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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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Resurrecting a Ghost: The Launch of Ghost Diving USA

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By Katie McWilliams. Photos courtesy of Ghost Diving USA unless noted. Header image by Jim Babor

Ghost Diving, formerly Ghost Fishing, has officially arrived in the United States. Naming Southern California as home for the United States chapter is not an expansion to a new territory; instead, it is a warm welcome home after a long journey. 

Ghost Fishing first arrived in Southern California in the mid 2000s spearheaded by Karim and Heather Hamza. Their team, a group of volunteer technical divers, set out to improve the health and viability of the Southern California waters. The team started with the Infidel, a sunken squid fishing vessel near Catalina Island in 45 m/150 ft. They diligently worked to clean the Infidel which took almost two years. This victory was huge for their effort. Sadly, due to lack of funding, they were unable to continue other projects. Despite this hardship and some time away from their pursuit of the ghosts, Karim and Heather are back and more motivated than ever. 

Heather’s passion is deeply rooted in her mission to advocate for animals. This passion has helped her to push through and focus on advocating for the animals that are often unseen. The marine life that goes undetected but is ever threatened in our oceans. These are the animals Heather makes very certain to see. Her passion and love for them is palpable; it radiates from her like the warmth of a sunny day. It beckons you to join her cause. This is what keeps the fire alive in her heart for Ghost Diving. She knows that she can turn the collection of nets and her experiences into educational opportunities. Heather’s aspirations for Ghost Diving USA include continuing to educate others regarding the threat of abandoned and discarded fishing gear, seeking legislative solutions to the problem, and ultimately, building an informed and empowered community that takes care of our oceans.

Karim thrives in situations that require precision and accuracy. He explains that for him, this new era of Ghost Diving is providing a fresh opportunity to build a community of elite divers that share a passion for and commitment to a great cause. He has the knowledge and experience to help train and mentor divers along their path to becoming ghost divers and intends to give all he can to the process. He wants to bring to fruition teams of divers who trust not only each other but also the process, as well as high training standards and passion for the cause. As Karim described all the things that a ghost diver needs to be, one of the original team members immediately sprang to mind, Jim Babor. 

Jim recounted the arduous process that is becoming a ghost diver and being active with projects. He started with the project as a safety diver. The deep team would come up from the dive to the nets, and Jim would ascend with them through their scheduled decompression. He then progressed into his technical training and began photographing and documenting the work the divers were doing. Jim shared something that truly captures the essence of the passion needed to be a ghost diver. When asked about some of his most memorable incidents, he recounted the amazing experience of rescuing live animals by cutting them out of nets they were trapped in.. When asked what it felt like to cut an animal out of the net and watch it swim away, Jim was simply at a loss for words. We spoke on the phone and despite Jim’s reflective pause as he gathered his thoughts, it was apparent that the experience resonates with him on a deep level rooted in compassion. For Jim, the Ghost Diving USA launch brings his commitment and journey as a ghost diver full circle.  

Helping to lead Ghost Diving USA into the future is scientific coordinator Norbert Lee, Scuba instructor, marine biologist, and active technical diver. To speak to Norbert is to feel his can-do attitude and realize his aspirations are rooted in protecting and fostering the growth of the underwater world while educating the community about ocean conservation. More importantly, his strong sense of commitment to the team effort shines through everything. In asking Norbert about his journey to becoming the US chapter coordinator, he cited the significance of the mentorship he has and continues to receive. This mentorship comes from a variety of sources including Pascal van Erp, the Hamzas and Jim Babor. 

Norbert Lee’s goal is to collect data about the environmental impact of ghost nets and how their removal impacts the health and growth of a given area. By collecting this data, he is confident he can help to educate the community about the true impact of abandoned fishing gear. He does not want to stop with nets. He wants to help recover lobster pots and other fishing apparatus that continue to catch fish after being left behind. Through educating the community, he does not want to villainize or chastise commercial fishing but rather to build working, symbiotic relationships with fishermen. By working together, Norbert hopes to have the nets removed before they do irreversible damage. 

The Founding of Ghost Diving

Pascal van Erp has a commanding grasp on the issue of abandoned fishing gear. As the founder of Ghost Diving. Pascal’s passion has built a formidable and forward-thinking movement. Speaking to Pascal is a unique experience. He exudes a quiet confidence that only time and experience can build. In researching his work to prepare for his visit and subsequent presentations, it became quite apparent that Pascal is consistent in his message. The message is that Ghost Diving breathes new life into abandoned nets that can be recycled or upcycled. To reuse and upcycle the nets means to actively contribute to the health of the planet for today and more importantly, future generations. 

Next, Pascal emphasizes Ghost Diving is dangerous. He explains that the dangers are not always apparent. Instead, they lurk in the shadows cast by ghost nets. Team dynamics are not only critical but a matter of life and death. Pascal frequently mentions the significance of trust. The ability to trust teammates to maintain composure in the face of adversity. Trusting that if something goes wrong, they can and will continue to problem solve. Trusting that they can and will save your life. The team must always perform at the highest levels. It is critical that the dive is executed according to plan and that the procedure is applied with absolute fidelity. The nets do not discriminate between human life and marine life. They are not forgiving. A diver can meet an untimely fate in the grasp of a ghost net. 

Ghost Diving USA provides a unique and exciting opportunity by planting its roots here. With support from Zen Dive Co., ghost divers will have access to equipment, standard gasses and service that will meet all their needs while ensuring the quality and reliability of these resources. While funding issues had previously plagued Ghost Fishing, the Ghost Diving partnership with Healthy Seas along with other community sponsors helps to ensure the security of the critical funding that makes these projects possible. 

Launching Ghost Diving USA

Zen Dive Co. hosted a launch event for Ghost Diving USA on Thursday, April 28. The energy in the building was electric. Everyone was thrilled to network, build community, and work towards supporting Ghost Diving USA in any possible way. Karim opened the evening by describing the net diving mission that the ghost divers had gone on earlier in the day. He explained in detail that the Moody, a Wickes class destroyer, sits at approximately 45m/150 ft. Conditions at sea were challenging. Spring is a rough season in Southern California. Variable winds cause large swells, and upwellings bring up life giving nutrients. Unfortunately, both phenomena significantly reduce visibility. This dive was no exception. Karim described a thick green cloud in the shallower depths cutting visibility to 4.5–6 m/15–20 ft. This green cloud blocked out all ambient light as the ghost divers descended, and then cutting the nets only made visibility worse. Essentially, there was no ambient light, and visibility quickly became next to zero. The ghost divers were forced to rely upon the light they brought with them. Despite the challenges, the net clean-up was successful, but the work is far from done. The ghost divers will have to return to remove more net. 

Pascal made a brief presentation about the problem of ghost nets. It was incredible to experience a room full of people feeling compelled to act, and everyone looking for the way they could best support the mission. Veronika Mikos of Healthy Seas helped to drive the point home when she explained that through partnerships with organizations such as Bracenet and Aquafil, the recycling and upcycling of nets can help to significantly reduce carbon emissions. Additionally, as the ability to recycle nets and the products made from nets grows, they become sustainable and renewable. The yarn made from the nets can be processed infinitely and never loses quality. 

The most precious resource to any of these projects is manpower. Volunteers. People willing to train hard, think of the many versus the one and ultimately focus on safety. A ghost diver is a technical diver that has successfully completed a series of training workshops that help to best prepare them for what they will experience on a net retrieval dive. The workshops also serve to build team cohesion. Pascal and Karim both explain that the need to work with technical divers is not to be exclusionary. Ghost divers need to be able to handle any situation that may arise at any moment. Technical divers are trained to do exactly that. 

For recreational divers and non-divers alike, there is a place for everyone. Ghost divers cannot do what they do without support. Jim shared with me that his son, middle-school-aged at the time, used to volunteer as surface support. He and a friend would help to bring nets onto the boat and then search through them meticulously for any trapped marine life that could be released back into the ocean. Not only did his son help to raise awareness through multiple award-winning science projects, but he also became a diver crediting his experience helping with ghost nets. The Hamzas and Norbert hope to grow Ghost Diving USA to include recreational limit projects that allow for the training and participation of recreational divers. 

Ghost Diving USA is hitting the ground running. If you are looking for a way to get involved, a great place to start is to follow them on their social media pages. They are on Facebook and Instagram as Ghost Diving USA or @GhostDivingUSA. If you would like to inquire about the application process, you can reach the USA chapter via email at info@ghostdivingusa.org

You can also act right now. Learn about what abandoned fishing gear does to our oceans and talk to others about it. Through raising awareness, you can help remind people that while the surface of the ocean is beautiful, it is what is below the surface that desperately needs our help.

Photo by Sean Farkas

Additional Resources

Ghost Diving International:https://ghostdiving.org
Aquafil:https://www.aquafil.com
Bracenet:https://bracenet.net/en
Healthy Seas:https://www.healthyseas.org
Alert Diver:Ghost Fishing by Michael Menduno. The story of Heather Hamza and her team (2014).


Katie McWilliams is an avid diver, spending every spare moment she can in the water. Currently completing her divemaster and training for her technical pass, she wants to not only further her education and ability to explore the ocean but help with the training of divers. Specifically, Katie wants to focus on spreading awareness of how we can help the health and conservation of the oceans and marine life. Outside of diving, Katie works in moderate/severe special education. She enjoys reading, exercise, off-roading, camping and spending time with her husband, family and friends. 

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