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BILL PURCELL
MAYOR
METROPOLITAN GOVERNMENT OF NASHVILLE AND DAVIDSON COUNTY
NASHVILLE FIRE DEPARTMENT
500 2ND AVENUE NORTH
NASHVILLE, TN 37201
(615) 862-5421
October 31, 2006
TO: Kevin Penney, Acting Director of Emergency Management
FROM: Stephen D. Halford, Director-Chief Fire Department
SUBJECT: Review of Recovery Operation: Tara Cole, August 11 – August
21, 2006
Purpose of Review
As you are aware I have conducted a review of OEM operations
regarding the recovery operation that began on August 11, 2006 and
concluded with the body discovery of Ms. Tara Cole on August 21,
2006. The purpose of the review is to critique OEM operations to
identify strengths and determine opportunities to improve future
operations. Additionally, there were several reports in the
broadcast and print media airing the concerns of an OEM volunteer
team member who asserted that recovery operations should have lead
to a speedier recovery of the victim. The specter was also raised
that because Ms. Cole was a homeless member of our community, the
recovery of her body was not as high a priority as it might
otherwise be. My review also sought to examine and respond to those
concerns.
While this review concerns the events and a process regarding the
recovery of a body and by its very nature is dispassionate and as
objective as possible, I am mindful and acknowledge that I am
discussing a human being, Ms. Tara Cole, who was loved very much by
her family.
Methodology of Review
Using a simple interview technique is effective when evaluating
operations such as these. As you recall, I initially began my review
with a group meeting of key members of your staff to understand the
actual operations timeline and action plan. Subsequent to this
initial meeting I conducted individual interviews with appropriate
OEM team members and volunteers involved in the recovery operation.
Additionally I interviewed other individuals who I felt could be of
assistance in answering questions or providing me with relevant or
clarifying information. One limitation of the interview process is
the inability at times of any person to recall event sequencing and
the specific details of who, what, where, when, why and how.
Remembering such things as specific dates and times, what was said,
who said what, etc., will invariably create conflicting information
when trying to piece the entire event together. This phenomenon
occurred in examining this event, but I found that all persons
interviewed sincerely tried to provide the best information
possible.
During the information gathering phase, I interviewed the following
people, some more than once:
• Mr. Kevin Penney, Acting Director of Metro’s Office of Emergency
Management (OEM)
• Mr. Scott Harris, Response Coordinator, Metro OEM
• Mr. Bob Trice, Volunteer Coordinator, Metro OEM
• Major Johnny Speight, Volunteer, Team Leader Emergency Support
Unit (ESU), Metro OEM
• Sergeant Nikki Ivey, Volunteer, K-9 Handler and Team Leader, Metro
OEM
• Captain David Crane, Volunteer, Dive Team Leader, Metro OEM
• Mr. Karl Dean, Esquire, Director, Metro Department of Law
• Mr. William Herbert, Esquire, Metro Department of Law
• Mr. Tom Cross, Esquire, Metro Department of Law
• Mr. Roy Wilson, Director, Metro Parks and Recreation
• Mr. James Gray, Finance Administrator, Metro Parks and Recreation
• Mr. Michael Bayes, Assistant Director in Charge for Consolidated
Maintenance, Metro Parks and Recreation
• District Chief George Hickey, Dive Team Leader, Nashville Fire
Department
• Mr. Ken Weidner, Director Sumner County Office of Emergency
Management, Sumner County Dive Team Director
• Ms. Patsy Hargis – State Coordinator, K-9 Special Services
Division, Emergency Management Association of Tennessee (EMAT)
• Captain Marvin Carter, Captain and Director, U.A.W. Ford Rescue
Squad
• Mr. Bill Wright, Team Member, U.A.W. Ford Rescue Squad
Summary of Recovery Event/Operations
During the early morning hours August 11, 2006 Metro OEM was called
to the Cumberland River, at Riverfront Park adjacent to 1st Avenue
in downtown Nashville to conduct a recovery operation for what was
believed to be a drowning victim, Ms. Tara Cole. Ms. Cole was
apparently sleeping along side of the river and was pushed into the
water. Utilizing Metro and external resources, OEM assumed
responsibility for the operation. A brief daily summary of the
operation is as follows:
Friday, 8-11-06 Day One
OEM Field Responder Bob Trice responded about 4:00AM and met the
fire department at Riverfront Park for a drowning victim incident in
the Cumberland River. OEM and the OEM Emergency Support Unit’s (ESU)
Major Johnnie Speight took command of the recovery operations from
Metro fire/rescue about one hour later. ESU personnel used two boats
with drag bars and sonar around the barge area. Scott Harris arrived
at the scene about 7:00 AM to assist. ESU K-9 member Nikki Ivey
arrived at Riverfront Park with her dog mid-morning and the ESU dive
team members arrived later this day. Shortly after arriving, Ivey
and her dog got in a boat and proceeded down river. ESU diver David
Crane requested permission from Scott Harris to dive under the barge
to search. Harris and acting OEM Director Kevin Penney discussed
this on the phone and decided dive operations could not be conducted
due to inexperience of ESU divers in river situations and safety
concerns (debris under barge, currents, poor visibility, limited
space, etc.). Operations continued all day.
Saturday, 8-12-06 Day Two
Bob Trice coordinated the search. Two OEM ESU boats and 4 ESU
members conducted bank searches on the river for a few hours that
morning and again that afternoon.
Sunday, 8-13-06 Day Three
Bob Trice coordinated the search. OEM’s ESU team and United Auto
Workers / Ford Rescue volunteers had nine boats on the water with
personnel to conduct river bank searches. Bob Trice also got an
Ingram tug boat operator to churn up the water around the barge
stage in an effort to free up the body from under it in the event it
was there. This was not successful and also caused damage to a
riverfront concrete stanchion and flag pole. Search operations were
conducted for several hours in the morning and afternoon.
Monday, 8-14-06 Day Four
Scott Harris coordinated the search. ESU put one boat in the water
at Shelby Park ramp doing a bank search for several hours in the
morning and afternoon. The police department helicopter was also
requested and used in the morning and afternoon. Scott Harris and
Kevin Penney called Metro Parks Director Roy Wilson at Metro Parks
to request moving the barge. Metro Parks contracts for barge
movement and set up. The barge was in position and the stage set up
upon it. Mr. Wilson advised he would get to work on the request.
Subsequently, Scott Harris receives a call from Mike Bayes of Metro
Parks advising the matter of moving the barge is being worked on by
the Parks Department.
Tuesday, 8-15-06 Day Five
Scott Harris coordinated the search. OEM’s ESU team had a boat in
the water for several hours that morning and afternoon conducting
bank searches. A Metro Police helicopter searched the river from the
air. Roy Wilson talked to Tom Cross in the Department of Law about a
proposed agreement from Ingram to Metro Parks regarding barge
movement. The proposed agreement from Ingram would require the
Metropolitan Government to pay any costs incurred by Ingram,
including damages caused by Ingram’s own negligent or intentional
acts relative to barge movement. Tom Cross immediately completed
review and explained to Roy Wilson that the indemnity provision
would need to be removed before the Metropolitan Government could
legally agree. In the afternoon Scott Harris called Metro Parks and
inquired into the status of moving the barge. Mike Bayes advises
that there is a specific legal issue involved with moving the barge
and that the proposed vendor, Ingram, advises that a hold harmless
agreement must be signed before they move the barge. Mike Bays
advises Scott Harris that they (Metro Parks) are working to resolve
the problem.
Wednesday, 8-16-06 Day Six
Scott Harris coordinates the search. OEM’s ESU personnel with boats
conduct search activities for several hours, both morning and
afternoon. Police helicopters search also. Scott Harris called
Cheatham County Emergency Management to be on the look out near the
Cheatham County dam. Sumner County Emergency Management also was
requested to assist by OEM’s Scott Harris. Sumner EMA arrived with a
boat to help on the bank search and used an underwater camera to
look under the barge and dock area. No conclusive evidence of a body
was found.
A body was reported by a citizen floating near the bank under the
Woodland Street Bridge and was recovered by Sumner EMA and Metro
Fire department. This body was not the missing female, Tara Cole.
Nikki Ivey arrives with her K-9, boarded one of the ESU boats, and
proceeded down river. Scott Harris reports she told him the K-9
alerted her regarding the location of the floating body previously
discovered (not that of Tara Cole’s). Scott Harris further states
that before leaving, Nikki Ivey reported to him her
K-9 alerted down river between the two bridges, but was not positive
on the alert. In contrast, Nikki Ivey states that she advised Scott
Harris that the body was under the barge and that she was 95%
certain. OEM requested Metro Water Services to respond and place dye
in the water to check the flow of the river around the barge. ESU
boats stayed on the water until dark doing bank searches.
Thursday, 8-17-06 Day Seven
Scott Harris coordinated the search. An ESU boat was on the water
again in the morning and afternoon conducting river bank searches. A
Metro police boat and helicopter were requested and used to continue
bank searches all the way to Cheatham County Dam.
Friday, 8-18-06 Day Eight
Scott Harris and Kevin Penney were at Riverfront Park late morning.
ESU had a boat in the water doing bank searches. Kevin Penney and
Scott Harris used an underwater camera to search around the barge at
Riverfront Park. Scott Harris went back with 4 ESU members at 10:00
PM to check out a report of someone floating in the water. It was
determined to be a buoy. The victim’s family was present.
Saturday, 8-19-06 Day Nine
Major Johnnie Speight and ESU had 2 boats with 4 personnel checking
the river banks to Cheatham County. Scott Harris requested certified
cadaver dogs and handlers through the Emergency Management
Association of Tennessee as Nikki Ivey was on vacation. Scott Harris
was referred to two dog handlers from Tennessee Task Force 1
(TNTF-1) out of Memphis. Both handlers agreed to arrive in Nashville
on Monday to perform their search.
Sunday, 8-20-06 Day Ten
Johnnie Speight and ESU used 4 boats and 8 personnel on river search
to Cheatham County, both morning and afternoon.
Monday, 8-21-06 Day Eleven
Scott Harris and Kevin Penney with 2 certified cadaver dogs/handlers
arrive at Riverfront Park at 8:00 AM to begin search. Both certified
cadaver dogs alerted several times around the barge area. An ESU
boat searched under the dock area and found nothing. Kevin Penney
directly contacted William Herbert with Metro Legal to determine the
status on the contract relative to barge movement. William Herbert
contacted Tom Cross. Tom Cross told William Herbert that he
explained the changes needed when he was contacted earlier. He and
William Herbert then discussed the explanation of the legal problem
that needed to be communicated to the Ingram attorneys so the
agreement could be revised. William Herbert contacted the Ingram
lawyers by telephone, explained the problem with the language, and
quickly came to an agreement with the Ingram attorneys on the
language. An experienced dive team from Sumner Country was requested
to respond. Ken Weidner with Sumner County Emergency Management
Agency stated that even his experienced dive team will not dive
under barge, but will enter water once the barge is moved. ESU’s
dive team arrived late afternoon. Recovery personnel determined a
course of action. Ingram barge tug operator was on the scene by 5:00
PM and the barge was moved at 6:00 PM after Sumner County divers
searched the area where the barge was moved from and under the dock.
No body was found. OEM divers were invited to participate under the
supervision of Sumner’s more experienced team and began to suit up.
An hour later cadaver dogs alerted to where the barge had been moved
down river. The tug operator was requested to thrust the tug motor
for several minutes and after doing so, a body appeared. The body
was turned over to police detectives and the medical examiner’s
office. It was later identified as Tara Cole.
Summary of Resources Utilized in Recovery Operations
Metro Emergency Communications Center
Metro Fire Department / Metro Fire Boat One
Fire Buffs
Metro OEM Staff, ESU’s, Dive Team, K-9 Unit
Metro Department of Law
Metro Water Services
Metro Public Works
Metro Police Homicide and Special Operations (Helicopter and
Response Boat team)
Metro OEM Emergency Support Unit
Metro Parks
Sumner County EMA
Tennessee Wild Life Resources Agency (TWRA) (requested but did not
respond)
Coast Guard alerted by OEM to issue BOLO alerts on the River
Ingram Barge Company
UAW Ford Rescue Volunteers
Cheatham County EMA alerts
Cheatham County dam operators alerts
Two Memphis / Shelby County USAR team dog handlers and K-9s
Emergency Management Association of Tennessee
Underwater sonar
Underwater cameras
Contact with Family
As the drowning of Ms. Cole appeared to be a criminal act, Metro
Police maintained contact with the victim’s family. Family members
came to Riverfront Park on Friday, August 18th, to participate in a
prayer vigil.
Drown Victim Recovery and Metro Practices
The Office of Emergency Management has engaged in many recovery
searches over the years and specifically have been involved in
recovery operations involving drowning victims. The principal
methods of search are the use of boats to search the river and its
banks and lately the use of underwater cameras and sonar.
Additionally, dragging operations can also be employed. Recently OEM
has developed a recovery dive team that can be used in still water
conditions, but is not experienced enough to safely perform dive
recovery in rivers.
Recovery of drowning victims can take considerable periods of time.
When conducting recovery operations, particularly on the water,
safety of the recovery personnel is essential. It must be
understood, that no exigent or life threatening circumstances exists
in a recovery mode of operation and it is accepted practice that
only reasonable risks should be taken for body recovery. The human
and personal side to this event is also well understood by recovery
personnel. All personnel who are involved in recovery operations
clearly understand that promptness in assisting families who want to
bring closure to the likely death of a loved one is important. The
time it takes to recover a drowning victim is totally contingent to
the specific circumstances of the situation. Such time period can
cover the gamut, from hours, to days to weeks and months including
times when a body is never recovered.
In general, drowning victims will surface on the body of water in
which they drown because of decomposition gases unless a barrier
exist keeping the body from rising. The location where the body
might surface depends on several factors, chief of which is the
direction and strength of the water current as well as debris,
obstructions, river traffic and other impediments. Bodies surfacing
in rivers may surface miles from the drowning location and may
travel considerable distances after that. Bodies in still lakes and
ponds will surface closer to the location of initial drowning.
Discussion and Analysis
As previously stated the purpose of this review was to critique OEM
recovery operations of this incident with the intent to identify
strengths and determine opportunities to improve future operations.
Additionally several issues and questions were raised regarding the
recovery operation. Based upon my analysis I have come to several
conclusions as follows:
1. The resources utilized and the methods of utilization were
appropriate.
The recovery operation was identical to other operations conducted
by OEM in the past. Modern and appropriate recovery practices were
implemented including underwater cameras and sonar. The magnitude of
resources committed to the recovery operations demonstrated Metro’s
commitment to locating the drowned victim. Until a victim is was
located, all acceptable practices of search and recovery should
continue as appropriate.
2. Safe operating methods were used.
No injuries were reported in this recovery operation. It has been
reported that the drowning victim could have been located sooner if
OEM’s dive team would have been permitted to dive under the barge.
The decision not to let OEM’s Dive Team dive is consistent with the
overall level of training for the team. Permitting diving in the
river, particularly an under barge dive would have been an
unacceptable level of risk to recover the body. Fire Department
District Chief George Hickey is training the OEM Dive Team. Chief
Hickey is a nationally recognized and well credentialed expert in
the field of dive rescue and recovery. Chief Hickey confirmed that
the decision by OEM not to let the OEM Dive Team dive was
appropriate. Additionally, a more experienced dive team brought in
by Sumner County and lead by Sumner County OEM Director Ken Weidner
advised that the barge would need to be moved before they would
dive.
3. A general vicinity of the body location was identified early in
the operation.
Because of witness statement regarding where Tara Cole had been
pushed into the river, it is clear to me that OEM personnel knew on
the day of the drowning there was a distinct possibility that the
body might be under the dock or the barge. Subsequent to that point,
however, there are significant discrepancies between Scott Harris,
Nikki Ivey, and some witnesses I interviewed as to what exactly
Nikki Ivey said regarding her K-9 search on August 11th. Scott
Harris stated that he and Nikki Ivey had no conversation on August
11th. Nikki Ivey noted in a report she gave me that Scott Harris was
present on August 11th when she reported her findings. In my
interview with her, she stated that she, “did not have a direct
conversation with Scott”. Bob Trice and Johnny Speight did in fact
recall Nikki Ivey stating where she thought the body might be
located on August 11th. When I interviewed Bob Trice and Johnny
Speight (each separately, without either knowing what the other
said) both of them stated clearly and promptly that on August 11th
Nikki Ivey said that she believed the body was located “between the
barge and the bridge” (Woodland Street). In contrast, David Crane
states that Nikki Ivey told him she believed the body was directly
under the barge.
I cannot reconcile the different accounts of what information was
provided regarding the potential location of Tara Cole’s body. I can
only state that all interviewed appeared to be direct and honest and
recalled the information as best they could. I cannot conclude that
one account is more valid than another. It is clear to me that at a
minimum; everyone thought the body may have been either under the
dock or barge, in the general around the dock or barge or upstream
as far as the Wooodland Street Bridge. Clearly no one dismissed the
possibility that the body might be located under the barge. While
degree of specificity is hotly contested, the inability to safely
dive under the barge makes most of this debate a moot point. The
fact of the matter is that the record of events indicates that the
dock and barge area were initially searched on Friday August 11th
via boats, sonar and dragging, consistent with routine procedures
and technology and later via underwater camera. It is very obvious
that OEM officials believed that the body might be under the barge
and searched that area appropriately with the technology that could
be safely utilized.
4. Searching areas other than the barge and dock was appropriate.
The Cumberland River has currents that have in the past demonstrated
that bodies can be moved many miles. Since the possibility existed
that Tara Cole’s body may have been carried beyond the boundaries of
the dock and barge area, it was appropriate to check river banks and
all areas of the river where the current could take the body. The
Cumberland River and its banks were searched exhaustively all the
way to the Cheatham County line. Until a drowning victim is found,
all safe avenues of recovery should continue to be employed for
reasonable periods of time.
5. The presence of the stage barge was a complicating factor.
Once recovery diving was ruled an unacceptable risk and other
conventional procedures were exhausted (dragging, sonar, attempting
to blow out from under the barge, etc.), OEM made the request to the
Metro Parks Department to have the barge moved out of the area so
that the remaining space could be examined further. The original
request was made on Monday, August 14th. There were a great many
concerns regarding the movement of the fully loaded entertainment
stage barge and this was an unusual circumstance for a recovery
operation. The contractor responsible for movement and set up of the
barge, the Ingram Barge Company, promptly received the request from
the Metro Parks on either Monday or Tuesday August 14th or 15th,
however, upon the advice of their legal counsel, Ingram advised they
could not move the fully loaded barge unless Metro would agree to
“indemnify” Ingram for any damages that might result from the move.
Ingram stated that they could move the barge on Tuesday evening
August 15th if the indemnity agreement they had proffered to Metro
Parks could be signed. On Tuesday August 15th, Roy Wilson presented
the “Indemnity Agreement” from Ingram to the attorney from the Metro
Department of Law they normally work with, Tom Cross. On Tuesday
August 15th, Tom Cross advised the Roy Wilson that Metro could not
agree to Ingram’s Indemnity Agreement as Metro was constitutionally
barred from signing such an indemnity agreement. James Gray advised
that he believes he followed up with Tom Cross regarding the request
after Tuesday, August 15th. It appears, however, that the initial
request to have the barge moved on Monday, August 14th was not
pursued after Wednesday August 16th.
On Monday August 21st, Metro Attorney William Herbert was contacted
directly by the Office of Emergency Management to get the barge
moved. William Herbert met on site with the legal counsel from
Ingram and a “Waiver Agreement” was executed. The barge was moved.
When reviewing the entire situation, the most significant question
begged is why no action was taken in executing the agreement to get
the barge moved between August 16th and August 20th. Karl Dean
advised that he believes it was clear that neither OEM nor Metro
Parks had actually made the decision to move the barge when the
Department of Law was first contacted and if and when that decision
was made, the Department of Law would be contacted by either OEM or
Metro Parks so an agreement could be completed. By contrast, Roy
Wilson advised that on August 15th, he thought it was made very
clear to Tom Cross that Metro Parks needed to get the barge moved;
it was in fact, Roy Wilson stated, the purpose of having Metro’s
Department of Law look at the originally proposed indemnity
agreement proposed by Ingram in the first place. It is obvious to me
that Roy Wilson acted promptly on the request to move the barge that
he received from OEM on Monday, August 14th. It is also obvious that
the Department of Law acted promptly on the request to move the
barge that they received on Monday August 21st. Both Roy Wilson and
Tom Cross are highly respected and responsible professionals. I
cannot reconcile the difference between the Metro Department of
Law’s understanding of the barge movement situation and that of
Metro Parks with regard to the Monday, August 14th request.
Conclusion
In conclusion, I believe that Metro OEM conducted an appropriate and
safe recovery operation utilizing all appropriate resources. Their
practices were consistent with other recovery operations. I do
believe, however, that there is a reasonable probability that Tara
Cole’s body could have been discovered sooner, had the barge been
moved sooner. I cannot find any basis to conclude that Tara Cole’s
homeless status factored into any decision making.
Recommendations
While finding the recovery operations appropriate, there are several
recommendations that I feel will enhance future recovery operations.
The recommendations are as follows:
1. Although recovery operations are not exigent in nature, the
incident management system or incident command system (IMS/ICS),
properly structured to the size of the incident, could enhance such
operations. As part of the implementation of this system, formal
briefing sessions should be conducted during recovery operations and
information gathering reports from these sessions should be formally
documented along with any associated action plans. Additionally,
command should be clearly established and transferred as necessary.
While they have been effective, prior OEM recovery operations are
loosely structured. They would benefit in terms of accountability if
the basic tenants of (IMS/ICS) are adhered to.
2. OEM should seek out additional opportunities to enhance its
interface with volunteers and volunteer recovery organizations. OEM
needs to communicate better with them, support their activities,
attend their training and social functions when invited and work on
developing positive interpersonal relationships with their key
leaders. Based upon my many years of experience working with
volunteer rescue organizations, establishing complete harmony
between a local government and such groups is challenging at times.
With all of the best intentions, volunteer rescue or recovery groups
are exceedingly passionate and opinionated about what they do and
how to do it best. This spirit at times can conflict with the
responsibility of local government to assume charge and direct those
volunteer resources in the manner it deems best. It is therefore
important that the highest level of trust and harmony exist before
recovery or other such operations occur.
3. The OEM Dive Team needs to be “river qualified” as soon as it can
be arranged, if possible. As previously stated, the relatively new
OEM Dive Team has not been sanctioned to dive in river currents,
only in still water ponds and lakes. In this recovery operation it
was appropriate that the team not be permitted to dive in the river,
particularly in the hazardous circumstances under a loaded barge. It
is important, however, that the team be trained and cleared for
river diving where many drownings do in fact occur. In addition, if
more experience is needed, it should be clearly defined and an
appropriate time period should be designated. Diving for body
recovery is a valuable resource that has been added to the arsenal
of OEM recovery assets. Dive team members need to be patient to
allow this process to be completed. Diving for body recovery is
inherently dangerous in many situations and should not be viewed as
a replacement for other conventional recovery practices that pose
little or no risk to recovery personnel.
4. A contract should be procured through the Purchasing Department
to have an appropriate boat on call at all times to handle issues
related to the moving of the barge should that become necessary
again.
5. When Metro officials are working in a recovery operation wherein
an emergency contract is needed, the proposed contractor and the
speed with which a signed agreement is needed should be clearly
communicated to the attorney involved and be followed up with a
written request as soon thereafter as possible.
6. It would be helpful to promulgate a general informational
document/packet that can be issued to the families of search and
recovery victims, both for land and water search/recovery efforts
that explains what to expect in the way of recovery operations
including any limitations. The information should also include a
well defined contact arrangement and the frequency of progress
reports.
7. I recommend that OEM not reconstitute its own K-9 team. Nikki
Ivey has expressed her desire to finish completion of her own canine
search and recovery team. She expresses that she will make her
organization available to Metro if needed. I recommend that when
needed, OEM utilize the resources of the E.M.A.T. K-9 program or the
K-9 assets of Metro’s Urban Search and Rescue (USAR) team.
I will assist you regarding implementing the above listed
recommendations.
Thank you for your time and attention regarding this matter.
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