A detailed report regarding the tragic death of a volunteer diver working with a team on a recovery on Shasta Lake in September 2013 shows multiple lapses.
KRCR was able to attain a copy of the lengthy investigation after filing a Public Record Act request with Shasta County.
Volunteer diver Ken Smith died September 8, 2013, while trying to recover a robotic vehicle being used in a search for a person who drowned in Shasta Lake.
A Shasta County deputy was also seriously hurt trying to save Smith.
Now a nearly 200-page report from the L.A. County Sheriff's department reveals exactly what went wrong.
Included are interviews with San Francisco Police Department divers who were also on hand, Shasta County sheriff's deputies at the scene as well as Smith's wife, Cheryl.
Among the pages, a diagram shows how the robotic vehicle became trapped in a large oak tree 143 feet below the water's surface.
And among the findings, the report claims Smith was not experienced enough for the deep dive. Smith had been referred to the sheriff's office by a friend who was requested to help in the search but was out of town.
The report also said he wasn't properly supported by personnel above and was without communication with a safety diver because of poor visibility.
It also said Smith didn't have enough air to make the dive and the air he was using wasn't adequate to support breathing at that depth. It says nitrogen levels in his air were too high and worked as a narcotic at the depth he was diving.
At the level Smith was diving he used his air six times faster than he would at the top.
What's more, Smith's regulator wasn't serviced properly and needed tuning before undertaking such a deep dive.
Smith was found at the bottom of the lake, some 173 feet below, weighed down by his gear and other apparatus meant to allow him to sink into the deep water. The report says the fact that he didn't released weights attached to him is an indication he never even made an attempt at an emergency ascent to the surface.
Smith's wife, Cheryl, filed a claim against Shasta County.
That claim was rejected, setting the stage for a court battle.
Shasta County Sheriff Tom Bosenko declined to comment on the report, citing legal reasons.