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Thread: Mk vi fatality - portugal

  1. #11
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    Re: Mk vi fatality - portugal

    Quote Originally Posted by psmedo  View Original Post
    You send your CCR machine to be "fixed" of some problem to the CCR dealer...wich happens to be your CCR instructor, your dive guru...

    Then you get the machine back and fix "ready to dive"..and ..lucky you, allready with O2 cylinder filling made. For some reason (trust complex) you do not check in the dive store with your dealer if the scrubber has been changed...you assume it was...or you do not even need to do it cause you had a used scrubber inside (still with some dive time) when you´ve send the machine to be fixed...and you assume (again) that it´s still in the machine..
    This is a mindset of the diver, it is not a unit specific problem. I would say that the instructor, your dive guru has failed in teaching the student if the student is willing to do a trust me dive with his rebreather. Assumption is the mother of all f-ups.

    Quote Originally Posted by psmedo  View Original Post

    CCR check lists should follow aviation most recent protocols (like the CCR Sentinel allready does), that if you fail to check the machine all items or perform predive tasks the CCR alerts for possible fatal outcome (for example failing to do the 4 minutes prebreath test..), as per item 20 in the MK VI before diving check list...

    Just my 2 cents...

    RGDS
    If we are going unit specific, the MkVI will perform all tasks needed to ensure that the unit is fully functional. However, this doesn't mean that you can leave your brain at the divecenter or in your car. There are still additional task that needs to be performed before you say that you are ok to dive.

    It's like saying Volvo is one of the safest cars in the world, so why did he die?
    - Well, he was doing 240 km/h when entering that curve there.
    - But, it is supposed to be safe, Volvo said so!
    - Well, yes, if you use it correctly and follow the rules.

    I can understand your viewpoint from the Poseidon Marketing statement, although I will not fully agree with you on this. it really doesn't matter what rebreather you are diving, during training you should be trained and aware of the consequences that scubadiving might have. Otherwise, the instructor has failed his job.

  2. #12
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    Re: Mk vi fatality - portugal

    I would have thought that the huge change in the buoyancy of the unit would have been a giveaway that something was wrong - take a scrubber out that weighs 2 or 3kg and leave an air space there...

  3. #13
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    Re: Mk vi fatality - portugal

    My Bauer compressor won't fill unless there is a filter present so it shouldn't be too difficult to implement in a low pressure environment as a scrubber.

    But do we really want that? Probably not some sort of check valve with the possibilty to fail closed? Additional wiring inside the canister? Neither will know if the scrubber is filled or if the lime is fresh enough.

    The only solution I can see is a CO2 sensor. Thoughts?


    /nils

  4. #14
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    Re: Mk vi fatality - portugal

    Now the known FACTS;

    Victim;
    Male aged 42, married with two kids. Had about 40 hours on the MK VI. Certified as OWSI in OC.

    A Dive Center owner and manager and was going with three customers to do the second service performed to customers from his Dive Center (it had opeened the previous weekend).

    Was using a borrowed MK VI CCR (was expecting his machine tobe delivered from factory). Some witness refer the victim as been very tiered due to a lot of work related with the dive center bussiness on the previous days to the accident including a night without any sleep.

    When deleivered the machine, he was asked if he had scrubber cartriges to put onto the CCR, to witch victim replyed yes, he had he did not need any supply of those.

    Dive site environment;
    Bottom depth 10/12 meters, god visibility, no current. God wether no strong winds, dive in the morning.


    The dive;
    Victim was trying to moor the boat on a sandy bottom. As it was getting difficult to get the anchor "stucked" and in order to "check" if it was fixed on botom victim entered the water equiped with the CCR to do a quick survey on the bottom. If all was well it was supused to resurface and descend together with all the others In spite of trying to go down he could´t due to excessive bouyancy, and requested 1 piece of 2 kgs to add to his weight belt. Still not achiving negative bouyancy another 2 kgs was added to the weight. Then he went down. About 8 minuts passed away and in the boat the other divers decided to go and check what was delaying the Instructor. They found him laying on bottom out of the loop nothing in mouth. Body was recovered and CPR performed at no avail.

    The CCR examination;
    Machine was with several alarms onging and in CCR mode. Loop was not flooded. When scrubber cover was remouved to check a complete scrubber flood,scrubber cartridge was found to be missing.


    R.I.P my friend

  5. #15
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    Talking Re: Mk vi fatality - portugal

    Quote Originally Posted by chunter  View Original Post
    My condolences to the family and friends. It is always sad to lose fellow divers.

    I don't know if the initial poster is speaking from fact or speculation. If he is relying on reliable sources, I'm all for posting the information. If it helps one of us, or someone considering diving rebreathers from dying in the same way, then that is a good thing. Everyone makes mistakes. I don't think it disparrages the deceased to talk about how it happened.

    I also don't think it is wrong to highlight the fact that Poseidon has marketed its unit as a recreational rebreather and has highlighted its safety. I'm not debating whether the unit is actually safer than other units...I'm just saying that they market in a certain way which could encourage people to dive their unit without understanding all of the risks involved. For instance, their website states, "Poseidon’s MKVI has 5 big advantages over traditional open circuit equipment: 3 hours typical dive time, Safer and easier to use, Lighter and smaller, No decompressions stops and Silent operation makes you part of the environment; not just a visitor. The MKVI, the first true technological breakthrough in decades, is a game*changer."

    Are they actually making the claim that their unit is safer and easier to use than traditional open circuit equipment? That is absurd.

    I point this out because this is in fact a FORUM. It is a place for people to discuss relevant things. I think that we all agree that it is very sad when people lose loved ones. That should not prevent us from talking about incidents and why they happen. This may include discussion of particular unit faults or even diver error.

    I'm tired of this subject being taboo. It is probably one of the most useful things to read about here. When I did my tech training I did tons of reading about dive incidents and what caused or may have caused them. I actually felt sick sometimes reading about these things and even on the verge of tears, but I am certain that going through that process makes me a more careful and less complacent rebreather diver. If we restrain the conversation to absolute facts, then there would be nothing to discuss. We never know exactly what happened because the best witness is no longer with us. That shouldn't prevent us from looking at the situation and trying to analyze what went wrong.

    Aloha,
    Charlie
    I agree. But i just like to have the facts first.from what I understand the op
    Was just speculating how it happened(most likely he is rite).
    I do feel there should be no thing called a recreational Ccr, they all should be considered tec gear m

  6. #16
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    Re: Mk vi fatality - portugal

    I don't believe it is practical nor desirable to attempt to engineer out all the potential human factor issues inherent in rebreather diving. a well trained, DISCIPLINED diver is the key to safely diving rebreathers, imho. if you do not have the type of personality that lends itself to this type of discipline, you should not be diving rebreathers. period.

    we are seeing some similar scenarios in commercial aviation with the tremendous dependence on automation in the cockpit. as a result, the skills necessary to cope with faulty or failed automation by the flight crews have in some cases, deteriorated. there has been a move a foot recently to reemphasize more discipline on the part of the crews in manual control of the machine, an emphasis i entirely agree with.

    you must have the discipline to ALWAYS:

    1) use checklists in assembly, pre dive and pre jump.
    2) abort a dive prior to water entry with any know critical item failure.
    3) never, ever dive a unit that you have not personally assembled or have overseen the assembly of.
    4) follow SOP's! ie, pre breath the unit for at at least 3 to 5 minutes prior to jump, don't cut corners!

    the effort to widen the market for rebreathers, to large numbers of "recreational" users, ie, build a "human error proof" machine by the use of of technology and automation is not, I believe, realistic at this point in time. I don't believe the current state of the art at the targeted end level consumer price point is there.... maybe some day, but not now.

  7. #17
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    Re: Mk vi fatality - portugal

    Quote Originally Posted by swadiver  View Original Post
    I don't believe it is practical nor desirable to attempt to engineer out all the potential human factor issues inherent in rebreather diving. a well trained, DISCIPLINED diver is the key to safely diving rebreathers, imho. if you do not have the type of personality that lends itself to this type of discipline, you should not be diving rebreathers. period.

    we are seeing some similar scenarios in commercial aviation with the tremendous dependence on automation in the cockpit. as a result, the skills necessary to cope with faulty or failed automation by the flight crews have in some cases, deteriorated. there has been a move a foot recently to reemphasize more discipline on the part of the crews in manual control of the machine, an emphasis i entirely agree with.

    you must have the discipline to ALWAYS:

    1) use checklists in assembly, pre dive and pre jump.
    2) abort a dive prior to water entry with any know critical item failure.
    3) never, ever dive a unit that you have not personally assembled or have overseen the assembly of.
    4) follow SOP's! ie, pre breath the unit for at at least 3 to 5 minutes prior to jump, don't cut corners!

    the effort to widen the market for rebreathers, to large numbers of "recreational" users, ie, build a "human error proof" machine by the use of of technology and automation is not, I believe, realistic at this point in time. I don't believe the current state of the art at the targeted end level consumer price point is there.... maybe some day, but not now.
    +1

  8. #18
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    Re: Mk vi fatality - portugal

    First of all let me say I am very sorry for the victim and his family.

    When I did a MKVI crossover with TDI in Florida last year we were at the poolside doing our predive. We were all experienced CCR instructors attending this course and we all (I believe) had some misgivings about the hype Poseidon was promoting about how the rebreather was safer and so easy to use blah blah blah.
    Just to make a point when we were assembling the rig poolside I intentionally left the scrubber cartridge out and commenced to automated pre-dive steps. The unit passed all checks and told me it was ready to dive. When I asked Jerry, our instructor if I needed to repeat the whole pre-dive sequence after installing the cartridge he seemed to be annoyed.
    It was later mentioned that they were going to install a cartridge detection switch but I guess that hasn't happened.

    This tragic accident shows once again that there is no foolproof way to remove the resonsibility of safe operation away from the diver.
    Cheers,

    Dave....

    www.wedivebc.com

  9. #19
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    Re: Mk vi fatality - portugal

    Quote Originally Posted by psmedo  View Original Post
    Just think about this scenario...just imagine it´s a possibility of a imaginary diving accident, i´m not stating this is "what happend"...but just give it a thought and think of it, as a real world scenario...not a perfect world scenario...

    THE STORY BELOW IS A COMPLETE FICTION SCENARIO...ANY RESEMBLANCE WITH KNOWN FACTS IS JUST PURE COINCIDENTAL...

    You send your CCR machine to be "fixed" of some problem to the CCR dealer...wich happens to be your CCR instructor, your dive guru...

    Then you get the machine back and fix "ready to dive"..and ..lucky you, allready with O2 cylinder filling made. For some reason (trust complex) you do not check in the dive store with your dealer if the scrubber has been changed...you assume it was...or you do not even need to do it cause you had a used scrubber inside (still with some dive time) when you´ve send the machine to be fixed...and you assume (again) that it´s still in the machine..

    Now you go diving...and you´re the dive leader and the dive center manager, going with your customers some OC divers, to make a nice weekend recreational shallow dive..you´re the only CCR diver also on board..eager to show the OC divers your fantastic machine, with the added tasks of mooring the boat, perfroming dive brifeings etc,,etc..(task load + peer pressure)...

    Jeppe, did you ever eard about "the God Complex" ??
    http://en.wikipedia.org/wiki/God_complex

    I think you should consider there´s a real world and there´s a perfect imaginary world...sold to inocent belivers

    CCR check lists should follow aviation most recent protocols (like the CCR Sentinel allready does), that if you fail to check the machine all items or perform predive tasks the CCR alerts for possible fatal outcome (for example failing to do the 4 minutes prebreath test..), as per item 20 in the MK VI before diving check list...

    Just my 2 cents...

    RGDS
    Sorry Psmedo but there's no assuming in Ccr diver or any other type of diver.
    People that assume should stick with a mask and snorkel.if I didn't assume so much I would be a rich man with the NYSE, even that might kill me (if wife finds out)).
    I understand the whole lets talk about it even if there not facts, but to be honest there is no place at this point in time (with all the training and forums) for someone to lose there life this way. I have seen plenty of guys walk out of dive shops without analizing there gas,crazy but it happens.
    Last edited by bmwgsboy; 26th April 2013 at 16:58.

  10. #20
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    Re: Mk vi fatality - portugal

    Quote Originally Posted by bmwgsboy  View Original Post
    Sorry Psmedo but there's no assuming in Ccr diver or any other type of diver.
    People that assume should stick with a mask and snorkel.if I didn't assume so much I would be a rich man with the NYSE, even that might kill me (if wife finds out)).
    I understand the whole lets talk about it even if there not facts, but to be honest there is no place at this point in time (with all the training and forums) for someone to lose there life this way. I have seen plenty of guys walk out of dive shops without analizing there gas,crazy but it happens.
    This issue is IMHO far more complex in process and in the chain of events than your simplistic example of the dive shop gas filling negligent process.

    An accident is the manifestation of a series of failures in the system ususlly refred as "a chain of events". Seldom a single cause (ie forgeting to do a check list) is THE ONLY cause. IMHO this accident reveals a very insidiuos LATENT FAILURE in the MK VI system without any resilience at all.

    Your statement "People that assume should stick with a mask and snorkel" shows a lot of arrongance and a worring GOD COMPLEX. FYI, the worst air disaster to date happened in Tenerife when two Jumbo Jets colided in the same runway. Did you know the KLM captain a senior instructor and considered to be the best instructor ASSUMEND he had a free runway for take off in the fog...

    Les presumtion and a litlle bit of humbling can show tons of respect to the lost diver and to all whom belive "it could happen to me"...I DO.

    RDGS

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