Coast Guard report cites long list of mistakes that led to deaths of divers from icebreaker

A series of mistakes in leadership, training and judgment led to the deaths of two U.S. Coast Guard divers from the U.S. Coast Guard Cutter Healy during a dive under the ice 500 miles northwest of Barrow, Alaska, according to a Coast Guard report on the accident.

The vessel’s three top officers were found to be in dereliction of duty at an admiral’s mast held on Jan. 11. The commanding officer and operations officer received letters of reprimand. The executive officer received a letter of admonition. Pay forfeitures for the commanding officer and operations officer were suspended.

Since the deaths, the Coast Guard has suspended all polar diving without prior approval from the Pacific Area Command, according to Lt. Cmdr. Glynn C. Smith, spokesman for the Pacific Area.
On Aug. 17 Lt. Jessica Hill, 31, and Petty Officer 2nd Class Steven Duque, 22, died during a cold-water dive from Healy. The 420-foot icebreaker had been on a research mission and stopped for the first time in a month on that day. Both died of asphyxia and injuries caused by expansion of air held in their lungs while they ascended. In such circumstances, the expanding air ruptures air sacs in the lungs and air bubbles form in the blood.
The Coast Guard report on the Healy investigation issued by Adm. Thad W. Allen, the Coast Guard commandant, on Jan. 10 highlighted oversight failures at every level and numerous departures from standard policy. A combination of shortcomings and “a lengthy error chain” meant the accident was not prevented; but no single person caused it, according to Vice Adm. Charles Wurster’s statement at a Jan. 12 press conference in Seattle, where Healy is based. Wurster is the Coast Guard’s Pacific Area commander.
The report depicted a poorly planned and executed dive, which took place while many other crewmembers were drinking beer and hard lemonade and playing football as part of approved liberty.
Those involved in liberty wandered in and out of the dive site, which was about 60 feet forward of Healy‘s bow. The dive area was not cordoned off, as required by the Navy Diving Manual, which is used along with the U.S. Coast Guard Diving Manual. There was no dive log, no time kept at the dive site and the Navy Dive Manual was not at the site, contrary to regulations.

The dive tender responsible for Hill drank one beer before the dive. Another dive tender assigned to conduct equipment checks and clip on Hill’s tending line drank three beers. The rule for ship’s liberty is two beers per person, but no record was kept of how much alcohol was distributed or who drank it.
Hill made a mistake in telling the four dive tenders the line-pull signals just before the dive. According to three of the tenders, Hill told them that one pull during the descent meant “OK.” In fact, one pull during decent by the diver or tender means “stop” according to the Navy Dive Manual. It was an informal brief with no checklist and no assessment of the dive’s risk.

Three divers were at the ice’s edge at about 1804. All divers wore a single tank with 100 cubic feet of air at standard temperature and pressure, which meant they had no backup SCUBA equipment in the case of an emergency, contrary to Navy dive regulations.
Hill and Duque wore split fins, which are designed for speed and provide minimal thrust. None of the divers wore weight belts, as required, which allow for getting rid of weight in an emergency, and two had more weight than was needed for their body sizes. There was no diving supervisor or standby diver on the surface.
Due to technical problems, the third diver left. Duque complained of cold hands and glove problems, so he and Hill changed the signal for OK from making a circle with the thumb and fingers to a thumbs-up sign.
The dive plan specified that on the first dive, divers would go to 20 feet. Shortly after the divers submerged, the tenders could not see them. As Hill descended, her dive tender gave several single pulls, which he thought was asking Hill if she was OK. He felt a single pull after each of his pulls, which he thought was Hill confirming she was OK.
Hill’s tender observed that both divers’ lines played out quickly. When he saw her line was close to played out, he stepped on it. About 2 to 3 minutes after the divers submerged, Duque’s tender noticed the line sped out forcefully.
At about 1835, the third diver returned, and saw the tenders were concerned. They said there had been no pulls recently.
A senior crewmember nearby recommended the divers be retrieved. At 1845, the tenders began to pull the divers up; when they came into view at 40 feet, both appeared unconscious. Attempts to resuscitate them were unsuccessful. According to depth gauges, Hill descended to 187 feet and Duque went to about 220 feet. It is likely that both divers lost consciousness before or during the ascent, according to the report. Duque’s air tank was depleted and Hill’s pressure was so low it was essentially empty.
By Professional Mariner Staff