DAN Recreational Diving Fatalities Workshop Proceedings - 2011

[Jax]

Workshop held 8-10 April.

Note: Big file, 268 pages

Recreational Diving Fatalities Workshop: Summary

http://archive.rubicon-foundation.org/xmlui/bitstream/handle/123456789/9303/DAN_Fatalities_Proceedings_2011.pdf

 

[bleeb]

BTW, does anyone remember seeing a request from the Rubicon Foundation or one of the individuals involved that when people want to post links to their collection, that they link to the article's record and not to the file itself, or was this just my imagination. The Rubicon FAQ does suggest this since the files themselves may move, but doesn't say that this is their preference.

In this case, it's Recreational Diving Fatalities Workshop: Summary.

 

[Thalassamania]

Just finished reading it. Not a whole lot new really. There were a few things that I'd like to make note of:

Reading between the lines the Training and Operations section must have been a bit of a fracas:

"Participants in the training panel were concerned before the workshop that the discussions might increase their liability, and several training agencies declined to attend. To allay these worries insofar as possible, discussions by the panel were not recorded."

and

"Workshop participants were encouraged to base their comments on evidence rather than opinion, and a few unsupported opinions led to sharp exchanges. The points made were often useful, but the tone was not, so an editorial summary is provided below rather than the verbatim transcript."

There were some amazingly simple and clear questions where were posed, and then left unanswered like:

'Running out of gas, emergency ascent, entanglement, equipment trouble, buoyancy trouble and rough water were risk factors associated with injuries leading to death. These occurred despite training. Might “overtraining” (excess skill repetition during training to make skills automatic/instinctive in emergencies) during initial training be applied to some skills to reduce the occurrence of the risk factors listed above?'

and

"What are the key factors in dive instructor and dive leader quality-control systems for maintaining instructor skills and performance?"

and

"How long (assuming a moderate teaching load) does a dive instructor need to work before gaining the experience to handle a wide range of students? Do instructors receive adequate motivation to encourage them to continue teaching for long enough to ensure that most active instructors have achieved an optimal level of experience?"

and what I consider to be a true inanity:

"Longer training courses with more dives are needed. This was disputed, but evidence to settle the issue wasn’t available."

since the answer (yes, more course and more dives equals fewer fatalities) is known and clearly demonstrable, the dispute should be solely over, "how much longer?"

 

[Gene_Hobbs]

Thank you! The whole file is here since there may have been a few link changes above.

Yes, we need to use the short links when we can. The best example of why this is a problem was our site update last month. I posted this news item about the problem but basically in updating our database from dspace v1.3.2 to v1.7.2, all the paths to documents changed. The short links that used to be labeled as "please use this link" on the old page were preserved. That upgrade resulted in MANY dead links throughout cyberspace...

I am splitting up the document so it is easier to find things with keywords in the database as well. As those get posted, the RSS gets picked up by our Twitter account and Facebook page.

bleeb - Thanks for the note on my sig. I am getting the re-direct created as I type. I'll also try to remember to get a new faq written on this but it will need to wait until I am back from Dr. Lambertsen's memorial in Philly tomorrow.

 

[lamont]

"The most frequently cited root cause among the independent population samples was insufficient gas or running out of gas."

[...]

"Divers are taught to avoid most of these during training, but many who died seemed not to have acted in accordance with instruction. It was unclear why this was so."

except of course that divers are taught to "be back on the boat with 500 psi" but not taught anything about gas consumption rates or minimum gas in order to have the tools to actually accomplish that.

its right in front of your face, staring at you, dive industry.

fix it.

 

[Thalassamania]

We have a saying at the ITCs: "If they have not learned, have you really taught?"

 

[Wookie]

except of course that divers are taught to "be back on the boat with 500 psi" but not taught anything about gas consumption rates or minimum gas in order to have the tools to actually accomplish that.

its right in front of your face, staring at you, dive industry.

fix it.

At what level should gas consumption rates be taught, and by whom? Not that I'm arguing with you, but you've got to understand what bad divers we "the dive industry" see, and that the divers themselves don't seem to know, or care how bad they are.

This summer it was divers who had not a care in the world that they were burying their computers in deco dive after dive after dive. 15 times on a 5 day trip. Were they surfacing in deco? No, they were honoring their decompression commitment as established by a $289 hockey puck computer in 40-80 feet of water. Diving nitrox, so they were having real O2 issues, but most computers don't accurately record O2 exposure, so they don't really understand the problem. Gas Management wasn't a problem, but no one had taught these divers the dangers of doing 4 deco dives per day. Nor did they care when we informed them.

I don't have near the problems that dayboats in the keys have. The folks I sometimes see on them have not a care in the world nor a clue what they are doing. After all, a divemaster will be right next to them to bail them out, right?

So, with all of the important considerations regarding diving, which ones are the most important, and where do these need to be taught to an unknowing and uncaring public? I want you to remember back to the days of NASDS, if you go back that far. NASDS ran an 11 module course that covered everything you might learn in a OW, AOW, and parts of a rescue course, including self rescue, but not necessarily buddy rescue beyond air sharing etc. NASDS failed, or was folded into SSI because they couldn't compete with the PADI 4 day weekend certification course for $99. The public doesn't want to know that diving can be dangerous, or that there are important considerations beyond be back on the boat with 500 PSI. They want to go see the pretty fishes.

 

[boulderjohn]

NASDS failed, or was folded into SSI because they couldn't compete with the PADI 4 day weekend certification course for $99. The public doesn't want to know that diving can be dangerous, or that there are important considerations beyond be back on the boat with 500 PSI. They want to go see the pretty fishes.

When I sat through a 5 day scuba marketing course taught by the former owner/president of NASDS, who is now the owner/president of SSI, I got a different version of this history. He said that the original merger with SSI was what he wanted to do to help expand the reach of the company. It was only a few years later that he purchased SSI out right and took over. We looked at the marketing materials of NASDS, and we looked at the new marketing materials for SSI. They are pretty much the same. The new SSI marketing philosophy is the old NASDS marketing philosophy, right down to how you lay out the store and how you promote gear sales through instructional practices. My summary would be that SSI got folded into NASDS, except that it kept its name.

 

[lamont]

At what level should gas consumption rates be taught, and by whom?

BOW, AOW and Rescue, all three of them, by every RSTC agency out there.

Not that I'm arguing with you, but you've got to understand what bad divers we "the dive industry" see, and that the divers themselves don't seem to know, or care how bad they are.

[...blah...blah...blah...]

1. there is a high correlation between OOA and fatalities
2. there is no training in the recreational scuba program that addresses this deficiency
3. the training burden on the agencies is incremental and not overly burdensome

and point #2 is critical since this isn't a case of "can't fix stupid" and people will do whatever they feel like after the course (like all the examples you cited), this is a case where there's simply no training and no information out there for people to ignore in the first place.

that makes it lowest hanging fruit, so yes that makes it critical to address, and all your arguments are useful for is business-as-usual. i guess you find the incident rate on your boat is acceptable and you can pay the bills, so why try to change anything... which is an entirely useless perspective.

 

[Thalassamania]

I agree wholeheartedly with Lamont, however, that is only one piece of the OOA problem. The entire issue is a bit more complex. In the DAN workshop report it is noted that:

Fundamental problems associated with diving fatalities have not changed significantly in recent history (Denoble et al. 2011; Lippmann 2011; Cumming et al. 2011; Richardson 2011). The most frequently cited root cause among the independent population samples was insufficient gas or running out of gas. Other common factors included entrapment or entanglement, buoyancy control, equipment misuse or problems and rough water. Emergency ascent was also common. The principal injuries or causes of death included drowning or asphyxia due to inhalation of water, air embolism and cardiac events.
​

Now, look at that statement closely for a moment. It says, "The most frequently cited root cause among the independent population samples was insufficient gas or running out of gas." Now, to my way of thinking, for "insufficient gas or running out of gas," to kill a diver, requires a failure of an emergency ascent .

Similarly, the DAN report states:

Equipment problems seldom directly cause the diver’s death, but the diver’s response to an equipment malfunction, especially if the response is panic and perhaps a rapid ascent to the surface, may be the catastrophic event in the sequence that results in a diving-related fatality.
​

So now we can add pretty much all equipment problems as well as insufficient gas or running out of gas to the, "failure of emergency ascent," category.

The DAN report, notes:

Gas-supply problems resulted mainly from inappropriate gas management. Most of the time, the trigger appeared at depth, and the diver drowned or suffered an AGE during emergency ascent.
​

I feel confident, at this point, to suggest that the most important unsolved issues is not gear manipulation (though that's important), nor is it gas planning (though good gas planning would remove a sizable chunk of cases), the problem is that when things go wrong divers are not able, at least some of the time, to make it to the surface without damage. So let's ask the $64,000 question, "why can't divers make a safe free ascent?"

The DAN Accident Workshop provides some insight into this:

A study in Belgium found 100–400 times increased risk of pulmonary barotrauma (PBT) during training dives, while emergency free-ascent training was associated with 500–1,500 times greater risk. These findings prompted Belgian sport diver federations to ban free-ascent training in 2006, after which there have been no further PBT cases related to training (Lafére et al. 2009).
​

I was party to many conversations in the USA that followed a similar path. Most recreational instructors are poorly trained in how to conduct free ascent training, when that is combined with the fact that recreational divers receive little training (usually one tense, frightened, trial) in how to do a free ascent, that combination is, understandably, deadly. There were a lot of free ascent training incidents, and the result was that the agencies tightly controlled the way in which free ascent training was conducted. During this process I pointed out that in the science community we did lots of free ascent training and had never had a single incident, but the agencies did not want to hear that. I think that the subtext of this entire topic was how to reduce the incidence of free ascent training accidents while reducing the required course hours at the same time (the shorter course hour discussion was going on at the same time).

So we are left with a situation in which we are prevented from taking the single biggest step to increase diving safety, effective free ascent training, by agency blindness and the fact that free ascents have not been a central pillar of diver training since the 1060s and the current instructor cadre has not been trained to conduct such training, but rather has been systematically terrified to do so.