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"WE'RE DIVING!!!!!!!!!" an enthusiastic Lt. Jessica Hill wrote to an unknown recipient in an e-mail Aug. 17, 2006 — the date that would mark her death.
The Coast Guard lieutenant dashed off the note after receiving approval from senior officers on the icebreaker Healy to conduct a cold-water familiarization dive with two other divers, even though she — the only trained dive officer and supervisor on the ship — did not have the required complement of personnel required for the exercise.
The Coast Guard released a report Wednesday detailing the factors that led to the deaths of Hill, 31, of St. Augustine, Fla., and Boatswain's Mate 2nd Class Stephen Duque, 26, of Miami, a year ago in the icy waters of the Arctic Ocean. It also spells out measures that must be taken with the Coast Guard's dive program to help guarantee that a similar tragedy never again occurs.
But in the most damning assessment of the accident released to date, it also analyzes how decisions that day by the command cadre — especially Hill — contributed significantly to the mishap.
Unlike previously released reports that detailed the events leading up to the accident and describing it in detail, the report lists "causal" factors that contributed to the accident. It reveals factors that, if they weren't present, "would most likely have broken the chain of errors and the mishap would not have occurred" — and the "contributory factors," which, by themselves wouldn't have caused the accident but influenced its progression.
Many of the causal errors point to poor decision-making on behalf of the command, including Hill herself.
For example, according to the report, Hill, as senior dive officer and dive supervisor aboard the ship, embarked on a dive operation in which she failed to mandate the use of a redundant scuba system, as required by Navy regulations.
She used excessive weight to avoid an uncontrolled ascent, and encouraged Duque to the same. This is dangerous because it can cause decompression sickness, commonly known as the bends.
Before the dive, Hill and Duque packed on nearly 60 pounds of weight, including steel tanks, that couldn't easily be jettisoned in an emergency.
Hill, along with the command cadre — including the commanding, executive and operations officers — failed to conduct a required risk assessment of the exercise, the report states. She also failed to call off the dive when the crew encountered equipment malfunctions and failures, and she alone told the command cadre that the "dive was within regulations," even though, according to Navy regulations, the team would have needed at least four qualified divers to conduct the exercise.
"The [dive officer] told the commanding officer that the dive was within regulations when it was not, and the CO, who was responsible for the safe conduct of all dive operations, lacked familiarity with the dive procedures and approved the plan," the report says.
Hill and Duque died when they entered 29-degree water, intending to conduct two 20-minute exercises at depths of 20 feet. Minutes into the exercise, Duque plunged to 220 feet below the surface, while Hill sank to 189 feet below.
It is thought that Duque lacked the manual dexterity and the expertise to control buoyancy by inflating or deflating the air in his dry suit. He had also experienced some seepage around his gloves, causing his hands to become so cold that he could not make proper hand signals or operate his equipment well.
The divers planned to travel only to depths of 20 feet. But in the unexpected event that they descended to 33 feet — which they did — they would have experienced a loss of buoyancy, because air volume compresses at that level and provides less buoyancy. Divers wearing excessive weight would have to counteract the loss by adding air to their suits or jettisoning weight.
The pair's added weights were zipped in to their dry suit pockets, making it impossible for them to drop them.
Tenders observing the dive failed to understand that the two had dropped to greater-than-planned depths until it was too late. Hill and Duque ran out of air, likely became unconscious, and then suffered barotraumas — ruptured lungs — as they were pulled to the surface.
The Coast Guard has released numerous documents related to the accident, and in January, it issued the details of the administrative investigation into the accident. The most recent memo, signed by chief of staff Vice Adm. Robert Papp, also includes recommendations for the Coast Guard's dive program if a study team determines that the program should remain organic to the service.
The detailed analysis released Wednesday blames "impulsive" decision-making and the divers' sense of bravado as main factors that led to the accident. According to the report, such causal factors were:
* "The dive officer [Hill] created an unsafe situation ? because during preparation for the dive, the officer's confidence projected in a way that others did not continue to question the officer's responses regarding the required number of divers and the use of weights in pockets that did not allow for jettison."
* "The dive officer demonstrated overconfidence when [she] did not engage in the required safety practices ... Diver 1 (Duque) and Diver 2 (a third diver whose equipment failed, canceling her participation) mirrored the overconfidence of the dive officer by proceeding with the dive without questioning whether it should have taken place."
* "'Get-Home-Itis' / 'Get-There-Itis' — the dive officer saw this as the only opportunity to do an ice dive. Once in the water, the divers were reluctant to cancel the dive operation even though [Duque] had a loss of manual dexterity and Diver 2 had to leave the dive side."
According to Navy regulations, there should have been at least four divers to conduct the exercise — two in the water, one on standby and a dive supervisor.
The Navy Dive Manual and Coast Guard regulations require risk assessments and preparation before any dive exercise. If they'd been followed, the checks and procedures would have halted the exercise before it started. For example, the Healy, which deployed that summer with a complement of four divers, only had three onboard that day because one was serving temporary duty elsewhere. Its dive locker was in a state of disarray, lacking proper equipment, safety paperwork, checklists and inspections. And the command cadre approved Hill's dive plan in 30 minutes that day, without the required risk assessments and checkout procedures.
The actions of Duque and other crew members also contributed to the accident, the report states. According to eyewitness reports, Duque arrived at the dive site at the appointed time, but as he waited for the other divers who were delayed, he lay down on the ice — an action prohibited by the Navy dive manual because it can cause heat loss and equipment failure.
Also, the dive tenders — the personnel who monitored the divers' tethers — were inexperienced. They received a cursory informational briefing from Hill about their duties, and at least one of them drank a beer during ice liberty prior to assisting with the dive.
The casual disregard for procedures led to failure up and down the chain of command, reports have concluded.
"The Healy command cadre also created an unsafe situation by not ensuring all sonar were secured, and in conducting ice liberty with alcohol and allowing a polar bear swim a the same time in very close proximity to the dive," the memo states.
The report's recommendations on the Coast Guard's dive program will be implemented once a study team completes its analysis of the program requirements, management and policies.
"It is imperative that we honor the memories of our fallen shipmates by diligently implementing the corrective actions directed in the final decision letter," Papp wrote in a Coast Guard-wide message Wednesday.
Immediately following the accident, the Coast Guard instituted a number of changes in its dive program. It conducted a safety standdown and inspections of all dive units, held training for divers who deployed last year on the icebreaker Polar Sea, and developed a dive training module for commanders at the Prospective Commanding Officer and Executive Officer Afloat Course and elsewhere.
According to Lt. j.g. Alexander Buchler, the Polar Sea's dive officer, the changes have influenced all members of the crew, at least on his ship.
"The big change that I have observed is a widespread increase in awareness and education of non-diving Coast Guard members on the dangers and risks associated with diving," Buchler wrote in an e-mail during the Polar Sea's deployment for Operation Deep Freeze earlier this year.
"Diving is always a high-risk mission, and this program has received the appropriate level of attention and support from all levels of the Coast Guard," he said. "Every aspect of the Polar Sea's dive program has been extensively reviewed by outside parties and evaluated for safety."
Related reading and multimedia
* PDF: The report
* Story: Admiral's mast punishes three
* Story: Investigation's findings
* On the Web: Official Coast Guard investigation documents