Martyn Horton, David Ramsden, Douglas Halliday and Alexander Isaac
PFD Report
All Responded
Ref: 2015-0164
All 1 response received
· Deadline: 23 Jun 2015
Coroner's Concerns (AI summary)
The Ridgeback vehicle, introduced for operational service, has unspecified "suspension issues" that raise concerns for safety.
View full coroner's concerns
In the circumstances it is my statutory duty to report those concerns to you: _ (I) 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
Responses
Action Planned
The Ministry of Defence is conducting a review of the vehicle suspension system, including data analysis and investigation into alternative bolts. They are also addressing the Vehicle Emergency Lighting System (VELS) modification, aiming for completion by the end of 2016. (AI summary)
The Ministry of Defence is conducting a review of the vehicle suspension system, including data analysis and investigation into alternative bolts. They are also addressing the Vehicle Emergency Lighting System (VELS) modification, aiming for completion by the end of 2016. (AI summary)
View full response
RECEIVED MINISTRY OF DEFENCE JUL 2015 FLOOR 5 ZONE B MAIN BUILDING WHITEHALL LONDON SWIA 2HB Ministry Telephone: 020 7218 9000 (Switchboard) of Defence PENNY MORDAUNT MP MINISTER OF STATE FOR THE ARMED FORCES DIMSU/4/7/1 2S June 2015 LU Nv 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 Iearn 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 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 2 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 3_ 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 full 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 (LA ) day
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 lights 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 main operating base. A unit of the Royal Electrical and Mechanical Engineers embedded within 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 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 modifications to date, the Army are expected to complete modifications on the active foepleyea 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 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 _ being %) . being
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 lights 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 main operating base. A unit of the Royal Electrical and Mechanical Engineers embedded within 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 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 modifications to date, the Army are expected to complete modifications on the active foepleyea 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 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 _ being %) . being
Sent To
- Ministry of Defence
Response Status
Linked responses
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56-Day Deadline
23 Jun 2015
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
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 narrativve 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 o 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 Afghanistan combined with 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, 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, and Alex were unable to escape and consequently drowned inside the vehicle. The following matters contributed to the collision: The speed the_Ridgeback_was_travelling_(more_than 3Omph but less than or equal to Tel 01722 438900 Fax 01722 332223 Doug Doug
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: The incident occurred at night and in the dark; 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 grogginesslunconsciousness (will appear in respect of Martyn, David and and; The wearing of essential body armour.
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: The incident occurred at night and in the dark; 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 grogginesslunconsciousness (will appear in respect of Martyn, David and and; The wearing of essential body armour.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths believe you have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.