Report on military incident with soldiers exposed to hypothermia at Råholt bad, Eidsvoll municipality 21 January 2023
Defence report 2024/01
The incident occurred during an exercise that involved "assault course", including staying in a cold plunge pool. As a result of sitting for too long in the cold plunge pool three conscript soldiers were exposed to varying degrees of hypothermia. The NSIA considers the incident serious because the soldiers involved were conscripts and their safety was not adequately provided for. The investigation has shown that the incident occurred as a result of inadequate planning and risk management, which in turn is related to level of expertise and framework conditions.
On 19–22 January 2023, the Garrison Company of the Garrison Unit at Sessvollmoen Garrison conducted an exercise for guard soldiers. The soldiers were split into three squads with conscripted squad leaders. As part of the “assault course” of the exercise, several activities were planned at Råholt Bad swimming pool, including immersion in a cold plunge pool with a temperature of 10–13 °C.According to the Norwegian Armed Forces’ Safety Rules and Regulations for Land Based Military Activities (UD 2-1), immersion in a water hazard with a temperature of 9–12 °C must not exceed 10 minutes.
There are several contributing factors to why planning was inadequate, including a high operational tempo and low staffing. The plan used for the exercise in autumn 2022 was largely reused for this exercise. That plan did not mention cold plunge pools, even though this was part of the exercise. During the exercise in autumn 2022, the soldiers also remained immersed in the cold plunge pool longer than that specified in UD 2-1, without this being identified. The NSIA considers it a weakness that the system repeatedly failed to identify that a sufficient plan and risk assessment was lacking for the coping exercise.
Exercises that involve “assault courses” place great demands on the personnel conducting the exercise and the accompanying personnel to take responsibility for the safety of the soldiers. This is because the soldiers are pushed out of their comfort zone and have a feeling it is not possible to say stop. The Armed Forces must therefore ensure that the personnel responsible for safety in connection with assault courses meet the defined requirements for expertise, and that they are given adequate conditions to utilise this expertise.
Both the Garrison Unit and the Garrison Company lacked command-teams, presumed by the scheme for military employees (OMT). There was also a gap between the assumptions that form the basis for UD 2-1 regarding clear roles and associated responsibilities and the organisation under the Joint Logistics Support Centre (FKL). The NSIA considers that the staffing and the expertise of personnel in all units in the Norwegian Armed Forces must reflect the unit’s activities and areas of responsibility.
A contributing factor to the incident was a lack of balance between duties and available resources. This has also been found in previous investigations conducted by the NSIA. The unit had identified the need for increased staffing several years before the incident. The unit was assigned more duties as a result of a change in the national security situation in autumn 2022. This exacerbated the imbalance between duties and lack of resources. The Armed Forces should systematically identify risk to personnel and prioritise resources at all levels when subordinated elements are assigned more duties or stripped of resources. This applies in particular to units responsible for conscripts.
The NSIA submits two safety recommendations as a result of the investigation.
Safety recommendation
Safety recommendation Defence no 2024/01T
The incident that caused three conscripts to develop hypothermia on 21 January 2023 occurred when the soldiers remained immersed in a cold plunge pool for an extended time period during an exercise at Råholt Bad. The investigation has shown that the exercise was carried out in a similar manner under the leadership of the previous company commander. The company did not have the positions required to form a command-team, as presumed under OMT. There was no interaction between officer and specialist, and the company commander had to fill all the roles in the command-team. This also applied to the command of the Garrison Unit. The NSIA believes that the staffing and the expertise of personnel in all units in the Norwegian Armed Forces must reflect the unit’s activities and areas of responsibility.
The Norwegian Safety Investigation Authority recommends that the Norwegian Armed Forces review the position structure and associated competence requirements so that personnel safety is ensured.
Safety recommendation Defence no 2024/02T
The incident that caused three conscripts to develop hypothermia on 21 January 2023 occurred when the soldiers remained immersed in a cold plunge pool for an extended time period during an exercise at Råholt Bad. The investigation has shown that it was challenging for the company to properly plan the exercise, partly as a result of a lack of balance between duties and resources. The national security policy situation in autumn 2022 also meant that the company was given additional duties, approximately three months before the exercise. The company nonetheless chose to go through with the exercise, based on the company’s experience of such exercises having a positive effect on the conscripts.
The Norwegian Safety Investigation Authority recommends that the Norwegian Armed Forces ensure that risks are identified, and measures taken, when subdivisions are assigned more duties or stripped of resources, so that personnel safety is ensured.
Facts
| Location | Råholt, Eidsvoll municipality |
| Occurrence date | 21.01.2023 |
| Category of Occurrence | Serious incident |
| Defence branch | Norwegian Defence Logistics Organisation |
| Incident type | Other |