Crew members drinking before deadly dive, report says

Anchorage Daily News ^ | January 12, 2007 | CURT WOODWARD

[skeptoid]

Two Coast Guard divers killed in a botched Arctic training dive were loaded with too much weight and were assisted by untrained crew members who had been drinking beer, an official investigation has found.

The two divers, from the Seattle-based icebreaker Healy, plunged to about 200 feet - about 10 times deeper than intended - shortly after entering the 29-degree water on Aug. 17, 2006.

[skeptoid]

The other shoe drops.

It was a really bad day.

[skeptoid]

A longer piece in the P. I. is here.

[tomcorn]

Whoa....Reading the story this was a VERY slack training operation. When a captain and exec are running a training evolution everyone involved should be scared shitless of not getting it absolutely 4.0 correct. The Disciplinary actions here were correct and given the outcomes even criminal specifications could have been considered.

[pepsionice]

If the beer story hangs true...then it probably contributed to the situation.

But you still have an episode in explaining how they got dragged down 200 feet so quickly. They could not have done that by themselves, and the training "slack" won't work in this case either. There is still more to explain in this whole story.

[Ninian Dryhope]

"But you still have an episode in explaining how they got dragged down 200 feet so quickly."

"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."

It sounds like the officers thought that Hill was a pro and instead she was a nitwit.

[spinestein]

[There is still more to explain in this whole story.]

There were many contributing factors, but the immediate cause was this:
{[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.]}

And the fact that there was no oversight or supervision and no competent help available to recognize their distress or to rescue them when it became necessary is what did them in.

[tomcorn]

Makes little sense to me either. The lined handlers should have noticed the descent rate and depth. 120 is narcosis and 200 is 02 toxicity.Somebody wasn't paying attention at all. The line signal system is archaic because a diver impaired from narcosis or O2 Toxicity would be unable to signal.

[thegreatbeast]

I don't buy this explanation. The whole thing about the weights seems specious to me. It is elementary that the weight belt be able to be jettisoned quickly. Something smells here.

[jsh3180]

200 feet=nitrogen narcosis in a bad way if they were not using tri-ox or something. And 29 degrees with nitrogen narcosis =recipe for disaster.

[Prodigal Son]

120 is narcosis and 200 is 02 toxicity.

Exactly. When I saw the 200 feet I was wondering what the hell they were doing at that depth. And why they took so much weight in their belts. Most buoyancy problems sort themselves out once you get deep enough (if you're carrying 3 or 4 pounds too little). But stuffing 30 extra pounds of weight in your pockets? Man, I can't imagine what anybody in this incident was thinking. And on top of it all- an ice dive.

[riverrunner]

60 lbs of weight must of wanted to get to the bottom in a hurry. I just weighed my belt it comes in at 25 lbs. I can't think why a normal dive would require or even need 60lbs.

I would question if even the divers had vaild dive training.

[Prodigal Son]

Aye. To need that much weight one would have to be grossly obese. Obviously this wasn't the case because they were in the military. I usually use 6 kilos with a 5mm wet suit. 4 kilos if I'm wearing a 3mm shorty in warm water. Like you, I can't even imagine why someone would think that putting that much weight on would be a good idea.

I have heard of guys trying to get down to 38- 40 meters as quickly as possible to get 'narced/narcked' (sp) and always thought that was a pretty stupid thing to do. Maybe they were doing something like this? Still, even then... Why all that weight?

[Ramius]

There's a pretty good write-up with some more detail here:

http://www.firstcoastnews.com/news/local/news-article.aspx?storyid=73249

[SC Swamp Fox]

It sounds like the officers thought that Hill was a pro and instead she was a nitwit.

Reading the report, that was my conclusion as well. She paid for her slackness with her life and took PO Duque with her.

[Ramius]

From the long article I linked in #13 I would point to the incorrect training for the support linehandlers being the most proximate cause, together with the inexplicable amount of weight the divers had added.

The topside linehandlers didn't know what to do because they didn't know what was happening because the tug-signals were not clearly understood.

This business of having had a couple of beers at the ice-liberty makes a sensational headline, but I doubt it really contributed to the actual problem. More of a problem was that the topside linehandlers were not trained for that role and all but one of them hadn't done it before.

[Cvengr]

Dry suit/ Deep diving suit?

[SC Swamp Fox]

From the link in #13:
She drafted a plan that included three divers — herself, Duque and a third diver who remains unnamed by the service — conducting a scuba exercise in dry suits, bulky one-piece jumpsuits that use air to provide insulation and buoyancy.

I'm not a diver....is this why she thought they needed more weight?

[driftdiver]

"But you still have an episode in explaining how they got dragged down 200 feet so quickly. They could not have done that by themselves, and the training "slack" won't work in this case either. There is still more to explain in this whole story."

If you're severely over weighted it would be very easy to lose control of your buoyancy and sink to 200ft. The drinking and lack of training explain why the safety observers didn't control the safety rope properly.

[Liberty Valance]

*diving ping*

[driftdiver]

"The whole thing about the weights seems specious to me. It is elementary that the weight belt be able to be jettisoned quickly. Something smells here."

I would buy the weights especially if they were tucked into pockets and such. Its easy for poorly trained divers to panic and forget about releasing their weights at all. If they weren't easily releasable then they probably couldn't dump enough weight fast enough. Toss in the frigid water and it would be surprising they didnt die under these conditions.

[driftdiver]

"I'm not a diver....is this why she thought they needed more weight?"

Could be why she thought she did but its not accurate. Theres no reason she would need as much as they had.

[maica]

###There were many contributing factors...###


As there are in so many preventable tragedies. One error can usually be overcome, but a series of 'somebody else will do their job, so I can be a little slack in mine'. is almost always the history of 'accidents' such as this.

I have known divers to get in trouble just for trying to ascend with found-on-the-bottom fishing weights that they stuffed in various places. Going down with weights not-jettisonable is mind-boggling.

[Ramius]

The lead diver (Hill) had done many ice dives with an air hose and many scuba dives in other places, but this was her first ice dive using scuba.

It doesn't sound like this would matter too much, but maybe the divers among us can comment on that.

Clearly the divers themselves were treating the whole evolution too informally.

I'm surprised that ice-diving wouldn't have raised everybody's antenna to pretty strictly go by the book. Diving under the ice is dangerous stuff, and this was treated like just some rec dive. The divers seemed a little too cocky and just assumed everything would be OK. So they took some chances that they shouldn't have.

Fundamentally, the attitude comes from the skipper. He created the atmosphere where the dive team figured they could just cowboy through the evolution. But there were several points where it seems that somebody could have waved the red flag and stopped the evolution to fix some slack missteps, and nobody did.

[Ramius]

That amount of weight really is kinda boggling. And its not like either of them were ~novice~ divers. They'd both done a lot of diving under various conditions, and it just seems obvious that weighting techniques and amounts aren't left for just the last lesson. It's pretty basic.

That they ~both~ added what amounts to double the usual weight ~and~ stuffed in pockets so to be impossible to quickly realease... is just imponderable. And to then end up without an observer there with enough experience to point it out...

Beats me.

[driftdiver]

Thats pretty sad. Seems to be a complete lack of discipline. As with most of these events there wasn't one single error which caused the accident but a whole series of things.

These officers shouldn't have been in command in the first place.

[driftdiver]

"They'd both done a lot of diving under various conditions, and it just seems obvious that weighting techniques and amounts aren't left for just the last lesson. It's pretty basic."

I don't see them as being really all that experienced. My original instructor warned us of the over confidence that sets in after you have a few dives in. You start out following all the rules and then when the dives go fine you start thinking you can bend the rules. Then something happens and you are reminded the rules are written in blood or you are dead.

[Ramius]

Seems to be a complete lack of discipline.

I was on the Polar Sea many many years ago. I understand about ice-liberty. It is a good morale boost after some months of isolation up in the ice.

I wonder if part of the beginning of the series of problems was the first decision to let the dive happen during the ice liberty instead of some other regular workday. The whole point of ice liberty is that there's a little relaxation of the usual intensity. It's not the beer that's the exact problem, its the suddenly casual attitude that takes over the whole ship. For just a few hours, people are focusing on ~not~ worrying about things for a change.

That skipper might otherwise have run a tight ship where everything clicks and snaps into the right spot. That what I remember, for sure. The Polar Sea was a no-nonsense operation, and I'd bet that Healy was no different on most days. But granting liberty changes the whole attitude, and even affects the duty section. Things relax for just a little while.

I'd say that's a bad time to pick to let your dive officer plan an impromptu dive just 'cause there's time and it would be fun to do.

[SauronOfMordor]

I would question if even the divers had vaild dive training.

This was not just one screwup, it was a chain, as the article points out. A competent diver would not have shoved weights into pockets rather than using a dive belt. A competent handler would not have allowed an untrained diver to do so. So we're seeing:

1. Inadequately trained divers performing a dangerous training exercise
2. Not using standard equipment
3. Assisted by untrained/incompetent handlers
4. Who had been drinking

The entire chain of command from divers to captain SHOULD be relieved. The officer in charge of the exercise for being incompetent, and the captain for tolerating an incompetent under his command (or worse being himself unable to tell the officers were incompetent)

[driftdiver]

"I'd say that's a bad time to pick to let your dive officer plan an impromptu dive just 'cause there's time and it would be fun to do."

I think you are probably right. One single lapse and look at the results.

[Ramius]

I don't see them as being really all that experienced. My original instructor warned us of the over confidence that sets in after you have a few dives in. You start out following all the rules and then when the dives go fine you start thinking you can bend the rules. Then something happens and you are reminded the rules are written in blood or you are dead.

Great point. Nobody is quite so cocky as somebody that's recently learned a new skill. Perhaps especially so if they are smart and find they are pretty good at it. Witness what happens to sixteen year olds with only a year or two behind the wheel of a car.

[Prodigal Son]

I'm not a diver....is this why she thought they needed more weight?

I'm not dry suit qualified (mainly because I don't like cold water ;-) but my ex-wife did her course. But it's the same principle.

When you dive to ten meters the pressure is twice as great as at the surface. The air in your lungs takes up half the room it normally does. When you get to 20 meters, it is one third. At thirty, 1/4. The biggest change happening in that first 10 meters. What makes you float (or positive buoyancy) is if you displace an amount of water that is greater than your own weight. So already at 10 meters you are dramatically less buoyant than you were at the surface because the air in your buoyancy control device has been compressed to half its size.

Fat people float pretty well because, although they're big, they displace a lot more water than the average person. Really muscular people don't float as well because their muscle makes them heavy but muscle is a lot denser than fat- meaning they don't displace as much water (they weigh the same but take up less space than an obese person).

What you try to achieve during a dive is a slight negative buoyancy during your descent so you go down nice and easy, mainly with your exhalations. But you are adding a bit of air the whole time because you are becoming more negatively buoyant the whole time you descend. Once you are at depth you want to fine tune your buoyancy so you neither rise nor drop any more. This is achieved with small adjustments in your buoyancy control device- a wee squirt of air in or a wee squirt out. It's not much that's needed. On your ascent, you let air out the whole way up and ideally, you would need to use fins slightly to get to safety stop depth (this safeguards against lung expansion injuries which are actually more common than the Bends).

For example, on a good drift dive where you are using the current to carry you along you should be able to make small changes in depth (needed to avoid coral formations that the current is carrying you towards) by simply breathing a bit deeper or pausing an extra second or two after an exhalation. It's not much that's needed.

You still don't need that much extra weight and the deeper you go, the less buoyant you are. What's difficult is diving shallow when you're too buoyant- say 40 feet or less. But as you go deeper, the pressure compresses the air in your buoyancy control devices which displaces less water- plus the water is denser- so buoyancy becomes less of an issue.

I've dove with some pretty big (obese) people and they had to use fins to get down whereas most people can just let a bit of air out of their BCD and use their exhales to descend. I have had dives where I was a bit too buoyant but this was easily remedied by another diver giving me a lead weight or two from his/her own belt. We're talking a couple of pounds though.

The same phenomenon would happen in a dry suit. I can imagine them having a bit of difficulty getting down, but once past 20 meters (60- 70 feet) it shouldn't have been an issue. In fact, they would have had to add air to their suit to remain neutrally buoyant (neutral buoyancy being what you are aiming at during a dive).

Putting that much extra weight on them before they ever get in the water seems pretty stupid and I can't figure why they would've done it.

[SauronOfMordor]

from the article:

Everyone looked forward to it, especially Lt. Jessica Hill, a 31-year-old officer from St. Augustine, Fla. Hill was the ship's marine safety and dive officer, and she had seized on the break as a chance to get some Coast Guard divers in the water.

Add to the list of who to cashier, everybody who thought that making this affirmative-action nitwit an officer would be good for the Navy. She had no business being in the Navy, much less being an officer

[Ramius]

Add to the list of who to cashier,

She's dead. So... I'd say the discipline has been meted out.

[rabidralph]

She wasn't in the Navy, she was in the Coast Guard.

[SauronOfMordor]

She's dead. So... I'd say the discipline has been meted out

I said " Add to the list of who to cashier, everybody who thought that making this affirmative-action nitwit[ie, Hill] an officer". The people who went along with making her a Lt are still around

[SandwicheGuy]

Add to the list of who to cashier, everybody who thought that making this affirmative-action nitwit an officer would be good for the Navy. She had no business being in the Navy, much less being an officer

Ah, and there you have it. You can add her name just below Lt. Kara Hultgreen, 29, US Navy. Lt. Hultgreen was the first woman to qualify in a combat-ready. F-14 Tomcat, graduating third in her pilot training class. ...

None are so blind as those who will not see.

[ansel12]

The story that is linked in post 13 is devastating,




"Hill had never taken part in a cold-water scuba dive. The previous summer, she'd had at least seven Arctic surface-supplied dives — assisted dives in which divers rely on air piped in from the surface. But she was eager to experience the freedom of scuba and train other divers as well.

Neither of the other two divers had conducted a cold-water dive.

Before the team could begin to prepare, however, the plan hit a snag. The captain previously had inquired whether regulations allowed all three divers to be in the water at the same time. Ship operations officer Lt. Cmdr. James Dalitsch again voiced the captain's concerns. Dalitsch says Hill responded affirmatively.

"I'm not sure you're correct, but I'll take your word for it," Dalitsch replied.

Had Dalitsch or Capt. Douglas Russell followed up on their initial concerns and looked up the regulations, Hill and Duque might be alive today.

The Navy Diving Manual, to which the Coast Guard adheres unless a regulation is specifically overridden by the Coast Guard Diving Manual, requires at least four divers in an operation as proposed by Hill: a buddy pair in the water, a fully equipped standby diver and trained dive supervisor overseeing the operation.

Healy has a diving allowance of six divers, but only three were on board the ship Aug. 17.

And one of them, Hill, had allowed her military dive qualifications to lapse."

[thinking]

Is she the one that didn't make it on to the deck, during an a single engine approach....

[painter]

I have been diving for 13yrs now and everything you said is right on.I'm not dry suit certified either mostly for lack of interest. The thought of 60lbs of weight is bazaar. I bet they were sinking fast enough before they hit 30ft after that they would have to have been "flying". I wounder if they had "busted" eardrums too from not being able to equalize fast enough.

[Prodigal Son]

I bet they were sinking fast enough before they hit 30ft after that they would have to have been "flying".

Yep. Falling fast and nitrogen narcosis, not a good combination. Probably didn't know which direction was up after 50 meters. It looks like from the article they got the bends and lung expansion injuries. They went waaayyy too deep and the people pulled 'em up too quick on the line.

When I was a novice I used to enjoy 'freefalling' to the bottom if I knew for a fact the bottom was within the dive table- say 20 meters or less. But it didn't take me long to realise that this was a silly thing to do (landing on a scorpion fish or lion fish is not good) and that nice and easy is the way to go in scuba. I love to dive. Most relaxing thing in the world- if done right...

[painter]

I love to dive too. When I'm diving the rest of the world above me "disappears". This coming March a group of us are going to Boinair(sp) to dive for a week and I'm looking forward to it.

[Brucifer]

I read the article in post #13 and I have got to say that this was a cluster f@#k from the start. So many things are just completely wrong that you just have to wonder how these people were trained.

The biggest single problem, besides nobody being trained worth a damn, is that Hill's previous diving experience was on surface-supplied air and not SCUBA. On surface air you've got an unlimited air supply. The deeper you go on compressed air in SCUBA tanks, the faster you use your air up. Without doing the math, I'd guess that a diver at 200 feet would use air from a tank 6 or 7 times faster than a diver at 20 feet. Figure in cold water (hypothermia) and stress (hyperventilation) and the air in a single tank would not have lasted long.

On surface-supplied air the diver dives with a bundle of lines which include a main air hose, an open ended air hose, communications line, and a safety line. Topside crew have something called a pneumofathometer that allows them to blow air through the diver's open ended air hose and tell them how deep the diver is. I never saw a diver on surface air that had to keep track of his own depth. If all a SCUBA diver has is a safety line, then there is no way for the surface crew to know whether the divers are 200 feet down in the water, or 200 feet away and still near the surface.

Divers on surface air also usually have speaker communications with the topside crew. Of course, you do train with line signals in case of an emergency, but you don't normally use them except on rare occasions when your speaker or communications wire goes out. The manual says that the line signal for an emergency ascent is 4-4-4 pulls on the line. 12 pulls in 3 groups of 4. In fact, if a diver wants to come up the surface crew will probably get a series of pulls so fast that they couldn't mean anything else.

There's probably about another half dozen major errors in this casual chain. Others have, and will point them out.

This dive, and these poor divers will be in the diving manuals and textbooks for years. Probably as long as there are divers. Diving seems to be safe and simple these days, but we forget that all around the world, next to harbors, are graveyards filled with divers from not so long ago.

I am profoundly saddened that these two fine people died on this dive. Nobody should die as they did. RIP

[Prodigal Son]

When I'm diving the rest of the world above me "disappears".

Yep. I was lucky enough to go to the Maldives with my ex. We stayed on a live-aboard replica of a Spanish galleon- the Barutheela (I hope they fared ok in the tsunami). Three dives a day and a gorgeous meal waiting on you when you peel off your wetsuit. Water temp 30 degrees celsius. More fish than you can shake a snorkel at... Drift dives that were just surreal... Moonfish that would follow you and play in your bubbles... Complete and utter bliss for two weeks... Diving is awesome.

Enjoy your trip!

[antivenom]

I dove 186 on regular air not a trimix and never got narced...been to over 150 ft many times...never got narced...known many divers who dove pass 200 on regular air...on a regular enough basis...known divers who got narced at 60 feet...some things that take place underwater with a diver has a lot to do with the "individual's condition and their body chemistry..."...

As a diver...I don't dive with amateurs...especially those who hold MY LIFE in their hands.

[VOA]

bump

[antivenom]

I did 2 weeks aboard the Manthiri...excellent deep diving...in fact it was this trip with the Italian divers who dove past 200 regularly...did one morning dive hung their dive computers at 200 so they wouldn't trip and went further down...they would decompress get back on board and drink the rest of the day...blew my mind...I much enjoyed the 3 dives a day and left drinking for when I was at home watching a dive video.

Have you dove Sulawesi or Borneo? I only ask because I thought the Maldives was good diving but only when you went past 125 feet...out on the points to see the great numbers of pelagics...

[Prodigal Son]

Have you dove Sulawesi or Borneo?

No. Not yet ;-)

I learned to dive in South Africa. Dove in Mozambique. Turkey. Maldives. That's it so far. I'm not a rich guy but I do it when I can! I don't really like deep diving. I like the colours you see on a reef but you get more colour at less than 20 meters. After that everything starts to look blue and green. I find the life on the reef to be completely mesmerizing. Usually, a dive at about 18- 22 meters with a hint of current is ideal. I'll just cross my arms and legs and watch all the strange creatures float by. Does it for me every time.

[tomcorn]

NN typically occurs a 120 or so...like drinking one can be habituated to NN and the symptoms are less apparent. I've done bumps to 307 on air on a dare. Looking back on it it is insane to do. While you may not seize on any single dive below 200, the risks increase exponentially. Basically dives on air below 200 are playing russian roulette with the partial pressures of oxygen. Exciting but very stupid. it has been my experience that the most risk prone divers are the new diver and the very experienced diver. The new diver is at risk for his lack of experience and the very experienced diver is at risk because he will take risks that most divers won't. Dives below 200 on air is one of those siren songs that experienced divers succumb to. Every year some guy disappears at 265 off of Little John or in Cozumel.

[antivenom]

We are in violent agreement...just noting that there is no "magic number" for narcing and or death (and I do believe we are both just talking about plain old diving)...what these folks got themselves into proves many points that really have "nothing" to do with diving...but that when a person engages in an event (could even be driving a car) that can lead to a catastrophic event...then that person should do everything possible to prevent the accident.

It just seems to me that diving already has inherent dangers, then compound it with what could be easily described as a "non-rec dive" and them introduce novices, alcohol and stupidity...you have a mix that is destined for disaster.

Never would I stand by and allow a person to collect that many events described and then jump into the water...even for 20 feet. Just blows my mind...and to honest makes my nipples want to shrivel up and drop off thinking about "jumping" into THAT COLD of water...YIKES I think 86 degree water is cold after a few days of diving! DOUBLE YIKES!!!

[antivenom]

Cozumel has some pretty unforgiving currents...suck you down the wall...met some of those in Northern end of Sulawesi...those dive briefings had EVERYONE'S attention...