DAN America and DAN Europe Datad35gjurzz1vdcl.cloudfront.net/ftw-files/Day1/Evidence/2.pdf ·...

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Common Factors in Diving Common Factors in Diving Fatalities Fatalities DAN America and DAN Europe Data Petar J. Denoble, MD., D.Sc. Alessandro Marroni, MD. D.Sc Richard D. Vann, Ph.D. Fatality Workshop, Durham April 8-10, 2010 1

Transcript of DAN America and DAN Europe Datad35gjurzz1vdcl.cloudfront.net/ftw-files/Day1/Evidence/2.pdf ·...

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Common Factors in DivingCommon Factors in Diving FatalitiesFatalities

DAN America and DAN Europe Data

Petar J. Denoble, MD., D.Sc.Alessandro Marroni, MD. D.Sc

Richard D. Vann, Ph.D.

Fatality Workshop, Durham April 8-10, 2010

1

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SourcesSources

• DAN Insured Members Claims 2000‐2006DAN Insured Members Claims 2000 2006– 187 dive‐related deaths

• EDAN Insured Members Claims 1996 2008• EDAN Insured Members Claims 1996‐2008– 144 dive‐related deaths

• DAN Fatality & Injury Database 1992‐2003: – Most common causes of deaths; 947 cases in OC diving

– Case control study: 165 fatal and 135 non‐fatal AGE case

– Diabetes mellitus:  37 cases  vs. 938 non DM cases

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Annual numbers of diving fatalitiesAnnual numbers of diving fatalities

160 USA & C d

120

140

160

ths

USA & CanadaBSACAustraliaEDAN, insured

80

100

er o

f Dea

t

20

40

60

Num

be

0

20

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2

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Annual Number of Diving FatalitiesAnnual Number of Diving Fatalities

160

120

140

60

USA & 

80

100

120

of D

eath

s

40

60

80

Num

ber

DAN

0

20

40 DAN 

4

01970 1975 1980 1985 1990 1995 2000 2005

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Study #2: Annual Fatality Rates of Insured DAN Members

• DAN diving accident insurance data, 2000‐2006

• 1,141,367 insured member years

• 187 diving related deaths• 187 diving related deaths

• Sex, age, cause of death

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Individual Risk Per Annum (IRPA)Individual Risk Per Annum (IRPA)

• IRPA = Probability (individual is killed during oneIRPA   Probability (individual is killed during one year of exposure)

• As safety performance measure:

Observed number of fatalities

IRPA = ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Total number of person‐years exposed

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DAN Membership IRPADAN Membership IRPA

187

63 * 0 6IRPA = ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ = 163 * 10‐6

1,141,367

1 in 6000 or 0 016%1 in 6000  or  0.016%

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Individual Risk Per Annum (IRPA)Individual Risk Per Annum (IRPA)

Industry sector Annual risk Annual risk

Recreational diving* 1 in 6,000 163 x 10‐6

Jogging 1 in 7,700 130 x 10‐6

6Mining and quarrying 1 in 9,200 109 x 10‐6

Construction 1 in 17,000 59 x 10‐6

Agriculture, hunting 1 in 17,200 58 x 10‐6Agriculture, hunting 1 in 17,200 58 x 10

Fatalities to self‐employed 1 in 50,000 20 x 10‐6

Manufacturing industry 1 in 77,000 13 x 10‐6

Fatalities to employees 1 in 125,000 8 x 10‐6

Service industry 1 in 333,000 3 x 10‐6

Data from “Reducing risks, protecting people” (HSE 2001)* DAN membership data

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BSAC & DAN Fatality Rates

50

60BSAC Fatality RateDAN Fatality Rate

y = -0.3456x + 704.87R2 = 0.1776 (p = 0.0016)40

50

Mem

bers

BSAC Fatality Rate Trendline

30

/ 100

,000

M

10

20

Dea

ths

0

10

9

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Rate (95%CI)

Scuba injury death rates 

Group Denominator Time periodRate (95%CI)

per 100,000 divers

per 100,000 dives

Cave Divers GB Measured 1957 1979 138Cave Divers, GB Measured 1957-1979 138Cave Divers, GB Measured 1980-2006 24.6USA Estimated 1986 3.4 to 4.2USA Estimated 1989 16.7 0.8 to 1.6Orkney, Scotland Measured 1999-2000 4Australia Estimated 1989 34 (1 in 3000) 1.7 to 3.4Victoria, Australia Tank fill count 1992-1996 2.5

SAustralia

Survey2000-2006 3.57 (1 in 28,000) 0.57

BC, Canada Tank fill count 1999-2000 2.04Japan Tank fill count (8 8-33 8) 1 0 to 2 4Japan (8.8 33.8) 1.0 to 2.4

BSAC Measured

2000-200614.4

(10.5-19.7)Measured 16.4 (1 in 6000)

DAN Insured 2000-2006 0.7*(14.2-18.9)

*estimated based on 25 dives/diver/year

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Acceptable RiskAcceptable Risk

Activities with a fatality risk greater than 1 ∙10−3Activities with a fatality risk greater than 1  10deaths/year to the general public are generally not acceptablenot acceptable.– Cars   3 ∙ 10−3 deaths/person‐year

– Falls   1 ∙ 10−4 deaths/person‐year

Scuba diving 1.6*10-4/p y

– Fires   4 ∙ 10−5 deaths/person‐year

– Drowning   4 ∙ 10−5 deaths/person‐year

– Firearms   1 ∙ 10−5 deaths/person‐year

– Poisoning   1 ∙ 10−5 deaths/person‐year

– Lightning   8 ∙ 10−7 deaths/person‐year

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Criteria for Acceptable Risk in the h l dNetherlands

Diving 1.6x10-4

J.K. Vrijlinga, P.H.A.J.M. van Geldera & S.J. OuwerkerkaDelft University of Technology

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ALARPALARPALARPALARP

•• As Low As Reasonable Practicable (ALRAP)As Low As Reasonable Practicable (ALRAP)As Low As Reasonable Practicable (ALRAP)As Low As Reasonable Practicable (ALRAP)

1.0E-01 1/10

1.0E-03

sk (I

R)

Unacceptable region

The ALARPTolerable only if risk reduction Is impracticable or cost is grossly disproportionate to

1/1,0001/6,000

1/30 000

1 0E 07

1.0E-05

Indi

vidu

al r

is

Broadly acceptable region

grossly disproportionate tothe improvement gained 1/100,000

1/10 000 000

1/30,000

1.0E-09

1.0E-07Negligible risk

1/10,000,000

1/1,000,000,000

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• 947 Open-Circuit Deaths from 1992-2003• 70% family interviews y

• 60% autopsy findings

• 52% witness reports p

• <52% investigative reports  • 28% equipment testing28% equipment testing

• 22% breathing gas analysis

14

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Cause of Death (DAN America n=814)(DAN America, n=814)

97% 99% 100%100%600

84%

97% 99% 100%

80%

400

500

70%

40%

60%

300

400

umul

ativ

e

requ

ency

20%

40%

100

200

CuFr

0%0

100

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Cause of Death (EDAN n=112)(EDAN, n=112)

100%95%100 100%

100%99%

83%80

90

80%

70%

50

60

70

uenc

y 60%

ulat

ive

30

40

50

Freq

40% Cum

0

10

20

0%

20%

0Drowning Cardiac AGE Trauma Marine life

0%

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Root Cause Analysis of Diving Deaths

TriggerFirst identified cause in the

chain

Example 1Out of Air

Example 2Entangled

chain

Harmful Agent/ActionI di t f di bli EmergencyImmediate cause of disabling

injuryEmergency

Ascent Out of Air

Disabling InjuryIncapacitates or kills diver Air

Embolism Asypxhia

Cause of Death (COD)

Embolism

Cause of Death (COD)Final cause of death as

specified by CoronerDrowned Drowned

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Root Causes

Causes Frequency

Role

Disabling TriggerAgent Trigger

Complication of a pre-existing disease 389 169 24

Buoyancy 293 43 18

Emergency ascent 289 187

Water movements 217 31

Gas supply problem 199 62 145

Equipment problem 109 6 56

Entrapment/Entanglement 75 61 68Entrapment/Entanglement 75 61 68

Injury 40 38 26

Wrong gas 14 8

Lost/separated 13 13Lost/separated 13 13

Total N/A 574 381

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Triggers (n=346)

92% 98% 100%100%150

60%

76%85%

92%

60%

80%

100

ulat

ive

uenc

y

41%

60%

20%

40%50 C

umu

Freq

u

0%

20%

0

21

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Disabling Agents (n=332)Disabling Agents (n=332)

94% 98% 100%100%200

60%

80%

94% 98%

60%

80%150

tive

ncy

60%

40%

50

100

Cum

ulat

Freq

uen

0%

20%

0

50

22

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Disabling Injuries (n=590)

93% 96% 98% 100%100%200

yjury

62%

88% 93%

60%

80%150

blin

g In

jury

sabl

ing

Inj

33%

62%

40%

50

100

lativ

e D

isab

ency

of D

is

33%

0%

20%

0

50

Cum

ul

Freq

u

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Triggers by Disabling Injury

Disabling Injuries

Trigger Asphyxia AGE CardiacTrigger Asphyxia AGE Cardiac

Insufficient gas 32% 63%

Entrapment 40% 9% REntrapment 40% 9%

Equipment trouble 15% 17%

Rough water 11%

Rarely Rough water 11% identiified

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Disabling Agent by Disabling Injury

Primary Disabling Injuries

Disabling Agent Asphyxia AGE CardiacDisabling Agent Asphyxia AGE Cardiac

Emergency ascent  13% 97%

Insufficient gas 62% RInsufficient gas 62%

Buoyancy trouble 17%

Rough water 11%

Rarely Rough water 11% identiffied

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Odds Ratios for Root Causes & I t i i F t& Intrinsic Factors

Asphyxia AGE Cardiacp yEntrapment ≥30Emergency ascent ≥30Emergency ascent ≥30Cardiovascular Disease ≥30Insufficient gas 16Insufficient gas 16Age > 40 years 6Equipment trouble 5Equipment trouble 5Rough water 4Female 2Female 2Depth < 80 fsw 2

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Cardiac Incidents (n=156)

• Body Mass Indexy– Cardiac incidents: 30.5 kg/m2

– AGE: 28 7AGE:  28.7

– Asphyxia: 27.8

• 60% of victims of cardiac incidents noted• 60% of victims of cardiac incidents noted dyspnea, fatigue, distress, chest pain, or felt ill

56% h d & ll id f• 56% had autopsy reports & usually evidence of CVD but not myocardial damage

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Case Control Study: Risk Factors for Fatal & Non‐Fatal  AGE, 2005

• What factors influence the risk of death?• What factors influence the risk of death?– Demographic

E i– Experience

– Medical history

– Dive profile

– Dive conditions

– Dive problems

28

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Buoyancy Trouble & Non‐Fatal AGEy y

10,928 i h10,928 i h

127i h AGE127i h AGE without AGEwithout AGE

7 with 

with AGEwith AGE

69 withbuoyancy69 withbuoyancy

buoyancy trouble

buoyancytroublebuoyancytroubleOdds of buoyancy

trouble with AGE= 7/(127‐7) = 0.06

Odds of buoyancy

trouble without AGE

= 69/(10,928‐69) = 0.0064

/( )

Odds Ratio (OR) of non‐fatal AGE

for divers with buoyancy trouble

29

for divers with buoyancy trouble 

= 0.06/0.0064 = 9.2

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AGE FindingsAGE Findings

• ~12% of all injuries were fatal12% of all injuries were fatal

• ~6% of non‐fatal injuries were AGE

O h lf f ll AGE f t l• Over half of all AGE were fatal

• Sex, CVD, diabetes & asthma not AGE risk factors

• Greater AGE risk for divers in 1st year of ycertification & on 1st dive of day

30

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AGE FindingsAGE Findings

• AGE risk decreases with experience p

• Dive problems appear strong risk factors although diagnostic bias is a problemalthough diagnostic bias is a problem– Rapid ascent, gas supply, buoyancy

• Factors associated with AGE death• Factors associated with AGE death– Higher risk: obesity, increasing age, use of helium increasing maximum depthhelium, increasing maximum depth

– Lower risk: healthy BMI

31

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Pulmonary Barotrauma in Divers During EmergencyFree Ascent Training: Review of 124 CasesFree Ascent Training: Review of 124 Cases

Pierre Lafère , Peter Germonpré ,and Costantino Balestra

• Risk of PBT during training dives 100‐400 x

• During ascent training dives 500‐1500x

• Most Belgian sport diver federations have modified their ascent training protocols since 2006– Since then, no cases of PBT related to ascent training

Aviat Space Environ Med 2009; 80: 371 – 5 .

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Diabetes & Fatalities

• Review DAN Fatality Database 1992‐2004• Total 975 fatalities

– 938 Non‐DM (96.2%)

– 37 with DM (3.8%)

• Variables: divers characteristic, accident scenario, , ,disabling conditions

• Age and dive depth tested with t‐test for independent g p psamples

• Contrasts tested with Chi squared analysis• Significance accepted at p<0.05

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Adverse Events Preceding DeathsAdverse Events Preceding Deaths

C diti% of Decedents

St ti tiCondition StatisticsDM Non-DM

Cardiac 40.5 15.9 p<0.001Unknown 27.0 37.8 NSAGE 10.8 17.9 NSD i 10 8 20 5 NSDrowning 10.8 20.5 NSUnexplained LOC* 10.8 1.3 p<0.001Trauma 0 3 5 NSTrauma 0 3.5 NSDCS 0 1.8 NSWrong gas 0 1.3 NS

* loss of consciousness

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Mean AgeDAN Members and Fatalities

50 Fatalities

y = 0 702x + 38 47rs)

Fatalities

DAN Members

y = 0.702x + 38.47R² = 0.838

40ge (Y

ear

y = 0.3287x + 36.53R² = 0.7475

Mea

n A

g

30

M

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003Calendar Year

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DAN Fatality Rates by Age DAN Fatality Rates by Age 

35

40

25

30

35

iver

s *

20

25

00,0

00 D

Males*

10

15

Per

10

Females* * *

0

5

36

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70Age (years)

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EDAN Insured Members200,000 insured years, 141 deaths

300

350

divers

63,000 Females137,000 Males

RR 0.2-10 (NS)

200

250

er 100,000

 d

RR 0.6-12 (NS)

100

150

ity rates pe

RR 0.6-3.6 (NS)RR 1.9-9.9

0

50

<20 20-29 30-39 40-49 50-59 60+

Fatali

Age

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Age & Cause Specific Relative Risk Age & Cause Specific Relative Risk 

Disabling Injury

<50 yearsn=788 489

≥50 yearsn=352 878 RRInjury n=788,489 n=352,878 RR

Cardiac 5* 29 12.9

AGE 8 14 3.9

Asphyxia 15 17 2 5Asphyxia 15 17 2.5

Total 50 79 3.5

* Number of deaths

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Conclusions

• Death while diving by insured DAN members occurs f 1 i 6000 diat rate of 1 in 6000 divers per year.

• Most common causes are gas supply problems, emergency ascent, cardiac health issues, entrapment/entanglement and buoyancy issuesentrapment/entanglement, and  buoyancy issues.

Ri k f d th hil di i i ith• Risk of death while diving increases with age.