11 .1515 Haas-? FDR General Man. H. Berry, The Adng Gemral. Harm Hazmal Guam, Camp Robmsm. Harm Lane Manse: SUSJECT Friding's and Emma: for Mm; Rm 15-5 ?rm-3.35 Amy Nathan! Guam. Tm: ng Amid-ant. Fatakry mm Trim-pg. For: 13.13.1535 1 .3 km of App-091m daied 15 $312,315. Amy Rm 15-5, Pm far Wm mm and Scams a! 35:25, dated 1 Apr} 3315. 1; AH 355?53. Rawge?afety. da?ieda?damml?ml 5-15.5: Unfambie mam, dated 19 Decanher E- AR BOD-2D. gnu-gm Pa?cy,da?ed 6 W314. {ARBEB-lEvzila?un H: ta??o??amai?s.daie??.h?y2?11 will. DepamnEa?af??ieArijampmel (DA 35%. Range 53:51: ?312: 15 Aw; Tedm?ques Fub?ca?an 5-19, Fith data! 14 Apr} 291:- j- A51 mm: (MST) 04252016, Heat E1253 Pram Ear 3315 He: 5535M, (?31951 Lia? FL Pram far 2015 mm? :32: ?25 Jun: 21315. United States Mae: Heat [319.55me ation 15-5. ul Training, Fort Gha?oe. is for Airti'f REQUI During Ann HEAR-AVH-SAU SUBJECT Finding Anny National Guaid. Training Accident. Arkansas 5 and Reconin'ieiidatioi F?t?ilt'f rant m. TRADCC Memorandum. Subject: TRADCC Heat Illness Prevention Frog 2B16. Dated Februarv Edt?. Site Commander Mentode . . .13? Sater SCP: Guidance and Procedures for Commanders Range Safety LEW Program to Certifv Ctiicers In Charge and Range Satetv Ci'licers i Firing on Small Amis Ranges. dated IE March 2MB. Regulation Fort ed 1? April EDBT. of Heat and Cold Iniurv. n. Fort Gha?ee Training ha?ee o- Arkansas Art'i'ii.r National Guard Maneuver Training Center Range Regulation. dat p. Corps and Fort Hood Regulation BSD-1B. Preventlo dated 25 April EBB-4. 2. Background. Ch 15 June 2MB Major General Marl-t H. Berry. The Adiutant General and Commanding General of the Arkansas National Suard. appointed me as an investigating of?cer IAW AR 15-5. Section 2-1. c. [See Eiihibit The purpose oi the investigation was to determine the facts and circumstances surrounding a training accident resulting In a fataiitvr of an Arkansas Anny National Guard Servicemember during Training Year 15 Annual Training at the Fort Charles Joint Maneuver Training Center on or about 14 June 2MB. The Servicemember was pronounced dead at approximater 131? hours. Tuesday June 141h at Mercy Hospital in Fort Smith. Arkansas. findin that the Brigade Support Battalion leadershi . in . Battalion Command Sergeant Maior. . tailed to adequater address known associa vii weather environment prior to training commencing on Range?t?d on June 2D1S applicable regulations, policyr 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 ton on 14 June 2B1B IAW applicable regulations. policv guidance. and standard reco nized ractices re ardin trainitt in a bi environment. Further. the . Battalion Coignman'ld Sgegaetgiftr Meier. rose eve diar'iIeg igence in eir mu an 14 June effects, of heat on 14 June 2MB. Finally. there are Some inconsistencies within the Arkansas Army National Board at the command me command. battalion. and training center levels In regards to policies roced I training. and leadership related to heal illness prevention programs I was. Cvervlevi'. 2 . In.de tad. rffu . [am 1545. Arkans?? HEAR nd i for Army Regulation 2 and Hecomnie a ions Amiy National ogre. Training Accident, Fatality During Annual Ch Arkansas it should be noted that the Findings and Recommendations contained herein are preliminary and may be supplemented, AR 15-5. Section 245:. after review ofa criminal Investigation being conducted by the Arkansas State Police. the Safety investigation being conducted AR The Army Safety Program {See Exhibit and the complete autopsy being conducted by the State Medical Examiner?s till-lice of the Arkansas State Crime Laboratory {See Exhibit The estimated completion dates of the Arkansas State Police criminal Investigation and Arkansas State Crime Laboratory autopsy are anywhere ?om three weeks to hvo months from the date of this memorandum. 4. Summary of Relevant Material Facts. After a thorough review of the evidence. the following relevant and material facts were iound during the course of this investigation: a. 2m 50515. ALARACT 1 [1151015. Heal Illness Prevention for EMS Heat Season, dated 25 June EMS is released (See Exhibit W). This annual guidance issued by HDDA 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. *1 201512. 39th see, in particular the lt?lAJ Adam Youn beg 1 - a Small Arms Perimeter Defense Live Fire Exercise ens 9' 3" amng ?3 {See Exhibit 31; i 1-in at AT In June of 2015 c. ED160115, Members of 39"? SSE, in particular MAJ Adam Young and CPT Theresa Walker visited which included visitin - - enge ED execute the SAPS LFX at AT In June 2015 [gSee Exhibit Slim d. ED160120. 39th Ist:T oeono 15?29 (TY1B Annual Tralnin ch is issued that includes an attached aggengqa1 anggfaag?a? slides {See Exhibit If! ?tlhunhnh It are.st .. liltii'm" in BUttlemmr-"Ht? ?iimlul lrntiiluu. ?If 1H1. 'i "may N-tlranel Guard. training .r'tceit I iturl Li" I Adm? I Huff-fl I ffmri int-13H. in ~11 :3 this [if-39 Theresa attend the IBGT AT Lt?f? PERM ION ?mu?H l?liffriilhu tliul units 1 - - - rr 1 I'll; I . {Bewie Annual 1 rnirung 'f?t'tl? i5 lei-?3: 1 mull mm [Hi pm [It wrullrl he weuld feilew the requirements at r?tTP 5- 1t] Farm 29?? Deliberate Risk r'tssessInentWeIlrsheels w?um executed la the level at missian execulien. and that titles uni:l ?mum ?in? Him? briefings fer safe range aperatiens during AT fren'i I "lift 5} EDIEIJEI I. the ??ltt IHGT hetilicatian that he weulrl as - 1 g. sates-115. 2LT Daniel Baum received emu GUNDP ?in? the BIG ef the BAPD LFirt train GPT Theresa Walker in the farm ?f Exhibit h. zaisesw. Members areal? in particular MAJ Adam Yeung and Brit Theresa Walker. visited ta cantinue planning far AT and executing the are it {See Exhibit 31}. q.2t1I1Bi:I51Ei. essems. Heat Illness Preventlen tar sate Heat Beasen. dated 15 May Eet? is released [See Exhibit i- 2a1sasaa.cvv2 Tatum made Heat Bafatleisk Assessment Reference cards available at the Brigade TUB [Bee Exhibit 92]. j. 2a1sasua. SGT Patten with Bange Central canducted a General Range Safety Brief {See Exhibits and 51). a Small Firms Safety Elrief [See Exhibit El]. and had participants sign in. Ft sign in sheet dated 4 June 2016 includes the signature pf 2LT Daniei J. Baum {See Exhibit 1a]. The General Range Safety Brief includes tanguage that its medic leaves the range. training will cease until hefshe returns er anether quali?ed medic is an site. It alse included language that range central weuld publish current wet bulb status haurly ever the primary FM when the heat categary reached green. and when time and ep tempa allawed as a caurtesy to training units. The Small Arms Safety Brief includes language that the minimum PPE level fer small arms range is 1 but the unit cammander may require a higher level and that cammunicatiens. medical requirements. and medical emergency procedures are the same as in the General Safety Brief. It. zarsastx. at the Battle Update Brief and the Cemmanders Update Assessment the Brigade Safety. CW2 Tatum. severed heat stress as a watch put te the can?trnanders? (See Exhibit 92}. I. sprees-12. a memerandum is cempleted certifying that the listed [this and BSDs t'i 1 1511. gun: munnml Army.1 Hahenal ?uent. Training 51.115155" 1 Ia Batuty Fragrant [er 51111111 email and met the aalety certificailah reguhemun a - hihit r.53.1. Range Regulallan {See Ex included the name at 2LT Daniel 51111111 ahri algneri by "an 9 Cemmanrier at the 35?? 5513 {See Exhibit 11}. LTG Gib Richardaeh he the UPERATIDNS UHDER 15-51 RAEGRD 51' Alpha. 35th 555 tatlng Charlie tiller} weuld traneltlen tree:j leucil 1 la Ifl?tf?? rrlireci See Exhibit Thin er er a 55 ncu magmathe training related in Flange 155 chmenl 1 and a timellna SAFE LFH HE mm Exhibit The SAPD LFX CDNUP 15 June as Attachment 2 [Bee 21$; ill-11119511159 Saler that it will be het ee hydration needa 15 be mehltered. 1 Range 155 at The hmetine ehewecl that Alpha Campany wee achedui?d te arrlue a appreximately 5535 and SP la the cantenment area at approximately 2555 heura. With the 35?? 1.155 were certified by it In rangea and all training arena ler T?r' 25 . . 5512. Charlie Med claee net traneitlen tram level 1 in level 2 medical care 2015 a elated tn 5? Alpha. 35th 1555 ?peratiena ?rcler cl 1 if a 3 mg iblta 5 and 45}. 55?? DIED. unite are made aware at the 1551 El eratlan See Exh changte 1'31 the Charlie Merl medical care level and the level at care preulciecl by the T5113 aa AT pregreaaed. c1. 25155512. FRAGDRD 55 Alpha. 35th 555 OPERATIDNS ORDER 15-51 STDNEHENGEJ la issued with a revised SAPD LFH EDNUP ae attachment 1 and Includes a map at ambulance exchange painte {See Exhibit 1'1. p. 25155512. 351? 555 cempletee Fri-t and meaea te cantenment area in begin preparatien fer EAPD LFX by can-ducting reheareala [See Exhibit 15]. 25155513 A Cer35m ESE cahducta recen ei' Range 155 with Key Leaders. r. 251555145555 2LT Daniel Baum [Range 155 515] 555 tar Flange 155. arriuea at 251555145545 and begins to receive the participant unit Gala-5'? {See Exhibit 35}. e, 251555145535. A 55135? 555 far Range 155AA U11l 5535 5171 in aupperi er Range 155. t. 251555145542. A 5511351? 555 at Henge 155AA 5535 51111 in auppert at Range 155. A 55155? 555 erlginallyr everehbt the Range 155AA. arriving at Range 155. then heading in backtrack ta the Range 155AA. u. 2515551451455. A 55135?'555recehrea hat breakfast at Range 155AA 5535 51 1. ulatien 1545. Arkansas mm 1 R39 Chafiee. -rn lugs and Annual Trainingr Feri . r. 4. Army Natrenal Guard. Training Arkansas fety Brie?ng ls preyided id 010 and y. 20I0001-10T00. General Range SEEDIG leaves with a patient yeu {See Exhibit 12}. This brie?ng states tirat if the "other medic-5 name must ge late a sheet-i ?re until they return er glye RENEE UNITE: The brie?ng alga I Eth? 12' Fag I at the training area will whe must meet the same requirements [See run Um states that any medieal eye-sue Ir States that wet bulb will be immediately reperted te Flange Bentrel. Finally. the brre ?fthe hmeeurtesy. time permitting. by range eentrel at DP eyer all means ef eemmunleatiens. w. 20100014. IBCT Battle Update Assessment brief eendueted enhth: 0f advised the weather fereeast fer Fart Chaffee at a high ef Elf: tang; h; heat 100 degrees [See Exhibit 13. page T). The lined Traeker slides shews E- mail related issues te this peint ef AT (See Exhibit 13. page 21}. Safetir Billie sh?giah rs B5B Litre Fire Range 100 sendueted by the Brigade Safety Dt?eer within last Heu {See Exhibit 13. page 40}. The Safety Trends slides stated memterwater usage {lee availability} en lanes and eaferee eanteenreamelbaex with water. x. 20150514. 39th B5B Deliberate Risk Assessment fer Small Arms Perimeter Defense LFX is prepared by LT Daniel Baum and signed eff an by Gib Brehardsen [See Exhibit 10]. The assessment list as a hazard hetreeld weather injury with an innial risx leyel ef mederate. Under eentrel. the assessment has meniter weather reperts. seldier hydratien. and wet glebe bulb temperature. ensure a water seuree and sunsereen is available. Under hew te implement. the assessment has ensure that seldiers arrwe is training hydrated. pessess a ?lled water seuree. and weather apprepriate elethingreduipment. meniter hydratien. and be prepared te treat casualties. Under whe will implement. the assessment has unit leadership. DIG. NCDIC. Range Safety. persennel superyise. medies are prepared in treat weather injuries. and RED issues safety briefing. Finally. the assessment lists the residual risk level as law. y. 201000140T00. 2LT Baum briefs the Bempany Cemmander and dietates the minimum unifenn fer the range as: AGU. ACH. FLC. hearing preteetibn. preteetien. and gleyes. IBAHDW will be wern during blank ?re and ?re (See Exhibit 30}. That said. there are repens that ttfl'l'lif's were wern during all phases bf the exercise. {See Exhibit 43 and Exhibit 44]. This ineensisteney will be further discussed belew. e. 201000140T50. A eerssm metres in Range 100 ie begin impreying ?ring pesitiens. Alter appreximately an heur. Beldiers began in make it aware that they were running but efwater {Bee Exhibits 30 and 52}. aa. 201000140000 appreximately. Pessible identi?ed an Range 100 near FP3-H.-ange 100 is delayed fer remeyal ef ill-(D. but Seldiers eentinne te impreye their Firing Paints la the 01' FPS is the Seuthernrnest FP en Range {See Exhibits 1130.43.55. and as). UUHJI. a; nun. Itm tut ill-tum 13. New numl, tintuliiu In lilutil, I nlnilly? t'uitulni ltulnttiu. I tut Hittite?. fall-tannin ht: ill that [It tin trintlitiiuh limt II It; ultuul'l'tt getting hut mi 1th] ?an litilttu in limit If! I ?J'h ?Ht? i'xlnhile :17} um] ?irt} tx; [tux run] :1 Mn Itiiltilntu tutliinet thuWutut ttultulu he tuuxetl hem Flange ?mm In 1th] (thin Ixtliltith 7171,1171, tilt, anti lit? Hie lHutu! Buffala wae mlnhulliy Iriuitml n1 Huttun ittiti?t?, mu: mile away ttiue Exhibit 3U. Exhibit .11, mull xhihit it?) Lit]. aetuuatdeetd. wunltuu all Hi HM ml ?with minute the heat uutex at; deuteua [l'taat L'tll it] lu Hue Fxtuhit 141]. ee. tjl'tl ?ex eutulu tuxl muuenuu in 1! 'l Huhln ?u 1e arrange for delivery- at fer Water liuttute. arttiillenal water, imrt I":tatetarie tfhte wee [itannutl It; he executed at ttjee 43]. ft. ameaemuaee. weather at Ht?tiht reperle the heat index at: (Heat Get it} te puhlleheu infuunatien hem f'lUft?. {tiee iixhttitt 14]. gg. Ejeittiere tram It. ?le alleweu? 1e l?i?tl?: tuat break after arriving at Range it; appraximatuiy at thie time the tialelure teuh a lunch break. [?ee Exhibit 31]. hh. 2015136141030. 'the Water Buffalo arrived at Range and peeitiuneu at the its Ca TOG [See Exhibit 31 and Exhibit 43}. Hanna 1fil'JetrutrJIer1tretrt FFtvU'u' {$9155 0035?: to FPE-UU {151135 at 415 metete. the In Ce TUE Ie identi?er] ta he leeatett {tireatljiI in the middie at Range 21m rnutere item the turtheet tiring paint an each end at Range 100 [See Exhiuna and 1th. 11. 201Ei??tett13? ?t it?? initiatee that iteratian all I'll? tire an Range 190 tthe unit will C?rt?tj'iiete at tear-.1 three iteratiene at the tire tx?ere ete?intt titanic tire-each iteratien at tint?r tire waa apprexunately ten-?D minutee, with a het-waeh between each iteratien] {See Exhibit 31}. jj. he 13%. the Brigade Safety Ditieer, GWE Tatumr wae an Range tut) during thia peried at time and epeke with the ?ange GIG. and the Cempany.t Cemmander Exhibit 92;. Tatum tale 2LT Baum ta ehut dawn the range it there were any aatetiir [See Exhibit 2LT Baum reperted that there had net been anjir heat at that paint {See Exhibit Tatum eheerued adequate ieaderahip eeuerage an the range and eheetuett ne immediate riex {?ee Exhibit eat. He. weather at Pit-?3M tenetta the heat index ae degreea {Heat 9 rat-tit? 1' ti Arkansas Helm-.14 and H: m1.?an 11-" mu?. ?1 .Ii i?tlmv Hatter.? limiting .rt. [1mm .1thin i-?13.41 in neterthrig le published mlemmhun [mm HUM {leperte? vendetta 1? WI rttr11.t.t1.'i'l lit-at Cal 5 this-ugh 201505142153} {See 13. 1'1. 4? 1' 1LT Kubin that the Ice "2015051411415 t-t 3 alrer I . Cex Cum 5 text mess igr man (35 HEB .?Ihd water nussren Is 10001.1 in SF, but they am waiting for LTG Gib tiattallen whe will ride with them in Range 1001:3125 43} mm 201505145522 II is unclear when. but semetime alter LTG Richardsen 3 R5059 100 and during the div tire iteratieris. the decisicn was made is drawn grade the uniform frem during all phases in ne during blank ?m 355 {See Exhibits 30. 31. and 51}. This alse centradicts the guidance in 2LT B?um'? statement (See Exhibit 30] advising the unifcrm was he lUT?v? until blank fire began. Several statements Identity Seldiers cenllnue tc wear the 10W threughcut the day 1559 41, 44. 52. 55 and 51]. Net Icng after LTE arrived en the range. 513T Cex. the 51-4 Safety Dt?cer. LTC Richardson that he had assessed and treated twe heat casualties alreadyr were ceeting effin an air cenditiened HMMUW [See Exhibit 54}- LTC discussed with SGT Dex heat mitigatien issues and assessed the measures that were being implemented (See Exhibit 54]. en. 201505141200 CPT identi?es in her swern statement the unit is in Heat Categerv 5 [See Exhibit 43]. be. 201505141235. 1LT Kubin arrives with 20 bags at ice and Gaterade {1 LT Kubin executed a secend Ice missien per Cex's request at 201505141530} LTC Gib Ftichardsee arrived with 1LT l-{ubin and stays until the end at the training dayr (See Exhibit 43}. pp. 201505141250. 55113 Jebe at Range Central placed a wet bulb cut and waited en [10] minutes te atlcw it te acclimate is the weather eutside {See Exhibit 45]. At areund 1300. 53G Jebe checked the reading and had SFC Mikkeisen verify that he was eading it cerrectlv. it was Heat Categcrv 5. SEE Jcbe bread casted it ever the net and :gged it intc the 1554 leg [See Exhibits 1? and 45}. ed. 201505141253. weather at HFSM reperts the heat index as 55.0 degrees teat Cat 5] accerding is published infermaticn frem NDAA [See Exhibits 15-14). rr. 201505141315. Heat categeryr put cut by 5513 Jcbe via net call at Heat Cat 5. 1 Degrees. and put intc the 1554 leg {See Exhibit page 10. and Exhibit 45). ss. 2015051413304 500. This is appreximatelv when the 3 dry ?re iteraticns were mplete. {See Exhibit 50}. tt- 201505141421. Range 100 calls in twe pessible UXDs [See Exhibit l0 Ea Em 33.33. cu n. ma: .3 En m??m mum. Em Em E?am Em HE .3 Emma 3mwm. Em Ram nanny. .5 E335 .m ?an. mmcm?? 3:535. .m 5.55?. .5 mm. u. ?n?mm Em .m?m .35. E3 3.9% n. Eon. nmm: Ema E33 99.3393 Ho .7312. .mme ((02 Eat Egan gn?uum Am ?mu $.33 mm E. Hana .3 .3 Em E?m HEEMmam. cEEmmum. Egght?m. HE un?? 33mm Hm? 335mth imu?. wwm. HEmm?mh?. 5 Eng mama. Enmm 5m .5333. .5 .23 3.3 mum. 3mm: ma. wanna. HEB ww? n. um?mrm. a. Em 5m .muwpuwwumEm ..mm Ex? Puma Hum :?m?l?mam. .nm?mn?hl?m HE n. 5E E??mhnn?. nan EMFWM Em wumm mun-HUer Hug mum ?any? yaw-pa .??Ww??wmuww? dun mM?uum mm mm. H?umm? mm ?mum. HE mu mm.er ?Em I?m. gunman u?um?u? HEM Dim Fi?l?w Fi?. 3.. .?mu .?hmum?L?u ant. Hm Wm. u??nm mLFH?ulm Hm. n?hn?- Hum 5.3% En EFF :m and mam. ??ax Duh. PH Ungm .5 Erw? um En mt.qu nu EMILE EU n?m P?rwr??nn HEEM rah WHEN .m ?by? h. Hm EHDQE ?mu? Hm hall?aw: wu?u?ff thrush. to?. 92 ?ham .ur?n?nd. TE. r?uu??um Egrn?um urd "Want: . lmd?? Ftll'??'jnl'i it} 15- "Hi ulatien ?in 5:13ng W15 and {m Training. Fert Chili-[? Arm} hiatuch Guard, Training Accelcnt. F?iilillj" Bun [1 Arkansas ti Ei?'l This cheat [Bee Exhibits 19.31.33, an gs sechan t3 BPS IEline and ethers. SP part in THC at FT was ?rtit Idem-hm} as sudcurt?lbing it! ill incurr-nsietencg.r W'lii be addressed belew In the ?ndin .1th le dical Irans During the the id the re Cline's ccndihbn werscned and missien turned late a me {Bee Exhibits 19 and 32} til. weather at HFBM the heat index as Cal 5} according te published inlermaticn lrem MUM f5 Decisien made te transbert SPB Cline Elites?)! 1e THE medics in FLA {See Exhibit 32]. arrival at frent gate te Fi? Bhatfee. BPC Blinc was demonstrating an altered mental state per medic. BGT Nathan Butten See [Exhibit 32}. BPB Cline arrives at and is treated by treatment team at THE. BPB Cline advised treatment team he ceuld net waiit {Bee Exhibits 1B and 35}. 2B15BB141 3?31, 9 Line I'vledevac called by BFC Jedv ltil-Fright en the directien et? MAJ Netascha ivchride advising BPC Cline was uncenscicus [Bee Exhibits 1B. 35 and Exhibit dd]. At the time at the call. Range 1GB was in in heti'iive ?re status and had net neti?ed range the heat casualtyr [See Exhibit 15]. Ftange 100 was placed intc a check ?re and instructed id have Fiange BIB call Range Central. kkh.2?1B?B141?32te1?52.2LT Baum called range centre]. Patten inquires as tc range had net been neti?ed cf the incident BPE Cline- 2LT Baum and inferrned FUD Patten that there were tvve ether heat casuaities. BPC Davis and SPC Batista, underthe care efthe unit medics that had been brcught te the barracks {See Exhibit 13}. ill. 2B1EBB?lfl1i3i'. Range jeumai leg un rt linng- unrestricted te ceasen?re [Bee Exhibit CPR initialed bn EPC Cline Exhibit 35 anti Exhibit 19}. Range tdEi was changed frem 2D16?d141?5?. Flight medic attempted in intubate BPC Cline {See Emma bee. CPT I?hieeds advised FliltllI Patten te kee Ran check ?re until current BIG and came te range tc re-tggiriign replaced with ether quali?ed persennel {See Exhibits 1B and 9 2D16d1 141152 {appreximatelv alter w. abeve}. 2LT Baum caited Patten at 4.. ill-?- . "55 or?: trust is! H154 - . 34-911 -. ?rd Tra "3211-5"! Fa'o '1-1 .i H-I?ti? Cuf?t'e? to rep-art nart'wr twat casoattv from 1511 3'37: 5?55 5'ccre momentum of 15.? 51542-1: Elh lots 15 15 and 5-51 33"! t? 7 t'vatco and resume-cl earn htercv Hosp-1M utter.- Erhbl 1'51 tat-5.. 3141753 weather at HF EM reports the heat index as 1W 7" ?31 5.1 3,1170?: 1:31 pub??hcd from HUI-ifs 1'35? EH11:va '13 3515551415m_ Medevac departed Fl Chaltee {See Exh 5:1 15.: 251555141555, htedevac arrived at Mercy Hospdal [See Ext-51 Jl 251555141517. 5P1: Cline pronounced dead by hospital staff ifsee Ext can 191 aw 251555141551weathm at HFSM rePCIrts the heat index as 55 3 degree?:? tHest ?at 5} according to published information from HUM {See 13?14; ivivw. 251555141514. 2LT Baum noti?es range control ot another heat sued; 5513 Mamet-c. and advises the Servicemember would be evaluated on site [Eee Ex: so 151. 251555141523. 2LT Baum noti?es range control that SP5 Maln?cx would be transported to the TM13 for further care {See Exhibit 15}. m. 251555141553. weather at HFSM reports the heat index as 5T5 degrees {Heat Cat 5] according to published information trom NDAA [See Exhibits 13?14]. 222'. 251555141555. Patten was advised thatSPC MalricI-t was ?own by .t-edevac to Mercy Hospital and anti-red there at 2552 hours {See Exhibit SP: Malrisi-t was released from Mercy Hospital around 214? hours {See Exhibit 15]. ease. 251555142215. BEE status on Range 155 changed from training complete to departed [See Exhibit 5. Findings. After a thorough review otthe evidence gathered in the course of my investigation. 1 have concluded that: a. Findings Related to the Incident: Battalion and companyr leadership failed to comply with the requirements of ALARACT 5421'251515ee Exhibits 1'5. 51. and 54]. ALARABT 5432515. which directs Amw units conducting operations in hot weather environments to develop a written heat stress prevention program and directs commanders to "immediatelv re-evaluate all unit 13 ht hansns [i Charlene at 15-11. tll'i?. 1"0 ulatien [?ll nn' m1 1 "with: I ?up and At that! it i? 1 1 - ?iianmtil AircrdeitL l-atality'l . 1. bn?ui .ii. mt ?gment Centred. I. is 15-1!- I- 53;] T5 1? ?itl'? m? :1 heat stress I. I11niuntu utter the initial heat M2 ethane when an?; (2015 is the?sweetRahal-eh amt mainstay lead- .Ht?t-e the-:1 tum-grant and did Hunt amp mt?l?t? I rest: tit-ea time-s ea. at. at. met at] extremal ta as 5th? dune WW5 59's: amt itt?i?tt?h?a?t?i? at tn the hen 'l-tt?t bate? (See Esme-.1 tat a?tdditnmaiw. by nth-ted rabbits. 15 su?mlng stett'swt at least one rat the medics an Rah ti w? erases ease: in the dart- rsee Eshtbit The leadership hm an Rnng? ma etaLa'tte all pet?s-Mite! at reassess the had It . atien it ever after exhausted three heat casualties them Range 100. drr??ygci?mgd rs We set net eease hearing an Flange until FT Rang? can mt dB and and R30 tar failure ta repart the heat casualli ?h?u ?1 5" m? '33? es threu 'Ithibt't?s 5H and 51}. 5: identity the hazards chased Range til-Cl. :t is? 555 teedership and start did net adequatel A deliberate rtsit bet weather enw?mnment en . t?t} [See 16] by 2LT 2LT Eiaum and appreued by trieusly used [er canned} ther injuryshew nulill ?m ntmmean at June a at [tantt? 1 mine had preuteusly in heat tee-seaweed training in the esteem-nah! FORM 297?} has prepared ter Hang attire The Detmmte Assessment temi prepared by Humanism, appears te have been adapted tram a pre statement with respect is the identi?ed hasard pt "hetlceld wea address the magnitude ef the hazard at training in a hat and humid weather est-.rcement [See Exhibit 16]. Additionally, unit leadership did net adequately identity. tmptemem. and menitar surlictent eentrels te mitigate the hazard The central and intpismentatsen guidance identi?ed an the deliberate rislr. assessment demenstrates the aware at the lime; guidance with respect te trainin . in a hat ?gait-tier em .r'pnment: Hes-ever. as the swam statements Identity. It is clear the in i?t. .euai unhemt mitigatien guidance Identi?ed en the deliberate risk assessment was net fellatth er strictly adhered te. armed and reseurced in accerdance with the re ulrent alien [See Exhibit and the AR ARNG Rang: Satetayms trip was adequate with the esceptlen at ensuring a it! {See Exhibits 6 and untuhst Chartee Range Regal {See Exhibit The plann su?'ieient and accessible water supp rship did net pmtride the Seldiers en Ran . 1th] wit threugheut the training gay. Waist: 1533133? I was net pushed is the ran a I I CPT Suaette Cert identified in her swam stalemengt graf?ti: the ?mm: 5 algae: Esg?ftt?gm and Baterade te supplement the water hutlales] her ne an to execute this Ei??anpe tea was planned is he conducted at lecatlens tt?l?llg?ueumh? mm . ply area) and the Range 100 firing line [See Exhibit this wategr bung:J?h {4}The unit leade access te appreprlate seu Gatarade was planned far It ?it? QE- Elt'ld Recernmendatienste A: I: A . . In; egutahenthR?A??ansas my ?annual Quard- Tm'mng Accident. Fatatrhr During annual Training. Chattee, Arkansas Prewded ter Range 1th] was initially pasted at the Range mean [See 43,: The assembly area W35 ene mile trern the tiring t:ne- Set-titers staned repcrL-ng Eta?? the Dr! 14 June their were running black en water [See Exhibits. 52;. a: the ?the. the water huftaIe was statiened at the Range tennis appreain-tatelj ene rnee the ?ring line (Exhibit 3D. Exhibit 31. and Exhibit 52}- The water leu?ate was treaty "titted ID Renee 1'33 at approximarety idea. [Exhibit at and Exhibit 52,. Based en the mndm?n? Present at Range 1013 en June 1491* the Eetdiers en the range requeeted and received permissien. then reseurced with their um tn mm the water hurrah tram me Range he a lecatien just behind the Range 1ee ?ring line. {Exhibit 3th The placed the water huftale ne rnere than EDD mete? trern any Eeldier trarning en Range 1E0 [See Exhibits 3. 31. it". 43}. Rise. CRT Celt marked with her 3'10, 1LT Rubin. it) arrange in metre the planned ice and Gaterade missien te eartier in the eta-1ir en June 11?: {See Exhibit 43]. The rnissien was delayed and did net arrinre until 12 39. 21 rnznetes prier in its planned time ef arrhral {See Exhibit 43]. The hattatien cen'lrnander decided in ride cut in the range with the can'irey bringing the ice and Gaterade {Baa Exhlhi 43] which resulted in the delay. The unit did net adequately the unif?rm far the S?h.?f5 an Range;- 1Dt?l. if guidance was prewded en the status at the men-idea} unecnn it was net adeguatehr disseminated with apprepriate cemrnand guidance (See Erhih?ts Elli. 31. 113. 91. and 94}. The unit did net tellew the fer repenmg medical eiracuahens frern Range 100 in Range Canticle: required by Range Salemr Briefing and the AR ARHG Range Sal'er SOP {See Extends 12 and The un:t tech the steps he have FT Ghaffee Range Centre! certify the ter the Range Dl?, thOlG. and R50 as required by FT Chalice Range [See Erniee 11] Despite the training. the unit tailed te repert te Range Centre! the eiracuaticn at three heat casualties frern Range we as required by the FT Chattee range safety brie?ng Thia resulted in Range Central decenitying the Range DIE. HEIDI: and R30. This resulted in Range Central placing Range 1Dt] in an check fire {See Esh:b:?t 51} It started getting het early that with the temperature te rise threugheut the day' [See Exhibits 14. 19+ and 49:. Based en puhtished histerical weather data, the unit was in a Heat Categerir 5 enwrenrnent trci'n heurs in the morning until 2153 heurs that same night [See Exhibits 14 and tlun'iereus swern statements indicate that the rnedics en the range were pushing cut the Heat Categerjr en net calls. 2LT Baum. CSM Franks, and CPT Ce: were present an Range 1m during the entirety cleperatiens. [See Eirhihit 30 and Exhibit 43}- {El} LTC Git-i Richardsen arrived en the range at appreairnatety 1239. Once 15 i tst?i hit-inns.? W1 chatter WI . 1. 11?s: 7" ill. 't I - i . .II. I. .. - .3 .ti?'t'tt? it h. It. . 1 I'tt' lung-EB?! on the. Lung: ?11" 1. I?ll-- . tel-pm t. nth-.13] nets 1.15.111 I i ?mu-w ?Ht. Hat?sta tit-3M Him51*: "my" :3 Her??it?t' uni-tun? 59mm11.1.15. II W35 this duh14: I?VE-rad en the cendlit?nth?! eneimnntent Th:h515 ?411-19 b~sk1fmt 11ht I t1 I the? ?ndI-H-Idual 1 rear 501.1 centu?ued [15" '1 at: M?snhh?; t? 1 "at" 407* is: the Rant.? 01:3. and SGT Call. the. Met Safety.F airmail? m: the .1 ?trees :9 LT: Rewardsen tear the. sate-w at the Setdiers due ta td. re. minute: aim Exhibit 3?1. 91. and 94} thh?'? 2LT Baum 3? the :ssu-e with the Battahen DEM. DEM Franks. [5'39 Exh'b? I. II. -. 'l-J . n: i: 5 at .teemwnuteh+ 15:30 153D. multiple Set-cliers were reperted 35 3: weer-e cries ?nsth, SP6 Eautiste. SPC Bat-rise SFC Cline, se a. -: ?t'a?xtt? tSee Emits-13E! and 55}. Multiple stated that despite the nenest LTC continued the training. {See 3D. 36. ?es: - 5* :13 es: en The unit did net cease training en Range 10!] until FT Cha?ee eecertFe?Ci the Range DIC and R30 her failure te report the heat shes: the cat; and ctesed Flange {See Exhibit 51 Etweeter Emee Cline shamed signs and at succumbing tn 1.111111%ny 3315031545 white at Range at {See Exhibit 32}. ear?. exceed after he was identi?ed as having a pessible heat retatect es}; at ten; pertemied, the results at which wiit be made available tn the Guard {See Exhibit threth the Arkansas National Guard Chief ailmh?". 113 "15.55 Ream..- reli- . . r: shetittjtelleted that the Findineseae t? Err: It: mm, be gupplen?teDt?dl ir?tw 154i SeetienE-s. .ea et? the complete eaten-?iv bein? 3mm medigal' et the Cn'me l__,n_b_etatenr {See Estiibit?'ft. The s: dates et the Ark?f?t??s slate Hump? i5 I ?53, be} Min menths frentthe date at this nteineranduht. new The man Incensistenctes in the witness statements relate tn the tintetine itcnn status? cycies as the ?st?li? by the Soldiers with respect he uh the time and scarce at the heat categew PM . ?ea: categenr changed threugheut the day. n5. rece-red by the ant! at Henge 100. the number at times SPC Cline was BDE as a heat easuetw. and the ebsereatinhs cf the 5%06'" ESEL 188?? INF ?l n55! In Haitian? huh-H triu'n tilltl Itnr I?m {tiring 1" It ?Inmanu I rllitltl'lr I r'h" Nit-ensue I I . my eenelurnen belew t, rixlrililttl mi in the rtl' ?1 I Wt? [Utrutll lturd tlttuttulmul ?Hit ?mim'? 1 lhu tut-.1 [m "m ?mile was delayed Ire l?ilt?t?llti {tum lxhilrit I 1h? et a suspected trtiritt 4 ?t [See [Exhibits 3t]. 43. F. Iib] the training let the unit was nine rlriluanrl the ?it? IJtr leadership diluelinu ttmullunu nt dry lite and tun irritant rm [mining delteluneiuti Itllr 31,41?, Ebb]. them tll?a? in the statements es la the precise lime tit't? Elihu ltrtil hirrisrtit as pet-turbidit- succumbing Ie the etluelu at the heat. {Sue lixhlhilb 31, 35!. 1th, I: it}. 'l really. It I: net etear beth whe end when the dirnetlen was given Ie ntIew t-tultertrtePrintian I Range wt] in the FLA with Duels. Emilietrt. rind It'illne. bier: itxhibils ?It. xr. a ex. 36, .5 43}. ii. As Is the dutyr uniterrn. there were insensisteneies In the urnterm indiultlual her]? status prescribed by leadership ter the ranger slueeilleeilg.l whether the armer waste be wern thteugheut the dayr ler all aetiuilles at. whether it weuld eel-f be wern when the blanlt lire iterallen was started and then let the live tire iteratlen. Ascending te 2LT Etaum's statement [See Exhibit 3th. the Initial briefing dietated a I minimum uniterm fer the range as: ECU. FLG. hearing breteetren. pretestren. and gteses. with te be wern during blanlt tire and lies tire. 2LT Baum later states that he requested that blant-t tire eperetlens be eendueted witheut the lEitt?u'lIZiT'tlt {See Exhibit 3d]. MAJ ?i?eung. heweuer, states that IDTU was initiallyr wern rturing all phases. but was dewngraded by LTC Riehardsen during blank and dry tire {See Exhibit 31 and st]. LTC Hiehardsen stated that he was lnfermed that the NCD's had the Eeldists wearing their IGW's etren tlteugh 2LT Etaum and MAJ "r'eung Ield them they didn't have te. and that a few NCG's eentinued te wear them all day {See Exhibit 44 and Exhibit 52. Statement ef2LT Jenatban Craig and Exhibit 93]. DEM Franks stated that the uniferm et the day was eriginaliy geing te be er FLC. helmet. gleses. water seurees. treat with plates. and weapens (See Exhibit 93]. CSM Franks stated that LTC Hiehardsen put eut that the uniterrn was net geing te be east with plates added until litre fire {See Exhibit 93 and 94}. GET Cex stated that the Seldiers were wearing their lDT?u" while building their tiring besitiens. in eenlradietlen te what 2LT Baum stated [See Exhib 43). SEC Davis stated that the Seldiers were in lull "battle rattle? areund [Exhibit 33. 63. and 39}. LTC Ftiehardsen stated that the initial plan waste eenduet the blank lit in hewetrer. based en the heat. he authetlxed the eendueting et the blank tire iteratien witheut adding the HDTV [See Exhibit 94L As Is the werlt restteyeles. the swern statements attached Ie the investigatiei de net relieet a deliberate deelslen by the leadership at Range 100. the eempany. at th battalren Ie alter the en Range td? speeifiealhr in resgeet Is the knewn er l'r' 5.5 hth??tS rm Chit??'t {Fth 1 nnual fra-n-ng ?up to! ?lm?s or ?me-11.1.11 at hr t?lu I I-"ld hats: 5L i. . 33 amt He. Amt [maid hart h} Accident I ?at-Kl "Ln. an ter training In a 1 . r; tl' shed funny he 113:: mm mmi?mg era-rest cycle [See nth-bis eyeral ef the Seiduers en ti {?le net View the washes' :15 a 1"1?d Utter-ir- ?watt.- ?nygl In 1 ttna heat er out 13! the prescribed unite-rm thee E'?hfbli?id?a. 55:563.: ant ??lth: st ler Heat Eaiegery an unptemented which tes ef werit {See TE lhi.? Pub? den-n11 el? the start-treats nit e. as ebselxing a It It] this. 5 eff?l FCJI he: em east-rat en the M- .31. 1:31 and t1.? Hewt?xx'tr in clear Range the teen an :t?st l?ti'tat?d eat 0 155" There at ne eat-stance that the stand des training. Wm rtxedetate in. which table ?nal-1}. h??nw l'l?ilnl'l ?13.95.: {one minutes at rest sug and 5.31 Th? 3121? Pubii?hs?d a digitat Battle Update Assessment [Bidet as part at he sea was a published 5- 5331's tel-tam fem-T 2016 lee-e Ethel: Included int page The weather fer c'iay- weather ferecast fer FT- Chattee. {See Exhibit 13. igh ef 95 degrees with an heat Tuesday. June H. 2016 was terecast fer a degrees This ferecast placed the training enyirenment In tit rest cycle mitigatiens per published tadex er ef 5 identi?es attendant uniform and we . ed te train wearing their individual bedy idance advises training while weanng Army gexdattce Exhibtt The unitptann arm-er as part ef the prescribed unifemi. Army gu Rise. the unit is directed by meniter it heady {See men-:dua! body armer raises the heat index by 5 degrees. Army guidance te maintain a Wet Bulb Glebe Thermemeter an Exhibit 3-1.1. hlumereus swem statements attest the unit was tract-ting the WBGT and atse ef the WEE-T index {See remixed net cal's frern Fl' Cha?ee Range Centret en the status Exhibits 35. 43. Si 55]. y- Accerding te the BSE Heat Casu SPC Cline was initially evaluated by Med appreximately 1 Edi} and the ceel dewn precess was begun. {Exhibit Tb]. The repert states that SP1: Cline then chase te retum te training at the range. {Exhibit 19}. A secend ei'aiuatien was perterrned by Med medias at apprexirnatety 1515. which resulted in Clines euacuatien. [Exhibit 19]. The initial eyatuatien was addressed in BPS ietds' secend statement. whereby SPG Fields? stated this evaluatien eccurred {Exhibit 39]. SEC Etine's initial heat iniury was during the dry cerreberated by SGT Heat [assigned te FP1 with SP0 Cline}. whereby he stated that SPC Cline ie? te ge te the shade te ceet eff. [Exhibit 41}. Per SGT Neat. Eline then retu med ene last time te attempt te centinue. but ceuld net and left. {Exhibit 41}. atty Medical care slides [See Exhibit 1a}. medics SFG Fields and PFC Hangett at yi. Address statements frern Dbsewers. I did net ?nd the statements frem LTC tit Ramen Reyes-Unis with the Ed?dii? Andrew tt-?laclt. MSG David Farquharsea. er CS 833. 153?? INF BUG {See Exhibit 25. 2B. persuasiye. These indiyiduals were net en the range the entire day. frem their statements they did net appear te haye t-tnewtedge ef the heat categer en the range. and nene et them preyided evidence they were familiar with the requirements at ALARACT [1432015 {See Exhibit i'Ei} and in particular the 15 HEAR 1: in ings and Fteccmmendaticns term Hegulatien 1545. satis?es "Tl? Haticnal Guard. Training Accident. Fatality:F During Annual Training. Fen Arkansas fEEtT-tirement tc ?imrriediateljiF re-evatuate all unit and mid-garish asst-ans when ?Eat Illness {See Exhibit at b. Findings Regarding De?ciencies with Felicv, F're-ciedureis1r Training. and Leadership. ll] Anny Technical Puhliticn Nu. 549 5-19} prev-ides ham-Jr saws-st gurdance nn Risk Management [See Exhibit Ed}- It the safety guest-ace and techniques cutiined in ether Anny publications In previde a name-actith Isaders tn Identity' and assess hazards then devet-np. irnplernent, and munitcr eunuch ta nicest-IE the hazards. The Army guidance assumes risk management win he a detssei'aE sta? Princess implemented in a manner he allow risk decisidns tn be made at the ageing-'33 level. ATP 5-19 [See Eshihit states that risk management is tn be a chi-decal and ccntinucus precess speci?cativ geared tn aiicw leaders tc accept cc unnecessary r?sfe at this incident, ALWCT All Army guidance nn Heat Illness Preventicn fer 21315 Heat Saascn was in ei?iect. {See attic: 75}. This ALARACT is annual guidance {See Exhibit 76 and Ti") issued by HDEA referencing nut all at the attendant Ant-iv guidance ch heat presets-:41- and mitigaticn. but alas prescribes annual training and rush assessrr?ricnt techniques is: training in a hut weather mung the references in MIRACT 543235 is TRADCIC Regulaticn 350?29. which inciudes specific guidance cn preparing the FDRM 297'? Deliberate Risk Assassrnent fer treating in a hut weather {ti-e regulatinn identi?es an earti-er term fer the ERA. but the substance is the same} and nutiin es and prevides cuncise guidance en the practical mistenentausn at man; at the mitigaticn techniques identified in ether Ann-v guidance [See Ems: Specff?'i't'f, ALARACT [1432015 {See Erich-it directs Army un?'s canducting cpEIat?icns in but weather envirenments In develcp a written heat stress preventicn ere-gram. The ALARACT tu rther directs ccmmanders tc ?imn-is-diatetv reevaluate a'J unit and mitigahcn actidns when any heat illness c-ccurs* [See Exhhit TE ats?j At the time anal Guard tact-ts a strategic level heat ccgniticn, preventicn, and rnidgatien strategies ined in WOT All Any See Edtihit The Arkansas Army Nati preventicn in regards tn the re related in heat Illness preventicn as nutt guidance an Heat Illness Preventicn fur Heat Seasent While the dues have same material ieiated tn teat Estess within its brie?ngs and {See Exh?aiss E. 9.12, 1?2 and i3}. it tastes a guide tc previde guidance tc came-lenders in presenting envhunrnentat heat casualties and is net as cemetete as reccmmended in WET A11 Army Activities guidance un Heat Illness Prevention far 2916 Heat Season {See Emiait 19 AaiJn-n. ?In utl l1u'?lh? ?PHI-lull.? 1" - - 4.x! Hm Tull'rlig1rid tuU!? 11..th 1- Mi Han-1:6 5411*? Ir; :11] 1. *1 amwum Hm cunrnt 591: i Harth A SILT HAHJL [hunt-i Hm i 3-1 I whee-21m: heat {Jifyh?? leash-:5 grr-en I L?Im?w malmml r-[uhw -. 5h1h~r1wnl? rt: ma?a-c out n: no: mt; {he Lag The F51L'1hh1f? R?uut?ni 501:3. and tm.r1.ng [?ll?s Ihh't'l - ?g the ?g rem I?m heal. ?51:31:05 [39:1 lulu-hits. Ell, 12'. leg-Hg ?5.99 Eunm 1:3} :1 Elm" ?55511} - he Range- Safery Br *1 :rtmh. ?g med-m1 eu-quamn cu :4 These other an: 3.31:9 to! ma": {mm-Hg mm ts?. wanted :3 Range Cont: [ml 115 ?fl-rm can mm he.th conducted on 2-3 Twang {See Exhimt 4] The T?t' 1 E- A. access or 1125:1155 hea'l ulna-55 prawn: - Findings Regarding In?ividual Subfects, J. 2" ind-ngs abm'e. ?nd that GEM Cha?es Frank-3 19"? r? . . .- 3.135 nag! gent In pe?nmance IE- duhes as _l 5: Ed: safety. DEM Franks faue: tn - - H39 HES {Ere-armed due tn the detennratmg H'reamar and did i 1 575:2 7-51? ESE 01:55:15th aPnr 3.. LII-Y - 3" Be 4.: I: raga; :15 a heat Linear. preventmn mace? and - r? neat reiated Lhasa: Adi-an I 51' :72 Ir . baSEd can hi5 a 4'15 seam L: the 123:3?an {333.1 Franhs? neg'ggenc? a: I: {1:22:13 a :0 mm.? . and "Lt" if . hm"! Fauna, In??rmrw: r?r Htimm (If The if.? ?1'1 NT: ?1 "a?il'm??hl? (af?ne: n'fri r. hnrJ-rgmunrl, am: rup?n?n??, -.- - 5315"" u- .. Recommendatlana, In wry: 5f the EEIE a Arkanaan Army Ha?una! Guard - SUBJECT Fmdings and Hocommoti 1 Ltratlmi, Army National Guard, Training accident. Arkansas Subjects: h. Specl?c Recommendations Hega rding his negligence CSM Charles Franks should he formallyr counseled regs CSM Franks should he considered for a Letter of Reprirnand and failures in leadership. AR ??iiv3i', Unfavorable Information, Chapter 3. it is further recommended consideration be given to relieving CSM Frant-ts from the command team at the '39? ESE isvv AR EDD-2D. lsrmi1r Command Policv. Consideration should be given to issuing GEM Front-ts a relief for cause Hon-Commissioned officer evaluation report isvr AR 5234, Evaluation Reporting System. Additionally, GEM Franks should receive recognition and individual training and on heat illness prevention to include the prevention of heat injury, and mitigation strategies [See Exhibits TB. 82, and 34). - 22 rum}? HIE-till? DU "n dahonsto ilt'v? NEAR SUBJECT: tha5 and Hemar?a?ana far An?y 15-5. Arkansas Guarda Taming Aeddani. Fatality During Annuai Training. Fa? Ghaffaa. The AR 15-5 investiga?anahaaid he referred la the Chief af In?litarydus?ee for review ta det'anaiaa aih'at aa?an. ifeny. may he-apprap?ate under. the Military Code af Arkansas paa'a'i?ia af-S'aatian Bi? -- Failure In abeyr order nr leguiatisan. in pa ll1eaffenae aif dereliatian in the pedanaame ef duties. or athEr puhi?ve'aeetiana ef'ihe MGR i i -. I it, iemaranizlum is the LindEl'EiQan at 23