The Department of the Interior employees all got this accident report this
morning. The accident involved a Park Service Ranger who died last year during
a rescue attempt. I know a lot of you are involved in rescues or at least
dangerous transits, so I hope you'll pay attention to what the Serious Accident
Investigation Team reported as the "real" cause of the death. I've highlighted
it in yellow.
Please cave and rescue safely. Your family and friends like having you around.
June 4, 2013
Memorandum
To: All Employees
From: Director /s/ Jonathan B. Jarvis
Subject: Nick Hall Serious Accident Report Released
On June 21st of last year, Park Ranger Nick Hall fell to his death during the
rescue of critically injured climbers at 13,800 ' elevation on Mount Rainier.
Nick, a 33-year-old former U.S. Marine sergeant, was in his fourth season with
the National Park Service (NPS). He was following his passion for the outdoors,
having worked in various jobs that developed his expertise as a ski patroller,
medical technician, and mountaineering and river ranger. Those who knew Nick
describe a quiet, competent leader with a strong, commanding presence.
The Serious Accident Investigation Team has completed its investigation and
determined Nick died because he was not anchored with fall protection during
the rescue. He lost his balance and fell while unhooking a litter from beneath
a hovering helicopter. Yet, the reason he died is far more complex. Nick was
not wearing fall protection likely because of a common human tendency known as
“normalization of risk” which is to become desensitized to the risk around us
and subconsciously accept high levels of risk as being normal after
continuously repeating the behavior without negative consequences.
In many recent NPS fatalities, we found the same failure in our system to
prevent employees from accepting unnecessary risk. The lesson for us all is to
make it a practice to carefully reevaluate the risks we accept as normal—or
even mundane—and to build in a margin for error, create and follow our written
procedures, and provide and use our training. Managers and supervisors need to
be watchful of the tendency of employees to “normalize” risks and must
implement robust management and supervisory controls to prevent this from
occurring in all types of field operations. We also have to look out for one
another and to get beyond the apprehension of correcting our peers when we see
them engaging or preparing to engage in behaviors that may get them or others
hurt.
When applied, the concepts in Operational Leadership should help to prevent
these tragic accidents. We have trained 15,000 employees; now it’s time we
implement what we have learned into our daily operations.
I encourage all of you to read and learn from the lessons included in the
Factual SAIT Report and Corrective Action Plan
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