Key Largo rebreather accident?

Unregistered

I got this from scubaboard. Someone can confirm it?

http://www.scubaboard.com/showthread.php?t=114676

Two very experienced tech divers and very good friends with the owner and crew of Tavernier Dive Center went out yesterday morning aboard the dive boat Shadow to do the Northern Lights. While at 180 feet a problem occured with a rebreather, which one of the divers was using. That diver mistakenly took a breath of pure O2 at depth, which caused his death. The other diver attempted to get his buddy to the surfaced as quick as possible and suffered DCS. They were only able to get the DCS diver aboard the boat and are still looking for the other diver.

The DCS diver was placed in the chamber here in Tavernier with paralisis, but has since been moved to a room. The hope is that the paralisis is temp.

Dave Young

My heartfelt condolences and sympathies go out to the family and friends of the diver who lost his life in this accident.

I know how hard it will be for the dive buddy just now, and I wish him a full and speedy recovery. My thoughts are with you mate.

Dave

PeteS

Ditto the above.

It's amazing how something so simple can have such disasterous consequences.

ericfine50

Below is a report from notes that took from a talk given by Tom Huff of Northeast Scuba. He trained both divers involved in this incident. Tom and Joe both reviewed and added facts to this report. Joe is a member of this board (JoeA is his name).

Notes from a talk by Tom Huff of Northeast Scuba.
Date: November 8, 2005
Subject: Northern Light Incident

Note: The details of the following incident report were written by Tom Huff and Eric Fine. Joe Augusto reviewed the details to insure accuracy. None of us has the answers as to why this tragic event happened. Please read with an open mind and remember we have lost a dear friend and valued member of the diving community.


Tom first talked about the differences between how recreational divers are trained and how they may react in the water verses how a technical divers may react in emergency situations. This would put his telling of the incident into perspective for club members who are strictly recreational divers. Tom went over technical diver buddy skills, training, dive planning and trimix as the gas of choice for these deeper dives. He also contrasted open circuit technical dives with rebreather technical dives and the differences in equipment and bail-out procedures these divers might use to accomplish the same tasks.

Both Joe and Paul were seasoned divers and had been diving for close to twenty years. They were also best friends. Both had worked their way through the various technical courses until they were certified as OC advanced trimix divers and trained as trimix divers on their respective rebreathers. They had numerous deep dives, some of which included the U-869, Andrea Doria, and various local deep dives in the 150-250 rage. Tom kept saying over and over again, how Joe and Paul were his two of his best students. One of the reasons Tom believed this was that even though they had completed courses and earned their certification, they practiced skills learned during those classes on many of their fun technical dives. Their intent was to stay sharp and be able to lend assistance or respond to an emergency situation should one arise. Whether it was sharing air, valve shut downs, bail-outs, etc., these guys were on top of their diving skills at all times. They were always methodical about gear preparation, pre-dive procedures and had constant awareness and monitoring of what was going on with their rebreathers. You would have trouble finding a pair of divers so attuned to each other’s ability as well as complimenting each other’s strength’s.

The following details and FACTS of the incident came from Joe and Scott. Scott was the boat captain in charge of the charter that day. Tom’s purpose is to make sure the facts, as known, are correctly explained without the temptation of others adding speculation to an already serious and tragic accident.

Joe and Paul went to Florida for a dive vacation and had planned to have 3-4 days of diving. Some of the dives would be more recreational while others would require their technical diving skills.

The first day of diving, they made two dives on the USCG Dwayne. The first dive was uneventful. Their rebreathers were working fine and they had fun. They surfaced and hung out during the SI. At the end of the second dive and at 20 FSW, Paul flushed his breathing loop with 100% 02 to gain the maximum effect of washing more nitrogen out of his system. Many technical divers, open and closed circuit, use 100% O2 during their final deco stop to achieve the maximum benefit. A rebreather diver can affect the same result as an open circuit diver by flushing the breathing loop with pure oxygen via a manual O2 addition valve. When Paul completed several flushes to ensure all diluent was removed from the loop he reviewed his handsets so he could verify the current PO2 in the loop. What he saw was that the three 02 sensors were not registering the expected PO2 of 1.6 (or close to it). All three sensors were reading low, with the highest showing a PO2 of 1.06. Since Paul, as part of his rebreather setup prior to making the dive, had already verified the contents of his oxygen source to be 99%+, he knew the sensors were not displaying the correct PO2, but he also knew the PO2 in the loop was 1.6. At 20feet these sensors, with a 100% O2 flush should have been reading a PO2 of 1.6 or close to it. Tom said that according to Joe, Paul took note of this and had even shown his handsets to Joe so he could see there was an issue with the sensors. These three sensors were installed in the unit less than a year ago. That night Paul swapped out all three of the sensors for new ones. (Tom mentioned the 3 old sensors will be sent out for testing).

Paul re-calibrated the rebreather after the new sensors were in and everything appeared fine and he was all set for the next day’s dive. Paul and Joe also put new scrubber medium in their Rebreather canisters for the next days dive on the Northern Light. They knew the expected max depth was about 190 feet. Fresh scrubber is essential when executing deep dives. New scrubber is essential in order to make sure CO2 can be efficiently processed during all phases of the dive in order to prevent excess CO2 from causing serious conditions underwater. They understood the need for new “lime” and made sure every aspect of their dive was covered as part of their dive plan.

Tom mentioned that Paul had spoken to his wife Thursday night, and she said he had a headache and took some Tylenol for it. According to Denise, Paul rarely got headaches. (Was this a problem related to the first dives? Maybe it was just a normal headache. Maybe it was something else?) So it was strange for him to have a headache. Paul went to bed early that night with expectations on tomorrow’s dive on a new wreck.

The second day of the trip, Paul and Joe head out to the Northern Light. Seas were about 3–4 ft with about a 10-knot wind. The boat they were diving off of was a commercial charter and only the captain was on board. Just Joe and Paul were onboard as divers.

The gases used for this dive as well as planned bailout were as follows:
10/50 diluent and bottom bailout
95% Oxygen
28% Nitrox
21% (Air)
They carried 45cuft tanks with the various bailout gases.

The gases selected would optimize their END (Equivalent Narcotic Depth) for the dive as well as provide them with safe bail-out options at any depth should a situation arise that would force one of them to bail-out to open circuit and abort and finish the dive accordingly. They also had, as part of their dive planning, a bail-out dive option that would show them the open circuit decompression stops should this option become necessary.

Paul and Joe both had VR3 computers and back up slates with their dive profiles written on them, Bottom Timers, Tables, and Depth Gauges. As a dive team on rebreathers, they planned to carry enough bail-out gas for 1.5 divers. They split the deco gas and bail-out gas between them thus ensuring either of them had immediate access to the necessary gas if a bailout and abort was needed. This is a normal procedure when planning a rebreather technical dive. Except in an emergency, these extra tanks of bail-out gas would never be used. This gas selection and rigging was part of their dive planning and their redundancy protocol.

When they arrived on-site the captain saw there was a surface current running and instead of anchoring to the wreck site, they opted to do a live drop. The boat could circle the area and pick them up when they completed their dive, no problem. There happened to a lobster pot just off the wreck. Before using the lobster pot line as a descent aid they captain made several passes over the area to insure the pot was indeed close to the wreck. After making sure the pot was near the wreck they decided to use the lobster pot’s line as their descent reference. The drop would be next to the buoy and Joe and Paul would descend down the lobster pot line and run their line from it over to the Northern Light as soon as they could see the wreck. The line from their wreck reel would also be their guide to lead them back to the point where they could easily ascend and perform the required decompression stops. Again, all normal procedure for executing a dive of this nature and something they had done many times before.

Both divers suited up and headed in. Joe mentioned that it was a tough surface swim due to the current and it took a while and some effort to descend far enough to get below the effects of the current. When they got below the current and arrived at a point where they should attach their reel, Paul ran the line and Joe followed him. The dive was uneventful with the exception of good visibility and warm water. Since Paul and Joe were accustomed to regular dives on the wrecks off of our New England shores with limited visibility and cold temperatures, this warm, clear water was a real treat for them.

Joe thinks they hit a max depth of 186 FSW and they started their ascent with about 20 minutes of bottom time or very close to it. Joe remembers reading his VR3 computer during his ascent and seeing a calculated deco obligation of about 50 minutes. The ascent from the wreck up to 130 feet was uneventful and went as expected. As Paul reeled in the line, Joe noticed Paul was going very slow and was very methodical about reeling the line in. At first Joe thought Paul was being a bit anal about the line reeling back onto the spool in very neat fashion. This would not have necessarily been out of character for Paul since he was very meticulous in all aspects of his diving.

During the ascent Joe signaled to Paul several times and asked if he wanted him to take over the reel. Paul indicated he was okay and for Joe to move on. At around 130 FSW, near or at their first decompression stop, Paul shoved the reel to Joe. This was Joe’s first indication Paul was in trouble. Paul went for his 28% bottle and was attempting to turn the tank valve to the “on” position so he could deploy his regulator. Joe saw Paul’s actions and went for his own bail-out gas (21%) just in case he could deploy it more quickly should Paul have any delay getting to his own. Joe said he saw Paul trying to turn the valve on and got maybe 2 or3 turns of the tank knob before Paul’s eyes rolled back, his chest puffed up, his arms became outstretched and he seemed to convulse for a few seconds before going went limp. These actions caused Paul’s breathing loop to leave his mouth and float over his head. Joe shoved his open circuit regulator into Paul’s mouth hoping a gag reflex might cause him to cough and take a breath and regain his breathing cycle.

Joe now had to make a decision. Does he attach Paul to a lift bag, inflate his BCD and send him up knowing if the boat does not see him almost immediately he will surely perish? Does Joe go on to complete his own 50 minutes of deco? Or, does Joe bring Paul and him immediately to the surface knowing he surely suffer a DCI hit of his own? Joe decided to bring Paul up from 130 FSW and forego any decompression stops for himself. Joe estimated it took him maybe 2 or 3 minutes to reach the surface.

When the two divers reached the surface, conditions had gotten much worse. The winds were now blowing 25 knots and the seas were 6 to 8 ft. These conditions made it hard for the Captain to see the divers. Joe used his Dive Alert Air Horn to signal the boat. The Captain headed over and saw there was a serious situation. The captain grabs Paul and Joe gets into the boat and strips out of his gear so he can assist the captain in getting Paul into the boat. Joe and the captain both try to bring Paul on-board but he is too heavy with all of his equipment still in place. The boat is pitching with the 6-8 foot waves and there is no way the two of them can lift Paul into the boat. The Captain asks Joe to re-enter the water and unclip Paul from his rebeather and stage bottles. Joe hops in wearing a 3mm j wetsuit (jumpsuit) and with one fin on. Joe had all the clips undone on the shoulders and then he got to the waist strap. The waist buckle is hidden by Paul’s utility pocket and the wave action was preventing Joe from gaining a good grasp on the pocket in order to pull the pocket to one side so he can release that buckle.

The captain sees the problem and tells Joe to cut the waist strap free. Joe reaches to get shears that are attached to the outside of Paul’s kit. As he reaches for the shears, this is when Joe’s DCI hit occurs and his entire body from the neck down goes numb. He has no use of his hands, arms, legs and no way of maintaining himself at the surface. Joe knows he has suffered a DCI hit to his spine and is helpless in the water. Within a matter of seconds Joe is 25-30 feet away from the boat and cannot swim, or use his arms. Joe can barely keep his lips above the breaking seas to catch a breath. The Captain throws Joe a line, but he can’t grab it due to the paralysis. Tom mentioned that Joe said he was thinking, “So this is it. This is how I’m going to die.” The Captain makes the decision to let go of Paul, back the boat to Joe and get him onboard and then head back and retrieve Paul. Paul’s BCD had been inflated but Paul was barely floating head level in the ocean because all of his equipment is still attached and hanging from his body.

With Joe onboard and situated, the Captain heads back to the area where Paul was. But, with the current and wave action, Paul’s body is gone and even though they searched the immediate area he could not find Paul.

Joe is rushed into a hyperbaric chamber at Mariners Hospital on the Keys and a Navy 6A treatment is done. During the first treatment, Joe regains use of his arms and legs. They remove from the chamber after the treatment and Joe suffers a relapse and another bout of paralysis, this time from the waist down. Joe had twelve chamber treatments before the hospital determined more chamber rides would be on no further use.

Joe is currently back in Massachusetts and going to rigorous Physical Therapy. He can now walk with the aid of crutches, a far cry from where he was three weeks before. His right leg is still weak and giving him problems but he is hopeful constant work and determination will reward him with a full recovery.

Paul’s body has not been found, but the rebreather was found not too far from the wreck about 4 days later. Since the rebreather was flooded and all testing on it has not been completed, it would be premature to suggest the rebreather was the sole cause of the Paul’s death. It can’t be ruled out at this time and neither is it a definitive answer to the question of “what happened”. It is simply a piece of tragic puzzle.

So, what happened to Paul and why did this tragic event take place? We may never know for sure what happened. It was a diving accident and it awakens all of us to the risks of diving. Was there a CO2 excess that may have contributed to a CNS hit? Maybe.
Could the rebreather have malfunctioned? Maybe. Could Paul have had an unknown physiological problem that ultimately resulted in his death? Maybe. We just don’t know at this time and may never know. Maybe it is enough to realize we must stay keen on our skills, maintain our equipment, keep learning as new diving theory comes out and most of all stay vigilant while diving.

You would have to know Paul and his love of diving to understand that he would not want people speculating about his cause of death. Finger pointing was not something Paul would have ever done. Paul was an engineer and he would analyze everything carefully before making a decision or statement. Tom believes in this situation, without conclusive proof of the cause of the accident, Paul most likely would have said, “It was an accident.”

Joe appreciates the support he has received from friends and local divers. If you know Joe and would like to email him feel free to do so. Before you ask him a bunch of questions about the accident please re-read this report. Joe reviewed the details written here and would have nothing more to add.

There is a memorial service for Paul Theriault on Nov. 12th at 4pm at the Renaissance Inn in Bedford, Massachusetts, located on the Middlesex Turnpike. Tom says based on Paul’s life and the way he lived he would have wanted a memorial service to celebrate his life. Paul would have wanted his all his friends together and to give a toast to him. According to Denise, Paul once said, “You know you are over 40 when you own a Hawaii shirt.” So if you plan to attend the memorial service, wear your Hawaii shirt.

schford

Tear's in my eyes reading this - thank you for sharing this, hopefully this will be of benefit to us all.

Here's to Paul and his accomplishments (in the spirit of the memorial service) and to Joes courage.

__________________
Bailout and Kit Management account for Murphy's Law

The only bad question is one you did not ask and later wish you had.

Use of RBW is subject to the Rebreather World Terms & Conditions of Use

Scuba_Vixen

Eric,

Welcome to RBW and thanks so much for sharing this with a community where it hits very close to home.


Come visit often.


Darlene

caveseeker7

Hi Eric,

what a chilling account of the happenings that day.
Thank you very much for posting it at our board, too.
Why we may never know why all this happened at least
now we know what did occur.

As Darlene says, you're welcome to poke around our site.

__________________
Cheers
Stefan



"Political Correctness is a doctrine, fostered by a delusional, illogical minority,
and rabidly promoted by an unscrupulous mainstream media,
which holds forth the proposition that it is entirely possible to pick up a turd by the clean end.!"

ericfine50

Thank you guys for the welcome. As someone that has no Rebreather expierence at all. I am going to lurke and learn. There will be time in the future, I think that I will want to try a RB.

I am sorry that my first post was for sad reasons, but I am glad that Joe and Tom were nice enough to review this and make sure the facts were correct.

Take Care
Eric

Scuba_Vixen

The account of this accident (as Eric posted) has gotten considerable response on TDS.

After re-reading the account, there's a couple things that don't seem to fall into the logical order of things.

I posted these questions on TDS, but really wanted to see what you guys thought. ( I hope cross posting is OK here)


One point that's not been discussed, and may be important, is the sensor issue from the previous day.

They all read slightly over 1.0 when they should have read 1.6.

This is a huge error! While cells age and typically loose output at the higher levels first, for 3 cells to loose this much in the time since they last were used, and to do it so evenly, is a RED FLAG that there may be other issues. (moisture on the cells from some sort of leak, or ADV leaking for example)

The other aspect of this issue with the cell's low output, is that if it were true, that they were actually reading .6 low, then Paul did his dive the first day at a PO2 of ~1.8 ...... And he didn't tox or have physiological isuues?

But there's even more that doesn't fall into place on this sensors issue.

If they read only 1.06 when they should have been 1.6 .... how did they manage a dive only minutes previous, when the cells should have been reading ~1.2 ?

With less than setpoint reading, Paul should have heard the solenoid firing constantly trying to maintain setpoint, This would have been a red flag to instantly go OC and abort, failure to do so would mean toxing. Since that isn't what the report says transpired, I have to wonder about what may have happened to the Rebreather on the ascent from that dive to the 20' point where they all of a sudden couldn't get a sensor reading past ~1.06 that may have contributed to the tragic dive the following day. A tiny leak that got the cells wet and caused them to read progressively lower throughout the dive, would have ended up as a TOX.


I think we need to look at a larger block of time and events here if we hope to make some sense of what happened.



Darlene

mverick

Condolences to the family. Horrible thing.

Were they both diving the same Rebreather?

Did they both know the others Rebreather well in case of problems? Being able to read each others HUD?