El Tribunal Constitucional

This report includes the investigation of a shooting incident during an exercise in a ‘shoot house’18 of the Police Academy, which was rented by the special forces of the Royal Netherlands Army, the KCT, for their counterterrorism (CT) training (DSB 2017a). The realistic shoot house simulates a building with several rooms set up with targets. It was used for dynamic firing exercises, whereby the KCT uses live ammunition. This specific exercise was part of practising Close Quarters Battle (CQB), which includes physical confrontation between multiple parties (DSB 2017a: 19). During this exercise, a trainee instructor was shot dead (DSB 2017a: 13). The DSB (2017a) found that in the past more military men were seriously or sometimes fatally injured during trainings and exercises. Therefore, the Safety Board decided to investigate the shooting, to study how the MoD handles risks during the firing training. The goal of this investigation is to find lessons that can contribute to minimizing these risks for participants in the future (DSB 2017a: 14).

18 _{A shoot house is a shooting range in which shooting with live ammunition is exercised for close contact}

engagements.

The shooting incident is conceptualized as a crisis, because (1) the core values of safety and security came under threat, (2) it involved a sense of urgency and (3) it contained a high degree of uncertainty (Boin et al. 2005: 3). This study analyses the ‘pre-crisis of management stage’ prior to the shooting incident (Smith & Elliott 2007: 525). Throughout the analysis the category ‘knowledge management’ was found eighteen times, the category ‘resistance to change’ four times and the category ‘organizational culture’ two times. Indicators of ‘organizational learning for crisis’ were encountered four times, which all concern ‘formal learning’. The sub-category ‘informal learning’ was not found in this case.

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Table 3.

4.2.1 Knowledge management

The category ‘knowledge management’ was identified eighteen times as a factor that influences organizational learning for crisis. This includes informal and formal data gathering and the transfer of spoken and written knowledge. The category will be analysed correspondingly.

Five of the text fragments indicated formal data gathering. The first two include the presence of data gathering through formal data collection systems. Units within the MoD can get permission to deviate from the official shooting policy. The commander of that unit has to draw up a differentiated shooting policy, which needs to fulfil the overall (safety) requirements of the general shooting policy. Subsequently, the Military Commission for Hazardous Materials (MCGS) has to test the differentiated policy (DSB 2017a: 26). The KCT drew up such a policy due to its extraordinary work tasks. On 14 November 2013 the MCGS tested the differentiated shooting policy of the KCT in accordance with its drawn up note (DMO 2013020475) and agreed to it (DSB 2017a: 26). The second example involves the safety management system of the MoD (VMS Defensie). The goal of VMS is to professionalize and strengthen safety and security within the Defence organization. VMS focuses on limiting risks, like amongst others a Risk inventory and evaluation (RI&E) (DSB 2017a: 27). At 21 January 2015, the Central Government Audit Service conducted an investigation into the workings of the safety management system. Serious shortcomings were found and it was concluded that “the risk of

an unstable safety organization exists, whereby operational business processes are not carried out safely” (DSB 2017a: 27). Both examples contain investigations, which indicate data gathering through formal data collection systems (Catignani 2014: 36). The collection of professional feedback could influence the organizational learning process for crisis. Whereas the first investigation merely approved of a new policy, the outcome of the second example was new and negative knowledge on the workings of the MoD. However, as this did not lead to any changes, no formal learning was accomplished (Bechtel 2017: 22).

Independent variables Dependent variables

Factor 1: ‘Knowledge management’ Factor 2: ‘Resistance to change’ Factor 3: ‘Organizational culture’

Organizational learning for crisis Formal learning Informal learning

Counted number

33 The other three examples demonstrate the lack of formal data gathering. They all involve the shoot house of the Police Academy that was rented by the KCT without (1) the conduct of an RI&E, (2) an inspection of the MCGS or (3) an own safety assessment by the KCT or the Staff Land Forces Command (CLAS) (DSB 2017a: 39, 47, 48). Without the collection of professional and operational feedback, the KCT and the MoD in general, did not acquire the needed knowledge on the safe use of the shoot house. This feedback could have been incorporated into their plans, which in turn could have led to organizational learning for crisis.

Three text parts indicated the spoken transfer of knowledge. The DSB (2017a: 21) states that

“the content of the shooting exercise was discussed by the course leader and the instructors, including the trainee instructor, in the evening prior to the exercise”. Moreover, after the students of the CT-training arrived in Ossendrecht, they were briefed on the objective of the exercise (DSB 2017a 23). Afterwards the group was split into two smaller groups, of which one group was going to conduct the shooting exercise. The smaller group was again split into two groups to do the exercise separately after each other. According to the DSB (2017a: 23) “before

the first group started with the exercise in the dock19, a general safety briefing was given, weapons were inspected and the exercise was briefly discussed”. These examples indicate a successful transfer of knowledge. Because all the participants of the exercise were briefed on safety issues and the content of the exercise, they exhibited the available knowledge on how they needed to act in case of a crisis.

A more profound influence on organizational learning for crisis was exerted by the unclear or lack of written transfer of knowledge. The official Regulation for the construction and use of firing ranges (Voorschrift voor de inrichting en het gebruik van schietinrichtingen) misses important information. According to the DSB (2017a: 25):

“The regulation does not include information concerning the construction and use of shooting ranges like a 360° shooting range (shooting facility for CQB). The regulation does include extraordinary shooting ranges, but further interpretation, as well as a description of these extraordinary shooting ranges, is missing. The regulation orders that the decentral employer of the shooting unit, as part of safety measures, is responsible for the regulations concerning the firing range organization, the level of education and the safety organization at the shooting

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range and shooting exercises. To what standards those regulations have to live up to is not prescribed”.

Similarly, the KCT did not possess syllabi for the CT-training lessons or the education of (head) shooting instructor in a CT-environment (DSB 2017a: 39). The missing information included a general procedure for the positioning of participants in this exercise, clear descriptions of the objectives, how the exercises should be taught, which risks should be considered and which points of attention are important. Furthermore, “the training to be an instructor completely

existed out of ‘training-on-the-job’” (DSB 2017a: 39). In general the DSB (2017a: 39) established that the (expert) knowledge within the KCT was too limited. Their safety functionary (functionary Personnel Risk Management PRM) had no function description within the KCT. The DSB (2017a: 39-40) found that even though general requirements regarding knowledge, skill, experience and educations for the PRM-functionary were drawn up at CLAS level, they were neither translated to the work environment and nor known by the functionary. These examples demonstrate that the relevant regulations were unclear and that vital information for the CT-training and the safety functionary was absent. This unclear documentation indicates a flawed transfer of written knowledge, which makes it difficult to implement and follow all existing procedures. When knowledge is not clearly communicated, it cannot be successfully exploited and thus obstructs organizational learning for crisis (Catignani 2014: 35).

What happened most in regard of ‘knowledge management’ is the false interpretation of present knowledge. Indicators of this situation were found on three separate occasions. First, the instructor during the exercise was a trainee himself (DSB 2017a: 35). He had never conducted the exercise using live ammunition. An additional risk was the absence of bulletproof inner walls in the shoot house. It was assumed that the trainee instructor could handle this situation with supervision of an instructor on the ‘catwalk’20. The DSB (2017a: 35) rightly argues that this knowledge should have led to the presence of a second instructor in the dock to guide the trainee during the exercise. Since this was not the case, the trainee had little room to make mistakes. As the DSB (2017a: 35) argues, “possible mistakes that were made by the trainee

instructor during the exercise, which could directly lead to safety risks, could therefore not be corrected on the spot”. The second example is similar and concerns the absence of the regular

20 _{The catwalk refers to the concrete construction above the docks on which instructors can walk and observe}

35 CT-instructor, also the appointed firing range commander, in the dock during the exercise (DSB 2017a: 35). Third, the choice for the instructors for the exercise was primarily based on their working experiences instead of their educations (DSB 2017a: 39). No or limited attention was given to whether the instructors who provided the trainings possessed the necessary qualifications to lead firing exercises. The firing range commander at time of the exercise, in addition to being absent, did indeed not possess the right qualifications for shooting exercises (DSB 2017a: 35). The examples demonstrate that a lot of important knowledge was available. This knowledge included the above-mentioned fact that the instructors who were present did not possess the required qualifications for leading shooting exercises. The trainee instructor needed a second instructor, preferably the appointed firing range commander, present in the dock for guidance. However, the participants interpreted the knowledge as that the trainee instructor could manage the exercise with an instructor on the catwalk. The examples demonstrate the importance of the subjectivity of knowledge (Catignani 2015: 36). If the knowledge had been interpreted differently, the shooting crisis have been dealt with differently.

4.2.2 Resistance to change

From a psychological perspective, the category was encountered one time. The earlier mentioned differentiated shooting policy of the KCT was officially valid until 31 December 2015. The DSB (2017a: 26) describes that the KCT staff realized this and had planned to draw up a supplementary note for an extension of the policy. However, the investigation report states that they abstained from this (DSB 2017a: 26). This refrainment signifies a negative attitude to change which is an indicator of ‘resistance to change’. Consequently, the policy was neither extended nor evaluated. On 22 March 2016, when the crisis happened, the KCT was still working under the differentiated shooting policy 2013. The resistance acted as a barrier to organizational change and thus hindered organizational learning that could have happened for the crisis (Alas & Sharifi 2002: 317).

From a structural perspective, the category ‘resistance to change’ was found three times. First, the DSB (2017a: 40-41) argues that “despite the absence of syllabi, the limitations in instruction

capacity and the errors in the shooting policy concerning extraordinary shooting ranges, the relevant educations at the KCT continued unchanged”. Despite the fact that the lack of thorough instruction methods and qualified personnel was reported somewhere ‘along the line’, this did not lead to any change in the situation (DSB 2017a: 9). Second, the MoD could have changed their policy concerning the regulations and use of shoot houses. The Ministry

36 conducted an internal investigation into a shooting incident at Aruba in 2014 (DBB 2017a: 47). It was concluded that flaws were present in the Regulation for the organization and use of firing ranges. Nonetheless, the Regulation did not change. Third, there were differences between the desired shoot house of the MoD and the shoot house of the Police Academy (DSB 2017a: 48). These differences were accompanied by safety risks for the KCT users. Nonetheless, no evident changes were initiated in the way of exercising or the thereby applied procedures (DSB 2017a: 48). All three examples demonstrate the continued presence of structures and procedures after changes were suggested. This could be connected to the organizational culture of the KCT and the MoD, since military cultures are generally conservative and resistant to change (Burr 1998: 9). If structural mechanisms, such as the Regulation for the organization and use of firing ranges, are not changed, organizational learning is hindered (Davidson 2010: 11).

In addition, the findings of the Central Government Audit Service that were conceptualized as outcomes of formal data gathering, belonging to ‘knowledge management’, did not lead to any concrete changes. This establishment could also be interpreted as a structural resistance to change. However, the DSB report (2017a) does not include more information on the actions taken after the investigation of the Audit Service.

4.2.3 Organizational culture

The category ‘organizational culture’ was encountered two times. The first text part that was interpreted as an indicator of this category concerns the ‘train-as-you-fight’ philosophy of the MoD (DSB 2017a: 30). The philosophy involves the use of live ammunition during exercises to simulate realistic fighting situations. This technique is meant to prevent mistakes during the actual mission. It is argued that “if shooting exercises are not conducted in as realistic as

possible circumstances, the safety of the exercise is heightened, but the success rate of the mission and the survival chance of the participants during fighting circumstances is decreased”

(DSB 2017a: 30). The philosophy can be conceptualized as a story and a practise that is part of an organization’s culture (Deverell 2010: 49). It also points to a ‘safety culture’, because it is believed that safety during the mission can be constructed if the employees participate in realistic trainings (Pidgeon 1998: 206).

Moreover, KCT employees indicated in interviews that “there is a strong group cohesion within

the unit and that people mostly think solution oriented” (DSB 2017a: 41). This involves giving a high degree of autonomy and responsibility to subordinate units within the KCT organization.

37 The high esprit de corps, which is focused on achieving results under difficult circumstances, characterises a certain dynamic within the KCT. The dynamic includes the presence of loyalty and a pressure to perform. This characteristic of the organizational culture influences organizational learning for crisis, because instructors and commanders want to ‘finish the job’, even if this means deviating from the rules and regulations (consciously or not).

4.2.4 Sub-conclusion

In this case, the factor ‘knowledge management’ influenced organizational learning for crisis the most. However, the factor was primarily found in a negative way, which includes the unclear transfer of knowledge. The role of subjectivity of knowledge was important as it influenced how vital knowledge was interpreted in multiple instances. The flawed management of knowledge probably prevented organizational learning processes for crisis. Moreover, ‘resistance to change’ was encountered four times. Three of these indicators involved structural refusals to incorporate changes after investigations were conducted. Overall, text fragments signifying ‘organizational learning for crisis’ were only found four times, of which two refer to the lack of learning. All these indicators point to a dynamic in the organization that does not reflect a ‘learning culture’ (Joseph and Dai 2009: 244). The KCT overall demonstrates the presence a safety culture, but with a pressure to perform and ‘finish the job’. These elements seemed to have been given preference over learning.