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From: "John Grogan" <john@ro*.co*.uk*>
To: "rebreather" <rebreather@nw*.co*>
Cc: "cavers" <cavers@ca*.co*>, "techdiver" <techdiver@aquanaut.com>
Subject: Inspiraion death - the facts
Date: Tue, 28 Jul 1998 10:04:13 +0100
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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. =20

Regards,
John Grogan.

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<BODY bgColor=3D#ffffff>
<DIV><FONT color=3D#000000><FONT size=3D3>The following are the events
=
that led to=20
the death of Nic Gotto whilst using the Buddy Inspiration rebreather=20
unit.</FONT></FONT><FONT size=3D3></FONT> </DIV>
<DIV><FONT color=3D#000000><FONT
size=3D3></FONT></FONT><FONT=20
size=3D3></FONT> </DIV>
<DIV><FONT color=3D#000000><FONT size=3D3>Nic ran Sundancer II
Charters =
out of Union=20
Hall in Cork (South coast of Ireland).  He was a very experienced =
diver and=20
skipper.  A number of weeks back, Nic purchased the Inspiration and =

attended a TDI weekend rebreather course.  I've been informed that =
the=20
practical aspects of this course consisted of a 1 hour pool session, a =
45 minute=20
dive and 1 change of scrubber sofnolime - this is on top of the usual =
lectures=20
and theory.</FONT></FONT><FONT size=3D3></FONT> </DIV>
<DIV><FONT color=3D#000000><FONT
size=3D3></FONT></FONT><FONT=20
size=3D3></FONT> </DIV>
<DIV><FONT size=3D3>On Saturday, Nic and 3 other divers went to the =
wreck of the=20
Kowloon Bridge (second largest wreck in the world).  Nic was with a =
buddy=20
and the other 2 dived together.  I do not know if Nic's buddy was =
using an=20
Inspiration or OC.  Whilst diving at a depth of 10m (ppO2 1.3 bar), =
Nic=20
encountered a down-draught that almost immediately swept him to 25m =
(assuming=20
same fraction of oxygen ppO2 2.3 bar).  An oxygen toxicity hit=20
occured.  (I can only assume that the unit did not respond to the =
increased=20
ppO2 in time and that Nic expended a lot of effort getting out of the=20
down-draught).  His buddy tried to assist and in the struggle lost =
his=20
weight belt and mask.  Buddy came to the surface, alerted the dive =
boat and=20
was given another mask.  He pulled his way down the shotline and =
found the=20
other 2 divers.  The situation was indicated to them and they =
commenced a=20
search.</FONT></DIV>
<DIV><FONT size=3D3></FONT> </DIV>
<DIV><FONT size=3D3>Nic's body was found and a rescue commenced.  =
At about=20
20m, Nic inverted in his drysuit and at about 14m contact was lost with =
him but=20
he went to the surface.  At the surface, these divers cut him out =
of the=20
harness.  As they knew nothing about rebreathers, they didn't close =
the=20
loop.  Subsequently, the loop flooded and the unit sank back down =
to the=20
seabed.  Nic was pulled onto the boat and blood was found foaming =
in this=20
mouth.  Boat crew immediately commenced AV and CPR for 45 minutes =
at which=20
point the lifeboat arrived.  Nic was declared DOA.</FONT></DIV>
<DIV><FONT size=3D3></FONT> </DIV>
<DIV>Army and civilian divers and currently searching for the unit that =
Nic was=20
diving.  I sincerely hope that no-one tries to pin the blame on any =
of the=20
3 divers in the water at the time.  They made a vallient attempt to =
save=20
Nic, but unfortunately it was stacked against them.</DIV>
<DIV> </DIV>
<DIV><FONT size=3D3>To date there have been 3 fatalities and 2 =
resuscitations with=20
Inspiration divers.  There have been about 120 units sent out and =
about 250=20
people trained on the unit.  That's 5 serious/fatal incidents for =
120 units=20
(4%).  There has been in the UK what I can only describe as a =
conspiracy of=20
silence regarding the Inspiration and more particularly the indicents=20
encountered.  I spoke to one diver yesterday who owns 2 units - he =
is=20
fuming at the lack of information forthcoming and refuses to use either =
unit=20
until there is more openness on it's failures and proper =
training.</FONT></DIV>
<DIV><FONT size=3D3></FONT> </DIV>
<DIV><FONT size=3D2><FONT size=3D3>David Shimell posted earlier on
this =
and pointed=20
out 3 main causes for the incidents:</FONT></FONT></DIV>
<DIV><FONT size=3D2></FONT> </DIV>
<DIV>>1. Equipment design or failure.<BR>>2. Poor =
training.<BR>>3. Poor=20
vetting of candidates for training. </DIV>
<DIV> </DIV>
<DIV>I think 1 & 2 apply.  Certainly 2 of the deaths and 1 of =
the=20
resuscitations were very experienced divers.  Why do some agencies =
seem to=20
think that a 2 day course can impart all the information required to =
safely dive=20
a rebreather?  The Navy spends months training their divers on a=20
unit!</DIV>
<DIV> </DIV>
<DIV>I am sure there will be a full police investigation into this =
matter and as=20
I receive more information, I will post it to the list.  </DIV>
<DIV> </DIV>
<DIV>Regards,</DIV>
<DIV><FONT color=3D#000000 face=3D"" size=3D3>John =
Grogan.</FONT></DIV></BODY></HTML>

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