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Nancy Peacock walked down a boat ramp that descends into the cool blue waters of Pohoiki Bay, anxious to try her new full-face snorkeling mask in an environment where she could see parrotfish, moorish idols, corals and other sea creatures.

She had ordered the mask on Amazon and tried it out in the local pool near her California home in preparation for the September trip to visit longtime friends on the Big Island.

But less than an hour after entering the relatively calm bay, Peacock was dead.

Five months later her husband, Guy Cooper, is still searching for answers.

Did she drown because of the mask’s unique design, which covers the entire face so you can breathe out of your mouth and nose as opposed to the traditional snorkel tube in your mouth? Or was it a freak accident, even for a healthy 70-year-old who was at least somewhat familiar with Hawaii’s waters?

Cooper’s quest has brought to light significant gaps in data collection by government agencies, inadequate policies with the chain of custody for evidence and confounding decisions by the county medical examiner.

“My God, these masks could be killing others and no one has a clue,” Cooper said. “Isn’t that something you would want to know, that the public needs to know?”

He��tried to warn others of what he sees as the mask’s hidden dangers by posting a ��about his wife’s death on Amazon, but it��has been removed from the website; he’s not sure who took it down or why.

In other reviews on Amazon and conversations with people who have used the Azorro mask, some customers have reported that it is prone to leaks and can be difficult to quickly remove because of straps designed for a snug fit. Users have also reported carbon dioxide buildups that could cause someone to pass out.

“I find this mask unusable,” Dan Deforest said��in his Aug. 4 of the mask on Amazon. “It fogs very quickly. It also does not expel all carbon dioxide before inhaling oxygen.”��

“Snorkel works fine until you go under water, then it’s as though the valve at the top gets jammed and it’s like breathing through a straw,” E.G. Bradlee said in his July 27 .

But there have also been numerous positive reviews, and hotels and tourist shops are renting out the new style of snorkeling mask with increasing frequency.��

“Works as advertised,” Machael Catlin said in his Aug. 22 . “Gives great angle of vision compared to usual masks.”

Some owners of companies carrying the mask have been��promoting it in the islands as a safe piece of equipment, especially for beginners, according to lifeguards, snorkel shop owners and fire department officials. Water safety officers��have been asked to endorse it, but have declined��as county policies generally prohibit product endorsements.

Robert Wintner, who owns Snorkel Bob’s snorkel-rental stores on four of the Main Hawaiian Islands, said his employees tested the full-face masks.

“They have been so aggressive in their marketing. ‘You’ve got to give it a try, you’ve got to give it a try, you’ve got to give it a try,'” he said. “We tested it and said, ‘No way. We won’t carry it.’”

Wintner noted its potential for carbon dioxide��buildup due to the full-face design and likelihood of leaking because of using a cheap��substitute for silicon to create a secure seal when worn.

“You have to base your assessments on experience, intuition and instinct,” he said. “When I saw that thing, it didn’t look right.”

Wintner said he could see how the mask could create a situation that causes its user��to panic, which ocean-safety experts often identify — along with age and underlying health conditions — as a primary reason why so many visitors die while snorkeling in Hawaii.

“No one is paying attention. In my wife’s case, neither the first responders nor the police nor the coroner had any concern for the equipment.” — Guy Cooper

“I was aghast when I started looking into it,” Cooper said in January when he visited the Big Island.

He was��driving south from Hilo to Pohoiki Bay, also known as Isaac Hale Beach Park, to visit the place where Peacock drowned. Cooper wanted to learn more about the incident from the lifeguards who responded from a nearby beach.

Cooper, a 68-year-old retired nurse who spent much of his��career��working in intensive care units, has been reaching out to government officials, water safety officers and others to piece together what happened and find ways to make snorkelers safer.

His most recent meeting was with Gerald Kosaski, the Hawaii County Fire Department’s battalion chief who oversees ocean safety.

“When something negative happens, it can bring a positive out of it,” Kosaki said. “Guy is pushing forward.”

On Sept. 6, the day Peacock drowned, Cooper was back in Martinez,��California, readying for a trip they were about to take to see his��family in Philadelphia. It was one of the only times they didn’t travel together.

He fondly recalled their adventures last June in Italy, where they hiked Mount Vesuvius, and their prior trips to Thailand, Japan and Cambodia — not to mention a four-month, 14,000-mile road trip across the United States in his 1968 Avion camper.

They met in 2007 at Burning Man, an annual festival of arts and music in Nevada’s Black Rock Desert. She was the first person he met there, and Cooper said they soon became inseparable.

Peacock was a costume designer as well as systems analyst and computer programmer.

“She really used both sides of the brain,” Cooper said.

It was a sunny January afternoon when he visited��Pohoiki Bay, where his wife drowned, and a mix of locals and visitors were out in the water.

A handful of surfers were riding waves and a swimmer was making his way back in, passing the no-swimming sign that’s posted by the state boat ramp and routinely ignored, like so many other warning signs around Hawaii.

“Sometimes, I’m just numb,” Cooper said as he stood near the shore.

It was a surfer who first sounded the alarm. She spotted Peacock floating on her back with the mask on slightly pulled up over her mouth and nose. She��grew alarmed when two small waves rolled over her and she did not respond.

The surfer paddled over and noticed Peacock was bloated and turning blue. The surfer yelled for help and kept Peacock��from sinking until others came to help.

After bringing Peacock to shore, lifeguards from an adjacent beach performed CPR in shifts for half an hour as paramedics made their way to this relatively remote part of the island.

Chris Birkholme, a water safety officer for Hilo and Puna with 18 years’ experience, was one of the first on the scene. He recalled in vivid detail the effort to revive her.

“We’re here to help,” he said. “But that place is blind to us.”

There’s a lifeguard tower a few hundred feet from the bay but it’s out of sight, facing east toward the open ocean, an area with rougher waters.

Lost Mask Leads To New Policy

The snorkeling mask that Peacock was wearing went missing sometime between when she was brought to shore and when she was pronounced dead at a hospital in Hilo.

While the lifeguards and paramedics did all they could to save Peacock, Kosaki said, “there were mistakes made.”

Specifically, he said, the mask should not have been lost. Kosaki plans to make it an official policy to ensure equipment, which could become evidence to help determine a cause of death, does not get tossed out regardless of its perceived value.

He expects��the policy to mandate that the equipment is first offered to the family, then the police. And if the person is transported via ambulance, the equipment goes with them.

“It’s pretty simple,” Kosaki said. “But we need it in writing.”

Cooper bought a snorkeling mask identical to the one his wife had worn and, on this visit to the Big Island, carried it with him to show lifeguards. He asked them if they had seen people wearing them lately and if they were aware of its potential hazards. Many said they had seen them and would ask people if they’ve had any problems.

Later that afternoon at Ahalanui Beach Park, a natural hot spring a mile up the road from Pohoiki, a middle-aged man was snorkeling with a similar full-face mask. He fidgeted with its fitting several times but otherwise appeared to be enjoying his experience in the placid waters.

Beef Up��Database To Identify Trends?

Preserving the equipment that a person was using in a drowning is just the first step to Cooper.

He ultimately wants to see a database that logs information about the equipment in each incident so authorities can identify dangerous trends, much the same way that the National��Highway Traffic Safety Administration collects data��to determine if a particular type of airbag is faulty in fatal car crashes.

Hawaii is not alone. Cooper has spent hours researching this issue but has been unable to find any government agency in the U.S. or abroad that has created a database that includes details about the equipment worn in a drowning or near-drowning incident.

“As I looked into it further, I was stunned to find that apparently no one in the world makes the connection,” he said. “No one is paying attention. In my wife’s case, neither the first responders nor the police nor the coroner had any concern for the equipment. My wife’s mask was just tossed in the trash. I also found no evidence of any independent testing or certification of these things.”

The Hawaii Department of Health’s Injury Prevention and Control Section compiles records about the number of ocean drownings, the location of the incident, the victim’s residence and what they were doing.

But there are few details beyond a label of “snorkeling,” for instance. Nothing about what brand of mask was worn, what type of snorkel or fins.

Cooper maintains that recording the make and manufacturer is critical. He said the Azorro brand of mask his wife wore seems to be a Chinese knock-off of the original French design.

The Azorro mask goes for $49.99 on Amazon, compared to up to $199 for the version by Tribord, which says on its website that it created the first full-face snorkeling mask “allowing you to breathe just as easily and naturally underwater as you would on land.”

Attempts to find contact information for Azorro were not successful.��

A representative from Amazon.com, which sells the mask through a third party, also could not find contact information for Azorro.

But the representative, who declined to give her name, said Amazon takes product safety “very seriously,” and won’t hesitate to quit carrying a product if it’s found to be unsafe. She did not know why Cooper’s review may have been taken down but said it most likely should not have unless it violated the site’s community rules, which bans��profanity.

When it comes to improving the department’s database of ocean-related incidents, Kosaki said it seems reasonable to add a new requirement to include what equipment, if any, the person was using.

“I think adding one more thing would be useful,” he said.

Kosaki plans to bring it up at the next quarterly meeting of the interagency Hawaii Drowning and Aquatic Injury Prevention Advisory Committee in March. He serves as co-chair with Jim Howe, a longtime ocean-safety expert who was recently appointed director of the Honolulu Emergency Services Department.

State epidemiologist Dan Galanis thinks��the use of these full-face snorkel masks will increase over time, and that logging data about the type of gear used in a drowning incident would be useful.

“The continuing story is people drowning while snorkeling here.” — Dan Galanis, state epidemiologist

“The basic design of snorkel gear really didn’t change for as long as I’ve been around to use them until these things came around,” he said. “It is definitely an unknown. I think that alone merits the distinction in their use at the autopsy level.”

But getting lifeguards or EMS personnel to log information about types of equipment would be more challenging, Galanis said.

At the autopsy level, it would just be a matter of talking to the four county medical examiners and having them add that additional level of detail in their reports.

That would help with fatalities, he said, but would not provide as robust a data set as having lifeguards log that information with each drowning or near-drowning incident. The hard part there is in the additional time involved and making it uniform across the state.

Galanis also sees an opportunity for the University of Hawaii or other research institutions to do a study of these new full-face masks to explore complaints of carbon dioxide buildup and other reported issues.

“The continuing story is people drowning while snorkeling here,” Galanis said. “It’s so persistent.”

Searching For Solutions

Hawaii had on average 58 drownings per year from 2006 to 2015, with the trend increasing since 2010, according to the most recent Department of Health data.

And visitors continue to die in Hawaii’s waters at a higher rate than residents, with snorkeling being the most common activity.

“We have identified that snorkeling is the reason why many visitors drown but we’ve never looked at the equipment,” Kosaki said.

A Civil Beat special project, published in January 2016, found Hawaii’s visitor-drowning rate is 13 times the national average and 10 times the rate of Hawaii residents. Local water safety experts have cited Hawaii’s unique ocean conditions, insufficient messaging to caution the public and the health of the individual as contributing factors.

Despite this longstanding problem, the state lacks specific prevention strategies, Galanis said, but it’s working toward them.

The Hawaii Drowning and Aquatic Injury Prevention Advisory Committee — which includes health officials, the Hawaii Tourism Authority, emergency responders, ocean safety advocates and others — has been working the past year to develop a safety message that could be disseminated to warn visitors of Hawaii’s hazardous waters.

At Black Rock, for instance, a popular tourist destination on the southwest shore of Maui, at least 21 people have drowned over the past decade. All but one was a visitor and two-thirds were snorkeling.

Looking at the demographics, 86 percent were male, 76 percent were over 40 years old and 43 percent had an underlying heart disease, according to the Department of Health, which compiled data from paramedics.

Delving Deeper Into Causes Of Drowning

Cooper has concerns about blaming��a drowning solely on someone’s age and overall health. He said it’s worth looking deeper:��Did something trigger a heart attack in the water, for instance, such as a mask that suddenly flooded with water?

He��found discrepancies in his wife’s autopsy report from the Hilo Medical Center.

The autopsy notes a “reported history of heart condition,” he said, but he is perplexed at to where that information came from because no one asked him about her health history.

The autopsy also lists “ischemic cardiac disease” as a contributing factor in her death even though she had no history of it, he said. Peacock had a history of moderate hypertension that was controlled with medicine, he said, adding that the physical findings ��in the autopsy and the estimations of her own cardiologist did not support the ischemic cardiac disease determination.

Cooper flew to the Big Island the day after he learned��that Peacock had drowned. It was his first time in Hawaii since 1970, when he was stationed at Hickam Air Force Base on Oahu.

“My point in reviewing all of this is that I think something else led to Nancy’s death that has implications generally for ocean safety, particularly as regards snorkeling,” Cooper wrote in a Dec. 7 letter to the doctors who pronounced her dead and performed the autopsy.

“I would think that any coroner investigation would insist this evidence be secured and examined,” he wrote. “This feedback seems critical to me. As doctors responsible for response and evaluation of such emergencies, I would hope that you would consider and spread the word that such information is crucial. You need it. First responders need it. Lifeguards need it. Consumers need it. And the snorkeling industry needs it.”

Cooper said he did not hear back from the doctors.

“I’m back in Hawaii not only to be close to where she last was, but to escape the life we shared,” Cooper said in an email last week.

He plans to attend the Hawaii Drowning and Aquatic Injury Prevention Advisory Committee’s March 15 meeting. The agenda includes a review of “lifeguard log and incident reporting in application to (drowning prevention).”

“That’s what I want to do — just get the word out — and hopefully prevent some of these,” Cooper said.

Bridget Velasco, state drowning and spinal cord injury prevention coordinator and a member of the advisory committee, said there are remarkably few proven strategies for drowning prevention, and even less for prevention of drowning during snorkeling.��

“We look forward to disseminating clear and accurate information but the process to get to that point is tedious and time-taking,” she said.

Cooper said he’ll probably never know the cause of Peacock’s death.

“Did she run out of air? Did a faulty mask flood with water? Did she quietly succumb to a buildup of CO2? Did she really have a heart attack?” he wrote in the email. “I suspect equipment failure and strongly suggest that it be considered in every case such as this. At the least, in the interest of public safety, some effort should be made to to secure, examine and record such information, so that potential equipment problems and/or trends might come to light. It could save lives.”