

Diving Safety
When Easy Doesn’t Do It: Dual Rebreathers in Extended-Range Cave Diving
Rebreather technology has enabled cave explorers to extend their underwater envelope significantly deeper and longer. As a result, a few teams are pushing beyond the practical limits of open circuit bailout and so have turned to bailout rebreathers. But they are not without challenges, as Tim Blömeke, who dives into the latest research and field experience, explains.
by Tim Blömeke. Lead image: KUR divers Bob Beckner and Derek Ferguson in the 124m/407 ft deep Mount Doom chamber in Weeki Wachee Spring, Florida, courtesy of Kirill Egorov.
Dual rebreathers are becoming a thing among the elite of extended-range cave diving. Yet the “Blueprint for Survival” for this type of equipment configuration has yet to be written, and practitioners are faced with difficult trade-offs between competing design goals—like fitness for purpose, logistical feasibility, simplicity, reliability, and ease of use, all of which interact with the peculiarities of human nature. A new research paper proposes a pathway for risk assessment.
The introduction of rebreathers has considerably extended the range of exploration in cave diving. This is true especially for deeper dives, where open circuit technology faces the combined challenges of greater required gas volumes and higher required helium content, which make such dives both difficult to execute logistically due to the sheer number of cylinders involved, and prohibitively expensive due to the amount of helium in each of these cylinders.
By conserving the metabolically inert components of the breathing gas (most notably the helium), the use of closed circuit rebreathers (CCR) eliminates a good chunk of this problem, but not all of it: Traditional CCR diving procedures require that each diver have enough open-circuit bailout gas available to safely end the dive in the event of a rebreather failure.
Granted, the amount of bailout gas required for a CCR dive is only a fraction of what would be needed to perform the same dive on open circuit, and if all goes well, the bailout gas will never be breathed by anyone and can be reused for future dives. However, bleeding-edge explorers being who they are and doing what they do, after having used their CCRs to push the range of operations a few miles deeper into the cave systems, they began to encounter an issue very similar to the one that prompted the switch to CCR in the first place: cost and logistics.
As a real-world example, bailing out from a long-distance cave penetration of 7,500 meters at an average diver propulsion vehicle (DPV) travel speed of 40 m/min takes 187 minutes. Assuming a mean ambient pressure of 6 ATA (50 m depth) and a respiratory minute volume (RMV) of 14 l/min, the amount of bailout gas (not including decompression) required to reach the entrance would be 15,708 liters, or more than seven AL80 cylinders filled to 200 bar. This RMV is likely not conservative enough, given the extreme distance and the possibility of a hypercapnic event being the cause of the bailout so, in practice, a safety margin of at about 50% would be added, giving a total of 10-11 AL80 bailout cylinders.
The required amount of bailout gas became too large to be carried on the person of the diver, so that cylinders again needed to be staged in a series of set-up dives. Preparations for extended range exploration dives became ever more involved, and logistics became just as difficult to manage as those of old-school open circuit dives–even more so, arguably, due to the considerably greater distance of the staging points from the cave exit. As happens so often, overcoming one obstacle resulted in the discovery of others further down the road.

New safety concerns started to appear as well: For large-scale exploration projects, bailout cylinders needed to remain in a cave system for months at a time, sustaining severe corrosion damage at the tank neck and tank valve interface in the process due to the galvanic reaction between the chrome-plated brass valve and the aluminum cylinder. This isn’t merely a hypothetical concern: On many occasions, the corrosion was so severe that the integrity of the seal was compromised, and explorers found their previously staged bailout cylinders empty when checking them on their way into the cave. While this can be counteracted by installing a magnesium anode on the cylinder (magnesium is lower in the Galvanic series than aluminum and replaces the latter in the reaction), explorers found that the countermeasure only mitigates the issue but does not eliminate it. Long story short, for extreme extended-range dives, open circuit bailout was becoming ever more impractical and problematic.
Enter The Bailout Rebreather
As a solution to these problems, some explorers began to do away with open circuit bailout altogether and carry a redundant rebreather system—a closed circuit rebreather, or a semi-closed rebreather (SCR) instead. While this practice has gained significant traction recently, the concept itself isn’t new. In his book The Darkness Beckons, famed Welsh explorer Martyn Farr reports that his German colleague, pioneering cave diver Jochen Hasenmayer, had experimented with a dual unit he dubbed the Speleo-Twin Rebreather (STR-80) as early as 1981.

In 1987, Dr. Bill Stone delivered a proof of concept by spending 24 hours underwater on a dual CCR, he dubbed “Failsafe Rebreather for Exploration Diving” (FRED), during his visionary Wakulla Springs Project 1987. However, it appears that the first person to utilize redundant rebreathers in actual exploration was Olivier Isler from Switzerland. On August 12, 1990, he first used a triple RI2000 semi-closed unit in his crossing of the Emergence du Ressel (Doux de Coly, France), covering a distance of 1850 m/6070 ft at a maximum depth of 81 m/266 ft. The following year, Isler went on to push through the 4000 m/2.5 mi penetration barrier for the first time. More than a decade later, in 2002, Reinhard Buchaly and Michael Waldbrenner pushed the exploration of the Doux de Coly farther using dual RB80s, which were originally designed by Buchaly and continue to be produced to this day by Halcyon.

The decision to replace open-circuit bailout with a rebreather is as obvious as it is bold: Obvious because it replicates the successful solution to a past problem and restores the ability of a diver to carry all the gas they need on their person. Bold because… well. Put yourself in the drysuit boots of a cave diver, hours and hours away from the surface, who just survived an assassination attempt by a complex piece of life support equipment. All technical aspects aside, wouldn’t it be reassuring to fall back on a less complex piece of life support equipment whose proper functioning can be ascertained reliably within a few seconds?

Expressed in numbers, a paper by Andrew Fock, Analysis of recreational closed-circuit rebreather deaths 1998-2010, published in 2013, analyzed dive accident statistics for the period from 1998 to 2010 and found that CCR diving is associated with an increase in the risk of death by a factor of up to ten compared with open circuit diving. That ratio essentially applied to CCR dives, which used open circuit bailout. Rebreather technology and diving practices certainly have improved since the time under investigation, but the fact still remains that the complexity of the equipment adds to the overall risk.
With this in mind, taking a closer look at and trying to define the specific risks and benefits of replacing open-circuit bailout with a redundant SCR or CCR seems a reasonable idea. And this is precisely what a team of authors headed by Derek B. Covington did in a recent (March 2022) research paper, asking the question, “Is more complex safer in the case of bailout rebreathers for extended range cave diving?”
Using a qualitative approach, the authors discuss the reasoning behind bailout rebreather use, its history, different configurations and the various advantages and disadvantages and, finally, the additional potential for human error created by increasing the complexity of the equipment.

Bailout SCR vs. Dual CCRs
In terms of configurations, there are two main choices for a bailout rebreather: SCR or CCR. With an SCR, the diver still has to carry bailout gas. However, an SCR (such as the side-mounted Halcyon RBK) extends the use of this gas by a factor somewhere between four and ten, thereby drastically reducing the number of cylinders needed while being only the size of a single AL80 cylinder itself. Other advantages of a bailout SCR are that its relative simplicity and lack of sensors or other electronics make it much easier to set up, maintain, and use than a secondary CCR.
These advantages, however, do not come without downsides. With an SCR, the diver does not have the option of adding oxygen into the loop, and the actual oxygen content of the gas breathed is always somewhat lower than the oxygen content of the gas in the cylinders carried. How much lower exactly depends on the portion of the gas vented into the water on each operating cycle of the unit—or the rate of fresh gas supply into the unit—as well as the metabolic needs of the diver.
Therein lies the crux: For normal operation, the amount of oxygen consumed by the diver, and thus the resulting effective composition of the breathing gas, can be calculated quite reliably. In a bailout scenario, however, it isn’t unlikely for the metabolic needs of the diver to be increased due to higher workload. Without sensors to measure PO2, the precise composition of the breathing gas in the SCR loop becomes unknown, creating a risk of hypoxia, with all the potential consequences that come with it. This risk is unique to SCRs and not present when diving open circuit (where the cylinder sticker tells us what we’re breathing) or while on a CCR (where sensors tell us what we’re breathing).
The other approach is to go for a redundant CCR, as Stone envisioned back in 1987. While seemingly the “purest” in concept—replacing like with like—and optimizing redundancy, the added complexity is significant. Everybody who owns a CCR (especially an eCCR) knows that these machines need lots of love to remain in good working condition. Now multiply that by two: twice the number of sensors, two scrubbers, two sets of primary electronics, two sets of secondary electronics … and that’s just out of the water.

To have the redundant system available to them at all times during the dive, divers now need to manage the contents of two breathing loops instead of one. Furthermore, in order to be able to provide assistance in the event of a problem, divers working in a team need to be aware of the failure modes of and emergency procedures for not only their own units, but also the units used by their teammates. Unless everybody on the team is using the same machines for primary and bailout, this considerably adds to the training requirements, as well as to the complexity of the decision-making tree in an emergency situation. Nevertheless, by maximally reducing the required amount of gas to be carried by each diver, a redundant CCR theoretically provides the greatest degree of independence and offers the greatest potential range of exploration.
Approaches to Risk Assessment
To date, the use of dual rebreathers is still too rare for a quantitative, empirical assessment of its safety to be practical, and there is no systematic process in place for collecting data on dual-rebreather dives. “It’s really almost impossible to put a number on it,” said researcher and explorer Andy Pitkin, who co-authored the study. “I think there are only a small number of divers in the world who really need a bailout rebreather, but there are probably quite a few who use them because the idea appeals to them more than using OC bailout. Of course, there is no hard dividing line between the two groups. Where does logistical difficulty become impossible? That’s a very subjective judgment.”
The diversity of configurations and procedures used is another obstacle to objective study. “Are we using identical primary and bailout rebreathers, or is one unit specifically designed as a backup? If the latter, should the bailout unit be another CCR or an SCR? If the former, what are the diving procedures? Does the diver switch between loops at regular intervals, analogous to the procedures for independent doubles or sidemount diving? This would arguably add to task loading. Do the units have separate DSVs or a single, shared one, like that used by Richard Harris and Craig Challen of the Wet Mules? If the diver doesn’t alternate between units, then what other procedures are in place to ensure that both loops remain breathable at all times, especially during depth changes? If using dual CCRs, then what is the approach to ensuring redundancy of the diluent and oxygen supplies?”

The number of open questions and the range of possible, viable answers seem endless. Similar to the situation in the early days of cave diving, the book on bailout rebreathers has yet to be written. While many of the timeless principles from Sheck Exley’s famous booklet, Basic Cave Diving: A Blueprint for Survival continue to apply accordingly, there is no broad consensus yet on best practices, no SOP Manual, no standardized configuration, no published training standards for dual rebreather diving by any training agency. People are still working things out for themselves or their teams.
In consideration of these difficulties, and as a starting point for a discussion, the authors of Is more complex safer… propose a generalized approach to assessing the risks of dual-rebreather diving. Rather than delving into the minutiae of the failure modes of each individual diver’s equipment setup and diving procedures, they outline a method for identifying potential error-producing conditions (i.e., opportunities for human operators to make mistakes) based on a theoretical model originating in risk assessment for nuclear power plants: the WITH/TWIN model (Table 1). The acronym WITH stands for Workplace Design, Individual Capabilities, Task Design, Human Nature. TWIN refers to the same items (Task, Workplace, Individual, Nature).

The underlying idea of this approach is to move beyond merely looking at “human error” prima facie—oh, the diver failed to pack his scrubber properly? How could they! They neglected to monitor their PO2? Pay more attention!—and instead, analyze the conditions that are conducive to such errors. For the purposes of the model, a diver’s equipment configuration is part of their Workplace, their training and fitness belong in Individual Capabilities, the mission, including not only managing one’s gear but also navigation, linework, photography/videography, and surveying fall under Task.
All these aspects interact with Human Nature. We get stressed when things get exciting, we get complacent when things go smoothly. We are prone to false assumptions, we are terrible at intuitive probability assessment, and our ability to pay attention falls off rapidly once the number of items that need our attention increases significantly beyond the number of voices in our heads. Much like running a nuclear power plant, excellence in cave diving isn’t achieved by sporadic strokes of genius but instead by consistently avoiding mistakes, and an important aspect of the design of equipment and procedures for either is to compensate for the inherent weaknesses of the human mind.
In the words of the study’s authors:
“Divers and explorers need to consider not just the technical aspects of operating the dual CCR as an equipment-based system, but also the socio-technical aspects and error-producing conditions that adding additional complicated equipment has to the wider system, especially when it comes to training for and executing abnormal operations when workout levels will be high and awareness will be reduced. Nonetheless, as the use of this configuration grows, the risks and benefits will become clearer to investigators and divers alike.”
It will be exciting to observe the future development of dual-rebreather diving as it matures and see where the consensus for best practices will end up… stay tuned and stay safe!
References:
Diving and Hyperbaric Medicine: Is more complex safer in the case of bail-out rebreathers for extended range cave diving? Derek B Covington, Charlotte Sadler, Anthony Bielawski, Gareth Lock, Andrew Pitkin
Fock AW. Analysis of recreational closed-circuit rebreather deaths 1998-2010. Diving Hyperb Med. 2013;43(2):78-85.
NSS-CDS (free download): Basic Cave Diving: A Blueprint for Survival by Sheck Exley
Dive Deeper
aquaCORPS N12: Designing a Redundant Life Support System by William C. Stone (1995)
InDEPTH: The RB80 Semi-closed Rebreather: A Successful Exploration Tool by David Rhea
Halcyon: Using The RB80 As A Side-mounted Bailout Rebreather by Andy Pitkin, Karst Underwater Research (2018)I
InDepth: Rebreather Holiday Shopping Guide (2020)
aquaCORPS Pioneer Interviews: Stoned: Interview With Dr. William Stone (1994) by Michael Menduno
InDEPTH: Diving Beyond 250 Meters: The Deepest Cave Dives Today Compared to the Nineties by Michael Menduno and Nuno Gomes
Deep Tech: Victory At Last (1998) by John Simenon: Olivier Isler is setting penetration records with a triple-redundant semi-closed rebreather

Tim Blömeke teaches technical and recreational diving in Taiwan and the Philippines. He is also a freelance writer and translator, as well as a member of the editorial team of Alert Diver. For questions, comments, and inquiries, you can contact him via his blog page or on Instagram.
Diving Safety
Does The Sport Diving Community Learn from Accidents?
Do we learn from accidents as a diving culture and, as a result, take the actions, where needed, to improve divers’ safety? Though we might like to think that’s the case, the reality is more complicated as human factors coach Gareth Lock explains in some detail. Lock offers a broad six-point plan to help the community boost its learning chops. We gave him an A for effort. See what you think.
by Gareth Lock

Learning is the ability to observe and reflect on previous actions and behaviours, and then modify or change future behaviours or actions to either get a different result or to reinforce the current behaviours. It can be single-loop, whereby we only focus on the immediate actions and change those, e.g., provide metrics for buoyancy control during a training course, or double-loop where the underlying assumptions are questioned, e.g., are we teaching instructors how to teach buoyancy and trim correctly? The latter has a great impact but takes more time, and more importantly, requires a different perspective. Culture is the ‘way things are done around here’ and is made up of many different elements as shown in this image from Rob Long. Learning culture is a subset of a wider safety culture.

Regarding a safety culture, in 2022 I wrote a piece for InDEPTH, “Can We Create A Safety Culture In Diving? Probably Not, Here’s Why,” about whether the diving industry could have a mature safety culture and concluded that it probably couldn’t happen for several reasons:
- First, ‘safe’ means different things to different people, especially when we are operating in an inherently hazardous environment. Recreational, technical, cave, CCR and wreck diving all have different types and severities of hazards, and there are varying levels of perception and acceptance of risk. The ultimate realisation of risk, death, was only acknowledged in the last couple of years by a major training agency in their training materials. Yet it is something that can happen on ANY dive.
- Second, given the loose training standards, multiple agencies, and instructors teaching for multiple agencies, there is a diffuse organisational influence across the industry which means it is hard to change the compliance-focus that is in place. From the outside looking in, there needs to be more evidence of leadership surrounding operational safety, as opposed to compliance-based safety e.g., ensuring that the standards are adhered to, even if the standards have conflicts or are not clear. This appears to be more acute when agencies have regional licensees who may not be active diving instructors and are focused on revenue generation and not the maintenance of skilled instructors. There is very little, if any, evidence that leadership skills, traits or behaviours are taught anywhere in the diving industry as part of the formal agency staff or professional development processes. This impacts what happens in terms of safety culture development.
- Finally, the focus on standards and rules aligns with the lowest level of the recognised safety culture models – Pathological from Hudson. Rules and standards do not create safety. Rules facilitate the discussion around what is acceptably safe, but they rarely consider the context surrounding the activities at the sharp end, i.e., dive centres and diving instructors and how they manage their businesses. These are grey areas. There is a difference between ‘Work as Imagined’ and ‘Work as Done,’ and individual instructors and dive centre managers must both ‘complete the design’ because the manuals and guides are generic, and manage the tension between safety, financial pressures, and people (or other resources) to maintain a viable business. Fundamentally, people create safety not through the blind adherence to rules, but through developed knowledge and reflecting on their experiences, and then sharing that knowledge with others so that they, too, may learn and not have to make the same mistakes themselves.

The proceeding discussion brings us to the main topics of this article, does the diving industry have a learning culture, and what is needed to support that learning culture?
What is a learning culture?
In the context of ‘safe’ diving operations, a learning culture could be defined as “the willingness and the competence to draw the right conclusions from its safety information system, and the will to implement major reforms when their need is indicated.” (Reason, 1997). Here we have a problem!
‘Willingness…’
The industry is based around siloed operations: equipment manufacturers, training agencies, dive centres/operations, and individual instructors. Adopting a genuine learning approach means that the barriers must be broken down and conversations happen between and within the silos. This is very difficult because of the commercial pressures present. The consumer market is small, and there are many agencies and equipment manufacturers that are competing for the same divers and instructors. Also, agencies and manufacturers have competing goals. Agencies want to maximise the number of dive centres/instructors to generate revenue, and one of the ways of doing that is to maximise the number of courses available and courses that can be taught by individual instructors e.g., different types of CCR units. Manufacturers don’t want to realise the reputational risk because their equipment/CCR is involved in a fatal diving accident, but they also want to maximise their return on investment by making it available to multiple agencies and instructors. The higher-level bodies (WRSTC, RTC, and RESA) are made up of the agencies and manufacturers that will inherit the standards set, so there is a vested interest in not making too much change. Furthermore, in some cases, there is a unanimous voting requirement which means it is easy to veto something that impacts one particular agency but benefits many others.
‘Competence…’
This will be expanded in the section below relating to information systems as they are highly interdependent.
What safety information systems do we have in the diving community?
Training agencies each have their own quality assurance/control/management systems, with varying levels of oversight. This oversight is determined by the questions they ask, the feedback they receive, and the actions they take. These are closed systems and based around compliance with the standards set by the agency – sometimes those standards are not available to be viewed by the students during or after their class! Research has been carried out on some of this quality data, but it appears to have focused on the wrong part e.g., in 2018, a paper was published by Shreeves at al, which looked at violations outside the training environment involving 122 diving fatalities. While the data would have been available, a corresponding research project involving fatalities inside the training environment was not completed (or if it was, it wasn’t published in the academic literature).
As the ex-head of Quality Control of a training agency, I would have been more interested in what happened inside my agency’s training operations than what occurred outside, not from a retributive perspective, but to understand how the systemic failures were occurring. I also understand that undertaking such research would mean it would be open for ‘legal discovery’, and likely lead to the organisation facing criticism if a punitive approach was taken rather than a restorative one.
Safety organisations like Divers Alert Network collect incident data, but their primary focus is on quantitative data (numbers and types of incidents), not narrative or qualitative data – it is the latter that helps learning because we can relate to it. The British Sub Aqua Club produce an annual report, but there is very limited analysis of the reported data, and there does not appear to be any attempt made to look at contributory or influential factors when categorising events. The report lists the events based on the most serious outcome and not on the factors which may have influenced or contributed to the event e.g., a serious DCI event could have been caused by rapid ascent, following an out-of-gas situation, preceded by a buddy separation, and inadequate planning. The learning is in the contributory factors, not in the outcome. In fairness, this is because the organizations do not have to undertake more detailed investigations, and because the information isn’t contained in the submitted reports.
Research from 2006 has shown that management in organisations often want quantitative data, whereas practitioners want narrative data about what happened, how it made sense, and what can be done to improve the situation. Statistical data in the diving domain regarding safety performance and the effectiveness of interventions e.g., changes to the number of fatalities or buoyancy issues is of poor quality and should not be relied upon to draw significant conclusions.

What is required to populate these systems?
There are several elements needed to support a safety information system.
- Learning-focused ‘investigations’.
- Competent ‘investigators’.
- Confidential and collaborative information management and dissemination systems.
- Social constructs that allow context-rich narratives to be told.
Learning-focused ‘investigations’. The diving industry does not have a structured or formal investigation or learning process, instead relying on law-enforcement and legal investigations. Consequently, investigations are not focused on learning, rather they are about attributing blame and non-compliance. As Sidney Dekker said, “you can learn or blame; you can’t do both”. The evidence that could be used to improve learning e.g., standards deviations, time pressures, adaptations, poor/inadequate rules, incompetence, and distractions… are the same elements of data that a prosecution would like to know about to hold people accountable. Rarely does the context come to the fore, and it is context that shapes the potential learning opportunities. “We cannot change the human condition, but we can change the conditions in which humans work.” (James Reason). Rather than asking ‘why did that happen’ or even ‘who was to blame’, we need to move to ‘how did it make sense to do what they did’. ‘Why’ asks for a justification of the status quo, ‘how’ looks at the behaviour and the context, not the individual.
Competent ‘investigators’. As there isn’t any training in the diving domain to undertake a learning-focused investigation, we shouldn’t be surprised that the investigations focus on the individual’s errant behaviour. Even those ‘investigations’ undertaken by bodies like DAN, the NSS-CDS Accident Committee or the BSAC do not involve individuals who have undertaken formal training in investigations processes or investigation tools. A comprehensive learning review is not quick, so who is going to pay for that? It is much easier to deflect the blame to an individual ‘at the sharp end’ than look further up the tree where systemic and cultural issues reside. The education process for learning-focused investigations starts with understanding human error and human factors. The Essentials class, 10-week programme, and face-to-face programmes provide this initial insight, but the uptake across the industry, at a leadership level, is almost non-existent. Four free workshops are planned for Rebreather Forum 4.0 to help address this.
Confidential information management system. Currently, no system allows the storage of context-rich diving incident data outside the law-enforcement or legal system in a manner that can be used for learning. After discussions with senior training agency staff, it appears that as little as possible is written down following an incident. When it is, it is shared with the attorney to enable the ‘attorney-client’ privilege to be invoked and protected from discovery. If internal communications occur via voice, then the potential learning is retained in the heads of those involved but will fade over time. Furthermore, if they leave that role or organisation, then the information is almost guaranteed to be lost.
Social Constructs: Two interdependent elements are needed to support learning: psychological safety and a “Just Culture.” With the former, the majority of modern research strongly suggests that it is the presence of psychological safety that allows organisations to develop and learn (Edmondson, 1999). Edmondson describes numerous case studies where organisational and team performance was improved because incidents, problems, and near-misses were reported. Paradoxically, the more reports of failure, the greater the learning. It was not because the teams were incompetent; they wanted to share the learning and realised that they could get better faster with rapid feedback. They also knew that they wouldn’t be punished because psychological safety is about taking an interpersonal risk without fear of retribution or reprisal – this could be speaking up, it could be challenging the status quo, it could be saying “I don’t know”, or it could be about trying something new and coming up with an unexpected outcome.
The second requirement is a Just Culture which recognises that everyone is fallible, irrespective of experience, knowledge, and skills. This fallibility includes when rules are broken too, although sabotage and gross negligence (a legal term) are exceptions. Neither a Just Culture nor psychological safety are visible in the diving industry, although some pockets are present. To support psychological safety (proactive/prospective) and a Just Culture (reactive), there is a need for strong, demonstrable leadership:
- Leaders who have integrity – they walk the talk.
- Leaders who show vulnerability – talking about their own mistakes including the context and drivers; leaders who want to look at organisational issues inside their own organisation – not just point fingers at others problems.
- Leaders who recognise that human error is only the starting point to understand something going wrong, not the end.
‘…the will to implement major reforms…’
This is probably the hardest part because learning involves change. Change is hard. It costs cognitive effort, time, and money, and this has an impact on commercial viability because of the need to generate new materials, to educate instructor trainers/instructors and divers about the change and do it in multiple languages. Unless there is a major external pressure, e.g., the insurance companies threaten to withdraw support, things are unlikely to change because there aren’t enough people dying in a single event to trigger an emotional response for change. For example, in the General Aviation sector in the US approximately 350 people die each year, but if these deaths happened in airliners, it would mean two to three crashes per year, and this would be considered unacceptable.
In 2022, more than 179 people died diving in the US. (personal communications with DAN)
The most radical changes happen when double-loop learning is applied.
NASA did not learn from the Challenger disaster because it focused on single-loop learning, and when Columbia was lost, the investigation unearthed a lack of organisational learning i.e., double-loop learning. Chapter 8 from the Columbia Accident Investigation Board provides many parallels with the diving industry. The recent changes to PADI drysuit training standards following a fatal dive on a training course provide an example of single-loop learning – fix the ‘broken instructor’ and clarify course training requirements. The double-loop learning approach would be to look at self-certification and the wider quality management across the agency/industry; however, such an approach has significant commercial disadvantages across the board.

Creating a Learning Culture
The previous paragraphs talk about many of the issues we’ve got, but how do we improve things?
- Move to using a language that is learning-based, not ‘knowing’-based. This video from Crista Vesel covers the topic relatively quickly. This includes not using counterfactuals (could have, should have, would have, failed to…) which are informed by hindsight bias. Fundamentally, counterfactuals tell a story that didn’t exist.
- Look to local rationality rather than judging others. Move from who (is to blame) and ‘why did you do that?’, to ‘how did it make sense for you to do that?’. Separate the individual from the actions/behaviours and stop applying the fundamental attribution bias where we believe the failure is due to an individual issue rather than the context.
- Look to break down the barriers between the silos and share information. Ultimately, the stakeholders within the diving community should be looking to create a safe diving environment. Throwing rocks and stones at each other for ‘incompetence’ is not going to help.
- Adopt the Five Principles of Human and Organisational Performance as outlined in this blog.
- Build ‘If Only…’ or something produced for the recreational market, into training programmes at the instructor trainer, instructor, and diver level. This way the culture can slowly change by telling context-rich stories that have ‘stickiness’. However, this requires a fundamental shift in terms of how stories are told and how risk is portrayed in the diving industry.
- Finally, recognise we are all fallible. Until we accept that all divers are fallible and are trying to do the best they can, with the knowledge they have, the money they have, the resources they have, the skills they’ve acquired, and the drivers and goals they are facing, then we are unlikely to move forward from where we are, and we’ll keep choosing the easy answer: ‘diver error’.
DIVE DEEPER
InDEPTH: Examining Early Technical Diving Deaths: The aquaCORPS Incident Reports (1992-1996) by Michael Menduno
InDEPTH: The Case for an Independent Investigation & Testing Laboratory by John Clarke

Gareth Lock has been involved in high-risk work since 1989. He spent 25 years in the Royal Air Force in a variety of front-line operational, research and development, and systems engineering roles which have given him a unique perspective. In 2005, he started his dive training with GUE and is now an advanced trimix diver (Tech 2) and JJ-CCR Normoxic trimix diver. In 2016, he formed The Human Diver with the goal of bringing his operational, human factors, and systems thinking to diving safety. Since then, he has trained more than 450 people face-to-face around the globe, taught nearly 2,000 people via online programmes, sold more than 4,000 copies of his book Under Pressure: Diving Deeper with Human Factors, and produced “If Only…,” a documentary about a fatal dive told through the lens of Human Factors and A Just Culture.