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Date: Fri, 21 Jun 2002 12:34:28 -0500
From: Chuck Noe <chucknoe@ca*.co*>
To: techdiver@aquanaut.com,
     Houston Cave Divers , Quest@gu*.co*
Subject: Lessons Learned
Re: Jonathan Gol fatality.

On October 26 of 2001 a good friend of mine died while performing a
relatively simple dive at Jackson Blue Springs in Marianna. Following
this accident there was considerable speculation about the cause.
Outspoken individuals within the community were quick to (erroneously)
blame Jonathan’s death on medical conditions he had encountered months
prior to this dive. My attempts to set the record straight were met with
vile and determined efforts to dishonor both Jonathan and myself. Let
this post serve to set the record straight, and to assure that
Jonathan’s death wasn’t in vain.

Those close to the investigation of this accident have indicated all
along that Jonathan’s death can be attributed to his breathing 100%
helium from an improperly handled cylinder while at deco. This deco
bottle was recovered at the dive site with a loosened valve after having
been drained of its pressurized contents. The bottle was marked with
"MOD 20" on its side and its contents label (tape) was marked “100% HE,
500 PSI, 3-15-01”. The bottle was turned over to the Navy Experimental
Diving Unit by the Jackson County Sheriff’s Department for further
analysis.

The NEDU pulled a vacuum on this cylinder and analyzed the contents to
be consistent with having originally contained a very high percentage of
helium with little or no oxygen. Specifically, the percentages of gasses
found in the cylinder following its contamination with air (from the
loosened valve) were: 13% oxygen, 43% helium, and 44% nitrogen.
Obviously, no person intentionally conducts decompression with 100%
helium or even 13% oxygen. Additionally there is no other reasonable
explanation how a  small (aluminum 40) deco cylinder could end up
containing this percentage of gasses at ambient pressure.

It is most likely that Jonathan made the fatal mistake of transferring
500 psi of helium into an empty cylinder months prior to this dive with
the intention of adding oxygen at a later date. He failed to properly
analyze and identify the contents of this cylinder prior to the dive,
mistakenly believing that it was 500 psi of 100% oxygen. Breathing the
contents of this cylinder most likely caused Jonathan to lose
consciousness due to hypoxia. No significant medical problems were
discovered in his subsequent autopsy.

The low pressure of this cylinder was a topic of discussion among his
dive buddies prior to the dive and he chose to dive with the cylinder
due to the short expected length of dive. He was found with this
cylinder’s regulator deployed and out of his mouth.

Let this tragic accident be a constant reminder to everyone that there
is no substitution for the proper analysis and management of every gas
cylinder. No cylinder should ever be taken to a dive site without having
been properly analyzed and labeled. It is imperative that divers do not
become complacent in this process.

These facts were all presented to me by individuals present on the scene
of the accident and by members of Jonathan’s immediate family.
Subsequent accident analysis reports submitted to the IUCRR verify the
facts stated above and may be viewed at their website (
http://www.iucrr.org ). It is the purpose of this post to educate the
public about the facts surrounding this incident and to hopefully help
prevent a future tragedy such as this.

Respectfully,

Chuck Noe


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