The death of gunner Matthew Psaila during a training exercise at Chadwick Lakes last February was labelled a "misadventure" by an inquiry board despite finding serious failures in the army's training structure.

The inquiry, chaired by retired judge Victor Caruana Colombo, went one step further and said that "no individual can be held to blame for the death of Gunner Matthew Psaila".

This conclusion flies in the face of criminal proceedings that were initiated by the police against two army officers earlier this year. Lieutenant Christian Vella and Lance Bombardier Marvic Peregin were charged in court with the involuntary homicide of Gunner Psaila through negligence. They were also charged with committing a crime they were duty bound to prevent.

The inquiry found that the safety arrangements in place were "inadequate" for an event such as happened on the fatal day. There were only three supervisory officers on the day when the "normal complement" should have been six.

Furthermore, the inquiry found that the Armed Forces had no standing orders that covered troop safety during training and no senior army officer connected in any way with training "assumed responsibility for safety of personnel whilst on training".

The inquiry said that the organisation and structure at the AFM showed that there was a "weak link in the training chain of command" so much so that the army commander was not in a position to be "fully aware of what is being done at unit level about safety on training".

Addressing the issue of Gunner Psaila's lack of ability to swim, the inquiry said that at a briefing before the start of the exercise, recruits were asked to raise their hands if they could not swim and Gunner Psaila did not raise his.

However, in one of its conclusions the report insisted that soldiers undergoing a high risk exercise such as the Chadwick Lakes one should be "competent swimmers".

Delving into the fatal events that occurred when the soldiers arrived under the bridge, the inquiry said that panic ensued after they reached deep water.

"It was from then on a situation of every man for himself," the inquiry said.

The panic meant that Gunner Psaila's absence was only noticed between five to 10 minutes after he had gone under the water.

The Chadwick Lakes exercise was a regular feature of the B III Infantry training course for the past 15 years. No significant incidents were ever reported throughout the years.

The objective of the exercise was to enhance team work under the hardship of wet and cold conditions.

The inquiry found no fault with the exercise's objectives, however it did point out that the Chadwick Lakes environment was one of "high risk" because of the fresh water's "lack of clarity, biological uncleanliness and varying depth which can be up to two metres".

The Board said alternative low risk locations for physical strength and endurance training in wet and cold conditions could be found. It even suggested Mellieha Bay as an alternative.

The total time that elapsed between Gunner Psaila's recovery from the water and his time of arrival at hospital was approximately 30 minutes.

The cause of death was deemed to be multiple organ failure and water-filled lungs.

According to doctors heard by the inquiry board, fresh water drowning is far worse than salt water drowning because greater damage is caused to the human body. Recovery is more difficult from fresh water drowning if efforts are not made "immediately after the event".

The inquiry also established that the water pollution at Chadwick Lakes was not a significant factor in the cause of death.

The inquiry board had been appointed by the Prime Minister and included former Brigadier John Spiteri and Joseph Sultana. Its terms of reference were to investigate the army's training processes, evaluate all the circumstances related to the fatal accident, determine whether the particular exercise was reasonable and make the necessary recommendations.

Factbox

What happened on the day
• On February 13 at 8 a.m., soldiers pertaining to C (Special Duties) Company AFM started out in three different groups, one after the other, from a spot near the San Pawl tal-Qlejgha chapel, wading through the water.

• They passed under the first bridge towards the first staired dam that overlooks the chapel.

• Soldiers from "1 Section" went up the staired dam carrying the log. At the top they lowered the log into the water and jumped in.

• They started wading in the water or swimming depending on the depth. They proceeded towards the two tunnels beneath the second bridge.

• Some soldiers were holding on to the log and others were not. Gunner Psaila was the last one in line.

• They waded for 30 or 40 metres and climbed onto the bank on their right hand side, walking towards the second bridge.

• The soldiers felt very cold but they did not encounter any problems.

• At the bridge they entered the right-hand tunnel, wading through the water.

• Towards the middle of the tunnel the water was deep and the log was ducking beneath the surface with the weight of those resting on it. Some soldiers were going under the water.

• The tunnel was dark and panic struck.

• Lance Bombardier Peregin pulled out three people from under the water. He started a head count but in the meantime the second group had caught up with them

• Some time after that Gunner Psaila was noticed missing

• A search was conducted and they found him under water in the tunnel. They took him on land and tried CPR. An ambulance was called in.

• After a few minutes the ambulance had not arrived and the victim was put in a Landrover and driven to hospital. They met the ambulance at Mosta and Gunner Psaila was transferred to the ambulance.

• After three days in intensive care Gunner Psaila passed away on February 16.

Chadwick Lakes exercise
• Lt Chris Vella was in charge of the training exercise.

• Soldiers were divided into three groups referred to as "1 Section, 2 Section and 3 Section" composed of between 12 and 13 soldiers each.

• The exercise consisted of the three sections walking in the water against the current one after the other along Chadwick Lakes.

• Each section had a wooden log, which was part of a telephone pole that had to serve as a floating aide when the water depth did not permit the soldiers to walk.

The kit
• Soldiers wore a helmet, boots, a rifle and other gear.

• The kit weighed about 13 kilogrammes.

Inquiry
• The chairman of the inquiry was Judge Victor Caruana Colombo and the other members of the board were Brigadier John Spiteri and Joseph Sultana.

• The board held six sessions, two onsite visits and interviewed 54 witnesses including army officers and soldiers.

ksansone@timesofmalta.com