As part of a chronological examination of the event, the MCIB report explains how the Gardai investigating the incident took the lifejacket to the nearest station where the valve on the manual inflation tube was found to be stuck open.
The report reads:
On inspection of the lifejacket at the Garda station, Blackrock, Cork on the 19th August 2003 it was noted that the lifejacket had not fully inflated and that the left side inflation chamber was still contained within its outer enclosure. The lifejacket inflation gas cylinder is fitted to the right side of the inflation chamber and the cylinder showed evidence of having been activated. The right side of the inflation chamber to which the cylinder was attached had inflated to some degree. On further examination it was noted that the non-return valve fitted to the mouthpiece (on left side of jacket), was stuck in an open position. If the valve was in that condition when the inflation cord was pulled it would have the effect of releasing the inflation gas to atmosphere as fast as it was entering the chamber and hence the reason for one side of the inflation chamber not inflating. The non-return valve had not operated correctly and this is borne out by the fact that water was found to be inside the lifejacket. If the jacket had inflated to the extent that a positive pressure was contained within it, then water would not have entered the chamber."
The lifejacket was of the standard inflatable type, held closed by velcro until the pressure of inflation blows it open to its full inflated size. One of the sides of the jacket had not done so.
The jacket was then taken to Midleton Marine, where further tests unjammed the valve and the jacket returned to normal operation. It was fitted with a new cylinder, and during ran inflation test there, worked without trouble.
Baltic, in their statement, said:
Baltic Safety Products deeply regrets the fatal accident in Ireland in 2003, and has invested considerable resources in trying to find out what happened in the incident, especially considering that there have been no such problems before or since with this type of lifejacket in the last 25 years."
After the incident and subsequent investigation, Baltic said they tested the jacket and its valve repeatedly, but that it worked without fault, even when the valve was jammed open. Baltic said:
he jacket was found to function properly on every occasion it was tested in accordance with the issued instructions. The non-return valve was checked numerous times using the cap fitted to the oral tube and it functioned correctly every time. It was discovered that it was possible to make the non-return valve in the oral tube stick open, when something other than the cap was used to push the valve further down the tube – even then, it did not stick on every occasion. However, it was also found that, even when the non-return valve was stuck open, the jacket still inflated properly – and stayed inflated – when the cap was fitted to the oral tube, even when tested on a person in a swimming pool.
Baltic said that it would take extenuating circumstances for the lifejacket to fail so catastrophically.
The only circumstances in which the jacket would not have inflated properly were if the non-return valve was stuck down AND the cap was off the tube – which was how it was found after Mr. Sweeney’s accident."
