No one failure can be blamed, but each contributed to a series of events resulting in a tragic loss to the families, friends and the Coast Guard. Their deaths will not be in vain if the actions proposed by the Coast Guard resulting from this investigation are implemented and no other family will go through what we have experienced.Indeed, this is paramount, that we improve our processes so that this does not happen again. As I've noted before, Admiral Allen is pulling the Service along to be a true "learning organization." We must learn from our mistakes, and we must learn from our successes. While the Coast Guard has, for years, done "more with less," perhaps it is time for us to do "less with more" and focus on getting it right.
And, now, a good and balanced story by Jonathan Martin in the Seattle Times. While some other news stories have been loud and have focused on a single element or two, Mr. Martin's story is a good, balanced overview. He doesn't ping on one or two specific causes for the accident, but rather puts the entire accident chain out there.
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.And, indeed, it was an accident chain. Like most of these types of incidents, break any one link, and we would have had a different outcome.
For me, one of the things the finding highlights is process, management, and leadership issues. The diving program has always been small, and unique. Too often, in other programs, there is a laissez faire attitude; things become common place and we take things for granted.
It is time, perhaps, for us to not cut corners as a service, but to realize we need to be fully staffed and need to do what we need to do with more people, more resources, and more time.