Diving Safety
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 (row %) | Injury (row %) | Total (col %) | |
| 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.]
Influencers
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?
References
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.
Community
Why It’s Okay To Make Mistakes
To err is human. To trimix is divine? Instructor evaluator Guy Shockey examines the importance of learning through one’s mistakes, and most important, being willing to admit and share them with others, especially for those in leadership positions. It’s the only way to create ‘psychological safety” within our community and improve our collective diving safety and performance. Wouldn’t that be divine?
By Guy Shockey. Images by Andrea Petersen
A few months back, I read an article about a club where members talked about failure and making mistakes. This club required that members freely discuss their mistakes and failures without fear of judgment. The goal was to destigmatize failure and recognize that we learn by making the very mistakes we are afraid to talk about! Moreover, to become truly high performing and develop unique and creative solutions to problems, the article argued that we needed to be free of the worry of failing—to understand that “to err is human.”
The article went on to mention that for high performing teams to be successful, they needed to operate in an environment of “psychological safety.” This term was originally coined by Harvard professor Amy Edmondson, and Gareth Lock has written about the concept extensively. In his work with The Human Diver, Lock identifies psychological safety as a key component primarily missing in our diving culture. As a full-time diving professional and someone who delivers The Human Diver programs, I couldn’t help but reflect on the failure-destigmatizing club in the context of our diving culture in general and, more specifically, dive training.
Consider the humble Roomba robot vacuum cleaner. The Roomba learns how to clean a room by bumping into nearly everything in the room and, with some nifty software, creates a “map” of all the “vacuumable” space in the room. Then, it goes about its business efficiently and repetitively cleaning the room. The Roomba has learned by making multiple mistakes—much like humans do.
Now imagine being able to transfer that new “map” from one Roomba to another so a new Roomba doesn’t have to repeat the mistakes of the first as it sets out to vacuum the room. Finally, imagine this transfer of data to be less-than-perfect—perhaps, occasionally, the new Roomba will make some mistakes (from which it will learn). But it will make far fewer mistakes than the original Roomba had to make.
I’m sure you can see where I’m going with this. Humans learn the same way Roomba vacuums do (hopefully without running into as many hard surfaces), and we can transfer information between each other. Because the transfer process is less than perfect, we still make some of the same old mistakes. This is particularly interesting because, despite drawing specific and repeated attention to these common errors, students often still make the same errors! One of the most important parts of instructor training is educating future instructors to recognize where these common mistakes will occur and encouraging them to ramp up to being hyper-vigilant rather than regular-vigilant.
Learning Through Mistakes
One way we learn is by making mistakes, talking about them, and sharing the experience in the hopes that future divers don’t have to make the same ones. At its core, this is the very essence of learning. Incidentally, this is also what makes experience such an important characteristic of a good teacher. The more experience the educator has, the more mistakes they’ve made and, consequently, the more information they can transfer. Fear of owning our mistakes keeps us from learning from them; perhaps more importantly, it means that others will miss out on these important lessons.
Yet, in diving culture, we (for the most part) shy away from discussing the mistakes and errors we (hopefully) learned from for fear of being considered a less than capable diver. When divers in influential or leadership roles do this, it is a tremendous loss for the diving community in general—it robs future groups of divers of the opportunity to learn. Sadly, because this commonly happens at the leadership level, it is hardly surprising that other divers further down the line copy that behavior, and we ultimately end up with a diving culture that emulates the example of the leadership.
I advocate for taking the opposite approach. In my teaching, I am very open about the mistakes or errors I have made while diving. I recognize that I am basically a smart Roomba, and I learn by making mistakes. Thus, it would be disingenuous to pretend that I don’t make mistakes—I had to learn somewhere! I believe this approach lends authenticity to my instruction and starts to create psychological safety in my classes. Ultimately, my goal is to encourage students to recognize that, “If the instructor can admit they make mistakes, then it is okay to talk about the ones our team made during the training dive.”
I have found that there is a remarkable change in the relationship between student and instructor when this happens. Learning becomes more of a collegial activity, and stress and performance anxiety significantly decrease. This leads to more successful learning outcomes and happier students. I am a firm believer that, while training can be serious, it should also be fun!
Creating Psychological Safety
Creating psychological safety in our diving culture is a daunting task, but every flood begins with a single raindrop. The first thing that needs to happen—at all levels—is an acknowledgement of failures and mistakes among those in positions of influence and leadership. Sadly, this is not as easy as it sounds, and there is frequent pushback. Ego is one of the most dangerous aspects of a personality and it frequently causes people to overreach, crippling growth and learning. The irony here is that every single one of us has made a mistake. We all understand that no one is perfect, yet many in leadership positions cling to the view that vulnerability is weakness—that demonstrating imperfection will cause others to stop trusting them (or revering them).
I propose that the opposite is true. I should also note that I believe every dive professional is acting in a leadership role. This means that, while creating psychological safety can best be started by those in senior leadership roles, it must also be encouraged at all levels of leadership, including anyone in supervisory or teaching roles. In a perfect world, every diver would embrace this approach and enable psychological safety within their team.
There are a few things you can do to help develop psychological safety. First, facilitate a debrief at the end of the dive and begin with “something that I as the leader did wrong or could have done better was…” This immediately creates fertile soil for psychological safety to flourish. When the leader is the first person to say, “I made a mistake,” it establishes that this is a safe place to discuss mistakes and errors with the intention of learning from them. This opens the door to follow-up discussions.
On the subject of transparency, in any organization it is often the voice of dissent—a contrary position—that is the most valuable. This voice causes the group to reflect on original assumptions and decisions and offer a perspective that “groupthink” does not. This means that we need to be open to different solutions to problems lest we be blinded by our own cognitive biases—ones that have been developed over thousands of years of evolution in order to make us more efficient Roombas.
We are essentially fighting against our own brains, and it takes a significant amount of effort to think outside the box. We are hard-wired to think in terms of “evolutionary” rather than “revolutionary” ideas, and we need to make a conscious effort to consider the voice of dissent and understand why it is so hard to do so.
In Conclusion
In psychologically safe environments, we experience a significant increase in “discretionary effort,” or shifts on the “need to do” and the “want to do” curves. If a team has a high degree of psychological safety, they are motivated to perform higher than the minimum standard. If you create a high degree of psychological safety, your team will perform better as a result.
This is where it all comes full circle. We want our dive teams to perform at a high level. We want them to have a high degree of discretionary effort. We want them to embrace our “commitment to excellence.” Therefore, we must be the ones to create the psychological safety necessary to facilitate this growth.
One of the most effective things you can do as a leader is to be open and willing to share that, in the end, you are human too. You make mistakes, you admit to them, you learn from them, and you share them with others so they can learn too.
One of the most effective things you can do as a leader is to be open and willing to share that, in the end, you are human too. You make mistakes, you admit to them, you learn from them, and you share them with others so they can learn too.
DIVE DEEPER
Other stories by Guy Shockey:
InDEPTH: Reflections on Twenty Years of Excellence: Holding The Line (2019)
InDEPTH: Situational Awareness and Decision Making in Diving (2020)
InDEPTH: The Flexibility of Standard Operating Procedures (2021)
InDEPTH: How to Become an Explorer: Passion, Partnership, and Exploration (2022)
InDEPTH: Errors In Diving Can Be Useful For Learning— ‘Human Error’ Is Not! by Gareth Lock
InDEPTH: Learning from Others’ Mistakes: The Power of Context-Rich “Second” Stories by Gareth Lock
Guy Shockey is a GUE instructor and instructor trainer who is actively involved in mentoring the next generation of GUE divers. He started diving in 1982 in a cold mountain lake in Alberta, Canada. Since then, he has logged somewhere close to 8,000 dives in most of the world’s oceans. He is a passionate technical diver with a particular interest in deeper ocean wreck diving. He is a former military officer and professional hunter with both bachelor’s and master’s degrees in political science. He is also an entrepreneur with several successful startup companies to his credit.
Low Cost DIY Rebreather Testing: Why and How
An Ice Water Museum Named SS Ohio
Finessing the Grande Dame of the Abyss
Why It’s Okay To Make Mistakes
GORG GROK
Is Oxygen Narcosis A Thing?
