Reveal: Unraveling the mysteries of the GI Bill, Coast Guard and EPA

Coast Guard’s deadly accidents highlight lapses in safety, leadership

Photo by G.W. Schulz

The Coast Guard must be ready for natural and man-made disasters. In Cape May, New Jersey, enlistees practice fighting a blaze using a fire simulator.

Robin Jerstad for CIR

After a fatal helicopter crash in 2010, Coast Guard officials blamed Lt. Lance Leone, the co-pilot. The move has divided the Coast Guard.

Photo by David DelPoio

Ronald Gill Sr. in the back yard of his home in Cranston Rhode Island. Ron's son, Ronnie Jr. was killed in the line of duty on Sunday, March 25, 2007 while conducting operations north of Vashon Island in Puget Sound. PS3 Gill was a member of Maritime Safety and Security Team (MSST 91111) deployed from Anchorage to Seattle when he was ejected from a 25-foot Defender Class Boat.

Photo by Ben Adair/ Reveal

A Defender class Coast Guard vessel checks on a fishing boat run aground at Cape Disappointment near the Oregon-Washington state line.


William J. Johnson saw danger on the beach. A retired master chief for the Coast Guard, he frequently jogged along the shoreline near James Island, Washington. During his runs, Johnson often worried about transmission wires that were draped over a channel.

Plastic safety balls – critical to helping pilots see the cables – appeared to be missing or were clumped at one end of the lines. Pieces of the safety markers littered the beach.

In an instant, the wires could rip apart a low-flying helicopter or plane.

He called a district office for the Coast Guard, which owned the transmission lines. Those wires seem to be poorly marked, he said. Johnson knew that at least one private aircraft had hit the lines before.

In 2010, a few years after Johnson’s call, a Coast Guard helicopter flew straight into those wires.

The tail section of the MH-60T Jayhawk immediately separated. The front part of the cabin vaulted over the open ocean and splashed into the water. The accident killed three crew members . Only co-pilot Lt.Lance Leone survived. Officials later charged him with negligent homicide, a move that has divided the Coast Guard.

Just as Johnson had warned , the crew never saw the lines.

The accident points to a larger pattern at the Coast Guard. Often overlooked as the fifth branch of the U.S. military, the Coast Guard has suffered a string of accidents amid questions about unsafe practices, poor oversight from leaders and a failure to respond to red flags.

Just months before the accident near James Island, a high-speed Coast Guard response craft in San Diego Bay smashed into a family boat carrying 8-year-old Anthony DeWeese and killed him. The boy’s death was a psychic blow to a military organization that prides itself on saving lives, not taking them.

Documents and accident data reviewed by The Center for Investigative Reporting reveal lapses in judgment and missed opportunities by the Coast Guard to strengthen safety standards and protect crew members and civilians.

Between 2000 and 2013, the Coast Guard witnessed dramatic spikes in accidents causing death, injury and equipment damage. During that time, 27 aviators and other personnel were killed on land, in the air and at sea. Last year, the number of recorded aviation accidents – from a minor fuel spill to a hard helicopter landing that caused $777,000 in damage – was higher than at any time since 2006.

The deadliest period was between 2008 and 2010, when 14 crew members died in aviation accidents. The loss of lives and equipment was worse than the Coast Guard had suffered in three decades.

Meanwhile, the number of Coast Guard injuries from aviation accidents has increased steadily, peaking in recent years. Last year, the Coast Guard reported 56 injuries from aviation accidents, the highest in the previous 13 years.

The service witnessed a marked increase in nonaviation accidents as well – on the water and during land operations – in 2012. In that year, some 600 accidents were reported, the highest number since 2005. The number dropped only slightly last year.

Critics of the Coast Guard say the service must hold itself accountable for the string of accidents instead of pointing the finger at a single officer, like Leone, after a high-profile incident.

“They've had a lot of accidents, had a lot of crashes,” said Jeffrey Addicott, a St. Mary's University law professor and former military lawyer who has assisted Leone with his case. “They obviously need better training, more training – accountability for people not doing their jobs.”

In an interview from the Department of Homeland Security's headquarters, then-Coast Guard Commandant Adm. Robert Papp acknowledged a significant problem with the accidents and said the service had conducted an internal review. By the time Papp took over as the Coast Guard's top admiral in 2010, he'd already begun to worry about complacency and “slackening proficiency,” as he's called it.

Papp, who retired in May, said the increase in accidents over the past decade came during a change in missions since 9/11 for the Coast Guard, which the public mainly has seen as search-and-rescuers.

After the 9/11 attacks, Papp said, the Coast Guard ramped up training for airborne marksmen on how to disable boat engines from the sky. It trained personnel on how to intercept aircraft that might pose a threat toWashington, D.C. It helped secure major public events like political conventions and the Super Bowl and launched armed escorts of ferries loaded with tourists and commuters throughout the country.

“You go from doing search and rescue to all kinds of tactical evolutions, which require additional skill sets,” Papp said. “We took on those missions very quickly, with little time to adapt. I thought we were getting task-saturated.”

Current Coast Guard officials said they had no additional comment about the accident rate beyond Papp's interview with CIR.

Beyond the injuries and deaths, the string of accidents carries a high cost to taxpayers. The Coast Guard recorded at least $375 million in property damage from accidents between 2000 and 2013, with $155 million occurring in 2010 from aviation accidents alone, according to the data analyzed by CIR.

The costly accidents are significant in light of the Coast Guard's relatively meager budget. Washington for years has sliced into Coast Guard spending and this year proposed giving it $2 billion less than the Navy has spent on a single $12 billion aircraft carrier. The Obama administration has proposed a total budget next year for the Coast Guard of $9.8 billion.

Coast Guard officials say their culture of reporting accidents has improved over the past decade, causing the numbers to climb. Aviators and sailors have increasingly realized the value of acknowledging accidents, they say.

But Papp, referring to a deadly boating accident in 2007, also said the rapid expansion of duties for the Coast Guard and the deployment of new equipment without adequate training has lead to missteps.

“We were deficient as a service in terms of preparing those young people to go out there,” Papp said. “… I'm not proud of that.”

Wide-ranging tasks

The Coast Guard has nine districts covering the United States and must be ready for an array of natural and man-made disasters: flooding in St. Louis, a ship collision on Lake Michigan or a hurricanepounding the Texas coast.

In the brutal chill of the Bering Sea off the coast of Alaska, Coast Guard teams enforce a complicated web of federal regulations and license requirements designed in part to protect the state's multibillion-dollar seafood industry. Off Cape Disappointment near the Oregon-Washington state line, elite “surfmen” endure fearsome wind and waves to reach stranded fishing trawlers and pull them to safety with special towlines that require careful maneuvering.

The Coast Guard inspects the construction plans of large ships before they're built, leads seasonal courses on civilian boating safety, conducts investigations into maritime accidents and hazardous spills, and pursues drug traffickers.

But a 2011 internal review concluded that a rising number of Coast Guard accidents were occurring during relatively benign activities, such as long-distance transits and hoisting exercises. In other words, service members grew complacent when the risk seemed low.

During the year of the study, Papp stood before a group of gathered service members – “Coasties,” as they’re known – for an annual speech outlining the Coast Guard’s achievements and challenges. Serious accidents were plaguing the Coast Guard, he said.

“This is unprecedented,” he told the audience. “It’s unacceptable. And we’ve got to do something about it.”

Papp’s remarks attracted almost no media attention. The following year, calamity struck again when an MH-65D Dolphin helicopter went down in southern Alabama during a training flight. Four people were killed.

The location was poignant: Thirty years earlier, another helicopter crashed in the same area, also taking the lives of four crew members. Today, two monuments stand together at the Coast Guard's AviationTraining Center in Mobile. Students pass them as they walk across campus from the training center's barracks to its classrooms and sophisticated flight simulators.

Etched into the bricks of the memorial is a refrain well known inside the Coast Guard: “So others may live.”

Little attention for accidents

When federal government ineptitude reached new heights in the days immediately following Hurricane Katrina, it was the Coast Guard that stepped in and rescued more than 33,000 people during the storm and its aftermath.

U.S. Coast Guard rescuers were among the first to arrive when a powerful earthquake struck Haiti in 2010 and killed thousands while leaving many more without shelter. When an oil rig exploded in the Gulf ofMexico that same year, setting off an environmental catastrophe, it was senior Coast Guard officials, including then-Commandant Adm. Thad Allen, who appeared night after night on news networks to briefAmericans on the response.

Despite these high-profile successes, its accidents and failures have garnered little national attention.

In 2008, two years before Leone’s deadly crash in Washington, four men were killed during a training exercise just south of Honolulu. A hoist cable attached to the crew's helicopter became caught on a CoastGuard boat and snapped. Severe vibrations overtook the aircraft, and the pilot eventually lost control. The helicopter dropped 450 feet into the water below.

The following year, an HC-130 Hercules airplane carrying seven Coast Guard crew members searching for a missing boat collided with a Cobra attack helicopter on a training mission from a nearby Marine base.All nine people aboard the two aircrafts were killed in the collision near San Clemente Island, California.

A Navy report determined that its own air traffic controllers had failed to inform the pilots that they were near one another. The Coast Guard separately called it a “tragic confluence of events.” It already had lost another HC-130 during a 2006 accident in Alaska attributed to an unauthorized landing. No one was killed, but the Coast Guard concluded the $15 million in repair costs were “beyond economical.”

Then a Jayhawk helicopter went down in 2010 some 50 miles east of Salt Lake City, the wreckage covering a snowy mountainside. The crew had been deployed for security operations in Washington state during the Winter Olympics.

Everyone on board survived, but three of the five crew members had to be airlifted for medical treatment. While the pilot and co-pilot were highly experienced, investigators later noted, they “demonstrated lapses in judgment and airmanship by failing to properly plan for or adapt to challenging and dynamic environmental conditions.”

The next month, yet another helicopter crash occurred, this time involving an HH-65C Dolphin. Three people on board were engaged in hoist training with a utility boat underneath when the aircraft crashed into Lake Huron northeast of Detroit.

All of the passengers survived, but the battered hulk they were flying sank. Investigators two years later blamed pilot error, lost situational awareness and inadequate command oversight. The co-pilot, they added, had “relatively little experience in over-water hover operations.”

On the December day of 2009 that 8-year-old Anthony DeWeese was killed in San Diego, the Coast Guard crew that struck his family’s boat was patrolling in a 33-foot boat with a trio of 300-horsepower engines.

The crew members were responding to a grounded sailboat that, according to investigative reports, was not in danger. Nevertheless, they gunned the engines.

The vessel smashed into the rear of the DeWeese family’s recreational Sea Ray and launched “straight up in the air,” the Coast Guard coxswain, or driver, told authorities. The powerful Coast Guard boat sheared off the Sea Ray’s windshield and tore through its fiberglass body.

Blunt force trauma killed Anthony while other passengers suffered skull fractures, concussions and cuts. The driver, Petty Officer Paul Ramos, 21 at the time, faced numerous charges in the boy's death, including involuntary manslaughter. A jury of Coast Guard service members, however, later acquitted him of all but dereliction of duty, which led to three months in a brig.

Investigators from the National Transportation Safety Board found in 2011 that oversight at the Coast Guard’s San Diego station was deficient and “ineffective in ensuring compliance with established policies forsafe operations.”

Anthony’s father, Alan DeWeese, said he was shocked by how fast the Coast Guard vessel was moving through the congested harbor that night for a nonemergency. The carnage would have been worse ifhe hadn't tried to throttle out of the way at the last minute, he said.

“We were in idle and just cruising along,” DeWeese said. “They came up so fast. We had no time to do anything.”

DeWeese said the accident showed a lack of basic boating skills: “You just know in these conditions you don’t drive at high speed. Especially at night. Especially in a crowded bay. It's common knowledge.”

It wasn’t the only boat-related fatality in recent years.

Changes come after tragedy

The neatly kept Gill family home in Cranston, Rhode Island, is filled with ladybug-themed mementos marking Ronald Gill Jr.’s first road trip to Alaska, when one of the beetles landed on his windshield during a particularly lonely stretch. The picture frames, magnets, and salt and pepper shakers remind Gill’s parents of their son, who was killed in 2007 while serving with the Coast Guard in Washington’s Puget Sound.

Called Ronnie by his friends, Gill was assigned to one of several special patrol units created after 9/11. He grew up in a tightly knit family and attended school to become a chef. But after watching the attacks play out on national television, Gill decided to enlist.

He was dispatched to Alaska, where he joined Marine Safety and Security Team 91111 , thousands of miles from home.

Gill’s team periodically was sent on tours to Puget Sound, where it would conduct ferry escorts. On March 25, 2007, Gill was standing as a gunner near the bow of one the unit's 25foot Defenders when the boat's driver decided to execute a high-speed maneuver known as a power turn without properly notifying Gill. He was thrown into the water and killed when the boat’s propellers struck his head. He was 26.

Such impromptu maneuvers are prohibited in the Coast Guard, investigators later wrote , but boat drivers believed the turns were necessary to deter potential threats and “show officer presence.” Investigators concluded that the driver also had become bored with “the routine nature of (ferry) escorts.”

Gill’s father, Ron Gill Sr., doesn't resent the Coast Guard today for what happened to his son. A year after the tragedy, however, Coast Guard officials invited him to Washington to show off new protective gear that gunners like his late son would now be using, along with a communications system enabling them to speak with the boat's driver.

“I'm glad they're doing it so that it doesn't happen to somebody else,” Gill’s father said recently. “But at the time, it wasn't something that I really cared to see. Something should have been in place before and not after. … I know that it takes a tragedy sometimes for us to change the things that we do, because we don't always look at the worst-case scenario.”

Problems for the Coast Guard didn’t end there. The communications headsets lauded during Gill’s father’s visit would abruptly lose power, according to a 2010 report from the inspector general of theDepartment of Homeland Security. The inspector general estimated a replacement fleet with improved communications equipment wouldn’t be ready until 2020.

A Coast Guard official worried to federal auditors in the report that accidents could continue. The type of vessel that fatally struck Gill reportedly was involved in 13 ejections and three rollovers between 2003and 2007.

Commandant Papp admits the steps taken were too late for Gill.

“The boat that Ronnie Gill was in when he was killed was only a couple of years old,” Papp said. “We bought 500 of those in rapid succession and fielded them without going through a process of establishing doctrine and training and other things. … We probably should have had some sort of straps up there to keep the person from being thrown from the boat.”

Coast Guard expert David Helvarg puts it another way. He said that while the Coast Guard trains an elite group of surfmen capable of handling 30-foot seas and winds beyond 50 mph, the majority of servicemembers driving small boats are far less trained than this special group.

“You have to make sure that the majority of the 21-year-olds behind the controls ... can operate safely, both for their own safety and the public’s,” said Helvarg, a journalist and conservationist who wrote the2009 book “Rescue Warriors: The U.S. Coast Guard, America’s Forgotten Heroes.”

The burden of blame

A common sentiment among Coast Guard recruits is that they wanted the discipline of the military but also wished to become lifesavers.

It's what attracted Lt. Lance Leone, 33, who grew up in Maine, where his parents worked for the National Park Service. As a young sailing instructor, Leone would see Coast Guard boats zip by on their way toa rescue and decided that was for him.

Leone made it into the Coast Guard Academy and eventually was accepted to flight school in Pensacola, Florida, shortly after marrying in 2004. From there, it was on to advanced flight training in Elizabeth City,North Carolina, where he became qualified to fly a Jayhawk, the Coast Guard's answer to the Black Hawk.

“I volunteered for every single mission,” Leone said of his time in Elizabeth City. “I wanted to be very proficient, and I wanted to be the best I could. I came away from there with two commendation medals. I gotto fly all the way down to Texas – down to Houston – and work Hurricane Ike. I got to meet the president down there.”

As a survival mechanism, Leone said, aviators often internalize that accidents won't happen to them. “No one wants to be scared every time they fly,” he said. “No one wants to actually think that the possibility ofdying is right there in front of you at all times.”

But Leone was disturbed enough by the string of major crashes before his own that he asked to be sent to a naval school in Pensacola to become a safety officer.

It was shortly afterward that his own helicopter crashed when it tangled with the transmission lines near James Island, Washington, and everything changed.

Leone was sitting in the co-pilot’s seat when the pilot in command, 33-year-old Lt. Sean Krueger, decided to conduct a low flyover to see if a Coast Guard boat below needed assistance. The gesture is typicalin the Coast Guard.

That’s when the MH-60T Jayhawk helicopter, worth $18 million, struck the power lines.

“It just felt like all of a sudden, I was being shaken and thrown around,” Leone said. “My head banged against the seat, and I completely lost control of my neck. My head was like a pingpong ball banging off ofdifferent parts of the aircraft.”

Leone sank to the water’s bottom.

“It was similar to being hit by a wave in the ocean where you can't fight it,” Leone said of the moment of impact. “You just give in. It felt like a long, long time and all motion stopped.”

Despite having a broken collarbone and dislocated shoulder, Leone managed to free himself and swim to the surface. Krueger was killed, along with two others in the crash, maintenance technicians BrettBanks, 33, and Adam Hoke, 40.

Elevated cables pose enough of a threat to aviators that every other branch of the military has equipped select aircraft with wire strike protection systems capable of slicing through transmission lines, according torepresentatives with the U.S. Army, Navy, Air Force and Marines. Only the Coast Guard has resisted.

For Leone, escaping death was just the beginning of a drama that continues today.

Coast Guard leaders pointed the finger at him and ultimately charged Leone with negligent homicide because of the aircraft’s low-flying maneuver over the Coast Guard boat. Even though he was only the co-pilot,officials argued that he was still responsible for ensuring the aircraft was navigated safely.

When a senior military judge disagreed with the Coast Guard’s view of the case and recommended that the charges be abandoned, officials sought to block him from promotion, which is where Leonefinds himself today.

“My wife was unbelievably supportive,” Leone said of the months of physical recovery required. “Dealing with a lot of midnight terrors and trauma, unable to wash myself because my arms wouldn’t work.Unable to hold the kids. Unable to prepare meals. She continued to work very hard for my family.”

Leone’s supporters say he has unfairly shouldered the burden of the Coast Guard’s spate of accidents. In fact, they say, much of the evidence in his case points to the Coast Guard itself.

The Coast Guard’s internal review of the accident found a 1,700-foot gap between the safety markers. The Federal Aviation Administration recommends markers every 200 feet. The Coast Guard has sinceremoved the transmission wires the helicopter struck.

“Those wires were invisible,” said Bernie Hoyland, a retired pilot who spent 30 years in the Coast Guard.

In an interview, Papp argued that the wires were a “red herring” and that it was the duty of the pilots to deliver the costly aircraft home to Alaska, not to go “sightseeing.”

“When it came to me, I reviewed the case completely and came to my determination,” Papp said. “The appeal went to (then-Homeland Security Secretary Janet Napolitano). I never spoke to her. She reviewed thecase, and presumably her lawyers reviewed the case. She sustained the decisions made previously. It's a whole process. It has to be done fairly. It has to be done legally, and I believe it was done in this case.”

Papp also said he's heard the argument for wire cutters, but much of the Coast Guard's work is done over water where there are generally no cables. When necessary, he said, the Coast Guard can fly at a higheraltitude to avoid hazards, and the crew is responsible for identifying such threats.

“There might be other equipment that has a higher priority for us than wire cutters,” Papp said. “But we can't put it on, because we're always trying to balance the weight of the aircraft against endurance and otherthings.”

Leone, in the meantime, received high marks in evaluation reports even after his crash. Two review boards found him fit to fly again .

But Coast Guard officials removed him from the promotions list, which will end his career with the service. A fitness report marked “negative” also was entered into his personnel file. It said that a failure toperform his duties “directly contributed” to the deaths of Leone's crewmates and that the aircraft was flying too low and fast. Further, it said, Leone “participated in numerous conversations unrelated to flying” asthe aircraft cruised at a low altitude.

Today, Leone is assigned to desk duty in San Antonio, where helicopters frequently fly over his home on their way to a nearby hospital. He plans to return to school and has started a business with his wife that willdevelop safety and wellness programs for aviators. Leone has spoken with the father of one of his fellow crewmates, who doesn't blame him for the tragedy and believes Leone is being mistreated by the CoastGuard.

“I've always loved the ideals of the Coast Guard,” Leone said. “… Everybody had the same sort of mindset that I did. It's like, 'Join this organization and do as much good as you possibly can.’ ”

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This story was edited by Robert Salladay and copy edited by Nikki Frick and Christine Lee.

This story was produced by The Center for Investigative Reporting, an independent, nonprofit newsroom based in the San Francisco Bay Area. For more, visit cironline.org. Schulz can be reached at gwschulz@cironline.org. Follow him at: @GWSchulzCIR


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