2019 JS Diving Incident Reports

The table below contains a sanitised version (no names or units!) of the service diving incidents that have been received by JSSADC in 2019.

19/39Following a moderately strenuous dive, a diver reported that they had a slight headache. After returning to shore, they reported feeling light headed and then fainted, although did not lose consciousness.

Oxygen was administered and the DDMO was contacted. The DDMO spoke to the casualty and diagnosed hypercapnia brought on by skip breathing and dehydration.

The casualty was taken to medical facilities. After further investigations they were discharged.
Care should be taken to ensure divers are properly hydrated and briefed of the dangers of skip breathing.
19/38As part of a dive lead assessment, three divers visited a large wreck some distance from shore at a depth of 30m. During the return mid-water swim, some of the divers struggled to maintain buoyancy and used more gas than planned.

The dive leader was not aware that their buddy reached 70 bar and only found out when they got to 50 bar. Whilst conducting a short decompression stop it was necessary for the diver low on gas to breathe from another's Alternate Source.

The group surfaced some way from the exit point and had to clamber over rocks to reach it.
Monitoring gas contents is a key aspect of dive leadership.
19/37Prior to deploying a second wave of divers, a MAYDAY call was heard and it was realised that the vessel in distress was approx 1 NM away. At the scene, a RIB was found with 1 x unconscious non-breathing casualty on board and two divers still in the water.

The team split with half conducting BLS on the casualty and the remainder recovering the divers once they surfaced.

After some time, the RNLI arrived and took over the casualty who was subsequently declared to have passed away. The other divers were returned to shore.
19/36After completing the training element of AO2, divers deployed DSMBs and ascended. One of the divers was unable to hold their safety stop and ascended to the surface. All divers reported well.

After a debrief, a training and assessment plan was agreed.
19/35Whilst entering the water for OD 4, a diver stated that they did not wish to do any further diving.

The diver was returned to the shore and removed from the diving programme.
19/34Following a dive to 15m, a diver complained that their legs felt 'funny and numb'. The diver was placed on oxygen and the DDMO contacted.

The casualty was taken to a medical facility and after additional consultation with the DDMO no further action was required.
19/33Following a dive to 30m, two divers were completing a 3 minute safety stop. One of the dive computers (Sub Gear XP10) showed error code E6. The diver switched to their backup device (depth timer) and completed the safety stop.

Subsequent investigation revealed that error code E6 is a battery failure although there was no indication of this during the pre-dive check.

No further diving was planned but if it had then the diver would have needed to have 24hrs clear before they could have returned to the water.
Where possible all divers should carry two computers.
19/32During pre-dive checks a BCD was noticed to be automatically inflating. The AP200 securing nut was checked and found to be tight.

Further investigation revealed that the inside of the inflator was heavily encrusted. Following ultra sonic cleaning the inflator functioned correctly.

The BCD had been received from the AT Loan Pool at Bicester so the reporting procedures in AGAI Vol 1 Chapter 11 were followed.
19/31A FACTAIR F2235 was used to test the gas from a commercial overseas provider. It was in date for calibration.

A short time into the test, the CO2 tube was completely purple with a reading of 2500ppm. The centre reported that they'd had no issues with gas.

The test was run again using tubes from a different source and had the same outcome.

Suspecting that the FACTAIR was faulty, a test device was obtained from another source and this produced a reading of 100ppm CO2 which is well within limits.

DDST were contacted and informed of the situation and the exped was given authorisation to dive using the gas.
19/30An Ocean Diver trainee was unable to equalise their ears at 6m whilst descending down a shelving shore. The dive was aborted and they were taken to the MRS where a partially blocked Eustachian tube was identified.
19/29An experienced diver was leading a depth progression dive to 35m wearing a main and pony cylinder. After approx 10 mins they felt breathing becoming tight on the DV in their mouth and approximately 2 breaths later it ceased delivery of gas.

The diver switched to what they believed to be their secondary DV but shortly afterwards reverted to the octopus as they did not wish to deplete it. The dive was aborted and they returned to the surface without further incident.

On the surface it was discovered that the pony cylinder was empty whilst the main had 170 bar.

Both the primary and secondary DV were the same colour and came from the right hand side. Whilst kitting up the diver believed they were distracted which caused them to use the incorrect DV.
Gas checks must include both primary & secondary (pony) cylinders.

It should be easy for divers to differentiate between the primary and secondary regulator to avoid them breathing off the incorrect one.
19/28During a sheltered water lesson (OS4) a diver was unable to clear their ears on the descent and they were removed from the water.

After medical examination they were found to be fit to dive.
19/27A short time into a dive, an instructor noticed that their student's Suunto dive computer had not entered dive mode. The dive was aborted using the secondary computer to provide dive information. On surfacing the computer was isolated.
19/26Whilst conducting a simulated ADP dive to 30m, a diver attempted to switch to their stage at approx 10m. With the mouthpiece in their mouth, they turned the cylinder on and the first stage immediately had a freeflow. Their buddy offered a spare regulator from their stage and the diver switched to this.

Once the diver had regained their composure they returned to breathing from their independent twins. They were observed to be breathing and finning hard to remain at 10m but then indicated that they were out of gas.

Again the buddy gave the diver a spare regulator from their stage but by this time they had descended to approx 15m. Whilst trying to regain neutral buoyancy they ascended to the surface missing 1 min of live deco.

The divers were placed on oxygen, the DDMO was called and evacuation arranged to the nearest chamber. After investigation the doctor decided that no further treatment was required.

The diver was found to have 70 bar in one cylinder and 10 in the other.

Cylinders should be turned on before putting the mouthpiece in. It is also recommended they they are switched on for the entire diver rather than leaving this to the deco stop

Ensure stage cylinders are included in buddy checks.

The immediate action for divers on independent twinsets who run out of gas in one is to switch to their other cylinder.
19/25Whilst diving in Cyprus, an exped called Aki Ops to book back in and were informed that the chamber had gone offline sometime previously. Despite the exped being booked out with the ops room this information had not been passed to them.
19/24During Sports diver depth progression, a diver conducted a gas contents check at 25m and were surprised at how much they had used to the extent that they refused to believe their contents gauge. The other divers in the water believed the diver to be experiencing the early onset of nitrogen narcosis and they ascended to a shallower depth.

As part of the debrief, the diver agreed that he had felt unusual which was also attributed to narcosis.
19/23Whilst exiting a swim through the integrated weight pouch on a BC was pulled out of it's pocket causing the diver to lose 2kg of lead. The diver was able to conduct a normal ascent.
19/22During a buddy check the inflator on an AP BC was depressed but continued to inflate even when released. All other BCs were checked and no issues were found.This can happen when the plastic securing nut is loosened and re-tightened.
19/21While descending to 18m a diver experienced pain in their ears. They tried to maintain neutral buoyancy and equalise them but instead ascended and surfaced.

On the surface both diver and buddy were placed on oxygen and the DDMO contacted. Following an examination by a doctor all divers were cleared to dive again.
19/20A trainee diver experienced difficulty equalizing their ears whilst conducting OO1. The dive was aborted and the diver sent for medical examination. Subsequently they were diagnosed with inflammed ear drums and removed from diving for 10 days.
19/19A trainee diver experienced difficulty equalizing their ears whilst conducting OS3 in a SWTA. The dive was aborted and the diver sent for medical examination. Subsequently they were cleared to continue diving
19/18A trainee CCR diver had descended to 13m, had switched to high set point and was in the process of conducting a linearity check. At this point the handset went into error, flicked between PO2 readings and went dead. The diver bailed out onto a 7 litre cylinder and recovered to the surface using their backup computer.
19/17During a CCR air diluent course, a trainee failed to hold a safety stop at 6m and gradually drifted to the surface. On arrival at the surface they were recovered to the boat.
19/16Whilst conducting training lifts on OO2, a trainee found they could only clear their ears by descending very slowly. This meant that it was not possible to complete all lifts during the table limits for the dive.

The trainee was taken to a doctor who was unable to find any problems but advised them not to dive the following day.
19/15An Ocean Diver trainee was unable to clear their ears after a CBL during OO3. The dive was aborted and the diver taken to a doctor who diagnosed slight redness of the ears and a possibility of a minor barotrauma. The trainee was unable to complete the course.
19/14An instructor on an Ocean Diver entered the water via a stride entry at which point their pony regulator started to freeflow. The instructor was able to turn it off and then back on again which stopped the freeflow.

With approx 100bar left in the cylinder, the instructor elected to continue the dive to 10m. No further problems were experienced.
19/13Following a dive to 14m for 17 mins, a diver experienced a headache after their evening meal. When they woke the next day the headache was still present so the DDMO was contacted.

The DDMO advised a visit to the local chamber where the doctor conducted recompression treatment which did not alleviate the symptoms. Subsequently a CT scan was also conducted to check for a stroke which did not identify any cause for the headache.

Subsequently the diver felt better and the headache has not returned.
19/12Following successful completion of OS1-3 in a swimming pool, a diver was completing OS4 in a SWTA. At a depth of 2.5m they indicated that they wished to ascend and on surfacing reported that they were unable to clear their ears.

The diver attended the medical centre but no ear problems were observed.
19/11A diver was carrying a twinset on their back when one of the shoulder clips failed. The increased weight caused the second clip to fail and the twinset fell to the floor bruising the diver's calf.
19/10During OS4 in a SWTA, a trainee diver signalled up to his instructor. On the surface the diver explained that they felt faint and were unable to clear their ears.

The dive was aborted and the diver was subsequently found fit to continue diving by a doctor.
19/9A diver realised that they required extra weight so placed it in the pocket of their BCD. During the dive this became dislodged and fell onto the seabed.

Although the weight was found by another diver in the group they did not try to ascertain whether it had been lost by anyone.

During the safety stop, the diver who had lost their weight was unable to control their buoyancy and slowly drifted to the surface.
19/8During an ADP dive, a diver switched to their 50% stage regulator and immediately received a wet breathe. The diver returned to their back gas until the buddy could hand over their own stage with a 50% mixture.

The regulator was inspected by a qualified technician on surfacing but no problem could be found with it.
19/7On surfacing a twinset diver heard an unusual noise from their wing. On investigation the wing dump valve was found to be u/s
19/6A diver entered the water and immediately signalled to the boat that there was an issue. When they were recovered to the boat it became clear that the diver's dry suit zip had not been closed.
19/5A CCR diver was operating from a hard boat with an unusual bench seat arrangement. In order to prevent twinsets slipping, a thin vertical angle bracket was installed on the seats.

Whilst kitting up in a swell, the CCR diver moved sufficiently that the angle is likely to have damaged the diluent cylinder. This was noticed when the diver entered the water and the dive was aborted.
19/4During a training Alternate Source ascent, a diver's fin came off and was lost. The buddy elected to carry out a CBL on the diver without a fin and both divers surfaced without further incident.
19/3Two divers were conducting training CBLs from 20-6m. After one successful ascent a diver was unable to equalise sufficient to allow a descent. The dive was aborted.
19/2A pair advanced divers were refreshing their skills by conducting two CBLs from 20-6m. During the second lift, one diver was unable to dump gas from their dry suit quickly enough to prevent both reaching the surface.

Subsequent analysis showed the that the dry suit auto dump valve was not operating correctly due to damage probably caused during transit to the dive site.