The Dutch Safety Board published its report ‘Mortar accident Mali’, on 28 September 2017. The investigation involved a fatal accident during a mortar firing exercise, that took place on 6 July 2016, in Mali. Two Dutch military personnel lost their lives and a third was seriously injured.

On 13 January 2022, the Dutch Safety Board reopened the investigation in response to claims that a follow-up investigation conducted by the Royal Netherlands Marechaussee (KMar) had revealed new facts. In its investigation, the KMar stated that the possibility could not be excluded that the investigated mortar round fragments had become mixed up with other mortar round fragments. This KMar investigation was not known to the Safety Board, until October 2021. After the Safety Board had been informed of the KMar investigation, it reopened its own accident investigation to examine the possible new facts.

Conclusions and recommendations from the 2017 report reconfirmed

The reopened investigation by the Dutch Safety Board did not reveal any new facts. The investigation did however provide additional information, confirming the previous conclusions. The Safety Board was able to confirm its findings about the gathering up of the mortar round fragments following the fatal accident. The investigated mortar round fragments had not been mixed up with other mortar round fragments. The fragments from the mortar round in the accident were gathered up and removed immediately following the accident. Other rounds were destroyed at a later date. These facts were confirmed by witnesses from the French unit present in Mali at the time.

Investigation publication

Investigation reconfirms conclusions of Dutch Safety Board report on the Mali mortar accident

The Dutch Safety Board has today published its findings from the reopened investigation into the Mortar Accident in Mali, in 2016. The Safety Board confirms that no new facts have emerged which could lead to a reconsideration of the conclusions from the previous investigation. The Dutch Safety Board reopened its own 2016 investigation following suggestions that a follow-up investigation by the Royal Netherlands Marechaussee (KMar) had revealed new facts. It was alleged that these new facts raised questions about the course of events of the accident, as determined by the Dutch Safety Board. Jeroen Dijsselbloem, Chairman of the Dutch Safety Board, commented, “It is our duty to the next of kin and society as a whole to re-examine the facts, in the face of doubt. It is vital for the Safety Board that our reports are beyond all doubt. However, the reopened investigation did in fact provide further confirmation of our previous conclusions.”

Doubts about the origin of the mortar round fragments

After next of kin submitted a complaint against the Ministry of Defence to the Public Prosecution Service (OM) in April 2018, the OM commissioned the Royal Netherlands Marechaussee (KMar) to conduct a further investigation. In this follow-up investigation, the KMar stated that the possibility could not be excluded that the investigated mortar round fragments had become mixed up with other mortar round fragments. This KMar investigation was not known to the Safety Board, until October 2021. After the Safety Board had been informed of the KMar investigation, it reopened its own accident investigation to examine the possible new facts.

Conclusions and recommendations from the 2017 report reconfirmed

The reopened investigation by the Dutch Safety Board did not reveal any new facts. The investigation did however provide additional information, confirming the previous conclusions. The Safety Board was able to confirm its findings about the gathering up of the mortar round fragments following the fatal accident. The investigated mortar round fragments had not been mixed up with other mortar round fragments. The fragments from the mortar round in the accident were gathered up and removed immediately following the accident. Other rounds were destroyed at a later date. These facts were confirmed by witnesses from the French unit present in Mali at the time.

In its first report, the Dutch Safety Board stated that the mortar round fragments showed that the detonator mechanism of the mortar round was unstable. As a result of moisture and heat, oxidation had taken place inside the mortar round. This in turn led to the formation of copper azide crystals in the detonator mechanism. Copper azide is a shock-sensitive, explosive substance, which caused the early detonation of the mortar round. This scenario was also confirmed by an ammunition expert, employed by the Defence Equipment and Support Division of the British Ministry of Defence, who prepared an independent report on behalf of the Dutch Public Prosecution Service.

Attention for ammunition management

The first investigation by the Dutch Safety Board revealed that the procedures for the procurement, management and use of ammunition within the Defence organization did not comply with the organization’s own guidelines. Following the fatal accident in Mali, the remaining around 10,000 rounds were removed from service and are still awaiting dismantling. To this day, it is important that the safety and health of the Defence employees involved in the dismantling process be safeguarded. In the light of the history of this fatal accident, it is recommended that the Minister of Defence periodically informs the Dutch House of Representatives about the progress of the dismantling process and the quality improvements in ammunition management procedures.

Recommendations

The Dutch Safety Board has found in 2017 serious shortcomings in the concern for the safety of Dutch military personnel during the mission in Mali, both with regard to management of the ammunition and to military healthcare. Previous investigations conducted by the Board have brought similar patterns to light. Therefore the Board is concerned about the Defence organisation’s virtually indiscernible motivation to learn from events.

A culture of safety and safety awareness form important pillars for a safe defence organisation, in the Netherlands and beyond. The Minister of Defence is ultimately responsible for this matter.

The Board issues the following recommendations to the Minister of Defence.

1. Ensure risk management is suitable for the current and future deployment of Dutch armed forces. Implement the changes necessary to form an organisation that actively learns.

  1. Invest in an organisational structure and culture in which management is receptive to critical signals from staff. Provide operational management that converts reports of safety shortcomings into improvements. Encourage free communication about safety risks to create broad safety awareness within the defence organisation. 
  2. Use incidents and accidents to learn lessons. Provide the capacity to evaluate incidents and accidents in an objective and independent manner, selecting and implementing points for improvement.

2. Prior to taking a final decision about participating in an international military mission, as well as when changes to missions occur, clarify whether, and in which way, the safety and health of the military personnel to be deployed will be safeguarded. Make this safeguard a prerequisite. Fulfil the role of ultimate responsibility for the safety and health of Dutch military personnel during international missions by, for example:

  1. drafting clear, verifiable criteria for the safety and medical care of Dutch military personnel during international missions;
  2. fully assessing the consequences for the safety of Dutch military personnel and the medical care available when taking crucial decisions about changes to international missions;
  3. actively monitoring safety aspects during missions, not from a distance, but in the deployment zone;
  4. increasing the effectiveness of current checks and balances related to the safety of Dutch military personnel by, for example, investing in substantive knowledge and the independent positions of inspectors and investigation commissions.

3. Improve care for weapons and ammunition so that they are suitable for use in the conditions that may occur during missions. In particular, ensure that:

  1. the mortar rounds currently in stock are checked to establish whether all safety procedures were followed correctly and - if this was not the case - carry them out;
  2. the established shortcomings in the organisation and regulations within the ammunition chain are eradicated;
  3. the storage, transport and use of ammunition is carefully documented, so that in the event of any seemingly unsafe performance all the ammunition concerned is traceable;
  4. the procurement process for weapons and ammunition is carefully documented and archived, so that it is possible to reconstruct how decisions were taken;
  5. the remaining stock of 60 mm HE80 rounds is no longer used;
  6. other countries that use these rounds are informed about the findings of this investigation.

4. Improve the acute medical care available during international military missions by:

  1. further defining the quality of medical care that must be available for Dutch contributions to UN missions and developing criteria for assessing this quality. When doing so, do not accept any dependence on medical care provided by UN Member States that is not able to meet with Dutch military standards;
  2. establishing the availability of the required care potential as a precondition before allowing a mission to begin;
  3. being aware of the consequences to medical care when relocating/extending missions;
  4. improving the care-related assessment of role 2/3 treatment facilities through standardisation and using specialist medical personnel with knowledge and experience of military trauma treatment and trauma surgery.

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