Source · Prevention of Future Deaths

Cameron Laing

Ref: 2015-0268 Date: 10 Jul 2015 Coroner: Elizabeth Earland Area: Exeter and Greater Devon Responses identified: 1 / 1 View PDF

Soldiers lacked critical understanding of trailer braking systems and safe extraction methods, leading to a fatal accident. The Ministry of Defence irrationally refused to teach alternative maneuvers not in official publications.

Date 10 Jul 2015

56-day deadline 4 Sep 2015 est.

Responses identified 1 of 1

Service Personnel related deaths

Coroner's concerns

AI summary

View full coroner's concerns

_ It was clear from the evidence, and reflected in the Juror' findings, that the Soldiers in Cameron's Packet were not aware that when the emergency brake locked on, upon depletion of air tanks on a kings Trailer; reconnection of the air (red Iine) would release the brakes once operating pressure was achieved Thus would cause the trailer to move out of control if the hand brake was not None of the witnesses who were trained to varying degrees understood this or the mechanism of brake action which was admittedly complicated. The Packet Commander was not fully trained in coupling and un-coupling procedures and relied on the Soldiers in her unit to advise her. This lack of understanding led to the accident that caused Cameron's death. We received evidence from the Vehicle Examiner that an alternative method of extracting the trailer from the confined area at Bracken Tor Hostel would have been able to pull the trailer backwards via a DROPS vehicle, which had the necessary towing attachments, from behind or "nose manoeuvre" the trailer: Neither of these possibilities (which would have avoided manual handling and vulnerability to being trapped between the trailer and the DROPS) were taught to the Soldiers or recognised by them to be a solution to recovery of the trailer am concerned that in WO1 Orpe's Table of Responses by the Ministry of Defence to the Land Accident Investigation Team report p8,paragraph 27,the_ lorry: rise; the applied,

Ministry of Defence Logistic training team take the view that such training of alternative manoeuvers cannot be delivered as they "do not appear in the Army Equipment Support Publication This does not appear to be a rational approach to the evident need for Soldiers to be given alternative methods of extracting themselvesIvehicles from difficult situations, which in this case resulted in Cameron's death:

Responses

1 respondent

Ministry of Defence Central Government

7 Sep 2015 PDF

Action Taken

The Ministry of Defence improved the training package for DROPS operators qualified to tow the KINGS trailer, supported by a video detailing coupling and uncoupling procedures. The Army will include clearer guidance for operation of the Shunt Valve in the AESP, and amend the Trainer instructor Specifications (ISpec). (AI summary)

View full response

MINISTRY OF DEFENCE FLOOR 5 ZONE B MAIN BUILDING WHITEHALL LONDON SWIA 2HB Ministry of Defence Telephone: 020 7218 9000 (Switchboard) MARK LANCASTER TD MP MINiSTER For DEFENCE PERSONNEL, WELFARE AND VETERANS MSU/4/3/11/2/is 34: September 2015 RECEIVED 7 SEP 2015 Eld , 'Jos Thank you for your letter of 13 in which vou enclose a copy of the Regulation 28 Report following the Inquest into the death of Private Cameron Laing: As you will be aware, my Department takes very seriously its relationship with Her Majesty's Coroners and we fully recognise how important it is that we learn all possible lessons to ensure that deaths under similar circumstances in the future can be prevented_ In your report you have raised concerns about the training given to soldiers in dealing with movement of trailers and DROPS vehicles, and the reinforcement of training regarding alternative methods of coupling and uncoupling: After the accident the training package was reviewed by the Training Requirements Authority and it was determined that additional manoeuvres should not be taught to operators_ The advanced techniques described by the Vehicle Examiner at the inquest are only to be conducted by the specialist mechanical engineers of the Royal Electrical and Mechanical Engineers (REME): It is not feasible or necessary for every vehicle operator to be trained to such specialist capability: The approach within the Army for recovery, as laid down in the All Arms Equipment Recovery Manual (AAERM) and taught to all operators, is that recovery by driverloperators is restricted to the capabilities of the recovery equipment held by the unit and as part of the vehicle's Complete Equipment Schedule: In this case the correct approach would have been to call for REME recovery assistance, rather than attempting a self- recovery task for which the soldiers present were neither trained nor equipped. However; the training package for DROPS operators qualified to tow the KINGS trailer was improved in order t0 reinforce the extant training objectives and is now supported by a video which details acceptable procedures step-by-step, covering all aspects of coupling and uncoupling the trailer; including the airlines, chocks and shunt Dr Elizabeth Earland HM Senior Coroner for the County of Devon Exeter and Greater Devon Coroners Office Room 226, Devon County Hall Topsham Road Exeter EX2 4QD July used

valve. The training package is delivered by competent instructors who are registered and authorised to deliver it by the Defence School of Transport It is policy that refresher training must be provided to any equipment user who has not operated a given piece of equipment within a 12 month period to ensure operators maintain currency and competency: The Army have reviewed the Army Equipment Support Publications (AESP) relating to the KINGS trailer and DROPS on Thursday 20 August 2015, and determined that it should include clearer guidance for the operation of the Shunt Valve_ warning will now be included in the AESP stating that the Shunt Valve must only be used for minor adjustment of trailer position (e.g. all coupling/uncoupling or maintenance activities within a workshop): The AESP will also state that; where reasonably practicable, the Shunt Valve must only be used on firm level ground; The Trainer instructor Specifications (ISpec) which down the specifics of what is to be taught to soldiers will also be amended accordingly. hope that this response helps to address your concerns. am content for you to copy this response to the Chief Coroner and other Interested Persons: 0 0 Le MARK LANCASTER TD MP the lay

Report sections

Investigation and inquest

On 18 May 2014 commenced an investigation into the death of Cameron William LAING, aged 20. The investigation concluded at the end of the inquest on 8" July 2015_ The conclusion of the inquest was a Narrative verdict Private Cameron of 7 Regiment Royal Logistic Corps was part of a unit which had taken a wrong turn when following an incorrect route card, arriving at Bracken Tor Youth Hostel instead of Okehampton Army Camp: At approximately 20.45hrs 29th April 2014 he was crushed between the back of a DROPS Lorry and the front of a 4 tonne; twin axle Kings Trailer: Death was virtually instantaneous The effect of re-attachment of the air line while the emergency brake was on was not appreciated by those involved: The jack leg supporting the A Frame of the trailer and wooden chocks were not deployed. The trailer was on a 12" slope_

Circumstances of the death

Male was a member of 7 Regiment RLC (Royal Logistic Corps). On 29/04/14 male was on duty delivering storage containers to Okehampton camp. It appears that the 4 vehicle convoy he was in took a wrong turn down a track to Bracken Tor. It is believed that the location is not MOD property: He became involved in assisting his colleagues to remove by hand a large gun trailer (weighing 4 tonnes) from the rear of one of the military lorries (second in the convoy) to allow it to turn around: The trailer was first to be turned around manually by personnel then the military wagon which was transporting the containers was manually turned around_ Laing

During the process of hitching the trailer back onto the lorry the deceased appears to have been bent down on one knee with his arm underneath the trailer wagon trying to re-attach the trailer A frame hook Another soldier was in charge of moving the trailer towards the wagon to enable re-attachment of the trailer by manual control using some kind of pneumonic device. Soldier shouted to make sure all soldiers were clear; the response was "yes" so the release button was pressed and the trailer moved very suddenly and relatively quickly (due to mass of trailer and also incline of the hill) and the trailer has then pinned the male's head and chest to the rear of the military Police have CCTV of the incident Male was heard to shout out (probably in the moments prior to crushing) and seen to immediately go limp on impact with a change in the shape of his skull The lorry was then moved very shortly after the incident and male's body fell to the ground and CPR was attempted: The ambulance was called at 20.48hrs and on arrival CPR was in progress, male had extensive facial, head and chest trauma: Airway was compromised by fractures of the jaw; eye sockets and skull with extensive bleeding: Male was intubated at the scene with full resuscitation (ALS): There was unequal chest right sided of chest deformed_ Male was asystolic throughout resuscitation. After 47 mins, male was declared dead at the scene at 21.49. Police; CID, SOCO and SCUI attended scene to conduct an investigation. Health and Safety (HSE) have been advised PMH from military: wrist and hand sprain (26/01/2012) , allergic reaction to insect bite (24/07/2012) , smoker (20 per day); no known allergies, not on any medication

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action and therefore require a review of the Logistic Training Teams position on this point:

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Report details

Reference: 2015-0268
Date of report: 10 July 2015
Coroner: Elizabeth Earland
Coroner area: Exeter and Greater Devon

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Sep 2015 (estimated).

Sent to

Ministry of Defence

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.