Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0100, written 16 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Mar 2015 |
|---|---|
| Reference | 2015-0100 |
| Deceased | Tom Sawyer and Danny Winters |
| Coroner | David Ridley |
| Coroner area | Wiltshire & Swindon |
| Category | Service Personnel related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
DAVID W. G. RIDLEY
Senior Coroner for Wiltshire and Swindon
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Rt Hon Mark Francois MP
Minister of State for the Armed Forces
Whitehall
London
SW1A 2HB
CORONER
lam DAVID RIDLEY, Senior Coroner for Wiltshire and Swindon
CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www. legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 26 January 2009 my predecessor, David Masters, opened the Inquests into the deaths of
Captain Tom Sawyer and Corporal Danny Winters following the repatriation of their bodies into
the UK from Afghanistan. The delay in the progress of the Inquest was due to waiting for the
outcome of a Service Inquiry into not only Tom and Danny's death but also the deaths of 2
Danish soldiers who were killed in an incident involving the Javelin missile system 2 years earlier
in Afghanistan. Delay also arose as a result of waiting for a decision out of the Supreme Court
relative to Article 1 (Jurisdiction Overseas) of the European Convention on Human Rights and
the application of Article 2 in relation to Military Operations overseas. The investigation was
finally concluded on 11 March 2015 at the end of nearly 3 weeks. | recorded as a conclusion a
Narrative Conclusion and recorded that both Danny and Tom died as a result injuries caused by
an explosion following the Javelin missile being launched and striking the compound roof where
Danny and Tom were located in Mirmindab area, Nahr-e-Saraj District, Helmand Province,
Southern Afghanistan on 14 January 2009.
CIRCUMSTANCES OF THE DEATH
{ have set out below the Narrative Conclusion that | recorded as follows:-
Narrative Conclusion
Danny died as a result of unsurvivable blast injuries caused by an explosion when a Javelin
missile fired by friendly forces at approximately 2050 on 14 January 2009 struck the roof of an
unnamed compound lying approx 1300m South West of FOB Gibraltar in the Mirmindab area of
the Nahr-e-Saraj District of Helmand Province, Afghanistan. Danny was killed outright.
The following factors contributed to the firing of the Javelin missile:
a) Poor weather conditions with low visibility and intensely pitch black night time conditions;
b) The late arrival of the Delta Company Javelin crew at the over watch rooftop position at
Compound 4 resulting in an inability to create a full battle card due to low visibility;
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
c) The late arrival of Zulu Company into position at the unnamed compound (Nitrogen) and
at significantly reduced numbers resulting in Zulu Company not permanently marking
their position with combat identification markers;
d) As a result of items a) and c) above the inability of the rooftop platoon to secure a known
permanent fix on Zulu Company's location;
e) Intelligence indicating the presence of enemy forces in the area and earlier enemy
contact prior to the incident;
f) Ineffective communications between an intermediary and the commander of the rooftop
platoon;
g) Loss of situational awareness on the part of key personnel;
h) Mistaken positive identification of Zulu Company's position as the location of enemy
forces; and
i) The failure to include in the Javelin safety case its use in the anti personnel role resulting
in the inadequate assessment of the risk of using that weapons system in that role
| would add further that the operation itself involved members of the British Armed Forces as well
as members of the Danish Armed Forces as coalition members of ISAF.
CORONER’S CONCERNS
During the course of the Inquest the evidence revealed matters giving rise to concern. In my
opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it
is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
Radio Equipment
During the course of the investigation | had access to hand written radio logs. There were
essentially 2 radio nets of interest in relation to the investigation of this incident, firstly the
BATTLE GROUP NET in respect of which | had some of the logs and secondly the FIRESNET in
respect of which no logs materialised despite efforts to locate them and this even included
attempts during the course of the final Inquest hearing.
As | indicated in Court ! find it hard to understand that in the 21% Century that there is still a huge
amount of dependence on hand written radio logs in respect of which “Coms” are recorded
subject to the judgement of that particular signaller relative to the skills of that signaller in
recognising what is relevant and what is not. One of the objectives of a Coronial Inquest where
especially Article 2 is engaged, as was the case in this Inquest, is to consider matters with a view
to the prevention of future deaths and of course this is an area which overlaps between my
Coronial function and that of a Service Inquiry. The absence of records/logs in relation to the
FIRESNET in my view was not helpful in getting to the bottom of what went wrong especially as
regards the communication between Tom, as a Forward Artillery Observer with Zulu Company,
and his Danish counterpart “Soldier I”. | found that on a balance of probabilities that something a
step away from express instruction to fire was said by Tom to Soldier | which was then mutated
when he relayed the signal to his colleague Soldier A, located on the rooftop of the compound
providing over the watch where of cause the Javelin detachment which fired the Javelin missile
was located. It was Soldier A who gave the order to fire. | found on the balance of probabilities
that there was ineffective communication between Soldier | and Soldier A.
Investigating such matters requires the best evidence available and as regards current
technology | am surprised that there is not the ability at least at one end of the radio
communications network to for example, securely digitally record the encrypted signals along
the lines of say a cockpit voice recorder. For security reasons such recordings could then be
decrypted and made available to any subsequent investigation that needs to be carried out. |
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
fully appreciate that such a system may not be appropriate for those actually on the ground for
reasons of additional weight but it was clear to me that communications were being monitored
back at the Forward Operating Bases and that perhaps may be a location where
communications being monitored/relayed could be recorded at the same time. It may be the
case that technology would allow some form of recording say on a 2 hour loop on equipment
given to soldiers on the ground but as | said earlier | am conscious of the amount of weight
soldiers on the ground have to carry in respect of their combat kit and weapon.
It is worth noting that Tom and Danny's respective families were also concerned as regards the
absence of FIRESNET logs.
Monitoring of the BATTLE GROUP NET in such a way would have also been helpful although
there were some logs in relation to communications over this net. The benefit of having
accurate records of communications bolsters the integrity and thoroughness of any investigation
and may have highlighted matters warranting further consideration with the view to the
prevention of future deaths. | am sure that such a system would be beneficial to future
investigations aimed at the prevention of future deaths.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you the Minister of
State for the Armed Forces have the power to take such action by way of a review.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
12 May 2015. |, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons
The Treasury Solicitor
The Defence Inquest Unit
Parker Bullen Solicitors
who may find it useful or of interest.
lam also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.
Dated 16 March 2015
Signature ar ays
Senior Coroner for Wiltshire and Swindon
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
ge RECEIVED eS) 29 APR 2015 MINISTRY OF DEFENCE _— FLOOR 5 ZONE B MAIN BUILDING Ministry = WHITEHALL LONDON SW1A 2HB of Defence Telephone: 020 7218 9000 (Switchboard) THE RT HON MARK FRANCOIS MINISTER OF STATE FOR THE ARMED FORCES D/MSU/4/7/1 27 April 2015 Veow Mr ra ly, Thank you for your letter of 16 March in which you enclose a copy of the Regulation 28 Report following the Inquest into the deaths of Captain Tom Sawyer and Corporal Danny Winter. As you will be aware, my Department takes its relationship with HM Coroners very seriously and we fully recognise how important it is that we learn all possible lessons to ensure that deaths under similar circumstances in the future can be prevented. In your report you have raised concerns about the possibility of voice recording radio communications in order that it may assist inquiries and investigations in the future, particularly with a view to identifying where future deaths may be prevented. In terms of the current situation, written logs of communicating and military command radio nets should be maintained and kept. Additionally, in 2009 some of our voice communication functions migrated to ‘Chat Net’ systems, which are computer-based, user-typed text exchanges, similar to a civilian internet chat room. These too are recorded and archived. However, currently none of our voice-based systems can be recorded. In terms of our future capabilities, the next generation of tactical command, control and communications system for Defence includes a requirement that “The [User] shall be able to access an automated secure voice log of their primary net.” The full scope of this requirement and its implications will be investigated during the Assessment phase of the programme in the period up to 2018, but it is unlikely that this will include the ability to record all communication networks ail the time due to practical limitations. Policy will therefore be developed by the newly appointed Army Chief Information Officer to determine when and how such a capability will be used in the future. | have ensured that your concerns have been passed to him. | hope that this response helps to address your concerns and | am content for you to copy this response to the Chief Coroner and other Interested Persons. Yorn wer RT HON MARK FRANCOIS Mr David Ridley HM Senior Coroner for Wiltshire & Swindon Wiltshire & Swindon Coroner's Court 26 Endless Street Salisbury Wiltshire SP1 1DP
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