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5. The dive team was unfamiliar with the new sonar equipment.
6. The dive team recently developed a new system for storing and transporting the umbilical. It consists of wrapping the hoses in a circular pattern in a handled bucket. This has been determined to weaken the interior fibers of the air-supply hose, causing it to be more susceptible to kinking.
7. The bailout bottle was inspected at the fire station, but not bled to remove residual pressure in the hose. When the pre-dive check was conducted at the dive site, the gauge indicated 2,400 psi, which was the air pressure in the hose; however, the bottle was never turned back on.
8. The diver failed to properly proceed with his safety check. He checked his bailout bottle gauge and activated the knob. He should have activated the knob, then checked the gauge. Had he followed the proper procedure, he would have notice a drop in pressure once he activated the knob. This would have alerted him that the emergency air cylinder was not on.
9. The primary diver’s tender failed to recognize the diver did not follow the proper procedure during the pre-dive checklist. Had he proceeded through the checklist with the diver, he would have noticed the proper procedure was not followed. He would have alerted the diver to recheck his bailout bottle. The tender is an additional safety mechanism to assure the diver is familiar with the equipment and the equipment is operating properly.
10. The boat operating the sonar was moved while the diver was close. It is unclear whether the anchor was completely retracted or was allowed to drift underwater. Possibly the boat was relocated to a deeper area of the reservoir and the anchor did not reach the reservoir bottom.
11. A review of training records indicated that many of the divers have an inadequate number of training dives.
12. The dive team should increase the number of active divers to be determined by Special Operations Command. The team should include support personnel to be trained for surface activities to include, communications, line tender, diver preparation and equipment familiarization.
13. The National Oceanic and Atmospheric Administration (NOAA) Diving Manual should be used as a guideline for the operation of the dive team.
1. During dive operations, the dive team supervisor should not participate in any activity associated with the dive. He should oversee all aspects of the dive operations assuring the procedures are followed. He should closely monitor all communications, assure silence during the dive, guide all operational aspects of the dive and monitor all safety checks.
2. When the Baltimore City Dive Team is activated, all members of the team who are available should participate in the operation. It is increasingly important when operations are conducted at a remote location that an adequate number of personnel are assembled to meet any challenge. This incident should have had a minimum of 10 dive personnel to assist with the operation.
3. The breathing-supply system, including reserve breathing-gas supplies, masks, helmets and thermal protection, must be inspected before each dive. For surface-supplied diving, the breathing-supply system equipment inspection includes diving umbilicals.
4. Stowing the umbilical in a plastic barrel should be discontinued. The coiling caused the umbilical to become twisted tighter until the assembly kinked.
5. A complete set of standard operating procedures (SOPs) should be developed for the dive team. They should include recruitment, staffing, equipment, training and operations.
6. The pre-dive check list should include a step that requires the diver to physically turn on the bailout bottle knob and record the pressure on the gauge. The pre-dive preparation should include a document that outlines the pre-dive checklist. The primary diver’s tender would check off each step of the pre-dive safety check confirming that the proper checks are made in the correct order. This would provide a written document of the action.