Sunday, January 14, 2007

USCGC Healy Diving Accident Report





Back in August, the Coast Guard lost two divers, LT Jessica Hill and BM2 Stephen Duque, in the Arctic Ocean. I posted about it here. The investigation is complete and the Commandant has placed the 33 page report on the internet. I encourage anyone who engages in high risk operations to read the report. There are lessons to be learned from this tragic event.






To the men and women of the Coast Guard:

On 17 August 2006, we lost two of our shipmates assigned to CGC HEALY, LT Jessica Hill and BM2 Steven Duque, in a tragic diving accident in the Arctic. There are valuable lessons to be learned by all of us regarding leadership, risk management, training and program oversight that apply to all Coast Guard operations. Therefore, I am directing all personnel to read my entire report. To help ensure public access to the report on the Internet, Coast Guard members with access to a CG Standard Workstation should view my report posted on CG Central at: (http://cgcentral.uscg.mil). Anyone without CGSW access can view a copy of the same report online at: (http://www.uscg.mil/ccs/cit/cim/foia/Electronic_Reading_Room.htm).

Consistent with my commitment to the families of LT Hill and BM2 Duque, each family was provided a copy of my report and has been personally briefed by the Coast Guard Chief of Staff, VADM Papp, earlier this week. We once again express our deepest sympathies as the entire Coast Guard continues to mourn the loss of these two dedicated, hard working individuals. Please keep them, their families and the HEALY crew in your thoughts and prayers. I understand that there is nothing which will make up for the loss of LT Hill and BM2 Duque. We will honor our lost shipmates by taking timely action, at all levels, to improve our dive program.

In addition to this administrative investigation, a Commandant’s Vessel Safety Board has been convened to prevent any similar mishap in the future. Its work is ongoing. The results of that mishap analysis will be disseminated via ALCOAST upon its completion in the coming months.

Concurrent with the public release of this investigation today, the Pacific Area Commander, VADM Wurster, is briefing HEALY crewmembers and the media in the cutter’s homeport of Seattle. As the convening authority, VADM Wurster has taken action to hold HEALY’s Commanding Officer, Executive Officer and Operations Officer accountable for failing to meet their personal responsibilities surrounding this mishap.

This is a brief summary of what occurred. In the late afternoon hours of 17 August 2006, three Coast Guard divers from HEALY attempted to conduct two, 20-minute cold water familiarization dives at 20-foot depth during an ice liberty stop in the Arctic ice approximately 490 nautical miles north of Barrow, Alaska. After one of the divers exited the water due to equipment malfunction, the other two divers continued the dive in 29-degree Fahrenheit waters. The divers quickly descended to depths far exceeding their planned depth, one diver descending to 187 feet and the other diver descending to at least 220 feet. Once it became evident that too much tending line had paid out to support a 20-foot dive depth, the divers were brought to the water surface. The divers were recovered with no vital signs and were pronounced dead after extensive resuscitative efforts failed. Final autopsies report cause of death for both LT Hill and BM2 Duque as “Asphyxia with pulmonary barotraumas with possible air embolism” (lack of oxygen with severe air pressure damage to the lungs, including possible air bubbles in the circulatory system).

The bottom line is that this dive should have never occurred. The investigation revealed numerous departures from standard Coast Guard policy that should have precluded diving under the circumstances. Had HEALY’s Commanding Officer, Executive Officer, Operations Officer and dive team followed policies established in Coast Guard and Navy Diving manuals, they would not have permitted diving operations.

HEALY had only two qualified and current divers that day; this dive evolution required at least three qualified and current divers, and one qualified Dive Supervisor not actually diving. Additionally, the Diver Tenders were not qualified. Despite these problems, the dive plan was approved by the Commanding Officer without a pre-brief, an operational risk assessment or any medical evacuation plan, as required by Coast Guard and Navy policy.

A critical factor in the loss of the divers was that neither diver wore a weight belt, as required by the Navy Diving Manual. Instead, both divers carried approximately 60 pounds of weight in the pockets of their buoyancy compensation devices (BCD), approximately 2-3 times more weight than normally used by experienced divers in similar cold water and ice dive conditions. The BCD has pockets to carry and, if necessary, jettison weight. However, LT Hill and BM2 Duque filled not only the weight pockets, but also the equipment pockets of the BCD. Thus, much of the divers’ weight was not easily jettisonable. Although LT Hill had some experience diving in the Arctic, this was her first SCUBA dive in the Arctic. This was BM2 Duque’s first cold water dive.

Adding to the risk of the operation, the ship was holding “ice liberty” at the same time, and in close proximity to the dive evolution. The ice liberty included “polar bear plunges,” football and consumption of both alcoholic and non-alcoholic beverages. Neither LT Hill nor BM2 Duque consumed alcohol prior to diving.

The deaths of LT Hill and BM2 Duque were preventable and resulted from failures at the Service, unit and individual levels. The investigation revealed failures in leadership within the chain of command aboard HEALY, as well as numerous departures from standard Coast Guard policy. Had a proper risk assessment been conducted, this tragedy could have been avoided. As a Service, we failed to exercise sufficient programmatic oversight of the dive program, including failures to adequately staff our dive units and conduct annual dive safety surveys. This mishap further highlighted our need to improve dive expertise in unit dive lockers and address shortfalls in dive program policy, guidance, training and experience. As a result, we will elevate program management on par with other high risk, training-intensive operations such as aviation. A comprehensive list of the corrective actions I have ordered, including those that have been completed, is contained in my report posted online.

We cannot prevent every Coast Guard casualty. Despite the professionalism, bravery, and dedication of our workforce, in rare cases we suffer a serious injury or death in the line of duty. As Coast Guard men and women we accept that risk, but we will not accept preventable loss or injury. This tragedy has prompted us to re-examine our dive program to ensure it is as well managed and safe as such inherently dangerous operations allow. The safe conduct of Coast Guard training is fundamental to Coast Guard readiness. Without it, there can be no successful Mission Execution. When it comes to dangerous operations such as diving, “good enough” is never good enough. We can do better. We will do better.

The sacrifices LT Hill and BM2 Duque made in service to their Nation will never be forgotten. Their loyalty and dedicated service will forever be appreciated by the U.S. Coast Guard.


Admiral Thad Allen

8 comments:

Diveshack said...

Excuse the pessimism, but this is a classic blaming the victim. I can't comment as to the report's accuracy, however, think about it. Sixty pounds of lead causing this event? No doubt they were over weighted and beyond the rule of 10s. However given their training and experience, the fact they were wearing thermals and dry suits with BC's and fins, I find it hard to believe both Hill and Dubois sank to their death as a result of an inexperienced tender! Something is very wrong with this report. Nuf said!

John said...

Diveshack,
If you read the entire report, you will see that this is not a case of simply blaming the victim. While LT Hill made plenty of errors, the report also holds the chain of command culpable as well for not stopping a dive that was in violation of regulations.

Read the whole report and then get back to me.

Diveshack said...
This comment has been removed by the author.
Diveshack said...

John ...

Yes, I understand from where your comments come and to a point agree with you. However, anyone associated with diving knows final control lies with the diver(s).

Yes, I have read the entire report, both the Coast Guard's published release with its associated documentation as well as the Navy's investigative document.

My comments come from having participated in, supervised, and instructed the art of diving for nearly 20 years military and civilian. Divers do in fact die from scenarios such as that presented in the USCG's final report. However it's unlikely one much less two would perish given the events as published.

The report troubles me because even with each egregious COC and dive team SOP violation as presented in the USCG report, this was a survivable event for one if not both divers. The key question is why both divers lost consciousness upon descent. BM2's profile was replicated as part of the USN investigation in Panama City. The dive was determined to be survivable even under more difficult circumstances (fresh v salt water).

Again, questions that need be asked and answered beyond the hypothetical are:

1. Why did both divers lose consciousness?
2. Why did both divers descend uncontrollably?

These questions are not answered by simply stating divers were overweighed, protocols were ignored, and tenders were inattentive. Thus, the questions remain.

The USN's report, photos showing both divers with positive in-water surface buoyancy and most importantly one innocuous and buried paragraph stating the Healy's operational sonar array was not locked out or tagged out begs me to make the statement that something is wrong with this report.

Resolve these questions and you'll have a definitive cause for the tragic and un-necessary loss of our two diving brethren.

Anonymous said...

Diveshack,

You sound like you somewhat know what you are talking about. However, if you are not in the Coast Guard, or maybe were in but decided to get out, I just wanted to say shut up. It's not your fucking problem. It doesn't affect you in any kind of way. Admiral Allen is the Commandant for a reason. He can make the best judgement about the incident and the best way to correct the mistakes that were made.

Anonymous said...

How the fuck can you say this shit. I am now in the USCG (uncle sam's confused group), and wish to support the previous poster's right to make observations upon this accident. Organizations like the coast guard can develope institutional myopia. When this happens it helps, to have an outside POV. If he is a civilian, he is our boss in every sense of the word. The only thing that I ask for is that the criticism try to be informed.

This is unlike the hatchet job done by NBC over deepwater. Not that there is not criticism to be waged over DW, its just that NBC, really fucked up in assigning blame to the wrong people. If NBC had actually been fullfilling thier role as watchdog, they would have done a 'documentary' 2+ years ago when COMDT Collins came up with the bone head plan. Any 6 year old could have told you that DW was an assine idea, but that criticism couldn't have come from within the CG.

Matt said...

To all who read this:
I was an RM2(DV) 2nd class deep sea diver onboard USCGC Northwind during Arctic East '86 and Arctic East '87. Multiple dives in 29 degree water north of Thule Greenland into the Kane basin. The dive operations were always and very strictly regulated and structured by USN Dive standards and USCG policy. I respect and concur with Admiral Allens report and conclusions. This of course is a tragic loss for the families and the USCG. The training that the Lt received at Panama City should have told her that dive operations were not to be held. Her leadership training within the USCG should have lead her to completely and always follow policy and safety standards without exception. It is the times that individuals in leadership situations make exceptions from set safety policies that preventable injuries and deaths occur. Always proud of my USCG service. Always proud of those serving today.
Matt Neff

Anonymous said...

Nobody is adding anything with foul language -stow it.

How could anyone who wasn't diving a drysuit in cold water for the 1st time in their life possibly think they should have 60 lbs of weight. If this was their 1st time either in cold (ie. COLD) water and/or using a drysuit, how on earth did they get an OK to go under the ice?

Arctic temps, drysuit, under ice are each in themselves big enough risks as a new skill that a diver should never had been allowed to combine more than 1 "first" in a single dive. I would have thought the Coast guard was a much more controlled environment, not one that would have allowed this.