Posttraumatic Stress Symptoms among U.S. Navy Divers Recovering TWA Flight 800.
1 Medical Department, Mobile Diving and Salvage Unit Two, Naval Amphibious Base Little Creek, Norfolk, Virginia.
2 Department of Psychiatry, Naval Medical Center, Portsmouth, Virginia 23708-2197. Send reprint requests to Capt. Dembert.
[This work is cited: Leffler CT, Dembert ML. Posttraumatic stress symptoms among U.S. Navy divers recovering TWA Flight 800. J Nervous Mental Dis 1998;186:566-9.
This work was done by federal employees, and therefore is not copyrighted.]
The views in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. The Chief, Navy Bureau of Medicine and Surgery, Washington, DC, Clinical Investigation Program sponsored this study (CIP #E97-314).
Studies on various disaster worker populations suggest the following may increase posttraumatic stress symptom experience: magnitude of the disaster (Jones, 1985; McCarroll et al., 1993); nature of the stressor (Ursano and McCarroll, 1994); exposure to victims remains (Ursano and McCarroll, 1990); failing to save immediate survivors (Fullerton et al., 1992); identifying with the victims (Ursano and McCarroll, 1994); an isolated working environment (Ersland et al., 1989); physical stress and fatigue (Fullerton et al., 1992); and potential for harm to the disaster worker (Ersland et al., 1989). Factors that may decrease this experience include: time to prepare for the specific disaster work (Alexander and Wells, 1991); worker training and experience (Ursano and McCarroll, 1994); and social support (McCarroll et al., 1996).
On July 17, 1996, TWA Flight 800 crashed into 120 feet of water off the coast of Long Island, New York, shortly after takeoff. All 230 passengers and aircrew died. Civilian and government emergency and disaster response teams, and civilian and U.S. Navy occupational divers, combined resources to begin recovery of the airplane wreckage and passenger remains. This unique effort was one of the largest recoveries using occupational divers ever conducted (Leffler and White, 1997). Much of the wreckage and human remains were at significant depths. Divers were exposed to hazards such as decompression sickness, hypothermia, and injury from debris. Diving lasted from mid-July to late October. Many victims were children and adolescents. There was intense media and government interest. Given these and other factors, our study was done to provide the first published investigation of posttraumatic stress and coping among occupational divers who perform disaster response work.
Back to Top
In January 1997, we presented groups of assembled Navy divers from Norfolk, Virginia, with a voluntary, anonymous, and confidential survey. Divers were able to later return completed surveys by mail or to a confidential drop box in their medical department. Sixty-six divers who participated in the recovery (TWA divers) voluntarily completed the survey. Fifty-nine divers from the same commands but assigned to teams not participating in the recovery enrolled as a comparison group. The 66 TWA divers and 59 comparison divers represented 72% and 68%, respectively, of the total diver populations contacted. All respondents were male, except for one female TWA diver. Our study met the requirements of the Naval Medical Center (Portsmouth, Virginia) Clinical Investigations Institutional Review Board.
We conducted the survey of TWA and comparison divers from January 15 to March 15, 1997. The time between concluding recovery diving and completing the survey varied for each TWA diver, from 2.5 to 7 months, but it was generally between 3 and 6 months.
The first section of our survey included demographic information and asked three questions: 1) Did you ever participate in operations involving recovery of human remains before July 1996?; 2) Do you feel more nervous about flying now than before 1996?; and 3) (asked only of TWA divers) Was the TWA job the most stressful experience you have had since January 1996?
The second section of our survey contained the Impact of Event Scale (IES), which measures intrusive and avoidant thoughts and behaviors (Horowitz et al., 1979) basic to post-traumatic stress disorders. We compared the mean total scores, and intrusion and avoidance subscales scores, of the TWA and comparison divers. Both groups were asked to respond to the IES with respect to their most stressful experience since January 1996 in terms of how they felt during the seven days prior to the survey.
The third section of our survey contained two parts: queries of factors we theorized as increasing experienced stress from the underwater recovery of human remains and debris; and queries of factors we theorized as reducing stress and enhancing coping (Table 1). Respondents answered with ratings of “Not at all,” “Somewhat,” or “Very,” respectively scored as 0, 1, or 2 (Ersland et al., 1989). Mean scores for all of the factors were then calculated for general ranking.
Chi-square analysis was used to determine differences between groups for categorical demographic variables. IES scores were compared by two-tailed t-tests for continuous variables, with a P < .05 level of statistical significance.
Back to Top
The demographic characteristics of the TWA divers did not differ significantly from those of the comparison divers. These were for: age ranges 20 to 29 (TWA N = 16, comparison N = 20), 30 to 39 (N = 43, N = 33), and >=40 (N = 6, N = 6); junior enlisted paygrades 1 to 3 (N = 0, N = 0), middle enlisted paygrades 4 to 6 (N = 28, N = 29), senior enlisted paygrades 7 to 9 (N = 21, N = 21), and officers (N = 16, N = 7); and years of Navy diving experience 1 (N = 1, N = 4), 2 to 5 (N = 14, N = 10), 5 to 10 (N = 21, N = 22), and >=11 (N = 29, N = 19). The two groups did not differ on the percent reporting prior experience in recovering human remains (53%, 53%). A significantly higher percent of TWA divers reported more anxiety about flying than did comparison divers [39%, 20%] [chi]2 = 5.35, df = 1, p < .025). Among the TWA divers, 47% reported the recovery to be the most stressful event since January 1996.
There were no significant differences when the TWA divers mean IES scores (total = 12.3, SD = 14.3; intrusion = 7.1, SD = 7.4; avoidance = 5.2, SD = 7.7) were compared with comparison divers’ scores (total = 12.1, SD = 16.4; intrusion = 5.9, SD = 8.5; avoidance = 6.3, SD = 8.5). There were no significant differences when the IES scores from the 35 TWA divers with prior remains handling experience (total = 12.7, SD = 13.3; intrusion = 7.1, SD = 6.7; avoidance = 5.6, SD = 7.3) were compared with the 31 divers with no prior remains handling experience (total = 11.9, SD = 15.5; intrusion = 7.2, SD = 8.3; avoidance = 4.7, SD = 8.3).
% divers reporting
Mean score “Some” (score=1) “Very” (score=2)
The TWA divers rated exposure to children’s remains and to their personal effects as the most stressful factors (Table 1). The prolonged recovery and exposure to adults’ remains were next highest. Navy diving training was the highest rated coping factor, followed by family telephone contact and a sense of mission purpose.
Back to Top
First, our study suggests that occupational divers who recover bodies after disasters find exposure to remains, especially those of children, and the isolated work environment to be more stressful than safety hazards. Second, and more important, our results suggest that occupational divers in disaster response work do not experience notable posttraumatic stress symptoms. The IES showed no increase compared with a nonexposed diver group. Although a significant number of divers reported anxiety over flying afterward, our informal clinical monitoring of these diver commands even several months after the survey period revealed no reports of specific phobias against air travel and there were no mental health evaluations of these divers for stress symptoms related to the TWA Flight 800 recovery in any way, e.g., mood or anxiety disorder, substance abuse, or decline in work performance.
We consider this apparent lack of clinically important stress symptoms remarkable, given the stressors endured by the divers. The sensory experience of recovering human remains and personal effects in this disaster was itself unique. The magnitude of the wreckage and bodies on the ocean floor was psychologically unsettling as it visually unfolded over the initial days of the recovery. There was limited visibility during night diving and after storms disturbed sediment. At these times, divers never knew if something suddenly coming into view was a body (Ursano and McCarroll, 1990). Diving gear helped to separate divers from body tissues and fluids, especially when diving helmets were worn. Some bodies showed little sign of injury, while others were severely damaged. Marine scavengers affected the visual presentation and the condition of the bodies. Bodies were bagged underwater when possible during surface-supplied diving to facilitate bagging and to limit the exposure of nondiving personnel. When children’s bodies were recovered, divers who were parents identified with the grieving parents.
In addition to the recovery of remains and personal effects, other major stressors were living at sea for the entire operation, long hours/shifts including thousands of dives, and separation from family members. One of the two diving and salvage ships had just completed a 5-month deployment and was only in home port for one weekend before the TWA recovery began. Family telephone contact was one of the highest rated coping factors and a likely emotional buffer against exposure to death and the dead, as well as the intense work demands; family support has been reported by others as a positive factor (McCarroll et al., 1993, 1996). There were few injuries overall and no fatalities, due in large part to the other highest rated coping factor, Navy occupational diving training. This training is very rigorous and fosters a highly adaptive sense of competence, camaraderie, and mission purpose. Divers are selected and trained on the basis that they perform well and do not panic when confronted with physically and emotionally challenging underwater situations. They have a spectrum of characteristic personality traits-strong analytic ability and rapid decision-making, adaptation to mission needs, avoidance of hopeless feelings, enhanced self-efficacy and self-control-that presage successful occupational diving (Beckman et al., 1996). It is not known, though, how much these characteristics could have modified an individual diver’s truly experiencing or reporting any posttraumatic stress symptoms in our study.
Comparison of the IES results with those from other studied disaster workers is instructive. The TWA divers’ mean IES total score was lower than that for mortuary workers surveyed three months after the USS Iowa incident (Ursano et al., 1995) and forensic dentists surveyed 6 months after their work in the Waco, Texas, Branch Davidian incident (McCarroll et al., 1996).
Other at-sea disasters can be compared. The mean IES scores for the TWA divers were much lower than those of mostly nondiving rescuers surveyed 9 months after the Alexander L. Kielland oil rig collapse (Ersland et al., 1989). Although 47% of the TWA divers reported the recovery to be the most stressful life experience in the previous year, 62% of the Kielland rescuers viewed that disaster to be the worst life event ever. The TWA diver experience was similar to that of policemen who recovered bodies from the exploded Piper Alpha oil rig (Alexander and Wells, 1991). In that disaster, bodies were entombed underwater in the destroyed rig, which was later towed to land where nondiving personnel recovered victims and mortuary workers handled remains. In both cases, the recovery site was isolated, work hazards were controlled, and workers had time to prepare for exposure to a large number of bodies. IES scores for the recovery workers were lower than those for the TWA divers, but the mortuary workers and TWA divers had very similar scores.
The mean IES for both comparison and TWA divers was in the range of medium clinical concern, 8.6 to 19.0, reported by Horowitz (1982). It is possible that these scores reflect previously unrecognized preexisting or cumulative stress levels in occupational divers. However, further detailed studies are needed before drawing this conclusion because several factors limit the validity of comparisons among studies. First, there may be substantial variation among specific populations in completeness, honesty, and interpretation when answering the IES. Second, the wording of the IES introduction is important. Studies that may have asked for responses to the specific disaster in question, or to “stressful life events” (Horowitz et al., 1979), imply an event limited to a discrete time, such as an accident, disaster, or crime. We selected the word “experience” because the recovery effort was prolonged. An experience can include not only a discrete event, but also a chronic problem related to relationships, work, finances, or health. The IES scores of both diver groups may be higher relative to other studies because the survey encompassed a wider range of life problems. However, comparisons between both diver groups in this study are valid, because both were asked the same question.
The primary study limitation was that our survey had to be anonymous and brief to be accepted by the diving community. This fact limited the scope of the questions, especially regarding personal, characterological, and occupational historical information from which more extensive correlations with psychological data could have been made.
Christopher T. Leffler, M.D.1
Capt. Mark L. Dembert, MC, USN, M.D., M.P.H.2
Alexander DA, Wells A (1991) Reactions of police officers to body handling after a major disaster: a before-and-after comparison. Br J Psychiatry 159:547-555.
Beckman TJ, Lall R, Johnson WB (1996) Salient personality characteristics among Navy divers. Mil Med 161:717-719.
Ersland S, Weisaeth L, Sund A (1989) The stress upon rescuers involved in an oil rig disaster “Alexander L Kielland.” Acta Psychiatr Scand 80(Suppl. 355):38-49.
Fullerton CS, McCarroll, Ursano RJ, Wright K (1992) Psychological responses of rescue workers: Fire fighters and trauma. Am J Orthopsychiatry 62:371-378.
Horowitz M (1982) Stress response syndromes and their treatment. In L Goldberger, S Breznitz (Eds), Handbook of stress: Theoretical and clinical aspects (pp 711-732). New York: Free Press.
Horowitz M, Wilner N, Alvarez W (1979) Impact of Event Scale: A measure of subjective stress. Psychosom Med 41:209-218.
Jones DR (1985) Secondary disaster victims: the emotional effects of recovering and identifying human remains. Am J Psychiatry 142:303-307.
Leffler CT, White JC (1997) Recompression treatments during the recovery of TWA Flight 800. Undersea Hyper Med 24:301-308.
McCarroll JE, Fullerton CS, Ursano RJ, Hermsen JM (1996) Post-traumatic stress symptoms following forensic dental identification: Mt. Carmel, Waco, Texas. Am J Psychiatry 153:778-782.
McCarroll JE, Ursano RJ, Wright KM, Fullerton CS (1993) Handling bodies after violent death: strategies for coping. Am J Orthopsychiatry 63:209-214.
Ursano RJ, Fullerton CS, Kao T-C, Bhartiya VR (1995) Longitudinal assessment of posttraumatic stress disorder and depression after exposure to traumatic death. J Nerv Ment Dis 183:36-42.
Ursano RJ, McCarroll JE (1990) The nature of the traumatic stressor: Handling dead bodies. J Nerv Ment Dis 178:396-398.
Ursano RJ, McCarroll JE (1994) Exposure to traumatic death: the nature of the stressor. In RJ Ursano, BG McCaughey, CS Fullerton (Eds), Individual and community responses to trauma and disaster: The structure of human chaos (pp 46-71). London: Cambridge University Press.