REPORT OF THE COURT OF INQUIRY
Executive Summary
What Happened

1. (U) On 12-13 October 2017, Squadron of 1 NZSAS Regiment were
conducting a regular Maritime Counter Terrorism (MCT) exercise with the
Motor Vessel (MV) Olivia Maersk. During the conduct of this activity, an
accident occurred that resulted in the death of M995290 SGT W.R. Taylor,


2. (U) The accident happened offshore to the east of the Coromandel
Peninsular at 0611. Weather conditions were moderate with good visibility,
and the accident occurred at or around civil twilight with light levels
sufficient for the operators to be able to see what they were doing clearly.

Taylor was the final person of as- 6(a) assault group from his
Rigid Hulled inflatable Boat (RHIB) to climb aS- 6(a) ladder that had been
attached to the MV Olivia Maersk by the group (a process known as
tagging). While the ?nal two climbers were on the ladder, the guardrail
onto which the ladder was attached deformed in the centre without fully
snapping. SGT Taylor reached approximately halfway up thes' 6(a) climb,
when he encountered difficulty, and, after a short 1-2 minute period, he fell
from the ladder.

4. (U) Having fallen from the ladder, SGT Taylor struck the below him
and was knocked unconscious. He then entered the water without further
contact with the orthe ship and was swept astern through the wake.
The life jacket he was wearing was not an auto-inflation model, and, during
the 1 to 2 minutes in the water before he was recovered, he inhaled
suf?cient seawater to cause drowning.

5. (U) Resuscitation efforts which commenced approximately 7 minutes after
the fall and continued during the emergency evacuation by RHIB to shore
were unsuccessful. SGT Taylor was landed to the beach at Port Jackson
at approximately 0710. Following further resuscitation efforts ashore both
by members of the assault team and an attending Westpac helicopter
crew, SGT Taylor was pronounced dead at 0745 13 October 2017.

6. (U) A timeline of events is at Annex A.

What the Court Found

7. (U) The Court made the following key findings:
at. There were two contributing factors to the death of SGT Taylor.
i. the difficulty associated with climbing using as- 6(a) ladder
which ultimately occasioned the fall;

ii. Secondly, the use, due to operational reasons, of a manually
activated life jacket which rendered him vulnerable to drowning
when entering the water unconscious.

b. All involved personnel were on duty at the time of the accident and were
appropriately qualified.

c. There were varying degrees of experience amongst the team with SGT
Taylor amongst the most experienced.

d. The level of difficulty of the climb was challenging and towards the upper
limit but within what would normally be expected of Special Forces
Operators and should normally have been within SGT Taylor?s ability.

e. The most likely reason for the fall was fatigue encountered during the
climb.

level of training conducted by Squadron personnel was found to
be suf?ciently robust to conduct tagging operations underway.

9. (U) The medical evidence provided in the autopsy and by the pathologist is
consistent with salt water drowning.

10. (U) All medical treatment given to SGT Taylor was of a high standard and
compliant with Defence Medical Treatment Protocols; no further treatment
could reasonably have been provided under the circumstances.

11. (U) The actions of the MV Olivia Maersk played no part in the cause or
subsequent effects of the accident.

12. (U) Planners carried out appropriate risk management steps for the
activity in accordance with established procedures, but improvements can
be made in the area of monitoring individual levels of currency for
underway tagging.

13. (U) The brie?ng process was in accordance with standing orders, and the
briefing of detailed contingency plans contributed to the rapid and effective
response by personnel when the accident occurred.

14. (U) SGT Taylor?s equipment was configured in a standard fashion that
was well-established and trusted by the operators; all the assault
equipment he was using had been introduced into service.

15. (U) Manufacturer?s speci?cations for the ladder and ancillary equipment
used in the operation indicate that it is ?t for purpose, however, some
documentation is incomplete and the current inspection regime does not
certify ladders to the appropriate specification.

16. (U) All safety equipment used by personnel during this activity functioned
as expected. The Special Forces Lifejacket remains fit for purpose in the
Maritime Counter Terrorism role; however, a new system currently under
trial may provide improved performance.

17. (U) The provision of an automatically activated Personal Flotation Device
(PF D) may have altered the outcome of this accident.




18. (U) The Court made a number of recommendations key amongst them
covenng:

a. Recertification of 5' 6(a) ladders and ancillary equipment to account for the
actual loads to which they are likely to be subjected 5' 6(a)

b. Investigation into the viability for the provision of an automatically activated
PFD.

0. Completion of the trial currently underway for a potential alternative to the
SFLJ.

d. Provision of guidance on expected currency for personnel conducting
underway tagging operations and a process to monitor such currency.

e. Formalising the use of systems for supporting a climber's weight as a
potential treatment to the hazard of fatigue leading to falls.

General

19. (U) The inquiry was carried out over the period 25 October 2017 to 15
May 2018. Evidence from 51 witnesses was considered.

20. (U) For security reasons, active members of Squadron are referred to in
this report by call signs. Exhibit is a list of personnel against their call
Signs.

Overview of the Accident

21. (U) On 12-13 October 2017, Squadron of 1 NZSAS Regiment were
conducting 5' a Maritime Counter
Terrorism (MCT) exercise with the Motor Vessel (MV) Olivia Maersk (Fig
1) as part of regular activity to maintain the required Operational Level of
Capability for counter terrorism outputs.2 During the conduct of
this activity, an accident occurred that resulted in the death of M995290
SGT W.R. Taylor, RNZIR.

22. (U) The accident happened offshore to the east of the Coromandel
Peninsular at 0611 on 13 October 20173 in position 175 35 24 East 36 26
10 South.

23. (U) Weather conditions were wind force 3-4 reducing, with a 1-2m swell
and good visibility in partly cloudy conditions. The accident occurred at or
around civii twilight with light levels sufficient to allow witnesses to clearly
see the events unfolding and for the operators to be able to ciearly see
what they were doing.

Taylor was the ?nal person of a 5' 6(a) assault group from
his Rigid Hulled Inflatable Boat (RHIB) to climb as- 6(a) adder that had
been attached to the MV Olivia Maersk by the group (a process known as
tagging).4 Approximately halfway up thes- 6(a) climb, he encountered
difficulty, and, after a short 1-2 minute period,5 he fell from the ladder.6

25. (U) There is no evidence to suggest that a material failure of any of the
equipment being used in the operation contributed to the felt.7

26. (U) Having fallen from the ladder, SGT Taylor struck the RHIB below him
and was knocked unconscious.8 He then entered the water without further
contact with the RHIB or the ship9 and was swept astern through the

 

1 The declared standard to which forces fit for operations are measured.

2 Witness 1, 30 November 2017, Witness 46, 25 January 2018, Q4-7.

3 Witness 12, 2 November 2017, Exhibit AP (Position marked Exhibit 44.

4Witness 35, 23 November 2017, Q3.

5 See para 64-68.

5 See pa ra 69-70.

7 See para 68.

8 Witness 43, 14 December 2017, 07; Exhibit CR 4 para 2.

9 See para 72,- Witness 9, 1 November 2017, Witness 6, 1 November 2017, Q73-7S.







wake.10 The life jacket he was wearing was not an auto?inflation model}1
and, during the 1 to 2 minutes in the water before he was recovered, he
inhaled sufficient seawater to cause drowning.12

27. (U) Resuscitation efforts which commenced approximately 7 minutes after
the fall13 and continued during the emergency evacuation by RHIB to
shore were unsuccessful. SGT Taylor was landed to the beach at Port
Jackson at approximately 0710.14 Following further resuscitation efforts
ashore both by members of the assault team and an attending Westpac
helicopter crew, SGT Taylor was pronounced dead at 0745 13 October
2017.15

28. (U) A timeline of events is at Annex A.

29. (U) In respect of the above incident and the terms of reference set out by
the assembling authority. the Court records its findings below.

 

 

(U) Fig 1 MV Olwra Maersk?

Duty Status of Personnet

30. (U) All involved personnel were on duty at the time of the incident.17

 

1? See para 72; Witness 29, 22 November 2017, 022-26.

1? Witness 1, 30 October 2017, 067.

?2 Witness 43, 05-6; Exhibit CR 3 para I, 5 para 8.

?3 See para 85-87.

1? Witness 1, 30 October 2017, Q77.

15 Ibid; Exhibit BF.

?6 Exhibit Q, 3.

?7 Witness 1, 30 October 2017, Witness 5, 31 October 2017, 03; Witness 2, 30 October 2017, Witness
6, 1 November 2017, Q6.


,m

Safety Supervising Staff and Qualifications

31. (U) The following personnel were employed in safety roles during the
incident:
safety supervisor;18
- Amphibious safety non-commissioned of?cer 
- ship safety officers" 6(a)
- ship safetys? 6(a)
- ship safety Bridge;22
- medical safety;23
safety comms;24
- coxswain of safety and
navigator of safety RHIB.26
32. (U) These personnel were ail properly quali?ed to hold these roles.27 The
rote of amphibious safety would normally be undertaken by the RHIB
detachment sergeant; however, this position was filled at the time by 5- 6(a)
who was the acting i/C of the detachment. As he was not qualified to hold
the safety role associated with his acting position} 6(a) took on that role for
the exercise.28 Personnel conducting safety roles are exposed to hazard
identification training during routine unit training periods.29
33. 6(a) the supervisor fors' 6(a) was not under training at the
time of the incident.30

5. 6(a)

Time and Exact Location of Accident

34. (U) The Court finds that the accident happened offshore to the east of the
Coromandel Peninsular at 0611 on 13 October in position 175 35 24 East
36 2610 South.

35. (U) The time and location were established to a high level of accuracy
from Global Positioning System (GPS) data taken from the navigation

 

?3 Witness 1, 30 October 2017, 05-8; Witness 2, 30 October 2017, Witness 3, 31 October 2017, Q67
?9 Witness 1, 30 October 2017, 05-8; Witness 2, 30 October 2017, (25-6; Witness 3, 31 October 2017, Q6-7.
2? Witness 1, 30 October 2017, (15-8; Witness 2, 30 October 2017, 05-6; Witness 3, 31 October 2017, 0.6-7.
2? Witness 3, 31 October 2017, (16-7; Witness 29, 22 November 2017, 02.

22 Witness 31, 22 November 2017, Q2.

23 Witness 20, 21 November 2017, Q3.

2? Witness l7, 3 November 2017, 06-8.

25 Witness 12, 2 November 2017, QB.

25 Witness 19, 3 November 2017, 06.
s. 6(a)

28 Witness 1, 30 October 2017, Q35.
29 Witness 1 4 May 2018 016
3? Witness 1, 30 November 2017, Witness 2, 30 November 2017, 05?8.







systems of the RHIBs undertaking the exercise31 combined with evidence
froms' 6(a) the coxswain of the safety boat, who was approximately 50-
100m from the accident.32

36. (U) The timing of the accident was corroborated by a number of other

witnesses, in particular Witness 133 and Witness 3.34

Light, Sea and Wind Conditions

37. (U) The Court finds the following:

a.

b.
c.

Wind Conditions: force 3-4 reducing. Moderate breeze around 15-20
knots from the west.

Sea Conditions: 1?2m swell from the west.

Light Conditions: good visibility in partly cloudy conditions. The accident
occurred at or around civil twilight with light levels sufficient to allow
witnesses to clearly see the events unfolding and for the operators to be
able to clearly see what they were doing?

38. (U) Weather conditions at the time were variously reported by witnesses

a. 5- 6(a) the Troop Commander,

C.

with a spread of interpretations depending on the witnesses? experience.
in determining the definitive conditions. the Court gave greater weight to
those with experience at sea and in reporting weather conditions, such as:
s. 6(a)

reported the conditions to be easterly 15-20 knots gusting 25
with a 1-2 swell.35

. Witness 45, 5- 6(a) who observed the

conditions shortly after the accident at 0630 reported westerly force 3 or 4
and reducing from an overnight westerly 4 or 5.36 The MV Olivia Maersk's
logbook indicates force 4 at 0300, 4 at 0400 and 5 at 0700, there was no
record of the wind strength for 0500 or 0600.37 The Court determines that
the increase in wind speed by 0700 is most likely due to the ship?s transit
through the less sheltered Colville Channel rather than an indication that
the weather was deteriorating.

5' acting detachment commander, had planned from a weather

forecast of swell westerly 2-2.5m, wind south westerly 20 gusting 30

 

3? Witness 10, 2 November 2017. (113-14; Witness 24, 30 November 2017, ?12; Exhibits Al 7 and Cl.
3? Witness 12, Exhibit AP.

33 Witness 1, 30 October 2017, Exhibit 45.

3" Witness 3, Q108.

35Witness 5, 31 October 2017, Q33.

?Witness 45, 21 December 2017, (114-16.

37 Exhibit CZ.








kts, sea state slight to moderate, in fair visibility with odd showers.38 He

recalled that conditions on the night were better than forecasted.39
d. 5' 6?5" indicated a westerly wind and

sea direction in his diagram showing the approach of the to the

target vessel."0 5' ela) and Ship Safety
Officer for the exercise. described visibility as good with a slight chop on
the sea.41

e. The Court considers that the discrepancy in wind direction given by 5- 6(a) is
a simple error in reporting the direction at the time of the interview.

39. (U) Sun rise and twilight data for the location and time of the accident
indicate that civil twilight occurred at 0611 with sunrise at 0637.42
Witnesses? recollection of light levels varied. but, for the final approach to
the target vessel? 6(a) provided a clear recollection which is consistent
with a civil twilight time of 061 1: colours could be discerned and
identi?cation of safety staff on the target vessel was easy from their high
visibility vests.43 5' 6(a) recalled that night vision goggles were not required
and that it was easy to see what he was doing and that climbers were
visible from the RHIB when at the top of the ladder.?

Detailed Description of the Accident

40. (U) The plan for the exercise called for 5- 6(a) to transport 5' 6(a)
assault teams and a command and safety element to intercept the MV
Olivia Maersk and conduct a waterborne assault.45 Already embarked in
the vessel prior to her sailing from Tauranga were additional safety

personnel includings- 6(a) a sergeant acting as the Ship Safety Officer,46
5. 6(a)

 

38 Witness 11, 2 November 2017, (18; Exhibit 5.

39 Witness 11, 2 November 2017, Q17.

4? Exhibit I.

?1 Witness 3, 31 October 2017, Q30.

42 Exhibit DM.

?3 Witness 2, 30 October 2017, Q44.

?4 Witness 6, 1 November 2017, 037-38.

45 Witness 5, 31 October 2017, (142-44.

?6 Witness 1, 30 October 2017, Witness 5, 31 October 2017, 04-5.
?7 Witness 3, 31 October 2017, 014-15.

s. 6(a)

(U) Fig 2 Disposition of Personnel at start of Assault.?I Not to Scale

41. (U) RHIB contained an assault team including 5' 6(a)
who was in tactical command.50
42. (U) 5? contained 5' 6(a) assault team including SGT Taylor, who
was Squadron's 5- 5(a) and second in command at the
tactical level.52
43. (U) Thes- boat. referred to as Safety contained:
a. 5' 6(a) Squadron?ss' 6(a) in overall command;54
b. 5- 6(a) acting as RHIB Safety Of?cer;55
c. 5- 6(a) a medic; and
d. 56(3) a signaller.
44's. 6(a)

45?s. 6(a)

The Safety RHIB would remains- 6(a) in a position to
maintain visual contact as far as possible with 5- 6(a) assault teams.55

46Wt approximately 0550, having intercepted the target vessel, the
weres' 6(a) 57 5' 6(a) had

 

s. 6(a)

52lbicl.
s. 6(a)

5? Ibid.

55 Witness 1, 30 October 2017, Witness 5, 31 October 2017, 04-5.
56 Witness 2, 30 October 2017, Exhibit 
57 Witness 5, 31 October 2017, Exhibit Al, 4.





contacted MV Olivia Maersk via radio to ensure that the ship was ready to
begin the exercise,58 and this had been confirmed;59 thes' 6(a)

then gave the order to commence the assauit.60 The MV

Olivia Maersk was on a course ofs' 6(8)
52

47's. 6(a)

48.5' 6(a)

37 The Safety RHIB now moved to a position in line with RHIB
about 50m off.?58 I

s. 6(a)

s. 6(a)

 

58Witness 2, 30 October 2017, C142.

59 Witness 31, 22 November 2017, Q7.

60Witness 5, 31 October 2017, Q66.

6? Witness 45, 21 December 2017, Exhibit CZ.

52 Witness 31, 22 November 2017, (112.

53 Further detail of this problem is expanded at para 187.

6"'Witness 18, 3 November 2017, (134; Witness 11, 02 November 2017, C149.

?55 Witness 5, 31 October 2017, Q63.

55 Witness 11, 2 November 2017, 050.

57 Witness 11, 2 November 2017, Q28 and 50-51; Witness 5, 31 October 2017, (168.
5" Witness 2, 30 October 2017, (135-42.

59 Exhibit V. NB appears in RHIB Exhibit as he transferred to this boat after the accident.




 made its approach 5' 6(a) :he target vessel; this

was the windward side,70 and as such conditions were more challenging.71
The RHIB approached 5' 6(a) and
proceeded alongside to the tag position?? 6(a) the coxswain) reported
that he was able to get alongside and maintain his position effectively;73
the challenge was comparable to what he had experienced during recent
RHIB to training74.5' RHIB navigator) commented that it took
approximatelys' 6(a) to establish a stable position. which was a littie
longer than average but commensurate with the fact this was a windward
tag.?

50. (U) The tag position was adjacent to 5- on the MV Olivia Maersk (Fig

51.

4), with the coxswain maintaining his positions" 6(a)

?6 This position wass- 5(a)

?7 affording a good point to maintain a stable position alongside.
5- 5(a) had a good view of the approach from his position on board the MV
Olivia Maersk and described the positioning of the RHIB as executed with
a little bit of difficulty but nothing out of the ordinary for this sort of
operation.78
6(a) worked together to keep the RHIB in the correct position
with 5- 6(a) This was complicated by a loss of
radio communication between them due to the coxswain's headset
becoming disconnected during the ?nal approach, but communication was
nonetheless effective.80

 

7? Witness 1, 2 November 2017, 028.

7? Witness 9, 1 November 2017, 060.

72 Witness 18, 2 November 2017, 035-36; Witness 9, 1 November 2017, C156.
73 Witness 18, 2 November 2017, C139.

7? Witness 18, 2 November 2017, Q40.

75 Witness 9,
7?5 Witness 18, 2 November 2017, 038; Exhibit Witness 9, 1 November 2017, 057-58; Witness 6, 1
November 2017, Exhibit Y.

77 Witness 9, 1 November 2017, Witness 2, 30 October 2017, 045-47.

73 Witness 3,
79 Conning is the technical term for steering a vessel.
80 Witness 18, 2 November 2017, C134 and 44.

1 November 2017, 060.

31 October 2017, 039-49.

s. 6(a)

s. 6(a)

52. (U) Whers' 6(a) was happy that the RHIB was in a good stable position, he
gave the order to commence the tag.82
53. Nas responsible for operating the 5' 6(a) and at this time he
moved into position and attempted tos' 6(a) He
found the conditions quite challenging as this was the first time he had
5' 6(3) 33 5- 6(a) 'eported the RHIB was surging up
and down by about a metre and that the change in angle of attack of the
RHIB against the hull of the target vessel was more signi?cant than
the heaving motion.84 5' 6(a) the Group Commander in RHIB and an
operator with Squadron for over 3 years,85 observed the conditions on
both sides of the vessel and concluded that. whilst conditions on thes- 6(a)
side were worse, the sea state was still quite good.86
54. (U) The actual tagging of the ship was assisted bys- the Ship Safety
Officer. After watching for a period, he assessed that, to expedite the
exercise and ensure a safe, secure tag, a small amount of assistance was
appropriate.87 5' 6(a)

 

3? Exhibit Q, 5.

82 Witness 9, 1 November 2017, Q63 and Q69.
33 Witness 8, 1 November 2017, Q37-42.

84 Witness 6, 1 November 2017, (130-31.

35 Witness 21, 21 November 2017, Q3.

'53 [bid 028

37 Witness 3, 31 October 2017, C149.





5- 6(a) Having done this, he
attached the safety strop to a lower guardrail and gave the signal for
climbers to begin the ascent of the ladder.89 Due to the conditions in the
RHIBF- checked 3 times with the Navigator that he was happy the
RHIB was positioned stably. Having veri?ed this and satis?ed himself the
team were ready, he gave the command to climb.90

55.5? 6(a) personnel climbed the ladder to board the MV Olivia Maersk
ahead of SGT Taylor. Although there were minor discrepancies as to the
order in which people climbed,91 the Court finds that the order of the

climbers was 5- 6(a) and SGT Taylor.92 This
finding is due to the weight placed on Witness 7?s recollection that he was
5' 6(a) climber.

565' 6(a)

There are no anti twist devices on the ladder.101

 

33 Witness 3, 31 October 2017, Witness 6, 1 N0vember 2017, (119-21; Exhibit X.
39 Witness 8, 1 November 2017, C160.

9? Witness 6, 1 November 2017, C129.

91 s. 6(a)

92 Witness 6, 1 November 2017, Witness 7, 1 November 2017, C131.
93 Witness 42, 14 December 2017, Q5.

9? Witness 42, 14 December 2017, Q7.

95 Exhibit 05; Exhibit DT.

93 Exhibit O, 37-38, Photos 51-52.

97 Exhibit Q, 39, Photo 53; Exhibit or.

98 Exhibit Exhibit Q, 39, Photo 54 and 40, Photo 56.

99 Exhibit Q, 39, Photo 54.

10? lbid.

Exhibit Q, 37-38, Photos 51-52.




s. 6(a) s. 6(a)

Fig 5 Views of Ladder

571mm standard operating procedure for tagging102 calls for one person
(the ladder man) to hold the bottom of the ladder in order to put weight on
it as the climbers start.1?3s' 6(a) commented that during this exercise the
conditions made it dif?cult for the ladder man to maintain weight on the
ladder at all times.104 When it is the ladder man?s turn to climb? 6(a)
takes over this duty.105 5' 6(a) the ladder man, reported handing
this duty to SGT Taylor.106 However. on the strength ofs? 6(a)

evidence, the Court ?nds that he in fact handed the ladder to
s. 6(a) s_ 6(a)

 

?02 Exhibit DV.
?03 Witness 6, 1 November 2017, (133; Witness 14, 3 November 2017, Q2.
Witness 8, 1 November 2017, (160.
?05 Witness 9, 1 November 2017, C175.
?06 Witness 14, 3 November 2017, (18-9.


s. 6(a)

interviews, the Court asked the climbers to describe the
difficulty of the climb. Their responses varied, particularly in light of their
individual experience levels,109 but the following represents some of their
comments:

a. 5' 6(a) estimated it tooks' 6(a) to climb the ladder.110 He paused
once to adjust a face mask after being splashed by a wave111 and rated
the climb as out of 10 for difficulty.

b. 5' 6(?described 3' 6(was battling at the bottom of the ladder but expressed
that was normal.112 He rated the dif?culty of the tag and climb as nut of
10,113 one of the harder ones he had experienced. He described
conditions getting onto the iadder as chalienging,114 but once a climber
started below the additional weight on the ladder made the second half of
the climb easier.115 5- 6(a) indicated that he was able to climb the ladder
without the ship?s hull causing undue problems.116

0. 5' 6(a) had fewer issues getting onto the iadder?17 but found that, at one
point, he became stuck between the ladder and the ship?s hull and had to
flip himself back round.118 He rated the climb as out of 10 for dif?culty.
describing it as ?a rough, hard climb?.?9

d. 5- 6(a) the Group Commander. rated the climb as 5- out of 10 but
commented it was easier than one conducted during a similar
exercise earlier in the year.120 He had considered the conditions and was
comfortable that the climb was manageable for his group.121 It took him

abouts' to climb the ladder.122 He started with his back
against the ship before pivoting round the ladder as it jammed up against
the hull.123

 

?07 Witness 8, 1 November 2017, Q56.

?03 Witness 6, 1 November 2017, 039; Exhibit F, Tag Climb para 3

?09 Generally, the more inexperienced members described it as a hard climb while the more experienced
members noted it was much easier than many climbs the unit had conducted in the past.
?0 Witness 15, 3 November 2017, Q53.

"1 Witness 15, 3 November 2017, Q54.

?2 Witness 8, 1 November 2017, C149.

"3 [bid Q45.

1? lbid (150-54.

?51bit! Q56.

?5 Ibid Q58.

?7 Witness 16, 3 November 2017, Q26.

118Witness 16, 3 November 2017, Witness 7, 1 November 2017, Q32.

?9 Witness 16, 3 November 2017, Q19-20.

?20 Witness 6, 1 November 2017, Q42.

?21 Ibid 043.

122 Ibid Q41.

?23 Ibid Q41.

e.




5' 6(a) for whom this was his first underway tag,124 reported the level of
difficulty as out of 10.125 He initially had his back to the hull and then
spun around to face the hull before climbing to the top.126 Despite this
being his first tag, he felt the climb was achievable.?7 He reported that, in
discussion with some of the other climbers immediately following the
incident. the consensus was that it wasn?t an easy climb.128

f. 5' 6?8) was the climber immediately ahead of SGT Taylor and, as the ladder

man, had been maintaining tension on the ladder for other climbers.129 He
reported conditions in the as "pretty rough? with water Splashing his
face.130 He rated the difficulty as as' 6(a) out of 10.131 While part way up
the climb, he felt a big jolt,132 and he twisted on the ladder through 360
degrees.133 The climb became more dif?cult after this point,134 and as he
reached the top he realised that the guard rail onto which the ladder had
been attached had deformed significantly.135

witnesses had differing perspectives on the difficulty of the

climb, with this difference likely related to their experience and vantage
point:
From his position on board the MV Olivia Maerskf? 6(a) with limited
experience of reported that his overall impression was
of a challenging climb.137 He noted that climbers took betweens? 

to climb the ladder.138

b.5- 5(a) the Navigator of RHIB with two and a half years with Squadron139

and sufficient experience to feel fully con?dent in his role?0 noted the
conditions could took intimidating,141 but in his experience this was normal,
and conditions were around out of 10 for difficulty.142

 

?24 Witness 7, 1 November 2017, 0.7,
?25 [bid Q55.

?26 lbid Q32.

127 lbid 052-54.

?23 lbid 0.61.

129Witness 14, 3 November 2017, 02.
13OWitness 14, 3 November 2017, (17-8.
13? lbid Q20.

?32 lbid Q14.

133 lbl'd Q22.

?34 lbid C120.

?35 Ibid (116.

136Witness 29, 22 November 2017, Q4.
137 lbid Q11.

1?mild Q12.

139Witness 9, 1 November 2017, Q3.
14? lbid 013-14.

lbid Q70.

142Ibid 0.71-74.

C.

5? 6(a) the Ship Safety Officer who has been with Squadron for eight

years, acknowledged that the conditions were such that particularly at the
start of the climb personnel were getting splashed by the waves. However,
given the vessel was travelling at around 5- 6(a) he noted that the
conditions were not at all out of the ordinary.143

d. 5- 6(a) Squadron 5- 6(a) was confident that the conditions alongside were

adequate for there to be no concerns around the activity being conducted
safely.?44

60. (U) Having examined the evidence of all those who climbed the ladder or

61.

observed the climb, the Court ?nds that, whilst the level of dif?culty was
challenging and towards the upper limit, it remained ?rmly within what
would normally be expected of Special Forces Operators at OLOC.

(U) While the final two climbers were on the ladder, the guardrail onto
which the ladder was attached failed. It deformed in the centre without
fully snapping.145 dropping by approximately 10 cm146 (see Fig 6). 5' 6?3)
was standing over the guardrail as it failed; he heard a crack and, seeing
the rail bending, instinctively grabbed 5' 6(a) to
provide extra support. He checked the safety strop was in place, which it
was 5' 6(a) ?47 and adjusted his position to allow him to

grasp tg(e)ladder and exert his full force to provide support.148
8. a

 

?43 Witness 3, 31 October 2017, Q42-49.

1? Witness 2, 30 November 2017, Q49.

?5 Witness 3, 31 October 2017, 051.

?5 Witness 3, 31 October 2017, Exhibit O, 8-22.

?7 Witness 6, 1 November 2017, 050-51; Exhibit X, photo 10.
?48 Witness 6, 1 November 2017, Q50.

?9 Exhibit O, 13.

62. 6(a) the Ship Safety Officer, informeds- 6(a) the Safety Officer,
of the incident and ordered no more climbers to mount the ladder,150 but,
at the time the guardrail had failed, SGT Taylor, the final climber, was
already on the ladder and committed to the climb.151 Ass- 
his climb, he was ordered to remove his pistol belt and improvise an
additional safety strop on the ladder.152

63. (U) As SGT Taylor began his climb from the RHIB. his foot was trapped
for 30-40 seconds by the twisting ladders- now acting as ladder man,
assisted him in freeing it, and SGT Taylor continued the climb.153 As SGT
Taylor continued the climb, his pace became noticeably slower than the
other climbers, and, about halfway up the ladder, he came to a stop.154

5. 6(a)

(U) Fig 7 Disposition of personnel prior to Taylor?s fall from ladder?55

64. (U) It is unclear why SGT Taylor stopped:
a. 5' 6(mobserving from the bottom of the ladder, thought it may have been
fatigue but was uncertain.155

 

15? Witness 3, 31 October 2017, Witness 2, 30 October 2017, Witness 6, 1 November 2017, 0.60,

Witness 2, 30 October 2017, 058. That is to say turning back would have meant more time on the ladder
(thus being a more dangerous option) than completing the climb.

?52 Witness 14, 3 November 2017, Witness 6, 1 November 2017, Q63.

?53 Witness 9, 1 November 2017, Q77.

?54 Witness 9, 1 November 2017, Witness 29, 22 November 2017, Q14,

?55 Witness 7, 1 November 2017, Exhibit Witness 6, 1 November 2017, 060-65; Exhibit X, photo 9;
Witness 15, 3 November 2017, Exhibit AV.

?55 Witness 9, 1 November 2017, Q77.

b. 5' 6(a) observing from the top of the ladder, first saw SGT Taylor halfway up
the ladder and already stationary.157 He felt that SGT Taylor may have
been snagged, as he was repeatedly cursing whiist adjusting his position
without moving up or down.158

65. (U) Witnesses in the safety RHIB had a clear view of climbers on the
ladder from approximately 50m away.159 They confirmed that SGT Taylor
was having some difficulty with the climb and had come to a stop for as
much as 60?90 seconds, approximately a body length from the ship?s
gunwale or 4-5m from the water.160 He was observed to climb down a
rung, although these witnesses were uncertain if this was due to fatigue
and anattempt to abort the climb or in an effort to disentangle himself from
the ladder.161

66. (U) Two witnesses saw SGT Taylor on the {adder from astern:

in RHIB approximately 100m behind RHIB '52 reported SGT
Taylor as stopping and moving up and down about a rung about midway
up the side of the ship.163

b. 5' 6(a) 3n board MV Olivia Maersk was thes? safety number and
had moved to 5' 6(a) continue to observe it
manoeuvred to that side.164 Observing froms' 6(a)

[55 he reported that SGT Taylor
seemed to be struggling, being turned around quite a lot on the ladder
especially being the last person. About halfway up he paused for what
seemed a long time before what looked like an attempt to descend.166

67. (U) In the opinion of the Court?- 6(a) mm was looking directly over the
guardrail, had the best view. Onces- 6(avhad cleared the ladder?? SW had a
clear view down to SGT Taylor. He gave the foilowing evidence:

a. The iadder wastwisting at the bottom since it only had one person on it,
and it appeared that SGT Taylor was getting into difficulty.167

b. It appeared that SGT Taylor?s foot had become caught in the ladder and
that he was holding on in that position.168

 

?57 Witness 15, 3 November 2017, Exhibit AV, position B.

?55 Witness 15, 3 November 2017, Q25.

?59 Witness 17, 3 November 2017, Witness 2, 30 October 2017, Exhibit l; Witness 19, 3 November
2017, Witness 12, 2 November 2017, Q23.

16? Witness 2, 30 October 2017, Witness 17, 3 November 2017, 021-22; Exhibit AY.

?51 Witness 2, 31 October 2017, Witness 1, 30 October 2017, Witness 12, 2 November 2017, 029.
?52 Witness 26, 21 November 2017, 

?53 Witness 26, 21 November 2017, Exhibit BJ.

?54 Witness 29, 22 November 2017, Q9.

?55 Witness 29, 22 November 2017, 013; Exhibit BK.

186Witness 29, 22 November 2017, Q14.

?67 Witness 3, 31 October 2017, Q66.

158 lbid Q66.

c. He could hear SGT Taylor becoming audibly frustrated as he tried to kick

his right foot free of the ladder.169

He kept his eyes on SGT Taylorthroughout this period.170

. 5' 6(a) sailed down to ask if SGT Taylor was OK. He got no response as

SGT Taylor was focussed on trying to free himself from the obstruction.171

f. As SGT Taylor cleared his foot from the ladder, he began to descend by
one rungs' 6(a) could not be sure if SGT Taylor was trying to reposition his
body.172

9. SGT Taylor appeared to have full freedom of motion up and down the

ladder, and 5' 6(a) concluded that it was the rotation of the ladder that had
trapped a foot.173

. 5' 6(a) was confident that SGT Taylor had freed his foot, but approximately

10 seconds later he fell.174

i. He concluded that ultimately it was fatigue that had caused SGT Taylor to
release from the ladder rather than a technical issue.175

68. (U) With one exception?"5 the witnesses who saw SGT Taylor fall report
consistently that he simply released from the ladder hands first and fell
backwards towards the 

3.5- 6(alat the bottom of the ladder could not tell why SGT Taylor climbed down
but thought it may have been fatigue.178 He didn?t notice any part of SGT
Taylor as being snagged179 and gave evidence that SGT Taylor had
released his grip without scrambling.?8?S' 6(a) concurred with this.181

b. At the top of the ladders' 6?8) further noted that, almost at the instant of
taking a step down, SGT Taylor fell backwards from the ladder almost
directly down into the 

c. The only variation from this description was froms- 6la) who described
some "false grabs on the ladder with his feet and hands?.183

we

3"

 

?59 lbid.

17? lbid.

lbid Q83-85.

?2 lbid Q66.

1?lbid 086-93.

?74 Witness 3, 31 October 2017, OBS-97.

?75 lbid ass-101.

?73 Witness 12, 2 November 2017, C129.

'77 Witness 1, 30 October 2017, 063-66; Witness 2, 30 October 2017, 059; Witness 3, 31 October 2017, 
Witness 9, 1 November 2017, 078; Witness 15, 3 November 2017, Witness 26, 21 November 2017,
C133.

?75 Witness 9, 1 November 2017, Q79.

?79 lbid (181.

lbid (185.

?81 Witness 29, 22 November 2017, Q14.

?32 Witness 3, 31 October 2017, Q67.

1B3wttness 12, 2 November 2017, Q29.

69. (U) After considering the evidence presented and giving weight to those
closest to the accident with the best vantage point, the Court finds that.
following a challenging climb having at least twice had to free his feet from
entanglement, SGT Taylor involuntarily released his grip due to fatigue in
his hands and forearms thus falling from the ladder.

70. (U) Having let go of the ladder, SGT Taylor was seen by five witnesses to
fall backwards into the RHIB striking thes- 6(a) in the vicinity
of the mast:

6Win the ands' 6(a) at the top of the ladder both saw him fall
backwards in the vicinity of the mast with his head in board (in relation to
the but could not con?rm he struck his head.184

b. 5' 6(a) 'eported that SGT Taylor struck the RHIB just forward of the mast.185

c. 5- from above reported seeing SGT Taylor strike the 
approximately adjacent to the mast186 though he only had a split second
view?e?7

d. 5- 6?3) with a good view from above reported seeing SGT Taylor fall
backwards and strike the on the 5' 6(a) pontoon 
forward of the mast,188 though couldn?t recall how Taylor was orientated as

he struck.189
s. 6(a)

71. (U) As soon as it was clear what had happened,s' 6(a) the coxswain of
RHIB began to manoeuvre in anticipation of recovering SGT Taylor.191

 

13? Witness 3, 31 October 2017, 067-80; Exhibit 0; Witness 9, 1 November 2017, (188-92 and 0117; Exhibit AG.
?35 Witness 29, 22 November 2017, 017-21; Exhibit BL.

?85 Witness 6, 1 November 2017, Exhibit 2.

?57 Witness 6, 1 November 2017, Q77.

?88 Witness 15, 3 November 2017, 034?40; Exhibit AW.

?89 Witness 15, 3 November 2017, Q39.

?90 Exhibit Q, 68.

Witness 18, 3 November 2017, Q48.

In the Safety RHIB, the coxswain also began to manoeuvre to provide
assistance.192

72. (U) From the moment that SGT Taylor entered the water, he was
observed almost constantly until recovery by personnel in RHIB ?93 No
witnesses reported any signs that he was conscious. Specifically, the
following personnel gave evidence:

a. In RHIB saw SGT Taylor bounce off the pontoon and into the water.
He was looking over the side and saw that SGT Taylor did not get crushed
between the RHIB and the hull of the MV Olivia Maersk nor come into
contact with the propellers.194 He recalled that the distance
between the RHIB and the hull of the ship was approximately 1.5m.195

b. Viewing from above} 6(a) 1oted that, having bounced off the pontoon, SGT
Taylor did not appear to come into contact with the RHIB or ship,196
although he did briefly lose sight of SGT Taylor between bouncing off the
pontoon and then seeing him in the water.197 5' 6(a) evidence was the gap
between the vessels was about 1m.198 On initial entry into the water? 6(a)
brie?y saw SGT Taylor appearing to float in a head up or vertical
position.199

0. Once clear of RHIB personnel on the upper deck of the ship followed
SGT Taylor?s progress in the water??0 5' 6(a) had the best unobstructed
View and was able to monitor SGT Taylor as he passed down the side of
the ship. His immediate sense was that SGT Taylor was unconscious,
floating on his back; as SGT Taylor passed through the wake,5' 6(a) felt he
had seen a hand raised but in hindsight feels what he saw was an
unconscious man being turned by the turbulent water.201

d. 3- Gla) also saw SGT Taylor floating horizontally but could not discern if he
was on his front or back. He watched'him float all the way down the ship?s
side about 2m off and did not see him come into contact with the ship.202

e. 5' 6(min RHIB having lost sight of the man as he fell, spotted him again as -
he came through the wake of the MV Olivia Maersk. Initially, he just saw a

 

?92 Witness 12, 2 November 2017, Q37.

?93 gave evidence of viewing him from entry into the water until clear of the RHIB. gave evidence of
viewing him from clearing the RHIB until partially down the ship?s side. gave evidence ofviewing him
from entry into the water until he had passed through the ship?s stern wave. and gave evidence of

viewing him from passing through the stern wave to the recovery.
?94 Witness 9, 1 November 2017, Q88.

?95 lbid 093-94.

?95 Witness 6, 1 November 2017, Q73-75.

197 Ibld 076-77.

195 [bid Q75.

199 lbid Q79.

20? Witness 3, 31 October 2017, (1103.

20? Witness 29, 22 November 2017, 022-26.

202 Witness 15, 2 November 2017, Q44 -52.

dark object, but as soon as it was close enough he made out an
unconscious figure floating face-down in the waiter.203

f. 5' 6(a) recalls first sighting SGT Taylor about 30 seconds after the alarm was
raised that someone had fallen. He was floating face-down positively
buoyant but with his life jacket not inflated.204 Evidence of other witnesses
in RHIB is consistent with these observations?? althoughs- 6(a)1itially
caught sight of SGT Taylor's head and shoulders out of the water, by the
time the RHIB was alongside him he was face down.206

73. (U) RHIB from its position astern of RHIB made an approach to
recover SGT Taylor from the water 5' 6(3)

207 On the approach, 5- 5(a) umped into
the sea in order to get SGT Taylor?s head out of the water quickly.208 Very
shortly thereafter, the came alongside, ands- 6(a) Ieant over and
activated SGT Taylor?s life jacket.? then entered the water to assist
getting SGT Taylor into the RHIB 5- 5(a)

personnel in the bow had recovered SGT

Taylor into the 6(a) was recovered by RHIB which had by this
stage arrived at the scene.211

74. (U) The court finds that. having fallen from the ladder, SGT Taylor struck
RHIB with sufficient force to render him unconscious and, taking into
consideration witness accounts and GPS timing data available from the
safety RHIB, that the time he was in the water unassisted was between
one and a half to two minutes.212

Cause of Death

75. (U) The Court finds that SGT Taylor drowned after being knocked
unconscious as a result of a fall from approximately 5m whilst attempting
to board the MV Olivia Maersk.

 

2?3Witness 26, 21 November 2017, Q36.

20? Witness 5, 31 October 2017, Q72.

205Wi?tness 11, 2 November 2017, Witness 21, 21 November 2017, Witness 25, 21 November 2017,
Witness 41, 14 December 2017,? Q3940.

20?5Witness 13, 2 November 2017, Q94 and 104.

207 ibid 0103.

20"Witness 22, 21 November 2017, Witness 11, 2 November 2017, (157.

2? Witness 21, 21 November 2017, Q34.

21? Witness 11, 2 November 2017, 057-58; Witness 21, 21 November 2017, (135.

2? Witness 18, 3 November 2017, Q48.

212 Witness 12, 2 November 2017, (147-51; Exhibit Witness 5, 31 October 2017, Q72. Exhibit BF contains a
note made at the time of the accident ?found face down after 1 -to 2 minutes?.

76. (U) The medical evidence provided in the autopsy and by the pathologist
is consistent with salt water drowning?13 The pathologist indicated that
certain elements within this evidence supported the conclusion that SGT
Taylor inhaled large quantities of sea water?14 The Court places
signi?cant weight on this evidence.

77. (U) witness evidence supports the conclusion that, having fallen, SGT
Taylor struck the he had climbed from215 and entered the water
unconscious.216 The evidence from the autopsy and from the pathologist
confirmed that injuries to the head were consistent with a fall from
height.217 Whilst it was not possible to confirm clinically that SGT Taylor
was unconscious when he entered the water,218 the Coronial Autopsy
Report states The injuries to the head may be sustained during the fail
and an element of unconsciousness would not be unexpected?;219 the
pathologist reiterated this in his evidence?20

78. (U) The Court finds that, prior to his fall, SGT Taylor was conducting
activities with suf?cient rigour to elevate his breathing rate to a high
level;221 all witnesses who had performed the climb ahead of him
commented on its demanding nature?22 The pathologist observed that 12
breaths can be sufficient to cause drowning for a normal person;223 with a
high breathing rate, it is likely SGT Taylor quickly inhaled large quantities
of sea water that made it unlikely that he could have been revived unless
immediately recovered from the water?24

immediate and Subsequent Casualty Treatment

79. (U) The Court finds that all medical treatment given to SGT Taylor was of
a high standard and compliant with Defence Medical Treatment
Protocols?25

80. (U) The Court further finds that no furthertreatment could reasonably have
been provided to SGT Taylor under the circumstances.

 

2?3 Witness 43, 14 December 2017, 05; Exhibit CR, 1 para 3.

2?4 Witness 43, 14 December 2017, (115?16.

2155ers para 70.

218See para 71-73.

2?7 Exhibit CR, 4 para 2.

218Witness 43, 14 December 2017, ?17.

2?9 Exhibit CR, 4 para 2.

22? Witness 43, 14 December 2017, Q7.

22? See para 64-67

222See para 58.

223 Witness 43, 14 December 2017, C114.

22? Ibid,

225 Witness 32, 22 November 2017, (18-19; Witness 5, 31 October 2017, 0121.


81. (U) Upon recovering SGT Taylor from the water, the embarked assault
group immediately initiated resuscitation efforts. Simultaneously, the
Safety RHIB made its way to the point of recovery. Upon marry up of the

5' 6(a) 6(a) (the Squadron medic) was transferred to to
provide primary medical care.226 5' 6(a) assessed that the transfer of the
medic probably occurred at approximately 0615.227 At this point, SGT
Taylor was being treated at the front of RHIB by up to three assault
group members-223 s. 6(a) and 

229

82. (U) Whilst members of the assault group removed SGT Taylor?s
equipment and clothing? 6(a) and 

330 As there was insufficient room at
the front of the RHIB in which to perform resuscitation, 5? 6(?ordered the
rear of the RHIB to be cleared and had SGT Taylor moved to that

location.231
83.5? 6(a) and 

33" and one described paint on the back of
his bump helmet235 consistent with that on the MV Olivia Maersk indicating
that the helmet had been in contact with the hull of the ship.

84. (U) 5' 6(mcommenced further treatment of SGT Taylor by checking his
airway for obstructions and checking his breathing.236 Soldiers
commenced Cardio Pulmonary Resuscitation this was recorded by
5' occurring at 0610.2375- ?ecalled that he begin titling in Exhibit

BF, the Medical Evacuation Card, sometime between CPR commencing
s. 

 

22? Witness 20, 21 November 2017, Q39.
227 Witness 12, 2 November 2017, Exhibit AP, Position (2.
228 Witness 12, 2 November 2017, Q40.
229 Witness 23, 21 November 2017, Witness 41, 14 December 2017, Q42.
23? Witness 20, 21 November 2017, Q40.
231 lbid
232 lbid, Q42.
233 Witness 21, 21 November 2017, Witness 23, 21 November 2017, Witness 27, 21 November 2017,
Q26.
23? Witness 27, 21 November 2017, Q26.
235 Witness 21, 21 November 2017, Q43.
23? Witness 20, 21 November 2017, Q42.
237 Witness 20, 21 November 2017, Witness 21, 21 November 2017, 052-53; Exhibit BF.
238 Witness 21, 21 November 2017, 052-62; Exhibit BF. .


85. (U) The Court finds that approximately three minutes elapsed from when
5' 6??hransferred to RHIB and CPR commenced.239

86. (U) Taking into account the more accurate timing data provided bys' 6(a) 3f
whens' 6(a) transferred to RHIB 340 the Court finds that the actual time
CPR commenced was approximately 0618. The Court further finds that

timings from Exhibit BF become accurate from 0630 onwards.
87.5' 

As
the RHIB made way to the evacuation point, the assault group cycled
through chest compressions initially at two-minute intervals;243 this was
then reduced to one-minute intervals due to the fatiguing effect of the
RHIB in transit.244 5' 6?3) comments that the speed of the boat was
reasonable245 and that CPR was being conducted effectively?6 at no more

than two minute cycles per person.247 Approximately 10 minutes into the
CPR s. 

88. (U) During the transit, in consultation with the crew of the WESTPAC
Rescue Helicopter, 5- 6(a) made the decision to make for Port Jackson.250
CPR continued until arrival at approximately 0710.251 At this point, SGT
Taylor was transferred ashore while a party was sent to identify and mark
a helicopter landing point.252 The WESTPAC Rescue Helicopter out of
Mechanics Bay arrived at 0715253 and responsibility for treatment was
handed over to the paramedics.254 Assault group personnel continued to

 

239 Witness 20, 21 November 2017, (142.

24? Witness 12, 2 November 2017, Exhibit AP, Position C.

2? Witness 20, 21 November 2017, Q42-43.

242 Witness 20, 21 November 2017, Q43-44.

24albid, Q44.

244Ibid.

245Ibid, 045.

246lbid, Q47.

247 lbid.

2?telb'ld, Exhibit BF.

2?9 Witness 20, 21 November 2017, Q57.

25? Witness 5, 31 October 2017, Q77.

25" Witness 1, 30 October 2017, Exhibit Al, 8.

252 Witness 2, 30 October 2017, Q77.

253 Witness 20, 21 November 2017, Witness 21, 21 November 2017, Q50.

25? Witness 20, 21 November 2017, Witness 21, 21 November 2017, C150.


provide assistance to the resuscitation efforts throughout.255 At 0725, the
ambulance arrived followed by the Colville One Response Team (and
doctor) at 0735.256 The doctor attending from the Coromandel Saint
John?s Ambulance pronounced SGT Taylor dead at 0745.257

Other Actions Taken After the Event

89. (U) The Court finds that actions immediately following the accident were in
accordance with relevant procedures and orders and that all possible
measures were taken in the immediate response to the events of 13
October 2017.

90. (U) The Court finds that casualty notification and reporting associated with
the accident was in accordance with standard procedures and that all
reports were made accurately and in a timely fashion.

91. (U) As a result of 111 calls by both 3- 6(aiand 5- 6Wand subsequent
activation of the Safety the following emergency
services responded:259

a. WESTPAC Rescue Helicopter out of Mechanics Bay. Auckiand; and

13. Saint John?s Ambulance out of Colville.

92. (U) Due to subsequent calls, other agencies responded, inciuding:260

a. New Zealand Police Criminal investigation Bureau,

b. Maritime New Zealand,

c. Maritime Police,

d. Search and Rescue, and

e. NZDF Military Police.

93 s. 6(a)

352 The NZSAS Regiment?s
Operations Staff initiated casualty notification procedures263 and the
5- released an e-mail
INCIDENTREP 002)264 to the Chief of Staff, 
(Army). 5' 6(a) sought assistance from Northern Region Legal Advisor and

 

255 Witness 21, 21 November 2017, Q73.
25? Witness 1, 30 October 2017, Q77.

257 Ibid.

258 Exhibit AR.

259Witness 1, 30 October 2017, (173.

26? ibid, Q79.

251 ?Did, Q73.

252 Witness 46, 25 January 2018, (113.
263Exhibits DN, 00.

25? Exhibit DJ.



from 5' (a previous Regimental Medical Officer 
who happened to be noti?ed by Search and 
94. (U) Safety staff on board the MV Olivia Maersk secured the 5- 5(a) ladder
and took photographs of the tag point and the failed railing.266 Within
Papakura Military Camp, 5- ?at who was acting as the
logistics staff officer at the time identi?ed a quarantine area and isolated
the equipment used during 5' 6(3) 257 Personnel involved in the
training activity commenced documenting their recollections of the
event.268
95. (U) 5' the General Staff Of?cer for Health and Safety
at Army General Staff, informed Work Safe New Zealand of the fatality (it .
being a notifiabie event) on 13 October 2017. A confirmation e-mail and
letter was received back on the same day.269
96. (U) Further noti?cations by the Regimental Operations and Headquarters
staff included a Follow Up Death NOTICAS270 and Safety Reporting
System (SRS) reporting.271 Two days after the event, Regimental
Operations staff sent a QUICKREP.272 The staff also put together a
briefing pack for Senior Leaders 5' 6(a) Brie?ng Pack).273
97. (U) The party left on board the MV Olivia Maersk did not receive any
notification of the death of SGT Taylor. The ?rst any of the party heard
was via a Short Message Service (SMS) or text message from a cousin of
one of those on board274 and then via an online news article.275 On arrival
back to Papakura Camp, the party received the news that the
fatality was SGT Taylor.276 The speed with which information was
released to the media was driven by the exposure to the public of the
casualty evacuation effort at Port Jackson.277 The Court ?nds that whilst
regrettable. given the circumstances, the balance between informing
personnel directly involved in the operation and reieasing information to
the media was appropriate.

 

255 Witness 1, 30 October 2017, 079-80.

266 Witness 3, 31 October 2017, Q103 and Exhibit AZ, 3; Exhibit Q, 3-34.
257 Witness 1, 30 October 2017, (1124.

253 These recoliections were included as Exhibits J, W, 36 and CO.

259 Exhibit DF.

27? Exhibit DI.

271 Exhibit 06.

272 Exhibit DP.

273 Exhibit 00.

27? Witness 31, 22 November 2017, Q26.

275 Witness 31, 22 November 2017, Witness 29, 22 November 2017, Witness 30, 22 November
2017, Q13.

276 Witness 28, 22 November 2017, C111.

277 Witness 46, 25 January 2018, 0.17.

98. (U) The Court ?nds that all personnel directly involved in the accident had
suf?cient access to counselling and that the support provided by 
Squadron and the wider organisation was strong.278

Actions of the MV Olivia Maersk

99. (U) The Court ?nds that the actions of the MV Olivia Maersk played no
part in the cause or subsequent effects of the accident and that the crew
acted appropriately in response to the circumstances of the accident.

100. (U) During the approach of the towards MV Olivia Maersk} 6(a)
was located on the bridge of the ship acting as a liaison officer.279 From
when the began their approach until after the accident had
occurred, the ship?s log records she maintained a steady course280 on a
heading of 289? True.281 5' 6(a) reported a speed ofs' 6(a) was maintained
throughout282 and that the ship did not alter course and appeared to be on
auto piiot.283 Automatic identification System (AIS) data obtained from
Maritime New Zealand con?rmed that the ship maintained her course and
speed throughout the accident.284

101. 6(a) quickly reported the accident to 3- the bridge, the Ship?s
staff asked if there was a requirement for the ship to alter course or speed.

5' 6(a) instructed them after consultation with 5' 6(a) to maintain their planned
course.285

102. (U) Initial reactions from the ship were taken by on watch 
The Master of the MV Olivia Maersk was informed by his staff after about
15 minutes that there had been a man over board incident, that the man
had been recovered and that no assistance was required.287 The vessel
then continued its passage to Auckland.288

SGT Taylor?s Training and Experience

103. 6(a) is the
current means/mechanism used to qualify Special Operations Forces
(SOF) personnel on the full range of Counter Terrorism (CT) options

 

273 Witness 12, 2 November 2017, Witness 6, 1 November 2017, (21122-123; Witness 20, 21 November
2017, Witness 46, 25 January 2018, 014-15.

27" Witness 31, 22 November 2017, Q5.

28? Witness 45, 21 December 2017, Exhibit CZ.

231 A compass bearing relative to True North as opposed to Magnetic North.
232 Witness 31, 22 November 2017, 012.

283 lbid (121-23.

23" Witness 10, 2 November 2017, (19-13; Exhibit AI, 4-6.

235 Witness 3, 31 October 2017, 0103; Witness 31, 22 November 2017, Q20.
235 Witness 31, 22 November 2017, 020.

287 Witness 45, 21 December 2017, 011.

2? Exhibit CZ.

including MCT activities.289 The tagging and boarding of the MV Olivia
Maersk was an MCT activitys' 6(a) 390

104' S. 

29? CTTAG was the precursor to 
Squadron. and the CTTAG training the precursor tos' 6(a) The Court
concludes that SGT Tayior was suitably qualified to participate in the
activity known ass' 6(a)

105. (U) The Court heard statements from multiple sources and viewed
evidence292 which corroborated the assertion that SGT Taylor was one of
the most experienced members of Squadron at MCT operations. Prior
to 5' 6(a) SGT Taylor conducted his most recent underway tag
during 5' 6(a) on 14 March 2017.293 The Court ?nds that SGT
Tayior was suitably experienced to participate in the activity known as 5' 6(8)

106. (U) The Squadron Physical Training instructor provided evidence
on SGT Taylor?s fitness294 and initial results on the Operator Performance
Programme The OPP is a monitored programme conducted by
the and deals with a wider range of fitness components than singie
service fitness tests. Components of the OPP include upper body
strength, muscular endurance, speed, lactic threshold amongst
others.296 The OPP tracks operator fitness levels rather than tests against
strict criteria.297 5' 

10'

PTI staff had no concerns
about his fitness with regards to the effective conduct of his duties within 
Squadron including climbing.300 The Court accepts this assessment.



 

2?39 Witness 35, 23 November 2017, (13.
29? Witness 1, 30 October 2017, (112; Witness 46, 25 January 2018, Q4.
29? Enciosure 3 to Exhibit BV.
292 Witness 35, 23 November 2017, Witness 1, 30 October 2017. 0110; Exhibit Enclosure 3 to Exhibit
BV, Witness 50, 04 May 2018, 046-47 and 51
293 Witness 5, 18 March 2018, Q4 and Exhibit DL (Orders for Ex SARACEN boarding of MV BERN HARD S).
29? Witness 39, 24 November 2017, (111-18.
295 Exhibit CH.
295 Witness 36, 23 November 2017, 05.
297 Ibid, Q7.
293 Witness 36, 23 November 2017, Witness 39, 24 November 2017, us.
299 Witness 39, 24 November 2017, C112.
30? lbid, Q17.


s. 6(a) 30? but that individual

experience will play a part in how such training should be conducted.302
The Court concludes that SGT Taylor had a suitable level of currency303
when compared with the requirements for similar hazardous in?ltration
activities but notes there is no standing currency requirement.304

109. (U) Having considered the evidence of others who conducted the
boarding operation of the MV Olivia Maersk during 5' 6(a) the
Court ?nds that the climb onto the MV Olivia Maersk should normally have
been within SGT Taylor?s ability: The Court ?nds no evidence of any
familial, emotional or mental wellbeing issues that might
have contributed to SGT Taylor?s death or that may have impaired his
performance in the conduct of his duties at that time??5

Squadron?s Training and Experience

110mm Court finds that the level of training conducted on 5' 6(a) to be
sufficiently robust to qualify individuals on the skills required to conduct
tagging operations undenrvay306 but noted there is no currency requirement
as with other infiltration skills such as fast-roping?O7

111. (U) The court found that those involved withs- 6(a) were of
varying levels of training and experience and some members of the team
had not had prior exposure to the level of difficulty anticipated (offshore at
night). For three of the team members, it was their first underway tag.?8
At the completion of the activity, one member had still to complete an
underway tag.309

112. (U) Tagging training is conducted as part ofs' 6(a) and consists of a
graduated approach moving from practicing on ships alongside before
moving to an underway tag.310 5' 6(a)

 

30? Witness 35, 23 November 2017, (110-11.

302 lbid, 0.12

303 See para 105.

30" Witness 2, Interview 2, Witness 35, 23 November 17, (118.

305 Witnesses 34, 23 November 2017, (24-5; Witness 37, 23 November 2017, 04-5; Witness 38, 23 November
2017, (13-5; Witness 39, 24 November 2017, Q18.

305 Witness 35, 23 November 2017, Witness 35, 14 December 2017, Q10-18.

307 Witness 35, 23 November 2017, Q19 and 22; Witness 2, 31 October 2017, QS.

30" Witness 7, 1 November 2017, Witness 23, 21 November 2017, 05-8; Witness 25, 21 November 2017,
020.

309 Witness 25, 21 November 2017, Q29.

31" Witness 42, 14 December 2017, Q19.

3? Witness 50, 4 May 2018, 39-41; Exhibit DV.

s. 6(a)

of the participants had completed theirs' 6(a) training in the
same calendar year as the accident (2017) and had done a considerable
amount of boarding usings? 6(a) ladders during theirs' 6(a) 3?5
Conversely, one team member had qualified many years prior but had little
current experience.316 

114. (U) The Court notes that those who had qualified more recently reported
?nding the boarding activity to be well within their capabilities even if
difficult.317

115. (U) 00 SOTC discussed the qualification and currency requirements in
general terms and acknowledged that it was up to Squadron to maintain
the level of training required to conduct activities such as 5' 6(a)
taking into account the individual levels of experience within the unit.318
He noted that for an activity of the nature conducted during 5' 6(a)

ideally a daylight underway tag would have been conducted
during the preparation.319

116. (U) OC SOTC commented on the culture of individuals monitoring their
own currency and competency. He felt personnel were equipped and
empowered to raise concerns within the unit if they felt an activity was
beyond them.320

117. (U) The CO 1 NZSAS Regiment acknowledged that there may be a
requirement for some individuals to conduct refresher training but that the
frequency of MCT Battle Handling Exercises (BHE) met that
requirement.321

118. (U) Due to there being no formal policy on training currency for
(underway) boarding operations via 3' 6(a) ladder, the Court recommends
that 1 NZSAS Regiment develop a formalised currency regime.

 

3?2 Ibid Q19-27.

3?3 Ibid (114-18.

3?4 Witness 35, 14 December 2017, C113.

3?5 Witness 14, 3 November 2017, 03?6; Witness 22, 21 November 2017, 04-7; Witness 24, 21 November
2017, (14-9; Witness 27, 21 November 2017, (214-10; Witness 41, 14 December 2017, 08-18.

3?6 Witness 26?s last underway tag was in 2014.

3?7 Witness 7, 1 November 2017, Witness 8, 1 November 2017, Witness 9, 1 November 2017,

3?8Witness 35, 23 November 2017, 018-22.
3?9 Witness 35, 14 December 2017, Q2.

32? Ibid 07-9.

32? Witness 46, 25 January 2018, Q18-20.

Duties or Activities of Personnel 24 Hours Prior to Accident

court ?nds that the tempo of activity for Squadron in the run up
to 5- 6(a) had been within its usual routine with a generai focus on
MCT training.322 The Court further finds that the team?s fatigue levels at
the commencement of the assault were within normal limits for MCT
operations and training.

activity had included assault trainings' 6?8)

which SGT Taylor had supervised;324
most operators had recently been involved in night training so were used
to the routine of overnight exercises.325 Routines for the Squadron during
the week commencing 9 October were based around Auckland with
training on the shooting ranges for the snipers326 and MCT training at
Devonport for other members of the assault groups??

121. (U) The accident occurred at 0611 on 13 October 2017.328 Activity in the
24 hours immediately prior can be divided into 3 phases; activity prior to
reporting for duty, preparation and briefing and transit to the target vessel.
Types of activity can be split between 3 distinct groups? 6(a)

embarked in the MV Olivia Maersk.

122. (U) Activity prior to reporting for duty. The Court ?nds that the tempo
within Squadron during the week of the 9 October ailowed personnel to
be fully rested ahead ofs' 6(a) on 12-13 October. Personnel
interviewed indicated that the tempo within Squadron meant that all
personnel had the opportunity for a full night?s rest before reporting for duty
on 12 October.?2 SGT Taylor had not been at work the previous day as
he was on leave 3' ?33 5' 6(a)

 

322 Witness 6, 1 November 2017, A5.

323 Witness 5, 31 October 2017, Q20.

32? Exhibit BV, Enclosure 3, 22-24; Witness 6, 1 November 2017, A5.
3?35 Witness 6, 1 November 2017, 016-17.

323 Witness 3, 31 October 2017, Witness 7, 1 November 2017, Q16.
32" Witness 1, 30 October 2017, 090-91.

328 See para 34.
s. 6(a)

33? 5. 6(a) and SGT Taylor.

331 s. 6(a)

332 Witness 20, 21 November 2017, (181-84; Witness 2, 30 October 2017, 085-89; Witness 1, 30 October 2017,
095?101; Witness 3, 31 October 2017, (19-12; Witness 7, 1 November 2017, 016-19.

333 Witness 5, 31 October 2017, Witness 1, 30 October 2017, 

33? Witness 5, 31 October 2017, Witness 3, 31 October 2017, Witness 1, 30 October 2017, 
Witness 2, 30 October 2017, (286-89.

s. 6(a)

 

335Witness 31 22 November 2017 Q3

335 Witness 6 1 November 2017 (114

337Witness 5, 31 October 2017, Witness 3, 31 October 2017, Witness 1, 30 October 2017, 
Witness 2, 30 October 2017, Q86-89.

338 Witness 5, 31 October 2017, Witness 1, 30 October 2017, 099.

339 Witness 31, 22 November 2017, Q3.

34? Witness 13, 31 October 2017, Witness 2, 30 October 2017, Witness 3, 31 October 2017, Q12.
3?1 Witness 6, 1 November 2017, 014.

3?2 Witness 31, 22 November 2017, Witness 5, 31 October 2017, Q23.

3?3 Witness 5, 31 October 2017, 023.

3?4 Witness 6, 31 October 2017, Q12.

345 Witness 5, 3 1 October 2017, Q23.

346 lbid, Q53.

3?7 Witness 3, 31 October 2017, Q15.

3?3 Witness 2, 30 October 2017, Q13.

349 Witness 3, 31 October 2017, 015.

35? Witness 1, 30 October 2017, 035; Witness 11, 1 November 2017, 024-34.

351 Witness 3, 31 October 2017, Q53.

352 Witness 5, 31 October 2017, Q54.

353lbid, Q55.

s. 6(a)

124. (U) Personnel had access to hydration and nutrition throughout the
preparation phase with 2 main meals scheduled at 1200 and 1800. Pay as
You Dine (PAYD) records indicate that SGT Taylor had lunch at 1214,356
dinner was provided at 1800 but as it was a duty meal there are no PAYD
records357. Once deployed from Papakura individuals were responsible for
their own nutrition and hydration. which is normal for any operation of short
duration358.

125. The Court ?nds that SGT Taylor had adequate opportunity to remain
properly fed and hydrated ahead of the accident and that, for a soldier of
his experience, lack of food or hydration is unlikely to have been a

signi?cant factor in the accident.
5. 

 

35" lbid, Q56.

355 Exhibit Al, 4.

35? Exhibit 

357 Witness 1, 4 May 2018, 2

358 Witness 1, 4 May 2018, 2-4

35" Exhibit CR 17?18, Tests conducted for a range of narcotics, antidepressants,
antihistamines, sedatives and drugs of abuse.

s. 

127. The Court ?nds that other than caffeine there were no drugs or alcohol

present in SGT Taylors system at the time of the accident.
5. 6(a)

35? Conditions
during the transit were described by 5- 6(alas manageable365 and bys' 
as nothing out of the ordinary366 allowing for
a transit for the majority of the passage.367 There was some
variation with rougher conditions experienced during the transit of the
. Colville Channel.368 A
129. (U) The remained in the waiting area until approximately 0500,369
during which time personnel were able to get some limited rest, although
conditions were such that an element of fatigue was inevitable.370 5- 6(a)
gave evidence that SGT Taylor remained awake throughout this period,
and 5? 6(a)gave evidence that SGT Taylor was in good spirits?. During
the transit, communications were maintained with the team on board MV
Olivia Maersk in order to monitor her progress from Tauranga.372 Some
minor re~planning was conducted during the wait due to the delayed arrival

of the target vessel and the desire to complete the activity before 0700.373
s. 6(a)

s. 6(a)

 

36? Witness 43, 14 December 2018, 05, (119-22
361 ibid 022
362 Witness 5, 31 October 2017, Q56.
353 Exhibit Al, 3; Witness 11, 2 November 2017, 037.
36? Exhibit Al, 4.
3?55 Witness 6, 1 November 2017, Q15.
36? Witness 19, 3 November 2017, 022; Witness 18, 3 November 2017, Q19.
357 Witness 5, 31 October 2017, Witness 13, 2 November 2017, Q59.
363Witness 18, 3 November 2017, (114-21.
369 Witness 5, 31 October 2017, Witness 1, 30 October 2017, Exhibit Al 4.
37? Witness 2, 30 October 2017, Witness 5, 31 October 2017, Witness 6, 1 November 2017,
Witness 22, 21 November 2017, Q1748.
37? Witness 16, 3 November 2017, 035: Witness 18, 3 November 2017, 027.
372 Witness 13, 31 October 2017, c150.
373Witness 5, 31 October 2017, Witness 1, 30 October 2017, Q50.
37? Witness 1, 30 October 2017, 0.51; Exhibit Al, 4.




5' 6(a) with the boats arriving in a position to commence the
assault at 0550.375
131. (U) During the final run in to the assault, the coxswain in RHIB was

receiving updates from SGT Taylor. He commented on SGT Taylor?s
elevated energy and enthusiasm for the task at hand.375

Planning and Risk Management

132. (U) The Court finds that the planners carried out appropriate risk
management steps for the activity in accordance with established
procedures.

133. (U) The Court further finds that whilst these procedures were sufficiently
robust, improvements can be made in the area of monitoring individual

levels of currency for underway tagging.
5. 6(a)

The plan was initially to have involved OTAGO in support??8 but,
due to the delayed departure of the target vessel and scheduling
constraints on OTAGO, this aspect of the exercise was cancelled.?9 The
Court ?nds this had no significant effect on the events surrounding the

accident.380
5. 6(a)

similar activity had been conducted in March 2017, 5- 5(a)
that had also focussed on MCT training.383 Command elements of 
Squadron and 1 NZSAS Regiment considered 5' to be a
follow?on activity?84 Although some personnel within the Squadron were
new, it was considered there were no significant increases in the drivers of
risk.385 CO 1 NZSAS Regiment was briefed on the activity during the

 

375 Witness 5, 31 October 2017, Q66.

375 Witness 13, 2 November 2017, 0132.

377 Witness 46, 25 january 2018, Witness 1, 30 October 2017, 012; Witness 5, 31 October 2017, 

Exhibit B, 15.

373 Witness 5, 31 October 2017, 09-11.

379 Witness 1, 30 October 2017, 021.

38?Witness 5, 31 October 2017, 040-41.

35? Witness 5, 31 October 2017, 012. .

3'32 Witness 1, 30 October 2017, Q1 and 2; Witness 5, 31 October 2017, 01 and 2. Planning Staff were 5- 6(a)
and SGT Taylor.

3?33 Witness 1, 30 October 2017, 012; Witness 46, 25 January 2018, Exhibit BV, Enclosure 10.

33? Witness 1, 30 October 2017, 012; Witness 46, 25 January 2018, Q7.

385 Witness 46, 25 January 2018, 07-8.

planning phase, provided guidance and was content with the
preparations.386

137. (U) Collective training to achieve OLOC for Counter Terrorism Response
is accepted by the Chief of Defence Force to be an operational activity
under section 7(5) of the Health and Safety at Work Act.387 The risk
appetite for this type of activity re?ects the fact that realistic field training in
the context of Special Forces is inherently dangerous but that it must not
come at the expense of safety and must be conducted under controlled
conditions?88

138. (U) The risk management policy within 1 NZSAS Regiment had been
subject to a continuous improvement review in order to develop tools that .
would improve risk assessment339 and, although the set of tools for MCT
had not been fully developed at the time of the accident,?0 guidance was
available from NZDF, Army and Unit policy.391 5' 5(a) utilised the risk
assessment matrix developed for the MCT Techniques Course392 as a
check list for hazard identification and mitigation strategies.393 This matrix
contains sections covering all aspects of the activities undertaken fors' 

396

The Court finds that the assessment of risk was a fundamental part of the
training planning process?7 and the procedures followed led to the
development of a comprehensive safety plan, of which the main output
was the safety brief.398

139. (U) The Court recommends that 1 NZSAS Regiment continue to develop
the tools available for risk assessment as a priority and bring them fully
into use as soon as practicable. A review of the hazards, hazard scores
and mitigation strategies associated with MCT should be conducted in light
of this report. As part of the planning process individually tailored matrices
should be generated each time activities of the scale of 5? 5(a)
are conducted.

140. (U) The planning process included contact with the target vessel MV
Olivia Maersk, initially via e-mail to establish the parameters of the

 

saslbid, 0.11.

39" Exhibit DH, Enclosure 2.

338 Exhibit 5, para 1.1.16.

39" Witness 46, 25 January 2017, Q9.

39? Witness 1, 30 October 2017, Q87.

391 Exhibit Exhibit Exhibit 5, para 1.1.17.
392 Exhibit DY

393 Witness 1, 4 May 2018, 011

394 Ibid 3-4

395 Ibid 6

398 lbidp6-7

39" Exhibit 5, para 1.1.16.

393 Witness 2, 30 October 2017, (112-15, see para 151.f.

exercise399 and then a face to face briefing and reconnoitre of the ship
immediately prior to the exercise.400 3- 6(a)

402 It also
covered the emergency procedures in the event of a casualty and no go
areas on the ship.?03

141. (U) Following the brie?ng, 5- accompanied the ship?s
Chief Engineer to reconnoitre the vessel in detail.? This included
examination of potential tagging points which included guardrails the use
of which raised no concerns at the time.?05 The operators forming the
enemy party who were to embark in the MV Olivia Maersk received a ship
safety brief and orientation tour on arrival on board.406

142. (U) The overarching safety plan for the exercise was developed bys- 6(a)
with input froms' 6(a) following the reconnaissance of the MV
Olivia Maersk.4?7 The plan was produced in accordance with guidance
from 1 NZSAS Regiment Standing Orderss' 

?08 Independent weather
planning was also conducted by and briefed to the RHIB crews and
command element.409 The Courtfinds that whilst there is no dedicated
meteorological support to Squadron, expertise within the unit is currently
suf?cient.410 

143. (U) The Court recommends that Squadron explore the formal provision
of meteorological support to ensure effective forecasting is available at all
times. .

144. (U) 1 NZSAS Regiment Standing Orderss' calls for a
medical plan approved by the Regimental Medical Officer (RMO) and
Officer Commanding the activity to be produced for all training.411 The
medical plan was generated by 5' 6(a) 3n return from the visit to MV Olivia
Maersk, and, although it was discussed withs? 6(a) [the medic assigned for
the exercise), it was not passed through the The plan as briefed

 

399 Exhibit Witness 45, 21 December 2017. 017.

?Witness 1, 30 October 2017, 021; Witness 2, 30 October 2017, C113.

40? Witness 1, 30 October 2017, 021; Witness 2, 30 October 2017, 013.

402 Witness 1, 30 October 2017, 021; Witness 2, 30 October 2017, 013; Witness 45, 21 December 2017, Q17.
?03 Witness 2, 30 October 2017, 013; Witness 1, 30 October 2017, 021; Witness 45, 21 December 2017, 017.
40? Witness 3, 31 October 2017, 013; Witness 45, 21 December 2017, 018.

Witness 1, 4 May 2018, 0 8-9.

?05 Witness 45, 21 December 2017, 019; Witness 29, 22 November 2017, 06-8.

?07 Witness 2, 30 October 2017, 015-18; Witness 1, October 30 2017, 022:

408 Witness 2, 30 October 2017, 015; Exhibit Exhibit 5, Ch 2; Exhibit U, Annex C.

409 Witness 1, 30 October 2017, 035; Witness 11, 2 November 2017, 08; Exhibit 5.

Witness 5, 31 October 2017, 030.

4" Exhibit 5, para 1.2.08.

412Witness 2, 14 December 2017, 08-13. -





contained the main elements required by standing orders.413 Contact
details of local medical facilities was not explicitly briefed?, however,
given the offshore location of the activity and that all evacuation plans
would be executed through emergency services.415 the Court does not
consider this to be a signi?cant shortcoming.

145. (U) The Court recommends that planning staff are reminded of the
necessity to pass medical plans through the RMO.

146. (U) During the brie?ng process, contingency pians were discussed in
detail including actions to be undertaken following RHIB malfunctions.415
man over board reactions?17 and casualty reactions??

147. (U) During the planning of training exercises, 1 NZSAS Regiment
Standing Orders 3' 6?8) requires that ?Training is to be
progressive to ensure that participants can build on previously learned
skills.?19 The Courtfound that the level of experience and currency in
underway offshore tagging varied widely amongst the participants420 with
some undertaking this activity for the ?rst time.421 There is currently no
mechanism for planning staff to monitor the experience and currency of
participants,422 and planning staff were unaware that some members of the
team had not previously conducted underway tags.423 There was a degree
of assumption that all personnel who had completed 5' 6(a) or equivalent
historic training would have completed sufficient training to conduct
underway tags.424

148. (U) The Court ?nds that despite the variation in experience of underway
tagging personnel were adequately prepared for the activity. However, the
lack of awareness of individual currency by planning staff meant
associated risks were not able to be identi?ed. This could have had a more
signi?cant impact had environmental conditions been more marginal or if
the activity had occurred during darkness as originally planned.

149. (U) The Court recommends that a process be developed by Squadron
to allow planning staff to monitor currency and shortfalls in experience for
personnel with regard to underway tagging.

 

4?3 Exhibit B, 32; Exhibit Exhibit 5, para 12.06-12.08.
Exhibit B, 32; Exhibit F.
MsWitness 5, 31 October 2017, 050.
4?5Witness S, 31 October 2017, (144.
?7 bid.
?8 lbid Q50.
4?9 Exhibit 5, para 1.2.03.f.
42?See paras 87-93 for discussion.
42? lbid.
?22 Witness 35, 14 December 2017, C119 and 22; Witness 2, 14 December 2017, Q5.
?23Witness l, 14 December 2017, 02; Witness 2, 12 December 2017, Witness 6, 1 November 2017, Q6.
424Witness 1, 14 December 2017, Q2.


Briefings

150. (U) The Court finds that the briefing process was in accordance with
standing orders and conducted comprehensively. Further, the Court finds
that the brie?ng of detailed contingency plans contributed to the rapid and
effective response by personnel when the accident occurred.

151. (U) As a no?notice exercise, brie?ng of personnel involved in the exercise
was conducted on 12 October once the operators had been activated by
pager to report for duty.425 Briefings fell into seven categories:

8. Initial Group Brie?ng. This was conducted bys' 6(a)
and was directed at all operators taking part in the assault, informing them
of the general nature of the task and equipment requirements."26

b. Formal Orders. Orders were issued verbally with PowerPoint slides427
between 5' 6(a) at a comprehensive briefing conducted bys' 6(a)
This brief covered all information required by operators to conduct group,
sub-team and personal planning.428 5? 6(a) the group
commanders, considered the brie?ngs thorough and well planned.?29

0. Group Orders. Group Commanders provided verbal briefs to thes- 6(a)

assault groups.430

d. Rehearsal of Concept Drill. This was conducted betweens'
and involved walking through the scheme of manoeuvre on a floor plan
showing key geographic features followed by stepping through each phase
of the activity and contingency plans. This included drills to follow in the
event of failed tags, man overboard action at different phases of the
scheme of manoeuvre and the relative movement of the various in
these situations.431

e. RHIB Brief. Following the Rehearsal of Concept Drill, back-briefed
5' 6(a) and SGT Taylor on the detailed planning.?2 Given
5- 5(a) position as acting commander of the Detachment} 6(a) wanted
to ensure planning was sound.433 Foilowing this back brief, the RHIB
detachment held its own detailed briefing.?4

6(a)

 

425Witness 5, 31 October 2017, Q23.

?25 lbid.

427 Exhibit B, 1-42.

423Witness 5, 31 October 2017, Q23-53.

?29 Witness 6, 31 October 2017, Witness 21, 21 November 2017, Q12.
43? Witness 5, 31 October 2017, 053.

43? Witness 1, 30 October 2017, 030-34; Witness 5, 31 October 2017, C153.
?32 Witness 11, 2 November 2017, Q23.

?33 Witness 1, 30 October 2017, Q35.

43? Witness 11, 2 November 2017, (124-34.



Safety Brief. 5' 6(a) :lelivered a final safety brief between 5? 6(a) ?35
this was in accordance with guidance in 1 NZSAS Regiment Standing
Orders 5' 6(a) ?35 The plan was briefed to all participants?37
and, whilst the weather portion of the brief does not appear on exhibit F,
that element had been incorporated into the formal orders by 3? and
was covered during the brief.?39 At the brief, it was confirmed with all
personnel that they were confident in their capability to conduct the
planned activity.?0

Briefing to Personnel in MV Olivia Maersk. The enemy party and safety
numbers in the MV Olivia Maersk were briefed on the overall plan on their
arrival in Tauranga prior to boarding the MV Olivia Maersk,441 they then
received a safety briefs once on board. from the ship?s Master and Chief
Of?cer covering actions in the event of an emergency in the ship;442 further
briefs an) the conduct of the exercise and safety were delivered bys- 5(a)
ands. a

SGT Taylor?s Equipment

Coun finds that SGT Taylor was wearing standard assault

a.



j.

sameness

equipment with some minor personai additions:444

Bump Helmet serial No 07616010;
s. 6(a)
Helmet mounted strobe light;
FRIS Suit?45
Boots;
Body Armours' 6(a)
Weapon Sling;
HK MP5 5- Machine Gun) Con?gured for 
Pistol belt and holster;
Glock SIMFIRE Pistol;

k. s. MP5 Magazine with SIMFIRE ammunition;
is Magazine with 5- 6(a) SIMFIRE ammunition;

 

?35 Witness 1, 30 October 2017, Witness 5, 31 October 2017, Q53.

435 Exhibit 5, Ch 2 Annex 8; Exhibit F.

?37 Witness 5, 31 October 2017, Q29.

4? Witness 5, 31 October 2017, (129-35; Exhibit B, 5-6.

439 Witness 1, 30 October 2017, 036.

44? Witness 2, 14 December 2017, Q4.

4? Witness 30, 22 November 2017, Q4.

?2 Witness 30, 22 November 2017, Witness 31, 22 November 2017, 04; Witness 45, 21 December 2017,

C119.

443 Witness 30, 22 November 2017, Witness 29, 22 November 2017, Q3.
4-14 Exhibit Q, 45-67, 87 and 97-109; Exhibit Ci, 1.
?5Witness 1, 30 October 2017, Q68.

m. Knife Marine Flare;

5 Cyalume chemical lights?;

0. ISP Mk 3 363N Special Forces Life Jacket Serial No 1482018;
. Webbing; 

. 5? 6(a) Radio headset;


Strike Face Mask;

s. 56(3) and


1

.3

'0

Watch.
53. (U) Fig 10 is representative of the con?guration SGT Taylor was wearing.

5' 6(a) checked SGT Taylor?s equipment configuration immediately ahead of
the exercise; there were no anomalies noted.447
154. (U) The Court finds that SGT Taylor?s equipment was configured in a
standard fashion that was well~estab ished and trusted by the operators;448
all the assault equipment he was using had been introduced into
service.449

 

?6 Four were in his webbing. One was in the sleeve of FRIS suit.

?7 Witness 5, 31 October 2017, Witness 2, 30 October 2017, Q91.
?Witness 6, 31 October 2017, 097-98.

449 Witness 1, 30 October 2017, 0112.

 .

 

 

(R) ig 10 Representative Con?guration of Equipment worn by SGT Taylor?50

 

45? Exhibit Q, 84.

Additional Equipment

155. (U) The Court ?nds on the balance of probabilities that the ladder and
ancillary equipment used in the climb were in date in terms of their testing
requirements and that specifications are appropriate for use in undenNay
tagging operations. However, test certificates for ladders rate them at
5- 6(a) and given that they are routinely used with 5' 6(a)

on the ladder the Court finds that the total dynamic load on the
ladders during tagging operations is likely to exceed this vaiue. Further
there is no documentation to support the rating for thes' 6?8)
used in conjunction with the ladders.

156. (U) The Court recommends that 1 NZSAS Regiment ensure alls- 5(a)
ladders are recertified and that specifications of associated ancillary
equipment is con?rmed to account for the actual loads to which they are
likely to be subjected. Further, until this occurs The Court recommends
the use of the ladders and ancillary equipment for underway tagging be
limited to activities directly linked to the generation and maintenance of

OLOC.
s. 6(a)

158. (U) Whilst test certi?cation only indicates a rating of 5- 6(a) ?53
manufactures speci?cations for the ladders rate the breaking load of the
5' 6(a) and failure of the rungs as greater thans- 5(a) 45?
The Court ?nds that the specification of the ladders is appropriate for their
use in underway tagging operations, however. they are not currently
certified to this level. .

159. (U) The weight of personnel using the ladder will be highly variable,
however, a DTA report examining suitability of life jackets455 used a
sample of 3 personnel from Squadron with an average weight of 85.2kg
with a standard deviation of 7.3kg and equipment weighing 28.5kg with a
standard deviation of 0.6kg455. This gives an indicative total weight of
113.7kg with a standard deviation of 7.9kg. A second DTA report457

 

?51 Exhibit 27-28

?52 Exhibit DR

?53 Exhibit p26-27, Exhibit DR
?54 Exhibit DT

?55 Exhibit DC para 7-9

?56 ibid

?57 Exhibit DX

comparing the SFLJ in water performance with that of the First Spear
Aegir 59 integrated body armour and PFD used a sample size of 8
personnel with a mean fully equipped weight of 120.8 with the heaviest
individual weighing 140.5kgs458. Using these ?gures the Court finds that
5' 6(a) Further the
Court ?nds that noting the acceleration personnel will be subjected to in
underway tagging operations, due to heave and roll of the target ship, it is
also possible that a single climber on the ladder may exceed thes- 6(a)
rating when dynamic loading is taken into account.

160. Ancillary load bearing equipment connected to the ladder for tagging
operations consists ofs' 6(a)

46?. 6(a) although recommended by

the ladder manufacturer do not currently have documentation available
within the specialist store at Papakura Camp that details their load
rating.461 These ancillary items have no life of type"'62 and fall under the
inspection regime for mountaineering equipment detailed in NZ P97
846501463, this equipment is visually inspected prior to issue from the
specialist store and prior to use by the operators.?64

161. (U) There was an accounting discrepancy with respect to the 
ladders in use. 5 6(8) ladders are registered and these had been
inspected by Cookes in two batches, December 2016 and February
2017.455 Invoices for both inspections were available,?6 but only 1
inspection certificate for as- 5(a) ladder from the February batch was
available for inspection.?67

162. (U) The ladder used in5- 6?3) was from the February batch.468
Further, the ladder used in the climb had had the metal serial number tag
removed. making a direct comparison with any records impossible.?69

163. (U) The Court recommends that all safety equipment requiring testing is
labelled suf?ciently to ensure accurate comparison with test certification.

 

?58 Exhibit DX

?59 Exhibit DU

46? Witness 40, 4 May 2018, Q27-29

45? Witness 50, 4 May 2018, 05: Witness 40, 4 May 2018, Q24
?32 Exhibit DZ Section 1 Ch 1 para 8

?53 Witness 40, 4 May 2018, 0.1925; Exhibit DZ Section 2 Ch 2
Witness 40, 4 May 2018, 31; Exhibit 02

?65 Witness 40, 24 November 2017, 014; Exhibit 24-28.
456 Exhibit 28.

457 Exhibit Cl p26-27; Exhibit DR, Witness 40, 24 November 2017, 014
?ssibid, Q19.

?sgibid, Q22.

Role of the Equipment in the Accident

164. (U) The Court finds that the main causal factor in SGT Taylor?s fall was
the hazard present due to the use of a 5- 6(a) ladder. The Court accepts
that this technique represents best practice; it has been in use for some
time, is widely used by other defence and security forces worldwide?0 and
allows for effective tagging.

165. (U) Whilst the hazards are known and mitigated by training, the Court
recommends that Force Development Wing and Squadron maintain
contact with partner organisations utilising this technique in order to remain
abreast of innovations that may further mitigate these hazards.

166. (U) The Court considered the evidence on the use of guardrails as an
attachment point during tagging operations. 5' 6(3)

167. (U) The Court finds that the failure of the guardrail during 5- 6(a)
was not a direct causal factor in the accident but that it may have
contributed to the difficulty of the? climb after it failed. The Court does
however identify the use of the guardrail for tagging as a safety issue as
the consequences of its faiiure could have been more severe. The use of
guardrails for tagging introduces an additional hazard of their failure under
the weight of climbers. The Court recommends that Squadron highlight
the risk of failure associated with the use of guardrails for tagging within
the overall risk assessment of the activity but accepts that for operational

reasons their use is often necessary.
3. 6(a)

 

Witness 50, 4 May 2018, 035-38

?71 Exhibit DV

?72 Witness 1 4 May 2018 10

?73 Witness 42 14 December 2017 

47? Witness 6, 1 November 2017, Exhibit Q. 5) 39 Photo 54.

s. 6(a)

475 The Court ?nds that these minor modifications
had no bearing on the occurrence or outcome of the accident.

169. (U) A number of witnesses identified the snagging hazards that are
present due to the nature of equipment worn and carried by assaulters.?76
These hazards which include the increased standoff from the ladder are
well understood and the interaction between the ladders used and
equipment is fully appreciated by assaulters.477 The increased standoff
from the ladder is in part a result of the bulk of the SFLJ and the effect is to
increase loading on the arms478, climbing techniques are utilised that
mitigate the impact as much as possible?? The Court finds that these
snagging hazards are suf?ciently mitigated by training and procedures.
The Court notes the anecdotal evidence of reduced snagging hazards that
the trial of the First Spear Armour System 48:?has identi?ed. The Court
recommends that Force Development Wing and Squadron expedites the
completion of the trial to identify if this equipment is a potential alternative .
to the SFLJ.

Court examined evidence of systems to mitigate against fatigue
when climbing during tagging operations. 5' 6(a)

However, for shorter climbs such as the one to the MV
Olivia Maersk, it is not generally used unless climbers lacked confidence
or experience?? SGT Taylor had used this system previously in his
career.483 Witness 50, who had seen SGT Taylor climb many times,484 felt
it was unlikely that SGT Taylor would have considered using this
arrangement on 13 October?? This technique was not specifically
considered as a mitigation strategy during the planning of the operation.486
The equipment to allow this technique to be used had not been formaily
introduced into service at the time of the accident but was raised with

 

475 Witness 40, 4 May 2018, 31-33
?76 Witness 6, 1 November 2017, (1198-99; Witness 50 4 May 2018, C153
477 Witness 6, 1 November 2017, 098-99; Witness 50, 4 May 2018, 26 &53
47" Witness 40, 4 May 2018, 026
479 ibid
48? Witness 6, 1 November 2017, 039-102; Witness 50, 4 May 2018, (129-30 
481 Witness 50, 4 May 2018, 14-19
482 lbid 022?23
483 Witness 50, 4 May 2018 C115 and 22
48? Ibid 0.44-45
?85 Ibid Q22
?83 Witness 2, 31 October 2017, C192.


Force Development Wing in May 2018.487 The Court recommends that 1
NZSAS Regiment and Force Development Wing introduces? 6(a)
or similar system into service and add it to the risk matrix

for activities using a 5' 6(a) ladder as a potential treatment to the hazard of
falls.
171. 6(a) worn by SGT Taylor488 is issued to divers

but not all members of Squadron.489 Whilst not a standard part of the
equipment, it was not unusual that it was worn and would not have had an
impact on the accident.490

Safety Equipment

172. (U) The Court finds that all safety equipment used by personnel during
this activity functioned as expected.

173. (U) Safety equipment used by personnel was drawn from 1 NZSAS
Regiment specialist stores at Papakura Military Camp.491 An inspection of
certification for safety equipment confirmed that all lifejackets in use on the
day were in date for SGT Taylor signed out SFLJ
1300470;493 however, he in fact wore SFLJ 1482018,494 which had been
signed out from the stores as part of thes' 6(3) 95

Further Safety Equipment Comments

174. (U) The Court finds that:

a. The Special Forces Lifejacket remains fit for purpose in the Maritime
Counter Terrorism role; and

b. Whilst there remain risks associated with its use, these are within an
acceptable limit given the overall nature of the task.

175. (U) Two types of life jacket are available for use during MCT activities:

c. The standard modeljs the international Safety Products Mk 3 363N
Special Forces Life Jacket 

d. The second type is the First Spear Armour System, which integrates a
personal ?otation device (PFD) with combat body armour??

 

4?37 Witness 50, 4 May 2018, 20

Para 152.5.

??Witness 1, 30 October 2017, Q68.

49? Ibid.

?91 Witness 40, 24 November 2017, 04-5.

?92 Exhibit CJ.

?93 ibid 3.

?94 Witness 40, 24 November 2017, 04-8.

?95 Exhibit O, 6; Witness 40, 24 November 2017, Q4.

?96 Exhibit DK.

?97 Witness 1, 30 October 2017, Q113 and Witness 6, 31 October 2017, (1100-101.


176. (U) The First Spear Armour System whilst not yet introduced into service
is approved by SOTC for use by MCT swimmers and RHIB detachment
personnel during MCT activities and training.498 The First Spear system
has the advantage of being less cumbersome and allowing better
movement whilst climbing.499 Both of these systems require manual
activation of the 

report was produced by the Defence Technology Agency (DTA) in
2014 to provide a rapid assessment of the SFLJ.501 This test was
conducted on three individuals in a number of equipment configurations,
one of which bore a close similarity to that worn by SGT Taylor on 13
October 2017'.502 Whilst acknowledging that the sample size of personnel
used in the test was below the recommended number503 and that the
freeboard5?4 measured in some circumstances did not meet with the
international standard being used,?5 the report concluded, "Taken as a
whole, the results provide indicative evidence that the ISP 363N SF (MK3)
PFD remains ?t for its current purpose (Le. Marine Counter Terrorism and
Strategic Reconnaissance Small Boat operations where the Userwili be
recovered 

178. (U) Two expert witnesses were consulted about the report and the
continued ?tness of the SFLJ for use in light of the accident on 13 October
2017. Witness 47 is a naval officer who was heavily involved in the
development of the Operational Personal Flotation Device
and Witness 48 is a DTA scientist who has been involved in the
testing and evaluation of 

179. (U) Witness 47, was concerned that the compromises that had to be
made when wearing the SFLJ in terms of its overall impact on operators'
ability to carry out their roles called its suitability into question.509 In
particular, he raised concerns about the lack of an automatic activation
system which would result in the life jacket not being effective for an
unconscious person.510 He suggested that consideration shouid be given

 

49? Exhibit BW.

?'99 Witness 6, 31 October 2017, C1102.

50? Witness 1, 30 October 2017, Q67.

50? Exhibit DC.

502 Witness 48, 15 February 2018, Q10.

503 Exhibit DC, para 32.

Freeboard is the clearance between the mouth and the water when the PFD is inflated.
505 Exhibit DC, para 26; Witness 48, 15 February 2018, Q11.
5?5 Exhibit DC, para 24.

507 Witness 47, 15 February 2018, 02-4.

508 Witness 48, 15 February 2018, 02-6.

509 Witness 47, 15 February 2018, C110.

51olbid, Q11.

to developing an automatic activation system511 and gave an example of
one such system currently available.512 He acknowledged that there would
be times during operations that automatically activated in?ation would not
be desirable.513

180. (U) Witness 48 who had been involved in the production of the DTA
report into the SFLJ supported the conclusion that it remained fit for
purpose within the limitations detailed in the report.514 Whilst he
acknowledged some compromises had to be made when wearing the
SFLJ in order to allow users suf?cient freedom of motion to conduct their
roles,515 he maintained that there was sufficient buoyancy within the
system to compensate for this.516 He explained that, in some
circumstances. the use of automatic activation of the SFLJ was not
appropriate in an SF environment.517

181. (U) Both Witness 47 and 48 acknowledged that the SFLJ is a robust and
effective system with a large provision of buoyancy capabie of supporting
fully equipped personnel when inflated.518

182. (U) Whilst the provision of an automatically activated PFD may have
altered the outcome of this accident, the Court accepts that for tactical
reasons in an operational environment it is unlikely that the use of such a
mechanism could be sanctioned. Given that the activity on 12-13 October
was a test of OLOC, it was reasonable for personnel to be configured as
fully as possible for a live operation.

183. (U) The Court recommends that, for training involving underway tagging
where a degree of compromise of operationai realism can be accepted, in
order to enhance safety. the use of an automatically activated PFD should
be Considered. As such, Force Development Wing should undertake an
investigation into the viability for the provision of such a suitable system.

184. (U) The Court further recommends that any decision to utilise
automatically activated PFDs should be taken in light of all identifiable
hazards associated with the activity and of the second and third order
effects of their use.

 

51"lbid, (114.

512Witness 47, 15 February 2018; Exhibit DE.

513 Witness 47, 15 February 2018, Q20.

5? Witness 48, 15 February 2018, 0.15.

515lbid, (113-14.

5?5 lbid, C114.

5?7 lbid, 016.

518Witness 15 February 2018, 0.10; Witness 48, 15 February 2018, Q12.

Post-Accident Examination of Equipment

185. (U) After the accident, the SWIFIRE attachments to SGT Taylor's HKMP5
was noted to have been damaged and an armourer?s inspection
conducted.519 The damage was found to be consistent with impact to hard
surface following a fall from 6-8m.520

186. (U) Life Jackets that required servicing following the exercise were
inspected by 5? 6(a) One of these failed the inspection
due to a damaged bladder.521 This life jacket had previously passed
inspection on 2 May 2017.522 The Court found no evidence as to when the
damage occurred and concludes this life jacket had no effect on the
outcome of the accident.

5. 6(a)

 

519 Witness 33, 22 November 2017, 06-7; Exhibit BR, para 5.
52? Witness 33, 22 November 2017, Q8-9.

52? Exhibit 19.

522 Exhibit 13.

523 See para 47-48.

52? Witness 12, 2 November 2017, 058?69.

525 Exhibit CK.

Similar Historical Accidents

190. (U) The Court found no evidence of similar accidents within the Army

Safety Reporting System (SRS) between January 2008 and May 2018.526

191. Witness 50 who had been with Squadron between May 2010 and

December 2017 before moving to SOTC as an instructor527 described
instances of being snagged and of one occurrence where he almost fell
from a ladder but was arrested by the use ofs' 6(a)

arrangement described earlier in the report523. He further reported that
there were instances of minor falls particularly during trainings29 but that he
was not aware of any falls similar to SGT Taylor?s during his time with 
Squadron although there may have been prior to his arrival in 2010530.

192. Witness 51 an NZDF analyst for the Directorate of Safety531 executed a

search of the SRS database that was refined for 1NZSAS Regiment and
focussed on key word searches associated with accidents involving 5- 6(a)
ladders or tagging operations.532 The results did not reveal any simiiar
accidents or incidents involving underway tagging operations or the use of
5' 6(a) ladders.?3

Recommendations and Impact on Operations

193. (U) The Court makes the following key recommendations:

3.

1 NZSAS Regiment must ensure all 5- 6(a) adders are recertified and that
speci?cations of associated ancillary equipment is confirmed to account for
the actual loads to which they are likely to be subjected.

Further until this occurs the use of the ladders and ancillary equipment for
undenNay tagging should be limited to activities directly linked to the
generation and maintenance of OLOC

Force Development Wing should undertake an investigation into the
viability for the provision of an automatically activated PFD for use in
underway tagging training where a degree of compromise of operational
realism can be accepted.

 

526 Witness 51, 15 May 2018, Q4-8 8: (114-15; Exhibit EA
527 Witness 50, 4 May 2018, 02

528 Ibid 012

525? lbid 012-13

53? lbid C113

53? Witness 51, 15 May 2018, 02
532 Witness 51J 15 May 2018, 4-7; Exhibit EA
533 Witness s1, 15 May 2018, {14-8 (214-15; Exhibit EA

d. Further. any decision to utilise automatically activated PFDs should be
taken in light of all identi?able hazards associated with the activity and of
the second and third order effects of their use.

e. Force Development Wing and Squadron should expedite the completion
of the trial of the First Spear Armour System as a potential alternative to
the SFLJ.

f. CO 1 NZSAS Regiment should provide guidance on expected currency for
personnel conducting underway tagging operations within 1 NZSAS
Regiment Standing Orders 5' 6(a)

g. Squadron should develop a process to allow planning staff to monitor
currency and shortfalis in experience for personnel with regard to
underway tagging. 

h. 1 NZSAS Regiment and Force DevelopmentWing should introduce the

use of? 6(a) or similar system for taking a climbers weight
into service.
i. Squadron should add the use of? 6(3) or similar system for

taking a climbers weight to the risk matrix for underway tagging as a
potential treatment to the hazard of fatigue leading to falls.

194. (U) The following other recommendations are made:

a. Squadron should highlight the risk of failure associated with the use of
guardrails for tagging within the overall risk assessment of the activity
given that for operational reasons their use is often necessary.

b. Force Development Wing and Squadron should maintain contact with
partner organisations utilising similar tagging techniques in order to remain
abreast of innovations that may further mitigate associated hazards.

c. Squadron should explore the formal provision of meteorological support

to ensure effective maritime forecasting is available at all times.
d.s' 6(a)

e.

f. 1 NZSAS Regiment should prioritise the development and publishing of
tools to support hazard identification and risk assessment of SOF
activities.

9. Squadron should review hazards, hazard scores and mitigation
strategies fortagging operations in light of this report.

h. Individually tailored risk matrices should be generated for training activities
of the scale ofs? as part of the planning process.

i. Squadron personnel should be reminded ofthe importance of raising
minor incidents within the safety reporting system.

j. All planning staff within 1 NZSAS Regiment should be reminded of the
necessity to pass medical plans through the RMO.

k. Specialist store staff should ensure all safety equipment requiring testing is
labelled sufficiently to ensure accurate comparison with test certification.

3. s. 
s. s. 
RNZN
Member Court of Inquiry President Court of inquiry
Date 21/57/3? Date 2/