The Service Inquiry report into the death of a soldier participating in a Night Live Firing Sniper

44V Defence Safety Authority

Service Inquiry

Death of a Soldier Participating in a Night Live Firing Sniper Cadre at RAF Tain Range Field Firing Area

1 Nov 16

Defence Safety Authority

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OFFICIAL—SENSITIVE

PART 1.1 — COVERING NOTE

SI/01/15/TAIN

20 April 18

DG DSA

SERVICE INQUIRY INTO THE FATAL ACCIDENT DURING THE 51 BRIGADE SNIPER

OPERATORS' COURSE AT TAIN AIR WEAPONS RANGE ON 1 NOV 16

1. The Service Inquiry Panel assembled in MOD Main Building on the 12 Jan 17 by order of

the DG DSA for the purpose of investigating the fatal accident during the 51 Brigade Sniper

Operators' Course at Tain Air Weapons Range (Tain AWR) on 1 Nov 16 and to make

recommendations in order to prevent reoccurrence. The Panel has concluded their inquiry and

submits the report for the Convening Authority's consideration.

2. The following inquiry papers are enclosed:

Part 1 The Report 1.1 Covering Note 1.2 Convening Order & TORs 1.3 Narrative of Events 1.4 Analysis and Findings 1.5 Recommendations 1.6 Convening Authority Comments

Part 2 The Record of Proceedings 2.1 Diary of Events 2.2 List of Witnesses 2.3 List of Interviews 2.4 List of Attendees 2.5 List of Exhibits 2.6 Exhibits 2.7 List of Annexes - Nil 2.8 Annexes - Nil 2.9 List of Non-Germane 2.10 Master Schedule

PRESIDENT

Wing Commander Royal Air Force Member

MEMBERS

Captain Army Member

Colour Sergeant Navy Member

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PART 1.2

Convening Order including Terms of Reference and Lexicon

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Service Inquiry Convening Order

12 Jan 17

SI President Hd Defence AIB SI Members DSA Legad

Copy to:

PS/SofS DPSO/CDS MA/Comd JFC

MA/Min(AF) MANC DS MA/CFA

PS/Min(DP) NA/CNS MA/GOC 1 (UK) Div

PS/Min(DVRP) MA/CGS Dir DDC

PS/PUS PSO/CAS CO 3 SCOTS

DSA DG/SI/01/17 - CONVENING ORDER FOR THE SERVICE INQUIRY INTO THE FATALITY

THAT OCCURRED DURING A SNIPER CADRE AT RAF TAIN RANGES ON 1 NOV 2016.

1. A Service Inquiry (SI) is to be held under Section 343 of Armed Forces Act 2006 and in

accordance with JSP 832 - Guide to Service Inquiries (Issue 1.0 Oct 08).

2. The purpose of this SI is to investigate the circumstances surrounding the incident and to

make recommendations in order to prevent recurrence.

3. The SI Panel will formally convene at Ministry of Defence Main Building, Whitehall, London at

1530L on Thursday 12 January 2017.

4. The SI Panel comprises:

President: Wing Commander RAF

Members: Captain Colour Sergeant RM

5. The legal advisor to the SI is Major (DSA LEGAD) and technical

investigation/inquiry support is to be provided by the Defence Accident Investigation Branch

(Defence AIB).

6. The SI is to investigate and report on the facts relating to the matters specified in its Terms of

Reference (TOR) and otherwise to comply with those TOR (at Annex). It is to record all evidence

and express opinions as directed in the TOR.

7. Attendance at the SI by advisors/observers is limited to the following:

Head Defence AIB - Unrestricted Attendance.

Defence AIB investigators in their capacity as advisors to the SI Panel - Unrestricted

Attendance.

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OFFICIAL-SE-NSITIVE

8. The SI Panel will work initially from the Defence AIB facilities at Farnborough. Permanent working accommodation, equipment and assistance suitable for the nature and duration of the SI will be requested by the SI President in due course.

9. Reasonable costs will be borne by DG DSA under UIN D0456A.

Original Signed

Sir R F Garwood Air Mshl DG DSA — Convening Authority

Annex:

A. Terms of Reference for the SI into the Fatality that Occurred During a Sniper Cadre at RAF Tain Ranges on 1 Nov 2016.

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Annex A To DSA DG/SI/01/17 Convening Order Dated 12 Jan 17

TERMS OF REFERENCE FOR THE SI INTO THE FATALITY THAT OCCURRED DURING A SNIPER CADRE AT RAF TAIN RANGES ON 1 NOV 2016.

1. As the nominated Inquiry Panel for the subject SI, you are to:

a. Investigate and, if possible, determine the cause of the occurrence, together with any contributory, aggravating and other factors and observations.

b. Examine what policies, orders and instructions were applicable and whether they were complied with.

c. Identify if the levels of planning and preparation met the activities' objectives.

d. Ascertain whether Service personnel were acting in the course of their duties.

e. Establish the level of training, relevant competencies, qualifications and currency of the individuals involved in the incident.

f. Investigate and comment on relevant fatigue implications of an individual's activities prior to the matter under investigation.

g. Determine the status of any equipment including serviceability, defects or deficiencies.

h. Determine and comment on any broader organisational and/or resource factors.

i. Make appropriate recommendations to DG DSA.

2. During the course of your investigations. should you identify a potential conflict of interest between the Convening Authority and the Inquiry, you are to pause work and consult DG DSA. Following that advice it may be necessary to reconvene reporting directly to MOD PUS.

3. If you become aware that a criminal or disciplinary offence may have been committed you should contact (DSA LEGAD) who will advise you accordingly.

4. You are to ensure that any material provided to the Inquiry by any foreign state. is properly identified as such, and is marked and handled in accordance with MOD security guidance. This material continues to belong to those nations throughout the SI process. Before the SI report is released to a third party, authorisation should be sought from the relevant authorities in those nations to release, whether in full or redacted form, any of their material included in the SI report, or amongst the documents supporting it. The relevant NATO European Policy (NEP) or International Policy and Plans (IPP) team should be informed early when dealing with any foreign state material.

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LEXICON

Abbreviation Definition Notes

hrs Hours

2ic Second in Command

ACMT Annual Combat Marksmanship Test

The culmination of training on a weapon system that tests accuracy of a firer. A pass is essential to be considered qualified to fire the weapon on exercise or operations.

Admin administration

AESP Army Equipment Support Publication

A document that contains the maintenance procedures for a weapon system.

ATO Ammunition Technical Officer A person trained to deal with ammunition incidents.

AWR Air Weapons Range A range used by aircraft to drop munitions and bombs as part of training serials.

BATSIM Battle Noise Simulator

A noise-making explosive device to simulate battlefield noises, i.e. artillery and explosions, ranging in size from hand held firecracker like devices to larger incendiary explosives.

BBTA Barry Buddon Training Area A range training area on the east coast of Scotland, North of Dundee.

Bde Brigade A formation in the Army consisting of several units (Battalions) that is commanded by a Brigadier (1*), normally consisting of approx. 3,000 personnel.

CAS Close Air Support

CFA Commander Field Army CFA is a senior officer of Lt Gen (3*) rank who provides properly trained Land Force Elements for operations, including wider support to the Joint Force.

CMT Combat Medical Technician A member of the Royal Army Medical Corps trained in emergency medicine.

CO Commanding Officer The senior officer in a Battalion in charge of four or more sub-units (Companies).

Comd Commander

Coy Company A sub-unit of a Battalion.

DPers Cap Directorate of Personnel Capability

DPers Cap is responsible for developing Army personnel strategy and engaging with Defence and the other services to shape and influence strategic personnel direction in order to sustain and enhance the operational effectiveness of the Army. Commanded by DPers, who holds Maj Gen (2*) rank.

Cpl Corporal

CSgt Colour Sergeant

CSS Combat Service Support A subset of military logistics that ensures that soldiers have the required equipment and supplies to carry out their tasks.

CT Collective Training

Collective Training is the name given to an Army standard of training. It comprises various levels from CT1 - Platoon, CT2 - Company, CT3 — Battlegroup, CT4 — Battlegroup in a Brigade context.

DCC Dismounted Close Combat The typical infantry role.

DH Duty Holder

A DH provides specific focus on safety and environmental protection management. DHs have a personal duty of care for personnel under their command or management, for those who, by virtue of their temporary involvement in activities, come within a

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DH's area of responsibility (AOR) and for the public who may be affected by their activities. DHs are accountable for the safety of activities in their AOR and for ensuring that risks are reduced As Low As is Reasonably Practicable (ALARP). In the execution of their specific responsibilities, DHs are accountable to Secretary of State for Defence (SofS), via their superior DH chain.

DAIB Defence Accident Investigation Branch

DAIB conducts impartial and expert no-blame safety investigations across Defence to ensure that causal factors are identified and understood as quickly as possible, and recommendations made to prevent recurrence and enhance safety, whilst preserving Operational capability.

DIO Defence Infrastructure Organisation

Responsible for the maintenance and compliance of land ranges with law and policy.

Div Division A formation in the Army consisting of several Brigades that is commanded by a Major General (2*), normally consisting of approx. 10,000 personnel.

DLE Defence Learning Environment

An online learning website used by Defence to distribute some training and education.

DPers Directorate Personnel

DPers is responsible for the employment, development and sustainability of British Army personnel, including regulars, reservists, contractors and civil servants. Commanded by a Maj Gen (2*).

DS Directing Staff The term given to personnel with the responsibility to train and mentor students as well as provide safety supervision.

DSAT Defence Systems Approach to Training

The DSAT ensures that all Defence training follows a proven system. This system must be used by those who are involved in the analysis, design, delivery, assurance, management and governance of Defence training and education.

DTC Distributed Training Cell The organisation that is responsible for distributed training policy.

EASP Exercise Action Safety Plan A document that outlines the safety procedures on a range, created by the Planning Officer in line with policy.

Ex Exercise

Ex RATTLE SNAKE

Exercise RATTLE SNAKE A Combined Joint exercise with the US armed forces in Atlanta, USA which ran in the latter half of 2015.

Ex WESSEX STORM

Exercise WESSEX STORM A CT4 exercise that runs several times a year for units on a rotational basis in Thetford and Salisbury Plain.

FP Wg Force Protection Wing A deployable Royal Air Force unit responsible for the protection of Air assets including aircraft, equipment and personnel.

Gillie Suit

A Gillie Suit is a mesh, sleeveless overall that is camouflaged with foliage, strips of hessian and Manilla rope. Each Gillie Suit is tailored to the individual and a sniper is expected to maintain and camouflage it to a high standard.

GOC General Officer Commanding The commander of a British Army Division, who holds Maj Gen (2") rank.

HF Human Factors HF is the study of how humans behave physically and psychologically in relation to particular environments, products, or services.

HHPTT Hand Held Push-to-talk A hand held radio.

HoC GM Head of Capability Ground Manoeuvre

Formally known as Head of Capability Combat, HoC GM is responsible for developing and delivering the

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British Army's mounted and dismounted close combat capability development and delivery.

HoC Trg Head of Capability Training HoC Trg is responsible for education and training policy across the British Army.

ISO International Standards Organisation

ISR Intelligence, Surveillance and Reconnaissance

ISR is the coordinated and integrated acquisition, processing and provision of timely, accurate, relevant, coherent and assured information and intelligence to support a commander's conduct of activities.

ISTAR Intelligence, Surveillance, Target Acquisition and Reconnaissance

ISTAR is a practice that links several battlefield functions together to assist a combat force in employing its sensors and managing the information they gather.

IW Individual Weapon The L85A3 (SA80) is the rifle employed by all 3 UK Armed Services.

JNCO Junior Non-commissioned Officer Persons that hold Lance Corporal or Corporal rank.

JSP Joint Service Publication Documents that outline Defence policy and rules.

LCLRR Large Calibre Long Range Rifle

The L115A3 rifle is the sniper rifle employed by all 3 UK Armed Services.

LCpl Lance Corporal

LF Live Fire

LFMT Life Fire Marksmanship Training

LFTT Live Fire Tactical Training Training that utilises live ammunition, conducted on a training area known as a range or a LFTTA.

LFTTA Live Fire Tactical Training Area

m Metres

Maj Major

MOD Ministry of Defence

NAS Naval Air Squadron

NCO Non-commissioned Officer A person that holds the rank of Lance Corporal, Corporal, Sergeant, Colour Sergeant or Warrant Officer.

NSPs Normal Safety Precautions

A set of drills used to take a weapon system from an unknown or unsafe state to a known safe state, for example by removing any rounds contained within the weapon.

ODH Operational Duty Holder

OSP Operational Shooting Policy The documents that describes the lessons and method of employment for a weapon system.

OTA Otterburn Training Area A range training area located in the Northeast of England, thirty miles Northwest of Newcastle.

Pam 21

Pamphlet No 21 'Training Regulations for Armoured Fighting Vehicles, Infantry Weapons Systems and Pyrotechnics'

The document that prescribes how to conduct LF training safely.

PF Procurator Fiscal

The Procurator Fiscal is a public prosecutor in Scotland. They investigate all sudden and suspicious deaths in Scotland (similar to a Coroner in other legal systems), and conduct fatal accident inquiries (a form of inquest unique to the Scottish legal system).

PI Platoon A body of approximately 25-30 soldiers normally commanded by a junior officer.

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QMSI Quarter Master Sergeant Instructor

A senior NCO from the Small Arms School Corps who is an SME on the employment and training of weapon systems.

RAF Royal Air Force

RASP Range Action Safety Plan The document that prescribes the safety policy of a range, produced by the RCO in accordance with Pam 21.

RCO Range Conducting Officer The person in charge of a range.

SAA Skill at Arms The overall name given to the lessons and skills required to operate a particular weapon system.

SAPU Small Arms Pop-Up targets Remotely controlled electronic targets used during live fire training.

SASC Small Arms School Corps The SASC is responsible for maintaining the proficiency of the Armed Forces in the use of small arms, support weapons and range management.

SI Service Inquiry

SME Subject Matter Expert

Sniping Pt 1 Sniping Part 1 The document that contains sniper specific training and information.

SOC Sniper Operators' Course A formal training course that qualifies a soldier as a sniper.

SPO Senior Planning Officer The person with overall responsibility for overseeing the planning of ranges. Normally of Major rank.

SQEP Suitably Qualified and Experienced Person

STIC Sniper Thermal Imaging Capability

A thermal sight that may be fitted to the L115A3.

STT Sniper Training Team A bespoke group of trained snipers responsible for training future snipers, sniper commanders and sniper platoon commanders.

SWS Specialist Weapons School Based at the Land Warfare School in Warminster these hold the corporate knowledge for specialist weapons and provide centralised courses for commanders.

T3 Train the Trainer

T3 courses enable the cascade of new training methodologies and processes whereby those that will be responsible for the conduct of training are trained in line with the latest policy.

Tain AWR Tain Air Weapons Range

Often referred to as RAF Tain. This is an Air/Ground range located on the East coast of Scotland approximately 30 miles North East of Inverness, near the town of Tain.

TCV Troop Carrying Variant A slang term for a MAN truck that is fitted with seats in the back to carry troops.

TDA Training Delivery Authority The TDA is the organisation responsible for training delivery, but not necessarily the conduct of the actual training itself.

THPS Tactical Hearing Protection System

This is a generic term for Peltor active noise-cancelling hearing protection. This allows normal levels of audio to be heard by the firer (i.e. speech) but blocks out loud audio (i.e. explosions and gunshot).

TOR Terms of Reference

TRA Training Requirements Authority

The TRA represents the end-user of the trained output and is the ultimate authority for the derivation and maintenance of the Role Performance Statement (Role PS). The TRA is responsible for the evaluation of the effect of the training in achieving the Role PS wherever the training is delivered.

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TrAD Training Authorisation Document

The TrAD is the formal document that authorises training to be conducted, signed by the TRA.

TRIM Trauma Risk Incident Management

The British Army's method for mitigating the effects of trauma on personnel following exposure to a traumatic event.

TSO Training Safety Officer The person responsible for maintaining safety on a specific range or training area.

UNFICYP United Nations Peacekeeping Force, C •rus

WHT Weapon Handling Test The culmination of learning on a weapon system to demonstrate that the operator is capable of handling it safely. This must be completed before live firing.

WO1 Warrant Officer Class 1 A senior Non-Commissioned Officer.

WO2 Warrant Officer Class 2 A senior Non-Commissioned Officer.

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PART 1.3

Narrative of Events

OFFICIAL - SENSITIVE

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PART 1.3 — NARRATIVE OF EVENTS

Synopsis Protagonists Background Pre-accident

Genesis Planning stage Course commencement

Accident Day shoot Night shoot

Post-accident Immediate action Response Emergency services Follow-on activity

Timeline

Page 2 Page 3 Page 6


Page 9 Page 12

Page 14 Page 15 Page 16 Page 17 Page 18

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All times local (GMT).

Synopsis

1.3.1 On 1 Nov 16 at approximately 1741 hrs a single-round was discharged

from an L115A3 sniper rifle, located inside an ISO shipping container' on Tain Air

Weapons Range (AWR), in the north of Scotland (Figure 1.3.1). At the time a group of soldiers were waiting in the ISO container to conduct a night shoot.

1.3.2 The soldiers were students attending the 51st Infantry Brigade (51 Bde) Sniper Operators' Course (SOC) between 2 Oct — 9 Dec 16. Under the auspices of

distributed training,2 this part of the course was delivered by The Black Watch, 3rd

Battalion, The Royal Regiment of Scotland (3 SCOTS) at Tain AWR. At this stage,

the course comprised 22 students drawn from 5 regiments. The students were conducting progressive Live Fire (LF) shoots in preparation for the assessed Annual Combat Marksmanship Test (ACMT).

1.3.3 One student, 30125761 Lance Corporal (LCpl) Joe William Spencer, sustained a fatal gunshot wound. He was subsequently pronounced dead at the scene.

Exhibit 001

Exhibit 019 Exhibit 020 Exhibit 002 Exhibit 005 Exhibit 006

Witness 41 Exhibit 128

Figure 1.3.1 — Map of Northern Scotland

An ISO container is a generic term for a shipping container used to transport freight on board ships. road and rail. These can be

adapted by the military for use as temporary shelters and storage. Distributed training is conducted to an approved and assured syllabus outside of bespoke centres of excellence (Phase 3,

specialist/role specific training establishment). This decentralisation allows increased training capacity and flexibility in order to meet the

Army's Training Delivery Authority's capability requirements. The Distributed Training Cell (DTC) is the body responsible for assuring

compliance with the Army's distributed training policy.

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OF- FICIAL---SE4SITIVE

Protagonists

1.3.4 In this report the Panel will refer to several individuals that played a role before, during and after the accident on 1 Nov 16. Their names have been redacted to protect their identity.

1.3.5 LCp1 Spencer. LCpI Spencer had 5 years' service with the Army. Following Infantry training at the Infantry Training Centre Catterick, he joined C Company (Coy), 3'd Battalion, The Rifles (3 RIFLES). He completed one operational tour in Afghanistan and 2 overseas exercises in Kenya and the USA. LCp1 Spencer won the "Chosen Man" competition for B Coy, 3 RIFLES, awarded to the most capable soldier in the sub-unit: he was subsequently rated the top soldier of B Coy in his annual report. At the time of the accident he was serving in 3 RIFLES Sniper Platoon and was attending his first SOC.

1.3.6 Senior Planning Officer (SPO). The SPO had 12 years' service in the Infantry, which included operational tours to Afghanistan and Bosnia. At the time of the accident he served as a company commander in 3 SCOTS and was the Range Conducting Officer's (RCO) immediate superior. He had overall responsibility for Phase 2 of the course. This included planning the Live Fire Marksmanship Training (LFMT) with specific responsibility for ensuring that the Range Action Safety Plan (RASP) was fit for purpose.

1.3.7 Colour Sergeant 1 (CSgt 1). CSgt 1 had 17 years' service in the Infantry, during which time he had completed operational tours to Afghanistan and Iraq, and had served as an instructor at the Infantry Training Centre. Catterick. Employed as the Sniper Platoon Commander in 3 SCOTS since 2014, he had overall responsibility for the planning and supervision of the SOC. He was the Planning Officer for Phase 2 with specific responsibility for the safe conduct of live fire ranges. He was the RCO on the afternoon/evening of 1 Nov 16.

1.3.8 Colour Sergeant 2 (CSgt 2). CSgt 2 had 21 years' service in the Infantry, which included operational tours to Afghanistan, Iraq and Northern Ireland. Since 2014 he had been employed as the Sniper Platoon Commander in The Royal Scots Borderers, 1s' Battalion, the Royal Regiment of Scotland (1 SCOTS). As the Phase 1 Planning Officer, he was responsible for the planning and delivery of Phase 1 of the 51 Bde SOC.

1.3.9 Sergeant 1 (Sgt 1). Sgt 1 had 11 years' service in the Infantry, which included operational tours to Afghanistan and Northern Ireland, and two overseas exercises to Kenya. Since 2015, he was the 3 SCOTS Sniper Platoon Second in Command responsible for administration and Combat Service Support (CSS). During Phase 2 he provided CSS and was RCO on the morning of 1 Nov 16.

1.3.10 Sergeant 2 (Sgt 2) Duty Controller. Sgt 2 had 14 years' service in the RAF as Trade Group 9 (Air Traffic Controller) which included overseas detachments to Canada, Italy, South Africa and USA. Sgt 2 had served at Tain AWR since 2016 as a member of the military permanent staff who were responsible for range safety. He was the on duty Main Tower Assistant (MTA) within Tain range control on the afternoon/evening of the accident and was located

Exhibit 112 Witness 26 Witness 48 Exhibit 141

Witness 23 Exhibit 005 Exhibit 006 Exhibit 093 Exhibit 096 Exhibit 028

Witness 24 Exhibit 034 Exhibit 094 Exhibit 043 Exhibit 072 Exhibit 073 Exhibit 074 Exhibit 023 Exhibit 028 Witness 25 Exhibit 035 Exhibit 055 Exhibit 056 Exhibit 057 Exhibit 021

Witness 28 Exhibit 028 Exhibit 129 Exhibit 076 Exhibit 077 Exhibit 078 Exhibit 095


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in the tower.

1.3.11 Directing Staff 1 (DS 1). DS 1 had 10 years' service in the Royal Armoured Corps (RAC), which included operational tours to Afghanistan and Iraq. Serving with the Royal Scots Dragoon Guards (SCOTS DG) as a Corporal he was initially trained on the Challenger 2 Main Battle Tank, before re-roling to Light Cavalry. DS 1 was a sniper and was Directing Staff on the SOC with specific responsibility for safety supervision during live fire ranges.

1.3.12 Directing Staff 2 (DS 2). DS 2 had 8 years' service in the Infantry, which included an operational tour to Afghanistan. At the time of the accident he was serving with 3 SCOTS as a Section Commander in the Sniper Platoon as a Corporal. DS 2 was a sniper and was Directing Staff on the SOC with specific responsibility for safety supervision during live fire ranges.

1.3.13 Directing Staff 3 (DS 3). DS 3 had 10 years' service in the Infantry, which included operational tours to Afghanistan. At the time of the accident he was serving with The Royal Highland Fusiliers, 2nd Battalion, The Royal Regiment of Scotland (2 SCOTS) as a Section Commander in the Sniper Platoon as a Corporal. DS 3 was a sniper and was Directing Staff on the SOC with specific responsibility for safety supervision during live fire ranges. During Phase 1. DS 3 conducted Weapon Handling Tests (WHTs) to qualify students to fire the L115A3.

1.3.14 Directing Staff 4 (DS 4). DS 4 had 7 years' service in the Infantry, which included operational tours to Afghanistan. At the time of the accident he was serving with 2 SCOTS as a Section Commander in the Sniper Platoon as a Corporal. DS 4 was a sniper and had completed the Sniper Section Commanders' Course. DS 4 was Directing Staff on the SOC with specific responsibility for safety supervision during live fire ranges. During Phase 1, DS 4 conducted WHTs to qualify students to fire the L115A3.

1.3.15 Directing Staff 5 (DS 5). DS 5 had 16 years' service in the Infantry. which included operational tours to Afghanistan and Iraq, and overseas exercises to Kenya, Jordan and Malawi. Since 2015, he was a member of the 1 SCOTS Sniper Platoon as a Sniper Instructor. DS 5 was a sniper and was Directing Staff on the SOC with specific responsibility for safety supervision during live fire ranges.

1.3.16 Directing Staff 6 (DS 6). DS 6 had 12 years' service in the Infantry which included operational tours to Iraq, Afghanistan and overseas exercises to Kenya. Since 2010 he was a member of the 3 SCOTS Sniper Platoon later qualifying as a Sniper Section Commander. DS 6 was a sniper and was Directing Staff on the SOC with a specific responsibility for safety supervision during live fire ranges.

1.3.17 Student A. Student A had 6 years' service in the Infantry, which included operational tours to Afghanistan and Kosovo. Serving with 3 RIFLES as a Rifleman3, he was a student on the course and was paired with LCpI Spencer during Phase 2, inter-changing with him between the role of Number 1 (firer) and

Witness 34 Exhibit 048 Exhibit 045 Exhibit 046



Witness 33 Exhibit 079 Exhibit 028


Witness 31 Exhibit 028 Exhibit 129 Exhibit 075 Exhibit 005 Exhibit 062 Witness 13 Exhibit 110 Exhibit 111

Across the Army the rank of Private has Regiment specific titles including. Rifleman for 3 RIFLES; Trooper for the SCOTS DG; Fusilier for 2 SCOTS: and Private for 1 and 3 SCOTS.

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Number 24 (spotter) during the afternoon shoot on 1 Nov 16.

1.3.18 Student B. Student B had 8 years' service in the Royal Armoured Corps,

which included 2 operational tours to Afghanistan and overseas exercises in

Canada. At the time of the accident he was serving with the SCOTS DG as a

Corporal and was the senior student on the course.

1.3.19 Student C. Student C had 9 years' service in the Royal Armoured Corps,

which included overseas exercises in Canada. At the time of the accident he was

serving with the SCOTS DG as a Trooper and was a student on the course.

1.3.20 Student D. Student D had 7 years' service in the Royal Armoured Corps,

which included overseas exercises in Canada, Italy and Kenya. At the time of the

accident he was serving with the SCOTS DG as a Trooper and was a student on

the course.

1.3.21 Student E. Student E had 3 years' service in the Infantry, which included

an overseas exercise in the USA. At the time of the accident he was serving with 3

RIFLES as a Rifleman and was a student on the course.

1.3.22 Student F. Student F had 3 years' service in the Royal Armoured Corps,

which included overseas exercises in Canada and Cyprus. At the time of the

accident he was serving with the SCOTS DG as a Trooper and was a student on

the course.

1.3.23 Student G. Student G had 5 years' service in the Royal Armoured Corps,

which included an operational tour in Afghanistan and an overseas exercise in

Cyprus. At the time of the accident he was serving with the SCOTS DG as a LCp1

and was a student on the course.

1.3.24 Student H. Student H had 6 years' service in the Infantry, which included

an operational tour in Afghanistan. At the time of the accident he was serving with

3 RIFLES as a Rifleman and was a student on the course.

1.3.25 Student I. Student I had 5 years' service in the Infantry, which included

an operational tour in the Falkland Islands and overseas exercises in Kenya, USA

and Tunisia. At the time of the accident he was serving with 3 RIFLES as a LCp1

and was a student on the course.

1.3.26 Student J. Student J had 5 years' service in the Infantry, which included

overseas exercises to Kenya. At the time of the accident he was serving with 3

SCOTS as a LCpl and was a student on the course.

1.3.27 CMT. The CMT had 11 years' service in the Royal Army Medical Corps as

a medic, which included operational tours in Iraq and Afghanistan and overseas







Witness 17 Exhibit 113 Exhibit 114 Exhibit 115 Exhibit 062

Witness 16 Exhibit 119 Exhibit 105 Exhibit 106 Exhibit 107 Exhibit 108 Exhibit 109



A firer is also referred to as a Number 1 and his partner is referred to as a Number 2. In this instance on the range the Number 2 is

responsible for assisting the firer by observing and correcting the fall of shot

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OFFICIAL,SENSITIVE

exercises in Kenya and France. At the time of the accident he was serving with 3

SCOTS as a Corporal and provided medical cover on the range.

1.3.28 Other Personnel. The other DS and students on the 51 Bde SOC did not

play a significant role in relation to the accident.

Background

1.3.29 3 SCOTS. At the time of the accident 3 SCOTS were based at Fort

George, Scotland and had just completed the process of converting from a light-

role battalions to a light-mechanised battalions. In preparation for the conversion to

the light mechanised role, 3 SCOTS completed progressive training throughout

2016, which encompassed individual, sub-unit and unit level training events. This

culminated in Exercise WESSEX STORM from Aug — Sep 16. The exercise activity

took place across the UK at; Otterburn Training Area, Northumbria; Salisbury Plain Training Area, Wiltshire; and Stanford Training Area, Norfolk. Upon completion of

the exercise 3 SCOTS recovered back to Fort George in late Sep 16.

1.3.30 Sniper role. On the battlefield, the sniper's primary role is to scout ahead

of the main force, carrying out reconnaissance and intelligence gathering while remaining undetected. They can also use their marksmanship skills to lethal effect against key enemy targets.

1.3.31 L115A3 Sniper Rifle. The L115A3 Sniper Rifle (see Figure 1.3.2) is a personal weapon issued to trained snipers in the dismounted close combat role across the 3 services. A bolt-action rifle produced by Accuracy International®, it fires a .338" (8.59 mm) round fed by a 5-round box magazine. The rifle has seen service on operations since 2008. The rifle measures 1265 mm in length and weighs 7.81 kg.

Exhibit 062

Witness 45 Witness 23 Exhibit 131

Exhibit 015 Exhibit 124 Exhibit 132

5 A Light-role Battalion is an Infantry unit that comprises of foot soldiers that are designed to manoeuvre around the battlefield on foot

and if they require transportation they must depend on external support. 6 A Light-mechanised Battalion is an Infantry unit that is equipped with Protected Mobility (i.e. lightly armoured) vehicles in order to

manoeuvre foot soldiers over greater distances, with a degree of enhanced protection and firepower_

Army Code 71544, Sniper Pocket Book, Chapter 2. Section 2.

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e. 111/11 null Bull `par or h Opal c. Suppressor d Adieu° le Bull Spar v. Hut Magian* AWN* Catch Horb Bp00 It Talelle.Ople SHIN I. Ariusre tee CUM, Pk. u MOM/dal WNW Slap k Owen HlrovAsasw6V

Figure 1.3.2 — L115A3 Sniper Rifle

Pre-accident

Exhibit 090 Exhibit 133

Witness 37 Exhibit 038 Exhibit 133 Witness 24 Witness 25 Witness 26

Witness 24 Witness 26


Genesis

1.3.32 Policy. On 1 Jul 16 the Army's Head of Capability Combat approved the Training Authorisation Document (TrAD) for the SOC. This policy revision resulted in the Army conducting sniper training down to unit-level under the banner of distributed training.

1.3.33 Train the Trainer (T3). In preparation for the policy revision, in Apr 16 Specialist Weapons School (SWS) delivered a course to train sniper platoon staff in the planning and delivery of distributed training. The course trained Sniper Platoon Commanders and Non-commissioned Officers (NCO) from across the Army. Students were briefed on the Army's distributed training policy. This included specific direction for units to collaborate and deliver the SOC as distributed training at brigade/divisional level. In the margins of this course, Sniper Platoon Commanders from 1 SCOTS, 3 SCOTS and 3 RIFLES agreed to jointly plan and deliver a SOC to train soldiers from their respective units.

Planning stage

1.3.34 Distance planning. Upon completion of the T3 course, the 3 Sniper Platoon Commanders continued planning for the Sniper Operators Course. There were no formal planning meetings; instead planning was conducted at distance via phone, email and WhatsApp TM CSgt 1, acting as the Course Planning Officer, provided the oversight and coordination during the planning stage.

1.3.35 Course construct. Planning resulted in the course being divided into 3 standalone phases, each with a different unit providing the lead. The 3 phases comprised: Phase 1 (2 — 28 Oct 16) — marksmanship at Barry Buddon Training Area (BBTA) led by 1 SCOTS; Phase 2 (31 Oct — 18 Nov 16) — fieldcraft at Tain

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AWR led by 3 SCOTS: and Phase 3 (21 Nov — 9 Dec 16) — consolidation and validation at Otterburn Training Area (OTA) led by 3 RIFLES.

1.3.36 Brigade interaction. 51 Bde staff were initially unaware of subordinate unit plans to deliver a SOC. Subsequently, during the 51 Bde Light Forces Symposium hosted by 3 SCOTS at Fort George on 18 — 19 Apr 16, attendees were briefed by CSgt 1 on emerging plans for a jointly delivered SOC. During discussions, a brigade staff officer within the audience suggested using 51 Bde in the course nomenclature which was duly adopted. Thereafter, interaction with 51 Bde staff was limited.

1.3.37 External engagement. While planning the course, CSgt 1 was solely responsible for external engagement with both the Distributed Training Cell (DTC) staff and SWS Sniper Wing staff. SWS Sniper Wing nominated a CSgt instructor to act as mentor during the planning stage. DTC formally sanctioned the 51 Bde SOC syllabus on 29 Sep 16.

1.3.38 Range withdrawal. Although 1 SCOTS booked BBTA for week 4 (the last week of Phase 1) the ranges were transferred to another unit with a higher training priority. As a workaround CSgt 1 and CSgt 2 revised the course programme. Phase 1, week 4 was swapped with Phase 2, week 1. This change resulted in 3 SCOTS being required to conduct both fieldcraft training and live firing practices culminating in the ACMT during their phase of the course. CSgt 1 conducted the planning and produced the mandatory Range Action Safety Plan (RASP) to conduct live firing at Tain AWR. The Senior Planning Officer (SPO) supervised the production of the RASP. In doing so, the SPO had the draft RASP checked by the 1st (United Kingdom) Division Quarter Master Sergeant Instructor (QMSI) Small Arms School Corps (SASC)8; thereafter, following minor improvements the SPO approved the RASP covering the period 31 Oct — 4 Nov 16.

Course commencement

1.3.39 Phase 1. Phase 1 of the 51 Bde SOC was conducted at BBTA between 2 — 28 Oct 16. 1 SCOTS were responsible for the delivery of this phase. 1 SCOTS instructors were augmented by NCO instructors provided from SCOTS DG, 2 SCOTS, 3 SCOTS, and 3 RIFLES. 23 students mustered at the start of the course; they were drawn from 5 regiments listed above. Week 1 comprised: summative assessments (Annual Fitness Test, Navigation and Service Knowledge); Skill at Arms Training on the L115 A3 sniper rifle (refresher rifle training and Weapon Handling Tests (WHTs)); and LF ranges. One student was returned to unit for failing the navigation summative assessment: 22 students remained on the course. Weeks 2 and 3 comprised progressive training shoots, culminating in the ACMT. During week 2, Warrant Officer Class 1 Assurance' from DTC visited the course to conduct an assurance visit. Due to unavailability of gallery ranges at BBTA, a revised Week 4 comprised fieldcraft skills. During this week CSgt 1 visited BBTA to brief the students about Phase 2 and to conduct a course handover with CSgt 2. On 28 Oct 16, the course was stood down for the weekend.

1.3.40 Phase 2. The second phase of the course was scheduled to run between 31 Oct — 18 Nov 16. DS and students were accommodated and administered at

Witness 23 Witness 24 Exhibit 032 Exhibit 080


Witness 25 Exhibit 030 Witness 24 Exhibit 025 Exhibit 005 Exhibit 012 Exhibit 134 Witness 23

Exhibit 020 Exhibit 021 Witness 25 Witness 34 Witness 27 Witness 33 Witness 29 Witness 32 Witness 38 Witness 24

Exhibit 019

A Quarter Master Sergeant Instructor (QMSI), Small Arms School Corps (SASC) is a subject matter expert in the conduct and planning of live-fire ranges.

Warrant Officer Class 1 Assurance works for the DTC and is responsible for overseeing compliance of distributed training.

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OFFICIAL---SENSITIVE

Fort George, with training activity conducted at nearby Tain AWR. 3 SCOTS were responsible for the training delivery and were augmented with the same DS that supported the previous phase.

1.3.41 Course muster. Students' parent units were responsible for coordinating the movement of their units' L115A3 rifles and ancillariesw from BBTA to Fort George prior to the start of Phase 2. LCpI Spencer together with 3 other students from 3 RIFLES travelled by road to Fort George on 28 Oct 16, with their weapons and ancillaries. Upon arrival, their rifles and ancillaries were secured in the 3 SCOTS armoury at Fort George. Staying at Fort George in transit accommodation, the 3 RIFLES soldiers spent the Saturday night socialising in nearby Inverness. The remainder of the students mustered at Fort George on the afternoon/evening of Sunday 30 Oct 16. That evening all the students received an administration brief, which included the next day's activity. The DS were accommodated with the students in transit accommodation at Fort George.

1.3.42 31 Oct 16. 31 Oct 16 was Day one of Phase 2. By 0730 hrs students had withdrawn their rifles and ancillaries from the 3 SCOTS armoury. Departure was delayed because the soldiers' dining facility for breakfast was not open and low visibility conditions at Tain AWR. The course travelled by road to Tain AWR and arrived mid-morning. On arrival, the students completed Normal Safety Precautions (NSPs11), supervised by the DS. Following a mandatory range safety brief from CSgt 1, DS and students set up locally produced targets at various distances beyond 300 m in readiness for Live Fire Marksmanship Training (LFMT). These targets proved problematic and resulted in a further delay; thus live firing was limited to the afternoon. Consequently, not all the students were able to conduct the shooting practice in preparation for the ACMT. On completion of the range the students unloaded their rifles and completed NSPs under DS supervision. Following a declaration12, DS and students recovered back to Fort George.

Accident

1.3.43 General. The accident section is bounded by activity on 1 Nov 16 from the course's arrival at Tain AWR to the round discharging that resulted in the death of LCpI Spencer. Immediate actions and response are covered in the post-accident section.

Day shoot

1.3.44 Career brief. CSgt 1 was required to attend an Army Personnel Centre career brief at Fort George on the morning of 1 Nov 16. To facilitate his attendance at this mandatory career brief, and unbeknown to the SPO, CSgt 1 arranged for Sgt 1 to cover the RCO role at Tain AWR during the morning of 1 Nov 16.

Witness 24 Witness 28 Witness 05 Witness 16


Witness 24 Witness 23 Exhibit 036 Witness 28

10 The ancillaries of the L115A3 Sniper Rifle include the protective case, sights, sling, cleaning kit and other minor components. " Normal Safety Precautions (NSPs) is a drill that is carried out at the beginning and end of every lesson, practice or range period, immediately on returning to barracks, operational base and on completion of any patrol or duty and on handing the weapon over to somebody else. This drill's purpose is to ensure that there are no rounds in the weapon system in order to prevent accidental discharge. 12 A 'declaration' is a statement made by soldiers at the end of a range that declares they have no ammunition in their possession and that they will report anyone who does. It amounts to a final check of all soldiers after their pouches and magazines have been checked for ammunition.

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1.3.45 Tain arrival. On the morning of 1 Nov 16, students and DS departed Fort

George for Tain AWR on completion of morning routine. Upon arrival at Tain AWR,

Sgt 1, in his capacity as the stand-in RCO, signed on to the range at 1000 hrs via

the Land Range Log (MOD Form 906). On arrival at the range. shortly after 1000

hrs, the students completed NSPs. Sgt 1 gave a standard range safety brief3 to

the DS and students.

1.3.46 Morning serial. Students who had not fired the previous day (31 Oct 16)

conducted data-collection shoots, using the same locally produced targets, fitted

with competition falling plates. As with the preceding day, the students engaged

targets at various distances over 300m. Often when a round struck the target, the

wire affixing the plate to the picket frame snapped. When the targets failed, firing

ceased and students moved to the targets to make the necessary repairs. Later

that morning, in consultation with CSgt 1, the DS and Range Staff, Sgt 1 decided to

replace these targets with the battery operated remotely controlled Small Arms

Pop-Up (SAPU) targets. Following the replacement of targets the DS and students

stopped for lunch.

1.3.47 Afternoon serial. CSgt 1 arrived at Tain AWR at approximately 1430

hrs. He signed on and assumed the role of RCO. Sgt 1 departed the range soon

thereafter to collect the evening meal from Fort George. The afternoon serial

comprised two details, each comprising 11 firers conducting a pre-Annual Combat

Marksmanship Test shoot, designed to gather data at various distances." LCp1

Spencer fired in the first detail and was partnered with Student A. LCp1Spencer

was located in the last firing position on the right hand-side of the range (see

Figure 1.3.3). Firers were issued two boxes of 10 rounds of ammunition; the

practice required a maximum of 14 rounds to be fired. As nominated by the RCO,

each firer in turn was to engage between 8 and 10 targets sequentially at different

distances. Firers were allowed up to two rounds per engagement (provided the

total rounds expended did not exceed 14 rounds); if they missed with the first round, they were to rapidly re-engage the same target with a second round in a

much-reduced time-frame to the first engagement. With the ammunition issued and the parameters for this shoot, firers could only re-engage a target on 4 separate occasions.



Witness 24 Witness 46 Exhibit 102 Witness 13

Pamphlet No 21, 'Training Regulations for Armoured Fighting Vehicles. Infantry Weapon Systems and Pyrotechnics.' para 4-37 —'The

RCO is to hold briefings prior to the LFMT. All range staff involved are to attend and must know the following: The Training Objective(s)

of the LFMT: the general outline and sequence of events; the signal to stop firing and the action to be taken in an emergency; The

actions on unplanned events (e.g. a firer being left behind during run downs) and if a dangerous practice is identified; any safety rules

peculiar to the range in use; the details of the practices and the way in which they are to be controlled; if persons, animals. vehicles,

ships or aircraft are seen to enter. or are about to enter the danger area, firing is to stop, safety catches are to be applied and the RCO

informed at once. Any further action is to be controlled by the RCO, and the actions on an incident or accident.'

14 The purpose of data gathering is to allow firers to assure accuracy of the L115A3 Sniper Rifle and understand how their rifle performs

over distances of 400 - 900m. The firer must log the elevation and deflection of all shots made, along with environmental factors; this is

referred to as 'data'. Thereafter. if the firer shoots in similar conditions they will have an indicator on how to set their sights to ensure a

first-round hit.

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Pair: Pair: 2 Pair: 3 Pair: 4 Pair: 5 Pair: 6 Pair: 7 Pair: 8

Firing Line on raised berm

Pair: 9 Pair: 10 Pair: 11

Lepl Spencer Student A

46m

Waiting Detail ISO

Administration ISO

ISO

TCV

Waiting Detail ISO

Of-I ICIAL---SEN SIT-W

Figure 1.3.3 — Depiction of the Firing Line at Tain AWR

1.3.48 Range layout. The range used at Tain was long and shallow. The firing line, which is where the students took up their firing positions, measured 46m long. The depth of the range was approximately 9m from firing point to the ammunition point with a vehicle track between the two. A series of ISO containers at the rear of the range was used as improvised troop shelters and administration points (see Figure 1.3.3 and 1.3.4).

Figure 1.3.4 — 51 Bde Sniper Operators' Course range layout at Tain AWR

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1.3.49 First detail. The first detail commenced firing at approximately 1500 hrs.

At some point before completion of the detail, DS 1 left the firing point to conduct

personal administration in the Administration (Admin) ISO Container at the rear of

the range. From this position he was unable to observe the firers, but could hear

words of command. LCp1Spencer was the last student to fire in the first detail.

After firing his first round and while awaiting confirmation that he had hit the target,

he was observed to chamber a second round. Upon confirmation that he hit the

target with the first round, the RCO ordered the detail to 'unload: LCpI Spencer

removed the magazine from his L115A3 Sniper Rifle, and handed it to Student

A. Soon thereafter, the RCO ordered the firers to 'show clear' and change. LCp1

Spencer removed his personal kit and rifle from the firing point. He then moved to

the ammunition point and collected Student A's ammunition for the next detail. Meanwhile, Student A moved his kit and rifle onto the firing point in

readiness for the second detail. LCpI Spencer returned to the firing position and

handed an unknown amount of ammunition to Student A. LCp1 Spencer then

assumed the role of Number 2 for the second detail. The panel has been unable to

find any evidence that LCpI Spencer completed a full unload after completing the first detail.

1.3.50 Second detail. The second detail commenced firing at approximately 1535 hrs. Following a similar pattern to the first detail, the RCO nominated targets and then nominated firers to engage the targets. On completion of the shoot at approximately 1600 hrs, the RCO gave the order to unload, followed by the order firers show clear. On completion of NSPs, the students from both details recovered their personal kit and rifles and withdrew from the firing point into ISO containers at the back of the range to seek shelter from the rain.

1.3.51 Night safety brief. Soon after the completion of the second detail, at approximately 1630 hrs, CSgt 1. acting as the RCO, delivered his night safety brief to DS and students. Not everyone was present for the brief. At this time 4 DS, were in nearby Tain town visiting local shops and Student E was talking on his mobile phone. On completion of the night safety brief, CSgt 1 ordered that each student be issued with 10 rounds of ammunition for the night serial. This was to be stored individually by the students. Student E, having missed the brief, failed to collect his ammunition.

Night shoot

1.3.52 Night serial. At the conclusion of the night safety brief. the students prepared for the forthcoming night shoot.

image intensifier sights, the DS divided the students into 3 details for the night shoot. LCpI Spencer was assigned to the third detail. Due to the inclement weather, the third detail occupied the Admin ISO Container. Meanwhile the second detail occupied the Waiting Detail ISO Container; both containers were located at the back of the range. Responding to a DS request for a volunteer, LCpI Spencer relocated from the Admin ISO Container to the Waiting Detail ISO Container to join the second detail. The second detail students had already stored their personal kit and rifles inside the Waiting Detail ISO Container (see Figure 1.3.3 and 1.3.6), and outside against the container wall. The students in Detail 2 were either standing at the entrance or inside the Waiting Detail ISO Container. LCpI Spencer arrived after the other members of the second detail had stored their kit and rifles. He was observed to be holding his rifle in an upright

Witness 13 Witness 34 Witness 33



Witness 32 Witness 30 Witness 07 Witness 05 Witness 44

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position while wearing his webbing and Gillie Suit (see Figure 1.3.4). He held his weapon by the suppressor, with the butt alternating between the floor and his boot. Meanwhile the first detail, comprising of 7 firers, was on the firing point and in the process of identifying targets. At some time prior, a Troop Carrying Variant (TCV) truck16 was moved directly behind the firing line in order to provide an elevated observation position, from which a member of the DS acted as the Number 2 for each firer in sequence. CSgt 1 requested permission from Range Control, at the time Sgt 2, to commence firing, which was given at 1740 hrs.

Figure 1.3.4 — Sniper wearing a Gillie Suit

1.3.53 The accident. Immediately prior to the accident, LCpI Spencer was standing in close proximity and chatting with a group of fellow students, comprising Students B, C, D, E, F and G. Inside the Waiting Detail ISO Container it was dark although it was partially illuminated by Cyalumes017 attached to the front of the ISO container and occasional light from mobile phones or head-torches. LCp1 Spencer was resting his chin on his rifle suppressor. At approximately 1741 hrs a round discharged from LCpI Spencer's rifle inside the Waiting Detail ISO Container accompanied by a flash and a loud bang. LCpI Spencer immediately fell to the floor inside the Waiting Detail ISO Container. The rifle discharge caused injuries that resulted in LCp1Spencer's death.

Witness 05 Witness 07 Witness 11 Witness 12 Witness 24 Witness 29 Exhibit 135

A Troop Carrying Variant (TCV) of a Support Vehicle truck manufactured by MAN. It is used for transporting up to 16 personnel 17 A Cyalume® is a military issue chemical glow stick used for identifying personnel or for marking areas at night

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Area of accident

Grid: NH8445 8410

Tain AWR Tower

Tain AWR main entrance

Post-accident

Immediate action

1.3.54 Reaction. Immediately after the rifle discharged confusion reigned inside

the Waiting Detail ISO Container amongst the students. Some thought a battle

noise simulator (BATSIM)18 had been initiated, or that someone had fallen from the

TCV truck parked on the track next to the ISO; others observed the muzzle flash

and realised that a round had discharged. From inside the Waiting Detail ISO

Container frantic incoherent shouting was heard along with shouts of 'man-down'.

Students then rushed out of the Waiting Detail ISO Container. Some were in a

state of shock and confusion. Students checked their person for injuries/wounds.

Students exiting the Waiting Detail ISO Container were visibly upset.

1.3.55 Confirmation. In response to the calls of 'man down', white light was

used to illuminate the inside of the ISO container. DS and students observed a

body lying motionless on the floor, with head injuries. A body was seen laying on

top of an L115A3 Sniper Rifle, with the legs positioned on an item of equipment.

Student E quickly identified the body as LCpI Spencer.



Figure 1.3.5 — Map of Tain AWR

1.3.56 Firing point. Immediately after the calls of 'man down', the order 'stop'

was issued by several people. The first detail on the firing point, who were in the

process of preparing to fire, ceased identifying targets. The RCO and several of

the DS acting as safety staff for the night shoot, moved to the Waiting Detail ISO

Container entrance where they observed LCpI Spencer's body. At 1742 hrs the

RCO informed Tain AWR Tower (see Figure 1.3.5) by range management radio that

they had a casualty with a gunshot wound.


A BATSIM is a military grade pyrotechnic that is used during training to simulate the noise and flash of explosions or weapon systems

in a safe manner.

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1.3.57 Medical assistance. Concurrently, there were calls for the 'medic' to attend the Waiting Detail ISO Container. On entering the ISO container the Combat Medical Technician (CMT) ordered a student near the doorway to fetch the medical bergan19 (rucksack containing combat medical supplies) from the admin ISO container. The CMT checked LCp1 Spencer's wrist for a radial pulse; none was found. At this stage the CMT opined that LCp1 Spencer's injuries were incompatible with life. The CMT remained with LCp1 Spencer's body pending the arrival of the emergency services.

Response

1.3.58 Tain Tower. Having been notified of a serious accident on the range, the Duty Controller attempted to ascertain more information from CSgt 1 about the accident and the state of weapons on the firing point. In the confusion, Sgt 2, the Duty Controller passed the number of Sgt 1 (the stand-in RCO from the morning serial) to the ambulance service. Sgt 1 received a call from the ambulance service while he was driving towards Tain AWR with the evening meal for the course. Until that time Sgt 1 was unaware of the accident. Sgt 2, located in the tower, managed to speak to CSgt 1. at the firing point, via range management radio. CSgt 1 then requested help from Sgt 2. In response, Sgt 2 summoned CSgt 1 to Tain Tower to assist with the coordination of the emergency services' response. Sgt 2 dispatched a member of the range staff in a vehicle to the firing point to collect CSgt 1 and fetch him to the tower. CSgt 1 briefed the safety staff on the range and left for Tain Tower: Sgt 2 was the senior DS at the scene.

Witness 36


Figure 1.3.6 — Tain AWR Tower and Waiting Detail ISO Container

A 'Bergan' is a large military camouflage-pattern rucksack.

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1.3.59 First detail. Meanwhile, the first detail was ordered by an unknown member of the DS to leave their personal kit and rifles in position on the firing point in order to preserve evidence. Some students had unloaded without being expressly ordered to do so. The first detail students were ordered to dress off the range and get into the back of the TCV truck. which was still parked on the track immediately adjacent to the firing point.

1.3.60 ISO weapons. In response to a radio order from Sgt 2 to ensure that all weapons were 'safe' on the range, CSgt 1 ordered rifles to be removed from the Waiting Detail ISO (see Figure 1.3.6). Container and placed on the firing point. Student D and the CMT entered the Waiting Detail ISO Container and removed all the rifles, less the one under LCpI Spencer's body. These rifles were handed to DS 2 and DS 3, who conveyed them to the firing point. DS 3 observed blood from handling the rifles. Soon thereafter, 3 members of the Directing Staff, DS 2, 3 and 4, cleared rifles that had been placed on the firing point; these included those from the first detail and those removed from the Waiting Detail ISO Container. Ammunition was removed from the students and stored centrally at the ammunition

point.

1.3.61 Students. Having been instructed to leave personal kit in situ, the DS placed the students on the back of the TCV truck. Meanwhile, the four remaining 3

RIFLES students and the solitary 3 RIFLES DS gathered together and discussed

the accident.

1.3.62 Arrival at the tower. At approximately 1815 hrs, CSgt 1 and DS1 arrived

at Tain Tower. CSgt 1 was visibly shaken and emotional when he met the Duty Controller. DS 1 remained inside the tower and was quiet and subdued. At some

point, DS 2 departed the range for Tain Tower to act as a relay back to the scene of

the accident.

Emergency services

1.3.63 Notification. On receipt of the initial report of a casualty at 1742 hrs, Sgt

2, located in the tower, called the emergency services at 1743 hrs to request an

ambulance to attend Tain AWR. Sgt 2 subsequently called the civilian police to inform them of a shooting accident and casualty at Tain AWR. The civilian police

then called Sgt 2 via landline; they confirmed that they had been made aware of

the accident by the Scottish Ambulance Service, following the initial 999 call. At

some time afterwards while in the tower. Sgt 2 and CSgt 1, assisted by DS 1,

reported the accident to their respective chains of command.

1.3.64 Access. Anticipating that the emergency services would experience problems gaining access to Tain AWR, Sgt 2 dispatched a member of the range staff to the main entrance' (see Figure 1.3.5) to act as a guide. An ambulance and

car from the Scottish Ambulance Service arrived at the Tain AWR main entrance

between 1815 hrs and 1835 hrs: they were escorted onto the range track behind

the firing point. Despite the deployment of a guide, the first Police Scotland vehicle

drove beyond the Tain AWR main entrance. Subsequently, the local doctor arrived

at Tain AWR.

1.3.65 Scene. After they arrived at the Waiting Detail ISO Container, the two

members of Scottish Ambulance Service looked inside and saw LCpI Spencer's



Witness 32





The main entrance is located approximately 500m due northeast from the turning with the 89174 (road from Tain village). See Fig 7.

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body. Having observed the injuries, the ambulance staff assessed that the visible injuries were not survivable and it was not necessary to enter the container and disturb the scene. Soon after arrival at the scene, a Police Scotland officer requested that one of the DS remove the rifle under LCp1Spencer's body. DS 3 was about to remove the rifle when the policeman issued a counter-order to leave the rifle in situ. Having touched LCp1Spencer's body and the rifle, DS 3's clothes were required for evidential purposes; thus he remained at the scene. The doctor arrived at the scene at 1840 hrs, he had a brief discussion with the two Scottish Ambulance Service personnel and the CMT, before he looked inside the Waiting Detail ISO Container. Having observed the scene, the doctor declared life extinct at 1845 hrs. Police Scotland then took control of the scene; placing a cordon, they secured the firing point and the Waiting Detail ISO Container.

Follow-on activity

1.3.66 Initial witness interviews. Later in the evening of 1 Nov 16, Police Scotland officers interviewed DS and students at Tain AWR Tower. The interviews continued into the early hours of 2 Nov 16. Initially, the police officers interviewed DS and students who were in the immediate vicinity of, or inside, the waiting detail ISO container at the time the rifle discharged. Over the next 24 hours, the remainder of the DS and students were subsequently interviewed by Police Scotland officers at Fort George.

1.3.67 3 SCOTS activity. Members of the 3 SCOTS chain of command, including the Commanding Officer and SPO, visited Tain AWR during the evening of 1 Nov 16 to check on the wellbeing of DS and students. On completion of the Police Scotland witness interviews, DS and students were offered Trauma Risk Incident Management (TRIM)1 support on 2 Nov 16 at Fort George. Not all soldiers accepted TRIM support. On 7 Nov 16, 3 SCOTS issued their Learning Account22 relating to the death of LCpI Spencer.

1.3.68 Defence Accident Investigation Branch (DAIB) activity. At 1828 hrs on 1 Nov 16, the DAIB duty investigator was notified of an occurrence at Tain AWR. Later that evening the DAIB lead investigator accompanied by the DAIB Service Police Advisor deployed to Tain AWR. On 2 Nov 16, the DAIB representatives were denied access to the accident scene at Tain AWR by Police Scotland officers. Due to Police Scotland primacy, the DAIB representatives were limited to viewing the site from the Tain AWR Tower and meeting with the Tain Training Safety Officer - a civilian employee responsible for range activity at Tain AWR. The DAIB Triage Report was submitted to DG DSA on 4 Nov 16.

1.3.69 Ammunition Technical Officer. Following notification of an incident at Tain AWR on 1 Nov 16, a military Ammunition Technical Officer' investigator deployed to Tain AWR at 1500 hrs on 2 Nov 16. Police Scotland denied ATO access to the scene. On 25 Nov 16, the ATO issued a report.




Exhibit 001

Exhibit 136

2' Trauma Risk Incident Management (TRIM) is MOD standard practice to assess people's wellbeing after traumatic events. 22 A Learning Account is a formal document that summarises the initial investigation conducted by the unit (in this instance, 3 SCOTS). The Learning Account seeks to identify urgent safety issues and failings.

An Ammunition Technical Officer (ATO) is a SME on explosives, ammunition and investigate any ammunition incidents that occur in the UK.

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1.3.70 Police Scotland investigation. On 2 Nov 16, while gathering evidence at the firing point, Police Scotland officers, who had primacy for the investigation, cleared the L115A3 sniper rifles left at the scene. When clearing a rifle, subsequently identified as LCpl Spencer's rifle, an empty cartridge was ejected from the weapon's chamber. Police Scotland confirmed that this weapon was not the one lying under LCpl Spencer's body inside the ISO container.

Timeline

1 3.71 Accident timeline. The accident timeline is at Figure 1.3.7.

Exhibit 010

Date Time Event

1 Jul 16 Revised Army sniper training policy issued; directing distributed sniper training

2 - 28 Oct 16 - SOC Phase 1 conducted at BBTA

28 Oct 16 LCpI Spencer and 3 other 3 RIFLES students move to Fort George

30 Oct 16 - Course musters at Fort George for Phase 2

31 Oct 16 Day 1 of Phase 2 - conduct LFMT at Tain AWR; on completion the course recovers to Fort George

1 Nov 16 - Course departs for Tain AWR. CSgt 1 remains at Fort George for a career brief

1 Nov 16 1000 Stand in RCO (Sgt 1) signs on at Tain AWR

1 Nov 16 -241005 Students conduct NSPs and receive a safety brief from stand in RCO (Sgt 1)

1 Nov 16 1030 - 1230 Students conduct LFMT - data collection shoot

1 Nov 16 - 1300 1500 Lunch delivered/eaten, while targets changed to Small Arms Pop Up (SAPU) targets

1 Nov 16 -1430 CSgt 1 signs on range at Tain AWR and assumes RCO function 1 Nov 16 1500 Detail 1 fires pre-ACMT shoot 1 Nov 16 1530 Detail 1 unloads on completion of pre-ACMT shoot 1 Nov 16 -1535 Detail 2 fires pre-ACMT shoot 1 Nov 16 -1600 Detail 2 unloads/NSPs on completion of pre-ACMT shoot 1 Nov 16 -1630 LF 11 (night shoot) brief delivered by RCO (CSgt 1) 1 Nov 16 1740 Tain AWR Range Control grants permission to fire LF11 1 Nov 16 -1741 Weapon discharges in Waiting Detail ISO Container

1 Nov 16 1742 RCO informs Tain AWR Range Control that he has a casualty with a gunshot wound

1 Nov 16 1743 Emergency Services informed

1 Nov 16 - 1815 1835 Scottish Ambulance Service ambulance and car arrive at Tain AWR

1 Nov 16 - 1820 Police Scotland arrives at Tain AWR 1 Nov 16 1840 Civilian doctor arrives at Tain AWR 1 Nov 16 1845 LCpI Spencer pronounced dead

2 Nov 16 - Police Scotland officers clear LCpI Spencer's L115A3 rifle; an expended case is ejected from the rifle

2 Nov 16 - DAIB deploys to Tain AWR Figure 1.3.7 — Accident timeline

- denotes approximate time

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PART 1.4

Analysis and Findings

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Part 1.4 — ANALYSIS AND FINDINGS

Introduction Methodology

Accident factors Human Factors (HF) Available evidence Services Issues considered by the Panel Probability language

Determining the cause of death Policy and documentation

Distributed Training policy for sniper training Range safety policy Pamphlet 21 Army Equipment Support Publication

Organisations Distributed Training Cell Specialist Weapons School, Sniper Wing 51st Infantry Brigade The Black Watch, 3rd Battalion The Royal Regiment of Scotland Taira Air Weapons Range

Governance Assurance Duty Holding

Organisational influences Sniper culture Untrained personnel within Sniper Platoons Directing Staff

Pre-accident Planning Range reconnaissance Range Action Safety Plan Pre-cadre Skill at Arms Fort George Range layout and targets Safety briefing

Accident Afternoon details Preparation for night ranges Ammunition control Waiting Detail ISO Container Indirect influence

Post-accident Immediate actions Emergency services response

Ammunition and weapons forensic analysis 0.338" ammunition Un-demanded discharge Mechanical failure of trigger mechanism Inadvertent trigger operation hypothesis

Summary of findings Causal Factors Contributory Factors Other Factors

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Page 8 Page 9 Page 9 Page 10


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Page 21 Page 23 Page 23 Page 24 Page 25 Page 27 Page 28 Page 31


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Page 47 Page 47 Page 47 Page 48



Observations 'Swiss Cheese' model

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OFFICIAL-SENSITIVE

Introduction

1.4.1. The Tain Service Inquiry (SI) was convened on 12 Jan 17 to investigate the circumstances behind a fatal accident at Tain Air Weapons Range (AWR) in the North of Scotland on 1 Nov 16. This resulted in the death of 30125761 Lance Corporal (LCp1) Joe William Spencer, who sustained a fatal gunshot wound to the head. At the time. LCpI Spencer was a student on the 51st Infantry Brigade's (51 Bde) Sniper Operators' Course (SOC), which was being run by The Black Watch, 3rd

Battalion Royal Regiment of Scotland (3 SCOTS). To establish the facts, the SI Panel initially focused on events leading up to the accident, the accident itself, and post-accident actions. Likewise, complying with the SI's Terms of Reference (TOR) the Panel also considered extant policy, broader organisational factors, including sniper platoon culture in the British Army, and equipment serviceability, which may have had a bearing on the accident, in order to prevent any reoccurrence.

1.4.2. The SI Panel was delayed in starting due to the ongoing Police Scotland investigation. This precluded an earlier commencement. Permission to interview witnesses was not received until February 2017.

1.4.3. Early in the SI, the Panel was allowed access to the Police Scotland witness statements, the Post-Mortem report and the forensic analysis of the deceased's rifle report. This provided Panel members with an understanding of events from the outset and ahead of commencing its own witness interviews. Importantly, the Panel had access to all those involved in the planning and execution of the SOC, and those who participated on the day. As such, most evidence was collated from 44 witness interviews and 4 written statements. In addition, the Panel visited the site of the accident on several occasions. This enabled the Panel to establish the sequence of events on 1 Nov 16 with a high degree of certainty. However, to help better understand how the accident happened the Panel conducted a range reconstruction with key witnesses at Tain AWR and forensic analysis of expended ammunition cases from the accident and similar L115A3 Sniper Rifle' to that of LCp1 Spencer's sniper rifle. The information gathered was supplemented by, and cross referenced against, extant policy and procedures, Subject Matter Expert (SME) opinion, and documentary evidence.

Methodology

1.4.4. Accident Factors. Once an accident factor had been determined it was then assigned to one the following categories:

a. Causal Factor. Causal factors are those factors that. in isolation or in combination with other factors and contextual details led directly to the accident. Therefore, if a causal factor is removed from the accident sequence, the accident would not have occurred.

b. Contributory Factor. Contributory factors are those factors that made the accident more likely to happen. That is, they did not directly cause the accident, therefore if a contributory factor is removed from the accident sequence, the accident may still have occurred.

c. Aggravating Factor. Aggravating factors are those factors that made the final outcome of an accident worse. However, aggravating factors do not cause or contribute to an accident, that is, in the absence of


Exhibit 002 Exhibit 004 Exhibit 010 Exhibit 011 Exhibit 125 Exhibit 148

The L115A3 Sniper Rifle is the MOD's sniper rifle employed by each of the 3 armed Services. For the purpose of this Report, it will be referred to as the L115A3 Sniper Rifle or the sniper rifle.

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OFF-ICIAL-SUISITIVE

the aggravating factor. the accident would have still occurred.

d. Other Factor. Other factors are those factors that, whilst they played no part in the accident in question, are noteworthy in that they could contribute to or cause a future accident. Typically, other factors would provide the basis for additional recommendations or observations.

e. Observations. Observations are points or issues worthy of

note to improve working practices that the SI Panel discovered

during their investigation, but that do not relate directly to the

accident being investigated.

1.4.5. Human Factors (HF). A psychologist from the Head of Capability Training (HoC Trg) at Army Headquarters (HQ) provided HF specialist support to the SI. This included participation in witness interviews and the range reconstruction, the production of a report, and advice to the Panel throughout their investigations. The observations in the main SI Report have considered the HF component.

1.4.6. Available Evidence. The Panel had access to the following evidence:

a. The Defence Accident Investigation Branch (DAIB) Triage Report.

b. Evidence released to the SI Panel by Police Scotland, with the caveat that some of it is not for public disclosure.

c. Post-Mortem Report produced by the Scottish Fatalities Investigation Unit — North Team.

d. Interviews with: SOC students and Directing Staff on the range at the time of the accident; Tain AWR staff; emergency services personnel involved in the post-accident response; 3 SCOTS chain of command; and other witnesses.

e. Formal written statements from witnesses.

f. Mapping and photographic products, and meteorological data from various sources.

g. Key documentation including: Training Authorisation Document (TrAD) for the SOC; SOC Administration Instruction; Range Action Safety Plan (RASP); and various Land Range Log Form 906s.

h. Pamphlet No 21 'Training Regulations for Armoured Fighting Vehicles. Infantry Weapons Systems and Pyrotechnics' (Pam 21) and the Army's Operational Shooting Policy (OSP).

i. Relevant standing orders.

j. Training records and butt registers.

k. Defence Learning Environment (DLE) course for a Senior Planning Officer (SPO).

I. Forensic analysis reports on expended ammunition cartridges and on the L115A3 Sniper Rifle.

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Exhibit 151

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m. ArroGen® report of LCpI Spencer's L115A3 Sniper Rifle, with the caveat that this is not for public disclosure.

n. DAIB (Land) Technical Investigation Report. Rifle 0.338 L115A3 08SM12449.

o. Evidence gained from the range reconstruction at Tain AWR.

p. HF Report provided by a psychologist from HoC Trg.

q. Comments received from personnel following the application of the Regulation 18 process.2

1.4.7. Services. The Panel was assisted by the following personnel and

agencies:

a. DAIB.

b. Crown Office and Procurator Fiscal Service.

c. Police Scotland.

d. HF specialist from Army Training Branch.

e. Distributed Training Cell (DTC), Army Directorate of Capability.

f. Specialist Weapons School (SWS), Army Recruiting and Training Division.

g. Royal Marines Sniper Training Team.

h. Royal Air Force Regiment Training Wing Sniper Training Team.

i. Light Weapons Wing, Ministry of Defence (MOD) Shrivenham.

j. Defence Infrastructure Organisation (D10).

k. Landmarc®.

I. ArroGen® Forensics Limited.

m. Defence Equipment and Support Weapons Engineering and Lethality, Surveillance and Target Acquisition Project Team.

n. QinetiQ.

o. Headquarters Field Army Support Branch.

If a Service Inquiry President considers that it is likely that a person's character or reputation may be questioned based on the findings

of the Service Inquiry they are considered a Potentially Affected Person (PAP) in accordance with Regulation 18 The Armed Forces

(service Inquiries) Regulations 2008. The intention behind the legislation is that the PAP is able to hear the evidence relating to the

issue and to respond to that evidence. A PAP is entitled to be present at the proceedings of a SI panel, may question witnesses and

may consider evidence provided to the panel. They may do this themselves or be represented by another person. The SI President

may impose such conditions and exclusions on the PAPs attendance at SI proceedings as are reasonable.

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OF-FICIAL-S-E-NSI-T4V-E

p. Command, Control, Communications, Computers and Intelligence (C41) Support Squadron, and the Meteorological Office, Royal Air Force (RAF) Lossiemouth.

q. Number 5 RAF Force Protection Wing (5 FP Wg).

r. Aviation Forensics Team, 1710 Naval Air Squadron (NAS).

1.4.8. Issues Considered by the Panel. The Panel analysed the following key factors:

a. Efficacy of distributed sniper training.

b. Efficacy of training delivery on the SOC.

c. British Army Sniper Platoon culture.

d. Range safety, including: organisation/laydown; supervision; and command and control.

e. Hearing protection.

f. The relevance of individual acts.

g. Equipment serviceability, defects and deficiencies.

h. Organisations.

1.4.9. Probability Language. This report uses a variety of terms to describe different levels of probability. The Panel considered it was helpful to define these terms, to assist readers and establish consistency. These definitions are found in DAIB's document 'Standard Operating Procedure 514' and highlighted in Figure 1.4.1. The percentage likelihoods in the figure are for indicative purposes only, and should not be taken to imply the Panel attempted to calculate probability with mathematical precision.

1 4 - 6


Extremely Likely / Almost Certain Impossible

Extremely Unlikely

Very Likely / Highly Probable

Very Unlikely / Highly Improbable

Unlikely I Improbable

More likely than not / On the balance of probabilities (Legal term for >50%)

About as likely as not Likely I Probable

100%

V1 0 12 Oct 17

Increasing levels

Figure 1.4.1 Probability expressions

Determining the cause of death

1.4.10. At approximately 1741 hrs on 1 Nov 16 one round discharged from LCp1

Spencer's rifle, inside an ISO shipping container,3 located on the Close Air Support

(CAS) range, within the Tain AWR complex in Northern Scotland. LCp1 Spencer was

fatally wounded. At 1845 hrs on 1 Nov 16 the on-call National Health Service doctor

who attended the scene pronounced 'life extinct.'

1.4.11. The Scottish Fatalities Investigation Unit (North) ordered a post-mortem

examination of LCp1Spencer's body. The post-mortem was conducted in Raigmore

Hospital, Inverness on 3 Nov 16.

1.4.12. The post-mortem report concluded that LCp1 Spencer sustained a fatal

injury from a gunshot wound to the head. The bullet's direction of travel was

consistent with the way in which LCp1 Spencer was reportedly holding his sniper rifle

at the time of the discharge. Toxicology analysis proved negative for both alcohol

and drugs.

1.4.13. At the time of writing this report there is an ongoing Scottish Fatalities

Investigation Unit investigation into the death of LCp1 Spencer. The outcome of this

investigation is pending.

1.4.14. The Panel opined that LCp1Spencer suffered an accidental, fatal gunshot

wound to the head, caused by the round discharged from his rifle, and that due to

the catastrophic nature of the injuries medical intervention would not have preserved

LCp1 Spencer's life.

Exhibit 128 Witness 41




3 International Organisation for Standardisation (ISO) shipping containers are routinely used by the MOD as temporary shelters or

secure storage.

1.4 - 7

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OFFICIAL-SENSITIVE

Policy and documentation

Distributed Training Policy for Sniper Training

1.4.15. On 1 Jul 16, the Army's Head of Capability Combat sanctioned the Training Authorisation Document (TrAD)4 for the SOC. This course was to be delivered as distributed training5 at unit level. The revised policy was introduced to better meet the Army's sniper capability requirement. This differs from the other two Services.°

1.4.16. Previous iterations of sniper training failed to meet the Army's needs. Initially the training was planned and delivered at unit level but the level of external assurance was limited and standards amongst units was variable. This was evident during Tri-Service and international sniper competitions. To raise standards across the Army, the Basic Sniper Course was centralised and delivered by SWS Sniper Wing at Brecon. However, the course failed to provide sufficient numbers of trained snipers to meet the Army's front line needs. This was due to limited course capacity and unacceptably high student failure rates.

1.4.17. Unit sniper staff were first informed of the switch to a distributed training format in Apr 16 during the introduction of the Sniper Platoon Commander and Sniper Section Commander Train the Trainer (T3) course at the School of Infantry's Infantry Battle School, Brecon. SWS Sniper Wing provided direction and guidance on planning, execution and assurance methodology for the SOC. This briefing was attended by the Sniper Platoon (PI) commanders from The Royal Scots Borderers, 1' Battalion the Royal Regiment of Scotland (1 SCOTS), 3 SCOTS and 3rd Battalion, The Rifles (3 RIFLES): who all subsequently became responsible for the planning and delivery of the 51 Bde SOC.

1.4.18. The Army has employed distributed training for specialist capabilities for many years (e.g. machine guns and mortars). It was well understood at unit level and was used for specialist role training, including mortar and machine guns, to good effect. The 51 Bde SOC was only the second such course delivered as distributed training under the revised policy.'

1.4.19. Given the shortcomings of the 2 previous iterations of sniper training, which did not produce sufficient throughput and quality, the SOC delivered as distributed training at unit level amounted to a compromise solution that might better meet the Army's front line sniper capability needs. The SOC embraced key elements 8of the previous 2 iterations of the Army's approach to sniper training, thereby increasing training capacity, while also aiming to maintain standards. As this was only the second SOC delivered under the revised policy at the time, it was therefore too early

Exhibit 090 Exhibit 118 Exhibit 118 Witness 38

Exhibit 133 Witness 37 Witness 38

Exhibit 038 Exhibit 097 Exhibit 133 Witness 24 Witness 25 Witness 26


Exhibit 116 Exhibit 121 Exhibit 122 Witness 37 Witness 38

4 Joint Service Publication (JSP) 822. Defence Direction and Guidance for Training and Education, Part 1: Directive, states 'the Defence Systems Approach to Training (DSAT) ensures that all Defence training follows a proven system. This system must be used by those who are involved in the analysis. design, delivery, assurance, management and governance of Defence training and education. Once a course is deemed fit-for-purpose a Training Authority Document (TrAD) is produced. This defines who is responsible for what during the life of a training activity. It is the signed contract between what is required and what is delivered It is the overarching document for accountability thus signed off at 1' level Every training activity across Defence must have a related TrAD, which periodically revised/reviewed.'

Distributed training is training conducted to an approved and assured syllabus outside bespoke centres of excellence (Phase 3 specialist. role specific training establishments). Decentralisation allows increased training capacity and flexibility in order to meet the Army's Training Requirements Authority's capability requirements.

The Royal Marines and Royal Air Force Regiment deliver centralised sniper training using established Sniper Training Teams attached to Commando Training Centre Royal Marines, Lympstone, and Royal Air Force Regiment Training Wing. Royal Air Force Honington. respectively.

2 MERCIAN delivered the first iteration of the SOC under the auspices of distributed training between 27 Jun — 2 Sep 16. 6 Previous centralised Sniper training comprised of training and evaluation of the seven key sniper skills, namely navigation, marksmanship. judging distance, static map reading. stalking, mobile observation and observation that were then formally evaluated during "badge week', passing this week of tests then qualified a student as a sniper and allowed them to wear a Sniper's badge on his uniform

1.4 - 8


to assess the effectiveness of the course in meeting the front-line sniper capability needs. 1.4.20. The Panel opined that the rationale for switching to distributed sniper training was a logical and pragmatic solution in meeting the Army's front line requirements in terms of throughput and quality. and therefore this was Not a Factor.

Range Safety Policy

1.4.21. Range Safety Policy is articulated in Joint Service Publication (JSP) 403, Handbook of Defence Ranges Safety, May 15.

1.4.22. The DIO was responsible for managing the MOD's training estate, which included live fire (LF) ranges, and provides a 'Safe Place for training. The Range or Training Safety Officer for each 010 range area is responsible for ensuring local compliance with mandatory policy, as detailed in JSP 403.10 Moreover, as required by JSP 403, each range location must adhere to bespoke Range Standing Orders that reflect nuances peculiar to that specific range location."

1.4.23. Upon reviewing the policy, the Panel opined that the Range Safety Policy was fit for purpose and therefore this was Not a Factor.

Pamphlet 21

1.4.24. Pamphlet 21 (Pam 21), Training Regulations for Armoured Fighting Vehicles, Infantry Weapons Systems and Pyrotechnics, Mar 16,1' provided appropriately qualified MOD personnel with direction and guidance on the safe conduct of LF ranges. This incorporates infantry weapons systems.

1.4.25. Pam 21 detailed the qualifications required by appropriately qualified personnel to be able to plan and conduct live-fire ranges, the specific roles and responsibilities for the planning and conduct of LF ranges, and direction on accident procedures. Prior to live firing, Pam 21 directs that the Planning Officer is to produce a written instruction, the Range Action Safety Plan (RASP), which indicates the recognised planning process has been followed. This incorporates all aspects of safety and 'necessary briefings to all staff and participants'.'

1.4.26. Pam 21 did not provide guidance for every scenario; for example, there was no guidance on the conduct of Live Fire Marksmanship Training (LFMT) using a Live Fire Tactical Training Area (LFTTA) — the scenario for the accident at Tain AWR on 1 Nov 16. However, provided appropriately qualified practitioners effectively applied the guidance contained within Pam 21, during the planning and execution of LF ranges, they would be able to deliver safe training.

1.4.27. The Panel opined that while Pam 21 did not cover every eventuality for the planning and conduct of safe LF ranges it was fit for purpose, therefore this was Not

Exhibit 137


Exhibit 013


Exhibit 013

JSP 403, Handbook of Defence Ranges Safety, May 15, states 'a Safe Place is one in which the controls necessary to enable

authorised training to be conducted safely have been identified by a site-specific risk assessment and directed through appropriate

Standing Orders such as Range Standing Orders. 10 Ibid. Part 1 Annex D-8, 'the Range Safety Officer is the Competent person on the range staff of the Range Administering Unit who is

responsible to the Commanding Officer/Manager of the Range Administering Unit for the day to day safe operation of a particular live

firing area or range complex and for range clearance. " !bid, Part 1. Annex D-9, range standing orders are defined as 'the set of orders. derived from a site-specific risk assessment, which

specify the control measures and procedures for the safe operation and use of the range. The Range Standing Orders are binding on

all persons authorised to be on the range.

12 The March 2016 version of Pam 21 was extant at the time.

'-" Pam 21, Training Regulations for Armoured Fighting Vehicles. Infantry Weapons Systems. and Pyrotechnics, March 2016, para 2-13.

1.4 - 9


a Factor in the accident. However, the Panel does consider that improvements to Pam 21 should be made; these are discussed later in this report.

Army Equipment Support Publication

1.4.28. The Army Equipment Support Publications (AESP) serve as reference publications for the maintenance, modification and use of specific equipment. The L115A3 Sniper Rifle is covered by AESP 1005-L-305-201 Rifle .338" L115A3 (AESP L115A3). This specific publication explained rifle maintenance procedures and user instructions and contained 2 separate safety warnings relating to the dropping of the L115A3 Sniper Rifle.14 These drills are specifically designed to cause minimal wear and tear on the moving parts of the weapon system.

1.4.29. There is a discrepancy between the AESP L115A3, the maintainers' guide, and the operators Skill at Arms (SAA) manual, namely Capability Directorate Combat Dismounted Close Combat Training - Volume 1 Skill at Arms - Individual Training Sniping - Part 1 The L115A3 Sniper Rifle 8.59mm and Associated Equipment 2016 (Sniping Part 1). Specifically, these related to the 'unload' drill, with different procedures described in each publication.15 On completion of the AESP drill the firing pin is forward and not under tension. In the unlikely scenario where one round was already erroneously chambered, the firing pin would be positioned against the base of the cartridge's percussion cap. Consequently, the weapon would be in an unsafe condition. In this scenario, the proximity of the firing pin to the percussion cap means that the weapon might be susceptible to an un-demanded discharge, should sufficient energy be forced through the firing pin

1.4.30. Generally, snipers would not routinely view the AESP L115A3 publication, rather they would rely on the Sniping Part 1. Notwithstanding this fact, prior to adopting the distributed training model, when sniper training was centralised and delivered by SWS, there were instances whereby students were taught the AESP Normal Safety Precaution (NSP) drill. Consequently, the Panel believes that 3 RIFLES Sniper Platoon soldiers were more likely than not to be aware of the AESP drill.

1.4.31. There is no supporting evidence that LCpl Spencer employed this drill at any stage during the SOC. Moreover, it is the opinion of the Panel that employing the AESP drill, which requires a two-handed operation, during LF training would be noticeable to fellow students and DS and would serve no practical benefit to the student.

1.4.32. The Panel concluded that while there were discrepancies between AESP L115A3 and Sniping Part 1, relating to the unload drill and while it is likely that 3 RIFLES students would have been aware of the drill it is very unlikely that the drill would have been employed as it served no practical benefit and therefore this is an Other Factor.

1.4.33. Recommendation. Programme Leader Dismounted Close Combat should ensure that the weapon handling drills in the Army Equipment Support Publication

Exhibit 124

Exhibit 015 Exhibit 031 Exhibit 124 Exhibit 148

Exhibit 015 Exhibit 124 Witness 48

AESP 1005-L-305-201 Rifle .338, Ch 4, page 2, describes 2 L115A3 Sniper Rifle drop hazards: first, due to the weapons design, the trigger mechanism is highly sensitive and that accidental activation may occur if the weapon is dropped: secondly, extreme care is to be exercised to avoid dropping the weapon when a round is in the chamber and the weapon is cocked with the safety lever set to the 'Fire' position. 15 AESP 10054-305-201 Rifle .338" L115A3, page vii, para 7.7.1 — 7.7.2, states that during the unload drill and normal safety precautions (NSPs) the user must: close the bolt while pulling the trigger and [concurrently] close the bolt, and then 'release the trigger.' In contrast, Capability Directorate Combat Dismounted Close Combat Training - Volume 1 Skill at Arms - Individual Training Sniping -Part 1 The L115A3 Sniper Rifle 8.59mm and Associated Equipment 2016, states that 'the action should be fired off after closing the bolt.'

1.4- 10


are aligned to those detailed in the Sniper Part 1 in order to reduce the potential for

confusion and to ensure safe and unambiguous weapon handling drills.

Organisations

Distributed Training Cell

1.4.34. The Distributed Training Cell (DTC) was the team responsible for the design, implementation and assurance of distributed training across the Army. At

the time leading up to the accident the DTC was under staffed with 3 of 4 senior NCO positions filled.

1.4.35. The DTC endorsed the 51 Bde SOC syllabus ensuring it complied with the

generic SOC syllabus. When planning the course, DTC dealt exclusively with the

SOC Planning Officer, CSgt 1. In addition, the DTC conducted a second party assurance16 visit to the 51 Bde SOC during the second week at Barry Buddon Training Area (BBTA). The visit focused on assuring the content of the syllabus to

ensure it met the needs of the Training Delivery Authority (TDA), 17 as opposed to

scrutinising the quality of training delivery.18 Due to competing demands on an understaffed DTC, this was the only planned visit to the 51 Bde SOC.

1.4.36. The Panel concluded that while DTC provided a SOC syllabus that was fit

for purpose, the second party assurance visit was limited in scope, in that it did not

assure training delivery, therefore this was considered an Other Factor.

1.4.37. Recommendation. Assistant Chief of Staff Training should ensure that

there is effective and documented assurance of the delivery of distributed training

courses, in order to ensure that the endorsed syllabus is being delivered as

designed and that training delivery is compliant, effective and safe.

Specialist Weapons School, Sniper Wing

1.4.38. In Jan 16, SWS, Sniper Wing, informed units possessing. or developing a

sniper capability of the impending change to the delivery of this training to a distributed training model. Brigade and Divisional HQs were not included in the distribution for this notification.19 Responsibility for training delivery would revert to

the Field Army from the School of Infantry. Moreover, SWS directed that the SOC

had been designed to be delivered at either unit or brigade level (by battalion/regimental staff), or by Divisional Training Teams, and the evaluation would

fall to the School of Infantry. This message was reinforced by SWS to unit sniper

platoon commanders and section commanders during T3 courses29 delivered during

the first half of 2016.

1.4.39. Under the distributed training model, SWS was responsible for providing units planning a SOC with SME advice during both planning and execution. In

addition, to ensure adherence to standards and provide independent assessment,


Exhibit 023 Exhibit 089 Exhibit 090 Exhibit 118 Witness 24 Witness 37

Exhibit 097 Exhibit 130 Exhibit 133 Witness 37


16 2" party assurance is conducted by an organisation comprising of Suitably Qualified and Experienced Personnel (SQEP) external to

the (training] activity taking place. This is done to ensure independent evaluation, auditing and inspection in order to assure the quality

of training being undertaken.

17 JSP 822, Defence Direction and Guidance for Training and Education Part 2: Guidance, v3 0 Apr 17, page 174, defines the TDA as

'the organisation responsible for training delivery. but not necessarily the conduct of the actual training itself.'

18 JSP 822, Defence Direction and Guidance for Training and Education Part 2: Guidance, v3.0 Apr 17. page 174, defines training

delivery as 'the provision of training based on the training Objectives/Collective Training Objectives produced by training Design.'

19 1 (United Kingdom) Division (1 Div) were made aware of the impending change to sniper training delivery in a routine briefing from

their Small Arms School Corps (SASC) staff. 2' Train the Trainer (T3) courses are courses that enables the cascade of new training methodologies and processes whereby those that

will be responsible for conduct of training are trained in line with the latest policy

1 4 - 11


on behalf of the School of Infantry, SWS Sniper Wing was responsible for the evaluation of students during the evaluation week of the SOC. In this instance. the accident happened before that point was reached in the course, as such, SWS Sniper Wg had not visited the course but had given advice to CSgt 1 in the planning of the SOC.

1.4.40. When notified that a unit intended to plan and deliver a SOC, SWS Sniper Wing assigned a SME, of CSgt rank, to act as both a mentor to the unit planning officer and the first point of contact (POC) for specialist advice. However, the initial mentor assigned to the course was relocated to another job in the Army; SWS Sniper Wing duly assigned another SME to fulfil the mentor/POC role. Despite this change, the interaction between the 51 Bde Planning Officer (CSgt 1) and the assigned SWS mentors was adequate.

1.4.41. Notwithstanding the implementation of policy to deliver the SOC as distributed training. SWS Sniper Wing retained training delivery responsibility for the Sniper Section Commanders' Course and the Sniper Platoon Commanders' Course. Both courses incorporated a T3 function which is a requirement to deliver a distributed SOC. At the time, only 3 of the 4 CSgt posts at the SWS Sniper Wing were filled. While stretched between instructing on several courses and mentoring a number of units, the shortfall of staff did not adversely impact the interaction between the 51 Bde SOC Planning Officer and the assigned mentor.

1.4.42. The Panel concluded that despite a manpower shortfall, SWS Sniper Wing provided adequate support during the planning of the 51 Bde SOC and therefore this was Not a Factor.

51st Infantry Brigade

1.4.43. 51 Bde held a Brigade Study Period at Fort George on 18 — 19 Apr 16; this was hosted by 3 SCOTS, with attendance from brigade staff and subordinate units. The study day focused on the light mechanised infantry role and conversion to the role.

1.4.44. During a briefing on Intelligence. Surveillance, Target Acquisition and Reconnaissance (ISTAR), CSgt 1, the SOC planning officer, informed the audience of his intention to deliver a SOC as distributed training, with assistance provided by 1 SCOTS and 3 RIFLES. A brigade staff officer within the audience suggested the course nomenclature was amended to 51 Bde SOC, and that course attendance was opened to brigade units with a sniper capability.

1.4.45. Interaction between 51 Bde staff and CSgt 1, in his capacity as 51 Bde SOC Planning Officer, was negligible thereafter. Despite the direction to amend the course nomenclature to include 51 Bde, brigade staff were largely unaware of the existence of the course. As such, the course was not captured on the 51 Bde forecast of events. However, the inclusion of 51 Bde in the title helped raise the profile of the course amongst brigade units.

1.4.46. 51 Bde provided no oversight, assistance or support at any stage during the planning of the course, which was appropriate given that it was unit-level training. 51 Bde did provide an ammunition uplift once the course had started. In the absence of Brigade involvement, planning was bottom-up led and centred on 3 SCOTS. Consequently, CSgt 1 had to plan and resource the course without Brigade support, and instead relied on grace and favour support from participating units to facilitate training areas, training ammunition and instructor support.




Exhibit 032 Exhibit 080 Witness 23 Witness 24

Exhibit 027 Exhibit 080 Exhibit 117 Exhibit 131 Exhibit 138 Exhibit 149 Witness 47


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1.4.47. The Panel concluded that while the 51 Bde SOC had the appearance of a brigade course, 51 Bde involvement was negligible, therefore this was considered an Other Factor.

1.4.48. Recommendation. Head of Capability Ground Manoeuvre should revise policy to ensure that brigades within the chain of command provide oversight of unit level training, including distributed training, in order to ensure that it is adequately resourced in terms of personnel, support and time.

The Black Watch, 3rd Battalion The Royal Regiment of Scotland

1.4.49. During 2014, 3 SCOTS trained Libyan armed forces in the UK, which proved an extremely challenging task. In 2015, elements of 3 SCOTS deployed to Cyprus on the UK's contribution to the United Nations Peacekeeping Force (UNFICYP) in Cyprus. The rest of the battalion remained at Fort George.

1.4.50. Throughout 2016, 3 SCOTS converted from Light Role Infantry to Light Mechanised Infantry. The conversion process required an

with the associated vehicle maintenance and training for commanders, drivers, gunners and maintainers. In conjunction, individual soldiers completed role specific training of up to 6-weeks duration. Likewise, progressive collective training (CT) was conducted from section level, through company and battalion, to brigade-level. This culminated in a CT 42' assessed exercise (Exercise WESSEX STORM) in Aug 16: this was a precursor to the unit achieving Full Operating Capability in the Light Mechanised role by Sep 16. Concurrently, 3 SCOTS had to complete routine tasks, including a succession of guard force commitments at MOD locations in Scotland.

1.4.51. The 3 SCOTS Sniper Platoon was part of the Delta Company (D Coy) order of battle. Commensurate with the conversion to Light Mechanised Infantry, D Coy converted from support weapons to an intelligence, surveillance and reconnaissance (ISR) role. As a result, mortars, anti-tank and communications information systems platoons were transferred to another company.

Periodically in 2016, key posts were gapped within the company, including both the Officer Commanding and Second in Command, albeit at different times.

1.4.52. Due to the dislocation of sub-units and commanders in 2014 and 2015 there were limited opportunities for the battalion command group to get together and plan for the impending light mechanised infantry conversion in 2016. This contributed to a busy programme for 3 SCOTS during 2016.

1.4.53. The conversion to Light Mechanised Infantry meant that soldiers were often dispersed on various courses, training and exercises, often with competing priorities, throughout 2016. Consequently, a demanding programme to meet the conversion timeline affected unit cohesion and individual harmony.

1.4.54. The Panel concluded that 3 SCOTS were extremely busy with several competing tasks during the conversion to Light Mechanised Infantry in 2016. This both compressed the time available for planning and reduced the chain of command's ability to effectively supervise the planning phase of the SOC: therefore, this was an Observation.






Collective Training is the level of readiness a unit is at CT 4 is the competence of a unit to operate as a Battlegroup in a Bde context

on operations.

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Tain Air Weapons Range

1.4.55. Tain AWR in Northern Scotland was licensed by the DIO for ground LF range use in Jun 14. The Independent Range Safety Inspection Report of 25 Oct 16 clearly stated that Tain AWR is suitable for ground LF, including sniper training.22 Moreover this inspection report concluded that Tain AWR was fit for ground use. Despite the increased utility, its geographic isolation to most MOD land units meant that the primary use of the facility was as an air weapons range. The main users of the ground LF ranges were locally based units, namely 3 SCOTS, from Fort George and 5 FP Wg, based at RAF Lossiemouth.


Figure 1.4.2 - Tain AWR Tower

1.4.56. Tain AWR was staffed by members of the DIO. The key DIO staff appointments comprised the Training Safety Officer (TSO), responsible for authorising live firing, and Range Wardens, responsible for maintenance of the range. DIO staff were augmented by RAF personnel who provided the Main Tower Assistant (MTA)23 role.

1.4.57. Orders for the operation of the range are contained within the Site Standing Orders (SSO) and Range Standing Orders (Ground Use) (RSO) documents. This includes duties of the TSO, Range Wardens and the MTA. The Panel noted that the role of the MTA in the SSOs were explicit for air use. Ground use was covered separately in the RSOs. Having reviewed the documents, the Panel opined that ground LF was being conducted in accordance with this documentation. Furthermore, while documents contained some minor incorrect cross-referencing, this did not contribute to the accident.


22 51 MOD Form 907B-5 Independent Range Safety Inspection Report for Tain ground fires, dated 25 Oct 16 states: "the FFA [Field Firing Area] is 2,700 acres of mainly low-lying heathland and salt marsh capable of conducting Dismounted Close Combat LFTT up to platoon level, ground training associated to close air support, vehicle mounted (wheeled) weapons and sniper training." 23 The MTA is a military air traffic controller that ensures safe airspace at Tain AWR.

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1.4.58. Incident/accident response was detailed in the Immediate Action Safety Plan within the RSOs. The application of this is covered further in the 'Immediate action' section of this report.

1.4.59. The Panel opined that Tain AWR was fit for purpose for the conduct of ground LF and was Not a Factor in the accident.

Governance

Assurance

1.4.60. JSP 822, Defence Direction and Guidance for Individual and Collective Training, Part 1: Directive (V.1.0 Dec 15): and Part 2: Guidance (V.1.0 Dec 15), explains the Defence Systems Approach to Training (DSAT) and the associated assurance of DSAT activity.

1.4.61. The SOC was a DSAT compliant course as it had been subject to the requisite analysis, design, delivery and assurance. For the sniper capability, the Training Requirement Authority (TRA)24 was Head of Capability Combat (HoC Cbt)25; he was the end user of the trained output and is responsible for the evaluation of the effect of the training. The School of Infantry acted as the Training Delivery Authority (TDA) for the SOC. It developed HoC Cbt's intent in partnership with the DTC and a civilian contractor to design the course. The Training Provider is the organisation that conducts the training; in this instance, it was 3 SCOTS, supported by 1 SCOTS and 3 RIFLES. Both the TDA and the Training Provider have an assurance responsibility.

1.4.62. JSP 822 describes assurance as 'an all-encompassing term used to describe the evaluation, audit and inspection activities of the Training System.' There are 3 levels of assurance within military training. The training provider

undertakes 1s' party assurance; this is a self-check of training delivered against policy. In contrast, 2"d party assurance comprises external checks completed by Defence organisations other than the training provider, to maintain standards across Defence. Likewise, 31d party assurance is completed by organisations external to the MOD (e.g. Ofsted), to compare training standards and qualifications across multiple organisations. On completion of an assurance event a report should be raised.

1.4.63. During Phase 1 of the SOC, no one from the 1 SCOTS or 3 SCOTS chain of command visited BBTA. Therefore, 15t party assurance of this Phase was not

conducted. Documented 1' party assurance would have offered an important opportunity to identify any potential shortfalls in training delivery, namely the omission of Skill at Arms (SAA) lessons 1 — 18 (see 'Skill at Arms' section of this report). However, a 2^d party assurance visit by a member of the DTC did take place during week 2 of this phase. This assurance visit focused exclusively on the validity of the SOC syllabus and did not assure the quality of training delivery. There was no expectation that 3 d̀ party assurance was required.

Exhibit 139

Exhibit 081 Exhibit 082 Exhibit 083 Exhibit 084 Exhibit 085 Exhibit 086 Exhibit 087 Exhibit 088 Exhibit 089 Exhibit 090 Exhibit 139 Exhibit 118

Exhibit 139


24 JSP 822, Defence Direction and Guidance for Individual and Collective Training; Part 1: Direction, v.1.0 Dec 15, p 6 'the TRA

represents the end-user of the trained output and is the ultimate authority for the derivation and maintenance of the Role Performance

Statement (Role PS). The TRA is responsible for the evaluation of the effect of the training in achieving the Role PS wherever the

training is delivered.' HoC Cbt is now retitled HoC Ground Manoeuvre (HoC GM).

15 JSP 822, Defence Direction and Guidance for Individual and Collective Training: Part 2. Guidance, v.1.0 Dec 15, p 108, para 2.

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1.4.64. The Panel opined that while the SOC syllabus was DSAT compliant, there was inadequate assurance of the training delivery; as the course was distributed, the need for assurance was essential. This lack of assurance resulted in a missed opportunity to confirm that the endorsed syllabus was being delivered. This was therefore a Contributory Factor.

1.4.65. Recommendation. Same recommendation as per the Distributed Training Cell section.

Duty Holding

1.4.66. Direction on how the Army deals with those activities that pose a Risk to Life (RtL) is encapsulated in the process known as Duty Holding (DH) and is found in Op Order 14-002, The Army's Approach to 'Risk to Life'27 and Land Forces Standing Order 3216.28

1.4.67. Duty Holders must be appointed and understand their role and responsibilities as a Duty Holder.29 The purpose of the Duty Holder is to ensure that activities that carry a Risk to Life are safe and that any risks are appropriately managed. Risks are managed using the principles of 'As Low as is Reasonably Practicable' (ALARP)3° and tolerable.

1.4.68. The Army has five tiers of DH; a breakdown of roles and responsibilities is contained in Figure 1.4.3. This report only considers the Delivery Duty Holder, the brigade level oversight and the Operating Duty Holder.

Exhibit 130


Exhibit 130

22 Op Order 14/002, The Army's Approach to 'Risk to Life', dated 28 Feb 14. Land Forces Standing Order No 3216, dated Mar 15.

29 JSP 403. Handbook of Defence Ranges Safety, Volume 1 Part 1 (V1.1 May 15), pD-4, defines a Duty Holder as 'employers, managers and employees all have duties under S&EP [safety and environmental protection] legislation, additionally it is appropriate in Defence to identify individual post-holders as Duty Holders (DHs) to provide specific focus on S&EP management. DHs have a personal duty of care for personnel under their command or management, for those who, by virtue of their temporary involvement in activities, come within a DH's area of responsibility (AOR) and for the public who may be affected by their activities. DH's are accountable for the safety of activities in their AOR and for ensuring that risks are reduced So Far As is Reasonably Practicable (SFAIRP). In the execution of their specific responsibilities. DHs are accountable to SofS [Secretary of State for Defence]. via their superior DH chain. 3° JSP 403, Handbook of Defence Ranges Safety, Volume 1 Part 1 (V1 1 May 15), pD-1, defines ALARP as 'a risk is ALARP when it has been demonstrated that the cost of further Risk Reduction, where the cost includes the loss of defence capability as well as financial or other resource costs. is grossly disproportionate to the benefit obtained from that Risk Reduction.'

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FIVE TIER ARMY DH MODEL - SPECIFIC RESPONSIBILITIES

LEADING

CGS • As the Senior Duty Holder, ensuring the Army has an

effective process for managing risk to life.

***

OVERSIGHT • Understanding RtL activities across HLBs.

CLF • Prioritising risk and ensuring it can be met within

AG delegations.

Comd F DT • Elevating those risks to the ACG that cannot be dealt with by the chain of command.

1Wt

OPERATING • Understand RtL activities within the command. • Balance risk, over time, within activity with resource.

GOCs • Sponsor the case for additional resource to mitigate risk

DG ARTD to command groups.

Comdt RMAS • Manage training and operational dispensations. • Develop linkages with relevant advisers. • Act as the ODH point of contact for other TLBs.

OVERSIGHT • Understand RtL activities within the brigade. • Oversee all COs' approaches to managing RtL.

Brigade • Mentor the assurance process by COs.

OF 5 Comds • Elevate and help prioritise COs' concerns to the operating level.

• Develop a safety conscience at the brigade level.

DI

DELIVERY • Understand RtL within the unit and ensure it is

appropriately managed.

COs • Stop or amend activity where risk is not ALARP given the

Independent OCs training/operational context. • Ensure equipment is operated with the relevant safety

case. • In extremis, appeal to the operating level where risk is no

longer tolerable to you. • Where training/operational dispensations exist, ensure

controls and mitigations are applied. • Act as the DDH point of contact for other TLBs.

Figure 1.4.3 — 5 Tier Army Duty Holding model


1.4.69. LF is listed as a RtL activity in the Army Competent Adviser and Inspector (ACAI) List of Responsibilities.' LF is considered a routine training activity and is delivered at Unit level across all 3 Services daily. All RtL activity must be conducted in accordance with the Safe System of Training (SST) and be risk assessed as appropriate. For LFTT the practice must be undertaken in accordance with the SST. whereby the following are complied with:

3' Army Competent Advisor and Inspector, Responsibilities Table, Jun 16, Serial 17, page 22.

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a. Safe Persons.

(1) The officers, warrant officers and NCOs who plan, conduct and supervise training with Armoured Fighting Vehicles, infantry weapon systems and pyrotechnics are to be properly qualified or authorised and are competent to discharge their duties.

(2) All exercising troops are to have the competency to handle, operate and fire the weapons, ammunition, pyrotechnics and vehicles they will use during the exercise or practice, and the experience needed for the demands of the training.

b. Safe Equipment. All weapon systems, ammunition, pyrotechnics and vehicles are exhaustively tested and certified as being 'Safe and Suitable' for Service (S3). The Project Team (PT) responsible gives this certification.

c. Safe Place. Ranges, Live Firing Tactical Training Areas (LFTTA) and Training Areas are properly prescribed, clearly marked and conform to the design and safety criteria given in JSP 403, including a regulated inspection programme.

d. Safe Practice.

(1) Pamphlet No. 21 prescribes the rules and regulations for the planning, conduct and supervision of firing and training with Armoured Fighting Vehicles, Infantry Weapon System and pyrotechnics to achieve procedural safety.

(2) Operational Shooting Policy (OSP) Volumes 1 to 4 states the mandatory criteria for training with AFV, Inf WS and pyrotechnics:

(a) Formally Trained. Trained by a qualified and competent SAA/Gunnery instructor, in accordance with the appropriate Training Publication.

(b) Formally Tested. Passed the Weapon Handling Test (WHT), conducted by a SAA instructor who is current with the weapon system, within the qualifying period. The results are to be recorded.

(c) Live Firing Tested. Passed the weapon live firing test within the qualifying period. The results are to be recorded.

(d) Training Progression. Having followed the progression of training stated in the Commanders Guides contained within the OSP.

(e) Practical Understanding. Having been suitably briefed on the requirements and constraints of the exercise or range practice.32

32 Dismounted Close Combat — Pamphlet No 21, Training Regulations for Armoured Fighting Vehicles, Infantry Weapon Systems and Pyrotechnics, Oct 17, page 1-2, 'Section 1. The Safe System of Training'.

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1.4.70. The Exercise Director33 (Commanding Officer 3 SCOTS), in his capacity as the DDH for the entire SOC, consulted with his staff prior to commencement of the course. Moreover, he assessed that this RtL activity was both ALARP and tolerable. as it complied with the SST. Therefore, in accordance with the DH policy34 there was no requirement upon him to elevate the risk higher as the risk was held by him. As the policy did not require elevation of RtL from a DH perspective, it was reasonable that neither the brigade level oversight (51 Bde Commander) nor the Operating Duty Holder (General Officer Commanding 1 (United Kingdom) Division) were aware of this RtL activity.

1.4.71. The Panel concluded that, in this instance, the Army's DH policy was adhered to and therefore was Not a Factor in this accident.

Organisational influences

Sniper culture

1.4.72. In accordance with Sniping - Part 2, Fieldcraft & Battle Exercises, 2016, sniper platoon candidates should ideally be of a high standard and have achieved 'Marksmanship' standard' in their Annual Combat Marksmanship Test (ACMT) with

the L85A2 (SA80 A2) (5.56mm) Individual Weapon (IW). Consequently, sniper platoons/troops normally consist of comparatively more experienced soldiers than their counterparts in a rifle company.

1.4.73. Witness testimony from students, DS and chain of command described Sniper platoons/troops as reflecting a distinct camaraderie, culture and ethos that sets them apart within their respective units. Furthermore, witness testimony shows that amongst the sniper cohort and the chain of command there is a perception that soldiers assigned to sniper duties are at a heightened level of professional competence and that thus, they can be trusted to complete their duties with a lower level of supervision than their colleagues in a rifle company. During the SI, witnesses commonly referred to this heightened trust and lower level of supervision

as 'big boys' rules'. Witnesses stated that this attitude prevailed during the SOC. The Panel opined that this was inappropriate for students undertaking formal training.36 Specifically, students were mistakenly held in higher regard than their limited sniper competencies and experience merited. This resulted in lower levels of supervision during the SOC and contributed to subsequent weapon handling errors on 1 Nov 16 (see 'Afternoon detail' section).

1.4.74. The Panel opined that there was a distinct sniper culture prevalent across the sniper units attending the SOC and that this resulted in lower levels of supervision that was inappropriate when supervising unqualified students and contributed towards subsequent weapon handling errors on 1 Nov 16. Therefore, this was a Contributory Factor in the accident.

Exhibit 155

Exhibit 016

Exhibit 086 Exhibit 139 Witness 12 Witness 24 Witness 27 Witness 33 Witness 37

JSP 403, Handbook of Defence Ranges Safety, Volume 1 Part 1 (V1.1 May 15). pD-5. defines Exercise Director as 'the person who

directs that a particular training exercise or practice is to be carried out and who appoints officers to plan and conduct the activity. The

Exercise Director cannot be the person appointed to plan or conduct the training but ensures those appointed are Competent and that

the plan meets the requirements of the aim of the exercise and that exercising troops are competent to undertake the training '

Op Order 14/002 - The Army's Approach to 'Risk to Life'. dated 28 Feb 14.

Sniping Part-2. Fieldcraft & Battle Exercise. 2016. page xii, para 9, states 'the potential sniper must be proficient in all basic infantry

skills, he must be a marksman on his individual weapon and be above average in fieldcraft skills. By being competent in all infantry skills

he can then advance to a specialist standard incorporating all the sniper skills".

JSP 822. Defence Direction and Guidance for Training and Education Pad 2: Guidance, v3.0 Apr 17, page 159. defines formal

training as 'training activity, no matter where or how it is delivered, derived as a result of the application of the Defence Systems

Approach to Training (DSAT) process and articulated in a Formal Training Statement (FTS). Formal training will, throughout its life,

continue to be subject to the rigours of DSAT and any associated MTS The FTS is the document that articulates the totality of the

formal training and drives the formal contract between the TRA/TDA and Training Provider which is articulated in the TrAD '

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1.4.75. Recommendation. Head of Capability Ground Manoeuvre should ensure that there is appropriate supervision of unqualified students during distributed sniper training, in order to ensure that sniper training at unit level is safe and that the high professional regard that is afforded to trained snipers is not prematurely allocated to unqualified students undergoing sniper training.

Untrained personnel within Sniper Platoons

1.4.76. There were several unqualified snipers assigned to unit sniper platoons for variable time periods before completing formal sniper training. Prior to attending the SOC. unqualified snipers received piecemeal training of variable content and quality. This was compounded by poor SAA record keeping at unit level. Despite the haphazard SAA training, to fulfil unit commitments, sniper platoons routinely employed unqualified snipers, alongside qualified snipers, on live-fire exercises in the UK and overseas.

1.4.77. Due to this combination of circumstances, unqualified snipers assigned to sniper platoons were, on occasions, exposed to non-standard practices or bad habits. It is likely these were ingrained because of inconsistent/incomplete SAA training at unit level. Amongst the sniper cohort, there was wide awareness of 'accepted' non-standard practices including the use of Vaseline to lubricate the rifle's bolt and the use of the 'combat load'.37 Likewise, there was an awareness of bad habits, including holding the L115A3 Sniper Rifle upright by the muzzle/suppressor. Consequently, this blurring between standard drills and non-standard practices or bad habits might have caused confusion, with the resultant potential for an error of drill by an unqualified sniper under stress e.g. during live firing exercises.

1.4.78. The Panel concluded that there were instances of soldiers not qualified as snipers being employed in a sniper role and allowed to fire the L115A3 Sniper Rifle whilst untrained. It is very likely that this situation resulted in their exposure to non-standard practices employed locally by personnel in those sniper units. These were likely ingrained and subsequently employed by students who attended the 51 Bde SOC. This was a Contributory Factor.

1.4.79. Recommendation. Head of Capability Ground Manoeuvre should ensure that unqualified snipers are only permitted to fire the L115A3 Sniper Rifle with appropriate supervision (in accordance with Pamphlet 21), or when they attend a Sniper Operators' Course, in order to prevent the adoption of non-standard practices and bad habits within sniper platoons/troops.

Directing Staff

1.4.80. The SOC comprised students drawn from 5 units;38 all of which provided suitably qualified and experienced persons (SQEP) of Non-Commissioned Officers (NCO) rank to act as Directing Staff (DS) and enable the course. There were sufficient appropriately qualified DS to deliver SAA training on the L115A3 Sniper Rifle, and all DS were appropriately qualified to mentor and safety supervise the LF ranges. Five DS, including CSgt 1 and CSgt 2, attended the SWS delivered T3


Witness 17 Witness 27 Witness 28 Witness 30 Witness 35 Witness 37

Exhibit 037 Witness 24 Witness 25 Witness 32

The use of Vaseline to lubricate the bolt is a legacy practice from an earlier sniper rifle variant the L96 and not relevant to the L115A3. The 'combat load' involves chambering a round, removing the magazine and replacing it with a fresh magazine of 5-rounds, resulting in the sniper rifle having 6 rounds available to fire. Evidence suggests this drill is widely employed in order to provide an advantage on the ACMT where firers have the option for up to 2 rounds per target exposure, if they miss with their first engagement. 38 The 5 units participating in the 51 Bde SOC were Royal Scots Dragoon Guards (SCOTS DG); The Royal Scots Borderers, Battalion the Royal Regiment of Scotland (1 SCOTS); The Royal Highland Fusiliers, 2" Battalion the Royal Regiment of Scotland (2 SCOTS) The Black Watch, 3`' Battalion the Royal Regiment of Scotland (3 SCOTS); and 3rd Battalion. The Rifles (3 RIFLES).

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course (10 — 15 Apr 16), outlining the switch to a distributed training model for sniper

training.

1.4.81. Sourced from 5 distinct units the DS had diverse experiences and habits.

This manifested itself in differences of culture, approaches to soldiering and training,

and a higher acceptance of risk as seen in soldiers returning from operations. This

eclectic mix of soldiers created disparate expectations amongst the DS and the

students as to training delivery, levels of supervision required, general conduct on

the range and increased acceptance of risk as reported to the Panel in numerous

instances. Moreover, the standard and experience of DS supporting the SOC was

deemed average by the Panel, with the majority finishing in the bottom third of

promotion courses and lacking instructional experience in an Army training unit.

Furthermore, unlike an established sniper training team, prior to the SOC the DS had

never worked together as a cohesive team. As a result, this contributed to a lack of

awareness of instructor strengths and weaknesses and small inconsistencies in the

quality of instruction, supervision and risk acceptance throughout the SOC, which

may have contributed to confusion amongst students and DS at key stages during

the course. This was evident in the different methods of indicating 'show clear' by

both firers and safety supervisors alike, as well as different ammunition distribution

routines during LF ranges between Phase 1 and Phase 2 of the SOC.

1.4.82. The Panel concluded that the differing backgrounds, unit cultures and

instructor experience of the DS. combined with the ad hoc nature of the SOC training

team, is likely to have contributed to a lack of adherence to standard procedures

during the course. and therefore this was a Contributory Factor.

1.4.83. Recommendation. Head of Capability Ground Manoeuvre should revise

policy to ensure that ad hoc training teams are appropriately task organised and

prepared prior to the commencement of distributed training in order to ensure a

consistent and robust safety culture appropriate to the training activity being

undertaken.

Pre-Accident

Planning

1.4.84. Acting on SWS direction to pool training resources, while in the margins of

the T3 course the sniper platoon commanders from 1 SCOTS, 3 SCOTS and 3

RIFLES agreed to jointly plan and deliver a SOC, to train soldiers from their

respective units. Thereafter, CSgt 1 assumed responsibility for the overall planning

and coordination of the SOC. Accordingly, he issued direction on the content of the

course to the other 2 platoon commanders. Planning evolved into 3 distinct phases:

Phase 1, marksmanship led by 1 SCOTS at BBTA between 2 — 28 Oct 16; Phase 2,

fieldcraft led by 3 SCOTS at Tain AWR, between 31 Oct — 18 Nov 16; and Phase 3,

consolidation/assessment led by 3 RIFLES at Otterburn Training Area (OTA),

Exhibit 049 Exhibit 050 Exhibit 052 Exhibit 053 Exhibit 055 Exhibit 056 Exhibit 057 Exhibit 058 Exhibit 059 Exhibit 060 Exhibit 061 Exhibit 063 Exhibit 064 Exhibit 065 Exhibit 066 Exhibit 070 Exhibit 071 Exhibit 072 Exhibit 073 Exhibit 074 Exhibit 075 Exhibit 076 Exhibit 077 Exhibit 078 Exhibit 079


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OFFICIAL- SENSITIVE

between 21 Nov — 9 Dec 1639. Each Platoon Commander was responsible for the planning and conduct of their respective standalone phase.

1.4.85. During the early stages of planning, the concept for distributed sniper training was in its infancy and unproven. Moreover, there was no lessons database available to assist planning. The modular approach to training appeared pragmatic to the 3 planners at the time, as it allowed each unit to focus planning, while utilising existing training area bookings (e.g. BBTA) and resources (e.g. qualified sniper staff), thereby sharing the training burden between the 3 units.

1.4.86. The SOC syllabus assumed that students had no prior sniper competence. Therefore, the syllabus was designed to equip students with the essential competencies40, including all SAA lessons on the L115A3 Sniper Rifle, needed to become a qualified sniper. CSgt 1 identified correctly that achieving the exacting standards required strict adherence to the syllabus. Unsurprisingly, he never considered deviating from the syllabus, or that others might do so.

1.4.87. CSgt 1 was not a qualified sniper, although he was qualified as a Sniper Platoon Commander, having completed the Sniper Platoon Commanders' Course at SWS Warminster. This is normal practice in Sniper Platoons. In contrast, CSgt 2 was a qualified sniper and possessed greater practical experience in the training and employment of snipers. Due to this disparity in experience, CSgt 1 understandably entrusted CSgt 2 with the planning and delivery of Phase 1. This faith and deference to CSgt 2's experience and expertise, explained why CSgt 1 provided minimal supervision during the planning and delivery of Phase 1. Moreover, the level of trust extended to CSgt 2 set the conditions for the subsequent omission of key elements of the endorsed syllabus during Phase 1, namely the L115A3 Sniper Rifle SAA lessons (see 'Skill at Arms' section).

1.4.88. By default, 3 SCOTS, through CSgt 1, provided the SOC planning lead, with support from the Sniper Platoon Commanders from 1 SCOTS and 3 RIFLES. The modular approach meant that planning was disjointed and stove piped, with each unit concentrating on their phase. This was evident by ad-hoc and un-structured communication between the three lead planners. This was conducted via WhatsApp® and phone on an as-needed basis, rather than face-to-face. Due to the light mechanised conversion and the key CT4 training event (Exercise WESSEX STORM), 3 SCOTS hierarchy did not appear to have the capacity to provide the requisite supervision and oversight. Highly regarded in the battalion, CSgt 1 was therefore left largely to his own devices. Notwithstanding his reputation and standing in the battalion. the panel opined that the supervision by his chain of command was insufficient given the complexity of the task.

1.4.89. This disjointed planning led to duplication. Conspicuously, each unit appointed a separate senior planning officer who authorised ranges during their specific phase. Additionally, there were notable shortfalls in that key elements of the endorsed SOC syllabus were not delivered (see 'Skill at Arms' section).

1.4.90. The Panel concluded that while CSgt 1 was SQEP, his trust in CSgt 2 was misplaced and notwithstanding CSgt 1's reputation and standing in the battalion, the supervision by his chain of command was insufficient given the complexity of the task. This along with the modular approach to delivering the SOC, resulted in sub-

Exhibit 021 Exhibit 022 Witness 24 Witness 25 Witness 26

Exhibit 027 Exhibit 084 Exhibit 085 Exhibit 086 Exhibit 089 Witness 24




In a change from the 51 Bde SOC Syllabus. due to range unavailability in the last week of Phase One at BBTA. the programme was revised. Week One, Phase 2 was rearranged and comprised LF ranges. culminating in the ACMT, conducted at Tain AWR. 4' To qualify as a sniper a student is required to pass each of the sniper competencies, which comprise: stalking, observation; judging distance: navigation/map reading: and marksmanship.

1.4 - 22


optimal planning which lacked appropriate chain of command oversight. This sub-

optimal planning was therefore a Contributory Factor.

1.4.91. Recommendation. Assistant Chief of Staff Training should revise planning

guidance for distributed training to reflect the need for a nominated single-planning

lead, with appropriate unambiguous terms of reference in order to ensure

appropriate planning of distributed sniper training.

Range reconnaissance

1.4.92. Pam 21 states" that a range reconnaissance is 'a vital part of the planning

process.' CSgt 1 had previously visited Tain AWR in May 16 to reconnoitre range

facilities in preparation for CT1 (platoon level) training, which included a LF sniper

range. In his capacity as the Range Conducting Officer (RCO) for Phase 2 of the

SOC, CSgt 1 conducted a range reconnaissance to Tain AWR in Jun 16 as detailed

on the RASP and by witness testimony.

1.4.93. The range reconnaissance to Tain AWR in preparation for the SOC's Phase

2 ranges was in accordance with Pam 21 planning guidelines.42 Additionally, CSgt 1

was familiar with Tain AWR having previously conducted LF sniper training there

earlier that year.

1.4.94. The Panel opined the reconnaissance to Tain AWR as part of the SOC

Phase 2 planning process adhered to policy and was effective, and that as such this

was Not a Factor.

Range Action Safety Plan

1.4.95. Pam 21 is the authoritative document against which all small-arms ranges

must comply. In compliance with Pam 21, a RASP must be endorsed by a SQEP

Senior Planning Officer (SPO)43 beforehand." In this instance the SPO was

adequately qualified and had completed the requisite SPO Course. In preparation

for the SOC Phase 2 ranges at Tain AWR on 13 Oct 16, CSgt 1 showed the draft

RASP to the Tain AWR Training Safety Officer (TSO). Likewise, on the same day.

the SPO sent the draft RASP to the 1st (United Kingdom) Division (1 Div)

Quartermaster Sergeant Instructor (QMSI) Small Arms School Corps (SASC) for

review.45 The SPO endorsed the RASP on 31 Oct 16.

1.4.96. CSgt 1 as the named RCO in the RASP did not inform the SPO of a

temporary change in RCO on 1 Nov 16 as required by Pam 21.46 Moreover, the

endorsed copy of the RASP which was held by the Tain AWR Range Control was

not amended to reflect the temporary change in RCO.


Exhibit 005 Exhibit 006 Exhibit 013 Exhibit 134 Witness 23 Witness 23 Witness 40


°I Pam 21, Training Regulations for Armoured Fighting Vehicles, Infantry Weapons Systems, and Pyrotechnics. March 2016, para 4-33

• /bid, Para 2-25 and 2-26, covers the responsibilities and actions required by 'all concerned with planning and conducting training

BEFORE planning starts. This applies equally to all ranges, training areas and LFTTAs.'

43 Ibid, Para 2-06, covered the responsibilities of the SPO who is responsible for appointing a Planning Officer and or a Range

Conducting Officer and to ensure that they are competent, qualified and of sufficient experience for the training, to give guidance and

supervision, give refresher training if required and give sufficient time. resources, manpower and medical cover.

44 Candidates must complete the Senior Planning Officer (SPO) Course via distance learning on the Defence Learning Environment

(DLE). The DLE states. 'the course is designed to provide the knowledge and skills required to assume the role of the Senior Planning

Officer (SPO).' • SASC is considered to be the authority in small arms weapons training planning and delivery.

• Pam 21, Training Regulations for Armoured Fighting Vehicles, Infantry Weapons Systems, and Pyrotechnics, March 2016, para 2-30

states 'if any changes are made after the SPO has countersigned the RASP or EASP then the Planning Officer must inform the SPO

and they must approve the changes. If any changes are made after the RASP or EASP has been submitted to Range Control they must

be informed.'

1.4 - 23

DSA/S1/01/17/TAIN OFFICIAL-SE-NSITIVE © Crown Copyright 2018

OFFICIAL-SENSITiVE

1.4.97. Considering a recent fatal range accident (Aug 16) involving 3 SCOTS, the SPO was understandably diligent in fulfilling his duties. In this instance, the SPO went beyond the obligatory standard required to check the RASP and sought SQEP advice in the guise of the 1 Div QMSI SASC. Moreover, to ensure the RASP was fit for purpose, several iterations of the draft were staffed between the author, Sgt 1, and the SPO via CSgt 1. Consequently, the SPO was content to countersign the document on the morning of 31 Oct 16, the first day of Phase 2 of the SOC.

1.4.98. Despite SQEP advice, the endorsed RASP contained errors. The training was classified as Live Fire Marksmanship Training (LFMT) utilising a Live Fire Tactical Training Area (LFTTA). As a result, an incorrect LFMT RASP template from Pam 21 was employed, when a LFTT template should have been used. The following errors were evident in the RASP:

a. There was no authority to dispense with Combat Body Armour and Helmet.

b. A reduced cone of fire of 12 mils was employed.'

c. Steel targets were used by unqualified snipers.48

d. The arcs and firing line were not recorded.

e. It did not state that high-visibility vests were always to be worn by safety staff.

1.4.99. The fact that CSgt 1 did not inform the SPO and Range Control of the temporary change in RCO on the morning of 1 Nov 16, as required by Pam 21. was very likely an oversight by CSgt 1. At this juncture CSgt 1 was busy with training delivery of the SOC while also having to ensure his own attendance at a mandatory career briefing.

1.4.100. The Panel concluded that the failure to record changes in RCO, within the RASP, amounted to a procedural error. however, despite the SPO's diligence and an external check. an incorrect template was used and the RASP contained errors. The errors within the RASP were therefore an Other Factor.

1.4.101. Recommendation. Head of Capability Ground Manoeuvre should revise Pamphlet 21 to clearly state the rules and procedures to be applied when conducting Live Fire Marksmanship Training on a Live Fire Tactical Training Area, in order remove ambiguity and to ensure that Range Action Safety Plans are compliant.

Pre-cadre

1.4.102. During the T3 course SWS guidance regarding the SOC was that unit delivered pre-cadre courses to prepare students for attendance on the SOC should focus on basic infantry skills."

1.4.103. In preparation for the 51 Bde SOC four of the units sending soldiers on the course conducted in-house pre-cadres. The 1 SCOTS and 2 SCOTS Cadres did not adhere to the SWS guidance; instead they replicated elements of the SOC syllabus.






'7 A reduced cone of fire is only permissible for qualified snipers, and therefore should not have been employed on this range as the firers were students at the time.

See 'Range layout and targets' section of this report. Generic soldiering skills would include fieldcraft, navigation, fitness and marksmanship on the Individual Weapon (IW).

1 4 - 24

DSA/SI/01/17rTAIN OFFICIAL-SENSITIVE © Crown Copyright 2018

OFFICIAL-SENSITIVE

As a result, students received an element of SAA training and passed weapon

handling tests (WHT) on the L115A3 Sniper Rifle. Moreover, the 1 SCOTS Cadre

was used to select the best soldiers to attend the SOC. In contrast, 3 SCOTS and 3

RIFLES Cadres followed the SWS guidance, with training focused on all-round

soldiering skills. During the 3 RIFLES Cadre, some unqualified snipers fired the

L115A3 Sniper Rifle. SCOTS DG soldiers attended the 3 RIFLES Cadre to prepare

for the SOC.

1.4.104. While SWS provided guidance on pre-cadre training ahead of the SOC,

they did not provide a generic syllabus for a pre-cadre course. Consequently. units

had latitude to interpret the SWS guidance as they saw fit. This explained the

variation in approach to and conduct of the pre-cadre unit training and differing

preparation of students attending the 51 Bde SOC.

1.4.105. As a result of the pre-cadre training, on commencement of the SOC soldiers

were at variable levels of experience and standards. A lack of accurate training

records at unit level compounded assumptions regarding the start states and

competencies of students, particularly with respect to SAA training on L115A3

Sniper Rifle. Consequently, this may have influenced DS assumptions as to the

students' competencies on the L115A3 Sniper Rifle. Therefore, at the start of the

SOC some students had completed SAA training and a WHT, some had completed

just a WHT, while other students had completed neither SAA on the L115A3 Sniper

Rifle, nor the associated WHT (see 'Skill at Arms' section).

1.4.106. The Panel opined that the disparate approach to pre-cadre training at unit

level and a lack of a generic pre-cadre syllabus led to highly variable standards of

L115A3 Sniper Rifle SAA expertise amongst students arriving on the SOC. This

influenced DS perceptions of students' L115A3 Sniper Rifle SAA competencies,

thereby leading to inadequate instruction and supervision on the SOC, and that this

was a Contributory Factor.

1.4.107. Recommendation. Assistant Chief of Staff Training should standardise

pre-cadre courses in order to ensure that:

a. The purpose of sniper pre-cadre training is clear and reflects extant

Specialist Weapons School direction.

b. Training completed by students on pre-cadres is accurately

documented.

c. Sniper Operators' Course planning officers are provided with accurate

and up-to-date student training records prior to commencement of a Sniper

Operators' Course.

Skill at Arms

1.4.108. 1 SCOTS was responsible for planning and execution of Phase 1 of the

SOC; this fell to CSgt 2 as the Phase 1 Planning Officer. The 51 Bde SOC syllabus,

endorsed by the DTC, referred to this as the Start Standard, Theory and

Marksmanship Module.5° This phase concentrated on marksmanship with a focus

on weapon handling and live firing practices. The syllabus for Week 1 of this module

incorporated 18 SAA lesson periods on the L115A3 Sniper Rifle and a lesson on the

Tactical Hearing Protection System (THPS) (see Figure 1.4.4). In accordance with




Exhibit 021 Exhibit 025 Exhibit 027 Exhibit 089 Witness 25

so 51 Bde Sniper Operator Course 1601, Phase 1 Barry Buddon Training Centre (Start Standard, Theory and Marksmanship Module)

02' October - 31' October 2016 (1 SCOTS), page 1.

1 4 - 25


OFFICIAL SENSITIVE

the syllabus, Rifle Lessons 1 — 18 should have been delivered on Days 3. 4 and 5 of the course (5 — 7 Oct 16). Upon completion of the mandatory rifle lessons, students were programmed to move to live firing in Week 2.

Phase 1 parlyBuddon Training Centre (Start Standard Theory and Marksmanship Module) 024° October 2016 — 31" October 2016 (1SCOTS) Week

1

Mon 3.0

Oct o ts

8 Aele Assessment BBTA

f4.1 Stag BBTC ii

Start 9tatn~a,rwtt

7u* oe. OCt

Collect

r; '?"'s "'"ur'' Si

tie rkey.on BBTC

DS lead NAVEX AO SW

JD Assessment

SS

OBS Assessment

SS

Static map Assessment

SS

Cam and Con Assessment

SS Naght Na Practice 1

Wed 6" Oct

Rile Lesson 1 Seceon Areas

BBTC

RAM Lesson 2 Swan Areas BBTC

Ibte Leeson 3 & 4 BEITC

Rille Lessai 5

BBTC

We Leeson 5

130TC

Rik Lesson 5

SI 144non MaasBBTC BBTC

Ntght 1141, *soon T Piaerce Perod 1 Nal Test 1

Blur 06' Oct

Me wsson 6 BBTC PP 2

BBTC

RIM Lesser

9 138TC

Ms 1 *mon BBTC

10 RAM Lamson e8TC

11 RA BBTC Lesson 12 11 Nyht Niti Test 2

Fri 7" Oct

Me t !WM 13 88TC

Rdle Lesson

to MC

_

PP 3 eerc — --

MIT Test Sedan Areas

— —

WHT Retest Sectwn Areas

RAO Lesson 15

BBTC Rte

Lesson 15 BBTC .

Me lesson

17 BBTC

Rifle Lemon 18 88T0

N' t/7

Figure 1.4.4 - 51 Bde Sniper Operator Course Week 1, Phase 1 syllabus

1.4.109. On Day 3 of the course (5 Oct 16), when students should have received Rifle Lesson 1 of 18 (highlighted in red in Figure 1.4.4) in accordance with the agreed syllabus, they were in fact live firing on the range. At this stage, they had not completed any of the mandated SAA training during the SOC. On the evening of Day 2 (4 Oct 16) students completed a WHT on the L115A3 Sniper Rifle. At no point were Rifle Lessons 1 — 18 delivered retrospectively. Because of this deviation from the endorsed SOC syllabus, students were then live firing the L115A3 Sniper Rifle on the range without having completed formal SAA instruction. The Operational Shooting Policy (OSP) states that 'it is also mandatory that the sniper completes all the basic sniper system weapon lessons contained in Reference H [Sniping Part 1] and successfully completes the sniper system Weapons Handling Test, before any live firing can take place.'5' This deviation from the approved syllabus was not noticed by the Phase 1 Planning Officer (CSgt 2). An additional lesson on the Tactical Hearing Protection System (THPS) (highlighted in green on Figure 1.4.4), mandated by CSgt 1 was also not delivered.

1.4.110. The DS confirmed that their students had completed pre-cadre training prior to arriving at BBTA. Subsequently, during a staff meeting, CSgt 2 issued direction to the DS. Specifically, he directed that all students must achieve the required standard to commence live-firing. However, he did not stipulate that students must complete Rifle Lessons 1 — 18 in accordance with the endorsed syllabus. As all students had completed a pre-cadre, most of the DS incorrectly assumed that students had completed SAA lessons 1 — 18 and WHTs prior to the course. This combination of a lack of clear direction from CSgt 2 along with the incorrect assumption by the DS resulted in the omission of SAA lessons 1 — 18. Consequently, some students attending the 51 Bde SOC commenced live firing having had no formal training on the L115A3 Sniper Rifle whatsoever.

1.4.111. Student A had recently joined the 3 RIFLES Sniper Platoon and was sent on the SOC with no SAA training on the L115A3 Sniper Rifle. As a result of the omission of SAA lessons 1 — 18, Student A received separate, minimal SAA training

The Operational Shooting Policy Volume 2. Section and Platoon Weapons 2016, Ch 9, para 0903 — 0904.

1.4 - 26


Exhibit 014 Exhibit 025 Exhibit 029 Exhibit 143 Exhibit 144 Exhibit 145 Exhibit 146 Exhibit 147 Exhibit 148 Witness 25 Witness 27



OFFICIAL SENSITIVE

from a member of the DS as a workaround. Student A was then able to pass the WHT despite not receiving the specified SAA training. Notably, this situation was not unique to Student A. The Panel discovered that several students attending the SOC had not received adequate SAA training on the L115A3 Sniper Rifle and thus should not have been live firing.

1.4.112. The situation was compounded by poor training records. Due to this poor record keeping and a lack of 1s' party assurance (see 'Assurance' section of this report), combined with the lack of SAA training on the 51 Bde SOC, there is no evidence to prove LCpI Spencer received any formal training on the L115A3 Sniper Rifle. Despite this, given previous unit sniper activity (e.g. Exercise RATTLESNAKE52) he would have informally gained some familiarity with the L115A3 Sniper Rifle. This superficial knowledge would likely have been sufficient to enable LCpI Spencer to pass a WHT and give the false impression that he was competent and experienced in handling the L115A3 Sniper Rifle.

1.4.113. The combination of inadequate oversight and supervision of the training delivery combined with a lack of adequate external assurance of training delivery meant that the omission of SAA training went unnoticed by those responsible for delivering and planning the training.

1.4.114. The Panel concluded that ambiguous direction led to the omission of SAA training on the SOC. This combined with inadequate assurance during Phase 1, resulted in students, including LCpI Spencer, live firing on the SOC, without having completed the mandatory SAA training. Therefore, this was a Contributory Factor in the accident.

1.4.115. Recommendation. Assistant Chief of Staff Training should direct that the endorsed syllabus for distributed training is rigorously followed and ensure that training delivery is assured in order to guarantee that students are trained to the recognised common standard prior to live fire training.

Fort George

1.4.116. While Phase 2 of the SOC was conducted at Tain AWR, DS and students were accommodated, fed and supported by 3 SCOTS at Fort George. Fort George was 45 miles from Tain AWR and the journey took approximately 60 mins via the A9 road. The course mustered at Fort George on Sunday 30 Oct 16, although some 3 RIFLES students, including LCpI Spencer, arrived earlier on 28 Oct 16. Both DS and students stayed in transit accommodation. The DS were assigned their own room, meanwhile students were split between 2 further rooms. As bed spaces were not individually allocated within rooms, students coalesced by regiment.

1.4.117. Whilst staying in Fort George, on the 2 nights prior to the accident (30 and 31 Oct 16) students were exempt guard duties and there is no evidence that they consumed alcohol. During free time in the evenings DS and students conducted personal administration and a few visited the Fort's gymnasium.

1.4.118. There were minor teething problems53 at Fort George on the morning of 31 Oct 16. although these were overcome. Moreover, the transit between the Fort and the training area was not unduly onerous or tiring. Accordingly, neither DS nor students should have been fatigued or stressed on arrival at Tain AWR.

Exhibit 014 Exhibit 151 Witness 17 Witness 26 Witness 32 Witness 32 Witness 48


Witness 28

Witness 28

" Exercise RATTLESNAKE was a combined infantry exercise involving elements of 3 RIFLES, augmented by two sniper pairs, working alongside the US Army that took place in Fort Polk, Louisiana, USA in March 2016.

Delayed opening of the dining facility/'cookhouse' for breakfast and delayed departure to Tain AWR being fog bound.

1.4 - 27

DSA/S1/01/17/TAIN OFFICIAL—SENSITIVE © Crown Copyright 2018

1.4.119. The Panel concluded that during the stay at Fort George, the accommodation, support and victuals provided by 3 SCOTS to the SOC was adequate, and that the daily commute was straightforward; therefore, the use of Fort George was Not a Factor.

Range layout and targets

1.4.120. The route to Tain Tower54 from the public road took approximately 5 — 10 mins, and a further 10 mins over rough tracks from the Tower to the vehicle park located approximately 100m south of the SOC Range firing line. The firing line could only be accessed by 4-wheel drive vehicles at this time.

1.4.121. Tain AWR is a licensed ground range capable of LF up to LFTT. The SOC sniper range was located within the Close Air Support (CAS) Village (Figure 1.4.5), within Tain AWR. Range Control was located approximately 800m south-west of the sniper range. The firing line was approximately 46m long and was located on a raised bank of earth, or bund line, which was interspersed with a waist-high gorse bush vegetation (Figure 1.4.6). The firing line faced north over flat tidal salt marsh (extending to the Dornoch Firth) where targets were positioned. Approximately 9m behind the firing line, separated by a rough vehicle track, was a series of small ISO shipping containers; these were utilised by the SOC for administration and as temporary troop shelters (Figure 1.4.6).

Exhibit 012 Exhibit 098 Exhibit 099 Exhibit 100 Witness 40

Figure 1.4.5 — Tain AWR location, showing the location of CAS Village

54 Range Control staff operated from Tain AWR Tower.

1.4 - 28


Waiting Detail ISO Administration ISO

Door position when shut Ammo

CSgt 1

Figure 1.4.6 - 51 Bde Sniper Operator Course range layout within the CAS Village, Tain AWR

1.4.122. Poor visibility on Day 1 (31 Oct 16) led to delayed departure from Fort George with the resultant later than planned start to live firing at Tain AWR. Further time was lost using locally produced targets on the afternoon of Day 1 and morning of Day 2 (1 Nov 16); these targets proved problematic. Targets comprised an A-frame fitted with a steel plate (referred to as a 'falling plate') and attached by wire (Figure 1.4.7). The targets were manually positioned within the range arcs. When the falling plate was struck by a round, the wires affixing the targets shattered, causing the targets to swing or spin, which made accurate shooting impossible. Despite attempts at rectification, the falling plate targets were eventually replaced by Small Arms Pop Up (SAPU) consoles configured with aluminium Figure 11 targets (Figure 1.4.8) in the afternoon of 1 Nov 16.

Exhibit 018 Witness 13 Witness 24 Witness 24 Witness 27 Witness 28

1 4 - 29

DSA/SI/01/17/TAIN OF F ICAL-SEN SITIVE © Crown Copyright 2018

Figure 1.4.7 - Locally produced competition falling plate target

Figure 11 Metal Target

Figure 1.4.8 - Small Arms Pop Up console with a Figure 11 target

Lifting Mechanism

1.4.123. During Phase 1. the SOC conducted live firing on purpose built gallery ranges at BBTA. In stark contrast, as a LFTTA, Tain AWR was bereft of dedicated ground range infrastructure: there were no butts to observe fall of shot; there were no dedicated lanes with dedicated lane targets; there was no permanent troop shelter; there were temporary toilet facilities; and vehicle access to the firing line was difficult. Despite the austere range infrastructure, CSgt 1 had used the CAS Village previously to conduct sniper LF training. While the lack of dedicated range infrastructure was not ideal, the RCO ensured students adapted to their environment


1.4 - 30


by clearing vegetation within arcs and using the ISO containers as shelter from the elements.

Exhibit 005 Exhibit 006 Exhibit 008 Exhibit 013 Exhibit 014 Exhibit 139 Witness 13 Witness 17 Witness 27 Witness 28 Witness 30



Exhibit 006 Witness 27 Witness 29 Witness 32 Witness 32 Witness 33 Witness 34

1.4.124. Pam 21 states that only qualified snipers are authorised to engage steel plate targets.' Accordingly, the students should not have been firing at falling plate targets.

SAPU consoles were available and should have been used from the outset. Once replaced on the afternoon of Day 2, these proved more reliable, although some were obscured from view, as they were positioned at ground level. Valuable range time was wasted positioning, rectifying and replacing targets over both Days 1 and 2. Consequently, the 2-days assigned for data collection and pre-ACMT preparation was reduced to one hour per detail of pre-ACMT preparation. Consequently, critical time for the all-important data-gathering LF practice was significantly compressed. Witness testimony stated that as daylight faded, the range became rushed. As such, the Panel opined that this time compression was extremely likely to have added to the students' stress as they prepared for the sniper ACMT. which was a summative assessment' for the SOC.

1.4.125. The Panel concluded that while the austere range layout was adequate. the time taken to replace unauthorised targets over 2 days caused delay, thereby compressing the time available to conduct the practice. Consequently, the reduced time available is extremely likely to have caused stress and self-induced pressures amongst students, encouraging shortening of procedures, thereby setting the conditions for subsequent procedural errors on the range on the afternoon of 1 Nov 16. Therefore, this was considered a Contributory Factor.

1.4.126. Recommendation. Head of Capability Ground Manoeuvre should ensure that RCOs adhere to the time guidance for Live Fire activity in accordance with the Operational Shooting Policy, in order to conduct safe and effective Live Fire practices.

Safety briefing

1.4.127. Prior to live firing on Day 1 (31 Oct 16), CSgt 1, as the RCO, delivered a standalone DS safety brief in accordance with Pam 21.

1.4.128. On the morning of Day 2 (1 Nov 16), Sgt 1 acted as the RCO due to the absence of CSgt 1. This change was not annotated in the RASP. On arrival at Tain AWR, Sgt 1 delivered the mandated safety brief to DS and students as per the RASP.

1.4.129. Witness testimony indicates that after the Day 2 safety brief, individual DS were unclear as to their specific roles and responsibilities on the ranges that day. Thus, DS were left to their own devices to assume a role on the range and fill the gaps, whether as a coach and mentor, as a safety supervisor, or in an administrative capacity. The Panel opined that this lack of clarity was sub-optimal and while not in contravention of Pam 21, good practice dictates the need for a stand-alone DS safety brief to ensure roles and responsibilities are understood.

ss Pam 21, Training Regulations for Armoured Fighting Vehicles. Infantry Weapons Systems, and Pyrotechnics. March 2016, para 7-62,

d, states 'steel targets are only authorised for use in accordance with the following: (1) Trained Snipers undergoing directed training.'

JSP 822. Defence Direction and Guidance for Training and Education Part 2: Guidance, v3.0 Apr 17. p 74, para 27 c.2. "Summative

tests are used to determine whether trainees have achieved the TOs [training objectives] /CTOs [collective training objectives], or

significant EOs [enabling objectives], which are deemed prerequisite to further training. They provide the required data to assign

pass/fail grades and are conducted at the end of training or at the end of each stage/module of training. The outcome of the assessment

is to determine whether the individual or team is competent to carry out the Role or task without supervision,"

1.4 - 31

DSA/SI/01/17/TAIN Gr-FIGIAL—SENSITIVE © Crown Copyright 2018

1.4.130. The Panel concluded that the safety briefings for DS were sub-optimal leaving them unclear about their roles and responsibilities, thereby setting the conditions for subsequent procedural errors in safety supervision during the afternoon of 1 Nov 16. Therefore, this was a Contributory Factor.

1.4.131. Recommendation. Head of Capability Ground Manoeuvre should revise Pamphlet 21 to clearly state the need for a stand-alone safety supervisor brief prior to live fire ranges, in order that safety supervisors are effective, safe and aware of their roles and responsibilities during the conduct of live fire training.

Accident

1.4.132. This section of the report will detail the events of the accident itself. It is structured in a chronological manner. The section begins by detailing the orders received and the planning prior to the accident before covering the instructors' activities and their supervision of the range followed by the details of the accident.

Afternoon details

1.4.133. Those students who had not fired on the previous afternoon (31 Oct 16) shot in the morning of 1 Nov 16 (Day 2, Phase 2). The shoot replicated the data-gathering shoot of Day 1. Firers encountered similar problems with inadequate steel falling plate targets. Range activity became disjointed to allow for rectification of the targets. The targets were eventually replaced by SAPU targets; this took approximately 2 hrs. During this period CSgt 1 arrived at the range, complete with lunch for the DS and students; live firing commenced in the afternoon.

1.4.134. For the afternoon shoots, the students were divided into two 11-man details. LCpI Spencer was in Detail 1 and was paired with Student A, who acted as his Number 2 (colloquially referred to as a 'spotter') and made up Pair 11. Initially, when setting up for the detail LCpI Spencer moved to a position towards the middle of the firing line, alongside fellow 3 RIFLES students. Unable to observe all the targets due to excessive foliage obscuring certain targets he subsequently moved to a better fire position. During the range reconstruction,57 Pair 10 students accurately pointed out where they were positioned in relation to Pair 11 (see Figure 1.4.6).

1.4.135. Eight DS were supporting Detail 1 in various guises. CSgt 1 had resumed the RCO role. DS 1 undertook safety supervision of the right-hand pairs on the range (pairs 9 — 11) as this is where most soldiers from his regiment were firing during Detail 1. This also included LCpI Spencer as Pair 11, occupying the furthest position on the right-hand side of the firing line (see Figure 1.4.9).




57 To better understand the range layout and conduct of the ranges on 1 Nov 16, the SI Panel conducted at range reconstruction at Tain AWR on 4 Jul 17. Demonstration troops were used to depict key locations and events; they were positioned by witnesses who were in attendance throughout the day. Photographs were taken throughout by a military photographer.

1.4 - 32


Pair: 9 Pair: 10 Pair: 11 Pair: 1 Pair: 2 Pair: 3 Pair: 4 Pair: 5 Pair: 6 Pair: 7 Pair: 8

• • DS 3 DS 4

9m

F. Witness 3 F. Student .1 F, Witness 22 S Witness I S. Witness 2 S - Witness 21

F: Seldom I F: wit., It F: Witness 20 F, Student Student G "V : Witness 19 F - Witness 10 F . I pl Spencer

5: student H 5: Student E 5: Student C Student F 5: Mtn** 15 5. Mlnras I I S Student B S Studom A

TCV

KEY

F: Firer s LS: Spotter

ISO

fliED CSGT 1

Ammunition

Waiting Detail ISO

Administration ISO

46 m

• DS DS 2

DS 1

Figure 1.4.9 — Detail 1 and DS locations at time of unload

1.4.136. Detail 1 commenced firing at approximately 1500 hrs and conducted Live Fire 9 (LF9), a practice shoot for the ACMT, whereby firers engaged nominated targets at distances between 300m — 900m, within a limited timeframe. Firers were nominated in ascending order during the detail, with LCpI Spencer being the last student to fire. At this time conditions were described as challenging: the temperature was 9°C; with a westerly wind58 of 20kph (moderate wind); intermittent rain showers towards the end of the practice; and prevailing visibility of 35km (good). Sunset was at 1628 hrs.

1.4.137. As a consequence of the morning's delays, at this stage of the afternoon daylight range time was at a premium. The OSP59 allocates a minimum of 60 mins per detail for LF9. Given Detail 1 only started firing at 1500 hrs and with the impending sunset at 1628 hrs, there was insufficient daylight remaining to fire both details in accordance with the OSP. To try and overcome this and speed proceedings up, at the end of Detail 1 the RCO is reported to have issued 3 separate orders in quick succession: to unload Detail 1; conduct normal safety precautions (NSPs); and then move Detail 2 onto the firing line.

1.4.138. The exact words used by the RCO to order students to unload were not clear. Students described discrepancies in the words of command used. The correct words of command for the unload drill and NSPs are clearly laid down in Pam 21; these are two distinct drills. The words of command for the unload drill are 'stop' followed by 'detail unload' and 'for inspection port arms' followed by 'firers show clear' for NSPs. On this occasion, it is likely that there was a blending of these words of command. Thus, it is likely these two distinct drills were combined into one. The Panel concluded that this use of non-standard words of command, possibly due to time pressures, is likely to have contributed to confusion amongst the students.




The westerly wind blew from left to right across the firing line. The Operational Shooting Policy Volume 2, Section and Platoon Weapons 2016, Ch 9, para 09176 and 09184, 'each detail will take

approximately 1 hour to complete,' furthermore, the hour breaks down as 'snipers will have 20 mins to produce a battle sketch and identify, judge the distance and plot all 10 targets, and will be marked with a number to assist indexing,' and 'targets must be nominated in a random order over a period of no less than 40 mins.'

1.4 - 33


Witness 01 Witness 01 Witness 08 Witness 08 Witness 12 Witness 12 Witness 16 Witness 17 Witness 30 Witness 31 Witness 31

Exhibit 151

Witness 01 Witness 13 Witness 24 Witness 30 Witness 31 Witness 33

Exhibit 015 Exhibit 018 Exhibit 151 Witness 13 Witness 24 Witness 33 Witness 34

Exhibit 015

1.4.139. On completion of Detail 1, the Panel discovered there were at least 2 errors of drill during the unload drill and NSPs. These comprised:

a. Student D's rifle was left in an unsafe condition and subsequently unloaded by Student F.

b. Student J's rifle was left in an unsafe condition and subsequently unloaded by DS 6 under the supervision of DS 2.

There was a further example of an error of drill during the unload on completion of Detail 2, whereby Student H's rifle was left in an unsafe condition and was subsequently unloaded by Student I.

1.4.140. As discussed previously, the limited time available in which to complete the two shoots due to fading daylight, combined with the use of non-standard language is likely to have caused confusion and self-induced pressure amongst the students. This led to abridged drills and unorthodox practices during the unload drill by student firers after the completion of each detail.

1.4.141. In Detail 1, one of the firers had already moved off the firing line to return expended cases and collect the ammunition for Detail 2 as ordered, while leaving his rifle in an unsafe condition. In the second instance, a member of the DS noticed that a weapon was in an unsafe condition and subsequently conducted NSPs under the supervision of another member of the DS. Neither DS informed the RCO of this unsafe weapon. The RCO was unaware that any weapons had been left unsafe at the end of Detail 1. The Panel opined that this represented a missed opportunity to recognise that other weapons may have been left in an unsafe condition on the firing line after Detail 1.

1.4.142. LCpI Spencer was the last person to fire on Detail 1. Immediately after engaging the last target, it is extremely likely that he automatically and sub-consciously chambered another round to re-engage the target, as part of the shoot, in case he missed with the first round.6° LCpI Spencer would have learned and practiced this drill during the LF ranges in Phase 1 and at this stage of the SOC he had already been firing for three weeks reinforcing this practice. Student A reported that on this occasion, LCpI Spencer hit the last target with his first shot. Therefore, when the order to unload was issued, it is highly likely that LCp1 Spencer still had a round chambered in his L115A3 Sniper Rifle. Before leaving the firing line to collect ammunition as ordered by the RCO, Student A reported that LCpI Spencer removed his magazine from the L115A3 Sniper Rifle and handed the partially full magazine to him. This was to allow him to refill the magazine to 5 rounds for use in Detail 2 thereby expediting the changeover of firers due to fading daylight. During interview, neither Student A or any other witnesses could confirm that LCpI Spencer completed the unload drill correctly. It is therefore extremely likely LCpI Spencer did not complete the unload drill and that his rifle was in an unsafe condition with a round chambered on completion of Detail 1.

1.4.143. The unload drill in accordance with Sniping Part 1 comprises 6 steps. Working sequentially these take the rifle from loaded and made ready (to fire), to the rifle being unloaded, and therefore safe (Figures 1.4.10 — 1.4.12).

6° There was a time lag between the round fired and confirmation that it had hit the target; during this lag, the firer would automatically and sub-consciously chamber a second round, in anticipation of re-engaging the same target, within a reduced timeframe (than that allocated for the first-round engagement) to replicate the battlefield.

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1. Loaded/made ready, safety catch position 2. Remove magazine

Figure 1.4.10 — Sniping Part 1 unload drill, steps 1 and 2

3. Draw bolt to rear, eject case 4. Visual physical checks.

Figure 1.4.11 — Sniping Part 1 unload drill, steps 3 and 4

5. Close bolt.

6. Fire off action (safe direction), sights. i

Firin? pin in un-cocked position II

Figure 1.4.12 — Sniping Part 1 unload drill, step 5 and 6. Positon of firing pin

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The spent case is not extracted Loaded/made ready/bolt not fully closed

Figure 1.4.13 — L115A3 Sniper Rifle bolt not fully closed, does not eject the round

OFFICIAL -SENSITIVE

1.4.144. For this accident to have occurred, there are 3 possible hypotheses as to how a round was left chambered in LCpI Spencer's L115A3 Sniper Rifle on completion of Detail 1. Each hypothesis incorporates a deviation from the unload drill, as stated in Sniping Part 1.

a. Failure to fully close the bolt. In this hypothesis, LCpI Spencer automatically and subconsciously would have operated the bolt of the L115A3 Sniper Rifle, but then would have failed to fully close the bolt when chambering the round in readiness to take the second shot at the target at the end of his LF shoot (see Figures 1.4.13 — 14). While in this condition, when conducting the unload drill, he would have removed the magazine from the L115A3 Sniper Rifle and passed it to Student A. Thereafter, he would have pulled the bolt rearwards. However, because the bolt had not been fully closed when previously chambering the round, the extractor on the face of the bolt would not have fully engaged with the rim on the base of the round, thereby leaving a live round in the chamber. For this hypothesis to be plausible, LCpI Spencer would not have inspected the chamber to ensure it was clear. He would have then returned the bolt forward and fired off the action as per the unload drill. The round would not have initiated due to a 'weak-strike'61 thereby leaving a live round in the chamber with the firing pin resting on the base of the 'weak strike' round. Forensic analysis of spent cartridges fired from LCpI Spencer's sniper rifle does not support the 'weak-strike' hypothesis. While the Panel cannot discount the possibility of the bolt not being fully closed leaving a round in the chamber, the Panel deemed this hypothesis to be extremely unlikely as this requires 3 successive failures; a failure to fully engage the bolt: a failure to sufficiently check the chamber for an un-ejected round; and a weak strike to occur.

Exhibit 015


el A weak strike, depicted by a shallow indentation on the primer cap. is usually a mechanical fault, caused by faulty/worn parts or the ingress of dirt into the mechanism. Weak Strikes are commonly reoccurring until the fault is rectified. Moreover, Sniping - Part 1 The L115A3 Sniper Rifle 8.591nrn and Associated Equipment. 2016, page 1-70, states that the 'bolt not locked' correctly may cause a 'weak strike'

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Magazine removed/live round in chamber/

firing pin cocked Firing pin in cocked position

Figure 1.4.14 — L115A3 Sniper Rifle bolt not fully closed, round in chamber firing pin cocked

b. AESP unload drill employed. In this hypothesis LCpI Spencer, would have left his magazine fitted to his rifle and conducted the AESP unload. This would leave a round chambered with the firing pin touching the base of the round. The AESP unload drill requires the firer to squeeze the trigger with one hand whilst moving the bolt forward with the other (see Figures 1.4.15 -1.4.16). This drill emanates from the weapon manufacturer, Accuracy International Ltd®, to minimise wear and tear on the firing mechanism. 3 RIFLES students were aware of the AESP unload/NSP drill but were unlikely to have employed it on the course. For this hypothesis to be plausible, the magazine would have to be erroneously left on the weapon during the unload drill. It is extremely unlikely that LCpI Spencer would have carried out the AESP unload drill causing a round to be chambered as the magazine had been removed from the sniper rifle. Furthermore, the complexity of the two handed AESP drill would have caused LCpI Spencer to break position which is counter intuitive for a sniper student who normally seeks to minimise all unnecessary movement. Moreover, this drill would be slower, thereby making it less probable given that he was in a time-limited LF shoot. Had he used the AESP drill at any time it is likely it would have been noticed by his Number 2 and there is no evidence to substantiate this hypothesis. Accordingly, the Panel deemed this hypothesis to be extremely unlikely.


Bolt forward whilst depressing trigger Live round fed into chamber

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© Crown Copyright 2018

Figure 1.4.15 — The AESP unload drill part 1

Loaded/firing pin forward/magazine removed

Firing pin in un-cocked position

Figure 1.4.16 — The AESP unload drill, part 2. Firing pin un-cocked

c. Incomplete unload. In this hypothesis and given the 2 other instances of unsafe weapons on the firing line at the end of Detail 1, it is assumed LCpl Spencer would not have completed the unload drill in accordance with Sniping Part 1. In this hypothesis, he would have been distracted part-way through the unload drill, and would not have pulled the bolt to the rear after removing the magazine. Thus, from this point in time, a live round would have remained chambered with the bolt forward and secure, the firing pin under tension and the safety catch set to 'Fire'. Importantly, the firing pin would have been protruding rearwards out of the bolt (Figure 1.4.17). This meant his rifle would have been in an unsafe condition with a round chambered. The Panel deemed this hypothesis to be extremely likely and will be used by the panel as the reason for a live round being chambered in LCpI Spencer's L115A3 Sniper Rifle.

Exhibit 015 Witness 12 Witness 13 Witness 17 Witness 30

Loaded/made ready/live round in chamber

Firing pin in cocked position

Figure 1.4.17 — L115A3 Sniper Rifle depicting incomplete unload

1.4.145. As previously discussed in the 'Safety Briefing' section, the briefing was sub-optimal in that there was a lack of clear direction given to the DS regarding their specific safety roles on the range. In the absence of clear direction and using his

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own initiative, DS 1 assumed responsibility for safety supervision on the right-hand side of the range to supervise his own soldiers. Prior to the unload drill and NSPs at the end of Detail 1, DS 1 had left his supervisory position without informing the RCO and was inside the Administration ISO Container located behind his firers. This situation would not have arisen had DS 1 complied with the RASP which states that a safety supervisor is to "ensure safe handling of weapons at all times" and "intervene if a breach of safety is about to occur". In the Panel's opinion, this can only be achieved if the safety supervisor is actively supervising his firers during LF. Good practice dictates that the safety supervisors should inform the RCO if they are unable to carry out their duties as a safety supervisor, so that they may be replaced to allow LF to continue in a safe manner. Given the inclement weather, DS 1 was applying warmer wet-weather clothing and eating a snack. From this position inside the Administration ISO Container, with a door partially shut (Figure 1.4.18) to provide protection from the elements, he was unable to observe and supervise the students in contravention of the RASP. DS 1 recalled hearing the words of command `unload' at the end of Detail 1. He did not step outside the ISO container and return to the firing line to supervise the students as he mistakenly believed that as the word of command given was "firers show clear" there was no requirement for him to supervise their unload drills. Consequently, the critical and mandated safety supervision of LCpI Spencer's unload drill and NSPs on completion of Detail 1 did not take place.

Witness 34

Figure 1.4.18 - DS1 and Administration ISO Container

1.4.146. The RCO stated that he counted the number of firers' legs to verify that NSPs had been completed at the end of Detail 1. In this instance the RCO was acting correctly as the command issued was 'firers show clear' and as such would not rely on the safety supervisors to show clear. Pam 21 only recognises one method for showing clear, it states62 that "Safety Supervisors or firers ensure weapons are clear and raise their hand to let the RCO know." In contrast, the Panel found that it is common practice across all 3 services for snipers to raise a leg to indicate that their weapon is clear and prevent any undue disturbance to their firing

Pam 21, Training Regulations for Armoured Fighting Vehicles, Infantry Weapons Systems and Pyrotechnics, Mar 16, para 4-78. page

4-21, states 'Safety Supervisors or firers ensure weapons are clear and raise their hand to let the RCO know.'

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OFFICIAL-SENSITIVE

position, as to do so would decrease accuracy for subsequent engagements.63 Despite the fact that the RCO counted 11 legs indicating to him that all the weapons were in a safe condition on the firing line at the end of Detail 1, 3 L115A3 Sniper Rifles, including LCpI Spencer's, were not unloaded, as discussed earlier in this section.

1.4.147. The Panel concluded that the unload drills conducted by the firers at the end of Detail 1 were inadequate. As a result, 2 unsafe weapons were left on the firing line and it is extremely likely, at this juncture, LCpI Spencer's weapon was also unsafe due to an erroneous unload drill. Due to a lack of SAA training, inadequate safety supervision, and poor command and control, the incomplete unload was a Causal Factor in this accident.

1.4.148. Recommendations. Head of Capability Ground Manoeuvre should ensure the following:

a. That safety supervisors remain in a position such that they may adequately supervise the drills of soldiers under their supervision in order to maintain safe practice during live fire activity.

b. That all firers employ the correct method of showing clear in order to eradicate the use of incorrect drills.

Preparation for night ranges

1.4.149. Detail 2 concluded at approximately 1600 hrs. Immediately afterwards, LCpI Spencer along with 3 other students and DS1 prepared the targets for the night shoot. At approximately 1630 hrs the RCO delivered a safety brief for the night range. At least one student did not attend the brief due to making a phone call. Furthermore, 3 DS joined the safety brief late, having visited local shops in Tain. An additional DS missed the brief altogether as he remained in Tain while at the shop purchasing victuals for the students. At the brief students were assigned to 3 details and issued with 10 rounds of ammunition for the night shoot.

1.4.150. Command and control of night ranges is more complex than day ranges because of reduced visibility and therefore greater emphasis should be placed upon control of movement, supervision of firers and the issue of ammunition. Pam 21 states that for night ranges, 'a high standard of supervision is necessary.' However, it does not provide guidance for a separate night safety brief. Given this was a change in range practices from earlier in the day, the RCO appropriately delivered a separate safety brief that included an explanation of the conduct of the range during the night LF practice to be conducted. Good practice was compromised as the RCO did not ensure all personnel attended the safety brief, including 4 safety supervisors and at least one student. Importantly, personnel that missed the night safety brief were unaware of elements of the safety procedures and conduct of the range. Meanwhile, at least one student did not collect his 10 rounds of ammunition for the night shoot.

1.4.151. The Panel concluded that night-brief was inadequate because the RCO did not ensure that all DS and students attended. Therefore, while this did not contribute to this accident it was an Other Factor.



Using a leg to indicate that the rifle is clear is a deviation from a competition shooting drill. whereby firers declare a shot by raising their leg.

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1.4.152. Recommendation. Head of Capability Ground Manoeuvre should revise

Pamphlet 21 to state the need for a specific night range safety brief, which incorporates relevant control measures in order to ensure effective command and

control during night live fire training.

Ammunition control

1.4.153. During the afternoon of 1 Nov 16 students were issued with their ammunition by detail, prior to commencing each live firing practice. This meant that unused ammunition and empty cases were returned on completion of each practice using up valuable time. Given the onset of dusk, this placed time pressures on the students to complete their shoot before they could progress onto the night LF shoot. The Panel opined ammunition management could have been better thereby minimising unnecessary movement around the firing line. Moreover, the control of ammunition batches was inadequate for a sniper range. It is imperative that snipers shoot with a consistent batch of ammunition to ensure accurate data collection. The Panel established that students were unaware of the batch number they were firing and its significance, and that the DS did not adequately control the issuing of ammunition by batch number. Consequently, the Panel opined that the data gathered for future shoots was compromised, however, this was Not a Factor.

1.4.154. Pam 21 states that firers can only be issued ammunition when they are under supervision.64 On completion of the night shoot safety brief, the RCO directed that all students collect their ammunition for the night shoot, regardless of which detail they had been assigned to. This ammunition was a different batch to that used during the day. As members of the DS were unclear as to which detail they had been assigned to supervise, students assigned to Details 2 and 3 were effectively unsupervised, and as such, should not have been issued their ammunition at this time.

1.4.155. There is no evidence to suggest that LCpI Spencer loaded his L115A3 Sniper Rifle while waiting for the night shoot. Police Scotland subsequently recovered all 10 rounds that had been issued to LCpI Spencer prior to the night shoot on 1 Nov 16. In addition, a cartridge was recovered from his L115A3 Sniper Rifle by Police Scotland on 2 Nov 16. Subsequent forensic analysis of the expended cartridge showed this cartridge to be from the batch used during Detail 1 in the afternoon of 1 Nov 16. This did not match the recovered 10 rounds of ammunition issued to LCpI Spencer for the night shoot. Therefore. it is extremely likely that a live round had remained chambered in his L115A3 Sniper Rifle from the afternoon shoot.

1.4.156. The Panel concluded that ammunition control during the afternoon and evening of 1 Nov 16 was sub-optimal and was in contravention of Pam 21 guidance; although this did not contribute to the accident it is, nonetheless, an Other Factor.

Waiting Detail ISO Container

1.4.157. LCpI Spencer was initially assigned to Detail 3 for the night shoot. At some point, he volunteered to be reassigned to Detail 2 and was escorted by DS 2 to the adjacent Waiting Detail ISO Container.

1.4.158. During the day, LCpI Spencer had fallen in water on the range. Whilst waiting in the Detail 3 ISO container, he put on warm/dry clothing to get warm.



Exhibit 125


Exhibit 142

" Pam 21. Training Regulations for Armoured Fighting Vehicles. Infantry Weapons Systems. and Pyrotechnics, March 2016. para 4-60

(5b), 'Ammunition is only to be issued to details about to fire. Once issued ammunition troops must be supervised by a NCO at all time.

Firers engaged in concurrent activity are not to have any live ammunition in their possession.'

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Witnesses describe that he was wearing every layer of clothing he had with him on the day. At this juncture, the weather appeared to get worse, raining continuously. Thus, it is very likely LCpI Spencer would have been cold, wet and uncomfortable.

1.4.159. LCpI Spencer had previously been wounded on operations in Afghanistan. Although declared fit for duty, witnesses remarked that he still felt the effects of his injuries which were likely exacerbated by cold and wet conditions. It is very likely that he responded positively to a request to voluntarily move to join Detail 2, to complete the night shoot earlier than had he remained in Detail 3. This would have enabled him to remove his wet webbing and Gillie Suit65(see Figure 1.3.4) sooner, to get dry. warm and comfortable.

1.4.160. Arriving at the Waiting Detail ISO Container, it is very likely that his L115A3 Sniper Rifle remained in an unsafe condition. LCpI Spencer elected to stand inside the Waiting Detail ISO Container, without removing his webbing and placing his rifle on the container floor, as the other students in the detail had already done. Moreover, at this time, the use of white light was minimal to allow eyes to adjust to the dark in preparation for the night shoot. The only light inside the container was provided by coloured Cyalumes TM located on the front of the container and occasional light from mobile phones or head-torches. As a result, inside the container was dark making visibility difficult. The L115A3 Sniper Rifle. once zeroed, amounts to a precision piece of equipment; the students knew that any knock might affect the accuracy of the rifle. As such, they were aware of the need for enhanced equipment husbandry, which included the correct stowage of the weapon when not in use. LCp1Spencer's sniper rifle was reported as having been knocked over, while on its bipod. in the Administration ISO Container prior to moving to Detail 2 in the Waiting Detail ISO Container. Therefore, the Panel concluded that it is likely that LCpI Spencer retained hold of his sniper rifle to protect it from damage. It is very likely that he did not attempt to position his kit and weapon in an already congested ISO container in darkness as that may have risked an accidental knock, thereby causing his weapon to lose accuracy and affect the outcome of the night shoot (see `Ammunition and weapons forensic analysis' section).

1.4.161. Once inside, LCpI Spencer engaged in conversation with fellow students gathered in a loose circle (Figure 1.4 19), all within arm's reach of each other. Despite the darkness and poor visibility inside the container, witnesses reported that LCpI Spencer was moving the rifle up and down, with the butt placed on his boot and his chin resting on top of the suppressor. The Panel opined that this movement was likely due to a mix of impatience and an attempt to keep warm. LCpI Spencer's incorrect handling of his sniper rifle went unchallenged by those inside the Waiting Detail ISO.





65 A Gillie Suit is a mesh, sleeveless overall that is camouflaged with foliage. strips of hessian and Manilla rope. Each Gillie Suit is tailored to the individual and a sniper is expected to maintain and camouflage it to a high standard

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Figure 1.4.19 — Waiting Detail ISO Container from range reconstruction

1.4.162. LCpI Spencer was held in high regard by some students on the course. This perception was likely due to LCpI Spencer's rank, comparatively greater experience working within a Sniper Platoon and his performance in unit. Consequently, despite recognising LCpI Spencer's incorrect weapon handling, the JNCOs amongst the students did not intervene likely due to their misplaced perception that LCpI Spencer's weapon was safe (unloaded). The Panel opined that this may have been a result of rank differential, perceived superior experience and competence of LCp1Spencer and the prevailing sniper culture of collective acceptance of non-standard and potentially unsafe practices by fellow students and the DS.

1.4.163. Before night-firing commenced: at approximately 1741 hrs a round discharged from LCp1Spencer's L115A3 Sniper Rifle, inside the Waiting Detail ISO Container. LCpI Spencer immediately fell to the floor of the container, fatally wounded.

1.4.164. The Panel concluded that LCpI Spencer was holding his L115A3 Sniper Rifle in an unorthodox and unsafe manner and that this was a Contributory Factor. Unbeknown to him or anyone else, his L115A3 Sniper Rifle was in an unsafe condition with a round in the chamber and combined with his colleagues' reluctance to challenge this unsafe behaviour amounted to a missed opportunity to intervene and prevent LCpI Spencer's death. His colleagues' reluctance to challenge his behaviour was therefore also a Contributory Factor.

1.4.165. Recommendation. Director Personnel should ensure that Command, Leadership and Management training reinforces the need to challenge unsafe or inappropriate actions whenever and wherever they are encountered, regardless of rank and experience in order to encourage safe practice.



DSA/SI/01/17/TAIN

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OFF-ICIAL-SEN-SITIVE

Indirect influence

1.4.166. Immediately after the round discharged the situation inside the ISO container was confused. On exiting the Waiting Detail ISO Container immediately after the L115A3 Sniper Rifle discharge, witnesses heard Student E saying that he had knocked into LCp1Spencer.

1.4.167. While there is evidence that witnesses heard a student claim that he knocked into LCp1Spencer. none of the witnesses observed anyone knock into him. Furthermore, when questioned, no witnesses remembered knocking into LCp1 Spencer. However, based on witness evidence, the cramped conditions within the ISO container and the number of weapons and kit on the floor, it is more likely than not that a student did knock into LCp1Spencer. Had this happened, the knock would likely have caused LCpI Spencer's sniper rifle butt to be dislodged from his boot and dropped onto the container floor. However, drop testing conducted on the L115A3 Sniper Rifle concluded that such a drop would not have caused the weapon to discharge. The cause of discharge is covered further in the 'Un-demanded discharge' section.

1.4.168. The Panel opined that it is more likely than not that a student did accidently knock into LCpI Spencer immediately prior to the discharge, thereby it may have caused the L115A3 Sniper Rifle to be dislodged from LCpI Spencer's boot. However, drop testing concluded that this would not have caused the L115A3 Sniper Rifle to discharge, therefore this is Not a Factor.

Post-Accident

Immediate actions

1.4.169. Immediately after hearing the shot and subsequent commotion, the RCO along with members of the DS moved to the Waiting Detail ISO Container. Inside LCpI Spencer lay motionless on the floor. The Combat Medic Technician (CMT) checked LCp1 Spencer for signs of life; none were found. The RCO informed Sgt 2, located in Tain Tower, of the accident at 1742 hrs.

1.4.170. The RASP immediate action drill for the night range on 1 Nov 16 comprised of 4 stages:

a. Stage 1. Stop all fire and movement (initiated by the command 'stop, stop, stop').

b. Stage 2. Give first aid, get medical help and implement the medical emergency plan.

c. Stage 3. Ensure weapon safety and preserve evidence.

d. Stage 4. Inform and seek advice (from Range Control located in Tain AWR Tower).

1.4.171. The RASP directed the use of 2 methods of communications in the immediate response; the primary means was AIRWAVE® radio66 and the secondary means was mobile phone. Faced with difficult radio communications and to better understand the situation and coordinate emergency services' support, Sgt 2 resorted to mobile phone to communicate with the RCO. The mobile phone number for the






`"' A Hand-Held Push-to-Talk (HHPTT) Very High Frequency (VHF) radio manufactured by AIRWAVEe_

1.4 - 44


RCO logged in Tain Tower had not been updated from the morning. Thus. this caused unnecessary delay as a wrong number was called. Moreover, due to a weak signal at the firing line, mobile phone communications were equally challenging as those with the AIRWAVE® radio. Whilst this was not a factor in this accident as LCpI Spencer had suffered fatal wounds, the difficult communications situation at Tain AWR may aggravate any future accident.

1.4.172. Given Tain AWR was primarily used for air ranges, understandably the Tain Tower staff were air focused. On 1 Nov 16, the Main Tower Assistant (MTA) appeared unaware of the ground centric Immediate Action Aide Memoire contained within Tain AWR (Ground Use) Range Standing Orders.67 Compounding this, the Panel could find no evidence that a ground response had been rehearsed that year with Tain AWR staff or emergency services. Consequently, the MTA, Sgt 2, relied on his experience with air accident response plans and applied common sense. Due to the devastating effect of air munitions, their safe conditioning is paramount in the immediate aftermath of an aircraft accident. Therefore, Sgt 2 placed a greater emphasis on ensuring that the weapons were in a safe condition and placed in a safe location. Whilst not a factor in this accident, the lack of awareness of the ground safety plan and the lack of rehearsals may aggravate a future accident.

1.4.173. The first 2 stages of the RASP immediate action drill were followed as written. The CMT rapidly assessed the situation to be a major-medical emergency that required assistance from the emergency services.

1.4.174. Stage 3 of the RASP was not strictly followed. The RCO misinterpreted Tain Tower's repeated requests for information as to the status of the weapons68 as an order to make weapons safe. This was compounded by the traumatic nature of the accident and the excessive shouting and movement around the Waiting Detail ISO Container. This understandably compromised the preservation of evidence at the accident scene whereby weapons were moved from inside the Waiting Detail ISO Container onto the firing line after the accident.

1.4.175. In the immediate aftermath of the accident, witnesses reported that command and control started to deteriorate on the firing line. This is likely due to the traumatic nature of the accident combined with the effect it had on students and DS alike. The Panel could neither establish who gave the order 'stop stop stop' nor who gave the order to remove the weapons from the Waiting Detail ISO Container. Moreover, once the order had been issued, weapons arrived in a piecemeal fashion as DS and students moved weapons to the firing line. Some members of the DS then began to unload these weapons. Once the weapons had been brought to the firing line, there was a belief amongst the DS that all weapons, less the one under LCpI Spencer's body, had been unloaded and were in a safe condition on the firing line. However, LCpI Spencer's L115A3 Sniper Rifle 69 which had been brought onto the firing line, was not unloaded by the DS in the immediate aftermath of the accident. Subsequently, his L115A3 Sniper Rifle was found to contain an empty case by Police Scotland staff the following morning (2 Nov 16). The Panel opined that command and control was sub-optimal and added to the confusion. While this had no bearing on the outcome of this accident, sub-optimal command and control could become an aggravating factor in a future accident.





Tain Air Weapons Range (Ground Use) Range Standing Orders. Jan 16 Annex D, pages D1 — D3, 'Immediate Action Aide Memoire. ' At this point, Tain Tower did not know the cause of the weapon discharge so their concern was logical.

"' There was confusion over which weapon belonged to LCp1 Spencer. This resulted in his weapon being moved to the firing point whilst another weapon was left lying beneath his body.

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1.4.176. The Panel concluded that a lack of awareness of ground accident plans and

procedures by the Tain Tower staff, compounded by difficult primary and secondary communications, and a deterioration of command and control at the accident site

resulted in a failure to preserve evidence as per the RASP. Whilst these three individual factors did not influence the outcome of the accident itself, they amount to Other Factors.

1.4.177. Recommendations.

a. Head of Capability Ground Manoeuvre should amend Pamphlet 21 to state that Range Conducting Officers are to rehearse/demonstrate the Range Action Safety Plan's post-accident immediate action drill' with safety staff and firers, as part of the range safety brief in order to improve the response to an accident.

b. Defence Infrastructure Organisation Service Delivery Training should ensure that all Tain Air Weapons Range staff are fully conversant with ground accident response procedures and that these are rehearsed with local emergency services at appropriate intervals in order to improve awareness and enhance accident response.

c. Defence Infrastructure Organisation Service Delivery Training should ensure robust and reliable communications are available and effective between the Tain Air Weapons Range Tower/Range Control Staff and range users in order to enable Range Control staff to communicate more effectively with range users.

Emergency services response

1.4.178. The emergency services were notified by 999 of the accident at Tain AWR by Sgt 2 in Tain Tower at 1743 hrs.

1.4.179. Police Scotland, Scottish Ambulance Service and the local on-duty NHS doctor attended the accident scene. Neither Police Scotland nor Scottish Ambulance had rehearsed responding to an incident at Tain AWR during 2016, nor could the Panel find any evidence that a rehearsal had taken place prior to 2016. Despite sending a member of the range staff to meet the emergency services as they arrived at the entrance to Tain AWR, both emergency services experienced difficulties locating the main entrance to Tain AWR from the B9174 road. This was compounded at the time by poor signage and lighting to denote the entrance to the range. Moreover, the exact location of the rendezvous point where the member of the range staff went to meet emergency services is unclear to the Panel. Notwithstanding the emergency services' lack of familiarity with both the range and the ground accident plan, their delayed arrival had no bearing on the outcome of this accident.

1.4.180. The Panel opined that the emergency services' delayed arrival at the scene of the accident was due a lack of familiarity with the Tain AWR ground accident plan and poor lighting and ineffective signage denoting the entrance to Tain AWR from the B9174 road and is therefore an Other Factor.

1.4.181. Recommendation. Defence Infrastructure Organisation Service Delivery Training should ensure signage and lighting is adequate to clearly denote the main



Post-accident immediate action drill limited to: stop activity: administer first aid/initiate the medical emergency plan weapon safety

and evidence preservation: and inform Range Control.

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entrance to Tain Air Weapons Range from public roads in order to better aid the emergency services when responding to an incident at Tain Air Weapons Range.

Ammunition and weapons forensic analysis

0.338" ammunition

1.4.182. Expended ammunition recovered from the accident scene by Police Scotland, including expended cartridges fired from LCpI Spencer's L115A3 Sniper Rifle, were subject to forensic analysis in Sep — Oct 17. This was conducted by the Aviation Forensics Team from 1710 Naval Air Squadron (NAS). The purpose of this forensic analysis was twofold; first, to determine any irregularities in the strike patterns in the indent on the base of the primer to determine if there had been an abnormal strike: and secondly to confirm the batch numbers of ammunition used on the range.

1.4.183. Following tests on 127 rounds of expended ammunition, including the case left in LCpI Spencer's L115A3 Sniper Rifle, only normal strike patterns were identified. Moreover, there were no irregularities with any of the ammunition. Given that no irregularities were identified with the strike patterns on the ammunition, the Panel could discount the possibility of an abnormal strike on the base of the expended case. As such, the absence of an abnormal strike on the base of the expended case indicates that the ASEP drill was not used, as it would have resulted in an abnormal strike pattern being observed during the forensic examination. The AESP drill hypothesis is covered in detail in the 'Afternoon detail' section of this report. The analysis of batch numbers allowed the Panel to establish that the round recovered from LCpI Spencer's L115A3 Sniper Rifle was issued for the afternoon shoot of Detail 1. This batch of ammunition was different to that issued for the night shoot. This therefore supports the hypothesis that LOpl Spencer's rifle had been in an unsafe condition since the conclusion of Detail 1 (see 'Afternoon detail' section).

1.4.184. The Panel concluded that ammunition fired from LCpI Spencer's L115A3 Sniper Rifle was not subject to an abnormal strike. Ammunition, therefore, was Not a Factor in the accident.

Un-demanded discharge

1.4.185. Given that the Panel established that LCpI Spencer's L115A3 Sniper Rifle had been in unsafe condition since the end of Detail 1 in the afternoon, the Panel then sought to determine potential causes of the un-demanded discharge of this L115A3 Sniper Rifle. The Panel determined that there were only two plausible causes: mechanical failure of the trigger mechanism; or, inadvertent trigger operation.

Mechanical failure of trigger mechanism

1.4.186. Forensic analysis was conducted by ArroGen Forensics Ltd® on LCp1 Spencer's L115A3 Sniper Rifle, in Mar 17, with further tests on two comparable L115A3 Sniper Rifles in Oct 17. The purpose of the forensic analysis was to establish whether LCpI Spencer's sniper rifle or comparable weapons were prone to mechanical failure of the trigger mechanism. Each weapon was examined by a forensic scientist to identify any existing faults/1 none were found. In subsequent

Exhibit 125

Exhibit 125



71 These tests to identify existing faults in each of the sniper rifles included a test of trigger pull weight tolerances in accordance with the AESP. All weapons were within permitted trigger pull weight tolerances. Moreover, the sniper rifles used by the remaining 3 RIFLES

1.4 - 47


OFFICIAL-SENSITIVE

testing, comparable sniper rifles were subjected to the same tests as LCpI Spencer's

sniper rifle had been previously by ArroGen Forensics Ltd®. These tests comprised;

bounce tests, drop tests (from different heights),72 and striking the exposed firing pin

(with a 1 kg weight). Throughout these tests, each weapon was loaded with a

simulation ammunition round, with the bolt forward and the safety catch tested in all

3-positions (Fire, Safety 1 and Safety 273).

1.4.187. None of the weapons had an un-demanded discharge during the drop or

bounce tests. With the weapon cocked and the firing pin shrouded by the bolt, there

was no discharge regardless of the safety catch position. In the next test, the bolt

was closed with the trigger depressed (the AESP drill), causing the firing pin to come

into contact with the base of the primer leaving the rear of the firing pin partially

exposed. In this configuration, when the partially exposed pin was struck, the

weapon discharged. To achieve this configuration the firer would have had to

employ the two-handed AESP drill or to have had an abnormal strike. The Panel

has discounted the use of the AESP drill and the possibility of an abnormal strike

(see 'Afternoon detail' and '0.338" ammunition' sections).

1.4.188. The Panel concluded that mechanical failure of the trigger mechanism was

extremely unlikely to have caused an accidental un-demanded discharge of the

L115A3 Sniper Rifle and therefore, this was Not a Factor in the accident.

Inadvertent trigger operation hypotheses

1.4.189. Three plausible hypotheses were considered by the Panel. In each case

LCpI Spencer's L115A3 Sniper Rifle was in an unsafe condition with a round

chambered (see 'Afternoon detail' section) - a fact unbeknown to LCp1Spencer and

students inside the Waiting Detail ISO Container. Additionally, LCpI Spencer was

reported to be moving the L115A3 Sniper Rifle up and down, with the butt placed on

top of his boot and his chin resting on the suppressor and, while dark, students had

sufficient ambient light to see each other clearly.

a. Self-operation by LCp1 Spencer. The Panel considered the possibility that LCpI Spencer had inadvertently operated the trigger of his L115A3 Sniper Rifle. To do this, LCpI Spencer would have had to remove

the suppressor from under his chin for him to be able to reach down to

operate the trigger manually with his finger (see Figure 1.4.20). This is

inconsistent with the conclusions of the post-mortem report. Moreover. none of the other witnesses inside the Waiting Detail ISO Container reported observing LCpI Spencer reaching towards his trigger. Therefore,

in the Panel's opinion, this hypothesis is extremely unlikely.




students on the course were subject to trigger pull weight checks by a qualified armourer upon return to the 3 RIFLES Armoury after the

accident. All were found to be within permitted trigger pull weight tolerances.

65mm and 300mm. /3 The L115A3 Sniper Rifle has a 3-position mechanical safety Fire (Forward). allows operation of both bolt, and trigger: the firing pin is

free to move, First Safety (Middle), allows operation of the bolt only; the firing pin and trigger are locked, Second Safety (Rear) prevents

operation of both bolt and trigger, the firing pin is locked.

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1[. 100cm extreme reach

Figure 1.4.20 — Self-operation of trigger

b. Operation by a third party. The Panel next considered the possibility of LCp1 Spencer's L115A3 Sniper Rifle's trigger being manually operated by a third party. In this hypothesis, a third party would have had to reach down to operate the trigger (Figure 1.4.21). The Panel interviewed all witnesses within the Waiting Detail ISO Container at the time to ascertain if there had been any observed interaction by a third party with LCp1 Spencer's rifle. No such activity was reported and would have been obvious to all witnesses due to their proximity within the ISO container. Therefore, the Panel considers that operation of the trigger by a third party is extremely unlikely.


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OFFICIAL SENSITIVE

Figure 1.4.21— Third party operation

c. Operation by equipment snagging. The Panel then considered the possibility that LCp1 Spencer's trigger had snagged on equipment causing an un-demanded discharge. It was reported that the floor of the container was cluttered with personal equipment and L115A3 Sniper Rifles. These were primarily placed along the inside wall of the container and reportedly the weapons were stowed with the bipods deployed.' Immediately after the un-demanded discharge, LCpI Spencer's body was found with his legs resting on top of an item of equipment that was likely near him before the weapon discharged. Given that LCp1 Spencer was bouncing the L115A3 Sniper Rifle with his chin resting on the suppressor, the Panel conducted an uncontrolled test of this hypothesis using an L115A3 Sniper Rifle and a standard-issue daysack. The test comprised of repeatedly moving the rifle in an up/down motion beside a daysack placed on the floor. This test demonstrated that it was sometimes possible to snag the daysack on the trigger mechanism housing. In the test, when a strap became snagged in


As described in the 'Immediate actions' section. the Panel were unable to ascertain the exact location of students' weapons and equipment as they had been moved after the accident.

1.4 - 50


the trigger mechanism housing, an upwards motion applied to the L115A3 Sniper Rifle resulted in the inadvertent operation of the trigger. Therefore, this uncontrolled test demonstrated that it is possible that whilst bouncing the L115A3 Sniper Rifle, the trigger can snag on a daysack, and subsequently, inadvertently operate the trigger (Figures 1.4.22 — 1.4.23). In the Panel's opinion, an un-demanded discharge of the L115A3 Sniper Rifle due to inadvertent operation of the trigger by equipment snagging is more likely than not. Consequently, Director General, Defence Safety Authority, issued an Urgent Safety Advice note on 9 Nov 17 highlighting the potential for an un-demanded discharge of the L115A3 Sniper Rifle due to inadvertent operation of the trigger by equipment snagging.

Trigger hooked on downwards motion

Trigger pulled down when rifle lifted, rifle discharges

Figure 1.4.22 — Equipment snagging on the trigger

Kit snagged when moving up and down next to daysack I

ITrigger pulled down when rifle lifted, rifle discharges I

Figure 1.4.23 — Equipment snagging on trigger

1.4.190. The Panel concluded that the most probable cause of the inadvertent trigger operation was by equipment snagging on the trigger. This inadvertent trigger operation resulted in an un-demanded discharge of LCpI Spencer's L115A3 Sniper Rifle and was therefore a Causal Factor.

Exhibit 126 1.4.191 Recommendation. Head of Capability Ground Manoeuvre should ensure that Sniping Part 1 highlights the potential risk of the trigger snagging on kit, equipment or foliage in order to reduce the possibility of un-demanded discharge.

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OFFICIAL-SENSITIVE

Summary of Findings

1.4.192. The Panel identified a number of accident factors during the course of the

SI. These are listed in the following paragraphs.

1.4.193. Causal Factors.

a. The Panel concluded that the unload drills conducted by the firers at

the end of Detail 1 were inadequate. As a result, 2 unsafe weapons were

left on the firing line and it is extremely likely, at this juncture. LCp1

Spencer's weapon was also unsafe due to an erroneous unload drill. Due

to a lack of SAA training, inadequate safety supervision, and poor command

and control, the incomplete unload was a Causal Factor in this accident

b. The Panel concluded that the most probable cause of the inadvertent

trigger operation was by equipment snagging on the trigger. This

inadvertent trigger operation resulted in an un-demanded discharge of LCp1

Spencer's L115A3 Sniper Rifle and was therefore a Causal Factor.

1.4.194. Contributory Factors.

a. The Panel opined that while the SOC syllabus was DSAT compliant,

there was inadequate assurance of the training delivery: as the course was

distributed, the need for assurance was essential. This lack of assurance

resulted in a missed opportunity to confirm that the endorsed syllabus was

being delivered. This was therefore a Contributory Factor.

b. The Panel opined that there was a distinct sniper culture prevalent

across the sniper units attending the SOC and that this resulted in lower

levels of supervision that was inappropriate when supervising unqualified

students and contributed towards subsequent weapon handling errors on 1

Nov 16. Therefore, this was a Contributory Factor in the accident.

c. The Panel concluded that there were instances of soldiers not

qualified as snipers being employed in a sniper role and allowed to fire the

L115A3 Sniper Rifle whilst untrained. It is very likely that this situation

resulted in their exposure to non-standard practices employed locally by

personnel in those sniper units. These were likely ingrained and subsequently employed by students who attended the 51 Bde SOC. This

was a Contributory Factor.

d. The Panel concluded that the differing backgrounds, unit cultures and

instructor experience of the DS, combined with the ad hoc nature of the SOC training team, is likely to have contributed to a lack of adherence to standard procedures during the course, and therefore this was a Contributory Factor.

e. The Panel concluded that while CSgt 1 was SQEP, his trust in CSgt 2

was misplaced and notwithstanding CSgt l's reputation and standing in the

battalion, the supervision by his chain of command was insufficient given the complexity of the task. This along with the modular approach to delivering the SOC, resulted in sub-optimal planning which lacked appropriate chain of command oversight. This sub-optimal planning was therefore a Contributory Factor.

1 4 - 52


f. The Panel opined that the disparate approach to pre-cadre training at unit level and a lack of a generic pre-cadre syllabus led to highly variable standards of L115A3 Sniper Rifle SAA expertise amongst students arriving on the SOC. This influenced DS perceptions of student L115A3 Sniper Rifle SAA competencies, thereby leading to inadequate instruction and supervision on the SOC. and that this was a Contributory Factor.

g. The Panel concluded that ambiguous direction led to the omission of SAA training on the SOC. This combined with inadequate assurance during Phase 1. resulted in students, including LCpI Spencer, live firing on the SOC, without having completed the mandatory SAA training. Therefore, this was a Contributory Factor in the accident.

h. The Panel concluded that while the austere range layout was adequate, the time taken to replace unauthorised targets over 2 days caused delay, thereby compressing the time available to conduct the practice. Consequently, the reduced time available caused stress and self-induced pressures amongst students, encouraging shortening of procedures, thereby setting the conditions for subsequent procedural errors on the range on the afternoon of 1 Nov 16. Therefore, this was considered a Contributory Factor.

i. The Panel concluded that the safety briefings for DS were sub-optimal leaving them unclear about their roles and responsibilities, thereby setting the conditions for subsequent procedural errors in safety supervision during the afternoon of 1 Nov 16. Therefore, this was a Contributory Factor.

j. The Panel concluded that LCpI Spencer was holding his L115A3 Sniper Rifle in an unorthodox and unsafe manner and that this was a Contributory Factor. Unbeknown to him or anyone else. his L115A3 Sniper Rifle was in an unsafe condition with a round in the chamber and combined with his colleagues' reluctance to challenge this unsafe behaviour amounted to a missed opportunity to intervene and prevent LCp1 Spencer's death. His colleagues' reluctance to challenge his behaviour was therefore also a Contributory Factor.

1.4.195. Other Factors.

a. The Panel concluded that while there were discrepancies between AESP L115A3 and Sniping Part 1, relating to the unload drill and while it is likely that 3 RIFLE students would have been aware of the drill it is very unlikely that the drill would have been employed as it served no practical benefit and therefore this is an Other Factor.

b. The Panel concluded that while DTC provided a SOC syllabus that was fit for purpose, the second party assurance visit was limited in scope, in that it did not assure training delivery, therefore this was considered an Other Factor.

c. The Panel concluded that while the 51 Bde SOC had the appearance of a brigade course, 51 Bde involvement was negligible, therefore this was considered an Other Factor.

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OFFICIAL SENSITIVE

d. The Panel concluded that the failure to record changes in RCO,

within the RASP, amounted to a procedural error, however, despite the

SPO's diligence and an external check. an incorrect template was used and

the RASP contained errors. The errors within the RASP were therefore an

Other Factor.

e. The Panel concluded that night-brief was inadequate because the

RCO did not ensure that all DS and students attended. Therefore, while

this did not contribute to this accident it was an Other Factor.

f. The Panel concluded that ammunition control during the afternoon

and evening of 1 Nov 16 was sub-optimal and was in contravention of Pam

21 guidance; although this did not contribute to the accident it is,

nonetheless, an Other Factor.

g. The Panel concluded that a lack of awareness of ground accident

plans and procedures by the Tain Tower staff, compounded by difficult

primary and secondary communications, and a deterioration of command

and control at the accident site resulted in a failure to preserve evidence as

per the RASP. Whilst these three individual factors did not influence the

outcome of the accident itself, they amount to Other Factors.

h. The Panel opined that the emergency services' delayed arrival at the

scene of the accident was due a lack of familiarity with the Tain AWR

ground accident plan and poor lighting and ineffective signage denoting the

entrance to Tain AWR from the B9174 road and is therefore an Other Factor.

1.4.196. Observations

a. The Panel concluded that 3 SCOTS were extremely busy with several

competing tasks during the conversion to Light Mechanised Infantry in

2016. This both compressed the time available for planning and reduced

the chain of command's ability to effectively supervise the planning phase

of the SOC: therefore, this was an Observation.

1 4 - 54


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PART 1.5

Recommendations


Intentionally Blank

Part 1.5 — RECOMMENDATIONS

Recommendations Analysis Reference

1.5.1 Introduction. The panel recommends the following:

1.5.2 Programme Leader Dismounted Close Combat. Should ensure that the 1.4.33 weapon handling drills in the Army Equipment Support Publication are aligned to those detailed in the Sniper Part 1 in order to reduce the potential for confusion and to ensure safe and unambiguous weapon handling drills.

1.5.3 Head of Combat Ground Manoeuvre

a. Should revise policy to ensure that brigades within the chain of 1.4.48 command provide oversight of unit level training, including distributed training, in order to ensure that it is adequately resourced in terms of personnel, support and time.

b. Should ensure that there is appropriate supervision of unqualified 1.4.75 students during distributed sniper training, in order to ensure that sniper training at unit level is safe and that the high professional regard that is afforded to trained snipers is not prematurely allocated to unqualified students undergoing sniper training.

c. Should ensure that unqualified snipers are only permitted to fire the 1.4.79 L115A3 Sniper Rifle with appropriate supervision (in accordance with Pamphlet 21), or when they attend a Sniper Operators' Course, in order to prevent the adoption of non-standard practices and bad habits within sniper platoons/troops.

d. Should revise policy to ensure that ad hoc training teams are 1.4.83 appropriately task organised and prepared prior to the commencement of distributed training in order to ensure a consistent and robust safety culture appropriate to the training activity being undertaken.

e. Should revise Pamphlet 21 to clearly state the rules and procedures 1.4.101 to be applied when conducting Live Fire Marksmanship Training on a Live Fire Tactical Training Area, in order remove ambiguity and to ensure that Range Action Safety Plans are compliant.

f. Should ensure that RCOs adhere to the time guidance for Live Fire 1.4.126 activity in accordance with the Operational Shooting Policy, in order to conduct safe and effective Live Fire practices.

g. Should revise Pamphlet 21 to clearly state the need for stand-alone 1.4.131 safety supervisor briefs prior to live fire ranges, in order that safety supervisors are effective, safe and aware of their roles and responsibilities during the conduct of live fire training.

h. Should ensure the following: 1.4.148

(1) That safety supervisors remain in a position such that they may adequately supervise the drills of soldiers under their supervision in order to maintain safe practice during live fire activity.

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(2) That all firers employ the correct method of showing clear in order to eradicate the use of incorrect drills.

i. Should revise Pamphlet 21 to state the need for a specific night 1.4.152 range safety brief, which incorporates relevant control measures in order to ensure effective command and control during night live fire training.

j. Should amend Pamphlet 21 to state that Range Conducting Officers 1.4.177a are to rehearse/demonstrate the Range Action Safety Plan's post-accident immediate action drill' with safety staff and firers, as part of the range safety brief in order to improve the response to an accident.

k. Should ensure that Sniping Part 1 highlights the potential risk of the 1.4.191 trigger snagging on kit, equipment or foliage in order to reduce the possibility of un-demanded discharge.

1.5.4 Assistant Chief of Staff Training

a. Should ensure that there is effective and documented assurance of 1.4.37 the delivery of distributed training courses, in order to ensure that the endorsed syllabus is being delivered as designed and that training delivery is compliant, effective and safe.

b. Should revise planning guidance for distributed training to reflect the 1.4.91 need for a nominated single-planning lead, with appropriate unambiguous terms of reference in order to ensure appropriate planning of distributed sniper training.

c. Should standardise pre-cadre courses in order to ensure that: 1.4.107

(1) The purpose of sniper pre-cadre training is clear and reflects extant Specialist Weapons School direction.

(2) Training completed by students on pre-cadres is accurately documented.

(3) Sniper Operators' Course planning officers are provided with accurate and up-to-date student training records prior to commencement of a Sniper Operators' Course.

d. Should direct that the endorsed syllabus for distributed training is 1.4.115 rigorously followed and ensure that training delivery is assured in order to guarantee that students are trained to the recognised common standard prior to live fire training.

1.5.5 Defence Infrastructure Organisation Service Delivery Training

a. Should ensure that all Tain Air Weapons Range staff are fully conversant with ground accident response procedures and that these are rehearsed with local emergency services at appropriate intervals in order to

1.4.177b

1 Post-accident immediate action drill limited to: stop activity; administer first aid/initiate the medical emergency plan: weapon safety and evidence preservation; and inform range control.

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improve awareness and enhance accident response.

b. Should ensure robust and reliable communications are available and 1.4.177c effective between the Tain Air Weapons Range Tower/Range Control Staff and range users in order to enable Range Control staff to communicate more effectively with range users.

c. Should ensure signage and lighting is adequate to clearly denote the 1.4.181 main entrance to Tain Air Weapons Range from public roads in order to better aid the emergency services when responding to an incident at Tain Air Weapons Range.

1.5.6 Director Personnel. Should ensure that Command. Leadership and 1.4.165 Management training reinforces the need to challenge unsafe or inappropriate actions whenever and wherever they are encountered, regardless of rank and experience in order to encourage safe practice.

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Intentionally Blank


PART 1.6

Convening Authority Comments

Intentionally Blank

OFFICIAL SENSITIVE

PART 1.6 — CONVENING AUTHORITY COMMENTS

1.6.1. In the early evening of 1 Nov 16 at approximately 1741hrs, LCpI Joe Spencer sustained a fatal gunshot wound. He was subsequently pronounced dead at the scene. He was taking part in military live-fire training on Tain Air Weapons Range (AWR) in the north of Scotland. He was one of 22 students attending the 51 Infantry Brigade Sniper Operators' Course (SOC).

1.6.2. LCpI Spencer was an Infantry soldier in the 3rd Battalion, The Rifles (3 RIFLES). In his 5 years in the Army, he had seen operational service in Afghanistan and deployed on 2 overseas exercises in the USA and Kenya. He was capable and very highly regarded, having been previously rated the top soldier in B Company, 3 RIFLES. In Nov 16 he was serving in the 3 RIFLES Sniper Platoon. He had received some unit-level sniper training beforehand and this was his first SOC.

1.6.3. This accident occurred during a course designed to train and subsequently qualify selected Infantry and Royal Armoured Corp soldiers as Snipers in the dismounted close combat role'. Although this training was regarded as specialist, involved live-fire and the Distributed Training model used by the SOC was new, it was designed to sit very much at the lower-end of complexity, demand and risk. LCp1 Spencer's tragic death serves as a reminder of the inherent risks associated with military training. Military training must, by necessity, be realistic in replicating the demands that the battlefield will place on both personnel and equipment. It must attain levels of complexity and challenge to generate the required operational capabilities and instil the confidence to win. Training must also be safe in that the risks to life in its conduct have been identified, understood and managed appropriately'. It must be progressive and conducted in a manner that promotes learning, understanding and wider development.

1.6.4. I am grateful to the President of this Service Inquiry (SI) and his Panel for their Report. It is logical in its analysis of the evidence and in making judgements on Accident Factors. I agree with its findings and support fully the Recommendations made. Along with the Urgent Safety Advice, issued during the conduct of this SI3, I am convinced that if met in full, the Recommendations made will help prevent a similar accident. This SI will have benefits beyond those specifically linked to the conduct of Sniper training. It highlights challenges faced by front-line units in delivering Distributed Training. It reinforces the need to follow mandated procedures and the requirement for effective assurance, oversight and safety supervision during the planning and conduct of training. It identifies the important part leadership has to play in promoting an appropriate Safety Culture, especially in organisations regarded as 'elite' or 'special'. I will return to Culture later.

1.6.5. LCpI Spencer's death was caused by the un-demanded discharge of his L115A3 Sniper Rifle4. Whilst resting his chin on the weapon's suppressor. equipment or clothing most probably snagged the rifle's trigger inadvertently, resulting in its discharge. That his weapon was in an unsafe condition with a round chambered, was extremely likely to have been caused by an incomplete unload drill being carried out earlier that day.

1.6.6. A consideration of the chain of events that led to this avoidable accident is fundamental to understanding why it happened and therefore in preventing recurrence. In structuring my comments, I will consider wider organisational influences regarding sniper training, some of the challenges faced in delivering Distributed Training, live-firing on Tain AWR and the post-accident response, before concluding.

1 A Sniper is a specialist qualification. with successful candidates needing to be proficient in all basic infantry skills, a marksman on their individual weapon and

above average in fielduaft skills. Traditionally, snipers tended to come from those soldiers regarded as being more experienced. capable and robust

2 Risks to Life should be identified, understood and managed so that they are mitigated to As Low As Reasonably Practicable (ALARP) and are

considered Tolerable.

3 20170922-DSA_SI_Tain_Urgent Safety Advice-OS SI - L115A3 Large Calibre Long Range Rifle — Urgent Safety Advice dated 22 Sep 17 and 20171109-

DSA_SI_Tain_Urgent Safety Advice-Update OS SI, dated 19 Nov 17.

4 I will refer to the L115A3 Sniper Rifle as the Sniper Rifle.

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Sniper Training and the SOC

1.6.7. The Army adopted a new Distributed model for sniper training in Jul 16 as the current method

was failing to produce sufficient numbers of qualified snipers. This effectively devolved the training, of

an approved and assured syllabus, to unit staff and the responsibility for training from the School of

Infantry to the Field Army. This was a logical and pragmatic solution and one already in use for other

specialist infantry capabilities5.

1.6.8. The 51 Infantry Brigade SOC was only the second course run under this construct'. Its genesis

was 'bottom-up' in that it had not been directed by the chain of command. Rather it was the result of

well-intended and commendable initiative shown by a number of the Brigade's unit Sniper Platoon

SNCO commanders'. Having met, during the course designed to train unit staff in how to conduct the

Distributed Training model, they agreed jointly to plan and run a SOC. They decided to split the course

into 3 x phases with each planned and led by one of the 3 x unit Sniper Platoon Commanders'. One of

the commanders (3 SCOTS) acted as the Course Planning Officer (CPO) to provide coordination,

oversight and to engage with the Army's Distributed Training Cell (DTC), set up specifically to assure

compliance with the Army's distributed training policy. 3 SCOTS were effectively the lead unit for the

course. Under the Army's Model for Duty Holding'. CO 3 SCOTS was the Delivery Duty Holder (DDH)

and the Exercise Director for the SOC. DH policy was followed correctly, with the CO assessing the

activity to be conducted as ALARP and tolerable. as it complied with the Safe System of Training

(SST)10. Content with holding risk at his level, there was no need for the CO to consult with GOC 1(UK)

Div who was the Operating Duty Holder (ODH).

The Challenges of Distributed Training

1.6.9. Planning. The SOC's modular construct, with each of the 3 x unit Sniper Platoon Commanders

leading a phase, resulted in disjointed and stove-piped planning. There were no formal planning

meetings and much of the coordination was achieved over the phone. email and WhatsAppTM. A very

busy unit programme limited the levels of supervision and oversight that could be provided to the SOC's

planning phase by the 3 SCOTS leadership11. Nevertheless, the DTC formally sanctioned the course's

syllabus on 29 Sep 16 and allocated a SNCO Mentor to the course. The Mentor's role included the

provision of 2nd Party Assurance (2PA). As this was a new training model, 2PA was essential in

confirming distributed courses complied with laid down Defence Systems Approach to Training' (DSAT)

syllabi and to confirm the quality of training delivery was appropriate. The Mentor visited Phase 1 of the

course, but his focus was on assuring the content of the syllabus (what was being taught) and not how

training was being delivered (how well it was being taught).

1.6.10. Directing Staff (DS). There were sufficient appropriately qualified DS on the SOC, but they

came from 5 different units and brought with them differences in culture, approaches to soldiering and

training. With the students similarly sourced, expectations regarding training delivery, levels of required

5 For example for mortar and machine gun platoon training

6 Although annotated as a 51 Infantry Brigade SOC. the Brigade had not been involved in the initiation of the course or had much interaction in its planning and

conduct

7 The units involved in the organization of the SOC were 1 SCOTS. 3 SCOTS and 3 RIFLES.

8 Phase 1 (2-28 Oct 16) — Marksmanship at Barry Buddon Training Area led by 1 SCOTS. Phase 2 (31 Oct — 18 Nov 16) — Fieldcraft at Tan AWR led by 3

SCOTS and Phase 3 (21 Nov 16 — 9 Dec 16) — Consolidation and Validation at Otterbum Training Area led by 3 RIFLES.

9 Land Forces Standing Order 3216, dated Mar 15

10 Pamphlet 21, Training Regulations for Armoured Fighting Vehicles. Infantry Weapon Systems and Pyrotechnics. dated Oct 17 — Section 1 The Safe System of

Training

11 Having recovered elements from a UN Peacekeeping Force in 2015, the unit were converting from Light Role infantry to the Light Mechanised Infantry role and

had spent most of 2016 conducting progressive training, which culminated in Exercise WESSEX STORM in Aug 16, prior to declaring Full Operating Capability in

the Light Mechanised Infantry role in Sep 16.

12 JSP 822. Defence Direction and Guidance for Training and Education. dated Apr 17 explains DSAT and its assurance.

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supervision, general range conduct and what constituted acceptable risk varied. Moreover, the majority of DS lacked instructional experience in an Army Training Unit and, unlike an established sniper training team, had never worked together. These differences and shortfalls, combined with the 'ad-hoc' construct of the SOC training team and lack of assurance, is likely to have contributed to the deviation from standard procedures during the SOC.

1.6.11. Student Competencies. Several students were already serving in their unit sniper platoons. despite not having completed formal sniper training. Some, including LCpI Spencer, had fired the Sniper Rifle, despite not being qualified to do so and in contravention of Army Operational Shooting Policy (AOSP). Specialist Weapons School (SWS) guidance was for units to run pre-course cadres focussing on basic infantry skills to prepare students for attendance on the SOC and to ensure all those attending would have a similar baseline of competencies. However, SWS did not provide a generic syllabus, which led to a difference in its interpretation. Some units did not adhere to the guidance and instead replicated elements of the SOC syllabus, with students receiving some Skill at Arms (SAA) training and passing Weapon Handling Tests (WHT) on the Sniper Rifle. One unit cadre even allowed unqualified snipers to fire the Sniper Rifle. This disparate approach to unit pre-course training resulted in students starting the SOC at variable levels of experience and standards. Incomplete training records compounded the problem and made it more difficult for the DS to assess correctly student competencies, especially regarding the Sniper Rifle. The result was manifested in inadequate instruction and supervision of students by DS on the SOC and made the accident more likely.

1.6.12. Skill at Arms (SAA) Training. Army Operational Shooting Policy (AOSP) clearly states' that it is mandatory to complete all basic sniper system weapon lessons and successfully complete the sniper system WHT before any live-firing can take place. Phase 1 of the SOC's DTC endorsed syllabus showed how all required 18 x SAA lessons would be delivered on Days 3-5 of the course. However, this did not take place. On Day 3 when students were supposed to be receiving SAA Lesson 1, they were instead live-firing on the range, having completed a WHT during the evening of Day 2. At no point were Lessons 1-18 retrospectively taught. As all students had completed some form of pre-course training, most of the DS incorrectly assumed this had included SAA Lessons 1-18 and WHTs. This led to some of the students commencing live-firing having had no formal SAA training on the Sniper Rifle. Specifically, there was no evidence to prove LCpI Spencer had received any formal SAA training on the Sniper Rifle. The combination of inadequate oversight and supervision of training delivery, a lack of adequate external assurance of training delivery and poor unit training records resulted in students live-firing on the SOC without having completed the mandatory SAA training. This made the accident more likely.

Tain AWR — Phase 2 of the SOC

1.6.13. Phase 2 of the SOC was led by the 3 SCOTS Sniper Platoon Commander and was to take place at Tain AWR between 31 Oct 16 and 16 Nov 16. Tain AWR is appropriately licensed for the conduct of live-fire required by the SOC and although deemed austere, its facilities were adequate. The 3 SCOTS Sniper Platoon Commander was the Range Conducting Officer (RCO) for this Phase and annotated as such in the Range Action Safety Plan (RASP). The aim was for all students to have completed data collection and pre-Annual Combat Marksmanship Test (ACMT) preparation shoots during Days 1 and 2. Prior to live-firing commencing, Safety Briefings were given. These met the requirements of Pamphlet 21, but left DS unclear on their roles and responsibilities.

1.6.14. The DS decided to use locally produced targets, which represented a steel (falling) plate. This was in contravention to Pamphlet 21, which endorses their use only by trained snipers. These targets proved problematic and caused significant delay to the firing programme. Delays continued into Day 2, until eventually it was decided to replace the unauthorised steel targets with authorised Small Arms Pop Up (SAPU) targets. The changeover was completed in the afternoon of Day 2. but subsequent delays

13 AOSP Vol 2, Section and Platoon Weapons 2016. Ch 9. Para 0903-0904

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had wasted valuable time and compressed the programme. placing significant pressure on both DS and

students In an attempt to complete Live Firing 914 (c--, in the remaining daylight of Day 2, it was

decided to fire 2 x details. each comprising 11 firers. LCpI Spencer was allocated to Detail 1. He was

placed at the right-hand end of the firing line (with his Number 2). Firing commenced at 1500hrs. The

weather was wet, windy and cold.

1.6.15. At this point, there was already insufficient daylight remaining for both details to complete their

shoots. The AOSP allocates at least 60 minutes for LF9 and sunset was timed at 1628hrs. In what might

have been an attempt to save time at the end of the first detail, the RCO seems to have used non-

standard words of command to 'unload' and conduct 'normal safety precautions' (NSP), or rushed the

process, for Detail 1 and to order Detail 2 onto the firing line. Witnesses were not clear in recalling the

exact words used, but the effect was a likely blending of 'unload' and 'NSP' orders for Detail 1. This

caused confusion amongst the students, the degree of which was manifested by at least 2 x errors in drill

that took place at the end of Detail 1, with a further error of drill at the end of Detail 2. Each of these

errors involved a weapon being left in a loaded and unsafe condition. These errors were discovered by

both DS and students once firers had withdrawn from the firing line, yet no one informed the RCO who

remained unaware of these errors. Had the RCO been informed, he might have paused activity and

directed a centralised unload and NSPs, as Pamphlet 21 would have compelled him to, having

discovered that an unsafe act had taken place.

1.6.16. In accordance with the RASP, the DS's role as Safety Supervisors was 'to ensure the safe

handling of weapons at all times' and to 'intervene if a breach of safety was about to occur'. Despite the

Safety Brief being unclear in allocating DS specific responsibilities, a DS had on his own initiative,

assumed responsibility for the firers on the right side of the firing line (including LCpI Spencer).

However. prior to the 'unload' and 'NSP' drills at the end of Detail 1, this DS had left his supervisory

position without informing the RCO and was unable to observe or supervise students''. LCpI Spencer

was the last to fire in Detail 1. No one saw him conduct a full unload. although he handed his part-filled

magazine to his Number 2. as he had been instructed. It is extremely likely he did not complete the

unload drill correctly and his rifle was in an unsafe condition with a round chambered at the end of Detail

Night Firing

1.6.17. With Detail 2 complete by 1600hrs. the RCO gave a Safety Brief for night firing and assigned

the students to 3 x Details16. Not all attended the brief, with one student and one DS missing it

completely and 3 other DS arriving late.

1.6.18. LCpI Spencer was originally assigned to Detail 3, but volunteered to change to Detail 2. This

was very likely as he suffering from the wet and cold weather (exacerbated by injuries he had received

during operations in Afghanistan). A DS escorted him to the ISO Container allocated to the Waiting

Detail. He chose to stand inside without removing his webbing and did not place his Sniper Rifle on the

floor, as other students had done. It was dark, to allow students' eyes to adjust in preparation to them

night firing, with the only light coming from coloured CyalumesTM. It was difficult to see and likely that

LCpI Spencer decided to keep hold of his Sniper Rifle to protect it from being inadvertently knocked as

had happened to him previously. He chatted with other students who reported him moving his Sniper

Rifle up and down, with the butt placed on his boot and his chin resting on the suppressor. No one

14 LF9 is a practice shoot for the ACMT

15 This DS was in the ISO Container allocated for Administration eating a snack and applying warmer clothes, owing to the inclement weather.

16 Although a separate night brief is not required, Pamphlet 21 states the need for a high standard of supervision during night firing.

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challenged his incorrect handing of his Sniper Rifle'. At 1741hrs LCpI Spencer's Sniper Rifle discharged18. He immediately fell to the floor fatally injured.

Post Accident Actions

1.6.19. The post accident response fell short in a number of areas. Whilst none of these would have saved LCpI Spencer, they might influence the outcome of a future accident. The RASP contains the actions that must be undertaken following an accident. These actions should be rehearsed, with local emergency services included in rehearsals, at least once per year. There was no evidence of required rehearsals having taken place with the emergency services during 2016 or at any date.

1.6,20. Tain AWR had been authorised for ground use in Jun 14, yet its staff appeared unaware of the ground-centric Immediate Action Aide Memoire contained within Range Standing Orders. Communications by either the range's AIRWAVE radio or mobile phone proved difficult, owing to poor signal reception and the mobile number held for the RCO being incorrect. The preservation of evidence was not adequately carried out. The shock and confusion amongst those in the close confines of the ISO Container following the discharge of LCpI Spencer's Sniper Rifle was completely understandable. However, the lack of effective command and control, despite these difficult conditions, contributed to the poor preservation of evidence. The emergency services were informed at 1743hrs. They were delayed in getting to the accident (Scottish Ambulance Service arrived at the Tain AWR main entrance between 1815hrs and 1835hrs. A doctor arrived at the site of the accident at 1840hrs and subsequently declared `life extinct' at 1845hrs). owing to their unfamiliarity with the range and its accident response plans. ineffective signage and poor lighting.

Concluding Comments

1.6.21. I hope the events that led to this tragic accident are now more evident. Whilst the initiative shown by the SNCOs in wanting to conduct a SOC is commendable, a series of errors, shortfalls and poor judgement conspired and ended in the death of a capable and highly regarded JNCO. The consequences of adopting a Distributed Training model and the challenges faced by the units who deliver this are difficult to predict, but had an Organisational Safety Assessment19 (OSA) been conducted prior to this change in policy, the need for better assurance within the unit (1' Party) and from the DTC (2nd Party) and its importance might have been recognised.

1.6.22. A failure to follow mandated procedures is one of the themes that runs through this SI. Knowing which procedures to follow must align better with qualification and should be more frequently assessed and assured. Insisting procedures are followed is everyone's responsibility, regardless of rank or seniority, and should be a basic leadership requirement. Poor supervision is another theme. Too often this fails as wrong assumptions are made regarding the competence and experience of those being supervised, and those supervising. There were many opportunities where getting this right might have broken the chain of events at Tain AWR, or even before.

17 That other students did not challenge his unsafe handling of his Sniper Rifle may have been a result of him being a JNCO, his perceived superior experience and competence and the prevailing sniper culture of collective acceptance of non-standard practices

18 The SI Panel investigated the cause of the un-demanded discharge. They determined 2 x possible causes - mechanical failure of the trigger mechanism or inadvertent tugger operation Failure of the trigger mechanism was found to be 'extremely unlikely'. Testing demonstrated the possibility of the trigger being operated by inadvertent snagging Combined with the conditions within the ISO Container at the time of the accident, the SI Panel concluded this to have been the most probable cause.

19 OSA - Changes to an organisation. if poorly conceived or controlled, have the potential to be detrimental to standards of HS&EP. An OSA of the impact on

existing safety baseline. HS&EP risks and performance should be conducted before change is implemented to identify and provide assessment of hazard and safety requirements. Ref - OSA01.2 - Implementation of Defence Policy for Health. Safety and Environmental Protection Chap 4 para 5

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1.6.23. I said I would return to the subject of Culture. The importance of instilling a Positive Safety

Culture' cannot be overstated. This takes time and strong leadership in ensuring a climate that

promotes Safety Culture and gives everyone, including the most junior members, the confidence to

challenge unsafe behaviour and practices. Had this been the case at Tain AWR, specifically with regards

to LCpI Spencer's unsafe handling of his Sniper Rifle going unchallenged, then the chain might have

been broken and the accident prevented. The second aspect regarding culture is that commonly

displayed by organisations considered 'special' or 'elite'. In this SI, witness testimony described sniper

platoons as having a distinct culture, ethos and camaraderie. owing to their specialised role and the high

levels of training they would need to attain to be successful. This led to a perception that snipers, owing

to their greater professional competence, could be trusted more to carry out their duties and needed less

supervision than their colleagues in rifle companies ('big-boys' rules'). Whilst it might be reasonable in

some cases for trained and experienced snipers to be supervised less, a similar attitude was prevalent

during the SOC. Students were mistakenly held in a higher regard than their limited sniper competencies

and experience merited. This was particularly inappropriate in this case for unqualified students

undertaking formal training and resulted in lower levels of supervision throughout the SOC and

specifically on 1 Nov 16.

1.6.24. In writing my comments as the Convening Authority, my thoughts have been with those

bereaved or close to LCpI Joe Spencer. On behalf of all members of the DSA, I offer my sincere

condolences.

Director General Defence Safety Authority

20 I regard Safety Culture as being the attitude, belief. perceptions and values that an organization shares in relation to safety in the workplace Safety Culture

comprises Just Reporting, Questioning Learning and Flexible cultures

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