Good Training Gone Bad
Author’s note: I’d like to thank survivors Christie Lynch, Melissa Dorrance Baray and Vivian Eney Cross. Many thanks go to Jennifer Thacker, COPS Director of National Outreach, for her assistance with this article. Visit the Concerns of Police Survivors (COPS) website, www.nationalcops.org, to learn more about their continued efforts to support the survivors of line-of-duty deaths.
The fifth tenant of the Below 100 Initiative is “Remember: Complacency kills!” Sadly, many LEOs die in training because they ignored this simple advice. We lose about 12 officers in training each year. The injuries sustained in training are countless. And the dangers aren’t specific to firearms training: They frequently occur during other training, such as force-on-force scenarios, physical control tactics, rappelling and SCUBA diving.
The statistics demonstrate the need to maintain vigilance during all training evolutions just as we should on the street. Although the number of deaths may not be as high as those from vehicle collisions or felonious assaults, every death prevented helps us meet the attainable Below 100 goal and keeps one more family and agency from dealing with the loss of a loved one. Bottom line: Training deaths are often preventable deaths. Safety must be a paramount concern in our training if we’re to prevent deaths like those that occurred in the following cases.
Sgt. Tate Lynch
Casa Grande (Ariz.) PD
End of Watch: October 25, 2007
Sgt. Tate Lynch was born into a law enforcement family. His father had been a police officer in Tucson and inspired Tate to follow in the same career path. Tate became an instinctive cop, who continued to pound the street, find bad guys and make arrests even after his promotion to sergeant. He took training seriously and was known to tape episodes of the television show Cops and review the tactics, good and bad, with the officers he supervised. In addition to his law enforcement service, Tate was a devoted family man. He worked in various roles at his church. Christie described Tate as the “most impressive human being” she’d ever met.
Tate was participating in rappelling exercises at a nearby prison as a member of a regional SWAT team run by a local sheriff’s department. Tate’s rappelling attempt was at least the 30th rappel on the same rope in that short time. Unable to control his rapid descent, Tate struck his head on a picnic table beneath the rappelling wall. He was treated on scene by prison medical staff before being airlifted to a hospital. He died later that evening, leaving a wife and three young children behind. As a final act of service, Sgt. Tate Lynch saved four lives that night by donating his organs.
A lengthy post-incident investigation identified numerous failures that stacked on top of one another resulting in Tate’s death. The officer leading the training hadn’t been certified to instruct rappelling. The rope that was used had been stored outside for five years, wasn’t the correct diameter for rappelling, and was fatigued due to numerous rappels that day. None of the officers were properly trained on new rappelling equipment. Common rappelling safety measures, such as the use of a belay, were ignored. In the end, a total of seven OSHA violations were identified against the team and sheriff’s department.
In addition, the team and the sheriff’s department reportedly had a history of refusing to conduct after action reviews (AAR) after training and real-world events. Officers were encouraged to keep their opinions to themselves prior to Tate’s death, even though some had expressed concerns privately about the manner in which callouts and training were handled.
A subsequent lawsuit against the sheriff’s department took three years to resolve. The team commanders were replaced, and management, training and command of the regional SWAT team reportedly improved greatly in the wake of this tragedy. An interagency agreement was formally signed for the first time, and team commanders now report to a committee consisting of members from the county and all the cities involved in the joint team. After-action reviews now take place encouraging team members to state their concerns and suggestions for improvement and training must be approved through formal channels.
Air Interdiction Agent Julio Baray
DHS; Customs & Border Protection, Air & Marine
End of Watch: September 24, 2007
Agent Julio Baray was born in Mexico but became a U.S. citizen before answering a calling to join the U.S. Border Patrol. He’d taken flying lessons since he was 16 years old, acquired his pilot’s license and hoped to combine his love of law enforcement with his love of flying.
Baray had a passion for helping others and he used the senses he developed as a law enforcement officer to carefully assess who would use his help to improve their lives and who would just continue living a life of crime and poverty. He was known to buy food for homeless people or give them money. He targeted much of his effort as an officer and as a citizen on helping children vulnerable to criminals. After several years in the Border Patrol, Baray got his wish to become a law enforcement pilot. He transferred to the newly created Air and Marine Division of Customs and Border Protection (CBP), which was undergoing a dramatic expansion of its air assets.
Baray was in his last day of training to be an Air and Marine pilot and flying with the last of his instructors. They had been performing a common maneuver known as “touch and goes” at a small local airport when an unexpected wind effect known as a “micro-burst” caused the nose of Baray’s plane to suddenly tip downward while at low altitude. The aircraft crashed on its left side where he was seated and caught fire. The injured instructor managed to remove Baray from the aircraft wreckage, but he died as a result of his injuries. He left behind a wife and two young sons.
Baray became the third pilot to be killed in an aircraft crash in less than a year for the newly created Air and Marine Division. The National Traffic Safety Bureau (NTSB) investigated all three crashes. While Julio’s crash was attributed mainly to the wind effects, NTSB also determined that Air and Marine had been rushing its pilot training program and that the compressed nature of the training schedule had been a contributing factor in the crashes. As a result, Air and Marine added safety guidelines, lengthened the training time and increased the number of training flight hours required before prospective pilots received their certifications.
Sgt. Christopher Eney
U.S. Capitol Police
End of Watch: August 24, 1984
Sgt. Christopher Eney joined the U.S. Capitol Police (USCP) after serving as a U.S. Army Special Forces medic. He was driven to law enforcement by his desire to help others in need. His experience and dedication made him a natural fit for the USCP’s Containment and Emergency Response Team (CERT).
Eney and the rest of the CERT were conducting building search training in small groups on multiple floors of an abandoned building near the Capitol. All officers had initially unloaded their weapons on the fifth floor, while training was conducted on the third and fourth floors. After several hours, Eney’s group finished on the third floor and one officer reloaded his weapon on the fifth floor while Eney and others had stayed behind on the fourth floor to watch the training that was still going on there. When the now-armed officer passed through the training area, he became involved in a dispute over tactics with other officers and was inserted into a scenario. The armed officer fired a shot from his pistol that struck Eney in the lower back with an upward trajectory that nicked his aorta. He was transported to a hospital where he died an hour later, leaving behind a wife and two young daughters.
Eney’s death was considered by some to be “an accident waiting to happen.” Some believed the USCP placed too much emphasis on teaching officers to recognize members of the House and Senate and not enough on officer survival and safety procedures, despite the fact that other training accidents had occurred. Training procedures were corrected in the aftermath to ensure that such a training death could not happen again.
At the time of Eney’s death, the USCP had no policies or procedures in place to deal with a line-of-duty death and numerous mistakes were made causing unnecessary emotional trauma. Realizing their errors, the USCP later approached Eney’s wife, Vivian, to help them revise their procedures making them better prepared for future line-of-duty deaths.
Risk management expert Gordon Graham is often quoted: “If it’s predictable, it’s preventable.” Training takes place in a controlled environment, which means that dangers are predictable compared to events on the street. Proper planning, preparation and practices take time and money, but they’re worth the effort to prevent training deaths and injuries.
Much like aircraft design or a nuclear weapons launch, multiple safeguards should be in place to ensure an overall “system save” if one or more safeguards fail. Sadly, too many police training deaths and injuries are the result of “error stacking,” in which multiple safeguards were ignored or bypassed resulting in deaths or injuries that were preventable. The results of a fatal training “accident” are much greater than the death of a single individual. Families, friends, co-workers and the involved instructors are all deeply affected. Positive change to policies and procedures often result from such tragic events but change shouldn’t demand such an unreasonable cost.
How do we prevent training deaths? Let’s ask the survivors what they think.
Christie Lynch suggests “officers need to put their egos aside and speak out about safety concerns instead of worrying about how their concerns will appear to other officers.” Melissa Dorrance Baray reminds us “this is for real and you have to get it right,” even if it’s a training event. Training deaths are no less painful than felonious deaths and families are still proud that their loved one was training to help other people in need. Lastly, Vivian Eney Cross says, “The pursuit of excellence is the best prevention for accidents. Don’t ever think it won’t happen in your department. When your procedures and safety checks are in place, you’ve knocked down the probability to the point where it is minimal.”
Below 100 is about more than seatbelts and body armor. Always invoke the last two tenets: W.I.N.—What’s Important Now? and Remember: Complacency kills! These two are absolutely crucial considerations when planning a training scenario. The challenge is to maximize safety while minimizing risk with training that is as realistic as possible.
1. National Tactical Officers Association (NTOA). “Training Fatality Study.” www.ntoa.org
2. Murray, Ken. Training at the Speed of Life. www.armiger.net
3. International Association of Law Enforcement Firearms Instructors (IALEFI). Guide for Simulation Safety. www.ialefi.com