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2016

09

December 15, 2021

Career Captain Drowns After Running Out of Air During 

Technical Rescue SCUBA Dive—North Carolina

Executive Summary

On June 6, 2016, a 28-year-old male,

part-time, career fire captain died 

after running out of air and suffering 

a pulmonary embolism during a 

technical rescue deep dive. The 

victim was a member of a local fire 

department dive team that was trying

to recover the body of a civilian who 

drowned the day before. The captain

(Diver 4 and victim) ran low on air at 

a depth of 80 feet. After 

communicating with surface crews, 

he and his dive partner (Diver 3) 

ascended to a depth of 12-14 feet. He 

then experienced an uncontrolled outof-air emergency and was unable to 

switch over to his or his partner’s 

redundent air system. Diver 3 tried 

unsuccessfully to assist Diver 4, but

Diver 4 pulled Diver 3’s mask off

forcing Diver 3 to kick away and 

swim to the surface while Diver 4

descended. According to the medical 

examiner, Diver 4 experienced an

arterial gas embolism, most likely from holding his breath on ascent and subsequent rupture of alveoli 

and drowned. Mutual aid technical rescue divers located Diver 4 on the lake bottom and removed him

approximately 2 hours later, and he was pronounced dead at the scene. Mutual aid technical rescue 

divers then recovered the civilian victim. 

Contributing Factors

• Pre-dive safety check

• Air management 

• Uncontrolled out-of-air emergency (not being able to use redundant air supply)

A career captain drowned after running out of air while 

searching for a civilian drowning victim during a technical 

rescue deep dive. Photo taken from Dive Boat 38 showing 

the bow of FD 4’s dive boat and divers having to surface 

swim to the descent buoy. Photo taken before the 

drowning.

(Photo Courtesy of mutual aid dive team.)
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• Panic/rapid uncontrolled ascent while holding breath

• Training and experience 

• SCUBA equipment issues affecting buoyancy control

• Lack of a safety officer trained in technical rescue SCUBA diving during the event.

Key Recommendations

• Fire departments should ensure that public safety divers always complete a pre-dive safety 

check (including adequate beginning air) with a qualified dive partner, witnessed by the dive 

safety officer.

• Fire departments should ensure that incident commanders and group leaders maintain frequent 

and accurate air status and accountability on all divers. Additionally, no diver should be 

allowed to start a deep dive with inadequate air and adequate air reserves and resources at the 

dive site.

• Fire departments should ensure that public safety divers are properly trained to recognize and 

have the repetitive skills training to control out-of-air emergencies and be able to use their 

redundant air before anxiety leads to panic. 

• Fire departments should provide annual training on dive hazards such as lung overexpansion 

injuries, out of air emergencies, emergency ascent procedures, including the dangers of breath 

holding, and emergency release of dive weights.

• Fire departments should ensure that a dive safety officer properly trained in technical rescue 

SCUBA diving is on-scene and integrated into the command structure.

The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and 

Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of 

work-related injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a firefighter initiative that resulted in the 

NIOSH Firefighter Fatality Investigation and Prevention Program, which examines line-of-duty deaths or on-duty deaths of 

firefighters to assist fire departments, firefighters, the fire service, and others to prevent similar firefighter deaths in the future. The 

agency does not enforce compliance with state or federal occupational safety and health standards and does not determine fault or 

assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH 

investigators interview persons with knowledge of the incident who agree to be interviewed and review available records to develop 

a description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and 

interviews are not recorded. The agency's reports do not name the victim, the fire department, or those interviewed. The NIOSH 

report's summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency's 

recommendations and is not intended to be definitive for purposes of determining any claim or benefit.

For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
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2016

09

December 15, 2021

Career Captain Drowns After Running Out of Air During 

Technical Rescue SCUBA Dive—North Carolina

Introduction

On June 6, 2016, a 28-year-old male, part-time, career fire captain (Diver 4) died while SCUBA1

diving during an attempted recovery of a civilian drowning victim. The captain ran out of air while 

underwater and suffered an air embolism during a rapid ascent that resulted in his drowning. 

On June 7, 2016, the U.S. Fire Administration notified the National Institute for Occupational Safety 

and Health (NIOSH), Division of Safety Research, Firefighter Fatality Investigation and Prevention 

Program of the incident. On June 20–28, 2016, three NIOSH investigators traveled to North Carolina

to conduct an investigation. The NIOSH investigators met with the fire chief, assistant fire chief,

members of the fire department dive team, members of the mutual aid dive team, and local law 

enforcement officials. The investigators reviewed the captain’s dive log, training records, training 

requirements, fire department standard operating procedures, training records from the department, and 

audio radio transmissions from the incident. During the investigation, witness statements were 

reviewed and interviews were conducted with the firefighters and fire officers involved in the incident. 

The local law enforcement agency sent the captain’s dive equipment, including regulators and dive 

computer, to a professional dive shop for evaluation and air quality sampling. (Note: The dive shop 

was not involved in the training of any of the local divers). After the dive gear was inspected, it was 

returned to the local law enforcement agency and placed in a secure evidence facility. On June 21, 

2016, NIOSH investigators inspected and photographed the SCUBA equipment, including the SCUBA 

gear the captain was using, and the captain’s dive computer. NIOSH requested the local law 

enforcement agency to send the captain’s dive computer to a dive rescue consultant. NIOSH contracted 

with a dive rescue consultant for further analysis and evaluation of the data contained on the dive 

computer, after which the dive computer was returned to the law enforcement agency with the results 

of the analysis. 

Fire Department

The fire department involved in this incident is a combination department consisting of 15 full-time 

firefighters (3 shifts 24 hours on – 48 hours off), two paid administrative staff, one paid fire chief, one

training captain, 13 part-time firefighters, and 15 volunteer firefighters. The department has 10 

1 Self-contained underwater breathing apparatus (SCUBA) is an underwater breathing system where the inspired gas is 

delivered by a demand regulator and exhaled into the surrounding water (open circuit), and the gas supply is carried on the

diver’s back [NOAA 2001].
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SCUBA divers. Four fire stations are located strategically throughout the city and serve a population of 

approximately 13,000 in a geographic area of approximately 47 square miles, responding to 

approximately 900 emergency incidents per year (of which approximately 600 are emergency medical 

calls). From June 2015 to June 2016, the department responded to two water-related incidents (one 

classified as surf rescue and the other a water rescue). The fire stations house five fire engines, one

ladder truck, one heavy rescue truck, three tankers, one boat, one dive trailer, and one air compressor 

trailer. Air quality records for the breathing air compressor were on-site and provided to NIOSH. 

Records indicated that all samples met or exceeded the specification of NFPA 1989-2013 Grade E 

(latest record was 2/19/2016).

In 2009, the department re-established the 10-member dive team. The SCUBA equipment for the dive 

team was purchased in 2012, and SCUBA training was initiated in 2012. The department has a fivepage Dive Operations Standard Operating Guidelines (SOG) (adopted in 2011 and revised 2013) for 

the dive team. The SOG provides dive team members with a list of basic items they must consider in 

the evaluation of tactical objectives on a dive call. The SOG details the steps needed to become a 

member of the dive team, including dive certification training, and requires all members of the dive 

team to maintain a minimum of eight dives per year to remain an active member of the dive team. The 

SOG requires all dive team members complete a swim test of no less than 200 meters with mask, fins,

and snorkle, and tread water for 5 minutes. The SOG describes a mandatory skills assessment; a 

probationary period of 3 months is given for any dive team member who fails a skills assessment or 

doesn’t get the required number of annual dives. The SOG also describes response procedures for 

operating on a recovery dive, including a pre-dive assessment, safety procedures, assignments for 

personnel on shore, equipment checks and procedures, and water hazards assessment. 

The SOG also describes minimum equipment all divers will wear, including a dry suit, full face mask 

and regulator, spare mask, dive knife, primary dive light and backup dive light, hood, gloves, boots, 

bouyancy compensating device (BCD), and redundant air supply system. The SOG states once the 

divers have completed the pre-dive checks of all equipment, the recovery operaton may begin. 

The SOG states: “If at any time a diver is not comfortable with the tasks or situation needing to be 

completed, the dive will be called off and the situation reviewed. There will be two divers in the water 

at all times conducting the recovery operation and a backup diver on the surface at 90% readiness for 

emergency situations. Two divers will submerge together for the recovery operation.” The SOG also 

mentions decontamination of the dive gear prior to doffing.

The mutual aid dive team (FD 3) assisted with boat and sonar operations on day one and two of the 

incident, and eventually was called to assist with the recovery of Diver 4 on day two. They also 

recovered the civilian victim on day two. The mutual aid dive team has 90 members and responds to 

24–36 dive incidents per year. Their dive team is stationed at three fire stations and consists of two 

heavy rescue companies, three boats, Haz Mat, and a technical rescue team. They are also supported 

with four law enforcement divers. Their department has 1150 career staff, 41 engines, 15 ladder trucks, 

six tenders, four hazmat vehicles, five brush trucks, one foam tanker, six aircraft rescue and 

firefighting (ARFF) vehicles at the international airport. They serve a city with a population of 
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approximately 850,000. Dive team members are required to complete six dives per year to be on the 

technical rescue SCUBA team.

Training and Experience

The captain (Diver 4) had 12 years of combined experience as a volunteer firefighter and as a part-time 

career firefighter for the responding fire department. He was also a full-time career firefighter/captain 

for 9 years at a neighboring fire department and had the following fire certifications:

• Firefighter 1

• Firefighter 2

• Fire Officer 1

• Hazardous Materials, Awareness and Operations

• Fire Instructor 1

• Fire Instructor 2

• Fire and Life Safety Educator 1

Diver 4 was a member of the department’s dive team and had a total of 2.5 years experience as a 

SCUBA diver with 2 years of experience as a rescue diver. 

He had completed the department’s required SCUBA training including the following

certifications/levels at a local dive shop with a certified dive instructor:

• Professional Association of Diving Instructors (PADI), Open Water Dive Certification; April 

26, 2013

• Night Dive and PADI Dry Suit; October 21, 2013

• Search and Recovery and Underwater Navigation Dive; October 22, 2013

• PADI Advanced Open Water; November 1, 2013

• PADI Rescue Diver Certification; July 16, 2014

• PADI Public Safety Dive Training; May 2015

The department’s training records show Diver 4 completed practical dive training for 8 hours on June 

8, 2015, 8 hours on June 9, 2015, 3 hours on April 14, 2016, and 4 hours May 5, 2016.

Diver 4’s personal dive log book recorded a total of 18 dives, with one deep dive of 80 feet and one

dive of 62 feet. 
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The state of North Carolina has specific requirements and recommendations to become either a 

volunteer or a career firefighter. Candidates must be 18 years old with a high school diploma or GED 

and have a valid Class C or better North Carolina driver's license. Firefighters must complete training 

equivalent to the NFPA 1001 Standard for Firefighter Professional Qualifications, Firefighter I and 

Firefighter II [NFPA 2013a] and must be certified to Haz Mat (Hazardous Materials) Awareness and 

Haz Mat Operations. The state recommends a physical exam conducted by a qualified medical 

practitioner, according to the current edition of the National Fire Protection Association (NFPA) 1582 

Standard on Comprehensive Occupational Medical Program for Fire Departments [NFPA 2013b]. 

At this department, dive team members are required to have the minimum training requirement met 

through a national certification agency in public safety dive training for their dive team.

In the department’s SOG on dive operations, the requirements for SCUBA proficiency and to remain 

active on the dive team are a minimum of eight dives per year.

SCUBA Equipment and Dive Computer Data Log Information

Note: The SCUBA equipment information, the equipment orientation and information from the victim’s

dive computer data logger is extensive and detailed in this section. Contributing factors and 

recommendations related to the equipment orientation and recommendations based on the data logger 

information are discussed further in the investigation and recommendations sections.

The SCUBA equipment used in this incident was owned by the fire department dive team and not 

personally issued to Diver 4. A list of gear examined at the local police evidence room is noted below. 

• 2 fins (2XL)

• Suit (Dry Suit)

Manufacturer date: 2010 

• 158 feet of 7/16th inch rope

• Body Bag Recovery System 

Main cylinder

80 cubic feet of air

3000 psi capacity (was found to be empty during examination) Manufacturer date: April 2010

• Alternate air cylinder with 19 cubic feet of air

3000 psi capacity (was found to be full during examination) Serial #V030629

• Regulators

#15068 DC2 Model

#HF001531 (Serial#)

#10577 

0088 dive computer
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• Facepiece (Full)

“One Size Fits All”

#15088 

CE #0098EN250

Serial #512904 with communication unit GSMQ3

• Buoyancy Control Device (BCD) Vest

Size XL

EN1809 Standard (1997)

213 Newtons (48 lbs.)

serial # 206274

With half mask (spare dive mask) in pocket

• Weights

2 lbs., 5 lbs., 6 lbs. (two of each). Total ditchable weights were 26 pounds. 

• Note: The victim’s ditchable weights were not jettisoned from the BCD and were still 

integrated into Diver 4’s BCD after he was recovered. Photos were taken of Diver 4 by the 

mutual aid department and his equipment and gear profile. No weight belt was recovered. It is 

unlikely that Diver 4 had a separate weight belt although some boat members (non-divers) 

reported to NIOSH investigators that they thought he may have had a weight belt. Diver 4’s

written dive log showed a consistent use of 22 pounds on all of his dry suit dives with the 

exception of 26 pounds noted on one shallow dive. Other divers on the boat that day were using 

weight belts.

• LED light

#15086 (SFTFR)

• Gloves

2XL

AKNG

PO #942966

Dive Boots, size 14

• Full Face Hood

• Knife (and scissors)

15104 

Diver 4 was using an integrated dive computer. This dive computer logged a dive profile and a number 

of data events for this incident (see Figures 1 and 2). The dive computer also logged a number of

previous dives but could not be attributed to this diver. After the incident, the SCUBA equipment was 

taken to the local sheriff’s department and stored in the evidence room. The local police department 

had the SCUBA equipment and dive computer examined by an independent expert SCUBA diving 

facility in North Carolina that provided the sheriff’s department a report. NIOSH investigators were 

provided a copy of this report along with the autopsy report by the sheriff’s department. 
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NIOSH investigators had the dive computer examined by a second independent expert in Boca Raton, 

Florida. Information from both reports were used in this investigation. Additionally, the independent 

expert also examined a photo of Diver 4 that presented the SCUBA gear and equipment profile and his 

entanglement with the search rope when he was recovered from the lake (see Photos 1 and 2). They 

also provided information that showed Diver 4’s BCD may have been unable to retain air, and 

therefore, he may not have been able to maintain positive buoyancy.

The orientation of Diver 4’s redundant air regulator was routed under the air fill for the dry suit and 

under the high chest strap for the BCD. Although the final location of the mouthpiece would have been 

close to the diver’s head, it would have been difficult to deploy (see Photo 3). NIOSH obtained a

sketch of the SCUBA gear and equipment profile and orientation to better show the equipment issues 

that were associated with this incident (see Figure 3, image created for NIOSH by Pelton Designs, a 

NIOSH graphics contractor).
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Figure 1. Screen shot of victim’s dive profile ascent warning at the 17 minute mark coming 

through 66 feet up to 12.8 feet at minute 18 and low air remaining from his dive computer 

(the dive set typically will cease to provide air at 150 psi). 

(Courtesy of Craig S. Jenni, Dive & Marine Consultants International, Inc.)
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Figure 2. Elapsed dive information page. Dive computer data logger shows the dive profile graph 

and beginning cylinder pressure at 2444 psi. Note the dive mode in gauge position and the 

decompression violation, also note alarm settings of 1500 psi turn pressure (similar to 50% alarm 

in SCBA), 800 psi end pressure (similar to EOSTI in SCBA) and dive time remaining alarm set at 

5 minutes. This dive computer was used by Diver 4 and assigned to the dive truck.

(Courtesy of Craig S. Jenni, Dive & Marine Consultants International, Inc.)
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Photo 1. Close up photo taken when the victim was recovered showed his shoulder dump 

valve was possibly pinned “open” by the body bag carabiner inside the D ring. This could 

have made maintaining positive bouncy difficult as any air pushed into the BCD may have 

escaped here.

(Photo by mutual aid dive team. Analysis by Dive & Marine Consultants International, Inc.)
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Photo 2. A 158 foot, 7/16th inch search rope tangled up around the lift bag attached to

the victim. The other end had a D-ring closure and was attached to the cage. A mutual 

aid diver cut the rope before recovering Diver 4.

(Photo courtesy of the mutual aid dive team, and cropped by NIOSH.)
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Figure 3. Sketch representing Diver 4 with body bag incorrectly attached to him and opened 

BCD dump valve. His ditchable weights are located in a difficult-to-release position due to 

incorrect sizing of buoyancy control (BC) vest. This sketch also showed the search rope he was 

entangled in. The redundant air regulator was profiled under his high chest strap and also under 

the dry suit air hose. Although it was close in proximity to his face, the fixed path orientation 

would have been difficult to back feed to provide more slack to orient in a useable position. A 

quick-release fastener may have been able to release without untangling.

(Image created for NIOSH by Pelton Designs, a NIOSH graphics contractor.)
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Photo 3. The photo shows the orientation of Diver 4’s redundant air regulator is routed under 

the air fill for the dry suit and also under the high chest strap for the BCD. Although the final 

location of the mouthpiece would have been close to the diver’s head, it would have been difficult 

to deploy. Diver 3 reported during interviews that Diver 4 was struggling with his redundant air 

regulator. Divers should always have easy access to the redundant and alternate air regulator. 

(Photo courtesy of the mutual aid dive team. The photograph was altered by NIOSH to obscure 

manufacturer’s name.)
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Timeline

This timeline is provided to set out, to the extent possible, the sequence of events according to 

recorded radio transmissions and event times gathered from dive computers and interview statements. 

Times are approximate and were obtained from review of the dispatch records, dive computer event 

data loggers, witness interviews, and other available information. Some of the times have been 

rounded to the nearest minute. This timeline is not intended, nor should it be used, as a formal record 

of events. The times in this sequence are approximate times for day 1 and day 2 of the incident. Sonar

operations by boat occurred on day 1, when crews were attempting to locate the civilian drowning 

victim; divers were present but did not dive because they were running out of daylight. 

Incident 

Conditions Time Response Operations

Day 1

911 call center received a phone call 

reporting a civilian drowned while 

swimming from an unanchored boat.

1530 Multi-agency, multi-jurisdictional response 

with boats. The firefighter victim’s 

department was dispatched to assist. 

Department 1 established command, initial 

sonar operations start with FD 2’s boat and 

FD 5’s boat.

Department 2 was the victim’s department 

boat with sonar and was on scene. 

Department 3 was requested to respond 

Dive Boat 38 via mutual aid by 

Department 1 for the use of sonar only.

(No divers were requested.)

1632 Department 3 dispatched a battalion chief, 

rescue truck and a dive boat with sonar. 

After arrival, they sent one FF over to FD 

2’s boat to assist getting their sonar working 

correctly

Department 3 was a large mutual aid 

department with a dive/sonar boat (Dive 

Boat 38) that was returning from a call 

upstate.

Department 4’s boat was a landing craft 

type bow from which FD 2 divers dove.

(See Photo 4.)

2000 Dive Boat 38 and 6 FF divers arrived at 

approximately 2000 hours and searched 

with sonar 1- 2 hours until dark when all 

sonar operations stopped.
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Incident 

Conditions Time Response Operations

Day 2

Five fire department boats operating on 

day 2 were FD 1 boat, used as security 

zone boat, FD 2 boat was also used as 

security zone boat, FD 3 providing Dive 

Boat 38 (career mutual aid dive boat,

see Photo 5), FD 4 boat was used as a 

dive boat for divers from FD 2, and FD

5 boat which ran sonar.

0900-1100 Multiple fire department boats and multiple 

agencies return to the lake to start the boat 

and dive operations.

Statewide mutual aid radio channel was not 

recorded so times are approximate.

0908 Command had requested Dive Boat 38 boat 

for sonar operations only, Dive Boat 38

arrived on scene.

Dive Boat 38 operated their advanced 

sonar and located the civilian victim

underwater.

1100 Dive Boat 38 marked the position and 

dropped the cage (see Photo 6). Once the 

cage was on bottom, Dive Boat 38 members 

positioned the cage closer to the civilian 

victim. They got the cage 18 feet from the 

civilian victim in 82 feet of water

FD 2’s dive team began diving 

operations off of the FD 4 boat.

1444 Diver 1 and Diver 2 entered the water. 

Diver 1 had the 158’ 7/16th inch search line, 

Diver 2 had the lift bag.

1458-1459 Divers submerged.

Approx 1500

1505 Divers had issues and had to come back up 

to the surface.

1541 Diver 4 and Diver 3 were in the water.
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Incident 

Conditions Time Response Operations

1541 Diver 4 and Diver 3 were on the bottom and 

discussed how to locate the civilian victim.

The first air check was requested by the 

boat crew 14 minutes and 30 seconds 

into the dive.

1555 Diver 4 reported 400 psi and Diver 3

reported 600 psi. They were told by the dive 

leader on the boat to surface.

Both divers began to surface. Both divers made it to the safety stop at 15-

20 feet and Diver 4 said on the 

communications line- “Hurry, I am out of 

air.”

Diver 4 ran out of air and reportedly 

grabbed and dislodged Diver 3’s facepiece.

Lieutenant on dive boat called a 

“Mayday” on the radio

Appr 1601-

1604

Diver 3 surfaced and yelled “firefighter

down, firefighter down.” Diver 3 was 

reported to be approximately 40 yards from 

the surface buoy. He was picked up by a 

North Carolina fish and wildlife boat, 

transferred to another FD boat and taken to 

shore. 

Appr 1601-

1604

A safety diver on the surface (Diver 5) 

entered the water, had trouble with water in

his mask, cleared it and then went under to 

search. Shortly afterward he surfaced and 

said he had him but then couldn’t get him.

This rescue attempt was likely caught on 

Diver 4’s dive computer data logger in 

Figure 5. 

Diver 5 was placed on another FD boat and 

taken to shore.

Appr 1601-

1604

The boat crew then pulled on Diver 4’s

communication line and it came apart.

BC from FD 3 requested ALS for dive 

boat.

1604 ALS was assigned.
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Incident 

Conditions Time Response Operations

BC from FD 3 requested that his divers 

respond. 

1604-1607 Assets from mutual aid station were 

dispatched.

1640 FD 3 divers arrived.

1640-1644 Dive Boat 38 went to shore to pick up FD 3 

divers and equipment. Mutual aid BC from 

dive team was assigned “water operations.”

Seven police boats and two fire boats 

established a water parameter control.

1640 Dive Boat 38 conducted a sonar search and 

located both targets. (See Figure 4.)

1

st Rescue (FD 3) diver entered the 

water.

Air checks were called for by 

communications box operator every 3 

minutes.

1651 He made it to bottom/cage, did not find FD 

victim (Diver 4), but found the search rope

and pulled slack out then ascended to safety 

stop.

1

st Rescue (FD 3) diver was out of the 

water.

1702

2

nd Rescue (FD 3) diver entered the 

water.

2

nd Rescue (FD 3) diver was out of the 

water.

1719-approx 

1730

He found FD victim (Diver 4) and dragged

him to cage on bottom then ascended to 

safety stop, then surfaced.

3

rd Rescue (FD 3) diver entered the 

water.

1734 Located FD victim at the cage, cut the 

search line that was connected to the cage 

that the victim was tangled in and connected

a rope to victim (Diver 4) then ascended to 

safety stop then the surface.

3

rd Rescue (FD 3) diver was out of the 

water.

1755

4

th Rescue (FD 3) diver entered the

water.

1815-1822 FD Victim (Diver 4) was brought to just 

below surface and placed in the recovery 

system then placed on Dive Boat 38.
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Incident 

Conditions Time Response Operations

1822-1830 FD Victim (Diver 4) pronounced deceased 

on Dive Boat 38.

Mutual aid dive operation phase 2-was

underway for civilian victim.

1838 Recovery of civilian victim began off Dive

Boat 38.

1910 Dive Boat 38 adjusted the cage closer to the 

civilian victim. (See Figure 4.)

5

th Rescue (FD 3) diver was in the 

water.

1927

Civilian victim was located. 1939

1942 Civilian victim was brought to surface and 

transferred to a different fire boat and then 

to shore. All divers were taken out of the 

water.
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Photo 4. Dive boat from fire department 4, from which Diver 4 was diving. It was not his 

department’s boat. (Photo courtesy of mutual aid fire department.)
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Photo 5. Dive Boat 38, a dive platform/vessel used by the mutual aid dive team. The team is a 

large municipal dive team that responds throughout NC. It has three dive stations, five dive 

companies and 92 dive personnel. (NIOSH Photo.)
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Photo 6. The “cage”. It is used to anchor the ascent/descent rope to the bottom and is the point of 

reference for sonar and divers when performing searches. Its metal construction and form 

provide a distinguishable target for the sonar operators. Once positioned, it can be later moved 

by surface boats with sonar closer to the “target” to reduce blind diving. (NIOSH Photo.)
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Figure 4. Sonar image showing the location of the cage (metal cage that the descent line is 

attached to), the civilian drowning victim’s location, and the downed firefighter/diver.

(Courtesy of mutual aid dive team.)
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Weather and Water Conditions

At approximately 1610 hours on June 6, 2016, the weather in the immediate area was 68.9° F, with a 

dew point of 68.9° F. Wind conditions were 3.5 miles per hour from the south with scattered clouds at 

1530 hours becoming clear at 1610 hours. Visibility was 10 miles [Weather Underground 2016].

The dive site was in a large, man-made lake created in 1963. The lake is the largest man-made lake in 

North Carolina and has 520 miles of shoreline, with a surface area of more than 32,475 acres (50 

square miles) and covering four counties (See Photo 7). It has an average depth of 33 feet and a 

maximum depth of 110 feet and is 33.5 miles long by 9 miles wide [Wikipedia 2017].

During interviews with divers, the lake depth was reported to be 80–83 feet at the site where the 

civilian drowning victim was located, where the dive site was established, and where Diver 4 was 

located and recovered (see Figure 4). Divers reported surface light disappearing at a depth of 60 feet; 

further underwater visibility was reported to be dark and cloudy (by silt) at depth (approximately 80 

feet) with zero visibility on the bottom. 

The water temperature was not recorded but reported to be cold with thermoclines, an abrupt change in 

water temperature encountered at varying depths [NOAA 2001]. According to the data logger on Diver 

4’s dive computer, the maximum water depth on his dive was 81 feet and the dive computer logged the 

water temperature at 57° F.

Photo 7. Location and site aerial view, (courtesy of Google Earth).
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Investigation

On June 5, 2016, at approximately 1530 hours, the local fire department was dispatched to the lake for 

a report of a civilian drowning. The first due Fire Department (FD 1) responded and established 

command and asked for assistance from Fire Department 2 (FD 2). FD 2 assistant chief assisted FD 1 

at the command post and FD 2 boat responded to assist. Once on scene the FD 2 boat ran sonar 

operations in a grid pattern and did not find anything on the first pass. On the second pass they located 

a mark (probable civilian drowning victim) in 55 feet of water, however they experienced a technical 

problem on the third pass and the mark had moved off of an underwater shelf and was then located in 

70 feet of water. The boat then dropped a cage but had issues stabilizing it and eventually retrieved it. 

The mark was continuing to move down the shelf into deeper water.

Fire Department 3 (FD 3 mutual aid department), was dispatched at 1630 to the lake to assist with 

sonar operations. Battalion 3, Rescue from FD 3 and the Dive unit from FD 3 responded. On arrival, 

Battalion 3 went to command and Rescue from FD 3 and Dive unit from FD 3 went to launch the boat.

There were equipment issues with sonar on FD 2’s boat. FD 3’s team lead offered one of his 

firefighters to assist in trouble shooting the sonar on FD 2’s boat. Eventually the firefighter was able to 

assist with the sonar and get it operational. At approximately 2030 hours FD 3’s large boat (Dive Boat 

38) arrived with two sonar fish and the stationary high-definition sonar system.

Fire Department 4’s boat had four divers from the victim’s department (FD 2) in the area where the 

sonar search was being conducted.

Operations to locate and retrieve the civilian drowning victim were suspended at 2200 hours.

On June 6, 2016, at approximately 0800 hours, search operations commenced. An initial briefing was 

held at Command. The FD 2 deputy chief was running the dive operation. Battalion 3 from FD 3 called 

command and asked if they needed to respond. They were told to respond with Dive Boat 38 with a 

battalion chief and the officer from the Rescue Truck from FD 3.

The search boats began a search with sonar. Fire Department 1 returned to the scene with their boat, a 

22-foot boat with a recreational fish finder sonar. Dive Boat 38, FD 3 Battalion Chief and Rescue from 

FD 3 arrived on the scene and then launched at approximately 1000 hours. They interviewed the 

civilian’s family members to try and get a better understanding of the location where the civilian 

victim jumped into the water the previous day. 

Dive Boat 38 asked command to search a grid with their sonar for 1 hour, and the other agency boats 

established a perimeter. Dive Boat 38 located a target, marked it in approximately 80 feet of depth,

dropped their cage and then returned to shore and asked the dive section leader for EMS to standby on 

scene. The crews had lunch and then returned to reposition the cage on the target. Dive Boat 38 moved

the cage within 18 feet of the target (civilian victim) at a bearing of 105 degrees from the cage in 80 

feet of water. 
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Although FD 3 had divers on the scene, they were not asked to assist in the dive and but asked to run 

sonar only. Dive Boat 38 located the target, refined the target and moved the cage closer to the target.

The FD 4 fire boat motored to the boat launch site and picked up the FD 2 divers and took them out to 

the dive site. The FD 4 fire boat arrived at the dive site (marked by Dive Boat 38’s buoy) but had to 

wait for another mask and hood to be brought from shore. The Captain on Dive Boat 38 boat told the 

FD 2 divers that the civilian victim was on the bottom at 80 feet, 18 feet from the cage at a bearing of 

105 degrees. This was derived from the sonar that Dive Boat 38 was using. Dive Boat 38 personnel 

then observed the divers from FD 2 on FD 4’s boat (See cover photo in the Executive Summary). Then 

FD 2 divers started their dive.

At approximately 1444 hours the first set of divers were reported in the water. Diver 1 had a 158-foot, 

7/16th inch search rope and the body bag and Diver 2 had the lift bag. They surface swam over to the 

descent buoy and started descending underwater at 1458. They were only down for 3-5 minutes when 

as they were descending, Diver 1 had trouble equalizing at 25 feet; he stopped and tried to equalize, 

surfaced and then descended back down to 40 feet. He continued to have trouble equalizing so Diver 1 

and Diver 2 surfaced together. At 1505 hours, both divers were back on the surface. Diver 3 was the 

safety diver on this dive and on the surface.

The boat crew called for two additional SCUBA cylinders and a hood from shore. The victim (Diver 4)

geared up to get in the dive rotation. The boat crew reported that they helped him get ready and that he 

checked his equipment before getting into the water. During interviews, the boat crew told NIOSH 

investigators that Diver 4 had a full tank of air.

Note: It was later discovered by NIOSH investigators that Diver 4’s starting air underwater was 

recorded as 2,444 psi by his dive computer. This recording is a “wet start” meaning an automatic 

activation of the dive computer at 5-6 feet underwater. NIOSH investigators received information from 

the dive computer dealer and manufacturer confirming that that model dive computer “only records 

underwater and not on the surface. The computer will start recording at 5-6 foot of depth.” If Diver 4 

checked his air pressure on the boat prior to the dive, it would not be recorded in the data log. There is 

a possibility that Diver 4 could have checked his air pressure and then had a large loss air event on 

the surface and that loss would not be recorded in the data logger. However, during interviews, no one

reported hearing a large air loss event and no one reported that they heard an air loss over the 

communications line to the surface. If Diver 4 used his tank air (instead of his atmosphere switch) for 

an extended surface swim to get from the boat to the descent buoy, this could account for the low 

starting volume recorded on the data logger at 5-6 feet.

The second set of divers in the water were Diver 3 and Diver 4 (the victim), and the safety diver, now 

Diver 5. Diver 3 and Diver 4 swim on the surface to the descent buoy. Diver 3 reported during 

interviews that he had 2900 psi of air and Diver 4 had 2850 psi air in their cylinders before they 

submerged. They both submerged and stopped at about 30-40 feet to equalize. Diver 4’s data logger 

showed a brief interruption in descent at 15 foot then a descent to the bottom. Diver 3 was to be the 

search diver and was carrying a 100 foot, 7/16th inch search rope with a carabiner and Diver 4 was to 
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be the anchor diver staying at the cage and was carrying the body recovery system and lift bag which 

he was supposed to leave at the cage. 

Diver 3 reported during interviews that he searched out approximately 9 feet in 3 feet of silt and 

reported having trouble maintaining neutral buoyancy; and he asked Diver 4 to switch, which they did. 

He reported that Diver 4 searched out approximately 9 feet on the search rope (one end of the search 

rope was secured to the cage). Note: Photo 2 shows that the search rope was also tangled around 

Diver 4’s lift bag. Rescue divers from FD 3 who later recovered Diver 4 reported that they cut the 

search rope from the cage.

At approximately 1545 hours Diver 4 and Diver 3 were on the bottom, discussing how to locate the 

civilian victim when an air check was called by the tender on the dive boat. The non-recorded 

communications line was connected between the dive leader on the boat and Diver 3 and Diver 4. The 

safety diver (Diver 5) was not connected and could not hear the communications. Diver 4 answered

450 psi and Diver 3 answered 630 psi. The dive leader on the boat ordered them to surface. Diver 3 

reported that he left the cage and went to meet Diver 4 in the middle (of the search line) and after 

meeting, they started their ascent. Diver 3 reported that they ascended to a 20-30 foot safety stop 

together. (Diver 4’s data logger shows he ascended to 12.8 feet, see Figure 5). 

After both divers made it to the safety stop, Diver 4 said on the communications line, “Hurry, I am out 

of air.” Diver 3 reported that both of them had started to descend back down to approximately 40 feet 

when he felt something hit his chest and saw Diver 4 trying to get to his pony (redundant air cylinder)

regulator. Diver 3 reported that Diver 4 was in a panic and then saw him pull his facepiece off and then 

Diver 4 attempted to pull off Diver 3’s facepiece, dislodging it. Diver 3 then kicked away from Diver 4 

and surfaced (without his facepiece on). Diver 4’s data logger and graph show this ascent, descent and 

rapid ascent in Figure 5.

Diver 3 reported during interviews that he did not drop his weight belt before surfacing. Diver 3 

surfaced and yelled, “Firefighter down, firefighter down.” He was reported to be approximately 40 

yards from the surface buoy. Diver 3 was picked up by a North Carolina fish and wildlife boat, 

transferred to a FD boat, and taken to shore then by ambulance to the hospital. The lieutenant on dive 

boat called a “Mayday” on the radio.

The FD 4 boat (dive boat) was not anchored when they saw Diver 3 break the surface and yell. The 

dive boat captain told Diver 5 that Diver 4 was out of air. Diver 5 had trouble with water in his mask 

and tried to purge it but was unsuccessful. One of the other divers on the boat helped him adjust his 

facepiece and Diver 5 entered the water and found the communication cable (connected from the 

surface boat to Diver 4) and followed it down to search for Diver 4.

Diver 5 reported following the communication line down and lost visibility at 25 feet and continued 

down to approximately 75 feet and found Diver 4. He reported finding Diver 4 on the bottom on his 

knees leaning to his side. This event is likely captured on the data log profile, approximately dive 

minute 21 through 23 in Figure 5.
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Diver 5 tried to inflate Diver 4’s BCD but it had no air. He then tried to release Diver 4’s weights (see 

Photo 8) and tried to inflate Diver 4’s dry suit with no success. Diver 5 was able to inflate his own 

BCD but knocked his facepiece loose trying to inflate Diver 4’s dry suit. Diver 5 then had to ascend

and during the ascent, he heard his ascent alarm sounding. He tried to release air from his BCD but 

was on the surface before he could release enough air to slow his ascent. A North Carolina fish and 

wildlife boat was the first to reach Diver 5 on the surface and pulled him into their boat. After Diver 5 

was picked up by the fish and wildlife boat, he was transferred to a FD boat, and taken to shore then to 

a hospital by ambulance.

The recovery of Diver 4. It is important to note that the divers listed below are divers from the mutual 

aid fire department dive team (FD 3). They are listed in the report as Divers 1-5 with recovery roles 

involving the fire department victim (Diver 4) and the civilian drowning victim. They are not the same 

Divers 1-5 as listed in this report above.

After the Mayday, Command asked BC 3 from the mutual aid department to send their dive team to 

assist. They were dispatched and arrived in 30 minutes. Since Dive Boat 38 was already on scene and 

anchored in a non-diving role, they immediately assisted.

Upon the declaration of a Mayday, Dive Boat 38 started a search for Diver 4 and quickly located him 

with the side scan sonar (See Figure 4). Additional mutual aid divers arrived on scene, and Dive Boat 

38 returned to shore to pick up the divers. 

Dive operations began off of Dive Boat 38 (now returned and anchored) to recover Diver 4. The first 

diver (Diver 1) entered the water at 1651 hours and made it to the bottom and the cage. He was on a 

communication line with the surface and told them he did not find the Diver 4 (victim) but did find 

Diver 4’s search rope. He pulled all the slack out. Diver 1 was then told to ascent to the safety stop and 

then surface. Air checks were performed every 2-3 minutes. Diver 1 was out of the water at 1702 

hours. Diver 2 entered the water at 1719 and descended. He reported during interviews that it was dark 

passing through 40-50 of depth. He got to the bottom and found the cage and the search rope and 

pulled it tight and followed it out. His flashlight revealed something yellow and he saw Diver 4 on his 

back with his face mask off and palms up. 

Diver 2 grabbed Diver 4 (victim) by the BCD strap and pulled him along the search line back to the 

cage. He told the tender on the boat (via the underwater communications line) that he had brought the 

victim back to the cage. Diver 2 was told to ascend to the safety stop and then surface. 

Diver 3 entered the water at 1734 hours and descended. He carried a rope to tie off to the victim and 

bring the other end back to the surface. Once Diver 3 reached the bottom he found the victim at the 

cage and connected the rope to the victim. He then cut the 7/16th inch search line that attached to the 

cage on one end and was wrapped around the victim. Air checks continued every 2-3 minutes by the 

surface tender. Diver 3 was told to ascend to the safety stop and then surface. Diver 3 was out of the 

water at 1755 hours. 
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The mutual aid dive team had a fourth diver enter the water at 1815 to assist when the crews on Dive 

Boat 38 brought Diver 4 (the victim) to Dive Boat 38, but just under the surface. Diver 4 (victim) was 

placed in a recovery system just under the water surface and then brought on board Dive Boat 38. The 

fourth diver from the mutual aid dive team was out of the water at 1822 hours.

Diver 4 (victim) was pronounced dead on Dive Boat 38. Dive Boat 38 then took Diver 4 to shore 

where he was transported by ambulance from the scene.

Dive Boat 38 then assisted with dive operations to locate and retrieve the civilian drowning victim. At 

1927 hours Diver 5 from the mutual aid department located and recovered the civilian drowning 

victim. At 1942 hours the civilian victim was brought to the surface and all divers were reported out of 

the water.

Additional investigative information. The following information from Diver 4’s dive computer data 

logger analysis assistance was provided by an expert contracted by NIOSH. The dive profile was 

expanded by a NIOSH statistician, and likely points plotted by the NIOSH investigator.

Diver 4 used a dive computer that logged data during his dive. It detailed a descent to 78–79 feet for 

approximately 17 minutes. During this time, Diver 4 had a rapid air usage (breathing rate). At the 10-

minute mark, Diver 4 had only 50% of the air supply left. According to the data logger, he reached the 

bottom in approximately 3 minutes and was using his breathing air at a high rate. His dive computer 

has a factory “turn pressure” setting of 1500 psi which should have alarmed and alerted him that he 

had 50% gas volume left 7 minutes into the dive. Additionally, the dive computer had a setting of 800 

psi for “end time” which should have alarmed and alerted him at 14-15 minutes into the dive. It is not 

known if Diver 4 acknowledged the alarms, however nothing was reported through his 

communications to the surface crew concerning alarms.

Figure 5 is the graphic of Diver 4’s dive profile produced by the NIOSH statistician. A likely synopsis 

is that Diver 4 started with 2,444 psi (size of tank not entered into dive computer). He had a gradual 

descent to 78-79 feet where he remained for approximately 17 min. At that time his cylinder pressure 

dropped below 250psi and he commenced a rapid ascent (> 30 feet/minute). Given the computer was 

set at a 15-second sampling period, it is impossible to determine whether Diver 4 actually made it to 

the surface (according to witness statements, it is likely that 12.8 feet was as shallow as he was able to 

ascend). The computer registered him as shallow as 12.8 feet at the start of minute 18 with a cylinder 

pressure of 151 psi (which is not sufficient to provide breathable air from the cylinder). Thereafter,

Diver 4 started a second descent at approximately minute 18:15. Diver 4 descended to 56.3 feet and 

then started a second ascent at minute 19:15, despite having only 56 psi of air. 

The second ascent registered 24.6 feet as the closest Diver 4 came to the surface before beginning a 

third descent at minute 19:45. Diver 4’s third descent ended at 79.2 feet, at minute 20:45 with 30 psi 

remaining in the cylinder. There was a fourth ascent to a shallowest depth of 58.9 feet at minute 24, but 

by minute 24:45 Diver 4 was back at 77.6 feet. This ascent may represent the rescue attempt by Diver 

5. At minute 26:30 Diver 4 had another brief ascent to a shallowest depth of 70.2 feet (unknown cause 
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but could have resulted from the attempt to raise him by the communications line by the surface crew), 

followed by a final descent to approximately 78.6 feet until Diver 4 was brought to the surface at hour 

2:40 (from the start of the dive).

Figure 5. Partial data logger profile expanded to show dive profile of Diver 4. This profile 

shows the beginning air pressure and rapid usage at depth and during his descent and his 

ascent. The data log shows that Diver 4 made it up to a depth of 12.8 feet just prior to the 

out of air event. Also shown is the rescue attempt by Diver 5. Note that this data only covers 

40 minutes of the 2 hours and 41 minutes of data. (Graphic and likely plots by NIOSH.)
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Photo 8. Photo of Diver 4’s buoyancy control device (BCD) vest showing ditchable weight 

release pull handles.

(Photo by NIOSH.)
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Contributing Factors

Occupational injuries and fatalities are often the result of one or more contributing factors or key 

events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH 

investigators identified the following items as key contributing factors in this incident that ultimately 

led to the fatality:

• Pre-dive safety check

• Air management 

• Uncontrolled out-of-air emergency (not being able to use redundant air supply)

• Panic/rapid uncontrolled ascent while holding breath

• Training and experience 

• SCUBA equipment issues affecting buoyancy control 

• Lack of a safety officer trained in technical rescue SCUBA diving during the event.

Cause of Death

According to the autopsy report, the cause of death was drowning due to arterial gas embolism while 

SCUBA diving. An arterial gas embolism is due to gas being directly introduced into the arterial 

circulation, most likely from breath holding on ascent and subsequent rupture of alveoli. The autopsy 

report listed the victim’s weight as 300 pounds and body length of 73.5 inches with a body mass index 

(BMI) of 39.

Recommendations

Recommendation #1: Fire departments should ensure that public safety divers complete a pre-dive 

safety check (including adequate beginning air) with a qualified dive partner, witnessed by the dive 

safety officer.

Discussion: A pre-dive safety check with a checklist sheet for each diver should be required. This 

checklist sheet should include a personal check by the diver and his/her partner (only divers should 

check another diver) and witnessed by the dive safety officer. This checklist sheet should include (but 

not limited to):

• Main cylinder beginning gas pressure

• Primary regulator function (facepiece check on full face)

• Alternate or secondary regulator (octopus) check

• Redundant cylinder gas pressure
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• Redundant cylinder main valve on and second stage in correct orientation or valve in correct 

position and function check (important to ensure valve is in correct position for start of dive)

• Dive computer check

• BCD function check

• Dry suit check

• Communications equipment check

• SCUBA equipment check including mask, fins, cutting tools, lights, and backup lights.

This pre-dive safety check is required for each diver and should be witnessed by the dive partner (or 

diver assistant) and the dive safety officer and this check should never be hurried. Inattention to any of 

these items can result in a malfunction that can be difficult to overcome underwater. 

This pre-dive safety check should be recorded on a formal checklist for each diver, noting every step 

with a checkmark and providing the actual recording of information for beginning air pressure for 

main and redundant air cylinders (pony cylinder). An example of a pre-dive checklist sheet is provided 

in Figure 6.
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Figure 6. An example of a pre-dive checklist. (Courtesy of Dive Rescue International.)
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In this incident, other divers on the boat indicated that they performed checks on themselves and the 

boat crew members indicated during interviews that they assisted. According to Diver 4’s dive 

computer data logger, the dive computer began recording when Diver 4 was underwater, passing 

through the 6-foot mark (see Figures 7 and 8). If Diver 4 had turned on the dive computer on the 

surface to check his beginning air pressure, the computer would not have recorded that event before 

the automatic activation at 6 feet of depth shown in the first row on Figure 4. According to the dive 

computer manufacturer, the dive computer does not log any information until 5-6 foot of depth.

Based on the dive computer evaluation provided by the local sheriff’s office dive expert, Diver 4’s

dive computer was in gauge mode and not in air mode (factory default setting is air mode). This mode 

means that only air pressure, time, depth, and temperature are available to the diver. Decompression 

planning, tissue loading and other topics are not calculated. This may have been an inadvertent mode 

change but was a deviation from all 72 of the previous dives logged on this particular computer. The

dive computer mode setting is an item on the pre-dive checklist.

Public safety divers should never assume that an unchecked cylinder is full. Many divers/dive boat

operations mark a full cylinder with a plastic boot over the valve body and indicate a used cylinder by 

leaving the plastic guard off. If a diver wants to replace a cylinder, this gives the diver a visual 

indication of which cylinders to choose from, but divers should always check with a gauge to ensure 

the cylinder is full. Divers should always check their own gas pressure before any dive; they should not

rely on someone saying a cylinder is full or a visual cue such as the plastic valve cover.
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Figure 7. Page 1 of Diver 4’s data logger showing the dive computer automatically turned on 

when he descended through the 6-foot mark. Note the logged air pressure at 2444 psi as his 

beginning air pressure. 
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Figure 8. Page 2 of Diver 4’s data logger showing Diver 4 made it to the safety stop at minute 

18 (12.8 feet) however his gas was depleted to 151 psi and likely not able to draw any more air 

and started descending back down to 56 feet before his final ascent back up to 24 feet at 

minute 19. He then began his final descent.
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Recommendation #2: Fire departments should ensure that incident commanders and group leaders

maintain frequent and accurate air status and accountability on all divers. Additionally, no diver 

should be allowed to start a deep dive with inadequate air and adequate air reserves and resources at 

the dive site. 

Discussion: Poor air management has resulted in firefighter and public safety diver deaths [NIOSH 

2005, 2009, 2012]. Public safety divers must manage their air effectively and must return to the surface 

with their reserve air intact. Reserve air is defined as emergency reserve air for the diver to use to 

escape in case of unforeseen occurrences or underwater emergencies. Public safety divers must 

manage their air so that they have adequate air to return to the ascent line, to make a controlled ascent,

for a safety decompression stop, and to still have their reserve air intact (1,000 psi) when they reach the 

surface. In recreational diving, 500 psi is a general reserve; however, many agencies and public safety 

courses recommend 1,000 psi as an adequate reserve.

Public safety divers and tactical and command officers need to recognize and communicate their air 

status and use air management on the incident scene. Air management happens at the diver (task) level, 

the crew (tactical) level, and at the command (strategic) level. Fire departments should ensure that air 

management is practiced at the task level (firefighters, divers), tactical level (unit or dive leaders), and 

the command level (command post, accountability or dive group leader).

At the task level, public safety divers need to ensure their air supply is adequate (full cylinder) at the 

start of the dive and need to control and monitor their air usage during a dive. They need to ensure that 

their backup air cylinder is full and in the on position and the regulator is accessible. They must be able 

to see and recognize the dive computer, pressure gauge, and pre-set air warnings and then 

communicate that information to their crew members. Fire department dive teams should use a predive safety checklist and the dive safety officer should witness the diver equipment checks. Figure 6 

provides an example of a pre-dive checklist. The safety checks for surface supplied-air systems with 

bailout bottles are different from the safety checks for self-contained underwater systems with 

redundant (pony) systems. Valve position(s) during air checks are important, especially when reading 

the correct cylinder or air status. The diver’s tender needs to be a diver and understand the system 

he/she is assisting the diver with. Additionally, the dive safety officer needs to be familiar with the 

system and witness the pre-dive safety check.

At the tactical level, crew or team leaders need to plan accordingly for the safe air management of all 

dive team members. They need to recognize when a diver is using excess air by frequent air status 

checks and by monitoring communications if using open communication systems. Surface support 

teams need to record the beginning air status and continuously monitor air status throughout the dive. 

If a diver misses an air status when a benchmark has been met (i.e., diver made the bottom, diver has 

found the target and is returning, or diver is ascending), the surface support team should prompt a 

response from the diver. The tactical level crew leader (dive leader) ensures that the dive plan is being 

followed and requests additional resources based on anticipated needs. All divers need to practice air 

management and return to the surface with their reserve air intact. Many public safety dive authorities 

recommend twice the remaining air in reserve as the recreational dive industry (i.e., 1,000-psi reserve 
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vs 500-psi reserve in a 3,000-psi, 80-cubic-foot cylinder). Escape, redundant, or backup cylinders and 

systems always need to be checked and in the correct status prior to diving (e.g., in-line valve in 

correct orientation and first-stage valve in correct position), and the diver needs to ensure that the 

backup air system regulator or secondary valve is in an accessible location.

Dive team leaders should be responsible for planning the dive using proper air management techniques 

and dive protocols for the particular dive and depth and then plan the dive accordingly. The technical 

rescue dive safety officer should review and agree with the dive plan. Air management is a constant 

and multi-level responsibility. It can be easy for divers to become distracted with the difficulty of the 

assignment, environmental conditions, and civilian body recovery issues and lose track of their air 

supply. The multi-level air management system for public safety SCUBA diving has constant checks 

and balances as there is less room for error underwater. 

Finally, air management at the strategic level ensures that the proper number of divers match the

capabilities and competencies of the teams. In most public safety dive events, time is on your side to 

ensure capability, capacity, and competency of the resources [Orusa 2007]. Once the incident is 

classified as a recovery mission, there are no urgency events and incident commanders, group leaders, 

safety officers, dive team leaders, and dive team members need to carefully plan, coordinate, and 

execute the mission with all of the focus on the safety of the dive team members in completing, 

terminating, postponing, transferring, sharing, or rejecting the mission. When rescue considerations are 

no longer viable and the mission is recovery, all of the emphasis is on the dive team member’s safety.

At the strategic level, Command needs to understand air management at the command level. This 

means that someone at the command post is monitoring or ensuring that air status is being monitored 

and recorded. Additionally, with the assistance of the safety officer, Command needs to monitor 

accountability of the crews. Command needs to estimate additional resource needs based on crew 

performance and how long they have been working (estimating air supply usage) and check on air 

status with the tactical-level crew leader. Command needs to ensure that the technical rescue team has 

all of the resources that are capable and competent to achieve its mission. This includes multi-agency, 

multi-jurisdiction cooperation and integration when appropriate. Command needs to ensure that all air 

management and accountability needs of the technical rescue dive team are met through the incident 

safety officer (ISO) and take action to halt any mission when any of the team’s needs are not met. 

Since most dive events are recoveries, time is typically on the technical rescue dive team’s side. Since 

technical rescue SCUBA diving is considered a high-risk/low-frequency mission, it is easier to error on 

the side of diver safety and halt an operation when all aspects of the mission are not ready. 

Public Safety divers need to understand and communicate their air supply status to their surface 

support team. Surface support teams need to monitor and record the beginning air and continuous air 

status throughout the dive. If a diver misses an air status update when a benchmark has been met (i.e., 

diver made the bottom or diver has found the target and returning, or diver is ascending) the surface 

support team should prompt a response.
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In some instances, public safety divers may not pay attention to their air usage and remaining air until 

they get a prompt by the dive team crew or, in the case of zero visibility, they hear an audible warning 

from the computer. This may be due to a number of reasons, including lack of familiarity with a new 

SCUBA gear setup (full-face vs half-face) or a lack of training. In modern firefighting SCBA,

firefighters have heads-up display (HUD). Lights inside the facepiece indicate air management 

milestones such as full, three-quarters, 50% flash, and 33% end-of-service-time indicator (EOSTI). 

Recommendation #3: SCUBA manufacturers and standard-setting organizations for public safety 

divers should consider including HUD in all full-face SCUBA apparatus due to the frequent zerovisibility conditions and silt-out in low-light conditions.

Discussion: It is extremely challenging for a diver without an HUD to give regular air status updates in 

low-light or zero-visibility conditions. In a low-light or zero-visibility condition at the bottom, even 

grabbing your dive computer with one hand and shining a light on it with your other hand can cause 

you to slightly drift down in a layer of silt while you are following a search rope. Silt-out conditions 

then may obscure the light source. 

A diver (just like a firefighter) should never have to guess how much air they have. Once the 

remaining air drops below milestone indicators, two sensory stimulations should activate (e.g., sound, 

light, and/or vibration). This ensures that the diver will not unknowingly pass through the remaining 

air milestones. Finally, the surface crew with wired communications needs to ensure air checks

through the communication line and all divers in the water should be on that communication line.

With the addition of HUD, public safety divers will have the ability to know their approximate air 

supply status by reading the milestone light(s) in their facepiece. Fire departments and public safety 

dive organizations should consider manufacturers that provide HUD for full facepiece for their 

purchasing whenever possible.

Recommendation #4: Fire departments should ensure that public safety divers are properly trained 

to recognize and have the repetitive skills training to control out-of-air emergencies and be able to 

use their redundant air before anxiety leads to panic. Additionally, when dive teams mix fullfacepiece regulators with stand-alone regulators from a pony system, the divers must be well-trained 

to accomplish the difficult removal and switch task.

Discussion: The ability of firefighters and divers to understand and control an out-of-air emergency is 

heavily reliant on repetitive-skill and, muscle-memory training in addition to didactic training.

It is critical that firefighters/divers understand how to avoid and how to react and control an out of air 

emergency. Over familiarization and practice with their equipment is one of the most effective ways to 

build repetitive-skill, muscle-memory capabilities. 

When a relatively minor situation such as initially missing an air status change or check (i.e., milestone 

lights in HUD or audible alarm from dive computer), redundant safety measures such as air status 
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prompts from a trained safety/accountability crew can help interrupt a complication before the 

situation escalates into an urgent response need. Once the initial situation goes beyond a simple 

adjustment or reaction, the public safety diver must react with over learned skill sets on their 

redundant or back up breathing air system, communicate and then exit the danger. 

Many recreational SCUBA diving scenarios have adequate visibility to read a depth and pressure 

gauge. Unfortunately, many if not most public safety SCUBA dive incidents occur in little- to novisibility conditions. Therefore, reading a depth and pressure gauge is difficult using an underwater 

light source. This can be especially difficult if the diver is using his/her hands to maneuver equipment, 

hold on to a descent line, manage a search rope, or even use the auto inflate/deflator to achieve neutral 

or desired buoyancy. Modern dive computers have audible alert signals that can be programed to meet 

the needs of the diver (e.g., audible alarm can be made to sound at 50% air and maximum desired 

depth in addition to automatic built-in protocol alarms for mandatory decompression stops). Only 

having one sensory stimulation in SCUBA diving (sound vs. sight) places the public safety SCUBA 

diver at a much greater risk of missing milestone signals. Public safety SCUBA divers should have a 

minimum of a full-face diving mask with an HUD. Unlike recreational diving, visibility is often poor,

and the audible sensory stimulation alone may not be sufficient.

Anxiety can lead to an increased heart rate, breathing rate, and large breathing air consumption rates. 

Over-familiarization with equipment can reduce anxiety before the anxiety develops into panic. Fight 

or flight responses to panic underwater have led to distressed divers in a panic attempting to dislodge a

partner’s mask or regulator (as happened in this incident) and other public safety diver incidents as 

well [NIOSH 2003, 2012].

Repetitive skills training with SCUBA is vital for the safety of all divers and can help to overcome 

anxiety should emergency situations be encountered. It is even more important for public safety 

SCUBA divers who don’t have the same mission and dive conditions that recreational divers have. 

Extreme climate and water conditions, limited or no visibility, extraordinary entanglement hazards, 

water pollution, challenging physical and mental conditions, heavy and cumbersome equipment, and a 

lack of repetitive skill opportunities are challenges that all public safety divers face.

Basic SCUBA skills training with the equipment divers will be using is an ongoing process that should 

be performed regularly to ensure that firefighters "know their SCUBA equipment just like firefighters 

must know their SCBA." Some benefits of repetitive dive skills training with a SCUBA include the 

following: 

• an increased comfort and competency level 

• decreased anxiety

• automatic muscle memory response for the vital function controls, such as pulls for the 

ditchable weights or release handle/buckle for weight belts
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• lower air consumption 

• increased awareness of the user's air level (noticing and using the HUD when equipped)

• automatic muscle memory response for other vital function controls, such as dive computer and 

air pressure function keys, the auto-inflate/deflate for the BCD, inflate/deflate controls for the 

dry suit, purge button for the facepiece to rid mask of water or knowing how to evacuate water 

from a flooded half facepiece. 

The public safety diver needs to have these primary control functions as a second nature response for 

normal diving operations. When any anxiety or panic begins, the only way that these functions will be 

second nature is for the diver to have over-trained on their use. Repetitive skills training also provides

the user with an increased ability to operate these functions and controls in a high-anxiety moment or 

an emergency. Many times, using these skills will be necessary with gloved hands, limited vision, and 

reduced ability to hear commands from others (especially if the full-face communications unit has been 

removed). These skill sets have to be second nature at all depths. If a public safety diver becomes too 

focused on a task or distracted, they can descend (or ascend) unknowingly into a more dangerous 

situation.

In most fire-fighting training scenarios, these skills can be performed in a non-immediately dangerous 

to life and health (IDLH) atmosphere. However, public safety SCUBA divers don’t have that luxury

and the need for repetitive skills training is just as great. The training necessary to master these skills is 

expensive and requires a commitment and a discipline from all levels of the agency(s) responsible for 

the team’s operation. Performed in conditions that are more controllable, such as pools, repetitive skills 

training helps build firefighter/divers' muscle memory so their hands will be able to activate the 

controls with gloves on and the operation will have a better chance to be a conditioned or secondnature response in case of an emergency [NIOSH 2011, 2012].

The first step in overcoming a SCUBA (and SCBA) out-of-air emergency is complete overfamiliarization with your specific equipment and your breathing air requirements and usage. 

Firefighters/divers need to understand that many out-of-air emergencies are caused by 

firefighters/divers not recognizing the remaining air supply relative to their depth and mission and then 

another event occurs, such as difficulty or being unable to maintain buoyancy control (positive, 

negative, or neutral). 

There are other events that can challenge a public safety diver’s ability to overcome an out-of-air 

emergency, such as using a full facepiece and having to switch to a standard regulator for your backup air. Removing the full facepiece causes a loss of visibility and/or cold shock to the face all while 

trying to get the spare air regulator in your mouth. Then you have to find your half mask in your BCD 

pocket and put it on and flush the water out of it (clear it with air from your nose) so you can see. All 

of this without losing buoyancy and drifting down deeper or popping to the surface uncontrolled while

doing this. This mask and regulator switch out is a learned skill that must be practiced. There are 

engineered solutions that allow the divers’ spare cylinder to be valved into the primary air system. This
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would allow the diver to just adjust a valve position instead of removing the full facepiece mask;

however, the redundant cylinder is no longer totally separate and independent. A disadvantage of this 

type of system could be starting the dive with the valve in the incorrect position and all of the air from 

both cylinders is used at the same rate and in the event of a diver needing the pony cylinder air, it 

would be empty. While there are advantages and disadvantages with both systems, the key take away 

is over-familiarization with the system your department or team uses.

Another challenge to a public safety diver’s ability to overcome an out-of-air emergency is using 

weight equipment they may not be overly familiar with. If a diver has always used a quick release 

weight belt and is less trained in ditchable and non-ditchable weights that are integrated into the BCD, 

they may not be able to locate and activate the release mechanisms and return to concentrating on the 

original out-of-air complication. Public safety divers have died from not being able to release the 

weights or being over-weighted (in non-ditchable pockets) [NIOSH 2005, 2013].

A public safety diver’s ability to overcome these events is directly related to their practical training and 

repetitive muscle memory skill. Many uncontrolled out-of-air emergencies can be overcome by 

repetitive skills training. NIOSH investigators have identified air management as a contributing factor 

on many investigations of firefighter and firefighter SCUBA diver line-of-duty deaths. Fire 

departments need to ensure that training on air management occurs at all levels of the command 

structure [NIOSH 2011, 2012].

Recommendation #5: Fire departments should ensure technical rescue SCUBA dive teams have a 

Dive Safety Officer on site who is trained in technical rescue SCUBA diving before commencing a 

dive. 

Discussion: A trained technical rescue SCUBA Dive Safety Officer should be on scene and part of the 

command structure and tactical planning for the dive. The Dive Safety Officer should be located at the 

dive site and available to the command post but not be in the planned dive rotation.

NFPA 1670, Chapter 4.5.2, states that “at technical search and rescue training exercises and in actual 

operations, the incident commander shall assign a safety officer with the specific knowledge and 

responsibility for the identification, evaluation, and where possible, correction of hazardous conditions 

and unsafe practices [NFPA 2014]. The assigned safety officer should meet the requirements specified 

in NFPA 1521 Standard for Fire Department Safety Officer [NFPA 2015]. 

Safety officers assigned to special operations incidents, such as technical rescue SCUBA diving 

incidents, need to have the expertise in the specific technical rescue field to effectively evaluate 

hazards and provide direction with respect to the safety of all personnel. The dive safety officer can 

help provide an additional level of safety review for the dive operation including, mission (risk vs. 

gain), personnel (are the public safety divers mentally prepared for the high risk/low frequency dive 

and is the skill required beyond the team members training and competencies?), available resources 

and equipment, back up divers or Rapid Intervention Crew (RIC) for the primary dive team, Advanced 

Life Support (ALS) medical group for the divers.
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A qualified fireground safety officer may not possess the necessary expertise in water rescue and, 

therefore, might not recognize or understand capabilities of the team members, limitations and hazards 

to rescue workers, the need for specialized equipment appropriate for water rescue operations problems 

with equipment, or performance issues of personnel. NFPA 1521 notes, “in cases where the designated 

incident safety officer does not possess the technician-level training, appointing a technician-level 

trained assistant or technical specialist with the necessary training will help satisfy the safety needs of 

the technician-level members.”

The dive safety officer has the critical advisory role to the ISO and the incident commander on the risk 

vs. benefit at the strategic and tactical level. A dive safety officer properly trained in the technical 

rescue field being performed can also help prevent a public safety diver from attempting a skill beyond 

their level of training. The diving safety officer and incident safety officer should be integrated into the 

incident command structure [NFPA 2015].

A specifically trained and qualified dive safety officer can monitor the incident action/dive plan 

(primary decisions regarding rescue/recovery, team capabilities, outside resources), dive conditions, 

dive plan activities such as water depth, dive plan complications, and operations to determine whether 

they fall within the criteria as defined by the fire department dive team’s risk management plan. The 

diving safety officer should also witness the diver(s) pre-dive safety checks as well as monitor the 

health and well-being of the divers pre- and post-dive. 

NFPA 1561 Standard on Emergency Services Incident Management System and Command Safety

states in Paragraph 5.3.1 that "the incident commander shall have overall authority for management of 

the incident". NFPA 1561 Paragraph 5.3.2 states, "The Incident Commander shall ensure that adequate 

safety measures are in place" [NFPA 2013c]. However, technical rescue incidents require that the 

incident commander have a safety officer who is trained in the discipline (SCUBA, Water Rescue, 

Confined Space Rescue, High Angle Rescue, Hazmat, and Trench Rescue) and dedicated to the specific 

operation. A safety officer for a Technical Rescue SCUBA incident should also be located where the dive 

operation is taking place. They can monitor the operation, evaluate resource status, ensure accountability 

and pre-dive safety and equipment/air checks, continuously evaluate member abilities and capabilities, and 

ensure that all operational function positions are staffed, and qualified backup rescue personnel are in place 

to aid in the event of complications. 

Based upon the size and complexity of an incident, Incident Commanders should delegate 

responsibilities that include a safety officer for the incident scene a safety officer for the technical 

discipline being performed (in this case, a Dive Safety Officer). The incident command system can be 

expanded to include functions necessary to effectively command and control an incident. Upon 

confirmation, the dive safety officer should obtain the following information: 

• Meet with the incident commander, command staff (including the Incident Safety Officer) and 

dive team leader and discuss the needs and advise on the risk vs. benefit analysis at the strategic 

level and the tactical level. Does the benefit of the operation justify the risks to the personnel to 

achieve it?
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• Overall situation status and resource status, resource capabilities 

• Strategy and incident action plan (dive plan)

• Known hazards and concerns (water depth, degree of difficulty, water and environmental 

complications, weather)

• Status of dive crews, crew leaders, crew capabilities, crew competencies, equipment, and 

personnel accountability

• Ensuring the dive crews are following the dive plan and accurate event monitoring and 

recording are taking place

• Back-up dive team assets

• ALS standby for medical care for divers

• Establishment of the rehabilitation group 

• Confirmation of established radio communication channels (command channel, tactical 

channels) 

• In summary, plan the dive, and dive the plan

The Dive Safety Officer should don the personal protective equipment appropriate for the potential 

hazards that he/she will be exposed to (e.g., auto-inflating or standard personal floatation device (PFD)

for protection around the water and/or float coat for colder weather). Also, the Dive Safety Officer 

should be identified by a vest or helmet. 

The Dive Safety Officer should meet with the Technical Rescue Group Leader, Incident Safety 

Officer, Incident Commander and develop a communication plan and coordinate their activities. The 

Incident Safety Officer is responsible for overall safety of the incident scene and reports to the incident 

commander. The Dive Safety Officer reports to the Technical Rescue Group Leader, however 

coordination and communication between the safety officers can be advantageous on large complex 

missions.

NFPA 1521 Standard for Fire Department Safety Officer Professional Qualifications defines the role 

of the Incident Safety Officer (ISO) at an incident scene and identifies duties such as recon of the 

incident scene and reporting pertinent information back to the Incident Commander; ensuring the 

department’s accountability system is in place and operational; monitoring radio transmissions and 

identifying barriers to effective communications; and ensuring established safety zones and other 

designated hazard areas are communicated to all members on scene [NFPA 2015].

The Incident Safety Officer and technical rescue group Dive Safety Officer add a higher level of 

training, attention, and expertise to help the Incident Commander. The Incident Safety Officer and 

technical rescue group Dive Safety Officer must have particular expertise in analyzing safety hazards 

and must know the particular uses and limitations of protective equipment. For example, while the 
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Dive Safety Officer may be focused on the safety of the divers, the incident safety officer can help 

ensure the safety of the boat teams and land support firefighters [Dodson 2007; Dunn 2000; NIOSH 

2009, 2010].

Experience in the technical rescue discipline being performed is an extremely valuable resource. The 

technical rescue group Dive Safety Officer has a different area of responsibility than the Incident 

Safety Officer. He/she has the specific knowledge, skills, qualifications, and experience to oversee the 

safety of the members of the technical rescue group and the mission they are performing. They must 

have that level of experience to recognize realistic mission goals, team and resource capabilities, team 

member capabilities, and team member limitations and have the discipline and authority to add, 

change, modify, intervene or stop an unsafe operation. This is especially important in technical rescue 

SCUBA operations where the largest portion of all operations is in a recovery vs a rescue mode and 

time is on the team’s side. The Incident Safety Officer working together with a trained and experienced 

the technical rescue group Dive Safety Officer can provide a fire department with a higher level of 

expertise to perform the necessary incident scene functions and assist the Incident Commander with 

incident scene safety.

In this incident, the assistant Chief of FD 2 was the Incident Commander and monitored and kept 

record as he received communication updates from operations (Dive Group Supervisor). The Dive 

Group Supervisor as a lieutenant from FD 2 on the dive boat and the communications officer was also 

from FD 2. They did have a safety diver on the surface during the dives however the role of Dive 

Safety Officer was not included at the dive site. 

Recommendation #6: Fire departments should provide annual training on dive hazards such as 

lung overexpansion injuries, out of air emergencies, emergency ascent procedures, including the 

dangers of breath holding, and emergency release of dive weights.

Discussion: Fire department dive teams need to provide annual refresher training on dive hazards such 

as lung overexpansion injuries, including arterial gas embolism, pneumothorax, mediastinal 

emphysema, and subcutaneous emphysema and their prevention. Diving hazards can include deadly 

medical conditions associated with lung overexpansion injuries. Public safety SCUBA divers need to 

have annual refresher training on these and other SCUBA diving hazards. While diving maladies and 

other hazards may be taught in formal basic SCUBA and other advanced SCUBA classes, the 

knowledge gained in class needs to be re-enforced through annual refresher training.

Lung overexpansion injuries include arterial gas embolism, pneumothorax, mediastinal emphysema 

and subcutaneous emphysema. What they all have in common is that each of these type of injuries can 

be induced by holding your breath for any reason during an ascent while on SCUBA or surfacesupplied air [Hendrick et al. 2000].

Understanding basic properties of gas when subjected to pressure is key to understanding dive hazards 

associated with lung overexpansion. According to Boyle’s Law, the volume of a parcel of gas varies 

inversely with the pressure exerted on it. If the pressure increases twofold, the volume of the gas will 
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be half its original volume, and its density will be twice as great [Hendrick et al. 2000]. If a person on 

the surface has 5 liters of air in his/her lungs and holds their breath and dives underwater, the pressure 

increases and the 5 liters of air are still there, but occupying a smaller space. If they descend down to 

99 feet (where the pressure is 4 times what it is at sea level) the 5 liters will only occupy 1/4 the 

volume space in the lungs. Then as they return to the surface—if they don’t inhale or exhale—the air 

will return to its normal volume and density once they are on the surface [Hendrick et al. 2000]. An 

example would be free diving from the surface while holding one’s breath. Breathing compressed gas 

underwater changes that dynamic significantly. When SCUBA divers inhale underwater, their lungs 

are filled with compressed air to keep their lungs the same size they were on the surface, which means 

that they are breathing increasingly denser air as they descend. To maintain 5 liters of air lung volume, 

a SCUBA diver needs to inhale the surface equivalent of 10 liters of compressed air at 33 feet, 15 liters 

of compressed air at 66 feet, and 20 liters of compressed air at 99 feet. This is accomplished through 

the functions of a diving regulator to deliver air to the diver at ambient pressure according to the depth

[Hendrick et al. 2000].

If SCUBA divers hold their breath while ascending, the denser air that they inhaled at depth will 

expand the lungs beyond their normal elastic capability, causing tissue damage [Hendrick et al. 2000].

These injuries can be life-threatening and result in catastrophic incapacitation and death.

In basic SCUBA diving education, divers are taught to always breathe continuously and normally,

never hold their breath and to exhale on ascent. However, there are instances where divers may be 

distracted and unintentionally ascend while holding their breath. Divers need to have refresher training 

on common conditions that could cause a distraction as ascent while holding their breath. Here are a 

few examples:

• Panic moment or uncontrolled anxiety

• Uncontrolled out-of-air emergency or low-air event

• Over-weighted (with dive weights or not being able to jettison weights as in this incident) 

• Accidental loss of a weight belt

• Preoccupation with an equipment issue, such as the mask 

• Managing buoyancy (failure to release necessary air in their BCD to maintain a controlled 

ascent; remember that any air you autofill into your BCD at depth will also expand as you 

ascend)

• Inability to maintain positive buoyancy (BCD shoulder dump valve accidently jammed open by 

carabiner for body bag)

• Exertion during a difficult task

• Coughing, sneezing, or vomiting

• Breathing heavy in response to finding the target [Hendrick et al. 2000].
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Because public safety diving is more dangerous than sport or recreational diving, public safety 

divers need to use every margin of safety available [Hendrick et al. 2000]. Ascending from depths 

needs to be a planned and trained-for evolution to keep from having serious medical complications 

associated with gas expansion. 

Many factors can lead to an underwater emergency and planning to avoid the events that lead to the 

emergency is the first step. Dive emergencies can arise from a number of causes including exhaustion, 

embolism, decompression sickness, nitrogen narcosis, heart attacks and other medical conditions, 

strong currents, entanglements, equipment failure, out of air emergencies and panic [NOAA 2001].

Divers need to be familiar with procedures to overcome these events. 

Divers should train to use task-level air management (diver always aware of their air remaining), 

tactical air management (dive team surface monitoring and recording) and strategic level air 

management (command and division level support through proper resources and personel) to avoid 

low air events that lead to out of air events. 

The first step in evaluating an out-of-air emergency is to confirm that the apparent air loss is real. For 

example, a tank valve not fully open can present as a difficulty to draw air, but is easily corrected if 

recognized. The diver needs to stop, think and attempt to breath and if it is possible to do so, proceed 

with a normal ascent [NOAA 2001]. If a diver determines that their air supply is depleted, the NOAA 

diving manual suggest the following order for managing air loss:

• Normal ascent

• Alternate [or redundant] air source ascent (alternate air is a second air line from the main tank, 

a redundant air source is a second “pony” cylinder with its own second stage regulator)

• Controlled emergency swimming ascent

• Buddy breathing ascent

• Emergency buoyant ascent (putting air in the BCD and dropping weights) [NOAA 2001].

A redundant air cylinder can provide emergency breathing air and is independent of the primary air 

supply. For example, these “pony” cylinders range in size from 1.7-15 cubic feet. A 4 cubic foot 

cylinder can provide 14-16 breaths at a depth of 100 feet and can provide 80 breaths in shallow water. 

There are also redundant air cylinders that can be manifolded into the diver’s primary air system, so 

they don’t have to remove the full facepiece dive mask and insert a regulator and then switch to a half 

mask.

During annual refresher training divers should be reminded of the hazards of an uncontrolled ascent as

well as how to release their weight belts or integrated ditchable and non-ditchable weights in an 

emergency ascent. However, an emergency buoyant ascent is difficult and hazardous and should 
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only be used as a last resort to resolve an emergency and the diver must be venting air continuously 

(exhaling all the way to the surface). A diver having difficulty ascending should release his/her weight 

belt and divers experiencing stress at the water’s surface should drop the weight belt immediately to 

ensure that they will float [NOAA 2001]. If a diver has traditionally used a weight belt and transitions 

over to integrated (ditchable) weights, they need to relearn the muscle memory to release. The first 

place they may reach for is the belt release if they haven’t relearned how to release the ditchable or 

integrated weights.

Recommendation #7: Fire departments should recognize public safety SCUBA diving as high 

risk/low frequency events and ensure public safety divers are properly trained, equipped, and 

supported to perform public safety diving responsibilities and integrate the training and SOPs with 

regional dive and water rescue team(s) with whom they regularly respond.

Discussion: Although there is no evidence that the following recommendation would have prevented 

this fatality, it is being provided as a reminder of best safety practice for the fire service. Fire 

departments should recognize public safety SCUBA diving as a high risk/low frequency event (Figure 

9) and use a risk assessment program to determine the level of involvement in which they wish to 

participate. During this assessment, departments can decide if they want to accept the risk (fully 

committed to equipping and training their own team), share the risk (integrate with other teams in a 

mutual aid or regional team) or decline the risk (using a program risk analysis to transfer SCUBA 

duties to other agencies). 

There is no standard scale to measure and evaluate frequency and severity of risk for the fire service. 

NFPA 1500 (Standard on fire department occupational safety and health program), provides guidance 

on risk assessment [NFPA 2018]. It is important that a fire department develop a risk management 

program that is based upon the process of identifying, evaluating, prioritizing, and controlling risk. The 

risk management plan incorporates a full range of control measures that may be used to limit, reduce, or 

eliminate the probability that an undesirable outcome will occur. 

An important factor is that fire departments should prepare and maintain a written statement or policy 

that establishes the existence of the fire department, the services the fire department is authorized and 

expected to perform, and the basic organizational structure. This will be the basis for the development 

of the risk management program. The frequency and severity of risk starts with a thorough community 

risk assessment [NFPA 2018]. 
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Figure 9. Risk vs. frequency scale. [NFPA 2018]

Fire departments should prepare and maintain written policies and standard operating procedures that 

document the organizational structure, membership, roles and responsibilities, expected functions, and 

training requirements, including the following:

• The types of standard evolutions that are expected to be performed and the evolutions that must 

be performed simultaneously or in sequence for different types of situations

• The minimum number of members who are required to perform each function or evolution and 

the manner in which the function is to be performed

• The number and types of apparatus and the number of personnel that will be dispatched to 

different types of incidents
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• The procedures that will be employed to initiate and manage operations at the scene of an 

emergency incident [NFPA 2018].

Fire departments that decide they want to accept the risk and perform technical rescue water 

operations, including SCUBA diving and water rescue, need to ensure that personnel receive the 

proper initial training, advanced training, repetitive skills training and interagency training with mutual 

aid or regional dive teams that they regularly respond with. Fire departments must also understand that 

the commitment will involve a continuing commitment to advanced and recurrent training and also 

equipment and marine apparatus purchasing and maintenance.

Managing risk includes mandatory continuing education and skills documentation programs. Steve 

Orusa, Fire Chief of Fishers Indiana Fire Department and nationally renowned expert and author of 

Dive Rescue Specialist, Operational Training for Public Safety Divers [Orusa 2007] notes, a lack of 

basic diving skills has been statistically identified as one of the leading causes of public safety diving 

fatalities. With 86% of the fatalities occurring in training and recovery modes (as was this incident), 

managing the components of rescue and recovery mode and the risk/benefit analysis in water rescue 

operations and training are critical. 

In his book Chief Orusa notes: “Inadequate SCUBA skills may be the leading cause of public safety 

diver accidents. In many cases, a problem developed that the diver was unable to solve due to a basic 

skill level. In most cases, divers had received either insufficient or nonexistent SCUBA skills refresher 

training after initial certification.” Public safety divers should have training and experience in a variety 

of environments likely to be encountered in rescue operations, such as deep-water complex dives, 

limited visibility, cold water diving, ice, current, contamination and hazardous materials, dry suit, and 

lifting operations.

Annual confirmation of these skills should be performed to ensure continued competency. Dive 

team(s) need to stay current on training and annual skills evaluation. An example of an evaluation form 

to assess skills of public safety divers is provided in Figure 10.

The level of knowledge, skills, ability, equipment and support required for a public safety SCUBA

diver are outlined in NFPA 1006 [NFPA 2017] and NFPA 1670 Standard on Operations and Training 

for Technical Search and Rescue Incidents [NFPA 2014]. Throughout NFPA 1006 and 1670, hazard 

analysis and risk assessment are addressed. One of the most hazardous events a diver can encounter is 

not being able to solve problems or make decisions underwater. The typical chain of events in a public 

safety diving accident is as follows:

• The public safety diver becomes cold and/or tired

• Their stress level, which is already high under such circumstances, increases

• The public safety diver encounters a problem or makes a mistake they cannot solve
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• Panic ensues

• Death or serious injury results [Orusa 2017].

Public safety diving requires emergency response teams with specific knowledge, skills, ability, 

equipment and continued support beyond basic firefighter or emergency responder requirements to 

resolve unique or complex rescue situations. Additionally, when the team is faced with complex, deep, 

highly technical recovery dives, it is important to realize the team’s limitations and when the team 

needs assistance and call additional resources (mutual aid). Some jurisdictions utilize regional teams to 

meet the goals of risk management for a specific risk (shared risk). 

A key part of an overall rescue strategy should be mutual aid. The use of formal or informal mutual aid 

can help share the risk by providing additional experience, equipment, personnel and other resources to 

a public safety diving event. Other benefits include, greater levels of coverage and redundancy, 

building trust between organizations and leadership benefits that can ultimately make for a safer dive 

environment. Additionally, it can remove destructive competitiveness and rivalries between 

departments and/or agencies. 

Since the resource requirements and commitments are very high, a shared risk approach may work for 

some jurisdictions. Regional or mutual aid teams need to train together (if they are going to work 

together) so they can recognize and work together and have a level of coverage and/or redundancy that 

they may not have otherwise. If regional teams are going to work and train together, they should 

consider integrating their standard operating procedures (SOPs) and standard operating guidelines 

(SOGs). The difference between SOPs and SOGs is the difference between a procedure, which must be 

followed, and a guideline, which is more flexible and allows the responder to tailor his/her actions to 

fit the situation. A set of SOPs would include any rules that should be inviolable. For example, a public 

safety diver should always end his/her dive with 1,000 psi remaining for emergency reserve air (3,000 

psi per 80-cubic-foot cylinder). The 1,000-psi rule should not be broken and is a good example of an 

SOP [Hendrick et al. 2000].

Fire department SCUBA dive teams need to stay current on new equipment available such as “in 

mask” air supply status or heads up display (HUD), communications and protective gear such as dry 

suits and redundant air supply options. Also, new high-definition sonar systems are available that can 

reduce a dive teams’ exposure to blind diving, by working to locate and isolate a dive target to within 

several feet. Blind underwater searches using search ropes and gridding-off areas are very taskoriented and time-consuming (underwater time) and therefore could require a significantly greater 

resource commitment for a significantly longer period of time. Reducing your exposure to the hazard is 

a recognized risk management principal. Dive teams should consider reducing the risk by reducing the 

exposure to the hazard (underwater) by spending more time and resources when they can on surface 

operations and technology to locate and mark targets with extreme accuracy.

Continued support for the team is an important component of the leadership of technical rescue teams. 

Once a team is properly trained and equipped, the organization must continue to provide support to 
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maintain the technical rescue team’s operational readiness through continued training and review of 

program goals and needs. Inadequately trained divers should not be allowed to participate in technical 

rescue SCUBA diving incidents beyond their level of training.

Figure 10. Annual Basic SCUBA Skills Evaluation.

(Courtesy of International Association of Dive Rescue Specialists.)
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Recommendation #8: Fire departments and other public safety dive teams should consider advanced 

level training courses/agencies that closely match the public safety dive team needs.

Discussion: Although there is no evidence that the following recommendation would have prevented 

this fatality, it is being provided as a reminder of best safety practice for the fire service. Public safety 

dive hazards are extreme and unforgiving. Public safety dive teams have to operate (or consider 

operating) in many extreme conditions such as ice-covered lakes, very cold diving conditions, limited 

or no visibility, a myriad of entanglement hazards, marine traffic, ship intakes and outflows, marine 

life hazards, biohazards and chemical pollutants, and technical deep water wreck penetration diving. 

As stated before, public safety SCUBA diving is a very high risk and low frequency discipline, 

therefore having personnel with high degree of experience in any one of the above-mentioned hazards 

is not always possible or available. 

Fire departments that incorporate public safety dive teams as part of their community risk assessment 

and have decided to provide a level of public safety SCUBA diving need to identify all of the possible 

dive possibilities and ensure that they select a training agency or organization that will match the dive 

training needs and discipline to the local dive response requirements.

For example, a public safety dive team that regularly dives in ice covered lakes should not select a 

training course/agency that specializes in warm water recreational diving for their advanced training.

When a department or dive team selects a training course/agency, some things they should consider 

are:

• Public safety diving specific training standards. Does the organization or agency have clearly 

defined standards that address the specific needs of public safety diving (benchmarks for 

instruction, equipment, safety, documentation, skill maintenance and conduct can help teams to 

judge the quality of a program).

• Public safety diving specific curriculum that provides clearly defined objectives for each 

classroom, pool and open water training session that is developed through experience in public 

safety diving and observations and tailored to help solve dive challenges in their respective 

water environments.

• Operational experience in their instructional staff. The instructor should be an experienced 

member of a public safety dive team and experienced in the specific discipline that the 

department has identified. In the public safety dive industry, experience must breed caution not 

complacency [Orusa 2017].
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• The instructional staff should be able to provide a list of references. The agency should be able 

to provide other types of dive team training that they have provided. This established the 

credibility of the agency as well as the instructors that will be training your divers.

• Departments should consider if the training agency will be a resource for dive team SOPs and 

templates from other safe and effective dive teams. The training agency or organization can 

also have in place programs that identify requirements for basic SCUBA rescue/recovery teams 

or highly technical SCUBA rescue/recovery teams.

• The agency should have a certification program that ensures continuing education and skills 

maintenance. Chief Orusa notes: “being a good public safety diver two years ago doesn’t mean 

you will function safely and effectively today. Skill levels, if not reinforced, deteriorate over 

time and public safety divers don’t have the luxury to be 99% efficient underwater. They have 

to be 100% effective and mandatory skills checks for efficiency are the answer.”

• Departments should do their homework and research successful teams throughout the country 

and use them as a resource to identify advanced training agencies [Orusa 2017].

Recommendation #9: Fire department dive teams should ensure vessels are properly equipped when 

used for supporting dive operations or consider other options.

Discussion: Although there is no evidence that the following recommendation would have prevented 

this fatality, it is being provided as a reminder of best safety practice for the fire service. Vessels/boats 

used to support diving operations should be staffed and equipped to support public safety dive 

operations. For example, vessels/boats should include emergency resuscitation gear (ideally ALS gear 

and ALS personnel if the dive site is a distance away from land units), communications equipment, 

anchoring gear, prop guards on propulsion motors, and adequate deck space for all divers and 

equipment. Protection from the sun and the elements, sanitary facilities, and rehydration liquids are 

also important. 

Additionally, vessels used for dive platforms should be capable of remaining stationary and close to 

the dive site without causing danger to the divers. This keeps the distance from the dive boat to the 

descent buoy at a minimum and causes less fatigue to the divers from extended surface swims (see 

cover photo in the Executive Summary). A drifting dive or support boat with unguarded propellers that 

are constantly engaging and maneuvering to stay close to the dive buoy is a danger to divers. The 

safest dive vessel is an anchored dive boat with the motors shut down. There may be occasions where 

currents may necessitate a dive boat that is drifting at the same rate as the divers and there is no 

descent buoy. In these instances, the dive boats should have prop guards or water jet propulsion and 

consider shutting engine(s) down while placing divers in the water or recovering divers (see Photos 9

and 10 for examples of prop guards and Photo 11 for an example of a jet drive on an outboard engine).

An unanchored dive boat can be more difficult to maintain a close distance to the descent buoy, and a 

drifting dive boat may force divers to swim greater distances than necessary on the surface before 
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submerging (see Photo 12). This surface swim can be exhausting when fighting any wind or current. 

Additionally, with the surface communication line tethered to the divers from the unanchored dive 

boat, the communication umbilical system could be put under a strain by wind or current effects on the 

surface vessel. This could cause a separation of the communications line or even an unneeded 

distraction or complication to the public safety diver.

The same challenging conditions (locating the dive boat and swimming over to it; the dive boat 

motoring into the dive area with unguarded props) may also be present after the returning divers follow 

the ascent line up. Another advantage of having the dive boat anchored is the ability to mark the safety 

stop on the descent/ascent line with emergency cylinders/regulators at the safety stop. If a diver has 

gotten close to their emergency reserve air, there should be a breathable air source at the safety stop.

Boat support personnel should be familiar with dive operations to assist dive crews when needed. 

However, only divers should perform a pre-dive check of another diver’s equipment. A non-diver can 

easily miss important equipment checks. Only divers should buddy check another diver.

Photo 9. An example of a propeller guard for a small and medium sized outboard engine. There 

are also jet drive propulsion options for outboard engines (Photo by NIOSH.)
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Photo 10. Example of propeller guards on larger twin outboards (Photo courtesy of Bing 

Images/Holtonmarine.)
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Photo 11.Example of a large horsepower outboard jet drive engine (Photo courtesy of Bing 

images.)
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Photo 12. Aerial photo of lake with the location of the dive site marked. Dive sites can often be in 

open areas and remote from the Command Post and boat launch site. 

(Courtesy of Google Earth.)
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Recommendation #10: Standards-setting organizations should consider adopting a national 

consensus standard for public safety SCUBA divers that includes minimum initial and refresher 

training and a SCUBA equipment standard that includes minimum respirator performance.

Discussion: Although there is no evidence that the following recommendation would have prevented 

this fatality, it is being provided as a reminder of best safety practice for the fire service. Currently, 

there is no national consensus standard for public safety SCUBA divers. A national standard could 

include minimum training requirements as well as quarterly training and annual skills review and 

refresher training. Public safety SCUBA diving is different than other public safety disciplines in that 

the training environment is just as dangerous as the work environment. Firefighter/divers have died 

during training and the level of training varies throughout the country in different jurisdictions. 

Proper training, equipment and continued administrative support (for program funding ) are equally 

important and would benefit from a national standard. For example, a high-quality commercial grade

heads-up display and a full-facepiece, dry suit and communications equipment should be a minimum 

requirement for public safety SCUBA divers. Although the equipment can be more expensive than 

recreational equipment, the benefits far outweigh the cost savings for departments that have to use 

recreational equipment (see Photo 13).

Recommendation #11: Fire departments should consider implementing a body recovery procedure 

to reduce the time dive teams spend at depth recovering a victim.

Discussion: Fire department should consider implementing a body recovery procedure that limits the 

hazards to divers. This procedure involves raising the victim up to a shallow depth while keeping 

divers clear of entanglement hazards before deploying the body recovery packaging system. The 

victim can then be packaged closer to the surface (an example could be bringing the body up to the 

recovery boat, but just below the surface) as a safer practice for divers and the assisting boat crew 

members verses carrying a body retrieval bag (see Photo 14) to the bottom and packaging on the 

bottom. There may be advantages to the recovery divers by not introducing additional entanglement 

hazards at greater depth with limited visibility and other hazards. 

Having a procedure for body recovery in place that minimizes diver exposure and is a good safety 

practice As Chief Orusa notes: “Very often it is a unique chain of events that leads to a water rescue 

line of duty death. Breaking one link in that chain sometimes can prevent a tragedy from occurring.” 

Minimizing diver exposure to the hazards should be a goal for all dive teams and having a procedure 

for body recovery closer to the surface reduces a number of hazards.
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Photo 13. Victim’s SCUBA gear and recovery bag he was carrying. 

(Photo by NIOSH.)
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Photo 14. Example photo of the same type recovery bag expanded that Diver 4 was carrying 

clipped to his BCD. 

(NIOSH Photo.)

Since this incident, the department was able to move forward by researching and obtaining a Remote 

Operations Vehicle (ROV) for underwater recovery operations. The ROV was first of its kind in the 

department’s region. It was equipped with sonar and video capabilities and can work up to a depth of 

1000 feet. Since acquiring this equipment, the department has assisted many agencies in and out of the 

state in making recoveries. The ROV along with other surface water technology equipment obtained 

by the department drastically reduces the need for members to have to get into the water. Should 

divers be required, the ROV can work in conjunction with the divers to enhance their safety as well as 

make recoveries, reducing the need for divers to take those unnecessary risks.
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References

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departments. Quincy, MA: National Fire Protection Association.

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command safety. Quincy, MA: National Fire Protection Association. 

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incidents. Quincy, MA: National Fire Protection Association.

NFPA [2015]. NFPA 1521 Standard for fire department safety officer professional qualifications. 

Quincy, MA: National Fire Protection Association.

NFPA [2017]. NFPA 1006 Standard for technical rescuer professional qualifications. Quincy, MA: 

National Fire Protection Association.

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Quincy, MA: National Fire Protection Association.

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Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health,

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NIOSH [2010]. Career lieutenant dies following floor collapse into basement fire and a career 

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Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and 

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Investigator Information

This incident was investigated by Stephen T. Miles, Investigator/Safety and Occupational Health 

Specialist, Matt Bowyer, Investigator/General Engineer and Murrey Loflin, Investigator/Safety and 

Occupational Health Specialist with the NIOSH Firefighter Fatality Investigation and Prevention 

Program, Surveillance and Field Investigations Branch, Division of Safety Research, located in 

Morgantown, West Virginia. A technical review was also provided by the National Fire Protection 

Association, Public Fire Protection Division.

An expert technical review was provided by Chief Steven Orusa, Fire Chief for the Fishers Fire and 

Emergency Services, Fishers, Indiana. Chief Orusa is also the author of Dive Rescue Specialist, 

Operational Training for Public Safety Divers. He has served over 33 years in law enforcement and 

fire service positions. He is past director of the International Association of Dive Rescue Specialists 

Response Team and has served on public safety and military dive operations worldwide. A second 

expert technical review was provided by Deputy Chief Ron Dorneker, Deputy District Chief, Marine & 

Dive Operations with the Chicago Fire Department. Chief Dorneker is certified as a Public Safety 

Diving Instructor by Emergency Response Diving International (ERDI). He is also certified by 

SCUBA Diving International (SDI), and Professional Association of Diving instructors (PADI).

An expert dive computer evaluation was performed for NIOSH investigators by Craig Jenni with Dive 

& Marine Consultants International, Inc., Boca Raton, Florida. An examination of dive equipment and

analysis of dive computer information were also performed by Air Hogs SCUBA for the local sheriff’s 

department and made available to NIOSH investigators courtesy of the local sheriff’s department. 

Information from both of these evaluations were incorporated into this report. Additional assistance 

was received from Pelton Designs, a NIOSH graphics contractor, to produce an illustration from a 

photo. Additional assistance was received from Mr. Blades Robinson and Dr. Richard Sadler with 

Dive Rescue International.

This report was authored by Stephen T. Miles. 

Additional Information

Additional information on Public Safety Diver Stress and helping with mental preparedness is 

available in the FireRescue magazine November, 2017 article, Staying Sharp Underwater by Lt. Scott 

Huff with the Indianapolis Fire Department Dive Team.

Disclaimer

Mention of any company or product does not constitute endorsement by the National Institute for

Occupational Safety and Health (NIOSH). In addition, citations to websites external to NIOSH do not 

constitute NIOSH endorsement of the sponsoring organizations or their programs or products. 
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Furthermore, NIOSH is not responsible for the content of these websites. All web addresses referenced 

in this document were accessible as of the publication date.