UK MAIB issues Jean Elaine Accident Investigation Report

Investigation of the death after a fall on board MV Jean Elaine on August 2012

Jean Elaine (Image Credit: UK MAIBREPORT NO 25/2013)

The UK MAIB has issued investigation report on the death of a recreational diver after a fall on board MV jean Elaine 15nm NW of Cape Wrath,UK on August 14, 2012.

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At 1607 (UTC+1) on 14 August 2012, Mr Lex Warner, an experienced recreational diver, fell onto the deck of the dive workboat Jean Elaine.When he fell, Lex was fully dressed and prepared for diving to a depth of 95m; he was wearing heavy equipment on his back and had additional diving gear attached to his front and sides. Although it was not immediately apparent, it was likely that the diving gear impacted into Lex’s abdomen during the fall and caused significant internal injuries.

Having been helped back to his feet by the boat’s crew, Lex made a positive indication that he wished to continue with the dive and he entered the water unaided. At a depth of 88m, Lex started an unplanned return to the surface. He lost control of his breathing and buoyancy shortly afterwards. Three of his fellow diversattempted to increase his buoyancy and administer breathing gases; however, Lex did not start breathing again. He was attached to a lifting bag and ascended to the surface from a depth of 65m. Despite further medical treatment on board Jean Elaine and by the emergency services, he could not be revived and was pronounced dead later that evening.

The MAIB investigation found that:

There was a significant risk to divers of tripping and falling when attempting to walk on the deck of a workboat in open sea while fully dressed and equipped for deep technical’ diving.
The effects of wearing a large amount of heavy diving equipment can significantly exacerbate theresults of what might otherwise be considered a relatively minor fall.
While other incidents underwater have not been considered, it is plausible that Lex Warner started his unplanned ascent, which led to his death, because he felt unwell as a result of internal injuries suffered during a pre-dive fall.
Although the skipper was aware of the demands of his working environment, there was no evidence of a formal assessment of the risks to a fully-dressed diver moving from his seated preparation area, to the point of entry into the water.
As a result of this investigation, two safety recommendations have been made to improve the arrangements for recreational divers when operating from workboats.

CONCLUSIONS

When fully prepared for diving, Lex Warner fell heavily onto the deck of the dive workboat, Jean Elaine. The fall almost certainly caused him to sustain serious internal injuries.
The effects of wearing a large amount of heavy diving equipment can significantly exacerbate the results of what might otherwise be considered a relatively minor fall.
It is entirely plausible that Lex Warner started his unplanned ascent because he felt unwell as a result of internal injuries he suffered during the fall.
Despite their efforts underwater, Lex Warner’s fellow divers were unable to assist him effectively when he was seen to be struggling with his breathing and buoyancy.
Jean Elaine was well suited to its operating environment and compliant with guidance for small, passenger-carrying workboats.
Although the skipper was aware of the demands of his working environment, there was no evidence of a formal assessment of the risks to a fully-dressed diver moving from his seated preparation area, to the point of entry into the water.
Due to the widely variable nature of employment of small commercial vessels, regulations for them and training for their crews are necessarily generic and do not focus on the specific issues involved in
operating a recreational diving workboat

Read the UK MAIB Investigation Report No 25/2013 here