George H. Lazzaro Jr. was diving at 127 feet to retrieve testing equipment in Aberdeen Proving Ground's Super Pond shortly after 1:30 p.m. last Jan. 30, when he told his dive mates via radio he was "losing air, losing air fast."
The civilian diver, who worked for the Aberdeen Test Center, was advised to surface rapidly and he would be decompressed, according to the Army's report on the 41-year-old Baltimore County man's death released to the public Friday.
But when Mr. Lazzaro reached the surface, he removed his face mask and within minutes submerged again, eyewitnesses told Army investigators. He was not found underwater for almost two hours and was eventually pronounced dead at nearby Harford Memorial Hospital in Havre de Grace at 5:38 p.m.
Mr. Lazzaro's death was the first of three diver deaths in the Super Pond, officially known as the Underwater Explosive Test Facility, within a span of three weeks. Navy Diver 1st Class James Reyher, 29, and Diver 2nd Class Ryan Harris, 22, drowned Feb. 26 during a training exercise that had been cleared by the APG command despite the earlier death. The pond has been closed to diving since.
The Army's report on Mr. Lazzaro's death, prepared by the U.S. Army Combat Readiness Center at Ft. Rucker, Ala., runs 135 pages with exhibits and appendices.
The diver's death is considered accidental, Eloise Lundgren, a spokesperson for the U.S. Army Test and Evaluation Command, which has jurisdiction over the Super Pond, said Tuesday, in noting that the Army's Criminal Investigation Division conducted a separate probe that ended in no finding, hence "nothing criminal, no negligence."
Citing Army regulations, the version of the accident report released to the media and public has been heavily redacted. Among the portions blacked out include findings about what caused the accident and to what extent, if any, human mistakes or equipment failure contributed. Also redacted are recommendations for avoiding similar accidents.
"My decision to withhold certain nonfactual portions of the accident report is based on the need to preserve the integrity and effectiveness of the safety investigation process, which in turn will greatly help to prevent future accidents and perhaps save lives," Lt. Col. Carl J. Schain, executive officer to the Combat Readiness/Safety Center commanding general, wrote in a cover letter that accompanies the release of the report.
Lundgren said she could not speak to the reasons for the redactions, other than they could be "operational security" or "under the privacy act."
Although the autopsy report on Mr. Lazzaro, performed by the Office of the State Medical Examiner in Baltimore, is also redacted from the Army report, other sections of the report state Mr. Lazzaro had an "air embolism in lungs" and died from a "bodily reaction" that affected his chest and heart. All indicate he suffered from the bends, air bubbles in the bloodstream, caused by ascending too rapidly from deeper depths. The condition is often fatal.
According to the report, Mr. Lazzaro was acting as dive team captain, during the absence of the regular captain, when he and five other divers went to the Super Pond to remove a submerged weight and pulley system used to attach explosives and/or targets used in an earlier testing exercise. Four divers went into the water sometime after 1 p.m., with two remaining on the surface.
The divers were equipped with dual oxygen tank self-contained breathing units, or SCUBA, and were wearing dry suits with weighted boots and equipped with underwater communications. They were working along a cable attached to a winch on a floating dock on the surface. Small boats were used to ferry the divers to the dock.
Ten minutes under
According to the report, the divers dropped to the bottom in two minutes and began working with the visibility estimated at 10 feet. While Mr. Lazzaro and a second diver found the weight and attached the winch cable, the third diver was nearby counting the time in the water and the fourth was a few feet above providing more light.
"Nine minutes after leaving the surface, the divers had the cable hooked up to the weight, and DFC Lazzaro told everyone to turn and head to the surface; he brought up the rear," the report states.
As the divers ascended in a line from left to right, one diver reported finding "a piece of residue" – mentioned as unexploded ordnance in one of the witness reports, to which Mr. Lazzaro replied to the effect, "Ahh, cool." A few moments later, the divers in the water and topside heard Mr. Lazzaro say, "I'm losing air, I'm losing air fast."
One diver still in the water told Mr. Lazzaro to "blow and go" to surface as quickly as possible, and they could "fix him on the surface" or "put him in the [decompression] chamber." Seconds later, according to the report, Mr. Lazzaro surfaced 80 to 100 feet away from the winch platform and "immediately removed his mask with his left hand."
A diver who remained on the surface got a boat and went toward Mr. Lazzaro, who submerged when the boat was about 30 feet away. After the divers on the scene could not find him, other divers and APG and Harford County rescue personnel were called at 1:46 p.m., six minutes after the diver went under.
Recovery divers did not find Mr. Lazzaro's body until about 4:11 p.m., according to the report and, using ropes, they finally brought him to the surface about 4:37. Efforts were made to revive Mr. Lazzaro in the boat. On shore, EMS personnel began advanced life support and continued while the diver was transported to the hospital, where he was pronounced dead at 5:38 p.m.
Safety violations found
In August, the U.S. Occupational Safety and Health Administration found multiple serious safety violations after it investigated Mr. Lazzaro's death, including seven serious violations, meaning there was "substantial probability that death or serious physical harm could result from a hazard about which the employer knew or should have known."
The serious violations found included improper training for divers; lack of a qualified, designated person in charge on the surface to manage all aspects of a dive; allowing diving activities to be performed without a standby diver; not maintaining continuous visual contact of other divers; no reserve breathing air supply during diving activities; and using breathing air to operate diver's buoyancy control rather than solely for breathing purposes.
Aberdeen Proving Ground and the Army Test Center did not contest any of the OSHA violations.
OSHA had jurisdiction to investigate Mr. Lazzaro's death because he was a civilian employee. The Navy, which investigated the Super Pond deaths of its two divers, has disciplined five sailors in connection with those deaths. That investigation is ongoing.
Lundgren, the Test and Evaluation Command spokesperson, said APG officials have decided future dives at the Super Pond will follow the Navy Dive Manual explicitly and use Navy divers exclusively and that "tweaks" are being made to standard operating procedures.
Diving in the pond could resume as early as April, she said, once a clean-up of the pond that is in progress has been completed.