"Inspirations/Rebreathers are Dangerous", "You're going to Die"

If you own an Inspiration you are going to hear this (a lot!). These comments are from the misinformed and those who favour or have bought other units or in George Irvine's case just pure venom and commercial interest. I have tried to source ALL the relevant information and reports here and to provide a subjective analysis (Bear in mind I have my own biases). Do not read this section if details of fatalities are upsetting to you.

Diving is a sport that carries risk of death or serious injury. Through training and good practice you can control and minimise these risks to levels that you may be prepared to accept. The decision of the risk level is yours. Neither Ambient Pressure diving, your training agency, your buddy or dive boat are responsible for decisions you make. Failure to carry out pre-dive checks or your training WILL definitely shorten you life expectancy.

 

So far there has been 25 fatalities amongst Inspiration users worldwide. Many of the so called facts are just postings on bulletin boards. I have tried to capture it all here. Coroners reports and official data are hard to come by and the grapevine works well. Unfortunately many people seem to have agenda's other than finding out the truth and quoting deaths per owners is meaningless, after all the wearing of fins is common to many more diver incidents, maybe they are the problem!!!!

Bear in mind that there are at least 5000 units out there (probably nearer 6000 as of summer 2004). Probably more than all the other rebreather makes combined several times over (For example the Prism is rumoured to have 200 units). So its not surprising that the Inspiration has the highest fatality listing (there have been deaths on other units). What we are interested in is WHY these fatalities occurred and if there are any lessons that we can learn. Far from proving the Inspiration as dangerous, I believe the evidence points to overconfidence, failure to follow basic procedure, stupidity and solo diving as the major factors. Here are the facts and rumours and I will highlight and differentiate my analysis so you can also draw your own conclusions.

Many of the cases also seem to be Solo Diving ones. Now I'm not going to preach on that subject as I do dive solo myself occasionally on open circuit and as an instructor I consider all dives taking in novices to be solo dives. But it does mean that we often have no details of eye witnesses to these cases. On a Rebreather to dive solo does seem much more hazardous to me. On open circuit if something goes wrong you are normally able to detect and fix the situation immediately. With a Rebreather many modes of failure result in unconsciousness as the first symptom (if you fail to do your checks), a situation that self help is not possible from. A buddy would seem to be the most sensible redundancy in this case. After all you carry redundant mix, computers etc, why not a redundant body and brain. Also there seems to be an increase in  the "Same Ocean" buddy system, this is a load of solo divers trying to convince themselves they aren't taking unnecessary risks

Also read this excellent note from Martin Parker about the incidents

Another good article From Dive magazine at https://secure.wsa.u-net.com/www.bsac.org/news/rebreather170700.htm

 

If you can provide any more details, facts or analysis please send them to me. 

 

My sympathies go to all those involved. It is sad when anyone dies and doubly sad when its an accident. Let us hope that we may learn something from them and that it will make our lives safer as a result.

 

 

Name Date Type My Analysis
Paul Haydon 23/5/1998 Solo Diving Hypoxia, due to cracked Handsets
Bob Forster 20/6/1998   Natural Causes
Nic Gotto 24/7/1998 Semi Solo Hyperoxia or hypercapnia?
Keith Milburn 13/9/1998 Hypoxia, Solo O2 Switched off. User did not do a Pre-dive breath on this second dive. User Error
Harry Norman Railing 25/5/1999 Burst Lung Argon suit inflator jammed open. Not Inspiration related
Maarten van der Weerdt 26/6/1999   Suspicion that unit was not switched on or in dive mode as problem occurred right at the start of the dive
Ian Swift 13/6/2000 Hyperoxia User Stupidity
Dr Max Hahn 6/2000   ?Unknown, Natural causes has been suggested
Mick Brennan 1/7/2001 Solo Diving Diving Trimix at depth when only trained on Air
Andy Wilde 6/8/2000   Rushed to surface during 6m stop
Jan-Magnus Soerboe 24/5/2001 Solo Diving ?Unknown
Steve Hughes 12/5/2001   BSAC Incident report,  nothing more
Garrett Weinberg 23/6/2001 Ascent Problem Cardiac Arrest. Not Inspiration related
Bernard Gonon 11/2001 Ascent No Surface Support
Dean Livesy 6/5/2002   ?Unknown
Bobby Barratt 3/8/2002 Solo Diving Awaiting autopsy and detailed reports
Tomas Rosenfeldt 6/2/2003 Solo Diving ?Unknown
Clemens Neuenhaus 26/10/2003 Few details
Luca "El Bombarolo" 7/3/2004 Solo Diving Not actually diving a true Inspiration!!!
Details emerging In US diving a disabled unit before receiving training
Peter 'Crusty' McDowell 24/4.2004 Solo Diving, Wreck penetration Had actually removed unit to go through small hole and snagged
Wiktor Bolek 1/5/2004   No details yet
Eddie Girvan 24/5/2004 Hypoxia Unit not in dive mode.
       
WEYREGG/ATTERSEE 25/03/2005 WOB Too deep, too soon
Unknown April 2005 Ascent Not enough details

Near Misses

Two others, who fortunately were resuscitated. Apparently handsets weren't in dive mode when they entered the water. If they're not in dive mode they don't control the O2 level, they don't give any warnings. What happened to pre-dive checks

Cautionary Tales A selection of near misses

Top...

 

Paul Haydon

23 May 1998. Diving the wreck of the Afric. The diver and equipment were recovered from a depth of 73.4m. two days after his death

Technical diver Paul Haydon, 33 dies on a solo dive to 80 m on the wreck of
the White Star liner Afric 18 miles off Looe, Cornwall. He was using Trimix
with the Buddy Inspiration rebreather.
He was diving with a ten strong group of technical divers, three from
Belgium the rest from the UK, from the Sea Urchin. After failing to return
from the dive a large scale search using underwater scooters was launched.
His body was found four days later.
An inquest will be held into the death of Mr. Haydon, from Hornchurch,
Essex.

Paul Haydon
  a.. May 1998, England
  b.. experienced OC tech. Diver, but limited experience on the Inspiration
(few months)
  c.. solo dive to the "Afrique" (73 meter)
  d.. reportedly experienced on OC trimix, but had not done formal CCR
Trimix training

################################################################

From: "Martin Parker" mjp@apvalves.avel.co.uk
Subject: Re: [Fwd: 20 K of bullshit - that is 10k per death, 5 k per accidents (that we know of)]
Date: Mon, 6 Jul 1998 00:23:22 +0100

Hi George,

The first was Paul Haydon, aged 32 - on the 23rd May. He'd had his unit four weeks. He did his basic rebreather training in March. He was
diving the Afric, 20 miles SW of Looe, Cornwall, which lies in 78m. I was involved, in a very minor way, with the first day's search for
Paul so had the opportunity to talk with all the divers concerned. Paul was found the following day. The Police boat took Paul to shore
with all kit on him. The equipment analysis was then done at the DDRC (Diving Diseases Research Centre), Plymouth. The Police asked me to
witness the equipment inspection.

Although I've got all the details of Paul's death and I have a lot to say on the subject, the Police have instructed me to say nothing
until after the coroner makes his report. When this is released I'll get back to you.

Regards, Martin

Martin Parker Managing Director A.P.Valves - Manufacturers of the Buddy Inspiration Closed Circuit Rebreather and Buddy Range of Buoyancy
Compensators. Water-ma-Trout Industrial Estate, Helston, Cornwall, UK. TR13 OLW Telephone: 01326 561040; Fax: 01326 573605. Website:
www.apvalves.com

##############################################################

From: "Martin Parker" mjp@apvalves.avel.co.uk
Subject: Re: Fwd 20k of bullshit etc
Date: Mon, 6 Jul 1998 19:23:03 +0100

Sorry Kevin,

I got my maths wrong - it was getting late last night by the time I got the reply off. Didn't mean to pull yours or anyone elses tail.

According to Paul - he never dived the other units - they wouldn't let him get in the water. Although the causes were trivial - I felt the
most satisfactory cure from the customer's point of view was to just replace it.

As the replacement wasn't sent until the 7th April - I assumed his experience on his own unit started on the 10th. His dive computer
showed he'd done 18 dives since the 10th. I have no way of knowing whether they were all closed circuit or not and whether he used the
dive computer on every dive - being his dive buddy - maybe you can spread some light on this?

Maybe he had dived the earlier units ? - that's just not what he had told me.

Rgds, Martin

 

###############################################################

From: "John Grogan" rockport@vossnet.co.uk
Subject: Re: Paul Haydon
Date: Tue, 2 Jun 1998 08:39:58 +0100

I thought that I'd post some further information that came to me on this - I think we can learn a lot from this.

1) Paul was diving with the Buddy Inspiration rebreather using trimix - although trimix qualified, Paul was not qualified to use mix in a
rebreather.

2) This was Pauls' third unit - the previous 2 developed problems and were replaced by AP Valves. The unit that he was using when he died
had already been back for repair - I believe (from someone that knew him) that the problem related to oxygen spiking - but I cannot
confirm this as yet.

3) Paul was said to have sufficient open circuit bailout.

4) Paul was diving 'solo'. Another diver in the group remembered seeing him at some point during the dive and all appeared ok.

5) I believe that when Paul was found, he appeared asleep - eyes closed, relaxed position, so hypoxia is a possibility.

6) The initial PM showed no signs of pyhsical problems such as a heart attack.

7) The rebreather unit is currently with DDRC for evaluation.

When the final details of the incident and police/coroners/DDRC reports are finished, I will post a summary.

Regards, John.

####################################################################

The inquest on Paul Haydon was concluded yesterday evening after nearly two full days of hearing. We promised that we'd provide more details of
the dive once that had occurred, so here they are. This is necessarily long and, whilst we've tried to be accurate, this happened nearly four
years ago. Where requested, we will endeavour to clarify any points that are unclear, but will not enter into long-winded correspondence
concerning "what if's", criticisms or flames, etc.

The following is Kevin Weller's account of the day Paul went missing and the subsequent searches:

[Start KW]

Early in the morning of Saturday 23rd May 1998 nine of us left Looe Harbour on board Sea Urchin to dive the Afric, a White Star liner lying
in 75+ metres of water 18 miles off the coast. The nine were three divers from the continent finishing off a trimix course, Peter
Osbourne, Teresa Telus, Kevin Pickering, Paul Haydon, Kevin Weller and one other British diver who I won't name as I've had no chance to ask
him to verify this account before posting.

Conditions were perfect for diving - a bright sunny day and a flat calm sea. The trip to the wreck site took about 2.5 hours. The shot went in
first time and we started to kit up. Everyone was on open circuit except Paul who was diving his Inspiration rebreather (Lynda and I
purchased Inspirations 5 months later). Paul and I were planning to dive together but the kit had been laid out on the boat such that Paul
was kitting up at the stern and I was nearer the bow on the starboard side. This wasn't really an issue as Paul didn't believe in buddy
checks and, while I like the comfort-blanket such a sanity check brings, I'd become quite used to not doing them when we dived together.

I'll limit my description to Paul's configuration as no-one else's kit is relevant. The on-board cylinders contained O2 and air, with the air
cylinder not being connected into the breathing loop. Paul carried an off-board 3l of O2 that was connected to the manual O2 addition valve, 
an off-board 7l of 16/45 connected to the manual diluent addition valve and a 7l 45% nitrox mix. (He also had a bailout Sentinel reg around his
neck but after this time I can't say what it was connected to with any certainty).

Peter Osbourne, who was planning to dive solo, and I were the first people to be ready. I glanced across to Paul who was just getting some
assistance with his fins - this only left his checks to do. Sea Urchin is not the biggest of boats and most people were struggling with the
amount of room they had. To make more room I left the boat with Peter Osbourne having arranged - or so I thought - to meet Paul over by the
shot buoy. As previously stated the sea was dead flat and I was quite comfortable floating by the buoy. I stayed on the surface for quite a
while watching the boat come round and dropping divers. I could see Paul's head in the boat on the first circuit then I couldn't see him
any more. I continued to wait until the boat came over to me and the skipper asked if I had a problem. When I explained I was waiting for
Paul he told me that Paul had already gone.

Underwater visibility was superb and most divers had descended away from the shot buoy making contact with the line well below the surface.
Paul had obviously done similarly. To be honest I was rather irritated. I'm a firm believer in buddy diving (my choice) and was neither keen on
diving solo nor experienced in doing so. Paul knew this and to this day I don't understand why he descended without me. I can only assume we
had some sort of communication breakdown and he hadn't understood I was still on the surface waiting for him.

Had I any sense I'd have got out of the water but...well it was the Afric and conditions couldn't be better so I descended hoping to meet
up with Paul underwater although I wasn't confident we would do so as it's a big wreck.

At the end of my planned bottom time I started to ascend the line. Bottom times for each of the divers were similar and there was quite a
bit of leap-frogging as we made our way to the surface and each diver followed his schedule. The continentals were there as was the other
British diver but I could see no sign of Paul, Peter Osbourne, Kevin or Teresa. I wasn't unduly concerned about Paul at this point as he had a
tendency to extend his dive times to take advantage of the rebreather. OTOH, when I'd been at the 6m stop for a while I was starting to wonder
if something was wrong as Paul generally made it back the shot and three others were 'missing' as well.

Having finished my deco the boat picked me up and, as I was climbing back on board, I could see Kevin, Teresa and Peter Osbourne on the
boat. I immediately asked the skipper if he'd seen Paul's DSMB - he hadn't. If a DSMB had been raised conditions were such there was no way
the skipper could have missed it.

Peter Osbourne was the only diver to see Paul on the dive, and he reported that he'd passed Paul about 12 minutes into his dive. Peter
was heading back to the shot, Paul towards the stern. Peter had given an 'OK' signal and Paul had nodded in return.

We waited for a while by the buoy and peered down the line occasionally to see if we could see Paul until we reached the conclusion that
something was wrong (I can't remember how long 'a while' was but it wasn't long). The skipper put in a call to the Coastguard and we were
ordered to remain by the buoy until the helicopter arrived so it could use us as a reference point for the start of its search. The helicopter
arrived shortly, put a diver on to the boat to ascertain the facts, then started its search pattern. We also started to search as did
several other boats in the area including two local lifeboats and two Navy vessels.

After several hours and in fading light we sadly returned to Polruan (the tide at Looe not being sufficient to allow us to return there). We
had been at sea for 13 hours.

The next day, Sunday, we went out to the Afric again accompanied by some other divers who had joined us to assist with the search. Martin
Parker of APV also arrived to assist in any way he could. The boat was very over-crowded. A search plan was agreed but we found nothing. The
following day five of us from the original party - Kevin Pickering, Teresa Telus, Peter Osbourne, the other British diver and I - were
joined by a Swedish diver and dived again on the Afric to resume the search. We split into three buddy pairs.

The plan was for the other Brit and I to descend the original shot line and attempt to fin the length of the Afric (checking out a report of
some line near the stern) while the other four descended a new shot near the bow with one pair heading towards the bow and the other pair
towards the stern. We picked up the line and I was pretty certain it was Paul's. Most divers use Stainless clips but Paul used some quite
distinctive brass clips. There was such a clip with the line. We hit the bow, missed the forward shot and released our DSMBs. When we got
back on the boat Paul's body was on the Police RIB that had joined us in case our search was successful.

[End KW]

The following is Kevin Pickering's account of the day Paul went missing and the subsequent searches:

[Start KP]
The accident occurred on the 23 May 1998 (day 1). At this time my partner, Teresa Telus, and I were open circuit divers. It would be
another 7 months before we bought our Inspirations.

The Hull of the Afric is basically intact and has a slight list to starboard IIRC. The decks have collapsed down into the wreck.

On the day of the incident we were the last to enter the water. Due to circumstances that I won't go into we failed to find the wreck. After a
quick search at 74m we ascended to our first stop and deployed our Surface Marker Buoys. We were the first back after a 63min dive.

If I remember rightly we could only see one SMB on the surface but this was of no concern as the plan had been to return to the shot for deco.
Paul failed to surface when expected. A short time later the Coastguard was informed of the situation.

Day 2. A search plan was put into action. If we found Paul we agreed to make mental notes of the condition of his equipment before attempting
to recover him ie check to see if cylinder valves open/closed, remaining gas in cylinders, position of switches on handsets etc.

I dived with Peter Osbourne and we, along with two other divers, searched the wreck aft of the shot. Another team searched fwd of the
shot and two divers searched the seabed around the wreck using scooters.

Close to the shot, which was against the outside of the wreck (this was the shot used on the day of the incident), I noticed a reel line
leading down into the centre of the wreck. I followed this down to the end where there was a brass clip. The clip wasn't attached to the
wreck. I then followed the line back up the inside of the wreck and down the outside. It was cut about two metres from the top edge of the
wreck.

Day 3. Six divers. The plan was for two divers to descend the original shot and retrieve the reel line for positive ID. The remaining divers
were to descend down a new shot placed between the existing shot and the bow. Teresa and I planned to search forward and the other pair aft.
Due to a navigational error on my part we ended up searching aft.

Teresa indicated that she was reaching her turn pressure. As we were heading up current we decided to search for an extra minute (it would
take less time/gas to fin down current to the shot). As we turned I could just make out a light coloured object on the far side of the
wreck. This was the yellow Inspiration on Paul's back.

Paul was resting on a steep slope of thick fishing net on the inside of the wreck. He wasn't snagged or entangled. His feet were uppermost. As
Teresa was attaching her lift bag I checked his two onboard cylinders' valves, which were open, and the position of his handset switches,
which were towards the display (on). As we were eating into our reserves of gas that was all we had time to check. I attached my lift
bag and we sent Paul to the surface. While attaching and inflating the lift bag I observed that his mouthpiece was in place and his mask was
about a quarter full of water. He looked asleep. There was no sign of an attempted bailout or distress.

On the surface Paul was recovered into a Police RIB (which had been with us for the two search days). The police stayed until Teresa and I
completed our deco then headed back to Plymouth

[End of KP]

We suspect the Inquest will be reported at length so here is a brief summary only.

The Inquest lasted two days and evidence was heard from:
- Paul's fiancee)
- Dive Shop Operator
- Divers on the boat (plus further written statements from people
  who were unable to attend)
- Dive equipment examiner
- Pathologist
- HSE/Trading Standards
- Manufacturer
together with a raft of supporting written/photographic evidence.

Paul tested negative for any drugs/alcohol.

Paul was wearing an Aladin dive computer. The dive profile showed no evidence of stop for a 6m bubble check and a descent time of about 4
minutes. After about 17 minutes there was a three metre ascent, followed by a drop back down with no apparent movement thereafter other
than what could be attributed to the tide.

Paul's kit was inspected shortly after Paul had been recovered and the on-board O2 cylinder was found to be empty. The off-board O2 was turned
off and it was felt there was no way Paul could have reached the valve to turn it on. The diaphragm was missing from the Poseidon second stage
attached to the off-board 16/45 (this was obviously designed to be Paul's open-circuit bail-out). There is no way of knowing whether this
occurred before, during or after the dive but it was concluded that it must have been loose at the start of the dive or it could not have come
off. The DIN hand wheel for the on-board O2 was loose by one and a half turns. It was concluded that this was enough to cause a reasonably
severe leak. There was some discussion about whether this could have been loosened post recovery but it was inside the Inspiration's outer
cover so that would have had to have been removed for anyone to disturb the equipment; no such removal had occurred.

A considerable amount of time was spent looking into the possibility of an electronic malfunction which could have caused the hypoxia.

The Coroner will not be making any recommendations to HSE or any other government body.

The Coroner's verdict was accidental death caused by hypoxia following leakage of the on-board O2.

This doesn't explain why Paul didn't do a diluent flush when he noticed the PO2 dropping dangerously which would have brought the oxygen up to
a life-sustaining level. That does of course assume he did notice. We'll never know.

Kevin Weller
Kevin Pickering

Further note from KW: I lost a close friend on the 23rd May in a senseless and unnecessary accident - I still miss him. If you learn
nothing else from this I hope it reinforces in your mind the Inspiration users mantra - Know Your PO2.

####################################################################################################

From the Forums

My source is that I was at the inquest, 18 Feb and 4th March.

The cracked handsets are shocking, but only seen when the black casing is pulled back.

The witness originally said Nic had told her the scrubber unit had a duration of 10 hours and he had used it for only eight. She then admitted that Nic may not have been referring to the scrubber, but to the oxygen cylinder or some other part of the unit. She was not sure.
Nic had purchased two 20kg tubs at sofnolime. Aprox 12kg was missing from one of them, about 4 fills. Nic had done about 10 dives, the coroner was happy that Nic had changed the scrubber.

Do bear in mind that Martin Parker is the manufacturer. If he admits liability or does not defend his product he will not sell many more and may leave himself open to legal action.

.....

Nic did not have side slung bailout but he had a regulator on his diluent bottle. This gave him access to 3l of air, on a non deco 24m dive. The cracked handsets were recognised by Dave Crockford when he inspected the unit. This then lead him to re-check Paul Haydon's unit where he found those handsets were cracked too, and evidence of sea water ingress ( salt crystals apparent).

It takes a lot of research to find the medical back ground to certain symptoms and occurrences. Speak to any anaesthetist and they will tell you that although it is not totally unknown, convulsions due to CO2 are not common.

The are natural systems within the body which recognise the level of CO2 being inhaled, the body has no natural way of recognising high or low O2. It is the level of CO2 which induces us to breath, and increases our desire to breath when CO2 levels go up. This is the reason that some medical grades of O2 contain a small level of CO2, in fact, lack of the CO2 effect can cause medical problems of death with people suffering certain medical conditions.

It was also recognised in the inquest that there was no data available as to what can happen when the handsets do flood.

.......

If you are a medic then here is something else Martin Parker will not tell you. Paul's pose mortem showed glial and neuronal changes due to a hypoxic event ( quoted as acute
hypoxia but in a medical context hypoxia would only be termed as chronic when going on for weeks eg in bronchitis, emplasaema etc). The pathologist stated that he had seen these changes in people who had suffered a hypoxic event hours or days before death. Continued perfusion of blood to the brain is needed for these changes to take place, so if death follows immediately after hypoxia then these changes do not appear.

Also bear in mind that if Paul was unconsious on the sea bed with the unit feeding him O2 at the level it believes it should, unless the unit is turned off or the diver dies and so stops metabolising the O2 in the loop then the unit will continue to feed O2 until the cylinder is exhausted - reputedly 10 hours at normal rates of metabolism according to AP Valves. This - obviously, leads to an empty cylinder.


The cracks in Paul Haydon's handsets were not noticed until after the initial inspection. The cylinder was partially loose but remember it is the gas pressure within the cylinder which keeps the o ring pushed in place and gas tight. AP recommend that this is not over tightened.

If there was no internal pressure at depth under water then there would have been water leakege in to the the cylinder. There was not.

Once the unit was brought on board the police RIB - he was recovered two days later, there was a two hour bumpy RIB journey followed by a road journey back to the police station. If the contact had been loose then this would possibly be agravated by the vibration of the journey.

Paul Haydon had made no attempt to use his bail out. The reg was still bungied along the cylinder Paul also had a regulator bungied around his neck. Dave Crockford also stated that it was not unusable.

.................

Paul's pose mortem showed glial and neuronal changes due to a hypoxic event ...........The pathologist stated that he had seen these changes in people who had suffered a hypoxic event hours or days before death. Continued perfusion of blood to the brain is needed for these changes to take place, so if death follows immediately after hypoxia then these changes do not appear.

But these changes were seen acording to your first statement. So are you saying that Paul had hypoxia on an earlier dive and not on this dive, or that Paul remained alive for some time after becomming incapacitated?

This was Paul's first dive for 2 weeks. You hit the nail on the head with your second point. Martin Parker was aware of this because of the pathologist's evidence. On the second day of the inquest he even attempted to admit a graph which was about 10 fold out on its figures ( this was pointed out and he withdrew the graph but the damage had been done), trying to show that the unit could sustain a diver for 45 minutes with no oxygen addition.

Also bear in mind that if Paul was unconscious on the sea bed with the unit feeding him O2 at the level it believes it should, unless the unit is turned off or the diver dies and so stops metabolising the O2 in the loop then the unit will continue to feed O2 until the cylinder is exhausted - reputedly 10 hours at normal rates of metabolism according to AP Valves. This - obviously, leads to an empty cylinder

True if Paul remained unconscious and breathing for 10 hours after his event, But The valve would not have come loose afterwards. There is a nasty problem on the old seeman sub first stages in that you HAVE to do them up very tightly before pressurising or they do leak. I have first hand experiance of this (as do many other owners). Paul would not have been the first person to dump his O2 during the dive. The tightness you have to do the first stages up to prevent leaks is very high, they are a real pain to undo most times.

Paul was meticulous with his preparation and was observed going through this prior to the dive. Especially after all the problems he had had with the unit. It is rather unlikely that he could dump 3l x 200bar O2 15 minutes in to a dive without being engufed in bubbles.

He he had stopped breathing and the loop was still intact, then the O2 would have remained in the Cylinder (assuming no loop leaks) as it was not being consumed and there was no need for injection

Handsets were inspected by DDRC at the request of the coroner with Martin Parker in attendance as a witness. No cracks were seen at this time. The diaphragm was missing from the off board bail out regulator so it was not viable. . They one thing that was noticed in the report that the coroner didn't pick up on was that 2 of Paul's 3 cells were severely current limited and probably would have miscalibrated and certainly could not react to a high PPO2. Paul's lack of training (2 days) and then diving to 70m+ with 10 hours on the unit was also a contributing factor

Dave Crockford has reported seeing salt crystals in the handsets. Paul had a regulator bungied around his neck. The one with the missing diaphragm was on his side slung bailout which remained in its keepers. Paul had done a 5 day module I instruction course with Dave Thompson and a second unofficial ( before it was formal) trimix course (a week in Scapa Flow with John Thornton before the official course was finalised. He had done around 20 rebreather dives, 5 on trimix totalling about 14 hours. His final dive was to 65m. Martin Parker was well aware of the level of trimix diving being performed, these were all being openly discussed on the Inspiration list, amongst about 10 divers. He had never warned the users of any danger of using the unit with trimix. - Perhaps Martin is confusing Paul with someone else, there are so many.
Martin Parker never mentioned the cells during the inquest. Paul had had a number of problems with his original unit, which was eventually replaced. He had only had his replacement for a few weeks, is it not rather poor for him to have been supplied cells in this condition? At the time of his death I cannot recall I saw any warning to divers to check the current generation of the cells, just to replace them after - something like a year.
 


Whereas I'm not against solo diving on OC gear (I cave dive Solo, and do some open water dives that way), it does seem a stupid thing to do on a rebreather. On OC most failure modes will notify me immediately and allow me to fix them. on the rebreather, most failure modes result in immediate unconsciousness (Unless youre monitoring properly), a situation not lending itself to self rescue. In the case of low O2 such as this, the alarm buzzer should have sounded to warm Paul, but Paul had an early unit with the buzzer on the lid. This was moved in later models because you Cant hear it!!!

Also the autopsy report and the empty cylinder, combined with the salt crystals found in the handsets means one comes to a horrible conclusion. Paul's unit was probably indicating to him that all was well, but in reality the salt water in the handsets meant that the O2 was low and Paul became unconscious. BUT the unit carried on maintaining Paul's minimal life support requirements for another 8 hours or so until the O2 in the cylinder emptied and Paul suffocated. Its a shame that Paul's unit which was cared for carefully for several years by certain people at DDRC was completely contaminated and stripped prior to the inquiry and hence was not suitable as evidence. It is vitally important that Units involved in incidents when recovered have all conditions logged and then are not touched and are secured until they can be examined by an investigating team

Top...

 

Bob Foster

20 June 1998. Diving the Windtown. Originally reported on Divernet .We know nothing for sure other than he was last seen at 15m during the ascent.

Bob Forster
  a.. June 1998, England
  b.. diver and configuration never recovered
  c.. amount of Inspiration experience unknown
  d.. accident happened during ascent
  e.. there were predictable rumours of a heart attack (Bob was 62) , but no
proof since no body was recovered

####################################################################

> Read this one on the Divernet this morning (excerpt from the August DIVER
> magazine (UK):(www.divernet.com)
>
> " On 20 June Bob Forster, 62, from Corby, was lost during the ascent from a
> mid-afternoon dive on the Windtown, which lies in about 30m of
> water 7 miles off Trimmingham in Norfolk. His body was not found.
> A member of North Sea BSAC of Peterborough, Bob was diving with two other
> members of the branch from a local charter boat, the Merlin.
> It is reported that, having ascended their shotline, the buddies deployed a
> surface marker buoy at a depth of 15m. When they looked around,
> Forster had disappeared from view.
> Unable to descend again in a building tidal race, the North Sea group
> issued a Pan Pan call and a major search was instigated by Yarmouth
> Coastguard involving inshore and offshore lifeboats, an RAF helicopter and
> a helicopter from HMS Invincible, exercising 50 miles away.
> It was calculated that Bob, who was using an Inspiration rebreather, could
> remain alive under water for several hours. In addition to surface
> and air searches, divers from HMS Invincible were dropped from a second
> helicopter during the evening's slack tide to search the Windtown.
> A number of diving boats joined the search, including four from East
> Anglian BSAC. One tied up to the wreck shotline and member Gary
> Bowden attempted a dive but had to turn back in a strong current at 20m."
> Looks like another one to add to the electronic rebreather list.

######################################################################


From: "Martin Parker" mjp@apvalves.avel.co.uk
Subject: Re: [Fwd: 20 K of bullshit - that is 10k per death, 5 k per accidents (that we know of)]
Date: Mon, 6 Jul 1998 00:23:22 +0100

Hi George,

The second death was two weeks ago. It was a guy called Bob Forster, aged 62. Bob had had his unit for 5 or 6 months and had been building
his experience up gradually in fresh water. This was Bob's first sea dive (with a rebreather) and his first rebreather dive without his
normal dive buddy. I spoke to his normal dive buddy for an hour the day after and he believes that Bob died of natural causes. This is an
opinion but speculation, as is any other conclusion - his body has not been recovered. The tides in this area are particularly strong. He
tells me the depth to the bottom was 34m.

Regards, Martin

Martin Parker Managing Director A.P.Valves - Manufacturers of the Buddy Inspiration Closed Circuit Rebreather and Buddy Range of Buoyancy
Compensators. Water-ma-Trout Industrial Estate, Helston, Cornwall, UK. TR13 OLW Telephone: 01326 561040; Fax: 01326 573605. Website:
www.apvalves.com

 

Top...

 

Nic Gotto

Saturday, July 24 1998. Initial Reports were followed by a more detailed account.

The statements regarding down-currents and short training courses are disputed.

The down currents apparently occur when the tide is running, which can be up to 4 knots across the top of the wreck. There is no down-draught at slack water, which is when they dived it.

The latest piece of information to be revealed was that he was diving with no open-circuit bail out fitted. During the course he had one fitted but didn't want to buy one from the Instructor as he had plenty at home. He ordered a combined BC inflator/regulator from the instructor. The Instructor assumed that in the meantime the diver would fit one of his own 2nd stages. Apparently he didn't.

Hopefully, his equipment will be recovered soon and information gleaned to piece together the bits of information so far revealed.

Subject: DEATH on "inspiration"
From: "Chris Tyler"
Newsgroups: rec.scuba.equipment

at the time of writing this I have very little information, my good friend
and buddy died yesterday evening whilst conducting a normal dive to 30mts
using a buddy inspiration rebreather.

he was a very highly qualified and respected diver that was very active and
in perfect health, this was a dive he had done a good number of times
before.
he was a very safe an conscientious diver, i my self attended the rebreather
course with him and purchased an inspiration also.

at this early stage no one has been told the exact cause of death yet, i am
waiting to hear,  in the mean time I have suspended diving on my
inspiration.

this is the second death i have herd of whilst using an inspiration, has any
one herd of similar incidents with Rebreathers and especially this one.


Chris Tyler
Ireland


Nic Gotto
  a.. July 1998, Ireland
  b.. experienced diver
  c.. solo dive to 24 meter
  d.. unknown problems during descent
  e.. buddies have indicated maybe signs of oxygen convulsion
  f.. speculations of having pressed O2 button instead of diluent button
during descent
  g.. no diluent OC regulator (2nd stage) was fitted; AutoAir was removed
awaiting delivery of OC reg.
  So no OC bailout option available

#######################################################################################

Cork City Coroner, Dr Myra Cullinane, last week recorded an open verdict at
the conclusion of the inquest into the death of Nic Gotto, Union Hall,
County Cork, who died in July 1998 whilst using the Buddy Inspiration
Rebreather. The coroners court heard that Nic and some friends were due to
dive to the Kowloon Bridge wreck, just a few miles south of Glandore harbour
in County Cork, when the tradgy happened. Nic and his buddy entered the
water as normal and proceeded to the bow of the wreck at 9m. All was well at
thisstage, Nic was seen to have looked at his handsets and then signalled Ok
to his buddy. He indicated a direction for the dive to continue and lead the
way with his buddy following behind. The visibility was very poor that day
and Nic's buddy lost sight of him for a few minutes only able to follow by
using Nic's torch beam for direction. Within a few minutes the buddy came
upon Nic lying on his back with his mouthpiece out and having what appeared
to be a convulsion. His buddy immediately realised that Nic was in trouble
and attempt to rescue him. In the rescue attempt Nic's buddy lost his own
mouthpiece and weight belt and started to ascend. He made it to the 9m mark
and managed to alert another pair of divers that Nic was in trouble. One of
the other divers quickly found Nic and assisted him to the surface where he
was taken onboard the boat and CPR was administered for 45 minutes after
which time the Air Sea Rescue helicopter winched him on board and flew him
to hospital where he was pronounced dead on arrival. The court heard that
Nic's rebreather was dropped during his rescue and was not recovered for
some days. On inspection the Buddy Inspiration Rebreather was found to be in
good working order and no alterations had been made to the kit. There was a
reading on both guages. Both handsets, when opened, were found to be cracked
and full of seawater. Nic had been seen to be having difficulties
calibrating his equipment prior to getting on the boat. On the boat prior to
the dive, Nic dismantled and cleaned and re assembled his equipment,
breathed from the unit and prepared to enter the water. It was noted that no
alarm was heard at anytime before, during and after Nic was brought to the
surface. Mr Hogan, the pathologist at Cork University Hospital, said that
Nic had suffered drowning after a metabolic event had occurred leading to
him losing consciousness, he said that it might have Hyperoxia or Hycapnia.
It was recorded that Nic had completed approx. 10 dives on the equipment. As
no one had witnessed Nic changing the scrubber canister the manufactures, AP
Valves, did make a submission that it might have been Hypercapnia that lead
to Nic's demise. Nic's widow Rachel was able to tell the court that of two
20kg drums of sofnalime at her house over half of one is gone. The coroner
seemed satisfied that this suggested that Nic had replaced the scruba
contents. At the end of three days the Jury were directed to return one of
three possible verdicts, accidental death, death by misadventure and open
verdict. They returned the latter.
During questioning, a witness who initially reported that Nic told her the
scrubber could last 10 hours, confirmed this 10 hours could well have
related to the O2 cylinder duration and not the scrubber.

#######################################################################################

From: "John Grogan" john@rockportcapital.co.uk
Subject: Buddy Inspiration - the facts
Date: Tue, 28 Jul 1998 10:24:28 +0100


The following are the events that led to the death of Nic Gotto whilst using the Buddy Inspiration rebreather unit.

Nic ran Sundancer II Charters out of Union Hall in Cork (South coast of Ireland). He was a very experienced diver and skipper. A number of
weeks back, Nic purchased the Inspiration and attended a TDI weekend rebreather course. I've been informed that the practical aspects of
this course consisted of a 1 hour pool session, a 45 minute dive and 1 change of scrubber sofnolime - this is on top of the usual lectures
and theory.

On Saturday, Nic and 3 other divers went to the wreck of the Kowloon Bridge (second largest wreck in the world). Nic was with a buddy and
the other 2 dived together. I do not know if Nic's buddy was using an Inspiration or OC. Whilst diving at a depth of 10m (ppO2 1.3 bar),
Nic encountered a down-draught that almost immediately swept him to 25m (assuming same fraction of oxygen ppO2 2.3 bar). An oxygen
toxicity hit occured. (I can only assume that the unit did not respond to the increased ppO2 in time and that Nic expended a lot of effort
getting out of the down-draught). His buddy tried to assist and in the struggle lost his weight belt and mask. Buddy came to the surface,
alerted the dive boat and was given another mask. He pulled his way down the shotline and found the other 2 divers. The situation was
indicated to them and they commenced a search.

Nic's body was found and a rescue commenced. At about 20m, Nic inverted in his drysuit and at about 14m contact was lost with him but he
went to the surface. At the surface, these divers cut him out of the harness. As they knew nothing about rebreathers, they didn't close
the loop. Subsequently, the loop flooded and the unit sank back down to the seabed. Nic was pulled onto the boat and blood was found
foaming in this mouth. Boat crew immediately commenced AV and CPR for 45 minutes at which point the lifeboat arrived. Nic was declared
DOA.

Army and civilian divers and currently searching for the unit that Nic was diving. I sincerely hope that no-one tries to pin the blame on
any of the 3 divers in the water at the time. They made a vallient attempt to save Nic, but unfortunately it was stacked against them.

To date there have been 3 fatalities and 2 resuscitations with Inspiration divers. There have been about 120 units sent out and about 250
people trained on the unit. That's 5 serious/fatal incidents for 120 units (4%). There has been in the UK what I can only describe as a
conspiracy of silence regarding the Inspiration and more particularly the indicents encountered. I spoke to one diver yesterday who owns 2
units - he is fuming at the lack of information forthcoming and refuses to use either unit until there is more openness on it's failures
and proper training.

David Shimell posted earlier on this and pointed out 3 main causes for the incidents:

>1. Equipment design or failure.
>2. Poor training.
>3. Poor vetting of candidates for training.

I think 1 & 2 apply. Certainly 2 of the deaths and 1 of the resuscitations were very experienced divers. Why do some agencies seem to
think that a 2 day course can impart all the information required to safely dive a rebreather? The Navy spends months training their
divers on a unit!

I am sure there will be a full police investigation into this matter and as I receive more information, I will post it to the list.

Regards,
John Grogan

########################################################################################################

Last week we attended the 2nd day of the Nic Gotto inquest.

Nic died at the end of July 1998 while diving the wreck of the Kowloon Bridge in Southern Ireland.

The jury weren't given sufficient information to decide between high O2 or high CO2 so they recorded an open verdict. Cause of death was "by a metabolic event", changed from the pathologist's original statement of Death by Drowning. Neither an expert diving pathologist nor I were allowed to give evidence. Quite why we weren't given the opportunity to prove it was CO2 I don't know. I guess the Coroner didn't want to see the controversial stuff argued or settled in her Court, she just needed to know who died, when, where and how and that's what she did.

I have no doubt that it was high CO2. I have to keep most of the proof of that to myself for now, but it is a matter of public record that Nic told a witness prior to the dive that the Calcium Hydroxide was good for 10 hours but he'd only used it for 8 ! The witness had a PhD in Chemistry.

The handset was checked at 9m and Nic continued. At no time were buzzers heard or bubbles seen. Nic moved ahead of his buddy and was out of his sight in the poor vis. for only 15 secs or so but was found by his buddy in approx. 24m of water, already on his back, mouthpiece out, arms shaking at his chest, eyes wide. He was unable to bring him to the surface, due to Nic being heavy. The time frame is 3 to 4 mins from leaving the surface. Nic was recovered later by another diver. The kit was jettisoned during the dive and was recovered 9 days later.

With this open verdict I'm afraid we are in for the usual critical press, one newspaper in Ireland stated that "the Buddy Inspiration is believed to have killed 15 other divers"

Bottom line: Take care of the CO2 issue before you get in the water:

- change your scrubber regularly, ensure the O ring is in place and well lubricated, ensure the spacer and scrubber side wall is free of dents and scratches, ensure the mouthpiece valves are working properly.

The CO2 duration is not just a 3 hour limit regardless of the type of dive. Once the scrubber time reaches 2hrs 20 mins you should be shallower than 20m, when the scrubber reaches 50 mins you should be shallower than 50m.

Your CO2 production is independent of depth but with DERA testing it is proven that depth has a great effect on reducing the scrubber life. Please bear in mind that the Inspiration's scrubber is one of the most efficient, if not the most efficient DERA have seen in cold water (that is it makes most use of the Calcium Hydroxide). This reduction in performance at depth is not due to poor design but is common to all rebreathers, the increase in gas density is going to apply to them as well as us- I guess the other manufacturers don't warn about the limitations because they haven't done the quantified CO2 tests that we have done?

 

Martin Parker

Managing Director

Ambient Pressure Diving

Manufacturers of the Inspiration Closed Circuit Rebreather Water-ma-Trout Industrial Estate, Helston, Cornwall, TR13 OLW, UK.

Tel: 01326 563834, Fax: 01326 573605.

Website: www.ambientpressurediving.com

Controversial as many would say the arm shaking was a symptom of an O-tox, but most don't realise that convulsions are also a documented feature of hypercapnia. As the alarms didn't sound  (and they are loud!!) its obvious that the handsets were happy in what they considered the PPO2 to be and hence it could be one of two scenario's

a) Hypercapnia as martin describes
b) Cracked handsets shorted handsets and allowed the PPO2 to rise without showing or sounding alarms

I have information that the Fits were actually more acute than described and this would support this. I believe the 8 hours on the scrubber to be wrong, I believe it was the O2 cylinder duration that was discussed and this fits with the 10 hour figure much better

This is the second incident where cracked and flooded handsets were seen, many folks reported this problem in the early days of the unit. APD did shorten the hoses and change the way the handsets were sealed and I have not seen a report recently. I would suggest all users regularly strip their handsets and inspect (lube the sliders and magnets while your in there!!)

Top...

 

Keith Milburn

September 13 1998

Keith Milburn, age 44, from County Down in Northern Ireland, was diving with five friends when he went missing.

Keith was trained in the UK by Dave Thompson some time in December or January 1998. He purchased his unit in early January, he was one of the first people to own an inspiration in northern Ireland. He was a very active diver, and it is believed that he would have made two or three dives a week until his death.

He had finished his dive and was about to get back in the boat when someone dropped something in the water. One can assume that he was in the process of turning the unit's cylinders off at this point. In an effort to retrieve the dropped item he commenced a dive for it. He did not return to the surface, and his body was recovered some time later.

On examination it was discovered that the oxygen cylinder in his unit was turned off. He apparently was trying to conduct an open circuit bail-out on his oxygen, but this would not have worked because the O2 tank was turned off.

This 2nd dive was apparently to a depth of 4m (12fsw).

Before choosing an O2 OC bail-out, He should have tried first an OC bail-out on his diluent, via his apparently still functional Auto Air.

Why he chose the O2 reg instead of the Auto Air, we may never know.

An inquest has been completed. The coroner, Mr. John Leckey, stated in closing "Keith Milburn was found dead on 13th September 1998 near Cloughan Head, Ardglass (Northern Ireland). The cause of death was salt water drowning and my verdict is that of accidental drowning. Examination of his diving equipment revealed nothing to account for his death. I am satisfied that the death was accidental."

The logic of carrying an separate O2 DV on the O2 cylinder deludes me. If the O2 cylinder is on and has some gas and the first stage is working then the gas is available via the solenoid or the manual injection. if the valve is Off, the cylinder is empty and/or the first stage fails then the DV wont work either as Keith unfortunately found out

THE TIMES MONDAY SEPTEMBER 14, 1998

Death of diver prompts breathing gear alert.
by Lisa Thomlinson

A DIVER found dead in 12ft of water after an extensive air and sea search was using a new type of equipment that has been blamed for the deaths of three people this year.

Keith Milburn, 44, a business consultant from Carryduff in Belfast, had been diving for edible crabs with five others from a boat off Cloghan Head, near Ardglass, Co Down. He completed his dive safely but returned to the water to retrieve a piece of equipment and failed to resurface at 7:30pm on Saturday. His body was found near the diving site at noon yesterday.

Mr. Milburn is thought to have died of oxygen poisoning. He was using breathing apparatus that has only been on the market a year, and is a modern version of equipment developed by the military during the Second World War. It works by re-oxygenating exhaled air by filtering it through a series of chemicals, to be re-breathed by the diver.

The British Sub Aqua Club has warned its 50,000 members not to use it while they carry out a safety check following the previous three deaths.

Ian Murdock, watch manager at Belfast Marine Rescue Subcentre, said: "It is not safe. Four people have died now and thousands of these diving set have apparently been sold. One death is too many, but four from the same system is not acceptable. This needs to be looked into urgently. Divers using the equipment are either not heeding the warnings or they are not using the system properly."

The system, which costs about (pounds)3,000 compared with a few hundred pounds for normal breathing apparatus, has proved popular for underwater photography because it does not generate bubbles. During the war it enabled divers to sneak unseen into enemy harbours. It also allows divers to stay under water for up to 12 hours.

David Vincent, the owner of DV Diving in Bangor, Co Down, said he may stop selling the re-breather gear after the most recent death. He said that he had taught the new system to a diver, Nick Gotto, who died while using it off Cork last month.

Divers using the equipment have also died off the Norfolk coast and in the English Channel in the last year.

He said: "I would only train qualified divers to use the equipment. It is complex and that is what I aim to explain to the divers. It is not as simple to use as an open circuit breather."

Keith Milburn
  a.. September 1999, Ireland
  b.. solo dive
  c.. 2nd dive on the day, to only 4 meters of depth
  d.. indications that O2 valve wasn't opened (skipped pre-dive check?)
  e.. presumably found with OC O2 reg in his mouth, but not operational
(shut-off valve closed),  CC mouthpiece out & closed

A clear case of not doing the pre-dive checks. This is a very unfortunate incident as I'm sure we've all done similar things on OC. Proof again that you cannot cut corners on a rebreather and MUST always do the pre-dive checks. Why he didn't bail out to the diluent we will never know

Top...

 

Harry Norman Railing

May 26th 1999

Reported on techdiver. The following is from the Maritime and Coastguard Agency web site

Press Notice No : 149/99 26 May 1999

DIVING FATALITY OFF PORTLAND

Portland Coastguard were this afternoon alerted to an incident involving a diver in difficulty off Portland.

The Coastguard received a call on Channel 16 at 1530 hours from the sport diving vessel "DIVETIME", who reported that a member of their diving party had surfaced and appeared to be in an unconscious state.

Portland Coastguard immediately tasked the Coastguard Rescue Helicopter, Whisky Bravo, to the scene, some 15 miles to the southeast of Portland. Poole Coastguard Rescue Team were also tasked to attend the helicopter landing site. The helicopter arrived at 1547hours and the casualty was winched aboard and transferred to Poole General Hospital where he was declared dead on arrival.

The weather on scene was good with light winds, good visibility and only a slight sea swell.

Harry Leslie, Watch Manager, Portland Coastguard said:

"At this stage it is not know what happened but it appears that the diver surfaced in some difficulty whilst the other members of the dive team remained below the surface. The skipper of the dive vessel contacted the Coastguard very swiftly and the rescue helicopter arrived on scene within a matter of minutes. Our sympathies go out to the family and friends of the diver."

From the post on techdiver:

"It has been stated in a local paper that the casualty is Harry Norman Railing, who was known to be a very experienced diver, trimix certified who got his Inspiration training last Easter. His aim was to dive a 54 meter deep wreck with the Inspiration. Not much of the cause is know nor made public. It was merely stated that the unit 'broke down' on ascent, but this has not been confirmed. Needless to say all this is hearsay and conjecture and pending the official enquiry must be treated as such."

From John Grogan:

The diver was Harry Railing - a very experienced mix diver. Harry was trying to build his own RB but gave up due to a number of problems and bought an Inspiration at Easter. He did many shallow dives with the unit in order to build his experience and this was his first deep dive using it. The wreck was the Warrior II - lying in about 54m of water SSE of Portland Bill on the South Coast UK. Conditions were good and there were a number of other divers on the boat that day. Harry was diving alone and (I think) was the last to enter the water. About 4-5 mins after descending, he reappeared on the surface "all blown up" according to the skipper - I assume he meant wing, suit and counter-lungs full to capacity. I do not know if Harry was conscious, unconscious or dead when he reached the surface but was unconscious when the boat reached him.

The skipper immediately called the coastguard and motored over to Harry. As there was no-one else on the boat, he had to haul Harry out himself. By then the helicopter had arrived and Harry was winched aboard for transport to Poole general hospital. Harry was pronounced dead on arrival. His equipment was examined afterwards and it was found that his Argon bottle was empty. He had been complaining of a sticky suit inflator prior to the dive.

The post-mortem took place and burst lung was recorded as the cause of death. Speculation is that his suit inflate jammed open and caused a rocket ascent to the surface. Off the record - Harry is not the type of person to ignore problems like a sticky inflator and would have disconnected the hose in the event of a problem - or just opened his neck seal to get the gas out if he needed to get rid of it fast. After 6 years of serious mix diving, he was not a relative novice to this kind of thing. I suspect that something distracted him from taking the appropriate actions.

I forgot to mention that Harry had been using an air diluent in his unit. As I understand it, you are required to do a set number of dives using an air diluent before they allow you to do the next level up at which point you can use mix or heliox as a diluent.

See also the summary of the inquest, which returned an open verdict.

Inquest, Harry Railing, Bournemouth coroner's office, 19th October 1999

Harry was using a standard argon bottle for suit inflation, and for reasons
not yet established, his suit overinflated, and he made a rapid uncontrolled
ascent to the surface.

On testing, DERA found no evidence of the suit inflator  sticking, however,
the argon bottle supplying the suit had only approximately 14 bar of
pressure remaining. It was thought that he had filled this bottle from a
larger bottle he had had filled a few days earlier, and may have been used
on a previous dive. DERA changed the batteries and sensors, and found the
unit was 'functioning within acceptable allowances'.

Initially the unit, when removed from Harry, was attached to a buoy, and
left in the water. It was retrieved when the other divers surfaced,
approximately an hour later. It was not stated whether the mouthpiece had
been closed, but there was an amount of flooding of the loop.
The (his) left handset gave readouts of: cell error, master 0.7, low O2
0.12 0.61 0.14
0.12 0.62 0.16
The second handset had no display at all.
An alarm was sounding. This continued until the boat reached shore, some two
hours later, when it was switched off.

There was a demand regulator that had been bungied around his neck. This was
coming from the diluent bottle, and was noticed to have a slight free-flow.

His diluent hose had become detached, possibly during de-kiting prior to
airlift
his exhail hose ad been pulled away from the counterlung
O2cylinder was 170bar
diluent cylinder 70 bar
bailout: 7l 70% nitrox, 250 bar
7l trimix (reportedly 23/27) was lost during de-kiting

No questions were asked as to the handset readout, and the absence of a
readout on the second handset.

The PM showed Harry was a normal and healthy, with no indication of any
health problems. He had died from a pulmonary haemoragic baratrauma.

The helicopter winchman pointed out that his unfamiliarity with the
equipment and how to release the diver lead to delay. This was also stated
by the skipper of the boat

Harry's dive computer showed a descent time of 3 minutes, maximum depth of
54m ( normal descent rate as compared to previous profiles) followed by a
return to the surface in 54 seconds.

Harry had had the unit for only a short time, and it looked like new. He had
not reported any previous problems with it.

An open verdict was recorded.
 

Harry Railing
  a.. May 1999, England
  b.. solo-dive
  c.. 54 meter, wreck dive
  d.. little Inspiration experience (had unit 2 months), lots of OC Trimix
experience
  e.. too rapid ascent
  f.. strong indications of a stuck-open drysuit inflator, not sufficiently
reachable for detachment

A buoyant ascent is the obvious cause. Was this due to panic? bad procedures or buoyancy control? This was a dive to deeper than the unit is rated on air and the first deep dive by the victim. Too deep, too fast and was on air so would have been badly narced

Top...

 

Maarten van der Weerdt

36, from Hillegom. Saturday June 26, 1999.

Diving a wreck at a depth of 27 meters, situated north of Schiermonnikoog, with visibility a mere 1.5 to 2 meters. He never made contact with his buddy after jumping in. Body recovered two weeks later, about 1000 ft (300 meters) from wreck. Cause of the accident unknown.

Maarten van der Weerdt
  a.. June 1999, Schiermonnikoog, Holland
  b.. solo dive
  c.. 2nd dive on the day on same tide, to wreck on 27 meter, lots of
current
  d.. reasonable amount of Inspiration experience
  e.. strong indications of accident happening already during descent
  f.. had independent side-mounted bail-out, which wasn't used (CC
mouthpiece was in & open when recovered)
  g.. body recovered after three weeks
  h.. indications of insufficient checks and/or underestimated unit problems
(handsets)
 i.. report is formally out, official reason: unknown, probably user error

Top...

 

Ian Swift

on 13 June, Skin Deep was involved in a second fatality.
A charterer among a group of 10 diving the wreck of the Salsette, 10 miles west of Portland Bill, suffered what is thought to have been an oxygen toxicity fit while on the wreck at a depth of 43m.


Ian Swift, 41, was using an Inspiration rebreather and, when his fit began, is reported to have tried to switch to his bail-out system.
An accompanying diver tried in vain to replace his dislodged mouthpiece before beginning a buoyant lift. Swift, however, is reported to have became too buoyant, and had to be released to ascend quickly to the surface while the other diver completed his deco stop.
Spotting the unconscious Swift on the surface, Taylor used Skin Deep's winch-operated stern lift to get him back aboard.
"The diving platform lowers to a point well under water," said Taylor, "so I was able to stand on it and guide Ian on. Without that it would have been a real problem getting him up."


First-aid procedures were started immediately, but Swift did not survive a helicopter journey to hospital.
Other divers on the boat have reported that Swift's rebreather emitted a series of warning beeps both before and during his dive. But Swift, who had two years' experience of the Inspiration, decided that no major problem existed and continued with his dive plan.


The equipment is being examined by an expert in Plymouth, whose report will be heard by the coroner for west Dorset.
Swift was known to Ian Taylor, who described the former London market trader, who had moved to Portland to open a cafe with his girlfriend, as a "likeable guy" who had helped out periodically as crew on a number of dive boats.


Meanwhile the Dorset police officer handling the cases of both Dean Chard and Ian Swift has commended the actions of Ian Taylor in both incidents as "exemplary in seamanship, provision of first aid and communication with the emergency services".

Posted by jon on May 18, 2002 at 14:20:39:

Newspaper reports this week on the inquest in to the death of a inspiration diver, Ian Swift. There have now been at least 16 fatal accidents. WAKE UP.

The coroner instructed the press to warn the diving community of his concerns.

The Times:
A coroner yesterday warned divers to be 'very worried' about a controversial piece of diving equipment after a former Royal Navy frogman became the 14th person to die whilst using one.
Ian Swift, 41, suffered a series of fits when his £2500 computer controlled rebreathing device malfunctioned and fed him pure oxygen while he was 156 ft below the surface off the Dorset coast.
Michael Johnson, the West Dorset coroner examining the death of the retired naval clearance diver, urged the manufacturers of the Buddy Inspiration Rebreather to install more safety devices after being told that one in 100 users had lost their lives while using it.
Mr. Swift's girlfriend, Melanie Scholfield, said that he had returned the equipment five times to the manufacturers, AP Valves, in Helston, Cornwall, because of problems.
The diver, who helped to recover bodies after the Marchioness disaster in 1989, was part of a nine-strong team on a wreck ten miles off Portland Bill in June 2000. His dive partner said that he suddenly collapsed, had fits, and went grey.
Nicola Finn, spokeswoman for AP Valves said that there was nothing wrong with the equipment as long as it was correctly used. She said "The figures one in 100 fatalities do seem high but they can only have been made up. Nobody would have the number we have sold. We have reason to believe Mr. Swift had been warned: the alarm was going off while he was on the boat"
Verdict: accidental death.

The Mirror:

A Coroner has rapped breathing equipment after an ex-Royal Navy frogman became the 14th diver to die while using it.
He said divers should be "very worried" about the Buddy Inspiration Rebreather, which lets them stay longer at deep levels.
Ian Swift, 41, of Portland, died of a brain seizure when the computer-driven device pumped too much oxygen into him nearly 200 ft down.
West Dorset coroner Michael Johnson said: "Fourteen deaths is staggering."


Dorset local paper:

A FORMER Royal Navy diver from Portland suffered an epileptic fit and died after his state-of-the-art equipment pumped a lethal amount of oxygen into his body, an inquest heard.
West Dorset Coroner Michael Johnston has warned divers they should be "very wary" of using the Buddy Inspirational re-breather after hearing that faults in the computerised diving kit had caused the deaths of 14 people.
Other divers told the court that one in 100 Buddy Inspirational re-breathers - which help people dive for longer with reduced decompression time - had caused death and that "everyone" using the apparatus had reported having problems.
The inquest into the death of 41-year-old Ian Alfred Swift, of Church Ope Road, who was one of the first 20 people in the world to own the kit, heard that he was one of 10 divers who had sailed on the boat Skin Deep to dive on the wreck of the Empress of India.
But the sea was so rough that skipper Ian Taylor decided to change course and dive on the Salsette, ten miles off Portland.
On the trip to the wreck on June 13, 2000, Mr Swift complained that the alarm was going off on his kit, but he banged it on the rail of the boat, complaining that the battery connections were faulty, and the alarm stopped. When he and his diving buddy Karl Harmsworth were ready to dive he had said that the carbon dioxide levels were "perfect".
Retired market policeman Mr Swift and his buddy dived first and went down 48 metres, swimming apart as they explored the wreck. Mr Harmsworth came to the engine room and wanted to explore, so he motioned to Mr Swift, who had experience of the engine room, to come over.
But as Mr Swift swam towards him he suddenly dropped to his knees and started bringing part of his kit over his head. He switched to his conventional mixed gas apparatus, by which time Mr Harmsworth was with him, ready to take him to the surface.
Mr Harmsworth had his arm around Mr Swift, trying to get his own regulator into Mr Swift's mouth when he started convulsing.
He said: "I thought when he took the mixed gas after the air of the re-breather that he was going to be narked out of his head so I went over to bring him up according to diving procedure.
"But then he started convulsing. I had inflated his gear, but I had exhausted myself getting him that far, I was more buoyant than him and the silt was clouding up the water. I had to release him."
Mr Harmsworth went back down to find Mr Swift, but he had risen to the surface, where Mr Taylor raised the alarm and pulled him on board.
Mr Taylor, who said that Mr Swift was one of the few divers who carried out thorough pre-dive checks, carried out resuscitation until the helicopter arrived to take Mr Swift to Dorset County Hospital, but he was declared dead on arrival.
Mr Swift's partner Melanie Schofield said: "Diving was Ian's life - he would often dive several times a week.
"When he got the Buddy Inspirational he undertook specialist training to use it. But every other month he would have to take it back to the manufacturer, AP Valves, with faults.
"Ian wouldn't dive if he knew there was a fault in his kit."
Coroner Michael Johnston said that the Buddy Inspiration recycles air, taking out carbon dioxide from the outward breath and automatically calculating how much oxygen the diver needs.
He said: "I believe that Mr Swift's death was due to the re-breather malfunctioning, whether he should have or could have known it was faulty or not.
"I am going to record a verdict of accidental death, but I have to say that I think the diving community should look very carefully at any piece of equipment which has a possible one per cent fatality rate."

Ian Swift
  a.. 13 june 2000, Salsette (wreck), Skin Deep, Weymouth (England)
  b.. solo dive? Not sure
  c.. found on 48 meter, unconscious
  d.. rumours say he had had cell errors, but did not respond to them

#########################################################################################

From: Steve Millard <ec96@liverpool.ac.uk>
Subject: Inspiration "Recalled" by BSAC
Date: Thu, 24 Sep 1998 15:29:45 +0100 (British Summer Time)

I have just spoken to the BSAC headquarters about this supposed 'statment' reported in the Times. They have informed me that there has
been *NO* such official statment issued following this 4th fatality by BSAC.

Back in October 1997 BSAC did formally announce that until an appropriate review had taken place, rebreathers of any kind should not be
used in a BSAC club environment. However the recent statement reported in the Times has no basis in fact...!!! It is quite simply
untrue.

It is of course possible that some individual somewhere in BSAC has expressed a personal opinion that he/she didn't think Inspirations
should be used until the air has cleared...but anyone can express an opinion about whatever they like. This is an entirely different
matter to a national organisation advising all their members not to use their Inspirations, as suggested in the Times article and echoed
in your web pages. Mistruths like this need to be quashed & I hope you will amend your website to this effect.

If anyone wishes to check the 'official' position of BSAC themselves, the
telephone number is (44)151-350 6200

Regards, SteveM
 #############################################################

From Dive magazine (Aug)

Diver Ian Swift was among a group of ten who were diving the wreck of the Salsette out of Weymouth. On board was DIVE contributor, recently retired Metropolitan Police inspector Colin Taylor, who noticed Swift talking to his buddy about his consoles, which were beeping before the dive. 'After a few minutes fiddling with the set, the computer cleared and [Swift] stated that it was okay. He was among the first into the water.'

Swift was found in a state of semi-consciousness at 46m with his bail-out demand valve in his mouth. He was seen to be shaking or convulsing. His buddy tried to get him to take his spare demand valve, but he would not take it. Faced with an almost impossible decision, the buddy - who had himself accumulated a significant amount of decompression time - inflated Smith's jacket to send him to the surface. 'In the circumstances, he did exactly the right thing,' Taylor told DIVE. 'Had he tried to do a controlled buoyant ascent, Ian would have been dead anyway, and his buddy would have run the risk of a serious bend had he surfaced straight away.' Swift was declared dead on arrival at hospital.

###############################################################################

I was shown Ian Swifts scrubber unit shortly after his death.
 
When switched on, it said "Must Calibrate, Yor N?". At "Must Calibrate", No was selected and was taken into Dive mode - it reported "Cell Error" continuously. When you took it through the "Must Calibrate" routine - it reported "Cell Failure, Replace, No Dive". 
For it to inject O2 continuously, two of the cells would have had to be reading below the setpoint and this was the case when we ran it at 1.3. One cell was shot, one cell was current limited. They were old and needed to be thrown away.
 
The reports received from the divers at the time matched these findings. The unit was beeping before he went in and beeped continuously for the duration of the dive.
 
Ian Swift's unit had last been returned to the factory in Oct 98, when a new solenoid was fitted. He died in June 2000.
 
I wasn't informed of the inquest date and wasn't requested to be present. I'm told Ian Swift's inquest lasted 1 1/2 hours which is incredibly short ( Paul Hayden's inquest lasted  2 days and at one time looked as though it would go into a third day). It doesn't sound as though they had a single rebreather expert or CCR diver in the Court. I've had some of the comments relayed to me that were made by some of the "Industry representatives" and their ignorance is unbelievable. One of them tried to compare the Inspiration to the British Navy's Mk16s in terms of cost - "how can it be any good at 1/10th of the price? being the gist" - the same Mk16, which two RN divers have died whilst using.
 
I have requested a transcript of the proceedings to see exactly what the Coroner did say. Each report I see words it differently. I expect he said " Divers should be wary using such equipment". - I think we all would agree with that statement. It is the unaware divers that get caught out.
 
So - why did Ian ignore the beeps? - probably because he thought he knew what the problem was and thought it was okay.
Why didn't he notice the gain in counterlung volume and possibly buoyancy?
Why didn't he realise that having to exhaust gas from the loop on a very regular basis is abnormal ?
 
Only Ian knows the answers to those questions.
 
I'm now off to dive the Colossus on the south side of Samson, (Isles of Scilly). The stern statue has been uncovered again and is nearly ready for lifting.
 
 
rgds
Martin
 
Martin Parker
Managing Director
Ambient Pressure Diving
Manufacturers of the Inspiration Closed Circuit Rebreather
Water-ma-Trout Industrial Estate, Helston, Cornwall, TR13 OLW, UK.
Tel: 01326 563834, Fax: 01326 573605.
Website: www.ambientpressurediving.com


 

Apart from the crass comments from the coroner who seems to have based his comments on misinformation. This is the easiest case to analyse and is obviously sheer stupidity. Anyone who ignores the units warning sounds and displays and bangs the handsets to shut them up is going to die sooner or later. After all you wouldn't dive on OC if the gauge said the tank was empty. Ian would have probably hit the gauge until it said he had some air!!!!!!

Top...

 

Dr Max Han

Max Hahn
  a.. 11 june 2000, Bigge-See (Germany)
  a.. huge amount of SCR/CCR experience, also on Inspiration (was a TDI &
RAB IT on the unit)
  a.. no solo dive
  b.. rapid ascent due to formally unknown reasons, but rumours of
non-standard procedures (i.e. closing valves during ascent), spent scrubber,
also predictably on natural causes
  c.. Max & buddy reach surface alive, but buddy does not succeed in keeping
him afloat
  d.. Buddy survives, but suffers big deco hit, treated in hospital/tank

################################################################

From Dive Magazine (aug)

Dr Max Hahn was an extremely experienced diver. A rebreather instructor with a long background in technical diving, he was a respected doctor of physics and had played a key role in writing decompression tables that thousands of divers use today. Still active at the age of 70, he was one of the world's most influential divers.

On 11 June, Hahn died while diving the Biggesee, a reservoir near the German town of Olpe, using an Inspiration. He started to ascend while his buddy Juergen Mathias was reeling in his delayed SMB, but for some reason the older man's ascent became faster. Juergen ignored his own decompression demands and followed Hahn up. At the surface, Hahn - his mouthpiece still in place - told Mathias to remove the 3kg weight that was attached to the top of the unit. But his buoyancy was failing and Mathias was faced with the increasingly difficult task of keeping his friend afloat. Hahn's buoyancy was so negative that Mathias had to kick hard to keep him at the surface, until the effort became too much and he passed out, losing Hahn. Mathias was saved by some nearby divers, but Hahn sank to the bottom of the reservoir.

He was found at 42m: his diluent tank was completely empty, his O2 tank had 15 bar left and the O2 valve was virtually closed. There was blood in his throat. When Hahn's body was recovered, the water was emptied out of the Inspiration and it appeared to be functioning properly. It is thought that he may have turned off his O2 valve to save gas during his ascent, but until an inquest has been completed no one will know for sure.
 

Top...

 

Mick Brennan

From the UK DIR list:

> On sunday 1st july a diver was lost doing a solo
> penetration into a wreck @120m, 20 miles north of Holyhead. He was
> diving with an experienced team, BUT was not qualified to dive mix on
> a breather and also ignored diving as an integral part of the team.
> He did not surface after dive, the team returned on Monday but
> nothing found, so are going back this coming weekend.
> Mick leaves a wife and two children, our thoughts are with them.
> This is a reason why we should all DIR and stay within our own
> limits,As it is not us that weeps at the grave!

Note: that's ON a Buddy  ... but not WITH a buddy :-(

Mick Brennan was lost while on a 120m-deep wreck dive
off Anglesey. Using an Inspiration rebreather, he was
with a group of mixed-gas divers known as the Northern
Gas Dive Team, using a mixture of rebreathers and
open-circuit trimix. He was diving alone at the time
of his disappearance.
 
Top...

 

Andy Wilde

Andy Wilde
  a.. 6 august 2000, wreck of the Bramley, 30 mile from the coast of
Plymouth (England)
  b.. 85 meter, 25 or 30 minutes divetime, 180-190 minutes runtime
  c.. experienced diver, both on OC and on the Inspiration
  d.. no solodive: was finishing his long deco with a group of other
Inspiration divers on a lazy shot
  e.. suddenly hit for the surface during last 10 minutes of his 6 meter
stop, after spitting out mouth piece (his buddy Ric Waring put a detailed
report on this list)
  f.. visibility at 6 meter was very bad (alges?), although very good at
depth (I was also on this dive)
  g.. buddy was so surprised by this sudden action that he did not follow
Andy; presumed a safe ascent from only 6 meters
  h.. body not recovered

 

Top...

 

Jan-Magnus Soerboe
 

Ingemar
Its Jan-Magnus "våt och Villig" that has died.
According to a Norwegian www-newspapers Jan-Magnus decided to continue the
dive for another two hours after his fiancé and another girl called a half
hour dive.
He was found half an hour later dead on surface.
Jan Magnus was solo diving, according to the papers investigation is under
way.
The shitty thing about solo diving is that it will be difficult to determine
cause.
News links is for you scandinavian speaking divers.
http://www.fedrelandsvennen.no/regional/kristiansand/81089.html
http://www.fedrelandsvennen.no/regional/kristiansand/81231.html
But as we all know newspapers write what they will so if the info is
correct is another matter.
The solo diving bit at least nobody contradicts. A friend of Jan-Magnus who
is interviewed in the papers actually claims that solo diving is safer than
team diving on rebreathers....go figure....
My deepest condolences to family and friends.
Best regards
Esbjorn
 

(Note by me. The Links above no longer exist)

May 24, Jan Magnus Soerboe died diving an Inspiration rebreather at 25-30m 
depth . When his buddies decided to call the dive after an hour he informed them that he was going  to continue the dive for another two hours solo. He 
was found floating in the surface after 1.5 hours.

More information might be available after the autopsy and technical 
investigation of his equipment.

My condolences to his family and friends.

Oystein

Solo diving on a rebreather. I've made my views clear on this already

Top...

 

Steve Hughes

BSAC 2001 Incident reports

May 2001 01/155
Two divers were completing a rebreather dive to a maximum depth of 50m. One of the pair prepared and deployed a delayed SMB. When he looked for his buddy he was not to be seen. The Coastguard was alerted and an extensive air and sea search, involving two lifeboats and two warships, was conducted. The missing diver was not found.

 

Top...

 

Bernard Gonon

yesterday (Tuesday) a rebreather diver died in the
South of France.

In the local newspapers, Jean-Pierre Joncheray (a specialist on French wrecks) is commenting that Bernard Gonon was a serious and thoughtful diver. When reading the report, you might however get another impression.

The 55 year old Bernard Gonon and his 30 year old buddy were making a dive on a wreck at a depth of more than 100 meters. They went there without any surface support - just a Zodiac inflatable boat and 2 divers. There was no line or system for making decompression stops, other than the anchor line from the boat.

A sailing boat spotted the dead diver at the surface. When the rescue helicopter arrived, resuscitation efforts were
unfortunately not successful. They found the zodiac and only when a Navy vessel wanted to take the boat with them, a second diver was noticed who was doing decompression stops at the anchor line. The diver surfaced an hour later
to be taken to hospital in a state of shock. Bernard Gonon had already been rescued by the Navy on October 5 this year at the same location, after an equipment incident on a dive at the same depth.

From the pictures, the rebreather used seems to be an "inspiration" (the former Buddy Inspiration). An extremely high percentage of accidents in Europe involve the use of this rebreather and it is understandable that buddy discontinued this product.


 
So diving without surface support is thoughtful. Could Bernard have surfaced alive and drowned on the surface? Interesting that the Inspiration has been discontinued as APD doesn't seem to know this

Top...

 

Dean Livesey

Thanks to all for their messages of sympathy and assistance.
At present details of Deans recovery cannot be disclosed.

Facts known so far,.

1. Entered water after calibrating his unit twice, reason unknown.
2. On surface of water before descending did not seem as lively as usual, i.e. race down to wreck first.
3. Did duck dive to descend shot, reason not clear.
4. Appeared to be unconscious at about 4m from surface still in head down position.
5. Rapidly gained speed and continued down making no movement, swept away by tide.

More details will be posted when facts are known


From: "Simon Bradbury"

The inquest has now taken place for the incident involving "Dean Livsey" inspiration diver.

The dive took place on the wreck known as the "Copper Wreck" on the 6th may 2002. Located, half way between Sark & Jersey in the Channel Islands.

It took 2 months to recover Dean's body, due to this, there was inconclusive medical data.

The equipment was intact but in a poor state, the cylinders which still contained gas were analysed and correct, as marked on the cylinders. No other evidence could be gained from the equipment.

There for the verdict was "open".

Our thoughts are with his family.

Simon Bradbury, "Guernsey"
Dean's dive buddy on the day.

 

Top...

 

Bobby Barrett

From: "Martin Parker" <MartinParker@dialin.net>
Date: Tue, 6 Aug 2002 10:33:11 +0100
To: "Inspiration Mailing List" <inspiration@drogon.net>
Subject: Bobby Barrett

It is with deep sadness that I report the death of Bobby Barrett. He died
on Saturday 3rd August whilst diving his Inspiration in a quarry in
Bainbridge, Pennsylvania, USA.

We have only scant information at this time. He was on his 2nd dive of the
day, he was found in 42 feet of water, mouthpiece out.

The autopsy was held yesterday. Hopefully, information will be released
soon.

My condolences to Stephanie and family.


Martin

Martin Parker
Managing Director
Ambient Pressure Diving
Manufacturers of the Inspiration Closed Circuit Rebreather
Water-ma-Trout Industrial Estate, Helston, Cornwall, TR13 OLW, UK.
Tel: 01326 563834, Fax: 01326 573605.
Website: www.ambientpressurediving.com
 

######################################################

Written by one of the "Buddies" of Bobby, I have talked to him and this is a pretty accurate account of what went on. 
The following is what I know firsthand.

The four of us drove up to Bainbridge on Saturday morning. Bobby was diving an
Inspiration Rebreather while instructing Adam on the use of a Drager
Rebreather. Sean and I were diving Nitrox and just tagging along to get more
dive time and check out a different quarry. I was the least experienced
of the group with 30 dives and PADI Rescue / TDI Nitrox certification.

The first dive was without incident. However, the water level of the quarry was
about ten feet low and the visibility was very bad, less than a foot
in some places once the bottom was stirred up. Sean and I were buddies and we
ended the dive early because the poor visibility. We were all familiar
with quarry diving in low visibility, having spent many hours in Millbrook, but
it just wasn't much fun. Bobby and Adam completed the training
requirements for the dive.

After eating lunch during the surface interval we started the second dive. We
moved to a different area of the quarry where we heard that visibility
was better. The plan for the dive was that Adam would perform the required
skills for the Drager Rebreather training and we would tag along. As a
secondary goal we had hoped to locate the cement mixer.

We started out as a group with Bobby and Adam as buddies and Sean and I as
buddies. We did a surface swim out to a buoy that we thought might mark the
location of Cement Mixer. To give you an idea of the visibility we could not
see the platform at 15 feet that the buoy marked until we started the
descent. We descended below the platform to the bottom at about 40 feet. 
There
was a thermo cline at about 25 feet below which the visibility was
really bad, about five feet. At that point Bobby ran Adam through some 
skills
while Sean and I looked around, we didn't go far because of the low
visibility.

At that point Bobby signaled to Adam to join our buddy team and went off by
himself. This was not unusual, as he was not only certified as a solo
diver but also as a solo diving instructor. At the time I thought that Bobby
had gone to find the cement mixer, since he was familiar with the quarry,
and would come back and lead us to it. After some period of time we decided to
go up to the platform where the visibility was better. We hung out on
the platform working on skills until Adam called and end to the dive. We 
made a
surface swim to shore and got out of the water about an hour after the
dive started.

Bobby had three hours of life support at the start of the dive but we were
concerned because it was unlike him to take off by himself for so long
without telling us where he was going and when to expect him back. An hour and
a half after the dive started the three of us agreed to consider Bobby
as a lost diver.

We decided that for several reasons we should not attempt a search on our own.
1. Visibly was very bad and there were only three of us.
2. We did not know where Bobby was going in a big quarry.
3. The quarry operators had a boat to facilitate the search and were 
familiar
with the quarry.
Sean remained at the entry point while I dropped Adam off at the top of the
cliff as a spotter while I continued on to the office to notify them. They
in turn notified the emergency response people and immediately sent down
people to operate the boat to conduct a search.

When I got back to the entry point Sean had suited up and started out on the
surface to look for Bobby. I started gearing up to join him but before I
got in the water the quarry operators had the boat moving and we decided 
that
since they were familiar with the quarry we should let them organize the
search and assist in any way we could.

The surface search with the boat was unsuccessful. By that time the water
rescue team had arrived. The plan was that the rescue team would search one
area and a second team including us would search another area under the
direction of the Quarry operator divers.

Before either team got in the water another instructor found Bobby on the
bottom near the platform where we had been. I never got a chance to talk to
him so I am not sure if he was searching or just happened upon him. Bobby was
brought to the shore and Dr. Newman who had responded with one of the
emergency teams led the efforts to resuscitate him to no avail.

Bobby was diving with an Inspiration Rebreather and redundant VR3 computers.

We
made sure that no one touched his equipment, which was taken into
custody by the authorities for analysis.

We notified DAN on Saturday an requested that they worked closely with the
Coroner to make them aware of any special considerations for the autopsy
because Bobby was diving a rebreather..

The following is what I have heard but have not personally confirmed.

The autopsy was to be performed Monday. As of yet I have not heard that the
results have been released.

Bobby's equipment was being inspected by the authorities with the 
cooperation
of the Inspiration's manufacturer. Again as of yet, I have not heard
that the results have been released.

I do not believe that Adam is Bobby's step son as stated but they were very
close and Bobby was his as well as our diving mentor.

My Speculations

I am not sure what happened but I believe that Bobby was unconscious before he
knew there was a problem. I hope this was the case and that he did not
suffer. This is speculation based on the fact that he had multiple alternate
air sources that were not used and he was only 40 feet of water were he
easily could have made an emergency ascent.

What I've concluded so far

Do not dive solo! Even if you are willing to take the risk you should 
consider
the effect that your accident will have on others, your family, other
divers, the quarry or boat operators. Bobby was the most knowledgeable and
experienced diver I know; if this could happen to him it certainly could to
me.

Keep track of your buddy! If for whatever reason they go unconscious you 
only
have five minutes to get them breathing again.
 

Top...

 

Garrett Weinberg

Posted by MHK on June 27, 2001 at 10:44:10:


[from posts on tech diving lists:
report written by Mr. Tom Mount, IANTD
Deceased, Mr. Garrett Weinberg
Dive Buddy, Ms. Claudia Milz, PhD
the device in question is a rebreather: http://www.ambientpressurediving.com/FrmsetNexus.html
Mr. Scamahorn is ??
opposing view commentary by Mr. George Irvine, et al ]

---------------------------------------------------------------------------------------------------------

Accident Report in Regard to Garrets Death
This is one of the rare times we have a detailed accident report to review:
Saturday June 23, 19:05, Garrett and Claudia started a dive to 300 feet at
Mukilteo, WA. The dive included a swim of 15 minutes down a gradual slope to
the planned 300-foot depth where 5 minutes were spent. The dive was planned
with software dive tables. Both knew the dive site very well.
Both were diving their inspiration units that had passed all pre-dive
checks. Onboard tanks were full (8/60 and O2), scrubber fresh (see below).
Also, they were carrying an Al80 (10/50) and an Al40 (O2) as bailout each,
equipped with inflator hoses, gauges, and second stage.
>From descent to ascent, including the deep stops, everything went smoothly
like usual.
After leaving the 100 ft stop to 60 feet (20 ft/min) Garrett started to
display he was having a problem.
The Inspiration was functioning correctly and there were no PO2 problems,
nor other CCR related problems. The after-market ADV was disengaged as it
always was on ascent. No alarms, no malfunctions were taking place.
Claudia: Starting at 100 feet, he was suddenly behind me, not next to me or
slightly in front. I looked back and saw him getting rid of occasional water
in the breathing hose (normal, although he usually did not do it on ascent,
rather at the stop). He seemed to be struggling slightly with 'something'.
(When someone had problems of any kind, they would stop and the buddy would
stop as well. In this case, although slightly slower, Garrett did not stop,
and no other communication indicated a serious problem, yet.)
Claudia: Then, arrived at the 60 ft stop, the communication was strange to
non-existent. All I understood, other than that he was getting in more and
more distress, was that his dry suit was not as quickly deflated. He showed
me that with opening the wrist seal slightly and bubbles coming out. Because
of the warm neck hood, it's very hard to open the neck seal that way, and
Garrett chose not to. "
Garrett presented more problems with buoyancy and a look of distress, and
surprise. After we had spent some time trying to stop the ascent by
releasing gas and swimming down - I could not get to the dry suit inflator
to detach it (although nothing indicated a runaway inflator) and worked on
the BC inflator - Garrett stopped kicking and continued to the surface. He
was just floating up, looking down to me. That look said that he knew what
was going to happen, and I did too."
(The longest deco in my life (60 minutes according to tables), on top a
stomach barotrauma that made breathing very hard.)
Comment: This is what we actually talked about with Leon yesterday
afternoon: Gary never really liked his deflator that does not have a rest
when fully opened, and together with the undergarment, it seemed difficult
to release the Argon in a timely manner. However, I have never seen him
having problems before.

According to a person at the surface that came to help, Garrett went to the
boat ramp and climbed out of the water. He then collapsed on the boat ramp,
and the guy pulled him from the ramp up.

Garrett said something about his dry suit to this person. He had him call
911, told him about his buddy doing deco and t