Fatality at Jersey Island

[gianaameri]

Coroner's Report:

“That she died in the afternoon of Saturday 15th March 2014 at St Catherine’s Slipway, St. Martin, [Jersey, Channel Islands] after having been found unconscious in the sea during an underwater dive at St Catherine’s Breakwater; the cause of death was asphyxia caused by obstruction of the airways by inhalation of gastric contents due to unconsciousness by hypercapnia; this occurred after failure of the incorrectly assembled ‘rebreather’ diving equipment that she was using whilst underwater during her dive.”

 

[Kairoos]

So sad :/. I wonder how experienced she was with rebreathers and the specific system she was using.

 

[Dr. Lecter]

Still waiting for actual details on what the assembly error(s) was and when/how the diver built her gear for that dive.

 

[darushin]

Still waiting for actual details on what the assembly error(s) was and when/how the diver built her gear for that dive.

If it is hypercapnia, it is either improper scrubber packing, or failure of the red sealing ring. Putting the hoses or mushroom valves on backwards (while possible) would easily be caught during pre-dive checks (assuming a list was involved). I have not been paying attention and put the hoses on backwards before and couldn't pass pre-dive checks with it in that state.

Daru

 

[gianaameri]

If it is hypercapnia, it is either improper scrubber packing, or failure of the red sealing ring. Putting the hoses or mushroom valves on backwards (while possible) would easily be caught during pre-dive checks (assuming a list was involved). I have not been paying attention and put the hoses on backwards before and couldn't pass pre-dive checks with it in that state.

Daru

If that were possible, the rebreather would not meet (according to experts) Clause 5.1 of BS EN 14143:2013 (or its prior wording in BS EN 14143:2003), which states:

“It shall not be possible to assemble or combine the components or parts in such a way that it can affect the safe operation and safe use of the apparatus, e.g. by incorrect connection of the hoses to the breathing circuit.”

 

[gianaameri]

No, He just thinks that they can only be used below 150 ft. He doesn't realize they do have other uses in shallower water. While yes, there some increased risks,... if ones head is screwed on correct & they are paying attention, one can catch most any problem that would also present deeper.

As for possible failures, if the loop hoses &/ or DSV/ BOV are incorrectly assembled, it will show in unsuccessful moving of gas through the unit & in the positive & negative tests that are run. If the check lists are followed, this will be caught. If the canister is inserted upside down, air will not pass though the unit. The only way for CO2 bypass, is failing to insert the Sorb canister, incorrect packing of the sorb, loose or missing CO2 seal ring or malfunctioning mushroom valves (this should be caught on the stereo breathing & plugging 1 end the inhaling & exhaling then doing the same to the other side). All of this is in the pre- dive check lists. Mechanically, the unit is not that complicated. During my MOD1 training, I completely broke down, rebuilt & tested the machine over a dozen times before even getting it into the water.

You got the new BOV?

News - Prism2 BOV Quality Notice

I think it might help, not sure though if it fixes all.

Does it?

 

[knotical]

Coroner's Report:

“That she died in the afternoon of Saturday 15th March 2014 at St Catherine’s Slipway, St. Martin, [Jersey, Channel Islands] after having been found unconscious in the sea during an underwater dive at St Catherine’s Breakwater; the cause of death was asphyxia caused by obstruction of the airways by inhalation of gastric contents due to unconsciousness by hypercapnia; this occurred after failure of the incorrectly assembled ‘rebreather’ diving equipment that she was using whilst underwater during her dive.”

Is that coroner's report publicly viewable somewhere? A link would be nice.

 

[dreamdive]

I just got it from the factory rep that it was NOT a Prism II.

 

[gianaameri]

I just got it from the factory rep that it was NOT a Prism II.

He/she must be not informed then (unless he/she is saying it was one of the various variants of the "Hollis Prism 2" giving it a different name or was modified by the user hence it was no longer a Hollis "factory" product).

Hollis (not a "contractor") can email me directly at gian @ gian.ameri.name (no spaces).

I am quoting from the Coroner ("Hollis Prism 2").

 

[rongoodman]

Is there any evidence that the unit was "incorrectly assembled" other than the coroner's report? Details on what exactly "incorrectly assembled" means? Any training or credentials cited that would allow the coroner to make that call? I'm willing to believe she died due to a CO2 hit, but beyond that, I'd want to hear more before I toss my Prism 2 in the dumpster.