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By Reilly Fogarty
Header image: Original Photo by Sean Romanowski, effects by the team at GUE HQ
There aren’t many technical divers exploring deeper than 153 m/500 ft on a regular basis—the logistical and physiological demands alone make sure of that. The small group of divers who do reach those depths without saturation chambers or other professional accoutrements face a daunting host of new concerns. At these depths, decompression models aren’t as well validated, and dives require precise gas planning and acknowledgement of extreme environmental exposures.
As if decompression illness (DCI) and oxygen toxicity risks weren’t enough, divers must prepare to deal with the possibility that they may get to depth and experience vertigo, confusion, seizures, and a varied list of other neurological maladies—sometimes without warning. These symptoms are the result of high-pressure nervous syndrome (sometimes called high-pressure neurological syndrome) or HPNS. Symptoms of HPNS are highly variable but primarily affect those who descend rapidly to 153 m/500 ft or deeper. HPNS may have played a role in the death of legendary cave explorer Sheck Exley, and it may have caused numerous close-calls in deep cave and wreck explorations. But, the extreme depth required to experience onset has relegated research and education on HPNS to a niche corner of the diving community—one with significant interplay with the commercial saturation diving world and the most extreme sport communities.
The Physiology of Deep Helium Diving
In 1961, G.L. Zal’tsman, who headed the Laboratory of Hyperbaric Physiology, St. Petersburg, Russia, first identified what would eventually become known as high-pressure nervous syndrome. The political climate of the period limited access to his work in the west, so credit for the discovery is often shared with Peter Bennett, D.Sc, who published a paper on the subject in 1965. While politics and international tensions separated them, both researchers described what they called “helium tremors” that occurred during experiments with military subjects. Using gases with the high helium content required to manage narcosis at depth, participants in these studies were observed experiencing uncontrollable muscle tremors upon compression in a chamber.
At the time, it was unknown if this was a function of the helium in their breathing gas or an effect of depth. The term “high-pressure nervous syndrome” originated just a few years after Zal’tsman’s study, when R.W. Brauer identified changes in the conscious states and electroencephalography data from subjects in a chamber dive to nearly 368 m/1,200 ft. In the decades since, several studies further illuminated what we now know as HPNS, primarily as a result of research into deep sea exploration from the 1970s to early 1990s. As it stands now, HPNS is primarily identified by a decreased mental status, dizziness, visual disturbances, nausea, drowsiness, muscle tremors, and seizures in divers rapidly reaching depths of 153 m/500 ft or more, or exploring the extremes of depth closer to 306 m/1,000 ft at any rate of compression while breathing a high helium content gas.
The prevailing theory is that a combination of speed of compression during descent, and the absolute pressure at depth, cause these symptoms. Symptoms are rare during dives above 153 m/500 ft, but dives that exceed that depth, or that reach depth quickly, increase the likelihood of symptom evolution. Symptoms do not appear to correlate to each other, and individual susceptibility is highly variable, which makes predicting onset difficult. Some researchers also theorize that there are two separate conditions caused individually by compression (the symptoms of which diminish at depth) and total pressure (the symptoms of which persist throughout the bottom portion of a dive). This two-part explanation for HPNS symptoms provides some interesting avenues for future research and could help solidify some of the theorized mechanisms underlying the condition, but it has yet to be expanded upon in a significant way.
The mechanism behind HPNS has yet to be proven, but most researchers choose to work upon the basis of a few reasonable theories. The first relies on the compression of the cell membranes in the central nervous system. In this model, the rapid compression of the lipid components of these membranes may alter the function of the inter-lipid structures that facilitate signal transmission within the central nervous system. This change in structure could facilitate hyperexcitability of some nervous system pathways and cause the types of tremors and seizures associated with serious HPNS cases. This membrane compression could also alter the signaling pathways required for motor function and cognition, resulting in confusion and assorted neurological symptoms that sometimes occur in divers with HPNS.
Another model focuses on the role of neurotransmitters themselves, rather than their signaling receptors. The various iterations of this model examine the effects of pressure and varying helium/oxygen exposures on the production or reception of these transmitters. In some ways, this method resembles our understanding of oxygen toxicity mechanisms, which could lead to some interesting interplay between future research projects and the balancing of oxygen and helium exposures at extreme depth. Some of the more promising studies in this area show evidence of NMDA receptor antagonists reducing convulsions in animal models, and describe the effectiveness of increased dopamine release in preventing increased motor activity under extreme pressure in rat models.
A third model focuses on the effect of helium on HPNS risk. This model functions on a yet-unidentified mechanism, but explores the potential distortion of lipid membranes by helium at depth. The data from these studies suggests that high pressure helium—not high hydrostatic pressure—may alter the tertiary structure of protein-lipid interactions and change signaling pathways within the nervous system. Numerous other avenues for research exist in this niche, including projects working on a great number of neurotransmitter related conditions and pre-treatment protocols for HPNS, oxygen toxicity, and possibly related normobaric diseases. Any of these models could prove accurate, but the interplay between the many neurotransmitters makes it most likely that a combination of these models will best illustrate what occurs in-situ.
Experienced firsthand, HPNS is far less academic, but equal parts confounding and terrifying. The variable onset and sometimes ambiguous symptom presentation make it difficult to discern from other conditions, and mild symptoms can be easily written off. By the same token, however, a serious bout of tremors or confusion as a result of a rapid descent to deep water can leave a diver terrified and unable to act. Dr. Richard “Harry” Harris, SC OAM, is a physician and technical diver with years of exploration in deep caves and shipwrecks. His experiences with HPNS mirror that of many. Most often, he’s observed symptoms like trembling hands or loss of coordination that could be attributed to either HPNS or the adrenaline rush of a fast hot-drop from a boat in heavy seas.
On one recent dive to 150 m/490 ft, Harris described becoming temporarily incapacitated on the bottom due to minor tremors, finding himself unable to clip his strobe to the shot line. The symptoms resemble common descriptions of mild HPNS symptoms, but the relatively shallow (in terms of HPNS, at least) depth still gives him pause when he tries to discern the specific cause of the symptoms. Dives past 200 m/656 ft have provided similar conundrums, but Harris has experienced tremors at extreme depths with enough regularity to notice that he is somewhat more susceptible than his regular dive buddy Craig Challen. “This [variation in symptom onset and presentation] has really made me question again the role of the mental state, approach, and perhaps even intentional mindfulness on these symptoms,” explains Harris.
By focusing on gas choices that strike a balance between gas density and the high concentrations of helium that can cause HPNS symptoms, and by descending relatively slowly, Harris has managed to alleviate symptoms on much deeper dives. A recent 245 m/799 ft dive with an intentionally slowed descent gave him none of the same complaints as his rapid descents to shallower water and felt “like a [much shallower] 150 m/490 ft dive.”
It’s worth noting at this point that Harris and Challen are extraordinarily capable and experienced divers, and HPNS is a condition that shouldn’t be taken lightly. Their approach—a combination of conservatism and safety—is likely key to their management of HPNS on extremely deep dives. Other divers, some equally experienced, have not been as fortunate in the past.
Sheck Exley reported a particularly bad case during a dive to 210 m/689 ft, with vision blurred to the extent that he was “looking through small circles with black dots, and started convulsing.” Despite these symptoms, he continued his dive, and proceeded to a maximum depth of 263 m/863 ft. It’s thought that Exley’s eventual death during an attempt to descend past 305 m/1,000 feet in the Mexican Zacatón cave system could have been caused in part by HPNS symptoms exacerbated by narcosis.
Nuno Gomes, a technical diver who holds several Guinness World Records for depth in open water and in caves, has also become intimately acquainted with HPNS, experiencing the following during a world record dive:
“As I descended past 250 m/816 ft, the HPNS set in. At first, relatively mild, then fairly strong. And later on, the symptoms became so extreme that my whole body shook uncontrollably. One other problem was lack of coordination of movement. I felt severely narcosed on my bottom trimix of 3.15/85. It had only a calculated END of 40 m/131 ft. From my experience, a more realistic narcosis level was 78 m/256 ft as calculated using the Total Narcotic Depth (TND). When I reached the tag marked 315 m/1,033 ft at an actual depth of between 322 m/1,056 ft and 323 m/1061 ft, I realized that this was as far as I was able to go. I was not sure that I would be able to return if I went any deeper. At that stage, I was not sure that I would be able to swim up from that depth.”
Gomes’s regular attempts to reach extreme depth made him uniquely prepared to identify symptoms of HPNS as they appeared, but even with his breadth of experience, the effects of the condition could have become lethal if allowed to continue.
Statistically, there just aren’t enough documented cases of HPNS to make for a meaningful analysis, but these incidents can provide a basis for education. The symptom severity and onset variability is enormous, but there are some trends that can be pulled from the stories of Harris, Exley, and Gomes. How to integrate those in your dive plan without meaningful data to back them up, however, falls to personal choice.
Planning for the Future
There are more than a few good reasons not to end this piece with a “how-to” on diving past 153 m/500 ft. With regard to HPNS specifically, the reality is that we just don’t know enough about the mechanisms that cause the symptoms divers experience. What we have is an understanding that high helium content and rapid descents likely contribute to HPNS risk, some people are more susceptible than others, and the symptom presentation is not uniform or predictable. Beyond these fundamental constants, we must piece together what we know from the limited research we do have and the experiences of others.
The data on compression speed appears to be pretty clear: HPNS symptoms may not be entirely preventable, but the risks can be somewhat ameliorated by slowing our descent speeds. There also appears to be an opposing effect between helium and nitrogen content in our breathing gas. This is likely due to changes in the structures of the membranes surrounding our central nervous system caused by helium and other inert gases, requiring divers to balance potential narcotic effects and HPNS risk in gas planning.
Using nitrogen as a protective gas seems counterintuitive, but in some extremely deep dives, adding just 5% nitrogen to a heliox mixture appeared to dramatically reduce HPNS symptoms in divers. However, the extent of practical efficacy remains to be seen. Promising studies researched using hydrogen to minimize HPNS risk, but this avenue of research is prohibitively expensive and logistically challenging due to the inherent fire risk.
The onset of HPNS symptoms also appears to be relatively gradual, although it’s important to recognize that not all data supports this and rapid onset can occur. With slow descent rates and intelligent gas choices, it seems unlikely that divers would experience HPNS severe enough to incapacitate them before they had a chance to turn their dive, but that is not to say that it cannot happen or should be ignored as a real concern. Symptoms of HPNS still haven’t been found to correlate with each other, and not only can new symptoms arise quickly, but also the nature of the ailments means that a diver may not be able to identify symptoms until it is too late to react.
The past decade has failed to provide much in significant data on HPNS as it pertains to recreational divers, certainly almost nothing in comparison to the deep-diving heyday that brought about the COMEX tables and Atlantis projects. Going forward, it seems likely that HPNS will become a greater concern. Technical divers will continue to explore the limits of depth with the widespread adoption of rebreathers, persisting in their search for deeper caves and unexplored wrecks. Hopefully, this ongoing—perhaps even increasing—activity will spur more research into HPNS and the potential interplay between the mechanisms of narcosis and oxygen toxicity. Until then, we’ll have to continue to glean what we can from the data we have and the experiences of the more ambitious among us.
- Naquet, R., Lemaire, C., J.-C. Rostain, & Angel, A. (1984). High Pressure Nervous Syndrome: Psychometric and Clinico- Electrophysiological Correlations [and Discussion]. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, 304(1118), 95-102. Retrieved May 21, 2021, from http://www.jstor.org/stable/2396156
- Talpalar, Adolfo. (2007). High pressure neurological syndrome. Revista de neurologia. 45. 631-636.
- Understanding Oxygen Toxicity: Part 1 – Looking Back
- Pearce PC, Halsey MJ, MacLean CJ, Ward EM, Webster MT, Luff NP, Pearson J, Charlett A, Meldrum BS. The effects of the competitive NMDA receptor antagonist CPP on the high pressure neurological syndrome in a primate model. Neuropharmacology. 1991 Jul;30(7):787-96. doi: 10.1016/0028-3908(91)90187-g. PMID: 1833661.
- Kriem B, Abraini JH, Rostain JC. Role of 5-HT1b receptor in the pressure-induced behavioral and neurochemical disorders in rats. Pharmacol Biochem Behav. 1996 Feb;53(2):257-64. doi: 10.1016/0091-3057(95)00209-x. PMID: 8808129.
- Bliznyuk, A., Grossman, Y. & Moskovitz, Y. The effect of high pressure on the NMDA receptor: molecular dynamics simulations. Sci Rep 9, 10814 (2019). https://doi.org/10.1038/s41598-019-47102-x
- High Pressure Neurological Syndrome, DIVER (2012) by Dr. David Sawatzky
InDepth: Diving Beyond 250 Meters: The Deepest Cave Dives Today Compared to the Nineties by Michael Menduno & Nuno Gomes
aquaCORPS:Accident Analysis Report from aquaCORPS #9 Wreckers (JAN95):What happened to Sheck Exley? by Bill Hamilton, Ann Kristovich And Jim Bowden
InDepth: Thoughts on Diving To Great Depths by Jim Bowden
InDepth: Playing with Fire: Hydrogen as a Diving Gas By Reilly Fogarty
Reilly Fogarty is an expert in diving safety, hyperbaric research, and risk management. Recent work has included research at the Duke Center for Hyperbaric Medicine and Environmental Physiology, risk management program creation at Divers Alert Network, and emergency simulation training for Harvard Medical School. A USCG licensed captain, he can most often be found running technical charters and teaching rebreather diving in Gloucester, Massachusetts.
Why Do Divers Run Out Of Gas?
Not surprising, the answer is more complicated than simply, they neglected to look at their gauges. Here Aussie diving medical researcher and former editor of DAN’s Annual Diving Report, Peter Buzzacott dives into several deep datasets including DAN’s Incident Reporting System (DIRS) and nearly four decades of cave diving incident data, to tease out some insights on gas emergencies and get a handle on the risks. Don’t stop those S-drills!
by Peter Buzzacott
See companion story for a guestimate of the risk: What is the Risk of Running Out of Gas?
Next year it will be 30 years since I first learned to dive. At the time, I had no idea that diving would occupy such a large part of my life. I distinctly remember kneeling on the sandy bottom end of the Great Barrier Reef, sharing a regulator with my buddy, and seeing sunlight rippling down through crystal clear water. On one of these “confined water” dives we had to swim horizontally for 10 m/30 ft holding our regulators out of our mouths and blowing a steady stream of bubbles. This wasn’t as easy as it sounds and we had to ration our bubbles to make it the whole way. Then, on an open water dive, the instructor took turns holding us with one hand and gripping a rope with the other while we took a breath, took the second stage out of our mouths, and then went for the surface, breathing out all the way. Up, down, up, down, the instructor went, with each student—one at a time.
Most of today’s recreational dive courses do not include buddy breathing, they teach gas sharing with an alternate air source (AAS). Even before COVID-19, the buddy breathing skill had disappeared from most recreational training programs. The controlled emergency swimming ascent (CESA) has also disappeared from some programs.
When I became an instructor, I made many hundreds of these but, now that I think about it, I don’t recall ever seeing anyone actually make one for real after running out of gas. These days everyone dives with two second stage regulators. In technical diving, we even dive with at least two cylinders; so, I wonder, do technical divers run out of gas and, if they do, then why?
What Do The Experts Say?
Some years ago, I asked a panel of 27 diving experts a similar question regarding recreational divers in general.1 The panel consisted of nine diving/hyperbaric doctors who had treated hundreds of injured divers; nine expert dive guides, most of whom were instructors; and nine expert recreational divers who had dived all over the world and written hundreds of feature articles for dive magazines.
At the time, I suspected divers mostly ran out of gas because they didn’t pay attention to their gauge. But, to my surprise, the experts suggested about 20 reasons, such as diving deeper than usual, diving in a current, not wanting to end the dive for their buddy, using a smaller tank than their buddy, being underweighted, and many others, all of which sounded plausible.
I sent the whole list of potential causes back to the group and asked them to rank, in their opinion, the five most likely causes. Then I gave five points to everyone’s most likely potential cause, four points to the second most likely, and so on. I added up all of the points and then ranked all the causes according to the total score. Then I sent this ranked list back to the group for one last review and asked them to consider the “weight of opinion” from the group as a whole, and to reconsider their top five reasons.
As an expert panel, the group moved toward consensus. Just as I’d suspected, failing to monitor the gauge was the number one proposed potential cause of running out of gas, followed by inexperience, overexertion, inadequate training, and poor dive planning. Other than perhaps an unexpected current or underweighting leading to overexertion, the proposed reasons leaned toward human factors rather than the other two types of factors in the classic diving injury causal triad—those being environmental factors and equipment factors (Figure 1).2,3,4
The process I’d followed to gather expert consensus of opinion is called a “Delphi” process, which was originally developed by International Business Machines Corporation (IBM) to make forecasts on matters about which there was considerable uncertainty i.e. where there is little data. Opinions aren’t solid evidence; however, they can point towards a direction worth investigating.
Next, I visited Divers Alert Network(DAN) as an intern and worked on an analysis of diving fatalities within a subset of technical divers—cave divers. More on that later, but while there, I had the opportunity to examine a large dataset of recorded dives from Project Dive Exploration, headed by Drs. Richard Vann and Petar Denoble.
The dataset we had at that time revealed over 50,000 dives recorded by more than 5,000 recreational divers, (including an unknown number of technical divers). We examined these data in two ways. First, to control for environmental and equipment factors, and to focus on demographic (or human) factors, we counted each diver just once and compared those divers who had reported running out of gas, (during any recorded dive in that dataset), with divers who had not run out of gas. Surprisingly (to me), having run out of gas was more common than expected among older females (males were more likely to report other problems, like rapid ascent).
Next, to control for the human factors, we looked at just the dives made by divers who had made both at least one dive where they ran out of gas, and at least one dive where they did not run out of gas. I wanted to know what it was about those dives that might have caused the divers to run out of gas. Well, it turned out the out-of-gas dives were deeper, shorter (probably because they were deeper), often made from a live-aboard or charter boat, and involved a higher perceived workload.5 Hmmm… Perhaps overexertion was a factor after all.
After returning to Western Australia to undertake a PhD researching this, I spent the next few years recording 1,000 recreational dive profiles made by 500 divers. I recorded their start and end pressures, tank size, and noted factors such as current, how they felt their workload was (resting/light, moderate, or severe/exhausting), how many dive experiences they had, and what previous dive training they had completed. For the analysis, dives made by divers who exited with <50 bar/725 psi of pressure (needle in the red zone, n=183) were compared with other dives recorded at the same time at the same dive site (n=510) by divers who exited with >50 bar/725 psi pressure remaining (needle not in the red zone).
Ending a dive low on gas was correlated with younger males with a longer break since their last dive, fewer lifetime dives, at deeper depth, and a higher rate of gas consumption (adjusted to an equivalent surface air consumption (SAC) rate, for comparison between dives made at different depths). Perhaps more tellingly, compared with 1% of the dives with >50 bar/725 psi at the exit, 11% of the low-on-gas divers reported being surprised at the end of the dive by how low their remaining gas pressure was.6 A more detailed analysis of the average workload associated with recreational diving, using this same dataset, identified that higher perceived SAC rate was not associated with sex but was associated with older age, lower dive certification, fewer years of diving, higher perceived workload, and other factors.7
Technically Out of Gas
Returning to the topic of technical diving, a colleague and I re-examined the DAN cave diving fatality reports collection that I had worked with as an intern, and this time we concentrated on the previous 30 years of data: 1985-2015. Dividing it into two equal halves which we referred to as the “early” and “late” groups, reading each report carefully, and using a reliable cave diving fatality factors flow-chart previously developed,5 we classified factors associated with each cave diving fatality and then compared the two groups.
In the late (more recent) group, the proportion of cave divers who were trained in cave diving had significantly improved, perhaps due to increased awareness of the need for proper cave diver training before entering a flooded cave. The majority of the 67 trained cave divers in our dataset were diving with two cylinders on their back (doubles), and the late group was diving further into the cave than the early group. Of the 67 trained cave divers, 41 (62%) had run out of gas. Looking at the five “golden rules” of cave diving, the “rule of thirds” was the most common (n=20) rule that was suspected to have been broken by the trained cave divers: the most lethal.9
So, it would seem that some technical divers do run out of gas, though thankfully that appears rare. We should bear in mind that cave divers may differ from other types of technical divers in their procedures, demography, and equipment; their environment (by definition) certainly differs from that of wreck divers.
Currently, I know of no ongoing research into out-of-gas incidents among technical divers, other than the current Diving Incident Reporting System, hosted by DAN. An analysis of the first 500 reported incidents recently examined every incident—recreational and/or technical—during which the diver ran out of gas.10 The sample (n=38) was divided into two groups: those who made a controlled ascent (e.g. on a buddy’s donated regulator) and those who made rapid ascent (e.g. a bolt to the surface).
Among divers who reported having run out of gas, but survived to report the incident, 57% of the rapid ascents resulted in a reported injury. Among the 24 controlled ascents, just 29% reported an injury.10
Among divers who reported having run out of gas, but survived to report the incident, 57% of the rapid ascents resulted in a reported injury. Among the 24 controlled ascents, just 29% reported an injury.10 This modern finding is in line with the statistics reported 27 years ago by Dr. Chris Acott when he analyzed more than 1,000 diving incident reports. Examining 189 out-of-gas incident reports, Dr. Acott found 89 made a rapid ascent, and 58% of those reported an injury. Among the 79 controlled ascents, only 6% reported an injury.11
Table 1 shows the total number of dive incidents in each category, after adding both studies together. It seems to me that, while we have moved on from buddy-breathing and the controlled emergency swimming ascent, in the last 30 years the problem of running out of gas has not gone away.
|No Injury |
|Non-rapid ascent||91 (88)||12 (12)||103 (50)|
|Rapid ascent||43 (42)||60 (58)||103 (50)|
|Total||134 (65)||72 (35)||206 (100)|
In conclusion, the evidence confirms what we all know: running out of gas is associated with diving injuries and fatalities. It appears that the level of correlation of demography information (like age and sex) with out-of-gas incidents may depend upon the study design, the pool of divers studied, and/or the specific potential causes of running out of gas being investigated. For example, in one study, older females were more likely to self-report out of gas problems; in another study, young males’ remaining gas was measured and observed to be low. In yet another study, SAC rate increased when perceived workload increased, regardless of sex.
Therefore, I’d suggest it is prudent to consider everyone potentially at risk of running out of gas and, in order to mitigate this risk, both recreational and technical divers should be proficient in gas planning and monitoring their remaining gas, regardless of age and/or sex.
[Ed.note—Most agencies today require some level of proficiency in managing emergency out of gas scenarios. For example, GUE requires divers at all levels to train regularly for this eventuality. This training also emphasizes gas management strategies like “minimum gas reserves” and the related “one third” rule to ensure divers always have enough supply to share gas aka buddy breathe from any point in the dive, and all the way to the surface. Violation of these strategies risks insufficient gas in all environments.]
The influence of workload is interesting, and technical divers who perceive an elevated workload may well remember that this has been associated with both higher rates of gas consumption and unexpectedly running low on gas. So, when detecting a current or perceiving an elevated workload, I recommend keeping a closer-than-usual eye on the remaining gas and, if a current is suspected before the dive, then plan for an elevated SAC rate.
The influence of training/certification consistently appears to be associated with the risk of running out of gas, as does having made fewer lifetime dives. Highly trained and experienced divers might bear this in mind when diving with buddies who are newer to our sport. Offer them opportunities to gain experience and recommend additional training when they are ready. We were all inexperienced once.
Technology has improved in recent years; for example, tank pressure transponders are more reliable today than ever before. It is possible that in the future these resources, coupled with audible alarms, may prove to be highly effective at preventing technical divers from running out of gas. Until we know how effective such alarms are at preventing out-of-gas dives, our best course of action is to dive within the limits of our training and experience, and to keep an eye on our remaining gas.
See companion story for an estimate of the risk: What is the Risk of Running Out of Gas?
Do you think that it could it happen to you?
1. Buzzacott P, Rosenberg M, Pikora T. Using a Delphi technique to rank potential causes of scuba diving incidents. Diving and Hyperbaric Medicine. 2009;39(1):29-32.
2. Edmonds, C. and Walker, D. Scuba diving fatalities in Australia and New Zealand: The human factor. SPUMS J. 1989;19(3): 94-104.
3. Edmonds, C. and Walker, D. Scuba diving fatalities in Australia and New Zealand: The environmental factor. SPUMS J. 1990;20(1): 2-4.
4. Edmonds, C. and Walker, D. Scuba diving fatalities in Australia and New Zealand: The equipment factor. SPUMS J. 1991;21(1): 2-5.
5. Buzzacott P, Denoble P, Dunford R, Vann R. Dive problems and risk factors for diving morbidity. Diving and Hyperbaric Medicine. 2009;39(4):205-9.
6. Buzzacott P, Rosenberg M, Heyworth J, Pikora T. Risk factors for running low on gas in recreational divers in Western Australia. Diving and Hyperbaric Medicine. 2011;41(2):85-9.
7. Buzzacott P, Pollock NW, Rosenberg M. Exercise intensity inferred from air consumption during recreational scuba diving. Diving and Hyperbaric Medicine. 2014;44(2):74-8.
8. Buzzacott P, Zeigler E, Denoble P, Vann R. American cave diving fatalities 1969-2007. International Journal of Aquatic Research and Education. 2009;3:162-77.
9. Potts L, Buzzacott P, Denoble P. Thirty years of American cave diving fatalities. Diving and Hyperbaric Medicine. 2016;46(3):150-4.
10. Buzzacott P, Bennett C, Denoble P, Gunderson J. The Diving Incident Reporting System. In: Denoble P, editor. DAN Annual Diving Report 2019 Edition: A Report on 2017 Diving Fatalities, Injuries, and Incidents. Durham (NC): Divers Alert Network; 2020. p. 49-67.
11. Acott C. Diving incidents – Errors divers make. Safe Limits: An international dive symposium; 1994; Cairns: Division of Workplace Health and Safety.
12. Buzzacott P, Schiller D, Crain J, Denoble PJ. (2018). Epidemiology of morbidity and mortality in US and Canadian recreational scuba diving. Public Health 155: 62-68.
13. Buzzacott P. (editor) (2016). DAN Annual Diving Report 2016 Edition: A report on 2014 data on diving fatalities, injuries, and incidents. Durham, NC, Divers Alert Network
14. Buzzacott P (editor) (2017). DAN Annual Diving Report 2017 Edition: A Report on 2015 Diving Fatalities, Injuries, and Incidents. Durham (NC), Divers Alert Network.
15. Buzzacott P and Denoble PJ. (editors) (2018). DAN Annual Diving Report 2018 Edition: A report on 2016 data on diving fatalities, injuries, and incidents. Durham, NC, Divers Alert Network
16. Denoble PJ. (editor) (2019). DAN Annual Diving Report 2019 Edition: A Report on 2017 Diving Fatalities, Injuries, and Incidents. Durham (NC), Divers Alert Network.
You can add a diving incident to the DAN database by name or anonymously here: Diving Incident Reporting System (DIRS).
Dr. Peter Buzzacott MPH, PhD, FUHM, is a former PADI Master Instructor and TDI Advanced Nitrox/Decompression Procedures instructor, having issued >500 diver certifications. Today he is an active cave diver, holding various advanced cave diver certifications including advanced (hypoxic) trimix diver, and he is gradually gaining experience with CCR diving. To finance this, he conducts research into diving injuries and decompression/bubble modeling at Curtin University in Perth, Western Australia.
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If you’re diving beyond 150 m/490 ft you’re likely to experience the effects of High Pressure Nervous Syndrome (HPNS). Here...