Memorandum submitted by the Ministry of Defence

The Sub-Committee of the HCDC announced a new inquiry titled Beyond Endurance? Military Exercises and the Duty of Care on 19 October 2015.  This paper is intended to inform the Sub-Committee’s work and provide an overview of the Ministry of Defence’s (MOD) policy and processes related to military exercises and duty of care.  

1.              Number of deaths whilst on training or exercises.

Between 1 January 2000 and 24 October 2015, 131 members of the UK Armed Forces (Regulars and Reserves) have died whilst on training or exercise.  Of these 22 were from the Royal Navy, 88 from the Army and 21 from the Royal Air Force.  22 deaths occurred whilst on Adventurous Training and 109 deaths whilst on all other types of training or exercise.  98 deaths were the result of injuries, 29 deaths were due to natural causes or cause unascertained at inquest and four are ‘cause not yet known’. Of those who have died 13 were untrained personnel (classed as Personnel in Phase 1 or Phase 2 training[1]) and 118 were trained personnel. The biggest single cause of death due to injury is aircraft accidents from which 28 personnel have died.

2.              Policy. 

There are a number of overarching Defence policy documents which set out processes for governance of training and education within Defence and health and safety and risk assessment requirements.  An overview of the main policy documents is included below but how these policies are applied will depend on the individual nature of the activity.  Each Service will contextualise the overarching policies within their own policy documents.  Additionally, when greater details of the deaths emerge, for example if the cause of death is identified as a road traffic accident or as a result of adventure training, it might be determined that other policies related to that specific activity also apply.

All individual training and education within Defence should comply Joint Service Publication (JSP) 822, Governance and Management of Defence Individual Training and Education which is aligned with ISO 9001.  The JSP details how training will be governed, managed, analysed, designed, delivered and assured. This applies across the Whole Force which includes Regular and Reserve personnel, Specialist Military Units, MOD Civil Servants and Contractors delivering an endorsed training requirement that appears on a Statement of Trained Requirement.  The revised JSP, due in December 2015, will incorporate collective training as well as individual training. All training activities, wherever they take place, require a risk assessment.

Further policy is set out in JSP 898, Defence Direction and Guidance on Training, Education and Skills which includes Supervisory Care for Phase 1 Recruits and Phase 2 Trainees and Robust Training[2] which applies to all phases of training.  More specific policy is set out in JSP 419, Joint Services Adventurous Training; and JSP 538, Climatic Illness and Injury.

The overarching MOD policy on health and safety and risk assessment is set out in JSP 375, The Management of Health and Safety in Defence.  This sets out the Department’s requirements to comply with all applicable Health and Safety legislation (including legislation giving effect to the UK’s international obligations).  The Department’s approach to how and when risk assessments should be carried out set out in JSP 375 is based on the Health and Safety Executive’s recommended “5 Steps to Risk Assessment” which satisfies the requirements for risk assessment as set out in the legislation Management of Health and Safety at Work Regulations (1999).

3.              Assurance.

A key outcome of the Haddon-Cave report was a need ‘to clearly identify, and mark out, the Senior Duty Holders that have both the authority and legal responsibility with respect to the operation of military equipment.’  The MOD standards of supervision, responsibility and accountability for Health and Safety and Environmental Protection are set out in JSP 815, which specifically lays out the requirements of Duty Holding for high risk or risk to life activities.  The Duty Holder construct is the means by which specific individuals are made personally accountable and responsible for potential Risk to Life decisions.  As an example the Army uses a tiered Duty Holder construct consisting of; Senior Duty Holder, Chief of the General Staff; Operating Duty Holder, appointed for specific activities or groups of activities, normally at the 2* General Officer Commanding level; and Delivery Duty Holder, appointed for specific activities or groups of activities, normally at Unit Commanding Officer level.

Under MOD policy Defence Trainers are qualified and are monitored, assessed and mentored by qualified Defence Training Supervisors (DTS). In turn the DTS are managed by Defence Trainer Managers. Additionally Defence offers specific training courses for Heads of Training Environments which covers care and welfare responsibilities.

MOD training is governed by a structure of meetings which provide a forum for the escalation of risk and issues. For example, for individual training various working groups and steering groups feed into the 1* Training, Education, Skills Recruiting and Resettlement Policy and Assurance Group, the 2* Defence Training Policy Group and the 3* chaired Defence People and Training Board.  There is a similar structure for collective training governance although this was only captured in Collective Training Policy published as a standalone document in June 2015.

Training and education is also subject to a range of assurance activities outlined in JSP 822. These comprise continuous improvement, evaluation, and audit and inspection activities by first, second and third party agents.  First party audit and inspection is undertaken by those who have delivered the activity; second party audit and inspection is provided by an agent internal to Defence but external to those delivering the activity.  Third party audit and inspection is conducted by external organisations such as OFSTED and National Governing Bodies. 

4.              Investigation.

With effect from 1 April 2015 the Director General of the Defence Safety Authority (DSA) is the primary convening authority for all safety-related Service Inquiries (SIs).  The purpose of an SI is to determine the facts of an incident and identify any lessons to ensure that it is not repeated. It is mandated by statute[3] that a SI is to be held in the event of the death of a Service person, unless in the opinion of the Convening Authority there is nothing of consequence to be learnt by the Regular or Reserve forces that in his opinion was not apparent from the death.

The establishment of DSA brought together the Military Aviation Authority and the Defence Safety and Environmental Authority under the command of a single 3 star officer.  The establishment of a single DSA was a recommendation made by both Sir Charles Haddon-Cave[4] and Lord Levene[5]. 

An SI panel must comprise of a president and at least two other members[6].  The president must be an officer, subject to Service Law and of or above the rank of lieutenant commander, major or squadron leader.  The panel members must be an officer, warrant officer or senior non-commissioned officer of any of Her Majesty’s Armed Forces; or a crown servant.   All DSA convened SIs into circumstances resulting in a fatality have been convened with the president of the rank of commander, lieutenant colonel or wing commander.

The experience and qualifications of the SI panel members are carefully configured to ensure the appropriate subject matter expertise is available within the team relevant to the matter under investigation.  The panel is further provided expert support when required, such as in the field of aviation pathology, human factors and forensics.

Additionally, DSA SI panels are comprised of personnel drawn from across the 3 single Services to provide balance and independence from the Command in which the accident occurred

Where a Coroner’s Inquest (Fatal Accident Inquiries in Scotland) is convened, the Defence Inquests Unit (DIU) is the Departmental focus relating to the deaths of members of the Armed Forces (or civilians) who die as a result of operations or non-operational activity, including training.

The Coroners and Justice Act 2009 requires coroners to make reports to a person, organisation, local authority, government department or agency where the coroner believes that action should be taken to prevent future deaths.  Such recommendations are issued by coroners in the form of a formal “Report to Prevent Future Deaths” (also known as a Regulation 28 report).  For Defence inquests this is usually issued by the coroner to the Secretary of State or Defence Minister.  MOD has 56 days from the date of the letter to respond to the coroner.  If it is not possible to provide the coroner with an answer within the timeframe for response (56 days), the coroner has the power to grant an extension on application. 

On receipt, the Regulation 28 report is passed to the DIU to coordinate a response on behalf of the Department.  Having attended the inquest, and therefore being aware of the background to the coroners concerns, DIU tasks the relevant business areas with providing subject matter / policy advice on the matters raised.  Business units are advised to address the coroner’s concerns or give sound reasons as to the basis on which they are not accepted.  The DIU scrutinises the advice received from the relevant business area(s), then brings together all relevant advice to provide a draft response of the Department’s position which is circulated to relevant parties for review.  Once a final draft is agreed, it is submitted to the appropriate Defence Minister for final approval and onward transmission to the coroner.

5.              Lessons.

From 1 April 2015 the DSA has been responsible for managing recommendations arising from all DSA convened SIs in order to ensure an auditable trail exists regarding the implementation of those recommendations.  Each recommendation is assigned to an action authority[7].  The action authority is requested to nominate an appropriate point of contact known as the action appointment who is authorised and empowered to deliver the recommendation on behalf of the chain of command.

Each recommendation is assigned a lead official within the Defence Accident Investigation Branch (Defence AIB) and this lead works closely with the action appointee to agree an action plan, timeline and the required evidence / burden of proof that will be required in order for the Convening Authority to close the recommendation.  An update is required on progress every quarter with a formal report submitted to the Director General (DG) DSA bi-annually detailing the plan, actions to date and evidence of progress.  Where appropriate the Defence AIB official can make a recommendation for closure or, if insufficient progress has been made, recommend engagement by DG DSA directly with the action authority. The DG DSA is the only person who is empowered to close a recommendation arising from a safety–related SI.

In the event of a SI identifying an on-going hazard resulting in a continuing risk to life an Urgent Safety Advice note will be raised to all stakeholders / Operating Duty Holders identifying the hazard and highlighting the required action to be taken.

Since 1 April 2015 DG DSA has been responsible for the Defence safety regulators and investigators who operate across the Air, Maritime, Land, Nuclear, Ordnance and Fire domains. As such, there has been a much greater opportunity to ensure that recommendations arising from SIs can, if appropriate, be acted upon in terms of either regulatory change or assurance activity. This means that lessons are not only captured but also that they can be acted upon by the Regulator. 

Moving forward, one of the primary objectives of the DSA is to provide a means by which all such deaths are properly investigated, lessons identified and acted upon.

A number of systems exist across the Service Commands to capture lessons but the Defence-wide system is the Defence Lessons Implementation and Management System (DLIMS).  An example of how this is applied is the RAF which uses DLIMS and the DSA’s Air Safety and Management System (ASIMS) together with the bespoke Air Command Incident Reporting System (AIRS). Reporting to ASIMS occurs via three methods depending on the nature of the incident. AIRS is analysed for trends, monitored and a summary produced on a weekly basis for 3* consideration.  All of these systems allow individuals to raise lessons and for these to be tracked, monitored, analysed and reviewed in order to prevent recurrence.

A further example of how lessons are applied followed the tragic events of July 2013 involving Specialist Military Units. There have been a number of investigations and inquests which have identified shortcomings in the application of health and safety and risk assessment processes applied at that time.  As a result improvements have been made to the training packages in Health and Safety and Risk Assessment provided to the Commanders and Directing Staff involved in these exercises and other training activity. There is an ongoing SI which may identify further lessons from the events of 2013.  The approach to Health and Safety and Risk Assessment is one of continuous improvement.  Where issues are identified, these are examined and appropriate mitigating action undertaken to ensure Commanders fulfil their responsibility to reduce risk to As Low As Reasonably Practicable (ALARP)[8]

November 2015