On a day when everything seemed so right, everything went so wrong.

Aug. 17 was a sunny polar day when shortly after 6 p.m., Coast Guard Lt. Jessica Hill and Boatswain's Mate Steven Duque descended into the 29-degree Arctic Ocean. It was to be a familiarization scuba dive in cold water during a festive "ice liberty" granted the crew and scientists by the skipper of the Seattle-based icebreaker Healy.

Around the diving site were frivolity and relaxation as the crew of 84 and 35 scientists celebrated mission's end with football, strolls, photographs and approved cans of beer. Some even violated the executive officer's direct order against polar bear plunges, jumping into the chill water within 30 feet of the divers -- the skipper nonplused watching nearby.

To help with the diver's lifelines, Hill recruited a few crew members partying nearby as "dive tenders." They had no training or experience in the work, so she gave them an informal briefing. Two of the tenders had been drinking.

She and Duque entered the water at 6:10 p.m. for what was to be a 20-minute, 20-foot-deep dive.

One tug means "OK," she had told the tenders. One tug upon descent, however, according to the Navy Dive Manual, the bible for military divers, also means "stop." None of the tenders remembers her telling them that.

It probably will never be known what Hill meant when her tender felt her first pull, according to a detailed Coast Guard investigation released Friday in Seattle by a panel of admirals.

Hill, 31, of St. Augustine, Fla., and Duque, 22, of Miami, each loaded with too much weight and their buoyancy equipment incorrectly installed, died. They had descended uncontrollably, Hill to 187 feet and Duque to nearly 220 feet, the investigation found.

Safety regulations were either violated or non-existent, and there were judgment lapses across the board, from the Healy's captain and senior officers to the divers themselves and throughout the Coast Guard, a bluntly worded report, the Commandant's Final Action Memo, said Friday.

The investigation found no criminal wrongdoing.

Vice Adm. Charles Wurster, commander of the Coast Guard's Pacific Area, who fired the Healy's skipper, Capt. Douglas Russell after the accident, released the findings at Pier 36, home of Coast Guard Sector Seattle and the nation's polar icebreakers.

"The investigation uncovered a chain of events and decisions which, had any link been broken, this tragedy would not have occurred," Wurster said. Russell and the executive officer and operations officer, who were not identified, each received punitive letters of reprimand.

Although it might not sound like much, such letters are career enders, especially for Russell. Wurster said the other two officers remain on the Healy in part because absolute authority rested with Russell.

Wurster, based in Alameda, Calif., was joined in Seattle by officers from Washington, D.C., Rear Adm. David Pekoske, assistant commandant of Coast Guard operations, and Rear Adm. Paul Higgins, a physician and director of the U.S. Public Health Service's health and safety directorate.

The Coast Guard's chief of staff told Hill's and Duque's families about the report.

Hill's family said in a statement that the report "answered many questions" and agreed that the deaths were "a failure" of the Coast Guard, the Healy's command staff and the dive team.

"Their deaths will not be in vain if the actions proposed by the Coast Guard resulting from this investigation are implemented and no other family will go through what we have experienced," Hill's family said.

The report portrays a lax, informal, almost casual atmosphere surrounding the Coast Guard's entire dive program, which had grown so fast, from five units to 17 nationwide in five years, that current policies are "inadequate to properly guide and manage" the program.

The Healy's festive "ice liberty" seems a metaphorical backdrop for what the admirals called the "error chain." On the Healy, investigators found no safety survey of the dive program had ever been conducted, and no discernible records since 2002 for preventive maintenance on dive equipment were found.

The report blistered the Healy's "command cadre," Russell and the unidentified executive and operations officers. Together, they "failed to exercise leadership and supervision expected in command afloat. Their actions demonstrated a lack of knowledge of the Coast Guard's dive program and a lack of knowledge and disregard for the high level of risk of cold-water diving," the report said.

Hill shared in the responsibility, the report said.

Planning to leave the service in February, she was intent on imparting her skills and training to other divers the Coast Guard has sorely needed since 9/11.

However, twice when informally asked whether her dive plan for Aug. 17 met standards, Hill told Russell and the operations officer it did. A check by either senior officer would have shown she was wrong, the report said.

On the day of the dive, the area was not cordoned off from ice liberty revelers. The site was 60 feet off the port bow of the Healy but out of view of the pilothouse. There was no communication link between the dive team and wheelhouse.

Hill and Duque had not taken part in the ice liberty and hadn't been drinking before the dive.

As Hill and Duque slipped into the water and their tethers began to spin away, the untrained dive tenders at first thought they might still be at 20 feet but swimming under the ice, Pekoske said.

The report then describes a scene of increasing confusion and chaos, as the divers' lines sank faster and faster and the novice diver tenders grew increasingly confused and alarmed, before some ice-liberty revelers took notice and ended the party, pitching in to help.

They pulled the divers up at a rate of a foot a second. Duque and Hill were first spotted, unconscious, at about 40 feet. They were never revived. An autopsy found both divers died from lack of oxygen with severe air pressure damage to the lungs, including possible air bubbles in the circulatory system.

Duque had never done a cold-water dive. Hill, who had done seven previously with surface-supplied air through a hose, had never before done a cold-water scuba dive, the report said. Neither Hill nor Duque wore weight belts that could be easily jettisoned. Instead, they jammed weights into whatever pockets and pouches they had. Each carried at least 60 pounds ballast, with their tanks, instead of the 20 to 30 pounds most divers recommend, the report said.

The investigation also found that Hill's diving certificate had lapsed. The Healy's previous commander in April signed one, but of the four dives in six months Hill was to have made to requalify for her certification, two were later found to have been recreational, so they didn't count, the report said.

TO LEARN MORE

The Coast Guard's final action memorandum into the deaths of Lt. Jessica Hill and Boatswain's Mate Steven Duque can be seen online, with privacy redactions, at:

www.uscg.mil/ccs/cit/cim/foia/Electronic_Reading_Room.htm

FINDINGS IN BRIEF

A Coast Guard investigation into the deaths of Lt. Jessica Hill and Boatswain's Mate Steven Duque of the Seattle-based icebreaker Healy concluded that:

The Healy's top three commanders -- the captain, executive officer and operations officer -- and the dive team failed to properly plan and execute a standard cold-water dive, violating numerous Coast Guard policies and procedures, including inadequate preparation, improper use of dive equipment, unqualified diver tenders and failure to ensure proper supervision of the dive and to carry two air tanks each and have a standby diver in case of emergency.

Overall management of the Healy's dive program was inadequate and did not comply with Coast Guard policies.

Hill's and Duque's experience, readiness and training levels were inadequate for the dive.

The Healy's top three commanders lacked leadership and knowledge about the dive program and disregarded the high risks of cold-water diving.

Administration without proper oversight was left to Hill, the diving officer. Her dive plan for Aug. 17 was too quickly approved in 30 minutes, with no briefing or risk assessment.

No medical evacuation plan was drafted, and the dive occurred while the ship was 490 miles from Barrow, Alaska, out of range for a quick medical evacuation.

Ice-liberty activities were held simultaneously with diver operations, without segregating the two.

The Healy was supposed to carry six divers, had only three and was not properly staffed to safely conduct dive operations. A safety survey after the accident found that the Healy's dive program was deficient in a third of its Coast Guard requirements.

The Coast Guard's dive program needs to be elevated on a par with other high-risk training operations such as aviation. The program did not keep pace with the growth of Coast Guard missions after 9/11, and the overall structure and policies are inadequate to properly guide and manage it.

Soundoff (Read 9 comments)
What do you think?