On September 12, 2013, the California National Guard invited Shane Krogen, the executive director of the High Sierra Volunteer Trail Crew and the U.S. Forest Service’s Regional Forester’s Volunteer of the Year for 2012, to assist in the reclamation effort of a portion of the Sequoia National Forest where a marijuana crop had been removed three weeks earlier. Because the terrain in the area was steep, the team was to be lowered from a helicopter into the area.
After Mr. Krogen left the helicopter to be lowered, an equipment failure caused the volunteer to fall 40 feet. He later died from blunt force trauma injuries. The Air Force’s report on the incident, which was released in January, determined that Mr. Krogen had been improperly harnessed. The report also found that he should have never been invited on the flight.
To show the combination of factors that resulted in the death of the volunteer, we can capture the information from the Air Force report in a Cause Map, or visual root cause analysis. First it’s important to determine the impacts to the goals. In this case, Mr. Krogen’s death is an impact to the safety goal, and of primary consideration. Additionally, the improper harnessing can be considered an impact to the customer service goal, as Mr. Krogen was dependent on the expertise of National Guard personnel to ensure he was properly outfitted. Because it was contrary to Air Force regulations, which say civilian volunteers cannot be passengers on counter-drug operations, the fact that Mr. Krogen was allowed on the flight can be considered an impact to the regulatory goal. Lastly, the time spend performing the investigation impacts the labor goal because of the resources used during the investigation.
Beginning with the impacted goal of primary concern – the safety goal – asking “Why” questions allows for the determination of causes that resulted in the impacted goal (the end effect). In this case, Mr. Kroger died of blunt force trauma injuries from falling 40 feet. He fell 40 feet because he was being lowered from a helicopter and his rigging failed. He was being lowered from a helicopter to aid in reclamation efforts and because the terrain was too steep for the helicopter to land.
The rigging failure resulted from the failure of a D-ring which was used to connect the harness to the hoist. Specifically, the D-ring was not strong enough to handle the weight of a person being lowered on it. This is because the hoist was connected to Mr. Krogen’s personal, plastic D-ring instead of a government-issued, load-bearing metal D-ring. After Mr. Krogen mistakenly connected the wrong D-ring, his rigging was checked by National Guard personnel. The airman doing the checking didn’t notice the mistake, likely because of the proximity of the two D-rings and the fact that Mr. Krogen was wearing his own tactical vest, loaded with equipment, over the harness to which the metal D-ring was connected.
I think Mark Thompson sums up the incident best in his article for Time: “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.”
To view the Outline and Cause Map, please click “Download PDF” above. Or click here to read more.