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

GAO United States

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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Background The Ranger Training Brigade, under the command of the U.S. Training and

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.

Results in Brief The Ranger Training Brigade has completed most of the corrective actions

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.

Most Corrective

Actions to Improve

Safety Are Complete

The Ranger Training Brigade has completed action on 38 of the 41

(93 percent) recommendations designed to improve training safety. The

remaining three recommendations, involving increases in personnel and a

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

Been Improved

All three training battalions have updated their overall assessments of

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

Procedures Have Been

Revised

The 6th Battalion completed a comprehensive standard operating

procedure revision in December 1995 that references all training-related

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

Support Capabilities

Increased

The Florida camp has now revised and rehearsed air, water, and ground

evacuation plans, and mass casualty and joint evacuation procedures with

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.

Army Oversight Needs

Improvement to

Preserve Key

Corrective Actions

If the Army is to sustain the key corrective actions instituted after the

accident in the future, it must institutionalize them. One important way to

achieve this objective is to expand the focus of formal Army inspections to

include testing or observing the key safety controls to determine whether

they are working effectively. Neither formal Army Safety Program

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

Command Inspections of

Training Safety Controls

Are Limited

According to Brigade and other Army officials, there are two basic keys to

ensuring that safety controls operate as intended over time in an

environment of rapid personnel turnover. First, controls must be clearly

institutionalized in written operating procedures. Second, leaders must

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

Army Chief of Staff

Commander,

Training & Doctrine Command

Commander,

Army Infantry Center

Ft. Benning

Commander,

Ranger Training Brigade

Ft. Benning

4th Ranger Training Battalion

(Ft. Benning Phase)

5th Ranger Training Battalion

(Georgia Mountain Phase)

6th Ranger Training Battalion

(Florida Swamp Phase)

 Training & Doctrine Command

 Safety Office 

Installation Safety Office

Ft. Benning

Inspector General

Director of Army Safety

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

Inspections

Inspected Not inspected

1. Has a unit safety program

document been published?

1. Are communications systems linking training

instructors, supervisory personnel, and emergency

assistance fully operational before each exercise?

2. Are unit personnel aware

of the notification procedures

in the event of an accident?

2. Are the minimum air and land evacuation systems in

place before daily training is conducted?

3. Are risk management

worksheets completed for all

operations and training?

3. Are instructors adhering to the rule requiring them to

walk planned swamp routes the morning of each

exercise?

4. Are newly assigned

personnel briefed on unit and

installation safety policy

within 3 days of arrival?

4. Are instructors adhering to the rule prohibiting

deviations from planned swamp training routes?

5. Have part-time assistant

safety officers been

appointed?

5. Are fully qualified instructors used for each training

event?

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

Safety Has Been Improved

The 6th Ranger Training Battalion has improved its daily oversight of

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.

Priority for Officer

Staffing Increased, but

Enlisted Personnel

Levels Are Lower

Than Brigade

Requests

The Army plans to staff the Ranger Training Brigade at the required

90-percent level by February 1997 and submitted its plan for doing so to

Congress in November 1996.7

 To meet the law’s requirement, the Army

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

requires quarterly reports to ensure that the required staffing levels are

maintained.

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

required

Percentage of

required

Percentage of

required

Percentage of

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

Competes With Army

Priorities for Allocating

Personnel Shortages

Officer shortages, such as those experienced by the Ranger Training

Brigade, are not unique. Our June 1995 report on the drawdown of military

personnel found that most Army positions were kept filled at high rates

during the early 1990s.10 However, certain specialties and ranks,

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.

10Military 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

Levels Lower Than Brigade

Estimates

Brigade officials believe the school needs about 624 enlisted personnel to

operate safely and effectively. This number equates to about 112 percent

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.

12Public 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.

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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

Defined or Recognized in

Personnel Assignment

Priorities

According to TRADOC and Army Safety Center officials, recognition of the

high rate of accidental deaths and injuries has increased the emphasis on

risk management in the Army. TRADOC currently is rewriting combat

doctrine to recognize risk management and better integrate it into Army

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.

Safety Cell

Organization Status

Currently, members of the Ranger Training Brigade and battalion chains of

command serve as the safety cell organization established pursuant to the

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

Mirrors Existing Army

Policy

The act required the Army to

• 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

13At 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.

14A 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

Cell Organization Are

Being Reviewed

Late in our review, the Brigade’s approach to the safety cells was reviewed

by the new Brigade Commander and the new Commander of the Army

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.

Recommendations We recommend that the Secretary of the Army

• 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.

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

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

Agency Comments

and Our Evaluation

In written comments on a draft of this report (see app. VI), the Department

of Defense said that it generally agreed with our findings and

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.

Scope and

Methodology

To determine the status and implementation of corrective actions taken to

improve Ranger training safety, we received briefings from Brigade

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 

Status of Actions to

Improve Safety

Management: Risk

Assessments

26

Appendix II 

Status of Actions to

Improve Safety

Management:

Command and

Control, Equipment,

and Training

27

Appendix III 

Status of Actions to

Improve Safety

Management: Medical

Support and

Evacuation

Procedures

28

Appendix IV 

Status of Actions to

Preserve Lessons

Learned

29

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

Appendix V 

Status of Actions to

Increase Personnel

Staffing

30

Appendix VI 

Comments From the

Department of

Defense

31

Appendix VII 

Major Contributors to

This Report

33

Tables Table 1: Oversight of Selected Safety Controls During Fort

Benning Safety Inspections

11

Table 2: Ranger Training Brigade Staffing 13

Figure Figure 1: Army Organizations That Oversee Ranger Training

Brigade Safety

9

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

use river level forecast information from local agencies.

Completed Weather, river, and swamp information obtained from local

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

class/platoon strengths and weaknesses as each class

moves to a new training phase.

Completed Medical and other information on selected students and

student platoons is forwarded to each training phase’s

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

class.

Completed The 6th Battalion now assigns a captain or senior

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

guide.

Completed The water immersion guide is briefed at the beginning of

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

for possible use in Florida.

Completed Experimental monitors tested in June 1996, but no

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

training at the 6th Ranger Training Battalion.

Completed Procedure for Florida training phase is completed.

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

instructors.

Completed The Ranger Training Brigade developed a standardized

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

operations.

Completed Communications and computer upgrades installed at

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

prepared to conduct stream crossing operations.

Completed 6th Battalion students must demonstrate their ability to

properly construct a one-rope bridge in 8 minutes prior to

entering the swamp.

7. Develop a decision paper on the use of precision

lightweight global-position receivers by instructors during

emergencies.

Completed A Ranger Training Brigade decision paper concluded that

global-position receivers will be used by medical

evacuation helicopters and Ranger instructors. The

Brigade acquired 66 receivers to track the movement of

students.

8. Develop standard packing lists for instructors, medics,

and aeromedevac crews.

Completed Equipment and supply packing lists for instructors,

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

evacuation.

Completed Air, water surface, and ground evacuation procedures

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

Florida.

Completed The 6th Ranger Training Battalion Commander concluded

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

Florida training site.

Completed A 2,000-gallon tanker is on hand at the Florida camp and

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

manning.

Completed All three Ranger Training Battalions now have full-time,

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

helicopters.

Completed All medevac emergency equipment is inspected for

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

procedures.

Completed Revised standard operating procedures outline cold and

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

is not less than 90 percent of required staffing levels.a

In process The Army plans to staff the Brigade at the 90-percent level

by early February 1997.

2. Obtain a brigade medical adviser, communications

officer, and air operations officer.

In process Increases currently under review in TRADOC. However,

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

locations to advise the officers in charge, and assist in daily

go/no go decisions on training.a

Completed Brigade personnel named as safety cell members and

Infantry Center is considering requesting additional civilian

and military personnel.

aRequired 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

National Security and

International Affairs

Division, Washington,

D.C.

Sharon A. Cekala

Charles J. Bonanno, Jr.

Harry L. Purdy

Atlanta Field Office John W. Nelson

Kevin C. Handley

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