OPITO SAFETY NOTE

SYNOPSIS
In March 2017 an incident occurred during a FOET Course at an OPITO Approved Training
Provider. A 57 year old delegate presented his medical report on Registration. The Report
was issued by and Authorised and Approved Medical Examiner. His Report highlighted
Hypertension and Diabetes Mellitus.
It is a Standard Procedure at the Training Centre to examine verbally and take the BP of all
delegates over 50 years of age and all delegates who have notations of their Medicals of
Hypertension, Respiration problems (Asthma) or obesity. The delegate was examined by the
Training Centre State registered Nurse and his BP was in the low to normal range. (These are
all recorded in a Medical Log)
In the afternoon session the delegate carried out the EBS dry and wet training. After the
Underwater Module 5, which is to activate the EBS and pull along a bar, submerged at a
depth of 2ft and 6inches, for 20 feet – which he completed with no apparent problem. He
then asked the Instructor if he could rest before undertaking the next module. In
accordance with SOPs this was permitted and he was assisted in leaving the pool. The two
medics (both registered nurses with ACLS), took him to be seated and to check him over.
The delegate can be seen (HD video of the training is captured for all exercises), talking to
his fellow delegates, removing his transit suit and resting for a further 10 minutes with the
Medics in constant attendance.
The delegate then stated he was an asthmatic and had not brought his inhaler. (There was
no mention by the Delegate or notation on the AME report about Asthma)The delegate was
then isolated and put on 97% O2, but then displayed signs of cardio arrest, CPR and
Defibrillation was applied, “no shock” was advised, the delegate was then sent to the
nearest hospital, despite further resuscitation attempts, the delegate did not recover.
Cause of Death: Cardio Pulmonary Odema.

ACTION TAKEN
A full HSE Investigation was carried out under the direction of the National Authority.
QUOTE FROM FINAL REPORT
On review of the video footage it was noted that during the course of training the delegate
was clearly visible and participating in full capacity. He did not seem to have any difficulty
during the training. The video showed that there was no apparent training exposure which
could have significantly contributed to the cause of death. The delegate exited the pool
normally, he was relatively well, speaking (to his crew) and walking about on his own before
his condition suddenly deteriorated.

REPORT CONCLUDES
The Incident is classified as a “ Non Accidental Death due to an illness”. The delegate had
passed his fitness to work offshore evaluation. The training related activity is unlikely to
have contributed to the cause of death.

ACTION TAKEN
 Training centres to remind and ensure that delegates declare any medical or physical
condition that may be aggravated by exertion – this to be done during registration
and to advise their Instructor immediately if they feel unwell or suffer abnormal
stress.
 Where any doubt exists regarding the fitness of any delegate, medical staff should
consult the Centre’s appointed Doctor for advice or where possible, the AME Doctor
who signed the medical report
 The Training Centre maintains the right to refuse to accept any delegate for training
where there is any doubt concerning their medical fitness.
 Self- Assessment medical declarations are no longer accepted. AME Certification is
required.
 The Registered Nurse is to be in attendance with delegates whilst undergoing ‘stress
training’ ie HUET and Sea Survival.
 Constant monitoring of delegates with abnormal BP is to be undertaken and logged.

LESSONS LEARNED
Where doubt exists with the AME Report, ensure that it is discussed with the delegate and
the Medical Centre.
Always constantly assess and monitor delegates who are hypertensive or display related
medical issues on testing. Stop their training immediately if elevated levels appear.
Ensure continuous training of DFA is carried out by the Registered Medics to ensure that
correct procedures are followed.
MER drills must include the call out of the Ambulance Service to assess the time delay and
timing from the Training Centre to the designated Emergency hospital.
A telephone number directly to the National Oil and Gas Authority should be available to
enable defensive PR statement to be issued at senior level.

SUMMARY
Even with excellent medical cover, the rapid onset of cardio arrest and cardio pulmonary
odema cannot be foreseen by Training Centres. It is in a scenario where the delegate dies
within minutes even when in the Emergency Theatre of a Hospital.
High definition video coverage of all training is essential in clarifying Accidental and Non
Accidental Emergencies. In this incident the video made the investigation by HSE easier as
they didn’t have to rely solely on eyewitness statements.