Page i 

2018

09

June 28, 2021

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Executive Summary

On May 28, 2018, a 46-year-old career 

firefighter/SCUBA diver drowned while searching for 

a civilian who fell off of a boat into an industrialized

river. At 1951 hours, SCUBA Team 687, Fast Boat 

688, Ambulance 66, and Helicopter 682 were 

dispatched. Two divers (Diver 1 served as a stationary 

underwater line tender, while Diver 2 searched in a 

circular pattern) deployed from the fire department 

helicopter, which hovered about 5 feet above the river. 

After jumping in, the two divers swam on the surface

to a civilian boat to get a last-seen point from the 

missing civilian’s party. The two divers then 

descended to the bottom and commenced a search. 

The dive supervisor arrived at 2005 hours on the south shoreline, then contacted the divers via a 

underwater radio and directed them to surface to reposition them. During the second dive, the dive 

supervisor requested an air check, and Diver 1 reported 1400 pounds per square inch (psi) and Diver 2

(the victim) reported 1200 psi. They were instructed to complete their search pattern and surface. The 

fire department’s fast boat arrived on scene with relief divers. The dive supervisor instructed the fast

boat to pick up the helicopter divers and deploy their divers. A police boat that was on scene prior to 

the fast boat was near the divers when they surfaced, but the fast boat informed the police boat that it 

would pick up the divers. After the two divers surfaced and came together, Diver 1 was assisting Diver 

2 because it appeared that Diver 2 was having difficulty maintaining positive buoyancy. The police 

boat threw a life ring toward the divers. The fire department’s fast boat instructed the divers to come to

its boat and drove the boat toward the divers, causing the police boat to relocate away from the divers.

The divers then started to drift in a circular pattern toward the bow of the fast boat. Diver 1’s hands 

were on the hull, and Diver 2 simultaneously pulled Diver 1’s mask off. While Diver 1 inflated his

buoyancy compensating device, Diver 2 disappeared under the water. Two divers from the fast boat

and police divers were deployed. The fire department’s rapid intervention team divers on the shoreline 

also were deployed via a rapid deployment craft. Approximately 8 minutes later, Diver 2 was located 

by the police boat diver. Diver 2 was brought on board the police boat and was transferred to 

paramedics onshore. Advanced life support measures were performed, and Diver 2 was transported to 

a local hospital, where Diver 2 was pronounced dead. The civilian drowning victim was recovered the 

next day farther down the river by the police marine unit. 

Helicopter makes approach to deploy 

the divers.

(Courtesy of the fire department.)
Page ii

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Contributing Factors

• Air management 

• Fundamental SCUBA skills 

• Buoyancy control (inability to maintain positive buoyancy) 

• Members unaware of distress

• Multiple agency integration and cooperation. 

Key Recommendations

• Fire departments and public safety dive agencies should ensure regular training on 

fundamental dive skills, such as air management, buoyancy control, redundant air and out-ofair procedures 

• Fire departments and public safety dive agencies should ensure that incident commanders, dive 

group leaders, and members maintain situational awareness, accountability, and frequent and 

accurate air status on all divers 

• Fire departments and public safety dive agencies should ensure all public safety divers use dive 

computers 

• Fire departments, standard-setting organizations, public safety dive agencies, and SCUBA

manufacturers should consider adding heads-up displays in all full face mask SCUBA because 

of frequent zero-visibility/silt-out conditions. 

• Fire departments and public safety dive agencies should ensure that a properly trained dive 

safety officer is on scene and integrated into the command structure 

• Fire departments and public safety dive agencies should recognize public safety SCUBA diving 

as a high-risk/low-frequency event and ensure that public safety divers are properly trained,

equipped, and supported to perform dives; training and standard operating 

procedures/standard operating guidelines (SOPs/SOGs) should include the regional dive and 

water rescue team(s) who regularly respond with interagency cooperation

• Fire departments and public safety dive agencies should ensure that the helicopter SOPs/SOGs 

address diver in distress situations when divers are deployed prior to the arrival of shore 

and/or marine units 

• Fire departments and public safety dive agencies should ensure that communications 

equipment is reliable and has interoperability 

• Standards-setting organizations should consider developing and adopting national consensus 

standards for Public Safety Diver (PSD) and equipment that address initial and refresher 

training and respirator performance.
Page iii

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and 

Prevention, is the federal agency responsible for conducting research and making recommendations for the prevention of workrelated injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a firefighter initiative that resulted in the 

NIOSH Firefighter Fatality Investigation and Prevention Program, which examines line-of-duty deaths or on-duty deaths of 

firefighters to assist fire departments, firefighters, the fire service, and others to prevent similar firefighter deaths in the future. The 

agency does not enforce compliance with state or federal occupational safety and health standards and does not determine fault or 

assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH 

investigators interview persons with knowledge of the incident who agree to the interview and review available records to develop a 

description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and 

interviews are not recorded. The agency's reports do not name the victim, the fire department, or those interviewed. The NIOSH 

report's summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency's 

recommendations and is not definitive for purposes of determining any claim or benefit.

For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
Page 1 

2018

09

June 28, 2021

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Introduction

On May 28, 2018, a 46-year-old male, career firefighter/SCUBA diver drowned after searching for a 

civilian in an industrial river. 

On May 29, 2018, the United States Fire Administration notified the National Institute for 

Occupational Safety and Health (NIOSH), Division of Safety Research, Firefighter Fatality 

Investigation and Prevention Program of the incident. On June 7–13, 2018, and June 24–30, 2018, two 

NIOSH investigators traveled to Illinois to conduct an investigation. The NIOSH investigators met 

with the district chief/director of safety, deputy fire commissioner, deputy district chief/marine and 

dive operations, members of the fire department dive team, members of the marine police dive team, 

and an attorney representing the local police union. The investigators reviewed training records, 

training requirements, and standard operating procedures (SOPs) used by the fire department. A 

complete record of the radio transmissions also was reviewed. During the investigation, NIOSH 

investigators conducted interviews with the firefighters/fire officers and marine police involved in the 

incident. 

On June 24, 2018, NIOSH investigators inspected and photographed the SCUBA equipment used 

during the incident. NIOSH asked the fire department to send the firefighter’s SCUBA gear to a dive 

rescue consultant for further analysis and evaluation of the data contained in the equipment. Note: This 

department does not use dive computers. This was done at NIOSH’s expense, after which the dive 

equipment was returned to the fire department. The dive equipment evaluation is included in the 

Appendix. 

Fire Department

The fire department involved in this incident is a career department. At the time of the incident it had

5,143 full-time employees. The fire department is led by the fire commissioner and is assisted by a first 

deputy commissioner. The first deputy commissioner oversees the four bureaus—Operations, Fire 

Prevention, Administrative Services, and Logistics. The fire department has 5 divisions, 25 batallions 

occupying 98 stations (including a fire boat station as well as police boats). The fire department has 96 

engines, 61 trucks, 4 squads, 80 advanced life support (ALS) ambulances, 2 hazardous materials 

(hazmat) units, 2 urban search and rescue units, 10 airport crash apparatus, 2 helicopters, and 2 fire 

boats. The operations bureau is the largest in the fire department, consisting of four divisions—fire 

suppression and rescue, emergency medical services, special operations, and the office of fire 

investigation. The operations bureau is comprised of more than 4,500 firefighters and paramedics, 

which are commanded by the deputy fire commissioner. 
Page 2

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

The fire department has a Special Operations Division which is commanded by an assistant deputy fire 

commissioner and is subdivided into Hazmat and Air-Sea Rescue. Hazmat, Air Operations, and 

SCUBA Operations are each commanded by a deputy district chief. An on-duty special operations 

battalion chief reports to the assistant deputy commissioner of the division, as well as the three special 

operations deputy district chiefs. The special operations battalion handles all specialized units and 

companies. Currently, four special operations squad companies respond to special operation calls and

working fires. The squads are housed at four different stations. Each squad has an officer and three

divers.

The Special Operations Division is responsible for 37 miles of lakefront, 80 square miles of Lake 

Michigan, 28 miles of two major river systems, and various ponds and lagoons. During the past 3 

years, the division has responded to 700 water rescue incidents and recovered/rescued more than 200 

individuals from the water.

The fire department also has an Air Operations Station, with two Bell 412 EP helicopters, staffed with 

two pilots and two divers per shift. The Air Sea Rescue Unit for this fire department was established in 

1965. The busy lakefront presents the Air Sea Rescue Unit unique emergency challenges, including 

providing assistance to boats in distress, performing water rescues, and conducting air search missions. 

Divers assigned to the Air Sea Rescue Unit are trained under public safety rescue diver guidelines 

specific to the fire department’s needs and particular environment. The air pilots are trained in 

helicopter search and rescue and hoist rescue techniques patterned after nationally recognized 

standards. The Air Sea Rescue Unit uses the two Bell 412 EP helicopters to aid in its efforts. This 

equipment is used for multi-mission roles, which are primarily search-and-rescue flights, but also 

include administrative and law enforcement roles. 

The Fireboat Station houses a dive truck; a fast boat with three 300 horsepower outboard engines, 1200 

gallons per minute (gpm) fire suppression pump, GPS, radar, thermal imaging, and two rafts; and a fire 

boat engine (capable of breaking 12-inch thick ice) that is 90 feet long and weighs 228 tons, has 15,000 

gpm pump capacity with three monitors on the bow, a monitor on a 30-foot elevated platform toward 

the rear, a 1,000-gallon tank of foam; and several 30-foot by 12-foot rafts.

Standard operating procedures (SOPs) exist for water rescue incidents and Emergency Response Diver 

International (ERDI) standards are followed. General dive equipment consists of thermal 

undergarments, a dry suit, a full face mask, redundant air supplies, and cutting tools. All divers are 

tender directed and on tether lines at all times. 

Note: A tender is a diver that is stationary and serves as the anchor for the tethered line to the search 

diver. The search diver reels out several feet of tethered line then conducts a search pattern looking for 

the missing victim. This is repeated until the victim is found or has time to resurface. In this case, 

Diver 1 was the tender and Diver 2 was the search diver.
Page 3

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Training and Experience

In 2015, the Illinois Office of the State Fire Marshal implemented new minimum certification 

standards for all firefighters in the state, and these standards meet or exceed the requirements of 

National Fire Protection Association (NFPA) 1001 Standard on Firefighter Professional 

Qualifications for Firefighter I and Firefighter II [NFPA 2019]. 

As of December 2015, the Illinois Firefighter Requirements for Basic Operations included: 

• 180 course hours with written and practical exams 

• Fire Service Vehicle Operator Course

• Hazmat Awareness 

• Hazmat Operations 

• Technical Rescue Awareness

• Cardiopulmonary resuscitation (CPR)/Basic First Aid 

• National Incident Management System (NIMS) 100 and 700 

• National Fallen Firefighters Foundation Courage to Be Safe Course. 

This career fire department enacted requirements that exceed the state’s requirements. The fire 

department hires candidates through the city career civil service process. The fire department gives 

recruitment tests for both single-role paramedics and firefighter positions. Candidates that pass the 

exam are placed on an eligibility list and that list is sorted in lottery order. The lottery order is then 

referred to the department as vacancies become available. Candidates must pass a background check. 

Once a candidate is selected by the city, the candidate is sent to the fire department for a candidate 

physical ability test.

Firefighter recruits must complete a probationary period, which is considered 9 months of continuous 

employment from the date of initial hire. The fire department operates its own recruit training 

academy, which recruits attend for at least 6 months, exceeding the state requirement. In addition to 

completing Basic Operations Firefighter certification requirements referred to above, recruits receive 

approximately 150 additional hours of firefighting training at the academy. Each recruit also must 

complete instruction in emergency medical services and receive emergency medical technician (EMT) 

certification as a state of Illinois EMT-Basic. After completing the recruit training, candidates are 

further reviewed during the candidate field evaluation period, which is a period of 12 months of postfire academy assignment on a company (engine or truck). 

Firefighters are required to participate in 2 hours of training per work shift, which is documented by 

the company officer. All firefighters complete a 30-minute mask drill (self-contained breathing 

apparatus [SCBA]) at the beginning of each work shift, which includes monitoring the air pressure in 

their SCBA cylinder. During the mask drill, firefighters add their personal accountability system 

identification tag to the personal accountability report apparatus collection ring located on the 

apparatus they are assigned to. 
Page 4

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

All pump operators on the fire department hold the career service rank of fire engineer, which requires 

them to pass competitive written and practical examinations. Engineers also complete a 5-week class at 

the fire academy. Ladder/truck apparatus do not have pumps. Ladder/truck operators are referred to as 

a driver. The fire department’s engineer and driver training requirements exceed the requirements of 

NFPA 1002 Standard for Fire Apparatus Driver/Operator Professional Qualifications [NFPA 2017a].

Promotion to the lieutenant rank involves a written test and an oral interview process. Note: Seniority 

is 30% of the promotion criteria for those competing for Lieutenant and Captain. Newly promoted 

lieutenants go through a 5-week training program at the fire academy, which covers fire officer, fire 

dynamics, water rescue, high-rise operations, medical form documentation, and employee-assistance 

program classes. The training program includes 3 days of live fire burns, including flashover 

simulation. The 5-week class covers the entire curriculum of the NFPA 1021 Standard on Fire Officer 

Professional Qualifications [NFPA 2020a]. 

Promotion to the captain rank involves both a written examination and oral interview process. Selected 

officers attend a 2-week training program that covers incident safety officer (ISO) training, fire 

dynamics, motor vehicle accidents, personal protective equipment (PPE), the employee-assistance 

program, and Fire Officer 1.

The battalion chief position is the highest tested rank. The 4-week training program for battalion chief 

officers includes incident safety officer, Fire Instructor 1, Fire Officer 1, and employee assistance 

programs. 

All officer training classes involve tactical, hands-on training with simulators and tactical boards. 

Officers at the deputy district chief rank and above are appointed by the fire commissioner. 

In compliance with the NIMS training requirement, the fire department requires all firefighters to 

complete NIMS training commensurate with their rank. The fire department’s NIMS training 

requirements for firefighters, fire engineers, and battalion chiefs are greater than the federally 

mandated minimum requirements. Company officers are provided with opportunities to complete 

advanced NIMS training (Incident Command Systems [ICS] 300, ICS 400, All-Hazards Incident 

Management Team Training) that exceeds the federal minimum requirements for their rank.

Special operations battalion chiefs must have the following minimum qualifications for training and 

experience: career service rank of battalion chief; battalion chief-EMT or battalion chief-paramedic in 

this fire department. Minimum Certified Open Water Diver, as recognized by United StatesRecreational SCUBA Training Council, which currently is the National Association of Underwater 

Instructors, Professional Association of Diving Instructors (PADI), Professional Diving Instructors 

Corporation, SCUBA Diving International, SCUBA Schools International, and SCUBA and Nitrox 

Safety International; Department of Homeland Security/Federal Emergency Management Agency ICS 

100, 200, 300, 400, 700, 703, and 800; and the Fire Department Incident Safety Officer Course. 

Candidates must pass a physical/medical examination (Chicago Fire Department [CFD] Special Teams 

Medical Examination) as required and must possess the following license and Illinois Office of the 
Page 5 

Report #F2018-09

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

State Fire Marshal certifications: Instructor I, Confined Spaces, Structural Collapse Operations, 

Firefighter III, Hazardous Material Tech A or B, Rope Rescue Operations, and Trench Operations. 

Note: It is not clear that the special operations battalion chief who responded to this incident had a 

recognized open water diver certification. 

To become a diver you must have 5 years of service in a fire department and apply with a Public 

Safety Diver (PSD) Open Water Certification. Diver training and operations are conducted under 

current PSD Standards. An interview and vetting process is completed with all applicants. The 

application consists of work experience, ERDI skills, and a 40-hour diver endorsement program. 

The endorsement program consists of the following: 

• Equipment handling and set up

o Properly assemble equipment

o Demonstrate familiarity and comfort with equipment

o Properly protect equipment (tank valve, regulator, AGA mask, dry suit)

o Properly don the VikingTM dry suit

o Properly don all PSD SCUBA gear (according to CFD procedures)

o Properly set up the communications system (communications box, headset, and

communications lines)

o Understand hand signals

o Demonstrate familiarity and comfort with rapid intervention team (RIT) bottle and

contingency plans

• Watermanship skills

o Swim 500 meters or equivalent (no backstroke)

o Tread 5 minutes in water

o Swim 35 feet underwater

o Perform a surface dive to a depth of 10 feet and recover a 10-pound object

• SCUBA diving skills

o Entries (giant stride, seated or controlled entry)

o Buoyancy control (inflator hose malfunction)

o Proper use of AGA mask

o AGA mask clearing

o AGA removal, switch to pony and normal swimming ascent

o Dry suit emergency procedures (inflator hose malfunction, flooding)

o Descent procedures (feet first)

o Ascent procedures with victim (secure victim with right hand, normal ascent to surface, left

hand for buoyancy compensator inflation, roll on back, position communications line,

support victim’s head above water)

o Proper handling of victim during removal from water

o Emergency swimming ascent procedures (simulate out of air in primary tank)

o Weight belt removal and replacement on the surface and bottom
Page 6 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

o Removal and replacement of buoyancy control device on surface and bottom

o Proper use of cutting tools

o Rapid intervention techniques and contingency plans

• Equipment care and storage

o Properly disassemble equipment

o Restore all equipment so it is ready to use

o Properly store the Viking dry suit (zipper waxed, latex parts powdered, suit rolled).

The Deputy District Chief of Safety, in-charge of dive operations, holds all possible ERDI 

certifications and certifies all divers. A dedicated swimming pool is used for training members. 

The divers complete the PSD training and are issued internationally recognized certifications. This 

training and certifications assure that the fire department is compliant, so it can continue standardized 

dive operations with other fire departments in the county and throughout Illinois. Public safety diving 

is different from recreational diving in many aspects. PSDs are trained to understand a large variety of 

specialized equipment, including harnesses, quick release pony bottles, line handling, underwater 

extrication tools, cutting tools, full face masks, and contingency lines. These divers also are trained to 

implement tender and profiler protocols. Public safety diving is undertaken 24 hours a day under all 

weather conditions and includes night diving and ice diving. Divers encounter potential contamination 

problems, high-risk entanglement, entrapment environments, and black water. 

Standards are in place regarding how, what, and where to instruct public safety diving, including 

standards for equipment and mandates for recurrent training. The standards help to ensure the safety of 

divers, as well as successful rescue operations. Current national standards recommend that departments 

certify their divers in the skills below. 

Emergency Response Diving 1 and 2 

In this training, divers learn the fundamentals of dive operations from scene evaluation through 

incident debriefing. It also prepares PSDs and surface-support personnel to respond effectively to a 

water-incident scene. 

Topics include: 

• Overview of public safety drowning accidents

• Selecting, training, and equipping dive teams

• Family media and other agency relations

• Search pattern fundamentals

• Victim retrieval tactics

• Responding to vehicle accidents

• Accident scene documentation

• An introduction to specialized equipment and RIT operations.
Page 7 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Ice Diver

This training focuses on planning and implementing an ice diving operation. Techniques of diving 

beneath the ice for operations in rescue and recovery modes are introduced. 

Topics include: 

• Ice diving protocols

• Multiple subsurface ice dives

• RIT operations during subsurface operations.

Full Face Mask Diver

The full face mask training provides the skills and knowledge for the diver to utilize full face masks for 

emergency response diving. Basic full face mask topics and skills are presented. 

Other topics and skills include: 

• Encapsulation, communications with a full face mask

• Selecting proper masks for emergency response diving

• Decontamination procedures

• RIT operations.

Dry Suit Diver

Dry suit diving training addresses the proper precautions required when diving in potentially hazardous 

conditions. 

Dry suit diving topics include: 

• Suit types

• Accessories

• Sizing, custom adjustments

• Emergency procedures

• Repairs

• Maintenance

• RIT operations.

Surface Ice Rescue

This training focuses on planning and implementing a surface ice rescue operation. Techniques of how 

to approach several types of victims in varying environments as a primary tender, primary rescuer, 

backup rescuer, and backup tender are introduced. 

Contaminated Water Diver 

In this training divers demonstrate proficiency of all contaminated water skills and techniques, dive 

assessment and parameters, and a high level of awareness. Training dives incorporate hazard 
Page 8 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

recognition and handling, use of specialized equipment, and decontamination of equipment, and learn 

about environmental risk assessment, resulting in short- and long-term health benefits.

Underwater Vehicle Search and Rescue

This training focuses on planning and implementing an underwater vehicle search-and-rescue

operation and introduces the techniques of diving in rescue and recovery modes. 

Topics include diving protocols, which deal with: 

• Entanglement

• Confined space

• Contaminated water

• RIT operations

• Contingency planning for safe and effective operations.

Diver 2 Training and Certifications

Diver 2 had 15 years of service as career firefighter and had the following fire certifications:

• Firefighter 1

• Firefighter 2

• Firefighter 3

• Emergency Medical Technician

• Hazardous Materials, First Responder Operations

• Hazardous Materials, Technician A.

Diver 2 was a member the department’s dive team for 5.5 years. 

Diver 2’s activity log was up to date with the last entry on May 4, 2018. Diver 2 attended 

company school and open water dive training with SCUBA Team 687 for witness interviewing 

techniques, scene set up, searching the box area, and safety guidelines for divers, and also attended 

search patterns for divers using communications systems, dealing with entanglement hazards and 

limited visibility, locating a submerged victim, making a proper ascent, and putting the victim in the 

handcuff knot for removal from the water. During this dive training, team members were properly 

removed from the water using the diver dress down as prescribed. In addition, divers received confined 

water training for fitness and endurance and performed lifeguarding evolutions for surface rescue. 

Incident Commander Training

The deputy district chief of the Marine and Dive Operations served as the incident commander for the 

incident described in this report. The deputy district chief has led the Marine and Dive Operations 

since 2001 and is responsible for maintaining the daily functioning of the fire department marine 
Page 9 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

operations, including dive team training and safety operations for more than 160 personnel. The deputy 

district chief responds to incidents and executes coordinated rescues and recoveries, certifies all divers, 

and holds all of the ERDI certifications previously described. 

SCUBA Equipment 

The SCUBA equipment used in this incident was owned by the fire department dive team and is

personally issued to each diver. A list of the gear examined by the NIOSH investigators at the fire 

department with local police present includes: 

• One dry suit

• One harness

• One buoyancy compensating device

• One pony attachment

• One 80-cubic foot bottle

• One 19-cubic foot pony bottle (redundant cylinder)

• One EMT scissors with sheath

• One Shortie knife

• One Frameless mask with manually operated ambient breathing valve

• One underwater light

• One retractor (The retractor was missing except for approximately 15 feet of rope and NIOSH 

could not confirm if the retractor had been entangled in the M2 Police boat prop)

• Two regulators (one for primary and the second for the redundant)

• One stand-alone analog pressure gauge

• One full face mask

• One ambient breathing valve for full face mask

• One through water communications device (wireless)

• Two SCUBA fins w/springs

• One pair of 5-milliliter gloves

• One 2-inch stainless steel cam buckle

• One 2-inch webbing (for weight belt)

• Two 10-pound lead weights (The diver’s weight belt was not jettisoned.)

• Two 4-pound lead weights. 

Note: The diver was not using an integrated dive computer.

The fire department had a local dive shop evaluate the SCUBA gear as part of its investigation. NIOSH 

was informed that the results of that evaluation concluded that the SCUBA was functional. NIOSH 

investigators had a second independent expert in Boca Raton, Florida, evaluate the SCUBA gear. The 

expert concluded that the SCUBA equipment functioned as designed. The full report is provided in the 

Appendix. The SCUBA equipment used in this incident was owned by the fire department dive team 

and is issued personally to each diver (see Photo 1). 
Page 10 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Timeline

This timeline is provided to set out, to the extent possible, the sequence of events according to 

recorded radio transmissions and event times gathered from interview statements. Times are 

approximate and were obtained from review of the dispatch records, witness interviews, and other 

available information. Some of the times were rounded to the nearest minute. This timeline is not 

intended for use as a formal record of events. 

Photo 1: Example of a suited up diver.

(Courtesy of the fire department.)
Page 11

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Incident 

Conditions Time Response Operations

The 911 Call Center receives a phone 

call reporting that a civilian fell off the 

back of a boat while traveling upriver.

1945 Dispatch asks caller for the location of the 

boat.

Location of the boat is determined. 1950 Engine 39, Ladder 5, Squad 1, Ambulance 

19, Unit 515, and Battalion Chief (BC) 15 

are dispatched. 

Engine 39, Ladder 5, Squad 1, 

Ambulance 19, Unit 515, and BC15 are 

en route. 

1951 Unit 682 (helicopter with two divers),

Ambulance 66, SCUBA team 687, and Fast

Boat 688 are dispatched.

1952 Engine 2 is dispatched. Police marine boats,

Police Boat M2 and Police Boat M4, are

dispatched to assist.

Engine 39 and BC15 arrive on scene. 1953

Ladder 5 arrives on scene. BC15 makes 

cell phone contact with the civilian boat.

1954

1956 Dive Team Supervisor 686 is dispatched.

Ambulance 19 arrives on scene. 1957

Ambulance 66 arrives on scene. 1958

Unit 515 arrives on scene. 2000

Squad 1 arrives on scene; watches 

Helicopter 682 deploy divers.

2001 Helicopter 682 deploys two divers 10 feet 

off the water and 20 feet west of the boat. 

Divers swim over to the civilian boat to get 

to the last-seen point.

2003 Tender (Diver 1) and Diver 2 make their 

first descent. Diver 2 gets hung up a few 

times but gets clear. Four search patterns, 

each of 2-foot increments, are conducted.
Page 12

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Incident 

Conditions Time Response Operations

SCUBA Team 687 arrives on scene and 

sets up land-to-underwater 

communications. The dive group 

supervisor (Unit 686) arrives on scene

and takes command.

2005 SCUBA Team 687 establishes wireless 

voice communications with Diver 1. The 

dive group supervisor instructs the civilian 

boat to come to the south shore to verify the 

last-seen point, then relocates the dive team 

20 feet north for the second dive.

2008 Ambulance 65 is dispatched.

2019 Engine 28 is dispatched.

Engine 28 arrives on scene. 2026

Ambulance 65 arrives on scene. 2030

Engine 2 arrives on scene. 2035

2036 Ambulance 8 and DDC1 is dispatched.

2037 Ambulance 34 is dispatched.

Ambulance 8 arrives on scene. 2039 Squad 5 is dispatched.

Deputy District Chief (DDC) 4 arrives 

on scene.

2040 DDC4 is dispatched.

DDC1 arrives on scene. 2041

2046 Diver 2 is missing.

Ambulance 34 arrives on scene. 2048

Police diver finds Diver 2. 2054

Squad 5 arrives on scene. 2055

2110 Diver 2 is loaded into Ambulance 8.

2129 Diver 2 is in critical condition.

2143 Ambulance 68 is dispatched.

Ambulance 68 arrives on scene. 2148

Diver 2 is pronounced at hospital. 2202
Page 13 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Weather and Water Conditions

At approximately 1945 hours, the weather in the immediate area was 81° degrees Fahrenheit (81° F), 

the dew point was 63° F, and the relative humidity was 29%. Wind conditions were 15 miles per hour 

from the south. Visibility was 10 miles and partly cloudy [Weather Underground 2018]. 

The dive site was on the south branch of an 156-mile industrialized river. This area of the river passes 

railroad yards and an industrial area. It has an a maximum depth of 16 feet and is an average of 300 

feet wide. 

Interviewed divers reported that this part of the river was dark with zero visibility and consisted of 

entanglement hazards from illegal dumping and metal structures. The water temperature was not 

recorded but was reported as cold. 

Investigation

On May 28, 2018, a 46-year-old career firefighter/SCUBA diver drowned, while searching for a 

civilian in an industrialized river. At approximately 1945 hours, a cell phone call came in from a boat 

on the river stating that a male occupant had fallen off the back of the boat while traveling up the river. 

After approximately 5 minutes of communication to determine the boat’s location, Engine 39, Ladder 

5, Squad 1, Ambulance 19, Batallion 15, and Unit 515 were dispatched. 

SCUBA Team 687, Fast Boat 688, Ambulance 66, and Helicopter 682 with two divers were 

dispatched. At approximately 1952 hours, Engine 2 and police marine boats (Police Boat M2 and 

Police Boat M4) were dispatched. At 1953 hours, Engine 39 and BC15 arrived on scene looking for 

access to the south side of the river, which provided visual contact with the civilian boat. BC15 

observed two individuals in the boat and requested cell

phone contact from Dispatch. At 1956 hours, Dive Group 

Supervisor 686 (deputy district chief of Marine and Dive 

Operations) was dispatched. During the next several 

minutes, Ambulance 19, Ambulance 66, and Unit 515 

arrived on scene. 

At 2001 hours, Squad 1 arrived on scene just as Helicopter 

682 deployed two divers while hovering about 10 feet over

the river and 20 feet south of the boat (see Photo 2). Diver 

1 deployed first. Tapping the top of the head, Diver 1 

indicated an okay status and moved to the west so Diver 2 

could deploy. While enroute, the two divers had determined 

that Diver 1 would serve as a stationary underwater line 

tender, while Diver 2 would search in a circular pattern 

tethered to Diver 1. 

Photo 2: Helicopter 682 makes

approach to deploy the divers.

(Courtesy of the fire department.) 
Page 14

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Both divers swam to the civilian boat to obtain the last-seen point from the missing civilian’s party. 

Note: Sixteen minutes after initial 911 call, Helicopter 682 headed to the local airfield to refuel, 

leaving two divers from the helicopter in the river with no support vessels close by to block the river 

and ensure the safety of the divers from potential boat/barge traffic that could have endangered the 

divers. 

The civilians directed the divers to about 20 feet east of the boat. Diver 1 clipped the trident reel to 

Diver 2 and descended to the bottom. On the bottom, Diver 1 hit the push-to-talk button and told Diver 

2 to start a search pattern to the left. Diver 1 let out 2 feet of rope per circular pass. On the fourth pass 

Diver 2 was hung up on bottom debris and could not free himself. Diver 1 told Diver 2 to follow the 

line back, which was succesful. Diver 2 made it back to Diver 1 and indicated “I got you.”

At 2005 hours, SCUBA Team 687 and supervisor for Dive Group 686 arrived on scene. SCUBA Team 

687 set up wireless communications. The team established contact with Diver 1 and Diver 2 and 

instructed them to come topside for communications. Diver 1 acknowledged on the underwater radio 

twice that they were coming to the surface. The dive group supervisor waved the civilian boat over to 

the south side of the shore, so the supervisor could interview the civilians and get a better look at 

where the civilian had fallen off the boat. The dive group supervisor experienced difficulty 

communicating because the civilians only spoke Spanish. A bilingual police officer served as a 

translator. A civilian on the boat pointed out a blue boat tie-off as a reference for the last-seen point. 

When the dive team surfaced, the dive group supervisor asked if they could see the him and they both 

signaled “yes” by putting their hands on top their heads. The dive group supervisor then instructed 

Diver 1 and Diver 2 to move 20 feet north and conduct a second search based on the last-seen point 

provided by the civilian. 

During the second dive, the dive group supervisor requested an air check. Diver 2 communicated 1200 

psi and Diver 1 had 1400 psi. This was repeated twice. The divers were instructed to complete their 

pattern and surface. The fire department Fast Boat 688 arrived on scene with relief divers. The dive 

group supervisor instructed the fast boat to pick up the helicopter divers and deploy its divers. The dive 

group supervisor terminated the dive by the helicopter divers and told them to surface. The dive group 

supervisor indicated that Diver 1 responded “surfacing.” 

Police Boat M2 was on scene prior to Fast Boat 688 and was near the divers when they surfaced. 

Note: Police Boat M2 was contacted to provide support by the fire department’s dive group supervisor

via ship-to-shore radio, which was the only means of communication between fire and marine police at 

the time of this incident.

The dive group supervisor reported seeing Diver 2 surface first, and Diver 1 surfaced about 3 seconds 

later. Diver 1 had to reel up the tethered line on the reeling spool while surfacing near Diver 2. One of 

the police officers attempted to deploy a life ring to the surfaced divers several times (see Photo 3).

Note: Deploying the life ring to assist divers to the boat is a best practice used by the Police Marine 

Unit. NIOSH investigators were told the police officer believed Diver 2 was in distress.
Page 15 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Diver 2 and Diver 1 came together, and Diver 1’s left hand was on Diver 2’s right shoulder strap (see 

Figure 1). Diver 2 appeared to have difficulty maintaining positive buoyancy. Fast Boat 688 

approached the area by doing a 180-degree turn to face south and perpendicular to the river. The 

lieutenant of Fast Boat 688 told Police Boat M2 that it would pick up their divers. Police Boat M2, 

which was facing east on the river, briefly engaged its engines to avoid getting too close while Fast

Boat 688 was trying to get the two divers to come toward them. The lieutenant on Fast Boat 688 yelled 

to both divers to come to the boarding door of the fast boat. The two divers then started to drift in a 

circular pattern toward the bow of the Fireboat 688. This was possible because of the positioning and 

movement of both Fast Boat 688 and Police Boat M2. Diver 1 was able to put a hand on the hull of 

Fast Boat 688. Diver 2 grabbed the Diver 1’s mask and pulled it off of Diver 1’s face. Diver 2 also 

pulled the line reel out of Diver 1’s right hand. Diver 1 inflated the buoyancy compensating device

(BCD) and stayed on the surface. Diver 2 disappeared beneath the surface of the water. 

Photo 3: Officer on Police Boat M2 throws life ring to Diver 2.

(Courtesy of the fire department.) 
Page 16 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Diver 1 last saw Diver 2 lying flat on his back near the water’s surface. Diver 2 was about 12 feet away

from Diver 1 and drifting southwest of Fast Boat 688. Police Boat M2 radioed the dive group 

Figure 1: Apparatus and crew placement when helicopter drivers surfaced.
Page 17

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

supervisor and asked if the dive group was missing a diver. No response was received. The lieutenant

on Fast Boat 688 threw a retrieval line to assist Diver 1 in getting onto the boat. After getting on the 

boat, it was reported that Diver 1 had lost Diver 2. The fast boat lieutenant radioed the dive group 

supervisor to report that contact was lost with Diver 2. The dive group supervisor advised everyone to 

look for the diver and advised Fast Boat 688 and Police Boat M2 to establish a last-seen point. The 

dive group supervisor then advised the deputy district chief that a search had begun for Diver 2. 

Fast Boat 688 was directed to do a subsurface search, and Police Boat M2 was asked to go to the shore 

and pick up the dive group supervisor. Police Boat M4 with divers was tied up to a barge on the north 

shore. Police Boat M2 moored to the shoreline, while the dive group supervisor talked to the 

ambulance and truck crews to see if they had seen anything. The view from the ambulance and truck 

crews was obstructed. Ambulance 65 and Ambulance 8 were on the north shore of the river, 

Ambulance 65 was dispatched for the missing civilian, and Ambulance 8 was the assigned RIT 

ambulance for the divers. Shortly after arrival, Ambulance 8 learned that a firefighter was missing, so 

it expedited removal of its equipment. 

The dive group supervisor radioed the deputy district chief to deploy SCUBA Team 687 RIT divers on 

the shoreline via a rapid depoyment craft to cross the river. Police Boat M4 transferred its divers to

Police Boat M2, and it maneuvered to approximately 10 feet from the last-seen point. Police Boat M4 

then tied up next to Police Boat M2 and deployed a diver off the back of the boat.

At approximately 2054 hours, Diver 2 was located by a Police Boat M4 diver, who was deployed from 

the north side of the river just west of Fireboat 688. Diver 2 was brought on board Police Boat M2,

where police divers removed Diver 2’s mask but left the other equipment on, including the weight belt.

Note: According to the National Oceanic and Atmospheric Administration, a diver who is having

bouyancy issues should jettison the weight belt [NOAA 2001].

The police divers noted that Diver 1’s main tank was empty but the auxiliary (pony bottle) tank was 

full. The fire department dive group supervisor, who had come on board Police Boat M2, assisted in 

removing the SCUBA gear and cutting off his dry suit. CPR was started on Diver 2. A stokes basket 

was lowered down the river bank approximately 30 feet to Police Boat M2 and Diver 2 was put in a 

stokes basket. 

Divers, firefighters, and paramedics formed a chain to lift and pull the stokes basket with Diver 2 to 

Ambulance 8’s awaiting stretcher. At approximately 2110 hours, Diver 2 was in Ambulance 8. Two

paramedics and two firefighter/paramedics began ALS care in the rear of the ambulance while enroute 

to the hospital. The ambulance crew continued CPR and ventilation until they were relieved by the 

emergency room doctor. Diver 2 was pronounced dead at the hospital. The civilian victim was 

recovered the next day down river by the marine police unit.
Page 18 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Contributing Factors

Occupational injuries and fatalities are often the result of one or more contributing factors or key 

events in a larger sequence of events. NIOSH investigators identified the following items as key 

contributing factors in this incident, which ultimately led to the fatality: 

• Air management

• Fundamental SCUBA skills 

• Buoyancy control (inability to maintain positive buoyancy) 

• Members unaware of distress

• Multiple agency integration and cooperation. 

Cause of Death 

According to the autopsy report, the cause of death was drowning. 

Recommendations

Recommendation #1: Fire departments and public safety dive agencies should ensure regular 

training on fundamental dive skills, such as air management, buoyancy control, and redundant air 

and out-of-air procedures. 

Discussion: Public safety dive teams should regularly train on air management to ensure that PSDs 

know how to have enough breathing air to complete their primary mission and allow enough reserve 

air to return to the surface or escape an unforeseen emergency. Divers should train to use task-level air 

management (always aware of their remaining air), tactical air management (dive team surface 

monitoring and recording), and strategic level air management (command and division level support 

through proper resources and personel) to avoid low-air events that may lead to out-of-air events. 

The first step in overcoming a SCUBA (and SCBA) out-of-air emergency is complete familiarization 

with the specific equipment and breathing air requirements and usage. When another event occurs 

simultaneously, firefighters/divers need to understand that many out-of-air emergencies occur when 

they do not maintain a sufficient air supply relative to their depth and mission, such as the inability to 

maintain buoyancy control (positive, negative, or neutral). 

During an out-of-air emergency, it is important to confirm that the apparent air loss is real. For 

example, a tank valve that is not fully open can make it difficult to draw air, but it is easily corrected if 

recognized. Divers need to stop, think, and attempt to breathe. If it is possible to do so, divers should 

proceed with a normal ascent [National Oceanic and Atmospheric Administration [NOAA] 2001]. 

If divers determine that their air supply is depleted, the NOAA Diving Manual prioritizes the following 

ascent approaches for managing air loss:
Page 19

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

• Normal ascent

• Alternate or redundant air source ascent (alternate air is a second air line from the main tank; a 

redundant air source is a second pony cylinder with its own second-stage regulator)

• Controlled emergency swimming ascent

• Buddy breathing ascent

• Emergency buoyant ascent (putting air in the BCD and dropping weights) [NOAA 2001].

A redundant air or pony cylinder can provide emergency breathing air and is independent of the 

primary air supply. These pony cylinders range in size from 1.7 to 15 cubic feet. A 4-cubic-foot 

cylinder can provide 14 to 16 breaths at a depth of 100 feet and 80 breaths in shallow water. It is 

possible to manifold some redundant air cylinders into the diver’s primary air system. This allows

divers to continue to wear the full face piece dive mask and insert a regulator before switching to a half 

mask.

Other conditions can challenge a PSD’s ability to overcome an out-of-air emergency, such as removing

a full face piece to switch to a standard regulator to access the backup air. Removing the full face piece 

causes a loss of visibility and/or cold shock to the face, all while trying to get the spare air regulator in 

the mouth. Once the face piece is removed, the diver needs to find the half mask from the buoyancy

(BCD) compensating device pocket, put it on, and flush the water out of it by clearing it with air from 

the nose so the diver can see. It is necessary to do all of this without losing buoyancy and drifting 

down deeper or popping to the surface uncontrolled. This is a learned skill that divers must practice. 

However, engineered solutions allow the diver’s spare cylinder to connect to the primary air system. 

This allows the diver to just adjust the valve position instead of removing the full face mask, but in 

these systems the redundant cylinder is no longer separate and independent. 

The ability of PSDs to overcome low air and out-of-air events is directly related to their practical skills 

training and repetitive muscle memory. Repetitive skills training is very important for PSDs who often 

perform dive operations in extreme climate and water conditions that have limited or no visibility, 

extraordinary entanglement hazards, pollution, and challenging physical and mental conditions, while 

using heavy and cumbersome equipment. Many times, these skills are performed with gloved hands, 

limited vision, and reduced ability to hear commands from others, especially if the full face 

communications unit is removed. Repetitive skills training provides divers with an increased ability to 

perform the needed skills effectively and operate controls in a high-anxiety moment or an emergency. 

It is possible to overcome many uncontrolled out-of-air emergencies by repetitive skills training. 

NIOSH investigators have identified air management as a contributing factor on many investigations 

of structural firefighter and firefighter SCUBA diver line-of-duty deaths. Fire departments should 

ensure that training on air management occurs at all levels of the command structure [NIOSH 2011, 

2012]. The mastery of these skills is expensive and requires a commitment and a discipline from all 

levels of the agency(s) that are responsible for the team’s operation. Performed in conditions that are 

controllable, such as pools, repetitive skills training helps build firefighters/divers' muscle memory so 
Page 20

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

that in an emergency their hands are able to activate the controls with gloves on and the operation will 

become a second-nature response [NIOSH 2011, 2012].

The benefits of repetitive dive skills training with a SCUBA are to increase comfort and competency 

level, which in turn will:

• Decrease anxiety

• Lower air consumption

• Increase awareness of the user's air level (noticing and using the HUD when equipped) and an 

automatic muscle memory response for the vital function controls

o Dive computer and air pressure function keys

o Auto-inflate/deflate for the BCD

o Inflate/deflate controls for the dry suit

o Pulls for the detachable weights (or release handle/buckle for weight belts)

o Purge button for the face piece to rid mask of water or method for evacuating water from a 

flooded half face piece. 

When a relatively minor situation occurs, such as initially missing an air status change or air status 

check (milestone lights in heads-up display or audible alarm from dive computer), redundant safety 

measures, such as air status prompts from the tactical level or trained safety/accountability crew, along 

with learned equipment skills, can halt the escalation of the situation into an urgent response need. 

Once the initial situation goes beyond a simple adjustment or reaction, PSDs must react with learned 

skills on their redundant or backup breathing air system, communicate, and exit the danger. 

Unfortunately, many public safety SCUBA dive incidents occur in little-to-no visibility conditions. 

Therefore, reading a depth and pressure gauge requires using an underwater light source. This is

especially difficult if divers are using their hands to maneuver equipment, hold onto a descent line, 

manage a search rope, or even use the auto inflator/deflator to achieve neutral or desired buoyancy. 

Modern dive computers have audible alert signals that are programable to meet the needs of the diver 

(e.g., audible alarm sounding at 50% air and maximum desired depth, in addition to automatic built-in 

protocol alarms for mandatory decompression stops). Only having one sensory stimulation in SCUBA

diving (sound versus sight) places the PSD at a much greater risk of missing milestone signals. PSDs 

should have a minimum of a full face diving mask with a heads-up display (HUD) inside the mask. 

Unlike recreational diving, visibility often is poor and audible sensory stimulation alone is insufficient.

These factors and others can bring on anxiety.

Anxiety can lead to an increased heart and breathing rate and large air consumption rates. Proficiency, 

experience, and muscle memory with equipment can reduce anxiety before it develops into panic. 

Fight or flight response to underwater panic has a history of lethal consequences for PSDs. Very often,

a distressed diver in a panic may dislodge a partner’s mask or regulator as happened in this incident 

and other PSD incidents as well [NIOSH 2003, 2012]. When any anxiety or panic begins, the only way 

that dive skills will stay second nature is if the divers overtrain on their use.
Page 21

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Divers control their buoyancy by adding weight to achieve neutral and negative buoyancy. This 

involves the use of ditchable or non-ditchable lead weights, which are either integrated or on a quickrelease belt. They use devices such as BCDs, dry suits, and emergency air devices to achieve neutral 

and positive buoyancy, but they also can use full inflation of their lungs and manual propulsion by 

finning to achieve positive buoyancy. Understanding how to maintain control of all buoyancy is a 

critical skill that all PSDs must have a proficiency in and stay well trained in to ensure their safety. 

Divers face extreme dangers that can result in death from conditions associated with ascending too

rapidly. However, maintaining positive buoyancy once on the surface is critical. Normally, divers use 

their BCD to add air from their primary compressed air supply or they manually add air with an oral 

inflator. Divers also can add air into their dry suit for positive buoyancy. Divers need to understand 

that one of the most effective emergency means to achieve or maintain positive buoyancy is to ditch 

their weights. Divers should only use this procedure as an emergency action because of the severe 

consequences of a rapid uncontrolled ascent. In an out-of-air emergency, divers on or close to the 

surface cannot activate their redundant air, so they should consider ditching their weights.

Fire department dive teams need to provide regular refresher training on mitigating dive hazards by 

using buoyancy controls and the emergency release of dive weights. PSDs should have annual 

refresher training on these and other critical SCUBA diving skills. Because public safety diving is 

more dangerous than sport or recreational diving, PSDs need to use every margin of safety available 

[Hendrick et al. 2000].

Agencies offering advanced SCUBA levels of certification should stay consistent with national 

consensus standards. According to NFPA 1006 Standard for Technical Rescuer Professional 

Qualifications, 2017 edition, Annex A [NFPA 2017b]:

“The committee is of the opinion that Advanced Open Water certification provided by 

most nationally recognized certifying agencies (agencies associated with the Recreational 

SCUBA Training Council) builds an acceptable foundation for the basic SCUBA skills 

required for dive technical rescuer. These courses do not, however, offer all of the skills 

required to meet these standards, and further training and experience in special hazards 

expected to be encountered in the [authority having jurisdiction’s] territory should be 

sought.”

As the director of the International Association of Dive Rescue Specialists Response Team, Chief 

Steven Orusa has taught the importance of advanced repetitive skill dive training beyond recreational 

dive skills for many years. Public safety SCUBA diving is a technical skill that greatly exceeds 

recreational SCUBA certification levels. He notes, “Recreational diving agencies provide safe and 

effective dive training for the enjoyment of the public. The business model of a recreational SCUBA

agency is to teach the client to have fun underwater. John Q. Public is not performing dives in zero 

visibility, dives with prolonged bottom times, dives with entanglement hazards, dives requiring heavy 

physical exertion, dives at all times of the day and night, and dives in extreme weather conditions. That 

is public safety diving.” [Orusa 2017].
Page 22

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

In his book Chief Orusa notes: “Inadequate SCUBA skills may be the leading cause of PSD accidents. 

In many cases, a problem developed that the diver was unable to solve due to a basic skill level. In 

most cases, divers had received either insufficient or nonexistent SCUBA skills refresher training after 

initial certification.” PSDs should have training and experience in a variety of environments that are 

likely to occur during rescue operations, such as deep-water complex dives, limited visibility, cold 

water diving, ice, swift water current conditions, water contamination and hazardous materials, 

moisture retention within the dry suit, and lifting operations.

Annual confirmation of dive skills should help ensure continued competency. Dive teams need to stay 

current on training and annual skills evaluation. An example of an evaluation form to assess skills of 

PSDs, including controlling and maintaining buoyancy, is provided in Figure 2.

The level of knowledge, skills, ability, equipment, and support required for a PSD are outlined in 

NFPA 1006 [NFPA 2017b] and NFPA 1670 Standard on Operations and Training for Technical 

Search and Rescue Incidents [NFPA 2017c]. Throughout NFPA 1006 and NFPA 1670, hazard analysis 

and risk assessment are addressed. One of the most hazardous events a diver can encounter is the 

inability to solve problems or make decisions underwater. 

The typical chain of events in a public safety diving accident is as follows:

• The PSD becomes cold and/or tired

• The diver’s stress level, which is already high under such circumstances, increases

• The PSD encounters a problem or makes a mistake that is not solvable

• Panic ensues

• Death or serious injury results [Orusa 2017].

Annual refresher training should remind divers of the hazards of an uncontrolled ascent, as well as how 

to release their weight belts or integrated ditchable and non-ditchable weights in an emergency ascent. 

Note: An emergency buoyant ascent is difficult and hazardous and only used as a last resort to resolve 

an emergency, while the diver is venting air continuously (exhaling all the way to the surface).

Divers having difficulty ascending should release their weight belt. Divers experiencing stress at the 

water’s surface should drop the weight belt immediately to ensure that they will float [NOAA 2001]. If 

divers have traditionally used a weight belt and then transition over to integrated ditchable weights, 

they need to learn the muscle memory to release the weights. The first place they may reach for is the 

belt release if they have not relearned how to release the ditchable weights.

In basic SCUBA diving education, divers are taught to always breathe continuously and normally. 

They should never hold their breath, and they must exhale on ascent. However, instances have 

occurred where divers are distracted and unintentionally ascend while holding their breath. Divers need 

to have refresher training on common conditions that could cause ascent while holding their breath. 

Those conditions include:

• Panic moment or uncontrolled anxiety
Page 23

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

• Uncontrolled out-of-air emergency or low-air event

• Overweighted (with dive weights or not having the ability to jettison weights, as in this 

incident) 

• Accidental loss of a weight belt

• Preoccupation with an equipment issue, such as the mask 

• Not managing buoyancy (failure to release necessary air in their BCD to maintain a controlled 

ascent, remembering that any air they autofill into their BCD at depth also will expand as they 

ascend

• Inability to maintain positive buoyancy 

• Exertion during a difficult task

• Coughing, sneezing, or vomiting

• Breathing heavy in response to finding the target [Hendrick et al. 2000].

Lung overexpansion injuries include arterial gas emboli, pneumothoraces, mediastinal emphysemas,

and subcutaneous emphysemas. It is possible for divers to induce each of these injuries by holding 

their breath for any reason during an ascent while on SCUBA or surface-supplied air [Hendrick et al. 

2000].
Page 24 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Understanding the basic properties of gas when subjected to pressure is key to understanding dive 

hazards associated with lung overexpansion. According to Boyle’s Law, the volume of a parcel of gas 

varies inversely with the pressure exerted on it. If the pressure increases twofold, the volume of the gas 

is half its original volume and its density is twice as great [Hendrick et al. 2000]. If individuals on the 

surface have 5 liters of air in their lungs and hold their breath and dive underwater, the pressure 

increases and the 5 liters of air are still there, but just occupying a smaller space. If they descend to 99 

feet (where the pressure is four times what it is at sea level), the 5 liters will occupy only one-fourth 

Figure 2. Annual Basic SCUBA Skills Evaluation.

(Figure courtesy of the International Association of Dive Rescue 

Specialists.)
Page 25 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

the volume of space in the lungs. Then as they return to the surface—if they do not inhale or exhale—

the air will return to its normal volume and density once they are on the surface [Hendrick et al. 2000]. 

When SCUBA divers inhale underwater, their lungs are filled with compressed air to keep their lungs 

the same size as they were on the surface, which means that they are breathing increasingly denser air 

as they descend. To maintain 5 liters of air lung volume, a SCUBA diver needs to inhale the surface 

equivalent of 10 liters of compressed air at 33 feet, 15 liters of compressed air at 66 feet, and 20 liters 

of compressed air at 99 feet. This is accomplished by using a diving regulator to deliver air to the diver 

at ambient pressure according to the depth [Hendrick et al. 2000]. 

If SCUBA divers hold their breath while ascending, the denser air that they inhaled at depth will 

expand the lungs beyond their normal elastic capability, causing tissue damage [Hendrick et al. 2000]. 

Sometimes these are life-threatening injuries, resulting in catastrophic incapacitation and death.

Many factors can lead to an underwater emergency. Planning and training to avoid the factors that lead 

to the emergency is the first step in prevention. Dive emergencies can arise from a number of causes, 

including exhaustion, embolism, decompression sickness, nitrogen narcosis, heart attacks and other 

medical conditions, strong currents, entanglements, equipment failure, out-of-air emergencies, and 

panic [NOAA 2001]. Divers who are familiar with procedures can overcome these events.

Recommendation #2: Fire departments and public safety dive agencies should ensure that incident 

commanders, dive group leaders, and dive group members maintain situational awareness,

accountability, and frequent and accurate air status on all divers.

Discussion: Incident commanders, along with dive group leaders and members, are perhaps in the best 

position to evaluate and advise on the conditions/performance of PSDs. Having the ability to recognize 

a PSD showing signs of distress requires knowledge of public safety diving and close and constant 

attention to the divers. This requisite knowledge may allow a dive group leader or safety officer better 

situational awareness on the air use of a particular diver or dive team in order to make adjustments for 

consumption rates. Dive team accountability is an important benchmark that not only provides 

information on the diver’s progress (depth and/or completion of search patterns), but keeps a constant 

check on the air status, as well as the diver’s physical and mental status. Poor air management has 

resulted in many structural firefighter and PSD deaths [NIOSH 2005, 2009, 2012]. PSDs must manage 

their air effectively and must return to the surface with their reserve air intact. Reserve air is defined as 

emergency reserve air for the diver to use to escape unforeseen occurrences or underwater 

emergencies. 

Air management is a program that the fire service can use to ensure that PSDs have enough breathing 

air to complete their primary mission and allow enough reserve air to return to the surface or escape an 

unforeseen emergency. PSDs and tactical and command officers need to recognize and communicate 

their air status and use air management on the incident scene. Air management happens at the 

individual PSD (task) level, the crew (tactical) level, and the command (strategic) level. 
Page 26

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

At the task level, PSDs need to ensure that their cylinder is full at the start of the dive, and they need to 

control and monitor their air usage during a dive. They need to ensure that their backup air cylinder is 

full and in the on position and that the regulator is accessible. They must see and recognize the dive 

computer, pressure gauge, and preset air warnings and then communicate that information to their crew 

members. Fire department dive teams should use a predive safety checklist, and the dive safety officer 

should witness the divers’ equipment checks. The safety checks for surface supplied-air systems with 

bailout bottles are different than the safety checks for self-contained underwater systems with 

redundant (pony) systems. Valve position(s) during air checks are important, especially when reading 

the correct cylinder or air status. It is necessary that the diver equipment assistants are also divers. 

They must understand the system they are assisting with. In addition, the dive safety officer needs to 

have familiarity with the system and witness the predive safety check.

At the tactical level, crew or team leaders need to plan accordingly for the safe air management of all 

dive team members. They need to recognize when a diver is using excess air by frequent air status 

checks and by monitoring communications, if using open communications systems. Surface support 

teams need to record the beginning air status and continuously monitor air status throughout the dive. 

If a diver misses an air status when a benchmark has been met (i.e., diver made the bottom, diver has 

found the target and is returning, or diver is ascending), the surface support team should prompt a 

response from the diver. The tactical level crew leader (dive leader) ensures that the dive plan is 

followed and requests additional resources based on predictions and anticipated needs. All divers need 

to practice air management and return to the surface with their reserve air intact. Many public safety 

dive authorities recommend twice the remaining air in reserve as the recreational dive industry (i.e.,

1,000-psi reserve vs 500-psi reserve in a 3,000-psi, 80-cubic-foot cylinder). It is always necessary to 

check escape, redundant, or backup cylinders and systems and ensure they are in the correct status 

prior to diving (e.g., in-line valve in correct orientation and first-stage valve in correct position), and 

the diver needs to ensure that the backup air system regulator or secondary valve is in an accessible 

location.

It is the dive team leader’s responsibility to plan the dive using proper air management techniques and 

dive protocols for the particular dive and depth, and then dive the plan. The technical rescue dive 

safety officer needs to review and agree with the dive plan. Air management is a constant and 

multilevel responsibility. Divers can become easily distracted with the difficulty of the assignment, 

environmental conditions, and civilian body recovery issues and lose track of their air supply. The 

multilevel air management system for public safety SCUBA diving has constant checks and balances 

because there is less room for error underwater. 

Finally, air management at the strategic level ensures that the proper number of divers and the team’s

capabilities and competencies are matched. In most public safety dive events, time is of the essence to 

ensure capability, capacity, and competency of the resources. Once the incident is classified as a 

recovery mission, no urgent events should occur and incident commanders, group leaders, safety 

officers, dive team leaders, and dive team members need to carefully plan, coordinate, and execute the 

mission. They must focus on the safety of the dive team members in completing, terminating, 
Page 27 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

postponing, transferring, sharing, or rejecting the mission. When rescue considerations are no longer 

viable and the mission is recovery, the dive team members’ safety should be the focus. 

At the strategic level, someone at the Command Post should monitor or ensure that air status is being 

monitored and recorded. In addition, with the assistance of the safety officer, Command needs to 

monitor accountability of the crews. Command needs to estimate additional resource needs based on 

crew performance and how long the crew has worked (estimating air supply usage) and also check on 

air status with the tactical-level crew leader. Command should ensure that the technical rescue team 

has all of the resources needed to achieve its mission. This includes multiagency, multi-jurisdiction 

cooperation and integration when appropriate. Command should ensure that all air management and 

accountability needs of the technical rescue dive team are met through the incident safety officer. 

Command should halt any mission when any of the team’s needs are not met. Time is on the technical 

rescue dive team’s side and because technical rescue SCUBA diving is such a high-risk/low-frequency 

mission, it is better to err on the side of diver safety and halt an operation when all aspects of the 

mission are not ready. 

In some instances, PSDs may not pay attention to their air usage and remaining air until they get a 

prompt by the dive team crew or, in the case of zero visibility, they hear an audible warning from the 

computer. This can occur for a number of reasons, including lack of familiarity with a new SCUBA

gear setup (full face versus half face) or a lack of training. In modern firefighting SCBA, firefighters 

have HUD. Lights inside the face piece indicate air management milestones, such as full, three-fourths 

full, 50% flash, and 33% end-of-service-time indicator. 

In this incident, the dive team leader called for air checks and responses were given. It is unclear if the 

diver was able to read the gauge correctly in the zero-visibility water. Additionally, the divers 

deployed from a helicopter prior to having back-up resources on land in place in case RIT was needed. 

Also, Diver 2 displayed signs of distress after surfacing; however, it is unclear whether he was able to

verbalize any priority benchmarks via the diver communications line. 

Recommendation #3: Fire departments and public safety dive agencies should ensure all PSDs use 

dive computers.

Discussion: Dive computers allow divers to monitor the depth of their dive and ascent to help avoid 

decompression sickness. These dive computers include wrist computers, console computers, compass 

computers, or hoseless computers, which access underwater data and keep divers informed. They 

eliminate the need to carry a separate dive watch and depth gauge. Dive computers track the divers’ 

profile accurately and give the divers more time underwater than dive tables. It is possible to set up 

computers to audibly alert the diver at a given depth or time. Integrated dive computers monitor 

cylinder pressure and provide divers with an accurate remaining time based on their air consumption 

and current depth. A wrist-mounted computer can give the same information, but it relies on a 

transmitter from the first-stage regulator, which is not fail-safe. Dive computers are fairly easy to use 

and interpret after becoming familiar with their features. They allow divers to scrutinize the dive and 

create a dive log. If an issue arises, the data can help accurately answer related questions such as what 
Page 28 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

depth the diver was when he ran out of air and what the time during the incident. While they are not 

foolproof, they do help eliminate mistakes that occur when using dive tables and relying on separate or 

multiple devices/gauges.

In this incident, the fire department dive team was not using dive computers. An audible alarm may 

have helped the diver know his air pressure without having to read a gauge in near-zero visibility water

using a flashlight. In addition, the downloaded data may have provided time stamps and air pressures 

that would help answer questions about the sequence of events.

Recommendation #4: Fire departments, standard-setting organizations, public safety dive agencies, 

and SCUBA manufacturers should consider adding heads-up displays in all full-face mask SCUBA

apparatus because of the frequent zero-visibility/silt-out conditions that are experienced. 

It is extremely challenging for a diver without a HUD to report regular air status in low-light or zerovisibility conditions. In a low-light or zero-visibility condition at the bottom, even grabbing the dive 

computer with one hand and shining a light on it with the other hand can cause the diver to drift 

slightly down in a major layer of silt while following a search rope. Silt-out conditions can obscure the 

light source. Like firefighters, divers should never have to guess how much air they have. Once the 

remaining air drops below milestone indicators, at least two sensory stimulations should activate (e.g., 

sound, light, vibration). This ensures that the diver will not unknowingly pass through the remaining 

air benchmarks. Finally, the surface crew with wired communications need to ensure that air checks 

are requested and heard by the divers. The addition of HUDs allows PSDs to know their approximate 

air supply status by reading the milestone lights in their face piece. 

In this incident, the river had a large amounts debris refuge and discarded matter with very limited 

visibility. This made using a flashlight to read a gauge accurately difficult. The use of a HUD would 

improve diver safety .

Recommendation #5: Fire departments and public safety dive agencies should ensure that a

properly trained dive safety officer is on-scene and integrated into the command structure. 

Discussion: Fire departments should include a dive safety officer trained in technical rescue SCUBA

diving on-scene and as part of the command structure and tactical planning for dive responses. The 

planned dive rotation should not include the dive safety officer, but instead require the dive safety 

officer to remain at the dive site and available to the Command Post. 

NFPA 1670, Chapter 4.5.2, states that “at technical search and rescue training exercises and in actual 

operations, the incident commander shall assign a member to fulfill the duties of a safety officer with 

the specific knowledge and responsibility for the identification, evaluation, and where possible, 

correction of hazardous conditions and unsafe practices specific to the operational capabilities 

employed” [NFPA 2017c]. The assigned safety officer should meet the requirements specified in 

NFPA 1521 Standard for Fire Department Safety Officer Professional Qualifications [NFPA 2020a]. 
Page 29

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Safety officers assigned to special operations incidents, such as technical rescue SCUBA diving 

incidents, need to have expertise in the specific technical rescue field to effectively evaluate hazards 

and provide safe direction of all personnel. Qualified fireground safety officers might not possess the 

necessary expertise in water rescue. Therefore, they might not recognize or understand capabilities of 

the team members, limitations and hazards to rescue workers, the need for specialized equipment 

appropriate for water rescue operations, problems with equipment, or performance issues of personnel 

(e.g., undertrained for the mission at hand). NFPA 1521 notes, “in cases where the designated ‘safety 

officer’ does not possess the technician-level training, appointing a technician-level trained assistant 

safety officer (ASO-HM) or technical specialist with the necessary training will help satisfy the safety 

needs of the technician-level members.” [NFPA 2020a]

The dive safety officer has a critical advisory role to the ISO and the incident commander on the risk 

versus benefit on the strategic and tactical levels. A dive safety officer properly trained in the 

corresponding technical rescue field also can help prevent PSDs from attempting a skill beyond their 

level of training. The incident command structure should include the ISO.

A specifically trained and qualified dive safety officer should monitor the incident action/dive plan by 

making primary decisions regarding rescue/recovery, team capabilities, and the need for outside 

resources. They also should monitor dive conditions and dive plan activities, such as water depth, dive 

plan complications, and operations, to determine whether they fall within the criteria as defined by the 

fire department dive team’s risk management plan. The ISO also should witness the diver(s) predive 

safety checks, as well as monitor the health and well-being of the divers predive and postdive. 

NFPA 1561 Standard on Emergency Services Incident Management System and Command Safety

states in paragraph 5.3.1 that “the incident commander shall have overall authority for management of 

the incident” [NFPA 2020b]. NFPA 1561 paragraph 5.3.2 states, “the incident commander shall ensure 

that adequate safety measures are in place” [NFPA 2020b]. However, technical rescue incidents require 

that the incident commander have a safety officer who is trained in the discipline (SCUBA, water rescue, 

confined space rescue, high-angle rescue, hazmat, and trench rescue) and dedicated to the specific 

operation. It also is necessary to locate the safety officers for a technical rescue SCUBA incident at the dive 

operation. This allows the safety officer to monitor the operation, evaluate the resource status, ensure 

accountability and predive safety and equipment/air checks, continuously evaluate member abilities and 

capabilities, and ensure that all operational function positions are staffed and qualified backup rescue 

personnel are in place to aid in the event of complications. 

Based upon the size and complexity of an incident, incident commanders should delegate 

responsibilities that include safety for the technical discipline performed. They also should assign a 

safety officer for the incident scene. The Incident Command System (ICS) can expand to include 

functions necessary to effectively command and control an incident. Though the incident commander 

is still responsible for the safety and welfare of all members and first responders on scene, this 

responsibility is delegated to the ISO [NFPA 2020b]. Upon confirmation, the dive safety officer should

meet with the incident commander, command staff, and dive team leader to discuss the needs and 
Page 30

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

advise on the risk versus benefit analysis at the strategic and tactical level (i.e., Does the benefit of the 

operation justify the risks to the personnel to achieve it?). 

The dive safety officer should obtain the following information: 

• Overall situation status and resource status, resource capabilities 

• Strategy and incident action plan (dive plan)

• Known hazards and concerns (water depth, degree of difficulty, water and environmental 

complications, weather)

• Status of dive crews, crew leaders, crew capabilities, crew competencies, equipment, and 

personnel accountability

• Adherence to the dive plan and accurate event monitoring and recording 

• Back-up dive team assets

• ALS standby for the divers’ medical care 

• Establishment of the rehabilitation group 

• Confirmation of established radio communications channels (command channel, tactical 

channel).

In summary, plan the dive and dive the plan.

The technical rescue group or dive safety officer should don the PPE appropriate for exposure to the 

potential hazards at the scene (e.g., autopersonal inflating or standard personal floatation device or 

float coat for colder weather). Also, a vest or helmet will help identify the dive safety officer. 

The dive safety officer should meet with the technical rescue group leader, ISO, and incident 

commander to develop a communications plan and coordinate their activities. The ISO is responsible 

for the overall safety of the incident scene and reports to the incident commander. The dive safety 

officer reports to the technical rescue group leader. However, coordination and communication 

between safety officers can have advantages on large complex missions.

NFPA 1521 Standard for Fire Department Safety Officer Professional Qualifications defines the role 

of the ISO at an incident scene and identifies duties, such as:

• Reconning of the incident scene and reporting pertinent information back to the incident 

commander

• Ensuring the department’s accountability system is in place and operational

• Monitoring radio transmissions and identifying barriers to effective communications

• Ensuring established safety zones and other designated hazard areas are communicated to all 

members on scene [NFPA 2020a].
Page 31 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

The presence of an ISO or technical rescue group dive safety officer does not diminish the 

responsibility of individual divers and group leaders for their own safety and the safety of others. The 

dedicated ISO and technical rescue group dive safety officer add a higher level of training, attention, 

and expertise to help the incident commander. The ISO and technical rescue group dive safety officer 

must have particular expertise in analyzing safety hazards and must know the particular uses and 

limitations of protective equipment. For example, while the technical rescue group safety officer is 

focused on the safety of the divers, the ISO can help ensure the safety of the boat teams and land 

support firefighters [Dodson 2007; Dunn 2000; NIOSH 2009, 2010].

Experience in the technical rescue discipline is an extremely valuable resource. The technical rescue 

group dive safety officer has the specific knowledge, skills, qualifications, and experience to oversee 

the safety of the members of the technical rescue group and the mission they are performing, (different 

from the ISO). They must have the level of experience needed to recognize realistic mission goals, 

team and resource capabilities, team member capabilities, and team member limitations. They also 

must have the discipline and authority to add, change, modify, intervene, or stop an unsafe operation. 

This is especially important in technical rescue SCUBA operations, where the largest portion of all 

operations is in a recovery rather than rescue mode, and time is on the team’s side. The ISO working 

together with a trained and experienced technical rescue group dive safety officer can provide a fire 

department with a higher level of expertise to perform the necessary incident scene functions and assist 

the incident commander with incident scene safety.

In this incident, the deputy district chief of Special Operations was the dive group supervisor and 

Command shore side. The deputy district chief was well qualified to act in the role of dive safety 

officer. However, the deputy chief already was filling the role of dive group leader on the shore. 

Several technical rescue SCUBA diving officers were at the scene who had the experience and perhaps 

training to oversee the diving operation as the dive safety officer. The Special Operations Division 

requires that battalion chiefs are ISO Certified and have PADI Diver Certification or an equivalent. It 

is not clear if BC15 had the latter certification. 

Recommendation #6: Fire departments and public safety dive agencies should recognize public 

safety SCUBA diving as a high-risk/low-frequency event and ensure that PSDs are properly trained,

equipped, and supported to perform public safety diving. The training and SOPs should include

regional dive and water rescue team(s) that regularly respond with interagency cooperation. 

Discussion: Although no evidence shows that the following recommendation would have prevented 

this fatality, it is provided as a reminder of best safety practice for the fire service. Fire departments 

should recognize public safety SCUBA diving as a high-risk/low-frequency event and use a risk

assessment program to determine the extent to which they want to participate. During this assessment, 

departments can decide if they want to accept the risk (fully committed to equipping and training their 

own teams), share the risk (integrate with other teams in a mutual aid or regional team), or decline the 

risk (using a program risk analysis to transfer SCUBA duties to other agencies). 
Page 32 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

No standard scale is available to measure and evaluate frequency and severity of risk for the fire 

service. It is imperative that a fire department develop a risk management program that is based upon 

the process of identifying, evaluating, prioritizing, and controlling risk. The risk management plan 

must incorporate a full range of control measures to use for limiting, reducing, or eliminating the 

probability that an undesirable outcome will occur. 

The basis for the development of a risk management program is the preparation and maintenance of a 

written statement or policy that establishes the existence of the fire department, the services the fire 

department is authorized and expected to perform, and the basic organizational structure. The 

frequency and severity of risk starts with a thorough community risk assessment [NFPA 2014]. 

The tolerance for risk varies by fire department. The intent of the risk management process is for a fire 

department to develop a standard level of safety. This defines the parameters of the acceptable degree 

of risk within which members perform their job functions. No single method or solution is available 

for effectively managing risk. Determining how to manage risk is a decision each fire department must 

make based on the risk management model (see Figure 3) [NFA 2009].

 

High Frequency

Low Risk

Low Frequency

Low Risk

High Frequency

High Risk

Low Frequency

High Risk

 

FREQUENCY

R

I

S

K 

Figure 3: The Risk Management Model.

(Figure courtesy of Graham Research Consultants.) 
Page 33

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Fire department leadership should have a covenant with its public safety dive team through the 

department’s or municipality’s risk manager to make diver safety its top priority by managing the risk. 

The risk manager should focus on sound resources based on research, training, and experience. The 

leadership should consider sound risk management if it is going to commit to working in an 

underwater environment. The department has an ethical, moral, and legal duty to prepare effective 

PSDs. No greater responsibility exists in public safety SCUBA diving than safety [Orusa 2017].

Fire departments should prepare and maintain written policies and SOPs that document the 

organizational structure, membership, roles and responsibilities, expected functions, and training 

requirements, including the following:

• The types of standard evolutions that are expected and the evolutions that are necessary to

perform simultaneously or in sequence for different types of situations

• The minimum number of members who are required to perform each function or evolution and 

the manner in which the function is performed

• The number and types of apparatus and the number of personnel that are dispatched to different 

types of incidents

• The procedures that are employed to initiate and manage operations at the scene of an 

emergency incident [NFPA 2014].

Fire departments that decide they want to accept the risk and perform technical rescue water 

operations, including SCUBA diving and water rescue, need to ensure that personnel receive the 

proper initial training, advanced training, repetitive skills training, and interagency training with 

mutual aid or regional dive teams that they regularly respond with. Fire departments also must 

understand that this involves a continuing commitment to advanced and recurrent training and also to 

equipment and marine apparatus purchasing and maintenance.

Managing risk includes mandatory continuing education and skills documentation programs. Chief 

Orusa, fire chief of Fishers Indiana Fire Department and nationally renowned expert and author of 

Dive Rescue Specialist, Operational Training for Public Safety Divers [Orusa 2007] notes that a lack 

of basic diving skills is statistically identified as one of the leading causes of public safety diving 

fatalities. With 86% of the fatalities occurring in training and recovery mode (as was this incident), 

managing the components of the rescue and recovery mode and the risk/benefit analysis in water 

rescue operations and training are critical. Overwhelming documentation provides evidence of serious 

safety concerns when relying solely on recreational training for public safety dive teams. 

Public safety diving requires emergency response teams with specific knowledge, skills, ability, 

equipment, and continued support beyond basic firefighter or emergency responder requirements to 

resolve unique or complex rescue situations. When the team is faced with complex, deep, highly 

technical recovery dives, it is important to realize the team’s limitations, when the team needs 

assistance, and when to call for additional resources (mutual aid). Some jurisdictions utilize regional 

teams to meet the goals of risk management for a specific risk (shared risk). Better communications are
Page 34

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

needed between the fire and police marine units. They need to ensure they have the proper equipment 

(radios, etc.) and a better real-time understanding of the plan and operational situation. 

A key part of an overall rescue strategy should include mutual aid. The use of formal or informal 

mutual aid can help share the risk by providing additional experience, equipment, personnel, and other 

resources to a public safety diving event. Other benefits include greater levels of coverage and 

redundancy, building trust between organizations, and leadership benefits that can ultimately make for 

a safer dive environment. In addition, mutual aid can remove destructive competitiveness and rivalries 

between departments and/or agencies. 

Because the resource requirements and commitments are very high, a shared risk approach may prove 

beneficial for some jurisdictions. Regional or mutual aid teams need to train together so they can 

recognize each team’s strengths and work together to become aware of the level of coverage and/or 

redundancy present in joint operations. If regional teams are going to work and train together, they 

should consider integrating their SOPs and standard operating guidelines (SOGs). The difference 

between SOPs and SOGs is the difference between a procedure, which must be followed, and a 

guideline, which is more flexible and allows the responders to tailor their actions to fit the situation. A 

set of SOPs would include any rules that are inviolable. For example, PSDs should always end their

dive with 1,000 psi remaining for emergency reserve air (3,000 psi per 80-cubic-foot cylinder). Divers 

should not break the 1,000 psi rule. This is a good example of an SOP [Hendrick et al. 2000].

Fire department and other public safety dive agencies’ SCUBA dive teams need to stay current on new 

available equipment, such as in-mask air supply status or HUD, communications, and protective gear,

such as dry suits and redundant air supply options. Also, new high-definition sonar systems are 

available that can reduce exposure to blind diving by working to locate and isolate a dive target to 

within 1 to 2 feet. Blind underwater searches using search ropes and gridding-off areas are very taskoriented and time-consuming and can require a significantly greater resource commitment for a much

longer period of time. Reducing your exposure to the hazard is a recognized risk management 

principal. Dive teams should consider reducing the risk by reducing the exposure to the hazard 

(underwater time). This is accomplished by spending more time and available resources on surface 

operations and technology to locate and mark targets with extreme accuracy.

Continued support for the team is an important component of the leadership of technical rescue teams. 

Once a team is properly trained and equipped, the organization must continue to provide support to 

maintain the technical rescue team’s operational readiness through continued training and review of 

program goals and needs (see Figure 2). Inadequately trained divers should not participate in technical 

rescue SCUBA diving incidents beyond their level of training.

In the incident, the fire and police marine units, as well as the U.S. Coast Guard share the same marine 

station, but they are separate. SOPs outline the duties and responsibilities of both the fire department’s 

and police department’s marine units. The lack of joint training contributed to unknown expectations 

and lack of knowledge of the activities of the other department during an event. Joint trainingwould 
Page 35 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

facilitate working together as a team with each unit understanding and assisting the primary role of 

its partner agency to reduce risks. 

Recommendation #7: Fire departments and public safety dive agencies should ensure helicopter 

SOGs/SOPs address divers in distress situations when divers are deployed prior to shore and/or 

marine unit arrival.

Discussion: Although no evidence indicates that the following recommendation would have prevented 

this fatality, it is provided as a reminder of best safety practice for the fire service. Many of the larger 

fire departments in the country have incorporated the use of helicopters in their firefighting operations. 

While supporting firefighting operations is the primary mission of the air operations program, they also 

serve in hoist-air rescue, short-haul air rescue, shoreline rescue, helicopter swift-water rescue, night 

vision goggle operations, patient transport, vehicle rescue, large animal rescue, fire mapping, infrared 

detection, disaster assessment, and high-rise fire incidents.

In this incident, as for the role of water rescue and diver deployment, SOPs were in place and 

followed. The helicopter unit 682 arrived in minutes and deployed divers just as Engine 39 and 

Battalion Chief 15 were arriving. Once divers were in the water, they hand-signaled the pilot that they 

were okay, and Unit 682 departed. No SOPs were in place to guide Unit 682 if the divers had signaled 

that they were not okay, and Engine 39 was not set up. In addition to an SOP, training on these 

deployment skills is recommended. 

Recommendation #8: Fire departments and public safety dive agencies should ensure that 

communications equipment is reliable and has interoperability. 

Discussion: Although no evidence shows that following this recommendation would have prevented 

this fatality, it is provided as a reminder of best safety practice for the fire service and public safety 

dive agencies. In the initial years, underwater communication systems relied on hand signals, slates 

and pencils, and rope tugs. These types of signals can and often are misunderstood and difficult to use 

when hands get cold or if divers are affected by moving water conditions. Today, the two choices of 

underwater communications are hardwired (uses a cable to transfer the communications) and wireless

(uses the water to transfer the communications). Wireless freely provides individuals diving where 

they need to go with the ability to communicate easily and quickly, whereas hardwired 

communications confines divers to the length of a cable. Wireless underwater communications uses 

water to carry an acoustical signal from one transceiver to another, much like the use of sonar to 

communicate. Hardwired sends the signal down the cable, much like a landline. Like most products, 

multiple manufacturers exist, with models of various quality, functions, and price. In general, the 

equipment employed by the elite military units have a proven record of reliability, but usually come 

with a higher price tag.

At the incident scene, the communication between the fire and police marine units took place by either 

face-to-face communications or a patch through Dispatch. No interoperability occurred with the radios 

at the incident scene. This impacts real-time communications and the command structure. 
Page 36 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

During the interview process, several interviewees had mentioned that the wireless communications 

equipment used by Fire and Police Marine Units was subpar. The communications between divers 

and the boats were unreliable. The Fire and Police Marine Units communications may have been 

improved with military grade equipment.. 

Recommendation #9: Standards-setting organizations should consider developing and adopting 

national consensus standards for PSDs and equipment that address initial respirator performance 

training, as well as refresher training. 

Discussion: Although no evidence indicates that the following recommendation would have prevented 

this fatality, it is provided as a reminder of best safety practice for the fire service. Currently, no 

national consensus standard is in place for PSDs. A national standard could include minimum training 

requirements, as well as quarterly training and annual skills review and refresher training. Public safety 

SCUBA diving is different than other public safety disciplines in that the training environment is just 

as dangerous as the work environment. Firefighters/divers have died during training, and the level of 

training varies throughout the country in different jurisdictions. 

Proper equipment and continued administrative support are equally important and would benefit from 

a national standard. Administrative resource staff may not understand the importance of equipment that 

is designed for much more dangerous and extensive work than recreational SCUBA equipment. PSDs 

should have a minimum requirement of a high-quality, commercial grade heads-up display and a full

face piece, dry suit, and wireless. Although the equipment is more expensive than recreational 

equipment, the safety and lifesaving benefits far outweigh the cost savings for departments that use 

recreational equipment.

References

Dodson D [2007]. Fire department incident safety officer. 2nd ed. New York: Thomson Delmar 

Learning. 

Dunn V [2000]. Command and control of fires and emergencies. Saddle Brook, NJ: Fire Engineering 

Book and Videos. 

Hendrick W, Zaferes A, Nelson C [2000]. Public safety diving. Saddle Brook, NJ: PennWell. 

NFA [2009]. Health and safety officer course (HSO). Emmitsburg, MD: Federal Emergency 

Management Agency, United States Fire Administration, National Fire Academy.

NFPA [2014]. NFPA 1500 Standard on fire department occupational safety, health, and wellness

program. Quincy, MA: National Fire Protection Association. 

NFPA [2017a]. NFPA 1002 Standard for fire apparatus driver/operator professional qualifications. 

Quincy, MA: National Fire Protection Association.
Page 37

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

NFPA [2017b]. NFPA 1006 Standard for technical rescuer professional qualifications. Quincy, MA: 

National Fire Protection Association.

NFPA [2017c]. NFPA 1670 Standard on operations and training for technical search and rescue 

incidents. Quincy, MA: National Fire Protection Association.

NFPA [2019]. NFPA 1001 Standard for firefighter professional qualifications. Quincy, MA: National 

Fire Protection Association.

NFPA [2020a]. NFPA 1521 Standard for fire department safety officer professional qualifications. 

Quincy, MA: National Fire Protection Association.

NFPA [2020b]. NFPA 1561 Standard on emergency services incident management system and 

command safety. Quincy, MA: National Fire Protection Association. 

NIOSH [2003]. Career firefighter drowns during final dive of training course—Indiana. By Tarley J.

Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Institute for Occupational Safety and Health, F2002-15.

NIOSH [2005]. Career fire fighter drowns while conducting training dive—New Hampshire. 

Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Institute for Occupational Safety and Health, F2004-36.

NIOSH [2009]. Career fire fighter dies while diving for a civilian drowning victim—Rhode Island. By 

Miles ST, Tarley J, Baldwin T. Morgantown, WV: U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health,

F2008-32.

NIOSH [2010]. Career lieutenant dies following floor collapse into basement fire and a career fire

fighter dies attempting to rescue the career lieutenant—New York. By Wertman S, Bowyer M. 

Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Institute for Occupational Safety and Health, F2009-23.

NIOSH [2011]. Career fire fighter dies while conducting a search in a residential house fire—Kansas. 

Revised. By Bowyer M, Miles ST. Morgantown, WV: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and 

Health, F2010-13.

NIOSH [2012]. A career captain dies and 9 fire fighters injured in a multistory medical building fire—

North Carolina. Revised. By Bowyer M, Miles ST, Loflin M. Morgantown, WV: U.S. Department of 

Health and Human Services, Centers for Disease Control and Prevention, National Institute for 

Occupational Safety and Health, F2011-18.
Page 38 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

NOAA [2001]. NOAA diving manual. 4th ed. Flagstaff, AZ: Best Publishing Company. 

Orusa S [2007]. Dive rescue specialist, operational training for public safety divers. 3rd ed. Fort 

Collins, CO: Dive Rescue International.

Orusa S [2017]. Report from S. Orusa, Dive & Marine Consultants International, Inc, to S. Miles, 

Division of Safety Research, National Institute for Occupational Safety and Health, Centers for 

Disease Control, U.S. Department of Health and Human Services, June 14.

Weather Underground [2018]. Chicago, IL, weather history. Brookhaven, GA.The Weather Company.

Investigator Information

This incident was investigated by Matt Bowyer, general engineer, and Stephen T. Miles, investigator, 

of the NIOSH Firefighter Fatality Investigation and Prevention Program, Surveillance and Field 

Investigations Branch, Division of Safety Research, located in Morgantown, West Virginia. 

An expert technical review was provided by Captain Thomas Haus, Los Angeles Fire Department. He 

has more than 28 years of technical and water rescue experience. 

Matt Bowyer was the author of this report. 

Disclaimer

Mention of any company or product does not constitute endorsement by NIOSH. In addition, citations 

to websites external to NIOSH do not constitute NIOSH endorsement of the sponsoring organizations 

or their programs or products. Furthermore, NIOSH is not responsible for the content of these 

websites. All web addresses referenced in this document were accessible as of the publication date.
Page 39 

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09

Appendix

Dive & Marine Consultants International, Inc., Report
Page 40

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09
Page 41

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09
Page 42

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09
Page 43

Career Firefighter/SCUBA Diver Drowns While Searching 

for Civilian in an Industrialized River—Illinois

Report #F2018-09