In February 2009, the National Tactical Officers Association (NTOA) published an update of its “Police Training Fatality Report.” The update was broken down into different sections with one of the sections covering training fatalities by fall/trauma. Four of these fall/trauma accidents involved rappelling or rope rescue training.

After reviewing the NTOA report, I decided to do some additional research and analysis to gain more information into the circumstances surrounding these fatalities and see if I could find more examples of these tragedies. My research revealed seven additional training fatalities involving rope rescue or tactical rappelling training involving law enforcement officers, firefighters, and military personnel.

I contacted the investigating authorities for each of these 11 fatal accidents to get copies of the reports. In most cases I was able to get copies of the fatality report through professional cooperation from the respective agency. In other cases I had to write and request copies of the reports through public record request or under the Freedom of Information Act (FOIA). Nonetheless, by February of this year, I had copies of the reports from 10 of the 11 incidents. The eleventh incident was still under investigation as of March.

The National Institute for Occupational Safety and Health (NIOSH) is the U.S. federal agency that conducts research and makes recommendations to prevent worker injury and illness. The NIOSH Fire Fighter Fatality Investigation and Prevention Program conduct’s independent investigations of select firefighter line-of-duty deaths. Following the same direction and process of the NIOSH program, I started to research and review each case by reading each investigation and medical examiner's report. I also reviewed the photos and video that was provided with some of the reports. My goal was to find out what led to these tragedies and to find ways to prevent them.

Overall, these incidents occurred while each respective team was rappelling for traditional SWAT/rescue training in preparation for a public relations demonstration or for some type of team assessment/team tryout.

Here’s some lessons learned from these tragedies.

Safety Lapses

The first trait that is consistent with all the case studies is safety lapses. In each incident the training lacked one or more of the following:

• A designated safety officer. In some cases there was a safety officer, but that person was never clearly identified.

• A safety briefing before the training evolutions. Though briefings did occur in some of the cases, not all of them addressed safety.

• A qualified instructor to oversee each rappel operation from the rappel point. A qualified instructor is a certified rappel master, rope rescue instructor, or someone who has been authorized by his or her agency to supervise rappel operations. During many of these incidents, a qualified instructor was on hand to oversee the rappel, but in some cases, the qualified instructor was not monitoring the rappelling atop the departure point.

• A primary and/or secondary safety check of the systems and system components as well as the equipment and personal protective equipment (PPE) worn by the person rappelling.

Poor Training

In most of the accidents that I researched the person who was killed lacked proper training in rappelling or a specific technique involved in the exercise. Additionally, the rappel instructor was not qualified to supervise these techniques.

A few of the cases had the trainees rappel Australian style using a Swiss seat, a type of harness commonly used in the military. The Swiss seat is nothing more than a section of rope tied around the waist, thighs, and buttocks. A carabiner (“D” ring) is then connected to the front section of rope that is wrapped around the user’s waist. A rappeller can, in fact, rappel Australian style safely using a Swiss Seat, but the rappeller must have proper training.

The findings on some of these cases involving a Swiss Seat clearly identified lack of training in Australian style as well as lack of training in emergency procedures. There was a bottom belay person in these few cases. The bottom belay person’s responsibility is to physically pull the rope, which puts pressure on the descent control device, ultimately creating friction, thus forcing the person from moving. This technique is ineffective if the system is not rigged properly. It’s also ineffective if the person rappelling is moving too fast for human interaction to engage or if he or she is rappelling from a short distance to the ground and the belay person is not paying attention.

That’s what happened in one case that I examined. The rappeller had rigged the rope around the carabiner, which was the first failure point. The carabiner was not rigged properly and the officer fell to the ground.

Communications Failures

Communications was also an integral factor in these incidents. A main finding regarding communications was the failure to effectively communicate with the team members on the training evolutions. This breakdown included not properly educating the team members of the training goals and objectives.

Other communication failures included lack of proper communication with the chain of command as to the type of training that was being executed. In one particular case, the chain of command was told that the training would cover certain aspects, but the actual training was different and not consistent with the plan or with departmental policy.

Other communications breakdowns revealed by my research included failure to conduct briefings and assign roles and responsibilities. Some people stated in their witness statements there was no clear identification of the trainers’ and participants’ roles or their responsibilities.

In one military rappelling demonstration involving a helicopter, the ropes were to be cut at the end of the exercise. The rappel had been practiced prior to the day leading up to the incident. Though much of the report from the military was redacted for security purposes, the cause and determination were still able to be interpreted from reading the interviews.

Following the rappel demonstration, the ropes were cut by two different people in the helicopter; one of the cutters was the rappel master. Post-incident analysis revealed that there was no communications before, during, or after the rappel as to who was going to cut which ropes. Cutting the ropes was never practiced in training, only discussed. The interviews also revealed that neither of the people cutting the ropes had ever discussed what they were going to do before they cut them. Sadly, no one ever looked out of the helicopter to verify if this rappeller had, in fact, made it to the ground safely. The person rappelling was hung up because the rappelling rope became tangled on the skid, and by the time the rope was cut, it was too late.

Equipment Issues

Some fatal rappelling accidents involved equipment failure; others involved improper use of equipment. It should be noted that in only one of the incidents I researched the rope separated. The rope separation was due to number of factors:

• The team was using the wrong type of rope for the rappel training.

• The person rappelling was doing so with a second individual on the same line. The rope was not rated for the weight.

• The rope was run across a railing system atop the rappelling tower. As the rappellers were descending, the rope moved left and right until it became caught on a sharp object. The separation was due to the sharp object cutting the rope.

Another significant case involved a department that felt helmets were not needed during a particular training evolution. The officers all had NIJ-certified threat level III ballistic helmets. According to someone from the team leadership, these helmets were not recommended for use for rappelling due to their weight. It was believed by this team leader that the sudden stop during the rappel could “snap your neck.” This would prove to be a fatal decision. In this particular case, the official report from the office of the medical examiner stated that the cause of death was “blunt force head trauma due to fall.” The department had purchased helmets to use for rappelling, but when they came in they were too small. This incident illustrates the need for wearing proper PPE.

Inattention

One of the significant findings that has its own category is a phenomenon called inattentional blindness. One of the case studies explained this in detail: “Inattentional blindness is the ‘looked-but-failed-to-see’ effect. It occurs when attention is focused on one aspect of a scene and overlooks an object that is prominent in the visual field and is well above sensory threshold,” Jim Saveland and Ivan Pupulidy wrote in “Rappel Accident-Human Performance Analysis.”

I equate the inattentional blindness phenomenon to looking for your car keys all over the house and then noticing them right where you looked the first time.

Inattentional blindness is something that can be addressed through training, diligence, and redundancy. The purpose of having redundancy is that it hopefully provides a series of levels of checks and balances to ensure the health and safety of the trainees.

Officers should be encouraged to ask questions and learn. Good instructors will see this as a tool to teach and mentor and shouldn’t get offended because someone is asking questions or double-checking their work.

Having a second qualified person check and double-check equipment also provides multiple layers of these needed checks and balances. Periodically inspecting equipment and communicating with people are also good avenues to pursue.

And it’s very important to clearly communicate to the participants whether the rappelling evolution is training or a drill. One of Merriam-Webster’s definitions of “training” is a “process by which someone is taught the skills that are needed for an art, profession, or job.” One of the definitions of “drill” states “to fix something in the mind or habit pattern of by repetitive instruction.”

When departments are conducting rappelling or any other type of training or drill, it is paramount to identify if it is training or a drill. This will aid with the risk assessment of the evolutions and guide you in the necessary direction. If you’re drilling, ideally you have people who are trained and proficient in their tasks. If you’re training, you may have people who have never done that task before and need to start from the ground up. Identify participants’ skill levels to determine where in the training or drill you are going to put them.

When an officer dies in a training accident, it is incumbent upon us to do our research before we train or drill. My review of these rappelling fatalities reveals some of the contributing factors in these cases. They include inadequate skills training for the instructors and individuals, failure to implement a risk assessment and hazard analysis, poor supervision of individuals due to lack of qualified instructors, a breakdown in communications between the instructors and students, and a failure to follow safety procedures, manufacturer guidelines, or good industry practices.

Rappelling is a very effective skill to have, and I believe that a good law enforcement tactical team should have the ability to rappel. A well-trained team can use rappelling for reconnaissance and intelligence gathering, introduction of less-than-lethal, hostage rescue, to gain stealthy access, and to prevent jump suicides. But perhaps the most important benefit of rappelling exercises for tactical teams is team building.

Rappelling is a perishable skill, so training is paramount. The rappelling risk can be minimized by simply following updated procedures, utilizing proper equipment, performing a risk assessment, and most importantly, having trained and qualified people.

Chris Feder Chris, an Army Veteran, has more than 20 years of experience in emergency services, including eight years with the Federal Bureau of Prisons. He served on a regional SORT team for five years. Feder is a rappel master and a technical rope rescue instructor and has written numerous articles relating to rope rescue. He is the rescue training coordinator for the Montgomery County (Pa.) Fire Academy.