Comprehensive list of all accidents

UWSojourner

I saw the estimates of units on the Meg. Do you have an Alex-type (by year) estimate of units for the Inspo? If so, could you post it or PM? Thanks.

AD_ward9

Not every year, but we did a survey in 1999 of Inspos and that concluded that there were not more than 150 in use at that time. If I post any other useage figures here, there could be pressure on Rebreather World so I will refrain other than pointing out that I have stated my own estimates here, of 1650 in use at the end of 2006 plus on top of that there are 500 Evos at least. I note the rapid rise in numbers on RBW, but many are second units.

In Scotland there were just 2 Inspos in 1999, and a chap in Glasgow died on one of those: I remember his family were trying to sell the unit via an (non-rebreather) instructor at a dive centre in Renfrew. Unless there was someone out in the sticks who never went near a mainstream dive shop or dive boat, these were the only 2.

The reason we did the survey in the UK in 1999 is because we had bought the European Technical Dive Centre in Orkney and were planning to pump over £1.5mn into it to develop technical and rebreather diving. Our survey involved contacting dive boats informally and phoning around dive shops to find out how many of their customers were technical divers and how many were rebreather divers. Rebreather divers stand out to a dive operation not least because of needing pure O2, and have tiny tanks needing to be certified. 9 to 90 Journal did a survey as well, suggesting that technical diving was very low but would take off soon. I have not done any survey like this after 1999, and in any case after 2000 would be less valid because of the international sales that AP Valves were developing. We trimmed the budget down for the dive centre in 2001 and pulled out in 2002 after spending over £1mn because the numbers of divers who were actually turning up with rebreathers, on our vessels and on our competitors, turned out to be even less than our survey indicated. Misinformation from the industry with inflated rebreather figures, that we got taken in by, was an expensive lesson for us. There are far fewer active users than most manufacturers would have us believe.

We are still trying to put dates and names on a reported 14 total fatal accidents on Inspos prior to 2000. We do not have these in the list but the figure is reported at a coroner's inquest. It could be the number is wrong, or it could be there are more accidents out there.

I agree it would be very useful to separate Inspo Visions from Inspo Classics. Where we know it is a Vision, we are putting it on the list as Inspiration Vision (still doing that, so wait a day for the update). However in many cases we do not know. We believe the Vision is MUCH safer than the Classic, but do not have the facts to support that other than an understanding of the failure modes. However it still lacks basic safety features, such as turning on automatically with falling PPO2, does not use any recognised safety architecture (e.g. TTA), and neither the code, compiler or the processor has been verified. There are quite a few Vision fatal accidents.

On a couple of other units, Optima for example and a persistent rumour of an Ouroboros accident: these are not on the list until verified. We are doing our best to ensure we have a data and name for every accident unless it appears from a quotable source, such as BSAC's annual accident report or DAN: that is primarily where the "unknowns" come from. The Optima is now confirmed and will be added today. The Boris cave diving accident is still on our list of unsubstantiated rumour which we think can be traced to a diver who was taken to hospital but did not pass away.

There are several accidents where the diver was rescued by a very attentive buddy and resucitated. We are debating about whether to add these. It seems to go beyond the incident, and without the intervention of a third party after the diver lost consciousness the diver would have stayed dead. There is a lot of valuable information in these cases because the diver is around to explain what happened, and there is a buddy there to support that information.

Finally the weakest area is Asia: we are searching in the english language. If anyone can try searching in asian languages, that would be very helpful in filling in gaps: newspaper reports giving the name of the diver or the date and location are an excellent starting point which we can follow up with by contacting the local police department.

Alex

CharlieT

I think we all agree that we need to be able to have the facts/circumstances behind the fatalites made aware to other rebreather users. Not just to a select few.

How many were originally caused by what human error on part of the diver?

How many of these might have been prevented by a change in design/specification?

Was that change available/feasible at the time of the fatality?

Was the diver solo or with a buddy at the time the incident started?

Was the diver someone generally suitable for rebreather diving? How did he/she get on with the early stages of their diving, when had they last dived and what type of dive was it compared to the dive they died on?

If with a buddy/buddies, what was their role and why was it unsuccessful?

Was the equipment flooded or had the diver come off the loop allowing a normal examination of his/her kit?

Did the diver maintain a logbook and what information was logged? Does the information include analysis of gases, when scrubber and batteries changed, when sensors were changed? My logbook contains all this information.

Was the diver on a system that records the level of info available from the Vision/Evolution? What does this tell us?

Until we are able to analyse the circumstances of the fatality, how can we really move our safety forward?

Then, and not before, we will be properly able to decide whether the average specification of the rebreathers currently available is too low and what needs (on average) improving.

If I have the proper facts behind the more recent fatalities ie those where we should be able to obtain the facts (2004-2007) then I can decide whether I should be willingly paying for the extra safety features discussed on this website.

Due to the death of an ex-club member in May 2006 and my direct involvement in the fatality on 29 July 2007, I urge us all to look at every aspect of fatalities to see if this could prevent another fatality in the future. (This is where this now edited sentence should have gone)

Charlie

CharlieT

I simply said that I found his body, I didn't say that I recovered his body on my own, did I? I have always accurately described what happened on that day, ask Dave Cooper who will confirm this.

The lift bags disapeared at the start of the search. They were carried by one of the FOUR divers who agreed to participate in the search. I don't own any liftbags. The other buddy pair didn't have any lift bags either.

If you have any further issues, kindly either ring me or send me a PM. At the moment I have no idea of what point you're trying to make here.

I mentioned this situation only because this is the 2nd fatality where I have known the diver and this makes it much more personal.

That motivates me to participate in this thread as I'm sure you understand.

Drmike

with 130 odd dead Rebreather divers - we all know someone who has died on them and many of us have had to deal with death 1st hand. This isnt something to be claiming bragging rights about guys. lets drop it

__________________
Cave diving is a sport
Wreck diving is a sport
Diving in general is a sport

'Rebreather diving' is not a sport
its the delusional obsession with a highly dangerous and often inappropriate piece of equipment

Bobnob

your dead right ,

AD_ward9

I am sorry this is turning into a brawl with the last few posts. An accident is very traumatic for all involved, not just the victim. I hope we can forgive lapses people have in these situations. Some have to talk about it to vent their stress, others bottle it up. Let us not get off focus: we are trying to gather the facts here and that is all.

So getting back to the topic, here is the list updated. Tally is now 133 and the number is still expected to finalise at around 150 to date.

In the list of accidents per unit, I posted earlier, I made an error: the Inspo seems to have been involved in 59 fatal accidents, not 50. The error was a simple typo (the number was 60 on the database at the time, but we have since moved one to "unknown" in the latest list as the quality of the data on that accident was considered poor - it might be an Evo).

Please do cross-post this list if people on different forums would like to take the lead in filling in the gaps. If you would like to be the key contact person for a forum, please PM me. We would ideally like one for each forum, but it will involve some hours of your time, not just five minutes.

Before we add an accident from a forum contact, we need the date, name and location. This allows us to double check the information. Please could you emphasise this when asking people to give you information: the information has to be either traceable to a reputable source or checkable, otherwise we dilute the quality of the database with errors.

Alex

Attached Images

Fatal Accident Report 071025s.pdf (70.4 KB, 130 views)

sven

Bobnob & CharlieT. Please take your differences offline - they don't add anything to this rather sombre thread.

Please refer to the Rebreather World Terms of use, especially #18 and #22.

Be good

Greetings from rainy Sydney.

__________________
Regards,
Sven

[SIZE=1]The Sydney Project website: [URL]http://www.sydneyproject.com[/URL]
My Blog: [URL]http://sven.rebreatherworld.com[/URL]

"Whenever you find yourself on the side of the majority, it's time to pause and reflect." Mark Twain[/SIZE]

AD_ward9

Today's update, and probably the last for a couple of weeks.

The tally remains 133, and the eventual number is reduced from 150 to a figure expected to be around 142. Nice to see numbers come down for once.

We have names for all but 35 of these. The next couple of weeks should see that number reduce a lot.

The facts of each accident are being collated into a file for review by a panel that is being assembled. This will be an international panel of diving experts, with mutiple independent review of each case, then a combined panel review of the conclusion. If you would like to join the panel and have at least 5 years rebreather or rebreather medical experience, please email me a CV. It will take about 80 hours of your time. Each reviewer will be expected to do the analysis in a structured manner, putting together a timeline of the events, and then running that through the FMECA. A training paper is being written on how to do this. No manufacturer will be asked to review an accident that occured on their own unit, and no instructor will be asked for a unit they teach.

Very preliminary information of the most plausible causes, is that hypoxia seems to figure high, as does CO2 issues. There are instances of CNS hits in circumstances where these should not have occurred. Ice diving and solo diving occur disproportionately often. Some rebreathers have a considerably worse safety record than others relative to either their sales or their user base: this is a matter being taken up by several specialists who are writing scientific papers on this that will be published much more quickly than is usual. A truly independent PPO2 monitor being fitted is a feature of the rebreathers that are not on this list, or have a very low frequency on the list relative to their sales. Beyond this, I look to the Analysis thread with interest.

Thank you all for encouragement in doing this, providing information and correcting mistakes or gaps in information. We are still looking for the information on those accidents marked in blue or "unknown", as well as any we have missed.

Alex

Attached Images

Fatal Accident Report 071026s.pdf (70.1 KB, 105 views)

koputai

Alex,
As there are Mk16's on the list it seems you've included military accidents.
Do you consider these relevant to this analysis?
An interesting note, if you are including military, is that there were NO fatals on the MK15, amazing really when you consider the sheer volume of dives done on this unit over a 25 plus year lifespan with the military. Any chance that you are missing some accidents there?

Regards,
Jason.