Authorities' response to a suicidal man who waded into the ocean and drowned while rescuers watched was marked by miscommunication and missteps, according to an independent review of the incident.
The review by Firechiefs.com, a consulting company headed by former state fire marshal Ruben D. Grijalva, faulted the island city of Alameda for not having a water rescue program in place when 52-year-old Raymond Zack went into the shallow water off Crown Beach on Memorial Day.
The incident sparked outrage after bystanders said they watched police and fire personnel do nothing as Zack succumbed in the 54-degree water. His body was later retrieved by a bystander. The Alameda County Coroner attributed the cause of death to drowning.
"Not providing public safety personnel with the tools and training necessary to respond to water emergencies, in a city surrounded by water, places the employees in unsafe and precarious situations," the review said. "It is a formula for failure."
The review was requested by Alameda Mayor Marie Gilmore and released Thursday.
Authorities have said they didn't enter the water in part because they lacked water rescue training _ an argument the review seems to support. They also believed rescue crews from other agencies would arrive in time to assist Zack, according to the review.
But they failed to immediately contact the Oakland Fire Department, the closest agency with a shallow water rescue boat, according to the review. In addition, the use of jargon led to a misunderstanding about the type of boat the Coast Guard was sending.
When the vessel arrived minutes after Zack was reported face-down, it could not access the shallow water. The Oakland Fire Department was contacted then, according to the review.
"On the day of the incident, neither police nor fire personnel on the scene demonstrated a good understanding of what mutual aid resources were available, what the capabilities were of each mutual aid asset, and what resources had the closest proximity and best estimated response times," the review said.
The Associated Press could not reach Alameda officials for comment because city offices were closed on Friday. A police spokesman was unavailable for comment. Fire officials referred comment to city officials.
The city, which has reinstated its water rescue program, will take the report's 14 recommendations seriously, City Manager John Russo told the San Francisco Chronicle (http://bit.ly/qjAQUi ).
"No excuses," he said, vowing that a similar incident would never happen again. "It was not Alameda's finest hour."
Zack suffered from depression and had been hospitalized at a psychiatric facility last year, according to his family.
Information from: San Francisco Chronicle, http://www.sfgate.com