{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,6]],"date-time":"2026-03-06T02:25:40Z","timestamp":1772763940108,"version":"3.50.1"},"reference-count":58,"publisher":"MDPI AG","issue":"18","license":[{"start":{"date-parts":[[2020,9,22]],"date-time":"2020-09-22T00:00:00Z","timestamp":1600732800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Although drowning is a common phenomenon, the behaviour of drowning persons is poorly understood. The purpose of this study is to provide a quantitative and qualitative analysis of this behaviour. This was an observational study of drowning videos observed by 20 international experts in the field of water safety. For quantitative analysis, each video was analysed with Lince observation software by four participants. A Nominal Group Technique generated input for the qualitative analysis and the two principal investigators conducted a post-hoc analysis. A total of 87.5% of the 23 videos showed drowning in swimming pools, 50% of the drowned persons were male, and 58.3% were children or teenagers. Nineteen persons were rescued before unconsciousness and showed just the beginning of downing behaviour. Another five were rescued after unconsciousness, which allowed the observation of their drowning behaviour from the beginning to the end. Significant differences were found comparing both groups regarding the length of disappearances underwater, number, and length of resurfacing (resp. p = 0.003, 0.016, 0.005) and the interval from the beginning of the incident to the rescue (p = 0.004). All persons drowned within 2 min. The qualitative analysis showed previously suggested behaviour patterns (immediate disappearance n = 5, distress n = 6, instinctive drowning response n = 6, climbing ladder motion n = 3) but also a striking new pattern (backward water milling n = 19). This study confirms previous assumptions of drowning behaviour and provides novel evidence-based information about the large variety of visible behaviours of drowning persons. New behaviours, which mainly include high-frequency resurfacing during a struggle for less than 2 min and backward water milling, have been recognised in this study.<\/jats:p>","DOI":"10.3390\/ijerph17186930","type":"journal-article","created":{"date-parts":[[2020,9,22]],"date-time":"2020-09-22T09:40:56Z","timestamp":1600767656000},"page":"6930","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":29,"title":["The Visible Behaviour of Drowning Persons: A Pilot Observational Study Using Analytic Software and a Nominal Group Technique"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6615-9821","authenticated-orcid":false,"given":"Aida","family":"Carballo-Fazanes","sequence":"first","affiliation":[{"name":"CLINURSID Research Group &amp; Santiago de Compostela\u2019s Health Research Institute (IDIS), Universidade de Santiago de Compostela, 15705 Santiago de Compostela, Spain"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4467-8211","authenticated-orcid":false,"given":"Joost J.L.M.","family":"Bierens","sequence":"additional","affiliation":[{"name":"Research Group Emergency and Disaster Medicine, Vrije Universiteit Brussel, 1090 Brussels, Belgium"}]},{"name":"the International Expert Group to Study Drowning Behaviour","sequence":"additional","affiliation":[]}],"member":"1968","published-online":{"date-parts":[[2020,9,22]]},"reference":[{"key":"ref_1","first-page":"221","article-title":"The 4W model of Drowning","volume":"1","author":"Avramidis","year":"2007","journal-title":"Int. J. Aquat. Res. Educ."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Bierens, J.J.L.M. (2014). Scanning and surveillance: Swimming pools, beaches, open sea. Drowning, Springer.","DOI":"10.1007\/978-3-642-04253-9"},{"key":"ref_3","unstructured":"Tribune Media Wire (2020, July 25). In pool full of people, no one saw woman, child drown. WGNO, Available online: https:\/\/wgno.com\/news\/in-pool-full-of-people-no-one-saw-woman-child-drown\/."},{"key":"ref_4","unstructured":"Willis, A. (2020, July 25). Horror as five-year-old boy \u2018drowns\u2019 in swimming pool\u2014And nobody notices. Mirror, Available online: https:\/\/www.mirror.co.uk\/news\/world-news\/horror-five-year-old-boy-10585736."},{"key":"ref_5","unstructured":"World Health Organization (2014). Global Report on Drowning, World Health Organization."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"26","DOI":"10.2174\/1875399X01811010026","article-title":"The relation of drowning rescue methods with the rescuer in cinema","volume":"11","author":"Avramidis","year":"2018","journal-title":"Open Sports Sci. J."},{"key":"ref_7","unstructured":"Eaton, D. (1995). Lifesaving, The Royal Life Saving Society UK."},{"key":"ref_8","first-page":"164","article-title":"Observations on the drowning of non-swimmers","volume":"71","author":"Pia","year":"1974","journal-title":"J. Phys. Educ."},{"key":"ref_9","first-page":"52","article-title":"The RID factor as a cause of drowning","volume":"19","author":"Pia","year":"1984","journal-title":"Parks Recreat."},{"key":"ref_10","unstructured":"Fidehacker (2020, July 25). Recognize the Real Signs of Drowning and Save a Life. Available online: https:\/\/lifehacker.com\/recognize-the-real-signs-of-drowning-and-save-a-life-5578943."},{"key":"ref_11","first-page":"203","article-title":"Identification of critical events by lifeguards, instructors, and non-lifeguards","volume":"6","year":"2012","journal-title":"Int. J. Aquat. Res. Educ."},{"key":"ref_12","unstructured":"Kjendlie, P.L., Stallman, R.K., and Cabri, J. (2010). Applying a development perspective to aquatics and swimming. Biomechanics and Medicine in Swimming XI, Norwegian School of Sport Sciences."},{"key":"ref_13","unstructured":"Royal Life Saving Western Australia (2020, July 25). Recognising a Person Who Is Drowning. Available online: https:\/\/royallifesavingwa.com.au\/your-safety\/first-aid-and-emergency-care\/recognising-a-person-is-drowning."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1016\/j.jsr.2012.05.001","article-title":"A study on rescuer drowning and multiple drowning incidents","volume":"43","author":"Turgut","year":"2012","journal-title":"J. Saf. Res."},{"key":"ref_15","first-page":"9","article-title":"The C-Zones framework","volume":"6","author":"Connolly","year":"2012","journal-title":"Int. J. Aquat. Res. Educ."},{"key":"ref_16","unstructured":"Doyle, B., and Webber, J. (2007, January 27\u201329). SENTINEL\u2014A systematic approach to the early recognition of drowning; the right response, to the right victim, at the right time. Proceedings of the World Water Safety Conference and Exhibition, Matosinhos and Porto, Portugal."},{"key":"ref_17","unstructured":"Pascual-Gomez, L.M. (2011, January 22\u201324). Early recognition of a person at risk of drowning. Proceedings of the Dublin Lifesaving Conference, Dublin, Ireland."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Bierens, J.J.L.M. (2014). Recognition of the person in distress. Drowning, Springer.","DOI":"10.1007\/978-3-642-04253-9"},{"key":"ref_19","first-page":"853","article-title":"A new definition of drowning: Towards documentation and prevention of a global public health problem","volume":"83","author":"Branche","year":"2005","journal-title":"Bull. World Health Organ."},{"key":"ref_20","unstructured":"Carballo-Fazanes, A., and Alonso-Calvete, A. (2018). An\u00e1lisis del proceso de ahogamiento en espacios acu\u00e1ticos, Unpublished Work."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"4692","DOI":"10.1016\/j.sbspro.2012.06.320","article-title":"Lince: Multiplatform sport analysis software","volume":"46","author":"Gabin","year":"2012","journal-title":"Procedia Soc. Behav. Sci."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"191","DOI":"10.2478\/hukin-2019-0011","article-title":"Analysis of successful offensive play patterns by the Spanish soccer team","volume":"69","author":"Amatria","year":"2019","journal-title":"J. Hum. Kinet."},{"key":"ref_23","first-page":"36","article-title":"Stability of patterns of behaviour in the butterfly technique of the elite swimmers","volume":"9","author":"Louro","year":"2010","journal-title":"J. Sports Sci. Med."},{"key":"ref_24","unstructured":"Avramidis, S. (2012). Hollywood films: Truths and myths in relation to drowning and lifesaving. The IAHSFF Book, International Aquatic History Symposium, International Swimming Hall of Fame."},{"key":"ref_25","unstructured":"Fletemeyer, J.R., and Freas, S.J. (1999). Reflections on lifeguarding surveillance programs. Drowning: New Perspectives on Intervention and Prevention, CRC."},{"key":"ref_26","unstructured":"The Beach Company (2020, August 03). Instinctive Drowning Response. Available online: https:\/\/www.thebeachcompany.in\/blogs\/be-beachy\/105947655-instinctive-drowning-response-know-more."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"44","DOI":"10.1111\/j.1440-1754.2010.01889.x","article-title":"Drowning for love: The aquatic victim-instead-of-rescuer syndrome: Drowning fatalities involving those attempting to rescue a child","volume":"47","author":"Franklin","year":"2011","journal-title":"J. Paediatr. Child Health"},{"key":"ref_28","first-page":"325","article-title":"\u201cThe impulse to rescue\u201d: Rescue altruism and the challenge of saving the rescuer","volume":"6","author":"Pearn","year":"2012","journal-title":"Int. J. Aquat. Res. Educ."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Zhu, Y., Jiang, X., Li, H., Li, F., and Chen, J. (2015). Mortality among drowning rescuers in China, 2013: A review of 225 rescue incidents from the press. BMC Public Health, 15.","DOI":"10.1186\/s12889-015-2010-0"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1111\/1753-6405.12900","article-title":"Who rescues who? Understanding aquatic rescues in Australia using coronial data and a survey","volume":"43","author":"Franklin","year":"2019","journal-title":"Aust. N. Z. J. Public Health"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"44","DOI":"10.11622\/smedj.2017021","article-title":"Drowning in swimming pools: Clinical features and safety recommendations based on a study of descriptive records by emergency medical services attending to 995 calls","volume":"59","author":"Chan","year":"2018","journal-title":"Singap. Med. J."},{"key":"ref_32","first-page":"56","article-title":"Internal noise distractions in lifeguarding","volume":"7","author":"Griffiths","year":"2013","journal-title":"Int. J. Aquat. Res. Educ."},{"key":"ref_33","first-page":"59","article-title":"How lifeguards overlook victims: Vision and signal detection","volume":"2","author":"Hunsucker","year":"2008","journal-title":"Int. J. Aquat. Res. Educ."},{"key":"ref_34","unstructured":"International Life Saving Federation (ILS) (2020, July 25). Factors Affecting Lifeguard Recognition of the Submerged Victim: Implications for Lifeguard Training, Lifeguarding Systems and Aquatic Facility Design. Available online: https:\/\/www.ilsf.org\/library\/factors-affecting-lifeguard-recognition-of-the-submerged-victim-implications-for-lifeguard-training-lifeguarding-systems-and-aquatic-facility-design\/."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"650","DOI":"10.1097\/SMJ.0b013e3181e10564","article-title":"Prevention of needless deaths from drowning","volume":"103","author":"Modell","year":"2010","journal-title":"South Med. J."},{"key":"ref_36","unstructured":"National Aquatic Safety Company (NASCO) (1999). Lifeguard Textbook, The National Aquatic Safety Company, LLC."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Bierens, J.J.L.M. (2014). Vigilance. Drowning, Springer.","DOI":"10.1007\/978-3-642-04253-9"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"367","DOI":"10.1016\/j.jsr.2007.01.010","article-title":"Ecology of drowning risk at a public swimming pool","volume":"38","author":"Schwebel","year":"2007","journal-title":"J. Saf. Res."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"268","DOI":"10.1136\/injuryprev-2016-041962","article-title":"Quantification of degraded supervision of bathing in 108 French public swimming pools","volume":"23","author":"Vignac","year":"2017","journal-title":"Inj. Prev."},{"key":"ref_40","first-page":"7","article-title":"Learning from incidents to reduce the risk of drowning in swimming pools: Implementation of experience-based feedback regarding near-misses in four public facilities in France","volume":"12","author":"Vignac","year":"2019","journal-title":"Int. J. Aquat. Res. Educ."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Bierens, J.J.L.M. (2014). Evidence-based standards in lifesaving: The conclusions of the United States lifeguard coalition. Drowning, Springer.","DOI":"10.1007\/978-3-642-04253-9"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"371","DOI":"10.1080\/17457300.2016.1200630","article-title":"Constant supervision of bathing in French public swimming pools: An unrealistic regulatory requirement?","volume":"24","author":"Vignac","year":"2017","journal-title":"Int. J. Inj. Control Saf. Promot."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"270","DOI":"10.1016\/j.resuscitation.2006.09.001","article-title":"The chain of survival","volume":"71","author":"Nolan","year":"2006","journal-title":"Resuscitation"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1016\/j.resuscitation.2016.04.006","article-title":"Predicting outcome of drowning at scene: A systematic review and meta-analyses","volume":"104","author":"Quan","year":"2016","journal-title":"Resuscitation"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1149","DOI":"10.1016\/j.resuscitation.2014.05.034","article-title":"Creating a drowning chain of survival","volume":"85","author":"Szpilman","year":"2014","journal-title":"Resuscitation"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1017\/S1092852900001954","article-title":"Freeze, flight, fight, fright, faint: Adaptationist perspectives on the acute stress response spectrum","volume":"9","author":"Bracha","year":"2004","journal-title":"CNS Spectr."},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Peden, A.E., Franklin, R.C., and Clemens, T. (2019). Exploring the burden of fatal drowning and data characteristics in three high income countries: Australia, Canada and New Zealand. BMC Public Health, 19.","DOI":"10.1186\/s12889-019-7152-z"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1016\/j.microc.2013.10.003","article-title":"Drowning in swimming pools","volume":"113","author":"Bierens","year":"2014","journal-title":"Microchem. J."},{"key":"ref_49","first-page":"3","article-title":"Association of drowning mortality with preventive interventions: A quarter of a million deaths evaluation in Brazil","volume":"12","author":"Szpilman","year":"2020","journal-title":"Int. J. Aquat. Res. Educ."},{"key":"ref_50","unstructured":"Coral Manta (2020, July 25). Pool Safety Redefined. Available online: https:\/\/coraldrowningdetection.com\/."},{"key":"ref_51","doi-asserted-by":"crossref","unstructured":"Eng, H.L., Toh, K.A., Kam, A.H., Wang, J., and Yau, W.Y. (2003, January 13\u201316). An automatic drowning detection surveillance system for challenging outdoor pool environments. Proceedings of the Ninth IEEE International Conference on Computer Vision, Nice, France.","DOI":"10.1109\/ICCV.2003.1238393"},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Kharrat, M., Wakuda, Y., Koshizuka, N., and Sakamura, K. (2013, January 11\u201314). Automatic waist airbag drowning prevention system based on underwater time-lapse and motion information measured by smartphone\u2019s pressure sensor and accelerometer. Proceedings of the IEEE International Conference on Consumer Electronics (ICCE), Las Vegas, NV, USA.","DOI":"10.1109\/ICCE.2013.6486891"},{"key":"ref_53","unstructured":"(2020, July 25). Pos\u00e9idon. Available online: http:\/\/www.poseidonsaveslives.com."},{"key":"ref_54","unstructured":"SwimEye (2020, July 25). A Drowning Detection and Prevention System. Available online: https:\/\/swimeye.com."},{"key":"ref_55","unstructured":"(2020, July 25). Wave. Available online: https:\/\/www.wavedds.com\/."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1109\/TCSVT.2003.821980","article-title":"A vision-based approach to early detection of drowning incidents in swimming pools","volume":"14","author":"Wenmiao","year":"2004","journal-title":"IEEE Trans. Circuits Syst. Video Technol."},{"key":"ref_57","first-page":"224","article-title":"A novel camera-based drowning detection algorithm","volume":"Volume 525","author":"Tan","year":"2015","journal-title":"Advances in Image and Graphics Technologies. IGTA 2015. Communications in Computer and Information Science"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"450","DOI":"10.1111\/jpc.14668","article-title":"Causes of distraction leading to supervision lapses in cases of fatal drowning of children 04\u2013years in Australia: A 15-year review","volume":"56","author":"Peden","year":"2019","journal-title":"J. Paediatr. Child Health"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/18\/6930\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T10:12:32Z","timestamp":1760177552000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/18\/6930"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,9,22]]},"references-count":58,"journal-issue":{"issue":"18","published-online":{"date-parts":[[2020,9]]}},"alternative-id":["ijerph17186930"],"URL":"https:\/\/doi.org\/10.3390\/ijerph17186930","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,9,22]]}}}