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It was a clear, sunny day on Aug. 17, 2006, 903 miles north of the Arctic Circle, and the crew of the Coast Guard cutter Healy prepared for liberty, having completed a rigorous scientific support mission just hours before.
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A guard had been assigned as watch for hungry polar bears, and beer — a rare treat for military personnel who hadn't seen a port in 40 days — was brought out onto the gleaming polar ice.
The crew had left their home port of Seattle on July 6, conducting operations with civilian science teams along the way. Healy, a 420-foot icebreaker, is designed primarily for research work, a giant, red steel box of high-tech gear and ice-cutting power, manned by ship handlers and marine science technicians.
For the crew, liberty meant a chance to stretch their legs, play games and walk somewhere other than a hard, flat deck.
Everyone looked forward to it, especially Lt. Jessica Hill, a 31-year-old officer from St. Augustine, Fla. Hill was the ship's marine safety and dive officer, and she had seized on the break as a chance to get some Coast Guard divers in the water. The lieutenant, on her third summer float with Healy, had been below the ice pack seven times the previous summer and was eager to submerge again in the cloudless Arctic Sea.
Weeks before, Hill had asked permission to conduct a cold-water familiarization operation for herself and other divers assigned to the ship, but the request had been denied due to the busy pace of ongoing operations. This liberty meant another chance for a plunge. Although a dive operation was scheduled in the future at Dutch Harbor, Alaska, Hill wanted the additional time in the water — for her divers and herself.
"She loved being in the water and being on boats. She loved her work," Hill's mother, Dawn Zimmerman, said.
But Hill's enthusiasm, zeal and what would later be revealed as inexperience, would cost her and the Coast Guard dearly. She and a second diver, Boatswain's Mate 2nd Class Steven Duque, died that day in the 29-degree ocean, plunging 200 feet below the ice , suffocating when they ran out of air, lungs rupturing as they were brought to the surface. In the aftermath, three senior officers' careers lie in shambles, families grieve and numerous Healy crew members are forever haunted by the day's horrific events.
This is a story about errors — specifically in matters of judgment and command responsibility, up and down the chain. It's a story of disregard for Navy and Coast Guard regulations and recommendations. It's a tragic tale of myriad leadership failures that shouldn't have to be told.
The following account of the fatal accident off the CGC Healy is based on the Coast Guard's administrative investigation, which was released Jan. 12. It also includes information from other official documents and interviews with family, Coast Guardsmen and members of the Navy's dive community.
The dive plan
The morning of Aug. 17, 2006, the sky was clear and sunny, with 28 degree air temperatures and 29-degree water temperatures. Hill, a lieutenant who'd been in the Coast Guard five years, two years on Healy, sought permission for a cold water familiarization dive. She drafted a plan that included three divers — herself, Duque and a third diver who remains unnamed by the service — conducting a scuba exercise in dry suits, bulky one-piece jumpsuits that use air to provide insulation and buoyancy.
According to the plan, the three would take part in two 20-minute dives at a depth of 20 feet, with all three in the water at the same time. Divers would be tethered to "tenders" — Coast Guardsman on the surface who served as safety handlers — as is required by the Coast Guard and Navy diving manuals. Hill routed the plan up the chain of command and, in 30 minutes, it was approved.
Hill had never taken part in a cold-water scuba dive. The previous summer, she'd had at least seven Arctic surface-supplied dives — assisted dives in which divers rely on air piped in from the surface. But she was eager to experience the freedom of scuba and train other divers as well.
Neither of the other two divers had conducted a cold-water dive.
Before the team could begin to prepare, however, the plan hit a snag. The captain previously had inquired whether regulations allowed all three divers to be in the water at the same time. Ship operations officer Lt. Cmdr. James Dalitsch again voiced the captain's concerns. Dalitsch says Hill responded affirmatively.
"I'm not sure you're correct, but I'll take your word for it," Dalitsch replied.
Had Dalitsch or Capt. Douglas Russell followed up on their initial concerns and looked up the regulations, Hill and Duque might be alive today.
The Navy Diving Manual, to which the Coast Guard adheres unless a regulation is specifically overridden by the Coast Guard Diving Manual, requires at least four divers in an operation as proposed by Hill: a buddy pair in the water, a fully equipped standby diver and trained dive supervisor overseeing the operation.
Healy has a diving allowance of six divers, but only three were on board the ship Aug. 17.
And one of them, Hill, had allowed her military dive qualifications to lapse.
"Healy's previous commanding officer signed a diving requalification letter for Hill on April 28, 2006, however, two of the four dives used to substantiate requalification were recreational dives ? not authorized to count. Hill was not qualified for diving duty on Aug. 17, 2006," the investigation report states.
Hill likely never gave her qualifications a single thought. As far as she was concerned, she was the ship's dive officer, had at least 24 military dives and she had numerous recreational dives before and during her military service. So, after she received approval, her cadre of swimmers readied for their plunge.
Party on the ice
As divers suited up for the operation, other crew members prepared for fun on the ice. They followed an established safety checklist, assigning the polar bear watch and issuing radios. They brought out the footballs and the refreshments: 192 cans of beer, 24 bottles of hard lemonade and 32 sodas.
Two beers were set aside for Hill and Duque to drink after their dive.
Liberty began at 4:30 p.m.
At nearly 5 p.m., Duque reached the dive site, an area marked off near the ship's bow. It was close enough to the ship for safety reasons, but also relatively close to the liberty site. This was Duque's first cold water dive as a Coast Guardsman. He recently had graduated from Navy Diving and Salvage Training Center and was looking forward to the experience. Duque was lanky, carrying a mere 163 pounds on his nearly 6-foot frame. For Duque, a boatswain's mate who had enlisted in 2002, the dive, and the Healy assignment were a dream. He had recently re-enlisted because he was so excited at his job prospects. Hill did the swearing in.
"He had the characteristics of being a good leader. We get sea cadets in here from time to time, and when they walk in, most people walk the other way," said a former supervisor, Boatswain's Mate Gene Daigle of Station Fort Lauderdale. "Not Duque, he headed straight toward them, wanting to make sure they got the training they needed.
Duque set his gear down on the ice — an act frowned upon by Navy divers because it can cause equipment to cool or ice up in the water — and chatted with personnel who moved in and out of the operational area, like attendees at a tail-gate party.
He even lay on the ice as he waited for Hill and the third diver to arrive at the site.
Forty minutes later, Hill and third diver, referred to as Diver 3 in reports, arrived at the operational area. Hill had previously recruited four crew members as dive tenders, and she launched into a briefing for the four would-be handlers. According to the investigation report, none of the handlers wasqualified for the task.
Duque's tender, for example, had worked several surface-supplied dives the previous summer, but had no scuba tending experience. None of the other three had ever assisted with a dive, and all three had only recently reported aboard the ship.
To make matters worse, Hill's tender had consumed a beer, the report said. The fourth tender, who wasn't responsible for a person but stood as backup, had consumed three (Coast Guard regulations state that personnel can have no more than two beers during ice liberty). Yet preparations for the dive proceeded.
Hill briefed the tenders on line signals they might receive from her and the other divers. All four tenders remember her saying that one pull on the line meant 'OK,' two pulls meant give slack, three pulls meant take in slack and four or more pulls signaled trouble.
Those instructions, however, were not exactly correct. According to the Navy Diving Manual, one pull on descent means "stop." None of the four tenders recall Hill telling them this important piece of information. It may well have gotten her and Duque killed.
Because of the ill-defined pre-dive briefing, there was no way for the tenders to know what exactly what Hill later meant by one pull as she slipped under the ice. Nor could they look it up, because a Navy Diving Manual wasn't located at the dive site, as is required.
One dive expert who has read the investigation report thinks Hill, for some reason, was freefalling below her intended 20-foot depth, and was signaling for tenders to stop giving out line. They didn't understand, or misunderstood, the request. They kept giving out line.
Despite these deviations from Navy regs, preparations continued for the operation. Around 6 p.m., the three divers were ready. Their choice of gear — single air tanks with no backup or "pony bottle" supply of air, split fins that provide speed and thrust but lack lift, and weights zipped into the pockets of their gear, instead of weight belts that are easily jettisoned in emergency and are recommended in the Navy Diving Manual — is questionable, experts say.
"Certainly these are poor practices at the least," said Jeremy Stewart, a supervisor at Canada's Freshwater Institute who has dived hundreds of times in the Arctic.
And they had packed on the pounds. In 2005, Hill had experienced an uncontrolled ascent — a danger that can cause trauma to the lungs or hurl a diver into the ice. It had scared her. To ensure it didn't reoccur, she loaded herself down, adding more than 60 pounds to her 130-pound frame, including air tank, suit and lead.
Duque also loaded with the same amount, 60 pounds, after complaining he was "floating too much."
Near the surface, the extra weight may have felt appropriate. But at depth, the added weight poses a danger: When divers descend, air in their tanks and dry suits compresses, its volume decreases by 50 percent at 33 feet of depth. Such changes require divers to compensate for added weight with buoyancy devices or by adding weight to their suits, a tricky maneuver for the inexperienced.
"That's a lot of weight they were carrying. I can tell you, I've gone down hundreds of times, and I never carry more than 30 pounds, maybe 50 total with gear," Stewart said.
Hill and Duque hadn't anticipated dealing with buoyancy issues, so they zipped in weights and didn't hook up their buoyancy compensator devices. They would use the fill mechanism on their dry suits if they needed to add air for buoyancy.
As all three checked their gear in the water, Diver 3 experienced a gear malfunction. Her suit was leaking, and she couldn't locate the source. Disappointed, the diver, who had never experienced the Arctic's chills and thrills, got out of the water. She returned to the dive locker to find another suit, but when she realized that ice liberty was coming to an end, she changed back into her uniform.
At the dive site, the operation continued with equipment checks. Duque's gear was acting up: His gloves were leaking and his hands were cold. He exited the water to warm his hands and receive new glove liners, but he was unable to make the approved dive signals with his hands, including touching his fingers to his thumb in a "O" for OK. Hill told him to use a thumbs-up signal as a substitute.
Stewart said that was just one more critical mistake.
"Wow. Cold hands could render a tending line useless for communicating, as a diver needs to grasp the line to respond or transmit a line pull," Stewart said.
Impaired manual dexterity also would present a challenge if a diver needed to add air to his dry suit, manage zippers to jettison weight or drop a weight belt.
"A dive should be terminated upon the onset of involuntary shivering or severe impairment of manual dexterity," the Navy Diving Manual reads.
According to the investigation report, Capt. Russell saw Duque warming his hands, but said nothing. The boatswain's mate returned to the water and he and Hill finally submerged.
Divers disappeared quickly
No one knows exactly when the pair went under. There was no dive log at the site — another breach of Navy regulations. But the two went in, and tenders soon lost sight of them. While the plan called for the divers to submerge to 20 feet, a depth at which they likely could be seen in the crystalline Arctic waters, they disappeared fairly quickly, the tenders told investigators.
Hill gave her tender a short, single pull at roughly 3 to 4 feet, which he took as meaning "OK." He continued to pay out line, but once the divers disappeared, Hill's line began to run. The tender gave a series of pulls, which he believed was the proper way to ask whether Hill was OK. Each time, she responded with a single pull.
"The tenders said in the [accident] report that when Hill's line was paying out they got a single pull — if that was true, it was Hill saying stop me -— she was asking for help!" said retired Navy Master Chief Boatswain's Mate (MDV) Ernie Caltenback, a former 36-year master diver who has also worked as a safety observer for the Army's 10th Mountain Division in Fort Drum, N.Y.
Roughly two minutes after the two divers submerged, Duque's line also speeded out, fast and furious. It ran so quickly that his tender asked others for help controlling it. It paid out for roughly 15 seconds, according to the tender. Then it slowed for a few seconds and continued to pay out at an even faster rate. With roughly 100 feet out, Duque's tender, attempted to stop it, but needed help from the extra tender. The tenders attempted to signal Duque with a tug on the line, but he never responded.
While the tenders puzzled over their tasks, other Healy crew members finished up ice liberty. A few took forbidden "polar bear plunges" near the dive site and continued a game of football. The CO began wrapping things up. He had indulged in one beer, while the XO had two and the operations officer, nearly three, the report concludes.
It was time to begin the day's final tasks.
Few had been paying much attention to the ongoing dive operation, that is, until the third diver returned to the site and noticed the amount of missing line.
She barked an order to send the divers a signal of four pulls, meaning "Come up." A nearby chief noticed the activity and moved toward the operation. He told the diver and tenders to bring Hill and Duque to the surface. At 6:45 p.m., the tenders started pulling, at a rate of 1 foot per second, a rate considered safe and adequate. But as personnel grew more concerned, the pace of retrieval increased, and with it, risk of injury or death increased.
Pulmonary barotraumas occur when air in a diver's lungs expands with ascent. Divers, and even swimmers, must not hold their breath when ascending in water. Other injuries can occur as well, including decompression sickness or the bends.
Duque and Hill came into view at roughly 40 feet below the surface, tenders estimate. Once they were pulled out of the water, both were unconscious and without vital signs. Personnel leapt into action, performing resuscitation techniques, unsuccessfully. According to a Coast Guard officer familiar with the investigation, as the two were being worked on, Russell reportedly walked over to Diver 3 and told the young ensign, "You're in charge."
In an hour, Healy had learned the treachery of world's harshest environment.
Uncontrolled descent
Much has been learned in the aftermath about what happened to Hill and Duque. Their depth gauges indicated that they had entered into an uncontrolled descent, with Hill going to 187 feet and Duque pegging his gauge to at least 220 feet.
When they were pulled from the water, Duque was out of air, and Hill's tank was essentially empty. The air was tested, and found to be good. But the two had suffocated and experienced lung injuries on the trip back to the surface. The coroner said it was likely the two lost consciousness before or during their ascent.
Caltenback, the former master Navy diver, said he's not surprised they died by asphyxiation.
"The report says they were using fancy fins that weren't designed to give a lot of thrust, so I can see them struggling and still sinking — unable to dump weights and eventually passing out when their air was gone because the deeper you go, the faster you use air anyway. Add them struggling to swim up [and] the air goes even quicker," he said.
Perhaps, if Healy had a decompression chamber onboard, the two may have survived, dive experts contend. Sometimes, divers who are clinically dead can be revived with minimal injury, especially with proper equipment.
"I've seen it happen before," Caltenback said.
Healy had only a special stretcher that limits recompression depth to 60 feet. It is designed for transportation, not treatment. Most Navy salvage ships carry both stretchers and recompression chambers, Caltenback said.
"When the Navy goes on arduous or high-risk dives, especially under the ice, they bring recompression chambers because they don't take chances," he said. "How the hell are you going to get out of there and to a treatment facility in time? You can't. You have to bring it with you."
In addition to lacking a recompression chamber, the Healy's dive locker room was described in after-action reports as being in severe disarray. No dive safety survey had been conducted on the ship since its commissioning in 1999. No preventive maintenance system records were found since 2002. Most of the nonserviceable gear was mixed in with the working equipment.
"The investigation ? revealed failures in oversight at every level aboard Healy as well as numerous departures from standard Coast Guard policy," commandant Adm. Thad Allen confirmed in a statement Jan. 12. "When it comes to dangerous operations such as diving, "good enough" is never good enough."
On Aug. 25, Coast Guard chief of staff Vice Adm. Robert Papp suspended all Coast Guard ice diving operations, saying they wouldn't be resumed until the investigation was complete and follow-on recommendations are implemented.
Based on the report, the Coast Guard's diving program faces a long recovery process, if it isn't outsourced to another military service or civilian dive outfit. The report makes a number of administrative recommendations and changes to procedures, policies and oversight.
Allen has held the three officers, Russell, Jackson and Dalitsch, accountable, first by firing Russell and sending all three before an admiral for non-judicial punishment.
Yet despite the investigations, reports, summaries and actions, no one really knows what exactly happened that day under the ice. Did Duque enter into an uncontrolled dive, and Hill pursue to help? Were both in an uncontrollable tailspin, unable to take emergency action? Could they have been saved, even once they'd reached the surface without vital signs?
"From reading this, it sounds like they were free falling, sinking and because they were wearing so much weight, they couldn't counter that with buoyancy," Caltenback surmised. "Their only chance was to be stopped by the tenders."
In the days after the tragedy, Hill and Duque were returned to the sea. Both were buried in the tropical, aqua-blue waters off their home state, Florida. For many military and civilian divers, the deaths of Duque and Hill will forever remain an enigma, even as they benefit from the lessons learned of the accident.
"I'm still puzzled," Stewart said. "How the same thing could happen to both divers is a mystery."
