Fall-09

Fall Edition Diving Safety Lines 2009
1
Diving Safety Lines
Fall Edition 2009
Diving Safety Lines is a semi-annual release by the Afloat Safety Directorate of the Naval Safety Center. The information contained herein is a summary of
research from selected reports of diving hazards to assist you in your mishap prevention program. Diving Safety Lines is intended to give advance coverage of
safety-related information while reducing individual reading time. This bulletin does not, in itself, constitute authority but will cite authoritative references when
available. It is recommended that this bulletin be made available to all hands.
From the Diving Safety Division Head
CWO3 Jeff Annon
Email: Jeff.Annon@navy.mil
Welcome to the fall addition of the Diving Safety Lines. We hope you had a fun and safe summer with your family and friends.
Here at the Naval Safety Center, we strive to put out up-to-date information on important topics related to diving, and safety in
general. Please read through this entire edition; and if you have any feedback on safety practices, we look forward to reading your
input. On that note, if you have a safe practice at your command you believe may help operations in the field or at other
commands, please write an article and e-mail it to safe-divesalvage@navy.mil.
I am sad to report that the SPECWAR community suffered a diving fatality in May 2009. The Naval Safety Center provided two
advisors to assist in the grueling task of interviewing personnel and finding facts that may safe a life in the future. Our deepest
sympathy goes out to his friends and family.
Our job as divers is inherently dangerous and should never be taken lightly. We must stay vigilant in our safety practices and
procedures. The staff at the Naval Safety Center has been working hard to provide you with the most up-to-date safety
information. Please visit our web page to view the most current diving instructions and notices.
Dive Jump Reporting System (DJRS) Status - We have received many phone calls and e-mails about the DJRS and problems
encountered when using the system. We greatly appreciate the feedback and ask that you continue to provide us with any
information concerning issues with the system and its functionality. Currently, the system is operating under reduced capability
due to several critical problems found within the system. We are diligently working to resolve these issues and appreciate your
patience in this matter.
V/R,
CWO3 Jeff Annon
INSIDE THIS ISSUE
2-3MDV’s Corner
4Maintenance
5Top 10 Discrepancies
6Overbottoms
7Cold Weather
8PHAs
9Spotlight
10FY09 Navy Dives
11Motorvehicle
Statistics
Diving Safety Lines
Naval Safety Center
375 A Street
Norfolk, VA 23511-4399
Phone: (757) 444-3520 Ext. 7387, DSN 564-3520 Ext.
7387
Fax: (757) 444-8636, DSN 564-8636
E-mail: SAFE-DIVESALVAGE@NAVY.MIL
Head, Diving & Salvage – CWO3 Jeff Annon
Editor- CWO2 Hordinski

2
Master Diver’s Corner
NDCM (MDV/DSW/EXW/SW) Kent “Rock” Robarts
Email: Kent.Robarts@navy.mil
My deep sea brothers and sisters,
During my tour at the Naval Safety Center (NSC), I have experienced the high and low of my job. The high is conducting diving
safety surveys on commands throughout the fleet and having the opportunity to interact with the finest Sailors in the United States
Navy: Deep Sea Divers.
The low point has been being part of a safety investigation board (SIB) for a Class “A” mishap involving a diving fatality.
Senseless loss of life in any situation is devastating; but hopefully “lessons learned” from the fatality can help prevent mishaps.
The following is an overview and factors that contributed to the death..
Mishap victim (MV) was a SEAL delivery vehicle (SDV) navigator, conducting SDV combatant swimmer ship attack training
dive using a MK-16 MOD 0 UBA with a MK 24 full face mask (FFM). While partially outside the SDV, presumably checking
the SDV's stability and location under the target vessel, MV's FFM was removed for an unknown reason, either involuntarily or
voluntarily, and he aspirated an unknown quantity of seawater. MV got back in the SDV and shifted to his spare regulator
attached to SDV auxiliary life support system (ALSS) and signaled to the pilot for an emergency ascent.
Upon reaching the surface, the MV was unresponsive with the regulator out of his mouth. SDV pilot administered rescue
breathing while he and two mission specialist divers (SEALs) attempted to position him on the SDV strongback. The three
members signaled the diving supervisor and chase boats with flares, and once the diving supervisor boat (DSB) arrived on scene,
transferred MV to the DSB where the diving medical technician (DMT) rendered medical care during the transit to the pier.
Upon arrival there, MV was turned over to regional emergency medical technicians (EMT) who continued rescue efforts
administering advanced cardiac life support (ACLS), but achieved no response. MV was concurrently placed in the
recompression chamber on a Treatment Table 6.
MV remained unresponsive and was pronounced dead at 0217 the next day. The autopsy revealed the cause of death was
drowning. MV involuntarily or voluntarily removed his FFM and aspirated seawater. Further specificity is not possible since
there were no witnesses to the initiation of the casualty.
Due to privileged information and space constraints, I gave a condensed version of the casualty. Now I will give some of the
lessons learned:
1. Determining proper course of medical treatment: Recompression vs. ACLS. MV victim surfaced 7 minutes after initial
inspiration of water and had no pulse, no respiration, and was cyanotic. SDV pilot and two mission specialists (MS) placed the
MV on the SDV strongback and performed rescue breathing until the diving supervisor boat (DSB) arrived on the scene, six
minutes after the SDV surfaced. Eleven minutes after surfacing, the DSB got underway for the dive locker chamber. The MV
still has no pulse and no respiration. The DMT and crew administered oxygen and chest compressions during the 32 minute
transit. Once at the chamber, there was a disagreement between civilian emergency medical technicians (EMT) and the chamber
team whether to use ACLS or recompress the MV. He still had no pulse and no respiration. Approximately, 66 minutes after the
initial aspiration of water, ACLS began.
As divers we are trained from day one, when a diver surfaces with any sort of catastrophic injury, we immediately get underway
for the chamber. This situation was one of the rare diving casualties that EMT personnel should have been contacted and met at a
pre-determined location to perform ACLS, vice immediately heading to the chamber. This may sound obvious to some, but until
you are making the actual life or death decision, I wouldn’t be quick to judge. As a diving community, we need to take a closer
look at diving supervisor training-“Go to the chamber,” is not always the correct answer to a diving casualty. Even in the U.S.
Navy Diving Manual, it discusses the use of a defibrillator/ACLS as if you are already at the chamber. Today, we operate in an
expeditionary environment more than we ever have and that greatly decreases the immediate availability of a chamber. We need
to ensure that our training continues to evolve with our operating environment.

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2. Ensure diving supervisor drills reflect operating environment. Once the SDV surfaced, the pilot realized the MV was
unresponsive and the regulator was out of his mouth. The pilot followed standard operating procedures (SOP) and attempted to put
the MV on the SDV strongback. Unable to get the MV onto the strongback, the pilot inflated the MV’s combat swimmer assault
vest (CSRV) and ditched some of his weight. He was still unable to position the MV fully on the strongback and signaled the MSs
for assistance. They assisted the pilot in placing the MV on the strongback. The pilot continued to attempt rescue breathing, but
the pilot and MSs had a difficult time keeping the MV’s head above water. Approximately, six minutes after surfacing, the DSB
arrived and the standby diver entered the water to assist getting the MV into the DSB. Even with four personnel in the water
assisting topside personnel, they couldn’t get the MV up and over. The pilot got forced underwater as the DSB moved away from
the SDV. The pilot realized that he and the MV were connected to the SDV auxiliary life support system (ALSS) via their MK-16
and dry suit. The MV was disconnected from the ALSS. This greatly increased the MV’s buoyancy and they were able to get him
up and over.
SDVT personnel were not adequately trained in removing a disabled diver from an SDV, particularly when tethered to the
SDV’s ALSS in cumbersome dive gear (MK16, CSAV and dry suit). Although, SDVT had conducted diving supervisor drills
involving a disabled diver, the drills never involved decoupling a stricken diver from the SDV. Even the approved SOPs never
mention decoupling the diver. Every attempt must be made to ensure diving supervisor drills are realistic and, when possible,
cover the worst case operational situation. Reality sets in when a when a drill is run with an unresponsive diver vice “table
talking” the situation. Try putting a 200-pound mannequin, fully kitted out, on to stretcher and then haul it up and over a pier that
is 20 feet off the water; it is an eye opener.
3. Train like you operate. Shortly after surfacing, the pilot lit a flare that did not activate. MS #2 lit his flare and waved it over
his head to alert the support boats. Over the next 5 minutes, he lit three flares in succession, providing nearly 5 minutes of burn
time. The SDV surfaced on the starboard side of the target vessel and the DSB was on the port side and couldn’t see the flares.
The chase boat was 500 feet off the starboard side of the stern. From their vantage point, they assumed the DSB could see the red
flares. Chase boat personnel thought the flares were part of the training. Finally, the DSB contacted the chase boat and asked if
they can see the SDV. The chase boat replied that the SDV was on the starboard side lighting off flares.
The reaction of the chase boat personnel speaks for itself. Always react to any situation as if it were in an operational
environment. It may help prevent a catastrophe such as this and also identify deficiencies in training procedures.
These are only three of many lessons learn from this mishap. Unfortunately, the command in charge of the investigation released
the safety investigation report message in a format that does not allow the Naval Safety Center (NSC) to forward it to all diving
commands. We’re trying to get permission to scrub the message and release it. Please feel free to ask me to brief your command
while I am out conducting diving safety surveys.
NDCM (MDV/DSW/EXW/SW) Kent “Rock” Robarts
Naval Safety Center Master Diver

4
Contracting Out Your Maintenance
CWO2 Jim Horinski
E-mail: safe-divesalvage@navy.mil
This will be my last article as a member of the Naval Safety Center team. I have thoroughly enjoyed the time I have spent
here serving the fleet and interacting with more than 90 percent of the diving commands in the Navy and Marine Corps. I am
confident that we as divers are the best in the world at what we do and that we will continue to exemplify the hard working “can
do” attitude set forth by all the denizens of the deep that have come before us. Hoo-Yah!
Dive locker work loads continue to grow as our mission becomes more diversified. To better utilize our time, much of
our traditional in-house maintenance is now being accomplished by outside sources. During several of our surveys, we have
discovered some significant errors or misconceptions in the way in which dive lockers handle this particular situation. Therefore, I
have included some tips to ensure that when you contract out your maintenance, you are covering your bases;
1. Write your maintenance contract to reflect the current PMS revision, not the manufacturer’s manual (re-write your
contract each time maintenance changes in an FR).
2. Do not be generic! Ensure the company you are working with has a clear understanding of what your requirements are
for that equipment.
3. Provide the contractor a copy of the maintenance requirement card when applicable, needed, or allowable.
4. Finally keep the equipment on your planned maintenance schedule (PMS). Yes, we have had commands remove
equipment from their boards because personnel believed if a contractor was accomplishing the maintenance, they did not
need to track that piece of equipment anymore in SKED.
CWO2 Jim Hordinski

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Top Ten Discrepancies
2009 Top 10
Safety Center Survey
Discrepancies
1. Have applicable filter housings been tested and tagged as required?
2. Do the weight-handling equipment/points have test-data plates, and are the tests
current?
3. Is chamber log available on station with required minimum data, reviewed and signed by
Diving Officer and Master Diver?
4. Have all applicable moisture separators been inspected and tagged MIL-F-220 annually,
all others at 18M intervals?
5. Is the command using the Dive/Jump Reporting System (DJRS) and submitting
information to the NSC?
6. Is a primary medical kit near the chamber and does it contain the items listed in the
U.S. Navy Diving Manual?
7. Are personnel qualified to work on oxygen systems and do they re-qualify every 3 years?
8. Does the command maintain a smooth diving log and is it retained for 3 years?
9. Are compressor efficiency test being accomplished?
10. Does the diver’s training plan include emergency response drills?

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Over-bottoms
NDCS (DSW/EXW) Jeff J Poulin
Email: Jeffrey.J.Poulin@navy.mil
Here at the Naval Safety Center, we have a primary goal of preventing mishaps. Every month, we survey various commands
providing administrative assessments while preparing dive lockers for their bi-annual diving operational readiness assessment
(DORA). We’re also looking for trends in maintenance practices and operations that could lead to mishaps.
To reduce a burdensome work load, several years ago the 3M system was revamped and many PMS checks were eliminated or
the periodicity increased. This is the case with MIP 5921/019 A-2, “Verify Over-bottom Pressure of First Stage Regulator.”
Setting the over-bottom pressure of the first-stage regulator was changed from a prior to use R-check to an annual. I assume this
change was made because it was believed that all divers innately check their over-bottom pressure before every diving day. That
was the case until the over-bottom check became an A-2, and from our findings we believe this could lead to a mishap.
During three consecutive Naval Safety Center surveys, we checked the over-bottom pressure of 28 first-stage regulators.
You’ll be surprised what we found.
10 regulators Set at a minimum of 135 psig or in
accordance with manufacturer’s
recommendation
Passed
Inspection
7 regulators Set pressure high. Highest set
pressure found was 171 psig
Failed
Inspection
11 regulators Set pressure low. Lowest pressure
found was 90 psig
Failed
Inspection
Although this is a small percentage of regulators tested as compared to the thousands of regulators used throughout the
Department of Defense (DOD) diving, we felt it significant enough to discuss at our bi-annual meeting with NAVSEA. At the
meeting, SUPDIVE, CDR Egan, agreed to take action and either change the A-2 to an A-2R or add an R-check, or add a scuba
pre-dive checklist to the U.S. Navy Diving Manual. Either way would require the over-bottom pressure to be set before use. The
Naval Safety Center highly recommends that you don’t wait for the change and start checking/setting your over bottom pressure
daily. If your command has several detachments or even issues gear out to detachments, ensure they are issued a calibrated over-
bottom gauge when diving scuba.
Know your gear and dive safe!
NDCS Jeff Poulin

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COLD WEATHER
HMC (DSW/EXW/FMF) Ron Nading
E-mail: ron.nading@navy.mil
With the fall and winter seasons coming up, I want to get everyone back in the mind set of some basic cold-weather
injuries. Every year, we hear about people dying of hypothermia and exposure when they could have been saved if they had
recognized the signs and symptoms. However, there are cold weather injuries that your dive tenders may be exposed to right on
the dive. It is the dive supervisor's responsibility to know and recognize these symptoms.
Some easily recognizable signs and symptoms include previous cold weather injuries, shivering, discoloration (cyanosis) of the
skin, or swelling of affected area. Possible psychosocial factors are more often associated with passive individuals or the less
physically active Sailors. Others may have adverse reactions to external stresses, such as cold, which may impede their taking
preventive measures. Still others may perspire excessively, thereby decreasing the insulating qualities of their clothing.
The type and extent of tissue injury depends on environmental temperature, the presence of wind chill, duration of exposure,
type of clothing and protection, nutrition, hydration, and general well-being of the Sailor. The different types you may see as a
dive supervisor include chilblains, immersion syndrome, frostbite, dehydration, and hypothermia. Unprotected exposure to the
cold may threaten or make the injuries worse.
The way we treat these injuries are by passive re-warming the body only if we are sure there is no way the body part will
refreeze. Do not massage with snow. Tissue damage may occur. Do not expose to fire or stove - again because there maybe nerve
damage and patient could suffer burns. Do not soak a cold-weather injury in cold water. Avoid walking on injured feet and if you
suspect a cold weather injury. Contact medical ASAP.
Stay warm,
HMC Nading

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From The Medical Department
Physical Health Assessments
HMC (DSW/EXW/FMF) Ron Nading
E-mail: ron.nading@navy.mil
I have noticed out in the fleet that many DMTs are missing the change regarding the PHA. I want to
make sure everyone is aware of Change 126 to the Manual of the Medical Department. Section 15-102 5(b)
States, “All members on diving duty will have annual periodic health assessment (PHA) to maintain diving
duty. PHA will include a skin cancer screening.” So, if a diver does not have a current PHA or skin cancer
screening, he or she is NPQ. Please take note and make the required changes for your upcoming inspections.
Thank you,
HMC Nading,

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Diver In The Spotlight
ND2 (DSW) Matthew J McGrath
Hailing from the New England area, ND2 (DSW) McGrath graduated from East Longmeadow High
School, subsequently earning a BA in Business Administration from New England College. After enlisting
in the U.S. Navy on April 2, 2007, he attended basic training and dive school. Upon completion of initial
training, Petty Officer McGrath was assigned to Naval Submarine Support Facility New London in
December of 2007. From the very first day, he’s been a hard charging second class diver and has quickly
become a subject matter expert in under water ship’s husbandry. Petty Officer McGrath’s on-site problem
solving skills played a key role in the development of several maintenance procedures for 774-class
submarines. He’s repeatedly been recognized for his outstanding technical abilities and attention to detail –
to date receiving three COMNAVSUBGRP2 flag letters of commendation, as well as, a Navy and Marine
Corps Achievement Medal his performance as Lead Diver during replacement of the secondary propulsion motor on the USS
Albuquerque (SSN706). His tour at NSSF has also given him the opportunity to visit Spain, Scotland, and Hawaii. Along with
his noteworthy amount of bottom time, ND2 McGrath has also completed eight credits towards an MBA.
The Naval Safety Center would like to congratulate ND2 McGrath
for conducting 56 approved dives from January 2009 to June 2009 and
accumulating a total bottom time of:
4 Days 2 hours and 49 minutes !
This is a new section in the Diving Safety Lines. Each issue, we would like to
acknowledge the Navy diver with the most bottom time reported in the Dive Jump
Reporting System (DJRS) for the last six months. This is not to discount our
civilian counterparts who are accumulating an exceptional amount of bottom time
themselves.
HOO-YAH! Dive Safe

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FY09 ReportNaval Safety Center
Web Enabled Safety System
10/01/2008 to 09/30/2009Rpt No:DV-300 Run Date:
Page 1 of 1
18-Nov-2009
Navy Dives
Total Number of Dives: 85,635
N0610A NAVDIVESALVTRACEN PANAMA CITY, FL14,308
N49746 NAVAL SPECIAL WARFARE BASIC TRNG8,841
N4523A PUGET SOUND NAVAL SHIPYARD3,753
N62640 NAVSCOLEOD EGLIN AFB FL2,595
N42838 MDSU TWO2,505
N41150 NORFOLK NAVAL SHIPYARD AND IMF2,368
N47898 NAVAL SPECIAL WARFARE DEVELOPMENT2,310
N08973 SDV TEAM ONE2,141
N42270 MDSU ONE2,113
N55236 SOUTHWEST RMC SAN DIEGO, CA2,107
41,899 SCUBA
10,514 MK-20 (Surf)
9,942 MK-25 Mod 2
8,232 MK-21 Mod 1
3,643 MK-16 Mod 1
Top Ten Diving Commands:
Top Five UBA's

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Motor Vehicle Statistics
Motor Vehicle Statistics (FY09)
Navy/Marine Military
Motor Vehicle Fatality Rates
Total PMV Fatalities Total PMV Fatality Rate
Navy 34 9.77
Marine Corps 43 20.33
Navy/Marine 77 13.76
4-wheel Fatalities 2-wheel Fatalities Pedestrian Fatalities
Navy 18 13 3
Marine Corps 26 14 3
Navy/Marine 44 27 6
On-Duty MV Fatalities On-Duty MV Fatality Rate
Navy 0 0.00
Marine Corps 5 2.36
Navy/Marine 5 0.86
Per 100,000 military personnel per year.

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