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