Chamber Incident Report — ISNI-2138-INC-017

INTERNATIONAL SEAM NAVIGATION INSTITUTE

OFFICE OF TRAINING STANDARDS · SVALFJELL RIDGE FACILITY · NORWAY

1 · SUMMARY

During a scheduled harmonic-resonance exercise in Chamber 4-B at 09:42 local on 14 October 2138, one (1) trainee of Cohort 12 sustained injuries inconsistent with continued life support. Medical recovery was effected within four minutes of the alarm. Death was declared on-scene at 09:53 by the facility medical officer.

Twenty-two (22) other trainees were present at the perimeter of Chamber 4-B during the exercise, in standard observation configuration. None sustained injury. All twenty-two have been debriefed.

2 · CASUALTY

3 · CAUSE

The Office of Training Standards finds the proximate cause of the event to be equipment failure in the chamber's primary harmonic stack. The stack registered a phase-stability excursion outside operational tolerance at 09:42:14. The chamber-safety interlock engaged within the specified response window. The interlock did not prevent exposure.

The stack has been removed from service and is held by ISNI Engineering pending metallurgical review. No comparable filing has been entered against this chamber since its commissioning in 2135.

4 · FINDINGS · TRAINEE CONDUCT

The Office finds no fault in trainee conduct on the date of the event. Standard observation distances were maintained. No trainee was within the chamber's inner perimeter at the time of the stack excursion. The fatality was contained to the trainee whose position was directly proximate to the equipment failure.

Debriefs of the twenty-two surviving trainees of Cohort 12 are recorded under separate cover (DEBRIEF-2138-W16, restricted access). The cohort returns to standard curriculum on 18 October 2138.

5 · RECOMMENDATION

The Office recommends no curriculum change at this time. Cohort 12 will proceed to graduation on the standard schedule. The filing officer recommends Chamber 4-B be returned to service following stack replacement and standard recertification. Replacement to be completed by 21 October 2138.