R 191808Z MAR 12

ALCOAST 133/12
COMDTNOTE 5100
SUBJ: SHIPMATES 21: FINAL ACTION ON THE ADMINISTRATIVE INVESTIGATION
INTO THE CRASH OF CG 6017 THAT OCCURRED ON 7 JULY 2010
1. SHIPMATES, THE VICE COMMANDANT HAS SIGNED THE FINAL ACTION ON THE
ADMINISTRATIVE INVESTIGATION INTO THE CRASH OF CG 6017 THAT OCCURRED
NEAR QUILLAYUTE RIVER, WA ON 7 JULY 2010, RESULTING IN THE DEATHS OF
LT SEAN KRUEGER, AMT1 ADAM HOKE AND AMT2 BRETT BANKS, AND SERIOUS
INJURY TO LT LANCE LEONE.  THE VICE COMMANDANT MADE A NUMBER OF
FINDINGS, IDENTIFIED CAUSAL FACTORS FOR THE INCIDENT, AND DIRECTED A
SERIES OF ACTIONS TO ENSURE THIS TYPE OF ACCIDENT DOES NOT OCCUR IN
THE FUTURE.  MANY OF THOSE ACTIONS HAVE BEEN COMPLETED (AVIATION
SAFETY ASSESSMENT ACTION PLAN) OR ARE IN PROGRESS AND PENDING
COMPLETION.  THE FINAL ACTION MEMORANDUM IS AVAILABLE IN THE COAST
GUARD FOIA READING ROOM AT:
HTTP://WWW.USCG.MIL/FOIA/FOIA(UNDERSCORE)LIBRARY.ASP (CUT AND PASTE
TO BROWSER, ADD UNDERSCORE, ENTER, THEN SCROLL TO ADMINISTRATIVE
INVESTIGATIONS).  I ENCOURAGE ALL OF YOU TO READ IT, THINK ABOUT IT,
TALK ABOUT IT WITH YOUR SHIPMATES AND CONSIDER IT WHEN PLANNING
OPERATIONS.
2. THE TRAGIC LOSS OF THE CREW OF CG 6017 WAS CLEARLY AVOIDABLE.  IT
LEADS ME TO ADDRESS ALL OF YOU WITH A PERSPECTIVE BROADER THAN THE
INCIDENT ITSELF.
3. PUBLICATION 3-0: OPERATIONS PLACES SPECIAL EMPHASIS ON TWO
FUNDAMENTAL ELEMENTS: LEADERSHIP AND PROFICIENCY.  I RELY ON LEADERS
AT EVERY LEVEL OF COMMAND TO CONDUCT OPERATIONS SAFELY AND
EFFECTIVELY IN AN INHERENTLY DANGEROUS MARITIME ENVIRONMENT.  THERE
IS NO SUBSTITUTE FOR PROFICIENCY IN THE OPERATIONAL ARTS OF OUR
PROFESSION, AND WE MUST ALL RELY ON EACH OTHERS PROFICIENCY TO
EXECUTE OUR MISSIONS.
4. THOSE WHO LEAD HOLD THE LIVES OF THEIR CREW IN THEIR HANDS.  I
EMPHASIZE TRADITIONAL CONCEPTS OF LEADERSHIP, IN PARTICULAR COMMAND
AUTHORITY, RESPONSIBILITY AND ACCOUNTABILITY.  THOSE PRINCIPLES APPLY
NOT ONLY TO COMMANDERS, COMMANDING OFFICERS AND OFFICERS-IN-CHARGE,
BUT ALSO TO THE OFFICERS, CHIEFS AND PETTY OFFICERS ENTRUSTED WITH
THE RESPONSIBILITY FOR SAFELY AND EFFECTIVELY CONDUCTING OPERATIONS,
INCLUDING ENSURING THE WELFARE OF THEIR CREW.  THEY EQUALLY APPLY TO
CIVILIANS AND AUXILIARISTS RESPONSIBLE FOR OTHERS IN THEIR CHARGE.
AIRCRAFT COMMANDERS, COXSWAINS, BOARDING OFFICERS, TEAM LEADERS-EACH
HAS A SOLEMN DUTY AND RESPONSIBILITY IN THIS REGARD.  EVERY MEMBER OF
A CREW MUST TAKE RESPONSIBILITY FOR THEMSELVES, THEIR SHIPMATES AND
THE CONDUCT OF OPERATIONS.  WE ARE ALL OBLIGED TO FOLLOW DOCTRINE,
POLICY AND REGULATIONS IN EVERY ASPECT OF OUR CONDUCT, CONSTANTLY
ASSESS RISK, AND SPEAK UP WHEN OTHERS DO NOT.  LAPSES IN LEADERSHIP,
COMPLACENCY, AND DISREGARD FOR SAFETY POLICIES CAN HAVE GRAVE
CONSEQUENCES.
5. THE INHERENTLY DANGEROUS NATURE OF THE AIR AND SEA IN WHICH WE
OPERATE PUTS COAST GUARDSMEN AND CUTTERS, BOATS AND AIRCRAFT AT RISK.
I KNOW THE NATURE OF WHAT WE DO.  I REALIZE THAT IN EXTRAORDINARY
CIRCUMSTANCES LOSSES MAY OCCUR, BUT THEY ARE NEVER ACCEPTABLE AS THE
COST OF DOING BUSINESS.
6. OUR DUTY TO SAFELY OPERATE DEMANDS LEADERSHIP AND PROFICIENCY TO
ENSURE MISSION SUCCESS.  WE MUST REMAIN EVER VIGILANT AND CONTINUE
OUR COMMITMENT TO MITIGATING THE RISKS WE ENCOUNTER FOR OURSELVES,
FOR EACH OTHER, AND FOR THE PUBLIC WE SERVE.
7. AGAIN, IF WERE GOING TO DO IT - AND WE ARE - WERE GOING TO DO IT
RIGHT.
8. STAND A TAUT WATCH.  SEMPER PARATUS.
9. ADM BOB PAPP, COMMANDANT, SENDS.
10. INTERNET RELEASE AUTHORIZED.