Gunner Psaila's death: Inquiry faults AFM training safety structure
An inquiry into the death of an AFM soldier during a training exercise at Chadwick Lakes on February 13 has concluded that no individual could be held to blame, but the safety arrangements put in place for the exercise were inadequate.
The inquiry was appointed by the Prime Minister and was headed by Judge Victor Caruana Colombo, assisted by Brig (retired) John Spiteri, former AFM commander, and Mr Joseph Sultana.
Gunner Matthew Psaila, 19, died in hospital three days after the incident, during which he was under water for up to 10 minutes as his section ran into difficulties while wading under a bridge.
"The events of 13 February 2009 have shown that the safety arrangements put in place for the training exercise were inadequate for an event such as happened to One Section under the Rabat-Mosta road bridge, and these arrangements could, at most, be sufficient to deal with one or two persons at the most.
"The possibility that practically all of a platoon section's trainee members (8 to 10 men) could get into difficulties simultaneously was apparently never contemplated, or was considered too remote by exercise planners ever since this type of exercise first started being carried out by the AFM in Chadwick Lakes years ago," the report says.
The report also says that in volunteering to undergo the B III infanty training course to become a fully fledged member of C (Special Duties) Company, Gunner Psaila was well aware of the high risk tasks and situations that he would have encountered both on training and on operations.
"The Board is of the opinion that no individual can be held to blame for the death of Gunner Matthew Psaila. The cause was misadventure," the Inquiry found.
WEAK LINK IN CHAIN OF COMMAND
The inquiry found that the organisation and structure of HQ, AFM had a weak link in the training chain of command. A Staff Officer 2 (Major) with very little authority was the officer responsible for policy and planning, which should include safety during training. The board was of the opinion that such duties should be carried by a much higher ranking officer.
It said that in training matters, the HQ organisation was practically concerned solely with the administrative aspects of the courses.
"No member of those interviewed could provide the Board with any AFM Standing Orders which cover safety of troops while undergoing infantry training."
It said no staff officer assumed responsibility for safety of personnel while on training. Neither general basic guidelines, nor instructions for safety of personnel while training were issued by HQ except where firing on ranges and some field training exercised were concerned. This responsibility was left entirely to AFM unit commanders.
This left the Commander, AFM in a position where he was not fully aware of what was being done at unit level about safety on training.
"The Board is of the opinion that the AFM should reconsider the training structure at headquarters and the compiling of Standing Orders while carrying out Infantry training, and in particular, high risk exercises such as that which was carried out on the 13 February 2009 at Chadwick Lakes," the board said.
RECOMMENDATIONS
Among its recommendations, the board said the AFM should reconsider its training chain of command at HQ level with a view to upgrading the appointment of the training officer responsible for policy, planning and safety
The upgraded staff officer respoinsible for training should ideally be part of the Operations Branch and should also involve himself in the oversight of safety on training in military courses..
For training under wet and cold conditions, an alternative wading exercise site should be considered, where environmental risks were lower while similar harsh conditions as those at Chadwick Lakes were found. Mellieha Bay could be considered for this purpose.
"Complex or multi-disciplinary high risk exercises should be carried out after regular and progressively more difficult training is carried out, so that there may be successful outcomes with possibly no injuries to participants, and certainly no fatalities," the inquiry board said.
It said the AFM should encourage its personnel to learn to swim and also provide swimming training sessions, including in non-salty water, especially for C Company staff in view of their possible deployment on rescue missions.
Soldiers should also be trained to cope with difficult conditions such as those experienced at Chadwick Lakes. Soldiers had to be competent swimmers. They should also be trained to remove their equipment and weapon under water and swim to safety, the board said.
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Charmaine Borg
Jul 4th 2009, 11:11
A glossed report by a tame Board. Fully concur with Pamela Hansen in calling it a whitewash, especially the references to swimming! As if anybody can swim under those circumstances. And what about the other 'swimmers' who also ended under, but were lucky enough to be rescued?? the question remains, conevniently skimmed over, how can nobody have realised the boy was missing underwater for all that time. Had they done their job, he would have been rescued, alive today, and then be assessed for his suitability to continue or not, something which should have been done before anyhow. It is solely the selctor's responsibility to assess suitability, the supervosors' to ensure safety, and the total hierarchy of the army to see that all is ticking as it should BEFORE such a banal and unnecessary fatal accident had to happen. I add one word to Pamela Hansen's 'WHITEWASH' - SHAME!
J. Psaila
Jul 3rd 2009, 21:08
This is strange just heard the news and AFM proposed that training shall be made with better measurements and safer locations but excuse me these are supposed to be the 'C special company', our 'Elites' so if they are working abroad are they gonna choose safe grounds to train or deploy? Should not in such training each soldier has a buddy and act as his shadow?
This was an unfortunate incident but are the squads prepared in such comradeship and taking care of their buddies? This accident is not bad leadership only, these are no boy scoats cubs but the infantry. The squad N.C.O. and comrades should account for each soldier and not all the pressure on the Lt. If they were fording a river abroad or exercising an amphibious landing would this have not been riskier? Difficulty in water is not only a matter that you now how to swim but how your squad team up. Swimming with over a 15Kg gear is no joke ... and it seems from what was said on the report when difficulty came on the squad, panic overtook the training and the result was to loose one good soldier.
Malvin Debono
Jul 3rd 2009, 19:49
@Mike Micallef Unfortunately sides were drawn up when 2 people where charged with a crime before all the facts were known and the inquiries were concluded. Apart from the pain and sorrow this incident has caused to Matthew's family can you imagine the worry inflicted on the men who were doing their duty? Joining the army is not a walk in the park and there is an element of risk involved which any soldier has to accept when joining. Also when somone questions your abilities and you plough on regardless of whether you can tackle something or not, then you take on some of the responsibility for your safety. Responsibility needs to be shared within the army ranks, that is obvious. But again, there needs to be a change in culture if there is to be an improvement in how this country works.
Joe Morana
Jul 3rd 2009, 19:19
The report is damning, yet it exonerates overyone. My thoughts go to Mathew's family for they need all the sympathy and moral support they can get .
Mike Micallef
Jul 3rd 2009, 18:36
@ Malvin Debono. There are no two sides. Matthew's family are probably still devastated at their loss, and the families of the men currently being tried are worried sick about the problems their family members are facing. they are two totally unconnected matters, and personally, I happen to feel both the sentiments you expressed, and do not feel like I have to choose between one and the other. If these two peopel are being 'scapegoated' then it is by someone who has something to hide or brush under the carpet, and not by Matthew's family. And may I ask what mistakes (Matthew's) you are referring to? Not being pulled out of the water like his other mates who were also underwater? or maybe, his biggest mistake was joining, and believing in the professionalism of the army? this was not an accident in a swimming pool, but one in filthy, freezing water, while fully laden, an exercise which the same report is recommending should not happen again! If it is not to happen again then it was not OK was it, or is that simple logic too much to grasp???
r pace bonello
Jul 3rd 2009, 17:49
Safety arrangements inadequate! A weak link in the chain of command! Perhaps no individual was to blame but who runs the show? A disappointing verdict and one which makes no sense to me. But misadventure........... How can the soldiers have faith in their leaders? This finding will adversely affect their morale.
Fully agree with the sentiments expressed by other bloggers.
Heads must roll
Malvin Debono
Jul 3rd 2009, 17:46
Apportioning blame is not going to help anyone as this is not a question of blame but of the underlying culture within the AFM and within the way things are done in Malta as well. There are two sides in this issue, those supporting Matthew and his family and those who feel that the two people currently standing trial for his death are being victimised. I am very comfortable in saying that I stand with the latter. Not just because of personal reasons, but also because I believe that this was an accident waiting to happen and not just in the army. A culture where people just don't pay attention to what they are doing or what consequences their actions will have is bound to create these sorts of situations.
@Mike Micallef. You are right. Matthew cannot defend himself from his grave. But neither can he admit to his mistakes.
Charles J. Buttigieg
Jul 3rd 2009, 17:35
One doesn’t need to be an expert in military operations for one to conclude that the fatal ending of this young man was the result of the bad management, by his superiors, of the safety rules and equipment for an exercise of that nature. Had the responsible officers provided the necessary training and provided the necessary equipment, Gunner Psaila would still be around. They did not and that tells me that they are to be processed by a court marshal and face the music. In management terms, mismanagement of funds is a criminal offence punishable by imprisonment, are we to accept that mismanagement of health and safety rules is not even a felony?
If I were this victim’s father I’ll fight this case with AFM and the government if it takes my last hard earned penny.
Now let’s wait and see whether our PM will accept this verdict. I predict he would, he doesn’t want more trouble. But we are proud to be European.
Anthony Magri
Jul 3rd 2009, 17:34
It said that in training matters, the HQ organisation was practically concerned solely with the administrative aspects of the courses." Extract from the report.
Quite a shoking remark. Training matters do not tackle safety but how to draw up a report and a record of the happenings and present it to the superiors to be tapped on the back for how well written and given some points for future promotion.
Red tape is supreme even in the army!How would an army that does not go into the difficulties of a mission be called? It has to go by the book- theory! this is what the official report convey. No one responsibl; not even who drew up the plan of action and whoever gave the go ahead.
Of course nobody found guilty of causing voluntary harm. But nobody was declared responsible for the right supervision in case of unforseen circumstances. A soldier was forgotten that he formed part of the ranks, and diappeared (drowned) without anyone noticing it, though the place was crowded with soldiers and officers. This happened probably after a session of instructions of what to do: meaning military planning.
john fenech
Jul 3rd 2009, 17:22
This comment was penned on the 24 February 09:
It is the perception that at times, “collective responsibility might be a convenient excuse, so as to cancel out individual culpability!” That is, everyone is responsible but who is to blame? In such cases it is infrequent that harm can be clearly attributed to the particular actions or inactions of specific individuals.
Therefore this conclusion was expected although not accepted since negligence was the cause of a tragic loss! Furthermore precedence is set for those responsible for similar accident to plead for their innocence!
martin saliba
Jul 3rd 2009, 17:22
According to a report on the times all of the group were asked if anyone felt that they might find difficulties while in the water as parts of it were deep.Gunner Psaila did not raise his hand to say that he could not swim. What did you expect , a scape goat ? If you want to blame anybody apart from those mentioned above blame the AFM or the goverment for not providing the nessacary equipment. Please note that i have no connection whatsoever with the AFM or any of the recuits , this is my personal opinion but nonethe less i am relived for the unfortunate persons who were going to be charged with his untimley death.
Pamela Hansen
Jul 3rd 2009, 17:12
I only have two words for this inquiry "White wash".
MARK MIFSUD BONNICI
Jul 3rd 2009, 17:07
The outcome of this inquiry makes a mockery out of the Armed forces of Malta.
No one is to blame "No member of those interviewed could provide the Board with any AFM Standing Orders which cover safety of troops while undergoing infantry training. This left the Commander, AFM in a position where he was not fully aware of what was being done at unit level about safety on training."
Even scout groups cam account for more professionalism.
Rather then chopping of heads this report blames this incident on the system.
Poor Matthew, he thought he formed part of a "PROFESSIONAL ARMY"
What a disgrace.
Galea. L
Jul 3rd 2009, 17:07
If the person responsible for accepting his application when he applied to join C company knew that he was unable to swim then that person is guilty of his death.
Franco Farrugia
Jul 3rd 2009, 16:50
At this precise moment, my thoughts are with regard to what the Psaila family is going through right now.
Why do I get this feeling ... that in Malta, investigations and inquiries have the same ending?
wally vella-zarb
Jul 3rd 2009, 16:21
"if it was misadventure, may i humbly ask, then why are they making any recommendations?? "
Clearly, recommendations are made so that the chances of recurrence in future exercises are reduced to a minimum; they can never be totally eliminated. Unfortunately, misadventure is - and will forever remain - a fact of life.
John Montague
Jul 3rd 2009, 16:13
If "(8 to 10 men) could get into difficulties simultaneously ", only questionable management and/or procedures can plausibly be attributable to such an outcome. It is shocking to the public and unacceptable to the Psaila family for incompetence (at whatever level) probably verging towards gross negligence to be classified as misadventure.
If one, or two, or three, or four individuals were in difficulty, this possibly may be termed as misadventure - but eight to ten; give me a break!
I read that the inquiry was appointed by the Prime Minister. I , together with the whole of Malta, await his reaction with interest.
Accepting this verdict effectively condemns current and future recruits and their loved ones and families to a sad environment. Weak links and board recommendations are, by their own nature, admissions of fault.
Malta, and Europe, are watching....
Bill Millam
Jul 3rd 2009, 15:57
"An inquiry into the death of an AFM soldier during a training exercise at Chadwick Lakes on February 13 has concluded that no individual could be held to blame........"
The fact that the deceased knew the risks involved when he signed up to join the Armed Forces does not mean that his life was expendable and that he, or any other soldier should have to be
put thru any unnecessary dangers/risks DUE TO LACK of safety precautions WHILE TRAINING!
This inquiry and the conclusion it arrived at is a nothing but a sham! This man died WHILE IN TRAINING AND NOT WHILE IN COMBAT!!!!
What a shame, life must be really, really cheap in Malta for no-one to be held accountable for this young man's death! Shame! Shame! Shame!
Bill Millam
Los Angeles
Tony Caruana
Jul 3rd 2009, 15:43
in Malta Nobody is EVER to blame.
Mike Micallef
Jul 3rd 2009, 15:42
...and "The report also says that in volunteering to undergo the B III infanty training course to become a fully fledged member of C (Special Duties) Company, Gunner Psaila was well aware of the high risk tasks and situations that he would have encountered both on training and on operations. " The cheek!!!! So it's his (matthew's) fault now??? just because he's not around to answer for himself???? if it was misadventure, may i humbly ask, then why are they making any recommendations??
Mike Micallef
Jul 3rd 2009, 15:34
" concluded that no individual could be held to blame" vs " The events of 13 February 2009 have shown that the safety arrangements put in place for the training exercise were inadequate for an event ..." does not quite seem to be from the same hymn book, does it?? Noone is to blame, although everything was wrong! sounds like wish wash to me.