GAO report examining non-combat deaths finds lapses in training, oversight among Marines and Army

A M1085 cargo truck that rolled over on June 6, 2019, near the Camp Natural Bridge training site at the U.S. Military Academy at West Point, New York.

Erika I. Ritchie

The Orange County Register

A long-awaited report by the U.S. Government Accountability Office examining the high rate of non-combat training accidents involving tanks and trucks used by the Army and Marine Corps identified nine recommendations officials say the military services should enact to save lives.

The 103-page report released publicly on Wednesday, July 14, reviewed accidents between 2010 and 2019, saying driver inattentiveness, lapses in supervision and a lack of training were among the most common causes.

In that time period, the Army and Marines reported 3,753 non-combat vehicle accidents, in which 124 people died. Vehicle rollovers were the cause of death in 63% of the accidents.

The report also examined the training procedures and safety standards in place and how training ranges are operated at Camp Pendleton and Twentynine Palms in Southern California and Camp Lejeune in Jacksonville, N.C., and at six Army bases.

While the GAO analysts determined that both service branches have policies and practices in place to mitigate and prevent tactical vehicle accidents, they found both don’t always make use of them, the report said.

Nine recommendations were made, calling for the services to create more clearly defined roles for supervisors, to establish procedures and mechanisms for risk management and to ensure driver-training programs have a well-defined process with specific performance criteria, structure and consistent standards. The recommendations will now be passed along to the service branches for implementation. Lawmakers have also vowed to keep oversight and monitor the results.

“We found the application of safety practices were inconsistent, we need to make sure there are good safety practices among vehicle commanders, ” said Cary Russell, director of the GAO’s Defense Capabilities and Management and who oversaw the project. “Training is done at the unit level through practice and getting a license is pretty rudimentary. There is no prescribed training program there.”

As an example, Russell pointed to the training a crew of a Bradley Fighting Vehicle would typically receive.

“A gunner on the vehicle has to get through more prescribed shooting capabilities, but a driver doesn’t have such prescribed standards,” he said. “They come into the vehicle and learn by doing. You may have a driver that may have not had nighttime driving experience or driving on varied terrain.”

“Essentially, we want it to be across the services that there are more defined roles for vehicle commanders,” Russell added. “There have to be procedures, but command influences play a role. Safety officers also play a critical role. The Marines have one full-time safety officer for a Marine division, which is 22,000 Marines. There are also part-time safety officers in each unit. But, the part-time officers are limited in the amount of time they can spend on safety matters.”

Russell said the GAO also learned that “time pressures to meet missions” caused some of the challenges, including vehicles that were speeding — a common thread in the report.

Some surprising information Russell said he came across was that in some cases “seat belts were actually removed to get in and out of vehicles quicker.” And, a 2019 Marine Corps survey found 45% of Marines did not know their unit had a safety officer, he said.

“It’s clear that improvement was needed,” Russell said. “Before we knew it anecdotally, but now we definitely see gaps that need to be fixed.”

The report took 21 months to complete and was done at the direction of the House Armed Services Committee. It included more than 100 interviews with drivers, unit commanders, safety officers and those in higher commands in both services.

“I feel very comfortable with the information,” Russell said. “I don’t think anyone was holding back.”

In the summer of 2019, lawmakers requested the GAO conduct a study of non-combat deaths involving tactical vehicles — spurred on by the lobbying of families, including the parents and fiancee of 1st Lt. Conor McDowell, 24, who died in a training rollover accident in the Las Pulgas area of Camp Pendleton on May 9, 2019. Six other Marines suffered moderate injuries.

Less than a month before McDowell died, another Camp Pendleton Marine, Staff Sgt. Joshua Braica, 29, a member of the 1st Marine Raider Battalion, was also killed in a rollover accident. The men were two of six killed and nine injured in a two-month period that year.

Rep. John Garamendi, D- Walnut Grove, chairman of the House Armed Services Readiness Subcommittee was among several lawmakers who were pivotal in pushing for the GAO review.

He has held more than 30 hearings on military readiness in the last three years and said in each case he became increasingly more aware of the dangers befalling service members during training.

The results of the report were not surprising to him, he said.

“This is a very important and useful report,” he said. “It confirms the problem and confirms there are procedures that must be put in place. When those recommendations become standard operating procedures, we should see improvement in these tragic accidents and deaths.”

Specifically addressing the death of McDowell, Garamendi said a focus on training range safety is key.

“We need to make sure they are as safe as they can be,” he said. “We do know some of these are a direct result of the range facility itself not being safe. Clearly, this was the problem at Camp Pendleton.”

An investigation into the accident previously released by the Marines said the rollover was caused by dangerous terrain and high grasses. Human error did not factor into that accident, officials said. And, McDowell was credited for saving the lives of the Marines he led as a platoon commander.

Enforcing a culture of safety and accountability in the military is key, Garamendi said.

He and other lawmakers will keep on top of the two branches to ensure they are following the GAO’s recommendations, he said.

“We’ll hear from the military if they can do it, or if they can’t, why?” he said. “I’m absolutely convinced if Congress ignores this issue for four or five more years, the military will lapse and repeat the problems of the last decade. Safety needs to be attended to every day.”

That oversight by lawmakers is what Michael McDowell, his wife, Susan Flanigan, and Kathleen Bourque, Conor McDowell’s fiancee, want to see happen.

“Recommendations by the GAO probe into fatal military vehicle rollovers need to go further, and are too short on specific remedies,” Micheal McDowell said. “Only strong Congressional and public action ordering the Department of Defense to improve safety will lower the shocking death toll.”

And it needs to be ensured those orders are followed, he said.

Retired Marine Col. Walt Yates, who was the program manager for training systems at Marine Corps Systems Command, said the use of driving simulators as part of the licensing program for military vehicle drivers has been mandated, but hasn’t actually been carried out.

“None have lifted a finger to execute the task,” he said. “Why does the commandant tolerate this failure to execute published policy?

“Training always plays second fiddle to the acquisition of new technology, weapons and combat vehicles,” he said. “Training people to operate them safely isn’t as sexy when it comes to deciding what gets funded and what does not.”

For Conor McDowell’s mother, seeing the GAO’s report come out provides a sense of accomplishment, she said. The family has been working with lawmakers and military members for nearly two years to push for better safety.

“We know it’s still a stepping stone in the process,” Flanigan said. “Holding the Marines and Army accountable, that’s the next series of hurdles.”

Most important for her is that her son’s death wasn’t in vain.

“When the three uniformed Marines came to the door, I knew what that meant. I asked, ‘Is he injured or dead?’ When they said he was dead, that was the pencil down moment,” she said, using a metaphor of a test given in school when time is up.

“It was the end of his story and his life was over,” she said. “But, we’re convinced that the spirit of his life didn’t end with that pencil-down moment. We’re not going to stop until we’re satisfied that the Marines, Army and the Department of Defense put safety first in training.

“We also want Congress, the White House and the DOD to give more recognition to Marines and sailors who have died in training,” she said. “There is still this sense of being overlooked.”

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