An improperly configured back-up parachute inadvertently opened into the wind during a jump training mission, pulling a special tactics airman out of an aircraft and causing his death, according to a new investigation.
The Air Force on Tuesday released its months-long Accident Investigation Board report, which concluded that the unexpected deployment of a T-11R emergency reserve parachute led to the death of Staff Sgt. Cole Condiff, a Special Tactics combat controller with the 23rd Special Tactics Squadron, part of the 24th Special Operations Wing at Hurlburt Field, Florida. The Nov. 5 accident led to a 17-day search for Condiff over the Gulf of Mexico. His body was never recovered.
In addition to improper parachute assembly, the head of Air Force Special Operations Command said deficiencies and lapses in judgment across the community contributed to the accident.
The command "prioritized operations over in-garrison training and predictable deployment scheduling, resulting in stressed units across the command and leaders accepting unnecessary risk for the sake of mission completion," according to a news release accompanying the report.
Since 9/11, "we normalized a culture overly focused on mission accomplishment, causing a lapse in training rigor, strict adherence to standards, and vigorous oversight of high-risk activities at all command echelons," said AFSOC commander Lt. Gen. Jim Slife.
The command noted that, like the overall Special Operations Command community, "mission execution was prioritized to the detriment of leadership, discipline, and accountability practices."
On the day of the accident, Condiff, 29, was assigned to one of six teams participating in a training event known as a rodeo competition to test aircrews and special operators on how quickly and accurately they can get to their target location. The teams were conducting a static-line jump out of an MC-130H Combat Talon II and had already completed a few jumps earlier in the training.
The tasks for Nov. 5 included the jump operations, an obstacle course and land navigation, with teams landing at the "Air Commando" drop zone at Hurlburt, which is specifically designated for personnel parachute operations, according to the report.
Condiff was the designated jumpmaster, scouting ahead from the right paratroop door of the aircraft for the drop zone below. Three teams had already jumped; Condiff's team was slated to jump next. At around 11:14 a.m. local time, Condiff looked out the door of the MC-130, which was flying at an altitude of 1,012 feet above mean sea level at roughly 150 miles per hour.
Witnesses testified that Condiff's top and bottom tuck tab inserts, which help hold the parachute securely in place, were "not flush with the green pockets on his T-11R parachute ripcord assembly" even before his first jump earlier in the day, the report states.
A photo in the report shows Condiff's bottom tuck tab insert sticking out "approximately one inch from the edge of its pocket," and a loose left side tuck tab showed two seams on the parachute pack, making the ripcord assembly vulnerable to wind gusts outside the aircraft.
As the MC-130 turned toward the jump location, airmen on board saw Condiff's reserve parachute inflate outside the right door, pulling at him.
Condiff "impacted the aft door frame 'violently'" before his legs were airborne outside the frame.
"Several witnesses heard a second loud noise that could have been [Condiff] impacting the exterior of the aircraft," the report states. "The evidence indicated he likely sustained fatal injuries upon being pulled from the aircraft."
An immediate search and rescue began for Condiff, who descended under fully inflated reserve and main parachute canopies into the water, approximately two-and-a-half nautical miles south of the coast.
Multiple agencies, including the Navy and Coast Guard, were involved in the search, which included aircraft, underwater drones and scuba divers. Troops and support personnel canvassed 700 square miles of the Gulf stretching between Fort Walton Beach and Pensacola, Florida.
The search was suspended Nov. 22.
Maj. Gen. L. Kip Clark, president of the convening board, found a number of training and procedural issues within the wing that contributed to the fatal mishap.
For example, the designated jumpmaster personnel inspectors "did not check the proper configuration of the T-11R inserts and side tuck tabs" for the flights that day.
Furthermore, "the technical order management process failed to effectively distribute and communicate sister-service guidance on the proper configuration and storage of T-11R parachute systems, resulting in incomplete knowledge of the standards throughout the special tactics community," Clark said.
The Army studied the effectiveness of tuck tabs, which led to updated safety procedures for that service, as well as the Air Force and Navy, in 2015, he said.
Life Preserver Units, or LPUs, should also have been present, given the training was near or over water. Planning officials could not agree whether to use lifeboats on standby as well, Clark said.
"Inadequate organizational leadership led to insufficient command oversight of this event," he said. "I find by a preponderance of the evidence that event planners, safety personnel, numerous jumpmasters, and jumpers did not understand regulatory requirements for safe static-line jump operations. I view this widespread misunderstanding to be a training issue within the 24 SOW."
AFSOC ordered a suspension in December for its parachute, dive and mountaineering training to allow officials to inspect equipment and review safety procedures. The move followed the deaths of Condiff and Tech. Sgt. Peter Kraines, a pararescueman with the 24th Special Operations Wing at Hurlburt. The suspension was lifted in May.
Last month, officials revealed through a separate investigation that Kraines' death was due to a rock-climbing anchor system that unexpectedly failed, causing him to fall to his death. He and his team were participating in a routine, six-day mountain rescue training event at the Black Cliffs near Boise, Idaho, in October when the accident occurred.
In light of the findings from both the parachute and mountaineering accident investigation boards and AFSOC's operational stand-down, two squadron commanders within the 24th Special Operations Wing were relieved of duty, said Maj. Amanda Reeves, AFSOC spokeswoman.
"The decision was not related to misconduct, but was determined to be in the best interest of the units," she said in an email.
Following the parachute accident, 18 jumpmasters were also "temporarily decertified and five people were issued letters of reprimand," Reeves said.
"The 24 SOW has placed substantial emphasis on strengthening oversight of high-risk activities and increased safety and risk management processes," she added. "Specifically, they've implemented new positions for full-spectrum safety and standards and evaluation functions, and updated training standards."
Speaking to the deaths, Slife said, "It is apparent that these losses are a tragic consequence of a culture shaped by the demands of the last 20 years.
"Our people truly are our greatest asset," he said. "We owe it to them to continually evaluate how we operate and how we can be more effective."
Editor's note: This story has been updated to correct Clark's role and to list punitive actions taken after the investigation boards.
-- Oriana Pawlyk can be reached at firstname.lastname@example.org. Follow her on Twitter at @oriana0214.