Further written evidence from 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.  The UK Minister of State for the Armed Forces and Commander Joint Forces Command, along with two MOD lawyers, gave evidence to the Sub-Committee on 2 March.  This paper is designed to answer the supplementary questions raised by the Sub-Committee as a result of that session.  

1. Further information on the Minister’s initiatives, particularly on the Surgeon General’s review of deaths looking at trends.

Background.  In early January 2016 the Surgeon General, during his joining call with Minister of State for the Armed Forces, articulated that he felt that the Defence Medical Services (DMS) could do more to support our understanding of UK MOD non-operational fatalities, in the same way that the DMS supported operational deaths.  Minister was interested in the proposition, and was keen to receive a Ministerial Submission on the proposal once a methodology had been fully developed and staffed.  This proposition was first raised in November 2015 when the Sub-Committee started to look into endurance related fatalities.  The Surgeon General is keen that this proposition is taken forward in conjunction with other Defence organisations, and to ensure that the framework surrounding this proposition does not compromise the independence of the Defence Safety Authority (DSA) and the Service Inquiry process.   

Current progress.  The development of this proposition is in the early stages and will be subject to further staffing and agreement.  The DMS Medical Director is in the process of drafting the scientific methodology which will be ready for an internal DMS circulation by the end of March 2016.  MOD staffing will then be required in order to confirm the requirement and to determine what benefits could be derived from such a proposal.  A key element is how and when this work would be undertaken to not compromise the extant Service Inquiry process and other statutory inquiry processes.

Defibrillators. Since its formation in April 2015 the Defence Safety Authority (DSA) has conducted two Service Inquiries and one non-statutory inquiry into cardiac event related fatalities. In light of these, they have written to all Top Level Budget (TLB) Command Environmental Safety Officers and asked them, within existing policy guidance, to review local risk assessments at locations where organised physical training takes place (which have been linked to trigger events) in order to be assured that access to automated external defibrillators (AEDs) has been considered and that they have been provided where a need has been identified.

2. Please provide copies of the “potted guides” for training, exercises and selection events.

In addition to the DSMU which we have previously provided to the Committee, individual examples of “potted guides” have been provided by the Single Services.

• Army.  The Army has provided the following examples:

• Enclosure 1 – Instructions for Exercise FAN DANCE. [Not published]
• Enclosure 2 – Platoon Commander’s Battle Course Live Firing Tactical Training Instruction for Days 1 and 2. [Not published]

• Royal Air Force (RAF).  The RAF has provided the following example:

• Enclosure 3 – Letter of Authority for Adventurous Training (AT) activity that comprises clear direction with regard to the safe conduct of an expedition. [Not published]

• Royal Navy.  After Armed Forces Careers Office (AFCO) selection and pre-Potential Royal Marines Course (PRMC), candidates are directed by AFCOs to the Royal Navy and Royal Marines (RM) website for guidance and preparation; a key part of which is the RM Fitness Tool.  Post PRMC candidates are provided with the RM Recruit Handbook which provides detailed guidance on everything including nutrition, physical preparation, kit, and discipline.

• Enclosure 4 – RM Recruit Handbook. [Not published]

• The Royal Navy Reserves (RNR) uses a Virtual Learning Environment where students and instructors have access (away from RNR Units) to a range of presentations, material and forums whilst progressing through training.

3. Further information on Defence Safety Authority work streams and on updates of guidance for training, exercises and selection events. 

The DSA has initiated a series of workstreams to improve the approach to safety across the Department since its inception on 1 April 2015. Collectively they are referred to as the PRISM programme (Programme for Regulation and Investigation of Safety in the MOD).  This work will improve the way in which independent regulation and investigation is undertaken across all domains. Some parts of PRISM have delivered already - for example, the Defence Accident Investigation Branch was formed on 1 October 2015 – whilst others will take longer to deliver – for example, the rationalisation and simplification of the Defence Regulations contained within the Joint Service Publications (JSPs).

The Single Services have provided the following responses regarding updates of guidance for training, exercises, and selection events:

• Army.  The SO1 Physical Development Assurance has undertaken a review into the Assurance of PD (Physical Training (PT), AT and Sport) in order to establish what practices and procedures are in place in respect of first, second and third  Party Audit.  The first draft is due 19 March 2016.  However, it should be noted that since commencing the review the Training Delivery Authorities (TDA), Headquarters Royal Army Physical Training Corps (HQ RAPTC), Headquarters AT Group (Army) (HQ ATG(A)), Army School of Physical Training (ASPT) and Army Sports Control Board (ASCB) have enhanced their process, procedures and practices regarding assurance/audit.

Army Training Board are supporting DSA with the implementation of a Third Party Audit mechanism for AT Centres. This is work in progress which HQ ATG(A) are fully engaged with and supporting. The roll out of the process commences on 1 April 2016 and will be done in four tranches, each of 6 months duration. The first tranche commences with the Cadet AT centres.  The second tranche will be Phase 1 AT Centres (basic training).  The third tranche will be JSAT AT Centres and the fourth tranche will be remaining AT Centres.  Thus, all AT Centres will be inspected and licenced by 31 March 2018 at the latest.  Centres will be able to continue to deliver AT until they have either been inspected/licensed or until the end date of each tranche, whichever comes first.  Failure to obtain a licence from DSA by this date will result in the AT Centre having to cease delivery.  It was further agreed that, in order to ensure that any differences between Cadet and Regular AT Centres are properly considered, a second pilot of a Regular AT Centre will take place in Summer 2016.

• RAF.  The RAF does not believe there has been any updates in guidance during the past twelve months.

• Royal Navy. The DSA has responsibility for the production and publication of safety regulation/policy and, where necessary, appropriate guidance. The Navy Command, primarily through the Navy Safety Centre (NSC), will provide input to the development of policy and guidance relating to training, exercises and selection events as and when requested by the DSA.

• Joint Forces Command (JFC).  Director General Joint Force Development recently concluded and assurance analysis of JFC’s Training and Education and provided the JFC Board with an assessment of levels of training and Education across all JFC training providers.  This work focused on risk to life during training and education and in subsequent primary duty, care of trainees and compliance with statutes and regulations.  The JFC Board endorsed the recommendation to establish a Joint Individual Training and Assurance Team to bring coherence to training and education assurance activity and promote a culture of continuous improvement across training providers in JFC.

4. Examples, including dates, of training, exercises and selection events cancelled following dynamic risk assessments (including examples of events cancelled on the day).

Dynamic risk assessments form a vital part of the risk assessment process which is laid out in JSP 375.  Personnel at all levels are able to raise concerns over any activity.  As part of the formal risk assessment process additional dynamic risk assessments can be conducted if it is felt that something has changed that will affect the activity or adversely affect the safety of participants such as climatic extremes.

Examples of where exercises, training and selection events have been cancelled have been provided by the Single Services.

• Army. The Army provided the following examples:

• On 21 January 2016 a 6-mile loaded march retest was cancelled as there was no water available.
• On 29 January 2016 a Trainasium (aerial assault course) session was cancelled due to weather conditions being too windy.
• In the past Exercise FAN DANCE has been cancelled due to adverse weather conditions.

• RAF. The RAF provided the following examples:

• Exercise TELEMARK EAGLE 2 was an RAF sponsored expedition organised in order to expose RAF personnel to training and working in a winter environment using the medium of parachuting and Nordic ski touring, thereby, meeting the aims of AT.  It took place between 20 February – 9 March 2014.  On 1 March 2014, low level cloud made it too difficult for the aircraft to land at the landing site to collect the parachute team. Therefore, the parachute jump was cancelled. 
• During the Pre-Parachute Selection Course (PPSC) Instructors will hold a daily meeting to discuss the climatic conditions and whether the assessment timings need to be altered; Physical education staff will conduct a wet bulb globe thermometer test (in accordance with JSP 539).  The outcome of the daily meeting is recorded by exception (in accordance with JSP 375).  Examples of amendments to avoid climatic conditions were:

• PPSC 3/08 (March 2009). The 3 Peaks event was moved to STANTA due to adverse weather conditions in Yorkshire when snow and ice made the route dangerous and inaccessible.
• PPSC 1/09 (June 2009). The increased midday temperatures caused events to be planned for 0900-1000 and then from 1500-1800.
• PPSC 1/15 (April 2015). Due to the potential of increased daytime temperatures the 14 mile endurance event was moved to early morning.

• Royal Navy. A 30 mile speed march was cancelled in 2015 when it was assessed that two separate medical incidents resulted in an unacceptable level of medical risk remaining to those that remained.

5. Details of how an audit trail is maintained of risk assessments.

Records of risk assessments should be maintained in accordance with JSP 375, Part 2, Volume 1, Chapter 39 – Retention of Records and examples of an MOD risk assessment have already been provided to the Sub-Committee.  There is no specific legal requirement to retain some records once they have been replaced or are no longer relevant (e.g. risk assessments where the assessment has been replaced or the activity is no longer performed).  However, they should be retained for as long as they are needed and enable Defence to meet its legal and statutory obligations. For example, it may be required to demonstrate that there is a history of effective safety management within an establishment or unit, as part of a defence against litigation, or for evaluating the validity of a claim.

The Single Services have provided further information below.

• Army.  The Army has provided an example of an audit form of risk assessments at Enclosure 5. [Not published]

• RAF.  In relation to all Formal Training, all activities are conducted in accordance with a standard operating procedure (SOP), which incorporates the activity risk assessment, all of which are held on MOSS (an electronic filing system).  All SOPs are reviewed on a rolling annual basis.  The Chief Instructor is tasked as responsible for ensuring safe conduct on a daily basis.

• Royal Navy.  Navy Command implements the process of risk assessment in accordance with JSP 375, Part 2, Volume 1, Chapter 8. This requires the Commanding Officer or Head of Establishment to have in place a system for identifying and evaluating risk. Managers are responsible for the conduct, implementation and review of risk assessments and this includes informing personnel of any significant risks and their subsequent controls. Internal checks of risk assessment are conducted in accordance with JSP 375, Part 2, Volume 1 Chap 4. Compliance with MOD policy/guidance relating to risk assessment is further assured through the conduct of NSC safety and environmental protection audits, the frequency of which is dependent on risk.

All exercises within Phase 1 training have an associated risk assessment which resides on MOSS and a hard copy is included in every Officer In Charge Exercise pack.  It is subject to scrutiny at first, second and third party audits, establishment Safety, Health, Environment and Fire (SHEF) audits and routine Defence Systems Approach to Training (DSAT) inspection plus it will appear on monthly / termly Quality Improvement Plan discussions.

6. Further details of the adaptations made to training/selection pipelines, for example Reservists spending a week with their instructors before selection events.

The Single Services have provided the following information.

• Army.  Training progression for Phase 1 and Phase 2 is designed to dove tail one with the other and where special preparation is necessary it has been articulated.  In routine Phase 1 training the Army has the ability to use ‘visiting instructors’ which could be instructors from the recruit’s unit who both give the instruction during the training event and prepare and mentor the recruit between formal training events. 

• RAF.  The RAF provided the following examples:

• 10-week Basic Recruit Training Course at RAF Halton. During this supervisory staff have daily contact with the recruits within the Flights and therefore very quickly build rapport with those that they are supervising (maximum Instructor/Recruit ratio of 1:20).  Should the recruits have any issues, their first point of contact is their Flight Staff.  The recruits are all given an opportunity for a private and personal meeting with the Flight Staff at the end of each training day, but they also have access to the Welfare and Support Personnel, Padres, Duty Non-Commissioned Officer (NCO) and Medical Centre Staff (through the Duty NCO 24/7).  Additionally, the supervisory staff will read all the pen pictures of all the recruits prior to their arrival so that they are aware of any elements of their past that may potentially cause an issue through training.

• Furthermore, when the recruits undertake the practical elements (i.e. weapon training, First Aid, Chemical Biological Radiological and Nuclear) of Initial Force Protection Training, the Instructor/Recruit ratio is reduced to 1/10, therefore allowing closer supervision of the trainees. 

• Finally, Officer Commanding Recruit Training Squadron holds an ‘At Risk’ meeting on a weekly basis.  This will highlight where individuals are showing signs that will prevent them from progressing/graduating (i.e. fitness, welfare, Specific Learning Difficulty, external issues).  This is logged in a Welfare Register which is updated at each meeting.  Any on-going issues will be passed on to the Phase 2 Training Schools for their awareness so that they can monitor the situation as necessary.  

• Officers and Aircrew Cadet Training Unit at RAF Cranwell.  For this there is an ‘At Risk’ Register that contains the details of cadets who may be in circumstances that place them in a position where they are more emotionally vulnerable and make allowances to their training if necessary/possible.  Furthermore, each cadet must present their Flight Staff with any medical chits they have which highlight any physical limitations.  The staff will then decide if the cadet can undertake each training event.  This was highlighted as good practice in the Ofsted Inspection held in December 2015 where the RAF received ‘Outstanding’ in the 3 assessed areas.

• Royal Navy.  Unit Maritime Reserves instructors delivering Initial naval and military training during training evenings also attend training weekends as staff with their recruits and will invariably be part of the training team at HMS RALEIGH, Britannia Royal Naval College and Command Training Centre Royal Marines for the Confirmation Courses

7. Since the Reserves White Paper of 2013 with its identifications of new reliance and roles on Reservists, have each of the Services conducted a review of all individual and collective training events involving Reservists according to the DSAT methodology of JSP 822, namely; "training analysis, design, delivery and assurance of all Defence training, both individual and collective, across the Whole Force". What changes have been made to such Reserve training events and are yet to be made accordingly?

The Single Services have provided the following information.

• Army.  All training activity is reviewed in accordance with JSP 822 on a rolling basis as part of a planned programme by capability.  Planned evaluation focuses on the validity and efficiency of all training.  Courses are reprioritised annually against directed criteria so that highest priority courses are reviewed first.  As such not all Reserve training has been reviewed in the period as it falls outside of the mandated programme and the resources and requirement have not meant that this is possible.  Courses that have been identified as in need of specific change have been reviewed and many changes have been made across the totality of Army courses. 

The number of courses delivered to personnel in the Army means that to identify all individual changes would be impractical in the timeframe given.  However, the approach has been to remove the unnecessary distinctions between Regular and Reserve training as appropriate.  Where possible common training is used for both cohorts, either the personnel are trained together or on the same material or in some cases to the same standard but on different methods and media in order to optimise the training to fit the opportunities for training.  The resources for the development of courses are limited so both Regular and Reserve courses are developed as the resources allow.

A review of Collective Training has confirmed that the exiting model is still appropriate in that the Reserve unit follows the same Formation readiness Cycle as their paired unit.  Each sub unit completes collective training at level 1 and every third year undertakes level 2 training.  Some specialists do participate in level 3 training in order to support their paired units on exercises, but this is not mandated. 

Generic Pan Army Training (relates to second part of the question)

A review of Phase 1 training for all Reserve officers and soldiers was concluded in December 2014.  The content of the training review has been implemented across all Phase 1 training in accordance with DSAT as directed in JSP 822.  Additional reviews of training later in the officers’ career are on-going.  Whilst all Command Leadership and Management courses for Reserve soldiers have been reviewed and brought in line with regular training, the new training solutions have yet to be delivered.

Special to Arm Training

The majority of Reserve training has had to be re-developed as a result of the White paper.  Technical training pipelines have been reviewed and where necessary overhauled to ensure that Regulars and Reserves are trained to the same standard.  Where possible courses are open to both Regulars and Reserves with courses running over weekends to facilitate reserve attendance.  In some trades, transformation has already occurred and the reserve is already benefiting from this revision. 

Summary

In accordance with Defence Policy all training is subject to review on a rolling prioritised programme.  Wherever possible a single training solution is developed to meet both Regular and Reserve requirement, where not possible timeframes are varied to achieve a satisfactory outcome.

• RAF.  The RAF is in the process of finalising Leaflet 2410 which will form part of AP 3379.  The Leaflet aims to clearly articulate the Policy for the requirement  and involvement of all elements of the Whole Force in relation to all Force Development (FD) activities, including: Adventurous Personnel Development (formerly AT), Staff Rides, Team Building, military field training (in relations to FD only) and sport (when used as a vehicle for delivering FD).  In the case of Adventurous Personal Development, Reservists have been eligible and have participated under the same rules and regulations as Regular serving personnel for many years.

• Royal Navy.  The review of Royal Marine Reserves (RMR) and Royal Naval Reserve (RNR) requirements and Phase 1 syllabus has been conducted using DSAT methodology in line with JSP 822.  All other RMR training courses are reviewed in line with the regular course changes through Human Resources Training Services Group.  A further review was conducted last year of RNR Specialisation training and 27 Role Performance Statements are now in the course of final development.  Training Delivery using DSAT methodology has commenced with delivery of new RNR dedicated courses being piloted in Training Year 2016/17 and 2017/18.

8. Further information (including start date, terms of reference, and estimated end date) of the non-statutory inquiry commissioned by the Minister into MoD’s liaison and support to families of Service personnel who die or are injured?

A Non-Statutory Inquiry was convened on 25 September 2015 by General Officer Commanding 1st (United Kingdom) Division, Major General Giles Hill.  A copy of the Terms of Reference is included as Enclosure 6 to this response. [Not published]

In summary the Non-Statutory Inquiry has two key aims:

• Investigate and comment upon the notification process and after care of the families of the deceased

• Investigate and comment upon the welfare management of the personnel responsible for running the selection course

A Non-Statutory Inquiry is convened where there is no requirement in Statute for the authority to conduct an investigation, however the authority determines that there would be merit in exploring whether lessons can be learned. 

At this stage we are not able to provide an estimated completion date as investigations are continuing.    

Furthermore, the policy and processes supporting the delivery of Casualty and Compassionate procedures cannot be seen to fail as the risk is considered too great. Therefore Chief of Defence People’s area has commissioned an audit of the Casualty and Compassionate policy and processes to provide an independent and objective opinion to its adequacy and effectiveness.  The audit will review the process and procedures from the point of incident to the period post inquest. This will be an end to end process.  The Defence Internal Audit has been tasked with conducting this audit and is planning to produce their report in early August. However, it is acknowledged that this is both a live and complicated process and therefore additional time may be required. Furthermore, the process has been honed for the last 8 years and is working; however, there may be better and more effective ways of delivering.

9. Whether a corporate prosecution of the MOD would be handled by Police, Service Police or the Health and Safety Executive?

As the Health and Safety Executive’s (HSE) Director, Dr Snowball, explained in his oral evidence to the Sub-Committee on 25 November 2015, the Police take the lead in investigating where there is an indication that an offence of manslaughter, or some other serious offence, has occurred.  This is in accordance with the “Work-related Deaths Protocol” agreed between HSE, the Association of Chief Police Officers (ACPO), the Local Government Association and others.  In parallel with a Police investigation, HSE may also investigate possible Health and Safety at Work Act offences. The decision to prosecute will be coordinated between the Crown Prosecution Service (CPS) and the HSE on the basis of the Code for Crown Prosecutors. Under Section 17 of the Corporate Manslaughter and Corporate Homicide Act 2007, proceedings for an offence of corporate manslaughter may not be instituted in England and Wales without the consent of the Director of Public Prosecutions.

Legal guidance on the offence of corporate manslaughter can be found on the CPS’s website at http://www.cps.gov.uk/legal/a_to_c/corporate_manslaughter/

10. What assessment has been made of the roll out of the Duty Holder Concept in each Service? Where is it yet to be implemented? In which parts of each Service is the roll out most challenging and what continue to be the obstacles?

The Duty Holding (DH) construct is intended to enable each Top Level Budget (TLB) to design and implement its own safety management system for Risks to Life, structured around a coherent and broadly common structure for understanding, managing and transferring risk up and down each of the TLB’s organisational hierarchies.

The DSA has considered what needs to be done next to further enshrine this important construct and ensure that safety outcomes and operational flexibility are enhanced by its use. Since each domain (Maritime, Land, Air) has its own particular set of characteristics, the construct needs to be carefully adapted to ensure that still achieves its objectives while suiting the developing needs of each respective domain. To support this process the DSA is overseeing renewed efforts to enshrine the DH construct across each Service to ensure that its key principles are widely understood. Most recently, the Royal Navy has begun a trial to implement its own DH construct with DSA support. The Army and any other Defence organisations will be supported by the DSA as they further develop their own models.

At its heart, DH is about clearly identifying who in an organisation has the appropriate level of authority, both in a command and financial sense, to assess risks and ensure that they are content that their subordinates are not taking, or being exposed to, unnecessary hazards that could threaten life. In reality, this means that the rank or grade of DHs may need to differ between FLC, depending on how they are structured to deliver their Defence Outputs. For example, it may be that the Delivery DH (DDH) level sits naturally at the OF5 level in the Aviation domain, but rests more easily at OF6 in Maritime or OF4 in Land as is currently the case. Such distinctions are fundamental, if accountability is to be truly exercised and enabled through Letters of Delegation for example.

To provide more context examples from a couple of the Services are provided below:

• Royal Navy.  The Assistant Chief of the Naval Staff (Training) (ACNS(T)) safety structure, managed through the Operating DH (ODH) Working Group continues to provide the necessary information and assurance required by the ODH and his Commanding Officer Duty Holders (CODHs) to discharge their duties.  Self-assessment, combined with reported occurrences and near misses through the Navy Lessons Identified Management System (NLIMS) management tool, delivers the evidence that an appropriate safety culture is present throughout the ACNS(T) command.   Assessment  of performance against mandated Health, Safety and Environment Protection levels is formally reported to Chief Environment and Safety Officer (CESO) Royal Navy (RN) annually (last report 2 February 2016).

Navy Command’s response to the introduction of the DH construct has highlighted some areas for improvement. These improvements are currently focussed on the maritime environment which was identified as the area requiring the most urgent attention. The intention is to widen the scope of review and possible improvement to the other non-maritime areas when the maritime work was complete, however the DH construct is now being further developed under DSA PRISM Project 5. This work will likely impact on how Navy Command develops and implements its DH construct. The NSC is in the process assessing the effectiveness of the ODHs through assurance auditing.  It should be noted that any changes or difficulties implementing DH should not make activities unsafe due to the continued statutory requirement to exercise the employer’s duty of care.

• JFC.  In JFC the DH concept was set out in SOP 0013 which was first issued in October 2013. Higher Level Budgets and Permanent Joint Operating Bases were asked to report progress to CESO JFC and CESO monitors arrangements during routine SHEP audits and quarterly reporting and during discussions with Defence Regulators. The most challenging elements continue to be in Joint Operations, where, at times, there has been some confusion over DH responsibilities; however Duty of Care responsibilities are much clearer and typically ensures that ALARP status is achieved.

11. Are there any aspects of training, exercises and selection events where the Defence Safety Authority is not responsible for safety governance? 

First and foremost, the DSA must use its Regulators to regulate where the Department has exemptions from UK legislation instead of them replicating the Health & Safety at Work Act (HSWA).  Defence must comply with the HSWA and this is why the Duty of Care responsibility remains important in everything Defence does.  However, while the DSA does not need to duplicate the HSWA through its Regulators, as a Defence Authority it must direct Front Line Commands and support organisations to comply with HSWA.  Put simply, the HSWA is mandatory and must be followed at all levels of Defence.  In practice, this means that the DSA, in its Defence Authority role, instructs the Commands to follow the Act and provide assurance as to whether or not they are adhering to it. To close the assurance feed-back loop, the DSA is then responsible for providing the confirmation that the SofS needs that each TLB is compliant with the provisions of the HSWA. The DSA’s Defence Authority responsibility extends little further than this unless there is evidence of increased Risk-to-Life stemming from lapses in adherence with the Act or that mitigation is not in place to reduce Health, Safety and Environmental Protection risks to ALARP.  In areas such as these, DG DSA will be interested in any failure to meet the HSWA or other legislation, and what is being done by the Commands to make improvements.  

12. When will the Defence Board conduct its first assessment of the Defence Safety Authority? Similarly, what other organisations will audit or part-audit the DSA, as suggested by the Minister?

The Defence Safety Review will recommend that the requirement for periodic external audit of the DSA should be undertaken by an externally recruited team or organisation to provide an appropriate safeguard. This approach has already been successfully used to audit the Military Aviation Authority (MAA).  If this recommendation from the Defence Safety Review is accepted by the Defence Board, the first external audit of the DSA would be undertaken early in Financial Year 2017/18.

13. How many people have been removed from post [since 2000], by Service, for failures relating to the supervision of training or selection events? What other sanctions have been made for such failures?

It is worth explaining the purpose of Administrative Action.  Administrative Action is taken where there are professional or personal failings.  It can be taken in addition to disciplinary action but disciplinary action must take precedence before Administrative Action can be considered.  The emphasis is on rehabilitation.  The level of proof for Administrative Action is ‘on the balance of probability’.  The outcome can be either Minor or Major Administrative Action. 

Minor Administrative Action is covered in JSP 833, action can be either informal or formal interview; a period of three months is allowed for rehabilitation. 

There is also a range of major Administrative Action that can be taken. As an example in the RAF these are covered in AP3392 Volume 5, with two types of major Administrative Action available:

• Formal warning (Leaflet 129) which results in a three month rehabilitation period; mentioned in next annual appraisal; graded C at next Promotion Selection Board (no eligible for promotion for one year).  In addition, the individual is not posted or detached for the three month rehabilitation period.
• QR1027 action results in discharge from service, reduction in rank, re-muster to different trade (may also result in a reduction of rank), posting or, exceptionally, retention.

A further example of what options the Army use for major Administrative Action include:

• A Censure (No Discipline Entry). A Censure (No Discipline Entry) is intended to make a serviceman aware of the fact that his behaviour has breached the Service Test and fallen below acceptable standards but without the matter being reported to career boards.
• Censure (Discipline Entry). A Censure (Discipline Entry) is a more serious sanction than a Censure (No Discipline Entry). The Censure (Discipline Entry) is recorded by a Discipline Entry that remains on record for the remainder of the rehabilitation period or for 12 months if not based on a conviction.
• Reduction in Rank. The ordering of a reduction in rank is made under the authority of s.332 of the Armed Forces Act 2006 as amended by s.19 of the Armed Forces Act 2011. The rules applicable to reduction in rank apply irrespective of whether the rank is substantive or acting.
• Removal from Appointment. Exceptionally, the Army Board is permitted to order removal from appointment as part of the deciding of a case.  This is not to be confused with removal on the grounds that the subject is no longer tenable in post which is not of itself a sanction.
• Forfeiture of Seniority. In Administrative Action this sanction can be applied to officers only. Forfeiture will reset the officer’s Seniority Date and Incremental Base Date. The effect is that the officer’s seniority for both pay and seniority will be set back.
• Premature Termination of an FTRS Commitment. In this sanction the Deciding officer orders that FTRS Commitment is to be terminated 28 days from the date that the Directed Letter is signed.  The Reservist will be returned to the strength of the unit on which he was prior to the FTRS post.  The sanctioned Reservist is not prevented from applying for another FTRS post at any time.
• Termination of Service (Conduct). In common with modern employment practice, the Army will terminate the service of those servicemen whose conduct is deemed to be, in common parlance, ‘Gross Misconduct’.
• Termination of Service (Inefficiency).  Administrative Action that results in a sanction of Termination of Service for inefficiency will have always been preceded by a period of Formal Warning in which the serviceman showed an inability or unwillingness to improve

To give a full answer to the question has not been possible as it would require a recall and search of large volume of individual records over a number of years.  However, the Single Services have offered the following information:

• Army. Out of eight cases which have been found from a search of Army records there have been four letters of censure and four formal warnings linked to training incidents.

• RAF.  RAF records indicate that no Major Administrative Action has been actioned over at least the past five years in relation to a death in training.

• Royal Navy. In the Royal Navy there does not appear to have been any Administrative Action or disciplinary investigation initiated in the last year as a result of training safety incidents. However, since the beginning of January 2014, according to the Naval Casework Cell’s records, seven instructors have been removed from their posts within training establishments, but none of these were for failures relating to the supervision of training or selection events.  This does however show that training establishments are aware that this form of Administrative Action is available, and will use it if deemed appropriate

Administrative Action is very much like the action any employer can take.  It may be used to improve a person’s performance, but where that is not going to work, it can used to remove the person from his or her job, or from the Armed Forces. It is flexible and can be used to great effect but, as with similar action by other employers, it is an internal matter and not one for achieving public accountability.

It is worth highlighting that where an incident does happen it is investigated by the necessary bodies (for example, Civilian Police, HSE or Service Police) and their conclusions, independent of the chain of command are sent to the CPS or the Service Prosecuting Authority for action as required.

14. Further information on the changes to mechanisms for Service personnel to report safety concerns.

The Air Safety Information Management System (ASIMS) is an IT-based system that spans the Defence Aviation Environment.  It can be informed by personnel at all levels.  ASIMS has collected almost 200,000 separate reports to date, averaging over one thousand submissions per month. Not only does this information enable trends to be spotted by the Regulator but it is also used to feed the Military Aviation Authority’s (MAA) Air Safety Dashboard. This provides the evidence on which the MAA’s physical assurance audit programme is planned and adjusted according to the risk picture it portrays. Furthermore, ASIMS has been a significant contributory factor in fostering an open, honest, blame-free, learning culture with respect to aviation safety across all three Services.

Elsewhere, both Army and Navy Commands have introduced respectively the Army and Navy Lessons and Incident Management Systems (ALIMS and NLIMS). These are used primarily as accident and incident management tools, enabling the respective Commands to identify and track the lessons learned through a variety of different reporting mechanisms. Both Army and Navy systems are relatively new and therefore still evolving.

NLIMS incorporates a facility to record near-misses, the reporting of which is being promoted by the NSC.  Improvements to this system are constantly being developed and the NSC is conducting targeted training to improve the standard of reporting and analysis and the number of reports being made. The NSC is also working to improve safety culture through a dedicated team. Their work is further supported through the recent adoption of safety culture measurement which is conducted by NSC staff during the safety and environmental protection assurance audit process. 

Furthermore, the RAF has established the RAF Safety Centre based at RAF High Wycombe, which encompasses Total Safety.  Personnel across the AIR TLB receive a variety of promotional material/publications detailing points of contact, specific methods of reporting and wide ranging safety information.  Reporting of safety concerns is actively encouraged by the Senior Duty Holder and a Just Culture that supports open reporting is well established.  On the rare occasion when an individual feels unable to openly report a safety concern, confidential methods of reporting are available to our personnel through the Defence Confidential Occurrence Reporting System and through ‘In-form’.

15. What assessment has been made of the potential frictions and transferral of risk that can be caused in a training practice involving more than one Operating Duty Holder, including where ODHs concerned may sit within different chains of command? What steps have and need to be taken to reduce such friction and transfer of risk?

There has been some anecdotal reporting of the potential frictions that can occur at the boundaries between Duty Holders in different command chains, however, there has also been evidence of the system working as intended leading to examples of clearly identified risks being managed well and transferred effectively between supporting and supported Commanders. The DSA experience has been that when both Commanders understand the principles behind the Duty Holding construct well the system works, enhancing a Commander’s ability to take informed risk, either in training or on operations.  As a result of this experience, it has been a priority of the DSA to issue a common set of Duty Holder principles to all Defence stakeholders, and to work with all TLBs to ensure that they are understood consistently and intelligently applied in each specific domain.

To provide a couple of examples to add further context on this within JFC SOP 0013 (Duty Holder Concept) covers the responsibility for this (closely mirrored in JSP 815). It stipulates the process to follow to identify the appropriate Duty Holder (DH), including the need for stakeholders to meet and agree who the DH will be. A review of DH responsibilities in the MOD is currently underway and a proposal has been made that the single Services retain DH responsibilities on Joint Operations. However, this needs further work before becoming policy.

Within the Navy the only significant change to this structure has seen the splitting out of safety responsibility within 1 Assault Group Royal Marines (1AGRM) differentiating between training responsibilities answering to ACNS(T) as the Operational DH (ODH) and a new Delivery Duty Holder (DDH) responsibility for the provision of operationally ready Landing Craft to ACNS (Aviation & Carriers).  This differentiating of where DH responsibility lies has clarified the relationships between the Commanding Officer of 1AGRM and his respective training and operational delivery ODHs.

Issues of acceptance of responsibility to act as ODH have been identified in areas such as Adventurous Training. These issues are being taken forward under the general DH work which forms part of the DSA PRISM Project 5.

01 April 2016