Dive-Related Death Investigations

After investigating a specific dive-related death last year, a coroner made headlines by expressing concerns about how the dive industry self-regulates itself and that the government should step in. Soon afterwards, another coroner criticized training standards after investigating three separate dive deaths within a week, telling the media that inexperienced divers were too often certified as “advanced.”

The first event happened in Australia, the second in the United Kingdom. The U.S. has many more dive-related deaths than these countries, but rarely does a medical expert here publicly call for more industry accountability or regulation. (In the case of Markus Groh, who died of a shark bite to the leg while diving from the Florida-based Shear Water in February, it was the media doing the demanding.) As many as 100 American divers die annually. Do we do enough to investigate and explain dive-related deaths so as to improve the safety of the sport? Do countries like Australia and the U.K. do a better job? We talked to experts here and abroad to find out.

DAN’s Dilemma

Every year, Undercurrent publishes a series of articles called “Why Divers Die,” describing the details of dive deaths and explaining how they could have happened. Our work is essentially a summary of the Divers Alert Network’s (DAN) Annual Diving Report, which reports diving accident and fatality cases that occurred in one year. We select cases, doing additional research where we can, that will help readers understand how fatalities actually occur and ensure they don’t make the same mistakes. Analyzing diver deaths has been an editorial mainstay of Undercurrent’s effort to improve diver safety, even before DAN was founded.

DAN, of course, is a medical organization, not an investigative agency, but it has evolved a system that gathers information about diving fatalities from public, private, and official sources. It’s the most extensive document of its kind in the U.S. Trouble is, even DAN admits its report is far from accurate.

“How many cases the system misses is unknown,” DAN stated in a 2008 report about the common causes of recreational dive deaths. “Questions about how and why accidents occur are frequently difficult to answer because of missing data, particularly common in diving fatalities. Bodies may not have been recovered, critical events may not have been witnessed, and medical examiner reports may have been unavailable.”

To find dive deaths, DAN searches news reports, the Internet, and taps its network of individuals and organizations. It then contacts investigative agencies, medical examiners, hyperbaric chambers, witnesses, and the deceased divers’ families. They may hit pay dirt or they may strike out, depending on the charity of each donor. “These contacts could be helpful to a greater or lesser degree. Reports might include barest details, or a full analysis of equipment, breathing gases, and a complete autopsy.” The entire process can take up to 18 months to complete.

How Australia Does It

Compare DAN’s report to Project Stickybeak, a similar report put together by one man, Douglas Walker, M.D., who has reported Australian dive deaths since 1972. Walker says he obtains copies of the investigation documents from the Australian states’ coroners, police departments and other sources, “due to a ‘grace and favor’ agreement through a succession of contacts. It was good fortune that they provided this support as my investigation was unfunded and the copying costs would have defeated me.” Because Walker works virtually alone, Project Stickybeak reports take much longer to issue than DAN’s.

One critique of Stickybeak is that it relies too heavily on his opinions. “In one case when a guy was diving alone and died, Walker’s reason was that he was diving solo, although there may have been other reasons,” says John Lippmann, executive director of DAN’s Asia-Pacific office, who publishes Walker’s findings. “It’s not as clear-cut as it appears.”

The biggest plus Stickybeak has over DAN is that Australia has the world’s only national database of coroner reports, allowing Walker, Lippmann and others to get timely information and calculate Australia’s dive death and injury rates. Case information includes death date and location, medical cause, circumstances, police summaries, toxicology and autopsy reports, and the coroner’s findings.

How the United Kingdom Does It

Australia, along with Canada, follows the U.K.’s process of having a coroner lead an inquest, a detailed investigation into the death. He is either a lawyer or a medical doctor, appointed by the local authority as an independent judicial officer. Dive-fatality investigations attempt to identify medical, equipment and procedural causes of death. All coroners are qualified to assess cardiovascular disease, but diving injuries - - e.g., cerebral gas embolism - - require special training. (Only two physicians are allowed to do diving postmortems in the U.K.) If there is suspicion of an unnatural death (anything from an equipment malfunction to violence) or the cause is unknown, he will call for a public inquest.

There, the coroner questions witnesses under oath about the deceased and how he died, but there are no attorneys arguing against each other, and most inquests don’t involve a jury. Attendees may be the coroner, a dive gear manufacturer’s representative, a police representative, the investigating officer and the next of kin. The verdict is usually the coroners’ statement about the events and cause of death. If he thinks a crime has been committed, he’ll pass the case on to the Crown Prosecution Service, which determines if someone should be charged.

Here’s a recent example of a dive-related death inquiry. In August 2005, 22-year-old Mark Steel from Northamptonshire was exploring the WWI wreck Kyarra when he disappeared. His body wasn’t found until two years later. At the inquest, his father described Steel’s passion for diving. The dive instructor who organized the dive trip said Steel was a competent diver. The dive buddy recalled how he lost sight of Steel, and said the two only did visual checks of their gear instead of a hands-on review. The dive boat captain said he saw Steel surfacing, roll onto his back and go back under. A postmortem showed he had inhaled water and drowned, while an examination of his gear showed that the isolation valve between his two tanks had not been turned on and he had run out of air. The coroner announced that inadequate safety checks led to Steel’s demise and recorded a verdict of accidental death.

How America Does It

In the U.S., relatives of deceased sue people they believe responsible for a death. Very rarely do police investigate and indict. But there is no formal inquest system to gather information just to understand the causes of a death to improve diver safety.

While countries like the U.K. have this, Petar Denoble, M.D., senior research director at DAN, says it’s unfair to compare the U.S. to them. “They have a smaller population and fewer dive sites, while the U.S. has a huge population and many different agencies. Australia is stricter about fitness for dive requirements but when it comes to deaths, that has no influence. I don’t think regulation is a reason for fewer deaths there, and it can be burdensome. The U.S. is more liberal than in Australia and the U.K., and the industry here is self-regulating.”

But he admits, “In Australia, if a dive fatality occurs, police know what doctor(s) to call to report it, not like here. All we must do is educate the medical examiners.”

They have a lot of educating to do. If you read the DAN report, you’ll see it sometimes disagrees with the coroner’s stated cause of death and suggests its own. Each case is reviewed by Jim Caruso, a Navy diving medical officer and forensic pathologist. Caruso assigns a probable causeof- death if enough information is available. In the U.S., he says, “not every coroner is a medical examiner - - some are funeral home directors, local sheriffs, even justices of the peace. So when someone dies, it’s up to the whim of whoever’s in charge. In urban areas, the medical examiner evaluates all cases in the same fashion. But if you’re diving off the rural coast in North Carolina, even though there’s a medical examiner in Chapel Hill, the county you died in makes a first decision about whether there will be an autopsy, and they usually say no.”

Caruso says tight budgets and lack of experience often lead to a quick ruling of death by drowning, and no autopsy. “That’s a big error - - you won’t know if the true cause was a heart attack, drugs, or air embolism. In places where there’s not a lot of diving done, with maybe one related death every five years, they often don’t know what to do with it.” Mike Murphy, coroner of Nevada’s Clark County, said many coroner offices rely on outside expertise. “When we have a dive death, it will be at Lake Mead, a national park, so we rely on the Park Service to check equipment and determine any malfunctions.”

Investigation seems to be improving, Caruso says. DAN sponsors a workshop for the American Academy of Forensic Science, teaching a half-day of dive-death investigations like checking out gear, sending the gases to be analyzed, looking at dive profiles and downloading dive computer information. Caruso offers pro-bono consultations and says more medical examiners are calling him.

The Ideal Investigation

For a report on rebreather fatality investigations, DAN officials met with representatives from rebreather manufacturers, dive training agencies and the government, to determine the best way to handle them. Their statement could also apply to recreational diving.

“Equipment testing is important because the next of kin tend to focus on equipment error rather than human error as the root cause . . . All equipment should be preserved . . . Everything has to be counted in until it can be positively ruled out . . . Buoyancy management is particularly important. Weights and the BC must be inspected because many fatality victims were overweighted or did not ditch their weights. Equipment should not be disassembled. If equipment is to be shipped, it should be packed and protected in hard containers on-site, and on-site interviews should be conducted when possible [because] finding recreational divers after they have left a dive site can be difficult.

“Every diving fatality or potential fatality should be treated as a homicide, and the equipment subjected to a chain of custody . . . to be certain that damage may not have occurred during handling after the dive or during shipping rather than during the dive . . . Ideally, dive supervisors and boat captains would be familiar with evidencepreservation procedures and could assist on-site.”

But collecting details will be harder to change because of confidentiality laws, says Murphy. “In many states, the patient-doctor relationship extends to the family after the patient’s death. In Nevada, photos and toxicology reports aren’t public info, and the family must grant permission.”

And often it’s the family that covers up the most pertinent details, says Edmond Kay, M.D., a diving medical examiner and diving medical officer for the University of Washington. “I was involved in three investigations and each time, the family shielded some information because they didn’t want it to reflect adversely on the deceased. Nearly every family doesn’t want to have their name in a negative light.”

Also, fear of a lawsuit can prevent dive experts from investigating, Kay says. “If you make opinions and someone thinks the opposite, you could get drawn into a lawsuit. That’s the big glaring fault of our system and why there’s no good way to collect data about diving fatalities.”

What Is The Dive Industry’s Role?

To see what the training agencies do, Undercurrent called PADI, NAUI, SSI and SDI/TDI, but only the last one replied. “Our training department reviews reports from DAN, the Cave Diving Association, and technical diving and sports agencies,” says Steve Lewis, SDI/TDI’s director of communications. “They’re a huge component of courses. Studying individual accidents is done internally, especially if it’s an instructor registered with us or happened in one of our courses. We try to determine whether it was caused by external avoidable circumstances, a deficit in training, or something in the program that hadn’t been covered.”

Bret Gilliam, the founder of SDI/TDI and now an expert witness in dive-related trial cases, says agencies’ responses in the aftermath are directed by their insurance firms. “They get an instant report, then assess on their own to see if there was a breach of standard, but they won’t do a damn thing while the threat of litigation is outstanding. They may red-flag it and once litigation has finished, they’ll fire the instigator, but that could take years. They’re more preoccupied about keeping their insurance program than they are with preventing the next accident.”

- - Vanessa Richardson