Comprehensive list of all accidents

AD_ward9 · 5th October 2007, 08:38

We are reviewing our list of fatal accidents on rebreathers, with a view to publishing it this year. The has a table listing all accidents we can trace, and a section containing the facts we know about the accident, including reference to the report.

The reason we are doing this work is to check that each of the plausible causes of each accident are handled by the Open Revoution designs, as part of its safety review, if it is within the ALARP principle to do so. That is, it is a genuine effort to learn from past errors. It will be published so all Rebreather manufacturers can use this.

There are some accidents we know happened, where we are short on details.
We would much appreciate PMs from those on this forum with any information on these. They are:

Cis-Lunar Accidents. We have 4 but see reports of 5. We have:

1994 Ian Rolland, Cis Lunar Mk4, Type: Cave diving. Location: San Augustin, Huautla Cave System, Probable Cause: Diver was a diabetic, and forgot to bring chocolate. Diver passed out on rebreather as a result.
Reference: "Beyond the Deep", W. Stone and B. Ende, ISBN 0-446-52709-2

1998 Dr Henry W. Kendall, Wakula 2. Cis-Lunar Mk5 Cause: unknown, but likely hypoxia as O2 was reportedly turned off. Reference: Wrolf's Wreck - Cautionary Tales

7th Aug 1999, Peter Osbourne. Cis-Lunar Mk5P. Reference: Wrolf's Wreck - Cautionary Tales

16th September 2001 Eric Reichardt, Florida, Cis-Lunar Mk5P. Probable cause: shark attack on diver who then lost mouthpiece and drowned. Reference: ScubaBoard - View Single Post - Expert: Shark attack and
ScubaBoard - View Single Post - Expert: Shark probably killed diver.

We are looking for information on the 5th accident, if there was a 5th accident.

Inspo Accident. We are missing several Inspo/Evo accidents. One in particular: there was a fatal accident in the Clyde in summer of 2000 by a team planning a dive on HMS Dasher. We cannot find the details, even after checking lifeboat station records, but remember it clearly as it occurred just after our own Dasher expedition: a diver was on deco, then just disappeared. Details of name, location, etc greatly appreciated.

Meg Accidents. We are short on information. We had a list of 9 but lost it on a multiple disk crash on two servers due to lightning disturbance. In reconstructing this, searching the internet we see reference to 14 accidents and cannot find the five missing, if they are missing. Please PM all Meg accidents you know of. We would rather sift through 100 PMs than have patchy data.

We have only one accident on a RB80 clone, but on our list lost on the two servers, we had 6. Any details please.

Finally, there is one Halcyon Fridge accident (the only one, we are aware of), on which more info is needed.

Incidentally, our tally is 83.

Thanks,

Alex

onetime · 5th October 2007, 12:57

Sorry don't have any details for you but do have a question. Not sure if anyone knows the answer but how many Rebreather divers are there? Just trying to get some perspective on 83 deaths in x number of divers (obviously the ideal would also be the number of dives all RB divers have completed but since we aren't going to get that simply the number would shed some light).

--Paul

babar · 5th October 2007, 13:59

There has been a prism fatality this year. I didn't see prism mentioned.

AD_ward9 · 5th October 2007, 14:04

Quote: (Originally Posted by babar)

There has been a prism fatality this year. I didn't see prism mentioned.

We only have one Prism fatality on our list, and I checked that personally with Peter at Steam Machines last year. It was:

7/10/2006 Robert Crawford Normal buddy diving. Prism Topaz
No further details as accident investigation was irregular (manufacturer not even informed, authorities prevented proper investigation of the unit despite offer by Steam Machines).

Please could you PM the name, date and location if there has been another so we can follow up.

Thanks

Alex

babar · 5th October 2007, 14:06

Quote: (Originally Posted by AD_ward9)

We only have one Prism fatality on our list, and I checked that personally with Peter at Steam Machines last year. It was:

7/10/2006 Robert Crawford Normal buddy diving. Prism Topaz
No further details as accident investigation was irregular (manufacturer not even informed, authorities prevented proper investigation of the unit despite offer by Steam Machines).

Please could you PM the name, date and location if there has been another so we can follow up.

Thanks

Alex

No, Bob Crawford is the one I was thinking of.

AD_ward9 · 5th October 2007, 14:18

Quote: (Originally Posted by onetime)

Sorry don't have any details for you but do have a question. Not sure if anyone knows the answer but how many Rebreather divers are there? Just trying to get some perspective on 83 deaths in x number of divers (obviously the ideal would also be the number of dives all RB divers have completed but since we aren't going to get that simply the number would shed some light).

--Paul

I would like to keep analysis separate, so we can focus on gathering factual data. As soon as there is an analysis, there is a debate, and in this case it can cloud the facts.

Once the accident list is updated, we will publish that. It would then be appropriate for a separate thread to discuss the analysis of that data.

I think it is very important that all involved in rebreather design, manufacture or training have access to a reliable list of all fatal accidents, with as accurate a factual content as possible.

Alex

silent running · 5th October 2007, 16:02

Hi Alex, there was another death of a Prism diver on a Thai liveaboard back in 2004. It was thought to be caused by a massive heart attack by a physician and EMT fellow passenger who tied to revive him on the dive deck. If I remember correctly, he jumped in for his morning dive and came back to the surface quickly, unconcious and died shortly thereafter. I think the Thai coroner held onto the body for a very long time and never did an autopsy. You should confirm this with SMI as I don't know if my recollection is very accurate. -Andy

SteveJ · 5th October 2007, 16:31

Quote: (Originally Posted by silent running)

Hi Alex, there was another death of a Prism diver on a Thai liveaboard back in 2004. It was thought to be caused by a massive heart attack by a physician and EMT fellow passenger who tied to revive him on the dive deck. If I remember correctly, he jumped in for his morning dive and came back to the surface quickly, unconcious and died shortly thereafter. I think the Thai coroner held onto the body for a very long time and never did an autopsy. You should confirm this with SMI as I don't know if my recollection is very accurate. -Andy

This illustrates one of the problems of rebreather fatalities very well. Unconscious diver. Attempted resuscitation by persons with medical credentials, 'looks like a massive heart attack', before you know it, it's treated as fact. 'Massive heart attack' is what we physicians too often ascribe to any unexpected death, pending a post mortem examination.

Even if an MI was implicated, it is only in the final pathway that lead to death and could well have been preceded by equipment issues.

silent running · 5th October 2007, 16:45

Quote: (Originally Posted by SteveJ)

This illustrates one of the problems of rebreather fatalities very well. Unconscious diver. Attempted resuscitation by persons with medical credentials, 'looks like a massive heart attack', before you know it, it's treated as fact. 'Massive heart attack' is what we physicians too often ascribe to any unexpected death, pending a post mortem examination.

Even if an MI was implicated, it is only in the final pathway that lead to death and could well have been preceded by equipment issues.

Hello Steve, I never suggested that any of it was fact, only that it's what I remember hearing. Anybody who stops thinking about it there and decides that it's now a "fact" that such an occurence is merely an MI is not a very thorough or curious person and not someone who's opinion I would be concerned with... -Andy

***jradomski*** · 5th October 2007, 16:57

Quote: (Originally Posted by silent running)

Hi Alex, there was another death of a Prism diver on a Thai liveaboard back in 2004. It was thought to be caused by a massive heart attack by a physician and EMT fellow passenger who tied to revive him on the dive deck. If I remember correctly, he jumped in for his morning dive and came back to the surface quickly, unconcious and died shortly thereafter. I think the Thai coroner held onto the body for a very long time and never did an autopsy. You should confirm this with SMI as I don't know if my recollection is very accurate. -Andy

that report sounds familiar.. I can't remember the name..

5th October 2007, 08:38	#1 (permalink)
AD_ward9 So much more to learn Current Rebreather/s: Other CCR Other Rebreather/s: Other CCR Join Date: Jun 2005 Location: Scotland Posts: 1,732	Comprehensive list of all accidents We are reviewing our list of fatal accidents on rebreathers, with a view to publishing it this year. The has a table listing all accidents we can trace, and a section containing the facts we know about the accident, including reference to the report. The reason we are doing this work is to check that each of the plausible causes of each accident are handled by the Open Revoution designs, as part of its safety review, if it is within the ALARP principle to do so. That is, it is a genuine effort to learn from past errors. It will be published so all Rebreather manufacturers can use this. There are some accidents we know happened, where we are short on details. We would much appreciate PMs from those on this forum with any information on these. They are: Cis-Lunar Accidents. We have 4 but see reports of 5. We have: 1994 Ian Rolland, Cis Lunar Mk4, Type: Cave diving. Location: San Augustin, Huautla Cave System, Probable Cause: Diver was a diabetic, and forgot to bring chocolate. Diver passed out on rebreather as a result. Reference: "Beyond the Deep", W. Stone and B. Ende, ISBN 0-446-52709-2 1998 Dr Henry W. Kendall, Wakula 2. Cis-Lunar Mk5 Cause: unknown, but likely hypoxia as O2 was reportedly turned off. Reference: Wrolf's Wreck - Cautionary Tales 7th Aug 1999, Peter Osbourne. Cis-Lunar Mk5P. Reference: Wrolf's Wreck - Cautionary Tales 16th September 2001 Eric Reichardt, Florida, Cis-Lunar Mk5P. Probable cause: shark attack on diver who then lost mouthpiece and drowned. Reference: ScubaBoard - View Single Post - Expert: Shark attack and ScubaBoard - View Single Post - Expert: Shark probably killed diver. We are looking for information on the 5th accident, if there was a 5th accident. Inspo Accident. We are missing several Inspo/Evo accidents. One in particular: there was a fatal accident in the Clyde in summer of 2000 by a team planning a dive on HMS Dasher. We cannot find the details, even after checking lifeboat station records, but remember it clearly as it occurred just after our own Dasher expedition: a diver was on deco, then just disappeared. Details of name, location, etc greatly appreciated. Meg Accidents. We are short on information. We had a list of 9 but lost it on a multiple disk crash on two servers due to lightning disturbance. In reconstructing this, searching the internet we see reference to 14 accidents and cannot find the five missing, if they are missing. Please PM all Meg accidents you know of. We would rather sift through 100 PMs than have patchy data. We have only one accident on a RB80 clone, but on our list lost on the two servers, we had 6. Any details please. Finally, there is one Halcyon Fridge accident (the only one, we are aware of), on which more info is needed. Incidentally, our tally is 83. Thanks, Alex Last edited by AD_ward9 : 5th October 2007 at 08:44.
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5th October 2007, 12:57	#2 (permalink)
onetime Classic KISSer #138 Current Rebreather/s: Classic Kiss Other Rebreather/s: Join Date: Mar 2005 Location: US, NJ Posts: 672	Re: Comprehensive list of all accidents Sorry don't have any details for you but do have a question. Not sure if anyone knows the answer but how many Rebreather divers are there? Just trying to get some perspective on 83 deaths in x number of divers (obviously the ideal would also be the number of dives all RB divers have completed but since we aren't going to get that simply the number would shed some light). --Paul
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5th October 2007, 13:59	#3 (permalink)
babar Curmudgeon Current Rebreather/s: Evolution Sport Kiss Other CCR Other Rebreather/s: Inspiration Classic Inspiration Vision Evolution Other CCR Join Date: Apr 2005 Location: Southern California Posts: 421	Re: Comprehensive list of all accidents There has been a prism fatality this year. I didn't see prism mentioned. __________________ Babar Evolution Plus Sport kiss
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5th October 2007, 14:04	#4 (permalink)
AD_ward9 So much more to learn Current Rebreather/s: Other CCR Other Rebreather/s: Other CCR Join Date: Jun 2005 Location: Scotland Posts: 1,732	Re: Comprehensive list of all accidents Quote: (Originally Posted by babar) There has been a prism fatality this year. I didn't see prism mentioned. We only have one Prism fatality on our list, and I checked that personally with Peter at Steam Machines last year. It was: 7/10/2006 Robert Crawford Normal buddy diving. Prism Topaz No further details as accident investigation was irregular (manufacturer not even informed, authorities prevented proper investigation of the unit despite offer by Steam Machines). Please could you PM the name, date and location if there has been another so we can follow up. Thanks Alex
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5th October 2007, 14:06	#5 (permalink)
babar Curmudgeon Current Rebreather/s: Evolution Sport Kiss Other CCR Other Rebreather/s: Inspiration Classic Inspiration Vision Evolution Other CCR Join Date: Apr 2005 Location: Southern California Posts: 421	Re: Comprehensive list of all accidents Quote: (Originally Posted by AD_ward9) We only have one Prism fatality on our list, and I checked that personally with Peter at Steam Machines last year. It was: 7/10/2006 Robert Crawford Normal buddy diving. Prism Topaz No further details as accident investigation was irregular (manufacturer not even informed, authorities prevented proper investigation of the unit despite offer by Steam Machines). Please could you PM the name, date and location if there has been another so we can follow up. Thanks Alex No, Bob Crawford is the one I was thinking of. __________________ Babar Evolution Plus Sport kiss
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5th October 2007, 14:18	#6 (permalink)
AD_ward9 So much more to learn Current Rebreather/s: Other CCR Other Rebreather/s: Other CCR Join Date: Jun 2005 Location: Scotland Posts: 1,732	Re: Comprehensive list of all accidents Quote: (Originally Posted by onetime) Sorry don't have any details for you but do have a question. Not sure if anyone knows the answer but how many Rebreather divers are there? Just trying to get some perspective on 83 deaths in x number of divers (obviously the ideal would also be the number of dives all RB divers have completed but since we aren't going to get that simply the number would shed some light). --Paul I would like to keep analysis separate, so we can focus on gathering factual data. As soon as there is an analysis, there is a debate, and in this case it can cloud the facts. Once the accident list is updated, we will publish that. It would then be appropriate for a separate thread to discuss the analysis of that data. I think it is very important that all involved in rebreather design, manufacture or training have access to a reliable list of all fatal accidents, with as accurate a factual content as possible. Alex Last edited by AD_ward9 : 5th October 2007 at 23:21.
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5th October 2007, 16:02	#7 (permalink)
silent running Mature mouth breather Current Rebreather/s: Prism Topaz Other Rebreather/s: Join Date: Jun 2005 Location: U.S.A. Brooklyn, New York Posts: 1,814	Re: Comprehensive list of all accidents Hi Alex, there was another death of a Prism diver on a Thai liveaboard back in 2004. It was thought to be caused by a massive heart attack by a physician and EMT fellow passenger who tied to revive him on the dive deck. If I remember correctly, he jumped in for his morning dive and came back to the surface quickly, unconcious and died shortly thereafter. I think the Thai coroner held onto the body for a very long time and never did an autopsy. You should confirm this with SMI as I don't know if my recollection is very accurate. -Andy
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5th October 2007, 16:31	#8 (permalink)
SteveJ New Member Current Rebreather/s: Classic Kiss Other Rebreather/s: Inspiration Classic Inspiration Vision Join Date: Mar 2006 Location: Whitby Posts: 98	Re: Comprehensive list of all accidents Quote: (Originally Posted by silent running) Hi Alex, there was another death of a Prism diver on a Thai liveaboard back in 2004. It was thought to be caused by a massive heart attack by a physician and EMT fellow passenger who tied to revive him on the dive deck. If I remember correctly, he jumped in for his morning dive and came back to the surface quickly, unconcious and died shortly thereafter. I think the Thai coroner held onto the body for a very long time and never did an autopsy. You should confirm this with SMI as I don't know if my recollection is very accurate. -Andy This illustrates one of the problems of rebreather fatalities very well. Unconscious diver. Attempted resuscitation by persons with medical credentials, 'looks like a massive heart attack', before you know it, it's treated as fact. 'Massive heart attack' is what we physicians too often ascribe to any unexpected death, pending a post mortem examination. Even if an MI was implicated, it is only in the final pathway that lead to death and could well have been preceded by equipment issues.
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5th October 2007, 16:45	#9 (permalink)
silent running Mature mouth breather Current Rebreather/s: Prism Topaz Other Rebreather/s: Join Date: Jun 2005 Location: U.S.A. Brooklyn, New York Posts: 1,814	Re: Comprehensive list of all accidents Quote: (Originally Posted by SteveJ) This illustrates one of the problems of rebreather fatalities very well. Unconscious diver. Attempted resuscitation by persons with medical credentials, 'looks like a massive heart attack', before you know it, it's treated as fact. 'Massive heart attack' is what we physicians too often ascribe to any unexpected death, pending a post mortem examination. Even if an MI was implicated, it is only in the final pathway that lead to death and could well have been preceded by equipment issues. Hello Steve, I never suggested that any of it was fact, only that it's what I remember hearing. Anybody who stops thinking about it there and decides that it's now a "fact" that such an occurence is merely an MI is not a very thorough or curious person and not someone who's opinion I would be concerned with... -Andy
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5th October 2007, 16:57	#10 (permalink)
*jradomski* Moderator Current Rebreather/s: Inspiration Classic Sport Kiss Optima rEvo Other CCR Home Build Other Rebreather/s: Inspiration Vision Evolution Megalodon Classic Kiss rEvo Other CCR Home Build Join Date: Mar 2005 Location: "Da" Bronx Posts: 2,895	Re: Comprehensive list of all accidents Quote: (Originally Posted by silent running) Hi Alex, there was another death of a Prism diver on a Thai liveaboard back in 2004. It was thought to be caused by a massive heart attack by a physician and EMT fellow passenger who tied to revive him on the dive deck. If I remember correctly, he jumped in for his morning dive and came back to the surface quickly, unconcious and died shortly thereafter. I think the Thai coroner held onto the body for a very long time and never did an autopsy. You should confirm this with SMI as I don't know if my recollection is very accurate. -Andy that report sounds familiar.. I can't remember the name.. __________________ Joe Radomski CCR Trimix Instructor Trainer ANDI Instructor Trainer Director #10 All posts are personal opinions and DO NOT reflect any affiliated agency unless specifically stated.
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