"Admitted failings" by the army when it came to training and safety procedures during the death of a soldier in a training ground exercise have been highlighted after an inquest into his death.
Questions over staff training, lack of risk assessments, suitability of the training ground used and the supervisor's experience were all noted during the inquest of Staff Sergeant John McKelvie.
Sgt McKelvie, 51, was at Gandale Camp in Catterick Garrison on January 29, 2019, when the open-top military vehicle he was driving, a Jackal, overturned on a site known as 'the land of nod' while he was attempting a steep incline dubbed 'the three sisters'.
At the time, Sgt McKelvie was undertaking an off-road training course on the vehicle, led by Sgt Craig Dunleavy, who was instructing a training course for only the second time.
Following the tragic incident, Sgt McKelvie was airlifted to James Cook Hospital in Middlesbrough where he died on February 4, 2019, from complex brain injuries and severe injuries to his spine.
This week, an inquest into the 51-year-old's death held at Thirsk Racecourse has heard witnesses including military personnel, medical professionals, and engineers who created the Jackal vehicle give evidence.
Recording a narrative verdict at the end of the inquest, the jury cited lack of supervision, lack of chain of command, and a lack of understanding and enforcement as factors in Sgt McKelvie's death.
During the testimonies at the inquest, it was heard from Wing Commander Paul Summers, who was on the enquiry panel investigating Sgt McKelvie's death, that "at the time, the army wasn't a safe organisation" and there was a "systematic failure" within the army.
Further into his witness account, Wing Commander Summers said the army "didn't have a reporting culture" regarding safety and that "safety systems were missed that could have stopped this incident".
This was backed up by the witness account of Sgt Craig Dunleavy, who was a driving maintenance instructor - and was in the car with Sgt McKelvie when he was killed.
The hearing was told this was only the second time Sgt Dunleavy had led a training course on the Jackal vehicle when the incident happened - which saw him not receive correct training in booking systems, risk assessments, or proper procedure when conducting training.
"I'd got lots of experience in driving vehicles of this kind, but not much experience of instructing them," Sgt Dunleavy said.
Further into the inquest, Sgt Dunleavy described his colleagues' final moments and how Sgt McKlevie said the "brakes had failed" - before the Jackal vehicle flipped down the hill.
The vehicle used during the fatal incident, the Jackal, has been involved in 40 other rollover incidents since 2009 - with three involving multiple rolls, like the one that took Sgt McKelvie's life.
Elsewhere in the inquest, it was heard that Sgt McKelvie's life 'could have been saved' if a piece of safety equipment was included.
Pathologist Dr Jan Lowe, who performed an autopsy at James Cook Hospital mortuary, told the inquest that Sgt McKelvie's life could have been saved if a head and neck support device (HANS) had been worn when the incident happened.
Despite it not being normal procedure for soldiers to wear this equipment on the training, Sgt McKelvie's life 'could have' been saved if he was wearing the equipment, which is usually worn by racing drivers.
During the inquest, Dr Lowe said: "If worn, the HANS device could have made it survivable for Sgt McKelvie. The HANS device could have been used and a fatal outcome would have been prevented."
Dr Lowe also highlighted that the soldier's injuries were "worsened" by the fact that Sgt McKelvie's head was "thrown about" in the Jackal vehicle when it overturned.
It was also noted in the inquest from Martin Robson, the training safety marshal at Catterick Garrison, who ensures training is carried out safely for soldiers at the army base, that this fatality was "an accident waiting to happen".
During his evidence, Mr Robson, whose job it is to patrol training areas, went through the process soldiers would have to take to book a training area.
According to Mr Robson, safety checks weren't carried out just before the fatal incident - which would normally include a recce of the site by instructors - or correct procedure with instructors failing to check in with range control, who oversee training drills at Catterick Garrison.
The training safety marshal also highlighted that the Jackal shouldn't have been in a light vehicle training area, where the incident occurred, and should have been in a heavy vehicle training area instead - calling the Jackal "unsuitable for the area".
Mr Robson, who wasn't on site when the fatal incident happened in 2019, said: "The Jackal shouldn't have been there - it's too heavy for the surroundings and could end up ripping holes in the ground.
"It's also dangerous for other vehicles - if a motorbike or quadbike is in the light vehicle area - the Jackal driver could easily miss them.
"If I were on site that day - I would have stopped the training exercise because the Jackal is unsuitable for where it was."
As well as noting the safety issues, Mr Robson also highlighted that soldiers booking or travelling to incorrect training sites was a "common occurrence" and that the fatal incident that claimed Sgt McKelvie's life was an "accident waiting to happen".
Elsewhere in the inquest, Professor Steve Austin, engineer director of Supacat Ltd, who designed and developed the Jackal - which was created in the 1990s for military personnel, gave evidence to the inquest.
Since the fatal incident in the Jackal, Professor Austin noted that Supacat had worked with the Ministry of Defence to enhance the vehicles' anti-roll technology.
However, questions about the safety of the vehicles were raised by the legal team of the McKelvie family, who asked Professor Austin whether fatal incidents linked to Jackals had been reported before.
Questioned about whether Sgt McKelvie's height of 6ft4in was a factor in the soldier's death, Professor Austin said that the Jackal was geared up towards people measuring six feet and two inches but still protected taller people.
Professor Austin said: "In the aftermath of this tragic incident - we have made several changes to the Jackal - and while risk can't be eradicated, it can be reduced."
Supacat aren't the only agency to make changes in the aftermath of Sgt McKelvie's death - with the Ministry of Defence highlighting that "lessons have been learnt"
Colonel Graham Shannon, risk adviser to the Commander of the Field Army, told the hearing that alterations had been made in the aftermath of the fatal incident.
Most read:
- Life of soldier killed in vehicle roll 'could have been saved' with safety device
- Death of Sergeant John McKelvie 'accident waiting to happen'
- Safety and training questions raised at Sergeant's inquest
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However, he was forced to admit he could find "no evidence" that the recommendation made after a Jackal rollover incident at Catterick in 2016 had been acted upon.
Colonel Shannon told the inquest the McKelvie family could be "absolutely confident" there would be no further missed learning opportunities.
He added: "The Service Inquiry fundamentally impacted the Army.
"Of the 114 recommendations it made, 73 have been closed completely. Three have been submitted for closure and 30 remain open but every single one has an action plan against it.
"The MoD has completely revised its systems and policy to stop that happening again. It clarifies who is accountable for safety when delivering equipment into service."
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