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Incident Report: Denial Isn’t Just a River in Egypt

As counter-errorism expert Gareth Lock, principal of Human in The System, explains: the river of denial runs deep through the diving community as demonstrated by this actual DCS incident. His report may help you find safe passage.

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By Gareth Lock

A pair of divers was completing their final dive following a week of 60-70 m/197-230 ft trimix diving off Malta in the Mediterranean Sea. The week had been brilliant. Blue skies, calm seas, and some amazing wrecks from the World War II era. This final dive was to be on the Italian fast patrol/torpedo boat Schnellboot S-31. It lays at 63 m/207 ft, almost intact and upright but broken in the middle, looking like someone had partially snapped it, like a stick.

They were planning on a 30-minute bottom time on open circuit using trimix 15/55, and nitrox 50% and 100% breathing gases. The dive itself was uneventful with some brilliant opportunities for photos in the clear water, and the decompression was completed as planned.

The interesting part started when one of the divers got back on the boat. As he took off his twinset, he noticed some disturbances in his vision. He had never had a migraine before, but it appears. in hindsight, to have been the same as the aura that those who suffer from migraines get. Even though the disturbances were obvious, the diver didn’t say anything to his buddy or others on the boat because they didn’t perceive any neurological or musculoskeletal signs or symptoms. After 20 minutes or so, while they were on their way back to the quayside, the visual disturbances cleared.

Approximately 30 minutes after surfacing, the boat arrived back at the quayside and the divers started to unload their equipment. There were multiple twinsets and stages to lift from the boat to the quayside and from the quayside onto the back of the flatbed trucks.

As the diver lifted the final twinset up onto the back of the flatbed, he immediately had a large “burst of light,” and his vision was disturbed. The disturbance was like an out-of-focus area moving across his vision, which meant that he couldn’t see clearly, especially in the focal area of vision. In the past, the diver had researched diving medical issues like PFOs and the link to DCS, and that physical exertion can open a patent foramen ovale (PFO) thereby allowing bubbles to cross from the venous side to the arterial side, which can lead to decompression sickness. At this point, the diver said to himself “I have a PFO!” However, he didn’t articulate this to the others in the team, again because there were no other signs/symptoms present. In his mind, he couldn’t detect any signs/symptoms of DCS, so it couldn’t be DCS!

Decompressions above the Schnellboot. Photo courtesy of Gareth Lock.

The diver finished up moving the rest of the lighter equipment onto the flatbed and set off back to the dive center. He was unusually quiet, but no one mentioned anything to this effect. After 30-40 minutes, the visual disturbances cleared up. The diver still hadn’t said anything to anyone else at this stage, and there were still no signs or symptoms of DCS.

The following day the diver, his teammate, and the diver’s girlfriend flew back to the UK.

What are your thoughts on what happened? What do you think of the diver who didn’t declare his medical issue? Do your thoughts change if I said that diver was me?!

Most people have a negative thought process about the incident diver. If you fall into that category, you are likely to have one of the strongest biases people exhibit. It’s called a “fundamental attribution error.”

Most people have a negative thought process about the incident diver. If you fall into that category, you are likely to have one of the strongest biases people exhibit. It’s called a “fundamental attribution error.” This error can be summarized as: when a negative behavior is observed in someone else, we blame the individual, but when the same negative behavior is demonstrated by ourselves, then we attribute it to external factors. The Fundamental Attribution Error is one of the greatest barriers to learning when it comes to incidents and accidents because we don’t look at why it made sense for someone to do what they did. Lewin’s equation shows that our behaviour is a function of the person and the environment they are operating in. B=f(p,E). So before you judge, look at why it might have made sense for the person to do what they did. Local rationality is why something can appear irrational to someone on the outside, and yet make sense to the individual “inside”.

So what happened to me and why?

This was the last dive of a week’s great diving. My girlfriend (now wife) was holidaying with me in Malta while Howard (my teammate) and I went trimix diving. Kate doesn’t dive and was happy doing touristy stuff around the island while we dived.

I didn’t say anything to anyone on the quayside because I had a pretty good idea that if I did, I would be in a chamber and that would worry Kate; it would also mean we wouldn’t be flying back home the following day either, and I didn’t want to make a mess of the plans! In hindsight, it could have been a lot worse than it turned out. Irrational in hindsight. Locally rational if you think about what was going on in my head.

Upon my return to the UK, my tech instructor recommended a cardiologist who specializes in PFO treatments. I explained my circumstances to the doctor and told him that the dive had a conservative profile, explaining the gases and stops. He responded that “tech divers are a bunch of (expletive deleted)  guinea pigs,” and upon reflection, I agreed. As a naval diving doctor now involved in commercial dive medicine, he advocates for more control and oversight than is current practice. He does not agree with tech divers taking the risks they do. The only way to confirm that I had a PFO was with a test.

Howard inspecting the Schnellboot. Photo courtesy of Gareth Lock.

Within two weeks, I had a transthoracic echocardiogram (TTE) whereby bubbles and saline were injected into a major vein in my left arm as my heart was imaged with ultrasound. At a specific point I was told to do a Valsalva maneuver to observe if bubbles would cross the heart. No bubbles were seen to cross the area where a PFO would be during any of the three times I complied. However, when I did a massive “sniff” as the bubbles were injected, immediately a shower of bubbles was seen crossing my heart wall through the PFO. Post-test analysis showed that I had an 8 mm x 12 mm PFO. You can see a video of my test here. (See attached video in the email).

Video courtesy of Gareth Lock.

Three months later I was in the operating theatre having the PFO fixed with an Amplatzer device. This is best described as two folded-up umbrellas inserted into the heart; the first is deployed on the inside of the heart, the second on the outside, and then as tension is applied, the two umbrellas close together pulling in the flap and closing the hole. Three months after that, I was back to diving, having been signed off as having no bubbles passing across the PFO. Prior to that event, I had had no signs or symptoms of DCS or anything linked with a PFO despite having completed approximately 400 dives and approximately 15 advanced trimix dives to 60-70 m/197-230 ft.

Summary

Denial is a massive issue in diving incidents, especially when it comes to DCS. I have seen numerous incident reports where the one managing the event is the last person who should be involved in the critical decision-making process! In 1993, Michael Menduno published an excellent article in aquaCORPS #5, BENT, which looked at the stigma associated with DCS. You can find it here.

Because of this stigma, the true prevalence of DCS is not really known and therefore the biases that we use to determine the likelihood of a risk materializing lack the data to inform them. Speaking to experts in the field, the real number of DCS events is likely to be four to eight times the reported level. Consequently, we need to change the attitude toward DCS as Jennifer Hunt’s article in aquaCORPS highlights.

There are numerous biases at play when we examine incidents, accidents, and near-hits. The most powerful of these are hindsight bias (where we “know” it would have happened that way) and the fundamental attribution error. In many cases, it is difficult to resist the effect of these biases, but being aware of them is the first step to improving learning throughout the diving community.

No one gets up in the morning and says “Today is a good day to get bent and not tell anyone anything about it.” We are doing the best we can with the resources we have and the pressures and drivers we are subject to. As Sir Andrew Hidden QC said when discussing the 1988 Clapham Junction train crash in which 35 people were killed and 484 were injured, “There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight. It is essential that the critic should himself be constantly aware of the fact.”

Like incident reports? Read another. 


Gareth Lock is an OC and CCR technical diver with the personal goal of improving divingsafety and diver performance by enhancing the knowledge, skills, and attitudes towards human factors in diving. Although based in the UK, he runs training and development courses across the globe as well as via his online portal https://www.thehumandiver.com.He is the Director of Risk Management for GUE and has been involved with the organization since 2006 when he completed his Fundamentals class.

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Brits Brew Beer Booty

What do you get when you combine British divers’ proclivity for shipwreck exploration with their strong affinity for beer? A tasty treasure hunt on the “Wallachia” that resulted in swilling 126-year old reconstituted British beer. GUE Scotland’s detective chief inspector Andy Pilley recounts the tale.

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by Andy Pilley
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A. Pilley

Header Image: GUE Scotland’s brewmeisters enjoying their brew (L to R) Top: Owen Flowers, Andy Pilley, Wayne Heelbeck. Middle: Steve Symington, A. Pilley, O. Flowers, Bottom: W. Heelbeck, Sergej Maciuk, S. Symington

“Give my people plenty of beer, good beer, and cheap beer, and you will have no revolution among them.”

Queen Victoria

I never thought when I started diving 10 years ago, that one day I would be able to sit down for a pint of beer with the team from GUE Scotland recreated from a brew that has been hidden under the waves for 126 years. Let me explain.

The Wallachia was a single screw cargo steamer that was owned by William Burrell & Son of Glasgow, and employed on regular trips between Glasgow and the West Indies. On 29th September, 1895 she left Queen’s Dock, Glasgow at 10am bound for Trinidad and Demerara. On board was a valuable general cargo including whisky, gin, beer, acids, glassware, and earthenware plus building materials and footwear. By 1pm that afternoon she had settled on the seabed of the Clyde Estuary after colliding with another ship in a fog bank, she was forgotten until 1977 when a local sub-aqua club rediscovered the wreck site.

The wreck of the Wallachia lies on an even keel in approximately 34 metres of water on a sandy seabed. The wreck itself is largely intact and has six holds in total, three forward and three aft. In the rearmost hold there are thousands of bottles of beer, some still inscribed with the name of the maker, McEwans of Glasgow. This is where myself and the team from GUE Scotland enter the story.

The Wreck of the Wallachia 

The Wallachia is one of the more accessible sites on the west coast of Scotland, where we carry out most of our diving. Depending on weather and tidal conditions, visibility on the wreck can be +10m/33 ft on a very good day or less than 2m/6 ft if there has been a lot of rain due to the amount of particulate in the water. Other elements to consider are the tide as this can vary in its intensity, as well as surrounding boat traffic. The wreck lies in close proximity to a ferry route and care must be taken not to dive when the ferry is closeby. However despite the challenges, the wreck is very rewarding and offers a diver plenty of places to explore and items to look at. 

The main point of interest for most has been the rearmost hold, where the bottles of whisky and beer were stored. The majority of the whisky was removed in the 1980’s however a few bottles can be found on occasion, depending where you look. What remains are thousands of bottles of beer, still with the corks and contents intact. Over the course of 2018 & 2019, the team at GUE Scotland dived on the wreck and recovered a number of bottles from the hold. 

After a chance discussion with a friend at dinner one night, I was given contact details for a company called Brewlab, which is based in Sunderland in the north east of England. Brewlab specialise in the provision of specialist brewing training, as well as laboratory services such as quality assurance, product development, chemical/microbiology testing as well as long term research options. I made contact with Keith Thomas, the Director of Brewlab, to discuss whether he would be interested in analysing the beer and investigating whether it could be recreated. Needless to say the proposal piqued his interest and arrangements were made for the bottles to be shipped to his lab.

Unbeknownst to me, the recovery of historical beers is rare, due to various sources of degradation/contamination which can affect any residual microbial cells and chemical components left in the beer that were used as part of the brewing process. So these samples are a valuable source of information on past brewing and microbiology. Over the course of 2019/2020, Keith and I kept in regular contact over the progress of the investigations and the full analysis of the beer has recently been published.

A Brewing Interest

Between 1850 and 1950, the application of scientific principles to brewing was becoming increasingly prevalent and microbiology was playing an increasingly important role. A pertinent issue in brewing microbiology around 1900 was the application of pure Saccharomyces yeast cultures developed by Hansen at the Carlsberg laboratory in 1888. These were readily adopted by continental breweries as providing more controlled production and purer beers. Application to UK brewing was, however, less positively received, in part because of the belief that British beers possessed particular flavours arising from mixed yeast cultures and, specifically, the involvement of Brettanomyces species. This was especially believed to be essential for the character of ‘stock’ ales which were matured for extended periods.

While a number of breweries did try pure culture yeasts, UK brewing was resistant to change and, with the intervention of World War I, retained its indigenous yeast cultures. Since the 1940’s a more biotechnological approach to fermentation demonstrated the value of pure culture and was progressively applied to the larger breweries developing at that time. 

During the formative period of brewery microbiology after Pasteur, brewing yeast were identified as Saccharomyces species based on morphological features of shape, filamentous propensity and spore characteristics. Non brewing, ‘wild’ yeast was recognised and termed ‘Torula’ if non-sporulating. Of these Brettanomyces strains were identified as contributing important character to stock ales. It is also clear from brewing texts that bacteria were recognised as spoilage organisms in beer, as had been initially demonstrated by Pasteur in 1863. These species were mostly categorised as bacilli and typically portrayed as rods and associated with sarcina sickness – generally producing sourness. Some studies, nevertheless, identified lactic acid bacteria as indigenous components of standard beers.

Contemporary breweries are increasingly interested in using novel microbiology, either unconventional yeast strains or mixes of species and strains for sour and natural products. Identifying the specific strains and species of yeast and bacteria present in Victorian and Edwardian beers is directly relevant to this and has particular value if cultures of authentic microorganisms can be retrieved. Reports of retrieved historic brewery microbiology are limited but hold interesting promise for identifying novel microorganisms.

The specific parameters of the analysis are contained in a published research paper, Preliminary microbiological and chemical analysis of two historical stock ales from Victorian and Edwardian brewing.”

As I mentioned, the primary objective of the analysis was to confirm whether detail could be provided on the original brewing ingredients and the fermentation microbiology. The analysis confirmed the use of Brettanomyces/Dekkera bruxellensis and Debaryomyces hansenii, which are brewing and fermentation yeasts respectively. The presence of Debaryomyces is interesting as this genus has not been noted as a historic feature of historic brewing, but has been identified in spontaneous fermentations, for example in Belgian lambic beers. Although the strain was reported to the brewing industry in 1906, it has not featured as a major contributor to beer fermentations since.



The analysis has also provided relevant information of the beer character and has confirmed that the beer recovered from the Wallachia was a stout, close to style expectations of the time and had an alcohol content of c. 7.5%. The colour gravity was high, resulting in a much darker beer however a much lower level of bitterness. Again this was typical style of the time and differs from other modern stouts.

More interestingly is the presence of various types of bacteria, which will likely have been picked up during the brewing process. The table below lists these for reference. Needless to say, historic brewing was not a sterile process in comparison to modern methods!

Bacillus licheniformisPlant and soil bacterium
Finegoldia magnaCommensal skin bacterium
Fusobacterium sp.Possible pathogenic bacterium
Kocuria roseaPossible urinary tract pathogen
Mogibacterium pumilumPossible oral cavity bacterium
Shigella sonneiEnteric pathogen
Staphylococcus epidermidisCommensal skin bacterium
Stenotrophomonas maltophiliaSoil bacterium
Varibaculum cambriensePossible pathogenic bacterium

Table 1: The bacteria found in the Wallachia beer bottles

Due to the relatively stable conditions on the wreck, being in near darkness and at a relatively cold temperature (between 6º–14ºC/43º-57ºF depending on the time of year), the live yeast structures within the beer were protected from sources of stress and allowed them to survive over the past 126 years. Luckily, Keith was able to extract these samples and begin to recultivate the yeast, specifically the Debaryomyces, with the hope of being able to rebrew the beer.

Cheers Mates

Just before Christmas, I finally received word from Keith that he had completed a trial brew and seven bottles of the brew were on their way to me. A few excitement laden days later and a nondescript box arrived at my office with the beer inside. I called the guys on our Facebook group chat to show them the case and got each bottle packaged up and sent out to them. 

A few days later, once everyone had received their sample we got together again to try the samples. There was an air of excitement after the two years it had taken us to get to this point, the most anticipated pint ever! I’m no expert in the flavour profiles of beer so you will have to forgive me for my relatively basic analysis. In summary, I got flavours of coffee and chocolate and there was a relatively low level of carbonation, which made it very drinkable. The rest of the team got similar flavours, the only complaint being there wasn’t more to try!

There will of course be slight differences in flavour since we don’t normally add the bacteria listed above as ingredients. However, the recipe we have is as close as we can make it to the original stock version.

The next steps for the project are to carry out further investigation on the characteristics of the Debaryomyces yeast strain in order to determine their suitability for fermentation and potential use in future brewing production. We are making approaches to various commercial breweries in order to discuss future commercialisation of the recipe and produce the brew on large scale. With the story behind the original recipe, we’re hopeful that the provenance would be a key selling point to consumers. It is my hope that the recovery of these samples will open up new possibilities for different types of beers to be developed, and offer something different for beer enthusiasts to try.

I have also found out that there are other types of beer to be found on the wreck, specifically an IPA style. Once we’re allowed to begin diving again, I am hoping to return to the Wallachia and recover some of these bottles so we can carry out the same analysis and keep the project moving forward.

In the mean-time, cheers!

Additional Resources:

The Brewlab Podcast, Episode 2 (March 30, 2021): Lost Beers Recreated from Shipwreck Bottles

GUE Scotland vlog -Episode 1


Andy Pilley is a Chartered Surveyor, team member of GUE Scotland, passionate wreck & cave diver and Ghost Fishing UK team diver. Andy started diving with the Scottish Sub-Aqua club in 2011 and began diving with GUE in 2018. Andy dives on the east and west coasts of Scotland where there is a rich maritime history and an abundance of wrecks to be explored. He has a passion for project diving and is developing objectives for a number of sites with the GUE Scotland team. He hopes to assist on the Mars Project and with the WKPP in the future.

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