Outdated equipment linked to Vegas search and rescue officer’s death

The failure of Las Vegas police to replace outdated rescue helicopter equipment may have led to the death of an officer last year.

More than a year later, the death of Metro officer David VanBuskirk, who fell while hoisting a stranded hiker to a helicopter at Mount Charleston, remains under investigation. But VanBuskirk’s colleagues and national search and rescue experts suspect the officer fell because his department used a rescue hook without a locking safety latch.

Ken Phillips, chief of the National Park Service’s search and rescue branch, said most “progressive” helicopter rescue units long ago upgraded to the locking hook.

“They are so commonplace now in the helicopter rescue industry,” Phillips said.

Los Angeles County’s search and rescue team, for example, made the switch more than 15 years ago.

“If you’ve got nonlocking equipment in anything that’s got to do with rescue … you’re setting yourself up for failure,” said Hank Reimer, a veteran helicopter rescue crew chief in Los Angeles.

But Metro didn’t know of the problem until VanBuskirk died, officials said.

Capt. Charles Hank, who oversees the department’s aviation unit, said no one person is to blame.

“Safety is everyone’s responsibility, from the sheriff down,” Hank said.

Clark County Sheriff Doug Gillespie said he doesn’t think Metro failed to supervise the safety of the unit. When meeting with other agencies over the years, including many that used locking hooks, no one mentioned Metro’s hooks as a problem, he said.

“In all of the discussions we’ve had about a variety of things, nobody in any of those meetings said … ‘Hey, have you guys run across this faulty hook aspect?’ ” he said. “I don’t look at it as somebody dropping the ball.”

A few months after the accident, Metro replaced the hooks on all its rescue helicopters.

FORCED ROLLOUT

VanBuskirk, 36, was one of five officers on the rescue team sent to help a hiker stranded on a ledge at Mary Jane Falls on July 22, 2013.

The night mission was routine for Metro’s busy search and rescue unit, which performs more than 100 helicopter rescues each year. The weather was calm with little wind. The terrain was steep, but there was enough space for the officer to stand. VanBuskirk, with six years at search and rescue, was one of their most experienced officers.

After locating the hiker, the officer was lowered on a cable from the helicopter’s electric hoist. His harness was attached to the cable’s hook with a heavy-duty climber’s carabiner.

The plan was for VanBuskirk to put the hiker in a strop — a body harness — and attach him to the same hoist hook. Officers sometimes detach themselves from the cable while on the ground, but that wasn’t in this mission plan, and VanBuskirk never communicated that he intended to do so.

VanBuskirk gave the hoist operator the signal to raise him and the hiker, but the officer began struggling during the ascent and fell about 25 feet to his death. The hiker, whom Metro has not identified, made it safely into the helicopter.

Metro investigators have said none of VanBuskirk’s equipment broke, and nothing malfunctioned.

Search and rescue members soon focused on “forced rollout,” which can happen when a slack cable allows the carabiner on the rescuer’s harness to roll over the top of the hook, pushing open a spring-loaded gate and forcing the carabiner to separate from the hook.

Nonlocking hooks were first used by the military more than 50 years ago, but over the past two decades have been replaced by hooks with a gate safety lock that can’t open even if the carabiner rolls over it.

Reimer, like other industry experts aware of VanBuskirk’s death, expressed surprise that Metro wasn’t using locking hooks because forced rollout is common knowledge among rescuers and climbers.

“If you don’t have that kind of a background, and you just start putting something on a hook, accidents can happen,” he said. “It’s a lack of education, I guess, for lack of a better term.”

Phillips, who started a national search and rescue academy in 2012, last year published a 100-page training manual that covered forced rollout.

“All personnel involved in hoist rescue operations, particularly ground rescuers, should be well-briefed on the phenomenon of rollout and how to prevent it,” Phillips wrote. A locking hook provides the greatest security, he wrote.

But Hank said no one at Metro knew about it.

“Had we known that (before), we would have immediately changed,” Hank said.

A few months after the death, Metro ordered dual-locking hooks, which cost about $1,400 each.

Although Metro officers said they weren’t aware of forced rollout, many of their neighbors were. Los Angeles and California Highway Patrol search and rescue units, among others, knew of the problem and could have shared their knowledge had they been asked.

Metro is seeking advice, said Reimer, who is vice president of an organization focusing on helicopter rescue safety and training.

“Since this incident I’ve had numerous chats with different people from Metro inquiring about how we do stuff, how we train, what equipment we use. They realize there’s an issue now, and they’re trying to do it better,” he said.

“Unfortunately there was a loss of life for that to happen.”

‘WE DON’T KNOW WHAT HAPPENED’

Air Support Lt. Jack Clements said Metro is waiting for the National Transportation Safety Board to finish its investigation before releasing details of the officer’s death. He stressed that forced rollout hasn’t been proved as the official cause.

“There’s a lot of possibilities out there. That’s the thing … that drives us crazy,” he said. “We want to know what happened. And we don’t know what happened.”

But VanBuskirk’s colleagues seem convinced.

Nearly all of the officers on the mission cited forced rollout when interviewed by the Nevada Occupational Safety and Health Administration in October, months after the accident. Metro by then had replaced its hooks.

If it wasn’t forced rollout, the only other option was human error. According to OSHA, the hiker told authorities he didn’t think the officer was attached when the hoist operator started pulling them up.

But it’s unlikely that VanBuskirk would have unhooked without telling anyone.

“Dave went down with all intention of staying attached,” Hank said. “And I would say he was one of our best, very well-trained, a professional, and there was no concern and no issue of his competency. He was well above competent. And again, the best of the best.”

Clements said officers sometimes change their plans when facing un­expected conditions.

“Everything changes. Until you actually get down there, and touch ground and look at what you’ve got, there is no set plan because you don’t know what you’re going into,” Clements said.

At the same time, he said, witnesses often get details wrong, experience tunnel vision or temporary hearing loss.

“All of a sudden you’ve got a heli­copter with all these flood lights coming at you, and you’ve got somebody coming down on a hook to get you, and it’s loud and you’ve got a lot of things going on,” he said. “I think that (the hiker’s) recollection is the very best recollection he can give us, but understanding that stress does weird things to people.”

The OSHA investigator was unable to determine a cause and closed his case in January without issuing a citation to Metro.

NEW SAFETY PUSH

Metro officials say they’re now determined to keep up with industry standards. This year, veteran officer Bill Cassell assumed the newly created search and rescue safety officer position.

Cassell said his job is to document safety and “look at industry standards and see if there’s anything out there that possibly we should be doing that we’re not. Or, anything that we could do better that we are doing.”

Yet it’s unclear if VanBuskirk’s death would have been prevented had the department created the position sooner. Cassell said he doubts he would have identified the old hooks as a problem.

“There is absolutely nothing that would have focused my attention on that piece of equipment,” he said. “I could have been here for five years, and I don’t believe my presence would have in any way prevented that tragedy.”

Units across the country transitioned to locking hooks in the early 2000s, said Butch Flythe, a retired U.S. Coast Guard helicopter rescue officer who develops and sells products for Virginia-based Aerial Machine and Tool Corp., one of two U.S. companies that manufactures the hooks.

There’s “been a growing awareness in the military and in law enforcement,” he said. “People have come to the understanding that, for the way we operate, we have to go to the locking hook.”

But there isn’t a national standard for rescue hooks, Flythe said.

The military has been slow to adopt the new equipment because its large hierarchies are often harder to penetrate, he said.

Flythe said the Army’s special aviation unit, the Night Stalkers, began using locking hooks at the beginning of the Iraq and Afghanistan wars. The Coast Guard switched in 2005 or 2006, he said.

Yet the Navy switched to a locking hook just last month, Flythe said, while the Air Force buys nonlocking hooks and then modifies them to use locking pins.

Washoe County didn’t switch to locking hooks until VanBuskirk’s death, according to Metro officials. San Diego County only switched about a year ago.

“It’s one of those things people don’t do until something like this (VanBuskirk’s death) happens,” Flythe said. “At least in Vegas, they were reactive to the problem. They were one of the departments that said, ‘We’ve got to get a locking hook right away.’ ”

Although a fatal fall from a rescue helicopter in Australia in the 1990s was attributed to forced rollout, there have been few — if any — subsequent public warnings. The Federal Aviation Administration has apparently never issued a warning about nonlocking hooks.

And the hoist companies have never warned customers about nonlocking hooks, which they still sell.

“There was no recall,” Hank said. “There was nothing put out by the manufacturer. Because it’s not a failure of the hook. It’s a phenomenon that can occur.”

Hank’s boss, Deputy Chief Pat Neville, said there wasn’t widespread national discussion about the merits of the hook. It wasn’t treated as a glaring problem, he said.

“It just becomes one of the issues in an aviation unit with a lot of moving parts,” Neville said.

Cassell contends the nonlocking hook is safe, and said he would use it now with confidence.

“That is a perfectly safe piece of equipment,” Cassell said. “There’s absolutely nothing wrong with it. If we went out today, and we had to fly a mission, I would put you and me down on that hook in a heartbeat.”

Reimer notes that change comes slowly in emergency services.

“I go way outside the bubble when it comes to information. … But it’s more common that people have blinders on. Their way is the only way,” he said. “They don’t share information, don’t listen, don’t reach out to other agencies. This is very typical in law enforcement and fire service.

“You’ve got to look outside the box,” he said. “See what other people are doing, and find out why, instead of rebuilding the wheel themselves.”

Gillespie said Metro officials warned other departments about forced rollout and nonlocking hooks in the aftermath of VanBuskirk’s death.

“We changed. We’ve made that very clear to other police departments,” he said. “But even with that, we know that some of them have not changed.”

INCREASED SCRUTINY

Metro’s air unit has been intensely scrutinized since 2012 after two incidents.

In May 2012, a rescue helicopter clipped a Red Rock Canyon wall with its rotor blade during a training mission, nearly killing seven officers. And in September 2012, a $1 million helicopter was totaled and two pilots were injured when the aircraft rolled during a training exercise at the North Las Vegas Airport.

Metro assigned Lt. Gawain Guedry, a former police pilot, and two other officers to investigate. But the department has steadfastly refused to release their findings. According to several officials who read the report, Guedry identified a “cowboy culture” and a lack of administrative oversight that had plagued the unit for decades.

Metro pulled the plug on the investigation in July 2013, although a draft of the unfinished report was emailed to Undersheriff Jim Dixon with a chilling warning:

“Our agency has been incredibly lucky thus far, in terms of not losing a single life to an aviation accident. That luck may not continue,” Guedry wrote.

Within hours VanBuskirk was dead.

In refusing to release Guedry’s report, Metro cites executive privilege related to a document used for internal purposes. The department has said the report is unusable because it contains too much finger-pointing and “personality issues.”

In its investigation of VanBuskirk’s death, OSHA repeatedly asked for access to the report. But the investigator was rebuffed by Metro each time.

It’s unclear how Guedry’s report might relate to VanBuskirk’s death. Guedry, through his union lawyer, indicated he believes the report’s findings could prevent another death. He has asked both the Clark County district attorney’s office and the Nevada attorney general to determine whether Metro violated any laws in burying it.

Guedry retired Friday, just days after meeting with Clark County officials about his accusations.

It’s unclear whether the NTSB was able to get the report for its ongoing investigation.

“Everyone in the industry is very interested to see what the NTSB’s conclusions are,” Phillips said. “It kind of befuddles me why it’s taken so long to get it out.”

Clements said he isn’t certain the NTSB will shed light on the incident because it’s almost impossible to prove whether VanBuskirk made a mistake or if he was the victim of a forced rollout “phenomenon.”

But no one in search and rescue has stopped asking questions.

“The sad thing for us is … that every day when we come to work and we come in the front door, there’s a picture of him,” Clements said. “And we look at that. And everybody wants to know why.”

Database Editor Brian Haynes contributed to this report. Contact reporter Mike Blasky at mblasky@reviewjournal.com or 702-383-0283. Follow @blasky on Twitter.