The Northern Territory Coroner has handed down his findings in to the death of a solider, in a situation described as a shambles and a failure of the entire Australian Army chain of command.
The death of Private Jason Challis was unnecessary and avoidable. The trauma caused to three other servicemen involved in unintentionally shooting him in the head and knee was preventable. The military exercise where Pvt Challis lost his life was "shambolic", and the Australian Army failed to comply with its own doctrine and past reports.
These are the findings of the Northern Territory Coroner Judge Greg Cavanagh who handed down his inquest findings last week. The Coroner said that this "was not the failure of one or two or even a small group of individuals. It was not a mistake, forgetfulness or momentary inattention. It was a failure by the whole chain of command. It was a ‘systemic failure’ in the true sense of that phrase."
Jason Challis grew up in Geelong, Victoria and was an Army Cadet as a boy. Leaving school after Year 10 he worked as a joiner for 8 years before deciding to join the Australian Army in July 2016. After 6 months of basic and infantry training he was posted to the 5th Battalion RAR in Darwin, in February 2017.
In May 2017, the Army held Exercise Tiger's Run - a training and testing exercise including urban operations. This was Pvt Challis' first live-fire urban operations exercise; the rest of his section were also fresh, having joined the army between February and July 2016.
The exercise involved groups of four soldiers called a Brick - a Leader, a Point, a Cover, and a machine gunner. They were to practice taking down occupants of buildings. The mock buildings were made of plywood and the targets were drop-head dummies. Watching each brick was three safety supervisors, and the commanding officer remained in an armoured vehicle on the road.
The exercise started on 10 May 2017 and Pvt Challis was the machine-gunner; after engaging an "enemy" target, the four-man brick approached the first building. Challis went around the far side of the building for reasons unknown (the Coroner noted it may well have been appropriate given their limited knowledge of the building.) Two soldiers - the Point and Cover - went down the other side of the building and realised that they had been separated from their two fellow soldiers and the safety supervisors. They immediately agreed to halt, safed their weapons and called out.
The officer in charge of the drill yelled "STOP, STOP, STOP" and the Leader, Point and Cover returned to the armoured vehicle.
Private Challis did not. He remained on the far side of the plywood building, probably not realising the call to reset. Restarting the exercise took 53 seconds but no-one noticed Pvt Challis' absence. The other three soldiers in the brick restarted the exercise, entered the building, and shot at a "drop head" dummy inside the building.
Pvt Challis was on the outside of the plywood wall. The bullets passed through the dummy and the plywood; he was struck by bullets to the head and knee. The Leader then noticed that Challis was missing. He was found laying on the ground beside the wall, and died in hospital later that day.
The Failure of One and All
Three investigations were immediately started - the Inspector General of the Defence Force, led by Andrew Kirkham QC; Comcare regarding the workplace health and safety issues; and the NT Coronial investigation.
Army documents and doctrine required that soldiers be provided with a walk through of the exercise, first without weapons, then with blank ammunition, before any live fire exercise. This was done with other sections in the exercises - but not with Pvt Challis' section.
At least one officer said that the walk-throughs did not happen "because if they did, it would not be a test and that when they go to war they do not do that." However, in this case, clearly Private Challis and his fellows were being tested on something that they had not even been trained in yet.
In Judge Cavanagh's words, "The reasons for that failure seem either not to have been appreciated or there is an unwillingness to confront them."
The findings of Judge Cavanagh mentioned above started with this:
PTE Challis was inexperienced. He had not had the benefit of being trained on a complex urban operations range before. He was not provided the progression of training on the range anticipated by doctrine (i.e. rehearsals). If he had been given a walk-through, a dry fire rehearsal or a blank fire rehearsal it is unimaginable that he would have been at the back of the building in line with the concealed target. His death was clearly preventable as was conceded by Army at the outset of the Inquest.
Or in simple terms: this wasn't just a minor failure, or something that would not have happened if one person had acted differently. The exercise "was a shambles." This was a pervasive, complete failure of the Army's training and testing processes, and for this failure a young man lost his life.
Has Army Learnt It's Lesson? Possibly Not.
The greater concern is, despite the Coroner's findings and the internal investigation report, little may change:
The characterisation of the issues as merely “vulnerabilities” is particularly perplexing given the then Commandant CATC had already concluded that it was clear that the “planning, supervision, development and subsequent war gaming or rehearsals were absent or ineffective”.
Judge Cavanagh made note of helpfulness from many - but not some of the Army officers involved. The formal response from the Army was supplied to the Army's own lawyers by the Commandant of the Combined Arms Training Centre (CCATC, a Colonel) only 4 days before the inquest was due to start - despite witness statements having been prepared and ready months earlier. In an example of understatement, Judge Cavanagh described this as "unhelpful".
The formal response from CCATC was 860 pages long and contained a range of changes in procedures and processes. However, "It was not clear that they were responsive to any system failures identified as being present in the circumstances of the death of PTE Challis."
Indeed, the same Colonel under cross-examination could not say what failures resulted in the death of Private Challis - despite findings from the internal investigation and more than 18 months since the shooting. Many changes had been discussed or made - but no-one had asked if that these things were the right changes, or even good ones.
Further formal response from the Australian Defence Force as to the coronial findings is expected later in 2019.