The brake failure of a Jackal armoured vehicle which caused it to roll backwards and crush a "kind, thoughtful, enthusiastic", young Exmouth RAF serviceman to death, was the result of a "lack of driver and commander experience", an inquest has heard.
RAF Senior Aircraftsman Kinikki Griffiths, 20, from Exmouth died during an incident at around 11pm on July 16, 2010, 10 weeks after arriving in Helmand Province as part of Herrick 12. He joined the RAF as a gunner and was posted to 1 Squadron.
In his post-mortem examination report, pathologist Dr Nicholas Hunt reported that SAC Griffiths died by crush injuries to his chest and abdomen caused when a Jackal armoured vehicle rolled on top of him and pinned him underneath the rear wheel for two or three minutes.
In her conclusion, the Coroner, Dr Elizabeth Earland, said: "Kinikki Griffiths died as a result of crush injuries sustained while serving in Afghanistan as a signaler on a Panther in a three vehicle patrol at 11.10pm when a fuel leak on the Jackal prompted a patrol halt in a lay by at 11.12pm and an unqualified driver parked the Jackal, put the gear in drive and a defective park brake on.
"As SAC Griffiths lay partially under the rear right wheel of the Jackal assisting with a torch, at 11.18pm the engine was switched off to avoid an explosion and the Jackal rolled backwards crushing him.
"The resultant brake failure was not appreciated due to a lack of driver and command training and experience.
"The cause of his death was crush injuries to his chest and abdomen. His death was confirmed at 11.46pm."
She added: "My deepest sympathies go to Mr and Mrs Griffiths in what has been a terrible ordeal for them.
"We must not forget Kinikki Griffiths' comrades who have shown a different sort of courage being frank and open in this court about what happened that day.
"As we sit in this beautiful county of Devon it is almost impossible for us to imagine the horrors and dangers they've been facing on our behalf in Afghanistan, let alone the added burden of losing their friend.
"We hope they will carry on and are grateful to their service."
SAC Griffiths was born in Exeter but grew up in Hampshire before moving with his family to Exmouth aged 17. He was due to celebrate his 21st birthday three weeks after his death. He left behind parents Tracey and Nick, two sisters, at the time aged 18 and 15, a 12-year-old brother, and girlfriend Chloe Gunn.
In a statement after the inquest, the family said: "Kinikki was a kind, thoughtful, family orientated son. He was always laughing and had a smile on his face. He lived life to the full. We have heard this week how respected he was by is fellow servicemen. We are honoured to have been his parents and are so very proud of him.
"We have been through years of agony not knowing fully what happened to him on July 16, 2010. A this week's inquest we have learned a number of failures relating to the errors made while Kinikki was out on patrol, of vehicles owing driven by people who were not trained to do so, orders being breaches, and that the vehicle was driven incorrectly with the hand brake on.
"In light of all we have heard, we call upon the RAF to re-open their investigations into what happened to our son so that those who may have been responsible are properly held to account.
"We leave this inquest with thanks to all those who have given us their support over the past four years. We simply could not have got to this point without their assistance.
"Our son, our brother, our hero - forever in our hearts."
In the two day inquest, the court heard that the patrol had gone out to locate a day sack with essential kit such as night vision equipment and ammunition which had accidently been left behind on a patrol earlier in the day, as they were concerned it may fall into enemy hands.
The group set off in three vehicles, the Jackal, Panther and Coyote, at around 9.30pm. SAC Griffiths was a signaler in the Panther.
The patrol pulled off the highway and into a lay by when a problem with the Jackal was noticed. The court heard that the vehicle had gone quite "heavily" into a dip prior to this.
On closer inspection Sergeant James Whitby, who was leading the patrol, knelt down and noticed a leak, possibly diesel, coming from one of the pipes. He said he smelt diesel and described it as "gushing" from a tube and said he noticed black tape which looked like a repair had previously been attempted as a "quick fix".
He told the court, fearing that the leak could cause an explosion, he shouted for assistance for someone to hold his torch.
SAC Griffiths crawled under the jackal with the sergeant who immediately requested that the engine of the vehicle be switched off.
Corporal William Wortley, who was employed as a vehicle commander on the patrol, but who insisted on driving the Jackal instead because he knew the route and had the GPS, said he immediately reached inside the door of the Jackal and switched the engine off.
The court heard that the vehicle began to roll backwards as soon as the engine went off and there were subsequent problems restarting the vehicle and driving it forwards and then reversing it.
The court heard that panic ensued.
Giving evidence, SAC John Kennedy who was in the Jackal at the point it rolled, said as soon as it started to roll backwards when the engine was switched off, he "slammed" his foot into the brake pedal and when it failed to stop he "pumped" the brakes again.
In a statement read out to the court on the second day of the inquest, SAC Anthony Holman, who was part of the Panther crew, said that SAC Griffiths became "pinned" underneath the rear right wheel. He said there was panic among the group who "didn't seem to know what to do" and he heard people shouting "get it off him".
He said that when SAC Richard Gannon, the qualified driver of the Jackal, got into it and tried to start the engine, it was turning over but only started after a few attempts. He said he could hear it revving but it wouldn't go forward. He said he heard someone shout, "If it won't go forward it needs to come backwards". The vehicle subsequently rolled backwards off SAC Griffiths – it was unclear if the Jackal was reversed off or simply rolled off. He said SAC Gannon put the Jackal in neutral and the hand brake on.
The Jackal received the military equivalent of an MOT four months prior in the March but was subject, as all the vehicles were, to a 21 day interim inspection which included brake function tests.
In his report which was read out to the court, Warrant Officer 1 Matthew Dickenson, a vehicle investigator part of the Serious Equipment Failure Investigation Team concluded that:• The park break had been applied by whoever had been driving the Jackal prior to the incident but did not roll backwards initially, until the engine was turned off, because it had been put in 'drive'.• Gannon had not been able to start the Jackal because it was in drive.• The park break was incorrectly adjusted, i.e. faulty, because it had been damaged because, at some point prior to the incident, the vehicle had been driven with the hand brake on which damages the break and its ability to hold it stationary on a gradient of six degrees. He said the gradient of the ground at the site of the incident was around 10 degrees.• He said "significant" damage can be caused to the break over a short distance of a few miles but it was "impossible" to tell if the damage had been caused on the current patrol or a previous one.• When the brake was tested as part of the investigation the brake worked when the engine was running and in drive, but in three out of six tests, immediately rolled backwards when the engine was switched off at 1,200rpm.
WO2 Dickenson branded the testing procedure as "wholly inadequate" as he said that the test should be conducted on a steeper gradient than six degrees. He said that more "robust" testing would identify hand brake problems sooner.
Colonel William Bowles, who ran the initial investigation team to complete an emergency report within 30 days, said that the limited experience of the members of the patrol may have had a bearing on the events which took place after the engine was switched off.
He said that a "lack of information, supervision and training provided for them to be competent" may have contributed to the incident.
He said vehicle reliability was "not good". He said that a Coyote had been exchanged for a Jackal in lieu. And he affirmed that "lack of driver command experience" resulted in adverse treatment of the vehicles.
He made a series of recommendations including additional training in the operation, maintenance and repair of vehicles.
Group Commander Captain Scott Miller, Commanding Officer of the RAF, said that the combination of an inexperienced driver, referring to Aircraftsman Gannon, and an inexperienced commander, could have been a contributing factor to drive off SAC Griffiths in a timely manner. He said that the circumstances were "exacerbated" that SAC Gannon had been placed with an inexperienced commander.
"Immediately prior to the accident it was parked with the hand brake applied in drive," he said. "But had it been parked properly, it would have been in neutral and therefore been obvious that the hand brake wasn't holding on the slope, therefore it was a cause or factor in the incident," he said.
"At approximately 11pm, the Jackal was driven down a drop causing a violent jolt to those inside - this may have been a factor in the incident because a more experienced driver would have perhaps negotiated the dip better, and this possibly led to the fuel leak. Therefore the correct driver may have affected the chain of events leading up to the accident," he added.
He also said a lack of formal command training could have been a contributing factor.
Regarding Jackal maintenance, he said that the inadequacy of the 1,200rpm brake test at 21 days, which was unapproved by the manufacturer, was also a contributing factor.
A series of recommendations were made to improve vehicle safety and competence of personnel, which he said had been adopted by the regiment and which were under continual assessment.
A statement by Group Captain Scott Miller on behalf of the MoD, said: "SAC Griffiths was part of the RAF family and the tragic loss of this fine young gunner while deployed to Afghanistan supporting Operation Herrick in July 2010 continues to be keenly felt by us all.
"Our thoughts and prayers remain with his mother Tracey, father Nicholas, brother Jake and sisters Bianca-Jade and Sammy-Jo at this difficult time. The RAF will continue to support them.
"Kinikki was a young, vibrant character with a keen sense of humour which enabled him to make friends easily.
"He could rally with his colleagues' spirits even in the most arduous conditions. He was liked by all who met him and his determination, professionalism and desire to succeed was clear for all to see.
"Kinikki had a very promising career ahead of him and his loss has been a blow to us all. Now that the inquest into this tragic even has concluded it is time to reflect on what a bright, talented and enthusiastic man and gunner Kinikki was – we were extremely privileged to have known him and to have had him within our corps.
"We are grateful to the coroner for her thorough examination of the facts. There have been a number of lessons for us and others to absorb and learn from and we have made and will continue to make every effort to ensure that such a tragic accident cannot occur again.
"As a result of these lessons and the steps we have taken, RAF Force Protection is a stronger, more capable and better team.
"Our thoughts are with Kinikki's family."
