Two divers critical - Hawaii

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1. Not sure what you mean by sleep mode, but the discussion so far about this case was about how the unit was in surface mode. In surface mode it continually reads and displays PO2, 4 places. Do you mean someone doing a prebreathe without the unit being powered up at all...?

In surface mode I assume it would fire the solenoid? Would it freak out/buzz if the PPO2 gets close to critical level?

2. Stick one of those AI transmitters that are so popular these days on your O2 first stage. Now you have data to tell if the valve is on with no wires, no problem swapping tanks.

If you opened then closed the valve the xmitter will read the high pressure (minus any that leaks over time) unless the solenoid fires. It wouldn't be a validation that the cylinder was on unfortunately. The software could fire solenoid and watch for pressure drop pre-dive, I thought of that but I can think of user error cases. Would be easier than having a valve with a switch in it.

Or, you could just actually do the preflight checklist. Tell yourself “if I’m gonna dive this thing, I’m committing to that checklist. Before every dive.”

Very true. But we still loose people, humans error.
 
In surface mode I assume it would fire the solenoid? Would it freak out/buzz if the PPO2 gets close to critical level?

Yup. In surface mode it holds a setpoint of 0.23.



If you opened then closed the valve the xmitter will read the high pressure (minus any that leaks over time) unless the solenoid fires. It wouldn't be a validation that the cylinder was on unfortunately. The software could fire solenoid and watch for pressure drop pre-dive, I thought of that but I can think of user error cases. Would be easier than having a valve with a switch in it.

Sure, it only tells you that the lines are pressurized. But if you want to watch for a closed valve in an eCCR, that pressure will drop as soon as the solenoid fires. I wasn't suggesting that, I was just saying that is a way of telling if the valve was opened. It wouldn't tell you if the valve was opened and then closed until someone started breathing off of it (surface or CCR mode).



Very true. But we still loose people, humans error.

Right, exactly. That is the whole point of a checklist - humans make errors, so a checklist is a simple and effective way of catching those errors. I mean, if you are going to say that human error is inevitable so we need engineering solutions rather than training solutions, you may actually increase the incident rate. Once you get it into your mind that your "smart" CCR is going to take care of everything, you pay less attention.

I'm not saying that engineering solutions have no place in making safer rebreathers - the manufacturers have incorporated many of these over the years, and it makes a difference. What I am saying is that for some things, the solution isn't engineering but training.

If you are going to say "we can't trust the user to turn on the O2, so we are going to make some elaborate mechanism to control for that", then why are you trusting that user to dive a CCR at all? I mean, there is no scuba police, but we don't spend a lot of time engineering planes so that drunk or untrained people can fly them. And that's not so much of an issue with planes because there is a lot of external control over flying (FAA, ATC, etc..). There isn't in diving, but the concept is the same.
 
So very sad, but she should be thanked for sharing the details as a public service.

Absolutely. Many (myself included) have done so on FB.
 
Yes.

Here is another FB link to his wife's summary of the incident.

Ashley Porsche Bugge
Doesn’t work for me. I don’t do stalkerbook.

My feeling is that it is totally unconscionable to have a student die during class from something stupid like that. Though apparently one agency didn’t care about their instructor who killed a student at Blue Grotto that way, so what do I know?
 
Doesn’t work for me. I don’t do stalkerbook.

Here you go:

"This is the very first photo taken of my daughter and I, taken two weeks ago on July 31st, 2018, approximately 10 minutes after she was born. If you look closely, you'll see she's clutching a photo of her dad, Brian James Bugge who passed away May 20th, 2018 during a closed circuit rebreather training dive. My daughter will never get to meet her dad and this is the only photo I'll ever have of the two of them together. Our other two children (ages 4 and 2) will have the photos and home videos to cherish, but will never know the incredible man their father was - all three of our children's story will forever be, "My dad died when I was a baby and I never knew him." I'm sharing this with you because my husbands death was preventable and after what I've been through the past 12 weeks since his death, I'm hoping sharing his story and the details of his final minutes will help any and all of you from having your family suffer the same fate as I/we are now.

Brian's work relocated our family to Hawaii in the summer of 2017 and we were ecstatic. We had spent a fair amount of time there prior and as open circuit divers we were thrilled about having this giant playground in our backyard to dive in as much as we wanted. Brian had been looking into technical diving for quite some time and was excited when he found a rebreather program close to our new home that would work for him and he enrolled. He soon became consumed with his CCR and had big dreams of diving the world on it. Although he was still in training on it, he was captivated and started daydreaming about expeditions to untouched wrecks in the South Pacific, looking into cave diving courses and planning for 10 years down the road when he could retire from his day job and open his own dive shop - teaching and sharing his love of this device.

This all came to an abrupt halt on the morning of May 20th, 2018. He left our home that morning to meet up with his class for a training dive and was nervous/excited because this was going to be the first time he'd be diving trimix (a blend of Helium, Nitrogren and Oxygen gasses) This was a big deal for him and he'd been talking about it for weeks prior. He met up with his class, hopped on the boat and headed out to the dive site where a number of mistakes were made in succession, causing my husband to lose consciousness and drown in these waters he loved so much.

I've attached a copy of his dive log as prepared by Divesoft- the manufacturer of his rebreather- from the morning of below. I know families of deceased divers don't typically release this type of information, however Brian loved this machine and I know if the roles were reversed, he'd be thankful for and humbled by any information which led to a rebreather fatality that he could possibly learn from. You are a small community and I believe there are lessons to be learned here, I hope you take them to heart.

As I mentioned, the actual black box dive log is below with a synopsis of events in those final minutes. What the report doesn't show is that Brian was a student in this class and as a student, he was still learning this device and specifically on this day; he was going to be learning to dive on a new gas mixture. As I mentioned above, he was both nervous and excited about this, especially since this dive would complete this specific portion of his training. He jumped in the water, gave his OK and swam in the current to the dive line while waiting for his instructor and the rest of the class to get geared up and in the water. During this short interim while waiting on the dive line, he asked for someone on the boat to hand him his (brand new) dive camera which he'd be bringing on the dive to document. From all available evidence it is assumed he was task loaded while making final adjustments to his camera that he failed to notice two very crucial things; 1. His CCR computer was in surface mode as opposed to dive mode and 2. He failed to open his O2 tank prior to jumping in the water. If either of these tasks had been completed (or checked) he would more than likely be here today. He also absolutely should not have had his camera with him during this class. He was already task loaded and still learning his CCR, having his camera without a doubt contributed to his being distracted. As the report below will show, he stayed at the surface for a few minutes but without any eyes on him and without any O2 filling his breathing loop, he very quickly lost consciousness and sank to the bottom of the ocean. Once it was realized that he was sinking, valiant rescue attempts were made by his instructor and classmates to bring him to the surface and attempt CPR on the way back to the marina, but it was too late and he was gone. My husband made these seemingly simple errors and they cost him his life. These errors cost the kids their dad, they cost me my best friend and partner. These mistakes happened on a planned dive, in good water conditions, during a class under the instruction of a trainer. If these could happen under those circumstances and with this outcome, I find it imperative to get this report out to you so that you don't over-estimate your confidence the next time you go to jump in the water. Check everything yourself and then ask your instructor, boat captain, dive buddy to double check it as well.

It's now been 12 weeks and I'm still receiving information from the number of agencies and people investigating the circumstances leading up to and including my husbands death. I will continue to release information as it becomes available from the medical examiner, US Coast Guard and others if I believe it will help anyone in this diving community from suffering the same fate as Brian. Releasing this report is done in good faith that it will help members of the diving community my husband loved so much, and I hope it will be received by you all in the same regard.

-Ashley Bugge"
 
Wow. Awful stuff can happen, but should not when participating in a class, that’s why you are paying the instructor serious money instead of just reading a manual and training yourself. Among other things I’m reminded of my instructors insistence to be the first in and last out...
 
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