Do you think this was an "Accident?"

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DeepSeaDan

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I'm a Fish!
My antivirus said that there was a "malicious add-on" on that website and it shut it down. Beware.
 
The victim was not a new recruit / trainee. Marine Captain Lightfoot was a career officer who volunteered to transfer from the Marine Corp. into the Army's Special Forces; Captain Lightfoot was already a recreational diver.

I don't know but it wasn't a diving accident, which is what the A&I forum is for discussing
What occurred sounds like immersion pulmonary edema (IPE), an often fatal condition for BOTH snorkelers/swimmers and scuba divers, that can be induced in healthy people (i.e. those without hypertension) by the combination of over hydration, exertion and negative-pressure breathing, or what hyperbaric MDs call "negative static lung-loading" (NSLL). When your body is immersed but your head is out of the water - bingo - you're experiencing NSLL, because of the pressure differential between the air pressure at your lips and the higher air pressure inside your lungs that has to counteract the water pressure surrounding your chest. And let's not forget the immersion effect - simply by being immersed, blood moves from your limbs to your core. During head-up immersion (or NSLL induced by a scuba regulator), the blood pressure inside your lungs is higher than what would be measured by a BP cuff. This excess blood pressure inside your lungs can reach a tipping point... blood plasma then leaks through the capillary walls in your alveoli...you literally drown in your own blood plasma.

As a diver wanting to avoid DCS, how many times have you been told, "hydrate, hydrate, hydrate!" But over-hydration can tip you dangerously close to IPE! You're at greater danger if you combine over hydration with a mechanically-induced dangerous level of NSLL, caused by a regulator that has excess inhalation resistance (because it's poorly designed, badly tuned, or inadvertently set to the "pre-dive" position).

Extensive research for military and commercial divers has proven the efficacy and safety of positive-pressure breathing systems. Why have recreational dive training agencies failed to educate and warn about NSLL and IPE? IPE has been discussed by diving MDs for over 30 years; 1950's US Navy dive-helmet training films warn of capillary bleeding if there's negative pressure inside the helmet; in the early 1970's, the Los Angeles County Underwater Instructors (the world's oldest recreational dive training organization) published accounts of unexplained deaths which perfectly match what we now know as IPE.

Victims don't have to drown in their own blood plasma if the recreational dive industry did a better job of education AND regulator specifications. But at autopsy, it's impossible to tell an IPE death from a natural drowning. Perhaps the industry has prevented teaching about IPE to avoid equipment liability exposure? For years, the US Navy has warned scuba divers not to over-hydrate because of the risk of IPE; you can download the latest edition of the US Navy diving manual for free here:
SEA 00C3 Diving Publications and Technical Documentation

Why do you think Cousteau wore his regulator on his chest (to enjoy positive-pressure breathing):
Cousteau_enjoying_positive-pressure_breathing.jpg


Family seeks answers in death of diver trainee
053011at_lightfoot03.JPG


By Joe Gould - Staff writer
Posted : Sunday May 29, 2011 10:02:24 EDT

ELMONT, N.Y. — It was the third day of Special Forces pre-scuba training and Capt. Juan E. Lightfoot was exhausted.

He gripped the edge of the pool and refused to let go. But an instructor peeled his hands from the edge of the pool and another dragged him away from the wall.
Lightfoot went limp and sank to the bottom of the 11-foot, 6-inch-deep pool.

Despite efforts to revive him, Lightfoot never woke up.

Four days later, his family had him removed from life support.

The armed forces medical examiner ruled Lightfoot’s death a homicide. The medical examiner, Mark Shelly, said Lightfoot, 34, died of complications from a near-drowning. He noted that Lightfoot, who was “anxious and hyperventilating,” tried to exit the pool, “but the instructors did not allow him to do so.” When the instructor pried his hands from the wall, he “immediately sank to the bottom,” Shelly wrote, adding that Lightfoot “would have survived if he had been able to exit the pool.”

Investigators with Special Forces Command (Airborne) said instructors failed to heed signs that Lightfoot was not aerobically fit for the course and to remove him.
So far, multiple investigations have stopped short of accusing anyone in the cadre of criminal negligence.

Lightfoot’s adoptive parents, Denise Carter and Damian Gennino, both New York City schoolteachers who live in Elmont, N.Y., insist that the instructors in his Special Forces pre-scuba training course should face criminal prosecution and that their commanders should be fired.

“My son’s death, in my opinion, was a murder,’ ” Carter said. “It was not an accidental thing.”

“These guys were overzealous, pushed him to the limit. He wasn’t thinking properly; he was physically exhausted and mentally exhausted after five days of brutal training,” Gennino said. “They knew he was exhausted and they pushed him off the side of the pool and into the water, and he was dead in three seconds.”
On Dec. 8, 2010, at the pool on what is now Pope Army Airfield, N.C., one student reported hearing Lightfoot ask, “Please let me hold the gunnel,” referring to the pool’s edge. On a video that was originally intended to be a training aid, investigators said, a voice is heard on the tape saying, “Say the word.”

But Lightfoot refused to say “I quit” — the words that would have ended his training and saved his life — and appeared to be trying to exit the pool, Shelly wrote.
The Army showed the video to a family member because Lightfoot’s parents did not want to watch it. The parents said they were told by the family member that the audio had been removed. However, the 15-6 investigation’s report makes reference to comments on the video and Lt. Col. Tom Bryant, spokesman for Army Special Operations Command, said the audio track was not removed.

Special Forces Command immediately ordered an investigation into Lightfoot’s Dec. 12 death. Although that 15-6 investigation has been completed, Army Criminal Investigation Division “is conducting an investigation into the training death of Captain Lightfoot and the investigation remains open,” Christopher Grey, a CID spokesman, wrote in an email to Army Times. Grey referred other questions to Special Forces Command.

Bryant said Lightfoot’s death sparked three investigations: the 15-6, an investigation by the Army Combat Readiness and Safety Center, and the CID investigation. Bryant said Brig. Gen. Edward M. Reeder Jr., a former commander of 7th Special Forces Group, to which Lightfoot was assigned, personally briefed the family on the 15-6’s results.

As with CID, Bryant stressed that the matter is not closed.
“At this time, the U.S. Army Special Forces Command has not initiated any criminal charges in this case,” Bryant said in an email to Army Times. However, Reeder “has initiated several adverse actions against instructors and leaders involved in the accident,” he said.

“Without question, those involved in this incident will be held accountable and appropriate action will be taken,” Bryant said in an earlier email. “Discussing specific disciplinary matters at this time would be premature.”

He stressed the commitment to safety: “On the day of the accident, a total of 12 instructors were at the pool leading the training for 11 students.”
The six-week 15-6 investigation produced a 563-page report from Special Forces Command (Airborne) investigators. That document, obtained by Lightfoot’s family through a freedom of information request, outlined a series of warning signs before Lightfoot’s death. The family gave a copy of the report to Army Times.

The report contains an analysis of various policies and regulations, dozens of sworn statements from instructors and students, and recommendations to improve Special Forces pre-scuba training.

To Lightfoot’s parents, this means the training program was flawed.
“If it wasn’t my son, I would say, ‘Thank God, at least they did the changes and this won’t happen to anybody else,’ ” Gennino said. “But this is just disturbing to me that he was pushed to that point.”

‘GREEN BERETS ARE BETTER’
Lightfoot was commissioned as a Marine infantry officer in 2004 and racked up three deployments to Afghanistan and Iraq. He sought out Special Forces because, Lightfoot said, “I heard that the Green Berets are better, tougher, and it’s a better gig,” according to Gennino.

In October 2009, Lightfoot transferred from the Marines to the Army.
A trim 6 feet and 178 pounds, Lightfoot appeared to be in great shape. He was a self-taught Spanish speaker, an avid reader and a math whiz whose passions included martial arts, skydiving, deep-sea diving, motorcycles and, most of all, Latin culture. He studied Latin America in college and traveled extensively in South America. He was a natural addition to 7th Special Forces Group, whose area of responsibility is Latin America.

But Lightfoot was designated to become a leader of one of the group’s scuba teams. He was in the third day of his pre-dive training and preparing for the grueling combat diver course, considered one of the toughest regimens in the Army.
Lightfoot’s last days are detailed in the report, which was heavily redacted to remove the names, ranks and positions of those involved and his fellow students.
Nevertheless, it paints a picture of a chaotic, anxious scene at the pool on Dec. 8, 2010.

What follows is from the report: A pre-training physical revealed that Lightfoot had an irregular heartbeat. On the first day of training, he failed to run two miles in the required time and vomited afterward. He performed poorly in other events and, on the day before he nearly drowned, suffered his first shallow-water blackout during a weight-belt swim. He was given oxygen while he lay on his back, then was sent to train again. That same day he struggled to take instruction and had difficulty
breathing, the report said.

“He seemed almost embarrassed and ashamed at his performance,” said a team member who spoke with Lightfoot during the training. “He stated once, ‘How can I lead this team after they have seen me like this.’ I tried to build his confidence by letting him know that he will lead by overcoming adversity.”

Special Forces units have for several years hosted their own courses designed to prepare students for the rigors of the Combat Dive Qualification Course. This training, designed to simulate training at the CDQC at Key West, Fla., includes pool, classroom and open-water training. So-called “stress” events are designed to get students comfortable in the water under extreme conditions. For example, “drown-proofing” requires students’ ankles and wrists to be bound with their hands behind their back. They then go through exercises such as bobbing for single gasps of air, moving certain distances and performing underwater flips.

Several of Lightfoot’s classmates told investigators that instructors had been aggressive during the training, according to the report. Some students’ heads were forcibly dunked underwater; another said he was sprayed with a hose while performing flutter kicks. One said instructors blocked students from reaching the “gunnel” when they wanted to rest.

‘BETTER, TOUGHER’
Relatives and friends said Lightfoot had mixed feelings about leading a scuba team, although he accepted the assignment in November. After graduating the challenging Special Forces Qualification Course in October at age 33, he was unsure he was up for another rigorous program.

His dream had been to fight Marxist guerrillas in South America, Carter said.
“He was one of the older guys and he felt it would be strenuous, especially after getting out of the Green Beret program,” she said of the scuba course, “but he also felt he was in good shape and he was capable of physical things.”

“He liked the men that he was with [in Special Forces],” Carter said. “He said, ‘These are good guys.’ He made very close friends.”

As a teenager, Lightfoot was a black belt in aikido; he had a job at a local comic book store and loved the X-Men. “I guess in his own way, he wanted to be a super-hero,” his father said.
Continued to part 2 of 2

Staff writer Sean D. Naylor contributed to this report.

(The posting of this copyrighted news article is protected under the "Fair-use" doctrine of US copyright laws, which allow the re-use of copyrighted matter, without permission, for reasons such as teaching and criticism of issues related to public health and safety. Click here for a further discussion of the Fair-use doctrine)
 
Lightfoot joined the Marines in 1995 after graduating from Xavier High School in Manhattan. He wanted to be independent and to repay Carter and Gennino, who are his biological aunt and uncle, for taking him in as a boy. The Marines would take care of his medical and college costs so they wouldn’t have to, Gennino said.
“He was always worried about being a burden,” Gennino said through tears. “He was always thinking about us — concerned about us, all the time. He didn’t smoke pot, he didn’t drink, he was always concerned about his body and doing everything right.”

Though he held civilian diving certificates, he was clear that military diving was altogether different, friends said. For several days in November, a teammate supervised Lightfoot’s training at Fort Bragg’s Tolson Pool. He noted that Lightfoot had difficulty with some practice events but that his swimming technique was strong.

“I felt comfortable sending the captain to pre-scuba and he looked determined to go,” a witness identified only as an “operations sergeant” said in a sworn statement.

But an electrocardiogram detected that Lightfoot had an irregular heartbeat, as had other physicals in 2006 and 2008. A battalion physician nevertheless recommended that Lightfoot proceed with pre-scuba training, a decision affirmed by multiple doctors, who said after Lightfoot’s death that the arrhythmia was minor and that they would have done the same.

On Dec. 3, Lightfoot took it hard when he did poorly in a pre-scuba fitness test; from there, his confidence and performance suffered as he struggled through a series of training events, the report said.

Because Lightfoot was training with members of his team, he would not let them see him quit, despite his problems in the water. One of his swimming buddies said Lightfoot feared he wouldn’t be able to lead his team because “they had seen him ‘lose his cool’ in the water.”

“Mentally, I believe Capt. Lightfoot was more afraid of failing his team than of the water,” the student said.

It is not uncommon for students to drop out and retake the test. One student in Lightfoot’s class was retaking the test for the fifth time. Several students in Lightfoot’s class dropped out, one after he punched a wall and broke his hand.

Lightfoot was not the only one who suffered medical difficulties. At least two others were given oxygen during the course for possible shallow-water blackouts.

On the morning of Dec. 8, the students performed hill sprints, upper-body exercises and flutter kicks. After breakfast, they met at the pool at 9 a.m. for a series of tough underwater swims and other exercises. During a treading-water exercise, students said, Lightfoot appeared to panic, according to the report.

In another exercise, students had to retrieve a 20-pound “clump” of stones from the bottom of the pool. When Lightfoot struggled, instructors blocked his way to the gunnel and made him repeat his efforts several times.

A non-commissioned officer who helped prepare Lightfoot for the pre-scuba course visited him during training and observed that Lightfoot was experiencing so much “self-induced stress” that he was having difficulty listening to instructions. The man took Lightfoot to the shallow end of the pool to help him through a knot-tying event and calm him down.

“He told me he was very concerned about team perception that he was fatigued,” the NCO said. “I told him to relax and take each event as it comes.”

For the equipment recovery exercise at about 11 a.m., Lightfoot and the others were to remove their weight belt, fins and goggles, and lay them at the bottom of the pool. They would tread water briefly while instructors checked their equipment before they were to put it all on again underwater.

At the start of the event, Lightfoot held on to the side of the pool. Witness accounts differ, and students heard him call out, “I can’t do it,” or “I need to get out.” One witness described Lightfoot as “in a state of blind panic,” before instructors said, “Don’t grab the gunnel, do the exercise.”

On the video, an instructor is seen prying Lightfoot’s hands from the edge of the pool while another pulled him into the pool, according to the report.

Lightfoot began to descend as if to take off his equipment, but turned to his side and lay on the bottom of the pool. Instructors who had followed him down realized there was a problem.

Two instructors retrieved an unconscious Lightfoot from the pool. He was given oxygen and mouth-to-mouth resuscitation, but he was not breathing and had no heartbeat. He was soon in an ambulance to Womack Army Medical Center, Fort Bragg, N.C.

The students were ordered to get out of the pool and face a wall while instructors worked on Lightfoot. “We were told he was taken to the hospital and not to worry, people black out,” one student said in a sworn statement.

According to the 15-6 report, instructors should have known Lightfoot’s ability to complete the training was “diminished.” The training cadre was “too focused on encouraging Capt. Lightfoot to overcome his perceived psychological stress and the mental barriers prohibiting his successful performance,” it reads.

Investigators said the pace of the wars in recent years has depleted the numbers of experienced Special Forces scuba instructors. The instructors at the 7th Group’s pre-scuba course would not have withdrawn a student unless the student said “I quit,” investigators said.

The training cadre “lacked the experience and judgment to successfully walk the line between pushing students to overcome their psychological limitations and recognizing when a student is physically incapable of safely conducting the training,” the findings read.

Gennino said his son should not have had to say “I quit.” He cited the medical examiner’s report, which said Lightfoot was attempting to leave the pool.

“I believe that he was having problems, and he was incoherent, and he wasn’t hearing and he wasn’t seeing and he wasn’t understanding,” Gennino said. “And I don’t understand why they didn’t pick up on that.”

Staff writer Sean D. Naylor contributed to this report.

(The posting of this copyrighted news article is protected under the "Fair-use" doctrine of US copyright laws, which allow the re-use of copyrighted matter, without permission, for reasons such as teaching and criticism of issues related to public health and safety. Click here for a further discussion of the Fair-use doctrine)
 
Reminds me of the "Shark and Dasies"incident at Pensacola Resue Swimmer School in the 1980's. The Navy revamped it's whole training system and allow training timeouts to prevent these types of accidents. I would not call it a homicide but someone needs to be held responsible for this unfortunate training accident. Training accidents happen daily in the military and for the most part can be prevented if the Chain of Command pays attention
 
Thanks, Jon, for your thorough treatment of this issue. A very sad and probably very avoidable situation.
I'm not sure I see anything here that would lead me to conclude that this was IPE. To me, it sounds more like plain exhaustion. The "irregular heartbeat" is likely a white elephant as CAPT Lightfoot would not have been allowed to participate in this training if he had any significant cardiac issues.
Also, though both are pulmonary edema, it's important to make the distinction between IPE and negative pressure pulmonary edema. IPE, as you pointed out, is related simply to immersion. We've studied it extensively here. Right now we know that, in susceptible people, it's typically brought about by cold water and exertion. For some reason their pulmonary arteries are unable to compensate for the influx of shunted blood from the extremities, and they develop pulmonary edema related to pulmonary hypertension. It's not related to negative pressure.
NPPE is a phenomena that to my knowledge has not been reported in divers in the medical literature, though I've heard anecdotal reports about it possibly happening in high negative static lung loading situations. It would occur independently of IPE, but admittedly may also aggravate it if it's already present.
 
Thanks so much for the NSLL/IPE discussion. Never heard of it before but have experienced it and will definitely pass the information along. I'm even thinking of putting together a handout explaining it for my dives with others. Please, if this information available in a form I could copy then let me know where to find it.

Now I'm going to be a bit cynical. My dad was a military man and I've got lots of friends and family in the military. My experience is that there can be change but that most of time no one pays for this type of crime in the military. This is one case that both those that directly responsible as well as the command (even less likely to pay for it) should be held accountable if all of the facts are substantiated.
 
If it was IPE, then they'll not get any more answers that anyone else has. If you search for IPE, you'll find it in many strange circumstances, like long-distance navy swimmers, that swim on their side, and they get IPE in only the lung that is underwater.
 
If it was IPE, then they'll not get any more answers that anyone else has. If you search for IPE, you'll find it in many strange circumstances, like long-distance navy swimmers, that swim on their side, and they get IPE in only the lung that is underwater.

Jax, can you link the reference where you got that information?
 
https://www.shearwater.com/products/teric/

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