DEATH OF TERRENCE LINSTON
DEATH OF TERRENCE LINSTON
In early July of 2019, I was asked to represent the four children of Mr. Terrence Linston, who died on June 29th on the Ohio River. Delise and Hall accepted this request and we immediately began our preliminary investigation to determine whether our clients had a legal cause of action. I began by contacting Terrence’s co-workers and further by interviewing those who called in response to my callout for assistance.
Following the investigation, I concluded that grave errors had occurred. Delise and Hall filed a legal claim against Terrence’s employer. Within 75 days of being hired we resolved the case for Terrence’s children at mediation on 29 September – exactly 90 days post incident.
Since the case was resolved our commercial diving community has for months asked me to provide the Delise and Hall Root Cause Analysis of this horrible event. I wanted time to pass for reasons I can not share. Here is what I can share about Terrence’s death, the bases of the children’s legal claim and my thoughts inn preventing such events occurring again.
In June of 2019 a major diving was engaged in providing commercial dive services to the U.S. Corps of Engineers at the Olmsted Dam on the Ohio River in Illinois. The diving contractor provided the vessel, dive crew and equipment to make repairs on subsurface areas of the dam.
Over the months there were operational challenges because of the cresting of the river and the currents on the project. In its DIVE OPERATIONS PLAN the diving contractor’s administrators recognized ahead of time that its [d}ives will encounter various water velocities of 0 to 3 knot, or (0-5 fps)” or 0-5 feet per second currents.
For the days leading up to Mr. Linston’s death the diver crew experienced several events where debris was causing havoc with the work and the extreme current was presenting major safety concerns for the divers in the water and the dive gear used at bottom. As a result of the problems a couple of divers “drug up” because of their concerns.
On the day of the incident the water velocity reading was documented at 4.2 to 4.50 feet per second or and equivalent of 2.49 knots. At the beginning of operation, it was learned that debris was caught of the down line to location and it was necessary for the removal of the debris by a tugboat and small crew boat. During the removal of the debris, or because of the debris hitting the down line, separation of the downline occurred.
As a result of the loss of the downline it was necessary for a diver to dive to location and re-establish the down line to the work location; that diver was Mr. Linston. The full scope of Mr. Linston’s dive was to re-establish the down line and, if he had remaining bottom time, to conduct some burning.
Mr. Linston reached bottom, re-established the down line and further set up burning gear on bottom. He then burned briefly on bottom before reporting his dive hose was fouled. Over the next minutes he attempted to un-foul his hose, he asked for slack three times and then reported that he was going back up current to attempt to clear his hose. The dive supervisor, who was communicating with Mr. Linston as the events unfolded, told the standby diver to dress out.
After reporting he was heading up current, the next sound over the comms on surface was the “free flow” sounds from Mr. Linston’s dive helmet. The supervisor then ordered the standby diver to dive; once on location the standby diver found Mr. Linston, freed him and attempted to provide assistance - first to calm him and then to assure that Mr. Linston was getting breathing gas.
The standby diver reached for his head and learned that Mr. Linston was without his helmet and convulsing. The dive supervisor ordered the dive crew to bring both divers to surface. Mr. Linston’s body was winched to surface; the standby diver climbed the dive ladder. It was revealed that the diver’s helmet was attached to the harness via the carabineer safety latch and was free-flowing. Once on surface, the dive crew attempted CPR; shortly on surface Mr. Linston was pronounced dead.
What happened and what should have happened?
Very simply stated, it was Delise and Hall’s position that diving operations should never have been conducted under these conditions, and, if operations had under emergency circumstances to have occurred, that proper JSA’s should have been conducted.
The diving contractor’s Diving Operations Manual mimics the International Marine Contractors Association (IMCA) regulations related to diving in current.
Under these regulations, here is the regulation:
Diving method [surface supply on bottom] in these currents should not be considered unless the operation has been pre-planned taking account of the presence of high current from the early stages of the project.
Special solutions involving equipment techniques and procedures should have been evolved to overcome - or protect the diver from – the effects of the current and to provide contingencies for foreseeable emergencies.
A current of 4.2 – 4.5 Feet Per Second current or 2.49 knots was recorded on the date of Mr. Linston’s death and was prevalent AND GROWING DAILY in the week prior. Techniques were put into place to recover divers such as topside’s fully coming up tight on the diver’s umbilical which had bellied out down current as the diver held onto the downline for dear life.
Unfortunately for Mr. Linston and our clients, the diving contractor grossly failed to adhere to its and IMCA’s regulations.
During my investigation I received several calls from the dive crew and was told by principal witnesses that this project was a “cluster F…” for weeks because of the current as the Ohio River crested and because of the continued shut downs and problems with the project. It was reported to me that some “more seasoned dinosaurs” had “drug up”. A couple of guys contacted by me confirmed such; some stories may have been fiction.
FOR THE GOODNESS OF ALL PLEASE DO NOT RESPOND BY IDENTIFYING YOURSELF AS BEING THERE BECAUSE THIS INDUSTRY STILL KEEPS LOGS OF “MISBEHAVING DIVERS” AND ENOUGH HARM TO CAREERS HAS BEEN DONE BY THIS INCIDENT FROM WHAT I’VE LEARNED.
Instead of responding to these continued problems in a way to provide stricter dive planning and preparations the opposite occurred. Planning meetings with Job Safety Analysis forms (JSA’s), requirements under the rules that govern commercial diving contractors, became less directed and emphasized because of low work morale and a “no one listens to us” attitude”.
In response to Delise and Hall’s claims the diving contractor suggested that Mr. Linston’s diving helmet “was not worn according to the manufacturer’s recommendations” because there was the “possibility that the helmet liner was not snapped in by Mr. Linston”. The liner was never recovered. The neck dam assembly was secured and locked into place.
Getting his helmet ripped off by debris traveling in this current had absolutely nothing to do with a helmet liner; such too may have been ripped off Terrence’s head. However, should one assume that Terrence failed to secure his helmet appropriately, we strongly replied that prior to the entry into the water it is a tender’s role to inspect and approve the dive’s helmet positioning, adjustments and fittings. Once the tender has confirmed “all is right with the diver’s hat” the tender gives a “thumbs up” to the diver and the supervisor prior to his being “clear to dive”.
According to all accounts the tender did his job correctly and gave the thumbs up. There was nothing improper about Terrence’s conduct before or during the fateful dive of 29 June.
Delise and Hall’s Root Cause Analysis
- Failure of diving contractor to assure on-site adherence to regulations of diving in current;
- Failure of diving contractor to cease operations when environmental conditions are inappropriate to diving;
- Failure of diving contractor to listen to dive team’s concerns about safety;
- Failure to employ strong JSA policies and procedures.
Such is all I am going to share publicly as some aspects of this tragedy was told in the strictest confidences and will be held in private.
What was telling and admirable is that, yet again, principal witnesses contacted me once it became known that we were heading the investigation because of our representation of Terrence’s children. This had become a trend in all of the last diver death cases we’ve handled. Once a tragedy occurs the diving community comes together and helps each other. Gone are the days – hopefully - when diving contractors “lock down”, “brow beat” and “threaten” witnesses not to speak the truth to family members or me.
How can this be prevented?
- Institute “work stop” authority;
- Communicate to your superiors and if you’re green find a buddy to help;
- Know the regulations clearly and do not be fearful to bring them up;
- FULLY PARTICIPATE IN JSA MEETING;
- Drag up when it’s too bad to remedy a safety concern.