Army Ranger Training: Safety Improvements Need to Be Institutionalized
(Letter Report, 01/02/97, GAO/NSIAD-97-29).

Pursuant to a legislative requirement, GAO reviewed the Army's legal
investigation of the February 1995 accident in which four Army Ranger
Training Brigade students died while training in a Florida swamp,
focusing on the: (1) status of all of the Army's corrective actions; (2)
adequacy of Army oversight to ensure that the corrective actions
instituted after the accident will be sustained in the future; (3)
Army's progress in implementing the authorization act's mandate to
increase Brigade staffing to 90 percent of requirements; and (4) Army's
progress in establishing safety cell organizations at the Brigade.

GAO found that: (1) the Ranger Training Brigade has completed most of
the corrective actions recommended by the Army; (2) the Brigade has
improved safety by developing systems to better monitor and predict
swamp conditions, and 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; (3) 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; (4) if the Army is to sustain the key
corrective actions taken after the accident in the future, GAO believes
that the actions must become institutionalized; (5) if the important
corrective actions are to become institutionalized, GAO believes that
formal Army inspections will have to be expanded to include testing or
observing to determine whether they are working effectively; (6) the
Army plans to fully staff the Ranger Training Brigade at the mandated
90-percent level by February 1997; (7) although the Army raised the
Brigade's staffing priority subsequent to GAO's field work, high-risk
training units generally are not recognized in Army personnel staffing
priorities; (8) 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; (9) currently, members of the Ranger Training
Brigade and battalion chains of command serve as the safety cell
organization established pursuant to the act; (10) the option chosen by
the Army represents little change from the safety oversight practice
that was in place at the time of the accident; (11) 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 or 3 years; and (12)
the Army Infantry Center is considering requesting authorization for
additional civilian and military positions to serve as full-time safety
cell members.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  NSIAD-97-29
     TITLE:  Army Ranger Training: Safety Improvements Need to Be 
             Institutionalized
      DATE:  01/02/97
   SUBJECT:  Military training
             Accident prevention
             Safety regulation
             Safety standards
             Inspection
             Occupational safety
             Emergency preparedness
             Army personnel
             Investigations by federal agencies
             Personnel management
IDENTIFIER:  Army Battle Command Training Program
             Army Aviation Safety Officer Program
             Florida
             Army Total Safety Professional Career Management Program
             
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Cover
================================================================ COVER


Report to Congressional Committees

January 1997

ARMY RANGER TRAINING - SAFETY
IMPROVEMENTS NEED TO BE
INSTITUTIONALIZED

GAO/NSIAD-97-29

Army Ranger Training

(703138)


Abbreviations
=============================================================== ABBREV

  TRADOC - Training and Doctrine Command
  GAO -

Letter
=============================================================== LETTER


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. 


   BACKGROUND
------------------------------------------------------------ Letter :1

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. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :2

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 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
------------------------------------------------------------ Letter :3

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
---------------------------------------------------------- Letter :3.1

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. 


      COMMAND AND CONTROL
      PROCEDURES HAVE BEEN REVISED
---------------------------------------------------------- Letter :3.2

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. 


      EVACUATION AND MEDICAL
      SUPPORT CAPABILITIES
      INCREASED
---------------------------------------------------------- Letter :3.3

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. 


   ARMY OVERSIGHT NEEDS
   IMPROVEMENT TO PRESERVE KEY
   CORRECTIVE ACTIONS
------------------------------------------------------------ Letter :4

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
---------------------------------------------------------- Letter :4.1

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. 
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. 

   Figure 1:  Army Organizations
   That Oversee Ranger Training
   Brigade Safety

   (See figure in printed
   edition.)

Army officials told us that representatives from these organizations
visited the Brigade a number of times, both before and after the
accident.  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. 



                                Table 1
                
                 Oversight of Selected Safety Controls
                 During Fort Benning Safety Inspections

Inspected               Not inspected
----------------------  ----------------------------------------------
1. Has a unit safety    1. Are communications systems linking training
program document been   instructors, supervisory personnel, and
published?              emergency assistance fully operational before
                        each exercise?

2. Are unit personnel   2. Are the minimum air and land evacuation
aware of the            systems in place before daily training is
notification            conducted?
procedures in the
event of an accident?

3. Are risk management  3. Are instructors adhering to the rule
worksheets completed    requiring them to walk planned swamp routes
for all operations and  the morning of each exercise?
training?

4. Are newly assigned   4. Are instructors adhering to the rule
personnel briefed on    prohibiting deviations from planned swamp
unit and installation   training routes?
safety policy within 3
days of arrival?

5. Have part-time       5. Are fully qualified instructors used for
assistant safety        each training event?
officers been
appointed?
----------------------------------------------------------------------
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. 

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. 


--------------------
\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. 

\5 Assessment of Army Safety Program, Department of the Army
Inspector General, April 1993. 

\6 Army Regulation 1-201, chapters 1-4, 3-3, and 3-4, Army Inspection
Policy, May 1993. 


      DAILY OVERSIGHT OF TRAINING
      SAFETY HAS BEEN IMPROVED
---------------------------------------------------------- Letter :4.2

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 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
------------------------------------------------------------ Letter :5

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    Percentage    Percentage    Percentage of
              of required   of required   of required   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
----------------------------------------------------------------------
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. 


--------------------
\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. 

\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. 


      INCREASED OFFICER STAFFING
      COMPETES WITH ARMY
      PRIORITIES FOR ALLOCATING
      PERSONNEL SHORTAGES
---------------------------------------------------------- Letter :5.1

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 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. 


--------------------
\10 Military Personnel:  High Aggregate Personnel Levels Maintained
Throughout Drawdown (GAO/NSIAD-95-97, June 2, 1995). 

\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. 

\12 Public 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. 


      REQUIRED ENLISTED STAFFING
      LEVELS LOWER THAN BRIGADE
      ESTIMATES
---------------------------------------------------------- Letter :5.2

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 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
---------------------------------------------------------- Letter :5.3

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 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
------------------------------------------------------------ Letter :6

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
---------------------------------------------------------- Letter :6.1

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 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 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. 


--------------------
\13 At 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. 

\14 A new Army Infantry Center Commander was assigned in July 1996,
and a new Brigade Commander in August 1996. 


      CHANGES TO CURRENT SAFETY
      CELL ORGANIZATION ARE BEING
      REVIEWED
---------------------------------------------------------- Letter :6.2

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. 

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. 


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


   RECOMMENDATIONS
------------------------------------------------------------ Letter :7

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. 


   AGENCY COMMENTS AND OUR
   EVALUATION
------------------------------------------------------------ Letter :8

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
------------------------------------------------------------ Letter :9

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 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. 


---------------------------------------------------------- Letter :9.1

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


STATUS OF ACTIONS TO IMPROVE
SAFETY MANAGEMENT:  RISK
ASSESSMENTS
=========================================================== Appendix I

Planned action                      Status    Comments
----------------------------------  --------  ----------------------------------
1. Develop a standard operating     Complete  Weather, river, and swamp
procedure to capture and use river  d         information obtained from local
level forecast information from               and federal agencies is integrated
local agencies.                               in training decision-making. Also,
                                              three remote weather sensors on
                                              the Yellow River provide real-
                                              time water depth and temperatures.

2. Update risk management           Complete  Risk management assessments have
assessment.                         d         been completed for all training
                                              activities.

3. Update daily risk assessment.    Complete  Daily risk assessments capture
                                    d         information on changing weather,
                                              water level, temperature, student
                                              conditions and readiness of
                                              support systems.

4. Update current immersion guide.  Complete  On the basis of the Army's
                                    d         November 1995 reevaluation of the
                                              original immersion guidelines, the
                                              Ranger Training Brigade lowered
                                              the guideline's water exposure
                                              times.

5. Standardize the in-walkers       Complete  Written standardized briefing
briefing for instructors.           d         formats are used for daily
                                              briefings of instructors at all
                                              three Ranger training battalions.

6. Provide commanders critical      Complete  Medical and other information on
requirements analysis of class/     d         selected students and student
platoon strengths and weaknesses              platoons is forwarded to each
as each class moves to a new                  training phase's incoming
training phase.                               commander.

7. Erect staff markers on the       Complete  The Army Corps of Engineers
lanes.                              d         erected 32 water depth markers
                                              along the Yellow River and
                                              training lanes in the swamps.

8. Examine the effectiveness of     Complete  System reviewed and remains a
the current buddy system.           d         first line of safety defense. When
                                              assigned buddy not available,
                                              teams will move to three-person
                                              system.

9. Reinstate the system of          Complete  The 6th Battalion now assigns a
assigning tactical officers to      d         captain or senior noncommissioned
each class.                                   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   Complete  The water immersion guide is
the use of the immersion guide.     d         briefed at the beginning of each
                                              training day and updated as
                                              conditions change.

11. Identify and mark weak          Complete  Weak swimmers are identified
swimmers.                           d         during the combat water survival
                                              test and marked on their headgear
                                              and equipment.

12. Obtain physiological            Complete  Experimental monitoring software
monitoring software.                d         was provided to Ranger medical
                                              clinics. Due to implementation
                                              problems, the Brigade has
                                              discontinued its use.

13. Conduct nutrition and           Complete  The Brigade Commander has
immunization study.                 d         increased meals provided Ranger
                                              students from 1-1/2 to 2 per day
                                              based on Army nutritional studies.

14. Develop personnel status        Complete  Experimental monitors tested in
monitoring system technology for    d         June 1996, but no procurement
possible use in Florida.                      made.
--------------------------------------------------------------------------------

STATUS OF ACTIONS TO IMPROVE
SAFETY MANAGEMENT:  COMMAND
AND CONTROL, EQUIPMENT, AND
TRAINING
========================================================== Appendix II

Planned action                      Status    Comments
----------------------------------  --------  ----------------------------------
1. Develop standard operating       Complete  Procedure for Florida training
procedure for conducting training   d         phase is completed. Rewrites for
at the 6th Ranger Training                    Brigade and remaining phases are
Battalion.                                    in process.


2. Clearly identify each training   Complete  The 6th Battalion identified
lane.                               d         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           Complete  The Ranger Training Brigade
certification program for           d         developed a standardized
instructors.                                  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      Complete  Communications and computer
center ability to monitor           d         upgrades installed at Florida and
operations.                                   mountain phases. Installation of
                                              tower and microwave antennae
                                              scheduled for completion in
                                              Florida by January 1, 1997.

5. Purchase earplug/silent radios.  Complete  The 6th Battalion acquired whisper
                                    d         mikes for use with Motorola radios
                                              during training exercises.

6. Ensure that all patrols are      Complete  6th Battalion students must
equipped, trained, and prepared to  d         demonstrate their ability to
conduct stream crossing                       properly construct a one-rope
operations.                                   bridge in 8 minutes prior to
                                              entering the swamp.

7. Develop a decision paper on the  Complete  A Ranger Training Brigade decision
use of precision lightweight        d         paper concluded that global-
global-position receivers by                  position receivers will be used by
instructors during emergencies.               medical evacuation helicopters and
                                              Ranger instructors. The Brigade
                                              acquired 66 receivers to track the
                                              movement of students.


8. Develop standard packing lists   Complete  Equipment and supply packing lists
for instructors, medics, and        d         for instructors, medics, and
aeromedevac crews.                            aeromedevac crews have been
                                              updated.

9. Review the winter rucksack       Complete  The winter packing list has been
packing list.                       d         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    Complete  A waterproofing lesson has been
program of instruction.             d         added to the Ranger course program
                                              of instruction.
--------------------------------------------------------------------------------

STATUS OF ACTIONS TO IMPROVE
SAFETY MANAGEMENT:  MEDICAL
SUPPORT AND EVACUATION PROCEDURES
========================================================= Appendix III

Planned action                      Status    Comments
----------------------------------  --------  ----------------------------------
1. Determine system necessary to    Complete  Air, water surface, and ground
ensure safe medical evacuation.     d         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          Complete  Mass casualty procedures have been
standard operating procedure.       d         included in each Ranger Training
                                              battalion's standard operating
                                              procedure.

3. Initiate a project to build a    Complete  The 6th Ranger Training Battalion
road into the swamp area in         d         Commander concluded that the road
Florida.                                      is not critical for safe training
                                              and, following an environmental
                                              assessment, costly construction
                                              and environmental mitigation is
                                              not justified.

4. Determine fuel requirement for   Complete  A 2,000-gallon tanker is on hand
medevac helicopters at Florida      d         at the Florida camp and two
training site.                                tankers with about 10,000 gallons
                                              fuel capacity are on hand at the
                                              mountain camp.

5. Implement plan to revert to      Complete  All three Ranger Training
full time ranger medic manning.     d         Battalions now have full-time,
                                              Ranger-qualified medics.

6. Obtain C0\2 inflatable 1-man     Complete  The Florida Ranger camp acquired
rafts.                              d         21 CO\2 inflatable rafts, which
                                              are used by each Ranger instructor
                                              team.

7. Obtain hypothermia bags.         Complete  Six hypothermia bags were issued
                                    d         to each of the Ranger training
                                              battalions.

8. Develop a system to check        Complete  All medevac emergency equipment is
packing list for medevac            d         inspected for accountability and
helicopters.                                  serviceability upon arrival at the
                                              training battalions.

9. Reinforce training and           Complete  Fort Benning Medical Command has
rehearsals of medical attachments.  d         developed training guidelines for
                                              medics and Physician's Assistants
                                              in each camp.

10. Ensure compliance with          Complete  Revised standard operating
previous cold weather procedures.   d         procedures outline cold and hot
                                              weather training procedures.
--------------------------------------------------------------------------------

STATUS OF ACTIONS TO PRESERVE
LESSONS LEARNED
========================================================== Appendix IV

Planned action                      Status    Comments
----------------------------------  --------  ----------------------------------
1. Determine how best to preserve   Complete  1977 and 1995 accident summaries
lessons learned.                    d         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          Complete  All battalions have been
inspection program.                 d         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       In        Secretary of the Army directed a
procedures.                         process   complete review of safety
                                              procedures and improvements now
                                              scheduled for completion in
                                              September 1997.
--------------------------------------------------------------------------------

STATUS OF ACTIONS TO INCREASE
PERSONNEL STAFFING
=========================================================== Appendix V

Planned action                      Status    Comments
----------------------------------  --------  ----------------------------------
1. Ensure that the number of        In        The Army plans to staff the
officers and enlisted personnel is  process   Brigade at the 90-percent level by
not less than 90 percent of                   early February 1997.
required staffing levels.\a

2. Obtain a brigade medical         In        Increases currently under review
adviser, communications officer,    process   in TRADOC. However, additional
and air operations officer.                   officers provided under the 1996
                                              legislation may be used for
                                              several of these positions.

3. Phase rotation of key personnel  Complete  Army Infantry Center conducts
to limit turbulence.                d         quarterly reviews of all officer
                                              rotations to help limit turnover.

4. Establish safety cells at each   Complete  Brigade personnel named as safety
of the three training school        d         cell members and Infantry Center
locations to advise the officers              is considering requesting
in charge, and assist in daily go/            additional civilian and military
no go decisions on training.\a                personnel.
--------------------------------------------------------------------------------
\a Required by the Fiscal Year 1996 National Defense Authorization
Act. 




(See figure in printed edition.)Appendix VI
COMMENTS FROM THE DEPARTMENT OF
DEFENSE
=========================================================== Appendix V



(See figure in printed edition.)


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================= Appendix VII

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


*** End of document. ***