Brecon Beacon soldier deaths – Army ‘drifted towards failure’
A military inquiry into the death of three soldiers on the Brecon Beacons in 2013 has found that more Army reservists risk dying on SAS selection training because commanders are not sufficiently preparing them for the gruelling test.
Three part time soldiers who died of heat exhaustion after a mountain endurance march had not had enough training for the test and were not ready, compared to regular Army comrades.
Although parts of the Defence Safety Authority (DSA) report have been withheld, its executive summary and 114 recommendations have been released.
On 13 July 2013, during a military exercise on the Brecon Beacons, a number of Service personnel succumbed to exertional heat illness, due to the demanding physical nature of the exercise and the prevailing temperatures. Of those who succumbed, two Reservists died that day, and a third died in hospital on 30 July 2013. There were a further eight heat illness casualties of which three were hospitalised after the event.
The investigation panel identified four causal factors which led directly to the incident, namely:
1. all three Reservists died from the effects of hyperthermia caused by exertional heat illness
2. the Reserve Units did not train their candidates to the same level as the Signals candidates
3. those planning the exercise did not ensure that there was a Safe System of Training in place
4. the exercise planners, those overseeing the exercise (including the medical support) and, most significantly the chain of command, did not understand exertional heat illness.
The report adds that there was a lack of understanding of the risks of exertional heat illness at all levels. The link between the design of the military exercise and the risk was not comprehended. This meant that the exercise planners and the chain of command did not recognise that the control measures they had put in place to help reduce the risk of injury were inadequate. Essentially, it was not recognised that there was a risk of sustaining serious casualties due to exertional heat illness in the UK.
The report suggests that the Signals Regiment that planned the trial had “drifted” towards failure, a phenomenon identified after other disasters such as the Space Shuttle Challenger.
The safety culture that was in place at the time is criticised in so far as the ‘routine training was not sufficiently mature’ to help identify the risk. The report makes some 114 recommendations, such as improving the Army’s “safety culture”, including factoring in individuals’ experience as a risk factor during exercise planning.
Clare Stevens, a lawyer representing the father of one of the deceased, said: “The inquiry admits that information from previous training fatalities was not exploited, lessons were identified but not learnt and opportunities to improve procedures were missed.
“It points to serious failings. Almost four years on, they admit lessons are only just being learnt despite a number of ‘near misses’ in the intervening years. There is no reassurance that this will not happen again. This is just not acceptable.”
The Army said it had already acted on the recommendations made by the coroner.
An MOD spokesman said: “Our deepest sympathies remain with the families of all three soldiers and, with all the recommendations from this report having been or being addressed, we are committed to doing all we can to ensure such a tragic event cannot happen again.”
The DSA was created in March 2015, combining the Defence Safety and Environment Authority (DSEA), the Military Aviation Authority (MAA) and the Defence Fire Safety Regulator (DFSR) in a single organisation.
Sleep and Fatigue: Director’s Briefing
Fatigue is common amongst the population, but particularly among those working abnormal hours, and can arise from excessive working time or poorly designed shift patterns. It is also related to workload, in that workers are more easily fatigued if their work is machine-paced, complex or monotonous.
This free director’s briefing contains:
- Key points;
- Recommendations for employers;
- Case law;
- Legal duties.