Source · Prevention of Future Deaths

William Savage

Date: 18 Dec 2014 Coroner: Darren Salter Area: Oxfordshire Responses identified: 1 / 1 View PDF

Intelligence regarding frequent "PISTOL hits" was inaccurately circulated, leading commanders to believe a route was cleared when it was not. More detailed consideration is needed before removing threat warnings.

Date 18 Dec 2014
56-day deadline 12 Feb 2015 est.
Responses identified 1 of 1
Service Personnel related deaths

Coroner's concerns

AI summary
Intelligence regarding frequent "PISTOL hits" was inaccurately circulated, leading commanders to believe a route was cleared when it was not. More detailed consideration is needed before removing threat warnings.
View full coroner's concerns
In the circumstances it is my statutory duty to make this report to you.

The MATTERS OF CONCERN do not solely relate to PISTOL hits but are potentially wider. They are the following:

- The nature of the hits and the period over which they were received should have been more accurately and widely circulated on the relevant Intelligence database. The commanders of the Patrol were aware there had been PISTOL hits at the location (but not frequent and continuous hits over 3/4 days) and were led to believe that the location had been cleared the day before on the 29 April when the US route clearing team travelled along Route 611.

- I fully appreciate of course that lessons have been learned as part of the normal process of investigation after such a tragic incident. I understand one of the lessons is in relation to the clearance of threat warnings from routes. It appears there may be a need for more detailed consideration before a threat is removed and marked as ‘cleared’.

Responses

1 respondent
Ministry of Defence Central Government
11 Feb 2015 PDF
Action Taken

The Ministry of Defence conducted an in-depth analysis and implemented a new Standard Operating Procedure (SOP) on 11 May 2013, which mandates passing all PISTOL data to Battle Captains, requires documentation of cross-cueing activity, and includes new training packages. Lessons learned, including on new insurgent tactics like tunnelling, have been captured for future operations. (AI summary)

View full response
Dear Mr Salter,

Thank you for your letter of 18 December 2014 following the inquest into the tragic deaths of Corporal William Savage, Fusilier Samuel Flint and Private Robert Hetherington. The Ministry of Defence takes its relationship with HM Coroners extremely seriously and we fully recognise how important it is that we learn all possible lessons to ensure that deaths in similar circumstances in the future are prevented.

Your Regulation 28 report focuses on the handling of information regarding potential threats on routes in Afghanistan, in particular 'hits' from the PISTOL system, and the clearance of threat warnings from routes.

As was explained at the inquest, PISTOL was brought into service as an addition to the suite of Counter Improvised Explosive Devices (C-IED) detectors and was designed to cross-cue other surveillance assets, as PISTOL was not able to provide a clear picture of what is taking place on its own. You heard that the PISTOL operators at the time of the incident on occasions cross-cued other surveillance assets to check locations without always informing the Battle Captain within the Operations Room, thus not allowing this officer to gain a clear and constant picture of information received, in this case along Route 611.

Immediately following this incident an in-depth analysis of the circumstances was conducted to ensure we identified and implemented all relevant lessons. The failure of effective communication of PISTOL information was highlighted and on 11 May 2013 a new Standard Operating Procedure (SOP) was issued and briefed to those operating PISTOL and to those using the information that PISTOL produced. This new SOP focussed on the passage of information and implemented the following changes:

* All PISTOL hits were to be reported to the Battle Captain or Duty Watch Keeper and entered onto JCHAT¹ as a PISTOL Report.

¹ JCHAT was a system that enabled secure text based instant messaging between UK and US users in theatre and beyond on their respective secret 'eyes only' systems.

Mr D Salter HM Senior Coroner for Oxfordshire Oxfordshire Coroner's Office The Oxford Register Office 2nd Floor 1 Tidmarsh Lane Oxford OX1 1NS

PAGE 2

* Task Force Helmand Joint Operations Centre was to ensure that all units transiting areas where PISTOL hits had been reported and not cleared should treat such locations as Vulnerable Areas, thus prompting specific clearance techniques. These Vulnerable Areas were also to be entered onto other route planning assets that were in use at the time. Further, should it be felt necessary, areas of concern were to be temporarily placed out of bounds until locations were subject to formal IED clearance by specialist search teams on the ground.

* If, following investigation of PISTOL hits with the surveillance assets immediately available to him, the Battle Captain or Duty Watch Keeper was still not confident that a false or non-threatening hit had been confirmed, then he should call upon higher formation (i.e. Task Force Helmand) surveillance assets and, following further investigation, he could recommend that the area be investigated by a specialist search team.

* On a daily basis all PISTOL hits should be converted into a 'heat map' which should be analysed by intelligence staff and promulgated to all those conducting tactical level planning and patrol activity.

The lessons process also identified that operations room staff were not as aware as they should have been concerning the PISTOL capability. This was addressed by specific operations room staff training, which also included a thorough briefing on the new SOP.

The incident on 30 April 2013 was, as you point out, unusual in that the insurgents successfully utilised a tunnel for the first time. The PISTOL SOP specifically raises the possibility of tunnelling and instructs that should normal surveillance be unable to identify the source of PISTOL hits, then ground based C-IED assets should be deployed. The discovery of the tunnelling technique was immediately promulgated throughout Task Force Helmand and briefed back to our training organisation, who updated their training material to incorporate this new insurgent tactic in order to provide clear guidance for those operating in Afghanistan.

As you may be aware, PISTOL is no longer in use now that combat operations in Afghanistan have ended, and the Army does not see a role for this specific piece of equipment procured for Afghanistan in the immediate future. However, our Land Warfare Centre has captured all the relevant lessons from use of the equipment in Afghanistan, which will be used in the event that similar technology is required for future operations. Central to this is the requirement to understand the individual capabilities of C-IED systems, the effective fusing of the information they generate to gain a clear intelligence picture and then for the most relevant actions to be taken to remove any potential risks.

I hope this letter provides the assurance you were seeking and I am content for you to copy it to other Interested Persons and the Chief Coroner. I am aware of the public interest in this inquest and am keen to demonstrate publicly that we learned lessons from the tragic deaths of Corporal Savage, Fusilier Flint and Private Hetherington; therefore I have no objections to the Chief Coroner publishing our response should he wish to do so.

Yours ever, Mstain RT HON MARK FRANCOIS MP

Report sections

Investigation and inquest
On the 14 May 2013 I opened Inquests into the deaths of Corporal William Savage, Fusilier Samuel Flint and Private Robert Hetherington who sadly died in Helmand, Afghanistan on 30 April 2013.

I concluded the Inquest into their deaths on 3rd December 2014 at Oxford Coroners Court. I gave a conclusion in each case of ‘Unlawfully Killed Whilst on Active Service’ and, on the Record of Inquest, I made the following finding:

William Savage, Samuel Flint and Robert Hetherington were travelling in the back of a Mastiff Armoured Patrol Vehicle at approximately 1115 hours on 30 April 2013 on Route 611, 6 kilometres north of Lashkar Gah Durai, when it was subjected to a very large strike from an Improvised Explosive Device resulting in their deaths. The IED was placed in a tunnel under the road and triggered by a command wire.

The medical cause of death in each case was blast injuries caused by an explosion.

The Inquest heard oral evidence from 14 witnesses. This was from soldiers (including other vehicle occupants) Commanders and subject matter experts from the MOD. There was also evidence from an independent expert who I instructed in the field of armoured fighting vehicle design, specialising in armoured vehicle survivability. The families had concerns about the Mastiff Vehicle and the protection it provided. In particular, there was a question about whether the occupants were made more vulnerable to injury because of damage caused in a previous IED strike on the same vehicle in 2009. In the event, I found there was no significant evidence that the vehicle did not provide the expected level of protection or that the occupants were more vulnerable to the injuries sustained because of the 2009 IED damage. Instead, it appeared to be a case of ‘blast overmatch’ and that the three soldiers who were killed were seated at the rear of the vehicle nearest the site of the explosion.

The other main issue, and the one which is the subject of this report, is the concern on the part of the families that the device could have been detected beforehand. I will address this issue below.

I have not provided you with a copy of the Inquest file as a full copy and other documents (some marked as secret) are held by the Defence Inquests Unit. This letter has been copied to the DIU.
Circumstances of the death
More specifically, in relation to intelligence, it was known that a surveillance capability (PISTOL) had recorded activity known as a ‘hit’ at the location in the days preceding the IED strike on 27, 28, 29 April and earlier in the morning of 30 April itself. These hits indicate activities which could include digging activity. On receipt of the hits, relevant personnel at the Patrol Base at Lashkar Gah Durai used other surveillance capabilities to look at the area of interest but nothing suspicious was observed. The hits that were received were frequent and continuous but the assessed threat that was recorded and made available to others (including those organising and conducting the patrol on 30 April) did not convey the fact that the hits were frequent and continuous and lasting over a period of 3/4 days.

If the true nature of the hits/ threat had been recorded and shared, the evidence at Inquest was that further actions and possibly a high risk search could have been considered at the location. There was therefore in my view a missed opportunity to carry out more informed consideration, although it is a matter of speculation as to whether in fact any such actions or a high risk search would have been authorised and would have discovered the tunnel/ device. The Battle Captain and Intelligence Analyst who initially received and assessed the possible threat indicated by the PISTOL hits considered tunnelling as a possible explanation but concluded that it was more likely to be due to faulty readings. The decision was also influenced, perhaps understandably, by the fact tunnelling was not a known tactic of the Insurgents.

The location of the IED blast on Route 611 was ‘cleared’ by a US route clearing unit on 29 April as a matter of routine but they did not have the information about frequent and continuous PISTOL hits at the location and carried out a normal ‘hasty’ clearance by driving along the road, looking for ground signs and utilising the specialist equipment that they have. On the morning of 30 April, in the hours before the IED blast, a UK Combat Logistics Patrol and an EOD Unit also travelled along the route but did not detect anything. Of course, there were no ground signs because, unusually, there was an underground tunnel stretching some 15/20 metres from a nearby compound to a point underneath the road. The IED had not been dug into the road or the side of the road as usual and, consequently, there were no ground signs to be seen.
Copies sent to
Mr D. M SalterHM Senior Coroner

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Report details

Date of report
18 December 2014
Coroner
Darren Salter
Coroner area
Oxfordshire

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: 12 Feb 2015 (estimated).

Sent to

Ministry of Defence

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