The American Journal of Forensic Medicine and Pathology 9(2): 94-101, 1988. © 1988 Raven Press, Ltd.

© 1988 Raven Press, Ltd., New York

An Explosive Decompression Accident

JC: Giertsen, M.D., E. Sandstad, M.D., I. Morild, M.D., G. Bang, M.D.,

A. J. Bjersand, M.D., and S. Eidsvik, M.D.

Four divers in a compression chamber system were suddenly On 5 November 1983, an accident resulting in the
decompressed from 9 atm to | atm. One of the divers was sudden decompression of four divers from a pressure
about to close the door between the chamber system and the
of 9 atm to | atm occurred on board the Norwegian
trunk when the accident happened. He was shot out through
the door and severely mutilated. The three others died on oil ng Byford Dolphin in the North Sea.
the spot. The autopsy results are described. The most con-
spicuous finding was large amounts of fat in the large arteries
THE ACCIDENT
and veins and in the cardiac chambers, as well as intravascular
fat in the organs, especially the liver. This fat can hardly have The situation just before this accident occurred was
been embolic, but must have “dropped out” ofthe blood in
as follows (Fig. 1). Compression chambers | and 2 were
situ. It is suggested that the boiling of the blood denatured
the lipoprotein complexes, rendering the lipids insoluble. connected via a trunk to a diving bell. This connection
Key Words: Decompression, explosive—Decompression, was sealed by a clamp operated by two tenders (Dt |
accident. and Dt 2), who themselves were experienced divers. A
third chamber was in fact connected to this system,
but was not involved. On this day, divers | (35 years
old) and 2 (38 years old) were resting in chamber 2 at
a pressure of 9 atm. The diving bell with divers 3 (29
years old) and 4 (34 years old) had just been winched
up after a dive and joined to the trunk. Leaving their
wet gear in the trunk, the divers had then crept through
the trunk into chamber |. The normal procedure would
have been to (a) close the bell door, (b) slightly increase
the bell pressure to seal this door tightly, (c) close the
door between the trunk and chamber 1, (d) depressurize
the trunk to | atm, and (e) open the clamp to separate
the bell from the chamber system.
Operations a and b had been completed and diver
4 was about to carry out operation c when, for some
inexplicable reason, one of the tenders opened the
clamp. The result was a free communication between
the chamber system with a pressure of 9 atm and the
surroundings with a pressure of | atm. A tremendous
blast shot from the chambers through the trunk, push-
From the University of Bergen, The Gade Institute, Bergen, Nor-
ing the bell away and hitting the two tenders. The one
way. Professor of Forensic Medicine (J.C.G.), Acting Head, The Gade
Institute, Section of Neuropathy (I.M.); Professor of Oral Pathology who had opened the clamp died, and the other was
(G.B.); Assisting Head, Haukeland University Hospital, Department severely injured. Unfortunately, the dead tender was
of Radiology (A.J.B.); Captain of the Royal Norwegian Navy, Senior
not sent to us for autopsy.
Diving Medical Officer (S.E.).
A preliminary version of this paper was given by Giertsen at the Figure 2 shows how diver 4 probably was about to
10th Meeting of the International Association of Forensic Sciences, close the chamber door when the accident occurred.
Oxford, England, 19 September 1984.
The chamber opening was 60 cm in diameter. Unfor-
Address correspondence and reprint requests to J. Chr. Giertsen,
M.D., University of Bergen, The Gade Institute, Department of Fo- tunately, the door jammed (Fig. 3) so firmly that it
rensic Medicine, 5021 Bergen. Norway. later had to be cut loose with an acetylene burner. Diver

94
 EXPLOSIVE DECOMPRESSION ACCIDENT 95

CHAMBER 2
CHAMBER 1
TO LIFEBOAT

DIVING BELL

FIG. 1. Sketch of the compression system and the involved

persons’ position just before the accident occurred.

4 was shot out through the opening and completely

disintegrated. Parts of him were found scattered about
the rig. One part was even found lying on the derrick,
10 m above the chambers!
The other three divers in the chambers died on the
spot, probably instantaneously (Figs. 4-6).

POSTMORTEM EXAMINATIONS
The remains of diver 4 were sent to us in four plastic
FIG. 3. The approximate position of the jammed chamber
bags (Fig. 7). All parts showed fractures and wounds.
door.
The fractures of the long bones were of transverse as
well as short and long oblique types, the fracture lines
being more irregular than usual, with small, splintered below the hip joint. The pelvis itself had been divided
fragments. into three parts. To one of these parts, a small segment
The scalp with long, blond hair was present, but the of the small bowel was attached. The penis was present,
top of the skull and the brain were missing. The base but invaginated. The soft tissues of the abdomen and
of the skull was a collection of tiny bone fragments the back had been cut straight through at a level about
only. The soft tissues of the face were found, however, midway between the umbilicus and the pelvis, and thus
completely separated from the bones (Fig. 8). The left had been separated from the pelvis. These soft tissues
upper arm had been separated from the body just below formed an empty sack. From above, one could look
the shoulder joint. The right upper arm was torn to down through the larynx. All the thoracic and abdom-
pieces, but still attached to the body. Both hands had inal organs had been expelled, except the trachea and
been separated from the lower arms. The right thigh, a fragment of the small bowel (Fig. 9). Even the spinal
leg, and foot were missing, but the knee joint was found. column (Fig. 10) and most of the ribs had been ex-
The left thigh had been separated from the pelvis just pelled. The liver had been found somewhere on the
deck. It was complete, as if dissected out of the body.
The autopsy on divers 1, 2, and 3 were performed
3 days after death, and the findings were essentially the
same in all three cases. The rigor mortis was unusually
strong. The hypostases were light red, and in two cases
there were numerous petechial hemorrhages in the li-
vores.
All the organs showed large amounts of gas in the
blood vessels, and scattered hemorrhages were found
in the soft tissues. One of the divers had a large sub-
conjunctival bulla (Fig. 11).
The lungs were edematous (1.250 g, 1.350 g, and
1.600 g) with bandlike subpleural hemorrhages cor-
responding to the intercostal areas (Fig. 12) and with
a number of subpleural bullae (Fig. 13). The cut surface
FIG. 2. The probable position of diver 4 about to close the
chamber door. showed intrapulmonary hemorrhages.

Am J Forensic Med Pathol, Vol. 9, No. 2, 1988

 96 J. C. GIERTSEN ET AL.

FIG. 4. Diver 1, who died on the spot.

FIG. 5. Diver 2, who died on the spot.

FIG. 6. Diver 3, who died on the spot.

Am J Forensic Med Pathol, Vol. 9, No. 2, 1988

 EXPLOSIVE DECOMPRESSION ACCIDENT 97

FIG. 7. The remains of diver 4.

The livers were fairly large and hyperemic (1,900 g, Microscopic examination showed free fat (Scarlet
2,140 g, 2,500 g). Red stain) in the blood vessels of the parenchymatous
The blood vessels of the stomach formed a promi- organs, especially in the liver but also to some extent
nent, dark network not unlike the findings in putrefied in the other organs (Figs. 16 and 17).
bodies (Fig. 14). No traces of alcohol or drugs were found.
In the cardiac chambers and in the great vessels
around the heart, both arteries and veins, large amounts NEUROPATHOLOGIC EXAMINATION
of free fat were found (Fig. 15). This fat was mixed
The brains and the spinal cords from divers 1, 2,
with gas bubbles, and looked like sizzling butter on a
and 3 were examined. The brains were very pale, and
frying pan.
the blood vessels were filled with gas (Fig. 18). In the
major blood vessels, a yellow substance looking like
?j fat was present. In the brain from diver 3, gross cystic
areas were found in the putamen, the internal capsule,
and the dentate nuclei. Otherwise, neither the brains
nor the spinal cords showed any old or recent patho-
logical lesions.
Microscopic sections from all levels of the brains
and the spinal cords revealed multiple cystic areas
without any vital reaction, especially near blood vessels
(Fig. 19). These were interpreted as air bubbles. A
Scarlet Red stain for fat was positive in some sections
(Fig. 17).
No old degenerative changes were found.

SKELETAL EXAMINATION

A roentgenologic examination was performed of the

bones of the shoulder, the hip, and the knee joints in
search for signs of aseptic bone necrosis (1). Approxi-
mately 2-mm-thick sections were cut from suspicious
lesions in the bones with a band saw equipped with a
diamond saw blade. The sections were fixed in 4%
neutralized formalin and decalcified. Thereafter, they
were embedded in paraffin, cut at 4 ~m and stained
with haematoxylin and eosin.
In diver 1, no suspicious changes were found.
In diver 2, an area of increased density of the bone
structure ~ 10 mm in diameter, was present in the neck
FIG. 8. The soft tissues of the face of diver 4. of the right free dissected femoral head (Fig. 20). This

Am J Forensic Med Pathol, Vol. 9, No. 2, 1988

98 J.C. GIERTSEN ET AL.

FIG. 9. The opened thoracoab-

dominal cavities of diver 4. Tra-
chea to the left. Remains of the
small bowel, otherwise empty.

area was cut out. Grossly, no pathologic changes were

observed. Microscopic examination revealed some
thickened trabeculae due to the apposition of new bone.
In some areas of the original trabeculae, the lacunae
appeared empty (Fig. 21). This was interpreted as an
aseptic bone necrosis.
In diver 3, a 22 X 12-mm area of intense slerosis
with a central lucency was found in the right femoral
neck. Roentgenologically it looked like a small osteoid
osteoma. Grossly, a sclerotic zone with a central empty
area was observed. Microscopic examination showed
a circular area of mature, lamellar bone circumscribing
a small empty area. There was no necrosis or inflam-
mation. This was interpreted as a nonspecific lesion.
In diver 4, no roentgenologically suspicious changes
were found.

FIG. 12. Bandlike subpleural hemorrhages corresponding

FIG. 10. Part of the spinal column of diver 4. to the intercostal areas. Diver 1.

Am J Forensic Med Pathol, Vol. 9, No. 2, 1988

 EXPLOSIVE DECOMPRESSION ACCIDENT 99

FIG. 13. Subpleural bullae. Diver 1.

FIG. 14. Stomach with prominent

blood vessels. Diver 1.

* >
Vite Lt Se ta ae,
FIG. 15. Cardiac chamber with large amounts of free fat
adhering to the papillary muscles (arrows). Diver 1. FIG. 16. Liver with positive fat stain (Scarlet Red). X67.

Am J Forensic Med Pathol, Vol. 9, No. 2, 1988

 100 J.C. GIERTSEN ET AL.

.
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FIG. 17. Cerebral vessel with positive fat stain (Scarlet
Red). X178.

FIG. 18. Surface of brain with gas-filled vessels. FIG. 20. Dysbaric bone necrosis in right femoral neck (ar-
row).

DISCUSSION would have closed automatically in case of an external

pressure drop, these four divers and the tender might
It was tragic that the door between the chambers have survived!
and the trunk jammed as it did. If the construction of The fate of diver 4 clearly demonstrates the tremen-
the hinge mechanism had been such that the door dous force released in an accident like this. He was

ays oe xe 7
ta aN Sap ee tet

FIG. 19. Gas bubbles in the brain. <110.

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 EXPLOSIVE DECOMPRESSION ACCIDENT 101

FIG. 21. Microscopic appearance

of the dysbaric bone necrosis sy
shown in Fig. 20. X200.

undoubtedly mutilated when he was shot out through rendering the lipids insoluble. If this is true, it seems
the small opening left by the jammed chamber door. appropriate to discontinue the use of the term “fat em-
However, the expulsion of all internal organs from the bolism” in decompression accidents and replace it with,
thoracoabdominal “sack,” including the spinal column for example, “‘fat precipitation.” It also seems that de-
and the ribs, suggests that he also must have exploded. compression fat precipitation may have a different
Unfortunately, we were not called to the scene. We etiology from traumatic fat embolism.
might then have found more organs from this diver. An expert committee investigated this accident and
On the other hand, the locality was such that parts of concluded that it was due to a human error. It is not
him may have been blown straight into the sea. clear whether the tender who opened the clamp before
Nonfatal decompression incidents may lead to in- the trunk was depressurized did so by order of the div-
juries, especially to the central nervous system and the ing supervisor or on his own initiative.
bones (2). In the central nervous system, the spinal In 1982, “Det norske Veritas” had issued revised
cord particularly is mostly affected. Small infarcts may regulations regarding the technical arrangement of
arise, with secondary ascending and descending tract diving spreads. One requirement was that the trunk
degeneration, and healing with gliosis. In the three div- should be impossible to open while it is pressurized.
ers examined in our case, no such lesions were found. The Byford Dolphin was, however, not rebuilt because
In the bones, aseptic or dysbaric necrosis may be found. the regulations were not retroactive. The expert com-
In one of our divers, one possible lesion was found. mittee recommended that the system on board the rig
Thus, in these divers, we could not demonstrate any should be rebuilt according to the new regulations. It
sequelae of previous serious decompression incidents. was further suggested that the doors between the var-
The most conspicuous finding in this case was the ious chambers of such a system should be kept closed
presence of large amounts of free fat in the cardiac during an operation like this, or a device should be
chambers and the great vessels, as well as in the smaller installed to ensure that they would close automatically
vessels of both the systemic and the pulmonary cir- in the case of a pressure drop. OD
culation. The occurrence of fat embolism in de-
compression accidents is well known (3,4). However,
an embolus is particulate matter transported by the REFERENCES
bloodstream from one part of the body,to another. In 1. Decompression Sickness Central Registry and Radiological Panel.
Aseptic bone necrosis in commercial divers. Lancet 1981.1:
our cases, the blood must have begun to boil instan- 384-8.
taneously, leading to an instantaneous and complete . Calder IM. Dysbarism. Forensic Sci Int 1986:30:237-66.
stop of the circulation. The fat cannot have been trans- ta
bo. Hendry WT, Childs CM, Proctor DM. The offshore scene and
its hazards. In: Mason JK, ed. The pathology of violent injury.
ported from anywhere, but must have “dropped out” London: Edward Arnold, 1978:289-317.
from the blood in situ. Possibly, the boiling of the blood 4. Mason JK. Aviation accident pathology. London: Butterworths,
led to a denaturation of the lipoprotein complexes, 1962:134-74.

Am J Forensic Med Pathol, Vol. 9, No. 2, 1988