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.