The Service Inquiry Report Into the Death of a Soldier Participating in a Night Live Firing Sniper Cadre at RAF Tain Range Field

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 Left Intentionally Blank 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

Convening Order including Terms of Reference and Lexicon

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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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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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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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Abbreviation Definition Notes hrs Hours 2ic Second in Command The culmination of training on a weapon system that Annual Combat tests accuracy of a firer. A pass is essential to be ACMT Marksmanship Test considered qualified to fire the weapon on exercise or operations. Admin administration Army Equipment Support A document that contains the maintenance procedures AESP Publication for a weapon system. ATO Ammunition Technical Officer A person trained to deal with ammunition incidents. A range used by aircraft to drop munitions and bombs AWR Air Weapons Range as part of training serials. A noise-making explosive device to simulate battlefield noises, i.e. artillery and explosions, ranging in size from BATSIM Battle Noise Simulator hand held firecracker like devices to larger incendiary explosives. A range training area on the east coast of Scotland, BBTA Barry Buddon Training Area North of Dundee. A formation in the Army consisting of several units Bde Brigade (Battalions) that is commanded by a Brigadier (1*), normally consisting of approx. 3,000 personnel. CAS Close Air Support CFA is a senior officer of Lt Gen (3*) rank who provides CFA Commander Field Army properly trained Land Force Elements for operations, including wider support to the Joint Force. A member of the Royal Army Medical Corps trained in CMT Combat Medical Technician emergency medicine. The senior officer in a Battalion in charge of four or CO Commanding Officer more sub-units (Companies). Comd Commander Coy Company A sub-unit of a Battalion. DPers Cap is responsible for developing Army personnel strategy and engaging with Defence and the Directorate of Personnel other services to shape and influence strategic DPers Cap Capability 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 A subset of military logistics that ensures that soldiers CSS Combat Service Support have the required equipment and supplies to carry out their tasks. Collective Training is the name given to an Army standard of training. It comprises various levels from CT Collective Training CT1 - Platoon, CT2 - Company, CT3 — Battlegroup, CT4 — Battlegroup in a Brigade context. DCC Dismounted Close Combat The typical infantry role. A DH provides specific focus on safety and environmental protection management. DHs have a DH Duty Holder 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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DSA/SI/01/17/TAIN OFFICIAL-SENSITIVE © Crown Copyright 2018 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 conducts impartial and expert no-blame safety investigations across Defence to ensure that causal Defence Accident factors are identified and understood as quickly as DAIB Investigation Branch possible, and recommendations made to prevent recurrence and enhance safety, whilst preserving Operational capability. Defence Infrastructure Responsible for the maintenance and compliance of DIO Organisation land ranges with law and policy. A formation in the Army consisting of several Brigades Div Division that is commanded by a Major General (2*), normally consisting of approx. 10,000 personnel. Defence Learning An online learning website used by Defence to distribute DLE Environment some training and education. DPers is responsible for the employment, development and sustainability of British Army personnel, including Directorate Personnel DPers regulars, reservists, contractors and civil servants. Commanded by a Maj Gen (2*). The term given to personnel with the responsibility to DS Directing Staff train and mentor students as well as provide safety supervision. The DSAT ensures that all Defence training follows a proven system. This system must be used by those Defence Systems Approach DSAT who are involved in the analysis, design, delivery, to Training assurance, management and governance of Defence training and education. The organisation that is responsible for distributed DTC Distributed Training Cell training policy. A document that outlines the safety procedures on a EASP Exercise Action Safety Plan range, created by the Planning Officer in line with policy. Ex Exercise Ex RATTLE A Combined Joint exercise with the US armed forces in Exercise RATTLE SNAKE SNAKE Atlanta, USA which ran in the latter half of 2015. Ex WESSEX A CT4 exercise that runs several times a year for units Exercise WESSEX STORM STORM on a rotational basis in Thetford and Salisbury Plain. A deployable Royal Air Force unit responsible for the FP Wg Force Protection Wing protection of Air assets including aircraft, equipment and personnel. A Gillie Suit is a mesh, sleeveless overall that is camouflaged with foliage, strips of hessian and Manilla Gillie Suit rope. Each Gillie Suit is tailored to the individual and a sniper is expected to maintain and camouflage it to a high standard. The commander of a British Army Division, who holds General Officer Commanding GOC Maj Gen (2") rank. HF is the study of how humans behave physically and HF Human Factors psychologically in relation to particular environments, products, or services. HHPTT Hand Held Push-to-talk A hand held radio. Head of Capability Ground Formally known as Head of Capability Combat, HoC HoC GM Manoeuvre GM is responsible for developing and delivering the

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DSA/SI/01/17/TAIN OFFICIAL SENSITIVE © Crown Copyright 2018 British Army's mounted and dismounted close combat capability development and delivery. HoC Trg is responsible for HoC Trg Head of Capability Training education and training policy across the British Army. International Standards ISO Organisation ISR is the coordinated and integrated acquisition, Intelligence, Surveillance and ISR processing and provision of timely, accurate, relevant, Reconnaissance coherent and assured information and intelligence to support a commander's conduct of activities. Intelligence, Surveillance, ISTAR is a practice that links several battlefield ISTAR Target Acquisition and functions together to assist a combat force in employing Reconnaissance its sensors and managing the information they gather. The L85A3 (SA80) is the rifle employed by IW Individual Weapon all 3 UK Armed Services. Junior Non-commissioned JNCO Persons that Officer hold Lance Corporal or Corporal rank. JSP Joint Service Publication Documents that outline Defence policy and rules. Large Long Range LCLRR Calibre The L115A3 rifle is the sniper rifle employed by all 3 UK Rifle Armed Services. LCpl Lance Corporal LF Live Fire Life Fire Marksmanship LFMT Training Training that utilises live ammunition, LFTT Live Fire Tactical Training conducted on a training area known as a range or a LFTTA. Live Fire Tactical Training LFTTA Area m Metres Maj Major MOD Ministry of Defence NAS Naval Air Squadron A person that holds the rank of Lance Corporal, NCO Non-commissioned Officer Corporal, Sergeant, Colour Sergeant or Warrant Officer. A set of drills used to take a weapon system from an unknown or unsafe state to a known safe state, NSPs Normal Safety Precautions for example by removing any rounds contained within the weapon. ODH Operational Duty Holder The documents that describes the lessons and method OSP Operational Shooting Policy of employment for a weapon system. A range training area located in the Northeast of OTA Otterburn Training Area England, thirty miles Northwest of Newcastle. Pamphlet No 21 'Training Regulations for Armoured The document that prescribes Pam 21 Fighting Vehicles, Infantry how to conduct LF training safely. Weapons Systems and Pyrotechnics' The Procurator Fiscal is a public prosecutor in Scotland. They investigate all sudden and suspicious deaths in PF Procurator Fiscal Scotland (similar to a Coroner in other legal systems), and conduct fatal accident inquiries (a form of inquest unique to the Scottish legal system). approximately PI Platoon A body of 25-30 soldiers normally commanded by a junior officer.

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DSA/S1/01/17/TAIN OFFICIAL-SENSITIVE © Crown Copyright 2018 A senior NCO from the Small Arms School Corps who is Quarter Master Sergeant QMSI an SME on the employment and training of weapon Instructor systems. RAF Royal Air Force The document that prescribes the safety policy of a RASP Range Action Safety Plan range, produced by the RCO in accordance with Pam 21. RCO Range Conducting Officer The person in charge of a range. The overall name given to the lessons and skills SAA Skill at Arms required to operate a particular weapon system. Remotely controlled electronic targets used during live SAPU Small Arms Pop-Up targets fire training. The SASC is responsible for maintaining the proficiency SASC Small Arms School Corps of the Armed Forces in the use of small arms, support weapons and range management. SI Service Inquiry SME Subject Matter Expert The document that contains sniper specific training and Sniping Pt 1 Sniping Part 1 information. A formal training course that qualifies a soldier as a SOC Sniper Operators' Course sniper. The person with overall responsibility for overseeing the SPO Senior Planning Officer planning of ranges. Normally of Major rank. Suitably Qualified and SQEP Experienced Person Sniper Thermal Imaging STIC A thermal sight that may be fitted to the L115A3. Capability A bespoke group of trained snipers responsible for STT Sniper Training Team training future snipers, sniper commanders and sniper platoon commanders. Based at the Land Warfare School in Warminster these SWS Specialist Weapons School hold the corporate knowledge for specialist weapons and provide centralised courses for commanders. T3 courses enable the cascade of new training methodologies and processes whereby those that will T3 Train the Trainer be responsible for the conduct of training are trained in line with the latest policy. Often referred to as RAF Tain. This is an Air/Ground range located on the East coast of Scotland Tain AWR Tain Air Weapons Range approximately 30 miles North East of Inverness, near the town of Tain. A slang term for a MAN truck that is fitted with seats in TCV Troop Carrying Variant the back to carry troops. The TDA is the organisation responsible for training TDA Training Delivery Authority delivery, but not necessarily the conduct of the actual training itself. This is a generic term for Peltor active noise-cancelling Tactical Hearing Protection hearing protection. This allows normal levels of audio to THPS System be heard by the firer (i.e. speech) but blocks out loud audio (i.e. explosions and gunshot). TOR Terms of Reference The TRA represents the end-user of the trained output and is the ultimate authority for the derivation and Training Requirements maintenance of the Role Performance Statement (Role TRA Authority 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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DSA/S1/01/17/TAIN OFF4CIAL-SUISI-T4VE © Crown Copyright 2018 Training Authorisation The TrAD is the formal document that authorises TrAD Document training to be conducted, signed by the TRA. The British Army's method for mitigating the effects of Trauma Risk Incident TRIM trauma on personnel following exposure to a traumatic Management event. The person responsible for maintaining safety on a TSO Training Safety Officer specific range or training area. United Nations Peacekeeping UNFICYP Force, C •rus The culmination of learning on a weapon system to WHT Weapon Handling Test 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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Narrative of Events

OFFICIAL - SENSITIVE Intentionally Blank

PART 1.3 — NARRATIVE OF EVENTS

Synopsis Page 2 Protagonists Page 3 Background Page 6 Pre-accident Genesis Page 7 Planning stage Page 7 Course commencement Page 8 Accident Day shoot Page 9 Night shoot Page 12 Post-accident Immediate action Page 14 Response Page 15 Emergency services Page 16 Follow-on activity Page 17 Timeline Page 18

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Synopsis

1.3.1 On 1 Nov 16 at approximately 1741 hrs a single-round was discharged Exhibit 001 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) Exhibit 019 Sniper Operators' Course (SOC) between 2 Oct — 9 Dec 16. Under the auspices of Exhibit 020 distributed training,2 this part of the course was delivered by The Black Watch, 3rd Exhibit 002 Battalion, The Royal Regiment of Scotland (3 SCOTS) at Tain AWR. At this stage, Exhibit 005 the course comprised 22 students drawn from 5 regiments. The students were Exhibit 006 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, Witness 41 sustained a fatal gunshot wound. He was subsequently pronounced dead at the Exhibit 128 scene.

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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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. Exhibit 112 Following Infantry training at the Infantry Training Centre Catterick, he joined C Witness 26 Company (Coy), 3'd Battalion, The Rifles (3 RIFLES). He completed one Witness 48 operational tour in Afghanistan and 2 overseas exercises in Kenya and the USA. Exhibit 141 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 Witness 23 Infantry, which included operational tours to Afghanistan and Bosnia. At the time of Exhibit 005 the accident he served as a company commander in 3 SCOTS and was the Range Exhibit 006 Conducting Officer's (RCO) immediate superior. He had overall responsibility for Exhibit 093 Phase 2 of the course. This included planning the Live Fire Marksmanship Exhibit 096 Training (LFMT) with specific responsibility for ensuring that the Range Action Exhibit 028 Safety Plan (RASP) was fit for purpose.

1.3.7 Colour Sergeant 1 (CSgt 1). CSgt 1 had 17 years' service in the Infantry, Witness 24 during which time he had completed operational tours to Afghanistan and Iraq, and Exhibit 034 had served as an instructor at the Infantry Training Centre. Catterick. Employed as Exhibit 094 the Sniper Platoon Commander in 3 SCOTS since 2014, he had overall Exhibit 043 responsibility for the planning and supervision of the SOC. He was the Planning Exhibit 072 Officer for Phase 2 with specific responsibility for the safe conduct of live fire Exhibit 073 ranges. He was the RCO on the afternoon/evening of 1 Nov 16. Exhibit 074 Exhibit 023 Exhibit 028 1.3.8 Colour Sergeant 2 (CSgt 2). CSgt 2 had 21 years' service in the Infantry, Witness 25 which included operational tours to Afghanistan, Iraq and Northern Ireland. Since Exhibit 035 2014 he had been employed as the Sniper Platoon Commander in The Royal Exhibit 055 Scots Borderers, 1s' Battalion, the Royal Regiment of Scotland (1 SCOTS). As the Exhibit 056 Phase 1 Planning Officer, he was responsible for the planning and delivery of Exhibit 057 Phase 1 of the 51 Bde SOC. Exhibit 021

1.3.9 Sergeant 1 (Sgt 1). Sgt 1 had 11 years' service in the Infantry, which Witness 28 included operational tours to Afghanistan and Northern Ireland, and two overseas Exhibit 028 exercises to Kenya. Since 2015, he was the 3 SCOTS Sniper Platoon Second in Exhibit 129 Command responsible for administration and Combat Service Support (CSS). Exhibit 076 During Phase 2 he provided CSS and was RCO on the morning of 1 Nov 16. Exhibit 077 Exhibit 078 Exhibit 095

1.3.10 Sergeant 2 (Sgt 2) Duty Controller. Sgt 2 had 14 years' service in the Witness 44 RAF as Trade Group 9 (Air Traffic Controller) which included overseas Exhibit 140 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

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1.3.11 Directing Staff 1 (DS 1). DS 1 had 10 years' service in the Royal Witness 34 Armoured Corps (RAC), which included operational tours to Afghanistan and Iraq. Exhibit 048 Serving with the Royal Scots Dragoon Guards (SCOTS DG) as a Corporal he was Exhibit 045 initially trained on the Challenger 2 Main Battle Tank, before re-roling to Light Exhibit 046 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 Witness 30 included an operational tour to Afghanistan. At the time of the accident he was Exhibit 028 serving with 3 SCOTS as a Section Commander in the Sniper Platoon as a Exhibit 129 Corporal. DS 2 was a sniper and was Directing Staff on the SOC with specific Exhibit 070 responsibility for safety supervision during live fire ranges. Exhibit 071 Exhibit 005

1.3.13 Directing Staff 3 (DS 3). DS 3 had 10 years' service in the Infantry, which Witness 29 included operational tours to Afghanistan. At the time of the accident he was Exhibit 060 serving with The Royal Highland Fusiliers, 2nd Battalion, The Royal Regiment of Exhibit 067 Scotland (2 SCOTS) as a Section Commander in the Sniper Platoon as a Corporal. Exhibit 068 DS 3 was a sniper and was Directing Staff on the SOC with specific responsibility Exhibit 069 for safety supervision during live fire ranges. During Phase 1. DS 3 conducted Exhibit 005 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 Witness 33 included operational tours to Afghanistan. At the time of the accident he was Exhibit 079 serving with 2 SCOTS as a Section Commander in the Sniper Platoon as a Exhibit 028 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 Witness 27 included operational tours to Afghanistan and Iraq, and overseas exercises to Exhibit 054 Kenya, Jordan and Malawi. Since 2015, he was a member of the 1 SCOTS Sniper Exhibit 051 Platoon as a Sniper Instructor. DS 5 was a sniper and was Directing Staff on the Exhibit 052 SOC with specific responsibility for safety supervision during live fire ranges. Exhibit 053 Exhibit 054

1.3.16 Directing Staff 6 (DS 6). DS 6 had 12 years' service in the Infantry which Witness 31 included operational tours to Iraq, Afghanistan and overseas exercises to Kenya. Exhibit 028 Since 2010 he was a member of the 3 SCOTS Sniper Platoon later qualifying as a Exhibit 129 Sniper Section Commander. DS 6 was a sniper and was Directing Staff on the Exhibit 075 SOC with a specific responsibility for safety supervision during live fire ranges. Exhibit 005 Exhibit 062 1.3.17 Student A. Student A had 6 years' service in the Infantry, which included Witness 13 operational tours to Afghanistan and Kosovo. Serving with 3 RIFLES as a Exhibit 110 Rifleman3, he was a student on the course and was paired with LCpI Spencer Exhibit 111 during Phase 2, inter-changing with him between the role of Number 1 (firer) and

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, Witness 07 which included 2 operational tours to Afghanistan and overseas exercises in Exhibit 033 Canada. At the time of the accident he was serving with the SCOTS DG as a Exhibit 044 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, Witness 11 which included overseas exercises in Canada. At the time of the accident he was Exhibit 062 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, Witness 08 which included overseas exercises in Canada, Italy and Kenya. At the time of the Exhibit 028 accident he was serving with the SCOTS DG as a Trooper and was a student on Exhibit 062 the course.

1.3.21 Student E. Student E had 3 years' service in the Infantry, which included Witness 05 an overseas exercise in the USA. At the time of the accident he was serving with 3 Exhibit 103 RIFLES as a Rifleman and was a student on the course. Exhibit 104 Exhibit 062

1.3.22 Student F. Student F had 3 years' service in the Royal Armoured Corps, Witness 12 which included overseas exercises in Canada and Cyprus. At the time of the Exhibit 062 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, Witness 06 which included an operational tour in Afghanistan and an overseas exercise in Exhibit 047 Cyprus. At the time of the accident he was serving with the SCOTS DG as a LCp1 Exhibit 062 and was a student on the course.

1.3.24 Student H. Student H had 6 years' service in the Infantry, which included Witness 17 an operational tour in Afghanistan. At the time of the accident he was serving with Exhibit 113 3 RIFLES as a Rifleman and was a student on the course. Exhibit 114 Exhibit 115 Exhibit 062

1.3.25 Student I. Student I had 5 years' service in the Infantry, which included Witness 16 an operational tour in the Falkland Islands and overseas exercises in Kenya, USA Exhibit 119 and Tunisia. At the time of the accident he was serving with 3 RIFLES as a LCp1 Exhibit 105 and was a student on the course. Exhibit 106 Exhibit 107 Exhibit 108 Exhibit 109

1.3.26 Student J. Student J had 5 years' service in the Infantry, which included Witness 01 overseas exercises to Kenya. At the time of the accident he was serving with 3 Exhibit 120 SCOTS as a LCpl and was a student on the course. Exhibit 028

1.3.27 CMT. The CMT had 11 years' service in the Royal Army Medical Corps as Witness 36 a medic, which included operational tours in Iraq and Afghanistan and overseas Exhibit 005

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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DSA/SI/01/17/TAIN OFFICIAL © Crown Copyright 2018 OFFICIAL,SENSITIVE exercises in Kenya and France. At the time of the accident he was serving with 3 Exhibit 062 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 Witness 45 George, Scotland and had just completed the process of converting from a light- Witness 23 role battalions to a light-mechanised battalions. In preparation for the conversion to Exhibit 131 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 Exhibit 015 personal weapon issued to trained snipers in the dismounted close combat role Exhibit 124 across the 3 services. A bolt-action rifle produced by Accuracy International®, it Exhibit 132 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.

on foot 5 A Light-role Battalion is an Infantry unit that comprises of foot soldiers that are designed to manoeuvre around the battlefield and if they require transportation they must depend on external support. in order to 6 A Light-mechanised Battalion is an Infantry unit that is equipped with Protected Mobility (i.e. lightly armoured) vehicles 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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DSA/SI/01/17/TAIN eFFrefAL----SENSKIVE- © Crown Copyright 2018 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

Genesis

1.3.32 Policy. On 1 Jul 16 the Army's Head of Capability Combat approved the Exhibit 090 Training Authorisation Document (TrAD) for the SOC. This policy revision resulted Exhibit 133 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 Witness 37 Specialist Weapons School (SWS) delivered a course to train sniper platoon staff in Exhibit 038 the planning and delivery of distributed training. The course trained Sniper Platoon Exhibit 133 Commanders and Non-commissioned Officers (NCO) from across the Army. Witness 24 Students were briefed on the Army's distributed training policy. This included Witness 25 specific direction for units to collaborate and deliver the SOC as distributed training Witness 26 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 Witness 24 Platoon Commanders continued planning for the Sniper Operators Course. There Witness 26 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 Witness 24 standalone phases, each with a different unit providing the lead. The 3 phases Exhibit 019 comprised: Phase 1 (2 — 28 Oct 16) — marksmanship at Barry Buddon Training Exhibit 021 Area (BBTA) led by 1 SCOTS; Phase 2 (31 Oct — 18 Nov 16) — fieldcraft at Tain Exhibit 022

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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 Witness 23 unit plans to deliver a SOC. Subsequently, during the 51 Bde Light Forces Witness 24 Symposium hosted by 3 SCOTS at Fort George on 18 — 19 Apr 16, attendees Exhibit 032 were briefed by CSgt 1 on emerging plans for a jointly delivered SOC. During Exhibit 080 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 Witness 24 responsible for external engagement with both the Distributed Training Cell (DTC) Exhibit 027 staff and SWS Sniper Wing staff. SWS Sniper Wing nominated a CSgt instructor to Exhibit 024 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 Witness 25 last week of Phase 1) the ranges were transferred to another unit with a higher Exhibit 030 training priority. As a workaround CSgt 1 and CSgt 2 revised the course Witness 24 programme. Phase 1, week 4 was swapped with Phase 2, week 1. This change Exhibit 025 resulted in 3 SCOTS being required to conduct both fieldcraft training and live firing Exhibit 005 practices culminating in the ACMT during their phase of the course. CSgt 1 Exhibit 012 conducted the planning and produced the mandatory Range Action Safety Plan Exhibit 134 (RASP) to conduct live firing at Tain AWR. The Senior Planning Officer (SPO) Witness 23 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 Exhibit 020 — 28 Oct 16. 1 SCOTS were responsible for the delivery of this phase. 1 SCOTS Exhibit 021 instructors were augmented by NCO instructors provided from SCOTS DG, 2 Witness 25 SCOTS, 3 SCOTS, and 3 RIFLES. 23 students mustered at the start of the Witness 34 course; they were drawn from 5 regiments listed above. Week 1 comprised: Witness 27 summative assessments (Annual Fitness Test, Navigation and Service Witness 33 Knowledge); Skill at Arms Training on the L115 A3 sniper rifle (refresher rifle Witness 29 training and Weapon Handling Tests (WHTs)); and LF ranges. One student was Witness 32 returned to unit for failing the navigation summative assessment: 22 students Witness 38 remained on the course. Weeks 2 and 3 comprised progressive training shoots, Witness 24 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 Exhibit 019 31 Oct — 18 Nov 16. DS and students were accommodated and administered at

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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DSA/SI/01/17/TAIN OFFICIAL — SENSITIVE © Crown Copyright 2018 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 Witness 24 the movement of their units' L115A3 rifles and ancillariesw from BBTA to Fort Witness 28 George prior to the start of Phase 2. LCpI Spencer together with 3 other students Witness 05 from 3 RIFLES travelled by road to Fort George on 28 Oct 16, with their weapons Witness 16 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 Witness 28 had withdrawn their rifles and ancillaries from the 3 SCOTS armoury. Departure Witness 24 was delayed because the soldiers' dining facility for breakfast was not open and Witness 27 low visibility conditions at Tain AWR. The course travelled by road to Tain AWR Witness 24 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 Witness 24 career brief at Fort George on the morning of 1 Nov 16. To facilitate his attendance Witness 23 at this mandatory career brief, and unbeknown to the SPO, CSgt 1 arranged for Exhibit 036 Sgt 1 to cover the RCO role at Tain AWR during the morning of 1 Nov 16. 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.

1.3 - 9

1.3.45 Tain arrival. On the morning of 1 Nov 16, students and DS departed Fort Witness 28 George for Tain AWR on completion of morning routine. Upon arrival at Tain AWR, Exhibit 102 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) Witness 29 conducted data-collection shoots, using the same locally produced targets, fitted Witness 27 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 Witness 24 hrs. He signed on and assumed the role of RCO. Sgt 1 departed the range soon Witness 46 thereafter to collect the evening meal from Fort George. The afternoon serial Exhibit 102 comprised two details, each comprising 11 firers conducting a pre-Annual Combat Witness 13 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.

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

1.3 - 10

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

Lepl Spencer Firing Line on raised berm Student A

TCV 46m

ISO Waiting Detail Administration ISO ISO

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).

Waiting Detail ISO

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

1.3 - 11

1.3.49 First detail. The first detail commenced firing at approximately 1500 hrs. Witness 13 At some point before completion of the detail, DS 1 left the firing point to conduct Witness 34 personal administration in the Administration (Admin) ISO Container at the rear of Witness 33 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 Witness 24 1535 hrs. Following a similar pattern to the first detail, the RCO nominated targets Witness 33 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 Witness 24 approximately 1630 hrs, CSgt 1. acting as the RCO, delivered his night safety brief Witness 32 to DS and students. Not everyone was present for the brief. At this time 4 DS, Witness 05 were in nearby Tain town visiting local shops and Student E was talking on his Witness 05 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 Witness 32 prepared for the forthcoming night shoot. Witness 30 image intensifier sights, the DS divided the students into 3 Witness 07 details for the night shoot. LCpI Spencer was assigned to the third detail. Due to Witness 05 the inclement weather, the third detail occupied the Admin ISO Container. Witness 44 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

1 3 - 12

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 Witness 05 standing in close proximity and chatting with a group of fellow students, comprising Witness 07 Students B, C, D, E, F and G. Inside the Waiting Detail ISO Container it was dark Witness 11 although it was partially illuminated by Cyalumes017 attached to the front of the Witness 12 ISO container and occasional light from mobile phones or head-torches. LCp1 Witness 24 Spencer was resting his chin on his rifle suppressor. At approximately 1741 hrs a Witness 29 round discharged from LCpI Spencer's rifle inside the Waiting Detail ISO Container Exhibit 135 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.

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

1.3- 13

Post-accident

Immediate action reigned inside Witness 06 1.3.54 Reaction. Immediately after the rifle discharged confusion a battle Witness 05 the Waiting Detail ISO Container amongst the students. Some thought fallen from the Witness 29 noise simulator (BATSIM)18 had been initiated, or that someone had flash TCV truck parked on the track next to the ISO; others observed the muzzle ISO and realised that a round had discharged. From inside the Waiting Detail Container frantic incoherent shouting was heard along with shouts of 'man-down'. in a Students then rushed out of the Waiting Detail ISO Container. Some were state of shock and confusion. Students checked their person for injuries/wounds. Students exiting the Waiting Detail ISO Container were visibly upset. was Witness 08 1.3.55 Confirmation. In response to the calls of 'man down', white light a Witness 05 used to illuminate the inside of the ISO container. DS and students observed on Witness 11 body lying motionless on the floor, with head injuries. A body was seen laying Witness 17 top of an L115A3 Sniper Rifle, with the legs positioned on an item of equipment. Student E quickly identified the body as LCpI Spencer.

Area of accident Grid: NH8445 8410

Tain AWR Tower

Tain AWR main entrance

Figure 1.3.5 — Map of Tain AWR

Witness 24 1.3.56 Firing point. Immediately after the calls of 'man down', the order 'stop' the Witness 32 was issued by several people. The first detail on the firing point, who were in process of preparing to fire, ceased identifying targets. The RCO and several of ISO the DS acting as safety staff for the night shoot, moved to the Waiting Detail 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.

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

1.3 - 14

1.3.57 Medical assistance. Concurrently, there were calls for the 'medic' to Witness 36 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 Witness 44 Duty Controller attempted to ascertain more information from CSgt 1 about the Witness 28 accident and the state of weapons on the firing point. In the confusion, Sgt 2, the Witness 44 Duty Controller passed the number of Sgt 1 (the stand-in RCO from the morning Witness 24 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.

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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DSA/SI/01/17/TAIN OFFICIAL---SENSITIVE © Crown Copyright 2018 1.3.59 First detail. Meanwhile, the first detail was ordered by an unknown Witness 30 member of the DS to leave their personal kit and rifles in position on the firing point Witness 29 in order to preserve evidence. Some students had unloaded without being Witness 33 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 Witness 24 weapons were 'safe' on the range, CSgt 1 ordered rifles to be removed from the Witness 08 Waiting Detail ISO (see Figure 1.3.6). Container and placed on the firing point. Witness 33 Student D and the CMT entered the Waiting Detail ISO Container and removed all Witness 29 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 Witness 32 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 Witness 24 at Tain Tower. CSgt 1 was visibly shaken and emotional when he met the Duty Witness 44 Controller. DS 1 remained inside the tower and was quiet and subdued. At some Witness 34 point, DS 2 departed the range for Tain Tower to act as a relay back to the scene of Witness 30 the accident.

Emergency services

1.3.63 Notification. On receipt of the initial report of a casualty at 1742 hrs, Sgt Witness 44 2, located in the tower, called the emergency services at 1743 hrs to request an Witness 41 ambulance to attend Tain AWR. Sgt 2 subsequently called the civilian police to Witness 42 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 Witness 44 problems gaining access to Tain AWR, Sgt 2 dispatched a member of the range Witness 41 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 Witness 42 members of Scottish Ambulance Service looked inside and saw LCpI Spencer's Witness 43

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

1.3 - 16

DSA/SI/01/17/TAIN © Crown Copyright 2018 OFFICIAL—SENSITIVE body. Having observed the injuries, the ambulance staff assessed that the visible Witness 29 injuries were not survivable and it was not necessary to enter the container and Witness 41 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 Witness 24 Scotland officers interviewed DS and students at Tain AWR Tower. The interviews Witness 40 continued into the early hours of 2 Nov 16. Initially, the police officers interviewed Witness 39 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, Witness 24 including the Commanding Officer and SPO, visited Tain AWR during the evening Exhibit 001 of 1 Nov 16 to check on the wellbeing of DS and students. On completion of the Exhibit 002 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 Exhibit 001 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 Exhibit 136 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.

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.

1.3 - 17

1.3.70 Police Scotland investigation. On 2 Nov 16, while gathering evidence Exhibit 010 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.

Date Time Event Revised Army sniper 1 Jul 16 training policy issued; directing distributed sniper training 2 - 28 Oct - SOC 16 Phase 1 conducted at BBTA LCpI Spencer 28 Oct 16 and 3 other 3 RIFLES students move to Fort George 30 Oct 16 - Course musters at Fort George for Phase 2 Day 1 of Phase 2 - 31 Oct 16 conduct LFMT at Tain AWR; on completion the course recovers to Fort George Course departs for Tain AWR. CSgt 1 remains 1 Nov 16 - at Fort George for a career brief 1 Nov 16 1000 Stand in RCO (Sgt 1) signs on at Tain AWR Students conduct NSPs and 1 Nov 16 -241005 receive a safety brief from stand in RCO (Sgt 1) 1 Nov 16 1030 - 1230 Students conduct LFMT - data collection shoot Lunch delivered/eaten, while targets 1 Nov 16 1300 - 1500 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 RCO informs Tain AWR Range 1 Nov 16 1742 Control that he has a casualty with a gunshot wound 1 Nov 16 1743 Emergency Services informed Scottish Ambulance Service ambulance and 1 Nov 16 1815 - 1835 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 Police Scotland officers clear LCpI 2 Nov 16 - 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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Analysis and Findings Intentionally Blank Part 1.4 — ANALYSIS AND FINDINGS

Introduction Page 3 Methodology Accident factors Page 3 Human Factors (HF) Page 4 Available evidence Page 4 Services Page 5 Issues considered by the Panel Page 6 Probability language Page 6 Determining the cause of death Page 7 Policy and documentation Distributed Training policy for sniper training Page 8 Range safety policy Page 9 Pamphlet 21 Page 9 Army Equipment Support Publication Page 10 Organisations Distributed Training Cell Page 11 Specialist Weapons School, Sniper Wing Page 11 51st Infantry Brigade Page 12 The Black Watch, 3rd Battalion The Royal Regiment of Scotland Page 13 Taira Air Weapons Range Page 14 Governance Assurance Page 15 Duty Holding Page 16 Organisational influences Sniper culture Page 19 Untrained personnel within Sniper Platoons Page 20 Directing Staff Page 20 Pre-accident Planning Page 21 Range reconnaissance Page 23 Range Action Safety Plan Page 23 Pre-cadre Page 24 Skill at Arms Page 25 Fort George Page 27 Range layout and targets Page 28 Safety briefing Page 31 Accident Afternoon details Page 32 Preparation for night ranges Page 40 Ammunition control Page 41 Waiting Detail ISO Container Page 41 Indirect influence Page 44 Post-accident Immediate actions Page 44 Emergency services response Page 46 Ammunition and weapons forensic analysis 0.338" ammunition Page 47 Un-demanded discharge Page 47 Mechanical failure of trigger mechanism Page 47 Inadvertent trigger operation hypothesis Page 48 Summary of findings Causal Factors Page 52 Contributory Factors Page 52 Other Factors Page 53

1 4 - 1

Observations Page 54 'Swiss Cheese' model Page 55

1.4 - 2

Introduction

1.4.1. The Tain Service Inquiry (SI) was convened on 12 Jan 17 to investigate the Exhibit 001 circumstances behind a fatal accident at Tain Air Weapons Range (AWR) in the Exhibit 003 North of Scotland on 1 Nov 16. This resulted in the death of 30125761 Lance Exhibit 020 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 Exhibit 002 witness statements, the Post-Mortem report and the forensic analysis of the Exhibit 004 deceased's rifle report. This provided Panel members with an understanding of Exhibit 010 events from the outset and ahead of commencing its own witness interviews. Exhibit 011 Importantly, the Panel had access to all those involved in the planning and execution Exhibit 125 of the SOC, and those who participated on the day. As such, most evidence was Exhibit 148 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

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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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 Exhibit 151 (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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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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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.

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Extremely Very Likely / Unlikely Highly Probable

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

Unlikely IImprobable About as likely as not Likely IProbable

100%

Increasing levels V1 0 12 Oct 17

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 Exhibit 128 Spencer's rifle, inside an ISO shipping container,3 located on the Close Air Support Witness 41 (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 Exhibit 128 examination of LCp1Spencer's body. The post-mortem was conducted in Raigmore Exhibit 150 Hospital, Inverness on 3 Nov 16.

1.4.12. The post-mortem report concluded that LCp1 Spencer sustained a fatal Exhibit 017 injury from a gunshot wound to the head. The bullet's direction of travel was Exhibit 128 consistent with the way in which LCp1 Spencer was reportedly holding his sniper rifle Exhibit 150 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 Exhibit 123 Investigation Unit investigation into the death of LCp1 Spencer. The outcome of this Exhibit 128 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.

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

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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 Exhibit 090 Authorisation Document (TrAD)4 for the SOC. This course was to be delivered as Exhibit 118 distributed training5 at unit level. The revised policy was introduced to better meet Exhibit 118 the Army's sniper capability requirement. This differs from the other two Services.° Witness 38

1.4.16. Previous iterations of sniper training failed to meet the Army's needs. Exhibit 133 Initially the training was planned and delivered at unit level but the level of external Witness 37 assurance was limited and standards amongst units was variable. This was evident Witness 38 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 Exhibit 038 format in Apr 16 during the introduction of the Sniper Platoon Commander and Exhibit 097 Sniper Section Commander Train the Trainer (T3) course at the School of Infantry's Exhibit 133 Infantry Battle School, Brecon. SWS Sniper Wing provided direction and guidance Witness 24 on planning, execution and assurance methodology for the SOC. This briefing was Witness 25 attended by the Sniper Platoon (PI) commanders from The Royal Scots Borderers, Witness 26 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 Witness 37 many years (e.g. machine guns and mortars). It was well understood at unit level Witness 38 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 Exhibit 116 did not produce sufficient throughput and quality, the SOC delivered as distributed Exhibit 121 training at unit level amounted to a compromise solution that might better meet the Exhibit 122 Army's front line sniper capability needs. The SOC embraced key elements 8of the Witness 37 previous 2 iterations of the Army's approach to sniper training, thereby increasing Witness 38 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

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

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DSA/SI/01/17/TAIN OFFICIAL-SENSITIVE © Crown Copyright 2018 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, Exhibit 137 Handbook of Defence Ranges Safety, May 15.

1.4.22. The DIO was responsible for managing the MOD's training estate, which Exhibit 137 included live fire (LF) ranges, and provides a 'Safe Place for training. The Range Witness 40 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 Exhibit 013 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 Exhibit 005 personnel to be able to plan and conduct live-fire ranges, the specific roles and Exhibit 006 responsibilities for the planning and conduct of LF ranges, and direction on accident Exhibit 007 procedures. Prior to live firing, Pam 21 directs that the Planning Officer is to produce Exhibit 008 a written instruction, the Range Action Safety Plan (RASP), which indicates the Exhibit 013 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 Exhibit 013 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

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.

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DSA/SI/01/17/TAIN OFFICIAL SENSITIVE © Crown Copyright 2018 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 Exhibit 124 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, Exhibit 015 and the operators Skill at Arms (SAA) manual, namely Capability Directorate Exhibit 031 Combat Dismounted Close Combat Training - Volume 1 Skill at Arms - Individual Exhibit 124 Training Sniping - Part 1 The L115A3 Sniper Rifle 8.59mm and Associated Exhibit 148 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, Exhibit 015 rather they would rely on the Sniping Part 1. Notwithstanding this fact, prior to Exhibit 124 adopting the distributed training model, when sniper training was centralised and Witness 48 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

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.'

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DSA/S1/01/17/TAIN OFFICIAL-SENSITIVE © Crown Copyright 2018 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 Witness 37 design, implementation and assurance of distributed training across the Army. At Witness 38 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 Exhibit 023 generic SOC syllabus. When planning the course, DTC dealt exclusively with the Exhibit 089 SOC Planning Officer, CSgt 1. In addition, the DTC conducted a second party Exhibit 090 assurance16 visit to the 51 Bde SOC during the second week at Barry Buddon Exhibit 118 Training Area (BBTA). The visit focused on assuring the content of the syllabus to Witness 24 ensure it met the needs of the Training Delivery Authority (TDA), 17 as opposed to Witness 37 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 Exhibit 097 sniper capability of the impending change to the delivery of this training to a Exhibit 130 distributed training model. Brigade and Divisional HQs were not included in the Exhibit 133 distribution for this notification.19 Responsibility for training delivery would revert to Witness 37 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 Exhibit 038 units planning a SOC with SME advice during both planning and execution. In Witness 37 addition, to ensure adherence to standards and provide independent assessment, Witness 38

Personnel (SQEP) external to 16 2" party assurance is conducted by an organisation comprising of Suitably Qualified and Experienced 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. defines the TDA as 17 JSP 822, Defence Direction and Guidance for Training and Education Part 2: Guidance, v3 0 Apr 17, page 174, '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.' from 19 1 (United Kingdom) Division (1 Div) were made aware of the impending change to sniper training delivery in a routine briefing their Small Arms School Corps (SASC) staff. whereby those that 2' Train the Trainer (T3) courses are courses that enables the cascade of new training methodologies and processes will be responsible for conduct of training are trained in line with the latest policy

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DSA/SI/01/17/TAIN OFFICIAL SENSITIVE © Crown Copyright 2018 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 Exhibit 023 Wing assigned a SME, of CSgt rank, to act as both a mentor to the unit planning Exhibit 024 officer and the first point of contact (POC) for specialist advice. However, the initial Exhibit 025 mentor assigned to the course was relocated to another job in the Army; SWS Exhibit 026 Sniper Wing duly assigned another SME to fulfil the mentor/POC role. Despite this Witness 24 change, the interaction between the 51 Bde Planning Officer (CSgt 1) and the Witness 37 assigned SWS mentors was adequate.

1.4.41. Notwithstanding the implementation of policy to deliver the SOC as Witness 24 distributed training. SWS Sniper Wing retained training delivery responsibility for the Witness 37 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 Exhibit 032 was hosted by 3 SCOTS, with attendance from brigade staff and subordinate units. Witness 23 The study day focused on the light mechanised infantry role and conversion to the Witness 24 role.

1.4.44. During a briefing on Intelligence. Surveillance, Target Acquisition and Exhibit 032 Reconnaissance (ISTAR), CSgt 1, the SOC planning officer, informed the audience Exhibit 080 of his intention to deliver a SOC as distributed training, with assistance provided by 1 Witness 23 SCOTS and 3 RIFLES. A brigade staff officer within the audience suggested the Witness 24 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 Exhibit 027 SOC Planning Officer, was negligible thereafter. Despite the direction to amend the Exhibit 080 course nomenclature to include 51 Bde, brigade staff were largely unaware of the Exhibit 117 existence of the course. As such, the course was not captured on the 51 Bde Exhibit 131 forecast of events. However, the inclusion of 51 Bde in the title helped raise the Exhibit 138 profile of the course amongst brigade units. Exhibit 149 Witness 47 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 Exhibit 009 Bde did provide an ammunition uplift once the course had started. In the absence of Exhibit 138 Brigade involvement, planning was bottom-up led and centred on 3 SCOTS. Exhibit 149 Consequently, CSgt 1 had to plan and resource the course without Brigade support, Witness 24 and instead relied on grace and favour support from participating units to facilitate Witness 25 training areas, training ammunition and instructor support. Witness 47

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DSA/S1/01/17/TAIN OFFICIAL-SENSITIVE 0 Crown Copyright 2018 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 Exhibit 131 proved an extremely challenging task. In 2015, elements of 3 SCOTS deployed to Witness 23 Cyprus on the UK's contribution to the United Nations Peacekeeping Force Witness 45 (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 Witness 23 Mechanised Infantry. The conversion process required an Witness 45 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 Witness 23 of battle. Commensurate with the conversion to Light Mechanised Infantry, D Coy Witness 45 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 Witness 23 were limited opportunities for the battalion command group to get together and plan Witness 45 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 Witness 23 dispersed on various courses, training and exercises, often with competing priorities, Witness 45 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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1.4.55. Tain AWR in Northern Scotland was licensed by the DIO for ground LF Exhibit 091 range use in Jun 14. The Independent Range Safety Inspection Report of 25 Oct 16 Exhibit 092 clearly stated that Tain AWR is suitable for ground LF, including sniper training.22 Exhibit 098 Moreover this inspection report concluded that Tain AWR was fit for ground use. Exhibit 099 Despite the increased utility, its geographic isolation to most MOD land units meant Witness 24 that the primary use of the facility was as an air weapons range. The main users of Witness 40 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 Exhibit 101 appointments comprised the Training Safety Officer (TSO), responsible for Witness 40 authorising live firing, and Range Wardens, responsible for maintenance of the Witness 44 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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DSA/SI/01/17/TAIN OFFICIALSENSITIVE © Crown Copyright 2018 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 Exhibit 139 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 Exhibit 081 requisite analysis, design, delivery and assurance. For the sniper capability, the Exhibit 082 Training Requirement Authority (TRA)24 was Head of Capability Combat (HoC Exhibit 083 Cbt)25; he was the end user of the trained output and is responsible for the Exhibit 084 evaluation of the effect of the training. The School of Infantry acted as the Training Exhibit 085 Delivery Authority (TDA) for the SOC. It developed HoC Cbt's intent in partnership Exhibit 086 with the DTC and a civilian contractor to design the course. The Training Provider is Exhibit 087 the organisation that conducts the training; in this instance, it was 3 SCOTS, Exhibit 088 supported by 1 SCOTS and 3 RIFLES. Both the TDA and the Training Provider Exhibit 089 have an assurance responsibility. Exhibit 090 Exhibit 139 Exhibit 118

1.4.62. JSP 822 describes assurance as 'an all-encompassing term used to Exhibit 139 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 Witness 24 of command visited BBTA. Therefore, 15t party assurance of this Phase was not Witness 25 conducted. Documented 1' party assurance would have offered an important Witness 38 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`d party assurance was required.

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

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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 Exhibit 130 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 Exhibit 005 responsibilities as a Duty Holder.29 The purpose of the Duty Holder is to ensure that Exhibit 130 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 Exhibit 130 contained in Figure 1.4.3. This report only considers the Delivery Duty Holder, the brigade level oversight and the Operating Duty Holder.

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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LEADING • As the Senior Duty Holder, ensuring the Army has an CGS 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 Exhibit 005 (ACAI) List of Responsibilities.' LF is considered a routine training activity and is Exhibit 006 delivered at Unit level across all 3 Services daily. All RtL activity must be conducted Exhibit 013 in accordance with the Safe System of Training (SST) and be risk assessed as Exhibit 014 appropriate. For LFTT the practice must be undertaken in accordance with the SST. Exhibit 130 whereby the following are complied with:

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

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(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.

(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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DSA/S1/01/17/TAIN OFfICIAL-SENSITIVE © Crown Copyright 2018 1.4.70. The Exercise Director33 (Commanding Officer 3 SCOTS), in his capacity as Exhibit 155 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, Exhibit 016 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 Exhibit 086 Sniper platoons/troops as reflecting a distinct camaraderie, culture and ethos that Exhibit 139 sets them apart within their respective units. Furthermore, witness testimony shows Witness 12 that amongst the sniper cohort and the chain of command there is a perception that Witness 24 soldiers assigned to sniper duties are at a heightened level of professional Witness 27 competence and that thus, they can be trusted to complete their duties with a lower Witness 33 level of supervision than their colleagues in a rifle company. During the SI, Witness 37 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.

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 Witness 24 variable time periods before completing formal sniper training. Prior to attending the Witness 25 SOC. unqualified snipers received piecemeal training of variable content and quality. Witness 26 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 Witness 17 sniper platoons were, on occasions, exposed to non-standard practices or bad Witness 27 habits. It is likely these were ingrained because of inconsistent/incomplete SAA Witness 28 training at unit level. Amongst the sniper cohort, there was wide awareness of Witness 30 'accepted' non-standard practices including the use of Vaseline to lubricate the rifle's Witness 35 bolt and the use of the 'combat load'.37 Likewise, there was an awareness of bad Witness 37 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 Exhibit 037 suitably qualified and experienced persons (SQEP) of Non-Commissioned Officers Witness 24 (NCO) rank to act as Directing Staff (DS) and enable the course. There were Witness 25 sufficient appropriately qualified DS to deliver SAA training on the L115A3 Sniper Witness 32 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

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).

1.4 - 20

1.4.81. Sourced from 5 distinct units the DS had diverse experiences and habits. Exhibit 049 This manifested itself in differences of culture, approaches to soldiering and training, Exhibit 050 and a higher acceptance of risk as seen in soldiers returning from operations. This Exhibit 052 eclectic mix of soldiers created disparate expectations amongst the DS and the Exhibit 053 students as to training delivery, levels of supervision required, general conduct on Exhibit 055 the range and increased acceptance of risk as reported to the Panel in numerous Exhibit 056 instances. Moreover, the standard and experience of DS supporting the SOC was Exhibit 057 deemed average by the Panel, with the majority finishing in the bottom third of Exhibit 058 promotion courses and lacking instructional experience in an Army training unit. Exhibit 059 Furthermore, unlike an established sniper training team, prior to the SOC the DS had Exhibit 060 never worked together as a cohesive team. As a result, this contributed to a lack of Exhibit 061 awareness of instructor strengths and weaknesses and small inconsistencies in the Exhibit 063 quality of instruction, supervision and risk acceptance throughout the SOC, which Exhibit 064 may have contributed to confusion amongst students and DS at key stages during Exhibit 065 the course. This was evident in the different methods of indicating 'show clear' by Exhibit 066 both firers and safety supervisors alike, as well as different ammunition distribution Exhibit 070 routines during LF ranges between Phase 1 and Phase 2 of the SOC. Exhibit 071 Exhibit 072 Exhibit 073 Exhibit 074 Exhibit 075 Exhibit 076 Exhibit 077 Exhibit 078 Exhibit 079 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 Exhibit 019 the T3 course the sniper platoon commanders from 1 SCOTS, 3 SCOTS and 3 Exhibit 021 RIFLES agreed to jointly plan and deliver a SOC, to train soldiers from their Exhibit 022 respective units. Thereafter, CSgt 1 assumed responsibility for the overall planning Witness 24 and coordination of the SOC. Accordingly, he issued direction on the content of the Witness 25 course to the other 2 platoon commanders. Planning evolved into 3 distinct phases: Witness 26 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),

1.4 - 21

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 Exhibit 021 training was in its infancy and unproven. Moreover, there was no lessons database Exhibit 022 available to assist planning. The modular approach to training appeared pragmatic Witness 24 to the 3 planners at the time, as it allowed each unit to focus planning, while utilising Witness 25 existing training area bookings (e.g. BBTA) and resources (e.g. qualified sniper Witness 26 staff), thereby sharing the training burden between the 3 units.

1.4.86. The SOC syllabus assumed that students had no prior sniper competence. Exhibit 027 Therefore, the syllabus was designed to equip students with the essential Exhibit 084 competencies40, including all SAA lessons on the L115A3 Sniper Rifle, needed to Exhibit 085 become a qualified sniper. CSgt 1 identified correctly that achieving the exacting Exhibit 086 standards required strict adherence to the syllabus. Unsurprisingly, he never Exhibit 089 considered deviating from the syllabus, or that others might do so. Witness 24

1.4.87. CSgt 1 was not a qualified sniper, although he was qualified as a Sniper Exhibit 025 Platoon Commander, having completed the Sniper Platoon Commanders' Course at Exhibit 035 SWS Warminster. This is normal practice in Sniper Platoons. In contrast, CSgt 2 Exhibit 074 was a qualified sniper and possessed greater practical experience in the training and Witness 24 employment of snipers. Due to this disparity in experience, CSgt 1 understandably Witness 25 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 Exhibit 019 support from the Sniper Platoon Commanders from 1 SCOTS and 3 RIFLES. The Exhibit 023 modular approach meant that planning was disjointed and stove piped, with each Exhibit 027 unit concentrating on their phase. This was evident by ad-hoc and un-structured Witness 23 communication between the three lead planners. This was conducted via Witness 24 WhatsApp® and phone on an as-needed basis, rather than face-to-face. Due to the Witness 25 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 Exhibit 002 appointed a separate senior planning officer who authorised ranges during their Witness 23 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-

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 DSA/SI/01/17/TAIN OFFICIAL—SENSITIVE © Crown Copyright 2018 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 Exhibit 005 process.' CSgt 1 had previously visited Tain AWR in May 16 to reconnoitre range Exhibit 006 facilities in preparation for CT1 (platoon level) training, which included a LF sniper Exhibit 013 range. In his capacity as the Range Conducting Officer (RCO) for Phase 2 of the Witness 23 40 SOC, CSgt 1 conducted a range reconnaissance to Tain AWR in Jun 16 as detailed Witness 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 Exhibit 005 must comply. In compliance with Pam 21, a RASP must be endorsed by a SQEP Exhibit 006 Senior Planning Officer (SPO)43 beforehand." In this instance the SPO was Exhibit 013 adequately qualified and had completed the requisite SPO Course. In preparation Exhibit 134 for the SOC Phase 2 ranges at Tain AWR on 13 Oct 16, CSgt 1 showed the draft Witness 23 RASP to the Tain AWR Training Safety Officer (TSO). Likewise, on the same day. Witness 23 the SPO sent the draft RASP to the 1st (United Kingdom) Division (1 Div) Witness 40 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 Exhibit 013 temporary change in RCO on 1 Nov 16 as required by Pam 21.46 Moreover, the Exhibit 134 endorsed copy of the RASP which was held by the Tain AWR Range Control was Witness 23 not amended to reflect the temporary change in RCO. Witness 28

Pyrotechnics. March 2016, para 4-33 °I Pam 21, Training Regulations for Armoured Fighting Vehicles, Infantry Weapons Systems, and and conducting training • /bid, Para 2-25 and 2-26, covers the responsibilities and actions required by 'all concerned with planning BEFORE planning starts. This applies equally to all ranges, training areas and LFTTAs.' for appointing a Planning Officer and or a Range 43 Ibid, Para 2-06, covered the responsibilities of the SPO who is responsible to give guidance and Conducting Officer and to ensure that they are competent, qualified and of sufficient experience for the training, cover. supervision, give refresher training if required and give sufficient time. resources, manpower and medical the Defence Learning Environment 44 Candidates must complete the Senior Planning Officer (SPO) Course via distance learning on the role of the Senior Planning (DLE). The DLE states. 'the course is designed to provide the knowledge and skills required to assume Officer (SPO).' • SASC is considered to be the authority in small arms weapons training planning and delivery. March 2016, para 2-30 • Pam 21, Training Regulations for Armoured Fighting Vehicles, Infantry Weapons Systems, and Pyrotechnics, must inform the SPO states 'if any changes are made after the SPO has countersigned the RASP or EASP then the Planning Officer to Range Control they must and they must approve the changes. If any changes are made after the RASP or EASP has been submitted be informed.' 1.4 - 23

1.4.97. Considering a recent fatal range accident (Aug 16) involving 3 SCOTS, the Exhibit 093 SPO was understandably diligent in fulfilling his duties. In this instance, the SPO Exhibit 096 went beyond the obligatory standard required to check the RASP and sought SQEP Exhibit 134 advice in the guise of the 1 Div QMSI SASC. Moreover, to ensure the RASP was fit Witness 23 for purpose, several iterations of the draft were staffed between the author, Sgt 1, Witness 23 and the SPO via CSgt 1. Consequently, the SPO was content to countersign the Witness 28 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 Exhibit 005 was classified as Live Fire Marksmanship Training (LFMT) utilising a Live Fire Exhibit 006 Tactical Training Area (LFTTA). As a result, an incorrect LFMT RASP template from Exhibit 008 Pam 21 was employed, when a LFTT template should have been used. The Exhibit 013 following errors were evident in the RASP: Exhibit 014

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 Exhibit 036 temporary change in RCO on the morning of 1 Nov 16, as required by Pam 21. was Witness 23 very likely an oversight by CSgt 1. At this juncture CSgt 1 was busy with training Witness 24 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 Exhibit 038 delivered pre-cadre courses to prepare students for attendance on the SOC should Witness 26 focus on basic infantry skills." Witness 37

1.4.103. In preparation for the 51 Bde SOC four of the units sending soldiers on the Exhibit 039 course conducted in-house pre-cadres. The 1 SCOTS and 2 SCOTS Cadres did not Exhibit 040 adhere to the SWS guidance; instead they replicated elements of the SOC syllabus. Exhibit 041

'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 Exhibit 042 As a result, students received an element of SAA training and passed weapon Witness 05 handling tests (WHT) on the L115A3 Sniper Rifle. Moreover, the 1 SCOTS Cadre Witness 26 was used to select the best soldiers to attend the SOC. In contrast, 3 SCOTS and 3 Witness 33 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. Exhibit 038 1.4.104. While SWS provided guidance on pre-cadre training ahead of the SOC, 24 they did not provide a generic syllabus for a pre-cadre course. Consequently. units Witness 37 had latitude to interpret the SWS guidance as they saw fit. This explained the Witness 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 Witness 13 were at variable levels of experience and standards. A lack of accurate training Witness 23 records at unit level compounded assumptions regarding the start states and Witness 26 competencies of students, particularly with respect to SAA training on L115A3 Witness 32 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 Exhibit 021 SOC; this fell to CSgt 2 as the Phase 1 Planning Officer. The 51 Bde SOC syllabus, Exhibit 025 endorsed by the DTC, referred to this as the Start Standard, Theory and Exhibit 027 Marksmanship Module.5° This phase concentrated on marksmanship with a focus Exhibit 089 on weapon handling and live firing practices. The syllabus for Week 1 of this module Witness 25 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

Module) so 51 Bde Sniper Operator Course 1601, Phase 1 Barry Buddon Training Centre (Start Standard, Theory and Marksmanship 02' October - 31' October 2016 (1 SCOTS), page 1. 1 4 - 25

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

Mon 8 Aele Assessment Start 9tatn~a,rwtt 3.0 ots BBTA f4.1 Stag Oct BBTC ii

7u* Collect Static map tie JD OBS Cam and Con oe. r;'?"'s DS lead NAVEX Assessment Naght Na Practice rkey.on AO SW Assessment Assessment Assessment OCt "'"ur'' BBTC SS SS 1 Si SS SS RAM Wed Rile Lesson 1 Lesson 2 Rille Rik Lesson Ibte Leeson 3 & 4 We Leeson 6" Seceon Areas Swan Lessai 5 5 5 1141, *soon T Piaerce Perod 1 BEITC 144non Ntght Nal Test 1 Oct BBTC Areas BBTC 130TC MaasBBTC BBTC BBTC SI RIM Blur Me wsson 6 PP 2 Lesser Ms 1*mon 10 RAM Lamson 11 06' BBTC RA Lesson 12 11 BBTC 9 BBTC e8TC BBTC Nyht Niti Test 2 Oct 138TC

Fri Rdle Me Me t!WM MIT Test WHT Retest RAO Lesson Lemon 18 13 Lesson PP 3 lesson Rifle 7" 88TC to eerc Sedan Areas Sectwn Areas 15 Rte 88T0 Oct BBTC Lesson 15 17 MC BBTC N' t/7 _ — -- — — BBTC . 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 Exhibit 014 Rifle Lesson 1 of 18 (highlighted in red in Figure 1.4.4) in accordance with the Exhibit 025 agreed syllabus, they were in fact live firing on the range. At this stage, they had not Exhibit 029 completed any of the mandated SAA training during the SOC. On the evening of Exhibit 143 Day 2 (4 Oct 16) students completed a WHT on the L115A3 Sniper Rifle. At no point Exhibit 144 were Rifle Lessons 1 — 18 delivered retrospectively. Because of this deviation from Exhibit 145 the endorsed SOC syllabus, students were then live firing the L115A3 Sniper Rifle Exhibit 146 on the range without having completed formal SAA instruction. The Operational Exhibit 147 Shooting Policy (OSP) states that 'it is also mandatory that the sniper completes all Exhibit 148 the basic sniper system weapon lessons contained in Reference H [Sniping Part 1] Witness 25 and successfully completes the sniper system Weapons Handling Test, before any Witness 27 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 Witness 13 to arriving at BBTA. Subsequently, during a staff meeting, CSgt 2 issued direction to Witness 25 the DS. Specifically, he directed that all students must achieve the required Witness 32 standard to commence live-firing. However, he did not stipulate that students must Witness 33 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 Witness 13 on the SOC with no SAA training on the L115A3 Sniper Rifle. As a result of the Witness 26 omission of SAA lessons 1 — 18, Student A received separate, minimal SAA training Witness 32

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

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 Exhibit 014 record keeping and a lack of 1s' party assurance (see 'Assurance' section of this Exhibit 151 report), combined with the lack of SAA training on the 51 Bde SOC, there is no Witness 17 evidence to prove LCpI Spencer received any formal training on the L115A3 Sniper Witness 26 Rifle. Despite this, given previous unit sniper activity (e.g. Exercise Witness 32 RATTLESNAKE52) he would have informally gained some familiarity with the L115A3 Witness 32 Sniper Rifle. This superficial knowledge would likely have been sufficient to enable Witness 48 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 Exhibit 019 were accommodated, fed and supported by 3 SCOTS at Fort George. Fort George Exhibit 025 was 45 miles from Tain AWR and the journey took approximately 60 mins via the A9 Witness 16 road. The course mustered at Fort George on Sunday 30 Oct 16, although some 3 Witness 28 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 Witness 28 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 Witness 28 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.

" 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 Exhibit 012 sniper range was located within the Close Air Support (CAS) Village (Figure 1.4.5), Exhibit 098 within Tain AWR. Range Control was located approximately 800m south-west of the Exhibit 099 sniper range. The firing line was approximately 46m long and was located on a Exhibit 100 raised bank of earth, or bund line, which was interspersed with a waist-high gorse Witness 40 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).

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

54 Range Control staff operated from Tain AWR Tower.

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Ammo Door position when shut

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 Exhibit 018 George with the resultant later than planned start to live firing at Tain AWR. Further Witness 13 time was lost using locally produced targets on the afternoon of Day 1 and morning Witness 24 of Day 2 (1 Nov 16); these targets proved problematic. Targets comprised an A- Witness 24 frame fitted with a steel plate (referred to as a 'falling plate') and attached by wire Witness 27 (Figure 1.4.7). The targets were manually positioned within the range arcs. When Witness 28 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.

1 4 - 29

Figure 1.4.7 - Locally produced competition falling plate target

Lifting Mechanism Figure 11 Metal Target

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

1.4.123. During Phase 1. the SOC conducted live firing on purpose built gallery Witness 24 ranges at BBTA. In stark contrast, as a LFTTA, Tain AWR was bereft of dedicated Witness 25 ground range infrastructure: there were no butts to observe fall of shot; there were Witness 31 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

1.4.124. Pam 21 states that only qualified snipers are authorised to engage steel Exhibit 005 plate targets.' Accordingly, the students should not have been firing at falling plate Exhibit 006 targets. Exhibit 008 Exhibit 013 SAPU consoles were available and should have been used Exhibit 014 from the outset. Once replaced on the afternoon of Day 2, these proved more Exhibit 139 reliable, although some were obscured from view, as they were positioned at ground Witness 13 level. Valuable range time was wasted positioning, rectifying and replacing targets Witness 17 over both Days 1 and 2. Consequently, the 2-days assigned for data collection and Witness 27 pre-ACMT preparation was reduced to one hour per detail of pre-ACMT preparation. Witness 28 Consequently, critical time for the all-important data-gathering LF practice was Witness 30 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 Exhibit 006 standalone DS safety brief in accordance with Pam 21. Witness 24

1.4.128. On the morning of Day 2 (1 Nov 16), Sgt 1 acted as the RCO due to the Witness 24 absence of CSgt 1. This change was not annotated in the RASP. On arrival at Tain Witness 28 AWR, Sgt 1 delivered the mandated safety brief to DS and students as per the Witness 33 RASP. Witness 34

1.4.129. Witness testimony indicates that after the Day 2 safety brief, individual DS Exhibit 006 were unclear as to their specific roles and responsibilities on the ranges that day. Witness 27 Thus, DS were left to their own devices to assume a role on the range and fill the Witness 29 gaps, whether as a coach and mentor, as a safety supervisor, or in an administrative Witness 32 capacity. The Panel opined that this lack of clarity was sub-optimal and while not in Witness 32 contravention of Pam 21, good practice dictates the need for a stand-alone DS Witness 33 safety brief to ensure roles and responsibilities are understood. Witness 34

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) Exhibit 006 shot in the morning of 1 Nov 16 (Day 2, Phase 2). The shoot replicated the data- Witness 13 gathering shoot of Day 1. Firers encountered similar problems with inadequate steel Witness 24 falling plate targets. Range activity became disjointed to allow for rectification of the Witness 27 targets. The targets were eventually replaced by SAPU targets; this took Witness 28 approximately 2 hrs. During this period CSgt 1 arrived at the range, complete with Witness 46 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. Witness 07 LCpI Spencer was in Detail 1 and was paired with Student A, who acted as his Witness 13 Number 2 (colloquially referred to as a 'spotter') and made up Pair 11. Initially, when Witness 31 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 Witness 07 the RCO role. DS 1 undertook safety supervision of the right-hand pairs on the Witness 13 range (pairs 9 — 11) as this is where most soldiers from his regiment were firing Witness 24 during Detail 1. This also included LCpI Spencer as Pair 11, occupying the furthest Witness 34 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.

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F. Witness 3 F. Student .1 F, Witness 22 F: Seldom I F: wit., It F: Witness 20 F, Student Student G "V : Witness 19 F - Witness 10 F . I pl Spencer S Witness I S. Witness 2 S- Witness 21 5: student H 5: Student E 5: Student C Student F 5: Mtn** 15 5. Mlnras II S Student B S Studom A

• 9m • • DS DS 3 DS 4 DS 2 TCV 46 m fliED CSGT 1

Ammunition

DS 1

KEY ISO Waiting Detail Administration ISO ISO F: Firer s LS: Spotter 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 Exhibit 006 Fire 9 (LF9), a practice shoot for the ACMT, whereby firers engaged nominated Exhibit 014 targets at distances between 300m — 900m, within a limited timeframe. Firers were Exhibit 018 nominated in ascending order during the detail, with LCpI Spencer being the last Witness 13 student to fire. At this time conditions were described as challenging: the Witness 24 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 Exhibit 014 daylight range time was at a premium. The OSP59 allocates a minimum of 60 mins Exhibit 018 per detail for LF9. Given Detail 1 only started firing at 1500 hrs and with the Witness 24 impending sunset at 1628 hrs, there was insufficient daylight remaining to fire both Witness 33 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 Exhibit 013 clear. Students described discrepancies in the words of command used. The Exhibit 151 correct words of command for the unload drill and NSPs are clearly laid down in Witness 07 Pam 21; these are two distinct drills. The words of command for the unload drill are Witness 13 '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.'

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DSA/SI/01/17/TAIN OFFICIAL—SENSITIVE © Crown Copyright 2018 1.4.139. On completion of Detail 1, the Panel discovered there were at least 2 errors Witness 01 of drill during the unload drill and NSPs. These comprised: Witness 01 Witness 08 Witness 08 a. Student D's rifle was left in an unsafe condition and subsequently Witness 12 unloaded by Student F. Witness 12 Witness 16 b. Student J's rifle was left in an unsafe condition and subsequently Witness 17 unloaded by DS 6 under the supervision of DS 2. Witness 30 Witness 31 There was a further example of an error of drill during the unload on completion of Witness 31 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 Exhibit 151 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 Witness 01 expended cases and collect the ammunition for Detail 2 as ordered, while leaving his Witness 13 rifle in an unsafe condition. In the second instance, a member of the DS noticed that Witness 24 a weapon was in an unsafe condition and subsequently conducted NSPs under the Witness 30 supervision of another member of the DS. Neither DS informed the RCO of this Witness 31 unsafe weapon. The RCO was unaware that any weapons had been left unsafe at Witness 33 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 Exhibit 015 engaging the last target, it is extremely likely that he automatically and sub- Exhibit 018 consciously chambered another round to re-engage the target, as part of the shoot, Exhibit 151 in case he missed with the first round.6° LCpI Spencer would have learned and Witness 13 practiced this drill during the LF ranges in Phase 1 and at this stage of the SOC he Witness 24 had already been firing for three weeks reinforcing this practice. Student A reported Witness 33 that on this occasion, LCpI Spencer hit the last target with his first shot. Therefore, Witness 34 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. Exhibit 015 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.

1.4 - 34

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. Firin? pin in un-cocked position II i

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

1 4 - 35

1.4.144. For this accident to have occurred, there are 3 possible hypotheses as to Exhibit 015 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 Exhibit 132 automatically and subconsciously would have operated the bolt of the Exhibit 148 L115A3 Sniper Rifle, but then would have failed to fully close the bolt when Exhibit 151 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.

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

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

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, Exhibit 124 would have left his magazine fitted to his rifle and conducted the AESP Exhibit 132 unload. This would leave a round chambered with the firing pin touching Exhibit 148 the base of the round. The AESP unload drill requires the firer to squeeze Witness 13 the trigger with one hand whilst moving the bolt forward with the other (see Witness 48 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

1.4 - 37

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 Exhibit 015 instances of unsafe weapons on the firing line at the end of Detail 1, it is Witness 12 assumed LCpl Spencer would not have completed the unload drill in Witness 13 accordance with Sniping Part 1. In this hypothesis, he would have been Witness 17 distracted part-way through the unload drill, and would not have pulled the Witness 30 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.

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 Exhibit 006 sub-optimal in that there was a lack of clear direction given to the DS regarding their Exhibit 018 specific safety roles on the range. In the absence of clear direction and using his Witness 24

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own initiative, DS 1 assumed responsibility for safety supervision on the right-hand Witness 34 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.

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 Exhibit 015 NSPs had been completed at the end of Detail 1. In this instance the RCO was Witness 12 acting correctly as the command issued was 'firers show clear' and as such would Witness 13 not rely on the safety supervisors to show clear. Pam 21 only recognises one Witness 17 method for showing clear, it states62 that "Safety Supervisors or firers ensure Witness 24 weapons are clear and raise their hand to let the RCO know." In contrast, the Panel Witness 30 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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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, Witness 05 LCpI Spencer along with 3 other students and DS1 prepared the targets for the night Witness 13 shoot. At approximately 1630 hrs the RCO delivered a safety brief for the night Witness 27 range. At least one student did not attend the brief due to making a phone call. Witness 32 Furthermore, 3 DS joined the safety brief late, having visited local shops in Tain. An Witness 35 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 Exhibit 013 because of reduced visibility and therefore greater emphasis should be placed upon Witness 05 control of movement, supervision of firers and the issue of ammunition. Pam 21 Witness 13 states that for night ranges, 'a high standard of supervision is necessary.' However, Witness 16 it does not provide guidance for a separate night safety brief. Given this was a Witness 24 change in range practices from earlier in the day, the RCO appropriately delivered a Witness 30 separate safety brief that included an explanation of the conduct of the range during Witness 34 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 Exhibit 013 ammunition by detail, prior to commencing each live firing practice. This meant that Exhibit 014 unused ammunition and empty cases were returned on completion of each practice Witness 17 using up valuable time. Given the onset of dusk, this placed time pressures on the Witness 24 students to complete their shoot before they could progress onto the night LF shoot. Witness 33 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 Exhibit 013 under supervision.64 On completion of the night shoot safety brief, the RCO directed Exhibit 018 that all students collect their ammunition for the night shoot, regardless of which Witness 24 detail they had been assigned to. This ammunition was a different batch to that Witness 30 used during the day. As members of the DS were unclear as to which detail they Witness 34 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 Exhibit 125 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 Witness 16 point, he volunteered to be reassigned to Detail 2 and was escorted by DS 2 to the Witness 30 adjacent Waiting Detail ISO Container.

1.4.158. During the day, LCpI Spencer had fallen in water on the range. Whilst Exhibit 142 waiting in the Detail 3 ISO container, he put on warm/dry clothing to get warm.

" 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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DSA/S1/01/17/TAIN OFFICIAL-SENSITIVE © Crown Copyright 2018 Witnesses describe that he was wearing every layer of clothing he had with him on Witness 05 the day. At this juncture, the weather appeared to get worse, raining continuously. Witness 13 Thus, it is very likely LCpI Spencer would have been cold, wet and uncomfortable. Witness 16

1.4.159. LCpI Spencer had previously been wounded on operations in Afghanistan. Exhibit 151 Although declared fit for duty, witnesses remarked that he still felt the effects of his Witness 16 injuries which were likely exacerbated by cold and wet conditions. It is very likely Witness 26 that he responded positively to a request to voluntarily move to join Detail 2, to Witness 30 complete the night shoot earlier than had he remained in Detail 3. This would have Witness 48 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 Witness 05 Sniper Rifle remained in an unsafe condition. LCpI Spencer elected to stand inside Witness 13 the Waiting Detail ISO Container, without removing his webbing and placing his rifle Witness 12 on the container floor, as the other students in the detail had already done. Witness 29 Moreover, at this time, the use of white light was minimal to allow eyes to adjust to Witness 30 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 Witness 05 gathered in a loose circle (Figure 1.4 19), all within arm's reach of each other. Witness 06 Despite the darkness and poor visibility inside the container, witnesses reported that Witness 07 LCpI Spencer was moving the rifle up and down, with the butt placed on his boot and Witness 08 his chin resting on top of the suppressor. The Panel opined that this movement was Witness 11 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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1.4.162. LCpI Spencer was held in high regard by some students on the course. Witness 05 This perception was likely due to LCpI Spencer's rank, comparatively greater Witness 06 experience working within a Sniper Platoon and his performance in unit. Witness 07 Consequently, despite recognising LCpI Spencer's incorrect weapon handling, the Witness 26 JNCOs amongst the students did not intervene likely due to their misplaced Witness 48 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 Exhibit 135 discharged from LCp1Spencer's L115A3 Sniper Rifle, inside the Waiting Detail ISO Witness 24 Container. LCpI Spencer immediately fell to the floor of the container, fatally Witness 40 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.

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Indirect influence

1.4.166. Immediately after the round discharged the situation inside the ISO Witness 17 container was confused. On exiting the Waiting Detail ISO Container immediately Witness 29 after the L115A3 Sniper Rifle discharge, witnesses heard Student E saying that he Witness 32 had knocked into LCp1Spencer. Witness 33

1.4.167. While there is evidence that witnesses heard a student claim that he Exhibit 148 knocked into LCp1Spencer. none of the witnesses observed anyone knock into him. Witness 05 Furthermore, when questioned, no witnesses remembered knocking into LCp1 Witness 17 Spencer. However, based on witness evidence, the cramped conditions within the Witness 29 ISO container and the number of weapons and kit on the floor, it is more likely than Witness 32 not that a student did knock into LCp1Spencer. Had this happened, the knock would Witness 32 likely have caused LCpI Spencer's sniper rifle butt to be dislodged from his boot and Witness 33 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 Exhibit 135 along with members of the DS moved to the Waiting Detail ISO Container. Inside Witness 24 LCpI Spencer lay motionless on the floor. The Combat Medic Technician (CMT) Witness 36 checked LCp1 Spencer for signs of life; none were found. The RCO informed Sgt 2, Witness 40 located in Tain Tower, of the accident at 1742 hrs. Witness 44

1.4.170. The RASP immediate action drill for the night range on 1 Nov 16 comprised Exhibit 005 of 4 stages: Exhibit 012

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 Exhibit 006 immediate response; the primary means was AIRWAVE® radio66 and the secondary Exhibit 012 means was mobile phone. Faced with difficult radio communications and to better Exhibit 135 understand the situation and coordinate emergency services' support, Sgt 2 resorted Witness 24 to mobile phone to communicate with the RCO. The mobile phone number for the Witness 44

`"' A Hand-Held Push-to-Talk (HHPTT) Very High Frequency (VHF) radio manufactured by AIRWAVEe_

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DSA/S1/01/17/TAIN OFFICIAL-SENSITIVE © Crown Copyright 2018 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 Exhibit 012 Tower staff were air focused. On 1 Nov 16, the Main Tower Assistant (MTA) Exhibit 100 appeared unaware of the ground centric Immediate Action Aide Memoire contained Witness 40 within Tain AWR (Ground Use) Range Standing Orders.67 Compounding this, the Witness 44 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 Exhibit 005 written. The CMT rapidly assessed the situation to be a major-medical emergency Witness 36 that required assistance from the emergency services.

1.4.174. Stage 3 of the RASP was not strictly followed. The RCO misinterpreted Exhibit 005 Tain Tower's repeated requests for information as to the status of the weapons68 as Witness 24 an order to make weapons safe. This was compounded by the traumatic nature of Witness 33 the accident and the excessive shouting and movement around the Waiting Detail Witness 29 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 Exhibit 010 command and control started to deteriorate on the firing line. This is likely due to the Witness 24 traumatic nature of the accident combined with the effect it had on students and DS Witness 27 alike. The Panel could neither establish who gave the order 'stop stop stop' nor who Witness 29 gave the order to remove the weapons from the Waiting Detail ISO Container. Witness 30 Moreover, once the order had been issued, weapons arrived in a piecemeal fashion Witness 33 as DS and students moved weapons to the firing line. Some members of the DS Witness 34 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 Exhibit 135 by Sgt 2 in Tain Tower at 1743 hrs. Witness 44

1.4.179. Police Scotland, Scottish Ambulance Service and the local on-duty NHS Exhibit 002 doctor attended the accident scene. Neither Police Scotland nor Scottish Witness 27 Ambulance had rehearsed responding to an incident at Tain AWR during 2016, nor Witness 41 could the Panel find any evidence that a rehearsal had taken place prior to 2016. Witness 42 Despite sending a member of the range staff to meet the emergency services as Witness 43 they arrived at the entrance to Tain AWR, both emergency services experienced Witness 44 This was difficulties locating the main entrance to Tain AWR from the B9174 road. Witness 49 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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DSA/S1/01 /1 7/TAI N OFFICIAL-SENSITIVE © Crown Copyright 2018 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 Exhibit 125 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 Exhibit 125 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 Exhibit 031 had been in unsafe condition since the end of Detail 1 in the afternoon, the Panel Exhibit 127 then sought to determine potential causes of the un-demanded discharge of this Exhibit 148 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 Exhibit 031 Spencer's L115A3 Sniper Rifle, in Mar 17, with further tests on two comparable Exhibit 148 L115A3 Sniper Rifles in Oct 17. The purpose of the forensic analysis was to Witness 09 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

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

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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 Exhibit 015 bounce tests. With the weapon cocked and the firing pin shrouded by the bolt, there Exhibit 031 was no discharge regardless of the safety catch position. In the next test, the bolt Exhibit 124 was closed with the trigger depressed (the AESP drill), causing the firing pin to come Exhibit 148 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 Exhibit 031 LCpI Spencer's L115A3 Sniper Rifle was in an unsafe condition with a round Exhibit 148 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 Exhibit 031 possibility that LCpI Spencer had inadvertently operated the trigger of his Exhibit 128 L115A3 Sniper Rifle. To do this, LCpI Spencer would have had to remove Exhibit 148 the suppressor from under his chin for him to be able to reach down to Exhibit 150 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. and trigger: the firing pin is /3 The L115A3 Sniper Rifle has a 3-position mechanical safety Fire (Forward). allows operation of both bolt, 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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Figure 1.4.20 — Self-operation of trigger

b. Operation by a third party. The Panel next considered the Exhibit 010 possibility of LCp1 Spencer's L115A3 Sniper Rifle's trigger being manually Exhibit 151 operated by a third party. In this hypothesis, a third party would have had Witness 05 to reach down to operate the trigger (Figure 1.4.21). The Panel interviewed Witness 07 all witnesses within the Waiting Detail ISO Container at the time to Witness 08 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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Figure 1.4.21— Third party operation

c. Operation by equipment snagging. The Panel then considered the Exhibit 126 possibility that LCp1 Spencer's trigger had snagged on equipment causing Witness 05 an un-demanded discharge. It was reported that the floor of the container Witness 11 was cluttered with personal equipment and L115A3 Sniper Rifles. These Witness 17 were primarily placed along the inside wall of the container and reportedly Witness 29 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 I Trigger 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.

1.4.191 Recommendation. Head of Capability Ground Manoeuvre should Exhibit 126 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.

1 4 - 51

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

DSA/SI/01/17/TAIN OFFICIAL SENSITIVE © Crown Copyright 2018 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.

1 4 - 53

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

1.4.197. 1.4.197.

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_ PART 1.5

Recommendations

OFFICIAL---SENSITIVE 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.

1 5 - 1

(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 1.4.177b conversant with ground accident response procedures and that these are rehearsed with local emergency services at appropriate intervals in order to

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. 1.5 2

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.

1 5 - 3

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.

1. 6 - 1

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. 1.6 - 2

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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both DS and had wasted valuable time and compressed the programme. placing significant pressure on 914 (c-- students In an attempt to complete Live Firing , in the remaining daylight of Day 2, it was was decided to fire 2 x details. each comprising 11 firers. LCpI Spencer was allocated to Detail 1. He The placed at the right-hand end of the firing line (with his Number 2). Firing commenced at 1500hrs. 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 inclement weather. 15 This DS was in the ISO Container allocated for Administration eating a snack and applying warmer clothes, owing to the night firing. 16 Although a separate night brief is not required, Pamphlet 21 states the need for a high standard of supervision during

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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 to promotes Safety Culture and gives everyone, including the most junior members, the confidence regards challenge unsafe behaviour and practices. Had this been the case at Tain AWR, specifically with have to LCpI Spencer's unsafe handling of his Sniper Rifle going unchallenged, then the chain might 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 high platoons as having a distinct culture, ethos and camaraderie. owing to their specialised role and the levels of training they would need to attain to be successful. This led to a perception that snipers, owing less to their greater professional competence, could be trusted more to carry out their duties and needed in supervision than their colleagues in rifle companies ('big-boys' rules'). Whilst it might be reasonable 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

to safety in the workplace Safety Culture 20 I regard Safety Culture as being the attitude, belief. perceptions and values that an organization shares in relation comprises Just Reporting, Questioning Learning and Flexible cultures 1.6 - 6