ERIC SCHWEGLER AND TIMOTHY EDGETTE
G3, Investigations, Reporting and Tracking
U.S. Army Combat Readiness Center
Fort Rucker, Alabama

A review of three recent M2A3 Bradley Fighting Vehicle (BFV) mishaps reveals a common theme. No, it’s not that two of the three mishaps involved rollovers, or that each resulted in at least one Soldier fatality. The commonality is risk management — more specifically, the lack thereof. The absence or lack of risk management is identified as a contributing factor in many fatal mishaps the U.S. Army Combat Readiness Center investigates. These BFV mishaps occurred in active-duty units in three very different locations. All three could have possibly been avoided had the leadership or the individuals involved just applied risk management.

Risk management is the Army’s process for helping organizations and individuals make informed decisions to reduce or offset risk. As defined in Army Techniques Publication (ATP) 5-19, Risk Management, the five steps of the risk management process are:

1. Identify the hazards.
2. Assess the hazards.
3. Develop controls and make risk decisions.
4. Implement controls.
5. Supervise and evaluate.

Using this process increases operational effectiveness and the probability of mission accomplishment.

While risk management is safety-related, it is not solely a warfighting function. It should apply to all on-duty and off-duty operations, tasks and activities. The principles of risk management include: integrate the process into all phases of missions and operations; make risk decisions at the appropriate level; accept no unnecessary risk; and apply risk management cyclically and continuously. In other words, apply risk management continuously on a recurring or repetitive basis. Soldiers should use a cyclical risk management process to identify and assess hazards; develop, choose, implement and supervise the controls; and evaluate and reapply the process as the outcomes and conditions change. Had this cyclical process been applied in any of the following three M2A3 BFV fatal mishaps, the outcomes could have (and should have) been different, if not avoided altogether.

While performing maintenance on a BFV in a maintenance bay with a 10-ton lifting crane, a motor sergeant made a wrong choice of action during a common maintenance procedure. He failed to use the required special tools when lowering the vehicle’s power unit access door (PUAD) as well as allowed a BFV maintainer to move between the PUAD and the engine compartment. When the improper piece of equipment — a troop strap — used to suspend the PUAD failed, it slammed shut on the maintainer.

The motor sergeant’s actions were in violation of the field maintenance manual and set the conditions for the mishap. In addition to the motor sergeant, the chain of command failed to provide adequate risk management. The motor sergeant and his Soldiers had worked 52 of the previous 72 hours preparing for a deployment. The chain of command’s failure to apply a cyclical risk management process to the deployment preparations, along with the motor sergeant’s failure to apply adequate risk management to his actions, resulted in the BFV maintainer’s fatal injuries.

The unit was conducting a nighttime tactical movement in combat vehicles using various night vision devices. Unfortunately, unit leadership did not identify the hazards associated with the night movement, including the impact the weather would have on the forward-looking infrared thermographic systems found on BFVs such as the driver’s vision enhancement (DVE), commander’s independent viewer (CIV) and improved Bradley acquisition subsystem (IBAS). The weather created a period of thermal crossover where the DVEs had limited contrast. Consequently, several drivers in the movement were unable to see the entrance to a bridge. Two BFVs drove onto the right guardrail but were able to recover and traverse the bridge. The mishap BFV, however, drove onto the left guardrail, which collapsed, causing the vehicle to roll off the bridge and into the creek. The vehicle came to rest on its turret, submerged in the water.

The leadership’s decision to conduct night tactical training in adverse environmental conditions (thermal crossover) with inexperienced crews was just one of the latent failures that contributed to this mishap. Had cyclical risk management been applied by the leadership, then maybe an administrative white-light movement would have been conducted instead. Leadership failed to cyclically identify and assess hazards. Their actions were in contravention to ATP 5-19 and resulted in three fatalities.

The unit was conducting a road test during daylight hours following vehicle maintenance. The driver was operating the BFV at a high rate of speed when he attempted to make a sharp, left-hand turn. The vehicle left the cement lane and its right track dug into the soft dirt and gravel shoulder. The BFV’s momentum caused the vehicle to overturn, crushing and killing the driver.

The vehicle commander exposed the crew and passengers to an unsafe course of action by not correcting the driver’s speed. He was overconfident that this road test was just a routine mission and set a portion of the conditions that led to this vehicle rollover and one Soldier fatality. Had the BFV commander assessed the hazards of allowing the driver to exceed the posted speed limit and of not enforcing standards, then he may have been able to apply a different course of action, thereby intervening prior to the mishap occurring. Additionally, unit leadership failed to provide adequate oversight on day-to-day tasks. When tasks/activities and day-to-day operations are viewed as routine, there is no cyclical application of the risk management process. When risk management is not applied at all levels during all phases, then there is a breakdown in the process.

These three BFV mishaps are all tragedies that did not have to occur. Had one individual, one leader or any member of the chain of command intervened and applied risk management to the task, activity or mission at hand, then the hazards might have been recognized and controls could have been implemented and supervised, which could have averted the action(s) that led to the mishaps. No planning, preparation or assessment can identify every hazard in a constantly changing environment. This is why a continuous reassessment should occur at the lowest level possible. Failure to apply risk management on a continuous basis throughout the planning, preparation and execution phases of a task, mission or in everyday life is contrary to ATP 5-19. If you don’t know how to adequately apply risk management, we suggest you familiarize yourself with ATP 5-19, Risk Management.