accident of 23/5/98        likely false, since divers were not separated until 90s into the dive.                                      in this model of the unit, causing it to hang. nger.htm
                                                                                                                          Schiermonnikoog                                                                                                                                                                                                        This is the same type of Rebreather as                                                                      Electronic rebreathers should meet
                                                                                                                                                                                                                                                                                                                                                                                                                                                             EN14143.
27   25/05/1999   Harry Norman            Inspiration         APD Classic          Semi Solo                54            South Coast UK,         Advanced OC mix         -    General diving hazard      Pulmonary barotrauma (Burst Argon suit inflator jammed open. Not rebreather related. Pulmonary barotrauma (Burst Lung)                                                                                           Use of dry suits.                                                                http://www.btinternet.com/~madmole/DiverMole/DMDa
                  Railing                                                                                                     Portland                  diver                                             Lung).                                                                                                                                                                                                                                                                                            nger.htm
26   15/02/1999   Henry Kendall         Cis-Lunar Mk5          Cis-Lunar          Solo Diving               3             Florida, Wakulla,            Expert            72    Rebreather design fault    Hypoxia                     Accident described in Wakulla 2 Expedition Statement by Dr. Bill Stone 18th February 1999,                 Diver won the Nobel prize for Physics in 1990. The reference to                                                                                            Pages from Feb 15 till the 17 were removed.
                                                                                                                          SpringsState Park                                                                                           suggested this was a heart attack during a period of hypercapnia. However, J. Caruso's Medical             other surface supplied rebreathers, refers to more modern                                                                                                   http://www.usdct.org/Updates-Feb/feb18.htm
                                                                                                                                                                                                                                      Examiner's Perspectives, DAN 2010 Fatality Workshop, showing cause was not natural but due to a            equipment, but one-way valves were put into that equipment from
                                                                                                                                                                                                                                      gas switch block being in the "External source" position (intended for use with surface supplied gas),     the outset as a result of running a HAZOP: a basic safety technique
                                                                                                                                                                                                                                      but as a SCUBA configured rebreather this position was one where the rebreather could not provide          that was widely known at the time the Cis Lunar was developed.
                                                                                                                                                                                                                                      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.
25   01/11/1998   Unknown diver             Dolphin            Unknown                                                     USA, Annacapa          Untrained Novice       39    Scant data                 AGE                             Night dive. Scant data.                                                                                                                                                                                                                                          J. Bozanic has extensive information as Deceased treated at his
                                                                                                                             Island, CA                                                                                                                                                                                                                                                                                                                                                                    hyperbaric facility
24   13/09/1998   Keith Milburn           Inspiration         APD Classic         Solo Diving               4             Northern Ireland,          Experienced         44    Human error                Hypoxia.                       O2 Switched off. User did not do a pre-dive breathe on this second dive. Hypoxia.                       Equipment should check the O2 is on if there is electronics to do so,                                       Needs auto-switch-on as an absolute           http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                              Ardglass                                                                                                                                                                                                           or failing that, provide clearer alarms so the accident can be averted.                                     minimum, and auto-shut-off valve. Tank        nger.htm
                                                                                                                                                                                                                                                                                                                                                 Another example where auto-switch on is a manifest requirement.                                             contents sensors need to be part of
                                                                                                                                                                                                                                                                                                                                                                                                                                                             rebreather monitoring.
23   24/07/1998   Nic Gotto               Inspiration         APD Classic          Semi Solo                24                 Ireland,              Experienced         49    Rebreather issue           Hypercapnia or hyperoxia       Scrubber was probably exhausted. Diver used scrubbers for a multiple of their safe duration due to      It was suggested that the diver was heavily overweighted, having an Awareness of scrubber life              CO2 sensor required. Simple switch to         http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                          Castletownshend,                                                                under conditions of            lack of information on safe limit and insufficient testing.                                             expensive camera in one hand and tools in the other. He may not                                             count down to zero when scrubber fitted.      nger.htm
                                                                                                                              Co Cork                                                                     hypercapnia.                                                                                                                           have wanted to jettison his equipment, so reacted to hypercapnia
                                                                                                                                                                                                                                                                                                                                                 poorly.
22   01/07/1998   Andrey Rodjkov              IDA              Unknown            Ice Diving                 -               North Pole,             Experienced          -    Exceeded Performance       Inhale counterlung or the      Based on tests on similar equipment, the most plausible cause is inhale counterlung or the inhale       The diver was ice diving at the North Pole as part of an expedition. A Awareness of the effects of          CL heaters required for dives in water        http://www.videodive.com/films/arktika.php
                                                                                                                             Expedition                                        Envelope                   inhale mushroom valve stuck    mushroom valve stuck together due to icing.                                                             video caught the whole dive, lasting just 8 minutes.                   extreme cold on rebreathers.         under 4C.
                                                                                                                                                                                                          together due to icing
21   20/06/1998   Bob Forster             Inspiration         APD Classic              -                    15               England,                     -                    Human error / Drowning     Drowning                       Stress on the rebreather led to diver dumping the equipment. Diver drowned because he attached a                                                                                  Awareness of effects of                                                         http://www.btinternet.com/~madmole/DiverMole/DMDa
                                                                                                                             Windtown                                                                                                    torch to the rebreather. All the divers in the group had dumped their equipment, which normally                                                                                   dumping equipment in the                                                        nger.htm
                                                                                                                                                                                                                                         floats. Diver's equipment carried his weights.                                                                                                                                    water.




                                                                                                                                                                                                                                                           Page 13 of 20
                                                                                                                                                                                                                                              d9081ce0-7e95-44ed-9e81-0fdd6fd43e58.xls




                                                                  Electronics
                                                                    fitted to
                                                                                                          Depth of accident
                                               Rebreather        rebreather for   Type of dive (Solo,                                                                               Root Case using fault       Disabling Injury using                                                                                                                     Comments or Discussion in arriving at most plausible cause,                                                                                                       An external reference confirming that accident
          Date         Deceased's Name                                                                   (/deepest/planned        Location               Experience           Age                                                              Key information received on accident                                                                                                                                    Training implications                                Design implications
                                                involved              PPo2        Group, Cave etc.)                                                                                 tree method                 fault tree method                                                                                                                          addition to use of the Fault Tree.                                                                                                                                                   occurred
                                                                                                               ) (m)
                                                                 Monitoring or
                                                                    Control
20     27/05/1998     Wesley Gradin              Dolphin           Unknown            Solo Diving               20               USA, Friday             Experienced          45    Rebreather issue / Human    Hypercapnia: WOB/CO2           Very heavy current, loss of consciousness and drowning. Diver also had task loading and further             Nitrox 86 was reported to used with a low flow rate, however,                Awareness of WOB limits for         Need method to monitor WOB actively.         http://www.nwdesigns.com/rebreathers/users/Paul/BodyC
                                                                                                                                 Harbor, WA                                         issue                       retention, and hyperoxia       exertion due to shooting video. Diver was using Nitrox 86 and is reported not to have analysed it           emptying the counterlung would cause pulses of this gas though that          depth and work rates. Diver         WOB should be less than EN14143:2003 ount.htm#Homebuilts
                                                                                                                                                                                                                                               prior to the dive.                                                                                          would occur when the PPO2 was lowered by metabolism and the                  must use the correct gas in an      limits. PPO2 monitor should be fitted to all
                                                                                                                                                                                                                                                                                                                                                           constant leak rate, so the FO2 in the loop would be around 45 to             SCR and it must be analysed         SCRs.
                                                                                                                                                                                                                                                                                                                                                           50%. This PPO2 at 20m is high but unlikely to be quite high                  before the dive.
                                                                                                                                                                                                                                                                                                                                                           enough for an 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.
19     23/05/1998     Paul Haydon               Inspiration       APD Classic      Solo Diving, Trimix          73             England, Devon,         Intermediate or              Rebreather design fault     Hypoxia                        Diver passed out from hypoxia 14 minutes into the dive. O2 tank was empty on recovery, but                   In pre Sept 2000 versions of the Inspiration there was no watchdog                                              Gross incompetence in design of electronic Confidential communication and detailed examination of the
                                                                                                                                  MV Afric               Experienced                                                                           probably from a leak. and during the dive the tank was full. Rebreather was examined by DDRC,               timer, no working brown out circuit, and Rebreather was liable to                                                portion of rebreather, with many single     handsets of the type involved. Inquest report. Full data from
                                                                                                                                                                                                                                               found to have cracked handsets and manufacturer advised of this failure. Cracked handset can cause          suffer battery bounce: the handsets would hang as a result. This                                                 points of failure. The model of Inspiration inquest.
                                                                                                                                                                                                                                               the Rebreather to fail to inject gas, however most likely cause in this case was not the cracked handsets   happened frequently. Deas notified manufacturer in April 2000, with                                              involved was prone to hang.
                                                                                                                                                                                                                                               but battery bounce. This is a very suspicious death, as the manufacturer claims the diver survived 14       report and recommendations in June 2000. Brown out circuit
                                                                                                                                                                                                                                               minutes without any oxygen available for the rebreather. This particular model was very prone to            added, but no recall was made, power system and software still
                                                                                                                                                                                                                                               battery bounce.                                                                                             unsafe.
18     09/05/1998     Unknown diver              Atlantis          Unknown            Solo Diving                                 Australia ?                                       Rebreather issue            Hypercapnia, Water in          Rebreather issue: Hypercapnia, Water in scrubber?                                                                                                                                                                       CO2 monitor, auto-loop shut off and flood K. Kramer, 1998, R-Files
                                                                                                                                                                                                                scrubber?                                                                                                                                                                                                                                              detection required.
17     04/04/1998     Unknown diver              Dolphin           Unknown             Scant data               29               New Guinea                    -                    Human error                 Hyperoxia from use of wrong    Gas was not analysed before the dive: it was Nitrox 86. Diver failed to follow clearly set down             Diver used a gas other than air, and failed to analyse it when he            Training agencies already      PPO2 monitor required on all rebreathers. http://www.nwdesigns.com/rebreathers/users/Paul/BodyC
                                                                                                                                                                                                                mix.                           procedures.                                                                                                 bought it/mixed it, and also when he went to use it.                         emphasise need to analyse gas,                                           ount.htm#Homebuilts
                                                                                                                                                                                                                                                                                                                                                                                                                                        but many users not aware of
                                                                                                                                                                                                                                                                                                                                                                                                                                        the effect of using less than
                                                                                                                                                                                                                                                                                                                                                                                                                                        pure O2 (argon, and N2
                                                                                                                                                                                                                                                                                                                                                                                                                                        needed to be flushed out).
16     01/01/1998     Unknown diver          CDBA in civil use       None                 None                  6m                 Canada                                           Rebreather design           Hypoxia from clogged mass      Poor maintenance allowed mass flow controller to become clogged. Also poor mass flow controller                                                                                                                              Poor equipment design: use a multi-orifice Sharron Readey, as reported to J. Bozanic
                                                                                                                                                                                    fault/human error           flow controller.               design, inadequate monitoring and alarms                                                                                                                                                                                     valve, use PPO2 monitoring, use auto-loop
                                                                                                                                                                                                                                                                                                                                                                                                                                                                            shut off valves.
15     01/01/1997     Unknown diver               MK 16            Unknown            Scant data                 -                 USA                        -                     Scant data                 Scant data                      Scant data                                                                                                  Scant data                                                                                                                                                  Confidential communication
14     01/06/1994     Ian Rolland             Cis Lunar Mk4        Cis-Lunar          Cave diving                3              Mexico, San              Experienced          29    Underlying illness / Human LOC diabetic                    Diver was a diabetic, and forgot to bring his chocolate on that dive. Diver passed out as a result.         Full cave diving investigation carried out. First Cis-Lunar accident.        Expeditions need buddy                                                         "Beyond the Deep", W. Stone and B. Ende, ISBN 0-446-52709-
                                                                                                                              Augustin, Huautla                                     error                                                                                                                                                                  Close friend of Bill Stone, diving as a group.                               checklists for divers, just as                                                 2 and www.cdnn.info/news/article/a041206.html
                                                                                                                                Cave System                                                                                                                                                                                                                                                                                             regular divers use checklists. If
                                                                                                                                                                                                                                                                                                                                                                                                                                        diver requires medication
                                                                                                                                                                                                                                                                                                                                                                                                                                        during dive, it should be on
                                                                                                                                                                                                                                                                                                                                                                                                                                        the checklist.
13     01/01/1992     Unknown diver             Unknown                                Scant data                -                 Australia              Scant data           -    Scant data                  Scant data                     The only reason the accident is known is that it is in the 2010 DAN Fatality presentation by J.                                                                                                                                                                          2010 DAN Fatality presentation by J. Lippmann
                                                                                                                                                                                                                                               Lippmann.
12     01/01/1989     Unknown diver              Atlantis          Unknown             Scant data                -                  Hawaii                                          Underlying Illness /        Heart attack from              From Dr. Jeff Bozanic's list.                                                                               Probably not an Atlantis (too early). Perhaps date is out?                                                                                                   J. Bozanic collation of diver fatality data for DAN
                                                                                                                                                                                    Rebreather design fault     hypercapnia: WOB caused
                                                                                                                                                                                                                CO2 retention
11     01/01/1984     Stefano? (surname         SuperARO                             Solo test diving           6m                   Italy               Test diving                Human Error                 Scant data                     Deceased was test diving a new rebreather design prior to a planned commencement of commercial              Scant data on accident, but diver should not be test diving a                                                                                                http://www.marescoop.com/ftopic-2433-15.html post by
                      unknown)                  Technisub                                                                                                                                                                                      sales. Died behind the breakwater at the port of Genoa - the Deceased was found stick in a gap in the       rebreather solo, hence human error is a factor.                                                                                                              "taxidiver"
                                                                                                                                                                                                                                               rocks at a depth of 6m.
10     01/01/1984     Unknown diver             Unknown                                Scant data                -                 Australia              Scant data           -    Scant data                  Scant data                     The only reason the accident is known is that it is in the 2010 DAN Fatality presentation by J.                                                                                                                                                                          2010 DAN Fatality presentation by J. Lippmann
                                                                                                                                                                                                                                               Lippmann.
9      01/01/1982     Unknown diver             Unknown                                Scant data                -                 Australia              Scant data           -    Scant data                  Scant data                     The only reason the accident is known is that it is in the 2010 DAN Fatality presentation by J.                                                                                                                                                                          2010 DAN Fatality presentation by J. Lippmann
                                                                                                                                                                                                                                               Lippmann.
8      01/01/1979     Unknown diver              LAR III?                             Solo Diving                0                     -                       -               -    Human error                 Hypoxia                        The diver died of hypoxia after failing to flush his counterlung on this O2 rebreather                                                                                                                                       Even O2 rebreathers require PPO2            J. Bozanic collation of diver fatality data for DAN
                                                                                                                                                                                                                                                                                                                                                                                                                                                                            monitors, and should have auto-loop shut
                                                                                                                                                                                                                                                                                                                                                                                                                                                                            off valves.
7      01/01/1971     Unknown diver          Electrolung EX19      Electrolung         Buddy dive                -                     -                       -               -    Scant data                  Scant data.                    Scant data.                                                                                                 Scant data.                                                                                                                                               http://www.nwdesigns.com/rebreathers/users/Paul/BodyC
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     ount.htm
6      01/01/1970     Unknown diver          Electrolung EX19      Electrolung         Buddy dive                -                     -                       -               -    Rebreather design fault /   Hypoxia                        The diver forgot to turn on the solenoid power switch after calibrating the unit, and the Rebreather        The power drain of logic at the time this equipment was made, was                                                Poor equipment design. There should have http://www.nwdesigns.com/rebreathers/Nuggets/BodyCo
                                                                                                                                                                                    Human error                                                did not have any automatic switch on, e.g. wet switches or PPO2 drop auto-on trigger.                       many orders of magnitude higher than that just 5 years later. This                                               been no such switch. Equipment needs     unt.htm#EX19
                                                                                                                                                                                                                                                                                                                                                           would have meant that the obvious risk identification may not have                                               auto-on feature.
                                                                                                                                                                                                                                                                                                                                                           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.
5      17/02/1969     Berry L. Cannon         Mark IX sCCR                             Buddy dive               203           USA, San Clemente          Experienced          33    Sabotage                    Hypercapnia from missing       No absorbent (baralyme) in rebreather. Rebreather prepped by technician, not checked by diver.              The frequency of similar incidents in the same facility suggests                                                 Provide means for divers to check the       Bunton WJ, 2000, Death of an Aquanaut, Best Publishing
                                                                                                                                 Island, CA                                                                     scrubber                       Died of CO2 toxicity - hypercapnia. Diver worked for the Sealab III project for US Navy. Some               strongly that this was not a simple procedural error. Accident                                                   scrubber is fitted in an assembled unit.    Corp., 69 pages
                                                                                                                                                                                                                                               evidence that the problem may have been intentional, i.e. someone attempting to sabotage the project        included in sports list as it is not military, nor is it umbilical diving,                                       Also identified as an issue at a HAZID
                                                                                                                                                                                                                                               (other related incidents at the same time), which if true would make this a murder.                         and accident can occur to sports divers.                                                                         meeting in Bergen in 2007 for commercial
                                                                                                                                                                                                                                                                                                                                                                                                                                                                            divers and solution proposed was to add a
                                                                                                                                                                                                                                                                                                                                                                                                                                                                            scrubber viewing window to the scrubber
4      01/01/1969     Unknown diver          Electrolung EX19      Electrolung              -                   70              Caman Islands                  -               -    Rebreather design fault /   Hyperoxia                      Diver mistakenly valving-in pure O2.                                                                                                                                                     Awareness of problem that           canisters.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Remove manual O2 valve: diver should        Confidential communication
                                                                                                                                                                                    Human error                                                                                                                                                                                                                                         some rebreathers have left to       inject make-up-gas instead.
                                                                                                                                                                                                                                                                                                                                                                                                                                        right flow, instead of more
                                                                                                                                                                                                                                                                                                                                                                                                                                        normal right to left.
3      03/11/1962     E J "Jack" Waddon        Homemade              None             Cave Diving                3            UK, Mineries Pool,         Experienced          30    Rebreather fault            Hypoxia, though cause of     Died of pulmonary oedema, most probably caused by hypoxia while training with experimental                                                                                                 Experimental divers require         Weights must be able to be ditched easily, The Darkness Beckons, M J Farr, 2nd Edition, Diadem
                                               rebreather                                                                         Somerset                                                                      death was pulmonary oedema equipment, due to error in adjusting flow regulator. Diver was also suffering from hypercapnia. No                                                                                           continuous monitoring.              and not move to entrap diver upside down. Books, 1991 and Caving Diving Accidents 1948 to 1978
                                                                                                                                                                                                                                             line connection was made to surface and the diver was unable to readily ditch weights and regain                                                                                                                               Divers should not be required to adjust    http://www.cavedivinggroup.org.uk/Articles/BCDA.pdf
                                                                                                                                                                                                                                             surface. Diver was unconscious in water for an hour, due to use of full face mask was resuscitated but                                                                                                                         flow regulators.
                                                                                                                                                                                                                                             died an hour later in hospital.
2      28/01/1951     John                    WWII O2 CCR            None             Solo Diving               3m             S. Australia, Port          Training           33    Human error/Thermal         Hyperoxia due to hypercapnia CNS fit from hyperoxia caused by hyercapnia in cold diver, Full Face Mask (FFM), seizure at the               Hypercapnia strongly predisposes a diver to hyperoxic seizures,              Awareness that CNS limits           Provide adequate margin for CNC clock.    J. Bozanic, Report by Peter Horne, Australia: Book "Diving
                                                                                                                                  Noarlunga                                         balance                     and cold.                    surface, line tended, 1st dive (training dive), hypothermic (inadequate exposure suit).                       reducing the CNS clock considerably.                                         need proper margins, and that       Provide CO2 monitoring, a simple switch fatalities of Western Australia"
                                                                                                                                                                                                                                                                                                                                                                                                                                        high CO2 causes limits to           to count down to zero, and a disable loop
                                                                                                                                                                                                                                                                                                                                                                                                                                        reduce dramatically.                that resets when scrubber fitted. WOB and
                                                                                                                                                                                                                                                                                                                                                                                                                                                                            dead space should not exceed
                                                                                                                                                                                                                                                                                                                                                                                                                                                                            EN14143:2003 limits.
1      09/04/1949     James Gordon            WWII O2 CCR            None             Cave Diving                5            UK, Wookey Hole       Novice on rebreathers.     -    Rebreather issue/Human      Hypoxia due to O2 exhausted LOC from hypoxia while returning through known sump. Ran out of oxygen due to faulty pressure                                                                                                                                                                               The Darkness Beckons, M J Farr, 2nd Edition, Diadem
                      Ingram-Marriott                                                                                          Cave, Somerset         Experienced open              error                                                   gauge on rebreather oxygen supply and failed to locate reserve cylinder, which was not adequately                                                                                                                                                                           Books, 1991; A Glimmering in Darkness, F G Balcombe,
                                                                                                                                                    water diver but no cave                                                                 attached to equipment.                                                                                                                                                                                                                                                      Cave Diving Group, 2007 and more detail in Cave Diving
                                                                                                                                                      diving experience.                                                                                                                                                                                                                                                                                                                                                Accidents 1948 to 1978
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        http://www.cavedivinggroup.org.uk/Articles/BCDA.pdf
     Pink background: basic information needs verification
     Sand background: might be a duplicate
     Blue background: needs confirmation of equipment type




                                                                                                                                                                                                                                                                 Page 14 of 20
     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
                                                                     4
                34                           37                  1
                 1
                14
                 5




                                 1
Number concluded
applying Pareto                      1   1
principle                                    2    11
                11
                11                                          11
                11
                 1
                                                                     11
                15
                 2
                34     59
                59
                                                                         15
                 1
                 1
                 1


                                                      34
                   2
             General diving hazard


             Exceeded performance
             envelope

             Human error


             Human error/Rebreather fault


             Non rebreather equipment

23           Marine life


             Rebreather design fault
8
             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

Pulmonary barotrauma

				
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