Y2023-03 Con­scripts falling into wa­ter in Dragsvik on 10 Oc­to­ber 2023

22.05.2024

Nine conscripts ended up in deep water and were injured during an exercise by the Nyland Brigade in Raseborg on 10 October 2023. The conscripts were completing a level test as a part of the coastal jaeger training and landing at the shore of the garrison at its end. One of the conscripts drowned, but the conscript was successfully brought back up to the surface and resuscitated.

The accident occurred, because the conscripts were ordered to leave the boat at a previously reconnoitred location, which was deep. The instructions received by the boat captain on the implementation of the control point were deficient. The risks related to landing had not been assessed and sufficient preparations for them had not been taken, even though the landing site had changed the previous spring.

During the investigation, it was found that physically and mentally difficult exercises are extremely important to the personnel, conscripts and reservists of the military units of the Finnish Defence Forces. This fact, the level of challenge of the exercise and the individual’s desire to perform well may lead to taking unnecessary risks.

The stress and hurry of the personnel of the Finnish Defence Forces and the lack of support received may lead to insufficient risk assessments. The content of training orders is copied from previous templates without systematically cross-checking them to make it possible to pay attention to risks caused by changed circumstances in particular.

The turnover in the personnel of the Finnish Defence Forces and the changes in the training system have led to the disappearance of the so-called tacit knowledge. In the hierarchic, performance-oriented culture of the Finnish Defence Forces, people may not dare or realise they should say that they do not know how to do something and ask for clarification to the instructions received.

The orders of the Finnish Defence Forces related to the accident were open to interpretation. The management of the safety of landing falls between the practices applied on land and at sea by the Finnish Defence Forces. Moreover, the existing regulations were not applied in the implementation of the exercise in a way that would improve safety.

Deviation reporting has not become routine in the Finnish Defence Forces. It is often difficult and remains partially undone, because people do not know what kind of deviations should be reported. Deviation reporting also varies by defence branch and unit.

Based on the investigation carried out, the Safety Investigation Authority, Finland, issues the following recommendations:

1. 1The Finnish Defence Forces draws up a scheduled action plan to promote an operating culture that encourages open dialogue and critical thinking without blame.
2. 2The Finnish Defence Forces implements a process for cross-checking training orders, in which an external party reviews the risks related to them especially in connection with changes related to the exercises.
3. The Finnish Defence Forces develops deviation reporting so that it becomes simpler and can be done via more channels, and ensures that all reports receive a reaction and feedback.

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