Note: On Wednesday, March 28, 2012, Coast Guard D-17 commander Adm. Thomas Ostebo met in Sitka with aviators under his command to review the Final Action Memorandum (FAM) on the crash of helicopter CG-6017 and the deaths of three of its four crew. Lt. Lance Leone, the lone survivor of the crash — and the aircraft’s co-pilot — was in attendance.
An excerpt of the following commentary was broadcast on KCAW. Smith’s comment appears in full text below. KCAW has afforded the Coast Guard D-17 Command an equal opportunity to respond.
This week Admiral Thomas Ostebo will address many of his subordinates in Sitka at an “All Hands” meeting. He is said to be briefing the so-called “Final Action Memorandum” (FAM), posted on the Coast Guard website last week, concerning the accident involving CG-6017 which resulted in the deaths of three crew members, the destruction of the Jayhawk helicopter and charges, now dismissed, leveled against the sole survivor and co-pilot, LT Lance Leone. LT Leone will no doubt be in the audience with his peers and fellow servicemen and women.
Under these circumstances, I must ask Admiral Ostebo and the Coast Guard Senior leadership the same question lawyer Joseph Welch asked Senator Joe McCarthy during the famous Army-McCarthy hearings in 1954, “Have you no sense of decency?” History will recall that Senator McCarthy, while taking liberties with half-truths, accused a young lieutenant of assisting the Communist Party – a certain and swift career ending accusation.
Admiral Ostebo, in briefing the Coast Guard’s FAM, not only follows this same path of half-truths, he will commit a far more serious blow to truth: he will disregard evidence demonstrating LT Leone’s innocence and, further, purposefully shield Coast Guard leadership from accountability for egregious lapses of safety concerns. The Coast Guard has institutionalized this disregard for the truth in its regulations. By its own rules, the FAM is a document used by the Coast Guard to summarize the usually lengthy Administrative Investigation of Mishap, known as the AIM. The FAM, prepared by the Coast Guard staff and signed usually by the Commandant of the Coast Guard, is meant to bring closure to accidents such as the one involving CG-6017. However, in this case, Coast Guard regulations seem to indicate that the FAM summarizes only the AIM and does not account for any other evidence developed by other investigations. In essence, this procedure allows the Coast Guard Senior leadership to willfully disregard clear evidence that would place accountability for this accident squarely on the Coast Guard leadership and prove to exonerate LT Leone and the crew.
To recount, the AIM was finished and submitted on November 11, 2010, some sixteen months ago. According to the lead investigator there has been NO additional investigative activity since then. In late September 2011, Admiral Ostebo, contrary to the opinion of LT Leone’s commanding officer, caused criminal charges to be sent to an Article 32 investigation, a grand jury equivalent. It was at this time that LT Leone’s defense team found and developed evidence that demonstrated that senior Coast Guard leadership recklessly failed to properly mark the 1900-foot span of wires that ensnared CG-6017 in July 2010. In addition, the defense found and developed evidence that showed the Coast Guard leadership’s blatant disregard for safety warnings voiced by one of its own Senior Enlisted leaders, the Officer-in-Charge of the Boat Station that had responsibility for the upkeep of the wires. The Master Chief in question clearly testified that in the year prior to the fatal mishap but before his own retirement, he notified his chain of command that the wires were inadequately marked and asked them to fix it because he was worried that they posed a grave risk to aviators operating in the area. The AIM mentions that the wires were invisible to the crew. It mentions little else about the deadly span that was the cause of at least two prior fatal entanglements; the first of which resulted in a federal judge ruling that the Coast Guard was negligent for failing to adequately mark the wires many years earlier. The Coast Guard appointed Article 32 Investigator, a Senior Coast Guard Military Judge, found that “reasonable grounds do not exist “ to charge LT Leone with the deaths of his fellow crew members. Note – the standard used to forward the charges is not evidence ‘beyond a reasonable doubt.’ At the Article 32 stage of the proceedings, the prosecution need only show a reasonable basis for the charges. The Senior Military Judge said, in essence, a person who views the evidence presented reasonably cannot link LT Leone’s actions or inactions to the deaths of the crew. He also said that a “reasonable” co-pilot doing LT Leone’s job that day would not have identified the wires as a hazard along the flight path since LT Leone had charted a course and set it on the autopilot which would have completely gone around and above any hazards.
Yet the FAM does not use this evidence. In fact, Admiral Ostebo expands the FAM by finding that LT Leone directly contributed to the deaths of the crew while charting a course that headed directly into the wires. Admiral Ostebo and the FAM both articulate ‘complacency’ of LT Leone and the crew as a cause for the accident. Yet they both both fail to mention the complacency of found in the execution of a robust safety program as a cause.
Today LT Leone faces the challenge of a overcoming a flawed report which has led to a poor performance rating and a other negative performance notes in his career personnel records. Why? I can only assume that the Admiral Ostebo believed that these actions would not be subject to the scrutiny of anyone, most especially, the ‘Court of Public Opinion.’ It is here that the actions of Coast Guard senior leadership rightly must be judged.
Along these lines, the Coast Guard has posted the FAM on its website, telling the public that the FAM is the ‘Final’ and ‘correct’ version of what happened. The Senior Coast Guard leadership wrote and approved this report purposefully laying the deaths of the crew at the feet of LT Leone. The Coast Guard leadership willfully disregards and omits evidence that points to the failure of accountability of the same leadership. The Coast Guard’s answer to its reckless failure to properly mark the span of wires is, simply, that any evidence that the wires, if properly marked, would have prevented this accident is “speculative.” This is the epitome of bureaucratic arrogance! Faceless ‘leaders’ make findings on an incomplete and biased report while blaming individuals who cannot speak either because they are dead or they are maligned by a system where their voice cannot be heard.
What is not speculation is that the Coast Guard’s failure to mark the wires, an action that would have cost less than $10,000, insured that the crew never would have seen the wires. The Coast Guard took away any chance for CG-6017 to avoid those wires by its failure to act on multiple occasions over the course of the decade prior.
In the end, I must question why the Coast Guard will use all its considerable skill to castigate the crew of CG-6017 and single out the co-pilot, LT Leone, for blame. Maybe the answer can be provided by the Commandant, Admiral Robert Papp, who so desperately wants ‘accountability.’ Perhaps the answer can be provided by Admiral Ostebo who wants to give Admiral Papp what he wants – an aviator held accountable. But maybe it is simpler than that. Maybe, if LT Leone is accountable, the Coast Guard can absolve itself from the horrible reality that its faceless bureaucracy failed to properly mark wires that now account for three downed aircraft and three of its own dead.
Therefore, like Mr. Welch some 60 years prior, I must ask Admiral Papp, the Coast Guard Senior leadership, and Admiral Ostebo:
“Have you no sense of decency? At long last, have you left no sense of decency?”
Opinions expressed in KCAW commentary are those of the author, and are not necessarily shared by the station’s board, staff, or volunteers.