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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.

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Fiona Sharp, You Will Be Sorely Missed

As you have likely heard, we’ve lost one of the irrepressible and much-loved characters in the tech and diving medicine community, 55-year old Australian anesthesiologist and diving physician Fiona Sharp.

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By Rosemary E Lunn
Header photo by Catherine Meehan. Fiona in Sodwana Bay.

Fiona at BonaireTek. Photo by Michael Menduno.

One of the colorful characters in the field of diving medicine died tragically in a rebreather diving accident on Thursday, October 17, 2019. Fifty-five-year-old, Australian diving physician and anesthetist Dr. Fiona Sharp, MBBS, FANZCA, was found unresponsive on a reef at 24 m/80 f. She had been solo diving on a rebreather, and she was discovered with her mouthpiece out. Fiona was medevaced but did not regain consciousness. The incident occurred on the last day of Fiona’s diving trip to Bonaire, located in the Leeward Antilles, Carribean Sea. It was the week after Bonaire Tek. Fiona enjoyed deep rebreather diving and was known to be a bit of a maverick.

“We are shattered.” Bruce and Lynn Partridge, Shearwater Research.

Fiona at AsiaTek. Photo by Michael Menduno.

The disturbing news of Fiona’s death rocketed around the world in a few hours. Many people from the diving medicine and technical diving communities expressed their dismay and distress at Fiona’s death. She was gregarious, fun-loving, irrepressible, and generous. Fiona was a friendly colleague and we had dived together a few times. I wrote a heartfelt tribute about Fiona’s bulldozer attitude to life and diving, and this was published by X-Ray Mag. It includes a myriad of voices from around the globe and amply illustrates just how well-loved she was by her colleagues and friends. 

“Fiona was an individual. She did what she wanted. She did what she loved. She was very much her own person, and drove us mad at times. Fiona was down to earth, had a massive heart, a huge personality, and was very dear to all of us. She will be greatly missed.

Dr. Catherine Meehan

Fiona Sharp was born in May, 1964, in Perth, Australia, and she was bright! She attended Mercedes College Perth, where she was “Dux” in her graduating year. [Dux: from Latin for ‘leader,’ the term that is now used in Australia and New Zealand to indicate the highest-ranking student in a specific achievement). 

Fiona in Sodwana Bay. Photo by Catherine Meehan.

After leaving high school, Fiona studied medicine at the University of Western Australia where she graduated in 1989 as a Bachelor of Medicine and Bachelor of Surgery (MBBS UWA). After serving an internship in Perth in 1989, followed by a year as a junior Resident in Sydney, Fiona moved to England where she gained her Diploma of Anaesthesia (DA) in 1992, whilst working as a Senior House Officer in Anaesthetics in Southend, Essex.

Fiona then returned to Australia and commenced specialist Anaesthetics training. In 2000, she flew once again to the UK where she spent five years practicing diving medicine at DDRC Healthcare (Diving Diseases and Research) in Plymouth. During this period, she was awarded a Fellow of the Australian and New Zealand College of Anaesthetists (FANZCA) Fellowship in 2004.

At the time of her death, Fiona Sharp was working at the Fiona Stanley Hyperbaric Medicine Unit (FSHHMU) in Perth, Western Australia. She had been in post since it opened in November 2014. Prior to that, she was employed at the HMU at Fremantle Hospital from 2007 to November 2014. (The department then relocated to the newly built department at FSH).

Fiona at an event with the Hyperbaric Technicians and Nurses Association. Photo courtesy of Catherine Meehan.

Whilst writing this, I spoke to Fiona’s family and asked: “why medicine?” They responded,

“If you are really smart at school, you are expected to be an architect, a lawyer, or a doctor. Medicine appealed to her; however, it was possible that she could have become a vet because the family did have a lot of animals.”

Fiona’s family

“She was nuts, about everything. But especially about diving.” 

Dirk Peterson

Fiona got into diving in her late teens after trying skydiving and scuba diving. Water prevailed and she learned to dive when she was 18 years old. She was a PADI Divemaster, cave certified and qualified to dive the Inspiration, Evolution, SF2, Drager Dolphin, Mark VI Poseidon, and JJ-CCR rebreathers. 

Fiona with Dr. Neal Pollock, Rosemary Lunn, and Dr. Richard “Harry” Harris at Rebreather Forum 3. Photo courtesy of Rosemary Lunn.

You cannot ever say that diving was her hobby. It was her all-encompassing great passion. Fiona recently told her older sister that she felt happiest when she was underwater. It was therefore natural that she would take an active interest in diving medicine, and she became a fixture at all the major diving medical or tech conferences. SPUMS, UHMS, EUBS, HTNA, as well as EUROTEK, OzTek, Rebreather Forum 3 and other diving industry events. These helped keep her current and educated in this niche sector. 

Fiona loved the diving, diving medicine, and the camaraderie around the bar. She was regularly first up and last to bed. Most often, Fiona could be heard well before she was seen on land and underwater!! She was well-loved by her colleagues at these events and, as many have said, the SPUMS Conference won’t be the same without her. I think she attended at least 17.” 

Dr. Neil Banham, Fiona Stanley Hospital

Fiona’s first South Pacific Underwater Medicine Society (SPUMS) Conference was at Layang, Layang island, in Malaysia in 1999,  a venue well suited to her type of diving because it was deep. It was at a later SPUMS, in 2008, that Fiona’s diving would change. Dr. Catherine Meehan takes up the story. 

I met Fiona at a SPUMS meeting about 20 years ago. In 2008, I chartered the ‘Golden Dawn’ liveaboard. Ten of us flew into Alotau in Papua. New Guinea. and we sailed and dived our way across to Kimbe Bay, West New Britain, to join the SPUMS annual scientific conference. There was a rebreather on board and Fiona had a guided rebreather dive. She enjoyed it so much that she dived with it for the rest of the week. I believe this was one of her earliest experiences rebreather diving, and I think that she embarked on her passion for diving rebreathers shortly afterward.

Catherine and Fiona would regularly dive together, at least two or three times a year, all over the world.

We did a lot of conferences and diving together. We were most recently in South Africa diving Sodwana Bay. She was dressed in her vibrant orange drysuit so it was easy to see where she was, doing her own thing. It was tough cold water diving, but she was very hardy and didn’t miss a dive, even when her suit leaked. It is a good lasting memory of her.”

It was like she had been shot out of a cannon when she entered a room.

Joanna Mikutowicz, DiveTech


Fiona Sharp never did anything by halves, and this is amply demonstrated by a classic Fiona story that her older sister Donna regaled to me.

Many years ago Fiona rang me up and said, ‘I have got two tickets to the rugby game on Friday night, do you want to come with me?’ I thought, ‘Why not?’ One of our kids plays rugby at school. I rocked up at the game and she said to me, ‘Here is your ticket. Don’t worry about paying. And by the way, these tickets are not just for tonight’s game. They are season tickets’.”

She goes on: 

“We ended up supporting the Western Force, a professional Perth-based rugby team, for the next twelve years and watched them play Super Rugby against New Zealand and South Africa. What I found ironic was that I went to nearly every game. I think Fiona missed more games than any of us because she was away diving so much.

Fiona Sharp drew no quarters when it came to life and diving. I only met her a few times, but she left an aircraft carrier shipwreck-sized impression on my psyche and we remained in contact.”

Laura James, Environmental Campaigner, Underwater Cinematographer

Many divers have been generous with their Fiona stories. Todd and Tiffany Winn of Silent O Solutions reached out to me with another classic Fiona tale and said I could share it. When Fiona decided you would be friends, the recipient really didn’t stand a chance. 

Fiona’s reputation as ‘difficult’ preceded her, and our first encounter with her was memorable, to say the least. It was in San Diego for an in-water recompression symposium and training event in 2014. She exceeded my expectations. I believe she only told me I was completely mistaken two or three times. I conceded two of three and agreed to disagree on the third. She had an uncanny ability to defuse my ire with a wry smirk. As she had already decided we’d be friends, I had little say in the matter.

Tiffany Winn
Fiona before a dive in Bonaire. Photo by Michael Menduno.

Tiff liked Fiona immediately and loved her unflinching honesty and authenticity. Fiona threatened to visit us on Maui on one of her transits across the globe, but unlike nearly everyone else she called and texted for a month straight, ironing out the details, and sure enough, one day, showed up. We loaded up our little boat for its maiden voyage, and Tiff and Fifi had a girl’s day rebreathering all by themselves. We had a beautiful day and a fabulous sunset. We will remember her fondly and often, and will miss her dearly.”

Todd Winn

It is only right that I leave the last words to her family. I was told that Fiona had wanted to climb Mount Everest, but she suffered so badly with altitude sickness, that she just about made it to base camp and no further. Fiona was always willing to take a risk, and push herself. Apparently she competed in triathlons in her early 20’s, and she liked challenges. Everyone who came into contact with her soon found out she had a very dry sense of humor.

Fiona didn’t like cheap champagne or wine. It had to be good quality and lots of it, and she always brought home two bottles of whiskey from every trip for her father.

Donna Sharp

Fiona was close to her family. She is survived by her mother, three sisters, a brother, and 18 cousins. She was an “oh so very proud” aunt to 13 nieces and nephews. Typically big-hearted and kind, Fiona had planned to take a nephew to Antarctica this November. You mad as a box of frogs lady, you will be missed. 

The author is very grateful for the assistance of the Sharp family and Dr. Neil Banham, Director of Hyperbaric Medicine at Fiona Stanley Hospital in writing this tribute. 


Dive industry fixer, Rosemary E Lunn (“Roz”) is the Business Development Director at The Underwater Marketing Company. This British firm specializes in providing marketing, communications, social media and event management for the “tecreational” and technical diving industry. Rosemary is a PADI IDC Staff Instructor, BSAC Advanced Instructor, Trimix, and CCR diver. Before moving into the public relations field, she worked as a professional recreational instructor, safety diver, and underwater model underwater and appeared on the History Channel and National Geographic documentaries. She established TEKDiveUSA and organized Rebreather Forum 3 on behalf of AAUS, DAN, and PADI. In 2008, Rosemary co-founded EUROTEK, the European advanced and technical diving biennial conference. She is a respected and prolific diving author, an SSI Platinum Diver, an Associate Member of the Women Divers Hall of Fame, and sits on the SITA Board (Scuba Industry Trade Association).

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