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Newsletter 09-40
June 2009

The First Nightmare: Complacency Kills

My dream, which later became a nightmare, began with my company just finishing our convoy live fire exercise, and in my opinion, my cadre executed it flawlessly. In fact, this had been the best-executed training event since I became their commander. I remembered feeling a sense of achievement as I spoke with First Sergeant Hill, thinking that my company knew what it was doing, and I was tremendously proud if not downright cocky. I spoke with the first sergeant and executive officer about our preparation for our upcoming tactical exercise, Dragon Challenge. It was the culminating field exercise for our Soldiers and our last prerequisite for graduation. However, we had done it before and based on our latest positive experience, our company was tracking. I reviewed what I thought to be the main tasks and asked if anyone had any questions. With no questions, I thought to myself, "It is good to be the commander." I left feeling confident as the senior drill sergeant smiled and said, "Sir, we got it; this is not rocket science." I was eager to get back and brief LTC Charles, my battalion commander, on what a fantastic training event we had executed that day.

I walked to my truck and noticed some Soldiers gathered around a Soldier lying on the ground. I ran over there to find the Soldier unconscious and Drill Sergeant Jones removing the Soldier's clothing while yelling for ice sheets. The temperature had remained in the mid-80s all day, and we had implemented our heat mitigations in accordance with our risk assessment. I was somewhat stunned that we were suffering a heat casualty. However, Drill Sergeant Jones was doing everything correctly. He quickly wrapped the Soldier with an ice sheet while simultaneously Drill Sergeant Smith called for a ground medical evacuation (MEDEVAC). Shortly afterward, the Soldier regained consciousness and began speaking. She said she had been drinking water, but in an attempt to lose weight, she had not been eating much and had also been taking cold medicine for the last three days. As I watched them load her into the ambulance, I spoke with Drill Sergeant Jones and commended him on a job well done. I told him to determine what measures we could have done to prevent this injury and to give me an update this evening. I left the scene pleased with our training and my drill sergeants' responses to the heat casualty.

My joyfulness was short-lived because I saw my battalion commander, also known as old "Mad Dog" Charles. He told me he received a Congressional that alleged my 3rd Platoon sergeant, SFC Johnson, abused a new Soldier. I thought, how could this be? SFC Johnson was not the sharpest tool in the shed, but he did not seem to be the type to abuse Soldiers. The accusation of SFC Johnson striking a Soldier did not make sense to me. I left the battalion commander's office brooding on what to do.

The Soldier who made the allegation was a new start from last cycle and was still in the company. I called First Sergeant Hill to give him the news. He told me he was coming back with the Soldier to discuss the matter, and he would leave the senior drill sergeant to clear the range. While waiting on the first sergeant, I notified Criminal Investigative Division (CID), told them of the possible assault, and coordinated a time and place for them to linkup with the Soldier as soon as she returned. After I spoke with the first sergeant about the situation, I walked out into the bay and was stunned to see SFC Johnson speaking with the battle buddy of the Soldier who had accused him of misconduct. I had forgotten to remove him from the company pending completion of the investigation. Wondering how I could have missed that, I sent SFC Johnson to the battalion S3 shop pending the investigation, thinking all the time that I hoped old "Mad Dog" Charles wouldn't find out about my blunder.

The company, under the supervision of my senior drill sergeant, cleared the range. It was about 1830 hours, a lot later than I had hoped. I knew everyone wanted to get back, so the Soldiers and cadre could get a good night's rest before deploying on the Dragon Challenge. However, our motor move arrived 20 minutes early, and this amplified the pressure to clear the range quicker than normal. We threw equipment onto the back of the trucks and started herding Soldiers onto the buses. The company returned around 2000 hours. We issued the Soldiers meals, ready to eat and gave them 30 minutes to eat before getting them to the barracks.

The next morning we got the Soldiers up and were supposed to begin our Dragon Challenge precombat inspections (PCI) and rehearsals at 0800. However, chow was late, and we still had to download our equipment from the previous night. Still frustrated over the misconduct allegation, I told the first sergeant I wanted to address the company concerning the drill sergeant's misconduct. Therefore, we started our PCIs around 1030. Sensing there was not enough time, I made the decision not to conduct rehearsals or our normal cadre back-briefs in order to allow additional time for the platoons to execute better PCIs.

My first platoon was deploying at 1300, and I was not going to miss our start time. I recalled that on a previous cycle, one of my fellow company commanders took a major butt chewing from LTC Charles for not starting training on time, even though LTC Charles always said, "If you have a good reason to adjust training, then do it." I did not want it to appear that the company could not adapt to the situation and still execute as intended. Also, I had no updates on the misconduct investigation, and I knew the colonel would ask.

At this point, my dream turned into a nightmare. The first element, 3rd Platoon, Mad Dawgs, began its tactical foot movement. The Mad Dawgs were led by Drill Sergeant Kelly who had just taken over platoon sergeant duties from SFC Johnson because he was being investigated for misconduct. Drill Sergeant Kelly was new to our company, and this was his first Dragon Challenge. However, the platoon did leave on time, and everything looked good as I watched them depart. The Soldiers were in the proper uniform, rucksacks were worn correctly, and weapons were at the ready. Three hours later when the Mad Dawg platoon began executing the react to contact training event, the opposing force (OPFOR) began firing. The platoon took cover, returned fire, and reported. After several rounds had been fired, someone yelled, "Cease fire, cease fire, cease fire! Soldier down, Soldier down!"

To my horror, three Soldiers had been struck: two by live rounds and one by a blank adapter fragment. Drill Sergeant Kelly ran to aid the wounded Soldiers, yelling to his fellow Drill Sergeant Currie to call for MEDEVAC. Drill Sergeant Currie dropped her rucksack, grabbed her brick radio, and anxiously called, "Range control, range control, this is Mad Dawg 3." Receiving no response, Drill Sergeant Currie again yelled, "Range control, range control, this is Mad Dawg 3. Request MEDEVAC." Again, there was no response. I thought, why was range control not answering? Then Drill Sergeant Currie yelled, "The brick battery is dead, and I don't have another battery. Do you have a cell phone?" Drill Sergeant Kelly angrily replied, "No!" as he opened the platoon's combat lifesaver bag to find no bandages and both IV bags expired.

The last thing I remembered before waking up petrified was the OPFOR Soldier who had shot the Mad Dawgs. He was crying and saying he had used the same magazines from yesterday's convoy live fire. Drill Sergeant Currie was running to the rear of the column to get the trail vehicle while Drill Sergeant Kelly feverishly conducted cardio-pulmonary resuscitation on the injured Soldier who had stopped breathing. I woke up abruptly, quickly gathered my thoughts, took a drink of water, and grabbed a pen to capture the lessons I had just experienced in my nightmare. The following are my thoughts:

No matter how confident you are, do not take shortcuts. Taking them for whatever reason will, at a minimum, degrade your training or in this case kill someone. The facts that you are tired, buses arrive early, and you are planning for an upcoming training event are not excuses. You must remember, "Resources do not drive training; training drives resources." By taking shortcuts, we did not properly have our Soldiers check for live rounds in their magazines. This oversight resulted in the loss of two American Soldiers.

Always do a thorough PCI in accordance with Field Manual 7-1, Battle Focused Training, no exceptions. If you need more time to train, ask for it. "Train to standard, not time." I should have asked LTC Charles to move my start point time back three hours. In doing so, I would have allowed the company the opportunity to conduct a PCI to standard, which would have included checking radios and combat lifesaver bags and test firing weapons. Remember, PCI is training; do not shortcut it.

The strength of our company has always been that we plan, back brief, and rehearse all training prior to execution. I should have followed and made my subordinates follow our standing troop leading procedures. By simply following our established standing operating procedures execution checklists, we could have prevented this tragedy. Again, if we had not been complacent or lazy, the mistakes would not have happened.

Training to standard is our number one priority. Getting distracted by a misconduct investigation, although extremely important, resulted in me not being focused on training. Once the Soldier was under care, the drill sergeant removed pending an investigation, and CID actively worked the investigation in accordance with Training and Doctrine Command (TRADOC) Regulation 1-8, U.S. Army Training and Doctrine Command Operations Reporting and TRADOC Regulation 350-6, Enlisted Initial Entry Training (IET) Policies and Administration; I had done my duty. I should have looked for a time at the end of the training day to speak to the company that would not have taken valuable training time. As a result, my eagerness to fix a potential problem contributed to more serious issues.

Although we had followed our risk mitigation measures correctly, we had failed to monitor the heat casualty's lack of food intake and medication use. The cumulative effect of the lack of food, dehydrating medicine, and training in the heat all day contributed to the heat injury. Cadre supervision must include monitoring Soldiers' medication use and the lack of food consumption.


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