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The Case for an Independent Investigation & Testing Laboratory

In the light of recent diving accidents, newly retired Scientific Director of the U.S. Navy Experimental Diving Unit (NEDU) Dr. John Clarke, makes the case for an independent community-based accident investigation and equipment testing lab, similar to the U.S. National Transportation Safety Board (NTSB), to provide vital information back to the diving community can improve diving safety. As Clarke points out, “A diver’s death should mean something besides a medical examiner’s verdict of Cause of Death: drowning.” He is hoping to start a discussion. Please chime in!

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by John R. Clarke Ph.D.

Header photo by Stephen Frink. Navy Experimental Dive Unit, Panama City, Florida.

With the recent loss of yet another loved, experienced, and competent rebreather diver, Fiona Sharp, MD, I would like to offer an idea whose time has perhaps come.

Until approximately ten years ago, the US Navy Experimental Diving Unit (NEDU)  tested new underwater breathing apparatus (UBA) and investigated UBA-related diving accident cases. Those cases were either military, or forwarded by the U.S. Coast Guard and, sometimes, by Medical Examiners. As the number of civilian cases increased, the time burden on NEDU’s Test and Evaluation laboratory became so all-consuming, that NEDU restricted outside accident cases to those UBA of military interest. They also started charging the fair cost for outside examinations. Not surprisingly, accident cases reviewed by the Navy have since plummeted.

Rebreather diving is very much like flying a small airplane. It’s highly enjoyable, highly technical, and quite useful; but also expensive, and in certain circumstances, lethal.

An aviation accident is accompanied by a Federal Aviation Administration (FAA) or National Transportation Safety Board (NTSB) investigation, which uses a recognized methodology that covers technical, human factors, environmental, social, and organizational factors. However, there is nothing similar for Scuba and rebreather diving accidents.

Most aviation accidents are pilot-induced, but not all. If there is an equipment or a procedural problem, the entire aviation community is alerted. Recently, after a wing fell off a Piper Arrow—in-flight!—just such an alarm went out.

Before I retired from NEDU, a couple of civilian accident cases came to me, which I forwarded to Gregg Stanton and Wakulla Diving, since government labs cannot compete with private industry. Gregg was doing some investigations but lacked an adequately-sized pressure chamber. Moreover, the business case for private accident testing laboratories is non-existent, and I don’t think existing civilian facilities can do what is needed in the long term. 

A couple of months ago, I was contacted by a rebreather manufacturer to see if I could arrange Navy-approved laboratory testing of their new rebreather design. I put him in touch with Kirby Morgan Diving Systems’ Dive Labs, but the Dive Lab schedule is taken up with not only their own needs but also an overflow of military testing. Even NEDU can’t keep up with the military’s testing demand.

Navy Experimental Dive Unit, Panama City, Florida. Photo by Stephen Fink.

As a result, some manufacturers might not be able to properly test their rebreathers before going to market, or after making design changes. Arguably, that’s not a good thing. Also, if there is an accident that needs investigating, like Fiona Sharp’s, where would we find a neutral third party to look at the ‘system’ as well as technical equipment issues? 

I think we can all agree that the case of underwater filmmaker and photographer, Wes Skiles, was tragic. Ultimately the jury decided that neither the equipment nor the manufacturer was at fault, but that sending the accident rig to Dive Rite for an initial evaluation was conflict of interest. That does not mean that things were done wrong. However, it does mean that extra care is required to ensure that things are not done wrong. In my opinion, it would have been far better to seal the UBA for immediate transport to a neutral investigation team.

Funding Options

An independent testing laboratory might initially be funded by manufacturers who want their equipment tested to Navy or CE standards. With proper protections in place, that laboratory could also conduct accident investigations. Rationally, it should use a recognized and standard methodology like the Human Factors Analysis Classification System (HFACS).

People buy time-shares in private jets to make them available when needed; a similar structure could be used to make testing equipment available on a “as-needed” basis. That way, when an accident case comes in, the laboratory would have the equipment and knowledge to conduct accident investigations pro-bono. Alternatively, taxes from scuba and rebreather sales, dive education, or dive resort diving fees, could perhaps sustain the facility. Of course, time and expertise could be purchased on a one-off, case-by-case basis. 

I am firmly against having the parties in litigation pay a testing laboratory. Consider the history of tobacco companies paying scientists and their laboratories to test the safety of tobacco products. It’s a sad fact, but money talks, even to scientists.

Admittedly, I’m a scientist, not a businessman, but the more I watch beautiful people dying in the water, and after observing the sometimes shoddy investigations that follow, I recognize that, well, it just isn’t right. A diver’s death should mean something besides a medical examiner’s verdict of “Cause of death: drowning.”

Just imagine if the NTSB cited the cause of death for pilots and passengers as “Crashing.” There would be public outrage, and neither pilots nor aircraft manufacturers would learn anything from it. In fact, the NTSB used to do just that, and called it ‘pilot error.’ And then, they realized that by analyzing cockpit voice recorder data and flight data recorders, the ‘pilot error’ was, in fact, a convergence of multiple systems and human factors.

The Navy considers both aviation and military diving to be a high-risk activity, and it goes to great lengths to manage those risks, usually with great success. Rebreather divers and training organizations also go to great lengths to manage risks. However, what seems to be lacking from some water fatality investigations, are the “lessons learned.” 

Dissemination

What good is knowledge gained from an accident investigation if it isn’t disseminated to the diving community at large?

NEDU diving accident investigation reports are rarely released to the public. One exception is the report on the death of cave diver Richard Mork in September 2008. It was released to the world by Mork’s widow. 

NEDU’s video deposition during the Wes Skiles fatality trial was also released through Courtroom View Network. Unfortunately, the testimony was not particularly revealing since the UBA components evaluated by NEDU were so fragmentary. 

To help prevent future diver fatalities, the publication of investigation results is essential. Arguably, that would be a more difficult task for an investigating agency that receives its funding from equipment manufacturers. Impunity from adverse action for their reports is precisely why the NTSB is so effective in improving aviation safety; they are not beholden to aircraft manufacturers or pilot unions. 

Since the threat of litigation has a stifling effect on dive accident reporting, will legislation protecting an independent investigation be required? That is something to consider. Hopefully, Giugi Carminati and David Concannon, or other attorneys, could contribute to this discussion.

The Complete Package

The UK’s Gareth Lock, founder of the The Human Diver, does a superb job of explaining the human factors side of risk management, but who does the equipment investigations, and how do they join up? In my opinion, we’re missing a critical factor in the risk avoidance equation.

I do not consider the court of public opinion via Facebook and rebreather forums to be the best we can do in terms of preventing future accidents. What do we divers learn from the deaths of Wes Skiles and Fiona Sharp? Until we recognize that we are all fallible and that those same issues can apply to us all, irrespective of experience and position, then diving safety is not likely to be improved. 

Perhaps it’s time to restart this conversation.

Editor’s Note:

Beginning in June 1993 with aquaCORPS #6 Computing (my old magazine from the 1990s), we added a new section called “Incident Reports,” in response to the spate of tech diving deaths in the summer and Fall of 1992. It soon became the best read section of the magazine. In it, we reported on fatalities and serious injuries that occurred in between publishing issues. I personally did much of the reporting. I would call the people involved after the news of an incident surfaced and write a non-judgemental report sans names stating what was believed to have happened, so that we could all learn from incident and hopefully improve diving safety. In total we reported 45 incidents between late 1992 to 1Q 1996, when aquaCORPS closed its doors.

Sadly, today, of course, this kind of reporting is almost impossible in most cases for fear of legal action—almost no one is willing to talk. However, even after legal cases are settled or dismissed, seldom is the relevant information forthcoming, i.e. what happened. As John points out in his post, we the diving community are the losers. However, I also recognize, that sometimes, the families don’t want information released. I respect that. I hope that you will share your thoughts regarding John’s ideas. Thank you.

Additional Resources:

A Profile of NEDU: Deep In The Science of Diving, Alert Diver Q3 Summer 2016

Rebreather Forum 3 Proceedings
-“Rebreather Accident Investigation,” by David G. Concannon, pg 128
-“Post-Incident Investigations Of Rebreathers For Underwater Diving,” by Oskar Frånberg, Mårten Silvanius, pg.230


John Clarke, also known as John R. Clarke, Ph.D., is a Navy diving researcher in physiology and physical science. Clarke was an early graduate of the Navy’s Scientist in the Sea Program. During his forty-year Navy career, he conducted physiological research on numerous experimental saturation dives. Two dives were to a pressure equivalent to 1500 fsw. For twenty-eight years he was the Scientific Director of the Navy Experimental Diving Unit in Panama City, FL. Although recently retired, Clarke still works for NEDU as a Scientist Emeritus and contractor, when he isn’t writing about diving, aviation, and space. He has authored a technothriller-science fiction series called the Jason Parker Trilogy available at Amazon and Barnes & Noble. His websites are www.johnclarkeonline.com and www.jasonparkertrilogy.com.

Cave

No Direction Home: A Slovenia Cave Diving Adventure

Suffering from Covid lockdown, young, poetic Italian explorer, instructor, and gear-maker, Andrea Murdock Alpini, decided to take social distancing to the max! He packed his specially designed cave-van and set out on a three-week solo road trip to dive the water-filled caves lying beneath the Slovenian soil. His report and must-see video log, dubbed, “No Direction Home”—an homage to Martin Scorsese’s Bob Dylan docu—will likely satisfy those deeper urges for adventure. Did I mention the killer soundtrack? Kids don’t try this at home!

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Text: Andrea Murdock Alpini

Photo & Video: Andrea Murdock Alpini

Ecco la storia originale così com’è stata scritta in italiano

Author’s note: I do not encourage other divers to conduct solo diving. The trip and the dives described in this article were conducted after significant training and experience.

Ed.Note: Global Underwater Explorers does not sanction solo diving.

Freedom!

That was the feeling I had last June 2020 when I left my home to begin a journey alone. Caves, abandoned mines, alpine lakes, and a few wrecks—that was my plan for a great adventure.  

The first COVID-19 lockdown had been in place for a couple of weeks, and I was afraid of going out and meeting people. Social distancing left an open wound. I loaded my wreck-van with plenty of stuff to survive alone for a long month traveling amongst rivers, lakes, mountains, and forests, and I was ready to practice scuba diving. 

At that time, tourist travel was impossible in Italy or abroad—anywhere  in Europe—because the coronavirus had locked the borders. I asked an editor in chief from a magazine—one whom I am used to sending articles to—to prepare a couple of official invitation letters for customs. For my trip, I converted my wreck van into a cave van. It was fully equipped with a 300-bar air compressor, helium, oxygen, deco cylinders, twinsets of different sizes, gas booster, fins, mountain boots, tent, camp burner, and brand-new dry suits, as well as thermal underwear to be tested for my company PHY Diving Equipment. 

I remember the day well. I was thrilled as I crossed the border between Italy and Slovenia. I had been restricted to nothing but a 200 m/650 ft walk from my house because of the pandemic restrictions, but with an eight-hour drive, I was free to enjoy walking into wild nature all alone.

The mental switch was awesome, and unexpected. I did make just one phone call from abroad. I talked to an incredible Russian who was the first guy I met in a small rural village in Slovenia. He had emigrated some years ago, and now he welcomed travelers by sharing his farmstead. 

However, once I arrived on site, I was not very welcomed by  the weather; instead, I was met by heavy rain. After the storm passed, I went out walking and filming with my phone. I had decided to record all of the trip. As luck would have it,  the rain returned again, and it never left me for the entire duration of my trip (almost a month).

My tour was articulated throughout Slovenia, Garda Lake (Italy), Austria, and South Tirol’s Alps, Tuscany’s caves, and finally I reached the central part of Italy—Appenini mountains and their peaks. I planned to reach two mines, but heavy rains stopped my dream. Excluding Slovenia, where I slept in a traditional bed, I passed all my time living in my tent. Cold weather and storms were my constant companions. 

I managed to see  a ray of light for just a few hours, I never had any chance to dry my equipment, and I warmed up inside my van. Every night I slept only a few hours because of loud wind noise or strong rain storms. Day-by-day I grew tireder and more feeble. One day, three weeks after I left home, I was in South Tirol descending a mountain when I decided to conclude my trip, and I returned home safe.

The goal of my trip was to tell scuba adventures from the surface point of view where the water is only a part of the context and not the objective. I made a mini-series film composed of three chapters. Each one brings you inside the scene. What  follows here is the first episode of the trip.

Social Distancing Beneath The Slovenian Soil

The first day of cave diving in Slovenia was very tricky and full of adventures. I had no idea how the second day would go. 

I left my accommodations around 6 a.m., after a good breakfast of cereal, dark chocolate with black coffee, dried fruit, and tasty Italian Parmesan cheese. I could not see anything from my window because what had fallen was not simply rain; it appeared to be an awesome flood. My plan for that day had been delayed.

I think that most parts of dry caves are condemned for hundreds of kilometers. So, I decided to check the weather forecast and water level conditions in caves close to the Croatian border. It would mean driving about four hours to see for myself whether scuba diving was allowed. I didn’t have to remind myself, I was alone here.



Wheels were on the road and local conditions seemed quite good. I had checked the weather on my laptop and understood the risk. If I was lucky, I could dive; if not, I would have to drive back. I drove through Slovenia forest meeting no one. With less than an hour left to my destination, I came across an abandoned farm village, completely empty.

The dive inside Bilpa Jama was breathtaking. Now I was seated beside the cave shore preparing soup to warm myself. After a stunning solo dive, I was cold and wanted only to taste the peace of this magnificent place. While I was dipping  the spoon in my soup cup, I heard a faraway voice, a police woman calling me and asking me to stop eating and come quickly to her. 

After I did as I was asked, she started examining my passport, documents, and permissions. A few minutes later, a huge National Army truck reached us. The soldier had  an abnormal body shape, a man the size of a walking mountain in an Army uniform. Can you imagine how I was feeling in those moments?!

Well, in the end, everything went really well, and I now have a story to tell my grandchildren. 

Once the passport control was over, and they had checked that I did not cross  the border from Croatia to Slovenia illegally (customs was only a few hundred meters  from us), I had the chance to get back to my soup, which by then had turned cold. I warmed it up again, and I spent half an hour seated on a slippery stone covered with moss and lichens watching the beauty of the forest surrounding me.

On the way back to my accomodations in my cave van, I  played a new playlist. 

Four hours later, I approached my country lodge. I was really exhausted,  but I had to refill tanks and plan the next scuba diving days. Once I finished, I watched the forecast again. Unfortunately, it was growing worse, so I decided not to dive and instead get a surface break. Tomorrow I would drive, search, and catch info and GPS coordinates of caves. My tomorrow plans had turned into a sketching and surveying day. 

The Road To Suha Dolca 

I drove and walked for hours and hours, up and down the forest or on lonely roads in search of caves where I could return in winter or perhaps next year. During the last survey of the day, I watched a talented young guy playing a traditional concertina and thought, what a lovely atmosphere and a fitting way to close my hard-working day!


I decided to give a last gaze to Suha Dolca cave, my favorite one, on the way home. This was the third consecutive day I had arrived back at this spot. Observing it day-by-day, I tried to find the best moment to dive this cave.

Until now, it was inaccessible due to the strong flow. I wanted to dive here before leaving Slovenia. Tired and  driving slowly, I parked my van away from my accommodation. Since I had no lunch, I started feeling very hungry. A simple dinner was quickly served: dried fruits and a cup of hot noodle soup.

My ‘NO DIRECTION HOME’ trip was now at its peak. I had become a wanderer. I was alone in a wild country with, yes, an internet connection for historical research and checking the weather. That was the only technology I used. Aside from that, I lived simply. I walked, dived, wrote, and filmed my experience all with my mobile phone.

Rain was tougher than expected. I had hoped to stop for one day, not the two that it took. Following the surveys, the next day I started fixing my video equipment and saving photos and videos I had made on my hard drive.

I had too many ideas, no one clear till the end, and too many cave sketches and GPS points to reorganize; I needed a day to regroup. I just went out for a few hours to check Suha Dolca’s Cave conditions. On this day it seemed that the flow was getting more stable, and general water conditions were growing better. I had to be patient and wait one or two days more for the right conditions. I tried and failed to find a solution on my own, but the water always showed me the way. She told me to wait and to go back to where I came from. Step-by-step I walked the path again.  

The third video chapter of Slovenia Solo Cave Diving is the one I prefer, because I remember the indecision I felt, to stay or to leave. Solo trips are strictly linked to life’s decision.


The last day I was in Slovenia I left the accommodations and asked a new farmer, close to a different cave, if I could sleep inside his barn and dive the river hole on the following day. I was at the same place where I had dived the first day. He told me I could not stay in the barn due to the high risk of bears who live in the surrounding area. I jumped in my van again and I drove to the lake beside Suha Dolca’s Cave. 

I descended the path several times and brought all my scuba gear piece-by-piece. I decided to give myself a chance to dive my dream cave in the late afternoon. I had no other choice. Once I was inside the cave it was unbelievable, and I had a very nice dive even though I was really tired, and again I broke my light arms and camera housing. I resurfaced after the dive into a reed’s lake, which made me feel like a beaver.

I had conflicting feelings as I left Slovenia that same night after making a tricky and stunning dive. Bears, awesome forests, and rural areas were now all behind me. The cave-van played a new disc, I needed to shake off these feelings and look forward to my new goals: Garda Lake’s wrecks, South Tyrol’s stunning lakes, and finally Austria. In the country of green and wide grazing land I wish to dive surrounded by the amazing scenario of beautiful Alps mountains. 

At 9:30 PM I crossed the border again, and  Italy was straight ahead.


Andrea Murdock Alpini is a TDI and CMAS technical trimix and advanced wreck-overhead instructor based in Italy. He is fascinated by deep wrecks, historical research, decompression studies, caves, filming, and writing. He holds a Master’s degree in Architecture and an MBA in Economics for The Arts. Andrea is also the founder of Phy Diving Equipment. His life revolves around teaching open circuit scuba diving, conducting expeditions, developing gear, and writing essays about his philosophy of wreck and cave diving. Recently he published his first book entitled, Deep Blue: storie di relitti e luoghi insoliti.

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