September 2001

The trial was heading into its third week. At stake was nearly $8 million and the future of diving. I was the last witness, called as a diving liability expert for the defense. Preliminary questions and direct examination established my qualifications, knowledge of the case and my opinion that the defendants — dive store, boat and dive leaders — were not at fault.

"So then, Mr. Hardy, in your expert opinion, who is negligent?"

"Mr. Paulis, the plaintiff."

"And how is he negligent for his own injuries?"

"Mr. Paulis is an experienced certified diver, and as such has certain responsibilities that only he can fulfill. He failed in several significant ways to meet those responsibilities."

"What are the specific responsibilities he failed to meet?"

"Mr. Paulis was not fit for this dive. His medical condition, his heart trouble that he concealed from the dive leaders, his lifestyle and recent illness all added to his physical and mental stress, which, when combined with the cold and fatigue he encountered on this dive, set him up for an accident. During the dive, he swam away not only from the group and the dive leader, but also from his buddy, so when he encountered difficulties, there was nobody there to help.

"Next, as the current increased, Mr. Paulis experienced difficulty swimming, breathing and controlling his buoyancy. Rather than pausing to regain control of the situation, he continued on until his level of stress was out of control, causing him to panic and begin an out-of-control ascent that led to an air embolism.

"The equipment, environment and the others on this dive were not the cause of Mr. Paulis's accident. He was. Fortunately, others were available when he surfaced unconscious, and they gave the best possible emergency care. Mr. Paulis is lucky to be alive."

And so it goes in case after case: Divers make mistakes, have accidents and then look for someone else to blame. Yes, there are cases where the dive leader, boat operator, store owner or manufacturer makes a mistake that harms the diver. That's why we have dive accident and liability insurance.

But the vast majority of diving accidents are caused by diver error. These accidents lead to legal actions and increased insurance costs for all. Most sadly, they lead to needless suffering and loss. After more than 25 years of investigating scuba accidents and testifying in trials all across the U.S., I've come to believe that most accidents can be prevented. How?

Below are 10 guidelines distilled from my involvement in hundreds of scuba accident investigations as well as from my experience as a dive instructor for nearly 40 years. Their purpose is to save lives. They are what I firmly believe instructors should emphasize in training courses.

Save Your Life: Have Good Overall Fitness

Rich swam over to his buddy, signaling frantically to share air. As the two share air, the buddy looks at Rich's pressure gauge. It still shows 1,500 psi. Suddenly Rich rejects his buddy's alternate air source and bolts for the surface, arriving unconscious and not breathing. Aggressive CPR brings him around, but he dies at the recompression chamber. An autopsy reveals a major heart attack, while the investigation uncovers a lifestyle that created a high risk of heart problems.

Several studies have indicated that 20 to 35 percent of all scuba fatalities result from heart and circulatory problems. Prior lifestyle and medical conditions set the stage, while the mental and physical stresses of diving trigger the event, usually in middle-aged men. Because the accident occurs in or under water, it is usually fatal and officially listed as a drowning.

Other fitness concerns include recent illness, the stresses of cold and fatigue, use of drugs and alcohol, and respiratory problems, including smoking. The keys to fitness are clear: eat well, exercise, get rest, and avoid stress and harmful habits. Easy to say, tough to do. What's easy, however, is for all divers, especially middle-aged men, to have a regular medical exam to determine whether they're fit for the stresses of diving. The small investment of time and money required for an annual physical is a big favor to yourself and everyone who cares about you — and could prevent as many as one-third of all scuba fatalities.

Save Your Life: Dive With Others & Know When and Where to Dive

While driving along the coast, Jan and Dave spot a beautiful cove. The surf's up, but it looks diveable to the experienced couple. They are alone as they climb down the cliff and prepare to dive. The swim out to the rock is easy, but then a large wave overwhelms them. When they bob back up to the surface Dave is unconscious and not breathing. Jan is trained in rescue, but it's too much for her. Alone in the water, she struggles to help Dave as he dies.

Diving solo or separated from other divers does not cause accidents, but it does mean that if something goes wrong, additional help is not available. Diving on organized trips, with dive clubs or dive stores, from dive boats or dive resorts, in dive classes or under other supervision ensures that dive professionals and emergency support equipment are available if a problem arises. Experience clearly demonstrates that when a dive leader is present, a potentially fatal accident often becomes a near-miss or a lesser injury. Diving with support and supervision is particularly important when you are new to diving or have been away from diving for a while.

Knowing when and where to dive takes skill and experience. One of diving's most important safety rules is that every diver has the right to make a "no dive" decision at any time before or during a dive, and that other divers will respect this decision regardless of whether it is based on environmental conditions, fitness, equipment or the planned dive activity. The bottom line: Know when to say no; know when to say enough.

Save Your Life: Pause for Comfort and Safety

Though somewhat demanding, the dive had been wonderful and very rewarding. Swimming slowly up the slope from 60 feet, Susan glances at her pressure gauge — just under 500 psi. "Oh my God," she thinks, "my instructor said never to surface with less than 500 psi!" She bolts to the surface, where her buddy finds her unconscious. Rescue services speed her to the recompression chamber, where she is treated for air embolism and released with no residual effects.

As divers, we learn many important diving practices, but they must be applied in a safe and sensible way. Surfacing slowly and under control is more important than how much air is left in your tank. We also learn to solve problems under water by stopping, breathing easy, getting under control, thinking, and then taking deliberate action. Let's apply this skill not just to problem solving, but also to problem prevention.

Every time you make a significant change during a dive — getting in or out of the water, going up or down — you should pause. Why? Your vision, respiration, heart rate, center of gravity, buoyancy, weight, hearing and body temperature change dramatically as you move up and down, and in and out of the water. The mind and body need time to process and react to these changes. A pause at each transition — to check yourself, your buddy, instruments and the environment — allows you to adjust to the changes and can prevent emergencies.

Save Your Life: Breathe for Life

The dive instructor is distraught. A prior student, now a certified diver, has died on his third open-water dive, with nearly 1,000 psi in his tank. The investigator has been asking the instructor questions to which he can only reply, "How can this be? He had plenty of air to ascend easily from 60 feet. His buddy said he started swimming hard for the surface, then just gave up and fell to the bottom. Why?"

Breathing under water is the most important adaptive skill we learn as scuba divers. It deserves far more attention in training than the simple admonishment "never hold your breath."

A case in point is overbreathing — demanding more from the regulator than it can supply. Overbreathing is implicated in a large number of diving accidents. On investigation the regulator works within specifications, but the evidence suggests the diver was not getting enough air. What happened? Adapting successfully to scuba includes breathing in a slow, deep and relaxed manner, paying particular attention to a deliberate and complete exhale — even in stressful situations. Otherwise, the result could be overbreathing a regulator, no matter how good it is or how well you've cared for it.

Another lifesaving point: It is nearly impossible to be out of air, but you can be very low on air. This means that if you breathe gently and ascend, more air will become available (one of the reasons you should keep your regulator in your mouth during emergencies). Your power inflator will also work when you are sharing air with another diver because you're low on air. Power inflators are simple on and off valves that equalize pressure between the tank and the BC, and at very low pressures they just do it more slowly.

Among the more preventable diver fatalities are the cases in which a tank valve is not turned completely on. If the tank valve is not completely open, the flow of air to the regulator is restricted and causes an apparent out-of-air situation, even though the pressure gauge shows plenty of air. The diver then overbreathes the regulator, panics and has a fatal accident. The best procedure is to open the tank valve gently until it stops and then turn it back an extremely small amount or not at all.

Save Your Life: Be In Control & Be Relaxed

Sharon's BC inflator has been leaking slightly on the last several dives, and now it's leaking even worse, requiring her to dump air from her BC every few minutes. Swimming slowly up the slope, she thinks, "What a pain," when a beautiful ray catches her attention for a few moments. Suddenly she notices that she is ascending out of control. "What to do? Where is the dump? How did this happen? Can't get a breath! Can't slow down!" She surfaces unconscious, and is fortunate that the chamber treatment is successful.

Control and relaxation are the keys to safe, comfortable and enjoyable diving. And the most important aspect of control is mental. In most cases, if you can think it, you can do it — whether it's equalizing, maintaining buoyancy and orientation, or breathing in a relaxed manner. In diving, your mind and body must work together.

However, scuba training seldom focuses directly on helping divers deal with the physical and mental stresses of diving that can diminish our control and relaxation. Unless contained, increasing stress can and often does lead to panic — that sudden, overwhelming loss of control. The key is an approach to skills development that teaches divers to remain relaxed and in control, to be aware of the situation yet able to focus on details at the same time. A diver who can do so seldom shows up in accident statistics.

Save Your Life: Ascend With Control

"I didn't want to miss anything, so I was using my last drop of air," Hal explains to the attendant.

"Did you come up slow and do a safety stop?"

"No, never do. It's never been a problem before."

The attendant puts the completed accident questionnaire down next to the cot in the recompression chamber to prepare Hal for his next oxygen period.

Ascending slowly, under control and with a safety stop helps prevent decompression sickness (DCS), reduces the risk of lung overpressure injuries including air embolism, prevents buddy separation, and minimizes the risk of colliding with a boat.

A normal ascent should be made with neutral buoyancy, venting air from your BC or dry suit as you ascend, and a minimum of swimming, which reduces stress. The ascent rate should be 30 feet or 10 meters per minute and a safety stop for three minutes at 15 feet should be included when ascending from deeper dives. Actually, a safety stop can be done anywhere from 10 to 30 feet and the appropriate length of time can be determined by monitoring a dive computer.

In an emergency, such as a low-on-air situation, your options are:

• Ascend at a normal rate, remembering that more air will become available as you ascend.

• Switch to a redundant air supply, yours or your buddy's, if available.

• Share air with your buddy using an alternate air source, if your buddy is closer than the surface.

• Make an emergency swimming ascent, swimming faster than normal and letting the expanding air in the BC or dry suit help with the ascent.

• Make an emergency buoyant ascent by inflating the BC, ditching weights, or both.

• As a last resort, consider classic buddy breathing, by sharing one regulator second stage, but only if you're well-trained and practiced in this technique.

Although divers can lose control of their ascent, serious injury is not the inevitable result. The risks of an out-of-control ascent can be greatly reduced by:

• Relaxing, breathing easy and looking up.

• Dumping all air from your BC or dry suit.

• Flaring as you approach the surface: head back, arms and legs spread-eagle, facing the surface.

Based on ScubaLab tests, these procedures can completely stop an out-of-control ascent if weights have not been ditched, and can cut the speed of ascent in half if weights have been ditched.

Save Your Life: Get Positive

Everything went wrong immediately. The guides missed the reef and dropped the divers into the water over the abyss. Everyone was falling deeper and deeper, faster and faster. All Marcus could remember were his instructor's words of advice, "If all hope is lost, get positive!" Marcus ditched his weights and held down the power inflator button. At first nothing seemed to happen, then everything seemed to go into reverse — less pressure, more light, easier to breathe — and then he remembered more advice: "Relax, breathe easy, look up." He finally broke the surface — a close call, but uninjured. Unfortunately, not everyone fared as well.

Every diving accident study has established that the vast majority — 80 to 100 percent — of dead divers have not ditched their weights. During major diving emergencies, ditching the victim's weights is one of the first and most important actions a rescuer can take. It is far better to be positive and on the surface, having risked DCS or AGE, than to be on the bottom with no air to breathe.

Fundamental to the weight-ditching problem is that divers do not get enough practice doing it correctly. Weight belt ditching is a two-handed process: The so-called "quick draw" method is to slap both hands on the hips, slide them to the weight belt, then in to the buckle, releasing the buckle and throwing the whole belt away from the body with whichever hand works best. Integrated weight systems in BCs may require one or both hands, may be right- or left-handed, may use a cross draw, or may ditch all or only part of the weights. The important aspect of integrated systems is that you and your buddies know how it works.

Another sad reality of fatal accidents is that victims sometimes ditch or attempt to ditch the scuba unit (regulator, BC and tank) instead of the weight belt. This seems bizarre until you realize that scuba instruction often puts more emphasis on removing and replacing the scuba unit than on ditching the weight belt.

Save Your Life: Get Proper Treatment

The instructor is beside herself as she confronts the emergency room doctor at the small hospital.

"Don't you understand? This diver surfaced unconscious. She has an air embolism. We need to give her more oxygen and get a helicopter to take her to the chamber immediately!"

"Now you just sit tight," the doctor replies. "I'm in charge here and we'll follow our protocol. Is that clear?"

"Please call DAN," the instructor pleads.

The first-aid and medical treatment of embolisms and DCS have improved significantly in the last 10 years. Unfortunately, we need more emergency equipment and a great deal more education for divers and the medical community.

The first step is recognizing problems by conducting a field neurological exam. The next steps include providing first-aid for shock and administering oxygen and, if possible, fluids. Of course CPR takes priority if needed. While reassuring the victim, establish communication and get transportation to the nearest appropriate medical facility. The only definitive medical treatment for embolism or DCS is hyperbaric oxygen.

Many hospitals have added small, single-lock chambers for treating other medical conditions, so more chambers are available. However, most of these are limited to a maximum depth of 60 feet and can give oxygen only for short periods of time.

Optimum medical treatment for embolism and DCS requires a large, double-lock chamber, where an attendant can stay with the patient; the ability to give frequent oxygen periods with air breaks, during which the doctor can treat symptoms; the ability to pressurize to 165 feet for embolism treatments and the capability to use mixed gases.

How Safe is Diving?

More dives are made each year by more people with fewer fatal accidents than ever before in the history of the sport. In gross numbers, during the 1970s, the average was 124 fatal scuba accidents per year. During the 1980s, the average was 90 per year, while in the 1990s, it was 89 per year. At the same time, there has been a great increase in the number of dives conducted per year, making the accident rate even lower.

Much of this improvement has come from a better understanding of the risks involved, better instruction, more supervised diving, better equipment (particularly regulators, BCs and dive computers), and more effective reactions to emergencies, leading more accidents to result in injuries instead of fatalities.

Get Real: Top 3 Dive Accident Myths

Despite what you may have heard, you'd have to search the accident reports long and hard to find any of the following listed as the primary cause of a fatal diving accident.

The Myth of: Shark Attacks!
Get Real: Of the extremely few shark attacks that occur, most involve nondivers — swimmers, surfers or people in the water as a result of another accident. Of the even smaller number of attacks on scuba divers, most are provoked by spearing or harassing, and almost all are nonfatal.

The Myth of: Killer Tanks!
Get Real: Bad air and tank explosions do occur, but the extremely low number of these events is a credit to the quality and care taken with air delivery systems and the effectiveness of cylinder inspection programs.

The Myth of: Dangerous Equipment!
Get Real: In the early days of diving, the regulator was blamed for many accidents; now BCs and dive computers are. Although equipment can fail or malfunction, thereby contributing to an accident, equipment is rarely the primary cause of a diving accident. The most common difficulties related to equipment are the lack of it, the incorrect use and fit of it, and the improper maintenance and adjustment of it — all human errors.

Are You Experienced?

Most diving accidents occur in open water on scuba, not in swimming pools or while snorkeling. Most accidents occur to recreational divers who have limited diving experience, including accidents during introductory scuba experiences and open-water training dives, dives by unqualified/uncertified divers, and to certified divers with limited experience diving on their own — a strong argument for continuing education and supervised diving.