-
What happened?
Before diving operations started, submersible diving chamber (SDC) full checks were completed by a diver new to the system, assisted by a diver familiar with the arrangements.
After the internal valve status and function, electrical and equipment checks were completed, the dive supervisor instructed the bellman to secure the gases due to a 2-hour delay.
Diver 1 locked out of the SDC and started to prepare another diver’s umbilical, when his gas became tight.
Diver 1 informed the dive supervisor that he is switching to bailout.
Dive supervisor informed divers in the SDC of the situation and asked them to check diver’s 1 surface gas supply.
By the time diver 1 reached the SDC, the bellman had opened the diver’s supply and onboard gas hull valves (providing the diver with surface gas again).
On confirmation of the diver’s primary and secondary gases being online, diver 1 locked out again.
-
Why did it happen?
Internal valves were not returned to their operational position as per the diving checklist.
Procedure used (securing internal valves when SDC launch is delayed) was outdated and no longer considered good practice. It was not included on any checklist, which meant the bellman would have to remember to put the gas back online before the divers lock out.
Checklist was invalidated as the status of equipment (valve) was modified after all checks were completed.
Deviation from normal procedure should have been captured in the diving supervisor’s log or handover and the checklist should have been repeated.
-
What did they learn?
If gas supplies are secured, a complete SDC internal valve check should be performed to confirm the status of all valves before diving operations.
Checklists and procedures are critical for safe operations and should be followed by all personnel. Safety critical checklists can only be effective if used at the correct stage in the process.
Any deviations from procedures and processes should be managed and communicated.
- If a deviation becomes standard, checklists should be reviewed and updated accordingly.
All workers should be trained on the importance of following procedures, using checklists, providing feedback on procedures, and using the management of change process for all deviations.
-
Ask yourself or your crew
What could they have done differently to prevent this near miss?
What checklists do you complete before beginning a dive?
Should you check your equipment after it has been looked at / serviced by other workers? Why?
What other factors could result in gas becoming tight during diving?
What other hazards should you look out for before or during diving operations?
Add to homescreen
Content name
Select existing category:
Content name
New collection
Edit collection
What happened?
Before diving operations started, submersible diving chamber (SDC) full checks were completed by a diver new to the system, assisted by a diver familiar with the arrangements.
After the internal valve status and function, electrical and equipment checks were completed, the dive supervisor instructed the bellman to secure the gases due to a 2-hour delay.
Diver 1 locked out of the SDC and started to prepare another diver’s umbilical, when his gas became tight.
Diver 1 informed the dive supervisor that he is switching to bailout.
Dive supervisor informed divers in the SDC of the situation and asked them to check diver’s 1 surface gas supply.
By the time diver 1 reached the SDC, the bellman had opened the diver’s supply and onboard gas hull valves (providing the diver with surface gas again).
On confirmation of the diver’s primary and secondary gases being online, diver 1 locked out again.
Why did it happen?
Internal valves were not returned to their operational position as per the diving checklist.
Procedure used (securing internal valves when SDC launch is delayed) was outdated and no longer considered good practice. It was not included on any checklist, which meant the bellman would have to remember to put the gas back online before the divers lock out.
Checklist was invalidated as the status of equipment (valve) was modified after all checks were completed.
Deviation from normal procedure should have been captured in the diving supervisor’s log or handover and the checklist should have been repeated.
What did they learn?
If gas supplies are secured, a complete SDC internal valve check should be performed to confirm the status of all valves before diving operations.
Checklists and procedures are critical for safe operations and should be followed by all personnel. Safety critical checklists can only be effective if used at the correct stage in the process.
Any deviations from procedures and processes should be managed and communicated.
- If a deviation becomes standard, checklists should be reviewed and updated accordingly.
All workers should be trained on the importance of following procedures, using checklists, providing feedback on procedures, and using the management of change process for all deviations.
Ask yourself or your crew
What could they have done differently to prevent this near miss?
What checklists do you complete before beginning a dive?
Should you check your equipment after it has been looked at / serviced by other workers? Why?
What other factors could result in gas becoming tight during diving?
What other hazards should you look out for before or during diving operations?
After a diver had his gas supply checked, the gases were secured. However, they were not returned to operational position before the diver recommenced their duties, so the surface gas became tight.
