A sharp turn at a high rate of speed caused an Army Polaris Ranger all-terrain utility vehicle to flip at Ali Al Salem Air Base, Kuwait, last September, pinning down and killing the airman in the passenger seat.
That's according to a new Air Force ground investigation report into the fatal mishap.
Staff Sgt. Ronald Ouellette, 23, of Merrimack, New Hampshire, died in the non-combat related accident Sept. 14. Ouellette and the driver, only identified as an active-duty staff sergeant, were not wearing seatbelts, helmets, eye protection or long-sleeved shirts as required by regulations, the mishap report released Tuesday states.
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Furthermore, investigators said, the driver made inconsistent claims into why the airmen were operating the Polaris when their mission was to move other vehicles.
A day prior, the driver, assigned to the 437th Aerial Port Squadron, Joint Base Charleston, South Carolina, picked up the Polaris vehicle, which had been offloaded from a C-17 Globemaster III. The plan was to keep the vehicle on base before turning it over to the Army downrange somewhere in the Middle East, the investigation states.
Both airmen were part of the 386th Expeditionary Logistics Readiness Squadron at the base.
The driver took the Polaris from the cargo loading area known as Whiskey ("W") pad and moved it to Bay 69, a cargo yard. In testimony, the driver said he felt that the Polaris was experiencing some mechanical issues and was "sputtering" -- but never notified vehicle maintenance personnel or his supervisors.
The driver and Ouellette were called the following day to move a Jeep Cherokee and a large recovery vehicle known as a "wrecker" that had come in on another C-17 from the loading area to a designated location in Bay 69. Their 12-hour shifts began at noon.
The driver took the wrecker, and Ouellette followed behind him in the Jeep. Their intended parking spots were on opposite sides of the lot, so when the driver finished parking the wrecker, he jumped into the Jeep with Ouellette to drop off the car on the other side. During the ride, the driver mentioned he wanted to drive the Polaris to "troubleshoot" the alleged sputtering. The two airmen parked the Jeep nearby and then got into the Polaris.
The driver stated he wanted to do a lap around Bay 69. Investigators noted that multiple signs near the base flight line and cargo lot instruct vehicle operators to limit speeds to 5 miles per hour for safety reasons. The vehicle itself had a "slow-moving vehicle" sign fastened to it behind the passenger seat, according to accompanying photographs in the report.
Around 5:00 p.m. local time, while finishing a lap around the yard, the driver lost control of the Polaris, skidding on the sand surface. The Polaris "rolled over onto its passenger side while performing a sharp left-hand turn, pinning [Ouellette] underneath the protective roll cage of the [vehicle]," the investigators said.
The driver got clear of the vehicle, then turned to see Ouellette "pinned underneath the protective roll cage." He "attempted to lift" the Polaris off of the pinned airman, the investigation states, then used his personal cell phone to call his supervisor and requested emergency assistance.
Ouellette was unresponsive, the driver told investigators. Emergency responders pronounced Ouellette dead at the scene roughly 10 minutes after the accident occurred.
The driver recalled taking his foot off of the gas prior to making the sharp turn, and "did not recall using the brake," the report says. He was also evaluated for injuries.
He estimated he was driving approximately 15 miles per hour.
Actually, it's likely the vehicle was traveling between 25 to 35 miles per hour, and drifted until it rolled onto its side, a criminal investigator and a traffic investigator, who responded to the scene and analyzed wheel marks and the vehicle's position, found. Days later, investigators working on the ground investigation report were unable to examine the same drift conditions because personnel from the base's civil engineering squadron "level[ed] out the sand across the entire lot ... to improve its condition."
Minutes after the accident, the driver told Security Forces airmen who arrived on the scene that he "wasn't going to lie to them" and that he and Ouellette were "just out joy-riding" and that he "hit the turn too hard" prior to the vehicle tipping over.
But in subsequent interviews, the driver said he wanted to determine the cause of the ATV's sputtering. Investigators said it would have been inappropriate for the driver to do this himself since he was not authorized, and he should have alerted vehicle maintenance instead.
To his leaders, the driver "expressed regret and sentiments that the mishap was 'his fault' but did not give any indication as to what he and [Ouellette] were doing in the [Polaris] prior to the rollover," the report says.
Ouellette was trained to operate 14 different types of vehicles or equipment, including aircraft staircase ramps, forklifts and passenger vans. By contrast, the driver was trained and licensed to operate only five types of similar machinery. However, investigators said that "there is no licensing required to operate a vehicle of the type involved in the mishap."
The Polaris ATV falls into the category of "non-tactical vehicles where gross vehicle weight rating is less than 26,000 pounds," and may be operated by airmen with a state-issued driver's license, the report states.
The driver was previously deployed to Al Udeid Air Base in Qatar for six months in 2017 and had also worked in cargo and special handling. No deficiencies were noted in either Ouellette or the driver's training or military personnel records.
Toxicology screenings conducted for Ouellette during the autopsy and for the driver via a urine sample were both negative for prescription medications, drugs and alcohol at the time of the accident.
New arrivals at the logistics squadron are required to take a safety briefing immediately when coming to the base, the report states, which details how airmen should operate local vehicles and the protective gear associated.
Of 12 airmen, including leaders, who were interviewed for the investigation, none were aware they should wear helmets, eye protection and long sleeves when operating the Polaris.
"Leadership also stated the manner in which the briefing is conducted -- as the members are getting off the bus at all hours of the day and night -- is probably not the most conducive manner for retention of information," investigators said. "No records or documentation were kept reflecting actual attendance or completion of the safety briefing by [logistics squadron] members, including [Ouellette and the driver]."
The Air Force Office of Special Investigation conducted its own analysis and determined "there was no evidence of foul play, criminal activity, or malicious intent, and therefore, the motor vehicle fatality did not fall within their jurisdiction," the report says. As a result, the Air Force did not open a criminal investigation.
The driver sat for three additional interviews with the safety investigation board before leaving Kuwait. Eight days after the accident, the driver returned to Charleston, and was cooperative "for an additional interview" in October. But he declined to give further input for the ground investigation board report.
The incident happened days after Senior Airman Jason Khai Phan, from the 66th Security Forces Squadron at Hanscom Air Force Base, Mass., died after being ejected from an all-terrain vehicle while on a routine perimeter sweep of Ali Al Salem.
An investigation released April 5 concluded that Phan and two other airmen, who were on a 12-hour night patrol in a Mine Resistant Ambush Protected All-Terrain Vehicle outside the fenced perimeter, were not wearing their seat belts or helmets when the accident occurred.
That investigation also found that, while all three airmen had completed local training and certification on how to operate the M-ATV, the in-person Tactical Vehicle Course requirement was waived for many Security Forces personnel deploying to the Middle East amid COVID-19 restrictions.
Phan and the two other airmen completed only the "Phase One" local welcome training given to newcomers within the first few days of arriving at the base, investigators said.
Ouellette, who joined the Air Force in 2014, was deployed from the 42nd Aerial Port Squadron, Westover Air Reserve Base, Massachusetts.
-- Oriana Pawlyk can be reached at oriana.pawlyk@military.com. Follow her on Twitter at @Oriana0214.
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