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Comprehensive list of all accidents



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Old 26th October 2007, 07:16   #101 (permalink)
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Re: Comprehensive list of all accidents

Quote: (Originally Posted by AD_ward9) View Original Post
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.

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

Alex, thanks again for your all your effort, diligence and remarkable patience. Seeing a chronological list of fatalities makes quite an impression of time moving on relentlessly towords even more sad facts. Let's hope there is some way to slow the march or stop it altogether.

And I too believe that the scarcity of units with truly independent PO2 monitors in this grim document is significant. IMHO, they are the most important diagnostic tool one can have, both above and especially below the water and I wouldn't dive without one. -Andy
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Old 26th October 2007, 07:27   #102 (permalink)
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Re: Comprehensive list of all accidents

Quote: (Originally Posted by koputai) View Original Post
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.
We are missing accidents. The only military ones on the list are the ones believed to be jollies, or involving activities akin to sport diving/training.

Military accidents in action are excluded from the list.

There is a very good comment in 1997 from then Retired Navy Captain Ed Thalmann, who ran the Navy Experimental Diving Unit’s life support testing program for 15 years. He reported that USN has had four incidents in 16,000 hours on the MK-16 mixed-gas rebreather; one of them resulted in a fatality. The Navy has substantial infrastructure to ensure divers are trained, and their dives are planned well within CO2 limits, CNS limits and the kit set up to manage risks of hypoxia. That does not exist in the sports environment. This is why the Commercial version of the Open Revolution rebreather passes our release review but the sports unit does not.

Ed Thalman looked at the entry of eCCRs into sports diving in 1997 and summed up things as follows: “A scuba regulator is the steam engine of diving gear. It’s been around for a long time and it’s incredibly reliable. By comparison, a rebreather is like a space shuttle. The problems are not academic. If you don’t know what you’re doing, then you’ll wind up dead.”.

eCCRs for sports diving need to be designed to operate with no support infrastructure, and with poor training.

Alex
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Old 26th October 2007, 07:32   #103 (permalink)
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Re: Comprehensive list of all accidents

Quote: (Originally Posted by koputai) View Original Post
Alex,
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.

This is very interesting Jason, thanks for pointing it out. Let's hope Alex didn't miss any MK15 incidents and that it is indeed a fact... -Andy
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Old 26th October 2007, 08:08   #104 (permalink)
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Re: Comprehensive list of all accidents

Quote: (Originally Posted by AD_ward9) View Original Post

eCCRs for sports diving need to be designed to operate with no support infrastructure, and with poor training.
Hear hear.
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Old 26th October 2007, 10:08   #105 (permalink)
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Re: Comprehensive list of all accidents

Quote: (Originally Posted by Mdemon) View Original Post
Hear hear.
And when things are full of sand and salt, and are probably improperly assembled.

Which is why I still think an Rebreather manufacturers' goal should be to design something which has obvious failure modes rather than to try to construct something that never fails.
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Old 26th October 2007, 11:53   #106 (permalink)
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Re: Comprehensive list of all accidents

Quote: (Originally Posted by David Pye) View Original Post
And when things are full of sand and salt, and are probably improperly assembled.

Which is why I still think an Rebreather manufacturers' goal should be to design something which has obvious failure modes rather than to try to construct something that never fails.
One can deal with the sand/salt:

1. An eCCR could easily force the user to do annual servicing by shutting down. Just like a modern car does.

2. An eCCR could easily check all its functions (doing the pos and neg check, requiring only that the diver apply neg pressure), check the injector rate, etc.

As regards incorrectly assembly, it is within ALARP to make that either impossible or to detect it.

However, the accidents that occur do not seem to be sand/salt issues. Looking at the accidents, most have as the obvious cause hypoxia, hypercapnia or hyperoxia. Maintenance would remove the few people from the list who died after not replacing the cells once in a 3 years, but then so would certain design changes. There are also the usual scattering of accidents that would have happened even if it had been O.C. SCUBA: 10 to 15% of those on the list read the same way as O.C. accidents.

Alex

Last edited by AD_ward9 : 26th October 2007 at 14:30.
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Old 26th October 2007, 13:13   #107 (permalink)
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Re: Comprehensive list of all accidents

There have been 3 rebreather deaths in Japan that I am aware of:

The first was in Okinawa. The 35 yr old diver got his open water cert in July '03, his Inspiration ticket in March 04, went diving solo in July '04 and was never seen again. The body has still not been found, but a funeral was held in Utsunomiya in October 04. It was his 324th dive, over a period of a little over a year. A supernova.

The second was in July 05. He was a 38 yr old diver with 2,000 dives under his belt. He was a judge and safety diver in an apnea freediving contest. The currents were savage that day, and nobody knew anything was amiss till his replacement got in the water, expecting to see him at the 6m deco stop. His body was never found.

The third was a 46 yr old heavy smoker with 20 yrs of diving under his belt. He had just surfaced from a dive with 4 mates when he had a heart attack and died. 29 April 07.

The first 2 were Inspos; the third was a Meg. The first 2 were solo dives. Nobody knows what happened in the first case, though the speed of progression raises suspicions. The investigation on the second concluded that the cause was the current, not the rebreather. People with whom I have discussed the third are adamant that the cause was the smoking not the rebreather.

I've waded through a lot of news reports and wish to God that I had not. It really is depressing, and a bottle of Chianti just isn't dulling it. There is no evidence that the machine should stand in the dock in any of these cases. The 3rd seems clearly a smoking death where a rebreather was a spectator.
With only 35 hours of rebreather experience I was doing deep penetrations on wrecks solo. I was a cretin. I'm now going to open another bottle. My heartfelt thanks to Alex: there is absolutely no way I could read 130 stories like those I've just read.
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Old 26th October 2007, 15:00   #108 (permalink)
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Re: Comprehensive list of all accidents

Thanks for your PM on the additional accident in Japan. I am working with Alex Deas on the compilation of the data behind the accidents.

In the Okinawa accident there seems to be a report that the rebreather had developed faults on dives on the previous days. The diver seems to put in a lot of hours on the unit in a short time. It is not clear whether the location was a cave or a canyon (open above). Any further info on this accident would be welcome.

It is good how they capture the victim's web site in Japan. Gives more presence to the lessons people can learn from.

(Dr.) Vladimir Komorov

Quote: (Originally Posted by Abbo) View Original Post
There have been 3 rebreather deaths in Japan that I am aware of:

The first was in Okinawa. The 35 yr old diver got his open water cert in July '03, his Inspiration ticket in March 04, went diving solo in July '04 and was never seen again. The body has still not been found, but a funeral was held in Utsunomiya in October 04. It was his 324th dive, over a period of a little over a year. A supernova.

The second was in July 05. He was a 38 yr old diver with 2,000 dives under his belt. He was a judge and safety diver in an apnea freediving contest. The currents were savage that day, and nobody knew anything was amiss till his replacement got in the water, expecting to see him at the 6m deco stop. His body was never found.

The third was a 46 yr old heavy smoker with 20 yrs of diving under his belt. He had just surfaced from a dive with 4 mates when he had a heart attack and died. 29 April 07.

The first 2 were Inspos; the third was a Meg. The first 2 were solo dives. Nobody knows what happened in the first case, though the speed of progression raises suspicions. The investigation on the second concluded that the cause was the current, not the rebreather. People with whom I have discussed the third are adamant that the cause was the smoking not the rebreather.

I've waded through a lot of news reports and wish to God that I had not. It really is depressing, and a bottle of Chianti just isn't dulling it. There is no evidence that the machine should stand in the dock in any of these cases. The 3rd seems clearly a smoking death where a rebreather was a spectator.
With only 35 hours of rebreather experience I was doing deep penetrations on wrecks solo. I was a cretin. I'm now going to open another bottle. My heartfelt thanks to Alex: there is absolutely no way I could read 130 stories like those I've just read.
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Old 26th October 2007, 19:58   #109 (permalink)
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Re: Comprehensive list of all accidents

Quote: (Originally Posted by AD_ward9) View Original Post
One can deal with the sand/salt:

1. An eCCR could easily force the user to do annual servicing by shutting down. Just like a modern car does.


Alex
Alex

so much of what you are doing I agree with but this is the one thing I do not. In Australia this is just not a feasible option. the cost of sending a rebreather around the world annually for servicing is prohibitive. I know no cars that shut down in Australia if you do not service them (a few beep at you like mine, but you can turn it off). The Australian Federal trade practices act requires that full and unencumbered title passes to you when you buy something here. So the only way this would work would be for user to lease their unit from the manufacturer, and that would open a wave of lawsuits if it didn't work and push ownership cost through the roof.


I think since this approach is fundermentally flawed and you should look for other means to improve safety. Pushing for something that will not work in all environments and will just cause as many problems as it "solves" is not a constructive solution
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Old 27th October 2007, 01:52   #110 (permalink)
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Re: Comprehensive list of all accidents

I've been watching this forum for quite a while now.

I seem to go between being mad to being appreciative of the efforts for the collection of data and in the hopes that this will save someone's life in the future...perhaps my own....given the stats, I suppose I have a fair chance of killing myself on my CCR over the next few years.....just a joke.

I tend to think that my current opinion resides closely to the sentiments shared by Drmike on page 10 of this thread....something akin to most folks knowing someone who died on CCR or 1st hand experience....

I suppose the ill thoughts of some lawyer collecting data for a case have passed, but then I see my friend listed as diver no. 131.....dang!...Diver No. 131.....he f'd up....made some really really bad decisions, but diver No. 131....guess it drives home the point that the sun will come up tomorrow...the world doesn't stop. If anything, my personal experience in being a witness to the death of a dear friend (diver 131) will make me and my other dive buddies safer divers.

Folks, watching a friend struggle and fight for life for a couple of hours on the deck of a dive boat is not something you want to see.

Please.....everyone, please dive within your training. Assemble your gear the night b4 a dive......and if anything is wrong...call the dive.

I suppose this is too much of an emotional response, but dang....diver 131 was a great friend.
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