External Review Panel: ”Faulty Diving Operation Plan”
-Harassment Involved in OIST Accident
In regard to the 2016 November OIST (President Peter Gruss) diving accident with a then 37-year-old male employee went missing while installing a measurement equipment on the seabed between Motobu Cho and Ie Island, on July 11, it was acknowledged that the Expert Review Panel concluded the accident as, “It was an accident which could have been totally avoided if there were no faulty, self-conceited, no-preparation diving plan, project procedures without any verification. OIST’s systematic mismanagement aggregated the above situations.” (related article also on page 27)
According to the Review Panel, this time’s difficult diving operation should have been conducted by those who are physically and mentally in sound condition. In the report, it was also stated that excessive mental burden inflicted upon the missing diver through uncoordinated people relationship, which reached to the level that cannot be denied as a main cause of the accident. The report also mentioned about the colleague diver’s past e-mails reprimanding the missing diver as, “Expressions beyond the bounds of socially accepted limits were used, and this case can be considered as a harassment to the missing diver and related staff members.”
Furthermore, the recognition of Dean of Research on risks with diving operation was not sufficient, and the fact of over-dependence on the colleague diver’s decision was overlooked, which lead to the accident. In this regard, it was emphasized that “This is the issue where the responsibility of OIST management is being questioned.”
Intrinsically, risk management of research, research support, health and safety management, research risk management should be independently controlled. However all those management was consolidated on one single person, the Dean of Research. It further states, “OIST executive members, who have neglected the faulty organizational structures should be blamed for the responsibility.”
In the diving operation plan, any possibility of troubles had not been considered, and “Ignorance and lack of understanding” of the associate professor who was the section leader on diving operations was serious, along with his “unconditional trust on the colleague diver,” and lack of responsibility for research safety management. The Panel concluded, “the lack of such consciousness largely caused the accident.”
Okinawa Labor Standard Office gave their recommendation for corrective measures pointing out 3 cases of OIST violation on Labor Safety and Health Law including not implementing every 6-month medical checkup.
According to OIST, the death of the missing diver was officially acknowledged in June 2017. Nago Coast Guard stated their comment saying, “Based upon the alleged professional negligence resulting in death, the investigation is still underway.” On July 12, OIST is going to disclose the full report on its webpage.
Questionable OIST Diving Accident: Unfamiliar special diving devices, 63-meter deep diving, Strong currents
In the diving accident where an OIST male employee went missing, it was acknowledged on July 11 that the External Review Panel pointed out that “it was a wrong decision to use Rebreather”, a special diving equipment which requires certain amount of diving experiences that had not been acquired by the OIST divers. A diving expert in Okinawa also commented, questioning the diving operation by OIST, “This time’s diving operation could not be handled by research members who do not have much experience. The operation itself should have been outsourced to outside experts.” (Also see the front page)
Experts: “Outsourcing was necessary.”
“Rebreather” is a closed circuit diving equipment which removes CO2 from a diver’s exhaled air and generates oxygen using special gas. By using Rebreather, divers can conduct deep water operation for a long time.
The Expert Review Panel commented on the use of Rebreather, “They (OIST employees) did not fully understand how to operate Rebreather and were not well versed with the techniques of using it.”
In addition, considering the diving operation to 63 meter depth with devices (such as measuring machine for current directions/velocities) which weighed more than 10 kg to be installed at the seabed, the Panel concluded, “The operation itself should not have been done using Rebreather.”
According to diving experts, the accident site, Ie Cannel, is known to have strong currents, and commented, “Among divers, the area is known to be dangerous. We assume the diving operation had been conducted under dangerous environment.”
Another expert commented regarding the diving operation using Rebreather, “Rebreather was perhaps chosen to dive deep for a long time, but in order to use the equipment, high level of technical skills are required. OIST lacks risk management, and the accident was waiting to happen.”
Carefully Watching the OIST Improvement Measures: Minister of State for Okinawa
Regarding the OIST employee diving accident, Yosuke Tsuruho, Minister of Okinawa, stated his idea in a meeting with reporters that he would be carefully watching the improvement measures to be conducted by OIST.
Mr. Tsuruho answered to the reporters, “We are aware that the accident report was published. As Cabinet Office, we will closely watch OIST improvement measures, and as a supervising office, when we face a situation where we need to state something to them, we would like to act accordingly in a swift manner.”
Pressure on OIST Employees
Prior to July 11, regarding the OIST diving accident, it was acknowledged that an OIST executive made statements to OIST employees, “actions that lead to damage to the reputation of the University will be disciplined up to the level of dismissal.” According to some sources who were aware of the situation said, “There were pressures from executives against opinions requesting information disclosure. Under such circumstances, OIST employees could no longer speak up.”
On July 10, Vice President Neil Calder (Communication and Public Relations) answered in our interview, “There was not a single intention trying to conceal (the issue of the accident internally).” Expert Panel pointed out that the diving equipment was not suited for the operation and the divers’ training was not sufficient, and there were no emergency plan nor reserve equipment.
However, it was also acknowledged that immediately after the accident, another OIST executive stated, “Divers were properly equipped and trained, and the dive complied with the regulations.”
“It was a fallacious statement by OIST executives,” according to related sources. “It was on the OIST management side who made statements that damage the reputation of the University. It is nonsense that management responsibility of OIST executives has not been questioned and those who assert right things become subject to disciplines.”