Divers died as party went on above

It was a frigid, clear Arctic evening last August, 500 miles north of Barrow, Alaska, when Coast Guard divers Steven Duque and Jessica Hill slipped through the thick ice and into the 29-degree water.

Hill, lead diver for the Seattle-based Coast Guard icebreaker Healy, hoped for a routine training dive. But Arctic diving is hazardous in the best of conditions, and these were not good conditions.

According to the Coast Guard's investigation, released Friday, the dive's untrained support team — some of whom had been drinking beer moments before — misinterpreted Hill and Duque's distress calls. Dive equipment, which had not been inspected for years, failed. Hill and Duque made a critical error in carrying 60 pounds of lead weight, twice as much as normal. And all this happened as an afternoon party with alcohol, an ice football game and "polar bear" swims went on above them.

Instead of a brief dive at 20 feet, Hill and Duque dropped like stones, to 200 feet or more. By the time the crew realized something was amiss, Hill and Duque had run out of air.

An investigation into the deaths — the first deaths of Coast Guard divers since 1974 — has prompted a wholesale review of the Coast Guard's dive program, and cost the Healy's captain, Douglas Russell, command of his ship.

"No single person caused this accident," Vice Adm. Charles Wurster, head of the Coast Guard's Pacific fleet, said at a news conference in Seattle on Friday. "Rather it was a chain of events and decisions, which, had any link been broken, this tragic accident would not have occurred."

The investigation found oversight of the Coast Guard's dive program was so lax that the Healy's dive equipment failed to meet one-third of safety standards during a review after the deaths. Coast Guard dives were halted after the deaths, and restarted only after all 17 dive units passed inspections.

Nathalie Duque Bello, Steven Duque's older sister, said their family is distraught that the 22-year-old's death was preventable. Graduating from the elite Navy dive school was Duque's proudest moment, and he had tattooed the Coast Guard motto — "semper paratus," or "always ready" — across his lower back.

"We were very shocked that the Healy was so unprepared," Bello said

from the family's home near Miami. "We're talking about diving in the open ocean, the Arctic Ocean."

The Healy, the Coast Guard's newest ship, sailed from Everett last July with a mission to accommodate four teams of scientists doing research on the Arctic.

The 84-member crew sailed three divers short of its full six-member dive crew, and did not have enough trained support staff to safely accommodate dives, according to the 27-page investigative report. Hill, 31, had 29 previous dives, but had let her certification lapse the previous May.

On Aug. 17, 40 days into the trip, the Healy's captain granted his crew an afternoon of "ice liberty" — an icebreaker's version of shore leave. After assigning crew members to polar-bear watch, 192 beers, 24 bottles of hard lemonade and a football were retrieved from the ship's "morale locker," and the crew and some scientists headed out on the ice for football and dips in the frigid water.

Amid the party, Hill got permission for a training dive to boost the experience of Duque and a third diver. The plan called for a 20-minute dive, no deeper than 20 feet. The third diver aborted after her dry suit leaked; Duque's glove also leaked, but he continued.

The Coast Guard diving manual calls for the tender line — a safety rope for each diver — to be monitored by another diver. But with the dive team short-handed, untrained crew filled in. Two of the four-person tender crew had been drinking beer before the dive.

In a previous dive, Hill had an uncontrolled ascent of 40 feet. This time, she and Duque tucked an unusually large amount of lead into zippered pockets of their buoyancy vests and, for unexplained reasons, did not connect their air tanks to the vests, which could have helped stop a sharp descent.

A few minutes into the dive, the tender lines for both Hill and Duque fed out quickly. Larry Phillips, a marine geologist from Tacoma, saw Duque's line feed out so fast it jerked out of the tender's hands.

"I think he descended so fast it was beyond the capacity for the diver to swim that fast," Phillips said.

In Coast Guard dive protocol, a single tug on the tender line means "stop." But the tender crew misinterpreted a series of single tugs by both divers, and continued feeding out line until Hill's was nearly empty.

That triggered alarm, and the tender crew began pulling up the divers. They were unconscious when first spotted at 40 feet, and did not respond to CPR.

The divers' depth meters indicated Hill was at least 200 feet deep and Duque reached 187 feet. An autopsy found that they died of asphyxia, and possibly air embolisms from the rapid ascent. Rear Adm. Paul Higgins, a doctor, said on Friday it was unclear why the divers dropped so fast.

"They may have not been able to jettison the weight. We may never know," Higgins said.

After the investigation, Vice Adm. Wurster cited the captain and two other commanders for "dereliction of duty." He did not refer the case to court-martial, but said other disciplinary action may follow. "The captain had 8,000 days of excellent service, and one very bad day," Wurster said. The tender crew members will not be disciplined.

Although the Coast Guard manual calls for annual inspections of equipment and personnel training, the Healy's dive unit had not been reviewed since it was launched in 1999. Coast Guard officials said oversight did not keep pace with a rapid expansion — from five dive units to 17 units — after the Sept. 11, 2001, attacks.

As a result of the deaths of Duque and Hill, all Coast Guard units were checked and dive training was added to the Coast Guard's school for commanding officers. The Coast Guard icebreaker Polar Sea, which is stationed in Antarctica, got extra attention with an administrative liaison from Coast Guard headquarters sent to ensure that the unit was safe.

Bello, Duque's sister, praised the Coast Guard's frank assessment of its failures and hopes that openness will continue in dive programs. "They were very honest. They cut corners," she said. "We hope the way they did this investigation, that's the way they'll do it now."

Jonathan Martin: 206-464-2605 or jmartin@seattletimes.com