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 ]
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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 to take care of her, and had
him help set up everything to breathe O2 until the ambulance would arrive.
He breathed oxygen until his onboard O2 was empty, and his stage / bailout
O2 to 1700 psi by the time the ambulance arrived to pick him up.
(Throughout the dive an ordeal. There was no alarm or even 'sanity break' at
any time. The scrubber was okay. Mine was new, his had 54 minutes on prior
to the dive.)
(Tom's comment) I think it is important that he made a conscious decision
not to descend back to his stop in the water and Garrett was fully aware of
the problems with an explosive decompression, so it would lead one to think
other factors many be involved. He also had adequate OC gas to do a deco
procedure, had OC gas been needed.
Claudia: We had talked about situations like that before and had he been
able to, he would have resumed his deco after fixing whatever problem he
had. I did not like the idea of leaving him alone when we discussed it, but
understand that otherwise we both would have been killed, and he never
wanted that to happen. In a similar situation, knowing that we were close to
the boat ramp on a Saturday evening with many people around, I would have
expected for him to stay down as well. A hard decision I never wanted to
have to make.
At the hospital where he also commented about his dry suit and then fell
unconscious after 5 minutes, due to his condition (good ECG at first, but a
drop to 40 over 20) he was treated for a heart attack (while explosive DSC
is life threatening, it was secondary to the seriousness of the heart attack
in the judgment of the attending physicians, and it is difficult if not
impossible to fully address the heart condition while in a chamber) for 5
hours prior to being placed in the chamber. 20 minutes into the chamber
treatment Garrett arrested and died.
Tom: Garrett was a really good friend and his loss saddens me greatly. He
had a tremendous amount of time on the inspiration (460 hours plus) and was
the most active instructor we have had on the west coast. And maybe the most
active inspiration instructor in the USA. We have shared many dives, deep
dives and recently he and Claudia went on a Blue Hole trip with several
others and myself. He was extremely competent and safety orientated. In fact
during a training program when he was doing his IT and Martin was doing his
instructors and Vicki her diver rating on the inspiration we hammered out
sequencing. On the skills that are now taught in the IANTD Inspiration
course. So he has contributed very much to our training programs and to
rebreather diving safety overall.
Patti, IANTD and I wish for Garrett the happiest after life possible and
know his energy will always be with those he cared for.
>From everything from observations to the medical reaction and diagnosis at
he hospital it would have lead one to accept that Garrett had a heart
attack.
True without the complication of an explosive decompression he may have had
a higher probability of surviving.
BUT after his body was reviewed by the ME the following was found
Claudia: According to the examiner, no enzymes could be built within the
time frame of 5-6 'alive' hours that would let trace a heart attack, and
they were not found. The final report may be shared with me in about 6-8
weeks. This morning, two friends of ours, and students of Garrett's, Ken
Rymal and Dave Hancock, and I were explaining the gear to the examiners to
shed some light for them on the subject. We tested the unit in front of
them, and everything worked properly.
Garrett and I were to get married 5 July, and had many good plans for
training and service, and just going diving all over the place. After
talking to Leon that afternoon, we produced even more ideas while driving
from the lunch place up North to Mukilteo. Except for the harsh and unfair
end, it was one of, of not the happiest weekend we had ever spent.
Tom: questions that remain:
1. What caused Garret to make the decision not to solve the problem in water
(maybe due to physiological stress if fact he was having a physical problem
as thought by the doctors )
2. Why once on the surface he elected not to return to the stops after
dealing with any other problems (again suggesting there was something else
taking place)
3. Why was he not put in the chamber earlier, (as stated by the attending
Doctor a heart attack but according to the ME no evidence of a heart attack
So we may or may not discover the answers to these as well as what if any
role a problem with the dry suit may or may not have had on this accident.
We do know it was not CCR related. And it appears that there was a
physiological problem taking place that influenced Garrett to allow himself
to go to the surface and to elect not to return to decompression.
It is sad that he was not placed in the chamber immediately as that would
have definitely increased the probability of his survival of the
decompression issue. But the attending doctors (s) had to make a decision
based on what they perceived to be most life threatening.
So we are still left with many questions
We do know Garrett was extremely competent as a diver and highly experienced
on the inspiration
Respectfully
Claudia Milz and Tom Mount