Air Force Report: String Of Errors Led to Civilian Helicopter Fatality

Split-second wrong decision, plus inadequate oversight and nonstandard equipment, led up to fatal fall of volunteer on a marijuana clean-up mission

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Air Force

Deadly Mistake: Instead of fastening the hoist A-Frame clasp to the upper black D-ring, Krogen mistakenly fastened it to the lower black D-ring. An airman charged with ensuring Krogen was securely fastened missed the error.

A nonprofit volunteer, who the California Air National Guard improperly invited to fly aboard one of its Pave Hawk helicopters on a marijuana-cleanup mission, fell to his death after the plastic ring he had mistakenly clipped to the hoist while being lowered from the aircraft snapped. His rigging had been checked before he was sent outside.

The death of Shane Krogen, executive director of the High Sierra Volunteer Trail Crew, last summer in the Sequoia National Forest, just south of Yosemite National Park, was a tragedy. But it was an entirely preventable one.

It stands as a reminder of how dangerous military missions can be, and on the importance of a second set of eyes to make sure that potentially deadly errors, whenever possible, are reviewed and reversed before it is too late.

Hoist 'im up

Air Force / Tech. Sgt. Ruby Zarzyczny

An Air Force HH-60 Pave Hawk during a hoist operation.

The HH-60 helicopter, a variant of the Army’s UH-60 Black Hawk, was conducting a California Joint Task Force Domestic Support counter-drug operation Sept. 12. Its mission that day was to ferry workers into the Dunn Grove marijuana growing site for “reclamation operations,” following eradication of the marijuana crop there three weeks earlier. The terrain was too steep for the chopper to land, so they had to be lowered in by a hoist from the aircraft.

But a string of errors and snafus led to calamity, according to a recently released Air Force investigation.

First of all, Krogen was improperly aboard the helicopter as “Mission-Essential Personnel”:

Individuals who are not designated as aircrew, but are required to perform unique ground support duties that are directly related to the unit’s mission can be approved as Mission Essential Personnel. However, civilian volunteers, like the members of the High Sierra Volunteer Trail Crew, cannot serve in Mission Essential Personnel roles nor be passengers on Joint Task Force Domestic Support-Counter drug operations…

On prior flights, Krogen had been hoisted off the helicopter with another person; on Sept. 12 he was being hoisted alone, which required different procedure:

…On the day of the mishap, the Mishap Special Missions Aviation, Right [the airman charged with ensuring Krogen’s gear was properly connected] configured the Mishap Aircraft cabin and secured the Civilian Fatality in a manner that was inconsistent with the Civilian Fatality’s training to expedite hoisting the Civilian Fatality into the Dunn Grow site…This configuration eliminated two opportunities for the Civilian Fatality to realize and correct the situation.

The extra gear Krogen was wearing complicated matters:

On the day of the mishap, the Civilian Fatality utilized self-procured and non-standardized personal equipment. The Civilian Fatality was wearing a Yates harness securely around his legs, torso, and shoulders, and a Condor tactical vest with water bottles, radio, and a handgun over the Yates harness…The Condor tactical vest D-ring overlaid the Yates harness load bearing D-ring.

Then came the first critical error:

When the Civilian Fatality entered the Mishap Aircraft cabin, the Mishap Special Missions Aviation, Right handed the Civilian Fatality the A-Frame clasp to connect to the Civilian Fatality’s Yates harness load bearing D-ring. However, the Civilian Fatality mistakenly connected the A-Frame clasp to his Condor tactical vest non-load bearing plastic D-ring.

Followed by the second critical error:

The Mishap Special Missions Aviation, Right then completed a visual inspection to ensure the Civilian Fatality was properly secured. Air Force Instruction 11-2HH-60V3, para 6.12.2 directs the designated Safetyman, in this case, the Mishap Special Missions Aviation, Right, to “continuously evaluate the safety of the operation, and immediately inform the rest of the crew, and take the necessary action to avert a hazardous situation.” A visual inspection minimally met the requirement of the Air Force Instruction for the Mishap Special Missions Aviation, Right, as Safetyman, to “take the necessary action to avert a hazardous situation.” Due to the extremely close proximity of the Yates harness load bearing D-ring in relation to the Condor tactical vest non-load bearing D-ring, and the concealment of both D-rings by the cluttered pouches on the Condor tactical vest, which included a handgun, the Mishap Special Missions Aviation, Right incorrectly concluded the Civilian Fatality was properly secured.

Which led to disaster:

During the process of hoisting the Civilian Fatality out of the Mishap Aircraft cabin, the Condor tactical vest non-load bearing plastic D-ring, which connected the Civilian Fatality to the hoist, broke. The broken D-ring, which was not intended to support the Civilian Fatality’s weight, caused the Civilian Fatality to become disconnected from the hoist. Upon disconnection from the hoist, the Civilian Fatality fell approximately 40 feet to the terrain below and sustained fatal injuries.

In its probe of the accident, the Air Force lauded the High Sierra Volunteer Trail Crew for its dedication to preserving the rugged public lands in the High Sierra mountains, and Krogen, “the highly respected Executive Director and founder of the HSVTC.” Krogen, 57, and his organization have worked with state and federal groups to remove trash and contaminants from remote marijuana plots for several years.

“We really want to see the fertilizers and these rodenticides get out of there,” Krogen said in a U.S. Forest Service program. “We’ve seen enough animals, dead animals and stuff.” In 2012, Krogen received the U.S. Forest Service’s Regional Forester’s Volunteer of the Year Award. “He not only engaged in the reclamation of hundreds of marijuana sites, but also cleared trails after fires,” the U.S. Forest Service said following his death. “His commitment and passion were evident in all the work he touched.”

Air Force Master Sergeant Randy Redman, a spokesman with the Air Force’s Air Combat Command, which conducted the investigation, said privacy rules bar making public whatever disciplinary action may have been taken against the airman responsible for ensuring Krogen’s harness was secured properly, even if that airman is unnamed in the report.

The helicopter belongs to the 129th Rescue Squadron, a Guard unit based at Silicon Valley’s Moffett Field, that has deployed to rescue downed pilots behind enemy lines in Afghanistan and Iraq.

“These Things We Do,” its motto says, “That Others May Live.”

Shane Krogen plays with Susan's dog Weezee in Fresno, Calif., in Feb. 2013.

Susan Barnett / AP

Shane Krogen, founder of the High Sierra Volunteer Trail Crew, in February 2013.