Information needed to complete:

This page was updated 1/15/01 with a very good report on a death that occurred on a Halcyon.  There are a few more to add, but a lack of time has kept me from updating this properly.  However the report deserves special attention because all of these should have something like this.


Rebreathers are not toys.  There are many ways to die on a rebreather, and it's often complacency, lack of training, or just plain lack of respect for these devices.   This page will try to collect the reports on deaths on rebreathers and the reason they happened.  If you are thinking of building your own, take special note of the deaths on commercial, tested rebreathers.

Do not for one instant regard this list as an endorsement or rejection of any particular rebreather.
Any commercial rebreather in existence will at some point be found attached to a dead diver.

Death report Index:

Incedent / near-death report Index:


Homebuilts / unknowns

None that I know or or could find.


Brownie's Third Lung Halcyon

case: Dennis Harding

For once, a good report is published.  All of these incidents should have a report like this.

Dennis Harding, Abridged Report


Atlantis/Dolphin

case: unnamed New Guinea death

Date: Thu, 4 Jun 1998 11:14:20 -0800
From: "Mr. Dude" heyydude@pipeline.com
Subject: The Body Count

Guys,

I don't like to comment on a particular fatality, since it involved the friend of a couple of my friends, but the New Guinea death was the result (from all that I've heard from Edward) of a very basic mistake - squared. 1st mistake: Mixing the gas wrong. 2nd mistake: Not taking the time to analyze the gas after mixing.

Lets face it, this was not a case of poor instruction, just complacency on the part of an experienced diver. And like Rich is fond of saying, its the complacency that kills you.


Date: Tue, 09 Jun 1998 12:48:07 -1000
From: Joseph Dituri dive4wrk@pixi.com
Subject: Re: Drager (was Re: Rebreather Choice) 

As two cases I am working on are still open for liabilty, I will not give specifics. One Death and one perm. disability are the two I'm working currently.


Date: Fri, 12 Jun 1998 08:02:58 +1000
From: Paul Davis paul.davis@drager.com.au
Subject: Re: Fatalities on the Adlantis Rebreather 

Kerry,

I read recently and have seen several comments being made about deaths on Atlantis/Dolphin units in Australia and I am really amazed at the numbers quoted. I do not propose to be an expert but I like to think of myself as informed and I am aware of only one incident here involving the Atlantis/Dolphin and it tragically involved a death.

Now before the requests for more information come through please understand that this is still subject to a coronial inquiry and as much as I would like to release details we are bound by both legal and moral obligations to wait until the findings have been officially published. It is up to the Coroner to decide this point and not me.

I do prefer though to stick to the facts and they are simply that the set performed as designed to manufacturers specifications when tested and that I personally will dive my Dolphin again this weekend and as I do whenever possible. Not as part of the job I do but because I enjoy doing it and I avoid open circuit wherever possible.

Paul Davis
Market Manager Defence & Diving
Drager Australia Pty Ltd


Case: Dr. Wesley C. Gradin

Date: Tue, 30 Jun 1998 15:13:31 -0700
From: pH heseltine@earthlink.net
Subject: Re: BODY COUNT: The NewPaper Article

Physician's death while diving probed

June 01,1998

Cheryl Reid; The News Tribune

Investigators are hoping a diving expert will tell them whether a Sumner doctor's high-tech scuba gear failed and killed him Wednesday.

Dr. Wesley C. Gradin, 45, was found in 67 feet of water at the edge of a kelp bed about one mile east of Friday Harbor Wednesday.

"He wasn't hit by a rock or tangled in seaweed or attacked by a shark," San Juan County Sheriff Bill Cumming said.

An experienced diver and underwater photographer, Gradin was shooting video when he died, Cumming said. That video shows a very fast current, and it's possible that Gradin simply ran out of air because he was exerting himself in the current.

Gradin was using a "rebreather" unit, the sheriff said. Rocky Atwood, a dive master with Underwater Sports Inc. in Tacoma, said rebreathers work by re-circulating and filtering a diver's exhalations.

A rebreather can more than double the amount of time a diver can spend underwater, he said.

The units have been available for for several years, but are too expensive for most recreational divers, Atwood said.

Cumming said investigators will know more about what caused Gradin's accident after an autopsy today by the King County medical examiner's office.

Cumming started his medical practice in 1983 in Wyoming, where he was born. He moved to Sumner in 1987, working with Sumner Family Medicine, Good Samaritan Hospital records show.

He later established his own family practice in Puyallup and had privileges at Good Samaritan.

When he wasn't practicing medicine he was diving or scouring dive shops for the latest equipment, said Randy Bierbaum, owner of Aquaquest Divers in Puyallup.

"He's an extremely experienced diver and he's a good diver," Bierbaum said. "He also delved into the latest technology. The very latest. If it was on the cutting edge of technology, he was involved in it."


Date: Tue, 30 Jun 1998 16:37:33 -1000 (HST)
From: "James D. Watt" watt@ilhawaii.net
Subject: Re: BODY

To set the record straight on this fatality the diver in question was on a SCR not CCR. How do I know? He was a friend to a lot of photographers, myself included. The details made the rounds quickly. The final word is not in but it looks like he overbreathed the bag in a strong current. He had bailout gas but never got to use it. No 02 sensor in line.

Jim Watt Kona Hawaii

INVESTIGATORS PROBE FOR CAUSE OF PHYSICIAN'S DEATH WHILE DIVING / SUMNER DOCTOR WAS USING HIGH-TECH 'REBREATHER' GEAR; AUTOPSY SCHEDULED
Investigators are hoping a diving expert will tell them whether a Sumner doctor's high-tech scuba gear failed and killed him Wednesday. Dr. Wesley C. Gradin, 45, was found in 67 feet of water at the edge of a kelp bed about one mile east of Friday Harbor Wednesday. There was no obvious cause for Gradin's accident, San Juan County Sheriff Bill Cumming said. "He wasn't hit by a rock or tangled in seaweed or attacked by a shark."
Article from The News Tribune Tacoma, WA 05/29/98


From: "Thomas Mitchell" tmitchell@isomedia.com
Subject: Re: Rebreather Death
Date: Fri, 3 Jul 1998 11:31:21 -0700

I may be mistaken but I think the incident you are referring to took place over Memorial Day weekend in the the San Juans. What I have heard here locally was that it was an Atlantis/Dolphin, the diver was alone(partner in the boat) and he was a very experienced OC diver. The best estimate on cause of death was overbreathing the unit in very heavy current(normal conditions here), loss of consciousness and drowning.

Granted, the above is dive shop 'Did you hear about...?' second hand info but probably reasonably accurate as it came from a local Atlantis/Dolphin dealership.

Thomas


Date: Fri, 3 Jul 1998 11:43:19 -0700 (PDT)
From: Jon Breazile breazile@netcom.com
Subject: Re: Rebreather Death

I don't know much about the rebreather death here in Washington, but here is another newspaper article from the Tacoma News Tribune:

June 05, 1998

Preliminary autopsy results on a Sumner physician who died in a scuba diving accident last week were inconclusive, a San Juan coroner's office spokesman said.

Dr. Wesley Gradin died May 27 while shooting underwater video near Friday Harbor.

The autopsy tentatively ruled out a medical problem, such as a heart attack, the coroner's spokesman said. It appears Gradin drowned, but the cause of the drowning is not yet clear.

Officials are awaiting toxicology results and a report from dive experts on the condition of his equipment. Gradin was using a high-tech "rebreather" unit, which works by recirculating and filtering a diver's exhalations.

A public memorial service for Gradin is set for noon today at Trinity Lutheran Church, 12115 Park Ave. S. in Parkland.

- Cheryl Reid, The News Tribune

-Jon


Date: Fri, 3 Jul 1998 11:49:22 -0700 (PDT)
From: Jon Breazile breazile@netcom.com
Subject: Re: Rebreather Death

Here is another article on the death in Washington:

Body of missing Sumner diver found in San Juans
June 01,1998
The Associated Press
FRIDAY HARBOR - Searchers on Wednesday night found the body of a Sumner scuba diver who had been shooting underwater video about 1 mile east of here off Turn Island.

San Juan County sheriff's divers found the man's video camera on an underwater ledge at a depth of 37 feet, Sheriff Bill Cumming said.

The body of Dr. Wesley C. Gradin, 45, was found in 67 feet of water at the edge of a kelp bed, the sheriff said. Gradin was a family practice physician.

The sheriff theorized Gradin set his camera down and attempted to fix a possible equipment problem. Video footage showed a very fast current and some air bubbles passing in front of the lens.

Gradin was an experienced diver using "very advanced diving equipment," the sheriff said.

The San Juan County coroner will schedule an autopsy to be done by a pathologist, possibly Thursday or Friday, Cumming said. Authorities hope to have a dive specialist attend in hopes of pinpointing what went wrong.

The Coast Guard received a distress call early Wednesday afternoon from the man's fiancee aboard the 17-foot aluminum vessel Sea Hunt, said Lt. Martha LaGuardia in Seattle.

She said the fiancee told authorities her companion had 90 minutes of oxygen in his tanks when he set out about 11:55 a.m.

When he failed to return, the woman called for help at about 1:45 p.m., LaGuardia said.

Turn Island is a popular diving area with very strong currents, the sheriff said. Wednesday's currents were especially strong.


Date: Sat, 04 Jul 1998 09:19:25 -0700
From: "Steven T. Stolen" stolens@serv.net
Subject: Re: Rebreather Death

Sorry for holding out so long before making a post on the subject, but I wanted to get more of an official word as to real cause of death. I knew Wes Gradin for about ten years. He has been an active SCC diver on his Atlantis-I for over two years. He got interested in rebreathers shortly after I started to train and actively dive on my BMR-155. He was well-known throughout the underwater photo community as an excellent photographer, utilizing his SCCR as his vehicle to get to his photo subjects, both in still photography and in digital video. His Family Practice office had very large framed pictures of his excellent works. I have been in touch with his mother since the memorial service and so far the autopsy is still awaiting unbiased rebreater expert study of the unit. In the interim, it was death by drowning.

So far the recent postings of the newspaper articles are all that I have seen in print on this tragic accident.

As I hear more definitive findings I will pass them along.

Wes was not only a friend, but my primary care physician for 8 years. I am heavilly saddened to see him go. Although we never linked up to do rebreather dives together, we did have lots of discussions on our experiences on rebreathers every time I had a professional visit to my favored doctor. Many divers in my area used Wes' professional services. He was one of a very few doctors in Western Washington who had studied dive medicine.

Steve Stolen


BMR 500

None reported on the list, yet.


Carleton/BMI (Biomarine) Mk 15, CCR155, 16, CCR-1000

Date: Fri, 05 Sep 1997 06:06:31 -0400
From: "G. Irvine" gmirvine@safari.net
Subject: More Gavin - rebreather death

We lost an EOD diver on a MK 16 this way within the past month. Details are sketchy, but it would appear a cable or connector failure caused the add valve to fail. The diver apparently never noticed the alarm indication or noticed it too late. This was a highly trained U.S. Navy diver using a UBA that has been in service for more than a decade.

Bill Gavin


Cis-Lunar Mk-4, Mk-5

Case: Ian Rolland

Date: Tue, 29 Jul 1997 15:23:12 -1000 (HST)
From: Richard Pyle deepreef@bishop.bishop.hawaii.org
Subject: Re: RB flight recorder

Which version of the Ian Rollin story are we going to use this time?

The version that was written by Bill Stone and Kenny Broad in 1994, shortly after Ian's death. The only other version I know of is the one that purports that Ian died of hypoxia. Because the emergency cut-off valve to the oxygen solenoid was found shut on Ian's rebreather, there was initial speculation that the cause of death was hypoxia. However, upon examination of the "black box" data, it was revealed that the PO2 in the breathing loop never was below 0.17, and was almost certainly 0.24 at the time Ian blacked out. This is the reason I said "these data were invaluable for understanding the circumstances of Ian Rolland's death" (which part of that statement is a lie, or was it something else in my message that prompted you to call me a liar?). The point to get from this is how premature speculation can lead to erroneous conclusions, when all available data have not yet been considered. All the ranting and raving in the world from you will not change the facts. I could repeat for the list all the reasons that I already told you in private for why I personally believe Stone and Broad came to the correct conclusions in their report (and why it is MUCH more important for me to know the truth than it is for me to protect Stone), but I don't have the time right now. I'll send the report to whomever asks for it, and let everyone who is interested judge for themselves. If there are questions that I can answer, I will be happy to do so.

The point that John Strohm raised, and the point I was agreeing with him on, is that "black box" data can be very useful and informative on electronically-controlled rebreathers. 

Aloha, Rich


Date: Wed, 30 Jul 1997 11:26:50 -1000 (HST)
From: Richard Pyle deepreef@bishop.bishop.hawaii.org
Subject: Re: RB flight recorder

[brownies@mailhost.netrunner.net]
I have a simple question that would seem obvious. If the black box were getting it's information from the same source that failed and killed the diver would you continue to rely upon the box or the symptom of the dead diver to determine whether something went wrong with the machine?

Why, Robert, that's an EXCELLENT question - one that I was hoping somebody would ask! Obviously, if the sensors are outputting garbage information, both the black box data and the solenoid control mechanism would be screwed. So, we need to look for evidence for whether or not the sensors were giving garbage information. Because both the black box recorder and the O2 control system operate with post-calibrated sensor data, there are two general locations for erroneous sensor reading: pre-calibration points, and post-calibration points. Because the calibrtion offsets were verified to be correct within 0.01 ATA both before and after the dive that ended Ian's life, it seems almost certain that if there was a problem with the readings, it would have been a pre-calibration failure (i.e., a failure between the sensors themselves and the electronics). So, now we have to figure out whether or not the sensors were providing incorrect information to the electronics. That question is best answered in the context of your next two questions:

1: If the machine averages the two closest sensors and ignores the third, what happens when two are dead wrong, but very close in reading?

and

2: Why would the valve be shut off?

Both good questions, which help lend insight into our accident analysis. As for the first question, the system averages all three sensor readings, not just the two closest (I think you're confusing the MK-4 with the Inspiriation here). If one of the calibrated sensor readings is out of synch with the other two, then yes, it does take the two that are closest to each other. However, that was not the case. The solenoid firing system uses the same varibale in the software that is logged in the black box, so whatever is recorded by the black box is used to control the solenoid. Of course, if there was a failure at the sensors, or between the sensors and the electronics, both the black box and the solenoid would be recording and responding to (respectively) the wrong information (we'll discuss that in a minute). But all that aside, I think you'll find that your question 1 above is rendered moot by what is revealed in your question 2: When Ian's body was found, the valve to the solenoid supply was shut. Hence, it doesn't matter one wit in this case whether or not the solenoid was firing - even if it was, no oxygen would be entering the breathing loop. As to why Ian had that valve shut, I honestly don't know. Because I was not involved with that project, I don't know what their protocol was. However, had you read the full report (which I gather you haven't, based on the nature of your questions), you would have found a possible explanation.

So...how do we know whether or not the sesnors were giving accurate information to the electronics? The black box data are recorded for each individual sensor, as well as the software-interpreted average (system) reading, with high resoultion. Looking at these four data sets together, the recorded readings yeild a certain "signature", which can reveal failure modes. One obvious failure mode is a break or malfunction of the electrical contacts between the sensors and the electronics. This would be manifest in the black box by a sudden shift in the registered PO2 reading. No such shift was registered. Another possible explanation was condensation formation on the sensor membranes. You see, if enough moisture condenses and gets on the sensor membranes, surface tension can hold a film of water over the sensor, isolating it from the breathing gas. This is a terribly insideous problem, and in fact is one of the explanations I have heard to account for what happened when a diver went unconscious on the EX-19 (bear in mind this is only what I have heard - I do not know what really happened in that case - perhaps someone else can shed more light).

I have seen this problem on the MK4 a couple of times after very long-duration dives. The problem is very stereotypic - one of the sensors will register a static reading while the other two are dynamic. (The MK-4 allows the diver to fix the problem with a simple blast of diluent.) When looking at the black box data, this problem is very obvious. Because of the high-resoultion recording of values, the black box records microfluctuations in PO2 that occur as the turblent flow of heterogenous breathing gas passes the sensors. On the few occassions when we've lost a sensor due to condensation on the membrane, the readings for that sensor in the black box go "flat-line" - i.e., static. In the case of the black box data on Ian's ring, the sensor readings were clearly "live" (and above 0.24 ATA) while he was at the surface. At one point during the dive, the depth abruptly increases, and the PO2 drops to 0.17 during the ensuing couple of minutes. These data strongly suggest that he went unconscious at the surface, when the PO2 was 0.24 ATA. At that point, the mouthpiece would have fallen out of his mouth, and the gas in the breathing loop would have vented, causing his abrupt descent to a depth of 9 feet, where he was found. Coinciding with this point in time, the readings of the three sensors simultaneously and steadily declined to 0.17, 0.17, and 0.19, where they remained for the duration of the recorded log data. This is consistent with what you would expect when the loop gas vented: the counterlungs would have collapsed, activating the automatic diluent addition valve, flushing heliox-14 through the loop. The PO2 of heliox-14 at a depth of 9 feet is 0.18 ATA. I'll let you read the full report yourself (sent by private email), and then if you still have questions, let me know.

Did the diver know the machine was overfirirng (due to inacurate sensor info) and choose this unexplained valve position just to go to far the opposite direction?

If the machine was overfiring, there would have been more O2 in the loop, reducing the probability of a hypoxic blackout. There is no evidence in the recorded sensor readings to support this hypothesis.

The fellow is dead, let's learn from it.

I agree completely. Let's look at the evidence without the hiderance of political bias. I will send the full report to anyone who asks for it, and let everyone judge for themselves. The only person that I have seen supporting the hypoxia explanation is George, and his only case is the "Liar, Liar, Pants on Fire." strategy. I don't know how to respond to that, other than the trusty "I know you are, but what am I?" retort. I'm not going to waste my time with that.

I can understand why George is very concerned with the perception of the truth in this case, for obvious reasons. I can imagine that you might be concerned with the perception of the truth as well, given that Cis-Lunar represents potential competition for the rebreather you are associated with. I am also a bit concerned with the perception of the truth myself, becasue Bill Stone is a friend of mine and I don't like to see him slandered (it doesn't bother me personally when George accuses me of lying, because I know that nobody on this list is naive enough to fall for that). However, unlike either you or George, I have a strong vested interest in the *actual* truth (regardless of what is perceived), because my life literally depends on it. For obvious reasons, I was very concerned about whether that report was accurate. After seeing the raw downloaded data from Ian's rig myself, and talking at length with Bill Stone, Noel Sloan, and Kenny Broad, I am still uncertain about the actual cause of Ian's death, but I am absolutely certain that it was not a result of a rebreather malfunction. You can draw your own conclusions for yourself.

Aloha, Rich


AP Valves Buddy Inspiration

4 confirmed deaths: Paul HaydenBob Forster, Nic Gotto, Keith Milburn
(Actually, there are 11 at the last report I heard, so this is woefully out of date and will require more research)

Case: Paul Hayden

Date: Tue, 02 Jun 1998 05:48:08 -0400
From: "Ian M. Irvine" kirvine@safari.net

Here is a message from Grogan in the UK. I have no comment on this, other than that I feel badly fro Martin Parker, since he is a nice guy.

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.


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


Date: Mon, 6 Jul 1998 10:13 +0100 (BST)
From: kweller@cix.co.uk (Kevin Weller)
Subject: Re: [Fwd: 20 K of bullshit - that is 10k per death, 5 k per accidents (that we

["Martin Parker" mjp@apvalves.avel.co.uk ]
He'd had his unit four weeks.

Whoah there. Paul bought his unit at the same time as he did his course which I thought was in February but you may be right about March. He may have had his *replacement* unit 4 weeks.

[Kevin later adds:]
Actually, that's not right either. He'd had the replacement for about 6 weeks so I've no idea where your 'four weeks' comes from.

If you remember, the first one kept breaking down (it started the first time he entered the pool with it when the computers flooded). It was sent back to be repaired, came back to Paul broken - the computers wouldn't turn off - he fixed it then it broke down again. He telephoned you for the car park at Stony Cove and you replaced it.

Paul also spent a lot of time in fresh water and shallow sea dives getting used to his unit.

Kevin Weller

kweller@cix.co.uk kweller@kalsys.demon.co.uk


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

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


Case: Bob Forster

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


Date: Mon, 27 Jul 1998 23:04:05 -0700
From: Patrick Duffy <pduffy@alaska.net>
Subject: Re: Rebreather Deathtrap?

Adriaan_Haine@cem.be wrote:
>
> 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. X:(
>
> --
> Send mail for the `techdiver' mailing list to `techdiver@aquanaut.com'.
> Send subscribe/unsubscribe requests to `techdiver-request@aquanaut.com'.


Case: Nic Gotto

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


Case: Keith Milburn

Date: Mon, 14 Sep 1998 11:38:22 -0400
From: Wrolf Courtney <wrolf@concentric.net>
Subject: Re: Which 2 rebreathers killed this week?

Katherine V. Irvine wrote:
> Here are your clues: both were in shallow water, one guy was revived,
> one guy died. Can you name these two rebreathers? Tom Mount , if you are
> on here, maybe you could win this contest with the correct answers?

Joseph Dituri wrote:
> >... , if you are
> > on here, maybe you could win this contest with the correct answers?
> Cut to the chase, who what when where and how??????
> JOE

I have one report from a very reliable source that Keith Milburn, age 44 from County Down in Northern Ireland went missing while diving with four friends. He was supposedly
using an Inspiration - this is yet to be confirmed. I also have no information yet about the dive profile, but going missing does not seem to match the shallow water revived vs. not revived profile referred to by George Irvine.

I have no idea whether he had had the A.P. Valves "top up" training.

As for a second thankfully non-fatal incident, that one will be news to me.

--
Wrolf


Date: Mon, 21 Sep 1998 13:30:33 -0400
From: Paul Elliott < >
Subject: News article regarding Keith Milburn's death

Here is an article that was faxed to us.
----------------------------------------------------
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."

--------------------------------------------------
Regards,


As a side note, BSAC did not actually ban the rebreather.  Steve Millard posted:


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


The only other potential information I have seen is the following post regarding failure to turn on the O2


From: "Jesse Armantrout" <armantrout@worldnet.att.net>
Subject: Re: News article regarding Keith Milburn's death
Date: Thu, 24 Sep 1998 14:15:33 -0500

How much more evidence (dead bodies) are we going to have to endure? Sure the latest fatality seems to be operator error, but then they all do. "The Rebreather was fine, the diver was dead" is the inspirations motto. But what a good machine would do would be to eliminate the odds of operator error.

For example, in the last case, the guy apparently did not turn on his oxygen. Is there a rebreather out there that this would not have been a problem for? Yes. Ok, then this is a machine flaw as well as an operator flaw. If the machine can be used with the oxygen supply off, that is a design flaw.

For what it is worth, the Atlantis has the same design flaw.

I know it is hard for you inspiration owners to accept, but if you guys won't deal with it, soon somebody else is going to do it for you.

Jess


Steam Machines PRISM Topaz

None yet.


CCR-2000/Aura (PADI endorsed)

One confirmed, and it was an active Rebreather list member.  This is the worst news I have heard in quite some time.

From: "Bruce Partridge" <bgpartri@istar.ca>
Subject: RE: Any news?
Date: Thu, 7 Jun 2001 09:04:51 -0700

Ghassem Gheissary died in France yesterday on a CCR 2000. I have heard
various versions of the accident, but none that completely explains what
happened. At this point it appears that he started the dive with a
malfunctioning unit.

Maybe the whole story will come out in the future, but at this point, I
don't think anyone over here knows what really happened.

Bruce Partridge

From: "Bruce Partridge" <bgpartri@istar.ca>
Subject: RE: Any News?
Date: Sat, 9 Jun 2001 12:31:02 -0700

I now believe that I know as much as we will ever know about what happened
to Ghassem. The pendant on another diver's CCR 2000 failed on the boat
before the dive. Ghassem gave his pendant to the other diver and started
the dive without a pendant. On the CCR 2000, there is only one display
unit. The backup computer maintains a PO2 of .7 if it is unable to
communicate with the pendant. Ghassem decided to rely on that backup
system to maintain PO2. He had no PO2 display.

After completing the dive, he experienced an oxygen convulsion as he started
his ascent or during the ascent. There are several possible reasons why the
system would not have maintained a PO2 of .7. It could have been manual
intervention to minimize deco, or problems with the solenoid. Ghassem was a
very skilled rebreather diver who had done a lot of practise with constant
loop volume maintenance of PO2, and other bailout scenarios. The CCR 2000
has two diluent tanks on a gas block, and a contantly enabled ADV. A common
way to control loop volume is to shut off one diluent, and switch to that
tank. Ghassem's diluent was turned off. I was shocked to hear that he had
successfully done dives without his pendant before.

PO2 maintenance by the backup computer was never intended for anything but
system failure bailout.

Ghassem was a very skilled diver who contributed a lot of knowledge to other
rebreather divers. His wife and infant daughter were on the boat at the
time of the accident. This is sad loss to the rebreather community.

Bruce Partridge

 


"Gator" ANDI international

None reported on the list, yet. (As I recall, offhand).  I have not yet heard of anybody owning one.


"Frog" Frog Rebreather SCUBA Diving Systems

Case: Ron Fuller

San Diego Union-Tribune Archive Document

Divers recover body off La Jolla | Victim was well-known in San Diego diving circles
San Diego Union-Tribune Archive Document


EX19

This post isn't much of a report, but is included for completeness.  Any more info would be appreciated.

Date: Tue, 18 Feb 1997 20:20:33 -0500 (EST)
From: DiveDeepSC@aol.com
Subject: Re: "Biomarine" rebreather

Roderick Farb wrote:
Two people have asked you questions about your post. One, what units did you see at DEMA were better than the BioMarine 500? and two, like Rich Pyle, I never heard of anyone dying during EX19 development much less several as you described. What's the story?

Yes I did see Mr. Pyle asking about deaths on the EX19. I'm afraid that my only answer to both of you is that I'm afraid that I cannot discuss any aspect of the EX19 development. I was, in fact, out of line bringing it into the discussion at all. Sorry I brought it up and sorry also that I cannot discuss it with you in detail.


Electrolung

Case: Three unnamed deaths, undetermined date

From: "Walter Starck" wstarck@ozemail.com.au
Subject: Reality Check
Date: Wed, 15 Jul 1998 11:09:19 +1000

Some answers about Robert's questions pertaining to the Electrolung. Over 100 units were sold. Some were used extensively for a number of years. I manufactured it for two years then sold it to Beckman. There were no deaths with the units built and sold by myself. I am aware of three deaths with units built and sold by Beckman.

One death was the result of a diver mistakenly valving in pure O2 at 200 FSW. He was new on the unit and apparently confused the manual O2 bypass for the inert gas valve despite the fact that the two valves were on opposite sides of the unit, required a different action to operate and access to the O2 valve required lifting a spring loaded cover to get at it.

Another death was through hypoxia. The diver forgot to turn on the solenoid power switch after calibrating the unit. He then ignored both visual readouts and the audible alarm, entered the water and failed to continue manual operation. The fact that he had been smoking dope just before deciding to make the dive may have been a contributing factor in the forgetfulness.

The third death was under circumstances where it was impossible to even hazard a guess as to probable cause. It is possible there were others but I have not heard of any. In terms of construction, design and reliability I suspect the Electrolung would stand up pretty well against any of the current units and it had several design features which I think were distinct advantages.

Walter Starck


At this point, I'd like to show some observations made on the list regarding the realities of making a rebreather when you make claims about death rates.


Walter Stark is the creator of the Electrolung, and was diving rebreathers before a lot of the current generation of divers were born.  His long experience in the industry gives a nice perspective of the realities in selling a rebreather.

From: "Walter Starck" wstarck@ozemail.com.au
Subject: Reality Check
Date: Wed, 15 Jul 1998 11:09:19 +1000

RMC raised the question of accidents due to poor purchasing decisions. I am not sure what this is about. If he is referring to the stupidity of buying any kind of rebreather then it would have to be 100%. If he means failures due to low grade components then the answer is none.

He also wonders about how to prevent a re-run and the possible effect of accidents on the RB community. Trying to tell yourself that it was all the fault of the Electrolung and it is different this time is like a second marriage, the triumph of hope over experience. In the last year the current generation of RB's have already ran up a higher body count than the Electrolung did in total. With respect to the Halcyon no matter how good it may be there are still numerous ways to kill yourself with it. Regardless of training, if any number of units are sold accidents will start to happen. The idea that superior design and training will prevent this is a fantasy which will last only so long as it is untested by reality. A handful of highly experienced technically oriented divers with elaborate backup and support making a successful series of long deep dives is not the reality of any economically viable marketplace.

The effect of accidents on the RB community will have one certain outcome and that is law suits. The further outcome will be economic inviability. The profit from the sale of a thousand units won't pay the cost of the law suits engendered and product liability insurance if available at all will add so much to unit cost they would be priced out of the market.

If not legislated out of existence altogether RB's will end up relegated to home builts and a tiny niche market of virtual cottage industry type companies each lasting until the first law suit.

Walter Starck


Date: Sat, 29 Mar 1997 00:10:28 -1000 (HST)
From: Richard Pyle deepreef@bishop.bishop.hawaii.org
Subject: Re: Panache

When I used to post regularly to the Techdiver email list, I had a little "motto" that went something like this (well...exactly like this):

*******************************************************************
"WHATEVER happens to you when you willingly go underwater is
COMPLETELY and ENTIRELY your own responsibility!
If you cannot accept this responsibility, stay out of the water!"
*******************************************************************

I think, if I'm not mistaken, this is sort of what's underlying Scott's personal ambitions to "test" his unit himself. I know it played a large role in my own approach to rebreather diving.

According to my philosophy, if a civilian gets killed while diving on a rebreather; no matter *WHAT* caused the accident, it's not the manufacturer's fault, it's not the test facility's fault, it's not the instructor's fault; it's COMPLETELY and ENTIRELY the unfortunate diver's fault. I know this sounds a bit extreme to some folk, but the bottom line is that we, as civilians, are *willingly* going under water. We humans are terrestrial, air-breathing mammals; we are simply not designed to operate in a subaquatic environment. We all know that, yet we insist on ignoring common sense and deliberately enter a realm that is particularly hostile to us. Because we do that under our own authority, it is entirely up to us to assume responsibility for the consequences, no matter what life-support system we choose.

Even if we ignore the issues of "fault" and "responsibility"; the person who loses most in a fatal accident is the deceased diver, followed closely by his/her family & friends. The point here is that it's our own lives that we're putting on the line, so we as the divers should be the ones most concerned about making sure we survive the dive in good health.

I don't care how deffective a rebreather is; if it fails in some way that leads to the death of a diver, it's the diver's fault for entrusting his/her life to that rebreather (incidentally, I don't believe "mechanical failure" is a valid cause of a fatality on a rebreather dive - it's almost always what I would categorize as "pilot error" -- but that's another thread).

Aloha,
Rich

Richard Pyle
Ichthyology, Bishop Museum
1525 Bernice St.
Honolulu, HI 96817-0916
PH: (808) 848-4115 / FAX: (808) 841-8968
email: deepreef@bishop.bishop.hawaii.org


Date: Wed, 17 Sep 1997 08:53:46 -1000 (HST)
From: Richard Pyle deepreef@bishop.bishop.hawaii.org
Subject: Re: Electron free diving

By the way - this concept [using depth changes to help get a known gas volume - ed.] is mostly academic, because the probability of loosing *ALL* electronics is likely much lower than the probability of not *noticing* a failure before it's too late. In other words, if you're good enough to live long enough after diving rebreathers enough to even encounter a full electronics loss, you're probably good enough to work it out on the deco one way or another.

I think you'd agree with me that the likely cause of death for most future rebreather divers will not be because the diver had a problem he/she couldn't solve, but rather because there was a problem that he/she didn't catch until it was too late.

Richard Pyle
Ichthyology, Bishop Museum
deepreef@bishop.bishop.hawaii.org
"The views are those of the sender and not of Bishop Museum"


This article was last updated: October 06, 2003