Wednesday, November 22, 2006

Ghosts of the abyss. From 20 feet to Davey Jones' Locker.

Lt. Jessica Hill, one of two Coast Guard divers who mysteriously died during a so-called routine training dive in the frozen Arctic on 17 August 2006 sank uncontrollably as far as 190 feet below the icy surface and suffocated, according to an autopsy summary released to The Associated Press on Tuesday, 21 November 2006.
Lt Hill and BM2 Steven Duque had slipped into a patch of open water near the ship's bow and were planning to dive to a maximum depth of 20 feet, in support of Arctic Research Operations onboard the Coast Guard Cutter Healy 500 miles north of Point Barrow, Alaska.
According to an informed source, a support team was supposed to hold ropes attached to the divers lest they became disoriented under the ice.
The Coast Guard has released little information about the deaths but relieved from command the Healy's Commanding Officer, Captain Douglas G. Russel, citing a loss of confidence in his ability. A spokesman said the Coast Guard would not discuss Hill's autopsy report pending the outcome of its investigations, expected next year.
The autopsy summary, written by Armed Forces Regional Medical Examiner Stanley D. Adams, said Hill suffered "an uncontrolled descent to a possible depth of 189 feet."
The amount of air in the divers' tanks would have lasted a half-hour at 20 feet, but only 10 minutes at 180, the report said. By the time Hill, 31, and Duque, 22, had been pulled up, their air tanks were empty or nearly empty, the report said.
The dive support team reportedly pulled the divers to the surface after becoming concerned; attempts to resuscitate the two failed.
The autopsy ruled Hill's death an accident. The cause was asphyxia, lung trauma caused as pressure decreases during ascents, and possible air bubbles in the blood.
It is quite likely the divers lost consciousness prior to or during the ascent. Adams added that his findings must be squared with investigations into the state of the divers' equipment and into the circumstances of the dive.
The autopsy summary also noted that a third diver planned to take part, but immediately aborted the dive for reasons that are not mentioned.
The icebreaker Healy was sailing through the Arctic with about 35 scientists to collect data that would help them map the ocean floor. Hill was the ship's dive officer, as well as the liaison between the scientists and the crew.
Lt Jessica Hill's father, William Hill Jr, of St. Augustine, Fla., said he plans to ask an independent pathologist to review the autopsy results.
His daughter's birthday would have been Monday, 20 November. she would have been 31 years old.
May God bless her and her grieving family.



Blogger ichbinalj said...

39nholdin writes:
Diving operations are the responsibility of the Diving supervisor, Master Diver, Diving Medical Officer and ultimately the C.O. Qualified tenders would never let out 190' of life-line in any SCUBA open ocean dive! The divers must have been unattended. In addition was a required Buddy Line used? Were the divers equipped with Bouyancy Controls or just weights? There are established line jerk signals and no doubt communications diver to diver and topside. Were predive checks accomplished, including Dive plan briefing, Comm checks and equipment verified certified man safe? Was the breathing medium confirmed safe and free of Carbon Dioxide and Carbon Monoxide? In that frigid environment a divers hot water (life support) system would be in use. If it was in use did it fail leading to hypothermia and imminent death? No mention of a diver stage being utilized for the divers to stand on for desent and assent. My condolences to the families for this tradegy resulting from incompetency. I suspect this tradegy was the result of poor planning, poor supervision and unqualified tenders. It should not have happened. This brings back memories of U.S. Navy Saturation Diver Barry Cannon during SELAB in the late 1960's. This should result in all Coast Guard Deep Sea and SCUBA divers retrain and requalify as NEC 5342 at Navy Diving School, Panama City, FL.
Warm Regards and Safe Diving,
J. Work MMC/SS(DV) USN Ret. NEC:5342/531

7:10 PM  
Blogger ichbinalj said...

Vanir97 writes:
Obviously we are not being told the entire story. Why didn't the other diver notice something was wrong when the one diver started decending beyond the planned 20 foot limit. Why wasn't neutral buoyancy maintained? Safety line not secured for 20 feet? Why not? And this was the dive officer? Sounds like nothing was planned out at the start. An accident just waiting to happen.

7:12 PM  
Blogger ichbinalj said...

dbutterbaugh writes:
I think there were two possible causes. (1) possible contamination of the air supply (this has happened to me on a trip once) (2) One of the individuals had a problem and the other attempted a rescue but was down to deep by the time he or she reached the other diver.
As far as letting out to much rope, if the above crew were not trained in Hard Hat diving procedures then it could have happened. It was a shame they did not have HOOKAH type masks equipped with intercom. Artic diving is very dangerous for many reasons. Any dive attempted without maximum safety equipment and proceedures is at a high risk.
But in all honesty all I am doing is guessing, I was not there and cannot judge. My deepest Sympathy does to both families. Semper Paratus!

7:14 PM  
Blogger ichbinalj said...

Chalkblock writes:
It SOUNDS like there is a lot of hidding of Information here. A lot more personnel needs their heads on the chopping block, other then the Capt.

I know it is his ship and he is responsible for everything, be he or she is ONLY one Person and can not be everywhere at once.

To the family I hope you get the WHOLE STORY and Sorry for your LOST.

7:16 PM  
Blogger ichbinalj said...

drslouha writes:
The missing info in conjunction with the relief of the CO indicates a significant deviation of standard policy and removes the possibility indigenous involvement. Having been on the short end of a few Alaskan “reactionary” operations myself, I’m sure there are quite a few of us out there who are very familiar with how forgiving the arctic can be towards un-preparedness.

1991 while stationed the Storis key personnel undertook Human Error Accident Reduction Training, which was focused on identifying error “links” that could lead to an error “chain”. If no tending line was used, the Safety Officer should have terminated the operation prior to entering the water. The list of errors is to long, the accident could not have happened if any one of the many variables were acted on. In the ordnance rate this would be tantamount to an un-intentional discharge of a weapon. Analytical bull cracky aside, I’m saddened at times at the direction my Coast Guard seems to be slipping. The “Goat Locker” is tasked with the smooth & safe operation of the CG, senior enlisted have the daunting task of ensuring those senior have the complete information package to base the direction that will lead to a safe Mission Complete.

My heart and prayers go out to the families of these two professionals. It’s not easy getting diver certified, they had the desire, the drive and understood the risks involved. Like all young Coasties, they lived life large.


7:20 PM  
Blogger ichbinalj said...

MLB377 writes:
I hope, at a minimum, that CGIS and the OIG have been assigned this incident to investigate. I'm not a diver, but I'm a 20 year police veteran. This incident stinks bad and needs to be properly investigated and brought before not only HQ, but Congress. I'm so sorry this happened. God bless the families and friends.

semper paratus

7:22 PM  
Blogger ichbinalj said...

peter3_1 writes:
Contamination of the air is my first guess too. Even a 190 ft. vertical dive on air would not have left BOTH unconsious and unable to react, even if they were on air rather than a gas mix. I have worked at 165 ft. on air with no ill effects. Something else went wrong that we don't know about.

7:24 PM  
Blogger ichbinalj said...

poconnor71 writes:

GROSS Negligence., and it is sickening.

7:25 PM  
Blogger ichbinalj said...

The proximate cause of most accidents onboard ship is human negligence, or equipment failure due to human negligence.

8:04 PM  
Blogger ichbinalj said...

ROADHOG53 writes:
What a horrible thing to happen.How could any one with an ounce of gray matter not know too much rope was out?? My Prayers go out to the family also. Somebody on that ship screwed up real bad and will hang for this one!

6:37 PM  
Blogger ichbinalj said...

Report: Coast Guard Arctic Diver Died of Trauma to the Lungs; Rapid Ascent Suspected
By News Service

Seattle, Washington (2006-11-21 19:10:30 EST) One of the two Coast Guard divers who perished in the Arctic last summer died of trauma to the lungs — a condition caused by rapid ascent — and possibly had dived deeper than planned, her father said Tuesday.

William Hill Jr., of St. Augustine, Fla., told The Associated Press that he finally received the autopsy report for his daughter, Lt. Jessica Hill, two weeks ago, but couldn`t bear to open it for several days.

"It was pulmonary barotrauma — trauma to the lungs — that was the immediate cause of death," Hill said. "There was speculation they were much deeper than they should have been, but why that happened I don`t know. The official report will go into much more detail about that."

Pulmonary barotrauma is caused by the rapid expansion of air held in the lungs, which can occur during ascents as pressure outside the body decreases. The family of Hill's diving partner, Boatswain's Mate Steven Duque, could not immediately be reached to confirm whether that was also the cause of his death.

The two died Aug. 17 about 500 miles north of Alaska, and the results of two Coast Guard investigations into the matter are not expected to be released until next year. A spokesman for the Coast Guard said Tuesday the agency was not releasing any information on the autopsy.

Hill, 31, and Duque, 22, of Miami, were shipmates on the Seattle-based icebreaker Healy, which was sailing through the region with about 35 scientists to collect data that would help them map the ocean floor. Hill was the ship`s dive officer, as well as the liaison between the scientists and the crew.

During a break in operations, she and Duque slipped into a small patch of open water near the Healy`s bow to conduct a cold-water training dive. They were tethered to the surface by ropes, lest they become disoriented under the ice, and were monitored by a support team.

Their dive plan called for them to descend 20 feet, Hill`s father said. Duque had never before gone diving in the Arctic, and only had been in a dry suit once before — while at the Coast Guard dive school in Panama City, Fla., he said.

2:14 PM  
Blogger ichbinalj said...

January 08, 2007

Healy investigation results may come this week.

By Patricia Kime
The Coast Guard is expected to release the results of its investigation into the deaths of two crew members of the icebreaker Healy by the end of the week, a family member confirmed Sunday.

Dawn Zimmerman, mother of Lt. Jessica Hill, said service officials notified her of the investigation’s wrap-up and have scheduled meetings with her family members.

Also contacted was the family of Boatswain’s Mate 2nd Class Steven Duque, who, along with Hill, died Aug. 17 during a cold-water familiarization dive roughly 500 miles north of Barrow, Alaska.

Autopsy results released to the families in November showed that Hill died of pulmonary barotrauma, or acute lung injury, which occurs as a result of rapid or excessive pressure changes.

According to statements released by the Coast Guard following the accident, Hill and Duque were conducting a training dive in a patch of open water off the ship’s bow at the time of the accident.

The dive plan called for the pair to descend to roughly 20 feet. A Navy officer who read the preliminary accident report, however, said the pair’s depth gauges indicated they descended to between 180 to 200 feet.

A descent or ascent at those depths would present challenges to the divers who were wearing dry suits, which use air pockets for insulation and provide buoyancy.

While effective against the 32- to 34-degree water temperatures, variable-volume dry suits are bulky and can restrict movement. According to the Navy dive manual, disadvantages to dry suits include increased swimmer fatigue due to the suit's bulkiness, a danger of a malfunction with the inlet and exhaust valves and a need for a diver to use additional weights with the suit to ensure neutral buoyancy.

Divers using dry suits must release air from the suits to control ascent. At the same time, they are required to exhale and follow decompression procedures to prevent injury to the lungs or nitrogen buildup in the bloodstream, according to Cmdr. Rich Mahon, head of the Undersea Medicine Department at the Naval Medical Research Center.

According to former Healy commanding officer Capt. Douglas Russell, Hill and Duque were tethered by lines to the surface during their dive and monitored by a support team.

The two were pulled up when the dive tenders detected “a problem,” Russell said. Medical personnel worked for more than an hour to revive the pair, but the two never regained consciousness.

Hill was the ship’s dive officer. The deployment was her third aboard the 420-foot icebreaker. It was Duque’s first.

Russell was relieved of command shortly after the accident. His senior officer, Pacific Area commander Vice Adm. Charles Wurster cited “loss of confidence” in Russell’s abilities to lead as the reason for the firing.

Healy’s new commander is Capt. Tedric R. Lindstrom.

The Navy dive manual states that cold-water dive operations must be deemed “operationally essential” before they are undertaken.

The manual also says divers must be tended, are required to use a buddy system and have a standby diver available.

Coast Guard divers attend Navy dive school and use Navy training and operations materials to plan and execute their dives.

Hill and Duque both graduated from the dive school at theNaval Diving and Salvage Training Center, Panama City, Fla.

Zimmerman said she looks forward to receiving the investigation results because it means she no longer must wait for answers. But she also downplayed the importance of its results, adding she thinks it’s more important to remember her daughter as a "real girl" who giggled, loved people and was dedicated to her work.

"She was never sophisticated or haughty. She loved being in the water and being on boats. She was so smart and yet she could be so silly. She was always a fun person," Zimmerman said.

After Hill was buried at sea, Zimmerman decided to memorialize her by planting a cutting garden of roses and other blooms in Jessica’s favorite color — pink — outside a window at her Florida home.

Zimmerman works in it often.

“It does help, when I’m having a hard time, to dig deep in my garden. And [Jessica’s] is really thriving,” Zimmerman said.

11:57 AM  
Blogger ichbinalj said...

From: Allen, Thad Admiral
Sent: Friday, January 12, 2007 3:05 PM
Subject: Commandant's All Hands - Final Action on CGC HEALY Mishap
To the men and women of the Coast Guard:
On 17 August 2006, we lost two of our shipmates assigned to CGC HEALY, LT Jessica Hill and BM2 Steven Duque, in a tragic diving accident in the Arctic. There are valuable lessons to be learned by all of us regarding leadership, risk management, training and program oversight that apply to all Coast Guard operations. Therefore, I am directing all personnel to read my entire report. To help ensure public access to the report on the Internet, Coast Guard members with access to a CG Standard Workstation should view my report posted on CG Central at: ( Anyone without CGSW access can view a copy of the same report online at: (
Consistent with my commitment to the families of LT Hill and BM2 Duque, each family was provided a copy of my report and has been personally briefed by the Coast Guard Chief of Staff, VADM Papp, earlier this week. We once again express our deepest sympathies as the entire Coast Guard continues to mourn the loss of these two dedicated, hard working individuals. Please keep them, their families and the HEALY crew in your thoughts and prayers. I understand that there is nothing which will make up for the loss of LT Hill and BM2 Duque. We will honor our lost shipmates by taking timely action, at all levels, to improve our dive program.
In addition to this administrative investigation, a Commandant's Vessel Safety Board has been convened to prevent any similar mishap in the future. Its work is ongoing. The results of that mishap analysis will be disseminated via ALCOAST upon its completion in the coming months.
Concurrent with the public release of this investigation today, the Pacific Area Commander, VADM Wurster, is briefing HEALY crewmembers and the media in the cutter's homeport of Seattle. As the convening authority, VADM Wurster has taken action to hold HEALY's Commanding Officer, Executive Officer and Operations Officer accountable for failing to meet their personal responsibilities surrounding this mishap.
This is a brief summary of what occurred. In the late afternoon hours of 17 August 2006, three Coast Guard divers from HEALY attempted to conduct two, 20-minute cold water familiarization dives at 20-foot depth during an ice liberty stop in the Arctic ice approximately 490 nautical miles north of Barrow, Alaska. After one of the divers exited the water due to equipment malfunction, the other two divers continued the dive in 29-degree Fahrenheit waters. The divers quickly descended to depths far exceeding their planned depth, one diver descending to 187 feet and the other diver descending to at least 220 feet. Once it became evident that too much tending line had paid out to support a 20-foot dive depth, the divers were brought to the water surface. The divers were recovered with no vital signs and were pronounced dead after extensive resuscitative efforts failed. Final autopsies report cause of death for both LT Hill and BM2 Duque as "Asphyxia with pulmonary barotraumas with possible air embolism" (lack of oxygen with severe air pressure damage to the lungs, including possible air bubbles in the circulatory system).
The bottom line is that this dive should have never occurred. The investigation revealed numerous departures from standard Coast Guard policy that should have precluded diving under the circumstances. Had HEALY's Commanding Officer, Executive Officer, Operations Officer and dive team followed policies established in Coast Guard and Navy Diving manuals, they would not have permitted diving operations.
HEALY had only two qualified and current divers that day; this dive evolution required at least three qualified and current divers, and one qualified Dive Supervisor not actually diving. Additionally, the Diver Tenders were not qualified. Despite these problems, the dive plan was approved by the Commanding Officer without a pre-brief, an operational risk assessment or any medical evacuation plan, as required by Coast Guard and Navy policy.
A critical factor in the loss of the divers was that neither diver wore a weight belt, as required by the Navy Diving Manual. Instead, both divers carried approximately 60 pounds of weight in the pockets of their buoyancy compensation devices (BCD), approximately 2-3 times more weight than normally used by experienced divers in similar cold water and ice dive conditions. The BCD has pockets to carry and, if necessary, jettison weight. However, LT Hill and BM2 Duque filled not only the weight pockets, but also the equipment pockets of the BCD. Thus, much of the divers' weight was not easily jettisonable. Although LT Hill had some experience diving in the Arctic, this was her first SCUBA dive in the Arctic. This was BM2 Duque's first cold water dive.
Adding to the risk of the operation, the ship was holding "ice liberty" at the same time, and in close proximity to the dive evolution. The ice liberty included "polar bear plunges," football and consumption of both alcoholic and non-alcoholic beverages. Neither LT Hill nor BM2 Duque consumed alcohol prior to diving.
The deaths of LT Hill and BM2 Duque were preventable and resulted from failures at the Service, unit and individual levels. The investigation revealed failures in leadership within the chain of command aboard HEALY, as well as numerous departures from standard Coast Guard policy. Had a proper risk assessment been conducted, this tragedy could have been avoided. As a Service, we failed to exercise sufficient programmatic oversight of the dive program, including failures to adequately staff our dive units and conduct annual dive safety surveys. This mishap further highlighted our need to improve dive expertise in unit dive lockers and address shortfalls in dive program policy, guidance, training and experience. As a result, we will elevate program management on par with other high risk, training-intensive operations such as aviation. A comprehensive list of the corrective actions I have ordered, including those that have been completed, is contained in my report posted online.
We cannot prevent every Coast Guard casualty. Despite the professionalism, bravery, and dedication of our workforce, in rare cases we suffer a serious injury or death in the line of duty. As Coast Guard men and women we accept that risk, but we will not accept preventable loss or injury. This tragedy has prompted us to re-examine our dive program to ensure it is as well managed and safe as such inherently dangerous operations allow. The safe conduct of Coast Guard training is fundamental to Coast Guard readiness. Without it, there can be no successful Mission Execution. When it comes to dangerous operations such as diving, "good enough" is never good enough. We can do better. We will do better.
The sacrifices LT Hill and BM2 Duque made in service to their Nation will never be forgotten. Their loyalty and dedicated service will forever be appreciated by the U.S. Coast Guard.
Admiral Thad Allen
This and other All Hands from the Commandant are posted on the Coast Guard Internet Home Page in the Commandant's Corner (WWW.USCG.MIL/COMDT) and on the OURCG Tab of CGCENTRAL at HTTP://CGCENTRAL.USCG.MIL.

4:58 PM  
Blogger ichbinalj said...

Crew Members Drinking Beer Before Deadly Coast Guard Dive.
The Associated Press

Crewmembers assisting a training dive that killed two Coast Guard divers in the Arctic were untrained for the job and had been drinking beer during a partylike leave beforehand, an official investigation said today.
The two divers, from the Seattle-based icebreaker Healy, also were loaded with too much weight before entering the water and plunging to about 200 feet, nearly 10 times further than intended.
Coast Guard Lt. Jessica Hill, 31, of St. Augustine, Fla., and Boatswain's Mate Steven Duque, 22, of Miami, Fla., were killed in the Aug. 17, 2006, accident, about 500 miles north of Alaska.
Their deaths were the result of a chain of mistakes, said Vice Adm. Charles Wurster, the Coast Guard's Pacific area commander.
"Had any link been broken, this accident would not have occurred," Wurster told a news conference.
That included the untrained "tenders," who were monitoring the divers from the ice above. Two of the tenders drank three beers or less during an "ice liberty" before the dive, the Coast Guard's report said.
The Healy was sailing through the Arctic with about 35 scientists to collect data that would help them map the ocean floor. Hill was the ship's dive officer, as well as the liaison between the scientists and the crew.
Shortly after the deaths, the Healy's commander, Capt. Douglas G. Russell, was relieved of duty and reassigned to administrative tasks. His superiors cited "a loss of confidence in Russell's continued ability to command."
Russell and other officers in charge of the ship received official reprimands or admonitions, Wurster said.

7:15 PM  
Blogger ichbinalj said...

Dive Officer was unqualified. Crew Tenders were drunk.
Lt. Jessica Hill reported aboard CGC HEALY on 6/23/04 for her first afloat tour. She had qualified as a Basic Diving Officer at NDSTC on 5/11/04. As the Diving Officer she was responsible for the safe conduct of all diving operations, training,and the supervision of all diving operations. Prior the fatal dive on 8/17/06, she had conducted 24 dives; none with SCUBA. This was her first cold water SCUBA dive. She had limited military dive experience. Her currency dive qualification had lapsed on 5/15/06. Lt. Hill was not qualified for diving duty on 8/17/06. The Dive Plan that she submitted for the dive on 8/17/06 did not name anyone on the surface as Diving Supervisor, or as Standby Diver, or as a Buddy Diver or Diver Tender. Nevertheless, the Dive Plan was approved by the Commanding Officer.
The dive occured while the crew was on ice liberty playing football and drinking beer. The CO drank at least one beer; the XO drank at least two beebs; the Ops Officer drank about two and one half beers; and, the Dive Tenders also drank several beers.

7:51 PM  

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