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by Jarrod Jablonski
This four-part series will explore the historical development of Global Underwater Explorers’ (GUE) decompression protocols with a focus on technical diving and the evolving trends in decompression research. The series will include aspects important in recreational diving but with a greater focus on the variables affecting technical divers. Those with less technical experience will hopefully benefit from a substantial number of reference materials linked throughout the series. These support materials and the balanced perspectives I am striving to present are designed to encourage a broader grasp of this complex subject. I also wish to take a few chances with this series by presenting some controversial positions in the hope they will stimulate open discussion and deeper consideration on all sides.
In the interest of disclosure, I would like to foreground my belief that it is impossible to reach a definitive conclusion regarding the most efficient or the safest decompression procedures, though such determinations depend largely on how you define these terms. Indeed, it is a lack of certainty that motivates me to write this series since most of us will experience our entire diving careers with uncertain knowledge and while evaluating contradictory advice. It is my intent to provide a balanced overview while asserting that one should pursue a measured response to the dictates of pundits on all sides of the debate, myself included. Most importantly, I will explore the idea that many details may not be as significant as we typically imagine. For the sake of informed consideration, we will even explore the idea that both sides—in fact, all of us—are wrong and that we might know less about decompression sickness than it appears.
One last word on the structure of this series. My intent here is more about establishing a broad perspective and less about arguing a narrow view of this elaborate subject. To this end, I hope you will join the discussion by posting in our comments, or that some of these ideas might stimulate discussions in your various communities. Let’s get started.
Part One: Contextualizing the problem of decompression.
Humans have been exploring the underwater world for hundreds of years, driven by a seemingly insatiable curiosity to reach ever farther below the mysterious surface. The brevity of early breath-hold dives gave way to technology with advances in diving bells in the 16th and 17th century and led to the development of independent diving with the Fleuss rebreather unit around 100 years later. The Fluess device was a self-contained underwater breathing apparatus (scuba) and helped develop the future of untethered diving, although excursions would remain short and/or shallow for many years to come.
Developing technology that could support extended time while working underwater was a necessary part of the construction of bridges such as the Brooklyn Bridge during the 1870s. This was accomplished by constructing underwater rooms that were pressurized to keep them dry. Few people would think of these immersions as “diving,” but the extended time breathing gas at pressure highlighted a problem that would become known as decompression sickness, which was later included as one of two distinct pathophysiologies.
The desire to understand and ultimately prevent the occurrence of decompression-related injury spans the life and interest of many researchers, nations, and individuals. In order to better appreciate some historical context, we can refer to the early work of Robert Boyle (1627 – 1691) who identified pressure-related problems when he spotted bubbles in the eye of a decompressed snake. Those not familiar with Robert Boyle may be familiar with J.S. Haldane (1860 – 1936) who is credited with establishing the first set of decompression tables while under commission by the Royal Navy.
Meanwhile, individuals like Albert Buhlmann (1923 – 1994) helped develop the science of decompression during a rich university career, including work for military, commercial, and even recreational diving interests. Decompression enthusiasts are likely familiar with early work done by researchers like Brian Hills (1934 – 2006) who focused on incorporating the formation of bubbles into decompression algorithms. Certainly, these few people do not properly represent the science of decompression, and we could list dozens of other important individuals who heavily shaped the science. My intent here is only to highlight the span of more than 5,000 years during which humans have been reaching ever farther below the watery surface. This history also includes roughly 200 years of research by a wide range of individuals, organizations, and governments seeking to understand the complications of breathing gas under increased pressure.
The development of decompression practices proved successful even in their first use with caisson work, notably reducing the problems associated with breathing gas while under pressure. This progress extended into diving activity, and included the first tables produced by Haldane in 1908 for the British Admiralty. His tables remained in use by the Royal Navy until 1955. These developments supported longer and more aggressive diving activity, inaugurating a new age of discoveries and their associated challenges.
Advancement tends to remove some or even many risks but also creates the possibility for new problems. These might develop from the ability to push boundaries farther or because more people can become involved in a given activity. We tend to build upon early success, refining safety protocols and treating a progressively smaller subset of incidents. Over time, the strategies to reduce injury become more refined and, to some extent, more individualized.
For example, early cities were very dangerous places before fire protection, building standards, health codes, and similar protections. These practices became more refined, focusing on workers, home dwellers, children, and others. Most advanced societies are now quite safe, and additional levels of refinement continue to tease individual safety concerns while striving for the elimination of accidents—requiring notably more effort and expense to remove progressively smaller amounts of risk. It is hard to clearly identify our place on this curve when it comes to decompression sickness, but we appear fairly well into the diminishing returns part of the process.
Exploring high-pressure environments began when elaborate mining, tunneling, and bridge-building projects resulted in problems of unknown origin. In subsequent years, we identified an arguably well-defined illness with a relatively clear causality. Many details remain vague, but our ability to characterize the problem supported the development of decompression strategies that significantly reduced injuries associated with breathing gas under pressure. These developments resulted in algorithms that predicted safe exposures and were codified into decompression tables and used for progressively deeper diving excursions.
Today, decompression-related problems are extremely uncommon, especially within the recreational diving community. We now find ourselves mostly managing problems within a small subset of incidents. We strive for clarity among these low-probability injuries, seeking to improve or at least maintain safe guidelines while expanding our understanding. We typically acknowledge some influence from pre-existing conditions that, for whatever collection of reasons, might make a person more susceptible to injury. We also strive to discourage diving activity that violates defined ascent speed or time limits while trying to establish a solid understanding of the constellation of problems we call decompression sickness.
Meanwhile, the safety of decompression among those who use algorithms within uncharted territory remains less certain. Individuals who dive very deep and/or over very long times may be outside the range where safe dives can be predicted. For example, a decompression algorithm developed for dives up to 30m/100 ft for immersions as long as one hour may or may not extrapolate for dives of longer duration and depth. It requires a great many dives in order to verify that a particular exposure will result in low risk for most people. Given the high cost, added complexity, and safety risk, these important data points are particularly limited with dives that are very deep and/or long. This is something we return to in a later discussion.
For the moment, we are mostly focused on dives with good supporting data and where notable improvement appears unlikely. Much of the sometimes raucous debate over decompression “correctness” involves teasing arguably minor benefits from already very low levels of risk. Can we change this reality? Can we find something that brings substantial improvement, perhaps allowing much longer dives with even shorter decompressions?
In thinking about the “problem” of decompression, we understand that scuba diving increases the pressure around us, also known as increased ambient pressure. We are now breathing gas that is at a higher pressure than normally exists in our body. The molecules we are breathing become dissolved in our blood, where they are transferred during normal circulation and accumulate in the tissues of our body. This occurs until the tissues are “full” or, more precisely, until they are saturated at the new inspired gas pressure. Reductions in the surrounding pressure reverse the gradient and encourage the molecules to leave the tissues through the blood.
Algorithms that strive to characterize this process are known as dissolved gas models. The transfer of dissolved gas from the tissues often results in the formation of bubbles in a way that is similar to releasing pressure from a carbonated beverage. Dissolved gas models do not ignore the risk of bubbles but also do not attempt to directly control their development. Attempts to directly limit the formation and development of bubbles are known as bubble models.
We imagine that both dissolved gas and bubbles are relevant and also that other individual factors play some role. The problems in finding the best strategy are numerous, but most will be managed in a later discussion. For now, I wish to highlight that tracking of dissolved gas has been our primary strategy, consuming all but a relative handful of the many decompression experiments through the history of decompression research.
Modeling bubbles is inevitably more theoretical and based upon mathematically derived predictions about bubble behavior, sometimes supported by lab experiments that measure the likelihood of bubble formation under certain conditions. Models can also be crafted as “dual-phase,” meaning they anticipate bubble development but also track dissolved gas, striving to ensure that both are within safe parameters. In all cases, we tend to develop more confidence in models that are tested empirically, though they may also be compared to a database of outcomes, supporting evaluation and calibration of the model particulars. The most modern approach is trending toward probabilistic models, and we will explore these in future treatment.
The presence of bubbles during decompression is well known, and to some extent is measurable by Doppler testing, which can detect bubbles in the venous part of the circulatory system. The venous system receives blood from tissues that are eliminating gas absorbed while diving, so the presence of at least some bubbles are expected. Unfortunately, there are many complications to the use of Doppler as a means to gauge decompression efficiency. Measures of venous bubbles may be useful for predicting decompression stress in populations of divers, but it fails to be a reliable measure of symptoms in an individual diver.
Despite the complications, most researchers agree that bubbles (though not necessarily those detectable in the venous blood) are a critical part of the causal chain. The consensus seems to be that these bubbles either directly cause decompression sickness and/or contribute to its severity. Even if we assume bubbles cause all decompression-related symptoms, predicting their effects might be overly complicated. Albert Buhlmann, a great contributor to dissolved gas models, knew about and acknowledged the relevance of bubbles. He nonetheless focused upon refining dissolved gas strategies as a way to minimize risk of decompression sickness. We don’t yet know if this is the best strategy, but it has been quite successful at allowing a very low level of risk during most dives.
Tracking other markers that might affect symptoms of decompression sickness is conceivable and is part of a body of research that seeks to better understand the full scope of decompression problems. For example, researchers are exploring immune-response factors, including genetic influences that might be involved in the body’s reaction to decompression. We might also learn more about heart rate variability (HRV), which has become popular as a way to measure physiological stress in the world of sport and exercise, and its potential involvement in DCS. These or other techniques could conceivably be used to establish upper limits on the stress accumulation that occurs during decompression, presumably avoiding some upper threshold before symptoms become problematic.
We might also find ways to reduce decompression time by eliminating or changing the gas at the source of the problem. For example, we might eventually manage to use a liquid carrier for the oxygen that sustains our lives. By eliminating or greatly reducing use of gases like nitrogen or helium, we should be able to notably change the relevance of bubbling during changes in pressure. Or, we might develop ways to prevent or greatly reduce the risk of bubble formation by using drugs or other prophylactics that could physically alter the circumstances under which bubbles form. These ideas and many others have been explored and may hold promise, but nothing that greatly departs from current practice appears likely in the foreseeable future.
Despite reasonable uncertainty about many details in decompression sickness, including the exact incident rate of DCS, which is unknown, divers following conventional decompression tables and diving within well-established limits have a very low risk of injury with rates of 0.01-0.1% per dive or about 1-10 incidents per 10,000 dives (the higher end reflecting rates for commercial dives, the lower end reflecting technical, scientific, and recreational dives). The risk is greater for certain types of very aggressive dives, but we will explore that aspect in a later discussion. Regardless of the actual risk, few divers would knowingly choose a less efficient ascent profile if a better option was available.
The pursuit of decompression efficiency is particularly relevant for the group of divers known as technical divers. For these divers, arguably small differences can involve additional hours decompressing in the water. These divers have been particularly interested in the problem of bubbles that might develop during long ascents in deep water. Many tech divers followed early research that concluded slower ascents from depth could greatly reduce decompression time. For some years, the convention of using “deep stops” to slow a diver’s ascent seemed to be the best way forward. Yet, new research argues they are actually part of the problem. Whether or not you feel sure about the value of deep stops, I hope you will join us for some engaging online discussions and especially for future sections as we dig deeper into areas that do not commonly appear in discussions orbiting decompression or deep stops. I look forward to reading your thoughts in the comments section and hope you will join part two of our series: “Tech Divers, Deep Stops, and the Coming Apocalypse”.
Please come back in two weeks when we release the next part in this series from President Jarrod Jablonski.
Jarrod is an avid explorer, researcher, author, and instructor who teaches and dives in oceans and caves around the world. Trained as a geologist, Jarrod is the founder and president of GUE and CEO of Halcyon and Extreme Exposure while remaining active in conservation, exploration, and filming projects worldwide. His explorations regularly place him in the most remote locations in the world, including numerous world record cave dives with total immersions near 30 hours. Jarrod is also an author with dozens of publications, including three books.
Learning from Others’ Mistakes: The Power of Context-Rich “Second” Stories
Proper storytelling is a key to learning from the mistakes of others. Human Factors consultant and educator Gareth Lock explains the power of context-rich stories to inform and help us to develop the non-technical skills needed to make better decisions, communicate more clearly, and lead/teach more effectively.
by Gareth Lock
Header image courtesy of Gareth Lock. Divers from Red Sea Explorers’ examining a magnificent gorgonian coral.
Diving can be a fun, sociable, and peaceful activity; it can be challenging and technically difficult; and it can be a way of escaping the hustle and bustle of modern life. Sometimes new wrecks are discovered, caves have new line laid in them, new encounters with wildlife are experienced, and in many cases, courses are completed where both instructors and students have learned something new.
However, it can also be scary, harrowing and frightening if things don’t go to plan or if the plan was flawed in the first place.
Fortunately, the majority of dives which take place are the former and we consider the outcomes to be positive. If we think about it, the goal for every dive should be to surface, having had an enjoyable time, with gas reserves intact and no-one feeling physically or emotionally injured. But how do we achieve this goal considering the inherent risks we face while diving?
The easy answer would be to have effective training, to have the correct equipment, and to have and apply the right mindset. These three things together then lead to safe diving practices. You could say that the majority of safe diving practices and safely designed and configured equipment comes from feedback following accidents, incidents, and near misses. You only have to look at the work which the late, famed cave explorer Sheck Exley did in terms of cave diving fatalities and his “Blueprint for Survival” to see how procedures and equipment have evolved.
What do we learn?
There are accident and incident reports available to us. What do we learn from them? Bearing in mind that the majority of reports which divers see are either in social media or summarised in reports like the Divers Alert Network Annual Incident Report or the BS-AC Annual Incident Report.
For example, the following incident reports are written in a style similar to those you would find on social media or in an organization’s incident report.
An inexperienced diver entered the water to provide support for a guided dive to 24m. They got separated from their buddy, made a rapid ascent to the surface after nearly running out of gas. They were recovered on the boat without any symptoms of DCS being present.
A diver on the final dive of a rebreather training course entered the water from a dive boat. The diver swam to the side of the boat to receive their bailout cylinder to clip on. While sorting their gear out alongside the boat, they appeared to go unconscious and descend below the surface. The diver was recovered from 38 m/124 ft and despite CPR and first aid being applied, they were pronounced dead on arrival at the hospital ER. On inspection, the oxygen cylinder on their rebreather was found to be turned off and the controller logs showed that the pO2 had dropped to 0.05 while they were on the surface.
How much learning do you get from these reports? What emotions did you feel while reading them? What did you think was the primary cause of each of these events? If you were to choose two or three words to describe the causes, what would they be?
Human error? Complacency? Inexperience? Rushing? Not paying attention? Overconfidence? Naivety? Arrogance? Stupidity? Who was it? Where was the instructor? Were they certified? Which agency? Were they qualified?
All of these are normal responses, and they make up the first story.
The First Story
The first story is the narrative we hear, and we start to make immediate judgments on. We can’t help making judgments, even when we try not to. We make judgments because we compare the stories we’ve just read or heard to our own previous experiences. We match patterns to what we ‘know’ and then fill in the gaps with what we think happened, all the time thinking about whether it was the ‘right thing’ to do based on our own experiences.
This ‘filling in gaps’ is normal human behavior. Because our brains are constantly trying to make sense of the situation when we don’t have enough information about a scene or a situation, we reflect on what we’ve seen, read, and heard in the past and then make a best guess or closest fit. During this process, we will be subject to a number of biases, and one of the strongest at this stage is called confirmation bias. This is where we think we know the answer to the question, then as we read or hear something in the story that aligns with our reasoning, we stop looking any further because we have confirmed our suspicions.
In many cases, we carry on and don’t think anything of the learning opportunities presented because we know what happened, we know that ‘we wouldn’t do that’ because we would have spotted the issue before it became critical. We often make use of counterfactuals (could have, should have, and would have) to describe how the incident could have been prevented.
Unfortunately, this means that often we don’t learn. There is a difference between a lesson identified and a lesson learned—a lesson learned is where we make a conscious decision to accept how we do things based on the conditions and outcomes, or we actually put something in place which is different than what was there before and see how effective it is to resolve the problem encountered.
If we are to make improvements, we need to look at the errors, mistakes, and deviations that were made. However, we must recognize that errors are outcomes, not causes of adverse events. If we want to stop an adverse event from occurring, we need to look closer at the conditions which led to the error occurring i.e., the error-producing conditions.
The easiest way to look for error-producing conditions in an event that has already happened is to get those involved to tell context-rich stories. This becomes the second story.
The Second Story
Second stories look much deeper than what we first hear. They look at the context, the local rationality, the conditions, especially those conditions which might lead to errors. Ultimately, they expose the inherent weakness and gaps in any system, where the system includes people, paperwork, equipment, relationships, the environment and their interactions.
Second stories also highlight how divers and instructors are constantly adapting and changing their behaviors/actions to deal with the dynamic nature of diving. They describe ‘normal work’. This adaptation could be moving dive sites, increasing or reducing the time for a course, the order in which skills are taught or the amount of gas used/planned for a dive. Second stories describe the difference between ‘Work as Imagined’, which is what is written down, what is expected to happen, and against which compliance is assessed, and ‘Work as Done’ which is what actually happens in the real world and takes into account the pressures, drivers, and constraints which are faced by those on the dive or the course.
The easiest way to see what a second story looks like is to tell it, and the following account is the same recreational event as above but told as a second story.
An Advanced Open Water (AOW) diver with around 50 dives was acting as an ‘assistant’ to the instructor and dive-centre owner on a guided dive with five Open Water (OW) divers and recent graduates from the school they themselves had learned at. The AOW diver felt a social obligation to help the Open Water Scuba Instructor (OWSI) who was leading the dive, because the OWSI had done so much to help her conquer her fear of mask-clearing during her own training. However, she was also wary that, over time, her role had moved from being a diver on the trip to being almost the divemaster by helping other divers out, which she wasn’t trained to do. In addition, the instructor regularly asked her, at the last minute, to help out and change teams to ensure the ‘experience’ dives happened.
On this particular occasion, the AOW diver was buddied with a low-skilled OW diver who acted arrogantly and did not communicate well. In fact, she didn’t believe that three of the five on this trip should have received their OW certificates, given their poor in-water skills. As they approached the dive site, the visibility could be seen to be poor from the boat and the surface conditions weren’t great. The instructor said to the AOW diver, “Don’t lose the divers. I want you at the back shepherding them.”
They entered the water and descended to 24 m/78 ft and made their way in the poor visibility. On two occasions, the OW buddy had to be brought back down by the AOW diver as they ascended out of control. At one point, the OW diver turned around quickly and accidently knocked the AOW diver into the reef. Unfortunately, the AOW diver became entangled in some line there, and the OW diver swam off oblivious to the entanglement. When the five divers and instructor reached the shot-line ready to ascend, the instructor realized the AOW diver was missing. The instructor couldn’t trust the five divers to ascend on their own and didn’t have enough time to wait at the bottom and conduct a search, so the six ascended. On the surface, the buddied OW diver said that the AOW diver had swum off looking at fish in a certain area.
In the meantime, the AOW diver had managed to free herself; but in her panic, while stuck on the bottom, she breathed her gas down to almost zero and had to do a rapid ascent. She surfaced, feeling very scared and sick with panic, just as the instructor was speaking to the other six on the surface. On seeing the AOW diver break the surface, the instructor swam to her but turned and shouted at the other divers, admonishing them for abandoning their buddy on the bottom. The AOW diver felt very alone and wanted to give up diving as she was not given the opportunity to tell her side of the story.
Observations on potential contributory factors and error-producing conditions:
- Deviation of standards on the part of the instructor/dive-center owner taking OW divers to 24 m/78 ft, maybe driven because of the need to generate revenue and offer something unique.
- Authority gradient between the instructor and AOW diver meant that the AOW diver felt they couldn’t end the dive before they even got in the water or once in the water.
- Inferred peer pressure to help out when they weren’t qualified or experienced enough to act in a supervisory role.
- Poor technical skills on the part of the OW divers and the AOW limited their situation awareness to be aware of hazards and risks.
- Limited awareness on the part of the instructor regarding the location of all the divers during the dive.
- Positive note – good decision on the part of the instructor to ascend with the five OW divers in poor conditions and not keep them on the bottom or get them to ascend on their own.
A full account of the second event can be found here where you can also download a guide which contains more detail than the video covers and also gives you details on how to run a learning event at your dive center or in your own classes.
We can see that the learning opportunities have increased in the second stories. They allow certain issues to be identified like time pressures, financial pressures, peer-pressure, authority gradient, teamwork, leadership, decision-making and situation awareness. These aspects are rarely captured or recounted in the narratives we see online or in incident reports. There are a number of reasons:
- They are often considered ‘common sense’,
- Our brains are constantly looking for simple answers to complicated or complex problems, and one of the easiest ways to do this is to find an individual or piece of equipment to ‘blame’ rather than look wider.
- Those involved don’t consider these factors to be important so they don’t write them down.
- Those involved don’t know about these error-producing conditions or human factors so they don’t know to include them.
- There is no formalised and structured investigation process for diving incidents by diving organisations to facilitate the capture, analysis and sharing of second stories.
Telling second stories isn’t enough to create learning though. We have to work out how to change our own behaviors, and that is where the free materials and courses which The Human Diver provides come in. They help develop these non-technical skills in divers, instructors, instructor trainers, and dive center managers/owners to help them make better decisions, communicate more clearly and lead/teach more effectively. Ultimately, it is about having more fun on the dive, and ending each dive with the goal described at the start of this article intact and creating learning in the process.
Since 2011, Gareth has been on a mission to take the human factors and crew resource management lessons learned from his 25 year military aviation career and apply it to diving. In 2016, he formed The Human Diver with the goal to bring human factors, non-technical skills and a Just Culture to the diving industry via a number of different online and face-to-face programmes. Since then, he has trained more than 350 divers from across the globe in face-to-face programmes and nearly 1500 people are subscribed to his online micro-class. In March 2019, he published ‘Under Pressure: Diving Deeper with Human Factors’ which has sold more than 4000 copies and on 20 May 2020, the documentary ‘If Only…’ was released which tells the story of a tragic diving accident through the lens of human factors and a Just Culture. He has presented around the globe at dive shows and conferences to share his passion and knowledge. He has also acted as a subject matter expert on a number of military diving incidents and accidents focusing on the role of human factors.
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