MIKE BARKSDALE and CHRIS FRAZIER
U.S. Army Combat Readiness Center
Fort Rucker, Alabama

For the past 20 years, the Army has attempted to integrate risk management into all areas of Soldiers’ lives both on and off duty. Publications, safety briefs and numerous products and tools are dedicated to risk management in hopes of preserving combat power and both human and materiel resources. Despite these efforts, some leaders and Soldiers still fail to apply the five-step risk management process — identify the hazards, assess the hazards, develop controls and make risk decisions, implement controls, and supervise and evaluate — into every operation. This is evident in several fatal mishaps investigated by the U.S. Army Combat Readiness Center.

Land navigation
While attempting to complete a three-hour land navigation exercise during heat category 4 and 5 conditions, a Soldier lost his phone, watch and was running low on water. He had yet to find any of his intermediate points when he encountered two other Soldiers on the course. One of the Soldiers had already located three of his four intermediate points and offered to lead everyone to the rally point. The second Soldier accepted the offer, but the mishap Soldier wanted to finish the course unassisted. After leaving the two Soldiers to resume the exercise, the mishap Soldier suffered an exertional heat illness, became disoriented and lost consciousness. When he failed to return to the rally point, leaders conducted an extensive search using helicopters, specialized canine teams, trained personnel recovery units and more than 500 personnel. The Soldier’s body was found two days later, south of where he last spoke to the other two Soldiers.

Where were the risk management failures?

• The cadre failed to evaluate the hazard associated with training in heat category 4 and 5 conditions and did not have the means to monitor the wet bulb temperature.


• A failure to evaluate the environmental hazards, followed by a failure to develop controls, led to Soldiers departing with a single 1-quart canteen. In addition, the implementation of control of water points did not mitigate the hazard associated with Soldiers running out of water. The Soldiers did not understand the placement of the water points, and the cadre did not place the water points at high-traffic areas on the course. The cadre also did not refer to Technical Bulletin Medical 507, Heat Stress Control and Heat Casualty Management, during the assessment of the hazards associated with the environmental conditions.


• At the instructional level, the Army failed to implement controls related to requiring the use of individual tracking devices on land navigation courses.


• Soldiers must assess the hazards of continuing training with no means of communication and an inadequate water supply. They must adhere to the heat illness prevention guidance provided to all Soldiers before conducting a land navigation exercise.


• Leaders must ensure Soldiers understand how to recognize and treat heat illnesses. TRADOC Regulation 350-29, Prevention of Heat and Cold Casualties, and TB MED 507 provide guidance on the use of iced sheets and treatment of potential heat illnesses.

Ground guiding
A specialist and two newly assigned wheeled vehicle mechanics, who recently graduated from advanced individual training, were tasked to move a disabled medium tactical vehicle from a maintenance bay with a tow bar. The crew spent the morning connecting the tow bar to a 10-ton dump truck and attempting to free the disabled vehicle’s brakes. They were unsuccessful, so they disconnected the tow bar, moved the dump truck and left for lunch. Afterward, the specialist went to a smoking area while the two mechanics resumed their efforts to move the MTV. One mechanic, who was untrained and unlicensed, backed the dump truck while the second mechanic attempted to align the tow bar. The driver lost sight of the second mechanic but did not stop the truck until he heard it strike the MTV. The second mechanic was trapped between the two vehicles and suffered fatal injuries.

What can the Army do to prevent similar mishaps from occurring in the future?

• Leaders must assess hazards with inexperienced mechanics and unlicensed drivers conducting maintenance tasks.


• Leaders must ensure team composition is appropriate for safe task completion.


• Cautions and warnings found in technical manuals constitute effective controls. In this mishap, leaders failed to supervise the implementation of those controls when they did not require inexperienced mechanics to have TMs on hand.


• Leaders failed to communicate the hazard and supervise controls related to ground guides and the hazard associated with Soldiers placing themselves between two vehicles or equipment, the requirement to remain visible to drivers at all times, and for drivers to stop if they lose sight of the ground guide.

Vehicle towing
While conducting like-vehicle towing, an M1151A1 HMMWV driver descended a hill on an interstate highway at an excessive speed. As the HMMWV approached a tractor-trailer ahead, the driver locked the brakes and lost control of the vehicle. The HMMWV left the roadway, continued down a severe downslope — shearing the tow bar from the towed M1151A1 — and overturned. The HMMWV driver was ejected from the vehicle and died at the scene, while the truck commander suffered minor injuries. Although the towed HMMWV did not overturn, it struck a stand of trees, causing damage to the vehicle.

What can the Army do to prevent similar mishaps from occurring in the future?

• When conducting towing operations, Soldiers must follow the guidance, which equates to steps three and four of the risk management process, in Training Circular 21-305-20, Manual for the Wheeled Vehicle Operator, Chapter 17, Vehicle Recovery.


• The technical manual must provide specific guidance regarding the maximum speed a Soldier should drive while conducting like-vehicle recovery. In addition, units should have a written standard operating procedure or deliberate risk management worksheet specific to the operation.


• Soldiers must always wear their seat belts when operating or riding in a vehicle. Truck commanders must verify Soldiers are wearing their seat belts properly.

Trailer hook-up
During a training rotation, the HEMTT fuel crews were directed to disconnect the M1076 trailers loaded with the M107 Modular Fuel System. When they finished, the crew did not place chock blocks behind a trailer, which was parked on a 7 degree downslope. After receiving simulated indirect fire from the opposing force, the unit decided to reposition. The distribution platoon sergeant directed a driver and assistant driver to connect the M1076 trailer to their HEMTT. While connecting the air hoses, the trailer’s spring brakes released, causing it to roll forward 4 feet into the rear of the HEMTT. The assistant driver was crushed between the trailer and HEMTT and died from her injuries.

What can the Army do to prevent similar mishaps from occurring in the future?

• Leaders must follow the cautions and warnings in the TM and ensure operators use chock blocks during hook-up operations to prevent inadvertent vehicle and equipment movement. Once again, TMs are a valuable source for hazards and the development of controls for Army equipment.


• Leaders must ensure Soldiers park equipment on level ground, rather than a slope, before emplacing chock blocks as required in the TM.


• Leaders must properly supervise preventive maintenance checks and services.


• Leaders must ensure they communicate deliberate risk management worksheet guidance to subordinate leaders who are responsible for the implementation of controls and supervision necessary to mitigate hazards.

Range operations
After firing more than 500 rounds of 5.56 mm ammunition within seven to eight minutes, a Soldier placed his M4A1 on the ground, oriented toward several other Soldiers. The heat generated from continuous automatic fire cooked off a round still loaded in the weapon, which struck a Soldier in the abdomen. The Soldier died from his injuries.

What can the Army do to prevent similar mishaps from occurring in the future?

• Leaders must prioritize the tasks of making weapons safe upon the cease-fire command.


• Leaders and Soldiers must ensure a loaded weapon is never placed on the ground, pointing at others.


• Leaders must enforce range safety standards by assigning line safeties, monitoring rates of fire and never deviating from the course of fire.


• Safe weapons handling must be incorporated in all training events with weapons, with particular attention being placed on muzzle awareness.

Conclusion
Risk management is more than just a check-the-block requirement; it’s a combat multiplier. Leaders must understand the importance in integrating risk management into the planning, preparing, executing and assessing of all operations. Failure to correct unsafe practices by enforcing basic standards, namely the five steps of the risk management process, was a common causal factor in each of the fatal mishaps discussed above. As a result, five Soldiers lost their lives, their families and friends lost loved ones, and their Army formations lost combat strength.