Exclusive: Coast Guard Deaths Were Preventable

Jan. 12, 2007 — -- A report released today sheds new light on the mysterious deaths of two U.S. Coast Guard divers killed during a training dive in the Arctic last summer. According to the report, the divers may have carried too much weight that they could not easily jettison in an underwater emergency.

Coast Guard investigators said the tragedy was preventable and resulted from a "failure" of the command staff and dive team to "properly plan for and execute" a standard cold water dive.

"We are totally committed to doing everything possible to ensure this tragedy is never repeated," said Real Admiral David Pekoske, the Coast Guard's assistant commandant for operations.

Thirty-one-year old Lt. Jessica Hill and 22-year-old boatswain's mate Steven Duque were killed Aug. 17, 2006, during what was supposed to be a routine training dive. The deaths -- the first Coast Guard diver fatalities in 30 years -- occurred about 500 miles north of Barrow Alaska. The divers were assigned to the Coast Guard icebreaker Healy.

'Numerous Violations'

The report cited "numerous violations of [Coast Guard] and Navy diving manuals," including inadequate preparation, improper use of the diving equipment, inadequately trained diver tenders, and a failure to ensure proper supervision and " redundancy " of the "dive capability in case of emergency."

Each of the divers carried approximately 60 pounds of weight-- twice the recommended amount-- in the pockets of their buoyancy compensation devices, or BCDs, the report says. The BCD provides neutral buoyancy underwater, using a combination of air pockets and weights.

Hill and Duque "filled not only the weight pockets but also the equipment pockets of the BCD. Thus, much of the divers' weight could not be easily jettisoned," the report says.

Soon after beginning the dive, Hill and Duque rapidly descended as much as 220 feet, according to the report. Dive tenders on the surface, who monitored ropelike lines connected to the divers, became concerned that too much tending line was being let out too quickly. They brought the divers to the surface at 6:48 PM. Despite efforts to resuscitate them, both divers were pronounced dead at about 8:00 PM.

An autopsy found the cause was a "lack of oxygen with severe air pressure damage to the lungs," according to the report, which notes that Hill and Duque were still carrying all the weight they had when they started the dive.

"The amount of weight used by the two divers is considered excessive," said Rear Admiral Paul Higgins in a statement released by the Coast Guard. Higgins is the Coast Guard's director of health and safety.

Higgins said that experienced divers typically wear 20 to 30 pounds of weight, but that Hill usually dove with about 50 pounds of weight, perhaps because of a rapid uncontrolled ascent to the surface she had experienced a year earlier.

Harsh Words for Command Staff

The report notes that neither diver wore weight belts, as required. In addition, the investigation found that not enough qualified dive staff was on hand during the dive. The dive tenders, for example, were not qualified.

But the report also has harsh words for the Healy's command staff. The ship's captain, executive officer and operations officer "failed to exercise leadership and supervision expected," in the words of the report.

"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," investigators found.

The ship's captain, Cmdr. Douglas Russell, was removed from command shortly after the incident.

"These unfortunate deaths were not caused by a single decision, or the failure of a single person or entity," said the Coast Guard's Pacific Area commander, Vice Admiral Charles Wurster. "We have learned many things from this accident. In years to come, when we look back on this tragedy, it will, without question, be seen as the distinct and positive turning point in the Coast Guard dive program."

In a statement, Hill's family said that "no one failure can be blamed, but each contributed to a series of events resulting in a tragic loss to the families, friends and the Coast Guard. 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."