Coast Guard Announces Results of Healy Investigation

SEATTLE – The following statements were delivered by Vice Adm. Charles Wurster, Pacific Area commander, Rear Adm. David Pekoske, the Coast Guard’s assistant commandant for operations, and Rear Adm. Paul Higgins, the Coast Guard’s director of health and safety, at a press briefing today at the Coast Guard’s Integrated Support Command:

Statement by Vice Adm. Wurster: Thank you for being here this morning. I would like to begin today’s press conference with a brief statement. Rear Adm. Pekoske and Rear Adm. Higgins will also provide brief remarks and then we will answer questions.

Let me start by saying the entire Coast Guard is deeply saddened by this accident. Our prayers, thoughts and sympathy continue to be with the families, friends, and shipmates of Lt. Jessica Hill and Petty Officer Steven Duque. Lt. Hill and Petty Officer Duque were proud, dedicated, American service members of the Coast Guard family who shared an enthusiasm for diving, and we miss them.

Since the tragic events of Aug. 17, 2006, the Coast Guard has been committed to determining the chain of events and decisions that led to this accident. The Coast Guard is committed to identifying all causal factors and is taking corrective actions.

The commandant’s final action memo, provided to you today, details the commandant’s findings in this investigation. Like many accidents, the investigation uncovered a chain of events and decisions,-which had any link been broken, this tragedy would not have occurred. As you will see in this document, there were failures at the service, unit and individual levels. The final action memo also details the commandant’s mandated specific actions to improve program management, leadership, training and overall experience in our dive program. It also restates our resolve to preclude a similar accident in the future.

As we announced from the outset of the investigation, once the facts from this accident were known and the families briefed, we would immediately provide the findings to the public. Vice Adm. Papp, the chief of staff for the United States Coast Guard, personally delivered this document and briefed the families of Lt. Hill and Petty Officer Duque earlier this week.

This Commandant’s Final Action Memo will be released to the public today, and over 200 documents and other data related to the incident are now available in the Coast Guard’s electronic reading room on the Internet. I will summarize major points from the final action memo and address accountability of the Healy commanding officer, executive officer, and operations Officer.

Rear Adm. Pekoske, assistant commandant for operations, will speak to the diving program aspects. Rear Adm. Higgins, director, health and safety directorate, will provide medical information.

An executive summary sheet was prepared to give you an overview of what happened, in summary:

At 3:55 p.m. on Aug. 17, 2006, U.S. Coast Guard cutter Healy pushed into an open water lead in the ice approximately 490 miles north of Barrow, Alaska. While not in the plan for the day, completion of an ambitious science schedule and excellent weather conditions provided an opportunity for “ice liberty” – an opportunity for the crew to disembark the vessel, stretch their legs and take a break from regularly scheduled operations.

The diving officer also sought out this opportunity to conduct a familiarization training dive with Healy’s newest divers. A dive plan was reviewed by the operations officer and executive officer and approved by the commanding officer. The plan called for all three divers to dive simultaneously using dry suits and SCUBA gear. Two consecutive dives, not exceeding 20-feet in depth, would be conducted lasting 20 minutes each.

At 4:30 p.m., “ice liberty” was granted to the crew; and was being conducted at the same time, and in the same general location, as the dive operation. Ice liberty included “polar bear plunges,” football, and consumption of alcoholic and non-alcoholic beverages. Neither Lt. Hill or Petty Officer Duque had consumed alcohol prior to diving.

At approximately 5 p.m., Petty Officer Duque arrived at the dive side (a military diving term that means the location where the divers will deploy into the water). Approximately 40 minutes later, the remaining two divers arrived. The dive officer briefed the divers and the diver tenders.

At approximately 6:10 p.m., the divers entered the water. Shortly after entering the water, Diver 3 had difficulty with the dry suit leaking, exited the water, and returned to the ship.

Lt. Hill and Petty Officer Duque continued the planned dive.

Petty Officer Duque experienced problems with his glove, briefly exited the water and warmed his hands. Petty Officer Duque returned to the water and Lt. Hill conducted in-water safety checks and they submerged.

After the divers were submerged for a few minutes, one of the tenders noted that the line sped out in a fast and forceful manner. Believing that about 100 feet of line had paid out, the tender asked for assistance in an attempt to stop the tending line from running further.

After changing out of the dive gear and into clothes, Diver 3 returned to the dive side and noted the diver tenders’ concerns. Attempts to communicate with the submerged divers failed and the tenders began retrieving both divers. The initial retrieval rate was approximately one foot per second. At approximately 40 feet of depth, the divers became visible and neither appeared to be conscious, both divers were brought rapidly to the surface, pulled from the water, and received emergency medical assistance that was unsuccessful.

It was later found that Petty Officer Duque’s air tank was empty and Lt. Hill’s air tank was at 90 psi; or essentially empty. The residual air was tested and it was good. It was later determined that approximately 200 feet of line had paid out for both divers.

The investigation uncovered failures at the service level, unit level, and individual level.

* CGC HEALY did not have a fully staffed dive team to safely conduct dive operations on August 17, 2006.
* The dive team and the command cadre failed to plan and conduct dive safety supervision and oversight as required by Coast Guard and Navy Diving Manuals. The dive side was not properly cordoned off from the recreational activities on the ice nearby.
* The divers departed from the standard procedures and safety practices required by the Coast Guard and Navy Diving Manuals.
* The overall management of the dive program aboard CGC HEALY was inadequate and did not comply with established policies.
* The overall structure, management, and implementation of the current Coast Guard dive program are not on par with other high risk operations. The Commandant has mandated specific action to improve program management, leadership, training and overall experience in our dive program.

It is clear that shortcomings at the service, unit and individual level combined to form a lengthy error chain that provided many opportunities to identify weaknesses, change direction, and prevent an accident. No single person caused this accident.

That said, responsibility of a Coast Guard commanding officer for the safety of the ship’s crew is absolute. Accordingly, considering his accountability for the day’s events, I relieved the commanding officer of his duties on August 29, 2006.

In addition, I determined that the performance of the commanding officer, executive officer and operations officer represented a serious departure from the high standards expected of officers assigned to these positions. Accordingly, I called them to account for their failure in leadership and supervision in connection with this incident. Yesterday, I imposed non-judicial punishment for dereliction of duty in accordance with the Uniform Code of Military Justice. The punishments I imposed were:

* For the commanding officer: A punitive letter of reprimand and forfeiture of one-half of his monthly pay per month for two months.
* For the executive officer: A punitive letter of admonition.
* For the operations officer: A punitive letter of reprimand and forfeiture of one-quarter of his monthly pay per month for two months.

The forfeitures were suspended. For a commissioned officer, the punitive letters have significant career impacts and trigger other administrative processes.

As I stated earlier, these unfortunate deaths were not caused by a single decision, or the failure of a single person or entity. 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. The top leaders of the Coast Guard individually and collectively, are steadfastly dedicated to making every effort to ensure it never happens again.

Once again, our thoughts and prayers are with the families, friends, and shipmates of Lt. Hill and Petty Officer Duque.

The final action memo provides the details of this accident and the corrective actions the Coast Guard is taking.

Rear Adm. Pekoske will speak to the program elements of this accident and the Coast Guard Service-wide implications.


Statement by Rear Adm. Pekoske: As assistant commandant for operations, I oversee the Coast Guard’s overall policy, doctrine, and management of the polar operations and dive programs. I am also responsible for resourcing these programs.

Accidents typically involve error chains – series of actions or inactions that collectively result in an accident.

In this case the error chain involved three levels of the Coast Guard – the service wide level – the unit level – and the individual level.

I will speak, and then I am available to answer your questions on service level issues.

The investigation revealed, among other things, the following:

* That the overall management, structure and policies of the current Coast Guard dive program are inadequate to properly guide and manage the dive program.
* The Coast Guard diving program has grown substantially over the past several years, yet our capability to oversee and manage that program from a service level – or headquarters perspective – has not grown.
* We will increase our active oversight especially our capability to conduct regular, comprehensive site visits to ensure dive unit’s gear is being properly maintained, personnel qualifications are current and standard procedures are understood and exercised.
* Additionally, the Coast Guard diving manual will be updated to provide comprehensive policy on cold water diving and the use of operational risk management in the planning of Coast Guard dive operations.
* Our personnel system needs better capability to track individual dive training and qualifications – and we need to improve our training program. We will ensure those assigned to diving duty receive the proper training.
* We will add a training module specifically dedicated to dive operations to our command and operations school curriculums for prospective commanding officers, executive officers and supervisors of dive programs.

Let me close my remarks by stating clearly that it is our obligation to honor our lost shipmates and to honor those who serve now and in the future will serve in Coast Guard diving billets by taking immediate action to remedy the deficiencies we have uncovered. We are totally committed to doing everything possible to ensure this tragedy is never repeated.


Statement by Rear Adm. Higgins: As director of health and safety, I am responsible for the Coast Guard’s medical and safety programs.

The administrative investigation revealed that each diver eventually departed the surface with over 60 pounds of weight (including lead shot and steel tank). The amount of weight used by the two divers is considered excessive. Experienced divers interviewed in connection with this investigation, diving with similar equipment, reported wearing typically 20-30 pounds of weight. As a diver descends, air compresses at a depth of 33 feet, its volume decreases by 50 percent. Therefore, to maintain buoyancy, the diver must add air to the BCD or dry suit during any descent. Thus, an over-weighted diver may be able to control his or her buoyancy on the surface, but enter an uncontrolled descent only a few feet from the surface.

In July 2005, Lt. Hill had experienced a rapid ascent from 40 feet to five feet while conducting surface-supplied dive operations in support of the ship’s “Arctic West 2005” deployment. As a result, Lt. Hill had expressed concern in the past of an uncontrolled ascent while diving. Lt. Hill typically dove with 50 pounds of weight.

Depth gauges revealed that Lt. Hill had descended to 187 feet, and Petty Officer Duque exceeded the maximum gauge reading of 200 feet. Both divers were brought rapidly to the surface. The divers were pulled from the water at approximately 6:48 p.m. and emergency assistance rendered to them. They were non-responsive to the attempts to resuscitate them. Both divers were brought to the sickbay. At 8:01 p.m. and 8:02 p.m. the divers were pronounced dead.

The post-incident autopsies reported that both Lt. Hill and Petty Officer Duque died of asphyxia with pulmonary barotrauma with possible air embolism. The opinion of the Office of the Armed Forces Medical Examiner is that “[i]t is quite likely that the divers lost consciousness prior to or during the ascent”. Neither autopsy revealed significant pre-existing medical conditions that would have contributed to the cause of death. Both divers were in good physical condition prior to the dive as evidenced by prior physical exams. Postmortem toxicology examinations for both Lt. Hill and Petty Officer Duque showed no evidence of carbon monoxide, ethanol or screened drug use.


A copy of the administrative investigation’s final action memo can be found online at the Coast Guard Reading Room.

Source: USCG Pacific Area Public Affairs

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