The Coast Guard Chief of Staff has released the final decision letter on the diving accident on board the USCGC HEALY.
R 291955Z AUG 07 ZUI ASN-A00241000009 ZYB
FM COMDT COGARD WASHINGTON DC//CG-01//
TO ALCOAST
BT
UNCLAS //N05101//
ALCOAST 426/07
COMDTNOTE 5101
SUBJ: RELEASE OF CHIEF OF STAFFS FINAL DECISION LETTER ON THE 17 AUGUST 2006 CGC HEALY CLASS A DIVER MISHAP
1. THE RELEASE OF THE CHIEF OF STAFFS FINAL DECISION LETTER SIGNALS THE COMPLETION OF A RIGOROUS SAFETY INVESTIGATION, MISHAP ANALYSIS, AND HIGH LEVEL REVIEW OF THE CIRCUMSTANCES WHICH LEAD TO AND CONTRIBUTED TO THE DEATHS OF TWO OF OUR SHIPMATES ON 17 AUGUST 2006. THIS IS THE SECOND OF TWO PROCESSES THAT INQUIRED INTO THIS MISHAP. THE FIRST PROCESS WAS AN ADMINISTRATIVE INVESTIGATION. FINAL ACTION WAS TAKEN ON THE ADMINISTRATIVE INVESTIGATION ON 10 JANUARY 2007. THE SOLE PURPOSE OF THIS SAFETY INVESTIGATION WAS TO FIND OUT WHY THE MISHAP OCCURRED SO SIMILAR MISHAPS CAN BE PREVENTED IN THE FUTURE. THE FINAL DECISION LETTER OUTLINES THE NUMEROUS CAUSAL AND CONTRIBUTING FACTORS THAT RESULTED IN THIS TRAGIC MISHAP. NO SIGNIFICANT ADDITIONAL FACTS WERE FOUND IN THIS INVESTIGATION BEYOND THOSE IDENTIFIED IN THE ADMINISTRATIVE INVESTIGATION. IT ALSO DIRECTS CHANGES TO VARIOUS COAST GUARD PROGRAMS IMPLICATED IN THIS MISHAP TO IDENTIFY/AVOID SIMILAR HAZARDS AND THEIR CONSEQUENCES IN THE FUTURE. IT IS IMPERATIVE THAT WE HONOR THE MEMORIES OF OUR FALLEN SHIPMATES BY DILIGENTLY IMPLEMENTING THE CORRECTIVE ACTIONS DIRECTED IN THE FINAL DECISION LETTER. ALL MEMBERS OF THE COAST GUARD ARE HIGHLY ENCOURAGED TO READ THE ENTIRE FINAL DECISION LETTER AS POSTED ON THE FOLLOWING WEBSITES:
A. COAST GUARD MEMBERS WITH ACCESS TO A CG STANDARD WORKSTATION SHOULD VIEW THE FINAL DECISION LETTER POSTED ON CG CENTRAL AT:
(HTTP://CGCENTRAL.USCG.MIL).
B. MBRS WITHOUT CGSW ACCESS CAN VIEW A COPY OF THE SAME LETTER AT:
(HTTP://WWW.USCG.MIL/CCS/CIT/CIM/FOIA/ELECTRONIC_READING_ROOM.HTM).
2. THERE WERE A TOTAL OF 26 CAUSAL FACTORS AND 48 CONTRIBUTORY FACTORS IDENTIFIED. THE CENTRAL THEMES WERE A LACK OF APPROPRIATE SUPERVISION, A LACK OF A RISK ASSESSMENT WHICH LED TO POOR DECISION MAKING, AND A LACK OF OPERATIONAL DISCIPLINE ON THE PART OF THE INDIVIDUALS INVOLVED.
3. WHILE THERE IS STILL MUCH WORK LEFT TO DO IN ORDER TO ADDRESS ALL OF THESE CAUSAL FACTORS, THE FOLLOWING CHANGES HAVE BEEN COMPLETED.
A. IN ACCORDANCE WITH ALCOAST 440/06, A ONE-DAY SAFETY STAND DOWN WAS ORDERED AND COMPLETED FOR ALL DIVING UNITS. IN ADDITION, A MODIFIED DIVING PROGRAM SAFETY SURVEY (NO TRAINING, INSPECTION
ONLY) WAS COMPLETED ON EVERY DIVING UNIT ON OR BEFORE 12 JANUARY 2007.
B. TO IMPROVE SUPERVISION AND OVERSIGHT, THE DIVE PROGRAM MANAGER BILLET WAS UPGRADED FROM AN O-3 TO AN O-4 AND A CHIEF PETTY OFFICER BILLET WAS ESTABLISHED AS THE ASSISTANT COAST GUARD DIVING PROGRAM MANAGER. AREA COMMANDERS, DISTRICT COMMANDERS, AND THE DEPLOYABLE OPERATIONS GROUP COMMANDER ALSO DESIGNATED DIVING PROGRAM OVERSIGHT BILLETS WITHIN THEIR COMMANDS. THE INDIVIDUALS FILLING THESE BILLETS ARE RESPONSIBLE FOR TRACKING THE READINESS, QUALIFICATION AND TRAINING STATUS OF THEIR DIVING UNITS.
C. PRIOR TO AND DURING OPERATION DEEP FREEZE 2007, USCGC POLAR SEA COMPLETED A DIVE RISK ASSESSMENT, COMPLETED PRESCRIBED DRY SUIT TRAINING, AND ADDED A TEMPORARY DUTY USCG DIVING ADVISOR TO SERVE AS DIVE TEAM SAFETY OBSERVER DURING ANTARCTIC TRAINING AND DIVE OPERATIONS.
D. THE ASSISTANT COMMANDANT FOR OPERATIONS REAFFIRMED AND EMPHASIZED THAT DIVING UNIT COMMANDERS ARE TO PROVIDE THE OPPORTUNITY FOR AND TO REQUIRE REGULARLY SCHEDULED TRAINING DIVES TO ALLOW DIVERS TO MAINTAIN PROFICIENCY AS REQUIRED BY THE CG DIVING POLICIES AND PROCEDURES MANUAL, COMDTINST M3150.1B.
E. THE ASSISTANT COMMANDANT FOR OPERATIONS SENT A DIVE PROGRAM REPRESENTATIVE TO THE DIVING IN THE ARCTIC ENVIRONMENT COURSE FROM
15 - 22 MARCH 2007 TO LEARN THE LATEST INFORMATION ON DIVING IN THE ARCTIC REGION.
F. THE ASSISTANT COMMANDANTS FOR OPERATIONS AND HUMAN RESOURCES DEVELOPED A DIVE TRAINING MODULE FOR INCLUSION IN APPROPRIATE TRAINING SYLLABI FOR COMMAND CADRE OF DIVE UNITS AND OTHER FIELD UNITS WHO MAY UTILIZE DIVERS. SPECIFICALLY, THE PROSPECTIVE COMMANDING OFFICER AND EXECUTIVE OFFICER (PCO/PXO) AFLOAT COURSE, THE PROSPECTIVE OPERATIONS OFFICER (POPS) AFLOAT COURSE, AND THE BOAT FORCES COMMAND CADRE COURSE ADDED A BLOCK OF INSTRUCTION.
G. THE ASSISTANT COMMANDANT FOR OPERATIONS UPDATED THE DIVE PROGRAM SAFETY SURVEY CHECKLISTS TO REFLECT CHANGES IN CG/NAVY POLICIES AS OF 23 APRIL 2007.
4. THE FOLLOWING DIRECTED CORRECTIVE ACTIONS STILL PEND BUT ARE WELL UNDERWAY TOWARDS COMPLETION:
A. THE ASSISTANT COMMANDANT FOR OPERATIONS CHARTERED A CROSS- DIRECTORATE STUDY TEAM, INCLUDING DIVE EXPERTISE FROM THE NAVY AND OTHER RECOGNIZED SOURCES OF DIVE EXPERTISE, TO EVALUATE REQUIREMENTS, MANAGEMENT, AND POLICY GUIDANCE FOR THE COAST GUARD DIVING PROGRAM WITH A REPORT OUT TO THE CHIEF OF STAFF. THE RESULTS OF THIS STUDY TEAM ARE CURRENTLY UNDER REVIEW FOR POTENTIAL CHANGES TO THE DIVE PROGRAM.
B. AMENDMENTS ARE BEING MADE TO THE CG DIVING POLICIES AND PROCEDURES MANUAL, COMDTINST M3150.1B, TO REFLECT DIRECTED CHANGES TO POLICIES, INCLUDING CHANGES TO THE DIVE STANDARDIZATION AND SITE VISIT PROGRAM, DIVING EQUIPMENT AND PREVENTIVE MAINTENANCE PROCEDURES, PERSONNEL ASSIGNMENTS, OPERATIONAL RISK MANAGEMENT FOR DIVE TEAMS, AND DIVE LOG KEEPING PROCEDURES.
C. ADDITIONAL DIRECTED ACTIONS ARE LISTED IN THE FINAL DECISION LETTER POSTED AT THE WEBSITES LISTED IN PARA 1.A. AND 1.B.
D. AMONG THE ADDITIONAL ACTIONS BEING DIRECTED IS A FORMAL ORGANIZATIONAL RISK ASSESSMENT TO BE CONDUCTED FOR ALL COAST GUARD OPERATIONAL MISSION AREAS TO IDENTIFY, CLARIFY, AND MITIGATE ASSOCIATED RISKS PARTICULARLY WITH RESPECT TO RAPIDLY EXPANDING/EMERGING MISSION AREAS.
5. AS THE COMMANDANT STATED IN HIS ALL HANDS MESSAGE THIS PAST JANUARY, AS COAST GUARD MEN AND WOMEN WE ACCEPT RISK, BUT WE WILL NOT ACCEPT PREVENTABLE LOSS OR INJURY. OUR SYMPATHIES CONTINUE TO GO OUT TO THE FAMILIES, FRIENDS AND SHIPMATES OF THOSE THAT LOST THEIR LIVES IN THIS MISHAP. THE LEADERSHIP OF THE COAST GUARD IS STEADFASTLY COMMITTED TO SAFE MISSION EXECUTION.
6. INTERNET RELEASE IS AUTHORIZED.
7. VADM R. J. PAPP, CHIEF OF STAFF, SENDS.
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