CCR Incident (Feb 2013) – Double Cell Failure, Human Factors – Inquest Report


Totally excellent article on the dramatic influences human factors can have on our behavior… both in and out of the water.

Cognitas Incident Research & Management

CCR FatalityAn instructor was teaching two students an advanced trimix CCR class. Unfortunately due to two of the cells being current limited and the voting logic voting out the ‘good cell’, and the instructor being a victim to a number of powerful human factor biases, they had an oxygen toxicity seizure at depth. One of this buddies took the diver to the surface but never recovered.

This incident happened in February 2013 and was widely reported in the (social) media at the time, especially as it quickly became known that the diver was using cells which were 40 months old (cells 1 & 3) and 17 months old (cell 2) and a significant amount of negative criticism raised, primarily how could someone so experienced undertake such a ‘stupid’ activity, using cells well past their use-by date. Immediately afterwards, AP issued a warning about using out-of-date cells.

Unfortunately a number of technical and…

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