Retired medic "dumbfounded" by CAF refusal to further investigate 2010 accident

[Halifax Tar]

Ex-army medic injured in training mishap 'dumbfounded' by military's refusal to launch inquiry

The Canadian military is closing the book on the investigation into a training accident that came close to leaving a former army combat medic paralyzed and ended her military career.

Chief of Defence Staff Gen. Jonathan Vance has elected not to conduct a follow-up inquiry into the case of retired master corporal Denise Hepburn, who fractured vertebrae in her neck while jumping from a helicopter into Lake Ontario, near Canadian Forces Base Trenton, during a multinational exercise.

More on link:
http://www.cbc.ca/news/politics/military-accident-investigation-1.3920855
- mod edit to clarify thread title -

 

[PuckChaser]

There is a likely a whole lot more to this story, than the onesided piece presented here. It reads as her demanding a pound of flesh for her injury, not real justice.

Also, she spent years as a competitive diver? She's probably the most qualified person there to decide whether something is unsafe or not, especially if the height looks way off (3.5m to 12+m is a huge difference).

Terrible accident, but seems like an unfortunate training injury during a high risk activity.

 

[McG]

From the article:

Vance, in his written decision not to pursue a follow-up inquiry, acknowledged there were problems with the way the case was handled and said the officer in charge of the exercise "should have remained at arm's length from the [investigation]."

"I find, since he did not, there was a reasonable apprehension of bias," Vance wrote.

However, that breach in regulation was "remedied," Vance said, by the intervention of a more senior officer. He said the fact that he personally reviewed the case means "outstanding flaws" in the investigation were being properly addressed.

What I see between the lines is that the existing investigation, despite biases, is sufficient to identify cause and (if it exists) blame.  Administrative action, if appropriate, will occur, but administrative action is protected information and it remain invisible to the injured individual (regardless of their being a BoI or not).

 

[Cloud Cover]

First of all, the article was heavily edited and spun to make it seem as if the military is acting out of order and I agree that is simply not the case. What she is after, and quite frankly requires, is documentation supporting her claim that she was not, repeat not, properly supervised at the time of her injury, as well as documentation and statements currently being withheld about the events leading up to her being placed aboard that helicopter in the first place and second, the circumstances leading to her exit of the helicopter at that altitude.  There is, somewhere in all that paperwork, the means to an end which is to move her life forward to the best of what remains of her ability.  Retribution is not the objective, despite how the article positions the matter, although she has every right to be bitter for a certain period of time about what happened.  She has a tough road ahead of her in all respects.

 

[daftandbarmy]

Slight tangent...I served with a Royal Marines CSgt who was paralyzed in a similar accident in the UK.

Chris has obviously not let this 'speed bump' slow him down, much:

http://www.bournemouthecho.co.uk/news/events/marathon/bournemouth_marathon_stories/10720809.Poole_man_only_wheelchair_racer_in_Bournemouth_Marathon/

The article mentions a 'climbing accident', but it was actually helo casting.

 

[Jarnhamar]

'It was a specialized manoeuvre for special ops'

Horse shit.

 

[McG]

What she is after, and quite frankly requires, is documentation supporting her claim that she was not, repeat not, properly supervised at the time of her injury, as well as documentation and statements currently being withheld about the events leading up to her being placed aboard that helicopter in the first place and second, the circumstances leading to her exit of the helicopter at that altitude. 

You seem to have first hand information.  The absence of such documentation should not impact her compensation and support entitlements.  So, for what purpose is this documentation required? 

 

[SeaKingTacco]

Horse crap.

Agreed. People get dispatched from the door of a Sea King into the water routinely. It is not a "Special Ops" manoeuvre.

Now, if the article is even reasonably accurate,  40 feet seems high as a dispatch altitude (our limits are 30 feet and up to 10 kts of forward speed. I have jumped from near the 30 ft mark and that is a loooong way to fall. I would not have wanted to be much higher.

 

[ballz]

From the article:What I see between the lines is that the existing investigation, despite biases, is sufficient to identify cause and (if it exists) blame.  Administrative action, if appropriate, will occur, but administrative action is protected information and it remain invisible to the injured individual (regardless of their being a BoI or not).

Notwithstanding if administrative action was taken against the OIC Exercise, I find the CDS's answer to the conflict of interest to be utter horseshit and in my opinion and lame attempt at brushing off something pretty important simply because to accept the truth for what it is would be inconvenient. My reading between the lines tells me that the investigation that was ordered was a summary investigation. Every SI is "reviewed" before getting to the person that ordered it, and obviously by the person who ordered it. To say that, because it was reviewed by someone higher mitigates risk that a conflict of interest could have affected the investigation results just makes absolutely no sense.

There's a reason the DAODs on SIs state the following...

"The existence of a real, potential or perceived conflict of interest, or one that might arise given the relationship of a potential investigator to the subject matter of the investigation, shall be considered prior to appointment."

"A CAF member shall not be appointed as an investigator if it appears likely that the CAF member or any superior of the CAF member may be:

adversely affected by the findings or recommendations of the SI; or
questioned as a witness during the conduct of the SI."

So to state what he states, is to effectively say this part of the DAOD never mattered and no longer matters for all SIs going forward.

[personal rant]The inconsistencies in safety is enough to drive people to alcoholism. The amount of time, resources, and other BS that we have to go through to let someone go in a canoe in 4 feet of water with a life jacket on is obscene, but a senior officer let's someone jump out of a moving helicopter at 40 feet into Lake Ontario on a whim and she almost gets killed over it and it's no big deal.[/personal rant]

 

[armyvern]

Notwithstanding if administrative action was taken against the OIC Exercise, I find the CDS's answer to the conflict of interest to be utter horseshit and in my opinion and lame attempt at brushing off something pretty important simply because to accept the truth for what it is would be inconvenient. My reading between the lines tells me that the investigation that was ordered was a summary investigation. Every SI is "reviewed" before getting to the person that ordered it, and obviously by the person who ordered it. To say that, because it was reviewed by someone higher mitigates risk that a conflict of interest could have affected the investigation results just makes absolutely no sense.

There's a reason the DAODs on SIs state the following...

"The existence of a real, potential or perceived conflict of interest, or one that might arise given the relationship of a potential investigator to the subject matter of the investigation, shall be considered prior to appointment."

"A CAF member shall not be appointed as an investigator if it appears likely that the CAF member or any superior of the CAF member may be:

adversely affected by the findings or recommendations of the SI; or
questioned as a witness during the conduct of the SI."

So to state what he states, is to effectively say this part of the DAOD never mattered and no longer matters for all SIs going forward.

[personal rant]The inconsistencies in safety is enough to drive people to alcoholism. The amount of time, resources, and other BS that we have to go through to let someone go in a canoe in 4 feet of water with a life jacket on is obscene, but a senior officer let's someone jump out of a moving helicopter at 40 feet into Lake Ontario on a whim and she almost gets killed over it and it's no big deal.[/personal rant]

What if it was simply an Admin Investigation for completion of the CF98/DND663?  Those can rightfully, and often are, done at the level of "Immediate Supervisor", so, if that's the "investigation" this article is referring to, then in-house by the Unit is perfectly proper.  If the CO did indeed appoint someone even higher than the "immediate supervisor" to do it (Adjt etc), then the CO had it completed by someone even higher in authority than he was required to do.  If the CDS then had it further reviewed by an even-more superior officer, then good on him and he therefore went ABOVE what the DAODs would require if that were the case.

As for any disciplinary actions that may have been taken against anyone in an administrative matter for example, that is Protected information and this young lady is not going to obtain that ...nor would any other person who was not the individual being corrected or that offender's supervisor.  This is NORMAL and has no basis in statement of "covering up" or trying to cover someone's ass.

Thing is:  You and I actually have NO clue as the article gives NO facts.  Broad strokes at assigning blame to the big, dirty CAF and it's leadership once again, but very flat-lined on ACTUAL facts.  I personally think that if the investigation was indeed an SI etc, then this article would have actually included that very important factoid -- instead it is vague and factless, but doing a fine job of creating, quite possibly, undue outrage by those who "assume" facts in place of diddly-squat.

 

[ballz]

What if it was simply an Admin Investigation for completion of the CF98/DND663? 

Then that alone is proof enough that it was mishandled. Someone was grievously injured during training, almost killed, a DND 663 isn't enough and shows the incident is not taken seriously or that no one actually wanted to find out what went wrong.

I do think, by reading it, that it was an SI. The only thing planting a seed of doubt in my mind on that is that it was conducted by the OIC's subordinate, everything else said lends itself to the SI. In either case, it was done pretty poorly. The normal 663 is not enough in my mind, but an SI conducted by the OIC's subordinate is just dumb.

As for any disciplinary administrative actions that may have been taken against anyone in an administrative matter for example, that is Protected information and this young lady is not going to obtain that ...nor would any other person who was not the individual being corrected or that offender's supervisor.  This is NORMAL and has no basis in statement of "covering up" or trying to cover someone's ***.

Sorry, I'm anal on these two terms for my own reasons as I have seen the problems that mixing them up causes. Administrative action is explicitly not disciplinary action. But yes, the spirit of your point is correct, admin actions are not going to be released, and I am not disputing that. My comment was geared toward the CDS's response to a conflict of interest.

 

[armyvern]

Then that alone is proof enough that it was mishandled. Someone was grievously injured during training, almost killed, a DND 663 isn't enough and shows the incident is not taken seriously or that no one actually wanted to find out what went wrong.

No; it's not.  An admin invest at the unit level for CF98/DND663 is always 10 000% normal in case of injury (just check the VAC threads - that's the doc they want).  In the article, she complains about the investigation done at the Unit, but by a subordinate of the CO.  NORMAL in admin investigations.  The Unit investigation is the one she is complaining about and that she doesn't know what action was taken against any 'offenders' (if there were indeed any found at fault).  Also normal in an Admin investigation.

Given that this accident took place during a multi-national joint exercise, than an SI would be a Joint-level investigation vice a Unit one (but she isn't complaining about a joint level investigation ... only the Unit level one [you assume no joint level SI occured]) ... and this article does NOT say that Joint level SI never happened and you don't know that it didn't happen either.  You are making assumptions based upon missing bits, critical bits, that the article does not even touch.

It only says "unit level" ... FACTS are missing from this article.  Two sides to a story and this article doesn't even give an accurate accounting of HER side, let alone the other side.

Simply too many critical details missing from this article to form an informed opinion on anything ... by anyone.

 

[ballz]

No; it's not.  An admin invest at the unit level for CF98/DND663 is always 10 000% normal in case of injury (just check the VAC threads - that's the doc they want).

The purpose of a DND-663 is to investigate whether or not the accident (or near-miss) could be prevented and how. It is required for every CF-98 that is submitted because that was ordered at Army level, or so I am told but I have never seen that directive. Of course its the "normal" for injuries, it is required. That said, whoever the Unit Safety Officer is (a senior Major in our Unit) is the person that signs off on it in the end and if the USO read that and did not bring it to the CO's attention for a possible SI / DI, then he just isn't taking his duty seriously.

Every time an injury is reported at our unit, a 663 is done. But if a member was grievously injured and the 663 brings up these types of conclusions (that the accident was preventable) and questions (why 40 ft when it was supposed to be 10 feet, why not prerequisite training occurred, etc), you can bet there will be an SI to further investigate, or at least there should be if we actually care to do our duties as we are charged to by our commissioning scroll.

In the article, she complains about the investigation done at the Unit, but by a subordinate of the CO.  NORMAL in admin investigations.

Normal in SIs as well. If a CO orders an SI, its almost always one of his subordinates. It's usually a junior officer in the unit that gets pegged with it, and what she is complaining about is that the person conducting the investigation was a subordinate of the OIC Exercise. What would not be proper is if Maj X is the OIC Exercise involving the incident, and Maj X's junior officer is selected to conduct an SI.

Given that this accident took place during a multi-national joint exercise, than an SI would be a Joint-level investigation vice a Unit one (but she isn't complaining about a joint level investigation ... only the Unit level one [you assume no joint level SI occured]) ... and this article does NOT say that Joint level SI never happened and you don't know that it didn't happen either.  You are making assumptions based upon missing bits, critical bits, that the article does not even touch.

Ummm, got a reference for that? I am not an expert of SIs but a CO can order an SI on anything he wants to be informed on within his unit. It is entirely unit-level investigation if the CO orders it for his unit. That the incident occurred in a joint exercise does not make it a "joint-level investigation."

Simply too many critical details missing from this article to form an informed opinion on anything ... by anyone.

There's enough there to see the BS. If you disagree, that's fine.

 

[the 48th regulator]

:goodpost:

Well said Ballz.

 

[SupersonicMax]

Perhaps a Flight Safety investigation would have been appropriate in this case.  It is, IMO, the most objective and comprehensive safety investigation type in our military that tends to really hit the nail on root causes, contributing factors and potential fixes.  The point is that this doesn't happen again, not some sort of finger pointing exercise.  If there was no ill-intent and no gross negligence, there is, IMO, no real incentive in nailing someone to the cross for a mistake.

 

[dimsum]

Perhaps a Flight Safety investigation would have been appropriate in this case.  It is, IMO, the most objective and comprehensive safety investigation type in our military that tends to really hit the nail on root causes, contributing factors and potential fixes.  The point is that this doesn't happen again, not some sort of finger pointing exercise.  If there was no ill-intent and no gross negligence, there is, IMO, no real incentive in nailing someone to the cross for a mistake.

I know nothing about this case aside from the news article, but wouldn't a FS be part of the investigation already since it involved aircraft? 

 

[SupersonicMax]

There should have been a flight safety occurence report completed.  Whether this was done or not, I am not sure.  Also, the occurence report doesn't mean a full, comprehensive investigation is launched.  It could have been conducted by the local FSO.

 

[PuckChaser]

I couldn't find a report for the incident here, is this only the full reports area? http://www.rcaf-arc.forces.gc.ca/en/flight-safety/investigation-reports.page