There's a February, 2011 news report RE a UK coroner's findings in this matter, below. But first, some observations. Coincidentally, the February, 2011 issue of the
Undercurrent newsletter includes a four-page article (pages 13-16):
"Who’s Responsible for a Diver’s Death? In the U.S., there’s no clear-cut way to assign proper blame to guilty parties."
Undercurrent's article laments that divers in the USA have no access to post-accident investigation data, as that information is claimed to be privileged by attorneys representing the training agencies and insurance underwriters. Never mind that complete investigations are incredibly rare in the USA in the first place.
Undercurrent details how most other English-speaking countries make coroners' findings public, such as what's posted below (this tragedy was not mentioned in
Undercurrent).
What
Undercurrent didn't say, but which I believe adds insult to US tragedies: equipment inspections after accidents are often conducted by the very same individuals who have a VERY long history as paid expert witnesses; they are well paid to give testimony that helps defend training agencies and dive insurance underwriters. When victims' families want to have access to accident reports, the defense's method to seal accident reports as "privileged" is to seek protection under the Fifth-Amendment; the courts often grant this request!
It's not only justice that seems inappropriately blinded. I think dive pros have been bamboozled into fearing the bogeyman of "ambulance-chasing" plaintiff attorneys, who, allegedly, don't care if they destroy the economic viability of the dive industry.
Yet many dive pros themselves have been the victims of dive hazards that were never disclosed to them. Dive gear evolved in the 1970's to be safer, because
accident reports were thorough and accessible. (Those "ANSI" reports began as a mechanism to avoid possible Federal intervention after a series of well-publicized incidents.) As the saying goes, "Daylight is a good disinfectant." But by 1991, the marketing mantra that diving was really really safe kicked into high gear.
Nowadays, few recreational dive professionals - even course directors - ever learn the following pivotal hard-won knowledge, gleaned from autopsies, that could save many lives each year. It appears, to many, that the recreational dive industry's standard-of-care has been intentionally lowered, to swap liability protection for safety. Yet claims that "diving is as safe as bowling" continue to lure would-be divers. Examples of what's NOT included in training material for dive professionals, which ALL divers should know:
- If IPE (immersion pulmonary edema / drowning in your own blood plasma) is so "rare," why has it been written about and discussed for 50 years within the military and commercial diving communities (from the UK's 1959 Journal of the Royal Naval Medical Service), but not the recreational dive industry? "Rare" when 70 Israeli combat swimmers suffer swimming-induced PE (SIPE) between 1998 and 2001? When recreational divers sign a medical liability release, they must acknowledge no history of IPE. But how would they know? Most non-diving doctors are unaware of IPE; at least one doctor almost drowned from IPE, and a coroner, arguably, died of IPE. I can find no mention of IPE in PADI's Encyclopedia of Recreational Diving as it relates to scuba diving - only lung edema suffered by some free-divers after a series of exceptionally deep dives (page 5-36). While IPE is described on page-3 of PADI's medical liability release, PADI's text fails to disclose that negative-pressure breathing and over-hydration can trigger IPE, even in young/fit divers. US Navy divers have been warned for years to avoid IPE during exertion by not over-hydrating and not using hard-breathing regulators. Anesthesiologists have long known that they can "turn on and off" PE of their anesthetized patients, within five breaths, merely by inducing negative-pressure or positive-pressure breathing. IPE can be virtually eliminated with positive-pressure breathing (PPB), because "negative static lung loading" (NSLL) is eliminated. Cold water, exertion, hypertension, coronary weakness or excess hydration all raise IPE risks, but NSLL is the trigger. How a regulator is designed and adjusted, or improperly designed and adjusted, goes a long way to trigger or prevent IPE. A search of the Rubicon-Foundation for immersion + "pulmonary edema" yields 419 matches: from 1966, another from 1966, 1974, and from 1978 by Dr. Glen Egstrom:
The sudden death syndrome has recently been described. Middle aged men return from a dive on the surface, are alright for a while then develop respiratory trouble and die. The post mortems have normally given the cause of death as drowning. There is speculation that what kills them is a hypertensive episode opening intracardiac shunts L-R.
Diuresis is almost inevitable. A diver working hard at 150 feet will develop a 3 to 4 pint (American) decrease in his plasma volume. Negative pressure breathing induces a diuresis of up to 500 ml/hour; diuresis subsides after 2-3 hours with individual variations. Sodium excretion is increased. Cold causes diuresis, as does alcohol. Respiratory water loss is 500 to 600 ml a day in normal air, dry gas increases the water loss. The effects of water loss in terms of performance, work capacity gas uptake, etc. is not understood. Immersion diuresis is reduced by positive pressure breathing. (emphasis added).
[*] Why do you think Cousteau wore his regulator on his chest (to enjoy positive-pressure breathing):
(Copyrighted photos used under the "Fair Use" doctrine of US copyright law, to advance understanding of safety and consumer issues, per Title 17 U.S.C. Section 107.)
[*]CO2 sensitivity: 20% of women and 10% of men can be perfectly calm, and not generally prone to panic... until they breathe ~15% CO2 for just a few seconds...then, WHAM! (They could still become divers; would-be divers could be inexpensively pre-screened, to be made aware before putting themselves and their buddies at risk.) The amalgamation of decades of peer-reviewed research finds that early-onset IPE - which could be caused by a marginal regulator - reduces a diver's normal ventilation ability, causing the retained % of CO2 to rapidly spiral far above normal, thus expediting a CO2-induced panic attack, before full onset IPE actually strikes. At autopsy, it's impossible to know the sequence of events that caused the panic, prior to drowning.
How many deaths does it take? New tragedies repeat past mistakes, ad nauseum, because of low standards of care (per at least one past civil RICO case brought against PADI). The US dive industry has architected a stratagem that, unarguably, is very lucrative to the industry's defense attorneys and expert witnesses. But when would-be divers ask their local dive retailer about dive accidents, and dive pros cite the bowling "statistic" (because that's what the industry's leaders teach them to say), that answer both fails the smell-test of savvy consumers, and "Safe as bowling"
also fails to be substantiated by any of the dive industry's own facts (that have remained hidden behind Fifth-Amendment protection). Some believe that the bowling claim is a fraud to induce commerce and the signing of liability waivers.
Do those at the top of the industry's pyramid not realize that pugnaciously blaming the victim, when maybe the industry shares some of the blame, generates MILLIONS OF DOLLARS in negative publicity for the industry? To be profoundly tone-deaf in this Internet era does not bode well...is it any wonder that the dive industry lags,
per Leisure Trends Group, Inc.,
ALL other recreational activities recovering from the recession?
A better way has been proven to reduce liability and SAVE LIVES:
Forward thinking doctors and administrators in the US health care industry have discovered over the last 10 years that it's good business to do the morally right thing - which is to admit mistakes quickly, clearly, and to make amends to mitigate future accidents. Their settlements are lower...and their defense attorneys make less money.
(Example from one of many hospitals proving it's smart business to do the right thing.) A vast amount of evidence supports this position, but vested interests and fear of change cling tight to the old ways.
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Published on Thu Feb 03 07:47:40 GMT 2011 in
The Star (UK)
Tragic diver was ‘in panic’ on sea wreck
A DIVER from South Yorkshire died while exploring a sea wreck after he descended beyond depths for which he was qualified, an inquest heard.
Dad-of-four Neil Rodgers, 40, became separated from two other more experienced divers when he got into difficulties. He was qualified to dive only to 35 metres but the trio descended to about 47m in the Sound of Mull off the west of Scotland before they hit trouble.
It is thought all three suffered nitrogen narcosis, which affects nerve cells in a similar way to alcohol, as they explored the wreck of the Rondo, a cargo vessel which sank in 1935.
As they became separated, Mr Rodgers’ ‘dive buddies’ Dr John Fallon and Sarah Brough each thought he was with the other.
Alarm engineer Mr Rodgers, of Chapelfield Crescent, Thorpe Hesley, near Rotherham, was on a club trip with other members of Doncaster Sub Aqua Club when he went missing in March 2008.
His body was finally found, lodged underwater between two boulders, 10 months later.
The inquest heard Mr Rodgers had been warned by the club’s dive officer not to go beyond 35m, a limit recommended for divers of his experience.
Independent diving expert Peter Church, asked by the coroner to investigate Mr Rodgers’ death, told a Sheffield hearing his two ‘dive buddies’ who were qualified to dive to 50m checked him only once at 11m. Mr Church said he would have expected “frequent” checks on the less experienced diver and for the trio to be close together as visibility lessened.
He said: “I would have expected the whole team to hold at 35m. Beyond that I would expect checks at every five metres.”
He said of exploring the Rondo: “It can be quite an ambitious dive. It’s a very steep dive and you can end up deeper than you planned to go because of the way the boat lies in the water.”
Pathologists could not give the exact cause of death which remains “unascertained”, although drowning was suspected.
The Sheffield hearing was told Mr Rodgers was up late the previous evening, drinking with other club members, but was “absolutely fine” in the morning.
Mrs Brough said it was more “challenging” for three divers to communicate than going in pairs, but after the check at 11m they descended “very quickly” with all three in touching distance.
She suddenly realised when she checked her depth gauge that they were at 47m and said: “I looked at Neil and he indicated he wanted to turn round.”
They stopped and sat in a triangle on the wreck to regroup. She said: “Neil started showing signs he was going into panic and really wanted to start going up. He wasn’t happy.”
She saw the other two divers face-to-face with their torches on. After about a minute she watched the torches ascend vertically from the wreck until they were out of sight. She then made her own controlled way up and was “pretty out of it”.
Dr Fallon told the inquest he had dived with Mr Rodgers before on trips well beyond 35m, and got the impression he was a “very capable” diver. Had he known his limits he would have tackled him about it, he said.
Assistant deputy coroner Donald Coutts-Wood said he was satisfied Mr Rodgers’ equipment played no part in his death and the dive plan beforehand and at the scene was adequate.
He said: “I am satisfied narcosis played a role. The effects could be exacerbated with the alcohol drunk the night before and lack of rest, but above all the question of depth comes in.”
The coroner said depth played a significant role in spreading confusion as Mr Rodgers was clearly in distress and panicking.
“It would appear he left that area never to be seen again,” said Mr Coutts-Wood, who recorded a verdict of death by misadventure.
