Martyn Horton, David Ramsden, Douglas Halliday and Alexander Isaac

Date of report	28 Apr 2015
Reference	2015-0164
Deceased	Martyn Horton, David Ramsden, Douglas Halliday and Alexander Isaac
Coroner	David Ridley
Coroner area	Wiltshire & Swindon
Category	Service Personnel related deaths
Source	judiciary.uk record · original PDF
Responses published	1

The report

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 Minister of State for the Armed Forces
Ministry of Defence

Floor 5, Zone A

Main Building

Whitehall

London

SW1A 2HB

CORONER

| am David Ridley, Senior Coroner, for the coroner area of Wiltshire & 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.

INVESTIGATION and INQUEST

On 5 July 2010 | opened the Inquests into the deaths of Colour Sergeant Martyn HORTON,
Lance Corporal David RAMSDEN, Private Douglas HALLIDAY and Private Alexander ISAAC
following the repatriation of their bodies into the United Kingdom from Afghanistan. | resumed
the Inquest on Monday 10 November 2014 but regrettably had to adjourn proceedings on 14
November 2014 as a result of potential evidence from an expert witness necessitating, in my
view, the need to recognise additional interested persons. The proceedings finally resumed on
Monday 21 April 2015 and | concluded all four Inquests on 24 April 2015. As a conclusion |
recorded a combined short form conclusion, that of road traffic collision, combined with a
narrative conclusion. | recorded in relation to the cause of death that all four had died as a result
of drowning when their vehicle became submerged following a road traffic collision that occurred
on the Bandi Baq Road, South of Gereshk, shortly after 2200 hours on 23 June 2010 in Helmand
Provence, Southern Afghanistan.

CIRCUMSTANCES OF THE DEATH

| have set out below the narrative conclusion that | recorded that sets out the circumstances of
death:

Road Traffic Collision whilst on Active Service in Afghanistan combined with a Narrative
Conclusion as follows:

Shortly after 2200 on 23 June 2010 the front left hand side of the Remote Weapons System
variant Ridgeback that Martyn, Doug and Alex were travelling in and that David was driving,
collided with the front right hand side of an Afghan National Police (“ANP”) Ranger vehicle that
had been parked on Bridge Harry with the front end of the vehicle protruding onto the Bandi Baq
Road, South of Gereshk, Helmand Province, Afghanistan. As a result of the collision the
Ridgeback veered to the left off the Bandi Baq Road and entered and overturned in the Narhr-e-
Bughra Canal that ran parallel to the road. Water quickly filled the Ridgeback and Martyn, David,
Doug and Alex were unable to escape and consequently drowned inside the vehicle.

The following matters contributed to the collision:
a) The speed the Ridgeback was travelling (more than 30mph but less than or equal to

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 { Fax 01722 332223

40mph) at the time of the collision;
b) The inconspicuous presence of the unlit and darkly coloured ANP patrol vehicle when
set against the dark background in the locality of the collision.

The following matters more likely than not impeded the ability to escape from the submerged
vehicle thereby contributing to the drowning:

c) The incident occurred at night and in the dark;

d) The water was cold and murky;

e) The force of the impact when the Ridgeback hit the water causing a blunt impact head
injury resulting in momentary grogginess/unconsciousness (will appear in respect of
Martyn, David and Alex) and;

f) The wearing of essential body armour.

CORONER’S CONCERNS

During the course of the inquest | heard evidence that gave rise to a number of concerns, some
of which | am aware are in the process of being addressed. In my view there is a risk that future
deaths will occur unless action is taken. In the circumstances it is my statutory duty to report
those concerns to you.

The MATTERS OF CONCERN are as follows. —

(lI) Suspension issues. During the course of the Inquest | heard how Ridgeback had been
introduced into UK operational service as part of an urgent operational requirement to provide
greater protection to UK service personnel on operation in Afghanistan due to the ever
increasing threat that had been developing from improvised explosive devices. | heard how the
original shell vehicle provided by the US manufacturer was modified to UK specifications by UK
Government contractors and | heard that the resultant additional weight appears to have in
particular resulted in an unusually large number of failures to the front spring hanger assembly,
mounting bracket as well as leaf spring failures with normal usage. Morgan Advanced Materials
have been contracted to remedy the problem and | understand that additional information
following the involvement of [J and members of the team of 710 Naval Squadron will be
helpful in trying to find a solution. | have been provided with a timetable in respect of which
various steps will be covered leading to a solution being found and rolled out which will exceed
the usual 56 day time period to respond to a Regulation 28 Report. As part of my Regulation 28
duty | would like to monitor the resolution of the issue relative to the failures in the front
suspension area and | am sure that the families of the four who died on 23 June 2010, even
though that the failure to that particular vehicle (Spring hanger bolt failure) did not cause or
contribute to their deaths, would also like to be appraised of developments insofar as sensitive
material is not disclosed. | am however still concerned that the focus appears to be solely on the
front suspension where the vast majority of the failures occurred. | would therefore ask for
confirmation that given the modifications affected the overall operational load of the vehicle that
the whole suspension system is reviewed with a view that ultimately it is fit for purpose having
regard to the additional operational load that UK specification vehicles are required to deal with
as compared to its American counterparts. In this respect | have suggested quarterly updates as
a way forward. For the avoidance of any doubt although the inquest focussed on the Ridgeback,
| am aware from the same Cougar family that the problem affected Wolfhound and Mastiff as
well which of course the UK Government purchased as well.

(Il) Height restrictions. During the course of hearing evidence, | heard that there were height
restrictions relative to the driver of Ridgeback vehicles as well as the designated Commander of
the vehicle. Ordinarily both the driver and Commander sit in the two front seats of the vehicle.
The vehicle involved in this particular incident was a remote weapon system variant Ridgeback
and unlike other variants, the right hand seat is occupied by the remote weapon gunner and the
Commander is moved to a position sitting at right angles to the driver who of course is occupying
the left hand front seat. Depending on operational assessment, |! am concerned that if there is a
height restriction for a driver and Commander that if a gunner is required to occupy the front right
hand seat, as is the case in the remote weapon system variant, that a height restriction ought to
apply to the gunner as well. !n this particular tragic incident | found no evidence that the height
of Private Alexander Isaac contributed to his inability to escape from the stricken Ridgeback
once it had entered the canal as he was able to remove his helmet and body armour and in fact
was one of the first bodies to have been recovered through the top hatch.

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223

(lll) Lighting. At the end of the day a Commander of a vehicle has overall control and a driver is
required to use his or her skill and judgement relative to road conditions and the vehicle
capabilities to drive at an appropriate speed taking into account speed limits. When responding
to an emergency such as in the QRF (Quick Reaction Force) role as is the case when UK civilian
emergency response vehicles are responding to a legitimate emergency, speed limits may not
ordinarily be adhered to and | very much take the view that it should be a matter of military
judgement taken by those who have situational awareness at the time. The evidence | heard
was that operationally drivers could realistically only see using white light approximately 10-15
metres in front of the vehicle. There was an issue with the Ridgeback involved in this incident in
that for some reason the main head lights had a lower specification bulb fitted 75/70 watts as
opposed to the specified 100/80 watt bulb. The Ridgeback is also fitted with 70 watt fog lamps
and set of 70 watt additional lights which were moved following the incident to the outside of the
bar armour. The main lights however still lie behind the bar armour and that must impede their
effectiveness. | would like you to review the effectiveness of Ridgeback lighting and arguably as
it is part of the Cougar fleet, the lighting of the Mastiff and Wolfhound also as they are similar
vehicles with the addition of an additional axle, as regards operational effectiveness especially if
such vehicles are intended to be used in a QRF role or when operational requirements dictate a
need to travel at speed. An operational limit of only 10-15 metres in front of the vehicle is in my
view restrictive and significantly restricts the safe speed of the vehicle allowing for reaction and
stoppage time. (retired) attempted as part of the LAIT investigation to carry out
tests on Salisbury Plain, although | do have some concerns in relation to the accuracy and
usefulness of the data obtained from those tests.

(IV) Tyre pressures. The Ridgeback in question following recovery was found to have under
inflated rear tyres some 13% less than the recommended PSI which | believe is 110. During the
course of the evidence | heard that the REME maintenance crew at MOB Price did not have
equipment to inflate tyres to that pressure and the on board compressor again did not have the
necessary capability to inflate tyres over and above 100 PSI. | was told that if the required tyre
pressure was to be achieved that the only equipment available was at Camp Bastion and of
course the vehicles were not regularly, when on operational service in Afghanistan, travelling to
Camp Bastion. | would ask that you review this concern. Tyre pressures are important. Both
under inflated and over inflated tyres can materially affect the handling of the vehicles and if
there is a specification for a certain tyre pressure then those operating or maintaining the vehicle
ought to have the ability to ensure the correct tyre pressure is achievable. Again this potentially
is applicable across the Cougar family fleet.

(V) AESP Torque references. During the course of the evidence | heard that the maintenance
of the Ridgeback vehicle was governed by AESP documentation. | was told by Craftsman
HEB that regularly at MOB Price during Herrick 12 whilst maintaining these vehicles that he
was unaware of the correct torque settings in relation to the front spring hanger assembly bolts
and would ensure in the circumstances that the bolts, to quote him, were “fucking tight’. There
were however torque settings but those settings appear to have been contained in the repair
section of the AESP documentation in Section 5 as opposed to the maintenance section in
Section 6. | fully accepted the evidence | heard that the AESP documentation is voluminous but
| am concerned and believe that it would be of assistance to REME personnel and those
responsible for the maintenance of the vehicles that consideration be given to ensuring mention
of a cross reference pointing in Section 6 at the relevant section to where the torque settings can
be found in Section 5 rather than repeating the verbatim the torque settings again. | would ask
that you give consideration to this so as to ensure correction maintenance procedures are
carried out.

(Vl) Ridgeback emergency lighting. | was pleased to hear that the luminescent tape that was
introduced following this incident is in the process of being replaced by an emergency lighting
system called VELS. | believe that the additional work and installation of this system has only
just started to be rolled out and | would be grateful for a timetable as regards its completion and
also given the similarity between Ridgeback, Wolfhound and Mastiff as to whether or not it will
include the other members of the Cougar family.

(VII) Component failure awareness. It was clear in 2010 that failures associated with the front
suspension and spring hanger assembly in the Cougar fleet were starting to develop and
following an incident involving a Ridgeback vehicle in Bovington in 2012, Qinetig were instructed

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223

to analyse these failures. During the course of the evidence | heard from those that were
maintaining these vehicles back in 2010 that the bolts on the front spring hanger assembly were
in need of regular tightening and the vehicle was subject to 21 day inspection checks. The joint
opinion of both A members of the team at 1710 Naval Squadron was that it should
not be necessary to repeatedly have to tighten the bolts relative to a component such as the
spring hanger assembly. The need for the retightening of bolts was in their view indicative of a
component issue and | would ask that you review from a learning point as regards raising the
awareness of Craftsmen and Technicians and not just in relation to Ridgeback or Mastiff but in
relation to any component across the services, that if an issue arises requiring regular or
unusually frequent tightening of component boits that that matter ought to be highlighted as a
concern warranting proportionate investigation relative to other similar pieces of equipment
experiencing the same issue, such as was the case here with the Cougar fleet of vehicles. The
retightening of bolts on a regular basis was something that was not captured as an issue in itself.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you have the power
to take such action.

YOUR RESPONSE

You are under a duty to respond to this report with the exception of item (I) within 56 days of the
date of this report, namely by 23 June 2015. As indicated in the respective item at 5.(I), | would
ask for quarterly updates until the issue is resolved. | am willing to consider varying that
frequency depending on the situation as it presents at the time if the request is made.

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
Messrs WilmerHale Solicitors, 49 Park Lane, London, W1K 1PS

Defence Inquest Unit, Floor 2, Zone 5, Ramillies Building, Marlborough Lines, Monxton Road,
Andover, Hampshire, SP11 8HJ

Government Legal Department, One Kemble Street, London, WC2B 4TS

| am 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 28 April 2015

Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223

Responses

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.

Response from Ministry of Defence (PDF)

®
Ministry
of Defence

RECEIVED
- 1 JUL 2015

MINISTRY OF DEFENCE
FLOOR 5 ZONE B MAIN BUILDING
WHITEHALL LONDON SW1A 2HB

Telephone: 020 7218 9000 (Switchboard)

PENNY MORDAUNT MP
MINISTER OF STATE FOR THE ARMED FORCES

D/MSU/4/7/1 25 June 2015

The Nv (iden,

Thank you for your Regulation 28 report of 28 April 2015 following the inquest into the deaths of
Private Douglas Halliday, Private Alexander Isaac, Lance Corporal David Ramsden and Colour
Sergeant Martyn Horton. The Ministry of Defence takes its relationship with HM Coroners
extremely seriously and we fully recognise how important it is that we learn all possible lessons
to ensure that deaths in similar circumstances in the future are prevented.

Your Regulation 28 Report raised seven concerns that | will address in turn. As you identify in
your report several of these concerns will be addressed over a period outside the usual 56 day
Regulation 28 report timeframe; the Defence Inquest Unit will provide you with quarterly updates
to allow you to monitor the resolution of the issues. The first update will be provided by 25
September 2015.

Suspension Issues

In response to your concerns we are conducting a review of the whole vehicle suspension
system with consideration also being given to the rest of the Cougar fleet of vehicles (Mastiff
and Wolfhound). This includes:

A review of all available data including that recently provided by 1710 Naval Air Squadron
(the Structural Materials Investigation team) in order to work out the best maintenance
schedule. We aim to complete this and release a safety notice with findings by 30 June
2015.

Morgan Advanced Materials has been asked to complete an investigation into alternative
bolts by 31 July 2015. Should the investigation prove that alternative bolts are required
then we will commence a programme of fleet modifications to replace all bolts across the
Cougar fleet of vehicles and review the associated maintenance routine by 31 August
2015.

An analysis of the entire spring hanger arrangement (front and rear) to identify potential
improvements. This will consist of an initial feasibility review of options, followed by the
design, prototyping and testing of proposed modifications or upgrades to ensure that the
issues identified have been successfully addressed. We aim to complete this by 30
September 2015 and will then make those improvements across the Cougar fleet of
vehicles (and review the associated maintenance regimes) by 31 January 2016.

A tull vehicle review of the Ridgback vehicle to determine the most effective suspension
system and options for implementation. This is a more complex piece of work with a
direct read-across from Ridgback to Mastiff and Wolfhound and will involve extensive
physical prototyping and trialling before design and testing of the safety and operational

Mr David Ridley

HM Senior Coroner for Wiltshire & Swindon
Wiltshire & Swindon Coroner's Court

26 Endless Street

Salisbury

Wiltshire

SP1 1DP

requirements for operating the vehicle. We will aim to complete the review by 31 October
2016 and make recommendations to Army HQ.

The dates stated at 2 and 3 above have both slipped by one month compared to those stated at
the inquest. This is following extensive work to cross-reference the activity that we are taking in
response to your concerns, with work already underway under contract with Morgan Advanced
Materials. This will help us to avoid overlap or clashing work programmes.

Height Restrictions

Following the conclusion of combat operations in Afghanistan, the Army Capability Directorate
for Combat has amended the height policy for vehicle crewmen across the range of in-service
platforms to maximise safety for those operating the vehicles. The new policy emphasises the
chain of command's responsibility to select and train personnel able to safely and effectively
carry out the tasks required of them. Commanders on operations are still able to re-impose
specific height restrictions on crew members should operational circumstances or the enemy
threat require it. In response to your concerns the Army Capability Directorate for Combat will
further review the wording of current policy on height restrictions for Ridgback and will ensure
this is based on seating position, rather than the individual's role as part of the crew. The
clarified policy is expected to be issued by 31 July 2015.

Lighting

In response to your concerns, Morgan Advanced Materials will provide an upgraded,
legislatively compliant lighting system across the Cougar fleet of vehicles. Establishing what this
means, and checking compliance with the Road Vehicle Lighting Regulations 1989, will be
different for each vehicle. As well as checking legislative compliance we will conduct a
subjective assessment of the performance of the fights in comparison with the old system from
the position of the crewmen. The final design review is planned for July 2015. The production
of circa 750 modification kits of a bespoke design will take 5 months after the final design review
has formally signed-off the modification; therefore modification kits are expected by 30
November 2015 and implementation will be complete by 31 December 2016.

Tyre Pressures

As your report identified, there is presently no on-board means (either in terms of vehicle
capabilities or by the use of carried tools) to inflate the tyres to the required pressure. The
requirement to check and adjust where necessary, tyre pressures is a daily task defined in the
relevant Army Equipment Support Publication (AESP). The MOD is currently investigating
means to provide the capability of inflating tyres to 110 PSI from systems contained or carried
on the vehicle; this work is being conducted in parallel with work to provide a similar capability
for the Jackal and Coyote fleets, consisting of circa 700 vehicles. We expect to have identified
options to provide this capability by 30 September 2015. In the interim, we have confirmed that
sufficient capability exists within the Army Light Aid Detachment! to ensure the tyres on
deployed vehicles can be maintained to the required pressure without having to return to a main
operating base.

‘ A unit of the Royal Electrical and Mechanical Engineers embedded within a deployed unit and charged with the provision of
immediate equipment support.

AESP Torque References

We are reviewing documentation to check for cross-referencing as you recommend. This
review will encompass all of the publications for the 21 different in-service Cougar-based vehicle
variants. The AESPs for the Cougar-based vehicle fleets are subject to a major update release
every six months. The next is due 31 August 2015; the review work is due to be completed
ahead of this date and any major findings will be issued in a Safety Notice prior to the formal
publication.

Emergency Lighting

The Vehicle Emergency Lighting System (VELS) modification is on-going. The VELS kits were
originally released to the Army and other users in June 2013; as at 02 June 2015 the

percentage of the Cougar fleet that has been modified is as follows, with the percentage of the
active fleet (vehicles actually being used by the Army and not in storage) shown in brackets:
Ridgback 74% (85%), Mastiff 72% (77%), Wolfhound 49% (61%). Based on the time taken to
complete modifications to date, the Army are expected to complete modifications on the active
fleet? by 30 June 2016 and will not be able to use active fleet vehicles after this date unless
VELS is fitted, with the whole of the fleet expected to be completed no later than the end of 2016.

| also wanted to provide you with the reassurance that the Roll Over Drills and Egress Trainer
(RODET) is being fitted with VELS as part of the Cougar fleet modifications. As at 02 June 2015
40% of the RODETs have been modified, with the rest of the fleet due to be modified by late
2016.

Component Failure Awareness

A review of current training in respect of component failure awareness has been completed.
This has resulted in direction to include additional lessons to reinforce the reasons and
timeframe for raising fault reports, and the importance of experienced tradespersons diagnosing
and reporting equipment failure to effective equipment support.

| hope this letter provides the reassurance and information that you were seeking and | am
content for you to copy it to other Interested Persons and the Chief Coroner.

PENNY MORDAUNT MP

? The active fleet is the vehicles that have been issued to field units.

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