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Thursday, May 01, 2008

My submission to the House of Commons Committee on Public Safety and National Security

Here is what I said to the House of Commons Standing Committee on Public Safety and National Security in Ottawa (Canada) on April 16, 2008:

Good afternoon, Chairman and members of the committee.

I'm relieved to be here today. For me and my family, this is an extremely important destination in what has been a very, very long journey.

As I'm sure you know, my brother, Robert Bagnell, died on June 23, 2004, moments after he was tasered by Vancouver police. Two days after his death, the Vancouver Police Department contacted my family to inform us that Bob died of an apparent drug overdose.

I know you won't be able to answer these questions, but my questions have always been as follows: If using tasers on my brother was the right thing to do, would the police not have disclosed the fact of their use immediately? Would they have concealed the fact that they used tasers, for an entire four weeks, before announcing to the media, not to us, that they used tasers the night my brother died? Would they have waited a further three weeks before coming up with a burning building from which Bob needed to be rescued?

No, I believe the police knew immediately that the force they used on my brother was excessive. They needed those seven weeks to pull together a plausible explanation to justify their use of the weapon whose manufacturer had aggressively marketed it to them, misleading them into believing that the taser could cause no harm.

More than two years after Bob died, a coroner's inquest was finally convened in September 2006. The inquest, in our opinion, was about saving the taser, not about the changes that might be made to prevent similar deaths in the future. No one, least of all the lawyer for the police and the two lawyers who had standing at the inquest for Taser International, was prepared to conceive of the possibility that the taser may not be the perfect weapon, that there may even exist the possibility that the taser could cause or in some way contribute to death.

We learned some interesting facts at the inquest. We learned that the four ERT members who were in physical contact with Bob when he stopped breathing delivered their mostly identical statements to investigators 17 days after the incident, after seeking legal advice. We learned from the advanced life support staff who attended to Bob right after he stopped breathing that every muscle in his body was spasmed. They said they had only ever seen that in rigor mortis, which they normally would not see until hours later.

We learned that it was possible that Bob had less than half the lethal amount of narcotics in his system, not nearly enough in and of themselves to kill him. We learned that the data download feature on both tasers that were used on Bob conveniently failed, so that the number, duration, and mode of uses were impossible to verify. We learned that police attended the autopsy. The pathologist testified that the cause of death was partly determined by information she was given. The cause of several taser-like marks on Bob's body were inconclusive and the pathologist was unable to determine whether Bob's heart underwent any electrical arrhythmia.

That's the thing about death that occurs after tasering. Even Dr. Butt testified recently to this committee that very uncommonly is there specific pathology with the taser. And I don't begin to understand the science behind the taser or how it affects the human body.

Coroners and medical examiners often choose to mention a condition they call “excited delirium” as the cause of death. They are influenced by Taser International to specifically not mention the taser. The manufacturer's aggressive approach against coroners and medical examiners explains why relatively few deaths have been found to be caused by tasers. Both so-called excited delirium and the taser are undetectable on autopsy, and therefore unprovable. However, as a friend of mine says, “Excited delirium doesn't sue coroners, Taser International does.” So drugs, psychosis, and excited delirium take the blame for these deaths despite the lack of any evidence to show that the taser did not cause or contribute to them in any way.

Tasers have not been safety-tested in this country, and nobody knows whether individual weapons match the manufacturer's specifications. The only truly independent testing I am aware of is what was done on the two tasers that were used on my brother the night he died. One of those two tasers was found to be 84.5 times more powerful than the manufacturer's specifications. Of course, Taser International reacted to those findings in its usual hostile manner, and the company that tested the tasers was made to resile from its findings. However, the author of the report, the man who tested the tasers, testified at my brother's inquest and stood steadfastly behind his methodology and his conclusions.

At this time the two tasers are still awaiting new testing protocols, protocols that are being developed by police. Today I learned that the two tasers used on my brother arrived in Ottawa this week.

Tasers urgently require expert and truly independent testing for safety on humans. Every time a police officer uses a taser they engage in a deadly game of Russian roulette with a potentially lethal weapon. Not so long ago, the past president of the Canada Safety Council urged that minimum standards for the efficacy and use of tasers be developed and noted that relying completely on specifications provided by the manufacturer of the taser is completely unacceptable. Since we are dealing with possible electrocution, it seems the Canadian Standards Association would be the most logical place to start. And if after the taser has been tested it is to remain in the police arsenal, then a much higher standard of necessity must be imposed upon its use in Canada so that police officers can better predict the potential for severe, unintended, and possibly deadly effects, and therefore consider their force options more carefully.

There has been a great deal of reluctance by law enforcement officials and coroners in Canada to admit that the taser may not be as safe as the manufacturer originally misled them to believe. This has only been exacerbated by the fact that the manufacturer has ingratiated itself into our law enforcement community by, for example, compensating individual police officers and at least one coroner, and spending thousands of dollars in sponsorship of Canadian law enforcement events. They have even recently announced that they'd like to be part of any inquests and reviews in Canada.

My brother Bob's death was the 58th in North America. According to my research, the number of dead now stands at 337. It's no coincidence that the taser is the common denominator in all of these deaths.

Canadians witnessed the last horrifying moments of Mr. Dziekanski's life as it was stolen from him. Had the events leading up to my brother's death been captured on video, Canadians would have been outraged in 2004, and perhaps many of those who have since died in Canada, including Mr. Dziekanski, might still be alive today.

What would we learn if we could bear witness to the last moments of the lives of Terry Hanna, Clayton Willey, Clark Whitehouse, Ronald Perry, Roman Andreichikov, Peter Lamonday, Robert Bagnell, Jerry Knight, Samuel Truscott, Kevin Geldart, Gurmeet Sandhu, James Foldi, Paul Saulnier, Alesandro Fiacco, Jason Dean, Claudio Castagnetta, Quilem Registre, Howard Hyde, and Robert Knipstrom?

Would we agree that taser use was justified during Clayton Willey's "altercation" at the mall? Were three taser jolts justified when Clark Whitehouse "tried to flee" from police on foot? What about when police arrived, tasers already drawn, to find Roman Andreichikov sitting on a couch rocking back and forth mumbling to himself? Was it okay to shock Peter Lamonday several times when he was already on the ground? How about Alesandro Fiacco, who "refused to cooperate" with police? These are but a few Canadian examples where the lives of these men and their loved ones went sideways in a heartbeat.

Would we agree that taser use was justified as my brother, all 136 pounds of him, lay on his back on a bathroom floor alone, unarmed, in extreme medical distress, resisting police attempts to drag him out by his feet by holding on to inanimate objects for dear life while 13 highly trained police officers stood by as the only witnesses to the last moments of Bob's life, watching as he was subdued to death?

No, I believe that if Canadians could see with their own eyes what really happened--not the police's tidy version of events, but what really happened when these 20 people died in this country--they would be outraged.

In the days leading up to today, I have wracked my brain trying to conjure up the words that might help you look at the issue of tasers from a different perspective: that of a person who has been deeply affected by the loss of a family member to this deadly weapon. I am but one grieving family member. Somewhere out there are thousands of other family members left behind to mourn the other 336 people who have died.

I know that the eyes of the world are on Canada at this pivotal point. They watch, and they wait. Those who know us know that we will do the right thing. Canada will take the lead and see these weapons finally and independently tested. Canada will set the standard and impose strict regulations that will not allow police unfettered access to this technology. And finally, they know that Canada will impose a much-needed moratorium on tasers until we know, beyond a shadow of a doubt, whether or not their use on human beings is safe. Canada will pay special attention to the studies that have found problems with tasers.

As the father of one taser victim said, "The issue is not whether or not the taser can be used in a high percentage of cases to reduce death and/or physical trauma to officers and civilians alike. The issue is whether or not it's OK to kill the rest through ignorance and rationalization just because it's a small percentage.... The successes aren't the problem--the failures are."

Thank you.


Kate said...

Excellent, eloquent, and must have been one of the most intense things you have ever said.
Thank you

Unknown said...

Dear TNT

In the TASER, the continuous mode while the trigger is held down should be eliminated in the design by a software upgrade.

What is also needed for the stun gun industry is a "stun test dummy" for testing stun guns like the TASER, analogous to a "crash test dummy" use to test cars. The standard test should able detect whether a a hit in the chest in the front from a stun gun used under worst case situations, (e.g., trigger held down continuously), is sufficient
cause ventricular fibrillation. The safety margin should be less than one in a million.

It appears that when officers were hit with TASERs during training they were always shot in the back. I wonder how many would survive if they were shot in the front with the with the barbs across the chest over the heart and the trigger held down continuously. I noticed that some police jurisdictions no longer allow
their officers to be stunned with a TASER while being trained due to the risk of injury or death.

Yours safely,

Jim Ronback,
Tsawwassen, BC

More References:

Postmortem Examination, Dr. C. Lee, Oct 16, 2007, exhibit #76

Medicolegal report. Dr. M. Pollanen, 20 October 2008, Exhibit #80

The use and abuse of restraints

RCMP media officers called to testify - Lemaitre told reporters Dziekanski had been Tasered on only two occasions

Electric shock

Ventricular fibrillation


Taser-related deaths in Canada, 2003-present

A stunning debate
Part 1: A joint CBC News/Radio-Canada investigation takes a
closer look at Taser International and its claims. Part 1 (13:51)

A stunning debate Part 2 (9:34)

Tasers potentially lethal, RCMP head tells MPs

Submission to the House of Commons Standing Committee
on Public Safety and National Security in Ottawa (Canada) on April 16, 2008:

PS Here's a letter I sent to the the Braidwood Inquiry and TASER International Inc.

-------- Original Message --------
Subject: Safety performance upgrade for the TASER® weapon
Date: Sat, 18 Apr 2009 20:35:23 -0700
From: James Ronback
To: Magne Nerheim , Braidwood Inquiry - Cathy Stooshnov
CC: Neal Hall vancouversun, Pierre Savard, "Thomas R. Braidwood" , Public Safety Canada, "Rob Nicholson (Hon) AG Canada" , John Cummins , aimember@aiusa.org, Amnesty Canada, Walter Kosteckyj, Honourable John van Dongen Oublic Safety BC, "Jessica Kerr (LMP)" Delta-Optimist, Honourable Wally Oppal Attorney General gov.bc.ca, Dileep Athaide , Vicki Huntington , John Shavluk , Graeme Drew'

Mr. Magne Nerheim, VP Research and Development,
TASER International, Inc.


CC: Thomas R. Braidwood, QC, Commissioner of Inquiry

Dear Mr. Nerheim,

It took a while to introduce safety belts and air bags in cars to reduce the carnage due to car crashes. In light of the large number of deaths associated with use of TASERs, it begs the question:

How soon could Taser International Inc., provide additional safety mechanisms and improved data recording capabilities to upgrade the design of TASER® weapons, as suggested below, to further mitigate the likelihood of deaths when TASERs are used and facilitate gatheringof more complete data on their use?

The video record (25) taken at the Vancouver International Airport showed that Mr. Robert Dziekanski was stunned five times. It's not clear if these stuns, their mode (probe or push) and their durations were also recorded on the TASER.

Recent testimony (23) at the Braidwood Inquiry shows that there were four marks found on Mr. Robert Dziekanski's body which suggests that the TASER was also used in a push mode with the TASER pressed against other areas on the body in addition to the area resulting from the initial probe mode when the pair of barbs were fired from a distance.

The claims for safety made by TASER International Inc., are mainly limited to the the effects experienced by the subject when the TASER is fired from a distance in the probe mode. There does not appear to be any studies available which shows the safety impact of using the TASER in a push mode when it is typically used for pain compliance.

The most significant difference may be that the initial burst of pulse current is stronger than the subsequent ones in the push mode. In the probe mode the initial pulse burst would occur while the barbs are traveling towards the victim.

Also the safety claims are based on the aggregate of TASER uses which often does not distinguish how they were used. Also in many instances the statistics may include uses where the TASER weapon is presented but not deployed.

For example, it would be useful to know what proportion of the reported incidents involved only a single stun (five second burst of 90 pulses) as opposed to multiple stuns. Also it would be meaningful to know what proportion of incidents were used in push mode versus probe mode. It would also be important to know how long the trigger was held down
continuously. It is not clear if the current data recording capability on the TASER can be enhanced to allow these kinds of details to be recorded, extracted and analyzed.

For example, one would expect that upon examining only the cases where multiple stuns or long continuous stuns were used that the death rate would be higher than for those cases where only a single short stun was used since the level of energy deployed is greater. Further information may be required on TASER usage to allow studies to confirm
these kinds of conjectures. Capturing this data within the TASER that can be readily downloaded and analyzed is vital.

One key area that has not been examined or challenged by the inquiries, briefs and studies into the tragic death of Robert Dziekanski, are the safety aspects of the detailed internal requirements and design of
the software and hardware used to control the TASERs and the potential to make them safer to mitigate the risk of death of the victim.

An independent formal System Safety Analysis of the internal requirements, design and implementation would be in order for a complex device which has the potential to kill when misused by humans. Techniques such as hazard analyses, fault tree analyses, failure modes and effects analyses,
complemented by dependability analyses, human factors analyses, etc., would help to assure that due diligence has been done to make the
product safe and reduce the risk of death to a level as low as reasonably practicable.

"System safety deals with systems as a whole rather than with subsystems or components: Safety is an emergent property of systems, not a component property. One of the principle responsibilities of system safety is to evaluate the interfaces between the system components and determine the effects of component interaction, where the set of components includeshumans, machines, and the environment.

System safety takes a larger view of hazards than just failures: Hazards are not always caused by failures, and all failures do not cause hazards. Serious accidents have occurred while system components were all
functioning exactly as specified — that is, without failure. If failures only are considered in a safety analysis, many potential accidents will be missed.In addition, the engineering approaches to preventing failures(increasing reliability) and preventing hazards(increasing safety) are
different and sometimes conflict"(28).

Currently, TASERs are programmed to be activated in automatic five second bursts, (about 90 pulses) although the officer can stop the energy charge at any time by engaging the safety switch. The charge can also be prolonged beyond five seconds if the trigger is held down continuously. The operator can also inflict repeated shock cycles with each pull of the trigger as long as both barbs remain attached to the subject. The only technical limit to the number or length of the electrical cycles is the life of the battery, which can be ten minutes or more.

The study (6) done by Pierre Savard, Ing., PhD., Ecole Polythechnique de Montreal, et al, for the CBC, indicated that the threshold of energy needed to induce ventricular fibrillation decreased dramatically with each successive burst of pulses. The threshold for women may be less.

The average single oscillating pulse from X26 TASER is specified for a 400 Ohm load to have a a peak voltage of 1200 Volts and a peak current amplitude of 3.3 amperes and a average current of 2.1 milliamperes for
an average duration of 60 microseconds. The average current is much lower than the peak since the oscillations die down quickly. The initial current pulse was measured on some models to have a peak current of 5.1 Amperes.
These pulses occur at a rate of about 18.2 (+ or - 1) pulses per second or one pulse every 55 milliseconds or 55,000 microseconds.

Several studies (4,26,27) recommend that police should, where possible, minimize multiple TASER applications particularly continuous cycling of the Taser for periods exceeding 15-20 seconds (270 to 360 pulses). The pulse rate and duration is controlled by a microprocessor which acts as a switch.
It is the accumulated energy from multiple pulses which can induce extra heartbeats which in turn may result in a lethal ventricular fibrillation.

Since TASERs can be downloaded with modified software onto their internal microprocesor to control its pulse switching function, there is an opportunity to improve their performance by modifying the software used
to control the TASER. In the absence of any additional safety options currently available, the procurement documents by law enforcement agencies should specify, for example, that:

a) the duration of a given burst of pulses shall be limited to TBD (4) seconds and the time between bursts shall be be limited
to TBD (10) seconds minimum, even if the trigger is held down continuously, and

b) the repeated shock cycles must have their bursts of pulses progressively reduced in duration to TBD (5 to 4 to 3 to 2) seconds and the strength is limited to TBD (?) joules to each 60 msec pulse within a burst, and

c) the minimum allowable interval between shock cycles is increased progressively from TBD (5 to 10 to 15)seconds and

d) the number of shock cycles allowed repetitively within any time interval of TBD (20) seconds is limited in number to TBD (3).

e) The TASER must record and distinguish when the weapon was used in the stun mode versus the probe mode

f) The TASER recordings must allow determination of the duration of the intervals when the trigger is held down continuously.

g) The TASER must record the time intervals
between shock cycles,

h) The TASER should record the time when it is removed from its holster to be able to readily determine how often it was only presented.

i) etc.

Items e to h should be implemented as soon as possible to facilitate gathering of data for analyses.

The above TBDs (to be determined) for the time values and limits required for these additional safety constraints should modifiable by software upgrades and be guided by IEC 60479-2 (third edition 2007)
"Effects of current on human beings and livestock, Part 2. Special aspects", with an adequate safety margin, as indicated by Professor Pierre Savard's study, so that the risks of death or serious harm have been reduced to a level as low as reasonably practicable.

It would be useful to know which of the above requirements could be incorporated by TASER International Inc., into the design and
implemented into production, and how soon.

Once the safety consraints and specifications have been established by independent studies, the RCMP and other law enforcement agencies
across Canada must be directed to use their combined procurement capabilities and policies and buying power to specify safer operating characteristics for TASERs used in Canada.

Since we are dealing with a weapon which has the potential to kill if inadvertently misapplied, TASER International Inc., needs to comply with a formal System Safety Program for the TASER weapon
(http://www.system-safety.org/resources/ ,
http://en.wikipedia.org/wiki/Safety_engineering ) which addresses
the above concerns.

In addition, the RCMP needs to have a System Safety Management program established to ensure safety of all their operations similar to the one established for aviation
(http://www.tc.gc.ca/CivilAviation/systemSafety/pubs/tp13739/menu.htm ).

Robert Dziekanski, died after being stunned repeatedly five times by a TASER. The initial police report said it was only two times but the video has proved it otherwise. This kind of scenario must never happen again.

Improving the RCMP training program is not sufficient. In the heat of an incident we cannot expect the officer to count how many seconds he or she pulled the trigger continuously or how many times stun cycles were applied and how close together they were in time .

Therefore, in addition to improved training, the TASER weapon must also be made safer so that its inadvertent potential lethal misuse is prevented by design.

I look forward to your timely response and potential upgrades for safer TASERs.
Please provide a copy of your response to the Braidwood Inquiry as well, so that the Commissioner Thomas R. Braidwood, QC can take these items and concerns into account in his final report.

Yours safely,

Jim Ronback, P.Eng. (retired System Safety Engineer)

1530 Kirkwood Road
Tsawwassen, BC
Canada V4L 1G1

+1 604 948 1589


1) Review of Findings and Recommendations of Justices O'Connor and Iacobucci

2) RCMP Use of the Conducted Energy Weapon (CEW): January 1, 2008 to December 31, 2008

3) RCMP Use of the Conducted Energy Weapon (CEW)Final Report - Including Recommendations for Immediate Implementation,
June 12, 2008

4) Nova Scotia – Conducted Energy Device (CED) Review , March 5, 2008

5) The Truth about TASERS

6) Analysis of the Quality and Safety of the Taser X26 devices tested
for Radio-Canada / Canadian Broadcasting Corporation by National
Technical Systems,
Test Report 41196‐08.SRC

7) The official statement from Taser International

8) TASER response to CBC

December 2008

10) A Qualitative & Quantitative Analysis of Conducted Energy Devices:
TASER X26 vs. Stinger S200

11) The use of Taser weapons by New South Wales Police Force, November 2008

12) Taser-Makers Blast Back at Danger Room
Taser Zaps Critics - So Far

13) New study fuels debate on Taser safety

14) Engineers counter company's claim CBC Taser tests flawed

15) RCMP to test some Tasers after CBC investigation

16) TASER stun guns: for a European moratorium

17) Quebec orders police to turn in Tasers

18) IEC 60479-2 (third edition 2007) "Effects of current on human beings and livestock. Part 2. Special aspects"

19) TASER ® X26E Operating Manual

20) The Electric Shock Questions - Effects and Symptoms

21) Electroshock weapon


23) Braidwood Inquiry Hearing Transcripts

24) TASER Seeks to Zap Safety Concerns

25) VIDEO: [graphic content] Paul Pritchard’s raw video of Dziekanski’s Taser death (Runs 10:00)

26) British Columbia Office of the Police Complaint Commissioner. Taser Technology Review Final Report. 2005

27) Analyses et recommandations pour une pratique policiere quebecoise sur l'utilisation du disposatif a impulsions
http://www.msp.gouv.qc.ca/police/publicat/Taser/rapport_Taser.pdf Dec 2007

28) White Paper on Approaches to Safety Engineering, Nancy Leveson

29) Electrical weapon having controller for timed current through target and date/time recording, TASER US patent

30)Taser's Delirium Defense

31) Safety flaw in police's new gun (fire hazard)


a) The most widely used conducted energy devices (CED for Nova Scotia police) or conducted energy weapons (CEW for RCMP) models in the in Canada are the Advanced TASER M26 and the more recent TASER X26,
produced by the Arizona-based company Taser International. They are hand-held, battery powered devices, shaped like handguns, which fire two darts (probes) propelled by compressed nitrogen from a replaceable
cartridge. The darts have barbs on the end designed to attach to the target’s clothing or skin; once fired, they remain connected to the handheld unit by thin wires which have a range of between 15 and 35 feet (4.5 and 10.6 meters). When the trigger is depressed, short pulses of high-voltage, low amperage, electrical current pass down the wires to
the barbs, delivering an incapacitating shock. As noted above, the charge is intended to temporarily override the body’s central nervous and skeletal system, causing the subject to collapse with uncontrollable
muscle spasms.

b) The penetrating darts are a bio-hazard, which need to be handled in a way that minimizes the risk of contamination of victim from his own clothes or skin as well as others handling the barbed darts. The arcing
is a potential fire hazard.

c) Both the M26 and X26 Tasers are programmed to be activated in automatic five-second bursts, although the officer can stop the charge at any time by engaging the safety switch. The charge can also be prolonged beyond five-seconds if the trigger is held down continuously.
The operator can also inflict repeated shock cycles with each pull of the trigger as long as both barbs remain attached to the subject. The only technical limit to the number or length of the electrical cycles is the life of the battery, which can be ten minutes or more.

d) Their features include::
• Software upgradable
• Integrated laser sight with low intensity lights
• Central Information Display (CID) indicates countdown timer during an activation, battery level and warranty information.

e) The TASER CAM is an audio-video recording device integrated into a rechargeable TASER X26 power supply that replaces the standard Digital PowerMagazine (DPM). The TASER CAM is activated anytime the safety switch is in the up (armed) position. This allows officers to capture vital information leading up to and after the potential deployment of a TASER X26 device.

d) The TASER CAM interfaces using a Universal Serial Bus (USB) “plug and play” adapter to connect any Windows® 2000, 2003, or XP-based computer. TheTASER CAM is an optional upgrade compatible with all TASER X26 devices and provides another layer of audio-video evidence to support officer’s reports.

e) THE TASER® DIGITAL POWER MAGAZINE (DPM™) AND THE EXTENDED DIGITAL POWER MAGAZINE (XDPM™) are much more than just a lithium energy cell power supply systems for the X26. In addition to the lithium energy cells that power the TASER X26, the DPM also contains an onboard memory chip that maintains a record of the remaining power level in the DPM.
The DPM memory also contains specific information of energy cell performance and life expectancy for the energy cell pack at various temperatures and for various loads.

f) SERIAL DATAPORT DOWNLOAD KIT Optional download kits are available to permit departments to access the deployment information in the M26 device memory. The M26 device has a download function that can help
protect an officer from claims of excessive use of force by providing documentation of the time and date for each firing. The data download records the date and time for the last 584 discharges. The M26 download interface uses a serial adapter to connect to any Windows® 98, 2000, NT, XP or ME computer. The cable connects to the M26 device through the dataport plug.

Tom Anderson said...

I sell stun guns, pepper spray and TASER devices because I believe they offer citizens a non-lethal alternative to defending themselves with fire arms. I think if these self-defense weapons are used as designed they are excellent products, but their use is primarily to allow citizens a little extra time to get to safety.

I have noticed, however, that in Canada the police do not seem to be well-trained. Again, the problem is with the people using the weapon. It is possible to abuse any weapon, so it is not reasonable to reject a potentially life-saving device for no better reason than it can be misused.

Do you really think it would be better for police to shoot a suspect with a fire arm rather than use a TASER device or Stun Gun on him?

Personally, I would rather be shot with a TASER device than a fire arm any time.

We must always remember that the police represent the public's interest in securing safety. I believe that as law-enforcement officers, police have to meet a much higher standard of personal responsibility and integrity precisely because to them has been delegated the enforcement power of the government.

We should train police well and give them the weapons they need to do their jobs. We should not blame inanimate objects for the misuse that is properly the responsibility of those who use weapons.

Stun Gunner