Report on serious incident involving a spontaneous smoke hand grenade in the Eastern Norway training area on 5 December 2023

The incident that caused caustic injuries to the eye area of a squad leader on 5 December 2023 occurred when the squad leader threw a TTC smoke hand grenade of the type NM239. In the squad leader’s opinion, the grenade detonated as soon as it was released from their hand. In the period 2008–2023, there have been at least eight incidents involving the NM239 that have resulted in personal injury, and where the user and/or the Norwegian Armed Forces have stated that the causes can be linked to the short delay time.

The safety and suitability for service and the technical and administrative approval for the NM239 were drawn up in 2008 and 2016, respectively. Neither have been subsequently revised. This is despite the fact that the NM239 has been blocked from use and subject to several limitations on use during the period 2008–2023, and that there have been several incidents involving the NM239 resulting in personal injury. Some of the lots of the NM239 have also undergone repairs in the form of component replacements. The NSIA is of the opinion that the safety and suitability for service and the technical and administrative approval for ammunition must be regularly reviewed and updated to reflect any risk factors that are identified over time.

The NSIA recommends that the Norwegian Defence Material Agency review and update the safety and suitability for service and the technical and administrative approval for ammunition intended for use in the defence sector.

The incident that caused caustic injuries to the eye area of a squad leader on 5 December 2023 occurred when the squad leader threw a TTC smoke hand grenade of the type NM239. In the squad leader’s opinion, the grenade detonated as soon as it was released from their hand. In the period 2008–2023, there have been at least eight incidents involving the NM239 that have resulted in personal injury, and where the user and/or the Norwegian Armed Forces have stated that the causes can be linked to the short delay time.

In the cover letter to the technical and administrative approval for the NM239, it is also required that the operational use of the NM239 must be approved by the heads of the operating units that use the grenade. The investigation has shown that neither the Army, the Home Guard nor the Navy have prepared an approval for use for the NM239. This is despite the fact that there have previously been incidents involving the NM239 in these operational units. The preparation of the approval for use could have contributed to increased risk awareness related to the operational use of the NM239 in each individual operating unit.

The NSIA recommends that the Norwegian Armed Forces ensure that ammunition intended for use in the defence sector has an approval for use in the operational units that will use the ammunition.

The incident that caused caustic injuries to the eye area of a squad leader on 5 December 2023 occurred when the squad leader threw a TTC smoke hand grenade of the type NM239. In the squad leader’s opinion, the grenade detonated as soon as it was released from their hand. In the period 2008–2023, there have been at least eight incidents involving the NM239 that have resulted in personal injury, and where the user and/or the Norwegian Armed Forces have stated that the causes can be linked to the short delay time.

The NM239 was not stored in accordance with the manufacturer’s guidelines in the ten months prior to the incident. Consequently, it has not been ensured that the properties of the ammunition were maintained during storage. The regulation for the ammunition service does not set requirements for how long ammunition can be stored in warehouses that do not have good insulation. The storage temperature of the NM239 is not specified on the grenade body or the grenade’s packaging (steel box). The storage time of the NM239 has been extended during the ammunition’s service life, but without the original or updated storage period having been stated in the Norwegian Armed Forces’ management systems.

The NSIA recommends that the Norwegian Armed Forces strive to ensure that ammunition is stored in accordance with the manufacturer’s guidelines, including raising awareness among users and managers about the ammunition’s storage temperature and storage time.

The incident that caused caustic injuries to the eye area of a squad leader on 5 December 2023 occurred when the squad leader threw a TTC smoke hand grenade of the type NM239. In the squad leader’s opinion, the grenade detonated as soon as it was released from their hand. In the period 2008–2023, there have been at least eight incidents involving the NM239 that have resulted in personal injury, and where the user and/or the Norwegian Armed Forces have stated that the causes can be linked to the short delay time.

On the day of the incident, the squad leader double-checked the inscription on the grenade before it was thrown and noted that it read ‘1.3 s’. This corresponded with the squad leader’s knowledge and perception of the grenade’s delay time. The investigation has shown that training in the Norwegian Armed Forces assumes that the NM239 has a delay time of 1.3 (± 0.3) seconds. It is also clear from the markings on the grenade body and packaging of the NM239 that the grenade has a delay time of 1.3 seconds. The NSIA believes that both the training and the marking appear unvarnished in light of the grenade’s real delay time. The NSIA also cannot see that knowledge from previous incidents and technical investigations of the NM239 has been reflected in the Norwegian Armed Forces’ training in the use of hand grenades.

The NSIA recommends that the Norwegian Armed Forces ensure that the actual properties of the NM239 are made clear to users, and that the associated risk is reflected in training and use.

The incident that caused caustic injuries to the eye area of a squad leader on 5 December 2023 occurred when the squad leader threw a TTC smoke hand grenade of the type NM239. In the squad leader’s opinion, the grenade detonated as soon as it was released from their hand. In the period 2008–2023, there have been at least eight incidents involving the NM239 that have resulted in personal injury, and where the user and/or the Norwegian Armed Forces have stated that the causes can be linked to the short delay time.

In-service surveillance must be conducted to ensure that ammunition remains in usable condition after the storage period has expired. In-service surveillance is also intended to identify any negative trends associated with ammunition. In-service surveillance is conducted in the form of, among other things, routine tests in accordance with an established test specification. The test specification for the routine test of the NM239 is insufficiently detailed and does not describe the test method, measurement method, temperature range or acceptance criteria. The test results from the routine tests are therefore not comparable.

The NSIA recommends that the Norwegian Defence Material Agency review and revise the test specifications for in-service surveillance of ammunition intended for use in the defence sector.

The incident that caused caustic injuries to the eye area of a squad leader on 5 December 2023 occurred when the squad leader threw a TTC smoke hand grenade of the type NM239. In the squad leader’s opinion, the grenade detonated as soon as it was released from their hand. In the period 2008–2023, there have been at least eight incidents involving the NM239 that have resulted in personal injury, and where the user and/or the Norwegian Armed Forces have stated that the causes can be linked to the short delay time.

The investigation has shown that the eight incidents involving the NM239 that resulted in personal injury were reported via HSE reports, BL-750 and Incident Spot Report (INCSPOTREP) forms. Incidents involving ammunition in the defence sector are reported through multiple channels that do not communicate with each other. The information sent via these channels is also received by different agencies.

The NSIA recommends that the Norwegian Defence Material Agency develop a comprehensive system for reporting incidents involving ammunition intended for use in the defence sector.

The incident that caused caustic injuries to the eye area of a squad leader on 5 December 2023 occurred when the squad leader threw a TTC smoke hand grenade of the type NM239. In the squad leader’s opinion, the grenade detonated as soon as it was released from their hand. In the period 2008–2023, there have been at least eight incidents involving the NM239 that have resulted in personal injury, and where the user and/or the Norwegian Armed Forces have stated that the causes can be linked to the short delay time.

The risk associated with the use of ammunition can be reduced by systematically conducting investigations of incidents and accidents, and by introducing appropriate measures. However, this presupposes that investigations into incidents involving ammunition are initiated to a far greater extent than has been the case for the NM239. This includes investigations of both technical and operational conditions.

The NSIA recommends that the Norwegian Defence Material Agency conduct investigations into technical conditions in the event of incidents involving ammunition. The investigations should be carried out in collaboration with the Norwegian Armed Forces, which are responsible for the operational use of the ammunition.

The incident that caused caustic injuries to the eye area of a squad leader on 5 December 2023 occurred when the squad leader threw a TTC smoke hand grenade of the type NM239. In the squad leader’s opinion, the grenade detonated as soon as it was released from their hand. In the period 2008–2023, there have been at least eight incidents involving the NM239 that have resulted in personal injury, and where the user and/or the Norwegian Armed Forces have stated that the causes can be linked to the short delay time.

The risk associated with the use of ammunition can be reduced by systematically conducting investigations of incidents and accidents, and by introducing appropriate measures. However, this presupposes that investigations into incidents involving ammunition are initiated to a far greater extent than has been the case for the NM239. This includes investigations of both technical and operational conditions.

The NSIA recommends that the Norwegian Armed Forces conduct investigations into operational conditions in the event of incidents involving ammunition. The investigations should be carried out in collaboration with the Norwegian Defence Material Agency as the competent authority for ammunition.

The incident that caused caustic injuries to the eye area of a squad leader on 5 December 2023 occurred when the squad leader threw a TTC smoke hand grenade of the type NM239. In the squad leader’s opinion, the grenade detonated as soon as it was released from their hand. In the period 2008–2023, there have been at least eight incidents involving the NM239 that have resulted in personal injury, and where the user and/or the Norwegian Armed Forces have stated that the causes can be linked to the short delay time.

The Norwegian Defence Material Agency must recommend the phasing out of ammunition if it is no longer possible to meet the requirements for performance, functionality or safety. By comparison, the Norwegian Armed Forces must identify ammunition in a decommissioning plan when the ammunition is no longer needed or no longer fulfils its operational purpose. There is no requirement for the Norwegian Armed Forces to assess whether user safety is ensured in this context.

The NSIA recommends that the Norwegian Armed Forces ensure that ammunition intended for use in the defence sector is recommended for phasing out if user safety is no longer ensured when using the ammunition.

The incident that caused caustic injuries to the eye area of a squad leader on 5 December 2023 occurred when the squad leader threw a TTC smoke hand grenade of the type NM239. In the squad leader’s opinion, the grenade detonated as soon as it was released from their hand. In the period 2008–2023, there have been at least eight incidents involving the NM239 that have resulted in personal injury, and where the user and/or the Norwegian Armed Forces have stated that the causes can be linked to the short delay time.

The investigation has shown that the Norwegian Defence Material Agency (NDMA) has not had a comprehensive overview of the life cycle of the NM239. The NDMA has been unable to explain why some of the planned routine tests have not been carried out. In several instances, the NDMA has also failed to forward information about investigations conducted of the NM239, as well as the associated test results. Nor has the NDMA been able to explain the reason for all the changes in the ammunition’s condition code. The NDMA has also provided incorrect information about completed maintenance of the NM239. The NSIA believes that the findings in the investigation support the need to review the history of ammunition. This is to ensure that the above-mentioned issues do not also apply to other types of ammunition.

The NSIA recommends that the Norwegian Defence Material Agency review the history of ammunition intended for use in the defence sector, so that safety assessments are documented and ammunition safety is maintained.