Investigation: Multiple Errors Contributed To Death Of Mount Rainier National Park Climbing Ranger
Climbing ranger Nick Hall was struggling to control a rescue litter on an icy, 35-degree slope while being buffeted by the swirling downwash from a Chinook helicopter when he slipped and fell 2,400 feet down Mount Rainier to his death last June, a National Park Service investigation has found.
The 33-year-old ranger was one of four rangers trying to rescue a party of four climbers high on the mountain that gave its name to Mount Rainier National Park in conditions made difficult not only by the degree and iciness of the slope but also by surface winds gusting possibly to 40 mph coupled with the rotor wash of 80 mph or more.
When Ranger Hall lost his balance, he tried desperately to self-arrest his slide down the mountain, but he lacked an ice axe that could have helped, the report stated.
"OK, this just got real serious," an unidentified ranger on the mountain radioed to the operations center. "Chopper 62 was lowering the litter down to Hall and Hall and the litter lost contact with the ground and he has gone for a slide down Emmons Glacier. We no longer have contact with Hall."
"You have contact with Hall?" the operations center radioed back.
"Negative. He was traveling at an extremely high rate of speed, he was out of control, and I saw him launch off a serac at some point..." the ranger replied.
Another ranger on the scene told the investigators that, "Nick was on his butt facing up the hill and picked up speed really rapid. Pretty scary rate how fast he was accelerating. He was spinning around while sitting upright, and he made a lot of attempts to reach out and stop himself but with no ice axe."
One of the rangers estimated that Ranger Hall was launched "30 or 40 feet in the air" by the serac.
The Chinook helicopter headed down the mountain to look for the ranger, who was found 2,400 vertical feet below the rescue site. Another ranger who was lowered to the scene determined that the fall had killed Ranger Hall.
While the 66-page report (attached below) cited the ranger's failure to properly anchor himself on the mountainside before trying to retrieve the litter that was being lowered from the helicopter as the key to his death, it also pointed to other errors that might have contributed to his death.
* The four rangers on the ground trying to rescue the injured climbers failed to clearly designate a team leader;
* The rangers were not properly trained for the complexity of the rescue before them;
* The ratio of one ranger to one injured climber increased the risk of the rescue;
* Communications were hampered by the inability of military personnel on the Chinook to communicate with Park Service personnel and failure of Mount Rainier's dispatch staff to restrict radio communications to emergency traffic.
The investigation also concluded that the Incident Command Team established for the rescue was not consolidated in one location but had to manage the operation over the telephone; that the park lacked a trained aviation manager at the time; that the mission briefing was incomplete, and; that the park lacked "standard operating procedures" for search-and-rescue missions.
Ranger Hall had helped rescue two of four climbers who had fallen into a crevasse and was helping to load them into a helicopter for a flight off the mountain when he fell, park officials said at the time.
The four, two men and two women from Waco, Texas, had gotten into trouble shortly before 2 p.m. at the 13,700-foot level of the Emmons Glacier as they were returning from summiting the 14,411-foot mountain. Two of the climbers had slid into a crevasse. A third member of the group was able to call for help using a cell phone.
Weather and avalanche conditions prevented rangers from retrieving their colleague's body for two weeks.
“While we can’t bring Nick back, we can and must learn and take action as a result of the accident that took his life,” Chris Lehnertz, the Park Service's Pacific West regional director, said Tuesday in releasing the report. "The investigation team determined that because the park’s mountaineering rangers had routinely performed high risk search and rescues on glaciers on the mountain, they had inadvertently become desensitized to the hazards of their job.
"This 'normalization' of risk doesn’t just happen in high risk operations on a mountain. It’s a systemic problem faced by employees across all disciplines; when we do things over and over again it’s human nature to 'normalize' risk, which can lead to injuries and death. We have a responsibility to our employees to create and implement systems to identify and prevent 'normalization' of risk.
"To that end, I have called for a regionally led evaluation of some of our other high-risk operations including snow plowing and boat/diving operations to help us identify areas of risk so we can prevent these types of accidents in the future.”
|MORA-Hall Investigation.pdf||1.14 MB|