Triggers of Dive Accidents

[Ken Kurtis]

. . . there are occasions where equipment failure may necessitate the need for air sharing . . .

Phenomenally rare. The equipment today is very reliable. (Wish we could say the same about the divers.) In the 30-or-so fatality cases where I've done equipment analysis for the L.A. County Coroner, we've seen only one case where the equipment factored in, and in that one, the diver basically pulled on the gear so hard he disabled the inflator by pulling it out of the hose (it was easily fixable by re-inserting the inflator into the corrugated hose) and then panicked. FYI, he had 1000psi still in his tank.

Bear in mind, my don't-teach-them-OOA-options is more for hyperbole than a practical solution. And consider this if you're an instructor: Suppose there were no OOA options. How would you change what and how you teach about gas management?

But I really DO think we send the wrong message with the way we teach and while you can easily make arguments for the unlikely events that might necessiate alternatives, it doesn't address the issue that divers are running out of air on a regular basis despite the fact that we tell them over and over again not to.

THAT'S the problem we've got to solve.

- Ken

 

[stadevene]

I'm not an instructor nor do I have a ton of dives under my belt so I'm not sure how much I should really comment but I find it an interesting thought.

I'm wondering if out of that 41% there are any stats on the experience/cert level of the divers? As a new diver you are often a little excited, some freaked out, over weighted, poor trim, and suffering from task overload. Does this correspond with more inexperienced divers having survivable OOA situations? I say survivable because as new divers we're infrequently far away from an instructor/DM and are often not at great depths.

As we get more experience often we get better at using our gas and we understand how much we typically use so we're less likely to run out if we're diving well within limits. The trick there is well within limits. The corollary is as divers get more experience they may start to push the envelop. Deep dives, wreck dives, cave dives, etc all seem to be attractive which I suspect can lead to more OOA issues.

I'm also wondering if the OOA accidents are attributed to other root causes. I've read a couple of accidents in lakes where it seemed a lack of visibility led to the diver running OOA. I'm wondering how DAN ranks these? Are they attributed to visibility/disoriented diver or due to OOA? Or if a diver gets lost in a cave or in a wreck is that considered OOA or due to another reason?

I'm also wondering what the OOA ratio between self catering divers and divers who go with a guide is?

Back to your original idea, I'm not sure you could police this consistently. I like your policy for your operation however will all operators employ the same rule or report the diver? Will a small dive operator who is running a very lean operation jeopardize future business on much needed tips by turning customers in? I've been on dive boats where divers complained because lunch wasn't to their liking or the drinking water wasn't the exact temperature they wanted. Could you imagine if these divers were reported? The dive op would get destroyed on Tripadvisor and the like.

Perhaps though it's an overall mindset shift which would need to take place. If training agencies made sure people knew they would get reported in they go OOA would they be more accepting? Tough to say.

It's a really interesting idea though and I hope it brings up good discussion.

 

[helimvee]

Not only should new divers be taught not to run OOA, but they should be taught how to do that. In other words, they should be taught gas management. There should be more than just the rule of thirds.

I think that not teaching what to do in an OOA situation is foolish, as it could be caused by an equipment failure and not poor gas management. Trying to scare people into compliance does not work.

We don't simply teach new car drivers how to operate a car and then tell them not to get into a collision. We teach them how to operate a car and then we also teach them how to avoid a collision. The same should be done with diving.

I didn't learn proper gas management until my solo course. It would have been great to learn that in the open water course, or at least the advanced course.

Good topic.

 

[zaberman1]

stadeven, thats precisely why I am interested in seeing their models. Its easy to get confused by numbers. If I say 100% of the divers that died received OOA training, it doesn't mean that there is a causal link to it. I wonder what the model says the contributing factors were...

 

[Crush]

That's about it in a very long nutshell. Thoughts???

- Ken

My thoughts Ken, while not gracious, is that I personally feel that I have not read such a spectacularly stupid post in some time. I apologize for the harsh wording, but in my opinion it is appropriate.

Maybe we need to change that school of thought. At Reef Seekers (my dive company) we've had a very simple rule on our charters: Run out of air, and you're done diving for the day. Period. No exceptions. Our thought is that you got lucky once, and we don't want to tempt fate twice. In 30 years, we've had exactly one person run out of air (and they lived).

I agree with your penalty system - it seems fair.

So then the question becomes: Why do people run out of air? The answer I've come up with is one that I think is controversial but true: Because we tell them it's OK to run out of air.

People run out of air for many reasons. I do not accept your over-simplification. I was trained in murky lakes and I checked my gauges all the time. When I hit the Pacific Northwest for the first time I was overwhelmed by the explosion of colour and the intervals between my pressure checks became less frequent. I was near-OOA (but not OOA) and surfaced, with a safety stop, without incident. I only checked my gauge to discover my near-OOA because I told by buddy that I was a newb and he signaled for me to check several times during the dive (I was also checking without his prompting) but on the last check was I found that I had under 400 psi at 70 ft. What saved me? My disclosure that I was a newb and the buddy system, not some OOA "don't dive for the rest of the day" penalty.

We've just inadvertently told them "Don't run out of air but if you do, it's OK because here's how you can solve that probem."

I think we need to stop doing that.

Would it be better simply NOT to teach OOA options? And to simply say, "If you run out of air, there's an excellent chance you're going to die, so don't do it." (Or maybe teach OOA options as an advanced skill.)

Rubbish. Divers should be trained to reason and use their brains to get them out of tight spots, even when under stress.

 

[Kilili]

Very thought provoking, and your argument makes sense to me. I think part of the problem is the promotion of buddy reliance in training, the notion that when you run into trouble, your buddy is somehow going to save you. Instead, the focus should be on self-reliance, that the only person you can truly count on is yourself.

By taking away the buddy crutch, one must [presumably] develop greater awareness of the environment, and consequences of one's actions.

It would be interesting to know the correlation between the data you reference and the experience level of the victim.

Whether I'm in the water with someone or not, I think of every dive as a solo dive, and plan accordingly. I've learned that it's extremely dangerous to think that help is just around the corner.

 

[Ken Kurtis]

I wonder what the model says the contributing factors were...

First of all, get a hold of Dick Vann at DAN. He's usually quite willing (and eager) to share info and data.

DAN's been using (and I personally like this form a lot) a four-step analysis which (in theory) should deal with some of the contributing factors. The four steps are:

1. Trigger
2. Disabling event
3. Disabling injury
4. Cause of death

For instance, a diver running out-of-air in the open water, panicking, and shooting to the surface might be:

1. Out-of-air (trigger)
2. Panicked ascent (disabling event)
3. Embolism (disabling injury)
4. Drowning (cause of death)

Suppose the same diver was in a cave, got lost, and ran out of air. The four steps might be:

1. Loss of orientation (trigger)
2. Out-of-air (disabling event)
3. Unable to reach surface (disabling injury)
4. Drowning (cause of death)

Both cases involve out-of-air but in one it's the trigger and in the other the contributing factor (disorientation in the cave) is the trigger.

- Ken

 

[zaberman1]

I will look up his information tomorrow and send him an email! Thanks again

 

[TSandM]

I do agree with teaching contingency procedures . . . but you can teach someone a coping strategy for an issue, and still make it abundantly clear that they should NEVER have to use that strategy. I was taught a lost line drill in my cave class, but I didn't come away with the idea that it's okay to lose the line. It was made abundantly clear that doing so could be the last mistake I ever made.

That's part of what's lacking in OW classes. You aren't supposed to scare people, and diving is FUN and FUN doesn't kill you . . . so telling students that running out of gas may well be a deadly event is not looked upon with favor by the folks running the shop, who want more divers.

But the biggest issue is that, although I'm pretty sure no one walks away from his open water class with the idea that running out of gas is perfectly fine -- nobody walks away with good tools to prevent doing it, either. In none of my mainstream classes was checking my gauges emphasized -- the instructor might swim by and ask me what my pressure was, but if I had to look at my gauge to answer him, that was fine. It shouldn't be. You should be able, at any point in a dive, to give a close approximation to your current pressure. You can do that one of two ways: Either you are diligently checking your gauges at regular intervals (which is what all new divers should be doing) or you have enough experience and a knowledge of your gas consumption, so you can estimate the change from the last check.

It is my personal opinion that more gas management needs to be taught, earlier in the curriculum. PADI, for example, does not teach gas management ANYWHERE in the recreational curriculum, beyond the basic discussion that you use your gas faster at depth. The concept of all available, halves and thirds dives isn't brought up; the concept of a minimum gas reserve is never discussed. I remember going to NW Grateful Diver's gas management seminar, and being rocked back on my heels by the information he gave us, and thinking, "Why didn't anybody tell me this before?"

People run out of gas and die. They do it because their situational awareness is poor, and/or their planning is faulty. Planning is EASY to teach; situational awareness takes much more work, but is so little addressed in basic training that it's very sad.

 

[Mr Carcharodon]

I agree completely with refocusing the OW curriculum to focus on the highest risk issues. Gas management gives divers the “how to” to be safer during their dives. Beyond that doing effective air shares, and having effective buddy teams are powerful tools in preventing panicked ascents that end in arterial gas embolism. The mainstream grip of death air share is based on the assumption that divers are incompetent. We can do better. Having students learn the techniques to do a non-stressed air share is key to an orderly and ultimately non-embolizing ascent. The “how to” of how to stick together and be an effective buddy team is an other area that needs to be improved. Just saying stick with your buddy is not enough.

Nanny charters with penalties are not a solution.