The state agency that oversees workplace safety has found several major violations surrounding the death of a Casa Grande police officer killed during a Pinal County Sheriff's Office SWAT training exercise.
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Sgt. Tate Lynch, 36, died Oct. 25 when he fell nearly 50 feet while rappelling off a Pinal County jail building in Florence. In a report released to the Tribune this week under a public records request, the Arizona Division of Occupational Safety and Health cited the sheriff's office for several infractions, finding:
No safety checks were done on equipment.
The instructor overseeing the exercise lacked qualification, with training only from an intermediate rappelling class.
No safety spotters or equipment, including helmets, were used.
The records include hundreds of pages documenting the incident and numerous interviews with officers present when Lynch fell.
The report compiled by ADOSH shows almost no safety measures or precautions were taken and little instruction, if any, was provided to the rappellers.
On Wednesday, Vanessa White, a spokeswoman for the sheriff's office, declined to comment on the ADOSH investigation as well as a separate investigation by the Arizona Department of Public Safety.
She did say that since Lynch's death, the sheriff's office has suspended all rappelling exercises and is reorganizing SWAT command and procedures. It has also created a position to oversee training and formed a review board of experts from outside police departments.
Lynch was a two-year member of the sheriff's office SWAT team, made up of officers from several county police departments.
On the day of his death, SWAT was conducting a variety of training exercises.
Lynch was one of the last officers scheduled to rappel - his turn was 22nd. After he climbed over the wall, Lynch dropped a short distance and stopped for a few seconds before going into a free-fall, records show.
On the way down, he hit his head on the wall and landed on a steel mesh picnic table.
Lynch suffered severe head injuries and was bleeding from the mouth when he was flown to Scottsdale Healthcare Osborn hospital, records show.
He died a short time later.
NO CERTIFIED INSTRUCTOR
According to the report:
Ben Cook, who is the county's search and rescue coordinator, was running the exercise. He was placed in charge by Sgt. Scott Gillen, former Pinal County SWAT commander.
When Gillen was asked by investigators why he placed Cook in charge and if he knew his qualifications, Gillen said, "I don't know his exact, I know DPS trained him ... He, uh, he's been search and rescue for a quite a while so if he wasn't qualified for it, I'm pretty sure he wouldn't be there."
Cook, who said he has rappelled hundreds of times, is not a certified instructor but has completed an intermediate rappelling course with the Department of Public Safety. The sheriff's office also doesn't have structured training or guidelines for rappelling, and Cook had never run an exercise alone.
No one verified or inquired if officers had prior rappelling experience or training, records show.
Lynch had not rappelled in more than 12 years - his last time was with a church youth group, his widow, Christie, told investigators. And for many of the officers, it was the first time they had done it.
It was also the first time SWAT had used a new piece of equipment that the rope runs through, which Cook and other officers didn't know how to properly use or set up.
Cook told investigators that he gave a brief demonstration, showing "how I used the device."
But those instructions were in direct violation of the manufacturer's specifications, ADOSH found.
The investigation also revealed that the rope Lynch used was several millimeters too thin for the rappelling equipment, not creating enough friction.
Lynch and others were allowed to set up their own gear and descend without any checks.
And for most participants there were no safety spotters, or belays - something required by safety regulations and used by rappelling experts and other SWAT teams, records show.
A belay is a spotter who stands above or below a rappeller and can pull on excess rope to stop a descent. At least five of the officers who rappelled later told investigators they didn't know what a belay was, records show.
The sheriff's office has hired a law firm to challenge citations from ADOSH, which issued two $7,000 fines, the most severe penalty allowed.
But it's unclear if further action or discipline will be taken against any officers or the sheriff's office.
The Department of Public Safety was assigned to investigate Lynch's death.
That report has been completed and forwarded to the sheriff's office and Casa Grande police, DPS officials said.
But DPS is not releasing the report or information about the agency's findings.
Records personnel for the Department of Public Safety have not responded to records requests, e-mails and phone calls. DPS spokesmen also said that they will not comment on the investigation without the permission of the sheriff's office or Casa Grande police.
Sheriff's officials say that the report must come from DPS.
Lynch leaves behind a wife and children. His family has not yet decided if they will file a lawsuit.
But Christie Lynch said Wednesday that she has hired an attorney and is discussing the matter with other family members.
"I know that none of the guys would have intentionally done anything to hurt my husband," she said. "But I just don't know. It's obviously very disturbing that they wouldn't put safety measures in place that are pretty standard."