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Date: Tue, 19 May 1998 11:36:47 -0400
From: Bill Mee <wwm@sa*.ne*>
To: cavers@ca*.co*
CC: techdiver@aquanaut.com
Subject: CAUSE OF DEATH?
We just talked to the coroner investigating the death of Jane
Orenstein.  Jane, as you may recall, perished recently during a socalled
"technical training" dive when her  IANTD instructor, Derek McNulty,
chose not to attempt a rescue as she drifted to bottom in 270fsw,
following an apparent loss of consciousness. Jane was carrying two deco
stage bottles.  According to the coroner one bottle contained 3300 psi
of EANX 35 and the other bottle contained 1900 psi of EANX 80. Based on
the time the divers were on deco as well as the neatly parked state of
the regulator on the EANX 35 bottle, observed by George Irvine, Robert
Carmichael and Dan Volker  on initial discovery, the 80/20 bottle, more
than likely, had been the one breathed. The bottles were unmarked with
either MOD or gas analysis at the time of her post mortem recovery. 

Based on these facts it seems clear that Jane probably breathed the
80/20 mix during the deep phase of her decompression. This problem,
possibly aggravated by CO2 buildup from breathing through the dead space
of a dive communicator, may have caused her to tox or lose
consciousness.  No one would dispute that breathing of the 80/20 mix at
the 130fsw deco stop is extremely dangerous if not potentially fatal
(ppo2 of approx 4.0).

Essentially, what we have here is a death, which may have directly
resulted from the unambiguous negligence of inadequate to nonexistent
bottle marking procedures.  We have repeatedly advised and argued ad
infinitum with IANTD over the issue of stage bottle marking. The WKPP
utilizes the only proven correct and acceptable method of bottle
marking. This involves stenciling of the MOD (maximum operating depth)
in large block letters (visible at least 20ft away) on the lower right
and left side of the bottle so that this depth marking is clearly
visible both to the diver and his or her team members. Additionally, all
gas bottles must have the dated analysis securely affixed to the bottle,
otherwise the gas cannot be used.  No other method is acceptable and the
track record of the WKPP in multi-team mixed gas long range, extreme
exposure decompression dives, indisputably validates this methodology. 
Certainly, in the sad case of Jane Orenstein, these warnings were either
flagrantly ignored or worse, the instructor was unaware of the life or
death significance of this procedure

Correct bottle marking procedures are the safety cornerstone of all
mixed gas technical diving. We know this and just about everyone else
out there knows this, or should know it. All of you are aware of those
who are now not with us as a result of improper gas characterization.  
This cannot go on any longer, yet we continue to witness absolutely
negligent behavior in regard to this most basic process.  Recently,
during our efforts in the West Palm Beach recovery attempt we observed a
dive operation loading nitrox bottles which were either unmarked or
spuriously designated. When this type of standards violation occurs the
most punitive measures must be taken against the offenders.  At a
minimum, an operation even suspected of such transgressions, should be
stripped of its franchise and the instructors expelled from the
organization with extreme prejudice.  If discovery and due process are
an issue, immediate and conditional suspensions should be executed
pending completion of the formal inquiries.
--
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