Inquest into the death of Jason Challis
Deceased
Jason Walter Challis
Demographics
25y, male
Date of death
2017-05-10
Finding date
2019-01-16
Cause of death
Gunshot wound to the head
AI-generated summary
Jason Walter Challis, a 25-year-old rifleman with only 10 months of Defence Force training, was fatally shot in the head during an urban operations live fire exercise at Mount Bundey on 10 May 2017. He was positioned behind a plywood building in line with a concealed target dummy when fellow soldiers fired rounds that penetrated the dummy and the wall, striking him. The coroner identified catastrophic systemic failure: his Section did not receive mandatory walk-throughs or rehearsals on the range before the live fire exercise despite Defence Force doctrine requiring progressive training (dry fire, blank fire, then live fire). No one counted stacks to verify all team members were positioned correctly before firing commenced. The coroner determined this death was entirely preventable had doctrine been followed. The failures reflected a 'dynamic tactical mindset' that resisted staged training progression, combined with inadequate command oversight and failure to implement previous recommendations from the 2009 Cultana incident.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Failure to conduct mandatory walk-throughs of the range for participants
- Failure to conduct mandatory dry fire rehearsals on the specific range
- Failure to conduct blank fire rehearsals before live fire
- Failure to count and check stacks to verify all team members were positioned correctly
- Inadequate progression of training for inexperienced soldiers
- No marking of no-go zones or danger areas outside buildings
- Conflicting interpretation of doctrine regarding dynamic versus staged training
- Inadequate command oversight and training
- Dislocation of the team during building entry, causing soldiers to separate
- No designated entrance briefing or familiarization with the range layout
- Inexperienced Section with all junior members having joined between February-July 2016
- Time pressures due to weather and scheduled exercises preventing proper training progression
- Resistance to implementing recommendations from the 2009 Cultana incident
Coroner's recommendations
- Army should resolve confusion as to the interpretation of Chapter 6 Annex J, LWP-G 7-3-1 by making explicit what rehearsals are mandatorily required to be undertaken by participants on a range prior to live fire exercise use
- If rehearsals are determined to be required, the mandatory requirement should be highlighted in the Annex as has been done with walk-through requirements
- The Cultana Report recommendation that 'no-go areas behind concealed targets be marked on the outside of the walls containing such targets' should be included in doctrine
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