PUBLIC SAFETY DIVER KILLED DURING TRAINING TRAINING NEGLIGENCE – INAPPROPRIATE RESCUE
PUBLIC SAFETY DIVER KILLED DURING TRAINING
TRAINING NEGLIGENCE – INAPPROPRIATE RESCUE
Root Causes of Incident:
- Improper Training Protocols for Public Safety Divers
- Inappropriate Rescue Protocol In Place
- Malfunctioning gear.
Delise and Hall represented the surviving wife and two children of JD, a 37 year old public safety diver (PSD) trainee who died during a class sanctioned by a major international diving certification organization. JD, a U.S. veteran and member of major metropolitan fire department, died during the 22nd dive of the training program.
Delise and Hall filed suit against the certification organization alleging that the training program created an unreasonable risk or harm to its students and such was a proximate cause of JD’s death. Delise and Hall further claimed that the training organization failed to establish and implement an effective rescue protocol which contributed to the incident.
The PSD class was sanctioned and designed by a major international diving certification organization. JD drowned during the final class exercise. Specifically while attempting an evolution that required him and his partner to locate a cinder block underwater and then raise that block using an air filled five gallon bucket connected to the block with a rope and a carabineer.
During the evolution, JD became affixed to the block and ran out of air. Due to a non-functioning communications system, of which his instructors were aware, JD was unable to relay his situation to his dive partner or topside. As a result of a lack of standardization of equipment, poor training, zero visibility, and extremely cold underwater temperatures, JD was unable to access emergency air supplies or free himself.
Multiple independent diving agencies, both private and public, investigated JD’s drowning and their conclusions can be summed up in an oft repeated theme: “divers are being accelerated beyond their capabilities”. “Too much, too fast” is the underlying theme of this entire tragedy.
The course in question was designed as a six week, 160 hour course comprising 50 sessions of classroom instruction, along with pool sessions and several open water dives covering the many aspects of public safety diving. The purpose was to certify the fire and law enforcement agents to be capable of responding to emergencies underwater.
The course in question differs vastly from those courses designed for and offered to recreational divers who typically undergo less than ten hours of classroom instruction, four or five pool sessions and four dives typically spread over two days. In fact, the recreational course is often taught in its entirety in a weekend or two. The recreational course is taught in calm, clear, usually warm water under the direct supervision of an instructor under controlled conditions. Divers successfully completing the course are capable of undertaking dives under benign conditions, such as are typically found in diving resort locations.
JD’s class was anything but benign. The instructor was attempting, under the auspices of a recreational course, to train divers to work in conditions that, according to instructor, were almost always extremely dangerous. This course attempted to train individuals, in just a few weeks, to do what the Navy and commercial dive academies spend months, if not years, teaching.
The training at issue began with an application process in which twenty-three (23) fire and police personnel were nominated by their respective supervisors and authorized to undertake the course. Each student’s fees were paid by their various employers.
Before being selected as a dive class participant, each student had to pass rigorous physical screening consisting of various timed runs, swims, breath hold swims, watermanship skills, and other physical events such as push ups, sit ups, etc.
The equipment utilized by the students was provided by the individual departments in accordance with a list supplied by Instructor. The individual items of equipment were inspected and approved by Instructor, who in his deposition admitted responsibility for ensuring that the equipment was safe. Notably, Instructor and his assistants were well aware that JD’s communication equipment was not working.
Details of the accident and failed rescue attempt are well understood and largely indisputed as the on-surface portions were videotaped. Additionally, nearly twenty (20) witnesses were deposed and largely agree as to the events.
The morning of the dive, began with a dockside meeting on the shore of the quarry, a 5 acre private, murky quarry created during excavation of fill material. The students in the class had previously made shallow dives but had not been exposed to the depth, zero visibility, and frigid temperatures associated with this day’s planned dive evolution. It is significant the instructor specifically intended to expose the students to deep water, cold temperatures, and zero visibility. The students, however, were not warned of these conditions.
Once on site, a briefing was given which included a short explanation of the day’s evolution. Specifically, the students were told that a cinder block with two air-filled jugs would be sunk within 10 feet of a buoy. The students in a timed event were to descend in teams of two in the immediate vicinity of the buoy. Once on the bottom they were to establish a search pattern to locate the cinder block. Once the block was located, the students were to cut loose the air-filled jugs signaling surface personnel that the block had been located. Thereafter, the students were to attach two lengths of line to the block and to a five gallon bucket. The bucket was then to be filled with air from the diver’s air tank, thus lifting the cinder block to the surface.
The students were allowed a dry run of this evolution on shore but significantly were never allowed the opportunity to practice in a controlled underwater environment with visibility or to practice while wearing their scuba gear or using the gear configuration that would be utilized underwater.
The staging area from which the class was operating consisted of the dock, a beach, and a loading ramp. One of the staff assistants, selected by Instructor, utilized a boat and placed buoy markers 30 to 40 feet apart in a straight line at a depth of approximately 50 feet. The buoys were counter-weighted so that depth could be adjusted. The staff then sank each cinder block assembly within 5 to 10 feet of the marker buoys. Individual teams consisting of two students were transported by boat to a buoy. Once there, the teams were told to wait on the surface until the signal was given to start the evolution.
JD and his dive buddy comprised team number six of the six teams in the second group of dive teams to attempt the evolution. Upon command, they descended on the buoy line to the bottom at a depth of approximately 50 feet. Once on the bottom, the buddy stayed at the buoy and allowed JD, to whom he was tethered, to move away from the buoy in a sweep search for the cinder block and jug. Visibility was zero. Communication was possible only through touch. After two sweeps, JD signaled with two tugs on the line held by his buddy that he had located the block who followed the line held by JD to JD’s side. Upon his arrival, JD and his buddy exchanged two squeezes on the arm to indicate that they were ok. Because JD’s communication system was inoperative, the team could not otherwise communicate.
JD’s buddy cut the line releasing the jug to the surface. The team had been underwater nearly twenty minutes. JD’s buddy then, in a kneeling position on the bottom began to attach his five-foot lanyard to the cinder block using a shackle. While in the process of inserting a pin into the shackle, JD’s buddy experienced what he perceived as JD pulling on his (JD’s buddy’s) mask. This was a prearranged signal to indicate that a diver was out of air and wished to share his partner’s air. JD’s buddy rolled to his side where he then felt JD’s weight belt drape over his arm. Unable to feel or hear JD, JD’s buddy then headed to the surface.
Although the course in question had been taught for several years, this was the first attempt to raise a partially embedded cinder block in deep, cold, black water. Investigators reviewing this class, evolution and resulting accident concluded that Instructor created an “unsafe training environment,” conducted training “inconsistent with industry standards” and “accelerated students beyond their capabilities”. They found the skill in question to be “contradictory to positive learning”.
The botched rescue was due to the training agency’s failure to follow even the most rudimentary rules of search and rescue. Once the training agency’s instructors learned that JD was in trouble, it still took over two hours to find him. Notwithstanding the fact that JD was attached to (or located within 10 feet of) a surface buoy, and despite the presence of numerous “trained” instructors and most of the underwater search and rescue equipment existing in that part of the state, all of which was at the quarry when the emergency arose, the rescue still took over two hours. Hence, what should have been a successful rescue, tragically turned into a body recovery search.
The first indication that something was amiss should have come long before the alarm was raised. In fact, one of instructors commented on videotape: “I bet they’re about out of air.” This comment was made at about 12:40 p.m. after the divers had been down for 21 minutes. More than another three minutes passed before JD’s partner, surfaced with JD’s weight belt. The Instructor and his staff knew JD and his partner had a limited amount of air and based on the time and depth of their dive, they should have been called to the surface. In fact, when another dive team surfaced at 22 ½ minutes into the same evolution, they aborted the dive, reporting only 1,000 psi of air remaining in their tank, which is the minimum amount of gas a diver should have left in their tank when they finish an evolution. It was abundantly clear that both JD and his buddy were dangerously approaching their limits. Without an effective recall system or working communications, there was no way to signal the team to the surface. Further, due to the zero visibility conditions and the nature of the evolution neither JD or his buddy would have necessarily been aware of the amount of time they had spent underwater, the depth, or amount of air remaining in their tanks.
The first overt sign of trouble came when JD’s buddy surfaced with JD’s weight belt and indicated to personnel on the boat that he did not know where his buddy was. The time was 12:43 p.m. A safety diver immediately descended the buoy line marking the area where JD and the cinder block were located. Notably, because the safety diver traced the buoy line to the bottom, he was aware that JD was not tangled in the buoy line. The line was clear and significantly within 10 feet of JD’s location. Shortly thereafter, the Instructor, who admitted this action, can be overheard on the radio transmission explicitly giving the order to raise the buoy. Such order by the Instructor is a blatant breach of the primary commandment of any search and rescue protocol, which is always to mark the last known location of the victim. That process is often hampered by the vagaries of witness memories. However in this case, the would-be rescuers had a preplaced buoy that they knew marked accurately JD’s location.
Not only did raising the buoy destroy the reference point, but it snagged the safety diver, bringing him rapidly to the surface causing him to suffer DCS and aborting what likely would have been a successful search, recovery and rescue. Once the buoy reference point was destroyed, the search continued without success for over two hours until JD’s lifeless body was finally located utilizing fishing sonar and a boat borrowed from the property owners.
The certified instructor, who tracked air consumption on earlier dives, was well aware that his students had different air consumption rates, which is also affected by the depth and the difficulty of the task. Instructor was also aware that JD, in particular, tended to have a high consumption rate.
When recovered, JD’s lanyard, which he had been instructed to transport by clipping it to his vest, was still so secured with the other end attached to the block. He apparently ran out of air while securing the free end to the cinder block, found himself unable to adequately communicate his need for air to his buddy, and drowned while attempting to swim with the block to the surface. The autopsy also found that JD had embolized as a result of the expansion of the air in his lungs either while he attempted to ascend or during the body recovery. Had JD been located and surfaced in a timely fashion, he would have had a chance. As it was, Instructor’s botched rescue attempt condemned JD to death.
JD was not the first local law enforcement agent killed while undergoing the certification agency’s sanctioned training under the guidance of the instructor at fault. Just 22 months earlier, a local police department student drowned during a continuing education training dive. Specifically, he was conducting an underwater search when he became entangled in lines buoyed to the surface and drowned and/or embolized while trying to regain the surface. Significantly, NIOSHA investigated this accident and found fault with the way in which Instructor conducted the evolution and offered numerous recommendations over a year prior to JD’s death.
Shamefully, the investigation following the death of JD found that many of these recommendations had still not been followed, including gear standardization and those regarding communications and redundant air.
Litigation over JD’s death continued over a number of years. Delise & Hall personally inspected and dove and videotaped the incident site, interviewed all available witnesses, conducted over twenty depositions, reviewed thousands of pages of documentation and training manuals. The case was settled for the maximum insurance limits near the eve of trial. As part of the settlement agreement the certification agency changed significantly it’s standards and procedures.