MEMORANDUM FOR Major General Mark H. Berry, The Adjutant General, Arkansas National Guard, Camp Joseph T. Robinson, North Little Rock, Arkansas 72199-9600 SUBJECT: Findings and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas 1. References. a. Memorandum of Appointment, dated 15 June, 2016. b. Army Regulation (AR) 15-6, Procedures for Administrative Investigations and Boards of Of?cers, dated 1 April 2016. 0. AR 385-63, Range Safety, dated 30 January 2012. d. AR 600-37, Unfavorable Information, dated 19 December 1986. e. AR 600-20, Army Command Policy, dated 6 November 2014. f. AR 623-3, Evaluation Reporting System, dated 4 November 2015. 9. Training and Doctrine Command (TRADOC) Regulation 350-29, Prevention of Heat and Cold Casualties, dated 6 July 2012. h. Department of the Army Pamphlet (DA PAM) 385-63, Range Safety, dated 16 April 2014. i. Army Techniques Publication 5-19, Risk Management, dated 14 April 2014. j. All Army Activities (ALARACT) 042/2016, Heat Illness Prevention for 2016 Heat Season, dated 18 May 2016. k. ALARACT 101/2015, Heat Illness Prevention for 2015 Heat Season, dated 25 June 2015. I. United States Army Medical Command (MEDCOM) Memorandum, Subject: Heat Illness Prevention Program for the 2015 Heat Season, dated 29 June 2015. SUBJECT: Findings and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas m. TRADOC Memorandum, Subject: TRADOC Heat Illness Prevention Program 2016, Dated 8 February 2016. n. Fort Chaffee Training Site Commander Memorandum, Subject: AR ARNG Range Safety SOP: Guidance and Procedures for Commanders Range Safety Certi?cation Program to Certify Of?cers in Charge (010) and Range Safety Of?cers (RSO) for Live Firing on Small Arms Ranges, dated 6 March 2013. 0. Arkansas Army National Guard (AR ARNG) Regulation 385-63-1, Fort Chaffee Maneuver Training Center Range Regulation, dated 17 April 2007. p. Ill Corps and Fort Hood Regulation 350-16, Prevention of Heat and Cold Injury, dated 26 April 2004. 2. Background. On 15 June 2016 Major General Mark H. Beny, The Adjutant General and Commanding General of the Arkansas National Guard, appointed me as an investigating of?cer IAW AR 15-6, Section 2-1. c. (See Exhibit 1). The purpose of the investigation was to determine the facts and circumstances surrounding a training accident resulting in a fatality of an Arkansas Army National Guard Servicemember during Training Year 16 Annual Training (AT) at the Fort Chaffee Joint Maneuver Training Center on or about 14 June 2016. The Servicemember was pronounced dead at approximately 1817 hours, Tuesday June 14th at Mercy Hospital in Fort Smith, Arkansas. wea her environment prior to training commencing on Range 100 on 14 June 2016 IAW applicable regulations, policy guidance, and standard recognized practices regarding training in a hot weather environment. These individuals failed to execute adequate heat illness prevention procedures while conducting training on Range 100 on 14 June 2016 IAW applicable regulations, policy guidance, and standard recognized practices regardin trainin in a hot weather environment. Further, une rose 0 eve neg Igence in en 0 0 protect soldiers from the adverse effects of heat on 14 June 2016. Finally, there are some apparent de?ciencies and inconsistencies within the Arkansas Army National Guard at the command, major command, battalion, and training center levels in regards to policies, procedures, training, and leadership related to heat illness prevention programs. Overview. Fln!lngs and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas SUBJECT: Findings and Recommendations for Army Regulation (AR) 15?6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Cha?ee, Arkansas SUBJECT: Findings and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas It should be noted that the Findings and Recommendations contained herein are preliminary and may be supplemented, IAW AR 15-6, Sectlon 2-5. after review of a criminal investigation being conducted by the Arkansas State Police, the Safety Investigation being conducted IAW AR 385-10, The Army Safety Program (See 2), and the complete autopsy being conducted by the State Medlcal Examiner?s Of?ce of the Arkansas State Crime Laboratory (See 87). The estimated completion dates of the Arkansas State Police criminal Investigation and Arkansas State Crime Laboratory autopsy are anywhere from three (3) weeks to two (2) months from the date of this memorandum. 4. Summary of Relevant 8 Material Facts. After a thorough review of the evidence, the following relevant and material facts were found during the course of this investigation: a. 20150615, ALARACT 101/2015, Heat Illness Prevention for 2015 Heat Season, dated 25 June 2015 is released (See Exhibit 77). This annual guidance issued by HQDA referenced all of the attendant Army guidance on heat illness, injury, prevention, and mitigation, and prescribed annual training and risk assessment techniques for training in a hot weather environment. b. 201512, 39?1 ESE?began planning for a Small Arms Perimeter Defense Live Fire Exercise (SAPD X) at AT in June of 2016 (See Exhibit 31). c. 20160115, Members of 39th Beam _visited which incu we: Ing ange ,an con Inue execute the SAPD LFX at AT in June 2016 (See Exhibit 31). d. 20160120, 39th IBCT OPORD 16-29 (TY 16 Annual Training Workshop) (UNCLASSIFIED) is issued that includes an attached agenda and draft staff slides (See Exhibit 4). SHEECT: Fln!ings and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas e. 20160202, Members of 39?? BSB, in particular attend the 39'11 IBCT AT 2016 Planning Conference at (See I I f. 20160211, the 39th IBCT OPERATION ORDER 16-35 OPERATION BOWIE SHIELD (Bowie Annual Training TY16) is issued that contains the directive that units would follow the requirements of ATP 5-19 Risk Management - April 2015, that a DD Form 2977 Deliberate Risk Assessment Worksheets (September 2015) would be executed to the level of mission execution, and that OICs and R80 would receive safety brie?ngs for safe range operations during AT from Range Control (See Exhibit 5). 9. 20160415, received email noti?cation that he would serve the form of a CONOP (See Exhibit 30). h. 20160517, Members of 39m B88, in particular? visited to continue planning or an execu PD ee Xll31). q. 20160518, ALARACT 042/2016, Heat Illness Prevention for 2016 Heat Season, dated 18 May 2016 is released (See Exhibit 76). i. 20160604, mmade Heat Safety/Risk Assessment Reference cards available at the Briga ee Exhibit 92). j. 20160604,m Range Control conducted a General Range Safety Brie ee and 51), a Small Arms Safety Brief (See Exhibit 9), and had artici ants sign in. A sign in sheet dated 4 June 2016 includes the signature of (See Exhibit 10). The General Range Safety Brief includes anguage a a medic leaves the range, training will cease until helshe returns or another quali?ed medic is on site. It also included language that range control would publish current wet bulb status hourly over the primary FM when the heat category reached green, and when time and op tempo allowed as a courtesy to training units. The Small Arms Safety Brief includes language that the minimum PPE level for small arms range is 1 but the unit commander may require a higher level and that communications, medical requirements, and medical emergency procedures are the same as in the General Safety Brief. k. 20160612, at the Battle Update Brief and the Commanders Update Assessment. the Brigade Safety, - covered heat stress as a watch out to the commanders (See Exhibit 92). I. 20160612, a memorandum is completed certifying that the listed 0le and R805 and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas with the 39?" BSB were certi?ed by the Organizational Safety Program for small arms ranges and all training areas for TY 2016, and met the safety certi?cation requirements as listed in AR ARNG 385?63-1, Ran 3 Re ulation See Exhibit 73 and RMTC Ran Re ulation that included m. 20160612, FRAGORD 07 Alpha, 39th BSB OPERATIONS ORDER 16-01 (OPERATION) is issued stating Charlie Med would transition from level 1 to level 2 medical care once the main body arrived (See Exhibit 6). This order also included an SAPD LFX CONOP as Attachment 1 and a timeline of the training related to Range 100 from 12 June through 15 June as Attachment 2 (See Exhibit 6). The SAPD LFX CONOP states under the heading Safety that it will be hot so hydration needs to be monitored. The timeline showed that Alpha Company was scheduled to arrive at Range 100 at approximately 0630 and SP to the cantonment area at approximately 2000 hours. n. 20160612, Charlie Med does not transition from level 1 to level 2 medical care due to staf?ng availability as stated in FRAGO 07 Alpha, 39th BSB Operations Order 1601 (Operation) (See Exhibits 6 and 40). 39th IBCT DCO, units are made aware of the change in the Charlie Med medical care level and the level of care provided by the TMC as AT progressed. 0. 20160612, FRAGORD 08 Alpha, 39th BSB OPERATIONS ORDER 1601 (OPERATION STONEHENGE) (UNCLASSIFIED) is issued with a revised SAPD LFX CONOP as attachment 1 and includes a map of ambulance exchange points (See Exhibit 7). p. 20160612, 39lh BSB completes FTX and moves to cantonment area to begin preparation for SAPD LFX by conducting rehearsals (See Exhibit 15). q. 20160613 A 00/39"1 BSB conducts recon of Range 100 with Key Leaders. for Range 100, arrives r. 20160614050m at 201606140540 and eglns 0 receive pa Iclpan unl 0/39?1 BSB). (See Exhibit 30). s. 201606140530, A Col39?I BSB SP's for Range 100AA UV 9938 0171 in support of Range 100. t. 201606140642, A Co/39th BSB RP's at Range 100AA 9938 0171 in support of Range 100. A 00/39?1 BSB originally overshot the Range 100AA, arriving at Range 100, then needing to backtrack to the Range 100AA. u. 201606140700, A 00/39"1 BSB receives hot breakfast at Range 100AA UV 9938 0171. I: !1 n!I ngs and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Cha?ee, Arkansas v. 201606140700, General Range Safety Brie?ng is provided to OIC and R30 (See Exhibit 12). This brie?ng states that if the MEDIC leaves with a patient you must go into a check ?re until they return or give Range Control another medic's name who must meet the same requirements (See Exhibit 12, page 2). The brie?ng also states that any accident/incident involving medical evacuation out of the training area will be immediately reported to Range Control. Finally, the brie?ng states that wet bulb will be put out as a courtesy, time permitting, by range control at top of the hour as a net call over all means of communications. w. 20160614, 39th IBCT Battle Update Assessment brief conducted on this date advised the weather forecast for Fort Chafiee of a high of 95 degrees and a heat index of 109 degrees (See Exhibit 13, page 7). The Med Tracker slides shows 833 had 10 heat related issues to this point of AT (See Exhibit 13, page 21). Safety Slide shows a visit to BSB Live Fire Range 100 conducted by the Brigade Safety Of?cer within last 24 hours (See Exhibit 13, page 40). The Safety Trends slides stated monitor water usage (ice availability) on lanes and enforce canteen/camelback with water. x. 20160614, 39th BSB Deliberate Risk Assessment for Small Arms Perimeter Defense LFX is prepared by! and signed off on by? (See Exhibit 16). The assessment Ist as a azard hotIcold weather Injury an rnItIa risk level of moderate. Under control, the assessment has monitor weather reports, soldier hydration, and wet globe bulb temperature, ensure a water source and sunscreen is available. Under how to implement, the assessment has ensure that soldiers arrive to training hydrated, possess a ?lled water source, and weather appropriate clothing/equipment, monitor hydration, and be prepared to treat casualties. Under who will implement, the assessment has unit leadership, OIC, NCOIC, Range Safety, personnel supervise, medics are prepared to treat weather injuries, and R80 issues safety brie?ng. Finally, the assessment lists the residual risk level as low. y. 201606140700? dictates the minimum uniform for the range as: eanng protection, protection, and gloves, IBAIIOTV will be worn during blank ?re and live ?re (See Exhibit 30). That said, there are reports that IOTV's were worn during all phases of the exercise. (See Exhibit 43 and Exhibit 44). This inconsistency will be further discussed below. z. 201606140750, A Co/39tl1 BSB moves to Range 100 to begin improving ?ring positions. After approximately an hour, Soldiers began to make it aware that they were running out of water (See Exhibits 30 and 52). aa. 201606140900 approximately, Possible UXO identi?ed on Range 100 near FP3-Range 100 is delayed for removal of UXO, but Soldiers continue to improve their Firing Points to the North of FP3 (FP3 is the Southemmost FP on Range 100). (See Exhibits 17, 30, 43, 55, and 93). Flngings and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas bb. 2016140900,? identi?es that it is already getting hot on Range 1 an ters were omg eve mg in their IOTV's (See Exhibits 43 and 52). cc. 2016140900, request the Water Buffalo be moved from Range 100AA to Range 100 (See Exhibits 33, 43, 52, 61, and 68). The Water Buffalo was originally located at Range 100AA, approximately one mile away (See Exhibit 30, Exhibit 31, and Exhibit 52). dd. 201606140914, weather at KFSM (Fort Smith Airport) reports the heat index as 84.2 degrees (Heat Cat 2) according to published information from NOAA (See Exhibit 14). ee. 201614060914, sends text message tom to arrange for delivery of ice or a er Buffalo, additional water, an a ora IS mission was previously planned to be executed at 201606141300) (See Exhibit 43). ff. 201606140953, weather at KFSM reports the heat index as 88.8 degrees (Heat Cat 4) according to published information from NOAA (See Exhibit 14). gg. 201606141000-30, Soldiers from A Co allowed to take ?rst break after arriving at Range 100?it is approximately at this time the Soldiers took a lunch break. (See Exhibit 31). hh. 201606141030, The Water Buffalo arrived at Range 100 and positioned at the A Co. TOC (See Exhibit 31 and Exhibit 43). Range 100 stretched from FP1-UV 99155 00256 to FP3-UV 99135 99841, or 415 meters, the A Co. T00 is identi?ed to be located directly in the middle of Range 100?approximately 200 meters from the furthest ?ring point on each end of Range 100 (See Exhibits 7 and 16). ii. 201606141030 (approximately), A C0139th BSB initiates ?rst iteration of dry ?re on Range 100 (the unit will complete at least three iterations of dry ?re before starting blank ?re-each iteration of dry ?re was approximately 20-30 minutes, with a hot-wash between each iteration) (See Exhibit 31). jj. 201606141045 to 1300, the Brigade Safety Of?cer, was on Range 100 during this period of time and oke with the Ran OIC, NCOIC, and the Company Commander (See Exhibit 92). to shut down the range if there were any safety issues (See Ex i i 92). re orted that there had not been any heat casualties at that point (See Exhi I . observed adequate leadership coverage on the range and observed no imme 1a ns See Exhibit 92). kk. 201606141053, weather at KFSM reports the heat index as 93.0 degrees (Heat I !I n!!ngs and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas Cat 5) according to published information from NOAA (reported weather at KFSM will remain at Heat Cat 5 through 201606142153). (See Exhibits 13, 14, and 93). ll. 201606141148,Hreceives text message from that the ice and water mission is rea to but they are waiting for ?who will ride with them to Range unclear when, but sometime after* arrived at Range 100 and during the dry ?re iterations, the decision was ma to own grade the uniform from IOTV during all phases to no during blank ?re and ?re (See Exhibits 30, 31, and 91). This also contradicts the guidance in# statement (See Exhibit 30) advising the uniform was no IOTV until an Ire egan. Several statements identify Soldiers continue to wear the IOTV throughout the dai iSee 41Not Ion after? arrived on the range, at 9 ad assessed and treate two eat casua ties a rea 0 were coo In 0 In an air conditioned (See Exhibit 94). discussed with ?shed mitigation issues and assessed the measurest at were being implements ee Exhibit 94). nn. 201606141200 (approximate) sworn statement the unit is in Heat Category 5 (See Exhibit 4 . oo. 201606141239, arrives with 20 bags of ice and Gatorade executed a second ce mISSlon perq request at 20160614163 arrived with - and stays untI and of the training day (See Xllt. pp. 201606141250, ten (10) minutes to allow it to acc mate to the weather around 1300, checked the reading and had reading it correct y. twas Heat Category 5. logged it into the 1594 log (See Exhibits 17 an 9 . Range Control placed a wet bulb out and waited outside See Exhibit 49). At verify that he was roa caste it over the net and qq. 201606141253, weather at KFSM reports the heat index as 96.0 degrees (Heat Cat 5) according to published information from NOAA (See Exhibits 13-14). rr. 201606141319, Heat category put out by? via net call at Heat Cat 5, 91 Degrees, and put into the 1594 log (See Exhibit 7, page 10, and Exhibit 49). ss. 201606141330-1500, This is approximately when the 3 dry ?re iterations were complete. (See Exhibit 30). tt. 201606141421, Range 100 calls in two possible UXOs (See Exhibit 17). IU I lingings and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas uu. 201606141453 weather at KFSM reports the heat index as 100.7 degrees (Heat Cat 5) according to published information from NOAA (See Exhibits 13-14). w. 201406141500 identi?ed as showing signs and mptoms of succumbing to the heat an 18 eva uate range medicsH (See Exhibits 19 and 31). There is an inconsistency on en was ?rst I entI ied as succumbing to the heat (See Exhibit 19, 32, and 93). This will be addressed below in the ?ndings section. ww. 201606141530 as a possible heat casualty, is treated at Range 100 I It 30 ut Is not later identi?ed as a heat casua ty In the 888 heat casualty slides (Exhibit 19). xx. 201606141530, are evaluated by medics an ater remove rom ange 100 by FLA to AXP 6, then transporte tot rear administratively in NTV (See Exhibits 19, 30, 32, and 93). . 201606141530-1613 (approximately), expresses tob- Wthat it was hot and not enoug breaks were elng taken ee I It 9. 22. 201606141545, - requests a ?hot time" for blank ?re?this is also re?ected in the Chaffee range control incident log (1594) (See Exhibit 18 and 30). 201606141545-1615 (approximately), made a recommendation to that at this point the level of trainin bein received was not worth the risk of Injury ee Exhibits 30 and 91). that he wanted it noted that he thought they needed to cease training as It was not ene?cial at that point and asked if he should direct that recommendation to (See Exhibits 30 and 91 said that he would sieak tom ee Exhibits 30 and 91). spo with and It was ecr at the blank ?re iteration woul! inlshed and reeva uate possibility of conducting the live ?re portion (See Exhibit 91 and 94). 201606141553, weather at KFSM reports the heat index as 103.2 degrees (Heat Cat 5) according to published information from NOAA (See Exhibits 13-14). 201606141613 advises he approved request of to evacuate 3 ambulatory suspected heat casua les to rear AD by FLA with exchange at Ambulance Exchange omt at intersection of Marietta Church Road and Highway 22 (See Exhibits 19, 31, d. 201606141615_evaluated again by medics (See Exhibits 19,88, and 90). There is an inconsistency on when 11 and 93). EHHEE !ln!ings and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas was ?rst identi?ed as succumbing to the heat (See Exhibits 19, 31, 88, and 90). This inconsistency will be addressed below in the ?ndings section. 201606141630, During the trip to the rear A0 for_ and others, ?condition worsened and mission turned into a medica transport to TMC at a ee (See Exhibits 19 and 32). 201606141653, weather at KFSM reports the heat index as 100.7 degrees (Heat Cat 5) according to published information from NOAA (See Exhibits 13-14). 201606141700, Decision made to transport_ directly to TMC by medics in FLA (See Exhibit 32). 201606141710, Upon arrival at front gate to FT Chaffee, was demonstrating an altered mental state per medic, ee xhibit 32). 201606141715, 201606141731, 9 Line Medevac called by *on the direction of ?advising? was unconscrous ee xhibits 18, 35 and It . tt time of the ca ange 00 was in in hot/live ?re status and had not noti?ed range control of the heat casualty (See Exhibit 18). Range 100 was placed into a check ?re and instructed to have Range OIC call Range Control. arrives at TMC and is treated by treatment team at advised treatment team he could not walk (See Exhibits 19 and 35). TMC, I 201606141732 to 1752,_called range control. ?ee as to why range control had not been noti?ed of the incident involving aioloiized and informed that there were two other eat casua ties, un ert care of the unit medics that had been brought to te arracs ee 201606141737, Range control journal log shows Range 100 was changed from unit ?ring- unrestricted to cease-?re (See Exhibit 17). 201606141740, CPR initiated on - (See Exhibit 35 and Exhibit 19). 201606141750, Flight medic attempted to intubate - (See Exhibit 19). 000. 201601141752,? to keep Range 100 in a check ?re until current an came to range con ro to receive re-training or replaced with other quali?ed personnel (See Exhibits 18 and 50). 201601141752 (approximately after yy. above), - called - at 12 I and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas Ran Control to report another heat casual from Range 100, m. is transported to the TMC. was later transporte to are ospital with a core temperature of 102.9 ee Exhibits 18, 19, and 68). i was treated and released from Mercy Hospital (See Exhibit 19). 201606141753, weather at KFSM reports the heat index as 100.7 degrees (Heat Cat 5) according to published information from NOAA (See Exhibits 13-14). 201606141800, Medevac departed FT Cha?ee (See Exhibit 19). 555. 201606141805, Medevac arrived at Mercy Hospital (See Exhibit 19). 201606141817, - pronounced dead by hospital staff (See Exhibit vw. 201606141853, weather at KFSM reports the heat index as 99.3 degrees (Heat Cat 5) according to published information from NOAA (See Exhibits 13-14). 01606141914, and advises th 18). 201606141923! noti?es range control that_ would be transported to the TMC for urt or care (See Exhibit 18). noti?es range control of another heat casualty, ervrcemember would be evaluated on site (See Exhibit 201606141953, weather at KFSM reports the heat index as 97.0 degrees (Heat Cat 5) according to published information from NOAA (See Exhibits 13-14). 222. 201606141956, was advised that was ?own Medevac to Mercy Hospita an arrived there at 2002 hours ee ibit 18). i was released from Mercy Hospital around 2147 hours (See Exhibit 19). 201606142215, 39th 388 status on Range 100 changed from training complete to departed (See Exhibit 17). 5. Findings. After a thorough review of the evidence gathered in the course of my investigation, I have concluded that: a. Findings Related to the Incident: (1) Battalion and company leadership failed to comply with the requirements of ALARACT 042/2016 (See Exhibits 76, 91, and 94). ALARACT 042/2016, which directs Army units conducting operations in hot weather environments to develop a written heat stress prevention program and directs commanders to ?immediately reuevaluate all unit 13 I: and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas personnel and mitigation actions when any heat illness occurs? (See Exhibit 76 at 4.8.1.0.). Battalion and company leadership did not develop a written heat stress prevention program and did not stop range operations to re-evaluate after the initial heat illness (See Exhibits 30, 31, 44, 91, and 94). The guidance in ALARACT 042/2016 is material to this investigation as was one of multiple Soldiers to show the signs and of succum ing tot heat at Range 100 on the afternoon of June 14th, 2016 (See Exhibit 19). Additionally, by mixed reports, had previously identi?ed to at least one of the medics on Range 100 that he was su ering from heat cramps earlier in the day (See Exhibit 19). The leadership on the range did not re- evaluate all personnel or reassess the mitigation actions it had in place on Range 100, even after it evacuated three heat casualties from Range 100. The leadership on the range did not cease training on Range 100 until Fl' Chaffee Range Control decerti?ed the Range and R80 for failure to report the heat casualties throughout the day and closed Range 100. (Exhibits 50 and 51). (2) 39?? 383 leadership and staff did not adequately identify the hazards associated with training in the hot weather environment on 20160614. A deliberate risk assessment (DD FORM 2977) was prepared for Range 100 See Exhibit 16) by The Deliberate Risk Assessment form prepared and approve by appears to have been adopted from a prevrous used (or canned) statement Wit respect to the identi?ed hazard of ?hot/cold weather injury" and did not suf?ciently address the magnitude of the hazard of training in a hot and humid weather environment (See Exhibit 16). Additionally, unit leadership did not adequately identify, implement, and monitor suf?cient controls to mitigate the hazard. The control and implementation guidance identi?ed on the deliberate risk assessment demonstrates the unit was tangentially aware of the Army guidance with respect to training in a hot weather environment. However. as the sworn statements identify, it is clear the individual uniform mitigation guidance identi?ed on the deliberate risk assessment was not followed or strictly adhered to. (3) Range 100 was planned and resourced in accordance with the requirements of the Ft Chaffee Range Regulation (See Exhibit 73) and the AR ARNG Range Safety SOP (See Exhibit 72). The planning was adequate with the exception of ensuring a suf?cient and accessible water supply (See Exhibits 6 and 7). (4) The unit leadership did not provide the Soldiers on Range 100 with suf?cient access to appropriate sources of hydration throughout the training day. Water. ice. and Gatorade was planned for Ran 100, but was not ushed to the range as early in the day as necessary. sworn statement (Exhibit 43)- company planned to resource Ice an atora to supplement the water buffalos available at Range 100, but did not plan to execute this mission until 1300 on the 14th. Also, Range 100 was planned to be conducted at two locations, the Range 100AA (assembly area) and the Range 100 ?ring line (See Exhibit 7). The water buffalo l4 I and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas provided for Range 100 was initially posted at the Range 100AA (See Exhibit 43). The assembly area was approximately one mile from the ?ring line. Soldiers started reporting early in the day on 14 June they were running black on water (See Exhibits 52). At this time, the water buffalo was stationed at the Range 100AA approximately one mile from the ?ring line (Exhibit 30, Exhibit 31, and Exhibit 52). The water buffalo was ?nally moved to Range 100 at approximately 1030. (Exhibit 31 and Exhibit 52). Based on the conditions present at Range 100 on June the Soldiers on the range requested and received permission, then resourced with their LMTV to move the water buffalo from the Range 100AA to a location just behind the Range 100 ?ring line. (Exhibit 30). This placed the water buffalo no more than 200 meters from an Soldier trainin on Range 100 (See Exhibits 8, 31, 43). Also, M, to arrange to move the planned ice and atora miseron to ear Ier In ay on June 14"1 (See Exhibit 43). The mission was delayed and did not arrive until 12:39, 21 minutes prior to its planned time of arrival (See Exhibit 43). ?decided to ride out to the range with the convoy bringing the ice and Gatorade (See Exhibit 43) which resulted in the delay. (5) The unit did not adequately mitigate the uniform for the Soldiers on Range 100. If guidance was provided on the status of the individual uniform, it was not adequately disseminated with appropriate command guidance. (See Exhibits 30, 31, 43, 91, and 94). (6) The unit did not follow the requirements for reporting medical evacuations from Range 100 to Range Control, as required by Range Safety Brie?ng and the AR ARNG Range Safety SOP (See Exhibits 12 and 72). The unit took the steps to have FT Chaffee Range Control certify the training for the Range OIC, NCOIC, and R80 as required by FT Chaffee Range Regulations (See Exhibit 11). Despite the training, the unit failed to report to Range Control the evacuation of three heat casualties from Range 100 as required by the FT Chaffee range safety brie?ng. This resulted in Range Control decertifying the Range OIC, NCOIC and R80. This resulted in Range Control placing Range 100 in an administrative check ?re (See Exhibit 51). (7) It started getting hot early that morning, with the temperature continuing to rise throughout the day (See Exhibits 14, 19, and 49). Based on published historical weather data, the unit was in a Heat Category 5 environment from 1053 hours in the morning until 2153 hours that same night. (See Exhibits 14 and 17). Numerous sworn statements indicate that the medics on the range were pushing out the Heat Category on net calls. were present on Range 100 during the entiretyo operations. ee I It an Ibit43). on the range at approximately 1239. Once 15 I !I n! ngs and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas m, was present on the range, ecame accounta ort eactlonso ea ers and the Soldiers with res ect to environment and the prescribed uniform. Further, was present on Range 100 from the initial set-up of the range on 20 606 roug decerti?cation of Ran 100 by Range Control that evening. From the time of the arrival it was tantamount to his duty to ensure every Soldier was ta mg a ro nate recautions to mitigate the effect of the environment. It was the duty of the to appropriately advise based on the conditions and the ect 9 conditions on the Soldiers In traInIng environment. Their respective duty included to ensure no Soldier continued to wear their individual body armor (until the live ?re iteration). voiced their concerns to ort esa etyo Iers ue tot 9 eat, however, training continue . ee I It 30, 34, 91,and 94 . Further, Hboth discussed the issue with . ee I it 0, 2,6 ,and 93). (11) Beginning at ap roximatel 1500 - 1530, multi le Soldiers were re orted as havin ossible heat in'uries #(See I It 30 an 68. utIpe Iers state at esptte the eat an eat re ated injuries, continued the training. (See 30and 91). The unit I not cease training on Range 100 until Fl' Chaffee Range Control decerti?ed the Range and R80 for failure to report the heat casualties throughout the day and closed Range 100 (See Exhibit 51). showed signs and of succumbing to heat at a roxrmate 20 606 5 5 re at Range 100 at (See Exhibit 32). death occurred after he was identi?ed as having a possible heat related Injury. aut0psy is being performed, the results of which will be made available to the Arkansas National Guard (See Exhibit 87) through the Arkansas National Guard Chief of Military Justice. It should be noted that the Findings and Recommendations contained herein are preliminary and may be supplemented. IAW AR 15-6. Section 2-5. after review of the complete autopsy being conducted by the State Medical Examiner's Of?ce of the Arkansas State Crime Laboratory (See Exhibit 87). The estimated com letion dates of the Arkansas State Crime Laborato auto 3 is anywhere from three (3) weeks to two (2) months from the date of this memorandum. (13) The main inconsistencies in the witness statements relate to the timeline, guidance received by the Soldiers with respect to uniform status, work/rest cycles as the heat category changed throughout the day, the time and source of the heat category warnings received by the unit at Range 100, the number of times? was reported as a heat casualty, and the observations of the 5-306?1 88 INF BDE lb I: and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas personnel. I address each of these inconsistencies, my conclusion, and how I reached my conclusion below: i. As to the timeline, a general reading of the statements attached as exhibits will reveal very few de?nite hard times throughout the day. It is clear the original timeline for the range was delayed by several factors (See Exhibit 7). The ?rst signi?cant delay was the discovery of a suspected unexploded ordnance (UXO) near ?ring point 3 (FP3) (See Exhibits 17, 30, 43, 55). The training for the unit was also delayed throughout the day by leadership directing multiple iterations of dry ?re and blank ?re based on perceived training de?ciencies. (See Exhibits 30, 31, 43, 55). There is also confusion in the statements as to the precise time SPC Cline ?rst identi?ed himself as potentially succumbing to the effects of the heat. (See Exhibits 30, 31, 32, 36, 43i. Finally, it is not clear both who and when the direction was iven to allow to depart Range 100 in the FLA with ?See Ex I Its .27, 30, 31, 32, 36, 8: 43). ii. As to the duty uniform, there were inconsistencies in the original uniform status prescribed by leadership for the range, speci?cally whether the individual body armor was to be worn throughout the day for all activities or, whether it would only be worn when the blank ?re iteration was started and then for the live ?re iteration. According tomwee Exhibit 30), the initial brie?ng dictated a minimum uni orm ort range as: CU, ACH, FLC, hearing protection, rotection, and gloves, with to be worn during blank ?re and live mew later states that he re uested that blank ?re Operations be conducted wit outt (See Exhibit 30)? however, states that IOTV was initially worn during all phases, but was own ra by? during blank and dry ?re (See Exhibit 31 and 91). state at was Informed that the N005 had the Soldiers wearing eir even though told them they didn?t have to, and that a few NCO's continue to weart em a as Exhibit 44 and Exhibit 52, Statement ofmm Exhibit 93). stated that the uniform of the day was gorng to LBV or FLC, he met, oves, water sources, vest with plates, and weapons (See Exhibit 93). #stated ma? put out that the uniform was not going to be vest Wit ates added untt ive ire ee xhibit 93 and 94). stated that the Soldiers were wearing their while buildin their ?ring positions, In contradiction to whaF stated (See Exhibit 43). stated that the Soldiers were in full ?battle ratt around 0630 (Exhibit 38, 6 an . stated that the initial plan was to conduct the blank ?re in IOTV however, ase on eat, he authorized the conducting of the blank ?re iteration without adding the IOTV (See Exhibit 94). As to the work rest/cycles, the sworn statements attached to the investigation do not re?ect a deliberate decision by the leadership at Range 100, the company, orthe battalion to alter the activity on Range 100 speci?cally in respect to the known or SHEECT: Fin!ings and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas identi?ed heat category and the published Army guidance on mitigation for training in a hot weather environment. Several of the statements do refer to the ?hot wash" following iterations on the range as proof the unit was observing a work/rest cycle (See Exhibits 25, 31, 91, and 93). However, in clear contradiction to this, several of the Soldiers on Range 100 identi?ed there were no ?rest cycles" and did not view the ?hot washes? as a rest period out of the heat or out of the prescribed uniform (See Exhibits 43, 55, 63, 8 68). There is no evidence that the standard work/rest times for Heat Category 5 and moderate work, which includes marksmanship training, were implemented which suggest forty (40) minutes of rest for every twenty (20) minutes of work (See Exhibits 78 and 83). iv. The 39th IBCT published a digital Battle Update Assessment (BUA) as part of its battle for AT 2016 (See Exhibit 13). Included in the BUA was a published 5- day weather forecast for FT. Chaffee. (See Exhibit 13, page 7). The weather for Tuesday, June 14, 2016 was forecast for a high of 95 degrees with an identi?ed heat index of 109 degrees. This forecast placed the training environment into a heat category of 5, which identi?es attendant uniform and work rest cycle mitigations per published Army guidance (See Exhibit 84). The unit planned to train wearing their individual body armor as part of the prescribed uniform. Army guidance advises training while wearing individual body armor raises the heat index by 5 degrees. Also, the unit is directed by Army guidance to maintain a Wet Bulb Globe Thermometer and monitor it hourly (See Exhibit 84). Numerous sworn statements attest the unit was tracking the WBGT and also received net calls from FT Chaffee Range Control on the status of the WBGT index (See Exhibits 36, 43, 8 68). v. According to the 888 Heat Casualty Medical care slides See Exhibit 19), was initially evaluated by Med medics ?at approxrmately 1500 and the cool down process was begun. (Exhibit 70). The report states that - then chose to return to training at the range. (Exhibit 19). A second evaluation was performed by Med medics at approximately 1615, which resulted in _evacuation. (Exhibit 19). The initial evaluation was addressed in econd statement, whereby?tated this evaluation occurred during the dry (Exhibit 89). nitial heat injury was corroborated by whereb he stated that _efttogoo . er?then returned one last time to attempt to continue, but could not and left. (Exhibit 41). vi. Address statements from Observers. I did not ?nd the statements from- ith the 5-306"1 888, 133th INF BDG (See Exhibit 25, 26, 27) persuasive. These individuals were not on the range the entire day, from their statements they did not appear to have knowledge of the heat category on the range, and none of them provided evidence they were familiar with the requirements of ALARACT 042/2016 (See Exhibit 76) and in particular the 18 I and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas requirement to "immediately re-evaluate all unit personnel and mitigation actions when any heat illness occurs" (See Exhibit 76 at 4.B.1.Q.). b. Findings Regarding De?ciencies with Policy, Procedures, Training, and Leadership. (1) Army Technical Publication No. 5-19 (ATP 5-19) provides Army doctrinal guidance on Risk Management (See Exhibit 86). It incorporates the safety guidance and techniques outlined in other Army publications to provide a framework for leaders to identify and assess hazards then develop, implement, and monitor controls to mitigate the hazards. The Army guidance assumes risk management will be a deliberate staff process implemented in a manner to allow risk decisions to be made at the appropriate level. ATP 5-19 (See Exhibit 86) states that risk management is to be a cyclical and continuous process speci?cally geared to allow leaders to accept no unnecessary risk. (2) At the time of this incident, ALARACT 042/2016 - All Army Activities guidance on Heat Illness Prevention for 2016 Heat Season was in effect. (See Exhibit 76). This ALARACT is annual guidance (See Exhibit 76 and 77) issued by HQDA referencing not only all of the attendant Army guidance on heat illness, injury, prevention, and mitigation, but also prescribes annual training and risk assessment techniques for training in a hot weather environment. Among the references in ALARACT 042/2016 is TRADOC Regulation 350-29, which includes speci?c guidance on preparing the DD FORM 2977 Deliberate Risk Assessment for training in a hot weather environment (the regulation identi?es an earlier form for the DRA, but the substance is the same) and outlines and provides concise guidance on the practical implementation of many of the mitigation techniques identi?ed in other Army guidance (See Exhibit 80). Speci?cally, ALARACT 042/2016 (See Exhibit 76), directs Army units conducting operations in hot weather environments to develop a written heat stress prevention program. The ALARACT further directs commanders to ?immediately re-evaluate all unit personnel and mitigation actions when any heat illness occurs? (See Exhibit 76 at 4.8.1.0.). (3) The Arkansas Army National Guard lacks a strategic level heat illness prevention program in regards to the recognition, prevention, and mitigation strategies related to heat Illness prevention as outlined in ALARACT 042/2016 - All Army Activities guidance on Heat Illness Prevention for 2016 Heat Season (See Exhibit 76). (4) While the does have some material related to heat illness prevention within its brie?ngs and SOPs (See Exhibits 8, 9, 12, 72 and 73), it lacks a comprehensive guide to provide guidance to commanders in preventing environmental heat casualties and is not as complete as recommended in ALARACT 042/2016 - All Army Activities guidance on Heat Illness Prevention for 2016 Heat Season (See Exhibit 76). I9 I: and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Chaffee, Arkansas (5) While the Fort Chaffee Training Site AR ARNG Range Safety SOP dated 6 March 2013 (See Exhibit 72) states that Range Control will announce the current wet bulb status AT THE RANGE CONTROL BUILDING hourly over the primary FM frequency when the heat category reaches green, other Fort Chaffee material states that this information will broadcast based on operation tempo or as time permitted (See Exhibits 8 and 12). It is apparent from numerous statements that the information was being pushed out but not put into the log. (6) The Fort Chaffee Regulations, SOPs, and training briefs have inconsistent language regarding the reporting requirements for heat casualties (See Exhibits 8,9, 12, 72, and 73). Only the Range Safety Brie?ng (See Exhibit 12) makes it clear that any accidentlincident involving medical evacuation out of the training area will be immediately reported to Range Control. These other materials are not as direct on this subject. (7) The TY16 Annual Training Workshop conducted on 2-3 February 2016 did not address or discuss heat illness prevention (See Exhibit 4). c. Regarding Subjects. SUBJECT: Findings and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Cha?ee, Arkansas 6. Recommendatlons. In view of the above ?ndings, I make the following recommendations: a. Arkansas Army Natlonal Guard Recommendatlons: 21 SUBJECT: Findings and Recommendations for Army Regulation (AR) 15-6, Arkansas Army National Guard, Training Accident, Fatality During Annual Training, Fort Cha?ee, Arkansas b. Specl?c Recommendatlons Subjects: SUBJECT: Findings and Recommendations for Anny Regulation (AR) 15-6. Arkansas Army National Guard. Training Accident. Fatality During Annual Training, Fort Chaffee, Arkansas REPORT OF PROCEEDINGS BY INVESTIGATING OFFICER Note. Completed forms may contain personally identi?able inforrnatlon and require handling as set forth in AR 340-21. For use of this' form. see AR 15-5; the proponent agency is OTJAG tF MORE SPA CE iS REQUIRED IN FILLING OUTANY PORTION OF FORM. ATTACH ADDITIONAL SHEETS SECTION I - APPOINTMENT Appointed by Maj Gen Mark Berry. TAG Arkansas {Appointing authority) on 20160615 {Attach enclosure 1: Letter of appointment or summary of orai appointment data.) {See para 3-15. AR 15-6 (Date) SECTION II . TIMELINE 1. The (investigation) commenced at Ft- Chaffcc, Arkansas at 1100 (Piece) (Time) on 20160615 (Date) 2. The (investigating officer) ?nished gatheringihearlng evidence a 0300 on 20160713 and completed (Time) (Date) findings and recommendations at 1200 on 20160714 (Time) (Date) SECTION - CHECKLIST FOR PROCEEDINGS A.COMPLETEIN ALLCASES EYES 1 1. Enclosures (para 3-13. AR 15-6) Are the following enclosed and numbered consecutivety with Roman numerals: (Attached in order tisted) a. The memorandum of appointment? b. All other written communications to or from the appointing authority? c. Privacy Act Statements (Certificate. if statement provided bratty)? d. Explanation by the investigating of?cer of any unusual delays. dif?culties. irregularities. or other problems encountered (9.9.. absence of materiai witnesses) a. Any other significant papers (other than evidence) relating to administrative aspects of the investigation? f. An Executive Summary. Index of Exhibits. of the Investigation and lists of all persons interviewed and evidence gathered. (Comptex, serious and/or high profits cases)? 2. Exhibits (para 3-14. AR 15-6) a. Are all items offered (whether or not received) or considered as evidence individually numbered or lettered as exhibits and attached to this report? b. Is an index of ail exhibits offered to or considered by Investigating of?cer attached before the ?rst exhibit? c. Has the testimonyistatement of each witness been recorded verbatim or been reduced to written form and attached as an exhibit? d. Are copies. descriptions. or depictions {if substituted for rest or documentary evidence) properly authenticated and Is the location of the original evidence indicated? a. Are descriptions or diagrams included of locations visited by the investigating of?cer (Appendix 6-3. AR 15-6)? i. la each written stipulation attached as an exhibit and is each oral stipulation either reduced to writing and made an exhibit or recorded? IZI UEEZIIZIIZIEI IZI DECIDED FOOTNOTES: 1; Expiain negative answers on an attached sheet. 21 Use of the MA cotumn constitutes a positive representation that the circumstances described in the question did not occur in this investigadon. DA FORM 1574-1, APR 2016 PREVIOUS EDITIONS ARE OBSOLETE. Page 1 of 4 APO LC SECTION IV - FINDINGS {para 3-10, AR 15-6) The (investigating officer). having carefully considered the evidence. ?nds: [Each paragraph should be one conclusion based on the evidence gathered during the investigation. These ?ndings should provide answers to each question posed by the appointing authority in the appointment memorandum. The evidence that supports each finding must be cited] IAW AR 15-6, 3-12. 21., my ?ndings are included in the attached memorandum. DA FORM 1574-1, APR 2016 Page 2 of 4 Alan LC SECTION VI (para 3-15, AR 15-6) SECTION VII - ACTION BY APPROVING AUTHORITY {para 2-8. AR 15-6) The ?ndings and recommendallons of the {investigating of?cer) are: DA FORM 1574-1, APR 2016 Page 4 of 4 APB Lc v1.01es MILITARY DEPARTMENT OF ARKANSAS OFFICE OF THE ADJUTANT GENERAL CAMP JOSEPH T. ROBINSON NORTH LITTLE ROCK. ARKANSAS 72199-9600 ASA MARK H. BERRY GOVERNOR MAJOR GENERAL THE ADJUTMIT GENERAL NGAR-TAG 15 June 2016 SUBJECT: Appointment as Army Regulation (AR) 15?6 Investigating Of?cer 1. Appointment. You are hereby appointed as an Investigating Of?cer (IO) pursuant to AR 15-6, Procedures for Administrative investigations and Boards of Officers, to conduct an administrative investigation into the facts and circumstances surrounding the death of a Service-member performing duties at range 100 at the Fort Chaffee Joint Maneuver Training Center during Training Year 16 Annual Training on or about 14 June 2016 (See Enclosed Serious Incident Report). Your responsibilities as an l0 take precedence over all other military duties. You have seven (7) days from the date of this appointment to conduct this investigation. Coordinate any request for extensions through your legal adviser. 2. General Instructions. a. The purpose of an AR 15-6 investigation is to elicit facts. You are directed to conduct an investigation into the matters set for in paragraph 3, below. Your Investigation should explore any issues or de?ciencies with policy, procedures, resources, doctrine, training. and leadership that might have contributed to this incident. Upon completion of this investigation. you will complete a report of investigation that conforms to the requirements in paragraph 5 of this memorandum and AR 15-6. You will provide your report to your legal adviser. who will arrange for a legal review. b. If, at any time in the conduct of your investigation, something happens that could cause me to consider enlarging. restricting, or terminating your investigation. or otherwise modifying any instruction in this memorandum of appointment. immediately report this situation to me, together with your recommendation as to [he action i should take in reSponse. 3. Scope of Investigation/Specific Instructions. NGAR- TAG SUBJECT: Accident investigation Board (Safety) Appointment Order a. You are hereby directed to conduct an investigation into the circumstances surrounding the death of a Servicemember performing duties at range 100 at the Fort Chaffee Joint Maneuver Training Center during Training Year 16 Annual Training on or about 14 June 2016 (See Enclosed Serious Incident Report). You should also report whether any personnel should be held accountable for any shortcomings or failures. You are to review the AR 15-6 dated 1 April 2016. and become familiar with the new requirements of th? the requirements of Section 3-19. You will make contact with Arkansas National Guard Sate Safety Manager, regarding the safety investigation being conducted AR 385-10. You will make contact with? Brigade Commander. 39lh IBCT regarding the line of duty investigation being conducted AR 60043-4. These investigations should be closely coordinated to ensure the integrity of each investigation and prevent any adverse impact on the resulting administrative or legal proceedings. b. During your investigation you will. at a minimum. ascertain the following: (1) An inquiry into all the facts and circumstances surrounding the events that transpired before, during, and after the Servicemember's death, particularly with respect to conduct of the Service Members involved; Your ?ndings should include a chronology; (2) A visit to the site of the incident, if possible, to visually reenact the incident, secure physical evidence, take photographs, and obtain accurate measurements; (3) identify and interview all relevant witnesses. Address any inconsistencies in witness statements; (4) Determine the cause of the Servicemember's death; and (5) Determine what. if any, policies, regulations. or Military Code of Arkansas articles, may have been violated. 4. Conduct of the Investigation. a. ?ls your legal advisor. You will consult with your legal adviser before making substantive efforts regarding your investigation. You may reguest that additional individuals or subject matter experts be appointed, in writingI to accompany you and assist you in your investigation. Coordinate such requests with your legal advisor. b. Evidence Collection. NGAR- TAG SUBJECT: Accident Investigation Board (Safety) Appointment Order (1) You are to conduct this investigation using the procedures outlined in Chapter 4, and the general guidance provided in Chapter 3, AR 15-6. No individual has been named a respondent at this time. (2) To the extent possible. witness statements will be written and sworn. You should record witness statements on a DA Form 2823 (Sworn Statement). If it is impracticable to obtain a written and/or sworn statement from a particular witness, you will attest to the accuracy of any transcription or summary of such witness testimony in whatever form it appears within your report of investigation. In accordance with AR 340-21, provide a Privacy Act statement to a witness Form 2823 to record the statement of that witness. and your report will be filed in a system of records from which It can be retrieved by reference to the name or other personal identifier of that witness. No U.S. Military or civilian witness can be ordered to provide information that may incriminate him or herself. You may order a military or Federal Government civilian employee witness to provide a statement if you believe that they have relevant Information that would not incriminate themselves. If. in the course of your Investigation. you come to suspect a person may have engaged in criminal conduct. you will consult with your legal advisor and inform me. Under no circumstances should you attempt to elicit any information from a suspect without ?rst advising that person of his/her rights under Article 31, UCMJ, or the Fifth Amendment of the U.S. Constitution, as appropriate. Document your rights advisement and witness waivers of their Article 31 or Fifth Amendment rights on a DA Form 3881 (Rights Warning Procedure/Waiver Certificate). (3) Where a civilian employee Is a member of a bargaining unit and reasonably believes that the inquiry could lead to disciplinary action against him or her, the employee may have a representative from the bargaining unit present during questioning. You will consult your legal advisor if you have any questions regarding these procedures. (4) Should you determine in the context of your investigation that a Soldier?s status has changed from favorable to unfavorable. as defined in AR 600-8-2, Suspension of Favorable Personnel Actions and National Guard Supplement 1 to AR 600?8-2, you must notify me immediately and consult with your legal advisor, to ensure that a flag is initiated against that Soldier. 5. Report of Investigation. a. General. Your report of investigation will be written. Use a DA Form 1574-1, Report of Proceedings by Investigating Officer, and attach all required enclosures and exhibits. NGAR- TAG SUBJECT: Accident Investigation Board (Safety) Appointment Order b. Assembly. Your completed AR 156 investigation will include: (1) This memorandum of appointment; (2) A completed DA Form 1574-1, Report of Proceedings by Investigating O?icer. (3) A detailed chronology of the daily actions you took during the investigation; (4) An index of all attached exhibits; (5) All exhibits. labeled and numbered; (6) A list of the witnesses you interviewed; (7) If applicable, proper classification markings for each paragraph, page, and exhibits included within your report of investigation; and (8) A memorandum with your findings and recommendations. Findings. You will reach your ?ndings by a preponderance of the evidence that you gather. A finding is a clear and concise statement of facts that can be readily deduced from evldence In the record. In your report, develop speci?c findings and cite the evidence that supports your findings. If evidence conflicts conflicting witness statements), make a finding as to which evidence is more credible and why you believe it to be more credible. Recommendations. Based on your findings. make recommendations as to what changes, if any, are needed in terms of policy, procedures, resources, doctrine, training, and leadership to avoid incidents of this nature in the future, as well as recommendations consistent with your ?ndings concerning other items your investigation revealed. You may not release any information related to this investlgation to anyone, other than your legal adviser, without my prior approval. Encl MARK H. BERRY Major General The Adjutant General MILITARY DEPARTMENT OF ARKANSAS OFFICE OF THE ADJUTANT GENERAL CAMP JOSEPH T. ROBINSON NORTH LITTLE ROCK ARKANSAS 72199 9600 ASA HUTCHINSON BERRY cavemen muck GENERAL ms ADJUTANT GENERAL 15 June 2016 MEMORANDUM FOR SEE DISTRIBUTION SUBJECT: Accident Investigation Board (Safety) Appointment Order 1. Under the Provisions of AR 385?10 and AR 384-40. the following individuals are a ointed as the Accident Investi ation Board members: 2. The purpose of the board is to gather and evaluate evidence, determine causal and/or contributing factors. and prepare ?ndings and recommendations to prevent future accidents. Individuals will be released from all other duties for full-time participation in the subject investigation. The ?ndings and recommendations will culminate in a brief back to the Appointment Authority and the 39-h Infantry Brigade Combat Team Commander. 3. These appointment orders are subject to subsequent amendment/augmentation to include additional subject matter experts at the direction of the board president. 4. In accordance with the Health Insurance Portability and Accountability Act (HIPAA) (Public Law 104-191 enacted by Congress on August 21. 1996), I delegate my authority as a military commander to members of the board to access protected health information about individuals who are Armed Forces personnel when it is deemed necessary by the board president to assure the proper investigation of this accident. NGAR- TAG SUBJECT: Accident Investigation Board (Safety) Appointment Order This delegation of authority shall expire upon the conclusion of the board ?5 findings and recommendations to the Appointing Authority. MARK H. BERRY Major General The Adjutant General DISTRIBUTION: Each Board Member Commander, 39th IBCT Investigation File 4 OI>_u_umm ?>ch