Human error found in Flight Sergeant's death

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Human error may have contributed to the death of an Air Force flight sergeant who was killed when an artillery shell exploded at the Waiouru Military Camp last year, a defence force investigation has found.

Flight Sergeant Andrew Forster, a 46-year-old father of three, was killed instantly in the explosion, which happened as he was marking the device's placement in the Waiouru training area last November.

Brigadier Dave Gawn, who assembled the court of inquiry into his death, today told media F/S Forster had not followed several standard procedures, although the report could not confirm that this led to the accident.

"The court of inquiry has been unable to unequivocally ascertain the circumstances surrounding the detonation of the unexploded ammunition that killed Flight Sergeant Forster," Brig Gawn said.

"What we do know from the conclusions of the court of inquiry, there has been some form of imparting of energy which has caused the 105mm ammunition to explode."

Brig Gawn said that energy was likely imparted by F/S Forster.

Among the procedures not followed was that F/S Forster used a rock to hammer in a stake marking the placement, rather than a mallet or hammer.

"Perhaps the rock that was being used to hammer the stake into the ground parted or was let go of."

The stake was also put into the ground about 50cm away from the shell, rather than the recommendation of at least a metre.

Brig Gawn said F/S Forster had shown a lapse of judgement in not following procedures precisely.

"But whether that materially caused the accident to occur, we cannot ascertain that from the evidence that has been identified within the court."

A second sergeant survived the explosion by sheer luck, having coincidentally stepped behind a vehicle at that moment.

"It was fortuitous, and not as a result of sound practices being followed, that in the circumstances no other serious injuries resulted."

The vehicle was parked about six to eight metres from the shell, rather than the army requirement of 30 metres.

The investigation had emphasised the importance for procedures to be followed by the book, Brig Gawn said.

"I think it's focused our attention on ensuring that the procedures that are in place are followed appropriately," he said.

"It was evident in this particular case that, for whatever reason, they weren't followed to the level that we would expect."

Brig Gawn stressed that F/S Forster was not inexperienced, having been a qualified explosive ordinance device operator with the RNZAF for more than 17 years.

"I guess in part it shows that, irrespective of our training, irrespective of our experience, we are human and we do make mistakes, and this business that we're in is dangerous."

In a statement, F/S Forster's wife Karen said the report supported what the family believed: that her husband's death was the result of an accident.

"We will never know why the 105mm shell exploded that day and possible scenarios have been outlined based on subjective and objective evidence."

Mrs Forster said her husband's sudden death was devastating, but that he had known the risk involved in his job.

"He was pedantic and professional in his work ethic and fully focused on every job he undertook. Andy approached every situation in his life using all the resources available to him of past experiences, education, life skills, logic and caring," she said.

"In all the years I knew him, I cannot recall a time he took an unnecessary risk, instead choosing to err on the side of caution as he was fully aware of the cause and effect or actions and consequences, a high ethical standard he has instilled in our children."

- NZPA