by Don Heres:
The Water Looks OK. Are You Willing To Stake Your Life On It?
Riding in the passenger seat of the truck pulling the dive team’s equipment trailer always gives you a chance to (somewhat) relax and plan the upcoming dive operation. Although your team is new, with only a couple of easy operations under its belt, it is made up of divers with plenty of open water experience. They are confident, capable and excited to be playing a part in the county’s expanding services role.
Today’s op however, is the type of call every responder dreads. Seven days ago, the five year old son of a prominent citizen disappeared while riding his bike around the neighborhood. Until today, there had been no clues as to his whereabouts. Early this morning, a golfer found a small shoe on the bank of the water hazard on the number 6 hole at the exclusive Bushwood Country Club. The shoe was similar to the type the missing boy was wearing on the day he disappeared.
Driving through the entrance of the finely manicured front gate, you are taken aback by the scenic beauty of this place. Today it is definitely above your pay grade, but thirty years ago it was rolling farmland where you hunted and rode your minibike. These manicured fairways and immaculate greens are a far cry from the corn and potatoes that were once grown here. Even the old farm ponds have been turned into scenic works of landscape art. Gently rolling fairways, perfect greens, blooming azaleas and the new green foliage on the trees complete a visual spectacle that makes golf courses in the spring something to behold, definitely a playground for the rich and famous.
Upon pulling into the parking lot you are met by a Who’s Who of local dignitaries, each with a look on their face that ranges from concern to angry impatience. The county manager, the sheriff, the fire chief, the mayor and several council members are there to brief, complain, and question your plan. Terrified family members gather around each other and watch in disbelief as you drive by. The local news channel’s van is parked in the main lot. It has its satellite dish aimed skyward and Danica Pomeroy, that cute reporter, is primping in its side mirror getting ready for a live feed as you drive by. As if the pressure being exerted by county officials was not enough, you cannot help but notice the 30 or so golfers all standing by the clubhouse looking impatiently at their watches as their appointed tee times have come and gone. You somehow did not expect this kind of pressure as you departed the station. To add to the surreal nature of being at Bushwood, you are practically assaulted by the course marshal and greens keeper when you tell them you will have to drive the equipment truck to the dive location. You are again accosted with the “hurry up, but don’t damage the course” attitude.
Upon arrival at the dive location you are pressed to make decisions quickly under the penetrating gaze of the county manager and the other officials who have followed you there in a parade of golf carts. They all know the missing child’s family, and each has surely received phone calls reminding them of that fact. You quickly decide that this is a simple search dive, probably more for show than anything else. Hopefully, you can get in and out quickly, without finding anything. It makes no sense that that the missing child would be in this location. It is well away from roads and several miles from his house. By donning wetsuits and simple open-circuit SCUBA gear, you can get divers into the water quickly and appease the impatient onlookers. These old ponds are usually 10-12 feet deep with sediment bottoms, so it will be a quick, easy search, even though recent spring rains have you a little concerned about visibility. Using two experienced divers and two tenders to assist, they quickly don their equipment and enter the water.
Within minutes, a surface marker appears in the middle of the pond. A muddy cloud also appears at the surface. Knowing this is not good, you ask law enforcement officers to clear the area and to secure the perimeter. EMS is called forward and tarps are brought out to mask what will probably unfold shortly.
Underwater, your divers have discovered the decomposing body of a young male, wrapped with heavy chains around him and his bicycle, resting on the bottom. Excited and fueled by a combination of semi-panic, adrenaline and the urgency to hurry that often follows the discovery of something ghastly, the divers drop to their knees and begin to try and dislodge the combined mass from the mud. Without communications gear, and feeling hard-pressed to recover the body quickly, the divers decide to remain submerged and press on. By using a small lift bag, they reason, they can lift the entire mass as a single package, thus maintaining the integrity of the grisly evidence. Getting the lift bag straps under the collection of metal and human remains requires digging a trench through the sediment with their hands. Visibility drops as the sediment cloud envelops the two divers. With no real current in the pond, the cloud seems to linger like a morning fog before eventually falling back to the bottom.
The yellow lift bag breaks the surface along with the divers accompanying it. The body is moved towards shore, and EMS and law enforcement take custody and begin their processing procedure. Realizing the two divers have been exposed to the biological hazards of a decomposing body, you expedite their exit from the water and begin washing them with fresh water from a nearby yard hydrant. Tenders mix a 5% solution of sodium hypochlorite and water and begin scrubbing all of the outer surfaces of their dive equipment in an attempt to kill any biological residue. The divers use soap on their skin and hair after removing their wetsuits. With the pressure off, another dive team, dressed in drysuits, full-faced masks and communications gear enter the pond to continue searching for evidence.
As your team prepares to depart, you are offered congratulations and compliments by the County officials who have been watching the operation. They felt your professionalism and rapid deployment helped bring a delicate situation to an end. After cleaning the equipment that was used, your team members disperse with many, like yourself, heading towards home and dinner. While relaxing, the events of the day run through your mind. Although rushed you feel you were able to lead a successful operation and bring closure to a grieving family.
As you start to walk up the stairs toward your bedroom, the phone rings. On the other end you hear crying, and the wife of one of your first-in divers tells you that her husband is in the Emergency Room after collapsing and going into convulsions right after dinner. As you drive towards the hospital, the questions start rolling through your head. What happened? Was it related to today’s dive operation? What did I miss?
As a training exercise, stop here and take out a piece of paper. Evaluate the preceding scenario listing all of the errors made during the operation, but most importantly list the root cause of each mistake. Mistakes in operational protocols are usually relatively easy to pick out for experienced dive team members; however, determining the root cause of errors sometimes takes a more detailed evaluation. It is imperative that anyone operating in “contaminated water” be able to see beyond the obvious. By not only evaluating what was done wrong, but also why it was done wrong, you as a team leader have the ability to be “pro-active” rather than simply taking “reactive” corrective actions.
First and foremost, this is a “contaminated water” dive. “Contaminated water” is simply what the term “Bad stuff” or “MEBS” (Methyl Ethyl Bad Stuff) was to HAZMAT teams before the implementation of CFR 1910.120 (HAZWOPER) in 1986. Like the term or not… this is a HAZMAT dive. It is no different than when a member of a Hazardous Materials Response Team dons a fully encapsulated Level A chemical suit to enter a hostile environment. It is time that divers recognize truly just what “contaminated water” really is, and the implications it may have on PSD’s. Simply camouflaging the term “HAZMAT” with catchy buzz words does not degrade or lessen the dangers of chemicals that may be present. Some of the potential HAZMAT problems are obvious, other are not.
While the team’s lack of practical training is obvious and plays a major role, let’s by-pass this for a moment and look at what is perhaps the biggest factor that contributed to the eventual negative outcome… pressure. From the outset, the dive team leader (DTL) was being pushed and pressured to hurry. The prominence of the missing child, the number of high ranking officials on-scene, the media, the presence of distraught family members, even the impatient golfers all contribute to the pressure the DTL was feeling to expedite the operation. This pressure also trickled down to the initial dive team as even they felt the need to hurry. This external pressure can, and did, force decisions without proper evaluation or size-up.
The point here is that you cannot be rushed… period. To the untrained observer, or “operationally ignorant”, it may appear that things are moving slowly for no reason. This lack of knowledge by observers is often expressed in the form of anger or impatience. It is not uncommon to hear things such as, “What are you waiting for?” or “Hurry up and just jump in the water, what’s so difficult about that?” It is up to the DTL to evaluate the scene and insure the safety of all personnel, not appease the crowd. Establish an operational dive plan and stick to your SOG’s. Under no circumstances should the priorities of others be allowed to compromise safety.
Another root cause of the negative outcome could very easily be contributed to complacency. In this case, the tranquil and scenic surroundings did not look like a crime scene. It apparently did not fit into the crime scene image visualized by the DTL. In this case his preconceived ideas immediately led him to believe this was probably a false alarm and that they would find nothing during their search. Complacency is a deadly trap and must be avoided. As any CSI will tell you, there is no such thing as a typical crime scene. Any dive, especially where the primary objective is looking for a body, must be treated as if a body will be found. Additionally, ponds, lakes and streams are likely to have a variety of wildlife decomposing on the bottom. Even a diver, changing the zinc anodes on the fishing trawler at the dock behind the local coastal seafood market will encounter fish carcasses rotting on the bottom. All of these biologicals pose a potential health threat that cannot be ignored.
Next let’s consider the team’s apparent lack of Standard Operating Guidelines. Guidance documents are critical to insure safety. These documents are developed, reviewed, and modified to address how a team will operate during a variety of situations. During early planning and strategy meetings, dive team members have the opportunity to evaluate the type of diving they are trained, equipped, and willing to do. Once these boundaries are established, procedural guidelines are put into place to provide a step-by-step roadmap that leads to a safe conclusion. They should be flexible enough to adapt to any situation, but rigid enough to insure that safety is neither by-passed nor compromised. “Contaminated water” diving is nothing new. The U.S. Navy, the EPA diving program, and PSD teams across the country have already established SOG’s that embrace entering contaminated water. Books, such as ERDI’s Contaminated Water Diving Operations by Michael Glenn, research and information published by Viking and DUI, have introduced divers to the dangers of “dirty water”. In the scenario above, it is apparent that SOG’s have neither been developed nor followed. The decision to use open-circuit SCUBA appeared almost to be off-the-cuff, because it was simple and fast. Diver safety and evidence recovery were compromised. If contaminated water SOG’s had been in place, no diver would have entered the water without appropriate protection from biological hazards… at a minimum.
In your opinion, was a comprehensive size-up and scene evaluation conducted? It is imperative that a complete and thorough evaluation of the dive location be conducted before any dive operations begin. A dive operations plan will pivot around this evaluation. The initial size-up conducted by the DTL was better suited for Golf Digest than a dive operation. Even the DTL’s own memories of the location provided valuable clues as to the potential dangers associated with the location, but were quickly discarded. He remembered the location as farmland where potatoes and corn grew. Both of these crops relied heavily on DDT-based pesticides to control insects. Even though DDT was banned in the 1970’s, it is a very persistent chemical that leeches into soil and sediment. Years of use would cause the pesticides to run into farm ponds and settle into the sediment at the bottom. These farm ponds would later become water hazards at Bushwood. As if ancient pesticides were not bad enough, golf courses do not just magically become landscape marvels. They require amazing amounts of fertilizer, herbicides, pesticides, and other chemicals being applied year round. Of the 30 most commonly used turf pesticides, 19 can cause cancer, 13 are linked to birth defects, 21 can affect reproduction and 15 are nervous system toxicants. Studies are even being conducted to determine the health effects of these chemicals on golfers. Warnings have been issued for golfers to wear long pants and long socks when playing to prevent contact with these chemicals. The most popular and widely used lawn chemical, 2,4-D, which kills broad leaf weeds like dandelions, is an endocrine disruptor with predicted human health hazards ranging from changes in estrogen and testosterone levels to thyroid problems, prostate cancer, and reproductive abnormalities. 2,4-D has also been linked to non-Hodgkin’s lymphoma. With the “recent spring rains” (i.e. the “first flush”), these chemicals wash into the same water hazards and also accumulate in the sediment, the same sediment the first dive team was aggressively working in. The same sediment that enveloped the divers in a dirty cloud while on the bottom. The same divers who entered the water wearing, what amounts to, recreational SCUBA equipment and worked feverishly in the cloud of hanging sediment. While biological hazards were indeed a problem, it appears that hazardous chemical problems were never even considered. Nothing can pose a threat to divers more than an inadequate scene size-up. Failure to carefully evaluate the scene leads to missed clues. Sometimes these clues are obvious, but a lack of training and knowledge can make them invisible. Only by training DTL’s, as well as team members, to properly conduct a size-up that extends beyond dive parameters, can we minimize the likelihood of a diver suffering a chemical related injury.
Most of you have probably already concluded that this particular team was inadequately trained to be conducting the operations in which they were engaging. Not only is inadequate training a serious root problem, it appears that a lack of knowledge about the type of training necessary may also be contributory. Diving, especially PSD diving is not diver friendly. Forget the beautiful, crystal clear open waters of the Bahamas. In public safety diving, visibility and mobility would be considered a luxury, as farm ponds and hog lagoons seldom offer either. PSD diving is always in the wrong place and at the wrong time. Why else would you be there? Simply acquiring diving equipment and recruiting experienced open water divers does not make for a successful dive team. In fact, it probably does just the opposite. Most open water divers complain when visibility drops to 10-15 feet. Operating in zero visibility creates a whole new set of problems for inexperienced “toilet water” divers. Fear and panic are the most common. Many problems will render a team operationally ineffective. Any team that begins operations without mastering the multitude of training required to operate in an overtly hostile environment is asking for problems such as the one described. Today’s firefighters are being required to obtain Firefighter I & II Certification through standardized agencies such as International Fire Service Accreditation Congress (IFSAC). This requires firefighters to master a variety of skill and knowledge challenges before they begin responding to actual emergencies. Additionally, they must attain HAZMAT Operations Level Certification to be prepared for the fact that they will inevitably encounter dangerous materials. The above scenario presents the case for establishing a mandatory certification program that guides public sector dive teams. Technical dive training that insures the proper use of drysuits, full face masks, and surface supplied air are obvious. Contaminated water training should also be mandatory, just as HAZMAT is for firefighters. Again, whether you like the term or not, contaminated water is HAZMAT. Unlike diving in the open ocean, there are very few inland water bodies that do not hold the potential of serious contamination. Any dive, no matter what the objective, should be treated as if there are contaminants in the water. Home and farm chemicals wind up in streams, lakes and ponds. Rivers, such as the Hudson in NY, may be contaminated with PCB’s or a variety of TIC’s (Toxic Industrial Chemicals).The Cuyahoga River in Ohio is so polluted that in 1969 it actually caught fire… for the 13th time. Transportation accidents can introduce innumerable chemicals into the water. Operating in these contaminated waters not only poses a risk to the diver, but also to tenders and support staff that may assist divers as they exit the water, which means team training needs to extend beyond just protecting the divers. Training that prepares DTL’s to better assess the hazards of a dive location are needed. Dive team members have to be trained in such a way that they can recognize hazardous water environments and insure their own safety. OSHA’s CFR 1910.120, the Hazardous Waste Operations and Emergency Response Standard applies to “employees” who operate in chemical environments or respond to situations where hazardous chemicals may be present. The EPA’s 40 CFR 311 mirrors the same mandatory requirements as put forth in OSHA’s HAZWOPER. Responders as a whole often shy away (better stated as RUN away) from HAZMAT training as misconceptions usually lead responders to believe it will be a detailed study of chemistry, physics, and math. It is not. While HAZMAT is obviously rooted in the advanced sciences, it is more of an acquisition of knowledge and the application of common sense. We live in a petro-chemical society, chemicals are everywhere. Simply put… chemicals are not going away, so we as divers need to accept this and “improvise, adapt, and overcome” to move forward, continue doing our jobs, and return home safely every night
The ERDI course, Contaminated Water Diving Operations, is an excellent first step towards recognizing the dangers associated with diving in “dirty water” and gaining a necessary competence in the subject matter. The objective of the program is to help divers establish recognition and planning methods for contaminated water diving.
Don Heres was certified in 1977 and after graduation from NCSU he worked for 6 years doing commercial diving and ship husbandry along the east coast. He has spent 30 years as a Firefighter, Officer, and Fire Service Instructor, retiring from active response as an Assistant Chief. He served as the Lead HAZMAT Instructor for the NC Office of the State Fire Marshal where he developed the original Hazardous Materials Responder Certification and HAZMAT Instructor Qualification programs for North Carolina and served on the Governor’s Committee that developed the NC’s HAZMAT Regional Response Teams. He also served as the Hazardous Materials Coordinator for Wake County Emergency Management where he was responsible for HAZMAT planning and SARA Title III Programs. Today he continues to teach Firefighters and owns Hazard-Risk Management Associates in Clayton, NC a company that specializes in OSHA Safety and training hazardous materials responders in both the public and private sectors. He continues to be an avid diver.