A-10A Friendly Fire Board of Inquiry Findings released

OTTAWA - Lieutenant-General Michel Gauthier, Commander Canadian Expeditionary Force Command (CEFCOM), released today the findings from the A-10A Friendly Fire Incident Board of Inquiry (BOI) that investigated the September 4, 2006, events during which a USAF aircraft opened fire on Canadian troops. This incident resulted in the death of Private Mark Anthony Graham and injuries to several other Canadian soldiers serving with Charles Company group, Royal Canadian Regiment, Joint Task Force – Afghanistan (JTF-Afg).

“Members of the Board of Inquiry produced a thorough report with recommendations which, I am convinced, will help safeguard the lives of our soldiers in the future”, said General Rick Hillier, Chief of the Defence Staff. “Risk is inherent to military operations, however we must always seek to mitigate it.” This BOI also received the full cooperation from US military authorities, specifically from the Commander of Ninth Air Force, Lieutenant-General Gary L. North, his staff, and US Central Command (CENTCOM). “We are grateful for their great collaboration in aiding this BOI,” he added.

A BOI is an administrative inquiry normally convened to examine and report on complex or significant events. It serves to determine what occurred, how and why it occurred and proposes measures that might prevent the possibility of recurrence. It is not a criminal investigation.

A summary of the A-10A Friendly Fire BOI findings and a statement from Lieutenant-General Gauthier, Commander CEFCOM, the convening authority for the BOI, are available at http://www.forces.gc.ca/site/focus/opmedusa/index_e.asp .

Statement by Lieutenant-General Michel Gauthier, Commander Canadian Expeditionary Force Command
July 13, 2007

OTTAWA - Lieutenant-General Michel Gauthier, Commander Canadian Expeditionary Force Command (CEFCOM) issued the following statement upon the release of the A-10A Friendly Fire Incident Board of Inquiry (BOI) findings.

The Chief of the Defence Staff and I have reviewed the Board’s report on the circumstances that led to the death of Private Mark Anthony Graham and injuries to several Canadian solders where they were mistakenly engaged by a United States Air Force (USAF) A-10A aircraft, during Operation MEDUSA, in the Panjwayi District of Afghanistan. The Board has effectively addressed all directed areas of inquiry, and has made clear and comprehensive findings in each, all of which I support. The report clearly documents the sequence of events and the situational context in which this unfortunate event occurred.

Operation MEDUSA was a NATO Operation, involving the Canadian Battle Group and other Coalition Forces, which commenced in mid-August 2006, to oust the Taliban from a traditional operating area in the Panjwayi district to the west of Kandahar City. The longer-term intention of the operation was to improve overall security for the Afghan people living in the vicinity, and to set the conditions for reconstruction and development activities. In this pitched battle, against a determined enemy, allied aircraft, including USAF A-10As, provided close air support for Canadian Troops and helped to save many Canadian lives.

September 4th, 2006, found the soldiers of Charles Company on the south side of the Arghandab River, and southeast of their objective area, which lay to the northwest on the opposite bank of the Arghandab.

Several targets in the objective area had been successfully attacked the previous day and throughout the night of September 3-4, 2006. At dawn on September 4, USAF A-10As were in the area actively attacking targets in the objective area under the control of a Canadian Forward Air Controller. It must be noted that from altitude, the pilots were in near day-like conditions but the ground still remained in shadows, making the visual sighting of the targets difficult.

The morning of the incident, soldiers from Charles Company had an early reveille. Its members were engaged in packing gear, having breakfast and preparing their vehicles for the upcoming combat operations scheduled for that morning. In accordance with common practice, a small fire was lit shortly after reveille to burn garbage.

Minutes before the incident, one of the A-10A aircraft engaged an intended target in the objective area, successfully dropping a guided bomb on the target which generated both fire and smoke. The incident pilot, who was to conduct the next attack run, relied on the fire and smoke generated by this bomb to assist him in identifying the target, which he was preparing to strafe.

In the changing light conditions as dawn approached, the A-10A pilot visually mistook the garbage fire at the Canadian location for the residual fire and smoke of the bomb just dropped on the objective. Because he did not verify the target with his equipment’s target displays, the pilot failed to detect his targeting error and strafed the Canadian position, killing Pte Graham and wounding many others. Shortly thereafter, the incident pilot acknowledged his mistake and requested, through his assigned radio network, medical assistance for the soldiers of Charles Company.

Following the incident, members of Charles Company (including some of the injured, Medical Technicians and Tactical-Combat-Casualty-Care-qualified soldiers) began to treat the wounded. Neighbouring friendly units came to render assistance in treating the injured.

Pte Graham, who had been standing near the garbage fire when the A-10A strafed the location, was found alive within seconds of the incident. First aid was rendered but his injuries were such that he passed away shortly thereafter.

The key findings of the board which I fully support are as follows:

The death of Private Graham, and the wounding of the other soldiers, was caused by friendly fire from a USAF A-10A aircraft engaged in close support of their Company’s actions during Operation MEDUSA.
The A10 pilot was responsible and that the incident was preventable. The pilot lost situational awareness and failed to confirm the target with his targeting displays before engaging.
The medical and administrative responses to the incident were exceptional in every respect. The soldiers of Charles Company responded immediately and effectively to the casualties, and close coordination between coalition medical units prevented the overwhelming of the medical facility at Kandahar Airfield.

The Board made additional findings concerning Forward Air Controller training and equipping and Tactical Air Control Party manning requirements in support of operations in Afghanistan. None of these findings were found to be causal to the death or injuries, but the Board deemed them to merit careful review and made very helpful recommendations aimed at improving the planning and coordination of air support operations. These recommendations have been carefully reviewed, and a plan developed for their expeditious implementation. While specific details cannot be provided for operational security reasons, most have already been implemented; the remainder are being implemented as quickly as possible.

Close air support is credited with saving numerous lives in Afghanistan, including the lives of Canadian soldiers, and has been a critical success factor in many combat engagements. The above-noted improvements in training and equipment will help in increasing the effectiveness of air-land operations and may contribute to reducing the risk to our soldiers; but given the nature of such operations, the associated risk cannot be reduced to zero.

It is important to highlight the exceptional work done by the medical staff of the Canadian Field Hospital in Kandahar, the allied medical facility, the Landstuhl Regional Medical Centre in Germany and our Canadian medical system in caring for the injured. The professionalism of all concerned saved Canadian lives.

The successful completion of this Board is due in part to the significant cooperation received from US military authorities and, more specifically, the Commander of Ninth Air Force, his staff, and US Central Command (CENTCOM). US authorities shared evidence gathered in the process of their own investigation, and also provided a USAF A-10A aircraft advisor, who remained attached to the Board throughout the investigation.

Finally, I wish to express my sympathies to the Graham family. The Board President has endeavoured to keep the family informed as the Board has progressed, and our thoughts and prayers are with them now.

"That still only leaves some skepticism in the finding in number 2."

Agreed.

A BOI can only gathre evidence after the fact, apply its expertise and evaluate the credibility of the witnesses and the documents, be as objective as possible and make the best evaluation possible in the circumstances.

A fratricide incident inquiry inevitably brings the causa causans to the guy who released the ordnance,

But, apart from cases of gross negligence, these accidents are usually the culmination of a cascade.

Here is an extract from the Executive Summanry:

MAIN FINDINGS AND RECOMMENDATIONS OF THE BOARD OF INQUIRY)
On 4 September 2006, a United States Air Force (USAF) A-10A mistakenly strafed the position of Charles Company (C Coy) group (gp) at Panjwayi District, Afghanistan, killing one Canadian soldier and wounding many others. The following are the major points from this investigation:
The incident pilot was responsible for the death and injuries of the Canadian soldiers in the incident. He lost his situational awareness. He mistook a garbage fire at the Canadian location for his target without verifying the target through his targeting pod and heads-up display;
The incident was preventable. If the incident pilot had verified the target using the targeting pod and heads-up display, he would have realized his error and discontinued the attack; and
Although not causal to the incident, the Board noted deficiencies in regards to Forward Air Controller (FAC) training and equipment and makes recommendations in that regard.
The A-10A friendly fire incident that occurred on 4 September 2006 was a result of the A-10A pilot losing his situational awareness in the changing light conditions in the transition between night and day and his failure to check his targeting pod and heads-up display to verify target location. Because he was disoriented, he mistook the garbage fire lit by the Canadian soldiers for the fire from a previous bomb impact on the target he was supposed to strafe. While firing his cannon at the garbage fire, he killed one Canadian soldier and wounded many others. The factors that contributed to the incident included a decision error by the pilot while pursuing his attack and a perceptual error when he incorrectly perceived the Canadian position to be the targeted location. Other contributing factors included the garbage fire that had been recently lit at the Canadian position and the changing light conditions in the transition from night to day.
The incident was preventable. The pilot had the target coordinates and had successfully strafed the target several times that morning. His visual reference point for the strafe was intended to be the residual fire and smoke from a bomb that had just been dropped by another A-10A. He padlocked (indicates that aircrew has locked his gaze onto an aircraft or ground target in order to maintain sight of it) on the garbage fire from C Coy gp, which was lit at about the same time and was the same distance from the A-10A as the target. If he had checked his targeting pod and heads-up display, he would have noticed the discrepancy between where his plane was pointed and the real target. That discrepancy should have caused him to abort that attack.
There were some extenuating circumstances. The incident pilot had removed his night vision goggles (NVGs) because the changing light conditions had limited their usefulness. They were removed less than a minute before he strafed C Coy gp. The transition period between night and day is a difficult one for the pilots because their eyes must adjust to ambient light and the cockpit instrumentation lighting also needs to be adjusted. The pilot was relying on his own visual perception to identify the target. Further, neither the pilot nor the FAC were aware that C Coy gp had lit a garbage fire.
Although not causal to the incident, the Board finds that there were deficiencies with the FAC pre-deployment training and equipment. The FACs were not qualified Combat Ready Night High (CR-NH) before deploying to theatre, thus not meeting the requirements of the International Security Assistance Force (ISAF) Standard Operating Procedure (SOP) 311. Furthermore, the pre-deployment training, while providing FACs with the minimum knowledge to conduct Close Air Support (CAS), was insufficient to prepare them for the conditions they faced during Op MEDUSA. In regards to equipment, the FACs were provided with the minimum required to control aircraft. Many of their controls involved CAS during the night where more sophisticated equipment such as infrared (IR) pointers and other such devices would have greatly facilitated identification of targets and friendly positions.
The Board was impressed with the post-incident response. When the incident occurred, the medical response was remarkable. The soldiers responded immediately employing techniques and equipment received during the Combat Related First Aid (CRFA) training. The Tactical Combat Casualty Course (TCCC) trained soldiers were of invaluable assistance to the Medical Technicians (Med Techs). The casualty evacuation system was efficient and well coordinated as the wounded were very quickly prioritized and flown out in dedicated aeromedevac (AE) helicopters. The most severely wounded were treated at the Kandahar Airfield (KAF), then evacuated to Landstuhl and then Canada. Other among the wounded were diverted to an allied Facility at Tarin Kowt, treated and then either brought back to KAF or evacuated to Landstuhl and Canada. Task Force Kandahar’s (TF-K) operational response in creating smoke to screen the situation from the enemy, coordinating A-10A presence to protect the AE and calling up the reserve Coy to enable the continuance of the mission were all timely and effective. The post-incident response in terms of next of kin (NOK) notification and chain of command information flow was excellent.
The post-incident response to Pte Graham’s mortal injury was swift and thorough. All those who handled him, from the location of the incident to his return to Canada, treated Pte Graham’s remains with deference and due respect.

These 3 paras explain a lot:

The A-10A friendly fire incident that occurred on 4 September 2006 was a result of the A-10A pilot losing his situational awareness in the changing light conditions in the transition between night and day and his failure to check his targeting pod and heads-up display to verify target location. Because he was disoriented, he mistook the garbage fire lit by the Canadian soldiers for the fire from a previous bomb impact on the target he was supposed to strafe. While firing his cannon at the garbage fire, he killed one Canadian soldier and wounded many others. The factors that contributed to the incident included a decision error by the pilot while pursuing his attack and a perceptual error when he incorrectly perceived the Canadian position to be the targeted location. Other contributing factors included the garbage fire that had been recently lit at the Canadian position and the changing light conditions in the transition from night to day.

The incident was preventable. The pilot had the target coordinates and had successfully strafed the target several times that morning. His visual reference point for the strafe was intended to be the residual fire and smoke from a bomb that had just been dropped by another A-10A. He padlocked (indicates that aircrew has locked his gaze onto an aircraft or ground target in order to maintain sight of it) on the garbage fire from C Coy gp, which was lit at about the same time and was the same distance from the A-10A as the target. If he had checked his targeting pod and heads-up display, he would have noticed the discrepancy between where his plane was pointed and the real target. That discrepancy should have caused him to abort that attack.

There were some extenuating circumstances. The incident pilot had removed his night vision goggles (NVGs) because the changing light conditions had limited their usefulness. They were removed less than a minute before he strafed C Coy gp. The transition period between night and day is a difficult one for the pilots because their eyes must adjust to ambient light and the cockpit instrumentation lighting also needs to be adjusted. The pilot was relying on his own visual perception to identify the target. Further, neither the pilot nor the FAC were aware that C Coy gp had lit a garbage fire.

Having been the Recorder on a BOI I can well imagine the heated discussions that took place to create the findings when in Executive Session (behind closed doors).

Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.