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In a Rush to Human Error

In a Rush to Human Error


I grew up in the Midwest and spent a large portion of my early childhood living out in the country. It was there I formed my earliest memories of using various firearms while under the direct supervision and training of my father.

My father, an Army veteran, was an outstanding instructor and always adamant about including firearms safety in every lesson taught. Growing up, he taught me how to safely operate and fire shotguns, semi-automatic pistols of just about every caliber, revolvers, single-action bolt rifles and more than a half-dozen semi-automatic rifles. Not surprisingly, I now own a variety of pistols and rifles I take to a local civilian range at least 12 or more times a year.

With more than 25 years of firearms experience, I enjoy shooting and often score “expert” during annual military range qualifications. I’ve been in the Army National Guard for 15 years, deployed once to Iraq and am currently on my second deployment to Afghanistan. I’m giving you my background because it is important to consider. Despite all of that experience and safety training, it only took one instant of not being mindful of the task at hand to make a serious human error.

My unit and I arrived at Kandahar Airfield, Afghanistan, in mid-July and had just completed the two-week relief in place/transfer of authority process with the outgoing unit. On this particular day, I was scheduled for my fourth flight in theater and would be meeting the rest of my crew outside our re-locatable living barracks at 1845. Being a new pilot to the airframe, I was excited to begin our mission to support the troops on the ground.

I awoke to the sound of the alarm clock at 1730. After getting out of bed, I completed the normal routine of personal hygiene and dressed. I glanced at my watch and noticed I was right on schedule. I still had 45 minutes until my hard time of 1845, which was plenty of time to make the short walk to the chow hall, grab some food and make it back to meet the rest of the crew.

I returned to the RLB about 1835. My roommate had gone on an earlier mission that day so I was alone in the room. It had been weeks since I last cleaned my weapon, so I decided to make use of the extra 10 minutes before I had to meet my crew. I unloaded my M9 pistol, cleared the chamber and then disassembled and cleaned the weapon. After a thorough cleaning, I realized I only had a few minutes to get my things together and meet my crew for our departure. In my haste to get out the door, I assembled the weapon, loaded the clip in accordance with the current KAF weapons status and gathered my things.

Totally engaged in the process of ensuring I had everything, I grabbed a water bottle from the fridge and quickly realized I had not yet performed a function check on my M9. I returned to my weapon and began to hastily perform a function check. With the safety selector on safe, I pulled back the slide, released and pulled the trigger. The firing pin moved up and down, and the hammer didn't move as advertised. OK, now on to check the double action of the trigger mechanism. Set the safety selector to fire, squeeze the trigger … BAM!

As my mind processed the noise, I tried to make sense of what had just occurred. I couldn't believe what I had done. I hadn’t properly cleared the weapon! How could I forget that just moments before I had loaded the weapon? To say the gravity of this action immediately weighed heavily on me would be an enormous understatement.

I placed the safety selector back on safe and immediately went outside to investigate where the round had gone and determine whether anyone had been injured. Fortunately, no one was outside the entire row of rooms at the time. The round had gone through the window and impacted the T-barrier wall directly outside. Without delay, I reported the incident to my commander. He, in turn, initiated the serious incident notification process and notified our flight operations to find a pilot replacement for my mission that evening.

When the military police arrived, I filled out a sworn statement while they took photographs and collected evidence. Prior to their arrival, the commander talked with me and set me on course by saying, "We are not defined by our challenges, but by how we overcome them."

"Slow down and use the checklist." In the aviation community, a number of accidents are attributable to an individual’s self-imposed cognitive stress of just being in a hurry. In their haste, important checks are missed prior to takeoff or landing which may ultimately contribute to an accident. It’s important to be able to recognize this self-imposed stress and how it may affect our thought process and subsequent response. This very same concept can be applied to the error I made with the firearm. When I rushed to get out the door, I failed to slow down and use the checklist.

A weapons function test is a deliberate sequence of actions that must to be done in a specific order. The use of a simple laminated card with the 9 mm function check procedures printed on it may have been enough to cause me to refocus onto the more important task at hand instead of rushing to get out the door. The main point is to recognize when you are in a hurry and tell yourself to slow down when conducting tasks of this nature. It allows your brain to focus on the present and push past distractions. I believe my failure to slow down and rush through this process was the root cause of my negligent discharge.

After the fact and during the investigative process, I was informed that KAF has a “no weapons cleaning in the living areas” policy. Although this does not directly prevent negligent discharges, it does mitigate the risk of personnel injury by restricting where such tasks should be performed. No one else in my unit, however, was aware of this policy. This leads me to conclude that the effectiveness of the current dissemination of such policy needs to be reconsidered.

The final lesson that can be pulled from this experience is an identified training deficiency going well beyond the individual. Let me first start this discussion by saying I own my mistake. Even if every reader of this article is unfamiliar with the M9 function check procedures, everyone should know step one is CLEAR THE WEAPON. That should be a given and, in my case, I am mortified I failed to properly execute this initial step. Clearing your weapon applies in all situations, not just after firing. You must always assume a weapon — any weapon, even yours — is loaded (Field Manual 3-23.35).

The following is an observation I’ve made to help organizations improve their knowledge of the M9 function check. Take me out of the equation for a moment. Ask yourself what are the steps to properly execute a M9 function check and what should you be looking for in each step. I believe you will find an overwhelming majority, perhaps to include yourself, don’t know. Now ask yourself what the function check steps are for the M4. Many may recall from memory the M16/M4 function check procedure because of the emphasis and repetitive training we received during basic combat training. It was drilled into us. That training was emphasized.

Now, some of you may already be chomping at the bit to argue that the need for a function check for an M9 is minimal because it doesn't have all the additional components an M16/M4 rifle has, such as a bolt, firing pin, retaining pin, bolt cam pin, etc. So does the Army want us to do an M9 function check after each cleaning procedure? The answer is yes. Field Manual 3-23.35, Combat Training with Pistols, M9 and M11, states, “Always perform a function check after reassembling the pistol to ensure it is working properly.” After completing the steps, which I’ve listed below this article, the field manual goes on to state, “If during the safety/function check the M9 performs as just described, then it is mission ready.” There needs to be more training and better emphasis on this procedure.

Not a day has gone by that I have not reflected on this event. Every day I thank God that no one was injured.  When I take myself out of this equation, when I take out all the self-inflicted humiliation, damaged pride/ego and shame caused by my negligence, there is a powerful and very humbling lesson that can be learned through my story. As humans, every single one of us has the capacity of making the very same mistake I did. Remember to recognize in yourself that when you get into a rush, this thought process negatively influences your actions, timing and sequence. Break this thought process by mentally telling yourself to stop for a second and “slow down and get out the checklist.”


So what are the proper clearing procedures for the M9?


The first step in maintenance is to clear the weapon. This applies in all situations, not just after firing. You must always assume that a weapon--any weapon, even yours--is loaded. To unload and clear the pistol, perform the following procedures:

  1. Point weapon in a safe direction.
  2. Place decocking/safety lever in the SAFE position.
  3. Remove the magazine by pressing the magazine catch button and pulling the magazine down.
  4. Grasp the slide serrations and fully retract the slide to remove the chambered cartridge.  Lock the slide to the rear by pushing the slide stop up. Check receiver and chamber to ensure these areas contain no ammunition.
  5. Release the slide by pushing the slide stop down. Ensure the decocking/safety lever is in the SAFE position.

What are the steps required to perform a function check for the M9?


Always perform a function check after reassembling the pistol, to ensure it is working properly:

  1. Clear the pistol in accordance with the unloading procedures.
  2. Depress the slide stop, letting the slide go forward.
  3. Insert an empty magazine into the pistol, and ensure that the magazine catch locks the magazine in place.
  4. Retract the slide fully and release it. The slide should lock to the rear.
  5. Depress the magazine release button and remove the magazine.
  6. Visually inspect to ensure the decocking/safety lever is in the SAFE (down) position.*
  7. Depress the slide stop. When the slide goes forward, the hammer should fall to the full forward position. The decocking/safety lever must remain in the SAFE (down) position.*
    *NOTE: If the safety lever moves to the fire position (up) during steps f. and g. above, then the weapon is non-mission capable. Evacuate the weapon to field-level maintenance for repair.
  8. Squeeze and release the trigger. The firing pin block should move up and down and the hammer should not move.
  9. Place the decocking/safety lever in the FIRE (up) position.
  10. Squeeze the trigger to check double action. The hammer should cock and fall.
  11. Squeeze the trigger again. Hold it to the rear. Manually retract and release the slide. Release the trigger. You should hear a click, and the hammer should not fall.
  12. Squeeze the trigger to check single action. The hammer should fall.
  • 1 January 2015
  • Author: Army Safety
  • Number of views: 11556
  • Comments: 0