Medical findings

Medical investigations were carried out on the remains of the four divers. The most notable finding was the presence of large amounts of fat in large arteries and veins and in the cardiac chambers, as well as intravascular fat in organs, especially the liver.^{[4]: 97, 101} This fat was unlikely to be embolic, but must have precipitated from the blood in situ.^[4]: 101 The autopsy suggested that bubble formation in the blood denatured the lipoprotein complexes, rendering the lipids insoluble.^[4]: 101 These, now insoluble lipids, are likely what stopped their circulation.^[4]: 101 The fourth diver died instantly from gross dismemberment when the blast forced his body out through the partially blocked doorway.^{[4]: 95, 100–101}

Coward, Lucas, and Bergersen were exposed to the effects of explosive decompression and died in the positions indicated by the diagram. Investigation by forensic pathologists determined that Hellevik, being exposed to the highest pressure gradient and in the process of moving to secure the inner door, was forced through the crescent-shaped opening measuring 60 centimetres (24 in) long created by the jammed interior trunk door. With the escaping air and pressure, it included bisection of his thoracoabdominal cavity, which resulted in fragmentation of his body, followed by expulsion of all of the internal organs of his chest and abdomen, except the trachea and a section of small intestine, and of the thoracic spine. These were projected some distance, one section being found 10 metres (30 ft) vertically above the exterior pressure door.^[4]: 95

Investigation

The committee investigating the accident concluded that it was caused by human error on the part of the dive tender who opened the clamp. The trunk door had a center hinge design, similar to a butterfly valve disc, and the door was rotated too far to the left, causing the rim of the interior hatch to lodge on the door opening. This left a crescent-shaped opening, similar to a manhole cover left ajar but held in place. This created an opening that was 24 inches (61 cm) across horizontally. It is not clear whether the tender who opened the clamp before the trunk was depressurized did so by order of his supervisor, on his own initiative, or because of miscommunication. At the time, the only communication the tenders on the outside of the chamber system had was through a bullhorn attached to the wall surface; with heavy noise from the rig and sea, it was hard to listen in on what was going on. Fatigue from many hard hours of work also took its toll among the divers, who often worked 16-hour shifts.

This incident was also attributed to engineering failure. The obsolete Byford Dolphin diving system, dating from 1975, was not equipped with fail-safe hatches, outboard pressure gauges, and an interlocking mechanism, which would have prevented the trunk from being opened while the system was under pressure.^[9] Prior to the accident, Norske Veritas had issued the following rule for certification: "Connecting mechanisms between bell and chambers are to be so arranged that they cannot be operated when the trunk is pressurized",^[10] therefore requiring such systems to have fail-safe seals and interlocking mechanisms. One month after the accident, Norske Veritas and the Norwegian oil directorate made the rule final for all bell systems.

Among others, former crew members of Byford Dolphin and NOPEF (a Norwegian oil and petro-chemical union) have come forward and claimed the investigation was a cover-up. They claimed that the commission investigating the accident did not mention in their report the irresponsible dispensations on vital equipment requested by Comex and authorized by the diving section to the Norwegian Petroleum Directorate, which played a vital role in the accident's occurrence. They also alleged the accident was due to a lack of proper equipment, including clamping mechanisms equipped with interlocking mechanisms (which would be impossible to open while the chamber system was still under pressure), outboard pressure gauges, and a safe communication system, all of which had been held back because of dispensations by the Norwegian Petroleum Directorate.^[11]

Lawsuit

The North Sea Divers Alliance, formed by early North Sea divers and the relatives of those killed, continued to press for further investigation and, in February 2008, obtained a report that indicated the real cause was faulty equipment. Clare Lucas, daughter of Roy Lucas, said: "I would go so far as to say that the Norwegian Government murdered my father because they knew that they were diving with an unsafe decompression chamber."^[12] The families of the divers eventually received compensation for the damages from the Norwegian government, 26 years after the incident.^[13]