oversight

Army Ranger Training: Safety Improvements Need to Be Institutionalized

Published by the Government Accountability Office on 1997-01-02.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                  United States General Accounting Office

GAO               Report to Congressional Committees




January 1997
                  ARMY RANGER
                  TRAINING
                  Safety Improvements
                  Need to Be
                  Institutionalized




GAO/NSIAD-97-29
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      National Security and
      International Affairs Division

      B-275298

      January 2, 1997

      The Honorable Dirk Kempthorne
      Chairman
      The Honorable Robert C. Byrd
      Ranking Minority Member
      Subcommittee on Personnel
      Committee on Armed Services
      United States Senate

      The Honorable Robert K. Dornan
      Chairman
      The Honorable Owen B. Pickett
      Ranking Minority Member
      Subcommittee on Military Personnel
      Committee on National Security
      House of Representatives

      In February 1995, four students from the Army’s Ranger Training Brigade
      died of hypothermia while training in a Florida swamp. The Army’s
      investigation of the accident concluded that a number of problems
      contributed to the students’ deaths, including the loss of important lessons
      learned about safety controls built up over the years, shortages of
      personnel, and undocumented safety responsibilities.1 The Fiscal Year
      1996 National Defense Authorization Act requires us to assess the
      implementation and effectiveness of all corrective actions taken by the
      Army.2

      This report provides our preliminary assessment of (1) the status of all of
      the Army’s corrective actions, (2) the adequacy of Army oversight to
      ensure that the corrective actions instituted after the accident will be
      sustained in the future, (3) the Army’s progress in implementing the
      authorization act’s mandate to increase Brigade staffing to 90 percent of
      requirements, and (4) the Army’s progress in establishing safety cell
      organizations at the Brigade.



      1
       The Army’s investigation included separate legal, Army Safety Center, and criminal investigations. The
      Army’s accident investigation discussed in this report is the legal investigation whose purpose was to
      determine the facts of the accident.
      2
       The act (P.L. 104-106, Feb. 10, 1996) requires us to provide a preliminary report within 1 year of its
      enactment. A final report, including our recommendation as to whether the legislation’s mandate for
      increased personnel staffing at the Brigade should be continued, is due within 2 years after the Brigade
      first meets the mandated staffing levels.



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             The Ranger Training Brigade, under the command of the U.S. Training and
Background   Doctrine Command (TRADOC) and the U.S. Army Infantry Center at Fort
             Benning, Georgia, conducts training to develop student skills in infantry,
             airborne, air assault, platoon, mountaineering, and waterborne operations.
             The initial training phase, conducted by the 4th Ranger Training Battalion
             at Fort Benning, focuses on basic Ranger skills. The second phase consists
             of training by the 5th Ranger Training Battalion in the Georgia mountains,
             and the third phase is conducted by the 6th Ranger Training Battalion in
             the swamps of Florida. The course is conducted in difficult terrain under
             mental and physical stresses, including nutritional and sleep deprivation,
             that are intended to approach those found in combat.

             Ranger and other kinds of high-risk military training are dangerous by
             their very nature. Since 1952, 56 Ranger students have died, 7 of
             hypothermia. According to the Army’s accident investigation report, the
             four casualties of February 15, 1995, occurred during what was expected
             to be a relatively easy exercise involving paddling boats 8 to 10 kilometers
             down the Yellow River, identifying a preplanned drop-off site, and
             navigating on foot about 1 kilometer through a swamp to an ambush site.
             The instructors were largely unaware of rising water levels in the swamp
             due to heavy rains upriver in Alabama and allowed the students to move
             into unfamiliar areas. The platoons encountered delays in evacuation and
             medical assistance, and the students were intermittently immersed in cold,
             deep water for over 6 hours.

             The Army investigation recommended corrective actions to improve the
             systems the instructors use to predict and monitor swamp conditions,
             revise command and control procedures, and increase evacuation and
             medical support capabilities. The investigation also raised questions about
             how best to preserve lessons learned and corrective actions instituted,
             how to mitigate high turnover and shortages of officers, and who should
             fulfill the role of safety officer.

             Corrective actions to improve the safety of Ranger training were also
             prescribed by the Fiscal Year 1996 National Defense Authorization Act.
             First, the act required the Army to staff the Brigade at 90 percent of
             requirements. Such requirements are defined by the Army as the minimum
             number of personnel a unit needs to perform its mission effectively. This
             mandate is to be continued for 2 years. Second, the act required the Army
             to establish at each of the three Ranger training locations an organization
             known as a “safety cell”, comprising individuals with the continuity and
             experience in each geographical area needed to advise the officers in



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                   charge of the potential impact of weather and other conditions on training
                   safety.

                   Since the late 1980s, Army safety policy has required that commanders at
                   all levels accept primary responsibility for integrating safety risk
                   management in daily operations at the unit level. External oversight is
                   provided by the Director of Army Safety, safety offices at major Army
                   commands and installations, and the Army Inspector General.


                   The Ranger Training Brigade has completed most of the corrective actions
Results in Brief   recommended by the Army. The Brigade has improved safety by
                   developing systems to better monitor and predict swamp conditions. It has
                   improved command and control by revising its procedures to move
                   training exercises outside high-risk areas of the swamp, eliminate
                   discretion to deviate from planned exercise locations, and incorporate the
                   latest guidance on training safety. Evacuation procedures have been
                   revised and rehearsed, new medevac helicopters and refueling capacity
                   have been obtained, and medics have been assigned directly to the
                   Brigade.

                   However, if the Army is to sustain the key corrective actions taken after
                   the accident in the future, we believe that the actions must become
                   institutionalized. At the time of the accident, important lessons about
                   safety controls built up over the years by personnel assigned to the Florida
                   training site had not been documented, were lost, or had simply atrophied
                   over time. Formal, written inspections performed by the Infantry Center,
                   Brigade, and the Fort Benning Safety Office do not monitor compliance
                   with training safety controls—such as whether minimum air and land
                   evacuation systems are in place before daily training is conducted and
                   whether instructors are adhering to the rule prohibiting deviations from
                   planned swamp training routes. The inspections are focused instead on
                   checklists of procedural matters, such as whether accidents are reported
                   and whether files of safety regulations and risk assessments are
                   maintained. If the important corrective actions are to become
                   institutionalized, we believe that formal Army inspections will have to be
                   expanded to include testing or observing to determine whether they are
                   working effectively.

                   The Army plans to fully staff the Ranger Training Brigade at the mandated
                   90-percent level by February 1997. However, it may be difficult to sustain
                   the required number of officers beyond the mandated 2 years, and even



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                        more than the required number of enlisted personnel may be needed.
                        Although the Army raised the Brigade’s staffing priority subsequent to our
                        field work, high-risk training units generally are not recognized in Army
                        personnel staffing priorities. And, the Brigade’s long-term ability to sustain
                        the required number of officers may be hindered by competition with
                        Army priorities given to units who are first to fight and with other
                        important noncombatant units, such as the National Training Center. The
                        supply of qualified personnel is already limited because of Army-wide
                        shortages of certain officers and legislative requirements giving priority for
                        staffing to such positions as those involving joint duty and advisers to
                        reserve units. Similarly, Brigade officials believe that current staffing
                        models substantially understate needs for enlisted personnel in general
                        support areas.

                        Currently, members of the Ranger Training Brigade and battalion chains of
                        command serve as the safety cell organization established pursuant to the
                        act. The act did not establish specific criteria to guide decisions on the
                        makeup of a safety cell, and the option chosen by the Army represents
                        little change from the safety oversight practice that was in place at the
                        time of the accident. There is, however, a higher level of attention to safety
                        at the Brigade, but the chain of command has long had dual responsibility
                        for mission accomplishment and safety oversight. Personnel in these
                        positions have limited experience in the local training areas due to the
                        Army’s policy of rotating them to new units every 2 to 3 years. The Army
                        Infantry Center is considering requesting authorization for additional
                        civilian and military positions to serve as full-time safety cell members.
                        Authorizing additional personnel based on safety considerations raises
                        questions about the desirability and affordability of expanding this
                        concept to other high-risk training activities.


                        The Ranger Training Brigade has completed action on 38 of the 41
Most Corrective         (93 percent) recommendations designed to improve training safety. The
Actions to Improve      remaining three recommendations, involving increases in personnel and a
Safety Are Complete     Secretary of the Army-directed follow-up review of safety improvements,
                        are expected to be completed by September 1997. Most of the
                        recommendations were focused on improving (1) risk assessments of
                        training conditions, (2) command and control of exercises, and
                        (3) evacuation and medical support.


Risk Assessments Have   All three training battalions have updated their overall assessments of
Been Improved           training risks. For example, the 6th Battalion in Florida worked with the


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                       National Oceanic and Atmospheric Administration and the U.S. Geological
                       Survey to develop detailed information on terrain, water, and tidal
                       patterns to better understand their impact on training. The 6th Battalion
                       also developed procedures to obtain river level and weather information
                       from local emergency forecasting organizations and incorporated reviews
                       of those risks in daily instructor briefings.

                       Water depth markers and electronic weather sensors were installed along
                       the Yellow River to measure water depth and temperature, air
                       temperature, and humidity readings. In 1995, primitive water level
                       markers, such as painted marks on a bridge and trees, were in place but
                       provided no common scale to judge water depths along training routes.
                       The Battalion also updated its water immersion safety guidelines to reduce
                       student exposure time in water waist deep from 3 to 7 hours to 2 to 3.5
                       hours, when air or water temperature is in the 55 to 64 degree range. The
                       Army’s November 1995 review of the existing guidelines found that
                       soldiers who had just completed the course had a core body temperature
                       about 2 degrees lower than normal soldiers and would thus reach
                       hypothermic conditions quicker than previously believed.


Command and Control    The 6th Battalion completed a comprehensive standard operating
Procedures Have Been   procedure revision in December 1995 that references all training-related
Revised                guidance, identifies key leader responsibilities, and defines the
                       decision-making process to be used when conditions deteriorate to higher
                       risk levels. The revised procedure includes adjustments to training routes
                       to avoid the most hazardous areas and the elimination of student
                       discretion to miss planned landing sites and choose their own.
                       Comprehensive procedures for the other training locations are also being
                       prepared.

                       According to the Army’s investigation, at the time of the accident, written
                       procedures were outdated and were disseminated throughout a variety of
                       instructions. As new cadre were assigned to the Battalion during the
                       normal personnel rotation process, training procedures were changed
                       both formally and informally. On the day of the accident, water at the
                       planned drop-off site was too deep for the students to disembark from
                       their boats. While one student platoon chose to abandon the swamp
                       movement and suffered no casualties, the other two platoons were
                       allowed to continue downriver and select an unplanned landing site.




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                         Moving to an unplanned landing site introduced many uncontrolled
                         variables into the exercise, such as water depth, underwater obstacles,
                         currents from underwater streams, and unfamiliar ground, the Army’s
                         investigation report said. The platoons quickly encountered water waist to
                         neck deep, but the instructors moved ahead, believing that the water
                         would get shallower and the platoon would have a short move to higher
                         ground. However, they continued to encounter deep water obstacles and
                         within 1 hour students began to enter the early stages of hypothermia.

                         The Brigade also developed a standardized, written instructor certification
                         program covering all battalions. Instruction is provided at each battalion in
                         areas such as training techniques and safety controls, emergency
                         procedures and contingency plans, and combat lifesaving techniques.
                         Emphasis is placed on a step-by-step progression from basic instructor up
                         to principal instructor, and personnel must be certified at each level
                         before serving in that capacity. According to Brigade officials, the program
                         increased the time required for certification from about 1.5 to 4 months.

                         The Brigade has generally completed a $1.1 million communications
                         system upgrade to improve communications at both the 6th Battalion and
                         the 5th Battalion in the Georgia mountains. The upgrade will connect
                         virtually all cadre participating in Florida exercises directly with one
                         another. Inadequate emergency communications slowed reaction times
                         during the accident, as well as the ability of the cadre to know what was
                         happening as conditions deteriorated.


Evacuation and Medical   The Florida camp has now revised and rehearsed air, water, and ground
Support Capabilities     evacuation plans, and mass casualty and joint evacuation procedures with
Increased                local medical services. According to Army officials and the investigation
                         report, at the time of the accident, the camp had not documented
                         preplanned surface evacuation routes and extraction points or standard
                         operating procedures for handling mass casualties, and surface evacuation
                         was not considered until late in the accident.

                         The camp has also obtained two new medevac helicopters, with more
                         cargo capacity and speed than their predecessor, and aircraft fuel in a
                         2,000-gallon tanker is now available at the camp. Although the camp’s only
                         medevac helicopter responded quickly to the accident, bad weather and
                         the lack of a refueling truck at the Florida camp delayed its second
                         evacuation run by over 2 hours.




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                           Full-time medics have also been assigned to the Brigade. Many of these
                           medics are Ranger-qualified and routinely walk on patrol with the
                           students. The Brigade was not previously authorized to have its own
                           medics, and difficulties were encountered during the accident because the
                           borrowed medics were not trained in some of the techniques used during
                           the evacuations.

                           Additional key corrective actions are discussed in the following sections.
                           The complete status of all corrective actions is included in appendixes I
                           through V.


                           If the Army is to sustain the key corrective actions instituted after the
Army Oversight Needs       accident in the future, it must institutionalize them. One important way to
Improvement to             achieve this objective is to expand the focus of formal Army inspections to
Preserve Key               include testing or observing the key safety controls to determine whether
                           they are working effectively. Neither formal Army Safety Program
Corrective Actions         inspections, required to be conducted annually by installation safety
                           offices, nor formal Army Infantry Center command inspections were
                           conducted at the Florida camp during the 2 years prior to the Ranger
                           student deaths. Even if such safety inspections had been conducted, it is
                           not likely that they would have identified the erosion in safety controls
                           because the inspections were focused on procedural issues such as
                           whether accidents are reported.

                           Army officials told us that less formal reviews of Ranger Training Brigade
                           operations were conducted by a variety of Army organizations both before
                           and after the accident. However, we found little or no documented record
                           of safety control inspections. Although important, these informal
                           inspections cannot substitute for documented safety reviews in sustaining
                           safety improvements over time.


Formal Installation and    According to Brigade and other Army officials, there are two basic keys to
Command Inspections of     ensuring that safety controls operate as intended over time in an
Training Safety Controls   environment of rapid personnel turnover. First, controls must be clearly
                           institutionalized in written operating procedures. Second, leaders must
Are Limited                visit training sites frequently and observe operations to ensure that the
                           safety controls are followed.

                           At the time of the accident, many of the important lessons about safety
                           controls that had been built up over the years by personnel assigned to the



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Florida training site were not in written form and had been lost over time.
For example, according to Brigade officials, at least until 1991 student
platoons were not allowed to miss planned drop sites and pick their own
routes through the swamp. Similarly, the Army investigation following the
1977 hypothermia deaths of two students recommended that an on-site
refueling capability for medevac helicopters be made available at the
Florida camp. However, these and other key safety measures were either
not institutionalized or simply atrophied over time.

As shown in figure 1, a variety of organizations have exercised oversight
over Ranger Training Brigade safety.




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Figure 1: Army Organizations That Oversee Ranger Training Brigade Safety




                                                       Secretary of The Army


                                                                                               Inspector General




                                                         Army Chief of Staff



                                                                                             Director of Army Safety


                                                            Commander,
                                                  Training & Doctrine Command


       Training & Doctrine Command
                   Safety Office

                                                           Commander,
                                                        Army Infantry Center
                                                           Ft. Benning
          Installation Safety Office
                 Ft. Benning


                                                          Commander,
                                                      Ranger Training Brigade
                                                           Ft. Benning




         4th Ranger Training Battalion              5th Ranger Training Battalion      6th Ranger Training Battalion
             (Ft. Benning Phase)                     (Georgia Mountain Phase)             (Florida Swamp Phase)




                                         Army officials told us that representatives from these organizations visited
                                         the Brigade a number of times, both before and after the accident.




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However, we found little or no documented record of safety control
inspections during these visits.

Although safety inspections are required at least once each year under the
Army Safety Program, the Fort Benning Installation Safety Office
conducted no inspections of training operations safety at the Brigade or its
battalions between March 1993 and March 1996.3 Moreover, Fort Benning
Safety Office officials acknowledge that even if the required inspections
had been performed before the 1995 accident, it is not likely that they
would have identified the erosion in safety controls. Formal inspections by
the Safety Office under the Army Safety Program comprise checklists
focused on procedural issues, such as whether accidents are reported and
files of safety regulations and risk assessments are maintained.

The Army’s process for identifying and controlling hazards in training
operations is termed risk management. This program consists of a formal
five-step process of (1) identifying training and other hazards,
(2) assessing the magnitude of each risk, (3) making risk decisions and
developing controls, (4) implementing the controls, and (5) supervising
and enforcing the controls.4 Although the process requires units to identify
safety controls as part of written training risk assessments, the controls
considered most important by the unit are not identified. And, as
illustrated in table 1, formal inspections by the installation Safety Office
and the Brigade do not include requirements for testing or observation to
determine whether the more important safety controls are working
effectively. Examples of important safety controls are testing instructors’
adherence to the rules requiring them to walk planned swamp routes
before each exercise and prohibiting deviations from planned swamp
training routes.




3
 Army Regulation 385-10, chapter 2-3.a., the Army Safety Program, June 1988.
4
 At our request, an official from the Army Safety Center, Fort Rucker, Alabama, reviewed the Brigade’s
risk management program and found it to be in accordance with the recommended approach. The
Army Safety Center supports the Director of Army Safety in managing the Safety Program and
integrating risk management into Army doctrine.



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Table 1: Oversight of Selected Safety
Controls During Fort Benning Safety     Inspected                         Not inspected
Inspections                             1. Has a unit safety program      1. Are communications systems linking training
                                        document been published?          instructors, supervisory personnel, and emergency
                                                                          assistance fully operational before each exercise?
                                        2. Are unit personnel aware    2. Are the minimum air and land evacuation systems in
                                        of the notification procedures place before daily training is conducted?
                                        in the event of an accident?
                                        3. Are risk management            3. Are instructors adhering to the rule requiring them to
                                        worksheets completed for all      walk planned swamp routes the morning of each
                                        operations and training?          exercise?
                                        4. Are newly assigned         4. Are instructors adhering to the rule prohibiting
                                        personnel briefed on unit and deviations from planned swamp training routes?
                                        installation safety policy
                                        within 3 days of arrival?
                                        5. Have part-time assistant       5. Are fully qualified instructors used for each training
                                        safety officers been              event?
                                        appointed?

                                        Safety office inspection responsibility includes a wide range of activities,
                                        including Occupational Safety and Health Act standards, ammunition and
                                        explosives operations and storage, and military training operations.
                                        According to Fort Benning installation Safety Office officials, they have
                                        not had the financial or personnel resources to inspect units as frequently
                                        as required. Since 1991, Safety Office personnel have been reduced from
                                        13 to 8.

                                        In 1993, the Army Inspector General found that resource constraints were
                                        impacting installation safety offices’ ability to fulfill their required safety
                                        responsibilities.5 The report concluded that when commanders were
                                        forced to make difficult resourcing decisions, safety officers often had
                                        difficulty competing for resources because of their orientation toward
                                        prevention. At that time the average percentage of assigned personnel in
                                        installation safety offices was 67 percent of requirements. Under the
                                        Army’s command and staff inspection program, individual units are also
                                        responsible for conducting periodic inspections of their subordinate
                                        commands’ operations. However, the Army Infantry Center did not
                                        conduct a formal command inspection of the Brigade for over 22 months
                                        prior to the accident. Similarly, the Brigade did not conduct a formal
                                        command inspection of the Florida camp’s operations for over 2 years
                                        prior to the accident.




                                        5
                                         Assessment of Army Safety Program, Department of the Army Inspector General, April 1993.



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                              Army inspection policy provides commanders flexibility to establish both
                              the frequency and criteria for the inspections, with guidance from their
                              major commands.6 Command inspections by the Infantry Center, and the
                              Brigade in turn, cover a broad range of unit activities, including safety.
                              However, these formal inspections use the same safety item checklist as
                              the installation Safety Office, which is focused on procedural matters and
                              does not evaluate the operation of important training safety controls.

                              The manager of Fort Benning’s installation Safety Office told us that,
                              without clear identification of the most important training safety controls,
                              his office does not have the expertise for in-depth assessments of
                              compliance. However, not all safety controls have been documented by
                              the battalions, and the most important controls have not been highlighted
                              to provide the foundation needed for effective external inspections. For
                              example, at one battalion the minimum evacuation resources needed to
                              conduct training safely were not identified. Some of these requirements,
                              such as having two ambulances available before certain dangerous
                              exercises can be conducted, were included in medics’ personal
                              documents—but not in battalion operating procedures.


Daily Oversight of Training   The 6th Ranger Training Battalion has improved its daily oversight of
Safety Has Been Improved      training safety by reinstating controls lost over the years, documenting
                              many of them, and ensuring that they are followed. For example,
                              instructors are now required to walk the planned training route through
                              the swamp the morning of each exercise. A variety of safety controls are
                              included throughout internal training risk assessments, individual training
                              exercise procedures, and draft training operating procedures. These
                              controls are enforced as part of the instructors’ daily supervision of
                              training, and compliance is generally documented in daily operations logs,
                              after-action reports, and other internal operations documents.

                              The Brigade has inspected each training battalion and instituted a written
                              policy of monthly visits by the Commander or other key leaders to ensure
                              that safety controls are adequate and executed as intended. The Infantry
                              Center Commander’s approval is now required before any reduction can
                              be made in the safety controls in place at the Brigade and its battalions.
                              The Secretary of the Army has also directed a follow-up review of safety
                              procedures at the school, currently scheduled for September 1997. In
                              addition, according to Army Inspector General officials, the Secretary has


                              6
                               Army Regulation 1-201, chapters 1-4, 3-3, and 3-4, Army Inspection Policy, May 1993.



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                                   asked their office to conduct periodic reviews of the Brigade, as well as
                                   other high-risk training units.


                                   The Army plans to staff the Ranger Training Brigade at the required
Priority for Officer               90-percent level by February 1997 and submitted its plan for doing so to
Staffing Increased, but            Congress in November 1996.7 To meet the law’s requirement, the Army
Enlisted Personnel                 placed the Brigade on the list of units excepted from normal Army staffing
                                   priorities and raised the unit’s priority to the highest level. The plan also
Levels Are Lower                   requires quarterly reports to ensure that the required staffing levels are
Than Brigade                       maintained.
Requests                           The Army’s investigation of the 1995 accident concluded that officer
                                   shortages and personnel turnover contributed to the accident by draining
                                   the experience and insight of the 6th Battalion and by limiting its ability to
                                   keep operating procedures current, supervise standards and policies, and
                                   allow officers to accompany and observe field training exercises. At the
                                   time of the accident, the Florida camp had 8 of the 11 authorized officers,
                                   but only 32 percent (8 of 25) of the required officers.8 In addition,
                                   42 percent (44 of 106) of the instructors were assigned only during the last
                                   year before the accident. According to officials at the Army Infantry
                                   Center, they attempt to limit turnover to about 33 percent of unit
                                   personnel each year.

                                   As shown in table 2, enlisted personnel have been assigned to the Brigade
                                   at levels close to or above those mandated for years.

Table 2: Ranger Training Brigade
Staffing (Fiscal Years 1994-97)                          Officers            Enlisted            Civilians            Total
                                   Date                  Percentage of       Percentage of       Percentage of        Percentage of
                                                         required            required            required             required
                                   2/94                  35                  98                  21                   85
                                   2/95                  32                  95                  21                   82
                                   2/96                  42                  94                  21                   82
                                   10/96                 88                  104                 20                   97



                                   7
                                    The 1996 act required the Army to submit a plan to Congress for meeting the mandated staffing levels
                                   by May 1996.
                                   8
                                    The Army allocates available personnel through a system that authorizes a percentage of the required
                                   number of personnel at each unit to be filled. The Army defines “required personnel” as the minimum
                                   number a unit needs to perform its mission effectively. Authorized personnel is the number that can
                                   actually be supported from the existing inventory of personnel. Actual assignments can be less than
                                   authorized levels.



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                             Army policy gives staffing of enlisted personnel at the school priority over
                             other units. However, until November 1996, staffing for Ranger Training
                             Brigade officers did not receive Army priority and averaged about
                             36 percent of required levels between 1994-96.9 As of October 1996, officer
                             staffing had been increased to 88 percent of required levels. Department of
                             Defense officials told us that raising the Brigade’s staffing priority to the
                             highest level would also significantly reduce the difficulties it faced in
                             competing for personnel resources and sustaining high staffing levels. The
                             Brigade Commander assigned at the time of the accident told us that the
                             unit needed about 50 officers to function safely and effectively. Staffing
                             the Brigade at the required 90-percent level would increase the number of
                             Brigade officers to 58, or 20 more than at the time of the accident. Despite
                             the low percentage of civilian staffing, the Brigade Commander believed
                             that the current number of civilian staff was adequate.

                             According to Army Infantry Center officials, the Center attempts to
                             manage turnover of key Brigade personnel through quarterly reviews of
                             upcoming officer changes. The Commanding General reviews all rotations
                             at the rank of major and above. These reviews have been a continuous
                             process over the years, but have received increased emphasis since the
                             accident. During 1996, turnover of key leaders (commanders, executive
                             officers, operations officers, and command sergeant majors) at each
                             battalion was halted during the high-risk winter training months. However,
                             the near-simultaneous replacement of the Brigade commander, executive
                             officer, and command sergeant major during the spring and summer raised
                             concerns at the Brigade.


Increased Officer Staffing   Officer shortages, such as those experienced by the Ranger Training
Competes With Army           Brigade, are not unique. Our June 1995 report on the drawdown of military
Priorities for Allocating    personnel found that most Army positions were kept filled at high rates
                             during the early 1990s.10 However, certain specialties and ranks,
Personnel Shortages          particularly field grade officers (majors, lieutenant colonels, and colonels)
                             were in short supply. According to Army officials, field grade officers, as


                             9
                              Between fiscal years 1996 and 1997 the requirement for officers was reduced from 111 to 64.
                             According to Brigade officials, this large reduction is due to long-delayed adjustments related to
                             reduced student loads and the disbanding of desert training at the 7th Ranger Training Battalion at the
                             end of 1995. Between fiscal years 1990 and 1996, the number of students authorized to attend the
                             Ranger training annually dropped from about 3,700 to 2,400. Brigade officials chose to take most of the
                             reduction in officers because the actual assignment rate of officers is much less than that of enlisted
                             personnel.
                             10
                              Military Personnel: High Aggregate Personnel Levels Maintained Throughout Drawdown
                             (GAO/NSIAD-95-97, June 2, 1995).



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                             well as branch-qualified captains, continue in short supply today.11 For
                             example, in 1997 the Army is expected to operate with about 1,200 fewer
                             branch-qualified captains, 3,200 fewer majors, and 1,000 fewer lieutenant
                             colonels than the nearly 24,000 authorized in force structure documents.

                             Army policy is that units that are first to fight are first to be resourced.
                             However, available officers are limited first by Army-wide shortages, and
                             then by legislative and other requirements such as giving priority to joint
                             duty assignments, duty as advisers to reserve units, and other special
                             considerations.12 In 1997, for example, the Army expects about 40,000
                             officers to be available for assignment. For fiscal year 1997, about 3,000
                             officers were authorized for joint duty positions, 1,600 for duty as advisers
                             to the reserves, and another 1,900 for acquisition positions. Following
                             satisfaction of these initial priorities, allocations flow down through major
                             commands such as TRADOC, to subordinate commands like the Army
                             Infantry Center, and on to individual units. Each level may add its own
                             priorities, further limiting the number of officers available to lower priority
                             units.

                             For example, in 1996 TRADOC, a noncombatant command, received
                             73 percent of its authorization for branch-qualified captains through
                             colonels, while the program providing advisers to reserve units received
                             104 percent. The Infantry Center then spread the officers allocated by
                             TRADOC in accordance with Army-wide, TRADOC, and local priorities,
                             including emphasis on all its high-risk training units. The officers
                             remaining allowed a fill rate at the Ranger Training Brigade of only about
                             85 percent of the authorized level, 42 percent of requirements. Our
                             analysis of allocations between 1991-97 found the Brigade’s experience to
                             be similar to that of other units at the Center. According to Army officials,
                             officers are being diverted from duty at such units as the National Training
                             Center, Joint Readiness Training Center, and Battle Command Training
                             Program to provide the mandated increase in staffing at the Brigade.


Required Enlisted Staffing   Brigade officials believe the school needs about 624 enlisted personnel to
Levels Lower Than Brigade    operate safely and effectively. This number equates to about 112 percent
Estimates                    of current requirements, or 68 enlisted soldiers more than assigned in
                             October 1996. The extra personnel requested are based on studies of the


                             11
                              “Branch-qualified” officers are those who have had advanced training and served in certain positions,
                             such as company commander, in the field to which they are assigned.
                             12
                              Public Laws 99-433, section 401, Oct. 1, 1986; 102-190, section 414, Dec. 5, 1991 and 102-484, section
                             1132, Oct. 23, 1992; and 101-510, section 1202, Nov. 5, 1990; respectively.



                             Page 15                                                    GAO/NSIAD-97-29 Army Ranger Training
                           B-275298




                           Brigade conducted in 1994 and 1995. On the basis of these studies, the
                           Brigade also called for a restructuring of staffing models for the unit.

                           Brigade officials believe that current staffing models are outdated and do
                           not accurately reflect the need for medical, boat safety, air operations, and
                           other general support personnel. The Brigade has diverted enlisted
                           instructors to fill these shortages. According to Brigade officials, enlisted
                           staffing would be sufficient if it were not for the drain caused by the lack
                           of support personnel. Army-wide, enlisted duty positions such as
                           recruiters, service school instructors, the operations group at the National
                           Training Center, and certain schools such as the Brigade, Joint Readiness
                           Training Center, and Special Warfare Center receive priority and are
                           staffed at about 98 to 105 percent of authorizations. TRADOC has been
                           studying the issues raised by the Brigade in schools across the command
                           since early 1996, and officials expect the studies to be completed by
                           April 1997.


High-Risk Training Not     According to TRADOC and Army Safety Center officials, recognition of the
Defined or Recognized in   high rate of accidental deaths and injuries has increased the emphasis on
Personnel Assignment       risk management in the Army. TRADOC currently is rewriting combat
                           doctrine to recognize risk management and better integrate it into Army
Priorities                 culture and decision-making.

                           Currently, however, the Army has no formal criteria to identify units
                           considered to be high risk and serve as a framework for allocating
                           personnel or other resource priorities to them. Following the death of a
                           Navy recruit during rescue swimmer training in 1988, TRADOC conducted a
                           study of high-risk/high-stress training (High-Risk/High-Stress Training
                           Special Study, April 1, 1989). The study developed a definition of
                           high-risk/high-stress training and identified a list of 92 courses categorized
                           as inherently dangerous, including the course conducted by the Ranger
                           Training Brigade. Similarly, the deaths of the Ranger students in 1995
                           spurred an ongoing review of high-risk training by the Army Inspector
                           General (Special Assessment of High Intensity Training). The first phase of
                           this review also developed a definition and identified a group of high-risk
                           units. However, according to TRADOC and Inspector General officials,
                           neither definition has been formally adopted by the Army.

                           We asked the Army Safety Center to provide information identifying units
                           that have had the most training deaths and serious accidents over the past
                           10 years. However, according to Center officials, this information is not



                           Page 16                                    GAO/NSIAD-97-29 Army Ranger Training
                               B-275298




                               readily available because of difficulties in aggregating data at levels below
                               installations, changes in reporting formats over time, and the sheer
                               number of units involved. Statistics such as those involving safety can be
                               difficult to interpret because of behavioral and other variables. For
                               example, some units may have superior safety programs, but higher rates
                               of accidents due to higher levels of inherent risk in their activities.


                               Currently, members of the Ranger Training Brigade and battalion chains of
Safety Cell                    command serve as the safety cell organization established pursuant to the
Organization Status            1996 act. Although there is a higher level of attention to safety, for the
                               most part, the safety cell organization established is no change from the
                               oversight practice that was in place at the time of the accident. At the
                               close of our review, however, the Infantry Center and Brigade were
                               considering requesting additional personnel to serve as full-time safety cell
                               members.


Current Brigade Approach       The act required the Army to
Mirrors Existing Army
Policy                     •   establish an organizational entity known as a safety cell at each of the
                               three phases of Ranger training,
                           •   ensure that safety cell personnel at each location have sufficient continuity
                               and experience in that area to understand local conditions and their
                               potential effect on training safety, and
                           •   assign sufficient numbers of safety cell personnel to serve as advisers to
                               the officers in charge at each location in making daily “go” and “no-go”
                               decisions on training.

                               The act, however, did not establish specific criteria to guide decisions on
                               the makeup of a safety cell. The Ranger Training Brigade established its
                               safety organization consistent with past operations and existing Army
                               policy. The battalion commanders were named as safety officers, with dual
                               responsibility for training operations and training safety. The Brigade
                               Commander is the overall safety officer. Operations sergeants at each
                               battalion were designated as assistant safety officers. The Brigade
                               Commander also named each battalion command sergeant major,
                               operations sergeant, and the primary instructor overseeing each day’s
                               exercise as part-time safety cell members.

                               The Brigade Commander chose these personnel because the personnel in
                               those positions generally have a relatively high degree of experience and



                               Page 17                                    GAO/NSIAD-97-29 Army Ranger Training
B-275298




knowledge of the area and close involvement in supervising and
monitoring operations. Even so, we noted that the personnel in these
positions have limited continuity and experience in the local training
areas. For example, the Brigade and battalion commanders normally
rotate to new units every 2 years and enlisted personnel every 3 to 3.5
years. At the time of our visits, the safety cell members had on average, 2.5
and 4.4 years of experience at the 6th Battalion in Florida and 5th
Battalion in the Georgia mountains, respectively, including time from prior
tours of duty.13 In comparison, a civilian training specialist at the Brigade
has been employed continuously for 11 years.

The Brigade has a higher level of attention to safety than in the past. For
example, the 6th Battalion Commander walks the planned route for
swamp training the day before each exercise. However, according to
battalion officials, the personnel and duties of the safety cell members are
not markedly different than those of safety officers in the past. The
battalion commander, command sergeant major, principal instructor, and
operations sergeant/officer were also responsible for overseeing safety in
past years. The Brigade’s approach makes no provision for expert advice
from outside the chain of command. According to the Brigade Commander
at the time of the accident, ideally, the safety cells should be staffed with
civilians with long-term continuity.14 However, budget constraints made
the hiring of civilians impractical.

The specific duties and identity of the safety cell members are now defined
in the draft Brigade operating procedures, unlike at the time of the
accident. However, they have not been incorporated into written battalion
procedures. We also noted that safety cell members in the Brigade are not
required to undertake any special training for their duties. Safety cell
members at the 6th Battalion were given the 4-hour Fort Benning assistant
safety officer course following the 1995 accident. However, in contrast,
safety officers in Army aviation units must take a 6-week safety course.

Since the late 1980s, Army policy has placed responsibility for safety in
each unit’s chain of command. The unit commander is the safety officer,
fulfilling dual responsibilities for mission completion as well as safe
operations. Unit commanders may appoint additional personnel at lower
echelons to serve as part-time assistant safety officers in addition to their


13
 At the time of our field work, the 4th Battalion had not named safety cell members. The Battalion
Commander was awaiting finalization of the Brigade standard operating procedure.
14
  A new Army Infantry Center Commander was assigned in July 1996, and a new Brigade Commander
in August 1996.



Page 18                                                  GAO/NSIAD-97-29 Army Ranger Training
                            B-275298




                            normal unit duties. According to the Director of Army Safety, this doctrine
                            was adopted at a time when accident rates were at high levels and
                            responsibility for safety was largely considered to be the province of
                            agencies external to the units. The new doctrine sought to make
                            commanders primarily responsible for safety and to use risk management
                            techniques to help identify and reduce unnecessary risks.


Changes to Current Safety   Late in our review, the Brigade’s approach to the safety cells was reviewed
Cell Organization Are       by the new Brigade Commander and the new Commander of the Army
Being Reviewed              Infantry Center. Because of the need for long-term continuity and other
                            considerations, the Infantry Center and Brigade are considering requesting
                            that four civilian and seven military personnel be added to the Brigade’s
                            authorized personnel to serve as safety cell members. The request would
                            authorize one civilian and one military position at the Brigade and one
                            civilian and two military positions at each battalion to handle the 24-hour
                            training operations at the camps and the possibility of temporary absences
                            of safety cell members.

                            Our discussions with the Army Safety Center, TRADOC, and the Army
                            Infantry Center identified a number of pros and cons with the use of
                            civilians as full-time safety officers. A safety cell made up of civilians
                            would provide a clear and highly visible professional advocate for safety
                            with long-term continuity and experience at training locations. This
                            approach also provides a measure of protection against commanders who
                            may overzealously pursue mission accomplishment to the unnecessary
                            detriment of safety. However, the use of civilians also includes some
                            potential for undermining the unit chain of command and diluting
                            commanders’ feelings of personal responsibility for safety. TRADOC and
                            other Army officials also raised concerns about a lack of experience in
                            military plans and operations that could limit the effectiveness of civilians
                            working in military units. This potential could be addressed by hiring
                            retired Ranger instructors or other appropriate military retirees. Cost is
                            also a significant concern.

                            According to TRADOC officials, authorizing additional personnel on the
                            basis of safety considerations raises questions about the desirability and
                            affordability of expanding this concept to other dangerous training
                            activities. The Ranger Training Brigade estimated that each civilian would
                            cost about $30,000-$39,000 annually. Authorizing TRADOC’s 1989 list of 92
                            high-risk schools with an average of 2 personnel each would require about
                            200 additional civilians.



                            Page 19                                    GAO/NSIAD-97-29 Army Ranger Training
                      B-275298




                      Alternatively, existing military personnel could be used in place of
                      civilians. The advantages of this approach include the same highly visible
                      professional advocate for safety without the increased cost. However, this
                      approach would also represent an additional drain on the Army’s limited
                      pool of officers, without providing increased long-term continuity. In
                      addition, officers we spoke to were concerned, again, that such positions
                      could undermine the unit chain of command as well as commanders’
                      feelings of personal responsibility for safety. The existing Army Aviation
                      Safety Officer program could serve as a model for this option. Army policy
                      authorizes formal positions for full-time safety officers at each Army
                      aviation unit.15 Army regulations for the program specifically state that
                      such officers will administer and monitor the overall safety program,
                      including halting unsafe actions, but they have no command authority.
                      There are currently some 900 aviation safety officers in the active Army
                      and reserves.

                      The number of additional military or civilian personnel needed for these
                      options might be reduced by training some of the existing 1,086 safety
                      civilians in technical fields such as occupational health and safety,
                      engineering, and health as unit operations safety personnel. The Army
                      Safety Center is currently restructuring its Total Safety Professional
                      Career Management Program to provide such training.


                      We recommend that the Secretary of the Army
Recommendations
                  •   direct that the Ranger Training Brigade identify critical training safety
                      controls at each training location;
                  •   ensure that TRADOC, the Army Infantry Center, Fort Benning safety office,
                      and Ranger Training Brigade conduct periodic inspections to determine
                      compliance with the identified safety controls; and
                  •   direct that inspections of critical safety controls be made periodically by
                      organizations outside the chain of command such as the Army Inspector
                      General.

                      We are deferring any recommendations on the issues of personnel staffing
                      levels and the appropriate organization of safety cells until we have
                      completed our final evaluation.




                      15
                        Army Regulation 385-95, chapter 1-5.b., Army Aviation Accident Prevention, May 1991.



                      Page 20                                                  GAO/NSIAD-97-29 Army Ranger Training
                     B-275298




                     In written comments on a draft of this report (see app. VI), the Department
Agency Comments      of Defense said that it generally agreed with our findings and
and Our Evaluation   recommendations and has completed or has in progress most of the
                     planned corrective measures. The Department said that the Brigade has
                     identified the critical safety controls and the Secretary of the Army has
                     directed that the chain of command and the Army Inspector General
                     conduct periodic inspections of the Brigade to ensure that the safety
                     controls and corrective actions are effective. We believe that such periodic
                     inspections, together with highly visible support for safety from the Army’s
                     leadership, will be critical to institutionalizing effective safety controls at
                     the Brigade.

                     The Department also noted that its regulations require leaders at all other
                     potentially hazardous training units to integrate risk management safety
                     principles into their training. Nonetheless, difficult long-term policy
                     questions remain regarding the appropriate priority for staffing and other
                     resources to be provided to the Department’s other high-risk training
                     units, as well as the need for safety organizations at such units.


                     To determine the status and implementation of corrective actions taken to
Scope and            improve Ranger training safety, we received briefings from Brigade
Methodology          officials, reviewed reports covering the Army’s investigation of the Ranger
                     students’ deaths, observed each Ranger battalion’s training facilities,
                     interviewed Army investigating officers and Brigade and battalion
                     commanders and instructors, reviewed training safety controls and
                     inspection procedures, and observed the site where the deaths occurred.
                     At our request, the Army Safety Center also conducted a review of the
                     Brigade’s risk management program. We did not review whether the
                     Army’s investigation of the accident was conducted in accordance with
                     regulations.

                     We assessed the ability of safety inspection and oversight procedures to
                     ensure that corrective actions will be sustained in the future through
                     review of Army and Infantry Center regulations and inspection records,
                     and interviewed officials at the Army Inspector General’s Office, Army
                     Safety Center, U.S. Forces Command, Army Special Operations Command,
                     TRADOC, the Fort Benning Safety Office, and the Ranger Training Brigade.


                     To assess progress made toward increasing personnel staffing to
                     legislatively mandated levels, we reviewed and analyzed personnel and
                     policy documents and data to determine staffing priorities, changes in



                     Page 21                                     GAO/NSIAD-97-29 Army Ranger Training
B-275298




requirements, assignments, student loads, and changes in staffing at the
Brigade and other Army Infantry Center units during fiscal years 1994-97.

We assessed the progress made toward establishing training safety cells by
reviewing records and interviewing Brigade and battalion officials
regarding the duties, qualifications, and experience of safety cell members.
We also discussed safety cell organizations with the Director of Army
Safety, Army Manpower and Reserve Affairs, TRADOC, and Army Infantry
Center officials.

We conducted our review at Department of Army headquarters, TRADOC,
Army Infantry Center, Ranger Training Brigade, the Ranger battalions, and
the Army Safety Center. Our review was conducted from April through
October 1996 in accordance with generally accepted government auditing
standards.


We are sending copies of this report to the Chairmen, Senate and House
Committees on Appropriations, Senate Committee on Armed Services, and
House Committee on National Security and to the Secretaries of Defense
and the Army. Copies will also be made available to others upon request.

The major contributors to this report are listed in appendix VII. If you or
your staff have questions about this report, please call me on
(202) 512-5140.




Mark E. Gebicke
Director, Military Operations
  and Capabilities Issues




Page 22                                    GAO/NSIAD-97-29 Army Ranger Training
Page 23   GAO/NSIAD-97-29 Army Ranger Training
Contents



Letter                                                             1


Appendix I                                                        26

Status of Actions to
Improve Safety
Management: Risk
Assessments
Appendix II                                                       27

Status of Actions to
Improve Safety
Management:
Command and
Control, Equipment,
and Training
Appendix III                                                      28

Status of Actions to
Improve Safety
Management: Medical
Support and
Evacuation
Procedures
Appendix IV                                                       29

Status of Actions to
Preserve Lessons
Learned




                       Page 24   GAO/NSIAD-97-29 Army Ranger Training
                        Contents




Appendix V                                                                                        30

Status of Actions to
Increase Personnel
Staffing
Appendix VI                                                                                       31

Comments From the
Department of
Defense
Appendix VII                                                                                      33

Major Contributors to
This Report
Tables                  Table 1: Oversight of Selected Safety Controls During Fort                11
                          Benning Safety Inspections
                        Table 2: Ranger Training Brigade Staffing                                 13

Figure                  Figure 1: Army Organizations That Oversee Ranger Training                  9
                          Brigade Safety




                        Abbreviations

                        TRADOC     Training and Doctrine Command


                        Page 25                                  GAO/NSIAD-97-29 Army Ranger Training
Appendix I

Status of Actions to Improve Safety
Management: Risk Assessments


Planned action                                               Status        Comments
1. Develop a standard operating procedure to capture and     Completed     Weather, river, and swamp information obtained from local
use river level forecast information from local agencies.                  and federal agencies is integrated in training
                                                                           decision-making. Also, three remote weather sensors on
                                                                           the Yellow River provide real-time water depth and
                                                                           temperatures.
2. Update risk management assessment.                        Completed     Risk management assessments have been completed for
                                                                           all training activities.
3. Update daily risk assessment.                             Completed     Daily risk assessments capture information on changing
                                                                           weather, water level, temperature, student conditions and
                                                                           readiness of support systems.
4. Update current immersion guide.                           Completed     On the basis of the Army’s November 1995 reevaluation of
                                                                           the original immersion guidelines, the Ranger Training
                                                                           Brigade lowered the guideline’s water exposure times.
5. Standardize the in-walkers briefing for instructors.      Completed     Written standardized briefing formats are used for daily
                                                                           briefings of instructors at all three Ranger training
                                                                           battalions.
6. Provide commanders critical requirements analysis of      Completed     Medical and other information on selected students and
class/platoon strengths and weaknesses as each class                       student platoons is forwarded to each training phase’s
moves to a new training phase.                                             incoming commander.
7. Erect staff markers on the lanes.                         Completed     The Army Corps of Engineers erected 32 water depth
                                                                           markers along the Yellow River and training lanes in the
                                                                           swamps.
8. Examine the effectiveness of the current buddy system.    Completed     System reviewed and remains a first line of safety defense.
                                                                           When assigned buddy not available, teams will move to
                                                                           three-person system.
9. Reinstate the system of assigning tactical officers to each Completed   The 6th Battalion now assigns a captain or senior
class.                                                                     noncommissioned officer and a staff sergeant to each
                                                                           class with responsibility for class cohesion, student
                                                                           advocacy, feedback to battalion commanders, and other
                                                                           issues.
10. Conduct refresher training on the use of the immersion   Completed     The water immersion guide is briefed at the beginning of
guide.                                                                     each training day and updated as conditions change.
11. Identify and mark weak swimmers.                         Completed     Weak swimmers are identified during the combat water
                                                                           survival test and marked on their headgear and equipment.
12. Obtain physiological monitoring software.                Completed     Experimental monitoring software was provided to Ranger
                                                                           medical clinics. Due to implementation problems, the
                                                                           Brigade has discontinued its use.
13. Conduct nutrition and immunization study.                Completed     The Brigade Commander has increased meals provided
                                                                           Ranger students from 1-1/2 to 2 per day based on Army
                                                                           nutritional studies.
14. Develop personnel status monitoring system technology Completed        Experimental monitors tested in June 1996, but no
for possible use in Florida.                                               procurement made.




                                                Page 26                                        GAO/NSIAD-97-29 Army Ranger Training
Appendix II

Status of Actions to Improve Safety
Management: Command and Control,
Equipment, and Training

Planned action                                                Status      Comments
1. Develop standard operating procedure for conducting        Completed   Procedure for Florida training phase is completed.
training at the 6th Ranger Training Battalion.                            Rewrites for Brigade and remaining phases are in process.

2. Clearly identify each training lane.                       Completed   The 6th Battalion identified specific lanes from the Yellow
                                                                          River through the swamps. The lanes were narrowed and
                                                                          adjusted to avoid hazardous areas. Students are no longer
                                                                          allowed to deviate from designated boat drop sites and
                                                                          training lanes.
3. Develop a training and certification program for           Completed   The Ranger Training Brigade developed a standardized
instructors.                                                              instructor certification program. The program focuses on
                                                                          the development of instructor competency, experience,
                                                                          and application of procedures, safety, and risk
                                                                          management.
4. Upgrade tactical operations center ability to monitor      Completed   Communications and computer upgrades installed at
operations.                                                               Florida and mountain phases. Installation of tower and
                                                                          microwave antennae scheduled for completion in Florida
                                                                          by January 1, 1997.
5. Purchase earplug/silent radios.                            Completed   The 6th Battalion acquired whisper mikes for use with
                                                                          Motorola radios during training exercises.
6. Ensure that all patrols are equipped, trained, and         Completed   6th Battalion students must demonstrate their ability to
prepared to conduct stream crossing operations.                           properly construct a one-rope bridge in 8 minutes prior to
                                                                          entering the swamp.
7. Develop a decision paper on the use of precision           Completed   A Ranger Training Brigade decision paper concluded that
lightweight global-position receivers by instructors during               global-position receivers will be used by medical
emergencies.                                                              evacuation helicopters and Ranger instructors. The
                                                                          Brigade acquired 66 receivers to track the movement of
                                                                          students.

8. Develop standard packing lists for instructors, medics,    Completed   Equipment and supply packing lists for instructors,
and aeromedevac crews.                                                    medics, and aeromedevac crews have been updated.
9. Review the winter rucksack packing list.                   Completed   The winter packing list has been reviewed and minor
                                                                          changes made. Instructors inspect student rucksacks to
                                                                          ensure they have been tailored, weight distributed, and
                                                                          waterproofed.
10. Add a waterproofing class to program of instruction.      Completed   A waterproofing lesson has been added to the Ranger
                                                                          course program of instruction.




                                               Page 27                                       GAO/NSIAD-97-29 Army Ranger Training
Appendix III

Status of Actions to Improve Safety
Management: Medical Support and
Evacuation Procedures

Planned action                                                 Status      Comments
1. Determine system necessary to ensure safe medical           Completed   Air, water surface, and ground evacuation procedures
evacuation.                                                                have been planned and rehearsed. Joint medical
                                                                           evacuation procedures have been established among the
                                                                           Ranger training battalions and local medical services.
2. Develop a mass casualty standard operating procedure.       Completed   Mass casualty procedures have been included in each
                                                                           Ranger Training battalion’s standard operating procedure.
3. Initiate a project to build a road into the swamp area in   Completed   The 6th Ranger Training Battalion Commander concluded
Florida.                                                                   that the road is not critical for safe training and, following
                                                                           an environmental assessment, costly construction and
                                                                           environmental mitigation is not justified.
4. Determine fuel requirement for medevac helicopters at       Completed   A 2,000-gallon tanker is on hand at the Florida camp and
Florida training site.                                                     two tankers with about 10,000 gallons fuel capacity are on
                                                                           hand at the mountain camp.
5. Implement plan to revert to full time ranger medic          Completed   All three Ranger Training Battalions now have full-time,
manning.                                                                   Ranger-qualified medics.
6. Obtain C02 inflatable 1-man rafts.                          Completed   The Florida Ranger camp acquired 21 CO2 inflatable rafts,
                                                                           which are used by each Ranger instructor team.
7. Obtain hypothermia bags.                                    Completed   Six hypothermia bags were issued to each of the Ranger
                                                                           training battalions.
8. Develop a system to check packing list for medevac          Completed   All medevac emergency equipment is inspected for
helicopters.                                                               accountability and serviceability upon arrival at the training
                                                                           battalions.
9. Reinforce training and rehearsals of medical attachments. Completed     Fort Benning Medical Command has developed training
                                                                           guidelines for medics and Physician’s Assistants in each
                                                                           camp.
10. Ensure compliance with previous cold weather               Completed   Revised standard operating procedures outline cold and
procedures.                                                                hot weather training procedures.




                                                Page 28                                         GAO/NSIAD-97-29 Army Ranger Training
Appendix IV

Status of Actions to Preserve Lessons
Learned


Planned action                                        Status       Comments
1. Determine how best to preserve lessons learned.    Completed    1977 and 1995 accident summaries have been integrated
                                                                   into instructor certification program and are required
                                                                   reading for new members of the chain of command.

                                                                   VCR tape summarizing the 1977 and 1995 accidents was
                                                                   produced and is in use in the instructor certification
                                                                   program.

                                                                   Monument to students who died was erected at the site of
                                                                   the accident.
2. Continue formal command inspection program.        Completed    All battalions have been inspected, and a senior
                                                                   supervision plan has been instituted, that consists of
                                                                   frequent visits to each training site by Brigade chain of
                                                                   command.
3. Review complete waterborne procedures.             In process   Secretary of the Army directed a complete review of safety
                                                                   procedures and improvements now scheduled for
                                                                   completion in September 1997.




                                            Page 29                                    GAO/NSIAD-97-29 Army Ranger Training
Appendix V

Status of Actions to Increase Personnel
Staffing


Planned action                                                      Status          Comments
1. Ensure that the number of officers and enlisted personnel In process             The Army plans to staff the Brigade at the 90-percent level
is not less than 90 percent of required staffing levels.a                           by early February 1997.
2. Obtain a brigade medical adviser, communications                 In process      Increases currently under review in TRADOC. However,
officer, and air operations officer.                                                additional officers provided under the 1996 legislation may
                                                                                    be used for several of these positions.
3. Phase rotation of key personnel to limit turbulence.             Completed       Army Infantry Center conducts quarterly reviews of all
                                                                                    officer rotations to help limit turnover.
4. Establish safety cells at each of the three training school      Completed       Brigade personnel named as safety cell members and
locations to advise the officers in charge, and assist in daily                     Infantry Center is considering requesting additional civilian
go/no go decisions on training.a                                                    and military personnel.
                                                a
                                                    Required by the Fiscal Year 1996 National Defense Authorization Act.




                                                Page 30                                                   GAO/NSIAD-97-29 Army Ranger Training
Appendix VI

Comments From the Department of Defense




              Page 31       GAO/NSIAD-97-29 Army Ranger Training
             Appendix VI
             Comments From the Department of Defense




See p. 20.




             Page 32                                   GAO/NSIAD-97-29 Army Ranger Training
Appendix VII

Major Contributors to This Report


                        Sharon A. Cekala
National Security and   Charles J. Bonanno, Jr.
International Affairs   Harry L. Purdy
Division, Washington,
D.C.
                        John W. Nelson
Atlanta Field Office    Kevin C. Handley




(703138)                Page 33                   GAO/NSIAD-97-29 Army Ranger Training
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