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The team arrived at the site and decided to conduct operations from a tree-lined shore approximately 60 feet from the identified targets. The sonar team was operating from a boat 100 to 150 feet from the shore. There are conflicting accounts as to how far the boat and diver were from shore. The team set up equipment and prepared the diver. The communications, air supply, equipment and diver were inspected and a pre-dive safety check was conducted. During that check, the diver reported he viewed his emergency air (bailout bottle) gauge, showing a reading of 2,400 psi. He then turned the knob associated with the bailout bottle on and off to show identification of its location.
The dive operation started at approximately 10 A.M. The diver went on air at 10:25, entered the water at 10:28 and reached bottom at 10:31. Two targets were searched with negative results. An order was transmitted from the sonar team to the dive communications operator to have the diver stand by while the sonar was to be repositioned to locate additional targets. The boat was moved 25 feet and the sonar was being deployed.
Shortly after the boat was moved, the diver reported he was struck by a heavy object. He grabbed the object, identifying it as an anchor. The dive communications operator requested information from the sonar team regarding an unsecured anchor. The sonar team indicated an anchor was not deployed. The diver was then instructed to start his ascent; the diver’s tender was to assist him by pulling him in. The diver then reported that he was being pulled from behind.
At this point, the diver reported he was out of air. The communications operator immediately viewed the pressure gauge on the air supply and reported no change. The diver advised he was going to his bailout bottle. The diver then reported no air coming from the bailout bottle and he was performing an emergency ascent. He dropped his weightbelt and surfaced. The recorded time the diver exited the water was 11:30. He was reported to be unconscious and cyanotic (blue, especially lips and fingers) with agonal respirations (gasping). The diver’s helmet was immediately removed by the personnel on the sonar boat. His respiration quickly increased and he gained consciousness. He was transported by a rescue boat to land and then transported to Shock Trauma Center in Baltimore.
As a result of the interviews conducted at the dive incident investigation, it was determined there was a need to test the air-supply system used during the incident. The test consisted of the umbilical, communication box and bailout bottle. At 8 A.M. on Jan. 29, 2012, Chief Louis R. Lago, Pump Operator Samuel Burrell, Lieutenant Kyle Caldwell and Emergency Vehicle Driver Andrew McAleer met at Baltimore City’s Steadman Fire Station. They collected the Kirby Morgan Superlight 17 Diving Helmet, bailout bottle, communication box and the damaged umbilical used in the dive incident. They assembled the helmet, umbilical, bailout bottle and communication box and charged the umbilical with air using two dive cylinders. The air pressure gauge on the communication box registered 145 psi.
The helmet’s air-supply knob was turned on and the pressure dropped to 120 psi. As the air continued to flow, a kink was made in the umbilical hose at the point of damage. The pressure gauge on the communication box increased to the original pressure of 145 psi, an increase of 25 psi. The bailout bottle was then activated and air flowed consistently into the helmet.
1. The operations were to take place in a remote location. The decision to only request six members from the dive team hampered operations and caused members to exceed their responsibility and span of control.
2. The sonar team did not participate in the formal briefing given by unified command. Their participation could have addressed the issue of the repositioning of the sonar and boat. There could have been clear-cut knowledge of what each participant in the operation was doing. It is unlikely that a missed communication would have occurred between the sonar team and the dive team that caused a considerably delay.
3. Based on the lack of communication between the sonar team and the dive team, there was a considerable amount of lapsed time. Once the call was received from the sonar team, it seems there was an elevated sense of urgency and rush to get dive operations underway.
4. The dive team leader was responsible for overall operations, safety officer, documenting the dive, communicating with the sonar team, and operating the communications box and air-supply control center. His span of control was exceeded and he was unable to properly oversee his personnel. The increase in pressure on the communications box should have alerted him to a problem with the air-supply hose.