<figure class="wp-block-image aligncenter size-full"><figcaption class="wp-element-caption">CG6016 was salvaged following the crash on Read Island on November 13, 2023, and then shipped to North Carolina for examination. Its mission to aid the fishing vessel Lydia Marie was considered medium risk and high gain at the time of launch, however the boat was still floating the next morning. Air Station Sitka commander Rand Semke believes that finding fault with the crew for not turning back after learning that the Lydia Marie was out of immediate danger is “hindsight bias,” and that the crew was correct to proceed, as the Lydia Marie’s circumstances could rapidly change. “Real time risk is more art than science,” says Semke. (USCG photo)</figcaption></figure>

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Note: The Coast Guard MII (Major Incident Investigation) report concluded that the November 23, 2023 crash was the result of “controlled flight into terrain.” Read the story.

Many remember the words of Logan Padgett, the skipper of the Lydia Marie, and his unusual role reversal: He and his brother rowed ashore on Read Island to help the members of the Coast Guard who had come to rescue them.

“It’s just people helping people at that point,” Padgett said.

The Coast Guard weighs every mission on risk versus gain. When it was thought that the Lydia Marie was sinking, and three lives at risk, the gain was clear, even on a stormy night in November.

Sitka Air Station commander Rand Semke, also a pilot, says this calculation is made prior to every flight.

“Every time we take off, we analyze the risk versus the gain of whatever it is we’re doing, whether that’s a local training flight here in Sitka, or a complex search and rescue mission,” said Semke. “And that’s really a whole crew discussion. Everybody’s dressed out, ready to go. We’re not running to the aircraft. We’re going to pause, even in the most urgent of cases, and talk about risk and gain for at least a few minutes.”

Coming to the aid of the Lydia Marie was determined to be medium risk, and high gain. But as Coast Guard helicopter 6016 flew toward Farragut Bay that night, that calculation changed.

“As this specific mission was unfolding, information was coming through that actually, the pumps are keeping up with the flooding,” said Semke. “When the crew received that piece of information, they did another risk assessment. Some of those during-mission risk assessment discussions are a little bit more conversational, a little bit less formal, because you’re in the mission. It really requires some maturity to take yourself outside of what is happening at that moment and think through ‘Okay, if we were back at Sitka in a warm and dry hanger, would we still be launching for this? But now we’re, we’re three quarters of the way there. Why don’t we just keep going anyway?’”

Semke says that CG6016 kept going, not because they were almost there anyway, but because the Lydia Marie’s circumstances could rapidly change. Cockpit voice recordings from CG6016 indicate that the crew had decided to lower a dewatering pump to the Lydia Marie as a precaution. Neither the Major Incident Investigation report or Cmdr. Semke faults the crew for continuing the mission.

“Real-time risk assessment is more of an art than a science,” he said. “As this crew, as the investigation notes, made it on scene, they observed that the Lydia Marie was still floating, and in their judgment, wasn’t in immediate danger of sinking. So this crew adjusted their mindset to, ‘Well, let’s try to just deliver a dewatering pump to the boat, which will help them keep up with the flooding.’ And that was ultimately what they were in the process of doing when the mishap occurred.”

The investigation determined that the four members of the CG6016 crew sustained their injuries “in the line of duty.” The pilots were able to walk away from the crash, one with a broken shoulder, the other with a concussion. The flight mechanic and rescue swimmer wore harnesses that allowed them to move about the cabin as they prepared to lower the pump to the Lydia Marie, but did nothing to protect them from the impact. Their litany of injuries was severe; broken vertebrae, broken femur, broken ribs, collapsed lung, and so on.

Cmdr. Semke says all are gradually returning to duty – even the pilots. Some incidents in the military are career-ending. Semke says this one wasn’t. It boiled down to a careful medical evaluation undergone by all military aviators.

“That’s a very careful and intentional process, for the aviation medicine enterprise to bless somebody for flying a $30 million public aircraft in some of the most challenging conditions,” said Semke. “So that process is ongoing. It was able to clear the pilots again to fly. The crew members are both miraculously having some really promising medical recoveries, and the doors are wide open for them too.”

The outcome for the crew could not be more different than the previous Air Station Sitka crash during a helicopter delivery flight in 2010 outside of La Push, Washington. In that incident, the pilot, flight mechanic, and rescue swimmer all died; the co-pilot survived and recovered, and was subject to military discipline that ended his career as a pilot.

Just as there was a lesson for Coast Guard aviators in that tragedy, there is a lesson in the loss of CG6016, and Semke says, a plan “to develop “actionable items to move forward.”

“We all know what happened,” said Semke. “We know that the aircraft hit the trees. We know that the Lydia Marie was floating the next morning. We know the outcome. So sometimes that hindsight bias when we’re analyzing an accident or a mishap can ultimately cloud our own judgment when we really want to put ourselves in the shoes of the mishap crew and figure out the reason why. Not just who was responsible, but why.”

Semke describes everyone involved in military aviation as high performing. The immediate consequence of the loss of CG6016 was to remind crews that high performing does not mean infallible. He believes transparency about this accident is beneficial, as is the humility that comes with it. In a 35-page incident report filled with data, Semke’s takeaway is “to make sure that we have protective factors in place for people when they do reach their limit, the person sitting next to them, … is ready to acknowledge that and back them up.”

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