Defence Force charged over soldier's death

[Dave Homewood]

Defence Force charged over soldier's death
Published: 6:11PM Sunday April 28, 2013

The New Zealand Defence Force has been charged over the death of a soldier who drowned during a training exercise.

Private Michael Ross died in September last year after he fell overboard from an inflatable boat while he was travelling across Lake Moawhango, near Waiouru.

Police and Navy divers searched the remote lake for several days before finding his body.

The Defence Force has been charged under the Health and Safety in Employment Act by the Ministry of Business, Innovation and Employment.

Parties involved are due to appear in court next month.

Ross was a Rifleman with 1 Royal New Zealand Infantry Regiment (1RNZIR) based at Linton. He joined the army in 2009, and has served in Timor Leste.

tvnz.co.nz/national-news/defence-force-charged-over-soldier-s-death-5420282

[jonesy]

Interesting case. The crux will be, did the Army fulfill its responsibilities as an employer in regard to providing a safe working environment?
"You have a responsibility to make the workplace safe, and to ensure the health and safety of those working in or visiting the workplace you control. To achieve this you are expected to:
• systematically identify hazards
• systematically manage those hazards
• manage hazards by eliminating them, isolating them or
minimising them, in that order of preference
• provide suitable protective clothing and equipment to staff
• provide safety information to staff
• provide training or supervision so that work is done safely
• monitor the health of employees to ensure that their work is not
having a detrimental effect on them
• provide opportunities for employees to participate in all of the above."

The employee also has responsibilities as well -
"Employees are required to take all practicable steps to ensure
the safety of themselves and others in the workplace. This includes considering both the things they do and the things they omit to do (such as not using safety gear).
You should make clear to employees their responsibilities to use
safety equipment provided and to wear protective clothing.
The expected level of an individual employee’s responsibility will
often be seen to increase with knowledge and seniority, but your
overall responsibility to ensure a safe workplace remains.
Practicable steps the employee can take also include reporting to you any hazards or incidents, so that you are able to investigate and put safeguards in place."
Tough call to make, but I think in the modern age it needs to be seen that Armed Forces are not immune to OH&S rules.

I'm just finishing my last assignment on my OH&S quals over here, and the more you learn about it the less tiresome it becomes!

[corsair67]

The saddest thing in all this was that it appeared his life vest didn't work as it had already been deployed previously - either as a 'joke' or by mistake - and was simply deflated and put back into stores for reissuing.............

Either way - there are some real bright f-wits out there!!!!

[phil82]

That was the part of the report that struck me! The fact that some utter moron took a piece of kit like an inflatable life jacket and didn't check any part of it before placing it back in store ready for the next user!

[Dave Homewood]

Now hang on a minute. The fact that the CO2 cylinder did not contain any gas does not necessarily mean it was the last user of the jackets fault. There are on occasions faulty bursting discs in the cylinders which allow the gas to slowly leak over time. When the cylinders are filled the bursting discs are checked and you'd be surprised how many showed signs of leaking, perhaps one in every hundred. But the leaking rate could easily be so slow that this test does not pick it up. The life preserver jackets have a shelf life of six months in service before their next servicing and gas bottle change. A very slow leak over that period can empty the bottle.

On the other hand people would bump these jackets about and perhaps a knock to the bottle loosened the bursting disc causing a leak.

A visual inspection by the user or the Safety Equipment Worker issuing the jacket may easily miss an empty CO2 bottle. The weight difference between empty and full is negligable in such a small bottle. Visually it looks all good. Perhaps it had gone in and ot of the SEQ section on many occasions with a crook bottle but no-one had realised because there is no way to tell till you actually pull the handle to inflate the vest.

I am not sure if they tell the army this but when we used to train aircrew in the safety equipment, we used to train them that on rare occasions due to circumstances the gas bottle may not work, and on their right hand side there's a tube for manual inflation in case of that.

I also recall a time when Cpl Andrew Maxwell who looked after the Safety Equipment section at Pilot Training Squadron was demonstrating the life preserver to a group of new students. He selected one that was in service but close to its time to be serviced in the bay. he pulled the handle and nothing. The cylinder was empty. An examination concluded that the only possible cause could be that the bursting disc had a very slow leak. No-one's fault except perhaps the bursting disc manufacturer. And certainly not "some utter moron" playing with it.

[Dave Homewood]

Having said the above, an 'expert' says it was human error...

Army chief points to human error
By Abby Gillies Email Abby 10:06 AM Monday Apr 29, 2013

Human error is likely to have contributed to the death of soldier Private Michael Ross who died during a training exercise near Waiouru, according to a former Army chief.

The New Zealand Defence Force has been charged with failing to ensure the safety of the soldier, who died when he fell from an inflatable boat.

He disappeared into Lake Moawhango in September last year and his body was found a week later.

Former Army chief Major General Louis Gardiner said today that during his 37 years in the military, a lot of emphasis was put on safety.

However, this couldn't prevent human error.

"It's almost in the military DNA to have SOPS (standard operating procedures) for almost everything but however, human beings are involved and human beings make judgements and occasionally get it wrong," he told RNZ today.

"Occasionally when people become familiar with procedures, they think they can drop one just for convenience sake these are the sort of things that creep into practices and these are when accidents occur," he said.

The NZDF was facing a single charge of failing to take all practicable steps to ensure the safety of Private Ross, a Defence Force spokesman said yesterday.

Private Ross, 29, was only weeks away from being discharged from the Army when he drowned in the lake during a training exercise.

His family believe he was unable to inflate his lifejacket because he was unconscious after being hit by the butt of his gun.

"If that canister had been used before that lifejacket should have been put aside as an unserviceable life jacket and shouldn't have got into a serviceable group of lifejackets. So there's a human error there somewhere," Major General Gardiner told RNZ.

NZDF safety practices came under the spotlight after a court of inquiry report found a number of safety factors were to blame for Private Ross' death.

- APNZ

By Abby Gillies Email

www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10880382

__________________________________

So, if he'd had a fully servicable life preserver, how would he have deployed it if he was unconscious from a knock to his head by his rifle butt? You still need to pull the handle even if you have a perfect gas bottle. Or do they have depth guages now that automatcailly dpeloy the gas??

[phil82]

There is a very simple, high-tech procedure for checking whether or not a cylinder of any kind is leaking. It's called a small paint brush dipped in soapy water. I used it thousands of times on all sorts of cylinders large and small! It still requires just an iota of competence I guess!

[Dave Homewood]

So you are issued with a life preserver off the shelf that's been three months since it's last service - which you as the wearer have no clue of in terms of last servicing - and let's think now, if that cylinder has leaked all its CO2 out in the month or two prior to your receiving it, and you do your test with the soapy water there will be no bubbles, so you assume it's fine. But it's empty.

The test was performed only when the cylinder was filled, but it's pointless to do it again over the next six months of service life, isn't it?

[phil82]

No it isn't! You are issuing a vital piece of safety equipment: the old air force adage would apply, "check, don't assume". To not do so is cavalier at best, and downright irresponsible at worst, and in this instance caused a death! When a death results, subsequent comments are mere platitudes! It could have been prevented , and that is the conclusion already reached.

[Dave Homewood]

OK then, you know it all - if it's not pointless to slosh soapy water on the gas bottle connection every single time you are issued a life preserver, then how on earth does your soap test tell you that it's leaking or not if it's empty already. Think about it!

It can't. So it is pointless. The bubbles will only show at the time that the gas is actually escaping after the bottle is ruptured. they don't keep coming out for the rest of the six months in service.

And the fact that he was allegedly unconscious already and thus could not deploy the jacket also speaks volumes. Whether the jacket was serviceable or not, the death would not be preventable if he's out cold and being dragged under the water.

[phil82]

Well, that really explains why the Army have been charged now doesn't it.

[Dave Homewood]

You said this was the fault of some utter moron - and I said it was not necessarily the case because there are other ways in which a bottle can be empty without any human error.

I just hope that the court case looks at all the possibilities before making a decision, and not simply pre-decide that the previous person who used that jacket, or the SEQ maintainer is at fault.

I am glad you're not on the panel that will be trying this case. You've already made your mind up that it is the fault of an 'utter moron'.

[lesterpk]

Dave and others - 99% of lifejacket cylinders are now of the disposable type, no bursting disc to leak. They were pretty much gone from the Air Force 20yrs ago, I never saw refillable ones except on course.
The cylinders are either serviceable or not, each annual servicing they get check weighed, there is a minimum weight stamped on each bottle and if they are below it they are rejected, I've never rejected one except for corrosion.

I cant speak for what the Army does but there should be a system in place that even if the item is used before its annual or 6 month service is due it should go through another full service before being returned to use. No end user should be expected to check their own bottle, there are specialists who didnt do their job, and quite a few of them in this case.

[Dave Homewood]

Thanks for clarifying the situation here Les. Although the same jackets are still used obviously the cylinders have changed.

That does make things clearer in the circumstances. I apologise to Colin, there clearly has been some sort of error by a person unknown. But I am correct that the end user is not expected to check their own cylinder every time they sign out a preserver, and such a test only happens at the scheduled maintenance.

[raymond]

I thought I heard early on that they were navy jackets just borrowed?

[ngatimozart]

Yeah and if they were they could've been ones in storage for a whiles. We had 20 roll up ones on the quarterdeck of the Kiwi for emergency use and they had gas bottles. Thats over and above what was in the life rafts which were a 20 man and a 10 man for a crew of 18. But thats 20 years ago and I think the greenies used to check those jackets. Only used one in training.

Having said that from what I have read in the media, the Army didn't exactly follow the safety protocols in that the assigned rescue diver wasn't on the water at the time and the rescue boat wasn't where it was supposed to be. That may or may not be correct but if it is that is very poor work on some peoples watch, i.e., the command team on the ground and on the water at the time.

[madmac]

It is a Charlie foxtrot all round. Once again, the joys of the the cheapest winning tender.

The other point is he was clipped to his machine gun, which i understand isn't SOP until close to shore, which maybe a reflection of loss of institutional knowledge.

[meo4]

Apr 29, 2013 17:23:31 GMT 12 raymond said:

I thought I heard early on that they were navy jackets just borrowed?

Probably we're most life jackets are products of SOS marine and serviced by a RNZAF S&S section based at Whenuapai.

www.sosmarine.com/Pages/Serials/Defence%20Product.htm