How Will You Try to Kill Me?

Émile Jean-Horace Vernet-The Angel of Death

It’s been over three years since I posted a cautionary tale about oxygen sensors in rebreathers, and the calamities they can cause. Since then, the toll of divers lured to their death has been steadily mounting. In one week alone in April 2016, at almost the same geographical latitude in Northern Florida, there were two diving fatalities involving rebreathers. It is an alarming and continuing trend.

I know a highly experienced diver who starts each dive by looking at his diving equipment, his underwater life support system, and asking it that title question: How will you try to kill me today?

This deep cave diver, equally at home with open circuit scuba and electronic rebreathers, is not a bold cave diver. He is exceptionally cautious, because he is also the U.S. Navy’s diving accident investigator. He has promised me that his diving equipment will never end up in our accident equipment cage.

He and I have seen far too many of the diving follies where underwater life support systems fail their divers. But the crucible in which those fatal failures are often born are errors of commission or omission by the deceased.

Carelessness and an attitude of “it can’t happen to me” seem all too prevalent, even among the best trained divers. Divers are human, and humans make mistakes. Statistically, those accidents happen across all lines of experience: from novice divers, to experienced professional and governmental divers, and even military divers. They all make mistakes that can, and often do, prove fatal.

It is exceedingly rare that a life support system fails all by itself, since by design they are robust, and have either simple, fool-proof designs, or redundancy. In theory a single failure should not bring a diver to his end.
The “head”, triplicate oxygen sensors, oxygen solenoid and wiring leading to the rebreather CPU. Image from


Are oxygen sensors trying to kill you? That depends on how old they are? Are they in date? Ignoring the expiration date on chocolate chip cookies probably won’t kill you, but ignoring the expiration date on oxygen sensors may well prove fatal. Complex systems like rebreathers depend upon critical subsystems that cannot be neglected without placing the diver at risk.

Oxygen sensors are usually found in triplicate, but if one or more are going bad during a dive, the diver and the rebreather can receive false warnings of oxygen content in the gas being breathed.  We have seen a rebreather computer “black box” record two sensor failures, and it’s CPU logic deduced that the single working sensor was the one in error.

The controller’s programmed logic forced it to ignore the good sensor, and thus the controller continued to open the oxygen solenoid and add oxygen in an attempt to make the two dying sensors read an appropriately high O2. Eventually, the diver, ignoring or not understanding various alarms he was being given, went unconscious due to an oxygen-induced seizure. His oxygen level was too high, not too low.

Unlike fuel for a car or airplane, you can have too much oxygen.

Oxygen sensors do not fail high, but they do fail low, due to age. Rebreather manufacturers should add that fact into their decision logic tree before triggering inaccurate alarms. But ultimately, it’s the diver’s responsibility to examine his own oxygen sensor readings and figure out what is happening. The analytical capability of the human brain should far exceed the capability of the rebreather CPU, at least for the foreseeable future.

JAKSA high pressure 6-volt solenoid used in a Megalodon rebreather. NEDU photo.

Oxygen addition solenoids hold back the flow of oxygen from a rebreather oxygen bottle until a voltage pulse from the rebreather controller signals it to open momentarily. The oxygen flow path is normally kept closed by a spring inside the solenoid, holding a plunger down against its seat.

But solenoids can fail on occasion, which means they will not provide life giving oxygen to the diver. The diver must then either manually add oxygen using an addition valve, or switch to bailout gas appropriate for the depth.

Cut-away diagram of a 24-volt Jaksa 200 bar solenoid.

Through either accident or design, divers have been known to invert their solenoid spring and plunger, thereby keeping the gas flow open. In that case, oxygen could not be controlled except by manually turning on and off the valve to the oxygen tank. Of course, knowing when oxygen is too low or too high would depend upon readings from the oxygen sensors.

Suffice it to say that such action would be extremely reckless. And if the oxygen sensors were old, and thus reading lower than the true oxygen partial pressure, the diver would be setting himself up for a fatal oxygen seizure. It has happened.

Assuming a solenoid has not been tampered with, alarms should warn the diver that either the solenoid has failed, or that the partial pressure of oxygen is dropping below tolerance limits.

But as the following figures reveal, if the diver does not react quickly enough to add oxygen manually, or switch to bail out gas, they might not make it to the surface.

The three figures below are screen captures from U.S. Navy software written by this author, that models various types of underwater breathing apparatus, rebreathers and scuba. In the setup of the model, an electronically controlled, constant PO2 rebreather is selected. In the next screen various rebreather parameters are selected, and in this case we model a very small oxygen bottle, simulating an oxygen solenoid failure during a dive. On another screen, a 60 feet sea water for 60 minutes dive is planned, with the swimming diver’s average oxygen consumption rate set at 1.5 standard liters per minute.

Screen shot 3Screen shot 2










On the large screen shot below, we see a black line representing diver depth as a function of time (increasing from the dashed grey line marked 0, to 60 fsw), a gray band of diver mouth pressure, and an all-important blue line showing the partial pressure of inspired oxygen as it initially increases as the diver descends, then overshoots, and finally settles off at the predetermined control level of oxygen partial pressure (in this case 1.3 atmospheres). Broken lines on the very bottom of the graph show automated activation of diluent add valve, oxygen add solenoid, and over pressure relief valve. Long horizontal colored dashes show critical levels of oxygen partial pressure, normal oxygen level (cyan) and the limit of consciousness (red).

Screen shot 1
Screen shot of UBASim results after an ill-fated 60 fsw dive.

The oxygen solenoid fails 53.7 minutes into the dive, no longer adding oxygen. Therefore the diver’s inhaled oxygen level begins to drop. Rather than follow the emergency procedures, or perhaps being oblivious to the emergency, this simulated diver begins an ascent. As ambient pressure drops during the ascent, the drop in oxygen pressure increases.

In this particular example, 62.5 minutes after the dive began, and at a depth of 13.5 feet, the diver loses consciousness. With the loss of consciousness, the diver’s survival depends on many variables; whether he’s wearing a full face mask, whether he sinks or continues to ascend, or is rescued immediately by an attentive boat crew or buddy diver. It’s a crap shoot.

So basically, the rebreather tried to kill the diver, but he would only die if he ignored repeated warnings and neglected emergency procedures.

What about your rebreather’s carbon dioxide scrubber canister? Do you know what the canister duration will be in cold water at high work rates? Do you really know, or are you and the manufacturer guessing? What about the effect of depth, or helium or trimix gas mixes? Where is the data upon which you are betting your life, and how was it acquired?

Scrubber canister and sodalime. NEDU Photo
NEDU photo.












Sadly, few rebreathers have dependable and well calibrated carbon dioxide sensors; which is unfortunate because a depleted or “broken through” scrubber canister can kill you just as dead as a lack of oxygen. The only difference is a matter of speed; carbon dioxide will knock you out relatively slowly, compared to a lack of oxygen.

But if you think coming up from a dive with a headache is normal, then maybe you should rethink that. It could be that your rebreather is trying to kill you.





Diving Accident Investigation

Diving helmets waiting for accident investigations. Click for a larger image.

Compared to aircraft accident investigations, diving accident investigations are often ad hoc in nature, poorly conceived and poorly funded. Nevertheless, these investigations are just as important for the safety of the diving public as are similar investigations for the flying public. Unfortunately, no national regulations presently address how investigations of diving accidents should be conducted: volunteer investigators have no legal status for extracting information about an accident, and they have no legally binding protection from litigation based on the conduct of their investigation or on its results. That is, no business case can be made for conducting diving accident investigations, in spite of the moral authority for conducting them.

With the conviction that this untenable situation must eventually change, this presentation will describe one approach to diving accident investigations with particular emphasis on rebreathers and will draw some comparisons to aviation accident investigations by the National Transportation Safety Board (NTSB).

Aircraft accident investigations

The "black box" containing data recorded just prior to, and during, a commercial aircraft accident.

Pilots know that if they are involved in a fatal crash, the NTSB will investigate the accident by examining in excruciating detail everything those pilots did for hours, perhaps even days or weeks, leading up to that accident. It will investigate how often they called flight service to check on the weather. The NTSB will go through those pilots’ personal logbooks to check on their currency and proficiency, and it will check Federal Aviation Administration (FAA) records for a history of violations. NTSB investigators will also examine an aircraft’s logbooks to scrutinize its maintenance records. They will play back voice and radar data, and if a data recorder is available, they will analyze its contents.

Then they get personal. The NTSB and its FAA counterparts will talk to mechanics, surviving passengers, and friends to ask questions such as, “What were the aviators’ attitudes toward flying? Were they cavalier? Did they take unnecessary risks, or were they careful and methodical?”

Accidents happen.

Due to the detailed, scripted nature of NTSB procedures, the investigation may take up to a year to complete.

A few years ago a pilot’s engine failed and he was forced to make a water landing just off a beach. The ditching should have been survivable, but he lost consciousness on impact and sank with the airplane as it settled to the bottom in relatively shallow water. He drowned.

If he had been a diver, that would have been the end of the story. The public judgment would have been, “A diver drowned. He tried to breathe underwater; this is what happens.” But this victim happened to drown inside an airplane. So instead of the medical examiner simply saying that he drowned, the NTSB started its very thorough investigation procedures.

Fortunately, the pilot also had a surviving passenger. From the survivor’s statement, the aircraft’s maintenance records, and the mechanic’s testimony, an ugly story of reckless disregard for the most basic safety rules of flying began to emerge.

Do divers ever show a reckless disregard for basic safety rules? You bet. It’s unfortunate that the pilot died, but the events leading to his death were a useful reminder that the media in which we work and play, high-altitude air and water, are not forgiving. Humans are not designed for flying or diving, and nature only begrudgingly lets us trespass — on its terms.

The U.S. Navy and Coast Guard are chartered to investigate diving accidents. Unfortunately, there is a huge discrepancy in the number of personnel and the amount of funding for aviation accident investigations compared to diving accident investigations. The NTSB has hundreds of personnel and tens of millions in funding available, whereas the entire U.S. Navy has at most a handful of investigators with no investigation-specific funding.

Investigation team requirements

In the best of all worlds, an investigation team should have access to both a manned and an unmanned test facility, access to experts in all diving equipment (scuba, rebreathers, helmets), and the ability to conduct and interpret gas analyses — sometimes from minuscule amounts of remaining gas. At a minimum, such a team needs the ability to download and interpret dive computer/recorder data. Some investigations may require the simulation of UBA-human interactions for “re-enactment” purposes. An investigation team should also have diving medical expertise available to review medical examiner reports for consistency with known or discovered facts regarding the accident. Last, it should have in-depth knowledge of police investigative procedures, particularly of the procedures and documentation for maintaining “chain of custody”.

Do rebreather investigations have a future?

Considering the resources and time-frames required for laboratories such as the Navy Experimental Diving Unit (NEDU) to conduct diving equipment evaluations on a limited set of accident cases, and the unfunded costs associated with those investigations, it is difficult to imagine a resolution to an ever-increasing need for rebreather investigations. Almost certainly, no independent federal agency similar to the NTSB will ever be responsible for investigating diving accidents, simply because diving accidents lack national attention: the public at large is not being placed in jeopardy.

It is also unlikely that diving equipment manufacturers would welcome federal agency oversight and regulations comparable to those engendered by the FAA and NTSB. Diving might become exorbitantly expensive. For instance, if a $5 part available for purchase in an automotive store were to be used in an aircraft, it would become a $50–$500 part because of FAA required  documentation that it meets airworthiness standards.

The U.S. Coast Guard initiates diving accident investigations and in some cases conducts hearings into those accidents; however, with its enhanced role in Homeland Security, the Coast Guard is unlikely to welcome any efforts to diversify its mission. The cost/benefit ratio would appear to be too great.

For the future, as Dick Vann of DAN has suggested, the resolution may ultimately depend on rebreather users funding a team of dedicated, professional accident investigators. The cost of conducting worthwhile investigations has yet to be determined, and therefore the amount of funding needed to support it is unknown. I suggest that obtaining those estimates should be a priority as we, rebreather users and the industry, decide the next steps in investigating rebreather accidents.


The above are highlights from this author’s publication of the same name, found in: Vann RD, Mitchell SJ, Denoble PJ, Anthony TG, eds. Technical Diving Conference, Proceedings. Durham, NC: Divers Alert Network; 2009; 394 pages. ISBN# 978-1-930536-53-1.

This book is available for download at no cost as a PDF file from the Divers Alert Network website ( from