Source · Prevention of Future Deaths

Stephen O’Malley

Ref: 2015-0363 Date: 14 Sep 2015 Coroner: Andre Rebello Area: Liverpool & Wirral Responses identified: 2 / 1 View PDF

Rescue was delayed due to the standby diver being unable to locate a critical harness c-clip, as pre-dive protocol checks do not include verifying its accessibility.

Date 14 Sep 2015

56-day deadline 9 Nov 2015 est.

Responses identified 2 of 1

Accident at Work and Health and Safety related deaths

Coroner's concerns

AI summary

Rescue was delayed due to the standby diver being unable to locate a critical harness c-clip, as pre-dive protocol checks do not include verifying its accessibility.

View full coroner's concerns

The court has been advised that rescue of Mr O’Malley from the sea was delayed because the standby diver could not locate the c-clip on the back of his harness which was to facilitate hoisting him from the water. The Court has heard that checking this c-clip is free and accessible is not part of the standard checks before a dive. Should such a check be part of the pre-dive protocol checks?

Responses

2 respondents

Sub C

PDF

Noted

SubC Partner refers to Danish authority findings, states it performs pre-dive checks according to standards and customer approval, and uses certified personnel. (AI summary)

View full response

Sub € Coroners Office Att : Andre J.A. Rebello Dato: 24. november 2015 File: C:|UsersIta|DesktoplDIVERIAnswer to Coroners office regulation 28 response docx Answer to regulation 28 request SubC Partner has no comments to the Coroner's office findings towards the cause of death, but refer to the Danish authority' s findings in this matter: Besides this, it is important for us to state that: We perform pre-dive checks before any diving projects, and these pre-dive checks are according to standards and customer approval. Check of c-clip (in our checklists defined as Harness straps) has been performed in the pre-dive check on the actual project. That all equipment is maintained, certified and approved before start of a project That we of course use the labor and rescue setup required by law and customer for each project: Danish maritime authorities (Sofartsstyrelsen) and customer, before any project start; approves SubC Partner setup, including equipment, checklists and rescue and emergency procedures. We can document the above mentioned 4 points have also been implemented and used during the actual project: That we only use certified and experienced personnel, all experienced in the use of diving equipment; and aware of the fact that they all approve the equipment (including the neck dam ring) before they g0 into water Regarding the concern of the c-clip we can state that: Our equipment and pre dive checklist is according to IMCA Guidelines and local requirements, which vary from each country. The check of c-clip (in our checklists defined as Harness Straps) was at the time as it is today, a part of the pre-dive check: Our current suits have both frontside and backside Harness straps. The hoist of the diver car be performed from both straps, depending on which one in the current case is easierto access Rejgards SubC Partner A/S Side 1 af 1 make offshore worko SubC Partner A/S Kogade 1A DK-6700 Esbjerg Tel: +45 7023 2122 WWW: subcpartner.com CVR No.: 28702612 Bank: Danske Bank 4394 0011319130 SWIFT: DABADKKK IBAN: DK9630000011319130 NS diving diving diving

Sub C Pre Dive Checklist

PDF

Noted

The response appears to be a pre-dive checklist form. (AI summary)

View full response

Sub C PARTNER Pre-Dive Checklist Project Number: Location: Supervisor: Date: 813 Ivz Mrt ALL BOXES ARE TO BE INITIALLED OR SIGNED BY SUPERVISOR DO NOT TICK BOXES Description Dive ? 12 Dive 2 Dive 3 Dive 4 Diver Diver Diver S'By Diver Vessel locked out and per- mission to dive given: Systems electrical check Compressor-LP Air Supply On Back Up HP Air Supply On Emergency Air Supply (Bar) 140 40 Comms Check Bail Out Pressure (Bar) 210 70 Off at Hat On at Bottle 10 Knife 11 Hat Locked on 12 Harness Straps 13 Flag Alpha Displayed 14 Hot Water Supply (If Appli- cable) 15 Diver Ready For Water General Remarks: z: Ildiving proceduresld 041 pre-dive check sheet doc Hands on energy SBy S'By S'By

Report sections

Investigation and inquest

On 23rd May 2012 I commenced an investigation into the death of Stephen Owen O'MALLEY Aged 48. The investigation commenced on the 23rd May 2012 and was concluded on the 14th September 2015.

Circumstances of the death

On Thursday, 3rd May 2012, Stephen Owen OMALLEY was working as a contracted commercial diver for Sub C Partners, based in Denmark. He was working in the North Sea on the Alpha Ventus offshore wind farm, some 45km North of Borkum, Northern Germany. He had been replacing bolts on the wind farm turbines. The vessel was approximately 25m away from the turbine he was working on. He was wearing a full diving suit, with a Kirby Morgan 27 watertight helmet, with an umbilical air supply of plain compressed air supplied by the surface vessel. The air is supplied directly into the helmet at face height and he also had reserve air supply in the tanks on his back. At approx. 3:32pm, he entered the water and began pulling himself along a guide rope towards the wind turbine structure. He was working at a depth of approximately 2m. Whilst making his way along the rope, he was observed to experience breathing difficulties. He complained that his neck dam was too tight and it was restricting his breathing. He was instructed to make his way back to the vessel which he did, unaided. It was not appreciated as to the extent of his distress and difficulties until a short time after arriving back at the ladder, he became unresponsive. A rescue diver entered the water and after initially not being able to locate the C-clip on the back of his harness Mr O’Malley was eventually hooked onto a winch and taken aboard the vessel where attempts at resuscitation were commenced for approximately one hour before a doctor was flown out and confirmed he had sadly died. It is found on the balance of probabilities that Mr O’Malley has suffered a cardiac arrest as a result of hypoxia caused by his respiratory function being impaired by him hyperventilating as a result of difficulty in breathing from the compression on his neck from the neck dam ring. There is no evidence of any previously undiagnosed cardiomyopathy having any role in his death.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2015-0363
Date of report: 14 September 2015
Coroner: Andre Rebello
Coroner area: Liverpool & Wirral

Responses identified

Responses identified 2 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Nov 2015 (estimated).

Sent to

SubCPartner

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.