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  1. #1
    TDF Member Michael Smart's Avatar
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    The 1975 Oceaneering Accident

    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.
    Endnotes:
    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.
    Last edited by Michael Smart; 19-12-2013 at 10:30 PM.

  2. #2
    Prior Member Tim Digger's Avatar
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    This speaks towards standardisation of equipment and design of systems to prevent human error. But at the time sat diving was still in a learning phase of how best to do things. The real tragedy is when things are learnt and not applied soon enough resulting in more deaths. But it is also easy to add on more safety systems until the whole set up becomes unusable and safety devices are removed or alarms disregarded because "they always go off".
    Thanks for bringing these incidents from the past to this forum, I learn from them and hope others may.
    Evolution is great at solving problems. It's the methods that concern me.
    Tim Digger

  3. #3
    Chris Brown Tech
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    I can't believe there wasn't a dedicated gauge for a chamber in a saturation diving system!!!????

    I don't know which job sounds worse - surface supplied diver who has to breathe what he's given or dive supervisor where your mistakes may cost the lives of others!!
    http://www.chrisbrowntecnical.co.uk

    TDI Instructor Trainer. IANTD, SDI, TDI & PADI technical & CCR instruction

  4. #4
    TDF Member Michael Smart's Avatar
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    Quote Originally Posted by Tim Digger View Post
    This speaks towards standardisation of equipment and design of systems to prevent human error. But at the time sat diving was still in a learning phase of how best to do things. The real tragedy is when things are learnt and not applied soon enough resulting in more deaths. But it is also easy to add on more safety systems until the whole set up becomes unusable and safety devices are removed or alarms disregarded because "they always go off".
    Thanks for bringing these incidents from the past to this forum, I learn from them and hope others may.
    In my view there are two halves to a public health and safety system. On one side, are the actors: the people who run the equipment and take the risks. These are the divers, supervisors, life-support technicians etc. The other half is the regulatory arm whose duties include, among other things, enforcement of the law and prevention of repeat accidents. The job of both sides is to mitigate the danger to human life, to reduce it to an acceptable level (“so far as is reasonably practicable” is the legal phrase used).

    What annoys me about the Oceaneering accident is how the government inspector behaved following his investigation. He was confronted with a dual fatality and he recognized that human error was heavily involved in the accident, and he also saw that the diving system contained a defect which had to be addressed.

    At that time, diving inspectors had the legal power to stop any person from doing any act which, in the opinion of the inspector, may result in a casualty whether that danger was imminent or not.1 It wasn’t necessary for him to ascertain the cause of death, or prove that Oceaneering had violated any laws in order to come to the conclusion that a safety problem existed. All that was necessary for him to take action was the belief that the crew were in danger of serious personal injury. With two men lying dead on the floor of chamber one, it would have been reasonable and prudent for him to have intervened on the side of caution and shut the operation down until the cause of the accident could be established, then institute a conduct remedy before allowing the company to resume work.

    But the Commander did not stop the Oceaneering operation from continuing. Instead, he determined that the system was safe to dive and that it had no significant defects, which would have compelled him to interrupt the job. He simply told the company that, ”subject to the divers being happy to dive, they could carry on.”2 And so they did.

    1 The Offshore Installations (Inspectors and Casualties) Regulations 1973, section 2(g). In addition, Section 22 of The Health and Safety at Work etc. Act 1974.

    2 Holmes/Baldwin FAI, p. 431, 439.

  5. #5
    TDF Member Michael Smart's Avatar
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    Quote Originally Posted by Chris Brown View Post
    I don't know which job sounds worse - surface supplied diver who has to breathe what he's given or dive supervisor where your mistakes may cost the lives of others!!
    I know--the whole system sounds precarious. But the guys offshore were then, and are now, extremely professional, serious, and no-nonsense about their work. The last thing they want is a fatality to live with for the rest of their lives. This is why I have the deepest respect for the supervisors who send divers into the water. Every day they risk their future peace of mind to a possible accident.

  6. #6
    Prior Member Tim Digger's Avatar
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    Quote Originally Posted by Michael Smart View Post
    I know--the whole system sounds precarious. But the guys offshore were then, and are now, extremely professional, serious, and no-nonsense about their work. The last thing they want is a fatality to live with for the rest of their lives. This is why I have the deepest respect for the supervisors who send divers into the water. Every day they risk their future peace of mind to a possible accident.
    Makes me think of a song. Red Red Wine. (original and REM). I wonder how many ended up retired and on the booze. It is very hard for most people to live with a fatality you might of prevented. Hind sight is a dreadful ability/affliction.
    Evolution is great at solving problems. It's the methods that concern me.
    Tim Digger

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    A very interesting article.

  8. #8
    TDF Member Michael Smart's Avatar
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    Quote Originally Posted by Tim Digger View Post
    Makes me think of a song. Red Red Wine. (original and REM). I wonder how many ended up retired and on the booze. It is very hard for most people to live with a fatality you might of prevented. Hind sight is a dreadful ability/affliction.
    Agreed.

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    I am the widow of Roger Baldwin. I believe that some of your account of this horrific event is incorrect. Information on this was severely lacking which is why so many political hoops had to be gotten through before some, I repeat some, of the truth of what happened on that day came to light. Many of you may only be interested in the equipment side of this event, obviously I was interested in knowing the true facts which I am not sure if any of you would be interested in. However, human error was involved but the main culprit in this was greed

  10. #10
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    Quote Originally Posted by oilrigwidow View Post
    I am the widow of Roger Baldwin. I believe that some of your account of this horrific event is incorrect. Information on this was severely lacking which is why so many political hoops had to be gotten through before some, I repeat some, of the truth of what happened on that day came to light. Many of you may only be interested in the equipment side of this event, obviously I was interested in knowing the true facts which I am not sure if any of you would be interested in. However, human error was involved but the main culprit in this was greed

    this is so true in so many work fatalities.

    I think a great many would be interested in the true facts , however I am not sure this would be the best place to air them .

    I hope over 40 years on from the incident your anger, pain and grief is subsiding.


 

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