R 041826Z OCT 11

ALCOAST 465/11
COMDTNOTE 1000
SUBJ: SHIPMATES 16: FINAL ACTION ON ADMINISTRATIVE INVESTIGATION INTO
DEATH OF COAST GUARDSMAN ON 13 OCTOBER 2010
1. THE VICE COMMANDANT HAS SIGNED THE FINAL ACTION ON THE
ADMINISTRATIVE INVESTIGATION INTO THE DEATH OF ME3 SHAUN LIN THAT
OCCURRED ON THE JAMES RIVER NEAR PORTSMOUTH, VA ON 13 OCTOBER 2010.
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. THE FINAL ACTION
MEMORANDUM IS AVAILABLE AT:
HTTP://WWW.USCG.MIL/FOIA/FOIA(UNDERSCORE)LIBRARY.ASP.
2. WHEN READING THE VICE COMMANDANTS FINAL ACTION ON THE
INVESTIGATION, THE TACTICAL CAUSAL LINKS OF THE MISHAP ARE CLEARLY
IDENTIFIED. THOSE ARE THE MOST CONCRETE FACTS AND DIRECTLY EVIDENT AS
PROXIMATE CAUSES OF THE INCIDENT THAT RESULTED IN PETTY OFFICER LINS
DEATH. ADDITIONALLY, THE BROADER TENSIONS AND MISALIGNMENT BETWEEN
FORCECOM, SMTC, AND THE DOG WERE IMPORTANT FACTORS THAT CONTRIBUTED
TO THE OVERALL CULTURE AND ENVIRONMENT, WHICH SET CONDITIONS FOR THIS
MISHAP.
3. IN MY JUDGMENT WE ARE DRAWING CLEAR LESSONS FROM EXAMINING THIS
INCIDENT, OUR REVIEW OF OTHER SERIOUS OPERATIONAL MISHAPS (AVIATION
SAFETY ASSESSMENT ACTION PLAN), AND THE DEPLOYABLE SPECIALIZED FORCES
(DSF) STEM TO STERN REVIEW. MANY OF THESE LESSONS ARE CURRENTLY BEING
ADDRESSED IN THE ONGOING DSF STEM TO STERN IMPLEMENTATION.
4. LAST MONTH I SENT OUT SHIPMATES 13 ON THE DSF STEM TO STERN REVIEW
UPDATE. IN THAT MESSAGE, I COMMUNICATED KEY POINTS ABOUT THE FUTURE
DIRECTION OF THE DSF:
    A. DSF ARE THE THIRD PRONG OF THE COAST GUARD MARITIME TRIDENT OF
FORCES: SHORE-BASED FORCES, MARITIME PATROL FORCES, AND DEPLOYABLE
SPECIALIZED FORCES.  DSF MUST BE FULLY INTEGRATED WITH OTHER
OPERATING FORCES UNDER THE LEADERSHIP OF SENIOR OPERATIONAL
COMMANDERS WHO ARE RESPONSIBLE AND ACCOUNTABLE FOR THEIR READINESS
AND OPERATIONS.
    B. THE CURRENT ORGANIZATIONAL STRUCTURE OF THE DEPLOYABLE
OPERATIONS GROUP (DOG) THAT DIVIDES OPERATIONAL FROM ADMINISTRATIVE
CONTROL, AND SEPARATES DSF FROM OTHER COAST GUARD FORCES, HAS
CHALLENGED COHESION, UNITY OF COMMAND AND EFFECTIVENESS OF OPERATING
FORCES.
    C. THE DEPUTY COMMANDANT FOR OPERATIONS IS RESPONSIBLE FOR
PROVIDING THE CONCEPT OF OPERATIONS, POLICY AND DOCTRINE GOVERNING
HOW ALL COAST GUARD OPERATING FORCES ARE EMPLOYED IN AN INTEGRATED,
SYNCHRONIZED MANNER CONSISTENT WITH HOW WE CONDUCT OPERATIONS.
    D. FORCECOM AND SUBORDINATE ELEMENTS, INCLUDING SPECIAL MISSION
TRAINING CENTER (SMTC), ARE RESPONSIBLE FOR PROVIDING TACTICS,
TECHNIQUES AND PROCEDURES (TTP), TRAINING AND STANDARDIZATION FOR ALL
FORCES.
5. THIS INCIDENT AND OUR OTHER DELIBERATE REVIEWS OF OPERATIONAL
MISHAPS REMIND US THAT WHEN WE UNDERTAKE NEW CAPABILITIES AND NEW
OPERATIONAL COMPETENCIES, AS WE DID AFTER 9/11 WITH THE MSSTS AND
MSRT, WE MUST REMAIN FOCUSED ON FUNDAMENTALS:
    A. ESTABLISH CLEAR REQUIREMENTS FOR THOSE CAPABILITIES,
    B. ESTABLISH MISSION ESSENTIAL TASKS AND THE COMPETENCIES
REQUIRED
FOR THOSE TASKS,
    C. PUT POLICY, DOCTRINE AND TTP IN PLACE BEFORE WE OPERATE,
    D. TRAIN COAST GUARDSMEN BEYOND QUALIFICATION TO PROFICIENCY AND
SUSTAIN THAT PROFICIENCY,
    E. PROVIDE STANDARDIZATION OF EQUIPMENT, OPERATIONS AND TACTICS,
AND EVALUATE READINESS, AND
    F. ALWAYS FOCUS ON MITIGATING OPERATIONAL RISK, SAFE TRAINING AND
EFFECTIVE OPERATIONS.
6. THE COAST GUARD IS GRATEFUL FOR ME3 SHAUN LINS SERVICE. HIS TRAGIC
LOSS IS A REMINDER THAT AS COAST GUARDSMEN WE OPERATE IN A DANGEROUS
AND HIGH-RISK ENVIRONMENT. IT IS THE NATURE OF OUR PROFESSION. YOU
RIGHTLY DEMAND AND DESERVE THE SERVICES TOTAL COMMITMENT TO PREPARE
AND LEAD YOU TO CONDUCT OPERATIONS IN THE MARITIME ENVIRONMENT. WE
ARE GOING TO DO IT RIGHT.
7. ADM BOB PAPP, COMMMANDANT, SENDS.
8. INTERNET RELEASE AUTHORIZED.