Report released on USFS rappelling fatality

Thomas Marovich died on July 21, 2009 when he fell while performing routine helicopter rappelling proficiency training while assigned to the Backbone fire near Willow Creek, California. On October 2, 2009 the Occupational Safety and Health Administration (OSHA) issued “serious” and “willful” violation notices to the U. S. Forest Service for the incident.

The USFS has just released their Preliminary Aircraft Accident Investigation Report which was completed on October 19, 2009, and a Safety Action Plan dated February 1, 2010. The report is 63 pages long, but I will mention a few of the key points. [UPDATE 9-13-2011; the Lessons Learned Center removed the two reports from their site at the direction of the U. S. Forest Service, who said they were not intended to be released to the public. They replaced the two reports with the National Transportation Safety Board narrative.]

A proficiency rappel is required every 14 days to maintain technical competency. Marovich was in his first season rappelling and was about to make his 11th rappel.

Before the rappelling training, Marovich noticed that the Kong clip on his Tri-link was broken. The Kong Clip is used to center the “J” hook at the forward corner of the Tri-link. It is a nice piece of equipment to have, but is not essential. Kong clips are prone to breaking and are not popular. He sought assistance from a spotter trainee who replaced the Kong clip with an “O” ring, which was an authorized substitution. If I interpreted the report correctly, the “O” ring was installed incorrectly.

Here are some photos from the report showing for illustration purposes examples of a correct and then an incorrect installation of an “O” ring on a Tri-link.

O Ring, correctly installed
“J” hook, Tri-link, and an “O” Ring, correctly installed. USFS photo.
O ring, incorrect
“J” hook, Tri-link, and an “O” Ring, incorrectly installed. USFS photo.
Rappelling rigs
Three different equipment rigging set ups. The top set up is rigged correctly using a Kong clip. The middle set up is rigged correctly using an O-ring. The bottom set up is rigged improperly using an O-ring. USFS photo.

Before the rappelling attempt, four people looked at or inspected Marovich’s rappelling gear: the spotter trainee who installed the “O” ring, Marovich, and in the helicopter a spotter, and another helitack crewperson who did a “buddy check”.

Rappellers just before accident
This photo was taken seconds before Marovich fell, unarrested. He is on the left side.

Marovich fell, unarrested, shortly after stepping out onto the helicopter skid. He was pronounced deceased about 30 minutes later.

The Human Factors section of the report, beginning on page 33, is particularly interesting. Written by Jim Saveland and Ivan Pupulidy, it discusses, along with other issues, the concept of not seeing elements in our visual field, or “blindness”.

Below are some quotes from that section:

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OSHA issues "Serious" and "Willfull" violation notices to USFS over rappelling fatality

On July 21, 2009 Thomas Marovich, 20, of Hayward California incurred fatal injuries when he fell while performing routine rappel proficiency skill training at the Backbone fire Helibase in Willow Creek, California. Wildfire Today covered it HERE, HERE, and HERE.

We have not seen an official accident report about the accident, but the Occupational Safety and Health Administration (OSHA) has issued violation notices to the U. S. Forest Service related to the incident.

The first one is a “Serious” violation that involves the procedures for the use of the rappel equipment. OSHA provided in the document four specific “abatement methods to correct these hazards”. They involve equipment such as the Bourdon snap hook, a Mallion Rapide Tri-Link, and the HR-2 rappel harness.

The second is a “Willful” violation of the Occupational Safety and Health Act of 1970.  OSHA accuses the USFS of failing to provide requested information about the accident. In fact, the USFS stated in writing that they would not comply with OSHA’s request.

Here is an excerpt from the violation notice OSHA sent to the U. S. Forest Service in Eureka, California, on October 2, 2009, about the “Willful” violation:

Excerpt from page 8 of OHSA’s notice to the U. S. Forest Service

OSHA apparently concludes that the only way the USFS could be in compliance with the Occupational Safety and Health Act and Executive Order No. 12196 is if the incident must be “kept secret in the interest of national defense or foreign policy”, but then says it involves neither.

One has to wonder if the recent trend of prosecuting people involved in accidents led to the refusal of the USFS to release the information OSHA requested.