The Tragic and Un-Necessary Death of Brian Bugge

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before you become a rebreather diver, you’d better read this

Conventional open-circuit scuba is sold as “not being rocket science.” PADI and its like have made it available to almost everyone. Scuba is fun. It’s for all the family. Once you’ve grasped Boyle’s Law and the repercussions of breathing compressed gas underwater, it’s only a matter of gaining the confidence to do things underwater. Well, that’s true if you confine yourself to open-water scuba depths in benign water conditions. Of course, mistakes can be made.

Scuba diving out in the ocean can introduce complications, and an understanding of seamanship might be required. It’s also all about your managing your air supply because if it stops, you can’t breathe.

Decompression requirements or the limits of no-stop diving can easily be taken care of by observing your diving computer.

Even when you want to go deeper than conventional diving depths using different mixed gases, some of which might be anoxic in the shallows, it’s not hard to understand scuba diving. In-water confidence plus the ability to put the right regulator in your mouth at the appropriate depth is all that’s required. Of course, mistakes can be made. The wrong regulator with the wrong gas mix can be selected, but it takes a conscious (if wrong) decision to do that.

Scuba diving without a visible surface above adds the proviso that you must be confident and not panic when unexpected circumstances arise. Cave systems and enclosed wrecks without direct access to the surface and fresh air are no place for beginners. That’s another thing that doesn’t take much to understand.

And that is why we have a culture of having fun and enjoying ourselves when learning to scuba dive. This is imparted by instructors who make sure to make it fun. They really want you to have a good time (something very clearly missing if you’ve ever seen Israeli army recruits learning to scuba). Generally speaking, training in open-circuit scuba is delivered in a light-hearted, even casual, manner.

But then there’s closed-circuit or CCR diving.

I met Buzz Aldrin briefly at a DEMA show. He was the guest on the booth of Silent Diving, one of the leading suppliers of closed-circuit rebreathers. It didn’t surprise me that the ex-astronaut was a competent CCR diver. There’s a lot in common with breathing from a system in the inhospitable vacuum of space and breathing from a closed-circuit system in the inhospitable environment that is water.

CCR diving is different from OC scuba in that you can always breathe, but you need to be confident in what you are actually breathing. Closed-circuit rebreathers recirculate the gas (either nitrox or mixed gas with added helium) in the system and your lungs so that the only gas you use is the oxygen you metabolize, which is surprisingly little. The gas is moved around in a loop between the user’s lungs and the CCR unit.

In the process, oxygen is added, either automatically or manually, to make up the difference in what is used, and the waste product of metabolism, carbon dioxide, is removed by a chemical scrubber that is packed by the user.

Hypoxia, caused by a shortfall in oxygen, has one symptom underwater — death. Hypercapnia, the poisoning caused by an excess of carbon dioxide in the breathing loop, results in breathlessness, confusion, and errors of judgment, very soon followed by death underwater.

How often were you told you might die during open-circuit scuba training? I doubt the subject ever came up. Statistically, the chances of dying on scuba are very remote indeed. Not so with CCR.

With few exceptions, divers gravitate to CCR after first learning conventional scuba techniques. The problem arises when scuba instructors gravitate to CCR instruction from conventional scuba instruction. Conventional scuba is not rocket science, but CCR diving is. There is no place for the cavalier attitudes of some scuba instructors in CCR training. Which brings us to the tragic story of Brian Bugge.

Brian Bugge, 35, a U.S. Pacific Fleet Integrated Undersea Surveillance Systems officer, was off-duty, on a closed-circuit rebreather training dive in Honolulu, when he died.

Brian obviously had good in-water confidence. He was quick to pick up the techniques of conventional scuba, but within two years, he had moved on to CCR training and training to use CCR with helium in the gas mix. That’s about as advanced as it can get.

His diving career is a litany of training mistakes. For example, he and his wife Ashley were allowed to dive in cenotes without a clear route to the surface, while still only open-water divers. They got away with all these risks without ill-effect. Brian’s confidence in his scuba abilities blossomed. However, he became the victim of casual CCR instruction allied to peer pressure. In my opinion, he moved on to mixed gas CCR too quickly, and the quality of the instruction he was given was too casual.

The outcome was for him to step off a dive boat and enter the water without his oxygen cylinder turned on. Unlike OC scuba, where, if your tank is not turned on, you soon know when you try to breathe because you get no air; a CCR can allow you to breathe a hypoxic mix. Within seconds Brian had used what little oxygen there was in the system. The effect is the same as a bullet in the brain.

Now many CCR divers will insist that cannot happen to them. There are warnings, both visual and aural, that trigger in a CCR unit if the partial pressure of oxygen in the breathing loop is either too high or too low. Brian obviously did not become aware of them. A new mixed-gas CCR diver, he was too distracted. Who was monitoring what he was doing? Where was his instructor at this time?

As what some would call a pioneer CCR diver (I started in 1993), I was always aware that my CCR unit could kill me. This led to a culture of checklists and double-checking, and doing the same for my dive buddy. I learned quickly how important it was to always know the partial pressure of oxygen in the gas I was breathing from the CCR unit.

Technical diving guru Rob Palmer advised me, “Get it wrong and you’re dead.” Good advice that I never forgot. However, it didn’t stop me writing numerous magazine articles extolling the advantages of CCR diving. CCRs have since become common on dives.

We do not go diving because we are fighting a war. We are only doing it for fun. The tragedy of Brian Bugge is that his death should never have happened. I suspect that many other CCR diving deaths should not have happened either.

You can see the whole tragic story of Brian Bugge unravel by watching the documentary If Only, bravely contributed to by his wife, Ashley.

In it, producer Gareth Lock, a high risk and human error expert (www.thehumandiver.com), contends that you can get away with errors 95 percent of the time. He says, “Brian Bugge made a number of mistakes on 20 May 2018, and a couple of them were critical. But there were also many other factors in place, including distractions and incomplete/inadequate training. This is no different from many other divers too. However, to focus on the fact that he didn’t turn on his oxygen valve misses a huge amount of learning that is available.”

I take some issue with this: Failing to open your oxygen tank valve on a CCR and becoming hypoxic is an error you can never, ever get away with. “Get it wrong and you’re dead.” You can watch the documentary made by Gareth Lock and Ashley Bugge here: https://vimeo.com/414325547

— John Bantin
Sr. Editor, Undercurrent

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12 comments for “The Tragic and Un-Necessary Death of Brian Bugge

  1. Hunter Smith
    June 29, 2020 at 11:35 pm

    Thanks John, A great article.About the risks and culture not the tech for once.
    I have a friend whos first husband died on CCR many years (circa 18) years ago. As 1,200+ Open Water diver and keen photographer CCR has many attractions and still does. However my fear is it would take some of the fun out of it and be addictive and a road to big debt!.

    ALL diving needs to be taken seriously however CCR is totally next ;level (as the younger ones might say). Look for the quiet one on the boat.

    Hope I am still diving when the tech gets so good and CCR more common that it involves less serious attention i.e up the fun factor. It must be amazing!.

    I will be looking for your articles from now on.

    Hunter Smith Australia

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  2. Claire Rausch
    June 17, 2020 at 5:33 am

    Thank you to Ashley Bugge for her courage in telling her part of this story and her integrity in trying to ensure other divers are alerted to the fallibilities inherent in many scuba training systems. I learned the importance of taking personal responsibility for my diving practices when working in hyperbaric medicine and over the years have since seen too many examples where certification was awarded to persons not competent in the sport. Thanks to UnderCurrent for putting this story out there.

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  3. Richard Jacoby
    June 13, 2020 at 5:57 pm

    Have I missed something? Nowhere was the inclusion of a buddy included in Brian’s accident. This doesn’t make sense to me. I began diving fifty-two years ago, and ended diving five years ago. How could Brian’s course NOT included the requirements of using a buddy? The buddy would have shared the gas difficulties that Brian underwent – and, almost certainly, would have prevented the fatality.

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  4. Memphis Bill
    June 10, 2020 at 5:10 pm

    fantastic video. The widow has made such an effort to warn/train others, I’ll donate to her scholarship fund

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  5. June 9, 2020 at 12:56 pm

    The story resembles my own observations from being involved in the investigation of many rebreather fatalities, notably Skiles. Like Bugge, in the case of Skiles there were an astounding number of opportunities to stop what I call the error cascade prior to his fatal dive. Combined failure of virtually every system we have in place to protect the community of recreational divers seem to have occurred in both Skiles, Bugge and others. The question we should ask ourselves is how does Bugge manage to get to that point that he enters the water with the burden of a “litany of training mistakes”?

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  6. Eric Hexdall
    June 9, 2020 at 12:08 pm

    John, excellent article, though I do think that in your last paragraph you misinterpret Gareth’s statement. Certainly the failure to turn the O2 valve on was the error most immediately related to Brian’s death; what I think he was saying is that one should not focus exclusively on that. There were a number of contributory factors, which happen frequently enough in diving and other high-consequence professions that there are volumes of publications dedicated to examining them, among them Gareth’s excellent book. To ignore them is to lose many of the valuable lessons that can be learned from Brian’s accident. Again, thank you for the article and to the link to the video.

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  7. John BANTIN
    June 6, 2020 at 11:32 am

    Quote from a pioneering closed-circuit rebreather diver: “If you are wearing a rebreather it must be on and running. You never turn anything off until after it’s taken off. Simple…. That’s a short book.”

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  8. Jef Proudfoot
    June 1, 2020 at 2:02 pm

    There are some people who are temperamentally unsuitable for CCR use. A friend of mine got one and I predicted he’d be dead within the year. They never did find his body.

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  9. George Lewbel
    June 1, 2020 at 12:12 pm

    Thanks for posting the CCR piece, John. Your analysis of this sad event is so reasonable and balanced that you’ll probably get lots of flak from everyone on every side of the issue. I’m an open-circuit guy, not a CCR diver, but it’s clear that CCR can be a lot more unforgiving of user errors, including some that have the potential to kill their users without much (or any) warning. Your article put that into perspective very well.

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  10. kevin monaghan
    June 1, 2020 at 9:13 am

    John Bantin referred to the OC diving course as fun, and i have no problem with that, learning something should be fun, I do however have a problem with instructors who never seem to instil in the students, how dangerous being underwater with just a tank of air to support you is. I can understand the commercial aspect of keeping the dangers low key, after all if your selling something you don’t really want to remind your client, that what he is buying can kill him/her so easily, but at the same time reminding students of the fact should be incumbent for the instructor. I have always taken diving very seriously, probably learning in the North sea helped that, but over the years I have seen so many, who just regard it as another sporting activity, amongst many they pursue, not to be taken very seriously.

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  11. Miami diver
    June 1, 2020 at 8:33 am

    This is a very timely article. I recently was on a recreational dive and one of the divers was diving closed circuit and extolling all of its virtues. He said everybody will be diving like this in five years.

    When he surfaced, we were in moderate seas, typical of our diving conditions here. He was floundering on the surface with so much cumbersome gear ( 3 tanks and all of the tubes) that he had extreme difficulty actually getting on board the dive platform.

    About 10 years ago, I read a really good book which was a collection of dive accident stories. I concluded that if you are an OW diver and make one mistake you will probably be ok. Two mistakes you may live. three mistakes and you’re probably hurt or dead. It appears that closed circuit diving is a “one mistake and you’re dead” sport.

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  12. Randall Preissig
    June 1, 2020 at 8:02 am

    Thank you. UnderCurrent became a valuable information source for divers when it first was published by exposing dangerous diving conditions as well as wonderful places to dive. UnderCurrent was able to do this by not being beholden to advertisers. Thank you for continuing this valuable tradition/mission which is to this day still unique in the diving industry. I believe exposing the high death rate in Cozumel during the 1970s was famously one of your first such exposes. My wife and I, in our thirties and relatively new to diving as was Mr. Bugge, experienced so many ridiculously dangerous situations during that era in Cozumel that we refused to return there until the late 1980s, and then only to protect a first time diver who was obsessed with experiencing Cozumel’s wonderful diving. Safety had improved by that time, and we now visit Cozumel yearly. Again, thank you. Please continue providing us with information on diving risks and safety as part of your mission.

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