Kirby Morgan SL 17C partially detached from neck dam

Following investigation of the incident, the contractor involved concluded that, rather than the securing pins becoming displaced during the dive, in all probability they were not secured at the beginning of the dive and that fault lay with the checking and confirmation process rather than with the hardware.

Members are reminded that human errors cannot be eliminated and that robust checking, confirmation and supervising processes need to be in place to prevent these human errors becoming single point failures.

In particular it should be ensured that:

• The roles and responsibilities during any pre-dive ‘dressing in’ checks are clearly defined and all the personnel involved are clear regarding their individual roles and responsibilities.
  
  
• Dive supervisors give their full attention during the checks and, if necessary, temporarily suspend any parallel work to ensure the appropriate level of supervision is applied.
  
  
• Checklists are used ‘actively’ – that is, the person in charge (dive supervisor) reads out the appropriate checks, one at a time; the person carrying out the checks (diver/bellman/tender) completes the checks and confirms this back to the person in charge, also one at a time, who records that the check has been carried out.
  
  
• The diver who is being ‘dressed in’ should carry out a cross-check to help eliminate the potential for single point failure. In the specific case of the SL 17C, the diver can confirm by touch that the neck dam and yoke are in place and also that the pins are in the latched position (i.e. the pins cannot be rotated).