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Analysis of List of Rebreather Accidents



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Old 15th October 2007, 14:56   #41 (permalink)
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Re: Analysis of List of Rebreather Accidents

Quote: (Originally Posted by Mdemon) View Original Post
I take the pragmatic approach. If it can go wrong, I need to know about it and what to do to rectify things.
When your controller hangs, how do you know about it?

Especially when that particular unit had no backlight, so half the places I dive, I cannot read the displays in any case.

Joe: you put things very well below. Thanks. Green sent.

Alex

Last edited by AD_ward9 : 15th October 2007 at 14:58.
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Old 16th October 2007, 00:02   #42 (permalink)
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Re: Analysis of List of Rebreather Accidents

Quote: (Originally Posted by AD_ward9) View Original Post
It is on our web site, and has been for some years.
Diver mole had something even closer to what you describe on his web site for years earlier.

Did not stop the deaths though.

The fix is to meet EN61508 safety standards in eCCRs, of which accident investigation is one little part, and for divers to have zero tolerance of kit that does not do that. It means sharing safety data, and openness, so all companies can benefit from lessons learned elsewhere.

Alex
The fix is NEVER going to happen so deal with it. Nobody making a ccr has to and you can keep preaching your specs till your blue in the face. If you truly want to save some lives, do what the other poster on here said and post USEFULL REAL WORLD INFO TO MAKE DIVING REBREATHERS SAFER!
Like the other posters example about the battery case on a YBOD. His post can possibly save many lives, your's on the other hand about spec this and spec that is a pipe dream that is just a bunch of hot air. Even if a mfg specs to your stringent specifications, 2 things will STILL happen.

1) people will buy other brands not spec approved
2) people will die on a brand that meets every spec you demand of it.

And the reason #2 will happen is due to both user error and parts failure.
While I agree specs are important, im just about sick of your non stop posting of specs. The rebreather world is small, and to ask of it for as you do will never happen. Well, I think never may be overreacting. Maybe when CC is as common as OC will it happen, and then only because a mfg will see a benifit as touting their device as "ce this or that" which will be used as marketing hype to show why you should buy their brand.
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Old 16th October 2007, 00:08   #43 (permalink)
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Re: Analysis of List of Rebreather Accidents

Quote: (Originally Posted by AD_ward9) View Original Post
Thanks. I did try to be as clear as I could, but just in case: my comments were specific to pre-backlit Inspirations. These were manufactured prior to September 2000, but some are still in use.

After 2000 there were various other Inspiration Classic fixes, one in later 2003/early 2004: the battery housing. That is worth replacing: it is implicated in at least one fatal accident, and is top of the plausible causes list on another. There are also some software fixes. The best way for users to get these is to send the unit back to APD for service. As the cost for a non-backlit unit will be high, divers should consider the alternatives before doing that. Brent's system looks the most promising, and is what I am doing with an Inspo here, but I have not got it yet or tested it yet.

The Vision controllers are a much better design than the Classic controllers, but still do not meet SIL 1 safety levels for a system in continuous use, as it is uses an unverified controller running unverified code compiled using an unverified compiler. There is also a need for a much wider FMECA: this has not been done because it would have caught a few things, such as those below.

The main safety weakness with Vision, is it should switch itself on when PPO2 falls, and always when the PPO2 is less than 0.19. We have published this algorithm. Methods using depth or wet contacts are not foolproof.

Second safety hazard with the Vision, is ensuring it always goes straight into dive mode when reset underwater.

These are safety hazards because in many accidents the diver has passed out in circumstances that indicate hypoxia, even though there is sufficient gas in the tanks. The above two items would address this risk directly.

Given the capability of electronics to hang, would recommend strongly that eCCR users fit a second HUD, e.g. the Uri HUD, not related at all to the primary controller. This would be after getting all upgrades to the controller in the case of Inspos.

Alex
By far the most usefull post you have ever contributed on here. This is what the majority of us are looking for. Not some mumbo jumbo ce crap.
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Old 16th October 2007, 00:25   #44 (permalink)
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Re: Analysis of List of Rebreather Accidents

Quote: (Originally Posted by am) View Original Post
Once again, your commentary fails to address a key issue. Bailout cannot provide any guarantees, no matter what the reason for the initial problem. So, if divers encounter potentially fatal problems as a result of bad design and they know bailout can't save them, they are, in essence, diving equipment that is not fit for the purpose. Encountering problems that are integral EXPECTED problems in rebreather diving is an entirely different matter. You are missing the point entirely about what constitutes REASONABLE EXPECTATIONS from consumers of LIFE SUPPORTING EQUIPMENT.

Whats your definition of bailout? Mine is redundancy that will get me back to the surface alive and without adverse risk (ie, make sure I can finish my deco). In that regard, I take enough bailout to ensure that if my Rebreather shits the bed, I can get back to the surface safely with the bailout gas I brought. Like the previous poster said, if a shark bites the RB in two, Im still getting back to the surface safe, even with a mess in my drysuit. I read once from a very well respected RB diver that said that almost EVERY problem hes ever encountered on a dive he fixed and continued the dive or at least aborted it and returned to the surface safely on the RB. To me, that is what we should all be thinking about when a problem arises. Get off the loop, fix the problem if possible, get back on the loop and either continue the dive or abort it and get to the surface. At worst case, Ill have to stay off the loop and use the bailout gas I brought to get back.
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Old 16th October 2007, 00:43   #45 (permalink)
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Re: Analysis of List of Rebreather Accidents

Quote: (Originally Posted by David Pye) View Original Post
Sorry to haul the thread back to this point, but I recall seeing that the reports from this chap's buddies seemed to suggest that he had drained his diluent followed by a pair of bailout stages they passed him as a result of a leaky mask, followed by panic. Also, on the surface, it seemed that several divers ditched their units, as well as the deceased. I'm sure the thread that this was reported in was on Rebreather World.

I suspect you might well have more information than I do, of course....

David
When i read things like this, I have to wonder that if we cant even get standards for training how the heck can we expect standards for equipment. I dont know about this guy, but a leaking mask should never end in death. I dont know how many classes I took that required removing the mask, not the least of which was my OC trimix that required me going to 60' with a set of doubles and 4 80cf stages and then removing my mask in 50 degree water and then removing all the stages and then clipping them back on and putting my mask on and clearing it, all in water that had about 10' of vis.
Now compare that to someone that is in the tropics and does his OW cert that required a mask drill removal in 80 degree water.

How do you think that person is going to fare if hes now diving a Rebreather with a drysuit on in 50 degree water and gets a mask leak?
The point being is that training doesent guarantee your ablity to handle different conditions. And thats not a certification agencies fault, its our own for not realizing our limitations. I am lucky enough to live and dive somewhere that subjects me to cold water, nasty conditions and horrible visibility on a regular basis. Sometimes it really sucks, but in the end, it makes me a better diver. Unfortunately, someone that doesent get subjected to those things and then dives in them can end up way over thier head, and thats about the only thing I can guess happened with the guy who died due to a mask leak.
The real question is, whos fault is it that this guy died of something so simple as a leaking mask? And does this consitute a "Rebreather death"? The same thing could have happened on OC.
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Old 16th October 2007, 01:27   #46 (permalink)
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Re: Analysis of List of Rebreather Accidents

Quote: (Originally Posted by what2be) View Original Post
Sometimes it really sucks, but in the end, it makes me a better diver. Unfortunately, someone that doesent get subjected to those things and then dives in them can end up way over thier head, and thats about the only thing I can guess happened with the guy who died due to a mask leak.
The real question is, whos fault is it that this guy died of something so simple as a leaking mask? And does this consitute a "Rebreather death"? The same thing could have happened on OC.

Maybe yes maybe no.. The guy should have been trained to breath without a mask on a Rebreather.. That being said I have seen more than one person who had absolutely no difficulty with no mask on OC, but had all sorts of tbls on a rebreather..
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Old 16th October 2007, 02:25   #47 (permalink)
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Re: Analysis of List of Rebreather Accidents

Quote: (Originally Posted by what2be) View Original Post
When i read things like this, I have to wonder that if we cant even get standards for training how the heck can we expect standards for equipment. I dont know about this guy, but a leaking mask should never end in death.
You seem a little over-caffeinated this morning. This was a real person with real loved ones. Let's hope they're not reading this thread. Saying the recently dead died of stupidity is, shall we say, "not done in polite society". Straws don't usually kill, but they break camels' backs. It can only take something small to tip someone down the incident pit. We aren't able to see inside this man's head and know all that was going on at the time. This incident makes clear the problem with compiling lists of this sort: when experienced divers goof, there are likely to be multiple distractions preventing them from doing what they have done a thousand times before. As the Japanese say 猿も木から落ちる - even monkeys sometimes fall from trees.

To steal a line from one of my kid's books, I'm a bear of little brain and long words bother me. I also find some of Alex's comments difficult to understand sometimes, but I would far rather he gave a precise comment in technical jargon than gave an imprecise comment to appeal to the masses. Science isn't decided by democracy, and when there's something I don't understand I know that Google is a teacher with boundless energy who works for free. Right now, Alex's database seems the best resource for understanding the rebreather community's little Friday the 13th problem. He has been giving it and his analysis for free. I, for one, won't be looking this gift horse in the mouth.
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Old 16th October 2007, 02:56   #48 (permalink)
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Re: Analysis of List of Rebreather Accidents

Quote: (Originally Posted by what2be) View Original Post
The fix is NEVER going to happen so deal with it. Nobody making a ccr has to and you can keep preaching your specs till your blue in the face. If you truly want to save some lives, do what the other poster on here said and post USEFULL REAL WORLD INFO TO MAKE DIVING REBREATHERS SAFER!
Like the other posters example about the battery case on a YBOD. His post can possibly save many lives, your's on the other hand about spec this and spec that is a pipe dream that is just a bunch of hot air. Even if a mfg specs to your stringent specifications, 2 things will STILL happen.

1) people will buy other brands not spec approved
2) people will die on a brand that meets every spec you demand of it.

And the reason #2 will happen is due to both user error and parts failure.
While I agree specs are important, im just about sick of your non stop posting of specs. The rebreather world is small, and to ask of it for as you do will never happen. Well, I think never may be overreacting. Maybe when CC is as common as OC will it happen, and then only because a mfg will see a benifit as touting their device as "ce this or that" which will be used as marketing hype to show why you should buy their brand.
time of the month?

Quick show of hands who feels who is doing more to increase awareness Alex or What2be? What price that awareness? Iritating a few individuals? Small price to pay

Thanks for your opinon though Oster rich has added some of them to his list


Re: CCR Fatality Statistics
GUIDE TO Rebreather REVIEW

by Oster Rich


1) Its ok to have a weakness in the design because so do other rebreathers

2) Its ok to have a weakness in the design because users are taught in training how to prevent that weakness from killing them (see 3)

3) Users always follow their training

4) If a user doesnt follow his training and a known design weakness kills them the unit is not at fault

5) No point trying to address all known weaknesses in the unit design because we can never make it idiot proof

6) Relying on user training and following protocals is always safer than making a design as foolproof as possible (see 3)

7) Its ok to accept some possibly fatal weakness in a design if there are other weaknesses that are more obvious or more likely to kill you.

8) Increasing safety automaticaly means increasing complexity

9) Increasing complexity automatically means reducing saftety

10) Increasing safety automatically means increasing cost

11) KISS is always safer (see 8, 9 and 3)

12) No point even trying to make unit idiot proof because idiots will always find a way around it

13) Relying on users following protocals to avoid a weakness in the design is safer than engineering out the weakness in the 1st place

14) Mechanical systems are always safer than electronic systems

15) Electronics can never be made foolproof or safe

16) Previous experiences (unreliable electronics) will aways be repeated

17) Engineering out weaknesses will result in reduction in user need to follow protocals (that were in place tio overcome weakness) and that will result in overall reduction in safety

18) Reviewers bias (if any) automatically has a bearing on the existance or validity of any weakness they report

19) Something to do with 747s, or was it trains...- I forget

20) attempting to make a Rebreather as safe as possible is a mistake because people then trust it and relax their safety mechanisms

21) attempting to make a Rebreather as fault free as possible is a mistake because humans design them and use and maintain them - and humans are prone to faults

22)The fix is NEVER going to happen so deal with it. Nobody making a ccr has to follow strict safety specs

23) No point promoting mnf try to follow strict safety specs beacuse 2 things will STILL happen.

1) people will buy other brands not spec approved
2) people will die on a brand that meets every spec you demand of it.

24) No point promoting mnf to try to follow strict safety specs because the rebreather world is small, and it will never happen.
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Old 16th October 2007, 03:07   #49 (permalink)
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Re: Analysis of List of Rebreather Accidents

Quote: (Originally Posted by Abbo) View Original Post
. He has been giving it and his analysis for free. I, for one, won't be looking this gift horse in the mouth.
here here!
very well said,


some recent posters have been ranting at him to do this and do that as if 1) hes being paid to share his opinion and 2) as if he owes them it
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Old 16th October 2007, 03:20   #50 (permalink)
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Re: Analysis of List of Rebreather Accidents

Couldn't agree more. Everytime someone comes on here and shares their expertise it is a gift.


Quote: (Originally Posted by Drmike) View Original Post
here here!
very well said,


some recent posters have been ranting at him to do this and do that as if 1) hes being paid to share his opinion and 2) as if he owes them it
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