SOp MEDUSA - Board of Inquiry

A-10A Friendly Fire Incident 4 September 2006, Panjwayi District, Afghanistan

EXECUTIVE SUMMARY

This summary sets the context surrounding the events connected with this tragic incident. It further explains how the Board was formed and how the investigation was conducted. It also contains the summary information on the Board of Inquiry's final report, drafted with the express aim of providing a condensed, but complete, unclassified rendition of the events, the findings, the conclusions and recommendations. It will enable the public to understand fully how the events unfolded while protecting the security of our members serving in Afghanistan.

FORMATION OF THE BOARD OF INQUIRY

At the direction of the Commander of the Canadian Expeditionary Force Command, Lieutenant-General Michel Gauthier, a four-member Board (referred to as the A-10A Friendly Fire Incident Board of Inquiry) chaired by Colonel Jean-Luc Milot, was convened on September 22, 2006, and tasked "to investigate the injuries and death of Canadian Forces personnel, during OPERATION MEDUSA, at or near Panjwayi District, Afghanistan, on or about 4 September 2006." Board members included Lieutenant-Commander Gary Davis, Major Gregory Shepherd, and Major James Allen. A USAF A-10A pilot specialist advisor in air operations, legal, medical, as well as public affairs advisors and administrative support augmented the Board.

In parallel other investigative bodies were convened to investigate this incident. The USAF convened a Combined Investigation Board (USAF CIB) and a CF General officer, Brigadier-General Charles Sullivan, was appointed as the co-president. NATO convened the NATO Bi-Strategic Analysis Lessons Learned team with a CF officer, Colonel Alan Stephenson, as a member of the team.

On the convening of the Board, the President met with the family of the deceased and those injured members who had been repatriated back to Canada. During the course of the Board's investigation the President endeavored to keep the families of the casualties informed as to the Board's progress.

CONDUCT OF THE INVESTIGATION

The BOI faced unique challenges. As the friendly fire incident took place in the Afghanistan theatre of operations, the Board was required to travel to theatre in order to hear the testimony of key witnesses. Further, the pilot and other aircrew witnesses involved in the incident were members of the USAF and as such could not be compelled to testify.

During their stay in the theatre of operations, the Board members heard testimony from witnesses in theatre. They also had the opportunity to walk the ground where the incident had occurred. Upon return to Canada, Board members heard testimony from further witnesses.

In total the Board heard from 32 witnesses in the course of their investigation. In order to ensure that the Board would have the broadest possible access to necessary evidence, US and Canadian authorities concluded a Statement of Understanding under which information would be exchanged between the two investigating bodies, in confidence. Some information provided by the US government is therefore protected under section 13 of the Access to Information Act and cannot be released without US Government consent.

CONTEXTUAL INFORMATION

Op MEDUSA commenced on 15 August 2006. This was a phased Battle Group level operation intended to defeat Taliban forces in Pashmul and in the vicinity of Bazar-e Panjwai in order to gain freedom of movement on Highway 1 (Hwy 1) as well as enable the establishment of the Kandahar Stability Zone (ASZ).

At the outset of Op MEDUSA, Taliban forces controlled Hwy 1 west of Kandahar City, as well as the route south from Hwy 1 to the town of Bazar-e Panjvai in Panjwayi district. These routes were important because they traversed a region known to be a Taliban stronghold approximately 27 km southwest of Kandahar city. The securing of these routes by the Afghan National Army, supported by TF-K, was a vital phase in Op MEDUSA.

The objective area on September 3-4, 2006 was on the northwest side of the Arghandab River. The soldiers of Charles Company (C Coy) were located on the other side of the Arghandab River, southeast from both the river and the general objective area.

Several targets had been successfully attacked from the air throughout the previous day and throughout the night of September 3-4, 2006. At dawn on September 4th, US A-10A aircraft were in the area, actively attacking targets in the objective area under the control of a Canadian Forward Air Controller (FAC). It must be noted that from altitude the pilots were in near day-like conditions but the ground still remained in shadows, making the visual sighting of the targets difficult..

Meanwhile, soldiers from C Coy gp had an early reveille. Its members were engaged in packing gear, having breakfast, preparing their vehicles for the upcoming combat operations scheduled for that morning. In accordance with common practice, a small fire was lit within unit lines shortly after reveille to burn garbage.

Minutes before the incident, one of the A-10A aircraft engaged an intended target in the objective area and successfully dropped a Guided Bomb Unit that generated both fire and smoke. The incident pilot was relying on the fire and smoke generated by this bomb to assist him in identifying the target that he was also to strafe. He mistook the garbage fire at the Canadians' location for the residual fire and smoke from the bomb just dropped on the objective.

MAIN FINDINGS AND RECOMMENDATIONS OF THE BOARD OF INQUIRY

On 4 September 2006, a United States Air Force (USAF) A-10A mistakenly strafed the position of Charles Company (C Coy) group (gp) at Panjwayi District, Afghanistan, killing one Canadian soldier and wounding many others. The following are the major points from this investigation:

The incident pilot was responsible for the death and injuries of the Canadian soldiers in the incident. He lost his situational awareness. He mistook a garbage fire at the Canadian location for his target without verifying the target through his targeting pod and heads-up display;

The incident was preventable. If the incident pilot had verified the target using the targeting pod and heads-up display, he would have realized his error and discontinued the attack; and

Although not causal to the incident, the Board noted deficiencies in regards to Forward Air Controller (FAC) training and equipment and makes recommendations in that regard.

The A-10A friendly fire incident that occurred on 4 September 2006 was a result of the A-10A pilot losing his situational awareness in the changing light conditions in the transition between night and day and his failure to check his targeting pod and heads-up display to verify target location. Because he was disoriented, he mistook the garbage fire lit by the Canadian soldiers for the fire from a previous bomb impact on the target he was supposed to strafe. While firing his cannon at the garbage fire, he killed one Canadian soldier and wounded many others. The factors that contributed to the incident included a decision error by the pilot while pursuing his attack and a perceptual error when he incorrectly perceived the Canadian position to be the targeted location. Other contributing factors included the garbage fire that had been recently lit at the Canadian position and the changing light conditions in the transition from night to day.

The incident was preventable. The pilot had the target coordinates and had successfully strafed the target several times that morning. His visual reference point for the strafe was intended to be the residual fire and smoke from a bomb that had just been dropped by another A-10A. He padlocked (indicates that aircrew has locked his gaze onto an aircraft or ground target in order to maintain sight of it) on the garbage fire from C Coy gp, which was lit at about the same time and was the same distance from the A-10A as the target. If he had checked his targeting pod and heads-up display, he would have noticed the discrepancy between where his plane was pointed and the real target. That discrepancy should have caused him to abort that attack.

There were some extenuating circumstances. The incident pilot had removed his night vision goggles (NVGs) because the changing light conditions had limited their usefulness. They were removed less than a minute before he strafed C Coy gp. The transition period between night and day is a difficult one for the pilots because their eyes must adjust to ambient light and the cockpit instrumentation lighting also needs to be adjusted. The pilot was relying on his own visual perception to identify the target. Further, neither the pilot nor the FAC were aware that C Coy gp had lit a garbage fire.

Although not causal to the incident, the Board finds that there were deficiencies with the FAC pre-deployment training and equipment. The FACs were not qualified Combat Ready Night High (CR-NH) before deploying to theatre, thus not meeting the requirements of the International Security Assistance Force (ISAF) Standard Operating Procedure (SOP) 311. Furthermore, the pre-deployment training, while providing FACs with the minimum knowledge to conduct Close Air Support (CAS), was insufficient to prepare them for the conditions they faced during Op MEDUSA. In regards to equipment, the FACs were provided with the minimum required to control aircraft. Many of their controls involved CAS during the night where more sophisticated equipment such as infrared (IR) pointers and other such devices would have greatly facilitated identification of targets and friendly positions.

The Board was impressed with the post-incident response. When the incident occurred, the medical response was remarkable. The soldiers responded immediately employing techniques and equipment received during the Combat Related First Aid (CRFA) training. The Tactical Combat Casualty Course (TCCC) trained soldiers were of invaluable assistance to the Medical Technicians (Med Techs). The casualty evacuation system was efficient and well coordinated as the wounded were very quickly prioritized and flown out in dedicated aeromedevac (AE) helicopters. The most severely wounded were treated at the Kandahar Airfield (KAF), then evacuated to Landstuhl and then Canada. Other among the wounded were diverted to an allied Facility at Tarin Kowt, treated and then either brought back to KAF or evacuated to Landstuhl and Canada. Task Force Kandahar's (TF-K) operational response in creating smoke to screen the situation from the enemy, coordinating A-10A presence to protect the AE and calling up the reserve Coy to enable the continuance of the mission were all timely and effective. The post-incident response in terms of next of kin (NOK) notification and chain of command information flow was excellent.

The post-incident response to Pte Graham's mortal injury was swift and thorough. All those who handled him, from the location of the incident to his return to Canada, treated Pte Graham's remains with deference and due respect.

CONCLUSION

Throughout the investigative process, the Board's focus was to produce a report that is clear, all encompassing, makes proper recommendations, and is in line with operational imperatives. In doing so, it demonstrates the efforts taken in ensuring transparency of the process to ensure Private Graham's family, his wounded comrades, and the Canadian public can be informed on what occurred on that day of September 4, 2006.

Board members express their condolences to the Graham family and wish those wounded a speedy recovery. Their sacrifices have not gone unseen and will be remembered.