Darren Neilson

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1. MOD
2. BAE Systems Ltd
CORONER

| am Louise Hunt Senior Coroner for Birmingham and Solihull

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 30/06/2017 | commenced an investigation into the deaths of Matthew Karl Hatfield and
Darren Paul Neilson. The investigation concluded at the end of an inquest on 17th July 2018.
The conclusion of the inquest was:

The main cause of this incident was the tank being able to fire without the BVA assembly being present.
During production and manufacture of the gun this hazard was not adequately considered or
investigated and therefore the ability of the gun to fire without the BVA assembly present when the FNA
with attached TVE is manually fitted in accordance with the TVEDU red drill went undetected. There were
other issues which contributed to the incident. At the time of the incident there was no written process
in place to check for the presence of the BVA assembly or any written process to confirm when it should
be removed and where it should be stored. The prove the gun drill was misunderstood and there was a
grey area around when it should be done. The decision to undertake an experience shoot was
opportunistic and not communicated adequately. There was no written handover procedure in place and
no handover occurred between the crews. Failure to correctly stow charges caused a secondary
explosion following failure of the breech block due to the absent BVA assembly. The practice of
unstowed charges was routine in the regiment and had not been identified or addressed by senior
officers.

CIRCUMSTANCES OF THE DEATH

The tank involved in this incident was a Challenger 2 call sign DS39AA which has a L30A1 120mm gun.
The gun was designed and manufactured in the 1980s coming into use in Challenger 2 in 1994, The gun
fires a projectile by a Tube Vent Electrical (TVE), which sits in the Bolt Vent Axial (BVA) assembly, igniting
a propelling bag charge which then leads to the build-up of hot pressured gases which force the
projectile out the barrel. The BVA assembly is a mushroom shape assembly. When the electrical circuit is
made the stalk of the BVA assembly safely retains the TVE during firing of the gun system and allows the
flame to be directed onto the charge through the flash panel to ignite the charge. The head of the BVA
assembly creates a rearward seal when the gun fires to stop the high pressured hot gases which form —
from the lit bag charge coming back into the turret thus facilitating the gun to fire the projectile. During
the manufacture and production of the gun it was not identified that the gun could fire without the BVA
assembly being present in combination with the Tube Vent Electrical Display Unit (TVEDU) red drill.

Cpls Hatfield and Neilson were Regimental Instructors Gunnery (RIGS) in Badger Squadron of the Royal
Tank Regiment. They were at Castlemartin firing range as part of a planned live firing exercise
culminating in a routine Annual Crew Test (ACT). The person in charge of the exercise was the Range
Conducting Officer (RCO). On 14/06/17 the final ACTs were concluded just before lunchtime. The BVA
assembly in tank DS39AA was removed, cleaned and replaced in the brew bin (a compartment in the

tank). It was wrapped in a rag and covered by a prestle and red mine tape. The outgoing crew from the

morning ACT were not aware that the tank would be used again that day. The white board showing the
day’s activities only detailed the morning ACT for the tank. There was no formal written process in place
at the time to say when the BVA assembly should be stripped and where it should be stored before being
checked by the armorer. A practice had developed for the BVA assembly to be taken out of the tank and
stored in the range tower at the end of the day to be inspected by the armourer that evening or the
following morning before being refitted to the tank by the first oncoming crew the next day. The RCO
was not aware that the tank had been stripped down and the BVA assembly removed. The RCO did not
adequately communicate that an experience shoot was taking place that afternoon as it was
opportunistic..An experience shoot involves a non-qualified person being in the tank in the gunner’s
position to fire the gun. The required permissions were not obtained for the experience shoot however
any risk was mitigated by the two RIGS (Cpl Hatfield as loader and Cpl Neilson as commander) being part
of the tank crew. The other tank crew consisted of i a: driver. 4 Shell 120mm TK practice SH
L36A6 projectiles with bag charges and 4 shot 120mm TK DS practice L29A1 projectiles with charges were
loaded into the tank with some additional rounds for the chain gun.

When the experience shoot crew entered the tank at around 15.00 hrs the tank was running. It was not
recognised that the BVA assembly was absent and they would not have expected it to be missing. The
loader placed his mobile phone in the brew bin and did not see the partially covered BVA assembly. At
some point the loaders tray was put in place and the firing needle assembly (FNA) inserted. The Prove
The Gun drill (PTG) ensures there is no ammunition within the gun and at step 6.13 requires the BVA to
be checked for any TVE. It'is not clear if this drill was done however it is possible to do the drill without
noticing if the BVA assembly is present. The crew prepared to fire a shell 120mm TK practice SH L36A6
projectile using a bag charge and got a TVEDU red light warning. The most likely explanation for the
TVEDU red light warning would be a failed vent tube insertion (the mechanism to ignite the charge bags
used to propel projectiles). The loader would have run the accepted TVEDU red drill which includes
manually fitting another vent tube on an ENA. It is possible to do this without noticing the BVA assembly
is absent. This would have achieved a green light on the electrical circuit as the BVA assembly is not part
of the electrical circuit. The tank would then have gone ahead to fire. As the BVA assembly was missing
no adequate rearward obturation would be achieved in the gun which resulted in extremely hot
pressurised gases from the ignited bag charge in the barrel coming back into the tank turret. This was the
hissing noise heard by witnesses andj’ he pressure then reached a point where the breech
block exploded causing the upper breech block to be severed off landing in the back of the turret. After
hearing the hissing Cp! Neilson was seen to attempt to leave the tank through the commander’s hatch, as
the breech exploded he was propelled out of the hatch landing on his head/face several meters away.
Flames were then seen to come from the commander’s and loader’s hatches and the barrel. These were
from the ignited unstowed propelling bag charges in the turret. One DST charge bag was on the charge
storage locker in front of and to the left of the loader and 3 HESH bag charges were in the projectile racks
‘to the right and slightly behind the loader. The DST bag charge likely ignited first followed by the other
bag charges causing an immensely hot fire ball in the turret. The fire from the ignited charges was similar
to a jet engine fire and was extremely intense. Cpl Hatfield was found wedged against the loading guard
and was seriously burnt with his coveralls and shoes melted. The gunner was found with serious burns in
the gunner’s seat. The driver (who is sitting in a different compartment of the tank) was injured but his
injuries were more minor. Army medics attended the scene within minutes and other emergency
services were called and arrived quickly. Cpl Neilson required CPR and intensive treatment before being
taken by air ambulance to University Hospital in Cardiff where despite further attempts to treat him he
died on 15/06/17. Cpl Hatfield was extracted from the tank and given first aid and taken by air
ambulance to Morriston hospital where despite further treatment he died on 15/06/17.

Following a post mortem, the medical cause of death was determined to be:

Cpl Hatfield: 1a BLAST RELATED BURNS

CpI Neilson: la HYPOXIC ISCHAEMIC ENCEPHALOPATHY FOLLOWING CARDIAC ARREST
1b BLAST RELATED INJURIES

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. -

1. Iremain concerned that soldiers are not clear about when to use the Prove The Gun drill and

the meaning of the word “work” in the drill. This was supported by the evidence of
ho stated there was still a lack of clarity. The MOD should ensure that soldiers are
clear about the meaning of the word work in the drill and when the drill should be undertaken.

2, One of the contributing factors to this tragedy was that the RCO, the person in charge of the live
firing exercise, did not know the state of the tanks on the range and therefore allocated a
stripped down tank for a live firing exercise. | remain concerned that it is vital that the person in
charge of such exercises has up to date knowledge about the status of the tanks on the range.
The MOD should look at what communication can be put in place to ensure the RCO is in fact in
charge and has all the correct information to make decisions during the exercise.

3 a the HSE confirmed that had applied advanced or developed risk assessment
techniques been undertaken then it would have been identified in the design and manufacture
of the gun that it could fire without the BVA assembly present when undertaking the TVEDU red
drill. BAE and the MOD should look at their process to ensure that their risk assessments are
suitable and importantly that drills are actively considered when assessing risk and identifying
hazards during manufacture.

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 within 56 days of the date of this report, namely by 12
September 2018. |, 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:
Family of Matthew Hatfield

- of Darren Neilson

Dyfed-Powys Police
HSE

{have also sent it to the Minister for Defence who may find it useful or of interest.

fam 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.

18/07/2018

Signature Botlied

Mrs Louise Hunt
HM Senior Coroner
Birmingham and Solihull

BAE SYSTEMS

RAE Systems Land UK
1 Radial Park Road
Washington
Tyne and Wear
NE37 1PA
United Kingdom
T+44(0)3300481 ill
baesystem scom

10/09/2018

Mrs Louise Hunt
HM Senior Coroner
Birmingham and Solihull Areas
50 Newton Street
Birmingham
B4 6NE

Dear Madam,

Inquest into the Deaths of Matthew Karl Hatfield - Deceased and Darren Paul Neilson -
Deceased

We refer to the Regulation 28 Report to Prevent Future Deaths following the completion of the
Inquest into the deaths of Matthew Hatfield and Darren Neilson. The information below is intended
to provide assurance that the issue raised through the findings of your investigation, has been fully
reviewed and adequately addressed by BAE Systems.

The Report raises three matters of concern. This letter responds on behalf of BAE Systems to the
third concern which is directed to both MoD and BAE Systems (the other two matters of concern
being directed to MoD alone).

The Inquest heard evidence that -

•

•

•

the gun was designed by the Government owned Royal Armaments Research and
Development Establishment (R.ARDE) and that thereafter it was brought into production by
the Government owned Royal Ordnance Factory Board, working together with RARDE.

there was a Design Freeze in 1987. After that date any modifications to the design had to
be approved by MoD.

the safety of the gun design and its suitability for use was separately assessed by the
MoDs Ordnance Board in 1989 and 1994.

In your narrative setting out the Circumstances of Death you accurately summarise that evidence
above “The gun was designed and manufactured in the I 980s coming into use in Challenger 2 in
1994”.

BAE Systems, as you are aware, had no involvement with the gun during this period and did not
come into existence until 1999. British Aerospace, a predecessor company of BAE Systems,
bought Royal Ordnance plc in 1987 after the design freeze was in place for the gun. As detailed
above, the work carried out prior to Design Freeze by Royal Ordnance in productionising the gun
was carried out when it was in government, rather than private ownership.

You also heard evidence that BAE Systems was not tasked by the MoD during the safety case
reports that were undertaken for the tank in 2010 and the gun in 2014 to review the original design
itself, as they were “in service” assessments based on user experience and upon assumptions that
training/procedures would be followed.

 BAE SYSTEMS

We set out such matters not because they diverge from your findings (they do not), but because
this letter maybe published by the Chief Coroner and we therefore wish to make the position clear,
so that it is not misunderstood. Following your findings of fact at the conclusion of the inquest, there
was some general misreporting in the media that BAE Systems had designed the gun, when in fact
it had not.

We understand, therefore, that your concern directed at BAE Systems relates to the company’s
role in any future design or design review of such armaments, and to seek reassurance that the
risk assessment processes that will be undertaken on those occasions will be suitable and will take
into account the way they will be used according to the army’s drills.

We can confirm that, were BAE Systems to be contracted in the future to design any such
armament, it would follow a thorough design analysis, in conformity with the current design
standards identified by
of that process, SAE Systems would apply the current MoD Defence Standard (07-085), which in
relation to obturation specifically states “It should not be possible to fire the ordnance if any
component of the obturation system is missing”. The Standard goes on to reference how ideally the
design should prevent that from happening.

HM Principal Inspector of Health and Safety (Explosives). As part

Accordingly, the current Design Standard, which BAE Systems, or any other designer, is currently
required to follow specifically identifies the issue you are concerned about. It requires the designer
to consider design solutions and their adherence to the relevant Standard, which would prevent the
issue from arising, whether in combination with the undertaking of a TVEDU red drill, or otherwise.

We can also confirm that any such design or assessment of design would take account of the
foreseeable use of the armament in practice, which would incorporate the army drills for training
and operations. The specific content of those drills is obviously a matter for the MoD but they
would be considered as part of any design process. However as explained above, such a gun
designed today in accordance with the relevant Standard should not be able to fire at all if a
component of the obturation system is missing.

While the concern expressed in your letter was to cover future designs, after the incident in June
2017 the MoD and BAE Systems are developing a design solution to eliminate the risk of this
happening again and to bring the current Challenger 2 gun up to date with the Standard outlined
above. At the Inquest two potential engineering solutions to prevent the gun being fired without the
BVA Assembly being present were highlighted. Following the inquest two additional proposals are
now also being considered further. Progress on all four solutions will be reviewed by the MoD
Challenger 2 Safety and Environmental Management Panel in October 2018.

We trust that the information contained in this letter and our commitment to continue working jointly
with the MoD on future solutions helps to address your concern.

Yours faithfully,

BAE Systems Land UK

2

SECRETARY OF STATE
Sa MINISTRY OF DEFENCE
eS) FLOOR 5, ZONE D, MAIN BUILDING
WHITEHALL LONDON SW1A 2HB

Ministry Telephone 020 7218 9000
of Defence Fax: 020 721 87140
wa ie
4.3.11.2 7 September 2018

Thank you for sending us a copy of your report and recommendations following
the inquest into the tragic death of Corporal Mathew Hatfield and Corporal Darren
Neilson. | hope that the information provided below offers assurances that the
findings of your investigations and the areas you have highlighted for the
prevention of future deaths have prompted action and been the focus of the
Ministry of Defence’s continuing commitment to improving the safety of all military
exercises.

Matter of Concern 1

“! remain concerned that soldiers are not clear about when to use the Prove The
Gun drill and the meaning of the word "work" in the drill. This was supported by
the evidence of Lt Col Ridgway who stated there was still a lack of clarity. The
MOD should ensure that soldiers are clear about the meaning of the word work
in the drill and when the drill should be undertaken.”

Immediately following the tragic accident, a ban on all 120mm _ training
ammunition natures was ordered by Defence General Munitions (“DGM”). Once
all live fire training on Challenger 2 (“CR2”) tanks was halted, an Extraordinary
Safety and Environmental Management Panel (“SEMP”) was convened. The
SEMP held a series of four extraordinary meetings (20 June, 12 July, 24 July and
4 August 2017) to investigate the incident. These meetings were chaired by the
then Brigadier (now Major Genera! a in his role at the time as Land
Equipment Vehicle Support Team Leader in Derence Equipment and Support
(‘DE&S”). The panel consisted of Subject Matter Experts (“SMEs”) involved in
all aspects of the CR2 capability; Defence Equipment and Support (“DE&S”)
(Heavy Vehicle Support, Weapons Engineering, Defence General Munitions,
safety experts), Defence Ordnance Safety Group, the Armoured Fighting Vehicle

Mrs Louise Hunt

HM Senior Coroner
Birmingham & Solihull Areas RECED
50 Newton Street | -4 OCT 2018

Birmingham
BY: —

B4 6NE

Technical Training School (AFVTTS) Gunnery Wing, Capability Directorate
Ground Manoeuvre (“Cap GM”) GM and the representatives of the manufacturer
of the CR2, BAE Systems Ltd.

The SEMP reviewed the procedures in the Army Equipment Support Publications
(“‘AESPs’) ‘2350-P-102-201 Tank, Combat, 120mm Gun Challenger 2 —
Operating Information’ and ‘2350-P-102-601 — Tank, Combat, 120mm Gun
Challenger 2 - Maintenance Schedule’. The SEMP concluded that had the extant
procedures detailed in the AESPs been followed, the absence of the obturator
assembly (consisting of the Bolt Vent Axial, thrust housing and shim) would have
been identified. However, it also concluded that the accident could be repeatable
and there were areas where procedures could be adjusted to reduce the risk of
a re-occurrence of the accident. The SEMP directed that:

(i) Changes be made to the AESPs to be explicitly clear when the
before use checks should be conducted, particularly the
requirement to prove the gun;

(ii) | Changes be made to the AESPs to include additional verification,
visual and physical, that the obturator assembly is fitted;

(iii) | BAES to be tasked by DE&S to explore the viability of a physical or
electronic safety mechanism to prevent the gun being fired when
the obturator assembly was not fitted;

(iv) The hazard log for CR2 to be reviewed.

A separate panel of SMEs was convened at the Armoured Fighting Vehicle
Technical Training School (“AFVTTS”) Gunnery Wing to consider the changes
required in the AESPs and how best to train these to crews. The panel consisted
of:

(i) Gunnery Wing Schools Instructors (SIs) teaching at the AFVTTS;

(ii) | Gunnery Training and Advisory Team (GTAT) staff (also Sls but
employed to advise on and assure the standard of gunnery training
in the Field Army);

(iii) | Capability Directorate Ground Manoeuvre staff;
(iv) | Technical publication authors;
(v) | DE&S representatives.

The panel of gunnery SMEs recommended specific adjustments to the AESPs.
These recommendations were presented to the SEMP, examined in detail and
then endorsed. The changes have been fully implemented in to the current
AESPs and all documents which support the delivery of training. Prior to
implementation, the AFVTTS Schools Instructors tested the new drills and
procedures. The new procedures were then cascaded down to Regimental

Instructors Gunnery (“RIG’s’) who then trained the CR2 crews. Itis Army policy
that CR2 commanders and loaders must pass a Weapons Handling test (“WHT”)
on both L30A1 120mm gun and L94 chain gun no more than 6 weeks before any
live firing. This training is further assured by the GTAT conducting a re-test of
WHTs of a random sample of 15% of the firing crews in the 6 weeks leading up
to live firing. This assurance was conducted on the crews after they had been
trained in the revised drills and procedures. All CR2 crews are now
comprehensively trained in the amended AESP’s.

The bans on both use of 120mm training ammunition and the firing of the L80A1
gun were lifted on 18 August 2017. The bans were lifted only after the SEMP
was satisfied that all the new procedures and drills had been implemented in the
AESPs, the training of crews in these procedures and drills had been fully
delivered and assured, and a review of the hazards of operating CR2 had taken
place. This was in place by 18 August 2017.

The changes to the AESP’s included:

e AESP’s '2350-P-102-201 Tank, Combat, 120mm Gun Challenger 2-
Operating Information’ - Chapter 2-8-2 — Prove the Gun

These drills establish that the gun is clear of any ammunition and while previously
the loader was required to check that the BVA was clear of any TVEs by running
his fingers down the back of the BVA (Paragraph 6.13), they were adjusted to
specifically check for the presence of the BVA, obturator and shim (Paragraph
6.19 and Paragraph 7).

Paragraph 5 of Chapter 2-8-2 previously stated: “Before any work is carried out
on the gun it must be ‘proved', that is to say, it must be checked to ensure that it
is clear of any ammunition and Is therefore safe to work on.” The revised AESPs
eliminate the requirement for individuals to interpret the definition of “work”. The
completion of the ‘prove the gun’ drill is now mandated in specified circumstances
(see below). Nevertheless, the AESP’s were updated to ensure clarity.
Paragraph 5 now reads:

“Before the qun is operated in any way or before any maintenance is carried
out it must be ‘proved’, that is to say, it must be checked to ensure that it is clear
of any ammunition and is therefore safe to work on”.

As part of the ongoing Army assurance regime the ‘prove the gun’ drill has now
been included into the CR2 Weapon Handling Test (“WHT”). In line with extant
policy, loaders and commanders will be required to pass their WHTs in the six
weeks leading up to any live fire training.

So far as relevant to a live firing exercise the ‘prove the gun’ drill is mandated in
the following circumstances:

e AESP '2350-P-102-601 — ‘Tank, Combat, 120mm Gun Challenger 2 -
Maintenance Schedule’ - Table 1 - Before Use Maintenance.

This maintenance must be carried out before the vehicle is used. Ser 19
mandates the loader to complete the ‘prove the gun’ drill in accordance with
AESP’s ‘2350-P-102-201 Chapter 2-8-2.

e AESP ‘2350-P-102-601 — ‘Tank, Combat, 120mm Gun Challenger 2 -
Maintenance Schedule’ - Table 2A - During Use Takeover - individual
Crew Member.

This maintenance is to be carried out when rotating vehicles between crews
during use. If there is no ‘hand over take over’ (“HOTO”) between crews or the
HOTO is deficient in any respect the crew is obliged to complete a full ‘Table 1
Before Use Maintenance’, including ‘prove the gun’ drill. In all circumstances (i.e.
even where there is a comprehensive HOTO) the crew is obliged to complete
Table 2A. Serial 8 of Table 2A mandates the loader to complete the ‘prove the
gun’ drill in accordance with AESP’s ‘2350-P-102-201 Chapter 2-8-2.

Further checks and assurances have been implemented to ensure that the main
gun cannot be fired without the BVA:

e AESP’s 2350-P-102-201 Tank, Combat, 120mm Gun Challenger 2 —
Operating Information’ - Chapter 2-8-2 — Going to Action with both the
breach open (Paragraph 10) and closed (Paragraph 9).

These drills dictate the procedures to load the gun on receipt of the order “Action
Load’. Paragraphs 9.6 and 10.6 provide that the loader must: “Check that the
BVA obturator and shim are fitted” and report the result of that check to the
commander. The commander is then obliged to carry out a secondary check of
the BVA, obturator and shim to ensure they are fitted. Only if all components are
fitted will the commander give the order “Carry on.”

° AESP’s ‘2350-P-102-201 Tank, Combat, 120mm Gun Challenger 2 —
Operating Information’ - Chapter 2-8-2 — The Tube Vent Electric Display
Unit (“TVEDU”) Red — No Vent Tube (Paragraph 33) or TVEDU No Display
(‘Paragraph 37’).

Paragraph 33 has been updated to recognise that the absence of a BVA may
cause a TVEDU Red indication. Paragraph 34.6.2 of the TVEDU Red drill now
mandates the loader to check for the presence of the BVA by checking through
the Firing Needle Assembly (“FNA”) aperture.

There is now no scenario in which a crew could proceed to fire the main gun
without first having completed the ‘prove the gun’ drill which mandates a specific
check for the presence of the BVA, obturator and shim (Paragraph 6.19). Even
if the ‘prove the gun’ drill was not adequately completed the presence of the BVA,
obturator and shim would be rechecked upon ‘going to action’ and again upon
receiving a ‘TVEDU — Red Indication or No Display’ (an inevitable consequence
if the BVA is missing).

The SEMP and the panel of SME’s convened at the AFVTTS Gunnery Wing
consider that the changes made to the AESPs have reduced the risk to a level
which is as low as reasonably practicable (‘ALARP”). All CR2 crews are
appropriately trained on the new drills, there is no lack of clarity about when drill
must be completed, the delivery of that training and the crew's understanding of
that training is appropriately assured and any risk of reoccurrence is ALARP.

Matter of Concern 2

“One of the contributing factors to this tragedy was that the RCO, the person in
charge of the live firing exercise, did not know the state of the tanks on the range
and therefore allocated a stripped-down tank for a live firing exercise. | remain
concerned that it is vital that the person in charge of such exercises has up to
date knowledge about the status of the tanks on the range. The MOD should
look at what communication can be put in place to ensure the RCO is in fact in
charge and has all the correct information to make decisions during the exercise.”

The Range Conducting Officer (“RCO”) is responsible for the safe conduct of the
firing, in accordance with the planned activity as laid out in the Range Action and
Safety Plan (“RASP”) which is produced for all live firing activities. However, a
live firing exercise is a dynamic and fluid environment. A plan for the exercise is
determined in advance but it is necessarily flexible to take account of changing
circumstances, for example: crews failing certain exercises and having to repeat
them; equipment developing faults requiring repair; routine but essential
maintenance of equipment; civilian violations within the safety zone or inclement
weather preventing firing. However, the primary duty of the RCO is the
supervision of the Armoured Fighting Vehicles (AFVs) that are at action and firing
on the range and any distractions from this duty must be minimized. Itis essential
that the RCO is focused on delivering a safe live firing exercise. Any
requirements for the RCO to keep contemporaneous records on the state of the
tanks would detract from his focus on the safety of the range as a.whole.

The use of a whiteboard or similar system to allow the forward planning is only a
planning aid. It allows the RCO, squadron sergeant major and crews to anticipate
what AFVs are likely to be used, what ammunition is required and the order in
which exercises are conducted. However, for the reasons indicated above, the
situation can and does frequently change quickly and therefore the plan will need
to be adjusted. Such a whiteboard must therefore not be relied upon as an
authority for maintenance states on every AFV on that range; it is extremely
difficult to guarantee that it is accurate on a minute by minute basis. It is also
important to note that the process used on fixed arc ranges (such as
Castlemartin) must be mimicked as closely as possible during the delivery of Live
Fire Tactical Training on field firing ranges. The majority of these ranges are
conducted at the British Army Training Unit Suffield (BATUS) in Canada but they
can, and routinely are, conducted elsewhere. This is an essential part of the
Army's ability to train around the world which not only maintains the Army’s
readiness but also contributes to deterring conflict in pursuit of the UK’s national
interest. These ranges have no fixed arcs or control tower. At these ranges the
RCO and safety supervisors are mounted on 4x4 vehicles and control the range
from their vehicles as the training AFVs conduct a live firing range in a tactical

scenario over several kms (some exercises see AFVs manoeuvring over ranges
in excess of 40km). Maintaining such a white board system during Live Fire
Tactical Training would not be practical. P

Not only would such a rigid system distract the RCO from his duties, be
impractical to maintain as an authoritative source of equipment maintenance
status and be impractical to implement on all ranges, it will also reduce the
responsibility that is quite rightly placed on crews to manage their own safety.
Ultimately, crews are training for warfighting operations where crew changes
between vehicles often occur at short notice. The need for crews to take
responsibility for their safety must be instilled throughout the training progression
to prepare crews to deploy on operations at short notice. A centrally managed
system in training where the responsibility for monitoring the maintenance status
of AFVs rests, either explicitly or implicitly, with the RCO is likely to introduce
complacency with crews. The crew are likely to have an expectation that if the
whiteboard says an AFV is ready to fire and the RCO has allocated it to a crew,
therefore the crew assume it is ready to fire. This therefore creates a reliance on
others to ensure the vehicle is ready to fire in training. However, there is no RCO
or any other safety supervision on warfighting operations beyond that imposed
by the crew commander. Such a reliance on the RCO or a centrally managed
system in training, widens the gaps between training and operations and
therefore transfers risk from training into operations.

The Army judges that any potential risk presented by the RCO not being aware
of the state of tanks on the range is ALARP. As indicated above the revised drills
and procedures ensure that there is no scenario in which a crew could proceed
to fire the main gun without first having completed the ‘prove the gun’ drill which
mandates a specific check for the presence of the BVA, obturator and shim
(Paragraph 6.19). Even if the ‘prove the gun’ drill was not adequately completed
the presence of the BVA, obturator and shim would be checked again upon ‘going
to action’ and if necessary again upon receiving a ‘TVEDU — Red Indication or
No Display’ (an inevitable consequence if the BVA is missing).

In addition to the above drills a ‘Do not use’ cover has been introduced. This
cover which is red in colour is now placed over the breach of the gun during
maintenance (i.e. if any part of the gun is removed, including the BVA) to provide
a very clear indication that the gun is in an unsafe state. Any oncoming crew
would be immediately aware that the gun was not ready to fire and would not
conduct further investigation until the reason for the cover being present is
identified and rectified. These changes are highlighted throughout the AESP’s.
As of 26 July 2018, there are sufficient covers to meet the requirement for the
circa 107 tanks that are in daily use across the Army.

The Army invests considerable time and resource to ensure its CR2 crews are
highly trained professionals. CR2 crew commanders undergo particularly
demanding training over and above the rest of the crew which reflects their
responsibility to command their tank and supervise their crew during both training
and operations. The crews’ ability to determine the readiness state of a tank
without external supervision is not only well within their capability but also
essential to maintain the flexibility that is required on operations. The

comprehensive training, based upon the revised drills and procedures in the
amended AESPs, and the supervision provided by experienced and well trained
crew commanders ensures that the risk of a tank being without safety critical
components fitted is ALARP. :

Finally, Defence Equipment & Support (DE&S) tasked BAES to conduct a safety
review of the L30A1 CR2 Main Armament. The BAES response was received by
DE&S on 20 June 2018. The findings of that response are set out below.

Matter of Concern 3

“ar Sime from the HSE confirmed that had applied advanced or developed risk
assessment techniques been undertaken then it would have been identified in
the design and manufacture of the gun that it could fire without the BVA assembly
present when undertaking the TVEDU red drill. BAE and the MOD should look at
their process to ensure that their risk assessments are suitable and importantly
that drills are actively considered when assessing risk and identifying hazards
during manufacture.”

As discussed previously, the SEMP directed, as part of their recommendations,
that BAES be tasked by DE&S to explore the viability of a physical or electronic
safety mechanism to prevent the gun being fired when the obturator assembly
was not fitted. This task was placed on BAES in August 2017 and the BAES
response was received by DE&S on the 26 June 2018. BAES were directed to:

a. Conduct a Failure Mode Effects and Criticality Analysis (FMECA) on the
L30A1, considering lessons learnt from this incident, to identify potential
failure modes. The report by BAES confirmed the omission of the BVA as
the only failure mode allowing the L30A1 gun to be fired with a catastrophic
loss of obturation;

b. Conduct a feasibility study into the introduction of a physical mechanism
to prevent firing with key components not fitted (to improve the level of safety
above procedure and drills). The report identified several possible design
solutions for a physical mechanism to prevent firing with key components
not fitted, exploring two candidate designs in further detail; and

c. Produce a Human Factors report into the operation of the CR2 Main
Armament in relation to the AESP changes made’. The report assessed
there to be no anticipated musculoskeletal related issues or effect on
system performance from the additional tasks placed on the
Loader/Operator to physically check critical obturator components and
conduct handover/takeover checks.

1 Army Equipment Support Publication (AESP) 201 (Operating Information) has been amended to reflect
the introduction of additional L30A1 loader drill to include physical (as opposed to visual) check of critical
components and AESP 601 (Maintenance Schedules) has been amended to reflect the introduction of
formal Handover/Takeover checks for the CR2 Main Battle Tank.

As above, two design options were identified that could potentially provide safe
and reliable mechanisms to prevent the gun being fired without the BVA being
fitted. However, following further review of the BAES report and discussion with
a wider stakeholder group, including the user community, work is now under way
to: .

a. Mature the additional options identified through further tasking on BAES;

b. Review four design solutions identified by the Design Authority to decide
which, if any, will be taken forward for further development and testing; and

c. Assess the effectiveness of all controls relating to obturation, taking full
account of the potential for human failure.

Progress against these tasks will be presented to the CR2 SEMP on 11 October
2018.

Furthermore, in response to advice offered by the HSE during our ongoing
engagement relating to this incident and their investigation, the Land Domain?
have reviewed all heavy weapon systems for the potential failure of obturation.
The review concluded that AS90 is the only other system using ‘rear obturation’,
but due to the design it is physically impossible to fire without the obturator fitted.
This is consistent with the findings of the related Service Inquiry?.

Work is also in hand to ensure that future procurement of all Land Systems
considers these matters fully. As a direct example CR2 Life Extension
Programme has a requirement for a FMECA to be produced during the
Assessment Phase as part of the wider Safety Documentation set required by the
MOD.

From a wider safety perspective, it is worth noting that we have, through this
process, identified three systemic issues that we are now working to resolve
across DE&S. These are:

a. Recognising where mitigations for significant risks are solely or heavily
reliant on human controls and reviewing how this is documented. This will
be subject to review to ensure that additional technical mitigations are
considered, as appropriate, to reduce this reliance;

b. The need of the MOD to get honest feedback on the behaviour of the
crew and their opinion on their role in safety, particularly when operating in
high risk situations; and

2 The Land Domain is a 3* Organisation within DE&S led by Chief of Material (Land) and comprises four 2*
led Operating Centres; Land Equipment, Logistic Delivery, Weapons and Support Enablers.

3 Service Inquiry — Challenger 2 Incident at Castlemartin Ranges, Pembrokeshire 14 Jun 17, Page 116
para 1.4.195 & 1.4.196

c. The need to review all Land Systems Safety Cases in conjunction with
the Front Line Command and other interested parties to ensure that we are
using the appropriate risk assessment methodology, proportionate to the
level of the risk and further ensuring that this is documented with the
supporting rationale.

The three issues above will take time to resolve but there is firm commitment from
the Senior Leadership within DE&S to drive this work forward in close
collaboration with the Army (and other Front Line Commands as appropriate), the
Defence Safety Authority, our internal Regulator and our industry partners, such
as BAES. .

| hope that the information provided offers assurances that the findings of your
investigations and the areas you have highlighted for the prevention of future
deaths have prompted action and been the focus of our continuing commitment
to improving the safety of all military exercises.

THE RT HON GAVIN WILLIAMSON CBE MP