ALAMEDA (CBS SF) – An independent investigation into the drowning death of a suicidal man while Alameda police officers and firefighters stood by has found that the death was caused by a breakdown in communications and a lack of training.

A 67-page report on the May 30 death of 53-year-old Raymond Zack in the water off Robert W. Crown Memorial State Beach that was written by former state Fire Marshal Ruben Grijalva said the city’s elimination of its fire department rescue boat in 2008 and its rescue swimmer program in 2009 resulted in total reliance on mutual aid.

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Relying on mutual aid for emergencies requiring a rapid response “provides a reduced likelihood of a successful outcome,” Grijalva said.

He said, “Lack of cross training between police and fire led to lack of understanding of each others’ resources and capabilities.”

The result was information gaps, independent actions, misinformation about the availability of resources, lack of coordination and a disjointed emergency response effort, Grijalva said.

He said police officers and firefighters should have called for an Oakland Fire Department shallow-water boat right away instead of a U.S. Coast Guard vessel, which was unable to attempt a rescue.

Summing up the report, Grijalva said, “Not providing public safety personnel with the tools and training necessary to respond to water emergencies, in a city surrounded by water, places the public at risk and employees in unsafe and precarious situations.”

He said, “It is a formula for failure.”

The report makes 14 recommendations for the city of Alameda, including having better training and policies for water emergencies and having its own water rescue operation because it’s an island city and response from other agencies will be slow.

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City Manager John Russo said Friday that he agrees with all of the report’s recommendations and Alameda is already making changes to its policies and procedures.

“We have no excuses,” he said.

Russo said the Alameda City Council will act on the report’s recommendations at its meeting Oct. 11 and there will be a follow-up report in February to ensure that the recommended changes are being implemented.

Mayor Marie Gilmore said in a statement, “I appreciate the frankness of Chief Grijalva’s report.

Gilmore said, “The failures of both policy and performance that he lists are disheartening to the city of Alameda and to me personally. Nevertheless, I am glad that we insisted upon an independent review of the facts.”



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