- THE FUTURE OF THE COAST GUARD DIVE PROGRAM

[Senate Hearing 110-1068]
[From the U.S. Government Publishing Office]

S. Hrg. 110-1068

THE FUTURE OF THE
COAST GUARD DIVE PROGRAM

=======================================================================

HEARING

before the

SUBCOMMITTEE ON OCEANS, ATMOSPHERE, FISHERIES, AND COAST GUARD

OF THE

COMMITTEE ON COMMERCE,
SCIENCE, AND TRANSPORTATION
UNITED STATES SENATE

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

__________

MARCH 28, 2007

__________

Printed for the use of the Committee on Commerce, Science, and
Transportation

U.S. GOVERNMENT PRINTING OFFICE
35-992 WASHINGTON : 2010
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing Office,
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, U.S. Government Printing Office. Phone 202�09512�091800, or 866�09512�091800 (toll-free). E-mail, [email protected].

SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

DANIEL K. INOUYE, Hawaii, Chairman
JOHN D. ROCKEFELLER IV, West TED STEVENS, Alaska, Vice Chairman
Virginia JOHN McCAIN, Arizona
JOHN F. KERRY, Massachusetts TRENT LOTT, Mississippi
BYRON L. DORGAN, North Dakota KAY BAILEY HUTCHISON, Texas
BARBARA BOXER, California OLYMPIA J. SNOWE, Maine
BILL NELSON, Florida GORDON H. SMITH, Oregon
MARIA CANTWELL, Washington JOHN ENSIGN, Nevada
FRANK R. LAUTENBERG, New Jersey JOHN E. SUNUNU, New Hampshire
MARK PRYOR, Arkansas JIM DeMINT, South Carolina
THOMAS R. CARPER, Delaware DAVID VITTER, Louisiana
CLAIRE McCASKILL, Missouri JOHN THUNE, South Dakota
AMY KLOBUCHAR, Minnesota
Margaret L. Cummisky, Democratic Staff Director and Chief Counsel
Lila Harper Helms, Democratic Deputy Staff Director and Policy Director
Margaret Spring, Democratic General Counsel
Christine D. Kurth, Republican Staff Director and General Counsel
Kenneth R. Nahigian, Republican Deputy Staff Director and Chief Counsel
------

SUBCOMMITTEE ON OCEANS, ATMOSPHERE, FISHERIES, AND COAST GUARD

MARIA CANTWELL, Washington, OLYMPIA J. SNOWE, Maine, Ranking
Chairman TRENT LOTT, Mississippi
JOHN F. KERRY, Massachusetts GORDON H. SMITH, Oregon
BARBARA BOXER, California JOHN E. SUNUNU, New Hampshire
BILL NELSON, Florida JIM DeMINT, South Carolina
FRANK R. LAUTENBERG, New Jersey DAVID VITTER, Louisiana
THOMAS R. CARPER, Delaware
AMY KLOBUCHAR, Minnesota

C O N T E N T S

----------
Page
Hearing held on March 28, 2007................................... 1
Statement of Senator Cantwell.................................... 1
Statement of Senator Snowe....................................... 3

Witnesses

Higgins, Rear Admiral Paul, Director, Health and Safety, U.S.
Coast Guard.................................................... 9
Joint prepared statement..................................... 7
Justice, Rear Admiral Wayne, Assistant Commandant for Response,
U.S. Coast Guard............................................... 5
Joint prepared statement..................................... 7
Tillotson, Rear Admiral Michael P., Deputy Director, Standing
Joint Force Headquarters, North American Aerospace Defense
Command (NORAD)................................................ 10
Prepared statement........................................... 12

Appendix

Inouye, Hon. Daniel K., U.S. Senator from Hawaii, prepared
statement...................................................... 39
Response to written questions submitted by Hon. Daniel K. Inouye
to:
Rear Admiral Paul Higgins.................................... 42
Rear Admiral Wayne Justice................................... 39
Rear Admiral Michael P. Tillotson............................ 44

THE FUTURE OF THE
COAST GUARD DIVE PROGRAM

----------

WEDNESDAY, MARCH 28, 2007

U.S. Senate,
Subcommittee on Oceans, Atmosphere, Fisheries, and
Coast Guard,
Committee on Commerce, Science, and Transportation,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10 a.m. in
room SR-253, Russell Senate Office Building, Hon. Maria
Cantwell, Chairman of the Subcommittee, presiding.

OPENING STATEMENT OF HON. MARIA CANTWELL,
U.S. SENATOR FROM WASHINGTON

Senator Cantwell. This Senate Committee on Commerce,
Science, and Transportation Subcommittee on Oceans, Atmosphere,
Fisheries, and Coast Guard will come to order. This morning we
are holding a hearing on the future of the Coast Guard dive
program, and I want to welcome the witnesses that we have
before us.
Rear Admiral Justice, who is Assistant Commandant for
Response for the U.S. Coast Guard, Rear Admiral Higgins,
Director of Health and Safety for the U.S. Coast Guard, and
Rear Admiral Tillotson--did I say that right? Tillotson,
Director, Deputy Director for the Standing Joint Force
Headquarters of the North for U.S. Navy. So, welcome gentlemen.
Thank you very much for being here.
I know I'm going to be joined momentarily by Senator Snowe,
and I will--when she comes--allow her to make her opening
remarks, and hear from other Committee members, if and when
they show up for the hearing, as well.
Thank you all for being here, and I want to thank my
colleague, Senator Snowe, for agreeing to this timeframe for
this important hearing on the Coast Guard dive program. And
again, I thank the witnesses for coming and giving what is
important testimony for a very important program within the
Coast Guard dive system.
On August 17, 2006, Lieutenant Jessica Hill and Petty
Officer Steven Duque lost their lives while conducting a
training dive off the polar icebreaker, HEALY. My office has
spoken with the families of Lt. Hill and Petty Officer Duque.
We shared with them our sadness over their loss, and told them
that we believe the death of these brave young people will not
be in vain if they result in the needed changes to the Coast
Guard dive program, in order to save future lives.
Petty Officer Duque's family would like everyone to know
that today is his birthday. While this is not by design, his
family feels that it is fitting, given his love for the Coast
Guard and the fact that he would do anything to protect his
fellow servicemen and servicewomen.
Let us be clear--this tragic incident, and these tragic
deaths were preventable. While there is plenty of blame to go
around, the honest truth is that the Coast Guard dive program
was an accident waiting to happen. We owe it to the young
divers who lost their lives, and to their families, to
understand the cause behind--or causes behind--this tragedy,
and make sure that this never happens again. We owe it to them
to make sure that there is real accountability and real change
in the program.
Diving is a risky activity, so I want you to know that
while diving has been deemed a risky activity, I believe it
also has been consistently neglected or ignored within the
Coast Guard system.
That people were allowed to consume alcohol so close to a
dive operation, and even serve as line tenders for those
operations, tells me that the Coast Guard does not put safety
first when it comes to this diving program. In diving, safety
must be the first consideration. I expect the Coast Guard to
convince me today that it will be in the future.
In the Coast Guard, diving is not considered a full-time
job, instead it is a collateral duty, and regulated to
secondary status. This tells me that the Coast Guard feels
diving is not as important as other programs. But, this is
dangerous duty, and requires full-time, professional attention.
If the Coast Guard feels it needs a dive team aboard polar
icebreakers, it needs to be sure that those divers are prepared
for the challenges that they will face.
Diving is particularly hazardous in Arctic conditions, and
is very risky. I don't understand how we can expect our young
men and women to perform their mission safely, when they don't
have the time or resources to devote to training, practice and
maintenance of equipment. Collateral duty simply won't do in
this case.
It is clear from the Commandant's January 10, 2007 final
accident report that the Coast Guard's dive program has
suffered from a culture of neglect.
For example, the required diving program safety surveys had
never happened aboard the HEALY before this incident. The Coast
Guard hasn't kept accurate records of its dive program,
especially equipment and safety checks, and much of the
equipment in the HEALY's dive locker was not functional.
The Dive Program has tripled in size post-9/11, but the
number of managers has remained the same, and no additional
funding has been requested. Coast Guard divers have little
incentive to get advanced training or accumulate experience--
two of the biggest factors in safe diving. In fact, the Coast
Guard does not have a single Master Diver, and only has one
First Class Diver.
It is clear from the HEALY accident that the Coast Guard's
program to train divers and other key operational personnel
must be improved. The Coast Guard divers are initially trained
in a rigorous Navy Dive School, but once they pass their
initial training period, they have little chance to maintain or
sharpen their skills, unlike Navy Divers.
For example, Coast Guard divers are not required to obtain
specialized training for cold water conditions. Expecting a
diver trained in the warm waters of Florida, to dive
professionally in 29 degree water for the first time on a
mission, is simply asking too much.
It is also apparent that the officers aboard the HEALY
lacked sufficient knowledge of diving protocols, which would
ensure safe operations.
The safety of the Coast Guard dive program will remain a
priority of this subcommittee. I understand that the Coast
Guard plans to release their report on how they will implement
the changes required by their initial review of the accident.
I want all of you to know that we will be watching this
closely, and while the Coast Guard has investigated this
incident carefully, and recommended improvements, this
subcommittee will continue to conduct oversight on this issue,
and offer legislation to improve this program.
I sincerely hope this hearing will shed enough light on the
Coast Guard dive program so that we can fix the mistakes of the
past, and protect the Coast Guard's present and future divers.
The families of Lt. Hill, and Petty Officer Duque deserve
no less. So, again, I want to thank each of you for being here
this morning, and for giving your testimony on this important,
and very serious issue for this subcommittee.
What we will do this morning is, I think votes have been
delayed this morning, but at the same time, I think what we
will do is have, you know, as much time as you gentlemen need
to express your comments and remarks about this incident. Then
Senator Snowe and I will go to rounds of questions, depending
on how many other colleagues--we may do 5-minute rounds if
we're joined by other people, or if it's just Senator Snowe and
I, I might start with longer rounds of questioning.
So, with that, Senator Snowe, I know you've just arrived,
but if you would like to make an opening statement before we go
to the witnesses.

STATEMENT OF HON. OLYMPIA J. SNOWE,
U.S. SENATOR FROM MAINE

Senator Snowe. Thank you very much, Madame Chair, for
calling this hearing this morning to explore the future of the
Coast Guard's dive program, and more specifically to review the
policies currently being developed to increase oversight of
this inherently dangerous specialty of the Service.
We are all aware of the tragic events that claimed the
lives of two crewmembers of the Coast Guard icebreaker HEALY on
August 17, 2006, and I'd like to express my deepest condolences
to the families of Lt. Jessica Hill, and Petty Officer Steven
Duque.
While it's inexcusable that such a tragedy had to occur to
expose the cracks that had developed in the foundation of the
Coast Guard's dive program, in its aftermath, I know that
Senator Cantwell and I pledge to do everything in our power to
minimize the possibility of such an incident occurring again.
I'd also like to thank Admirals Justice and Higgins for
being here today to share with us how the Coast Guard intends
to revive this dive training, both for the divers and for
shipboard command cadres to ensure that future missions are
treated with the same level of caution and gravity as are the
Coast Guard's other high-risk missions, such as aviation and
rescue swimming.
I'd also like to thank Admiral Tillotson for being here
today to discuss how similar operations are handled in the
Navy.
The Coast Guard has relied on divers to carry out elements
of its mission since 1940, and until last August they
experienced only a single fatality, in 1974. However, in a
series of events to take on additional homeland security
responsibilities following the attacks of September 11, its
dive program grew from a total of five teams to seventeen.
There are clear risks inherent in expanding capability, and
building experience concurrently, which is what the Coast Guard
was compelled to do in this instance.
Experience and oversight are complementary, and as one
dissipates, the other must increase. Tragically, in the case of
the Coast Guard diving specialty, this did not occur.
While the program expanded significantly, only one
additional person was added in an oversight capacity.
Naturally, inspections and policy development fell behind in
lieu of mission execution.
I've served on this subcommittee for more than 12 years,
and during that time I've developed an understanding for the
culture under which the Coast Guard operates. When issued a new
task--no matter the magnitude--the immediate reaction among
servicemen and women of all levels is a rousing ``can do''
spirit. Your service's reluctance to shrink from any task is
what makes it so valuable to our Nation.
So I understand how the Coast Guard could increase its dive
force by more than 300 percent, and choose to allocate nearly
all of that personnel increase to the front-line of our
national security, rather than holding some of these assets in
reserve to ensure the safety of the divers themselves.
But just as we must protect our Nation's shores, we must
also protect those who serve. The responsibility falls on a
ship's command cadre--the program managers, the Coast Guard
leadership, and ultimately, this Committee, to ensure that the
management oversight is in place to keep an experienced, but
highly motivated, young diver safe. And also to ensure that
oversight is commensurate with a level of risk associated with
diving.
I know that the Coast Guard has already initiated this
process. It's working with the Navy, as it has done for
decades, to develop stronger standards for diver qualifications
and tighter enforcement of safety regulations. It is developing
a training module for all operation officers, executive
officers and commanding officers, to familiarize them with
these procedures, and the dangers affiliated with dive
missions.
Perhaps most importantly, the Coast Guard is taking a long,
hard look--not just at the dive program, but also at the way in
which it approaches all high-risk missions, to ensure that
similar failings do not lead to further tragedies in the
future.
I look forward to all of your testimony here this morning.
Thank you, Madame Chair.
Senator Cantwell. Thank you, Senator Snowe. And again,
thank you for working with us and holding this hearing this
morning.
Rear Admiral Justice, we'll start with you and move down
the line.

STATEMENT OF REAR ADMIRAL WAYNE JUSTICE, ASSISTANT COMMANDANT
FOR RESPONSE, U.S. COAST GUARD

Admiral Justice. Thank you. Good morning, good morning,
Madame Chair, Senator Snowe.
Yes, our Coast Guard lost two service members during the
tragic ice diving mishap aboard HEALY on August 17th. Although
we could never recover the lives of Lt. Hill and Petty Officer
Duque, the Coast Guard has honored them, and will continue to
do so by taking steps to prevent future diving accidents.
We have conducted diving operations since the forties, we
have three primary diving missions: Ports and Waterways,
Coastal Security--that's the newer one, Aids to Navigation, and
polar icebreaking.
The events of 9/11 and subsequent mandates of the Maritime
Transportation Safety Act prompted a significant expansion of
the diving program into underwater security missions within our
Nation's ports. The Dive Program expanded from 6 to 17 dive-
capable units in just 2 years. In the immediate aftermath of
the tragedy aboard the HEALY, the Commandant made a commitment
for a complete and transparent investigation, regular, face-to-
face briefings to the Hill and Duque families, and public
release of the investigation, once completed. The
administrative investigation was completed and released to the
public in January of 2007.
Members of the Committee--the remainder of my statement
will focus on the proactive steps the Coast Guard has taken,
and the future steps the Coast Guard will take, to ensure this
tragedy is never repeated.
Immediately after the deaths on HEALY, dive operations
Coast Guard-wide were suspended until each unit had conducted a
safety stand-down to review Coast Guard dive policies and
procedures. We then inspected all dive units that had not
received an inspection within the preceding 12 months. Those
inspections revealed a Service dive program that was
fundamentally sound, well-documented, and within--with divers
properly trained in 15 out of 17 dive units. One of those
Units--HEALY itself--was found deficient. HEALY has not yet
been cleared to dive, and is still months away from resuming
dive operations.
Another shore-based unit was found not ready to dive, and
has completed a series of training, equipment, and policy
improvements, and has now been re-certified to conduct diving
operations.
Last November, POLAR SEA was scheduled to deploy to the
Antarctic with a dive team embarked for Operation Deep Freeze
2007. In advance of that deployment, the POLAR SEA successfully
completed a rigorous safety inspection, followed by a week of
pre-deployment work-up dives, and training provided by Coast
Guard personnel.
Additionally, an experienced dive advisor was temporarily
assigned to board POLAR SEA for the Commanding Officer to
ensure an independent and thorough assessment of any dives
undertaking by POLAR SEA during the extended deployment in the
ice. I will report that the POLAR SEA successfully completed 26
dives, both in training and for operational needs, without
mishap.
The Commandant has directed management and oversight of the
Coast Guard dive program be elevated to bring it up to par with
other high-risk training-intensive Coast Guard operations. The
Coast Guard has increased the seniority of the Program's
manager, and will be adding an additional senior enlisted diver
to the staff.
Additionally, operational Dive Program managers have
already been established in both of our areas--East and West
Coast, and in Hawaii--to better track the readiness,
qualification, and training of the dive units in the field.
The Commandant further directed a comprehensive review of
the entire diving program, to determine the best way to meet
the Coast Guard's requirements for diving services. The first
half of this was to validate the Coast Guard's operational
requirements for a diving program to accomplish its missions.
Senators, the Coast Guard does require a safe, effective
Dive Program to complete its missions. A senior-level review
team has been formed, including expert consultants from the
Navy, the Army, NOAA and Smithsonian Institute, to evaluate the
requirements, management training, structure and policy
guidance of the Coast Guard's dive program, and to recommend a
way forward. Its final report is expected 1 June of this year.
We anticipate that the review team will recommend
structural changes to the Dive Program, including a move away
from part-time divers to full-time divers, as well as improved
training for divers employed in specific missions, such as
polar ice diving.
The Coast Guard dive manual is being revised to include
comprehensive policy on cold water diving, to re-emphasize the
use of standard operational risk management for planning and
conducting Coast Guard dive operations.
Unit commanding officers who are not qualified divers have
been given more tools to ensure that the dives are properly
planned, conducted, and documented. The Coast Guard has added
specific checklists for diving conditions at the ship, near to
the ship, or from a small boat. Standards for re-qualification
dives have been clarified, the standard relief process for unit
Diving Officers have been added to ensure unit Commanding
Officers are fully aware of the status of dive teams at their
unit.
While we cannot prevent every casualty, the Coast Guard
strives to minimize hazards through sound judgment, planning
and risk management. Despite the professionalism, bravery and
dedication of our workforce, in rare cases, we suffer serious
death or injury in the line of duty, as unfortunately, as you
noted, we did last weekend up in Seattle.
As Coast Guard men and women, we accept that risk, but we
will not accept preventable loss or injury. When it comes to
dangerous operations such as diving, ``good enough'' is never
good enough.
Across the Coast Guard, we will honor Lt. Hill and Petty
Officer Duque through the actions we are taking at all levels
to prevent a tragedy such as this from occurring in the future.
This concludes my statement, thank you for the opportunity
to testify today. I look forward to your questions.
[The prepared statement of Admiral Justice and Admiral
Higgins follows:]

Joint Prepared Statement of Rear Admiral Wayne Justice, Assistant
Commandant for Response and Rear Admiral Paul Higgins, Director,
Health and Safety, U.S. Coast Guard

Good morning Madam Chairwoman and distinguished members of the
Committee. This is a joint statement of Rear Admiral Wayne Justice,
Assistant Commandant for Response, and Rear Admiral Paul Higgins, the
Director of the Health and Safety Directorate, at U.S. Coast Guard
Headquarters. We appear before you today to discuss the Coast Guard's
diving program, lessons learned from the accident onboard CGC HEALY,
and the steps taken to prevent future diving accidents.

Overview of Diving Program
The Coast Guard has conducted diving operations since the 1940s.
Early diving missions included Aids to Navigation (ATON) and Polar
Icebreaker Support. Recently, however, the events of September 11
prompted a significant expansion of the CG diving program.
Prior to September 11, there were only 6 dive capable units (3
Pacific-based buoy tenders and 3 polar icebreakers). After September
11, 13 Maritime Safety and Security Teams (MSST) were created, all with
a dive capability, to conduct our security mission. Presently, there
are 17 units with a designated diving capability (12 MSSTs and 5
cutters).

Diving Missions
The Coast Guard has three primary diving missions. Port, Waterway,
and Coastal Security; Aids to Navigation (ATON); and Polar Icebreaker
and Science Support.
Port, Waterways, and Coastal Security--Coast Guard port security
divers conduct routine and threat-driven underwater operations that
include sweeping of piers and vessel hulls to locate, identify, and
mark hazardous underwater devices. While public safety divers (those
belonging to the police and fire departments) may be available for
routine operations, it is likely that they will be unavailable to
support underwater port security missions during a crisis.
Aids to Navigation--The Coast Guard uses divers in the Pacific
region of Hawaii, Guam, American Samoa, Kwajalein, Midway Island, and
Wake Island to service navigation aids that are in shallow water and
beyond the reach of a cutter. Divers are the only resource with special
techniques and procedures capable of conducting these operations in
environmentally sensitive areas, and dive teams can be can be flown to
remote locations to provide a more rapid response time than can be
provided by cutters.
Polar Icebreaker and Science Support--Divers onboard the polar
icebreakers provide damage control and repair capability in remote and
harsh environments. Additionally, they conduct dive operations for
maintenance, calibration and inspections of hull and running gear. This
is particularly important to the Polar-class icebreakers due to the
maintenance requirements of their complex variable pitch propulsion
system. All polar divers provide science support by collecting
biological samples and installing/retrieving scientific equipment.

Diver Training
All Coast Guard divers are collateral duty volunteers who are
initially trained at the Naval Diving and Salvage Training Center
(NDSTC) in Panama City, Florida and are graduates of either the 17-week
Dive Officer course or 6-week SCUBA Diver course. Interested members
typically come from junior enlisted to junior officer ranks and must
pass stringent medical and physical fitness standards. Approximately 40
Coast Guard members graduate each year from the NDSTC to fill the
Service's 102 collateral duty diving positions. Because of this
relatively small number of positions, however, a typical diver has one
diving duty assignment during his/her career.
Over the past 50 plus years of diving operations, the Coast Guard
has had a nearly spotless record. Prior to the HEALY incident on August
17, 2006, the last Coast Guard death associated with dive operations
was on April 17, 1974. The diver, a member of the Atlantic Strike Team,
died during an incident on the Great Lakes and the cause of death
remains unknown.

HEALY Lessons Learned
The incident onboard HEALY highlighted failures at the Service,
unit, and individual levels. Mishaps typically involve a chain of
errors that if not broken, result in an accident, and that was true in
this case.
The investigation revealed a number of major systemic issues that
reduced the margin available to guard against human error. The Coast
Guard dive program has expanded substantially over the past several
years, yet there has not been commensurate growth in oversight and
management of that program from a Service--or Headquarters perspective.
This is reflected in the fact that HEALY's dive program had not been
inspected for compliance with Coast Guard dive safety standards since
the ship was placed in service in 1999.
As a result of this tragedy, the Commandant has elevated management
and oversight of the Coast Guard dive program to bring it on par with
other high-risk, training-intensive Coast Guard operations. We have
increased our active oversight by conducting regular, comprehensive
site visits to all operational Coast Guard dive units to ensure diving
gear is being properly maintained, personnel qualifications are current
and standard procedures are understood and exercised. All 17 dive units
have been inspected since the HEALY incident. A comprehensive review of
the entire diving program is underway to determine the best way to meet
the Coast Guard's requirements for diving services. Additionally, the
Coast Guard Dive Manual is being revised to include comprehensive
policy on cold water diving and the use of Operational Risk Management
for planning and conducting Coast Guard dive operations.
Our personnel system needs the capability to track dive training
and qualifications--and we need to improve our dive training program.
We will ensure those assigned to diving duty receive all the training
necessary to safely complete their mission and will indoctrinate
command cadre and supervisory personnel by adding a training module to
the Commanding Officers' indoctrination course specifically dedicated
to diving operations. These courses are being taught at our Command and
Operations School at the Leadership and Development Center in New
London, CT.

Actions Taken Thus Far
In the wake of the HEALY incident, the Coast Guard has upgraded the
Headquarters Diving Program Manager position from a Lieutenant to a
Lieutenant Commander, and has established a senior enlisted assistant
manager billet. Additionally, dive program managers have been
established at Coast Guard Area and District commands responsible for
dive capable units to better track the readiness, qualification, and
training status of these units.
In addition, a senior level work group has been formed, including
expert consultants from the U.S. Navy, U.S. Army, National
Oceanographic and Atmospheric Administration, and Smithsonian
Institute, to evaluate the requirements, management, and policy
guidance of the Coast Guard's diving program and recommend the way
forward. Its final report is expected by June 1, 2007.
In an effort to further our understanding of how our international
counterparts operate and train, a Coast Guard representative attended
the International Polar Diving Workshop in Svalbard, Norway on March
15-22, 2007. This workshop is an international, interdisciplinary
assessment of polar diving operations, and served as an excellent
baseline against which to measure Coast Guard polar diving policies and
procedures.
Immediately following the HEALY incident, a safety inspection was
conducted onboard HEALY, and the cutter's dive capabilities were
suspended. We also ensured all dive capable units had undergone a Dive
Program Safety survey within the previous 12 months. One unit was found
to be deficient in its readiness and training and was directed to
suspend dive operations. Upon correcting all discrepancies, the unit
successfully completed a follow-up inspection and was authorized to
resume all diving operations.
The Final Decision on the Commandant's Vessel Safety Board's report
is nearly complete.
The normal time-frame for completion of this type of accident
investigation and report can be as much as a year or more. For HEALY,
this process was accelerated and the results are expected to be
released in the next several weeks.
Conclusion
The Coast Guard strives to minimize hazards through sound judgment,
planning, and risk management. Despite the professionalism, bravery,
and dedication of our workforce, in rare cases we suffer serious injury
or death in the line of duty. As Coast Guard men and women we accept
that risk, but we will not accept preventable loss or injury. When it
comes to dangerous operations such as diving, ``good enough'' is never
good enough. Across the Coast Guard, we will honor Lt. Hill and Petty
Officer Duque through the actions we are taking at all levels to
prevent such a tragedy in the future.
This concludes our statement. Thank you for the opportunity to
testify before you today. We will be happy to answer any questions you
may have.

Senator Cantwell. Rear Admiral Higgins?

STATEMENT OF REAR ADMIRAL PAUL HIGGINS, DIRECTOR, HEALTH AND
SAFETY, U.S. COAST GUARD

Admiral Higgins. Good morning, Madame Chair, Senator Snowe.
Our deepest sympathies remain with the families of Lt.
Jessica Hill, and Petty Officer Steve Duque. We are also
mourning the loss of Petty Officer Ron Gill, who died while on
active duty on Sunday, March 25, 2007.
I'm Rear Admiral Paul Higgins, I currently serve as the
Director of Health and Safety at Coast Guard Headquarters here
at Washington, D.C. I'm a family physician and a flight
surgeon.
The goal of the Coast Guard Safety Program is to eliminate
mishaps. We are not--we can not--eliminate risk from Coast
Guard missions. We try to learn our lessons from minor mishaps
to prevent more serious mishaps. If a serious mishap does
occur, two investigations are immediately convened--an
administrative investigation, ordered by the unit commander,
and a Safety Mishap Analysis Board. The members of the Mishap
Analysis Board collect their information, data and
confidentially interview witnesses. They report their findings
to the Commandant's Vessel Safety Board, a Board convened by
the Chief of Staff of the U.S. Coast Guard. The Commandant's
Vessel Safety Board uses expert opinion, and often, outside
evaluations to make very detailed recommendations to avoid
future mishaps.
That process often takes over a year to complete, and the
final decision letter transmitting the HEALY Commandant's
Vessel Safety Board recommendations is nearly complete.
The HEALY Commandant's Vessel Safety Board issued interim
recommendations on December 18, 2006. Those recommendations
were transmitted via the Pacific Area Commander to the Coast
Guard POLAR SEA while in transit to Antarctica.
The recommendations specified interim changes, including a
Command Advisor who is an experienced ice diver, variable
volume dry suit dive training, cold water training dives to
Coast Guard and Navy dive standards, and regular time for
training for the divers, line handlers and medical staff aboard
the POLAR SEA.
The interim recommendations were completed, and the POLAR
SEA is about to complete a successful 3-month mission to
Antarctica. I believe it's due back to Seattle next week, it's
in Hawaii now, is my understanding.
On September 18, 2006, Admiral Thad Allen, the Commandant
of the Coast Guard ordered a safety stand-down for all Coast
Guard operational units. The stand-down required 4 to 5 hours
of all-hands safety training, focusing on existing Coast Guard
safety policy, crew endurance management, operational risk
management, and existing standard operating procedures. In
addition, a review of lessons learned from previous mishaps,
and reports from recent program inspections was recommended.
Finally, units were directed to complete a web-based survey
risk management factor assessment survey. Although the survey
was meant to be a simple tool for operational commanders, the
results of the surveys were collected and reviewed, and they
were briefed to Coast Guard safety professionals March 12 and
13, 2007.
Safety concerns identified by the survey of the safety
stand-down, recommended inclusion of safety policy into several
operational manuals, including the trailoring manual, motor
vehicles operations manual and others. Additional training was
recommended for specific units.
Other general safety improvements released since the safety
stand-down of September 18, 2006, include the completion of the
confined-space entry program policy, and incorporation of human
factors analysis of each Commandant's Vessel Safety Board that
allows for systemic identification of root and contributing
causes of all mishaps.
Thank you for allowing me the opportunity to discuss our
safety program. I'll be available for questions, as well.
Senator Cantwell. Thank you.
Rear Admiral Tillotson?

STATEMENT OF REAR ADMIRAL MICHAEL P. TILLOTSON,

DEPUTY DIRECTOR, STANDING JOINT FORCE HEADQUARTERS

NORTH AMERICAN AEROSPACE DEFENSE COMMAND (NORAD)

Admiral Tillotson. Good morning, Madame Chairwoman. Thank
you for inviting me to speak on the Navy's dive program.
The Navy is the DOD executive agent for diving. Your Navy
dive program is robust and mature. All aspects of the program
are continuously reviewed, and updated to meet current and
future requirements. Maintaining technical standards for Navy
diving serves as the foundation for personnel training, and for
the procurement and maintenance of diving systems. Adherence to
these technical standards and procedures lead to safe diving
practices, and ensures mission accomplishment. Our standards
and policies are set forth in the U.S. Navy Diving Manual)--the
gold standard for diving.
Oversight is fundamental to ensuring safe and effective
diving. Oversight of the Navy's diving program is maintained
through periodic diving assessments and diving safety surveys,
which assess a diving command's compliance with established
Navy safety programs and procedures that are outlined in the
Navy Diving Manual.
The Navy recently modified its diving personnel structure,
with the implementation of a single enlisted Navy Diving
Rating. This now allows the diver to concentrate on his or her
primary responsibilities as a diver, and focus all energies on
learning, and honing diving skills. This results in a more
dedicated, safe and effective force.
The enlisted Navy diving community has a well-defined
career path. Diver candidates must pass a rigorous screening
process, that includes dive medical evaluations, physical
screening, and a higher-than-average score on the Armed Service
Aptitude Test.
While at Naval Training Center, Great Lakes, they are given
a 7-week preparatory course prior to their transfer to the Dive
School down in Panama City, Florida. Dive school begins with a
15-week, Second-Class Diver course. The course trains students
in all diving rigs used by the Navy, underwater tools and
techniques, and advanced diving medicine. Attrition during this
initial training historically runs about 30 percent.
During their first 2 operational tours, normally 6 years,
Navy Divers are expected to complete demanding personal
qualification standards, and earn the Diving and Salvage
Warfare Specialist designation. Those who qualify return to the
Dive School for a 13-week, First-Class Diver course, which
stresses dive supervisor responsibilities, mixed gas diving,
and advanced salvage skills. A minimum of two more operational
tours, and advanced qualifications follow, and usually take 6
more years.
Qualified First-Class Navy Divers can apply for the Master
Diver qualification. This entails additional training, and a
rigorous performance evaluation. The Navy Master Diver
qualification, which normally takes about 14 years to achieve
from the time they enter the program, is the pinnacle
qualification for the enlisted Navy diver.
Above and beyond formal training requirements, all Navy
Divers are required to qualify at each command at all dive
watch stations--most significantly as the Diving Supervisor.
In addition to our fleet divers, the Navy also has
underwater construction team divers. Their primary missions are
to perform in-shore and deep ocean underwater construction and
demolition. Candidates for this diver community come from the
Naval Construction Force--the SEABEEs. They have normally
completed one tour of duty, and are relatively mature. Their
dive training and qualifications are similar to that of our
fleet divers.
SEABEE divers can expect repeat tours in one of two
underwater construction teams, as well as higher headquarters
and training commands.
The Navy also delivers a SCUBA-specific diving course to
DOD and inter-agency customers at the Navy Dive School in
Panama City, as well as in Pearl Harbor, Hawaii. The majority
of students for this program come from the Coast Guard and the
Navy submarine force.
The enlisted Navy diving program is very demanding and
rewarding. This, coupled with monetary incentives, results in a
retention rate that exceeds the Navy's overall averages.
Retention for Navy Divers in years 1 through 6 of service
average 78 percent. Retention for years 7 through 12 of service
is 88 percent. After 12 years, 94 percent choose to remain
until retirement-eligible.
On the officer side, Navy diving officers come from two
primary sources. From within the enlisted ranks, and direct
commissioning. Experienced enlisted Navy Divers have the
opportunity to apply for the Chief Warrant Officer, or Limited
Duty Diving Officer Programs. The direct accessions, through
Officer Commissioning Programs who desire to become Navy
Divers, must successfully complete screening and training
similar to that of our enlisted dive candidates.
Your Navy diving program follows a rigorous screening,
training and qualification regimen, with senior leadership
support throughout, which has led to sustained operational
readiness.
I appreciate the opportunity to brief the Committee on the
Navy dive program. Thank you very much.
[The prepared statement of Rear Admiral Tillotson follows:]

Prepared Statement of Rear Admiral Michael P. Tillotson, Deputy
Director, Standing Joint Force Headquarters, North American Aerospace
Defense Command

Thank you for inviting me to brief the Committee on the procedures,
programs, and processes the Navy has in place for the management and
execution of our diving program. I will also discuss the Navy's initial
Dive Training Pipeline. As the next Deputy Commander, Naval
Expeditionary Combat Command, among other responsibilities, I will be
responsible for manning, training and equipping the Navy's operational
Diving force.
The Navy dive program is robust and mature. All aspects of the
program are continuously reviewed and changes made based on current and
future operational requirements. Technical rigor and safe diving
practices are a hallmark of the Navy's role within the Department of
Defense as the lead service for diving policy, technology and training.
Establishing and maintaining Navy technical standards for diving serves
as the foundation for personnel training and for the procurement and
maintenance of diving systems. Rigorous adherence to these technical
standards and procedures is what leads to safe diving practices and
ensures mission accomplishment. The Navy updates those standards
through biomedical research that leads to continuous modifications of
Navy diving policy which is incorporated into the U.S. Navy Diving
Manual and associated publications. The Navy has institutionalized a
diving systems certification program that ensures the systems used for
Navy diving operations are maintained properly and are not a source of
risk to personnel. For portable and personal diving equipment, the Navy
publishes a list of acceptable equipment ``authorized for Navy use''
that has been tested at the Navy Experimental Diving Unit to ensure
dependable and safe operation.
The operational readiness of diving commands is monitored at the
fleet level by a formal assessment program called the Diving
Operational Readiness Assessment (DORA) that has the advocacy of all
levels of the chain of command. These assessments are conducted
periodically on all Navy diving commands and ensure all commands comply
with established policies and regulations in the areas of diving
program administration, and operational readiness. The diving
assessments performed by Fleet Forces Command parallel the operational
readiness assessments that are performed on afloat commands to ensure
their readiness for deployment. In addition to these command
operational assessments, the Naval Safety Center provides periodic
Diving Safety Survey (DSS) which assesses a diving command's compliance
with established naval safety programs including compliance with U.S.
Navy Diving Manual safety provisions. Naval Safety Center assessment
results are provided directly to the Commanding Officer of the diving
command and serve as a non-punitive feedback mechanism for command self
correction.
The Navy recently modified its diving personnel structure with the
implementation of a single enlisted Navy Diver rating. The rating
change was approved by the Chief of Naval Operations in October 2005.
The enlisted rating aligned 19 enlisted source ratings into one and
streamlines all aspects of force structure and training into a career
continuum. This now allows the Diver to concentrate on his or her
primary responsibilities as a Diver and focus all energies on learning
and honing diving skill sets thereby allowing for a more dedicated,
safe, and effective force.
Navy Divers are trained in all categories of diving, salvage, and
underwater ships husbandry missions. Navy Divers also conduct and
support a variety of unique mission areas to include open ocean towing,
command control and communications, fleet support operations, mobility,
non-combat operations, anti-terrorism/force protection, submarine
rescue and Naval Special Warfare and Explosive Ordnance Disposal
support. Navy Divers are also frequently tasked to participate in
coalition support (Theater Engagement Strategy), Civil Disaster
operations (post-Hurricane Katrina recovery), and Humanitarian
Assistance (tsunami relief in Indonesia). The Navy Diving force
provides specially trained, combat ready, highly mobile Divers in
support of Amphibious Task Forces, Special Forces, and contingency
operations. Contingency operations include emergent littoral, coastal,
and blue water salvage, range/waterway clearance, aircraft recovery,
Chief of Naval Operations priority projects, riverine operations, and
other operations as directed by higher authority. Navy Diving forces
are trained to operate in high density, multi-threat environments.
The enlisted Navy Diving community has a well-defined career path.
The Navy has an aggressive recruiting program for divers that is
designed to draw in individuals with a high probability of success.
Potential accessions into our program are required to pass a rigorous
screening process that includes a thorough dive medical evaluation,
physical screening test and a higher than average score on the Armed
Services Vocational Aptitude (ASVAB) test. Once accepted as a student,
the enlisted Sailor begins training at the Center for Explosive
Ordnance Disposal and Diving Detachment Great Lakes. This is a seven-
week preparatory course that delivers knowledge, skills and abilities
in fundamentals of diving, cardio pulmonary resuscitation, small arms
qualifications, and basic shipboard engineering. The course also
stresses the physical preparation for dive training by focusing on
aquatic adaptability, cardio vascular conditioning, and strength
improvement. Upon successful completion students are transferred to
Naval Diving and Salvage Training Center, Panama City, Florida. NDSTC,
as we refer to it, delivers 17 different courses of instruction
totaling 74 convenings per year. Annual throughput averages 1,450
students. It trains all military Divers (with the exception of Army
Special Forces and SEALs), foreign national students, and Department of
Defense and other Federal agency civilians. While some of the training
is similar regardless of service, for example Self Contained Underwater
Breathing Apparatus or SCUBA, each service is trained to its unique
requirements. However all procedures and policies at the school as well
as at the operational commands are governed by the U.S. Navy Diving
Manual.
The initial course in the Navy fleet diver training continuum is
``Second Class Diver.'' The 15-week Second Class Diver course trains
students in all diving rigs used by the Navy, underwater cutting and
welding, underwater pneumatic tools, salvage, basic demolitions, and
more advanced diving medicine and physics. The attrition in this
initial training pipeline historically runs 30 percent. (This course
touches briefly on cold water diving operations in the class room only.
Practical cold and extreme cold water diving training and
certifications occur at the operational command level.) Upon
completion, the Sailor is classified as a Navy Diver and sent to an
operational unit. During his or her first two operational tours,
normally 6 years, the Navy Diver is expected to complete demanding
personal qualifications standards and earn the Diving and Salvage
Warfare Specialist designation. Navy Divers are required to re-qualify
Diving and Salvage Warfare Specialist at each subsequent command
throughout their career, ensuring all team members are fully qualified
in the specific mission area of the command. Those who qualify and
complete the prerequisites are sent to formal advanced First Class
Diving training at the Naval Diving and Salvage Training Center. This
13-week course stresses supervisory, mixed gas diving, and advance
salvage skills. A minimum of two operational tours and advanced
qualifications follow and nominally take six more years. At this stage
in a Navy Diver's career, and with the recommendation of the commanding
officer, qualified Navy Divers who meet the demanding prerequisites
have the opportunity to attain the Master Diver qualification through
another rigorous formal school and performance evaluation at the Naval
Diving and Salvage Training Center. Few Navy Divers become Master
Divers. This course is arguably the hardest diving course the Navy
offers and has a failure rate of 50 percent. The Navy Master Diver
qualification is the pinnacle qualification for the enlisted Navy Diver
and represents the community's senior enlisted leadership. Master
Divers are operators. But more than that, they are intimately involved
in every facet of the Navy diving mission. They manage, supervise,
conduct long range deliberate planning, assess, inspect, train, and
participate in the requirements generations process. Becoming a Navy
Master Diver takes an average of 14 years.
The Underwater Construction Team, or UCT, Divers are another
distinct Navy diving community. The primary missions of the UCT is to
provide inshore and deep ocean underwater construction and demolition
capabilities to the Navy, Marine Corps, and other forces in joint
military operations, provide battle-damage repair, inspection and
engineering reconnaissance to ocean, waterfront, river and bridge
facilities, provide hydrographic reconnaissance to support amphibious
operations and subsequent combat support ashore, and provide ocean
bottom surveys for site selection of underwater facilities. These
missions include conducting defensive operations as required by the
deployment environment and operations in every extreme, from the desert
to the Arctic Circle. The secondary missions of a UCT are to conduct
disaster recovery, humanitarian assistance and civic action operations.
Accessions into this community primarily come from the fleet Navy
Mobile Construction Battalions. Sailors/SEABEES who have completed at
least one tour with the Naval Construction Force (SEABEEs) and have
earned their SEABEE Combat Warfare (SCW) qualification become eligible
for dive training. Basic and advance Diver Training is delivered at the
Naval Diving and Salvage Training Center. Like other diving students,
they are trained in the Diving Fundamentals (physics, physiology) and
SCUBA. Their training also includes unique SEABEE tools, tactics,
techniques, and procedures with an emphasis on underwater construction
and demolition procedures. SEABEE Divers can expect repeat tours in one
of two Underwater Construction Teams as well as higher headquarter and
training commands. SEABEE Divers return for 24 weeks of advanced
training after completing personal qualification standards and are
recommended by the commanding officers. They are also afforded the
opportunity to qualify as a UCT Master Underwater Construction Diver
through the formal Navy Master Diver qualification process followed by
Fleet Divers.
The Navy delivers SCUBA-only specific diving training to various
customers at the Naval Diving and Salvage Training Center in Panama
City, FL and Pearl Harbor, HI. The majority of the students come from
the Coast Guard and the Navy's submarine force. The Navy's submarine
force maintains an organic SCUBA capability in its submarines. The
SCUBA diving mission is a collateral duty for the submarine divers.
Their primary dive missions are: security hull inspections; emergency
voyage assessments; and minor repairs.
As a result of overall manning of 76 percent, combined with the
high risk nature of Navy Diving operations and the significant
investment in training, the Navy Diving community offers significant
monetary incentives for its Sailors. New recruits who chose to be Navy
Divers receive an enlistment bonus of $35,000 upon successful
completion of the initial training. Additionally, based on their
qualification levels, Navy Divers receive diving pay up to $340 per
month and demolition duty pay of $150 per month and special duty
assignment pay up to $375 per month. Selective reenlistment bonuses up
to $45,000 are offered through 16 years of service if they chose to
reenlist. The enlisted Navy Diving program is very demanding and
rewarding. This coupled with monetary incentives results in a retention
rate that exceeds the Navy's overall averages. Retention for the first-
term Navy Divers, years one through six, is 78 percent. Second term, or
years seven through twelve, retention is 88 percent. After that 94
percent chose to remain until retirement eligible.
On the officer side, Navy Diving officers come from two primary
sources, direct commissioning and from within the enlisted ranks.
Direct commission officers who desire to become Navy Divers must
successfully complete a screening process similar to that of the
enlisted person. The only difference being there is no requirement to
take the Armed Services Vocational Aptitude test I discussed earlier.
Several officer communities have qualified Divers and follow their own
career paths and qualifications. Their training mirrors enlisted
training. Experienced enlisted Navy Divers also have the opportunity to
apply for the Chief Warrant or Limited Duty Diving Officer programs.
In summary, the Navy diving program is robust, mature and
operationally effective. The Navy diving program follows a rigorous
screening, training, and qualification regimen, with senior leadership
support, which has led to exceptional operational readiness and an
enduring safety record.

Senator Cantwell. Thank you, Rear Admiral Tillotson, thank
you--all of you--for your testimony. And I look forward to this
round of questioning.
Senator Snowe, I'm going to start, and I may go a little
longer than 5 minutes at the beginning, and we can take it from
there.
Rear Admiral Tillotson, I'd like to start with you. You
described the Navy program, which is the primary source of
training for the Coast Guard diving program, is that correct?
Admiral Tillotson. Yes, ma'am.
The SCUBA school is the program for their enlisted divers,
it's a 6-week course, and their officer divers go through the
Officer Basic Diving Officer Course, which is 13-weeks long.
Senator Cantwell. And after they've graduated from your
program, what is your contact with them after that?
Admiral Tillotson. We have very little contact with the
Coast Guard divers, after they've graduated from our program.
Senator Cantwell. And what if you had very little contact
with your graduates after they left? Would you call that a
sufficient system?
Admiral Tillotson. Ma'am, what we do with ours is when they
get to their commands, there is a hierarchy within--a hierarchy
of support and oversight--within the command level. And as I
stated, they will go back to a more advanced dive training
after a few operational tours, normally 6 years--so they've
been in the program, they've gone through dive school, they've
been in the program for about 6 years, and then they return to
Dive School. During that 6-year period, they are assigned to a
unit that has First Class Divers, those with about 8-12 years
of experience, and----
Senator Cantwell. So, a mentoring can take place, is that
right?
Admiral Tillotson. Yes, ma'am.
Senator Cantwell. And, I'm sorry, I didn't mean to
interrupt.
Admiral Tillotson. The mentoring can take place, and they
are assigned, they will have a diving officer, and during that
period of time, while assigned to a unit, those units will
undergo operational inspections, as well as dive safety survey
inspections.
Senator Cantwell. And then they come back to you for
continued upgrade and skills and certification?
Admiral Tillotson. Yes, ma'am. Over time they will return
to school for additional qualifications.
Senator Cantwell. Are you familiar with what the Coast
Guard does with your graduates after they leave the dive
program on similar mentoring and upgrading of skills? Are you
familiar?
Admiral Tillotson. No, ma'am. I am not aware of their
procedures, and I cannot comment on that.
Senator Cantwell. OK, on the Navy process of the dive
program and deployment of those trained individuals. Is the
Navy--I'm assuming, because I've seen a copy of the Navy Dive
Manual, maybe we have one here in the hearing room, if someone
could just hold it up, since I've seen a copy of that--I'm
assuming that this Navy Diving Manual is something that many
people in the Navy are familiar with, is that correct?
Admiral Tillotson. Yes, ma'am, we're very familiar with it.
We have it in the immediate vicinity, or on every Navy Dive
Station, because of the volume of information that's in it
concerning procedures as well as medical treatments and
hyperbaric treatments.
Senator Cantwell. And would the Commanding Officer of such
vessels--if they were not dive-trained themselves--be aware of
dive training requirements? Is that a requirement in the Navy?
Admiral Tillotson. Yes, ma'am, what we do is we provide our
non-dive qualified Commanding Officers an abbreviated course
when they're going through prospective Commanding Officer
training on the hazards of diving.
Senator Cantwell. Are they supposed to know and report on
whether sufficient conditions exist for diving to take place?
Are they supposed to give the authority and OK for Navy dives
to occur?
Admiral Tillotson. Yes, ma'am, they are.
Senator Cantwell. Based on this manual and based on----
Admiral Tillotson. Yes, ma'am, they are.
Senator Cantwell. So, who on Navy vessels are required to
be familiar with the Navy dive procedures and under what
conditions diving can take place? Who, on Navy vessels are
required to know that?
Admiral Tillotson. The Diving Officer would report through,
most likely, the Operations Officer, and the Operations Officer
would be briefed on the dive operation. He would also brief the
Executive Officer, and the Commanding Officer prior to
conducting any dive operations.
Senator Cantwell. So, all three of those individuals would
be involved and would be responsible for knowledge about the
Dive Program, and whether diving can take place.
Admiral Tillotson. Yes, ma'am.
Senator Cantwell. And are you satisfied that the culture
within the Navy on the Dive Program is sufficient? I don't know
the history of Navy incidents of fatalities or other accidents
in this regard.
Admiral Tillotson. The Navy diving program--and any dive
program, like you stated in your opening statement--is a high-
risk evolution. Especially when we introduce the elements that
we're normally diving in when it comes to Navy dives. The
conditions can turn poor very rapidly. The ability and
oversight for anyone on the dive station to stop a dive adds to
the safety of these dives.
Senator Cantwell. When you say ``anyone'' meaning--what do
you mean by ``anyone?''
Admiral Tillotson. Any diver can stand up at any time and
say that he does not feel safe to dive in the conditions in
which they are diving. It is inherent and it is--we stress that
throughout their training this is not a hierarchical situation
where only the senior man can stop the operation. If a junior
person is not comfortable in performing the dive, he has the
ability to stand up and say, ``This is not safe.'' And, it
should bring a halt to dive operations, and basically cause a
huddle for everybody to take a look at what the situations are,
and re-evaluate whether they need to, or should, complete the
dive.
Senator Cantwell. So, Admiral Tillotson, how would you rank
the Navy culture, then, as it relates to the Dive Program?
Admiral Tillotson. The Navy's culture when it comes to any
high-risk evolution is always to err on the side of safety.
Senator Cantwell. So, on a scale of, you know, A being a
flying-color passing grade, and F being failing, what would you
give the Navy?
Admiral Tillotson. I would have to give the Navy,
somewhere--B, B +. There are individuals who sometimes feel
like they have to complete any mission at any cost. It is the
``can do'' attitude of all Service members when asked to do a
mission, to try to complete the mission, if possible. So, I
would give us--I would give the Navy a B+.
Senator Cantwell. OK, thank you.
Rear Admiral Justice--have you submitted any changes to
budget requests to help you in the upgrade of what you think
the Navy--of the dive program within the Coast Guard should be?
Admiral Justice. No, ma'am. Not in the 2008 cycle.
Senator Cantwell. And, why not?
Admiral Justice. We will be--Admiral Allen has chosen to
attend to this internally, meaning, we're re-programming from
within for this budget cycle. We are going to do--not do
something else--and take resources from within to attend to
these immediate fixes for the dive program.
Senator Cantwell. Has someone come up with an estimate of
what they think needs to be re-programmed into the dive program
to give the proper oversight and management of the program?
Admiral Justice. I don't have that answer. I can't exactly
tell you the dollar figure. We'll get that for you.
[The information referred to follows:]

To date. the Coast Guard has upgraded the Headquarters Diving
Program Manager billet from a Lieutenant (0-3) to a Lieutenant
Commander (0-4), established a Headquarters senior enlisted assistant
manager billet. and created collateral duty dive program managers at
Coast Guard Area and District commands responsible for better tracking
the status of dive units. All these billets have been reprogrammed from
within the Coast Guard base to implement changes in oversight and
management for the CG Dive Program, so no new costs have been incurred.
Following the HEALY investigation, the Coast Guard formed a senior
level work group, including expert consultants from the U.S. Navy, U.S.
Army, National Oceanographic and Atmospheric Administration, and
Smithsonian Institute, to evaluate the requirements, management, and
policy guidance of the Coast Guard diving program and to recommend a
way forward. Its final report is expected by June 1, 2007. Among the
issues being considered are:

1. Sending all CG divers through the Navy's Second Class Diver
course (or its equivalent);

2. Establishing regional dive lockers manned with primary duty
divers; and

3. Establishing a 3-tier dive unit inspection system.

Further resource requirements may emerge following the results of
this working group.

Senator Cantwell. But you think some re-programming has
occurred?
Admiral Justice. Absolutely. We've already taken, moved
people, we've taken some dollars from some places and attended
to some training and more inspections, and the things that I've
outlined that I happen to talk about again, we've done that
already, from within our base.
Senator Cantwell. Yes, I'd like you to talk about that
more, because obviously that's one of the concerns that I have
is, to what degree is the Coast Guard taking this issue in the
largest context? To me, it's a system failure, in many aspects.
I know you talk about a Service-level failure, and a Unit-level
failure, but to me--when I compare the two Dive Program
processes between the Coast Guard and the Navy--you have two
different cultures. I don't know where you would be on a scale
of A to F for the Coast Guard program. Would you care to give a
grade to what the Coast Guard dive program has been able to
carry out so far?
Admiral Justice. I would say, prior to the date of the
HEALY's accident, we were very low-grade. I will also say,
since then, that we have taken some immediate steps, and I
would give us a--from a preparedness and ready to do our
mission, B range now--but that's coming from a D or an F.
Senator Cantwell. You think from August of last year to now
you've gone from, say an F or a D, to a B?
Admiral Justice. Yes, ma'am.
Senator Cantwell. In a very short period of time?
Admiral Justice. Absolutely. And I say that because most
importantly, we have done the inspections, checked our
qualifications, got these people out there and confirmed their
equipment, confirmed their ability to maintain the standards
that they were trained with, and we've checked that and we're
moving forward with that.
Senator Cantwell. Well, if you don't have the same system
of mentoring and training and returning to the accreditation
system to upgrade their skills, and companionship diving with
mentor-seniors on very difficult dives, how would you achieve
that in such a short time period?
Admiral Justice. I'd like to differentiate between the type
of diving that the Navy Divers do and the type of diving we do.
It's a--from a difficulty scale--with the exception of the ice
diving--if you set the ice diving aside--if you talk about what
our ports, security, and safety people do, which is basic pier
sweeps and hull sweeps of vessels, and we talk about what our
Aids to Navigation people do, as far as checking the bases of
some our Aids to Navigation out in the Pacific, that type of
diving nowhere, in no way, compares to the complexity of some
of the sophisticated and intricate diving that's done with the
Navy. I just would kind of like to make that comparison.
Senator Cantwell. You're saying the Coast Guard isn't as
technical or sophisticated, is that what you're saying?
Admiral Justice. The dives are not as technical or
sophisticated. The amount of training, the sophistication of
the dives are not--compared to some of the extraordinary things
that the Navy Divers do. Thus, our level of required training--
the 6-week SCUBA diving course--it meets our requirements for
the type of diving that we do.
So, what we've done is made sure that our people have,
obviously, been through that course, and then the
requirements--and ma'am, that manual you've got right by your
left hand there, is part of our requirements, I mean, we--as
applicable, we use that manual as well, in addition to the
Coast Guard manual, to make sure that, that we're maintaining
our qualifications. And again, like I said----
Senator Cantwell. So, I'm hearing two different things, and
I want to--I also want to give my colleague, I've taken about
10 minutes, I want to give my colleague a chance--but you seem
to be saying two different things. You're saying, ``Well, I--
within a short span of time, almost 6 months we've turned this
around, but we also think that the training that is currently
underway is sufficient training.'' And, so that sounds to me
inconsistent.
I do want to ask before I turn it over to her, and I'll let
you comment on that, is--in this incident with the HEALY, why
did the dive even take place, if part of the dive requirement
is that there must be four dive individuals participating in
the dive? And, it was clear, from the beginning, that there
were not four individuals. So, why is it that the Executive
Officer, the Operations Officer, and the Commander all didn't
know right away that no dive could take place? Why wasn't it
known by everybody in the Coast Guard system that the HEALY
would be incapable of exercising any dives, if four dive
individuals are required, and the HEALY didn't have four dive
individuals?
Admiral Justice. I'll answer that question. The HEALY
sailed with four divers when she left the pier. One of the
divers suddenly left the ship and was not onboard. You're
absolutely right--that dive should not have taken place, should
not have been condoned by the Commanding Officer, Executive
Officer, or the Diving Officer. It should not have happened. It
did, unfortunately, and with tragic consequences.
Senator Cantwell. Well, why wasn't it known, system-wide,
within the Coast Guard that immediately, when that fourth
individual left the vessel--I mean, there was reference in your
report to the fact that a dive was going to take place at a
future time, for that vessel at that harbor. And that the day
of the incident, there was a request to have such dive training
that day, in advance of the Dutch Harbor stop. Why wouldn't it
have been known system-wide within the Coast Guard that no dive
could have taken place on the HEALY? Why--as soon as that dive
officer left, that was it for all HEALY dive activity for the
remainder of their deployment on this mission.
Admiral Justice. Yes, ma'am, and just like you articulated,
you are absolutely right. At that point our system didn't
monitor it. It didn't watch that. Our system--we had a system
in place, the Commanding Officer of the ship had a
responsibility to execute that system, and it was not done.
But, you are right, above that we did not know, we didn't have
a method by which we monitored how many divers were onboard, we
left it up to the unit to manage that. And that was wrong.
Senator Cantwell. Nor did the Commanding Officer say,
``There will be no more dives on the rest of this mission.''
Admiral Justice. That's correct, he did not either, yes,
ma'am.
Senator Cantwell. Senator Snowe, would you like to?
Senator Snowe. Admiral Justice, tell me, does the Coast
Guard follow every provision within the Navy Diving Manual?
Admiral Justice. As applicable, yes, ma'am.
Senator Snowe. As applicable. Obviously there were a lot of
deviations, then, in this instance, in this tragic accident,
which in many ways, I think, was an indication that there must
have been some kind of culture that didn't create an ingrained
system about diving and the procedures. I mean, it occurred to
me in reading the Coast Guard's report that was replete with so
many tragic failures across the board, that there was just no
ingrained process.
And, I was wondering, in a dive, is a commanding officer
required to be present for that specific dive?
Admiral Justice. No, ma'am. He's not required to be
present, right there, no. But, he is absolutely required to OK
the dive, to give it a blessing.
Senator Snowe. Yes, and it seems to be very casual in the
approval process along the way. I mean, for example, the
Operations Officer indicated that a verbal briefing wasn't
necessary, is that required in the Diving Manual?
Admiral Justice. Yes, ma'am.
Senator Snowe. It is, so that was something that didn't
happen as well. So, there aren't many deviations from the Navy
Diving Manual, at least in so far where it's applicable, is
that correct?
Admiral Justice. That's correct, yes ma'am.
Senator Snowe. In this instance, probably most, if all
activities were deviations from the manual? In what happened on
that day?
Admiral Justice. Yes, ma'am. Tragically so.
Senator Snowe. Tragically so.
The Diver Tenders, the three that were overseeing that
process, were not trained for that specifically? I assume that
that's a different requirement in the manual?
Admiral Justice. Yes. I don't think they were all not
trained, I think at least one of them was trained. But, yes
ma'am, they weren't adequately trained, and they--given the
condition of the situation that they were in, they should not
have been doing it. Meaning, they had also been to the party--
--
Senator Snowe. Right.
Admiral Justice. They should not have been doing it.
Senator Snowe. OK.
How many mishaps has the Coast Guard had, with respect to
diving? Do you keep a record of all of the mishaps that have
occurred over a period of time? I mean, I think in order to
compare?
Admiral Justice. Ma'am, all I----
Senator Snowe. Do you keep track of them?
Admiral Justice. Yes, we do. Admiral Higgins does not have
that specific--his office tracks that, I don't have that with
us, other than that we mentioned, only that one death has
happened in the 50 years.
Senator Snowe. Yes, but even if it didn't result in a
death----
Admiral Justice. Right.
Senator Snowe.--do you have mishaps? For example, the
United States Navy, at least insofar as our statistics, shows
that there were 40,000 dives per year since 1970, with 27
fatalities. But what I'm looking for is accident per number of
dives. Is there a possibility of getting that number? What is
the mishap rate? I mean, do you have mishaps?
Admiral Justice. Yes, we do, ma'am.
Senator Snowe. And they are recorded?
Admiral Justice. Yes, ma'am.
Senator Snowe. Who do they go to, to you, Admiral Higgins?
Admiral Higgins. Yes, Senator, they come to me.
Senator Snowe. They do, so to your knowledge, have there
been, you know, mishaps along the way?
Admiral Higgins. Yes, Senator, there have. We have, in
fact, even HEALY has had some, what we call Class C mishaps,
which might be something like an uncontrolled ascent, where the
diver comes up too quickly under the ice, and we do have some
reports of those.
Now, there obviously are mishaps that don't get reported,
and one of the things we've found from the investigations was
that there may have been other mishaps on the HEALY, much less
serious, but still that were not reported.
Senator Snowe. In that 6 months under this command, at the
time the Commanding Officer--wasn't he just in place on the
HEALY for 6 months, or so? Yes?
Admiral Higgins. Yes.
Senator Snowe. OK, so it would have been in that period of
time? Or was it longer than that?
Admiral Higgins. Ma'am, I don't believe so. I think that
the dives, the minor dive mishaps that were reported were
approximately a year before.
Senator Snowe. A year before.
Admiral Higgins. Yes, and I can get you those details, I
can take that for the record, and we can report those.
[The information referred to follows:]

In 2005, HEALY's dive team experienced three uncontrolled ascents
and one uncontrolled descent while using dry suits and surface supplied
equipment. Below is a brief description of each of these incidents:

Uncontrolled Ascents:

-- On 29 June 2005, two divers had an uncontrolled ascent
using dry suits and surface supplied equipment. Both divers
were uninjured and reported loss of situational awareness as
the cause. This mishap was not reported.

-- On 11 July 2005, a diver had an uncontrolled ascent and
suffered a ``sinus squeeze'' causing a nose bleed. The diver
reported loss of situational awareness as the cause. A mishap
was reported.

Uncontrolled Descent: In July 2005, a diver reported an
uncontrolled descent caused by an inability to adequately
inflate his dry suit after passing 20 ft in depth. He made
repeated verbal commands to the top side personnel to stop
paying out line and stop his descent. The diver was about to
activate his emergency weight release when the dive tender
stopped letting out line, halting the diver's descent around 60
ft. This mishap was not reported.

Risk is inherent in all Coast Guard operations, but proper risk
management, systematic oversight and professional training minimizes
the potential for mishaps. In the wake of the HEALY incident, and to
improve Dive Program oversight, the Coast Guard took the following
immediate actions:

Upgraded the Headquarters Diving Program Manager billet from
a Lieutenant (O-3) to a Lieutenant Commander (O-4).

Established a Headquarters senior enlisted assistant manager
billet.

Established dive program managers at all Coast Guard Area
and District commands responsible for tracking the status of
dive units.

Additionally, the Coast Guard formed a senior-level work group with
expert consultants from the U.S. Navy, U.S. Army, National
Oceanographic and Atmospheric Administration, and Smithsonian
Institute. This group will evaluate the requirements, management and
policy guidance of the Coast Guard's diving program and recommend
improvements. The group's final report is expected by June 1, 2007.
Improvements being considered include (but not limited to):

Sending all CG divers through the Navy's Second Class Diver
course (or its equivalent).

Establishing regional dive lockers with primary duty divers
and allowances for special duty assignment pay similar to DOD
counterparts.

To improve the leadership and command cadre understanding of the
dive program, a dive program brief was added to the Coast Guard's
Command and Operations School. This training includes all prospective
commanding officers and executive officers that will have
responsibility for dive units. The dive portion of this training will
provide a baseline knowledge of diving policies and procedures, which
in turn will allow them to make appropriate decisions for diver
deployments as well as provide oversight of dive planning and
operational risk management.

Senator Snowe. It just appears that, obviously--I don't
know, it just doesn't seem that the system flags, a deficiency
in the process. And, I'm just wondering, and I want to compare
with the Navy, Admiral Tillotson--is this a collateral
responsibility on the part of Navy Divers? Or is this their
only specific responsibility? Because it's collateral in the
Coast Guard, correct? Yes. And in the Navy?
Admiral Tillotson. Senator Snowe, our primary divers are
Primary Duty Divers. In Naval Special Warfare, Explosive
Ordnance Disposal, Fleet Divers, and SEABEE Divers, it's a
primary responsibility.
We do have on our submarines, collateral duty divers. Their
roles are very limited, and they are on there because of the
amount of independent steaming that our submarines do, and the
fact that we may not be able to get a full-time dive team to
them, we may use the embarked divers to do emergency hull
inspections, or very minor repairs, if they get a line fouled
in the screw, but primarily, the Navy uses divers that do this
as a living.
Senator Snowe. Is it a problem that it's a collateral
responsibility? That it's not their primary focus? I know they
like to do periodic training, do they?
Admiral Justice. Yes, Ma'am.
Senator Snowe. Admiral Justice, do you see that as a
problem? Or, is it just--there was a lack of supervision,
oversight, and failures across the system?
Admiral Justice. We're looking at that.
Senator Snowe. Are you?
Admiral Justice. We're looking at that, that's part of
that----
Senator Snowe. I was just wondering.
Admiral Justice.--that's part of that comprehensive study,
and that we have outside people looking at it as well as we
are, and we're looking for those recommendations, and I would
not be surprised at all if it's found--the word collateral is a
negative term----
Senator Snowe. Right.
Admiral Justice. If it's found that we need to be full-
time, then yes, ma'am, we'll take those recommendations.
Senator Snowe. Well, are they required to do more dive
training during the hiatus? Because obviously it's irregular.
And, so if it's just an adjunct to their many responsibilities,
obviously you can get lax, whatever can happen. I mean, it's
just like anything.
Admiral Justice. Yes, ma'am, you're correct.
Senator Snowe. And it just requires being always in the
mode, and I think that's very difficult to do. So, that's
something you're evaluating?
Admiral Justice. Yes, ma'am, absolutely. The question of
the required maintenance dives that have to be done--are they
enough? Are they being done? There's an oversight piece, and
there's also an internal--the divers themselves, making sure
they're doing it.
And so, you're right on, and we've got to look at that and
do better with it.
Senator Snowe. Well, I'm sure the Committee would be
interested in having information about the number of dives the
Coast Guard does, and how many mishaps have occurred per number
of dives? I think that would help us to evaluate and give a
benchmark in terms of the kinds of changes that are going to
take place.
Another example is, why were there not additional oversight
personnel assigned, given the fact that the diving teams
increased 300 percent since September 11?
Admiral Justice. It's--no excuse, ma'am.
Senator Snowe. No, OK.
Admiral Justice. But there has been since, there has been
since.
Senator Snowe. How many?
Admiral Justice. There have been three, four more people
assigned since, and there are more to come.
Senator Snowe. How many do you need per diving team? What
would be the ratio?
Admiral Justice. I can't answer that question.
Senator Snowe. OK, does the Navy, Admiral Tillotson, have a
ratio?
Admiral Tillotson. Ma'am, there's no solid ratio, we have,
of that pinnacle-level career diver, Master Diver, we have 98
of those in the United States Navy. As far as Master EOD
divers, we have 303 of those in the Navy for a force of about
1,700. So, we have no solid ratio, it is those that achieve
that master level qualification that are put into positions to
supervise operations, based upon the qualification.
Senator Snowe. Well, Admiral Justice, I think that would be
very important for us to have a response from you with respect
to how many additional personnel the Coast Guard really
believes it requires, in addition to the ones that you've
already assigned. I think that's going to be critical.
Admiral Justice. Yes, ma'am.
[The information referred to follows:]

The Coast Guard dive program is governed by the Coast Guard Diving
Policies and Procedures Manual (COMDTINST M3150.1B). The manual is
being revised and updated with an anticipated completion date of August
1, 2007. The Coast Guard can provide a copy once completed.

Senator Snowe. One other question--on the Commanding
Officer and the command cadre--do they get very specific
training? I mean, do they get totally immersed in the training
of the diving program, so that they understand it fully? That
when they hear there's a diving mission underway on the ship,
they understand that and what that means--are they totally
familiar?
Admiral Justice. They were not, they are now.
Senator Snowe. I know they weren't on the HEALY, but would
that have been the standard? Among all officers, generally
speaking, because they hadn't had the appropriate training?
Admiral Justice. It is now.
Senator Snowe. It is now.
Admiral Justice. OK.
Senator Snowe. But it wasn't before.
Admiral Justice. It was not before. Remembering, how few
ships we--I mean, we, it's five ships that have divers. And,
you're absolutely right, they did not have the appropriate, in-
depth work-up to truly appreciate what they were doing.
Senator Snowe. Well, it seems to me that any Commanding
Officer, not only should they have the training, no matter
what, but second, when they are about to take over and take
command of a ship, that command cadre ought to be fully
briefed, and immersed in a training program prior to assuming
the command of the ship.
Admiral Justice. Yes, ma'am.
Senator Snowe. Thank you.
Senator Cantwell. Thank you, Senator Snowe. And I
appreciate your attention and commitment to this issue, because
I think we do have a lot of oversight work to continue here.
Admiral Justice, to go back to the specifics of the Coast
Guard HEALY investigation, and the information that was
provided--I'm looking at something that was provided on January
12, 2007, about the results of the investigation. And in that,
it talks about the punishment for those who were involved in
the incident on the HEALY. Obviously there has been quite a bit
of news and information from the Coast Guard investigation
about how other activities were happening at the same time as
the dive, that some of the tenders had actually consumed
alcohol, that there was an atmosphere almost, of which, those
who are participating in an ice break activity, recreational
activity were also in the dive area, and so--leading to some
confusion.
Your Coast Guard report talked about the punitive letter of
reprimand and the forfeiture of salary--I think that was, the
forfeitures were later suspended--but it talked about the
commissioned, for a Commissioned Officer--I'm reading now from
the Report, ``For a Commissioned Officer the punitive letters
have a significant career impact, and trigger other
administrative processes.''
Admiral Justice. Yes, ma'am.
Senator Cantwell. How do you define significant?
Admiral Justice. There is nothing worse you can do to an
officer than that, other than a court martial, from a
punishment of that nature. And the Operational Commander,
Admiral Worster, who held the mast and chose that punishment,
effectively terminated the potential for promotion for these
officers. And, being a many-time promoted officer, and a career
ship-driver, and--that's very meaningful, and very devastating.
Senator Cantwell. Where is the Executive Officer and the
Operational Officer from the HEALY today?
Admiral Justice. As we speak, they are still on HEALY for a
couple of more months. They are transferring this summer, and
the ship has just finished a significant overhaul in the
shipyard, where their expertise was needed, and utilized, and
they will be onboard for the transition, for the release, and
they'll be departing this summer.
Senator Cantwell. How is it that the Coast Guard's initial
report, saying that these punitive letters have significant
career impacts, and then the Executive Officer and Operational
Officer are still in the same command as the time of the
incident?
Admiral Justice. Again, I'll stand by the Operational
Commander who made that decision. Admiral Worster, when he held
the mast, and chose to relieve the Commanding Officer and leave
the Executive Officer and the Ops Officer onboard, with those
letters, that was his fitting punishment.
Again, when it comes to promotions, when it comes to
further assignments of more responsibility, or any upward
mobility, those letters have significant, and impacting
results.
Senator Cantwell. What kind of message does that send
throughout the Coast Guard community, if the individuals are
still involved in the same deployment of the HEALY?
Admiral Justice. It sends the signal, ma'am, that the
Operational Commander felt like they've done--these were
superior officers who had done superior work, however, they did
make a significant mistake, and they've been held accountable
for it. The ship needed their services, which they've been
asked to, and they've offered, and then they will be moved on.
Senator Cantwell. Well, and not to focus too much on these
two individuals, because to me, this has been a system-wide
failure. It is a cultural issue within the Coast Guard about
the level of difficulty involved in this activity, and the
importance of creating a culture within the Coast Guard of zero
tolerance from deviation of process and procedure. But, I also
believe that there is not sufficient training.
But, before I get to that--tell me about the recordkeeping?
Because the Coast Guard recordkeeping--you've had the Dive
Program for over 50 years now. And so, but for 50 years we
haven't really had the proper records and equipment, safety
checks, so on and so forth.
Admiral Justice. Ma'am, I wouldn't say that. I would not
say that.
Senator Cantwell. OK, what would you say?
Admiral Justice. I would say that the Coast Guard over 50
years has had a program that has been sufficient, and efficient
and done the job, and had an inspection program that inspected
and found that the people who were doing the job competent and
qualified, that the job had gotten done competently, and in a
qualified manner. However, I will also say that there was a--
that there has been a lack of focus, and a loss of focus on the
mission, and because of that, we had these unacceptable
results.
I just would rather not damn the program for 50 years over
this. But, I will say, absolutely in the recent past, we've
proven that we needed to do better.
Senator Cantwell. Well, I have found in my own personal
experience of management, when you want to correct a problem
you have a common agreement with what the problem is.
Admiral Justice. Yes, ma'am.
Senator Cantwell. And when you don't have common agreement
with what the problem is, chances are you're not going to have
corrective results.
And so, what I'm trying to understand is, under the current
Coast Guard regulations, the Coast Guard is required to
maintain a dive reporting system, personnel and command dive
logs, and none of these were carried out aboard the HEALY,
which is another reason why the exact amount of time the divers
were in the water was not known. In addition to these
requirements, the operational risk assessment, the ORM, must be
conducted before each dive, the ORM assesses the factors,
environmental conditions, the vessel status and location,
access to emergency medical care that, you know, all of these
things, and an ORM was not conducted before the dive aboard the
HEALY.
So, to me, the Coast Guard lacks the records of the Dive
Program, and highlights the fact that when staff asked for a
brief history of the Coast Guard dive program, the Coast Guard
could not provide this on paper, and had to create, basically a
three-page bullet outline from scratch.
So, the fact that those things didn't exist in a document,
and weren't shared, and weren't part of the command of the
vessel, says to me that you don't have good reporting
requirements. So, maybe you're saying at some point in time--I
don't know, when did the Coast Guard take over diving program
Safety Surveys from the Navy?
Admiral Justice. It was in the late nineties. We couldn't
get the exact date. I looked, I couldn't find the exact date,
but in the late nineties.
Senator Cantwell. So, perhaps you're saying that at some
other point in time the Coast Guard might have kept sufficient
recordkeeping and reporting, but these are all regulations
under the Coast Guard, and they weren't being met.
Admiral Justice. Yes, ma'am. I'm agreeing with you, yes.
And again, as we noted, is the resulting tragedy.
That said----
Senator Cantwell. I guess I'm amazed that you wouldn't call
that a very big system failure with reporting and requirements.
Because if all of those things were, again, implemented in a
system--just for example, I would assume, not being a diver,
you know, myself, but some of my staff are professional divers
which helped in preparation for the hearing--I would assume
that part of the reason why you keep track of these dive logs
and reporting and information is because--in this case--and
again, I'm just piecing together information, that when you
keep a log and the person on the scene is keeping a log,
knowing that a dive is only supposed to last for a certain
amount of time, that the fact that these individuals were down
for much longer than what the normal dive was originally
anticipated, somebody might have known that there was a problem
earlier in the situation.
Who knows whether that would have helped in the survival of
these two individuals, but nonetheless, a systematic approach
to diving was not being carried out. And I would assume that
the Coast Guard would assume that that was a major--not only
failure in this instance, but a failure of the entire reporting
system of the Coast Guard and the fact that when we asked for
information, you had to create something that was as--has been
described by my staff--as three-page bullet outline, as opposed
to actual logs and records.
Admiral Justice. I'll acquiesce to that, ma'am. Yes.
Senator Cantwell. OK, so let's turn to training.
You said that you've improved the--in this process--
improved in training. Have you implemented a new system for
specific qualifications for cold water dives?
Admiral Justice. Yes, ma'am. Well, again and what we've
done--I'll use our example of the POLAR SEA--is that we've made
sure that the procedures that were made to be, were followed.
We made sure that the proper level of training that was needed,
if that meant going back for specific training with the Navy
was needed, that that had been done. We made sure that the
oversight person at the Commanding Officer level, as well as at
the Dive Officer level, was--they were qualified. And we made
sure that they did proper practice dives, we made sure that
they were ready to sail when they did sail.
Senator Cantwell. That's not my question. I'm asking you,
are there specific--have you changed the specific
qualifications for training and requirement for cold water
dives at this point? Have you taken assessment of the current
program and said, ``We don't have enough training necessary for
cold water dives in the current Coast Guard system?''
Admiral Justice. Yes, I would say, yes.
Senator Cantwell. Yes, that's just what you--so have you
implemented something? Has the Coast Guard implemented new
qualifications?
Admiral Justice. I don't want to get caught up in the--
we've recognized them, we've updated our diving manual--we
haven't officially re-promulgated it, so the correct answer
would be ``no'' however, we understand the procedures that have
to be done, they will be changed officially, and in the
meantime, we've made sure that practically, that the divers who
were asked to go do that, were ready to go.
Senator Cantwell. The reason why I'm confused here, is
because I think there are no specific qualifications or
training requirements at this point. Up until this HEALY
incident, for cold water dives. So, what I'm asking is, did you
create something in the last several months and have them
implemented, or are you referring to the fact that you just
went back and said, ``Follow the procedures that are in the
manual.'' So, I'm trying to get at the essence of what the
Coast Guard needs to implement for a cold water program.
Admiral Justice. We're making sure that our dive manual is
updated to properly reflect the--the requirements, the training
needed, to do a cold water dive. We're going to implement that.
Senator Cantwell. And, can we get a copy?
Admiral Justice. Yes, ma'am.
Senator Cantwell. Can you get me a copy of that?
Admiral Justice. Yes.
[The information referred to follows:]

The Coast Guard formed a senior-level work group with expert
consultants from the U.S. Navy, U.S. Army, National Oceanographic and
Atmospheric Administration, and Smithsonian Institute. This group will
evaluate the requirements, management and policy guidance of the Coast
Guard's diving program and recommend improvements. The group's final
report is expected by June 1, 2007. Improvements being considered
include (but are not limited to):

Sending all CG divers through the Navy's Second Class Diver
course (or its equivalent).

Establishing regional dive lockers with primary duty divers
and allowances for special duty assignment pay similar to DOD
counterparts.

The Coast Guard is also establishing a pre-deployment dive system
that will be implemented prior to polar deployments (cold water diving
operations). These dives will consist of a series of increasingly
complex dives starting with dry suit dives, followed by cold water
dives, and culminating in cold water, confined overhead dives. These
dives will be supervised by an experienced polar diver.
Additionally, the Coast Guard initiated a Front End Analysis to
examine current dive program training objectives and performance
requirements and to compare those to the training provided by the Navy,
NOAA and the Smithsonian Institute.

Senator Cantwell. And what new training would a Coast Guard
diver be subjected to? What new training? Not the reading of a
manual, but what new training?
Admiral Justice. I don't have the specific answer to that.
I'd rather give you the exact, specific answer. And I don't
have that.
Senator Cantwell. But you think that exists today.
Admiral Justice. Absolutely.
Senator Cantwell. You think there's an outline.
Admiral Justice. Absolutely.
Senator Cantwell. Along with how much money you're going to
spend on this.
Admiral Justice. Yes, ma'am.
Senator Cantwell. OK.
Admiral Justice. I do.
Senator Cantwell. OK.
Admiral Tillotson, does the Navy have any involvement in
cold water diving activities?
Admiral Tillotson. Senator, Chapter 11 of the U.S. Navy
Diving Manual addressed cold water diving. There is no specific
training at the Navy Dive School for cold water diving. When it
comes to units being assigned missions that would involve cold
water diving, local instructions and best practices by the unit
would dictate that they would do work-up dives, that they would
check out their equipment, that they would do those things that
are outlined at any Dive Station, normal safe procedures, to do
prior to conducting those operations.
So, we have the Navy Dive Manual Chapter 11, and we have
additional local instructions that each individual unit would
have for conducting dive operations in specific situations,
which would include diving under ice. The SEABEEs also have an
instruction on diving under ice.
Senator Cantwell. And are those, so as it relates to the
Navy diving program and training, are there specific training
missions during their accreditation in cold water dives?
Admiral Tillotson. The procedures that have been followed
for diving in cold water is normally, first to--especially with
the equipment--get familiar with the equipment. Cold water
diving involves dry suits, and we normally will have our divers
dive in warm water in their dive suit to ensure proper fit, to
ensure proper functioning, to get their weight adjusted
correctly, their added weight that they need to do. Once
they've done that in a controlled environment of a pool, we
will take them into the open ocean, and do that again, because
of the density of salt water, there will be minor differences.
We then take them up to a cold water area, where they will
do work-up dives in cold water, so that they understand how
that affects their mobility, how it affects their ability to
use their hands, and those will all take--they will do a series
of work-up dives, and all divers that are going to be working
under the ice, will have done work-up dives in both their gear,
as well as in cold water, prior to being put on a dive
underneath the ice. And that is our normal procedure.
Senator Cantwell. So, in this instance, by comparison to
the Navy requirements and training, Lt. Hill--who had never
done a SCUBA cold water dive, would not be, have been permitted
to dive without a work--without proper training? Or Petty
Officer Duque--who had never done a cold water dive at all--
would not have been permitted to dive under Navy requirements?
Admiral Tillotson. No, ma'am, they would have not made that
dive, if they were on a Navy Dive Station.
Senator Cantwell. Admiral Justice, did you want to comment
on that?
Admiral Justice. Yes, ma'am. I absolutely agree.
Senator Cantwell. And again, why wasn't, why wasn't that
known by all involved?
With the assignment of the HEALY in its ice breaking
capacity and region assignment, the chances of diving in
anything less than cold water are not great, so why wouldn't it
have been known, system-wide, that none of those individuals
had received the proper level of training to do a dive of that
nature, if in fact, they had never previously done a cold
water, unless, in this instance, the Coast Guard was deviating
from the Navy manual?
Admiral Justice. Ma'am, I wasn't going to get specific.
Specifically, Lt. Hill had done a cold water dive, and
specifically, this was a work-up dive. This was supposed to be
a one of a--as Admiral Tillotson mentioned--a test, a non-
threatening, non-operational, a cold water dive. This was going
to be a cold water dive.
Senator Cantwell. I'm not an expert on diving, but my
understanding is Lt. Hill had never done a SCUBA cold water
dive. So, now she was undertaking for the first time, with
SCUBA equipment, a cold water dive, without supervision of
anyone else, including taking along another individual, who had
no cold water dive experience, or work-up. So, I don't know
where the supervision was, for Lt. Hill, of experience of
someone else, because I think from what Admiral Tillotson is
saying, is that individual would have practiced--am I
correct?--would have practiced a full SCUBA dive with the
oversight of individuals who had accomplished similar tasks, is
that correct?
Admiral Tillotson. Yes, ma'am, under our procedures, the
individuals would have conducted a series of work-up dives
prior to conducting an under-ice dive.
Senator Cantwell. Thank you. Senator Snowe, did you?
Senator Snowe. Yes, just a follow-up question on that
point; Lt. Hill was the diving supervisor, so she wasn't able--
as I understand it from the report--to be both diving and
supervising concurrently, is that correct?
Admiral Tillotson. You can't, that's right, you cannot.
Senator Snowe. So, it's clear the Commanding Officer in all
of these instances was totally unfamiliar with all of the
established procedures for a diving mission.
Admiral Justice. Yes, ma'am. Not totally, but he was
definitely not, not--he was unfamiliar, yes ma'am.
Senator Snowe. Pretty much, totally.
Admiral Justice. Yes, ma'am.
Senator Snowe. For the result to be this tragedy. I mean,
it just seems to me he was totally out of the loop. Sort of
peripheral to the whole event.
Admiral Justice. Yes, ma'am.
Senator Snowe. And also the equipment. I was stunned by
these lines. ``Two hundred feet of line had been paid out for
the divers. But the exact amount of line that was paid is
unknown as the lines are not marked at 10-foot intervals, as is
recommended by the Navy Diving Manual.'' And then it talks
about the tanks and everything else, I mean, what are the
established procedures for equipment, are they reviewed?
Admiral Justice. Yes, ma'am.
Senator Snowe. So why wouldn't these lines be marked, why
wouldn't there just be standard equipment, that would be
automatically marked. Why were these lines even on the boat if
they are not marked? I mean, they're used specifically for
diving, and diving only?
Admiral Justice. Just one of the many, many failures of the
equipment and the decisionmaking on scene there. I agree, and
you're right and that's one of the--many of these issues that
we've made sure that we've gone back and done the proper
inspections and checked the equipment, and now we're--to make
sure that this doesn't happen again.
Senator Snowe. Well, if one of the diving tenders--you
mentioned one of the dive attendants was trained, or was
trained for this specific responsibility, is that correct? Out
of the three, one was trained? Why weren't they aware of the
fact that that amount of line was moving down?
Admiral Justice. From my understanding of the reading of
the investigation, that person--in the middle of the dive--
walked away from the scene, he was distracted for some reason,
and when he came back, noticed that there was a problem. So,
again, another one of the many problems.
Senator Snowe. Are they allowed to leave the scene of the
dive?
Admiral Justice. Well, there were two people there, and he
was the third one. The answer is no, ma'am.
Senator Snowe. Wow, it is stunning, to be honest with you.
I mean, really stunning that so much could have gone so wrong.
Admiral Justice. Yes, ma'am.
Senator Snowe. And it ultimately resulted in the loss of
two lives. It's across the board, that's why it's so
fundamental and structural that I wonder if the whole program
needs a total overhaul. I mean, from beginning to end. It
sounds like that to me.
Frankly, it sounds like it's a program that got established
many years ago, and nobody's gone back to review it or do
anything with it, and it's just been incidental to the Coast
Guard's responsibilities, and that's how it was viewed, and
that's how it was dealt with. And not with, I think, the level
of prudence that it required.
Admiral Justice. Ma'am, I will not say that it is
indicative of the entire program, but I will say that we
absolutely are going back through the entire program, inside
and out, top and bottom, to make sure that problems were
corrected, and I will assure you both Madame Chair, and Senator
Snowe, that we are going to do everything in our ability to
make sure it doesn't happen again.
Senator Snowe. Thank you.
Admiral Justice. Yes, ma'am.
Senator Cantwell. Thank you, Senator Snowe.
A couple of more questions, gentlemen. Currently there are
only four management personnel to oversee the 16 dive units
nationwide, and this was talked about in the Coast Guard
management review of the incident. Obviously, this hasn't
changed since 9/11, and yet the size of the program has
tripled. What are you doing in this period of adjustment on
oversight, and why--maybe you should start there, tell me what
has happened on this, management billets, oversight of the dive
operations, nationwide?
Admiral Justice. Yes, ma'am. We're upgrading the oversight
in our headquarters, we're also adding an enlisted, a senior
enlisted person with dive experience, to our headquarters
program. We have added--we've already added an Atlantic Area, a
Pacific Area, and out in Hawaii, oversight personnel to be
full-time dive people to be monitoring the programs. And then,
as well, of course, as you mentioned, we have the three people
who reside at the Navy Dive School, and those people who are to
monitor our people going through the program, but they are also
part of our inspection program, and when we inspect our units
annually, when we inspect them annually, they will be part of--
they will bring that wonderful expertise that the Navy provides
them to the field, to make sure that we have the highest level
of inspections that we can.
Senator Cantwell. So, you're taking the four-management
team operation, and you're doubling that? Is that what you're
doing?
Admiral Justice. Yes, ma'am.
Senator Cantwell. So, you'll have four individuals based at
Coast Guard headquarters and four individuals spread across
regions?
Admiral Justice. Two at headquarters, three in the regions,
and three more at the school.
Senator Cantwell. With current personnel. Total of how many
management operations.
Admiral Justice. That would be seven, ma'am.
Senator Cantwell. OK, so we went, we go from four to seven.
Admiral Justice. Yes, ma'am.
Senator Cantwell. And do we think that's--do you believe
that that's sufficient given the number of dive operations and
the problems with logs and manuals and management and
operations? Because part of it is, you know, dive units, and
then you have the operation in and of itself. And creating a
system-wide approach to security and safety.
Admiral Justice. Yes, ma'am. Don't get me wrong, as we have
our comprehensive report done in June, if the oversight numbers
don't appear to be right, we may not stay, last up like we are
right now. We may choose to, instead of having 100 collateral
duty divers, maybe we'll go to 50 full-time divers, in a
regional setting or some different way of doing it. But however
they--whatever they recommend and whatever decision we take to
move forward, we will make sure that we've got the appropriate
number, the amount of oversight to monitor the program.
Senator Cantwell. I'm sure the interest and commitment is
there, but I want to, what I want to understand is the level of
cultural change within the Coast Guard. So, if you could
provide the Committee with what you think the requirements and
job responsibilities of those seven individuals are, that would
be helpful.
Admiral Justice. Yes, ma'am.
Senator Cantwell. Why wasn't this kind of management
oversight of the program increased after 9/11 as the
responsibilities and the number of dive units increased?
Admiral Justice. It should have, should have been.
Senator Cantwell. You don't know a reason why it didn't?
Admiral Justice. I do not know.
Senator Cantwell. Admiral Higgins, would you have a comment
on this, given your safety and oversight responsibilities?
Admiral Higgins. Given the, some of the highly technical
programs in the Coast Guard like aviation and diving, we do not
have safety professionals doing those inspections. Those
inspections are done by the programs, because of the highly
technical nature for things like firefighting, which is on
every ship, or firefighting equipment, Coast Guard safety
professionals would perform those duties.
But these specific duties--although we track the mishaps,
and we also track our recommendations, so when the Commandant's
Vessel Safety Board is finally released, in its final decision
letter, we do track those recommendations, so we go back on a
regular basis and make sure that the recommendations that the
Chief of Staff signed, actually have been implemented. So, they
may be policy changes, they may be personnel changes, they may
be training changes, but we do have a regular program to go
back and track all of those official recommendations to make
sure that they have been implemented. And we intend to do that
with this as well.
Senator Cantwell. And, is your responsibility to make those
recommendations, or to carry out the implementation of these
regulations?
Admiral Higgins. The Commandant's Vessel Safety Board works
for me, as the Director of Health and Safety, but the actual
signature is by the Chief of Staff of the Coast Guard who is
senior to both of us, so he is ordering those changes which is
good, that it's a senior person ordering those changes.
Senator Cantwell. So, does your office order changes as
well?
Admiral Higgins. Yes, Senator, we can. So, some of the
changes that have already been made, actually, by Admiral
Pelkowski, some of the very obvious changes have already been
made to the Coast Guard Dive Manual, some of those were just
announced last week, in an ALCOAST that has been released, and
we've made some of the start changes, the extra personnel and
some of the checklist issues that we must change immediately.
The rest of the recommendations will come out later, some of
those will be in the safety manual, others will be in
operational manuals.
Senator Cantwell. Can we get a copy, Admiral Higgins, of
the recommendations that you've made, specifically, through
your office to the Commandant, or to others for system changes?
Admiral Higgins. The final decision letter is really what
that is. And, it's not--unfortunately, it's not complete yet.
The process is going along. But the final decision letter will
be that vehicle.
Senator Cantwell. Can we just get any recommendations that
you have made to the Commandant about safety changes, up until
this point in time, and then we'll look forward to your final
letter?
Admiral Higgins. For the Dive Program?
Senator Cantwell. Yes.
Admiral Higgins. Yes.
Senator Cantwell. Thank you.
Now, no one has mentioned, so far about the skill level of
the dive team, and keeping skilled divers in the Coast Guard.
Is there an issue with that? The professionalism? You know,
incentive programs, compensation, things of that nature?
Admiral Higgins. It's a challenge, yes ma'am. We have extra
pay, we have an incentive program to compensate for the extra
duties required. It is a challenge, it's a small program, and
we, we have to keep up, we have to find people, and make sure
we get them trained, and get them going there, so it's a
challenge, yes, ma'am.
Senator Cantwell. Has that been identified? I didn't see
that in the initial--I might have missed it--I didn't see that
in the initial report.
Admiral Higgins. It's--being as small as the Coast Guard
is, and many--this is a situation that parallels some of our
other missions, small technical sort of things, it's a
challenge to find and recruit people from within our ranks to
do that. It's an ongoing challenge, it hasn't changed, it's an
ongoing challenge for the service that we're working to meet,
and we're meeting. We have, our collateral duty dive billets
are filled, we have enough people signed up to do it. But, it's
an ongoing evolution.
Senator Cantwell. Again, Admiral Justice, I know you're
speaking here on behalf of the entire Coast Guard, so my
questions, obviously are pointed to you, but I'm asking the
entire Coast Guard system, so thank you for your answers, but
again, one of the things that I'm trying to assess here,
because I believe that there is a cultural failure here within
the Dive Program, and its importance as it relates to security,
so in fixing that, I want to understand whether the Coast Guard
understands what the problems and challenges are, and are
articulating those. So, I will look for comments in the Coast
Guard documentation about the professionalism of the dive men
and women that are part of the Coast Guard and want incentives.
Admiral Tillotson, is this a challenge within the Navy? Do
you have the personnel, do you have the proper incentives?
Admiral Tillotson. We believe that we have an incentive
program throughout the Navy that helps us to retain--recruit
and retain individuals for this duty. Our retention rates are
extremely high, we attribute that to--partly to our incentive
programs, and partly to the quality of individuals we get in
the beginning, and their job satisfaction. However, the Navy
does continue to have problems--and I won't say it's a major
problem--but recruiting the right people. As I said earlier, we
have 30 percent attrition through the initial dive phase.
Currently, Navy Divers are about 76 percent manned. Our
accessions come from both within the fleet--which is a large
pool to choose from, compared to the Coast Guard, and from our
fleet recruiter, or our recruiters that are recruiting men and
women out of high school, and recruiting individuals off the
street.
So, we have a very aggressive program of recruiting, we
have a very aggressive program, or a very large program of
incentives, re-enlistment bonuses, special duty assignment
pays, to----
Senator Cantwell. Specifically for the dives----
Admiral Tillotson. Specifically for diving communities,
yes, ma'am.
Senator Cantwell. So, the Navy has identified that as a
challenge, to keep the skill level that you need. The
investment you've already made in training them, then obviously
keeping that, and you've assigned specific incentives to that
program.
Admiral Tillotson. Yes, ma'am, we have.
Senator Cantwell. And, that's similar to the Coast Guard?
Admiral Justice. It's similar, ma'am, but it's not as
comprehensive, because we don't have a specific rate for
divers, that you can start as a junior person and stay in it
for a career, we don't have that progression. We just have a
need--I call it a low-end need for divers--so people come into
the program, they spend their time and then they move on. So,
it's a little different. But it's a flatter set up than the
comprehensive, long-term Navy program.
Senator Cantwell. Well, if you can, again, provide that
documentation to the Committee for our review, that would be
appreciated.
Admiral Justice. Yes, ma'am.
[The information referred to follows:]

There are now eight positions providing Coast Guard dive program
management. Seven positions are currently filled; the eighth will be
filled by 15 July 2007. The positions and responsibilities are:
1. Dive Program Manager (2 positions). The Dive Program Manager
(DPM) and Assistant Manager are assigned to CG Headquarters and have
the following responsibilities:

a. Develop and promulgate Coast Guard diving policy.

b. Identify, plan and budget for specific diving needs with
responsible Program Managers.

c. Authorize establishment of diving duty billets and units,
and periodically review the diving duty allowances.

d. Direct and advise operational units on matters of proper
diving procedures and training.

e. Assist operational units in locating and obtaining diving
and salvage services.

f. Review all Coast Guard diving accidents and casualties, and
initiate appropriate corrective action.

g. Authorize diving pay to personnel in excess of unit
allowance of divers at any operational diving unit.

h. Liaison with other Federal, state and local agencies and
civilian groups on matters affecting Coast Guard diving.

i. Participate in annual diving unit safety survey inspections
and refresher training.

j. Provide input to Coast Guard Personnel Command to facilitate
the assignment of divers and diver candidates to diving units.

k. Request training quotas, manage funding, and conduct task
and training analysis for the determination of training,
personnel and equipment needs.

2. Dive Program Technical Manager/CG Liaison Office (3 positions).
The Technical Manager and two enlisted personnel (chief petty officer
and first class petty officer) comprise the Coast Guard Liaison Office
(CGLO) at the Naval Diving and Salvage Training Center (NDSTC). The
CGLO has the following responsibilities:

a. Provide administrative support to Coast Guard students
training at the NDSTC.

b. Provide recommendations and technical support to Coast Guard
Headquarters for establishing policies and procedures for the
Coast Guard diving program.

c. Provide guidance and support on diving issues to non-diving
units.

d. Provide guidance and technical support to Coast Guard diving
units.

e. Provide administrative and technical support for conducting
the diving equipment program at Coast Guard diving units.

f. Coordinate, through Coast Guard Headquarters, the
standardization, distribution, maintenance and use of equipment
in the Coast Guard diving program.

g. Provide annual refresher training to Coast Guard units with
divers.

h. Develop and administer Coast Guard-specific training.

i. Review and process all diver application packages and
provide information on qualified candidates to Coast Guard
Headquarters.

3. At Coast Guard Area and District Commands (3 personnel): The
Coast Guard Atlantic Area Command, Pacific Area Command, and Fourteenth
Coast Guard District have designated dive program oversight billets.
These positions are responsible for tracking the readiness,
qualification and training status of their dive units and act as
liaisons between dive units and units requesting CG diving support.
4. Of these eight positions, four were added in the aftermath of
the HEALY mishap, one new position at Coast Guard Headquarters and
three in the Area and District commands.

Senator Cantwell. Either Admiral Higgins or Admiral
Justice--did the Coast Guard contemplate an independent review
of the HEALY situation? Did the Coast Guard talk about getting
an outside third party to review the incident of the HEALY?
Admiral Higgins. We brought outside parties like Navy, NOAA
and other organizations in to actually work with our Commandant
Vessel Safety Board. We have, at this point, not looked for a
complete outside review. The safety process is not yet
complete, and that could be easily discussed with the Chief of
Staff.
Senator Cantwell. Do you think that, Admiral Higgins, that
would be helpful?
Admiral Higgins. We got outstanding cooperation from many
people in the Federal Government, especially from the Navy,
also from NOAA and from the National Science Foundation, the
Smithsonian Institution. We brought in the best experts, and
they gave us terrific advice on how we should change the
program.
Certainly we've made some beginning changes, and I think
some of the things that Admiral Tillotson was talking about on
how to get an ice diver ready to ice dive is really exactly
what we did for the POLAR SEA. That, we put them in those
variable volume suits in warm water at dockside where it was a
controlled environment, and we took 13 dives to get those
people ready before they broke ice in Antarctica.
I think we've got an excellent opinion so far, we certainly
haven't fixed everything, although I think our plan is sound to
do that. Certainly, if we un--if anything else gets uncovered,
it might be worth asking for an outside look, but we've had
such terrific help so far, I'm not sure at this point that it's
necessary, Senator.
Senator Cantwell. Do you think in the case of fatalities
that there should be outside investigations?
Admiral Higgins. We do--I'm also the Health Director of the
Coast Guard. On the health side, we actually have an
accrediting firm come to all of our clinics, an outside
organization, it's actually a non-profit organization that
comes, so we do have a third-party look at our health, at what
we provide for healthcare.
On the safety side, we have trained safety professionals,
some of whom spend an entire career as safety professionals in
the Coast Guard, we do internal investigations, they take a
long time because they're so thorough, I think we do a good
job. My answer to you is, the safety program, I think, does a
good job of internally doing that, we have the professionals,
we have the capability of doing those internally. When we need
help, we either contract or ask one of the other Services to
help us.
Senator Cantwell. Thank you, I'm--I guess I would have to
disagree with you, Admiral, in this case, that I think--I think
the Coast Guard probably deserves a failing grade for where the
Dive Program was. I don't believe that it is up to a B
standard, given some of the details that have come out in the
hearing this morning, as it relates to the cold water program,
and specifications, as it relates to what's transpired with the
officers and the communication, and a variety of things, as it
relates to details about training and dollars and oversight.
But that's something the Committee will look at, but that's
the way we can encourage, or require the Coast Guard to
implement a system. Because I think, anytime you're dealing
with so many men and women, it has to be a system-wide culture
to adhere to the criteria of safety and precaution. And,
obviously in this case, you could point to many, many things--
not one thing, but many, many things that went wrong as it
related to the HEALY, where any one of the number of things,
that if someone had ingrained in them culturally, that this was
part of the safety regime, may have obviously prevented this
incident.
Let me turn just for a second, because it's hard not to,
given the subject of this hearing, I know it's not the subject
of this hearing, but we just in the last several days have had
an incident again in the Pacific Northwest as it relates to a
Fast Response Boat, one of the Defenders, that we appreciate
very much, the work that the Coast Guard does on the Defenders
in supporting the Washington State Ferry System.
I'll just point out for those who don't know, that the
Washington State Ferry System carries more passengers on an
annual basis than Amtrak. So, as we look at terrorist threat,
and security regimes for our transportation infrastructure,
it's a very popular transportation infrastructure for the
Northwest. So, we very much appreciate what the Coast Guard is
doing in working with the FBI, and Washington State patrol, and
various other individuals on the security of our maritime
transportation system.
Given that, it's very distressing to hear of another Coast
Guard fatality in a basic operation of the Coast Guard. So, I
don't know, Admiral Higgins or Admiral Justice--do you have any
comments on this most recent incident that happened--I believe
it was Sunday--Sunday off Vashon Island in Puget Sound?
Admiral Justice. Yes, ma'am, I will give that a go. Again,
of course, how distressing it is and how unfortunate and how
sorry we are for the family. That Ports and Coastal Water
Security System--those people work for the, our Marine--MSSTs,
our Safety and Security Teams--they're there to do exactly what
you're talking about, which is to provide escorts for those
ferries in a, in a port security manner. And, you can be
assured again, as Admiral Higgins will echo, that we will do an
investigation, understand the--we appreciate the safety
parameters that, what happened there and why that individual
unfortunately ejected from the boat, and we will make sure that
we do what we can that it doesn't happen again.
The work on the water, at high speeds, you know, is
dangerous, and our people--because they're out there every day,
but we think we have a--we actually we know of the issue, and
we're looking at the problem, and we'll work to resolve it.
Senator Cantwell. Are these individuals required to wear
safety gear, safety harnesses, or what have you?
Admiral Justice. No. No, in the situation that he was in at
the time, no. But, that's a great question, and we're going to
look at that and determine, maybe they should be, and maybe we
will.
Senator Cantwell. Have their been other incidents of
accidents or fatalities related to these vessels and this type
of activity?
Admiral Higgins. Senator, I don't believe we've had a
fatality with the MSSTs. We have investigated several, less
serious, accidents, including one from MSST Anchorage, where
the boat rolled over during a turn. We've also done preliminary
investigations on other members who have been--either fell
overboard or been ejected during a turn, especially in the
waves.
We have had these boats--very few of them before--we have
had a lot of them in the last 5 to 6 years. Prior to that, some
of the boats they replaced were much slower. And, there is a
learning curve, not only for our people, but for our training
and for the equipment, and we're still, I believe, in that
learning curve. We've had hundreds of thousands of operating
hours of these boats over the last several years, our
actually--man overboard and ejection rate is coming down, but
we still have incidents where people are knocked or thrown off
these boats, and we are very carefully studying the issue of a
harness. And I've been working our folks--and Admiral Justice's
folks--have been working on that very carefully, and we've been
working on that for some months now.
Senator Cantwell. Well, it sounds as if this is something
you've had prior knowledge about and challenge, and I guess my
concern is that it'll take a fatality to get the Coast Guard's
attention as it relates to the safety procedures. I don't want
to have another hearing on this incident and then hear, ``Well,
we're working on this, and we're working--'' I would assume
that, in this kind of instance, having both the HEALY and now
this Defender incident, that the Coast Guard would do a, you
know, bottom-up and top-down review of all safety procedures,
and whether those safety procedures are well-ingrained into the
workforce of the Coast Guard, and how they are being adhered to
from every individual. Since every individual is responsible
not only for the safety of their vessel, but for the safety of
their own lives. And, I would assume that that's something that
the Coast Guard--no, I'm not going to assume, I want the Coast
Guard to tell me----
Admiral Higgins. Admiral Allen did order a safety stand-
down on September 18th, I discussed that briefly in my opening
statement, and we are still working on all of the data that has
been produced from that safety stand-down. But, there was
mandatory training, there was a safety stand-down by all
operational units, and all-hands training for everyone in the
Coast Guard. We are collecting the data from that, and are
still working with that with our safety professionals.
Senator Cantwell. Well, again, I know it's not the focus of
this hearing--go ahead, Admiral Justice.
Admiral Justice. Ma'am, I'll just echo what Admiral Higgins
said, but be a little more specific. You are absolutely right.
As we've grown, our port security mission, as we do things with
the helicopters and our Marine Safety and Security Teams, we
dropped out of helicopters and we do different things with
boats and we arm them and we man them and we know we have to
look closer, as we're moving forward with these missions, the
safety side of it, and--and you're absolutely right, we need to
look at every facet of it, and this issue--I mean, it's been
brought to our attention, it's been looked at, there's a
solution there, it's not going to take 6 months to get it
solved, it just happened, the investigation is going to happen,
I want to get the details, I don't want to get caught up in--
but, I'm here to tell you that that's a soluble problem, and we
need to be looking at all of those things that we're hearing
from the field, and that we know are a concern, and we're
working to address them, aggressively, and as safely as
possible.
Senator Cantwell. Well, what I would like is to solve the
security issues and security regimes before we have another
incident. And so, I would appreciate, Admiral Higgins, if you
can get me what the stand-down security measure that was
implemented by the Commandant, how that intersected with this
previously known problem with the Defenders, and what was being
done during this time period to communicate the problem, and
perhaps to alleviate this incident.
Gentlemen, thank you for your testimony and your answering
questions today, this committee is going to continue to be
diligent about this issue. When I came into office in 2001 and
had the unfortunate circumstances of having a wild land fire
situation in Washington State in which four individuals lost
their lives, for several years, working on the Oversight
Committee, we did our responsibility to look at the safety and
security of firefighting, and the lack of security in these
systems with young men and women with very little training
coming into that system.
My only point is to say that I was diligent in that
situation, and I will be diligent in this situation. If I'm the
only member, I appreciate Senator Snowe being here, and I think
my colleagues from all over the country will be very interested
in this issue. But it is our responsibility as the oversight,
the legislative oversight for the Coast Guard to make sure that
these deaths were not in vain, and that we do implement the
safety regimes that all of those individuals coming to work for
the Coast Guard will have confidence in, and will provide--not
only for the Nation's security, but the security of these
individuals. So, again, and Admiral Tillotson, thank you for
being here, we'll look forward to continuing to communicate
with the Navy on these issues.
Gentlemen, thank you very much, the hearing is adjourned.
[Whereupon, at 11:42 p.m., the hearing was adjourned.]

A P P E N D I X

Prepared Statement of Hon. Daniel K. Inouye, U.S. Senator from Hawaii

My condolences go out to the families and friends of the two Coast
Guard divers who lost their lives in the tragic accident that occurred
aboard the HEALY icebreaker in August 2006. Our purpose at this hearing
today is to make sure the Coast Guard has taken every step necessary to
ensure a tragedy like the HEALY incident never happens again.
To that end, the Coast Guard must strengthen the management and
safety of its dive program.
The Coast Guard's dive program began during the 1940s and is a
vital component of many of the Coast Guard's missions today. Over time,
the program has expanded from performing ship husbandry and search and
recovery to assisting Maritime Safety and Security Teams, tending buoys
for Aids to Navigation, and lending scientific support to science teams
operating aboard the polar icebreakers. In recent history, the number
of operational Coast Guard dive teams has tripled from six to sixteen
since the events of September 11, 2001.
Unfortunately the manner in which the Coast Guard has been managing
the dive program does not reflect its growing importance to the agency.
The investigative report for the HEALY incident, which was released in
January 2007, found that the main cause for the accident was that the
HEALY crew did not follow any standard operating procedures. There is
no excuse for this absolute failure to follow, and enforce, such
procedures.
Protocols are put in place specifically to ensure the safety of
everyone involved and to minimize unnecessary risk. In addition, divers
and support crew need adequate training in such a dangerous activity.
The HEALY incident should be a constant reminder of the need for
protocols and the training to follow them.
My concern is that this lesson has not been learned. No additional
funding has been requested for this program since the events of 9/11,
even though the number of dive teams tripled. Although the Coast Guard
has indicated that it is strengthening the management and safety of the
program, the Fiscal Year 2008 budget provides no funding for the dive
program, much less for implementing the reforms. Starving the dive
program of funding sends the message that the Coast Guard has not taken
the HEALY incident seriously.
I look forward to the Admiral's testimony on the Coast Guard's
efforts to address the inadequacies with its dive program and how
Congress can help to ensure the dive program operates under the best
management and safety protocols possible.
I thank the witnesses for their testimony and look forward to
working with you on this important issue.
______

Response to Written Questions Submitted by Hon. Daniel K. Inouye to
Rear Admiral Wayne Justice

Question 1. How does the Coast Guard plan to ensure that more
stringent safety standards and reporting requirements will be upheld
long after the memory of this tragedy is fresh in our minds?
What specific actions are being taken to ensure that members of the
command cadre maintain that degree of respect within their crew once a
vessel has departed port?
Answer. Immediately following the HEALY incident, a safety
inspection was conducted onboard HEALY, and the cutter's dive
capabilities were suspended. Further, all dive capable units have
undergone a Dive Program Safety Survey (DPSS) within the previous 12
months, as of January 12, 2007. One unit was found to be deficient in
its readiness and training and was directed to suspend dive operations.
Upon correcting all discrepancies, the unit successfully completed a
follow-up inspection and was authorized to resume all diving
operations. In the future, a DPSS--an inspection of all records, logs
and equipment--will be conducted on an annual basis for every Coast
Guard unit with a Dive Team.
As part of the Mishap Investigation, the Commandant of the Coast
Guard required a thorough review of the Dive Program and ordered a
safety stand-down from operations. This stand-down included a
questionnaire/survey with an overall risk assessment of each unit. This
survey will be used as a baseline for future Safety Stand Down surveys.
The survey, and accompanying risk assessment and crew endurance
management tools will also be refined to be more mission and platform
specific, following the highly successful aviation risk management
model.
In the wake of the HEALY incident, and to improve Dive Program
oversight, the Coast Guard took the following immediate actions:

Upgraded the Headquarters Diving Program Manager billet from
a Lieutenant (O-3) to a Lieutenant Commander (O-4).

Established a Headquarters senior enlisted assistant manager
billet.

Established dive program managers at all Coast Guard Area
and District commands responsible for tracking the status of
dive units.

Additionally, the Coast Guard formed a senior-level work group with
expert consultants from the U.S. Navy, U.S. Army, National
Oceanographic and Atmospheric Administration, and Smithsonian
Institution. This group will evaluate the requirements, management and
policy guidance of the Coast Guard's diving program and recommend
improvements. The group's final report is expected by June 1, 2007.
Improvements being considered include (but not limited to):

Sending all CG divers through the Navy's Second Class Diver
course (or its equivalent).

Establishing regional dive lockers with primary duty divers
and allowances for special duty assignment pay similar to DOD
counterparts.

Question 2. What specific plans does the Coast Guard have for
ensuring that current members of its dive program maintain their
certification for diving while they are on deployment?
How do those plans incorporate members of the command cadre, to
ensure that they allow dive managers the resources and time to maintain
their certifications once they are deployed?
Is the Coast Guard implementing additional training for those
divers that may conduct cold&ter dive missions?
Who is being consulted as these plans are being developed, and how
is the Coast Guard evaluating the data it collects in order to develop
these plans?
Answer. The Coast Guard has upgraded the Headquarters Diving
Program Manager billet from a Lieutenant (O-3) to a Lieutenant
Commander (O-4), established a senior enlisted assistant manager
billet, and established dive program managers at Coast Guard Area and
District commands responsible for better tracking the status of dive
units.
Multiple diving opportunities are available throughout deployments
for divers to maintain their certifications. Commanding Officers are
responsible for providing adequate time during deployments for divers
to complete required recertification dives and diver training.
Presently, Coast Guard Headquarters is in the initial stages of
developing a centralized computer reporting system for individual dive
logs based on the best practices of DOD and other Federal agency dive
reporting standards. With this centralized dive log system, program
managers would be able to track diver qualifications and training to
prompt deployed units to complete required recertification dives and
diver training.
To improve the leadership and command cadre understanding of the
dive program, a dive program brief was added to the Coast Guard's
Command and Operations School. This training includes all prospective
commanding officers and executive officers that will have
responsibility for dive units. The dive portion of this training will
provide a baseline knowledge of diving policies and procedures, which
in turn will allow them to make appropriate decisions for diver
deployments, as well as provide oversight of dive planning and
operational risk management.
Yes, the Coast Guard is establishing a pre-deployment dive system
that will be implemented prior to polar deployments. These dives will
consist of a series of increasingly complex dives starting with dry
suit dives, followed by cold water dives, and culminating in cold
water, confined overhead dives. These dives will be supervised by an
experienced polar diver.
The Coast Guard is working with the top four Government dive
programs in the United States: the U.S. Navy, U.S. Army, NOAA, and the
Smithsonian Institution. The Coast Guard has established a diving work
group to collect and assess the various program requirements provided
by these dive programs. The findings of the work group will be used to
improve the Coast Guard diving program.

Question 3. In the existing operational risk assessments, how does
the Coast Guard weigh the various factors that might contribute to the
risk of a specific dive mission?
Is the Coast Guard planning to change its process of operational
risk assessments that are required prior to each dive mission? If so,
how?
As part of this plan, does the Coast Guard plan to change the way
in which it weighs different risk factors in these operational risk
assessments?
Answer. The risk assessment model requires a review of six
different elements (each are equally weighted):

Supervision assesses the qualifications of the supervisor
and whether or not he or she is actually supervising or is
required to be actively engaged in the hands-on part of the
operation.

Planning assesses how much information is available, how
clear it is, and how much time is available to plan the
evolution or evaluate the situation.

Crew and Watchstander Selection assesses the experience of
the persons performing the specific event or evolution, and if
individuals are replaced during the event or evolution, the
experience of the new team member's experience.

Crew and Watchstander Fitness assesses the team member's
physical and mental state, which is generally a function of how
much rest they've had, but may include other factors that
contribute to fatigue.

Environment assesses all factors affecting the personnel or
resource performance including time of day, lighting,
atmospheric and oceanic conditions, chemical hazards, and
proximity to other external and geographic hazards and
barriers.

Event or Evolution Complexity assesses both the time and
resources required to conduct the evolution, the proficiency of
the team, how long environmental factors are expected remain
stable, and the level of coordination needed to conduct the
evolution.

No, but additional emphasis has been placed on conducting risk
assessments. Further, to improve the leadership and command cadre
understanding of the dive program, a dive program brief was added to
the Coast Guard's Command and Operations School. This training includes
all prospective commanding officers and executive officers that will
have responsibility for dive units. The dive portion of this training
will provide a baseline knowledge of diving policies and procedures
which in turn will allow them to make appropriate decisions for diver
deployments as well as provide oversight of dive planning and
operational risk management.
No, the Coast Guard does not intend on changing the method way
these factors are weighed.

Question 4. How is the Coast Guard implementing a plan to increase
the quantity and quality of personnel in its dive program?
How does the Coast Guard plan to increase the incentives it
provides to ensure that those individuals earning certification as a
diver are retained in the dive program?
Answer. The Coast Guard formed a senior-level work group with
expert consultants from the U.S. Navy, U.S. Army, National
Oceanographic and Atmospheric Administration, and Smithsonian
Institution. This group will evaluate the requirements, management and
policy guidance of the Coast Guard's diving program and recommend
improvements. The group's final report is expected by June 1, 2007.
Improvements being considered include (but not limited to):

Sending all CG divers through the Navy's Second Class Diver
course (or its equivalent).

Establishing regional dive lockers with primary duty divers
and allowances for special duty assignment pay similar to DOD
counterparts.

Question 5. Does the Coast Guard plan to change the Diving Program
Safety Surveys it conducts of its dive teams? If so, how?
Will these changes require an increase in the resources the Coast
Guard needs to complete these safety surveys? If so, how?
How does the Coast Guard plan to meet these increased resource
demands?
Answer. Yes, the Diving Program Safety Surveys (DPSS) have been
updated and they include recent policy changes established by an
ALCOAST message released March 22, 2007. This message re-emphasized,
clarified, and/or updated Coast Guard diving policies and procedures. A
senior level work group has been formed, including expert consultants
from the U.S. Navy, U.S. Army, National Oceanographic and Atmospheric
Administration, and Smithsonian Institution, to evaluate the
requirements, management and policy guidance of the Coast Guard's
diving program and recommend improvements. The group's final report is
expected by June 1, 2007. Issues being considered include (but not
limited to) establishment of a 3-tier dive unit inspection system to be
executed by personnel from the soon to be commissioned Deployable
Operations Group (annually w/USN participation), Naval Diving and
Salvage Training Center Coast Guard Liaison Office and Coast Guard
Headquarters (annually), and each dive unit (semi-annually).
The Coast Guard already upgraded the Headquarters Diving Program
Manager billet from a Lieutenant (O-3) to a Lieutenant Commander (O-4),
established a Headquarters senior enlisted assistant manager billet,
and established dive program managers at Coast Guard Area and District
commands responsible for better tracking the status of dive units.
All of the billets were reprogrammed from existing billets.

Question 6. Is the Coast Guard planning to increase the number of
management personnel that have oversight responsibility of the dive
program?
What are some of the costs and benefit factors the Coast Guard is
evaluating to make the final determination of how best to develop its
internal oversight of the dive program?
Answer. The Coast Guard upgraded the Headquarters Diving Program
Manager billet from a Lieutenant (O-3) to a Lieutenant Commander (O-4),
established a Headquarters senior enlisted assistant manager billet,
and established dive program managers at Coast Guard Area and District
commands responsible for better tracking the status of dive units.
A senior level work group was formed, including expert consultants
from the U.S. Navy, U.S. Army, National Oceanographic and Atmospheric
Administration, and Smithsonian Institution, to evaluate the
requirements, management, and policy guidance of the Coast Guard's
diving program and recommend the way forward. Its final report is
expected by June 1, 2007. Issues being considered include (but are not
limited to) sending all CG divers through the Navy's Second Class Diver
course (or its equivalent), establishing regional dive lockers manned
with primary duty divers, allowances for special duty assignment pay
similar to DOD counterparts, and establishment of a 3-tier dive unit
inspection system to be executed by personnel from the soon to be
commissioned Deployable Operations Group (annually w/USN
participation), Naval Diving and Salvage Training Center Coast Guard
Liaison Office and Coast Guard Headquarters (annually), and each dive
unit (semi-annually).

Question 7. How does the Coast Guard plan to increase the rigor in
its process of recordkeeping and reporting?
Likewise, how is the Coast Guard going to ensure that those records
and reports are monitored and maintained in a manner consistent with
the Coast Guard Dive Manual?
Answer. A senior level work group has been formed, including expert
consultants from the U.S. Navy, U.S. Army, National Oceanographic and
Atmospheric Administration, and Smithsonian Institution, to evaluate
the requirements, management, and policy guidance of the Coast Guard's
diving program and recommend the way forward. Its final report is
expected by June 1, 2007. The work group is evaluating recordkeeping
methods and reporting requirements utilized by DOD and Federal
agencies.
Part of the annual Diving Program Safety Surveys (DPSS) includes a
review of all administrative dive logs and maintenance records. These
surveys may change depending on the recommendations of the work group.
______

Response to Written Questions Submitted by Hon. Daniel K. Inouye to
Rear Admiral Paul Higgins

Question 1. What steps are being taken by the Coast Guard to
examine its training program, and assess if its training program for
general certification is adequate?
Given the increased risk inherit with diving in cold water
environments, do you plan to implement a specific training program for
cold water divers?
How will the Coast Guard determine what qualifications are
necessary for cold water dives?
Answer. A senior level work group has been formed, including expert
consultants from the U.S. Navy, U.S. Army, National Oceanographic and
Atmospheric Administration, and Smithsonian Institute, to evaluate the
requirements, management, and policy guidance of the Coast Guard's
diving program and recommend the way forward. Its final report is
expected by June 1, 2007. Issues being considered include (but not
limited to) sending all Coast Guard divers through the Navy's Second
Class Diver course (or its equivalent), establishing regional dive
lockers manned with primary duty divers, and allowances for special
duty assignment pay similar to DOD counterparts. The Coast Guard has
funded and initiated a Front End Analysis to examine current training
objectives and performance requirements from program managers and to
compare those to the training provided by the Navy, NOAA and the
Smithsonian Institute.
Yes. The Coast Guard is establishing a pre-deployment dive system
that will be implemented prior to polar deployments. These dives will
consist of a series of increasingly complex dives starting with dry
suit dives, followed by cold water dives, and culminating in cold
water, confined overhead dives. These dives will be supervised by an
experienced polar diver.
In an effort to further our understanding of how our international
counterparts operate and train, a Coast Guard representative attended
the International Polar Diving Workshop in Svalbard, Norway on March
15-22, 2007. This workshop was an international, interdisciplinary
assessment of polar diving operations, and served as an excellent
baseline against which to measure Coast Guard polar diving policies and
procedures. Also, the Coast Guard convened a cold water diving
conference April 18-19, 2007 to develop cold water/ice diving policy in
addition to the U.S. Navy policy. The information and knowledge gained
from this conference will be incorporated into the next revision of the
Coast Guard Diving Policies and Procedures Manual.

Question 2. How does the Coast Guard plan to ensure that an
Operational Risk Assessment is completed before each dive?
Rear Admiral, will you be increasing the number of factors assessed
before each dive? If not, why not?
In the existing Operational Risk Assessments, how does the Coast
Guard weigh the various factors that might contribute to the risk of a
specific dive mission?
Answer. Every dive team has been directed to conduct an Operational
Risk Management Assessment during the planning of every dive mission,
and to continually reassess the risk throughout mission execution.
Documentation of the assessments is to be retained at the unit for 60
days following mission completion. Compliance will be confirmed during
the unit's annual Diving Program Safety Survey.
We are not planning to add to the number of factors assessed before
each dive. The current Operational Risk Management models are proven,
systematic methods of managing risk when conducted in accordance with
established protocols. They enable an operational unit to operate
within the constraints of an envelope of safety, and allow a high level
of flexibility within the risk management framework. They enable any
unit or team member to quickly recognize and notify other team members
of a change in any of the factors and make adjustments to reduce the
risk.
The risk assessment model requires a review of six different
elements (each are equally weighted):

Supervision, which assesses the qualifications of the
supervisor and whether or not he or she is actually supervising
or is required to be actively engaged in the hands-on part of
the operation.

Planning, which assesses how much information is available,
how clear it is, and how much time is available to plan the
evolution or evaluate the situation.

Crew and Watchstander Selection, which assesses the
experience of the persons performing the specific event or
evolution, and if individuals are replaced during the event or
evolution, the experience of the new team member's experience.

Crew and Watchstander Fitness, assesses the team member's
physical and mental state, which is generally a function of how
much rest they've had, but may include other factors that
contribute to fatigue.

Environment, assesses all factors affecting the personnel or
resource performance including time of day, lighting,
atmospheric and oceanic conditions, chemical hazards, and
proximity to other external and geographic hazards and
barriers.

Event or Evolution Complexity, assesses both the time and
resources required to conduct the evolution, the proficiency of
the team, how long environmental factors are expected remain
stable, and the level of coordination needed to conduct the
evolution.

Question 3. Ensuring that the Coast Guard is able to both recruit
and retain the quality and quantity of personnel to its dive program is
essential for the building a successful and reliable program. How does
the Coast Guard plan to increase incentives to recruit and retain the
divers necessary to complete its dive mission?
Answer. The Coast Guard formed a senior level work group, including
expert consultants from the U.S. Navy, U.S. Army, National
Oceanographic and Atmospheric Administration, and Smithsonian
Institute, to evaluate the requirements, management, and policy
guidance of the Coast Guard's diving program and recommend the way
forward. Its final report is expected by June 1, 2007. Issues being
considered include sending all CG divers through the Navy's Second
Class Diver course (or its equivalent), establishing regional dive
lockers manned with primary duty divers, and allowances for special
duty assignment pay similar to DOD counterparts.

Question 4. About how many years were the Diving Program Safety
Surveys not conducted within the Coast Guard?
Why is this?
If you did not have enough personnel to carry out these vital
surveys, why did you not ask for more funding? More importantly, why
did you not cancel the dives if the Coast Guard knew there was a good
chance they were putting their divers in jeopardy?
Answer. Diving Program Safety Surveys (DPSS) have been required
since the 1970s. U.S. Navy conducted DPSS for CG diving units until the
mid 1990s. Coast Guard diving program management staff took over DPSS.
At some point in the late 1990s, DPSS visits stopped. This was due to a
loss of organizational focus regarding the dive program. In 2004, the
DPSS was re-established by the Coast Guard Headquarters Diving Program
Manager.
Given the dive program's excellent safety record prior to the HEALY
mishap, the Coast Guard did not recognize a need to increase oversight
of the dive program and maintenance of service-wide standards.

Question 5. In the FY 2008 president's budget request you have
asked for $13 million dollars to build a new pool for training rescue
swimmers. Do you have any plans to use this pool for dive training? Why
not?
Answer. No. The Naval Diving and Salvage Training Center (NDSTC) in
Panama City, Florida conducts dive training for all services and has
the necessary training facilities and staff to train Coast Guard
divers. Additionally, NDSTC began construction of a new pool in March
2007 that will have greater diver training capabilities than existing
facilities. Rescue swimmer training is conducted at Elizabeth City,
North Carolina; this training is not co-located with any Coast Guard
diving units.

Question 6. How is the Coast Guard making sure that the proper
records are being kept for the dive program from here on out?
Besides the fact that safety inspections were not carried out for
many years, why is there a lack of personal and command dive logs?
Aren't these a requirement after each dive is completed?
Answer. Individual dive logs and maintenance records have always
been required and have been mostly well maintained at the individual
diver and dive unit level. These are checked and verified during the
Diving Program Safety Surveys (DPSS).
The Coast Guard Headquarters level records of DPSS results, past FY
budgets, and diving mishaps were incomplete and have been reconstructed
with limited success. Presently, Coast Guard Headquarters is in the
initial stages of developing a centralized computer reporting system
for individual dive logs based on the best practices of DOD and other
Federal agency dive reporting standards.
______

Response to Written Questions Submitted by Hon. Daniel K. Inouye to
Rear Admiral Michael P. Tillotson

Qualifications and Training
Question 1. Is the Coast Guard system of maintaining diver
qualifications, following initial certification, rigorous enough to
adequately minimize risks?
Answer. At the Coast Guard's request, the Navy has advised the
Coast Guard Headquarters leadership since the accident and provided
them with complete information on how the Navy manages its diving
program. The Navy has committed to continue to advise the Coast Guard
on alternatives as they restructure their program including actively
offering the USCG the same diving oversight techniques that the Navy
uses on itself.
The formal Coast Guard requirements for requalification do not
significantly differ from the Navy. The primary difference between the
Navy and the Coast Guard is the cadre of senior, experienced Navy
Divers, especially our senior enlisted Master Divers, who continuously
mentor junior sailors and manage our diving mission risks. During the
transition to a restructured Coast Guard diving program including more
experienced diving community leadership, there are advantages for the
Coast Guard to use targeted Navy experience to assure rigorous safety
standards are maintained at their diving commands.
Other advantageous Navy processes that ensure rigorous adherence to
established safe diving practices include operational readiness and
Navy Safety Center assessments of diving commands. The Coast Guard
might consider requesting these assessments from the Navy until they
can establish their own processes. The operational readiness of diving
commands is monitored at the Fleet level by a formal assessment program
that has the advocacy of all levels of the chain of command. These
assessments are conducted periodically on all Navy Diving commands and
ensure all commands comply with established policies and regulations in
the areas of diving program administration, and operational readiness.
The diving assessments performed by Fleet Forces Command parallel the
operational readiness assessments that are performed on afloat commands
to ensure their readiness for deployment. In addition to these command
operational assessments, the Naval Safety Center provides periodic
assessments of diving command's compliance with established Naval
Safety programs including compliance with U.S. Navy Diving Manual
safety provisions. Naval Safety Center assessment results are provided
directly to the Commanding Officer of the diving command and serve as a
non-punitive feedback mechanism for command self correction.

Question 2. What experience do you have with cold-water diving?
Answer. Selected Navy Dive Teams have significant experience in
cold-weather diving operations. Cold-water and/or ice diving performed
by the USN can be categorized in two ways:

a. Dive Teams working in homeports that experience regular
water temperatures below 37 degrees (e.g., Submarine Base New
London Connecticut and Portsmouth Naval Shipyard), have well
established and practiced techniques for dealing with low
surface and water temperatures. Divers assigned to these areas
are practiced in these techniques and operate under the close
control of experienced Master Divers. Accordingly, their level
of proficiency in their specific diving area remains high and
the need for extensive Fleet-wide cold-water/ice diving
training is low.

b. Dive Teams that deploy to remote sites to conduct cold-water
and/or ice diving invest significant time preparing for this
mission. The training will generally consist of specialized
equipment (e.g., dry-suits, heavy gloves, cold water air
systems, and emergency procedures unique to ice diving). The
preparation will begin prior to deploying to the ice mission
area. Upon arrival, the dive site will be prepared in
accordance with developed procedures. The combination of pre-
deployment training and dive site preparations adds weeks to an
ice diving operation.

Question 3. What are some of the additional risk factors that
divers face when making a cold-water dive?
Answer. Additional cold water diving risk factors include:

Diving with unfamiliar equipment.
Difficulty manipulating equipment with extremities.
Control of buoyancy.

The U.S. Navy Diving Manual identifies the following risk elements
in its planning guidelines for cold water diving:
Planning Guidelines. The following special planning considerations
relate to diving under/near ice cover or in water at or below a
temperature of 37+F:

The task and requirement for ice diving should be reviewed
to ascertain that it is operationally essential.

Environmental conditions such as ice thickness, water depth,
temperature, wind velocity, current, visibility, and light
conditions should be determined.

Ideally, a reconnaissance of the proposed dive site is
performed by the Diving Supervisor or a person with ice-covered
or cold water diving experience.

The type of dive equipment chosen must be suited for the
operation.

Logistical planning must include transportation, ancillary
equipment, provisioning, fuel, tools, clothing and bedding,
medical evacuation procedures, communications, etc.

Question 4. Did you have more formal cold-water training in order
to be certified for cold-water dives?
Answer. Since ice/cold water diving is not a routine tasking, in-
depth training is conducted at the unit level to ensure all team
members are familiar with the special procedural, equipment and
emergency procedures for ice diving prior to any operation. Specific
training points--(not all inclusive):

Prior to the use of variable volume dry suits and hot water
suits in cold and ice-covered waters, divers must be trained in
their use and be thoroughly familiar with the operation of
these suits.

Personnel Considerations. The supervisor of the dive must
ensure that all personnel required to make the dive have been
properly trained in ice diving techniques and are physically
fit. No diver may be allowed to make the dive if, in the
opinion of the Diving Supervisor, the diver is suffering from
the psychological stress of an ice dive (anxiety,
claustrophobia, or recklessness).

Divers must practice buddy breathing prior to the operation
because of the increased possibility that buddy breathing will
be required. Proficiency in the process will minimize loss of
valuable time during an emergency. Using approved cold water
scuba equipment will minimize or eliminate freeze-up problems.
(This means during work-ups and in cold water at the site).

Tending the Diver. The lifeline is to be held by the tender
at all times. As an additional safety measure during ice
diving, the end of the lifeline must be secured to a stationary
object to prevent it from falling into the entry hole should it
be dropped by the tender. It is recommended that the lifeline
be marked at 10-foot intervals to allow the tender and Diving
Supervisor to estimate the diver's position. However, the
diver's radial position can only be roughly estimated. The dive
team must be thoroughly familiar with the procedures for
lifeline tending in U.S. Navy dive manual Chapter 8. Tending
line sensitivity and awareness of the diver's position by
tenders may be difficult with the added factors of lifeline
drag on subsurface ice formations, line drag over the lip of
the under-ice hole, tending through heavy mittens, and the lack
of surface bubbles.

Operational Risk Assessments
Question 5. What are some of the more critical variables the Navy
evaluates when it assesses the risk of a proposed dive missions?
Answer. The U.S. Navy Diving Manual identifies the following
elements of Operational Risk Management (ORM) when planning a diving
mission:
General Planning and ORM Process. A successful diving mission is
the direct outcome of careful, thorough planning. The nature of each
operation determines the scope of the planning effort, but certain
general considerations apply to every operation.

Bottom Time. Bottom time is always at a premium. Developing
measures to conserve bottom time or increase diver
effectiveness is critical for success.

Preplanning. An operation that is delayed due to
unanticipated problems may fail. Preplanning the use of the
time available to accomplish specific objectives is a
prerequisite to success.

Equipment. Selecting the correct equipment for the job is
critical to success.

Environmental Conditions. Diving operational planners must
plan for safely mitigating extreme environmental conditions.
Personnel and support facility safety shall be given the
highest priority.

Diver Protection. It is critical to protect divers from
shipping hazards, temperature extremes, and dangerous pollution
during all operations.

Emergency Assistance. It is critical to coordinate emergency
assistance from outside sources before the operation begins.

Weather. Because diving operations are weather dependent,
dive planning shall allow for worst-case scenarios.

Concept of ORM:
ORM is a decisionmaking tool used by people at all levels to
increase operational effectiveness by: anticipating hazards and
reducing the potential for loss and, thereby, increasing the
probability of successful mission; increases our ability to make
informed decisions by providing the best baseline of knowledge and
experience available; and minimizes risks to acceptable levels,
commensurate with mission accomplishment. The amount of risk we will
take in war is much greater than that we should be willing to take in
peace, but the process is the same. Applying the ORM process will
reduce mishaps, lower costs, and provide for more efficient use of
resources.

Question 6. What roles do the Command Officers, Dive Managers, and
Members of the Dive Team play as these assessments are being conducted?
Answer. The U.S. Navy Diving Manual lists the following roles for
the Commanding Officer, Diving Supervisors and Dive Team Members:
Commanding Officer. The ultimate responsibility for the safe and
successful conduct of all diving operations rests with the Commanding
Officer. The Commanding Officer's responsibilities for diving
operations are defined and the provisions of U.S. Navy Regulations and
other fleet, force, or command regulations confirm specific authority.
To ensure diving operations are efficiently conducted, the Commanding
Officer delegates appropriate authority to selected members of the
command who, with subordinate personnel, make up the diving team.
Command Diving Officer. The Command Diving Officer's primary
responsibility is the safe conduct of all diving operations within the
command. The Command Diving Officer will become thoroughly familiar
with all command diving techniques and have a detailed knowledge of all
applicable regulations and is responsible for all operational and
administrative duties associated with the command diving program. The
Command Diving Officer is designated in writing by the Commanding
Officer and must be a qualified diver. In the absence of a commissioned
officer or a Master Diver, a senior enlisted diving supervisor may be
assigned as the Command Diving Officer. On submarines the senior
qualified diver may be assigned Command Diving Officer.
Master Diver. The Master Diver is the most qualified person to
supervise air and mixed-gas dives (using SCUBA and surface supplied
diving equipment) and recompression treatments. He is directly
responsible to the Commanding Officer, via the Diving Officer, for the
safe conduct of all phases of diving operations. The Master Diver
manages preventive and corrective maintenance on diving equipment,
support systems, salvage machinery, handling systems, and submarine
rescue equipment. The Master Diver, who also ensures that divers are
trained in emergency procedures, conducts training and re-qualification
of divers attached to the command. The Master Diver recommends to the
Commanding Officer, via the Diving Officer, which enlisted divers are
qualified to serve as Diving Supervisors. The Master Diver oversees the
efforts of the Diving Supervisor and provides advice and technical
expertise. If circumstances warrant, the Master Diver shall relieve the
Diving Supervisor and assume control of the dive station. In the
absence of a Diving Officer, the Master Diver can assume the duties and
responsibilities of the Diving Officer.
Diving Supervisor. While the Master Diver is in charge of the
overall diving operation, the Diving Supervisor is in charge of the
actual diving operation for a particular dive or series of dives.
Diving operations shall not be conducted without the presence of the
Diving Supervisor. The Diving Supervisor has the authority and
responsibility to discontinue diving operations in the event of unsafe
diving conditions.
Diving Personnel. While working, the diver shall keep topside
personnel informed of conditions on the bottom, progress of the task,
and of any developing problems that may indicate the need for changes
to the plan or a call for assistance from other divers. To ensure safe
conduct of the dive, the diver shall always obey a signal from the
surface and repeat all commands when using voice communications. The
diver is responsible for the diving gear worn and shall ensure that it
is complete and in good repair.
Diver Tender. The tender is the surface member of the diving team
who works closely with the diver on the bottom. At the start of a dive,
the tender checks the diver's equipment and topside air supply for
proper operation and dresses the diver. Once the diver is in the water,
the tender constantly tends the lines to eliminate excess slack or
tension (certain UWSH tasking may preclude this requirement, e.g.,
working in submarine ballast tanks, shaft lamination, dry habitat
welding, etc.). The tender exchanges line-pull signals with the diver,
keeps the Diving Supervisor informed of the line-pull signals and
amount of diving hose/tending line over the side and remains alert for
any signs of an emergency.

Question 7. How does the Navy weigh various risk factors as part of
its risk assessments?
Answer. The U.S. Navy Diving Manual lists the following process in
performing Operational Risk Management (ORM) for diving operations:
The five step process is:
1. Identify Hazards--Begin with an outline or chart of the major
steps in the operation (operational analysis). Next, conduct a
Preliminary Hazard Analysis by listing all of the hazards associated
with each step in the operational analysis along with possible causes
for those hazards.
2. Assess Hazards--For each hazard identified, determine the
associated degree of risk in terms of probability and severity.
Although not required, the use of a matrix may be helpful in assessing
hazards.
3. Make Risk Decisions--First, develop risk control options. Start
with the most serious risk first and select controls that will reduce
the risk to a minimum consistent with mission accomplishment. With
selected controls in place, decide if the benefit of the operation
outweighs the risk. If risk outweighs benefit or if assistance is
required to implement controls, communicate with higher authority in
the chain of command.
4. Implement Controls--The following measures can be used to
eliminate hazards or reduce the degree of risk. These are listed by
order of preference:

Administrative Controls--Controls that reduce risks through
specific administrative actions, such as:

Providing suitable warnings, markings, placards, signs, and
notices. Establishing written policies, programs, instructions
and standard operating procedures (SOP).

Training personnel to recognize hazards and take appropriate
precautionary measures.

Limiting the exposure to hazard (either by reducing the
number or personnel/assets or the length of time they are
exposed).

Engineering Controls--Controls that use engineering methods
to reduce risks by design, material selection or substitution
when technically or economically-feasible.

Personal Protective Equipment--Serves as a barrier between
personnel and hazard. It should be used when other controls do
not reduce the hazard to an acceptable level.

5. Supervise--conduct follow-up evaluations of the controls to
ensure they remain in place and have the desired effect. Monitor for
changes, which may require further ORM. Take corrective action when
necessary.
Incentives
Question 8. What incentives could the Coast Guard provide to
increase the quality of its program?
Answer. U.S. Navy Divers, both officers and enlisted, receive the
incentive of diving duty pay. In order to be eligible for the pay
members must be designated divers, be assigned to diving duty under
competent orders, and maintain their qualifications for diving.
Enlisted U.S. Navy Divers may also receive Special Duty Assignment Pay
(SDAP). These divers maybe entitled to SDAP if they are performing
duties in a billet which has been designated as extremely difficult or
involving an unusual degree of responsibility in a military skill.
Qualified Master Divers receive special Proficiently Pay (PROPAY) which
is an added incentive to obtain Master Diver qualifications and stay
with in the dive program.
Management Billets
Question 9. What is the ratio of Navy dive management to Navy
Divers? In your opinion, is the current ratio of 1 Coast Guard manager
for 4 dive teams adequate?
Answer. Dive team manning, both in numbers and experience level
will vary depending on dive mission. The U.S. Navy Diving Manual
defines minimum manning levels for each diving technique. These
minimums and the application of ORM determine the level of operational
oversight and are listed in the following table extracted from the Navy
Diving Manual:

Minimum Manning Levels for Air Diving
------------------------------------------------------------------------
Open circuit SCUBA
Operations Surface-
-------------------- Suppled
Single Buddy Operations
Diver Pair
------------------------------------------------------------------------
Diving Supervisor 1 1 1
Comms and Logs (a) (a) (a)
Console Operator (a)
Diver 1 2 1
Standby Diver 1 1 1
Diver Tender (b, c) 1 (b) 1 (b)
Standby Diver Tender (c) (c) 1
-------------------------------
Total 4 (d) 4 5 (e)
------------------------------------------------------------------------
WARNING--These are the minimum personnel levels required. ORM may
require these personnel levels be increased so the diving operations
can be conducted safely. See Paragraph 6-1.1 and 6-9.1
(a) Diving Supervisor may perform/assign Comms/Logs or Console Operator
positions as necessary or required by the system/operations/mission.
(b) See paragraph 6-8.8.5.2 for Tender Qualifications.
(c) If the standby diver is deployed, the Diving Supervisor shall tend
the standby diver.
(d) The diver will be tended or have a witness float attached, see
paragraph 7-3.1.7. A tender is required when the diver does not have
free access to the surface, see paragraph 7-8.2 for further guidance.
During mission essential open circuit SCUBA operations, minimum-
manning level may be reduced to three qualified divers at the Diving
Supervisor's discretion.
(e) Although five is the minimum number of personnel for the MKIII and
Extreme Lightweight Dive System (XLDS) operations, six or more is
highly recommended based on mission requirements and ORM.

Question 10. What operational benefits could be derived from
increasing the number of management personnel in the Coast Guard's dive
program?
Answer. Increasing the number of management personnel in the Coast
Guard's dive program would address the most significant difference
between the Navy and Coast Guard Diving Programs: the cadre of senior,
experienced Navy Divers, especially our senior enlisted Master Divers,
who continuously mentor junior sailors and manage our diving mission
risks. The ``human capital'' represented by the Navy's senior enlisted
diving leadership ensure that Navy diving is completed in accordance
with diving policy and that the material condition of the diving
systems are maintained in accordance with certification standards. Time
will be required for the Coast Guard to grow this experience, but
establishing and funding the management personnel (senior enlisted
divers) to oversee the waterfront execution of Coast Guard diving
represents a central, constructive action that would lead to safer,
less riskier Coast Guard diving operations.

Question 11. What is the approximate per capita budget for the Navy
dive program?
Answer. Approximately $13M in annual funding for the Navy diving
program provides for diving program management, centrally managed
diving equipment acquisition, diving system safety certification,
diving system lifecycle and configuration management, diving policy and
procedure management, major diving system procurement and procedural
testing, diving equipment and biomedical research to support 1,228
authorized FY06 enlisted Navy Diver rating authorized billets
($10,600/diver). This ratio only accounts for the authorized billets
in the Navy Diving rating. Many other enlisted ratings are also divers
and are the beneficiaries of the Navy diving program including SEAL,
EOD technicians, SEABEE divers, etc. The ratio also does not include
all U.S. Naval Officers who are Navy Divers. Inclusion of these
additional officer and enlisted authorized diving billets in the ratio
would dramatically reduce the cost per diver ratio. (The authorized
SEAL and EOD ratings alone outnumber the Navy Diver rating.)
This funding ratio does not include the costs associated with: the
Naval Safety Center's diving safety surveys, Fleet Operational
Readiness assessments performed on diving commands, the Center for EOD
and Diving's formal diver training courses, nor the mission specific
training, equipment and research for the Underwater Construction Teams
(UCT), the Explosive Ordnance Disposal (EOD) Teams or the Special
Warfare (SEAL) Teams. These costs are part of the general Navy safety,
training, UCT, EOD and SEAL mission funding.