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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.

1 Comment

1 Comment

  1. David Concannon

    November 16, 2019 at 8:49 pm

    Dr. Clarke,

    I am happy to contribute to this discussion and, as you know, it is one I have been trying to have for more than a decade.

    First, I agree with your premise that there needs to be an NTSB-like approach to diving accident investigations. Where you and I have disagreed in the past in on the topic of whether equipment manufacturers should be given an advisory role in such investigations, just like Cessna, Boeing and Piper are given with NTSB investigations into accidents involving their planes. I believe the manufacturers should be given such a role but, in the past, you have disagreed with me on this point. The problem with excluding the manufacturers is that, by doing so, you immediately exclude the party with the most knowledge about the design, testing, manufacture and use of the product from contributing that knowledge to the investigators. Whenever this happens, I have seen glaring mistakes made by the investigators: dive computer data is not downloaded or properly analyzed, equipment modifications are not recognized, dive conditions are not considered, etc., etc. If the investigators do not know what they do not know, how can they be expected to conduct a proper investigation?

    Second, in the Skiles case, the accident rig was not sent to Dive Rite for an initial evaluation. The rebreather was sent directly to NEDU by the Sheriff, and the dive computer was returned to the family without its data being saved, never to be seen again until it was pulled out of the plaintiff’s attorney’s pocket when he showed it to the jury at trial. In fact, the dive computer was in the possession of the family immediately after the accident. It was not given to the Sheriff until nearly a month after the accident, and it was never given to NEDU. Consequently, NEDU could not test the rebreather under circumstances identical to Mr. Skiles’ dive because NEDU did not have the profile of Mr. Skiles’ dive; it only had a photo of a graph taken from the dive computer screen.

    Third, some people don’t realize that diving equipment manufacturers currently conduct their own investigations into dive accidents not out of fear of litigation, but because federal law requires them to do so. The U.S. Consumer Product Safety Act requires product manufacturers to investigate incidents involving serious injury or death to determine if their product contributed to causing the incident and, if so, the manufacture is required to notify the U.S. Consumer Product Safety Commission within 24 hours. Consequently, the manufacturers routinely conduct their own independent investigations, usually with my assistance, and it makes perfect sense to cooperate with and assist the investigative authorities so resources are not wasted and critical information can be shared.

    Third, in my experience, investigative authorities are either exceedingly grateful to receive assistance from the manufacturer or remarkably unwilling to receive such assistance. NEDU, for example, has been decidedly unwilling, as has the US Coast Guard in many instances. In such instances, mistakes are almost inevitably made and, when they are, I point them out in a way that is sometimes considered unpleasant by the recipients. In my view, if assistance is offered and rejected, and mistakes are made because of ignorance, it is important to educate the party making the mistake so it does not happen again. Making mistakes is to be expected, but repeating mistakes should not be tolerated.

    Finally, as I have stated publicly on numerous occasions, I am a strong proponent of releasing accident information so people can learn from others’ mistakes and not repeat these mistakes. Unfortunately, not everyone agrees with me, and particularly not NEDU or the Coast Guard. I applaud the courage of Mrs. Mark and, more recently, Mrs. Ashley Bugge for their courage in releasing information that did not necessarily paint their husbands in the best light but certainly helped save the lives of other divers, and also spared other families the pain and grief these two brave women experienced.

    If only some of the federal and state officials charged with protecting the public showed as much courage, or even a smidgen of care in actually doing their jobs and fulfilling the mandates of their employers. As I said to a Commander in the U.S. Coast Guard after I was forbidden to speak about lessons learned in a recent U.S. Coast Guard investigation and a member of the audience died less than two weeks later: “Here is the answer to the question you will never ask me: Brian.” The question: “What is the name of the person whose life I could have saved if I had only done my job.”

    Thank you for starting the discussion. It’s important because, frankly, very little has changed or is going to change if people don’t receive the information they need to understand why accidents happen and how to avoid repeating mistakes.

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A Message From GUE’s President During These Challenging Times

GUE President, Jarrod Jablonski extends well wishes and informs community of how COVID will affect GUE.

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News from GUE HQ

I would like to offer my wishes for your safety and health during these challenging times. With most of the world heavily affected by the COVID-19 virus, I want to reiterate GUE’s sense of community and offer our wishes that each of you are able to minimize the impact of these difficult days. 

Given the many complications, we are monitoring the virus progression and global health recommendations on a daily basis. Given the variability of restrictions and diversity of exposure risk across the world, GUE is not currently prohibiting dive training. However, we do suggest that each person take their personal situation into account and act  based upon local rules, policies and implemented preventive measures. We urge you to consider the wellbeing and health of all involved. We are in direct communication with our instructors and working with them in support of class policies and training options that reduce transmission risk among those who remain desirous of undertaking training.

GUE divers wishing to postpone their training will receive an automatic extension to their registration grace period, allowing them to repurpose this fee to account for the time lost during the management of the virus. GUE will also extend the normal provisional window, allowing all students an opportunity to upgrade after the threat from the virus has receded. Your GUE instructor will work directly with you toward scheduling a new class and repurposing any deposits or fees paid for training. Please manage those costs directly with your instructor.

Please do contact us directly at info@gue.com if you have any questions. 

In the meantime please accept our heartfelt wishes for your well being. May you and yours remain safe and healthy.

Sincerely,

Jarrod Jablonski


Jarrod is an avid explorer, researcher, author, and instructor who teaches and dives in oceans and caves around the world. Trained as a geologist, Jarrod is the founder and president of GUE and CEO of Halcyon and Extreme Exposure while remaining active in conservation, exploration, and filming projects worldwide. His explorations regularly place him in the most remote locations in the world, including numerous world record cave dives with total immersions near 30 hours. Jarrod is also an author with dozens of publications, including three books.

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