In May 1996, I traveled to Aberdeen to gather information about the 1979 Wildrake accident. One of my primary targets was the Sheriff Clerk’s Office on Castle Street. I knew there was an archive inside with records of diving fatalities. Having previously recovered the Wildrake Fatal Accident Inquiry transcript by post, I was now interested in acquiring any transcript, of any other diving inquiry, that the Sheriff Clerk’s Office had in its possession. One week later I came away with the records of eleven more cases. Among them was the 1975 dual fatality of Oceaneering divers Peter Henry Michael Holmesa and Roger Baldwin. Their deaths were originally recounted in the first draft of my book, but for reasons of space I reluctantly removed their story from the narrative.
It is rare to find an investigative record—produced by a Court of Law—that delves into the death of a commercial diver. It is even rarer still to find Court documents that contain enough detail to wipe away the mystery of how the diver actually met his death. That Holmes and Baldwin’s story remains locked up in an archive, where industry eyes are unable to learn from their tragic end, seems terribly wrong to me. It’s almost as though their deaths have been banished to obscurity.
But their case is significant because it demonstrates how the lack of a small thing can lead to devastating results. For those of you who work in parts of the world where saturation systems are sometimes “economized,” I offer the following account to mark Holmes and Baldwin’s place in history, and to serve as a potential antidote to the consequences of not taking care of business. — MS
The 1975 Oceaneering Accident
On the afternoon of September 10, 1975, a diving inspector from the Department of Energy was flown out to an oil rig called the Waage Drill II, operating near the Bruce Field about 200 miles northeast of Aberdeen. The inspector, a former Royal Navy Commander, was there to investigate a dual fatality, which had claimed the lives of two Oceaneering divers the previous day. After the chopper touched down he made his way to the saturation complex where he found the company Safety Officer and a doctor already on the scene. When the inspector looked through one of the portholes of the chamber, he saw two men crumpled on the floor of the main chamber.1 During the course of his investigation he reviewed the dive log, accepted hand‑written notes of the incident produced by the supervisor,2 and questioned members of the crew who gave one of the most bizarre and disturbing accounts of how the men had died—not from the obvious dangers of hypothermia, but ironically from the lethal effects of heatstroke.
Sixteen hours earlier, divers Peter Holmes, 29, and Roger Baldwin, 24, had been hoisted from the North Sea in a bell and connected to the system’s entrance lock. The men had just completed a short dive to 390 feet to clear a tangle of rope that had wrapped itself around the guideposts of the Blow Out Preventer.3 The dive had gone well and now the plan was to decompress the men inside the bell to 310 feet, then transfer them into the chamber complex and hold them in saturation.
As with all deep-dive systems, each chamber on the supervisor’s control panel was represented by a series of valves and gauges. Redundancy in plumbing schemes was common and necessary, and with this particular system, by turning several valves on the console, any one depth gauge could be made to monitor the depth of a chamber other than for which it was normally intended.4
On chamber one’s panel, there was a 1000‑foot Heise gauge considered to be the most accurate. And because of the cross-referencing capabilities of the system, it became the practice of the shift supervisor to set the valves of this gauge to read the internal depth of the bell prior to the divers leaving bottom, then track their ascent through the lock‑on/transfer procedure. The rationale behind using this particular gauge throughout the operation was to avoid any potential decompression problems that might arise from using two separate gauges with a discrepancy problem.5 Once the divers had safely passed from the bell to the entrance lock to chamber one, the supervisor was then supposed to turn the valves back to their original positions in order to monitor the depth of the divers.
At 9:50 that evening, the crew mated the bell to the entrance lock as planned,6 but during the lock‑on procedure a gas leak developed between the mating flanges.7 The bell was removed, the flange surfaces were cleaned, and on the second attempt the bell was successfully sealed to the system. After Holmes and Baldwin equalized the bell with the rest of the complex, they opened the inside door and were in the process of transferring into the entrance lock when the gas leak suddenly returned.
With the needle on the Heise gauge dropping, an attempt was made to isolate the divers from the leak by sealing the door of the entrance lock that led to the bell, but according to the dive log this effort was “abandoned.”8
To protect Holmes and Baldwin from further pressure loss, the supervisor ordered them to climb into chamber one. There, they leaned against the inside hatch while the supervisor injected a small amount of helium inside the chamber to seal the door. At this point—perhaps due to the distractions of the emergency—the supervisor made the kind of nightmarish mistake that all supervisors who bear such enormous responsibilities fear; he forgot to reset the valves to reconnect the Heise gauge with chamber one.9 And because chamber one was not equipped with a dedicated depth gauge, Holmes and Baldwin were now in a part of the system not being monitored by any gauge at all.b
Meanwhile, the Heise gauge was still recording a pressure drop, which the supervisor erroneously believed was reading chamber one. Had he glanced down at his console and examined the telltale positions of the valve handles, he would have instantly realized that his divers were safe and that the Heise gauge was merely reading the continuing bell/entrance lock gas leak. But the supervisor thought that he had failed to achieve a seal on chamber one’s hatch, and so he began to feed large quantities of pure helium into the chamber where the two divers were stationed.10
By the time he realized his error, Holmes and Baldwin had been pressurized from 310 feet to 650 feet over the course of several minutes.11 The rapid compression, combined with the high thermal transfer property of helium, plus the high humidity factor of the atmosphere, turned the chamber into an oven, sending the temperature of the atmosphere soaring from an estimated 90 degrees F to 120.12 Frantic, the two divers began pulling desperately on the chamber hatch to escape the inferno, but nothing they could do would budge the door. The only minimal relief they received was to take the mattresses off their bunks and lie spread-eagled on the somewhat cooler aluminum surfaces.13 With no place to flee to, and forced to breathe an intolerable atmosphere, the men died several hours later of hyperthermia.
It was later pointed out by the presiding judge at the Fatal Accident Inquiry that, the way in which the diving system was designed and labeled, “especially as operated by Oceaneering, carried a high risk of human error, particularly during the distractions of an emergency.”14 Oceaneering’s Safety Officer testified that the manner in which the control panel was plumbed “was a contributory cause” of the accident, and that it probably would not have happened had the panel for chamber one been equipped with a dedicated depth gauge permanently fixed for the purpose of reading only that chamber.15 Had there been such a gauge, then the supervisor would not have been misled by the Heise gauge, and therefore would not have had any reason to inject the chamber with massive amounts of helium.16
a) Not to be confused with the Peter Holmes of the Wildrake tragedy.
b) Testimony at the Fatal Accident Inquiry revealed that the entrance lock depth gauge was turned off to avoid the confusion of getting different gauge readings. Source: Holmes/Baldwin FAI Transcript p. 367-368.
1 Holmes/Baldwin FAI (Fatal Accident Inquiry), p. 281.
2 Holmes/Baldwin FAI, p. 283.
3 Holmes/Baldwin FAI, p. 155.
4 Holmes/Baldwin FAI, p. 17, 309.
5 Holmes/Baldwin FAI, p. 16, 18, 302-303, 435.
6 Holmes/Baldwin FAI, p. 70.
7 Holmes/Baldwin FAI, p. 234.
8 Holmes/Baldwin FAI, p. 70-71.
9 Holmes/Baldwin FAI, p. 313.
10 Holmes/Baldwin FAI, p. 73.
11 Holmes/Baldwin FAI, p. 65; Sheriff Principal Gimson, Determinations of the Holmes/Baldwin FAI, p. 2‑3.
12 Holmes/Baldwin FAI, p. 234, 318.
13 Holmes/Baldwin FAI, p. 171.
14 Sheriff Principal Gimson, Determinations of the Holmes/Baldwin FAI, p. 4.
15 Holmes/Baldwin FAI, p. 316-317.
16 Holmes/Baldwin FAI, p. 317.