Recurring concern

Failure to maintain current tank-status information for live firing exercises

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First reported 18 Jul 2018•Latest report 18 Jul 2018

Definition

What this concern includes

Includes failures of the live-firing-exercise process that leave the responsible person without accurate, up-to-date tank-status information needed to allocate tanks and make safe exercise decisions.

Not included

  • Excludes generic communication, information-management, staffing or training deficiencies that are not specifically tied to maintaining or providing tank-status information for live firing exercises.
  • Excludes failures concerning other range hazards, equipment conditions or exercise controls unless they directly concern the currency or availability of tank-status information.
  • Excludes the particular wrong tank allocation as an outcome or manifestation rather than the underlying information-control failure.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2018–2018

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

BAE Systems plc2
Ministry of Defence2

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Birmingham and Solihull

    AI-generated summary

    Matthew Karl Hatfield and Darren Paul Neilson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Matthew Karl Hatfield and Darren Paul Neilson died after a Challenger 2 tank fired while its BVA assembly was absent, causing a breech explosion, intense fire and blast-related injuries. The principal concerns included unclear use and meaning of the Prove The Gun drill, inadequate communication about the condition of tanks and the absence of written procedures for checking, removing and storing the BVA assembly. The report also identified insufficient consideration of the hazard during the gun’s design and manufacture, inadequate communication about the opportunistic experience shoot, and routinely unstowed charges that caused a secondary explosion.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to maintain up-to-date knowledge of tank status on the range

    Wider context from the report

    “2. One of the contributing factors to this tragedy was that the RCO, the person in charge of the live firing exercise, did not know the state of the tanks on the range and therefore allocated a stripped down tank for a live firing exercise. I remain concerned that it is vital that the person in charge of such exercises has up to date knowledge about the status of the tanks on the range. The MOD should look at what communication can be put in place to ensure the RCO is in fact in charge and has all the correct information to make decisions during the exercise. ”

    Source location

    Matthew Karl Hatfield and Darren Paul Neilson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Requiring the RCO to keep contemporaneous tank-status records or maintain a centrally managed system would be impractical and distract from range safety duties.

    Verbatim wording from the response

    “It is essential that the RCO is focused on delivering a safe live firing exercise. Any requirements for the RCO to keep contemporaneous records on the state of the tanks would detract from his focus on the safety of the range as a whole.”

    Source location

    2018-0231-Response-by-Ministry-of-Defence
    Page 5 · response
    Published 23 September 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Crew responsibility, training, revised drills and repeated component checks make the risk of firing without safety-critical components acceptably low.

    Verbatim wording from the response

    “The Army judges that any potential risk presented by the RCO not being aware of the state of tanks on the range is ALARP. As indicated above the revised drills and procedures ensure that there is no scenario in which a crew could proceed to fire the main gun without first having completed the ‘prove the gun’ drill which mandates a specific check for the presence of the BVA, obturator and shim (Paragraph 6.19). Even if the ‘prove the gun’ drill was not adequately completed the presence of the BVA, obturator and shim would be checked again upon ‘going to action’ and if necessary again upon receiving a ‘TVEDU – Red Indication or No Display’ (an inevitable consequence if the BVA is missing).”

    Source location

    2018-0231-Response-by-Ministry-of-Defence
    Page 6 · response
    Published 23 September 2018

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Matthew Karl Hatfield and Darren Paul Neilson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Cpls Matthew Karl Hatfield and Darren Paul Neilson died after a Challenger 2 tank fired while its BVA assembly was absent, causing hot pressurised gases to enter the turret, the breech block to explode and a subsequent fire. The substantive concerns included unclear use and meaning of the Prove The Gun drill, inadequate information about tank status available to the Range Conducting Officer, and insufficient risk assessment of the gun’s ability to fire without the BVA assembly.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the person in charge of live firing exercises to maintain up-to-date knowledge of tank status on the range

    Wider context from the report

    “2. One of the contributing factors to this tragedy was that the RCO, the person in charge of the live firing exercise, did not know the state of the tanks on the range and therefore allocated a stripped down tank for a live firing exercise. I remain concerned that it is vital that the person in charge of such exercises has up to date knowledge about the status of the tanks on the range. The MOD should look at what communication can be put in place to ensure the RCO is in fact in charge and has all the correct information to make decisions during the exercise. ”

    Source location

    Matthew Karl Hatfield and Darren Paul Neilson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Requiring the RCO to keep contemporaneous tank-status records or maintain a centrally managed system would be impractical and distract from range safety duties.

    Verbatim wording from the response

    “It is essential that the RCO is focused on delivering a safe live firing exercise. Any requirements for the RCO to keep contemporaneous records on the state of the tanks would detract from his focus on the safety of the range as a whole.”

    Source location

    2018-0231-Response-by-Ministry-of-Defence
    Page 5 · response
    Published 23 September 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Crew responsibility, training, revised drills and repeated component checks make the risk of firing without safety-critical components acceptably low.

    Verbatim wording from the response

    “The Army judges that any potential risk presented by the RCO not being aware of the state of tanks on the range is ALARP. As indicated above the revised drills and procedures ensure that there is no scenario in which a crew could proceed to fire the main gun without first having completed the ‘prove the gun’ drill which mandates a specific check for the presence of the BVA, obturator and shim (Paragraph 6.19). Even if the ‘prove the gun’ drill was not adequately completed the presence of the BVA, obturator and shim would be checked again upon ‘going to action’ and if necessary again upon receiving a ‘TVEDU – Red Indication or No Display’ (an inevitable consequence if the BVA is missing).”

    Source location

    2018-0231-Response-by-Ministry-of-Defence
    Page 6 · response
    Published 23 September 2018

    Open published response
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Data last updated 7 September 2026