This is the cover story from our 2019 Summer edition of Two More Chains.
How do we move from heart-wrenching tragedy, through painful growth and into lifesaving standardization? The rappel community knows.
By Bre Orcasitas
Bre Orcasitas is the Field Operations Specialist for the Wildland Fire Lessons Learned Center. A former rappeller herself, in this article Bre walks us through the chain of events that led to monumental changes within the Helicopter Rappel Program.
Although there are many roads that eventually lead to standardization, each usually prompted by an event that highlighted a need for it, there are few examples more impactful than what happened within the Helicopter Rappel community.
In order to tell this story, we first need to provide some terminology to help you understand the situation more clearly.
Helicopter Rappeller: An aerially delivered wildland firefighter who rappels up to 300 feet down a rope from a helicopter to an initial attack fire.
Rookie Rappeller: A rookie Rappeller may have several years of fire experience but is a first-year Rappeller.
Vet Rappeller: A Rappeller with multiple years of rappel experience.
Spotter: The person who coordinates with the Pilot, selects the rappel site, and gives commands to Rappellers during rappel operations. They are also the ones authorized to make any adjustments to rappel gear and equipment. In order to be a Spotter a person must be a certified Rappeller and have gone through the extensive multi-year Spotter training.
Check Spotter: A senior level Spotter. One who would train Spotter trainees.
Rappel Proficiency: Essentially a practice rappel. A Rappeller must do a “Rappel Proficiency” every two weeks to maintain currency. If the Rappeller exceeds those two weeks, additional measures must be taken to regain that qualification.
Self Check: A safeguard measure where once a Rappeller has donned (put on) their equipment they check themselves head-to-toe.
Buddy Check: A safeguard measure where two Rappellers check one another’s gear head-to-toe. Each person undergoes a Buddy Check prior to entering the aircraft for a rappel.
Spotter Check: Similar to a Buddy Check, except the check is performed with a Spotter rather than a fellow Rappeller.
Kong Clip: A non-life bearing piece of equipment that is attached to a rappel harness in order to keep two metal components from cross-loading.
O-Ring: A hard rubber ring approximately the size of a small rubber band, which provided the same benefit as a Kong Clip.
The Loss of Tom Marovich
On July 21, 2009 Tom “TJ” Marovich Jr., a rookie Rappeller, was getting ready for a Proficiency Rappel at the Willow Creek Helibase (which was in support of the Backbone Fire in Northern California) when it was noticed during a gear check that a part of his rappel equipment (Kong Clip) was broken.
The decision was made to swap out the component prior to the Proficiency Rappel. Therefore, TJ quickly brought his gear to a Spotter Trainee for it to be fixed. The broken component of TJ’s gear was swapped out with a different but equal piece of equipment (called an O-Ring) and TJ went back to the aircraft. After the broken component was replaced, his gear was checked by the Spotter Trainee who had swapped the gear, as well by TJ himself. His gear was then also checked at the helicopter during his Buddy and Spotter checks prior to getting into the aircraft for the Rappel Proficiency.
Once airborne, everything was going as normal for the Rappel Proficiency. There was nothing out of the ordinary until the stage of the rappel sequence when TJ and his rappel partner (one rappeller on either helicopter skid rappel at the same time) got their “go to the skid” hand signal from the Spotter, which signifies a directive to transition from your seat, out to the skid of the helicopter. As TJ arrived on the skid, something went terribly wrong. Before anyone had an opportunity to do something about it, TJ began a rapid descent down the rope. He tried using his thick leather rappel gloves to slow himself and brake—without success. Onlookers at the Helibase instantly rushed to his location to provide medical assistance. Unfortunately, TJ’s injuries were catastrophic. He did not survive.
From the very moment this incident took place, the resounding question by all was: WHAT HAPPENED? This is a fair question, albeit an extremely complicated one with a whole lot of layers.
The quickest and easiest answer is to say that his gear was configured incorrectly when the Kong Clip was replaced with the O-Ring. The end result was that rather than having a configuration which could hold an extensive amount of weight, the configuration instead allowed for perhaps only 20 pounds before it would have failed.
Surely, you’re wondering: “How could so many people have missed something that was such a big deal?!?”
Although one could choose to point the finger of blame at the person who mis-configured the equipment, those who performed his Buddy/Spotter checks, or even TJ himself for not catching the issue, at the time of this event the system actually wasn’t very conducive to any of them discovering this specific issue during their checks. How is that possible?
Here’s a relatable example: If someone swapped out one of your car tires with a “dummy” tire meant to look the same would you catch it as you walked out to your car? Or would you glance over it, jump in and start driving only to quickly discover the issue once it was too late? This too could potentially have life and death consequences if you missed it. The ability for people to miss extremely important details has to do with a term called “Change Blindness,” but we’ll get to that later.
A Lack of Standardization
Ultimately, the factor with the largest hand in what went wrong was a lack of standardization within the rappel community. Rappelling prior to 2009 was setup to “choose your own adventure” so to speak. There was a wide variety of helicopter makes and models that were being used along with a multitude of ways to configure/deploy gear. An Interagency Rappel Guide existed but was seen by many to be open to interpretation.
In the early 2000s, Region 6 had begun standardizing their rappel training by bringing their Rookie Rappellers together for a “Rappel Academy” in John Day, Oregon. But even in Region 6, multiple helicopter platforms were being used. Pretty quickly after TJ’s accident it became apparent that the Rappel Program needed to either standardize or shut down entirely. Although this was a “top down” decision, the rappel community was reeling from the loss of TJ and felt duty-bound to institute any and all changes necessary to prevent this from happening in the future.
A Time for Change
Even though it was obvious that change was necessary and everyone was on board with the decision to standardize, it wasn’t an easy process. In order to get a true understanding of what a process like this entails I spoke with several Rappellers at the 2019 Rookie Rappel Academy (held at the Salmon Airbase in Salmon, Idaho) to get their perspectives about standardization as well as the impacts that were felt throughout the rappel community by losing one of their own.
Bre: 2019 marks the 10-year anniversary of the Rappel fatality, the loss of Tom Marovich. What changes were made to the Rappel process due to that incident? What Lessons Learned or shifts in the procedures stemmed from that?
Eric Bush (National Rappel Specialist – on scene during the rappel fatality): Well, there’s a lot of layers to that question. I guess I would say that, overall, the Rappel Program had to rethink where it was at entirely. Meaning, we had 50 Rappel Programs, over 500 Rappellers, and we were rappelling out of multiple makes and models of aircraft at the time.
When that happened it changed many things, it gut-checked us. What are we currently doing right and what needs to be improved? Are we too big, and should we refocus? And we did just that. So in 2009 after TJ’s incident the program was shut down. There was a model already out there of some standardized (rappel) training in Region 6. And so nationally they took a look at that model.
Then through those other programs that stood back up in Regions 4, 5 and Region 1, they worked with Region 6 on that model and they helped improve it, to streamline it even more. Then in 2011 we stood back up with those now just 12 programs and trained together in John Day, Oregon as one National Rappel Program and we did that with our Vet refresher training as well as the initial Rappel training.
Through that process came standardization, consolidated training, and revision of our Rappel Guide. We went from an Interagency Guide that those 50 programs were working under to a USFS Rappel Operations Guide that met that standardization model we were looking for.
Bre: How do you think TJ’s incident impacted the rappel community?
Mike Davis (Wenatchee Rappel Crew Base Manager): It’s unfortunate but like anything, it tends to take a catastrophic event to make changes and that’s what happened after TJ’s death. We had a catastrophic change to the Rappel Program, which was necessary.
I know a lot of the old guys would argue with me about this. But to have some sort of standardization with the rappel operations, something needed to change to be more efficient—otherwise our program would have just stayed stagnant. But a lot of people like that (keeping with the status quo), just due to the versatility of the tool where everybody could do their own thing. I think, inevitably, it was just a matter of time before something would have happened because we were rappelling out of so many different makes and models (of aircraft).
After TJ’s fatality, during the Fall of 2009, Vince (Vince Welbaum, the National Helicopter Operations Specialist at that time) had his marching orders that we will standardize the Rappel Program. But he left a lot of it up to us (as Check Spotters) to figure out what we think is the best process. That year we were in Boise for five weeks.
Bre: Just hashing it out?
Mike Davis: Oh, yeah, there was a lot of hashing. And you know, a lot of it was fighting for your own turf, fighting for what you believed was the right process, which way was the best way.
Eric Bush: All the way through to going out to (multiple types of) aircraft to do (Rappel Procedure) mock-ups (inside of aircraft) in the winter.
Mike Davis: Because even with one type of aircraft there were two different ways to get out of it. So, we had someone come in who basically acted as the mediator for the process to make sure that we didn’t get too close to ripping each other’s throats apart and to try and keep us down a path forward to standardization.
Our first task as a group was to identify what would be the best make and model of aircraft. Pretty early on, most of us realized that a Bell Medium would be the easiest to standardize.
Eric Bush: Yeah, because it was the same-same regardless of who had it on contract, and/or in what regions.
Incorporating New Procedures and Gear
Part of the standardization process included innovating New Gear, Procedures and Concepts then implementing them into the National Training Program.
Bre: You got to see what the rappel community was like previous to the rappel fatality and you’re still in the rappel community now. What do you think are some of the changes that were made in direct correlation with that incident?
Cory Dolberry (Price Valley Rappel Crew Superintendent): I think the biggest thing that came out of the National Standardization is: We now have a National Rappel Specialist, which all Rappel Programs are underneath so we have a point of contact, someone that ensures there is standardization. We also have a “working group.”
Those things combined with this consolidated training, the outcome of it has created a National Standard that is probably one of the best trainings that’s out there, honestly. People are doing things exactly the same and this goes across regional boundaries. The same expectation is there across the board as far as procedures and how we deliver firefighters to the ground. So that’s huge. That’s the biggest thing I’ve seen that came from (the fatality in) 2009.
Bre: What are some of the main things that shifted in procedures with Rappel Ops? What were some big things that came out of TJ’s accident?
Jeremy McIntosh (National Helicopter Rappel/Short-Haul Equipment Specialist): One of the big ones was, there were a few pieces of equipment that we modernized and changed as a result of the accident, primarily the connective hardware in the rappel harness. We eliminated some of the rigging that was causal to the accident. And now (in 2019) we are going to this new descent (device) equipment.
Implementing the Concept of ‘Change Blindness’
But one of the big learning lessons that we took away was that there was a lack of training in a term called “Change Blindness” within our program.
There are visual ques that the brain picks up if you’ve only seen things in a correct configuration. You superimpose and make the brain think that you are looking at a correct scenario when in fact it’s something you’ve never seen before. That’s known as “Change Blindness.”
So part of what we do in our training since the consolidation and within the national program is we incorporate Change Blindness training where we look at possible scenarios that could be mis-rigged. We introduce the Rappellers to those. We let them see those and catch those so that when and if it were ever to happen on a live operation, this Change Blindness training will hopefully assist them in not seeing what’s supposed to be there but seeing what is actually there.
All of this was a big shift and we honestly didn’t know that we had a problem. Then we took a hard look and acknowledged that we did have a problem and we put a lot of energy into making sure that we have the best program that we can.
Bre: Just what you said as far as Change Blindness, “we didn’t know we had a problem.” Yeah, how could you know unless it was tested to that capacity? You see what you expect to see and not necessarily what is actually there. And so now you said that you’ve instituted Change Blindness as a result of TJ’s incident but it’s not just for the Rappellers, it’s for the Spotters as well. You do it on both sides so that everyone is looking for that and everyone is recognizing those mis-rigs and those incorrect procedures, correct?
Eric Bush: Yes, absolutely. All the way from our Spotter immersion training that we put on for new Spotters and it’s in our curriculum for both carded Spotters and Rappellers.
Bre: You’re rappelling off of a helicopter from a high distance. The danger in that is real and you can’t eliminate everything possible from happening. With this new descent device, it’s not fail-safe—nothing is—but it offers more safety than the previous device, yeah?
Jeremy McIntosh: It still requires that the Rappeller properly rig the device. It does not
function properly if mis-rigged. However, we’ve incorporated an additional restraint tether that allows a Rappeller to “weight” the Rappel System prior to releasing that tether. So in the very rare event that the Rappeller mis-rigged the device and missed it in their self-inspection of the device and the Spotter missed it in their inspection, the Rappeller would be restrained with the aircraft in that mis-rig situation.
It’s a failsafe to a problem that is possible and we’re aware that it could happen—a mis-rig unidentified by multiple people. We spend a ton of time looking at what mis-rigs look like so that they know there’s only one way that it looks right and a lot of ways that it looks wrong.
Bre: The restraint tether is essentially a bungee leash, right? It’s hooked into the aircraft at the bench seat. In Rappel Ops they get the (hand) signal that directs them to actually go and stand out on the helicopter skid then they lean back in their harness and wait for the next (hand) signal from the Spotter.
So what you’re saying is that when they lean back into their harness, the weight of themselves is on their equipment and that bungee leash is still attached at that point, so if there was a mis-rigging they would feel that sensation but they would still be hooked to the helicopter, right?
Jeremy McIntosh: Yes. They would fall backward, depending on their height, about eight inches or so and they would immediately know that something was wrong.
Bre: If that piece of equipment was in utilization back when TJ’s incident happened then this would be a different story too, right? That’s a big thing that we’ve gained from his incident.
Jeremy McIntosh: That’s correct. We probably would not have that restraint because we would not have known that we had that problem. So yes, it’s a great safety piece of equipment that is a direct result of that accident.
Does Tradition Create a Standard or Does a Standard Create Tradition?
Mike Davis: We had a Kong Clip and also used the O-Ring and hindsight is 20/20. The only reason why we had any of that was because of when we used to “split the skids” in the L3 (helicopter). When you have a piece of equipment that you’re used to that prevented “cross-loading” (the binding up of two metal components that are attached to a rappel harness), it’s really hard to get away from it. History, you know? It’s what we’ve always done.
But the reality is, as soon as we got rid of that style exit+ aircraft we probably should have been done with it. You could still get cross-loaded out of a Bell Medium, but it wasn’t as drastic as with the L3. When you think back on history and relevance to a piece of equipment and how significantly that can affect a program… I like to think that due to our loss of TJ that day the Rappel Program has gotten to where it is now, and it’s way better. There was something good that came out of something bad and all I can do is feel thankful for that.
Eric Bush: It does still keep me up sometimes at night, running scenarios in my head. Thinking about that day at Willow Creek Helibase, about Tom and the rappellers that cared for him on that day; thinking about that O-ring.
Are there other “O-rings” or “ad-hock fixes” out there in fire and aviation operations? Maybe. And maybe for good reason, but we should always be asking ourselves: Why, and how is this a useful part of our operation? Is it necessary, or do we need to reassess? Are we properly trained on the what, why, and how?
I think that’s healthy to a degree, to wonder about. Because we’ve learned a hard lesson. Because had that piece of equipment not existed or had we not put it in play… So what other little things are out there? I think we’ve prevented and/or corrected more of those things in the past ten years.
We’ve prevented that creep back into our program just through proposal processes and talking it out. To be able to work together in an environment where people have the ability to say, “No, I don’t like that idea” and have that perspective be valued and respected.
We are better off now, but we had to get there in a very unfortunate way. I believe the rappel program collectively set a new standard in motion after the loss of TJ, a tradition of “see something – say something,” and then let’s step up and do something about it.
A Major Shift in a New Direction
There’s little doubt that the rappel community was shaped by the tragic loss of one of their own. The loss of TJ created a tightknit community that knows the importance of standardization in a way that few could ever understand. It’s with this sobering reality in the back of their minds that they took on the incredible task of transitioning to new rappel equipment.
After years of researching and testing new rappel gear, the moment finally arrived for a transition away from the original (legacy) rappel equipment, which has been the standard since helicopter rappelling first began back in the 1970s.
In the spring of 2019, the rappel community made the full transition (all Vet and Rookie Rappellers nationwide at once) to a new rappel rope and harness along with the restraint tether mentioned earlier. In order to do this, a new Rappel Guide had to be written, procedures were altered, and most importantly, Spotters and Rappellers had to learn new equipment, none of which were small feats to accomplish.
The transition was successful due in no small part to the dedication of the rappel community as a whole to set egos aside and work together for the greater good.
A Final Reflection
The loss of Tom Marovich has never been forgotten in the hearts and minds of the rappel community. Each rookie rappel class learns about TJ, as trainers carve out time to explain why they take the training process at Rappel Academy so seriously. To train rookie rappellers well, that is a way of paying it forward and honoring TJ’s memory with each passing year.
Bre: For having such a horrible event happen, I feel like the rappel community really took that seriously and instituted significant changes in the program. It’s a really solid program with excellent training at this stage.
Cory Dolberry: Where we’re at today is above and beyond where we were at in 2009, as far as a community nationally. Unfortunately, TJ suffered greatly, and the rappel community suffered greatly, too. However, from that outcome we are at five levels above where we were back then.
Matt Clinton (Salmon Rappel Crew Superintendent—on scene during the rappel fatality): Just simply saying that this program has changed doesn’t do it justice. This incident affected a lot of us, some more than others. For me to say that TJ’s incident changed my life would be an understatement. It affected every aspect of how I approach training and how I do and teach the job.