JUNEAU -- A lack of communication and the pilot and co-pilot's failure to properly perform their duties contributed to a 2010 helicopter crash that killed three Coast Guard members, according to the Guard's final report released Monday.
Vice Commandant Sally Brice-O'Hara's report came a day after the Guard's commander in Alaska found the actions of the sole survivor, co-pilot Lt. Lance Leone, directly contributed to the deaths of his colleagues and the helicopter's destruction.
Brice-O'Hara found that pilot Sean Krueger and Leone were flying too fast and too low, creating "a situation in which ... even a momentary lack of attention increased the potential for a mishap."
The report directed the Guard's Alaska commander, Rear Adm. Thomas Ostebo, to consider whether any additional personnel action would be appropriate. She said the commander of the Coast Guard Personnel Service Center also can decide whether to convene an aviator evaluation board to reconsider Leone's suitability to fly again.
Leone was co-pilot of an MH-60 Jayhawk helicopter flying from Astoria, Ore., to the crew's base in Sitka, Alaska, when it hit an unmarked span of low-hanging wires and crashed off the Washington coast in July 2010. Killed in the crash were Krueger, of Connecticut, and crewmen Brett Banks, of Wyoming, and Adam C. Hoke, of Montana.
Leone had recovered from his injuries and was cleared for flight re-training when he was charged last year with negligent homicide, dereliction of duty and destruction of government property. He was accused of not actively navigating or challenging Krueger's decision to drop in altitude seconds before the helicopter hit the 1,900-foot span of wires. The Coast Guard dismissed the charges earlier this month.
Brice-O'Hara found that a lack of adequate markings on the power transmission lines -- which were maintained by the Coast Guard -- may have contributed to the crash.
The wires, which were the site of at least two other accidents, sloped from 190 feet high to about 36 feet. According to testimony from a December military hearing on the incident, marking balls were not along the span at the time of the crash, instead pooled near a pole, above land, at a low point. The helicopter hit the wires at about 114 feet, according to testimony.
During the hearing, the crash's lead investigator also called the lines a contributing factor but said there was no reason for the aircraft to be flying so low.
Leone's civilian attorney, John Smith, argued that Leone had programmed the helicopter on a track that would have missed the wires, but Krueger deviated from it, dropping in altitude as he flew over a Coast Guard vessel in the channel seconds before the fatal strike.
The report is not intended to assign blame but rather to find out what went wrong and what could be done to prevent future accidents. It included a series of recommendations, including a study of the feasibility of equipping Coast Guard helicopters with wire strike prevention systems.
It did not incorporate testimony from the military hearing, which a Coast Guard spokesman called a separate process.
Smith said that move made the report "flawed and biased."
"Evidence showing the Coast Guard's callous disregard for the safety of aviators was developed and presented by the defense team," he said in a statement. "This evidence was not considered by the vice commandant. In addition, findings such as Lt. Leone 'failed to actively navigate' were debunked by evidence developed by the defense team" at the December hearing.
Leone has refused to sign a document from Ostebo that noted his failure to perform required duties directly contributed to the crash. A Guard spokeswoman said Monday that it was an internal personnel matter but could not comment on the ramifications of Leone's refusal.
Brice-O'Hara said the other contributing factors were a lack of proper communication among the crew, failure by Krueger and Leone to comply with altitude restrictions and policy for low-level flights and to maintain awareness, and Krueger's apparent decision to drop in altitude to fly over the Coast Guard vessel.
She noted that the Sitka region often gets poor weather that requires low-altitude flights, and that there was evidence to suggest that pilots were encouraged to fly lower and slower to increase their familiarity with the weather.
In December, the commander of Air Station Sitka, William Cameron, testified that, in Alaska, it was not uncommon to fly low along the coast. Cameron said Krueger -- who, like Leone, had a list of Coast Guard awards and accolades -- was comfortable at lower altitudes, but Leone had recently been assigned to Sitka.
Had Leone been at his prior station, he probably would have asked questions, Cameron said. But he added that he didn't think it would have made a difference if Leone had questioned the drop in altitude.
Brice-O'Hara's report noted the failure of the Guardsmen to follow policy and procedures and the "apparent complacency... and conduct" during the flight "must serve as a lesson for others."