Defence Safety Authority:

Annual Assurance Report
April 2018 to March 2019

 

Contents
1.

Introduction

2.

Context

3.

Safety Assurance

4.

DSA Maturity

5.

Analysis and Recommendations
•
•
•
•
•
•
•

6.

What’s Changed?
Brexit
The Modernising Defence Programme
Head Office Governance of Safety
Safety and Environmental Management System Baselining
‘Significant’ Safety Threats
Safety Think-pieces

Summary

Annexes
A.
B.
C.

Safety-Related Inquiries and Investigations April 2018 to March 2019.
Defence Nuclear Domain Safety Assurance (Limited Distribution).
Report Recommendations.

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i

 1.

Introduction

The Defence Safety Authority is an independent
authority that provides Defence with Health,
Safety & Environmental Protection (HS&EP)
regulation, assurance, enforcement and
investigation capabilities.1 It comprises seven
Defence Regulators for aviation, maritime, land,
nuclear, fire, ordnance and medical services
alongside HS&EP policy and business services
teams and the Defence Accident Investigation
Branch. Since its formation in 2015 the DSA has
substantially transformed attitudes and driven
improvements to HS&EP in Defence.
This Annual Assurance Report (AAR) provides
the Secretary of State (SofS) for Defence with
independent assurance that his policy for HS&EP
in Defence is being adequately promoted and
implemented. This is the DSA’s fifth AAR,
covering the period 1 April 2018 to 31 March
2019. This was a period of significant change,
both in the context in which Defence activities are
conducted and the way that HS&EP is managed
in Defence. The implications of these changes,
together with a review of what we have learned
from accidents, incidents, investigations and
enforcement action taken this year, are
considered in Section 2.

The DSA’s maturity and development are
considered in Section 4 which also describes the
recently published DSA Strategic Plan for 2019
to 2025 and the work being undertaken to
implement the recommendations of an
independent external audit of the DSA’s
effectiveness which took place last year.2

Previous AARs have highlighted a number of
long-standing and seemingly intractable issues,
so I am pleased to report signs of progress.
Increasingly mature Safety & Environmental
Management Systems (SEMS) are established in
many areas and are providing risk owners with
better visibility to manage those risks. Section 3
contains assurance assessments each of the
regulated domains. These improvements need
to be sustained and consolidated, with better
internal assurance mechanisms and
management information to support the work of
sufficient Suitably Qualified and Experienced
People (SQEP).

This AAR builds on the observations and
recommendations made by my predecessor in
last year’s AAR.3 That report was a critical
review of how well Defence was managing and
governing safety. It raised uncomfortable
questions and challenged the Department in
areas where we considered governance to be
lacking or where focus had been lost. In Section
5 this report reflects on how Defence, at all levels
and across its diverse range of high and low risk
activities, responded positively to that challenge.
It highlights some other emerging issues as our
collective understanding of HS&EP develops and
considers how the attitude and attention of the
Department have altered towards the goal of a
progressive and Just HS&EP culture.4 This is of
critical importance as a culture that is fit for
purpose will better enable delivery of the
Defence Purpose.5

This report also considers the maturity of the
DSA and its Regulators, which underpins
confidence in their assurance assessments. The
DSA will continue to develop its capabilities to
provide increasingly effective, proportional and
consistent HS&EP frameworks that are
transparent, accessible and practical.
1

4

Charter for the Defence Safety Authority dated 24 March 2015.
Parry, Report and Findings from the 2018 External Audit of the
DSA, November 2018.
3
MOD, Defence Safety Authority Annual Assurance Report April
2017 – March 2018, dated 26 October 2018.

DSA01.2, Implementation of Defence Policy for Health, Safety and
Environmental Protection, Chapter 5, Safety Culture, May 2018.
5
‘The Defence Purpose is to protect the people of the UK, prevent
conflict, be ready to fight our enemies. We are prepared for the
present, fit for the future’.

2

1-1

 Some of the most important changes during the
period of this report were the steps taken by
Head Office to address gaps in the governance
of HS&EP, supporting our military commands
and enabling organisations to deliver their
missions and services safely. The DSA is
working with the Chief Operating Officer and the
newly-established Directorate of HS&EP to
reinvigorate governance in this area and develop
HS&EP roles, responsibilities and policy
delineation between the Head Office and DSA.
The establishment of the Defence Safety &
Environmental Committee (DSEC), chaired by
the Permanent Secretary, is a particularly
welcome development which will provide vital
oversight and direction for HS&EP. This AAR
recommends areas where the Defence Board,
utilising the DSEC, may wish to further focus its
efforts and prioritise its investment in HS&EP.
The DSA will help set the standard for HS&EP in
Defence; knowing, sharing and demonstrating
what good HS&EP culture, leadership and
performance looks like. We do this specifically
through our regulatory set but also through our
embodiment and advocacy of a Just HS&EP
Culture and through our assurance, enforcement
and investigative activities. We act not only as a
regulator, but as a critical friend; working together
to keep Defence healthy, safe and
environmentally sound.

Air Marshal Sue Gray CB OBE FREng
Director General
Defence Safety Authority

1-2

 Context
2.1

Chief Operating Officer (COO) in summer 2018
and endorsed by the MOD Executive Committee
in January 2019, led to the establishment of a
new Defence Safety & Environment Committee
(DSEC), chaired by the Permanent Secretary
(Perm Sec) and with the Service Chiefs and
Chief Executive Officers (CEOs) of key Enabling
Organisations as members. A new Director
HS&EP role was also established to create new
governance structures to reinforce oversight of
Departmental safety management and
performance (See Section 5.4).

Operating Environment

The environment within which Defence operates
is complex. As the UK continues its
preparations to withdraw from the EU, the MOD
has begun to implement the outcomes of the
Modernising Defence Programme6 (MDP) and
play its part in the 2019 Spending Review. The
key themes of the MDP were to Mobilise
making the most of what we already have;
Modernise our forces and capabilities to be
more innovative and effective in maintaining our
strategic advantage; and Transform the way we
do business to create the financial headroom for
modernisation. This has been a decisive step
towards creating a whole-force structure with
capabilities to meet the Defence Purpose which
fits within our fiscal envelope and enables
Defence to sustain its required activity levels.
Whilst mobilisation and modernisation will allow
some ageing capabilities to be retired, it will also
necessitate change to the existing portfolio of
extensive business transformation7 and major
capability programmes.8 Therefore, the
importance of understanding, defining and
managing the safety and environmental
implications of each of these changes will
become more critical and an essential focus of
the Department’s senior risk owners, particularly
as they ensure their people, equipment, and
processes are both Safe to Operate and
Operate Safely. How these pressures may
impact Defence safety is discussed in Section 5
(Analysis).

2.2

Safety Performance

2.2.1 Safety Risks to Defence Personnel.
The specialist roles, activities and demands at
the very heart of Defence differentiates our
personnel from others. Whilst Defence
personnel are exposed to the same threats to
injury, ill health and death as the general public,
there is a unique mix of risk and rigour which
elevates that risk in some cases10, and reduces
it in others.11 Accountability for the management
of these risks in the MOD ultimately lies with the
Secretary of State for Defence (SofS), with the
Permanent Secretary (Perm Sec) as the
Principle Accounting Officer and Departmental
lead for Safety12, supported by the single
Service Chiefs13 and other Top Level Budget
Holders (TLBHs)14 as the Senior Duty Holders
(SDH) and risk owners for Defence.
2.2.2

Safety-Related Fatalities & Injuries.

•

Fatalities. There have been two
Defence safety-related fatalities15 during the
period of this report16 which are both subject to
Service Inquiries (SI) and two members of the
public died as a result of Defence activity.17

Integral to this have been the recommendations
from a Review of Head Office Governance of
Health Safety and Environmental protection
(HS&EP).9 This Review, commissioned by the

6

The MOD initiated a programme of modernisation following the
Government’s National Security and Capability Review in 2017/18.
7
Including the Army Command Review, the Defence Fire and
Rescue Project (DFRP) and DE&S Transformation.
8
Including the Queen Elizabeth Class carrier, Type 26 Global
Combat Ship, Astute and Dreadnought submarines, AJAX
mechanised infantry vehicle, Sea and Land Ceptor missiles,
Lightning II, P8A Poseidon, Crowsnest and E-7 Wedgetail.
9
MOD, Review into the MOD Head Office Governance of Health,
Safety and Environmental Protection, dated 18 December 2018.
10
Realistic training, operational flying, handling and use of firearms
and explosives and exposure to enemy action.
11
The UK Regular Armed Forces are at a statistically significant
lower risk of dying compared to the UK general population due in
part to the ‘healthy worker effect’, MOD, Deaths in the UK Regular

Armed Forces: Annual Summary and Trends over Time 1 January
2009 to 31 December 2018, published 28 March 2019.
12
The Perm Sec is nominated as the Departmental lead for safety
in the Charter for the Defence Safety Authority, dated 24 March
2015, para 6.
13
The heads of the Royal Navy, Army and Royal Air Force.
14
Comprising the Commander of Joint Forces Command (JFC)
and the Chief Executives of the various MOD Executive Agencies.
15
As determined by a Defence Accident Investigation Branch
triage or where a Service Inquiry and/or a coroner/procurator fiscal
(Scotland) has subsequently confirmed as safety related.
16
1 April 2018 to 31 March 2019.
17
Two Land Transport Accidents: MAN SV versus civilian pickup
truck (Belize, 7 May 2018) and MAN SV versus motorcyclist (East
Yorkshire, 24 August 2018). Both remain under police
investigation.

2-1

 2.2.3 Analysis. Supported by analysis
conducted by Defence Statistics - Health24, the
DSA continually reviews the data sources
available25 to identify any relationships or
significant trends in safety performance across
Defence, focussing on those areas that affect
personnel the most, in order to support senior
risk owners and help inform their risk
management activity.

Defence Safety-Related Fatalities
14 November 2018
Diving fatality, Portland Harbour
29 January 201918
Jackal vehicle accident19, Catterick Driving
Training Area
Figure 2-1

•
Injuries. Defence Statistics provides an
annual report on injuries, ill health and deaths
involving Defence Personnel and conduct
periodic analysis of trends.20 In addition to
investigating specific incidents, the DSA works
with Defence Statistics to understand the
underlying issues and trends which drive the
safety-related21 aspects of their statistical
analysis. The number of injuries reported in
2017/1822 are at Figure 2-2.

Figure 2-3
•

Safety-related Deaths. The level of
safety-related deaths26 has shown a reducing
trend (Figure 2-3), although it was recognised
that single accidents resulting in multiple deaths
(eg aircraft accidents) add volatility to this rate.
To place this into context, 61 Regular Armed
Forces personnel died in 2018 of which two of
the deaths (3%) were safety-related.27 From a
societal viewpoint, in comparison with other UK
industrial sectors over the period 2014 to 2018
the Defence sector carried a greater risk of
safety-related28 death than those working in
Construction, but was significantly better placed
than Waste/Recycling and Agriculture (Figure 24). In this reporting period the three leading
causes of death of Regular Armed Forces
personnel were Other Accidents (22), Cancers

Figure 2-223

18

24

The accident occurred on 29 January 2019; however, the soldier
succumbed to his injuries on 4 February 2019.
19
Jackal is a 4x4 High Mobility Tactical Vehicle.
20
MOD, Deaths in the UK Regular Armed Forces: Annual
Summary and Trends over Time 1 January 2009 to 31 December
2018, published 28 March 2019.
21
DSA focuses on safety-related deaths, injuries and near-misses
of on-duty Armed Forces personnel (including Reservists), Civil
Servants and Cadets.
22
The MOD Health and Safety statistics report for 2018/19 by
Defence Statistics has a provisional publication date of 31 October
2019, after this report has been finalised.
23
MOD, MOD Health and Safety Statistics: Annual Summary &
Trends Over Time 2013/14 – 2017/18, 20 September 2018.

ibid.
In conducting this analysis, the DSA has consulted the following
data sources: Service Inquiry Reports and Recommendations,
MoD and Statutory Regulator Enforcement Action, Air Safety and
Navy Safety Information Management Systems, Defence
Statistics, RIDDOR, TLB Risk Registers, DSA Annual Assurance
Reports and the Armed Forces Compensation Scheme.
26
Per 100,000 personnel.
27
One categorised as ‘Other Accident’ and 1 as ‘Land Transport
Accident.
28
For the purposes of this report, safety-related death equates to
work-related death as defined by the HSE.
25

2-2

 (10) and Land Transport Accidents (10).29 It
should be noted that there were 16 deaths
where the mechanism of injury suggests
possible suicide but a coroner’s inquest has not
yet been held. These deaths are categorised by
Defence Statistics as Other Accidents until the
coroner returns a verdict and therefore may be
determined as a suicide following inquest.

comprising the DSA’s Defence Land Safety
Regular, Devon and Somerset Fire & Rescue
Service and Dorset and Wiltshire Fire & Rescue
Service designed, produced and delivered a
compelling and innovative road safety film and
presentation aimed at reducing road traffic
collisions in Defence called ‘Survive the Drive’.
This initiative continues to be delivered at
Defence units and facilities to positive feedback
at all levels. While this campaign focuses on the
individual, these sobering statistics emphasise
the need for the continued attention of
commanders, line managers and the
Department as a whole to ensure the risk of
such accidents is reduced to a level that is as
low as reasonably practicable.

Figure 2-430

•
Suicide. The review of Service
Personnel suicides published last year31 made a
number of recommendations on what measures
could be taken to manage those at potential risk
of suicide. The recommendations have now
been transferred to the Chief of Defence
Personnel and are being actioned by the Suicide
Prevention Working Group (SPWG).

•
Injuries. The number of reported injury
and ill-health incidents across Defence remains
on a positive trend (Figure 2-5). Defence
Statistics reported that the rate of injury and illhealth for UK Armed Forces personnel had
‘significantly increased’34 over the last five years
even when considering the perennial issue of
late reporting.35 Previously this increase had in
part been attributed to factors unique to
Defence, such as the conclusion of Op
HERRICK36 and transition of Defence activity to
more smaller scale operations across a broader
range of skills and increased training activity.

•
Land Transport Accidents.32 Over the
last five-year period UK Regular Armed Forces
have been at a significantly increased risk of
dying as a result of Land Transport Accidents
compared to the UK general population.33 For
motor vehicle accidents the rate shows ‘no
statistically significant different risk to the UK
population’; however, our motorcyclists and
pedestrians are at a significantly greater risk
(123% and 252% respectively). During this
period a joint Road Safety Partnership Team

29

33

MOD, Deaths in the UK Regular Armed Forces: Annual
Summary and Trends over Time 1 January 2009 to 31 December
2018, published 28 March 2019.
30
Source: HSE, Fatal injuries arising from accidents at work in
Great Britain 2019, published 3 July 2019.
31
DSA, Defence Safety Authority Focused Review of Suicides
among Armed Forces Personnel – Final Report,
DSA/DMSR_04/Suicide Review dated 14 August 2018.
32
A land transport accident is defined as any accident involving a
device that has been designed for, or is being used at the time for,
the conveyance of either goods or people from one place to
another on land. The scope of this definition covers incidents that
occur on and off the public highways and incidents that involve
non-motorised forms of transport and does NOT include any
deaths occurring in a vehicle as a result of Hostile Action.

UK Regular Armed Forces personnel have a 66% increased risk
of dying as the result of an LTA compared to the UK general
population. Source: MOD, Deaths in the UK Regular Armed
Forces: Annual Summary and Trends over Time 1 January 2009 to
31 December 2018, published 28 March 2019.
34
MOD, MOD Health and Safety Statistics: Annual Summary &
Trends Over Time 2013/14 – 2017/18, 20 September 2018.
35
Late reporting and data corrections accounted for an additional
18% increase in reporting in 2016/17. Error bars have been added
to illustrate the range with which historical variations could affect
2017/18 figures.
36
UK combat operations in Afghanistan which concluded on 31
December 2014.

2-3

 investigations. The deployments included 13
vehicle incidents, 9 air systems, 3 maritime
platforms, 6 incidents involving weapons and
explosives, 4 involving heat injury, 1 suicide on
a weapons range and 1 fall. Whilst this has
been a similar number of deployments to last
year, it is a reduction compared to 2016/1739;
however, it is recognised that there will always
be fluctuations due to the nature of incidents.
Further analysis of the incident data40 shows
that in 2018/19, of the 37 incidents attended by
the DAIB, the triage reports41 highlighted that
failure to follow procedures, lack of appropriate
supervision, the taking of inappropriate levels of
risk and a lack of or inadequate leadership42
remain prevalent. However, two new themes
emerged:

Figure 2-537

However, whilst this was a plausible
assumption, the sustained increase in reported
injuries for the three years following Op
HERRICK would suggest otherwise. Instead,
this could either reflect an increased rate of
incident reporting or suggest that the current
measures TLBs have in place to reduce injuries
may not be effective or be appropriately focused
in the right areas. In reality it is likely to be a
combination of both. This is considered later at
Section 5.7.1.

•

Poor maintenance and equipment
husbandry. The loss of the WARRIOR in
BATUS and the fire on the FOXHOUND on the
M11 both had elements of poor maintenance.
The WARRIOR fire also had an element of poor
equipment husbandry, which had been seen in
similar WARRIOR fires in previous years.

•
Asbestos. A pan-domain issue for MOD
is the presence of asbestos, principally in the
built estate because of its age but also in some
older equipment. The DSA exercises oversight
of the way the Department discharges its legal
responsibilities to protect against exposure to
hazardous materials such as asbestos and other
harmful substances.

2.3
Defence Service Inquiries and
Non-Statutory Inquiries.
There are 12 Service Inquiries (SI)38 and 6 NonStatutory Inquiries (NSI) that have reported or
are on-going from this reporting period (see
Annex A). The Defence Accident Investigation
Branch (DAIB) was deployed on 37 occasions to
conduct the initial triage of these incidents and
has provided specialist support to SIs, NSIs and
MOD organisations conducting their own
‘Unknown’ is where the incident report did not specify the status
of the injured party.
38
11 DSA-convened SIs and 1 RN-convened SI.
39
35 DAIB deployments in 2017/18 and 48 in 2016/17.
40
Incident causes can only be confirmed following an investigation
and triage reports can only determine likely causes. Of 36 DAIB
deployments, 14 resulted in subsequent inquiries either by DSA or
Front-Line Commands.
37

41

An initial information gathering report, designed to furnish DG
DSA with sufficient information to determine follow-on investigation
requirements.
42
This includes the contribution of the Command level on an
incident as they allocate resource, set the organisation’s working
atmosphere (including Safety Culture) and generate the policy that
subordinate units work to.

2-4

 •
Training progression. The Glock pistol
NSI identified training progression as a factor,
with a subsequent incident resulting in injury
occurring in February 2019 in which training
progression was also likely to have been a
factor. This theme was also reflected in one of
the heat casualty incidents, where an individual
conducted an Annual Fitness Test with no prior
progressive build-up.

2.4.1 Enforcement by Statutory Regulators.
In the reporting period four Crown Improvement
Notices were served on the Department. Two
were served on the Defence Diving School44 in
October 2018 following the diving fatality on 26
March 2018. One enforcement notice was lifted
within the prescribed timescale and the other
required a short extension to ensure
compliance. Two were served on Joint Forces
Command in November 2018 following the
diving fatality in Portland Harbour which are
being complied with. Service Inquiries into both
incidents are ongoing. This upturn in Crown
enforcement notices (Figure 2-6) demonstrates
the reactive nature of Crown enforcement
activity normally as a consequence of an
incident, rather than the finding of a routine
audit. The necessary duration of statutory
investigations generates a natural lag between
when incidents occur and when enforcement
action is taken. On this basis, no statistical
parallel can be drawn between Crown
enforcement activity and rates of injury, except
for the direct relationship between Crown
Censures served on the MOD and the volume of
fatalities.

This is significant as both areas are pertinent
across most Defence activity and become
critical when managing high Risk to Life (RtL)
activities and exercising Duty of Care. The
evidence emphasises the importance of
leadership and the crucial role commanders and
supervisors play in personally influencing how
safely activity is conducted and engendering a
positive safety culture.

2.4

Enforcement Action

The majority of findings during DSA audits or
inspections are minor in nature and are dealt
with locally through Corrective Action
Requirements (CARs) or observations
documented in post-audit debriefs and reports.
Enforcement Action (EA) is utilised by statutory43
and Defence Regulators only where they find a
significant non-compliance or hazard which, if
left unaddressed, could impact safety, cause
environmental damage or place personnel and
operational capability at risk.

Figure 2-7

2.4.2 Enforcement by Defence Regulators
By having proportionally more resource
compared to the majority of statutory regulators
such as the HSE and being able to conduct
more comprehensive audit and inspection
activity, Defence Regulator EA is therefore able
to be more progressive. Trends in EA provide
valuable feedback and intelligence to both

Figure 2-6

43

External regulatory bodies that have the authority to enforce
compliance with applicable law and regulation. The MOD as a
Crown body cannot be prosecuted (except for charges of

corporate manslaughter), it can, however, be served improvement
notices or be censured.
44
Located at the privately-run National Diving Activity Centre in
Chepstow.

2-5

 Regulators and the Regulated Communities of
where weaknesses and non-compliances have
been detected. For Regulators this provides a
crucial input to their Analysis and Plans Cells, in
order to drive intelligence-led Risk-Based
Assurance (RBA).

2.5

Management Systems (SEMS) and compliance
with SofS HS&EP policy statements;48
•
Supported Senior Responsible Owners
(SROs) in generating effective Organisational
Safety Assessments (OSAs);49
•
Conducted work to determine the
potential effect of Brexit on Defence HS&EP
regulation;

DSA Activity

2.5.1 Context. There were three principle
inputs to DSA activity during 2018/19: the 14
recommendations from the preceding DSA
Annual Assurance Report (AAR), the External
Audit of the DSA and the Review of Head
Office Governance of Health, Safety and
Environmental Protection in Defence. In 2015
DG DSA committed to commissioning an
external audit of the DSA.45 The purpose of the
audit was to assess the quality of the DSA’s
work in order to demonstrate its effectiveness as
an organisation. The external audit took place
between September and November 2018 and
was led by Rear Admiral (Retd) Dr Chris Parry,
a former Director of DOC46 and an audit team
comprising a Principal Inspector from the HSE
and the Deputy Chief Inspector of the Office of
Nuclear Regulation (ONR). The audit made 5
findings and 65 recommendations to the SofS
(see Section 4.2). In addition, the Perm Sec
commissioned a review of Head Office
governance of HS&EP. The Review last year,
made 27 recommendations to the Perm Sec.
The outcomes and subsequent activities arising
from these 2 reports are discussed in detail at
Section 4.11 and Section 5.4 respectively.
These key recommendations ran in parallel with
the DSA’s standing commitments to its
Regulated Communities and its duties under the
DSA Charter.

•
Supported a successful International
Defence Safety Conference with SMI Group Ltd
in October 2018;50
•
Developed the framework policy on the
Duty of Care of deployed forces and Heads of
Establishment;
•
Commenced consultation with other
MOD Environmental Protection (EP) policy
owners to inform strategic oversight of EP
issues and help develop a strategy for EP
regulation and assurance within Defence.

2.5.2 Outputs. DSA outputs in 2018/19
included:
•
Conducted 1,462 audits and
inspections47 of Defence activity across all TLBs;
•
Commenced a programme of assurance
assessments of TLB Safety and Environmental

45

48

House of Commons Defence Committee, Beyond endurance?
Military exercises and the duty of care: Government Response to
the Committee’s Third Report of Session 2015–16, published on
24 April 2016,
https://publications.parliament.uk/pa/cm201617/cmselect/cmdfenc
e/525/52504.htm
46
Defence Operational Capability.
47
Comprising 362 Aviation, 254 Land, 90 Maritime, 533 OME, 170
Fire, 53 Medical Services audits and inspections.

Policy was promulgated at DSA01.2 Chapter 2, Organisation
and Arrangements; the Defence Safety and Environmental
Management System, December 2017.
49
The Defence Safety Policy and Assurance Team (DSPA) have
been providing a consultation service to a number of MOD
organisations who are either considering or are undertaking an
Organisational Safety Assessment.
50
Attended by over 200 personnel, with speakers from 10 allied
nations.

2-6

 Safety Assurance
3.1

Scope

Defence is bound by UK Health, Safety &
Environmental Protection (HS&EP) laws which
are appropriate and proportionate for managing
risks in the workplace and addressing the
effects of Defence activities on the natural
environment. This principle is at the core of the
Secretary of State’s (SofS) Policy Statement for
HS&EP.51 However, the span of Defence
activities includes inherently hazardous tasks for
which the well-ordered UK statutory health and
safety regime can in some cases be inadequate
or inappropriate. In these dynamic and
challenging environments, it is vital for military
commanders to be able to develop skills and
expertise in managing significant safety risks
during high fidelity and exacting military training,
where personnel ‘train as they fight’, to prevent
risk being transferred to the operational
commander.
To cater for these specific circumstances,
Defence has a number of disapplications,
exemptions and derogations (DEDs) from UK
Law.52 In the case of these DEDs it is the role of
the DSA, on behalf of the SofS, to maintain
arrangements in the form of regulations where
there is no statutory requirement or where
assurance of specific hazardous activities is
required.53 The DSA is also required to provide
independent assurance to the SofS that
Defence is complying with his HS&EP Policy
Statement,54 and to investigate accidents.

•
•
•
•
•
•
•

Aviation
Maritime
Land
Fire
Ordnance, Munitions and Explosives
Medical Services
Nuclear

Each Regulator assures, regulates and enforces
where the MOD has DEDs from statute, where
the MOD itself is considered to be the appointed
statutory regulator55 or for certain high hazard
activities in their domain for which civil statute
does not exist56, while the role of assuring
compliance with the SofS’s HS&EP policy is
currently being led by the Defence Safety Policy
& Assurance Team within DSA HQ.57

In this context regulation of Defence Safety is
divided into seven domains and functional
areas, each overseen by a Defence Safety
Regulator:

51

MOD, Health, Safety and Environmental Protection in Defence:
Policy Statement by the Secretary of State for Defence, dated 20
June 2018.
52
A disapplication means that a law or article does not apply to
the MOD. An exemption from an aspect of law can be granted by
the SofS for Defence in exceptional circumstances. Derogations
from particular provisions of legislation may be sought by the
MOD, normally during the drafting process.
53
‘To produce outcomes that are, so far as reasonably practicable,
at least as good as those required by UK legislation’, MOD, Health,
Safety and Environmental Protection in Defence: Policy Statement

by the Secretary of State for Defence, dated 20 June 2018, para
2d.
54
Defence Safety Authority Charter, para 2.
55
The Defence Fire Safety Regulator has statutory powers under
the Regulatory Reform (Fire Safety) Order 2005 and the Fire
Scotland (Regulations) 2006.
56
eg complex conventional or nuclear weapons systems.
57
Pending establishment of the Head Office Health, Safety &
Environmental Protection Directorate and delineation of policy
areas.

3-1

 3.1.1 Assurance Model. Defence Safety
uses a 3 Level Assurance Model:58
•
•
•

Assurance Levels
Full:
System of internal control established and
operating effectively.
Substantial:
System of internal control established and
operating effectively with some minor
weaknesses.
Limited:
System of internal control operating
effectively except for some areas where
significant weaknesses have been
identified.
No Assurance:
System of internal control poorly
developed or non-existent, or major levels
of non-compliance identified.

1st Party Assurance (1PA): Self-assurance
(formation/unit/section level)
2nd Party Assurance (2PA): Management
oversight (higher command (TLB)/formation)
3rd Party Assurance (3PA): Independent
assurance (DSA, statutory regulator or peer)

Each DSA regulator conducts 3PA in its domain
or functional area across all relevant TLBs to
make an evidence-led assessment of HS&EP
compliance. This is done by assuring the 2PA
and, where necessary, 1PA conducted by TLBs
in addition to conducting independent audits
and, in certain conditions, by inspection. The
DSA does not act on specific HS&EP risks
owned and managed by TLBs59, but assures
SofS of compliance with his policy. The DSA
also assists TLBs by drawing parallels or trends
where issues or causes are cross-cutting or
systemic.

Figure 3-2

3.1.2 Safety Assurance Assessment. The
DSA’s assessment of the Safety Assurance
Level of each of the regulated domains and
functional areas60 is based on the Regulators’
assurance assessments of each respective
Regulated Community (RC)61, based on
evidence collected throughout the reporting year
and inputs from TLBs.62 Levels of assurance
are categorised as: Full, Substantial, Limited or
No Assurance (see Figure 3-2).63

For each domain this report provides in the
following sections a clear statement of
regulatory assurance for the domain as a whole
and the regulatory assurance of each TLB
operating in the domain,64 with the report for the
Nuclear domain at Annex B.65 Each section
contains a graphical representation in the format
of Figure 3-1, showing relative levels of activity
by TLBs active in the domain, and an
assessment of assurance is given for each.
To provide TLBs and risk owners with guidance,
the report specifies any areas of significant
weakness within each domain or functional area
supported by evidence including, where
appropriate, examples of Acceptable Means of
Compliance (AMC) or Defence Codes of
Practice (DCo-P) in order to improve Safety
Assurance.66 Where the Safety Assurance
Level has changed from the preceding year, the
level of evidence provides sufficient detail to
support the change and provide the respective
TLB with guidance upon which they can act.

Figure 3-1
DSA01.1, Defence Policy for HS&EP, Chapter 5 – Checking and
Performance Reporting, para 3.
59
That is the role of the respective TLB senior risk owner and
Senior Duty Holder reporting through to the Defence Board risk
owner in accordance with existing Departmental policy.
60
For ease throughout this report the term ‘domain’ equates to
‘domain and functional area’.
61
defined as the organisations or units within a TLB or Executive
Agency whose activities fall under Defence safety regulations for a
specific domain.
58

62

Each TLB was invited to provide DSA with any additional
evidence (in the form of annual assurance report, risk registers,
etc) to inform the safety assurance assessment.
63
Defence Internal Audit definitions of assurance which originate
from the Chartered Institute of Internal Auditors.
64
Each TLB operates across many regulated domains and
functional areas.
65
Protectively marked SECRET.
66
It is the role of the DSA to advise Head Office of the ‘ends’,
allowing TLBs the freedoms to exploit the ‘ways’ and ‘means’.

3-2

 Aviation
3.2

Assurance Level

SUBSTANTIAL Assurance - Improved position, particularly across Army, JFC and Navy aviation.

3.2.1 Scope. Defence has an almost total
exemption from the United Kingdom’s Air
Navigation Order67 requiring it to regulate all
Defence aviation activity. This is done by the
Military Aviation Authority (MAA).68 All three
Services and JFC operate in the Aviation
Domain with significant support from DIO69,
DE&S70 and, through them, Industry which is
also subject to MAA regulation and assurance.

DE&S Delivery Teams (DT) subject to 61% of
surveillance activity. Applying a risk-based
approach, Industry was subject to high levels of
audit as they have comparatively less Duty
Holder (DH) assurance compared to military-led
aviation. DE&S DTs had the next level of focus
as they are fundamental in ensuring air
platforms and airborne systems are
appropriately certified and ‘Safe to Operate’.73

3.2.2 Regulator Activity. During the reporting
period the MAA conducted 362 audit, oversight
or surveillance events; reviewed/issued 106
organisation approvals71; issued 53 Type
Certificates and Certificates of Safety (Aviation)
and delivered 160 training courses to ~3650
delegates. This activity covered Industry
approved organisations, the four Front Line
Commands and DE&S. Industry approved
schemes had by far the most audits (58%)72 with

3.2.3 Findings. In a year with no fatal air
accidents and with the annual accident and
fatality rate continuing to decline74 (Figure 3-3)
there have been numerous improvements in
safety assurance across the Defence Air
Environment (DAE). Areas of previous
regulatory concern such as the management of
Ageing Aircraft, the conduct and oversight of
Display Flying, the governance of parachuting
and the inconsistencies and variability observed

Civil Aviation Authority Publication 393 (CAP 393), ‘The Air
Navigation Order 2016 (ANO) and Regulations’, Article 22, 25
August 2016.
68
The safety regulator for all military aviation within Defence.
69
Defence Infrastructure Organisation.
70
Defence Equipment & Support, a bespoke trading entity (BTE)
and arm’s length body of the MOD.

71

67

Under its Regulatory Articles, the MAA operates approvals
schemes for companies who wish to undertake the design,
maintenance, test or operation of UK military air vehicles.
72
76 of 130 audits.
73
Whereas the Front-Line Commands through their Duty Holders
(DHs) ensure they ‘Operate Safely’.
74
Average fatal military aviation accidents (and fatalities) per
annum have continued to reduce from 5(13) in the 1990s to 3(7) in
the 2000s and to 1(2) for the current decade.

3-3

 of Air System Safety Cases have all lessened,
with evidence of DHs managing their risks
effectively, thus demonstrating the supporting
regulations as fit for purpose. These
improvements alongside the existence of only
minor Air Safety control weaknesses are enough
to warrant raising the safety assessment to
SUBSTANTIAL safety assurance. However,
despite this level of assurance aviation safety is
still affected by Defence-wide issues such as
insufficient Suitably Qualified and Experienced
People (SQEP), significant organisational
change, shortfalls in 2PA, gaps in Continuing
Airworthiness activity and understanding, weak
air system configuration management by DE&S
DTs and declining/deteriorating infrastructure.
Mid-Air Collision (MAC) remains the dominant
threat in this domain in terms of severity or
reputational damage warranting continued
tracking, but it is not the only threat as there are
several emerging safety issues which will be
subject to directed activity in the coming year.

SQEP to deliver its full breadth and scale of
safety functions, requiring prioritisation of safety
functions. Whilst this is both unpalatable and
sub-optimal, it is being actively managed by
TLBs.76 Last year we highlighted the linkage
between ineffective assurance and instance
where personnel Fail to Follow Procedures
(F2FP).77 This has been subject to increased
focus during assurance visits78 including a
number of studies to consider the causal factors
of F2FP. MAA analysis will continue into
2019/20 as a number of mitigating measures are
developed with the Defence aviation community.

•

Infrastructure. TLB reporting of
infrastructure related air safety issues has
increased significantly over the last 5 years.79
Analysis of the issues identified do not
suggest an immediate unmanaged safety
hazard as DHs appear well-informed and are
actively managing the resultant risks. However,
critical infrastructure failures are often difficult to
predict, particularly where there has been
previous underinvestment in preventative
maintenance, leaving DHs little option but to
reduce outputs.80 It is evident that risk owners
are unable to effect much change due to
resource limitations. As part of the MAA’s riskbased assurance, infrastructure will remain an
element of the overall rich picture assessment,
particularly to monitor the 2nd and 3rd order
effects of deteriorating or unfit for purpose
facilities which could threaten the preservation
of air safety.81

•

•
2PA. With formal 2PA frameworks now
established and functioning across TLBs, MAA
assurance activity continues to indicate that 2PA
(and assurance in general) is not occurring
at a sufficient pace or consistency75 for TLBs
to assure safety effectively. This is more
prevalent where an organisation has insufficient

SQEP. The provision of SQEP across
TLBs remains challenging. In many cases the
proportion of Air Safety posts filled is greater
than that of other disciplines; however the
resourcing of Air Safety SQEP remains
patchy across the DAE.82 While shortfalls
have been formally acknowledged by DHs, they
have had limited success resolving them on an
enduring basis.83 MAA audits have continued to

75

79

Figure 3-3

Wide variances have been observed in the assurance
assessment by 2PA and 3PA organisations auditing the same unit
(eg unit assessed as at FULL assurance by 2PA but assessed as
LIMITED assurance by 3PA).
76
eg a decision by the 22 Gp Air Safety Team to cancel an Air
Safety Assurance Visit to 1 Flying Training Squadron was formally
staffed to the Operating Duty Holder to endorse the change.
77
Instances where users fail to follow or comply with published
procedures or SOPs either through ignorance, intent (for personal
or organisational gain) or procedures being unachievable.
78
MAA teams have used Regulated Community bow-ties on
Failure to Follow Procedure or Release of a non-Airworthy Aircraft
to examine the barriers that have been identified and where there
are issues with the efficacy of those barriers.

Infrastructure related reports were averaging ~15 per quarter in
2013, increasing to ~60 per quarter in 2018.
80
eg heating failures in technical facilities at RAF Benson were
delaying the output of Puma aircraft from Depth maintenance.
81
Poor working conditions and unreliable building services putting
stress on our people and in some cases requiring them to operate
differently or deviate from the norm.
82
Navy Comd has a suitably resourced and SQEP Air Safety
team, Joint Helicopter Comd (JHC) Air Safety teams are well
staffed against their established liability; whereas, there are
variances in staffing across Air Comd Air Safety teams.
83
eg the use of Holding Officers from the flying training system has
provided some Air Safety personnel who subsequently attain some
qualification and limited experience, but it is not a sustainable
solution.

3-4

 identify gaps in DH awareness of the
importance of Continuing Airworthiness
(CAw) activity and the role of CAMOs.84 Action
has therefore been taken to increase the
emphasis on CAw in DH training courses and a
review of CAMO training is underway. There
has been continuing evidence that SQEP
shortfalls of Aerospace Battle Managers and Air
Control Managers are requiring active
management to prevent it impacting safety in
the DAE. Gapping at Air Traffic Management
has resulted in reductions to the extent of
services provided to airspace users85 and
reduced aerodrome opening hours and the
provision of ATS for transiting aircraft. In DE&S
SQEP shortfalls across all functions mean that
while safety critical activity is completed other
programme activity which could have safety
impact is not being progressed, with ODHs often
unaware of this. Long-standing SQEP shortfalls
in airworthiness management in DE&S constrain
assurance levels,86 although there are
indications that the freedoms and levers
available by being a BTE may enable
improvements. Whilst discrete plans to manage
the effects are being dynamically managed
locally, the cumulative impact on Air Safety of
SQEP shortages will necessitate the continued
focus of DHs, DE&S and the Regulator.

conducted retrospectively, post the major
change decision88 which is entirely contrary to
the intent of the OSA. The DSA recognises the
need to educate and support TLBs in conducting
OSAs across all domains and has committed to
improving education and practical guidance on
this matter.
•
Mid Air Collision (MAC). Military
Airprox89 figures for the past year indicate little
change with approximately the same number of
events. Conversely, civilian Airprox has
increased markedly in recent years principally
through increasing numbers of Airprox reports
with drones (Figure 3-4). Airprox between
drones and military aircraft has not seen similar
increase, continuing at around 10-15 per year90
compared to 126 for civil aircraft in 2018.91
Analysis has shown that this issue is more
prevalent in built-up areas and around major
civilian aerodromes, areas that affect only a few
military operators. However, in addition to
increasing the size of the Flight Restriction Zone
(FRZ) introduced by the UK Civil Aviation
Authority in July 2018 to protect specified
aerodromes92, the Department for Transport has
agreed to work with MOD93 to address the risk of
drone MAC in the low flying environment. In
addition, the DSA continues to support the
fitment of Collision Warning and Traffic Alert
Systems to all military air platforms as an
important (but not fool proof) additional barrier to
potential MAC events, while continuing to work
with the Regulated Community (RC) to identify
other mitigation options. Contrary to general
practice in civil aviation, there is an operational
advantage and military need for Defence to
bring aircraft into close proximity.94 In these
instances the technical and airspace control
measures mitigating MAC have limited or no
value, with MAC avoidance relying heavily upon
airmanship, Standard Operating Procedures

•
Change. MAA assurance activity has
again highlighted the difficulties faced by DHs in
managing high levels of complex change, be
that the introduction of a new air platform or a
major organisational transformation.
Awareness of tools such as Organisational
Safety Assessments (OSAs)87 to help
preserve safety during change is growing
across the DAE; however, there continues to
be a general lack of understanding of their
purpose and the effort required to complete
them. All too often the OSAs have been

84

Continuing Airworthiness Management Organisations.
eg unavailability of staff had caused an instance where the RAF
unit embedded in London Area Control Centre (Swanwick) was
unable to provide an ATS to allow military aircraft to cross airways.
An alternative sortie content was devised and a curtailed sortie
remaining clear of Controlled Air Space was flown.
86
eg the issue of an Improvement Notice to the UK MFTS DT due
to long-standing SQEP shortfalls impacting on airworthiness
management of the Future Rotary Wing and Future Fixed Wing
programmes.
87
DSA01.2, Chapter 7, Assessment of Organisational Change on
Health, Safety and Environmental Protection, issued 8 July 2018.
88
such as the OSA supporting the transfer of aircraft trials and
evaluation (T&E) between Groups within Air Comd.
89
a situation in which, in the opinion of a pilot or air traffic services
personnel, the distance between aircraft as well as their relative
positions and speed have been such that the safety of the aircraft

involved may have been compromised. Source: UK Airprox
Board 2019. Statistics presented are limited to Airprox reporting in
the UK Flight Information Region (FIR) as published by the UK
Airprox Board. Military Airprox occurrences outside the UK FIR
are reported to the controlling nation where the instance occurred
and to the MAA. Specific analysis of overseas Airprox did not
determine any trends in relation to either area of operations or
causes of event.
90
12 reported in 2018 compared to 10 in 2017.
91
Source: UK Airprox Board.
92
https://www.caa.co.uk/Consumers/Unmanned-aircraft/Ourrole/Airspace-restrictions-for-unmanned-aircraft-and-drones/
93
through the Assistant Chief of the Air Staff as the Departmental
lead.
94
Aircraft interception, tactical formation flying, air combat, air-toair refuelling and display flying.

85

3-5

 •
Technical Data Exploitation (TDE).
Failings in adequate data analysis have been
identified in several Service Inquiries.98 The
Regulator has now initiated a Multi-Disciplinary
Team project to review TDE regulation;99

(SOPs), training and currency. Understandably,
this poses a significant risk of MAC to military
operators worldwide with the UK having had
three military-military MAC events in the last
nine years.95 Analysis of international military
MAC events since 2010 highlighted statistically
the likelihood of MAC is greater in the conduct of
pre-planned, authorized, high-risk activity in
which several military air platforms operate with
reduced separation. DHs have therefore been
asked to consider and review their mitigations in
light of this analysis.

•
Carriage of Passengers. The MAA has
commenced a complete review of the
categorisation by which individuals are carried
on UK military registered aircraft and the safety
management of non-Aircrew passengers and
supernumerary crew;100
•
Synthetic Training Devices. A review is
being conducted into qualification and
certification of synthetic training devices, to
ensure that synthetic training devices are
appropriately designed, qualified and maintained
in order to deliver the necessary training credit,
both in terms of quality and quantity as
stipulated in the Air System Safety Case.

Summary - SUBSTANTIAL
This improved assessment recognises the
progress that has been made in a number
of areas. However, minor weaknesses
remain and the picture is not consistent
across TLBs. Ineffective OSAs and lack of
robust 2PA remain control weaknesses, and
SQEP and infrastructure are considered as
managed issues. Change, SQEP and MAC
are complex and intertwined with initiatives
to address taking time to deliver, but the
steps being taken to improve matters are
recognised. Overall there have been
sufficient improvements across the DAE as
a whole to make the small but important
step up to a SUBSTANTIAL assessment,
noting the absence of any major control
weaknesses. However, there remains much
to do to embed the resource and behaviours
to achieve an enduring SUBSTANTIAL
assurance level across all TLBs and
continue driving Air Safety forwards.

Figure 3-4

3.2.4 Emerging Issues. Whilst none of the
following issues present an immediate threat to
safety, the Regulator has identified them as
requiring further review and analysis in the
coming year:
•
Defence Aeronautical Information. 96
Integral to the safe conduct of aviation, work is
being initiated to assure the origination,
management and publication of Defence
Aeronautical Information;
•
Safety Modification
Recommendations. A review of
recommendations following Service Inquiries
has highlighted a number of modifications that
have yet to be embodied. Whilst there are many
reasons for non-embodiment97, the MAA will
monitor progress of all safety modifications
through assurance activity;

95

3 July 2018: Phenom v Phenom, 3 July 2012: Tornado v
Tornado, 23 March 2010: Red Arrow v Red Arrow.
96
eg Aeronautical Information Publications (AIPs), low level charts,
meteorological information, etc.
97
ranging from lack of resource, prioritisation of design activity or
commercial constraints.
98
Including the Nimrod Review and the recent SI into the Griffin
ZJ241 (https://www.gov.uk/government/publications/service-

inquiry-into-the-accident-involving-a-griffin-mk1-zj241-at-yr-aransnowdonia-wales ).
99
MAA Regulatory Article 1140.
100
supernumerary crew are individuals who are temporarily
attached to an Air System’s crew for the purpose of carrying out a
specific duty.

3-6

 Maritime
3.3

Assurance Level

SUBSTANTIAL Assurance – significant improvements across the domain.

organisations104 to conduct audit and
certification interventions with 86 diving
certification audits during the period. DMR
surveillance and oversight activity is conducted
through attending safety meetings, regular
interactions with the Regulated Community (RC)
and a risk-based assurance programme coupled
to an audit programme of the key areas.
Notably in this period there was increased
activity with the Army in supporting the
transformation of Army Duty Holding particularly
in respect of Diving and Boat operations, as well
as engagement with DE&S Ships to review and
assure Project SALUS.105

3.3.1 Scope. The Maritime domain has over
250 DEDs from the numerous Acts, Charters
and international treaties which govern Defence
maritime activities (including ports and diving),
making it one of the more complex legislative
environments in which Defence operates. This
is simplified into the DSA’s regulation and
assurance of all Defence activity in MOD
Shipping101, MOD Ports at home and
overseas102 and MOD Diving103. The Defence
Maritime Regulator (DMR) fulfils these
regulatory roles for Defence, operating closely
with the Maritime and Coastguard Agency
(MCA) and the Health and Safety Executive
(HSE).
3.3.2 Regulator Activity. The DMR model
focuses on 3PA activity at the Operating Duty
Holder (ODH) or equivalent level and as such 4
formal audits were conducted during the period.
The Regulator uses 4 authorised

3.3.3 Findings. Evidence this year has
demonstrated significant improvement and
development at the core of the Maritime domain,
particularly with both DE&S Ships and Navy
Comd progressing onwards from Project SALUS
and Navy Comd’s Maritime Safety Strategy

101

104

Royal Navy, Royal Fleet Auxiliary, MOD Chartered, Army and
Adventurous Training.
102
Ports and harbours protected under the Dockyard Ports
Regulation Act 1865.
103
Military, MOD Commercial and AT Diving of which military
diving has some disapplications within the Diving at Work
Regulations 1997.

Naval Authority Group (NAG), Defence Diving Standards Team
(DDST), Capt Port Operations and FOST Operational Sea Training
Team.
105
Project SALUS – A DE&S Programme post the Independent
Maritime Safety Review to improve manning and documentation.

3-7

 2018 (MSS18). The majority of the Regulator’s
activity has been focused on assuring this work,
with clear evidence also obtained in the
Document of Compliance (DOC) Audits of
ACNS106 (Ships) and ACNS (Submarines) and a
review of Project SALUS. Following the fatality
of an Army diver during the previous reporting
period there was tragically a further fatality from
a separate and fundamentally different diver
training serial.107 Both fatalities are subject to
Service Inquiries and HSE Investigations that
are ongoing.108 Areas of previous regulatory
concern such as the effectiveness of Navy
Comd and DE&S Safety & Environmental
Management Systems (SEMS) 109 and the
provision of sufficient SQEP have all seen some
improvement. Based on the evidence from
extensive audit and assurance activity and the
consolidated improvements in both safety
practice and culture the Maritime domain has
warranted an overall grading of
SUBSTANTIAL safety assurance, noting that
some specific areas still remain at LIMITED.110
Despite this level of assurance, the Maritime
domain is still affected by Defence-wide issues
such as insufficient SQEP, significant
organisational change and shortfalls in
collectively assessed 2PA. Legislative noncompliance, driven by a complex and turbulent
legislative environment111, remains the dominant
threat in this domain in terms of liability or
reputational damage to the Department and
warrants particular oversight by all parties in the
coming year.

recruitment into safety tagged assignments
being slow.113 The Naval Authority Group
(NAG) in particular is having difficulty in
recruiting and retaining marine engineers and
naval architects which may impact the timely
certification of new maritime platforms. The
SQEP challenge within the Maritime domain is
therefore now shifting from ‘qualification’ to
‘experience’; a transient, though significant,
outcome of recovering SQEP shortfalls. This
lack of experience has begun to manifest itself
through the increased use of SQEP
concessions114 and increased numbers of
incidents115 with lack of experience or F2FP as
the cited cause. Whilst there may thus appear
to be an improving SQEP position, this transient
reduction in experience when coupled with a
taut operational programme could provide
commanders with a false sense of security.
Continued oversight should therefore be
maintained at all levels of assurance as
experience builds; however, the overall vector is
positive and the right actions are being taken.
•
Collectively Assessed 2PA. Improving
quality of 2PA has been apparent across the
Maritime domain underpinned by the update to
Navy Comd’s Maritime Safety Strategy (MSS)
and the conclusion of DE&S’s Project SALUS;
however, much of the 2PA remains stove
piped.116 This improvement is expected to
continue but is wholly reliant upon TLBs
maintaining the momentum they have built over
the last few years. This will not be a simple
task, but with more effective use of incident
reporting and Learning from Experience (LFE),
improved information exchange within and
across TLBs and the adoption of Operating
Safety Boards and the Operating Safety
Statement Reviews to further improve
understanding of the health of maritime
platforms, this positive trajectory can be

•
SQEP. The number of qualified
personnel across the Maritime domain has been
improving with evidence to suggest that
initiatives to generate and sustain SQEP in
the longer term are beginning to deliver.112
Despite this, a national shortage of engineers is
still presenting recruitment challenges with
106

Assistant Chief of the Naval Staff.
There was a fatality during diver training on 26 March 2018
(included in last year’s report) and a fatality during a combat diver
training serial on 14 November 2018 (see Annex A)
108
at publication of this report.
109
Audit and assurance activity during the year has identified that
the SEMS system employed by Navy Comd and within COM Ships
(DE&S) areas are broadly effective.
110
DH models and assurance programmes are still being
developed in the SDA, JFC and Army (2PA framework for Army
Comd boat operations), while the DIO are addressing shortfalls for
review in the next reporting period.
111
Evolving Environmental legislation, transfer of EU regulation to
UK statute as a result of UK withdrawal from the EU and the
resultant management of applicable disapplications, exemptions
and derogations.
112
Projects Faraday (Navy Command Engineer Manpower
Recovery Programme) and Keyham (Navy Command Junior

Engineer Officer Manning Recovery Programme) plus DE&S intent
to convert engineers from other disciplines into naval architects
and marine engineers.
113
particularly for environmental protection SQEP.
114
Concessions are issued by an organisation where it accepts
that an individual may not be considered fully SQEP but can still
perform their duties with limitations or conditions (eg supervision).
Of the 813 SQEP concessions in place across the Devonport and
Portsmouth flotillas, 45% (n = 369) were for Weapons Engineering
and 17% (n=137) for Mechanical Engineering. Type 23 vessels
held the majority of SQEP concessions (57%, n = 465).
115
as recorded on the Navy Lessons and Incident Management
System (NLIMS).
116
Audits of the two key Operating Duty Holders (ODHs) identified
inconsistencies in 2PA and a continued lack of collective
assessment of 2PA findings.

107

3-8

 maintained. The formation of the Internal
Technical Support (ITS) audit team within DE&S
with the aim to improve 2PA is welcomed and
has shown the potential to improve the quality
and consistency of assurance well beyond its
current range of acquisition projects. Overall,
this improving picture of 2PA activity is
encouraging but the lack of evidence of
collective analysis of the results means it will
remain a focus of the Regulator in the coming
year.

under the governance of the Maritime Safety
Board. In-year audits have demonstrated the
broad effectiveness of this update and supports
their SUBSTANTIAL assurance assessment.
Similarly, DE&S COM Ships has utilised the
conclusions of Project SALUS as the foundation
to improve and update its own SEMS
programme. Self-assessment utilising
ASSERT122 has helped drive continuous
improvements whilst also assessing their safety
assurance as SUBSTANTIAL; an assessment
shared and supported by the Regulator’s 3rd
party review of Project SALUS. As a new
organisation, the Submarine Delivery Agency’s
(SDA) SEMS is developing in a positive way as
it settles into normal routine and their
understanding of roles and responsibilities
consolidates. Their supporting documentation
has also improved, providing a good foundation
with updated Organisational Arrangements
published and a new higher-level SDA safety
committee having been stood up. The maritime
aspects of Army Comd's SEMS123 is recognised
as being at an early stage of development and
support is being provide by the Regulator with
developing their DH construct and assurance
activity for Army Small Boats. Overall, SEMS
activity across the Maritime Domain has
been extremely positive and is in a
considerably improved position on last year.

•
Legislative Compliance. The
legislative complexity of the Maritime domain,
from international treaties to domestic and
devolved legislation and evolving environmental
protection mandates117, presents a significant
challenge to Defence’s maritime operators and
platform delivery teams to establish and
maintain currency in the legal and regulatory
landscape in which they operate. The duty on
the Department to provide evidence of
statutory compliance (ie ensuring the MOD
complies with the law) is therefore a specific
risk. Last year we highlighted the difficulty
DE&S delivery teams had in demonstrating
regulatory compliance for new Maritime
projects.118 and in understanding what
regulations are applicable at each stage of the
Concept, Assessment, Demonstration,
Manufacture, In Service and
Disposal/Termination (CADMID/T) acquisition
lifecycle.119 The Regulator is of the opinion that
legislative compliance should be drawn out as a
main component of governance. By ensuring
compliance is a key and explicit component of
the safety & environmental cases developed by
delivery teams it would ensure legislative
compliance is then proactively managed by the
Accountable Person or DH as applicable.

Summary - SUBSTANTIAL
Safety assurance has continued to improve
throughout the Maritime domain. All the
processes and methodologies required exist
and are functioning, but there is still work to
be done. Previous progress in improving
TLB maritime Duty Holding frameworks has
been sustained, but with a need for further
progress in certain niche areas. SQEP
shortages and experience deficits, collective
analysis and exploitation of 2PA and the
consistent demonstration of legislative
compliance remain the principal challenges
facing those managing maritime activities.
However, improvements in safety practice
and culture warrant an overall grading of
SUBSTANTIAL safety assurance.

•
Safety & Environmental Management
Systems (SEMS). Audit and assurance activity
have identified that the SEMS employed by
Navy Comd and by Chief of Materiel (COM)
Ships within DE&S are broadly effective. The
revised Navy Comd SEMS120 is currently
undergoing a 12-month ratification period121
117

eg legislation to be introduced in 2020 is aimed at decreasing
SO2 emissions by setting limits for sulphur in fuel oil.
118
Recent ship acquisitions (Queen Elizabeth-class aircraft
carriers, River-class offshore patrol vessels, Tide-class tankers) all
have incorporated engineering monitoring systems with limited
supporting documentation and have had difficulty in demonstrating
legislative compliance.
119
eg during development of a vessel there may be a stage where
it is operated under civilian maritime regulations (Red Ensign), in

public service (Blue Ensign) or as a Royal Navy vessel (White
Ensign).
120
BRd 10 replacing BR9147d - Navy Command Safety and
Environmental Management System.
121
prior to formal application in November 2019.
122
ASSERT – Air Support Safety & Environmental Reporting Tool
(developed in DE&S for COM AIR, but now used across DE&S).
123
Army Command Standing Order (ACSO) No 3216
(Organization and Arrangements for the Management of S&EP),
1st revision, April 2019.

3-9

 Land
3.4

Assurance Level

LIMITED Assurance - Some improvements; however, major weaknesses remain in some specific
areas.

Almost all TLBs and the RFCA126 operate in
some aspect of the Land Domain with significant
acquisition and support activity from DE&S and
infrastructure maintenance and management by
the DIO.

3.4.1 Scope. The Land domain has the
broadest span of statutory regulation of all the
domains or functional areas.124 The majority of
activity is regulated by the UK’s statutory
regulators and not Defence.125 Consequently, a
high proportion of safety-related incidents and
injuries occur outside of Defence regulated
areas (see Section 2.2.2). The Defence Land
Safety Regulator (DLSR) regulates against
DEDs and high-risk activities in four areas:
•
•
•
•

3.4.2 Regulator Activity. During the reporting
period the DLSR conducted 254 audits and
inspections consisting of 118 Fuel & Gas
Infrastructure (FGI) installations, 93 Movement
& Transport activities, 16 Land Systems and 27
Adventurous Training Centres. This included
the inspection of all active Defence fuel
installations and 88 Liquid Petroleum Gas (LPG)
sites and the licensing of all Defence AT
Centres. DLSR also approved 9 requests for
exemption from statutory regulations.127

Fixed Fuel and Liquid Petroleum Gas (LPG)
Infrastructure.
Land Systems Acquisition,
Maintenance/Inspection and Disposal.
Movement and Transport activity across all
modes, including the carriage of dangerous
goods.
Defence Adventurous Training (AT) Centres.

3.4.3 Findings. Based on extensive audit
and inspection activity it is evident that the
deficiencies and risk held in Defence’s FGI have

Reserve Forces’ and Cadets’ Associations.
Through the Land Exemptions Committee the DLSR Team
Leader approves routine exemption requests on behalf of the SofS
under Carltona principles.

124

126

Examples such as the Health & Safety at Work Act 1974, Road
Traffic Act 1988, the Carriage of Dangerous Goods by Road
Regulations 1996, et al.
125
For example, the Health & Safety Executive (HSE), the Driver &
Vehicle Standards Agency (DVSA), the Driver & Vehicle Licensing
Agency (DVLA), the Office of Rail & Road (ORR).

127

3-10

 started to diminish, partly as a result of longterm fuel infrastructure investment. However,
considering the continuing level of Enforcement
Action (EA) and the scale of recovery required,
the risk of a major safety or environmental event
or accident will take many years to reduce.
Movement & Transport activities continue to
demonstrate weaknesses, particularly in having
sufficient and appropriate SQEP across a wide
range of activities and in the effective
management of safety-critical data. This year
unfortunately saw three fatalities128 across the
transport activities that the DLSR regulate (see
Section 2.2.2). Events this year also drew focus
onto Defence’s management and assurance of
Land Systems Safety Management and whether
risk owners and capability providers can
consistently demonstrate that their systems are
‘safe to operate’ and ‘operate safely’ to a similar
level to that being achieved in other regulated
domains129, particularly for Urgent Operational
Requirements.130 However, this year has seen
further improvement in the safety standards at
Defence AT Centres which, in the main, have
consolidated their previous assurance
assessment. Therefore, overall the evidence
has shown some minor improvements but the
regulated aspects of the Land domain firmly
remain at LIMITED safety assurance.131

can, at times, be considered tolerable by
organisations. However, as is the case in the
Maritime domain, these instances predominantly
reflected a lack of experience rather than
qualification. This has been exacerbated further
by common delays between qualification and
the application of learning, a matter highlighted
by the Army Inspector’s review of Dangerous
Goods non-compliances last year, which found
that whilst staff had been trained many did not
subsequently carry out that function for some
time, thus losing the knowledge in addition to
not building up experience.
•
2PA. Given that the DLSR regulates a
small but broad and diverse range of functions
within the vast array of land-based activity, its
view of 2PA is informed by observation of those
regulated activities. Generally, valuable and
effective 2PA is being delivered for those
activities which are core TLB outputs and
have been properly resourced.133 However,
areas where 2PA is less robust tend to be where
an activity is considered to be non-core.134 In
addition, we have seen limited collective
analysis or exploitation of the results of 2PA
within the TLBs, limiting the benefits good 2PA
can deliver. For JFC this has been an enduring
challenge as they are reliant on 2PA being
provided by the single Service TLBs135 for
certain specific activities on a Service Level
Agreement basis. Whilst much work this year
has gone into capturing, quantifying and
agreeing these dependencies at an inter-TLB
and Head Office level, JFC are still vicariously
affected by the resource challenges faced by the
supporting TLBs. Supported by a new
governance structure within Head Office, there
are now further opportunities on a quarterly
basis for Head Office and supported TLBs to
hold those they depend upon to account.136

•
SQEP. Insufficient SQEP remains a
general concern of the RC across a broad range
of land activities. This can be attributed to how
TLBs identify and set competency requirements
within their organisation, as much as to having
the means to establish and sustain sufficient
SQEP for their assigned duties. Assurance of
FGI has again identified active facilities which
lack competent staff to manage, operate and
maintain Defence fuel installations, albeit that
these occurrences have been at a reduced
rate132 to 2017/18. Within Movement &
Transport activities 26% of inspector
interventions were attributed to inadequate
supervision and/or control. These instances
indicate a culture where lack of competence

•
Land Systems Safety Management.
Following direction within Army Comd action has
been taken to address known weaknesses in
the management of Land Systems Safety Cases

128

133

2 civilian and 1 military (see Annex A).
Aviation, Maritime and Ordnance, Munitions & Explosives
domains have more structured and prescriptive certification
process than general Land systems.
130
Urgent Operational Requirements (UORs) are only subject to
limited safety assessments prior to fielding to reduce acquisition
times and maintain operational advantage.
131
Land Systems (LIMITED), Movement & Transport (LIMITED),
Fuel & Gas (LIMITED), Adventurous Training (SUBSTANTIAL).
132
Four Enforcement Notices were issued for installations being
operated by staff with inadequate training, a reduction on 13 in
2017/18.

eg The Army Petroleum Inspectorate and RAF Fuels Assurance
team, Adventurous Training Group (Army) assurance of AT
Centres and Army Land Equipment Assurance audits (for
equipment maintenance).
134
eg land systems in Air Comd and Navy Comd.
135
Navy, Army and Air Comds.
136
In addition to formal Quarterly Performance Reporting, Head
Office have established a quarterly Performance & Risk Review
processes where the Perm Sec and VCDS personally hold 4*
Commanders and Chief Executives to account.

129

3-11

 (LSSCs), with the recruitment of additional staff,
responsibility now assigned to a single 2*
authority within Army HQ137 and promulgation of
the revised policy.138 With over 90% of LSSCs
having been formally endorsed, Army Comd
now has an opportunity for a programme of
assessment and validation in order to assure the
quality and depth of evidence supporting each
case. The importance of this next phase of
activity and the need for its timely prioritisation is
based on the preliminary findings of a number of
recent accidents and incidents139 which have
found examples which could question the
depth or completeness of existing safety
cases which consider an equipment to be ‘Safe
to Operate’.140 This is of particular relevance to
those land systems which were quickly brought
into service as Urgent Operational
Requirements (UORs) and have been retained
subsequently141, where the scale and depth of
qualification and safety assessments were
balanced against urgency of protecting the lives
of personnel in operational theatres. Beyond
these instances the Regulator has noted
examples of some land systems being modified
or locally procured without full consideration of
the safety implications142 or where land systems
are being maintained in facilities that lacked the
required testing infrastructure and equipment
and by staff without the required training or
experience.

Figure 3-5

investment only covers programmed lifecycle
replacement and excludes preventative
maintenance or repair. Considering that
deficiencies in maintenance and repair were key
factors in the events which led to the explosion
at the Buncefield oil storage depot in 2005144,
this improvement should only be seen as one
aspect of improving safety. The continued
funding of a programme of mandatory
inspection, maintenance and repair145 should be
a priority for the Department in order to ensure
these improvements are sustained. Following
inspection of all active fuel sites/installations
across Defence146, all sites had examples of
non-compliance with regulations. Most of the

•

Fuel and Gas Infrastructure (FGI). In
order to mitigate the safety and environmental
risks posed by the extensive FGI that Defence
relies upon within the UK and overseas, last
year the Department allotted an additional £24M
towards a DIO-led plan to address previously
identified fuel infrastructure deficiencies.143
Despite this being the first year of reinvestment,
the impact has been evident with a reduction in
high-risk non-compliances observed during
audits. However, only 40% of non-compliances
this year were infrastructure-related and the

137

142

Director Capability within Army HQ.
Army Command Standing Order No 3216, The Army’s Safety
and Environmental Management System, issued April 2019.
139
eg the DAIB Non-Statutory Investigation (NSI) into the
crashworthiness of MAN SV logistics support vehicle and roll-overs
of Jackal High Mobility Tactical Vehicles.
140
the provision of equipment which is safe by design, fit for
purpose, and safe when operated/maintained in accordance with
its published documentation by appropriately trained and
competent personnel.
141
The Mastiff Protected Patrol Vehicle and Jackal High Mobility
Tactical Vehicle.

eg fitting of Bowman radio systems to vehicles, modifications to
the Challenger 2 tank invalidating tie-down schemes for its
transportation, modification of locally procured vehicles at
overseas locations.
143
includes equipment deficiencies, infrastructure repairs,
replacement of obsolete facilities and mandatory inspection and
maintenance activity.
144
COMAH, Buncefield: Why did it happen?, February 2011.
145
Noting there are legal requirements for inspection, maintenance
and serviceability of FGI for which the Department is not exempt.
146
Four fuel installations are currently ‘dormant’ and not in use
awaiting decommissioning decisions/action.

138

3-12

 non-compliances were minor in nature;
however, the inspections resulted in 27
Enforcement Notices (ENs) being issued,
compared with 31 last year. This represents a
9.5% failure rate147 for 2018/19, a slight
improvement on 2017/18 (10.2%) and the 4th
annual reduction in a row (Figure 3-5). Notably
the number of Prohibition Notices has reduced
to zero reflecting the increase in Heads of
Establishment acting to close facilities that they
find non-compliant from their own 1PA. This
year there have been improvements in some
parts of the overseas fuels estate with the failure
rate now close to that of UK facilities, with
improvements delivered at RAF Akrotiri and
plans to improve secondary containment at the
Oil Fuel Depot in Singapore now on contract.
The extensive work done by Head Office and
the DIO to begin moving our FGI from a position
of managed decline towards one which is more
proactive, sustainable and legally compliant has
been highly commendable. However, an HSE
intervention this year for statutory noncompliances in a bulk LPG facility148 reminded
us of the scale of this task and the need for the
sustained focus of Head Office.

behavioural change in Defence personnel.
Feedback from TLBs has been extremely
positive153, with several individuals commenting
on how effectively it has engaged such a broad
audience. Secondly, the DSA has initiated a
replacement of the current manual Road Traffic
Collision reporting system (IMPACT) with a new,
web-based application (eIMPACT) which should
significantly improve the level, detail and quality
of vehicle incident reporting and enable quicker
and more effective analysis and exploitation
allowing Defence to better target road safety
education, training and future initiatives. LTAs
continue to impact our personnel, their families
and the delivery of Defence’s capabilities. How
Defence should address this is discussed later
at Section 5.7.3.

Summary – LIMITED
Good progress has been evident across a
number of the regulated activities in the
Land domain. There was further
improvement in the safety standards at
Defence AT Centres; significant
reinvestment in our Fuel & Gas
Infrastructure has started to have an impact
on levels of non-compliance placing us on
the path to a legally compliant and fit-forpurpose fuel & gas estate; Movement &
Transport activities continued to
demonstrate some major weaknesses,
particularly in having sufficient and
appropriate SQEP across a wide range of
activities. However, events this year have
drawn focus on the management and
assurance of Land Systems and how
Defence demonstrates that systems are
‘safe to operate’ and ‘operate safely’. Bar
Defence AT Centres, all regulated activities
in the Land domain require continued focus
and investment by TLBs and Head Office to
build momentum on the improvements
made thus far and raise them beyond their
current position of LIMITED safety
assurance.

•
Land Transport Accidents (LTAs).
LTAs, whether on or off duty, remain among the
highest causes of accidents across Defence.
Over the last 5 years military personnel were
66% more likely to die as a result of an LTA
than the general population149. These figures,
standardised for age, gender and calendar
year150, highlighted that Army personnel aged
below 30 were at the greatest risk of dying in an
LTA. In addition, there were three fatal
accidents involving on-duty military vehicles,
resulting in the death of one soldier and two
members of the public. These incidents remain
under investigation. This year has seen two
initiatives progressed in this safety-critical area.
Firstly, in partnership with the Fire and Rescue
Services151 and building on good practice in the
civilian sector, the DSA jointly produced an
innovative road safety presentation called
‘Survive the Drive’152 aimed at instilling

‘Failure Rate’ is the % of inspections that result in a formal
Enforcement Notice (Prohibit/Urgent Improvement/Improvement).
148
Lydd Camp, Kent.
149
By Service, the Army is +123%, for the RAF +11% and Royal
Naval -41% compared against the general UK population. Source:
MOD, Deaths in the UK Regular Armed Forces: Annual Summary
and Trends over Time 1 January 2009 to 31 December 2018,
published 28 March 2019.
150
This allows the calculation of a Standardised Mortality Ratio
(SMR). An SMR below, equal to, or above 100 indicates that the
147

rate for the Armed Forces or the Service is respectively below,
equal to, or higher than the rate in the general UK population.
151
Devon and Somerset Fire & Rescue Service and Dorset and
Wiltshire Fire & Rescue Service.
152
http://roadsafetygb.org.uk/news/initiative-helps-militarypersonnel-survive-the-drive/
153
The partnership was subsequently recognised by a VCDS
Commendation.

3-13

 Fire
3.5

Assurance Level

LIMITED Assurance – Previous decline in safety assurance has been arrested and initial evidence
supports a marginal improvement.

3.5.1 Scope. As a statutory regulator154 the
Defence Fire Safety Regulator’s (DFSR) role is
to provide assurance that Defence is compliant
with the law155 and Defence Fire Safety
regulations and to issue enforcement notices
where regulatory breaches have been found.
This encompasses the legal requirement for
Responsible (Accountable) Persons156 to take
adequate fire precautions to ensure the safety of
all relevant persons in their AOR or
establishment. It is discharged through riskbased audits and an agreed formal consultation
process.157 Post-fire audits may also be
undertaken158 to determine possible failings in
compliance and suitable corrective/enforcement
action where appropriate. In delivering its role,
the DFSR works closely with its statutory peers

and is represented on the National Fire Chiefs’
Council (NFCC).

154

159

3.5.2 Regulator Activity. During the reporting
period there were 413 reported fires (up 11%
since last year159) and 3178 recorded false
alarms (down 7% since last year160). The DFSR
conducted 170 risk-based audits across all of
the TLBs which resulted in the issue of 4
Enforcement Notices and 1 Prohibition Notice.161
Under the Duty to Consult (D2C) process it
provided a further 823 consultations on building
works for TLBs and appointed Fire Safety
Inspectors on 539 occasions to advise on the
more technical and complex projects. Following
a DSA-led review of Fire Safety in Single Living
Accommodation (SLA) 162 the DFSR has put in

This differs from the other Defence safety regulators who
regulate where Defence has a disapplication, exemption or
derogation from law.
155
The Regulatory Reform (Fire Safety) Order 2005 and the Fire
Scotland (Regulations) 2006.
156
A legal duty of appointed Heads of Establishment (HoE) or
project leads for proposed building works.
157
2017DIN06-23, Duty to consult with the Defence Fire Safety
Regulator.
158
In concert with the Defence Accident Investigation Branch for
major incidents.

A 15% reduction over the last 3 years.
This represents a 31% reduction over the last 3 years; however,
it is recognised that there is a lack of consistent false alarm
reporting, particularly on Defence sites where there is DFR
presence.
161
A Prohibition Notice was served on Wellington Barracks for
significant deficiencies in the fire detection and alarm system as
installed.
162
DSA, Fire Safety Review: Defence Single Living
Accommodation, DFSR/18/001/Report dated 14 August 2018 and
published on gov.uk on 4 January 2019.
160

3-14

 place a system to track the progress TLBs are
making in implementing the review’s
recommendations. In addition, the DFSR has
remained closely engaged with Dame Judith
Hackitt’s Review163 which followed the Grenfell
Tower tragedy and her recommendations for
improving oversight of building regulations and
fire safety management.

and more collaborative working between
building control and regulatory authorities have
all contributed to a positive shift in fire safety
management across Defence. However, there
are still areas requiring further attention where
levels of regulatory compliance are still below
the standard expected; where unwanted fire
alarm signals remain at an undesirably high
rate; where the consequences of delay to the
implementation of the Defence Fire & Rescue
Project (DFRP) have stretched resource; and
where it has been more difficult to retain SQEP.
Overall, Fire Safety Management remains at
LIMITED safety assurance, but the efforts to
arrest the previous decline have been
worthwhile and the path has been set towards
reaching Substantial assurance in a number of
years.167
•
Fire Safety Governance. Senior
engagement by Head Office and TLBs in
response to the findings of last year’s AAR and
the SLA Fire Safety Review has been swift and
effective, with senior staff providing
unambiguous direction to their staff and
organisations and providing much needed clarity
to the Department’s numerous Heads of
Establishment (HoE).168 The roles and
responsibilities of the DFRMO which were
previously not broadly understood by Defence
have reportedly been clarified, including the
rebranding of DFRMO to Defence Fire and
Rescue (DFR). In consolidating its role as the
Department’s service delivery organisation for
fire and rescue services and the source of
professional fire safety advice to TLB risk
owners, the Chief Fire Officer (CFO) has also
established a new Defence Fire Safety
Management Committee.169 During the
reporting period Air Comd had led activity to reassess their existing fire safety management
systems down to unit level to understand the
current arrangements and create a new and
more effective operating model. This significant

Figure 3-6

3.5.3 Findings. This year DFSR’s audit
activities found that the majority of premises164
were ‘broadly compliant.’165 The management
of Fire Safety throughout Defence had been in
decline for the previous two years; however,
there was now evidence that this decline had
been arrested, with a resultant small but
measurable improvement in overall fire safety
assurance.166 Notably, there is insufficient
evidence to determine whether this change is
temporary or will be sustained. Whilst the
number of reported fires has increased this year
it remains on a reducing trend. False alarms
have reduced and the number of overall
regulatory non-compliances saw a marginal
improvement (see Figure 3-6). More
reassuringly, improvements in compliance have
been reflected across over half of the audit
categories compared to last year (Figure 3-7).
Senior engagement by Head Office and TLBs,
clarification of the roles and responsibilities of
the Defence Fire Risk Management
Organisation (DFRMO), additional training of fire
risk assessors, the establishment of a new
Defence Fire Safety Management Committee
163

166

Dame Judith Hackitt, Building a Safer Future: Independent
Review of Building Regulations and Fire Safety: Final Report,
dated May 2018.
164
64% (+3% compared to 2017/18).
165
NFCC term used for premises where very few deficiencies are
found during audit and any found are minor in nature. Compliance
is categorised as: broadly compliant, non-compliant minor
deficiency and non-compliant major deficiency.

Areas such as fire risk assessment, system maintenance and
process compliance.
167
which at the current pace of change could take several years.
168
MOD, Defence Safety Authority Annual Assurance Report April
2017 – March 2018, dated 26 October 2018, Recommendation 8.
169
supported by the DFR-led Defence Fire Safety Working Group
and DIO-led Strategic Compliance Committee.

3-15

 Figure 3-7

•
Change. The major change that is soon
to affect fire safety management in the
Department (from Head Office to unit level) is
the DFRP. Capita Business Services Ltd was
announced as the successful bidder on 18 June
2018173 for this 12-year contract valued at
around £550M.174 However, following a legal
challenge implementation of the contract was
delayed until May 2019. Unfortunately, this
delay generated an unplanned commitment on
DFR which was already being affected by
planned staff transfers and retirements. Whilst
this resulted in an unavoidable drop in service
delivery and some Key Performance Indicators
fell below agreed levels175, DFR should be
commended for minimising the impact this had
on Defence organisations. However, should
DFRP delay further, the CFO DFR has the
means should he wish, to continue minimising
the impact by drawing upon resource from within
its governance area.

piece of Air Comd work has been shared with
the other TLBs which, with the establishment of
new fire safety specialist positions in Air Comd,
JFC HQ and DE&S to add to the existing
position in Navy Comd, will unequivocally
improve their governance and assurance. The
challenge now lies with the other TLBs to match
these levels of assurance and good practice.
•
SQEP. Improved training170 and greater
recognition by TLBs of the importance of SQEP
has contributed to an improved picture to what
was reported last year.171 Instances of Project
Managers failing to follow safety compliance
processes have reduced172 due to an improved
understanding of their role in managing
regulatory compliance, and there has been
evidence of increasing instances of proactive
and informed behaviour from HoE and
supporting staff. However, these improvements
have not been universal, with pockets of
inadequate management or awareness still
evident across Defence and requiring the
momentum that has been established this year
to cast wider. Beyond the building of local
SQEP, the recruitment and retention of
Defence’s high-end fire safety specialists
remains a challenge across all TLBs, including
DFR and the Regulator. An increase in private
sector demand has out-stripped national
capacity, and the ability of the private sector to
recompense at market rates has placed
increased pressure on the retention of Defence
expertise.

•
SLA Fire Safety Review. The findings of
the SLA Fire Safety Review176 were not
unexpected and were consistent with the
content of previous DSA AARs. The principal
finding was that TLBs had a limited ability to fulfil
their statutory fire safety duties. In addition, the
Review identified risks that had been magnified
by cultural and management factors, all with the
potential to produce pan-Defence Safety and
Environmental Management System (SEMS)
failures particularly across the Army estate. The
Review attracted a high degree of public
scrutiny following media reports that attempted

170

174

such as the DFR course delivered to TLB staff which is
improving the quality and utility of Fire Risk Assessments (FRAs)
across the Defence Estate.
171
MOD, Defence Safety Authority Annual Assurance Report April
2017 – March 2018, dated 26 October 2018, Section 3.6
172
Infrastructure project managers within DIO Programme Project
Delivery.
173
Hansard, House of Commons Written Statement, Volume 643,
Contingent Liability, 18 June 2018.

Hansard, House of Lords Debate, Volume 643, Defence Fire
and Rescue Project: Capita, 21 June 2018, c467, [corrected
Volume 643, 25 June 2018].
175
eg delivery of Fire Risk Assessments fell to 86% against a
target of 95%.
176
DSA, Fire Safety Review: Defence Single Living
Accommodation, DFSR/18/001/Report dated 14 August 2018.

3-16

 to incorrectly align fire risks across the Defence
estate with that of the Grenfell fire. On behalf of
the newly formed Defence Safety and
Environment Committee (DSEC)177 the DSA has
begun tracking the implementation of the 8
recommendations which included the review of
TLB SEMS, the update of Joint Business
Agreements between TLBs and DFR and the
introduction of revised governance and audit
arrangement. Progress towards completion of
these recommendations has been made as fast
as resources have allowed. It was noted that
the original target dates were ambitious without
the benefit of any detailed planning estimates,
and as such six of the eight recommendations
had not been completed in the time allowed.
Revised target dates have been subsequently
agreed and all of the recommendations are
scheduled to be completed before April 2020.

cross-regulatory consultation and simplify the
existing D2C process during planning, design
and construction in order to provide verifiably
safe buildings for Defence.

Summary – LIMITED
The decisive leadership demonstrated by
Head Office in response to last year’s AAR
and the SLA Fire Safety Review kickstarted
a shift in awareness, engagement and
attitude across Defence. TLBs and their
HoE have begun to rise to that challenge,
with the previous decline in safety
assurance having been arrested and the
initial indications of a recovery evident in
some areas. Issues with establishing and
retaining SQEP, as promoting the fire safety
message out across the Defence Estate will
require the continued effort and resource of
TLBs to maintain the momentum achieved
thus far. This has impacted all areas of fire
safety assurance, management and service
delivery across Defence. Based on the
commitments shown by Head Office and the
TLBs, there is optimism for the future. New
governance arrangements will allow TLBs,
with Head Office, to oversee this work and
determine the pace of recovery, accepting
that after so many years of decline it may
take several years to return to Substantial
assurance. Until then fire safety will
continue to have LIMITED safety
assurance.

•
Governance post-Grenfell. During this
reporting period the Hackitt Review
recommended the creation of a National Joint
Competent Authority (JCA) to bring together
under a lead authority ‘Local Authority Building
Standards, fire and rescue authorities and the
Health and Safety Executive’ to ‘maximise the
focus on building safety’ to ‘ensure effective joint
working’.178 Recognising the potential benefits
this could have for Defence the DIO and DSA
formed a Defence Joint Competent Authority
Working Group (Defence JCAWG) in October
2018 to develop the building control and fire
safety regulatory framework model179 which
would mirror National JCA outcomes for the
Defence Estate. It is intended that the Defence
JCA model180, when approved, will enable early

177

179

see Section 5.4.
Dame Judith Hackitt, Building a Safer Future: Independent
Review of Building Regulations and Fire Safety: Final Report,
dated May 2018, Recommendation 1.2.

replacing the current DFSR D2C model, 2017DIN06-23, Duty to
consult with the Defence Fire Safety Regulator.
180
covering: design, construction and refurbishment; occupation
and maintenance; product safety; competence; regulation and
guidance.

178

3-17

 Ordnance, Munitions
& Explosives
3.6

Assurance Level

SUBSTANTIAL Assurance - partially reduced due to weaknesses in 2PA of DE&S OME acquisition.

3.6.1 Scope. Defence has a range of DEDs
from statute181 requiring regulation of all
Defence Ordnance, Munitions & Explosives
(OME) activity from acquisition to disposal. This
also includes regulating all MOD explosives
storage sites, ranges used for live firing, laser
safety and Major Accident Control (MACR)
establishments.182 This is conducted by the
Defence OME Safety Regulator (DOSR). Most
of the TLBs in Defence have some activity or
involvement in the OME area.

and 44% (12) of its MACR sites, spanning the 6
major TLBs.183 In addition, the DOSR provided
advice and assistance to TLBs on the following
operations: Op SHADER,184 the Joint Counter
Terrorist Training Advisory Team (JCTTAT)185,
Op AZOTIZE186 and Op NEWCOMBE.187 To
advance coalition interoperability, both the
Regulator and Regulated Community have been
working towards a common NATO standard and
methodology to Explosives Safety Cases
(ESCs) and integrating this into UK regulation.
In addition, this year DOSR conducted
assurance activity on the Acquisition
Management of the 1254 known OME systems
in Defence in order to determine a baseline level
of assurance. As a result of their audit and

3.6.2 Regulator Activity. During the reporting
period the DOSR conducted 533 audits and
inspections across Defence: 25% (498) of its
ranges, 4% (23) of its explosives establishments
181

183

Principally the Explosives Regulations 2014, the Health and
Safety at Work Act 1974 and the Dangerous Goods in Harbour
Areas Regulations 2016.
182
Major Accident Control Regulations (MACR, JSP 498) are the
equivalent of the Control of Major Accident Hazard Regulations
2015 (COMAH) for Defence sites, of which the Defence Ordnance
Safety Regulator also acts as the MOD’s Competent Authority.

Army (326 audits), Navy Comd (11 audits), Air Comd (30
audits), JFC (13 audits), HOCS (12 audits), DE&S (27 audits) and
DIO (114 audits).
184
Advice on explosives licensing at RAF Akrotiri.
185
Overseas range safety inspections including Operations.
186
Estonia.
187
Mali.

3-18

 assurance activity this year the Regulator issued
three Prohibit Notices (PNs)188 and seven
Improvement Notices (INs).
3.6.3 Findings. There was considerable
evidence that the safety systems and processes
delivering in-service and operational safety of
Defence’s ranges, explosives storage sites and
MACR establishments are robust and working
effectively across the entire functional area with
only minor weaknesses observed. In these
areas all TLBs had Substantial safety
assurance. However, the baseline assessment
of OME acquisition revealed significant shortfalls
in 2PA and process compliance across five of
the six DE&S Operating Centres189, ranging
from Limited to No Assurance. Whilst this
impacts the Regulator’s assessment of DE&S
safety assurance, it specifically relates to only
one of the four regulated OME functions;
therefore, OME across Defence is assessed as
having overall SUBSTANTIAL safety
assurance with a specific weakness in the 2PA
of DE&S in OME acquisition.

munitions are safe is lacking. While the reasons
for this level of omission/non-compliance are
investigated, each of the Operating Centres
have produced 'return-to-green' plans to bring
them back into full compliance and continue to
be supported by the Regulator as they
implement them.
•
Infrastructure. Despite the general
declining condition of the Defence Estate,191
Defence’s licensed explosives facilities continue
to be, in the main, fit-for-purpose and
compliant.192 Where necessary, enforcement
action has been taken and any emergent trends
have been reported.193 This has demonstrated
how TLBs have successfully prioritised activity
where resource and capacity is limited. With
infrastructure funding delegated back to TLBs194
there are now greater opportunities for them to
prioritise and manage their estate.

•

2PA. Regulatory awareness and
assurance practices are well established for
Defence’s Ranges, Explosives storage sites and
MACR establishments and the quality and
consistency of 2PA is collectively good, mainly
as a result of OME being a mature regulatory
domain comprising a small cadre of specialists.
However, the key finding of the Regulator’s
assurance of OME acquisition was that several
of our Defence’s in-service OME systems may
not have been subject to the prescribed levels of
robust 2PA and independent 3PA assurance
during their introduction to service.190 There is
no evidence to make the Regulator believe
that those OME systems are unsafe.
However, without this necessary level of
assurance a key element of the multi-layered
assurance model which demonstrates our

•
SQEP. Despite being a small and niche
cadre, TLB measures to maintain OME SQEP
continue to appear effective albeit the position is
fragile with an ageing SQEP demographic. All
TLBs have initiatives in place to manage their
levels of SQEP and the position continues to be
monitored at the DOSR-chaired functional safety
committee.

188

191

Prohibit Notices were served on 3 indoor weapons ranges due
to non-compliant infrastructure and equipment.
189
Weapons, Ships, Land Equipment, Air Support, Combat Air
Operating Centres. The Helicopter Operating Centre was
assessed as having Substantial assurance with regard to OME
acquisition. The Submarine Delivery Agency which is not part of
DE&S does acquire OME and was assessed as having Full
assurance.
190
Operating Centres are required to conduct 2nd Party OME
Safety Review Panels of each OME system to ensure the
assumptions and evidence underpinning the System’s safety case
remain valid and that risks associated with the OME have not been
unknowingly transferred to end-users or operating platforms.

House of Commons Library, Briefing Paper Number 07862,
Defence Estate strategy, 12 January 2017.
192
Explosives facilities are subject to a range of mandatory
building and electrical tests.
193
Evidence was found of some sub-contractors not conducting
inspections to the required standard. This was reported to DIO
who have reacted and progress is being made towards resolution.
194
Infrastructure funding in Defence was delegated back to TLBs
from DIO on 1 April 2018 following the Defence Infrastructure
Model Review (DIMR), providing TLBs with a greater ability to
manage and prioritise infrastructure maintenance and
procurement.

3-19

 Summary - SUBSTANTIAL
Defence’s Ranges, Explosives storage sites
and MACR establishments all have robust
safety systems and processes which
provide SUBSTANTIAL safety assurance.
However, a deeper look into the acquisition
processes for our OME has revealed a
weakness in one of the multiple layers of
assurance that underpins safety. This does
not suggest that matters are unsafe, but that
there are additional assurance checks that
should be done better. Therefore, for an
area that displays a positive, wellestablished safety culture, with solid
assurance across the majority of its
activities, the OME domain continues to
demonstrate overall SUBSTANTIAL safety
assurance.

•

Change. With several recent changes
occurring across the MOD’s Ports and Harbours
this has been an area requiring a higher level of
regulatory scrutiny and oversight. Since an HSE
intervention at SMC Marchwood195 and the
issuing of a Crown Prevention Notice 3 years
ago196, Defence has been improving its safety
arrangements in-line with statutory
requirements. In addition, the Regulator has
worked with NATO’s AC/326 CNAD197
Ammunition Safety Group to review and rewrite
the applicable NATO policy and standards.
Based on these regulations and policy the
Regulator has observed several examples
where changes in operation or infrastructure
have been implemented which have
necessitated additional mitigating activity in
order to maintain compliance with OME
regulation and minimise the Risk to Life of UK
and Host Nation personnel, assets and
infrastructure.198 It is also recognised that for a
number of our overseas locations Defence must
remain responsive to external influences, many
of which are outside its control, which require
the application of temporary operating limitations
and enhanced oversight by DHs where and
when necessary.

195

197

Sea Mounting Centre Marchwood is a dedicated military port
facility on the south coast.
196
The HSE issued a Crown Prohibition Notice for the handling
and storage of explosives as there were insufficient measures in
place to reduce the risk to members of the public from an
explosive event.

Conference of National Armaments Directors.
eg required additional resources such as additional guarding of
temporary perimeters or movement constraints such as the
temporary closing of public roads to allow weapon movement or
loading activities to take place.
198

3-20

 Medical Services
3.7

Assurance Level

LIMITED Assurance – unchanged from last year due to significant weaknesses in JCOS199 assurance
of medical provision overseas (including PJOBs200).

regulators204 when required. The DMSR does
not assure delivery of the care or treatment of
Service Personnel in NHS funded facilities205 nor
has it the authority to assure Host Nation
healthcare facilities overseas.

3.7.1 Scope. Defence Medical Services
(DMS)201 have a disapplication from the Health
and Social Care Act 2008 (Regulated Activities)
Regulations 2014. Defence is therefore
required to regulate and assure the delivery of
healthcare to Service Personnel and entitled
civilians202, a role conducted by the Defence
Medical Services Regulator (DMSR).203 The
DMSR is empowered to undertake proportional
and risk-based safety assurance, regulation and
enforcement of Defence Medical Services
(DMS) in order to enhance Defence capabilities.
It works closely with the Care Quality
Commission (CQC) and the other UK statutory

3.7.2 Regulator Activity. Individual Medical
Treatment Facilities (MTF) undertake 1PA; the
Commands,206 HQ Surgeon General (SG)207 and
PJHQ undertake 2PA and the DMSR
undertakes 3PA. During the period of this report
the CQC conducted a further208 34 initial209
inspections and 19 re-inspections210 of medical

199

Joint Command Overseas Support within JFC, this organisation was subsumed by the Director Overseas Bases (Dir OB) in March 2019.
Permanent Joint Operating Bases (Cyprus, Gibraltar, South Atlantic Islands, British Indian Overseas Territories) and British Defence
Singapore Support Unit.
201
Defence Medical Services (DMS) is the collective term for the personnel of the three single Services and the integrated civilian workforce
who provide medical operational capability, firm base healthcare and medical advice to Defence. The head of the DMS is Director General
DMS (formerly the Surgeon General) who is the Defence Authority for Healthcare and Medical.
202
Service personnel in the UK, abroad, those at sea, and in some circumstances family dependents of service personnel and entitled civilians.
203
formerly the Surgeon General’s Inspector General team which transferred to the DSA on 1 December 2017.
204
including non-healthcare regulatory bodies.
205
This is assured by the CQC as the statutory regulator in England.
206
Navy Command, Army HQ and Air Command.
207
Defence Primary Healthcare (DPHC) and the Joint Hospital Group (JHG).
208
The CQC published 63 inspection reports during the first year of the programme, CQC, Defence Medical Services CQC Inspection
Programme Annual Report Year 1 (2017/2018), dated 30 July 2018.
209
25 Medical Centres, 3 Dental Centres, 2 DCMH, 4 RRUs.
210
11 Medical Centres, 5 Dental Centres, 2 DCMH, 1 RRUs.
200

3-21

 within several areas delivering healthcare. This
view concurs with the self-assessment218 of the
majority of TLBs219 which each highlight
shortfalls in 2PA due to reduced levels of
staffing and insufficient SQEP. The impact of
the reduced 2PA is borne out by continued gaps
in assurance of healthcare activity220 in the
PJOBS, operations and high-risk activities. This
reduced assurance activity and increased
reliance on 1PA reduces confidence that all
risks are being identified and well-managed. Of
immediate concern has been the submission of
No Assurance by the JCOS for their inability
to assure Host Nation healthcare provision
for personnel at our overseas bases or
assure specialist activities such as diving. This
reflects the inability of JCOS to conduct
assurance and does not imply that Host Nation
healthcare provision is inadequate or unsafe. In
particular it should be noted that primary
healthcare at these locations is delivered by
Defence Primary Healthcare (DPHC) and has
been generally assessed to be of good
quality.221 The Regulator is closely engaged
with JCOS and JFC to ensure the impact to
patient safety is minimised and assist them in
devising an appropriate recovery plan.
However, DMS has warranted an overall
grading of LIMITED safety assurance.

facilities211, completing its second year of 3PA
inspections of Defence MTFs.212
Outcomes were marginally improved upon last
year with less than 40% of Medical Centres
(down ~10%) graded as ‘Requires Improvement’
or ‘Inadequate’ and 2 MTFs assessed as
‘Outstanding’.213 The Regional Rehabilitation
Units (RRUs) inspected were all ‘Good’ but
there was considerable variation with the three
Defence Community Mental Health centres
inspected ranging from ‘Requires Improvement’
to ‘Outstanding’. Good leadership, management
and governance are prerequisites for high
quality care. These factors were evident in those
NHS214 and DMS practices rated as Good or
Outstanding by the CQC.215 Based on these
inspections and additional evidence available to
the DMSR216 seven Enforcement Notices were
served comprising two Prohibit Notices (PNs)
and five Urgent Improvement Notices (UINs).
Of the two PNs, one medical facility217 has
subsequently closed permanently, and the other
is undergoing infrastructure work.
3.7.3 Findings. Based on the evidence
available to the DMSR it has concluded that
DMS has established systems and processes in
place; however, the effectiveness of the systems
is being compromised by shortfalls in SQEP
which has impacted the delivery of useful 2PA
211

217

53% of Medical Centres, 22% of Dental Centres, 33% of
Departments of Community Mental Health (DCMH) and 46% of
Regional Rehabilitation Units (RRUs) have been inspected.
212
CQC, CQC’s inspection programme of Defence Medical
Services Annual report for Year 2 (2018/19), dated July 2019.
213
The gradings are: Outstanding, Good, Requires Improvement
or Inadequate except for Dental Centres which either meet the
required standard or not.
214
CQC, The State of Care in General Practice 2014 to 2017,
published September 2017.
215
CQC, CQC’s inspection programme of Defence Medical
Services Annual report for Year 2 (2018/19), dated July 2019.
216
such as Common Assurance Framework reports, Healthcare
Governance & Assurance Visit Reports, Automated Significant
Event Reporting (ASER), Bi-Annual TLB Reporting and DPHC
Performance Reporting.

Deepcut MTF was served a Prohibit Notice in May 2018 due to
significant patient safety issues resulting from poor staffing levels
and lack of SQEP and has subsequently been closed.
218
reported through Stakeholder Biannual Assurance Reports
(BARs) to the Surgeon General.
219
, Army Comd, Air Comd and JFC (covering JCOS, DPHC and
PJHQ).
220
Diving and National Air Traffic Services in Gibraltar, Secondary
Healthcare in Cyprus, Gibraltar and the Falkland Islands, and
Aeromed from the Falkland Islands.
221
Healthcare Governance and Assurance Visit (HGAV) reported
assurance levels of ‘Substantial’ across PJOB DPHC locations
(Cyprus – February 2018, Gibraltar October 2018 and the Falkland
Islands May 2017).

3-22

 •
SQEP. Shortfalls in both the civilian and
military workforce have exposed the limited
availability of SQEP in specific healthcare
delivery areas as well as Governance and
Assurance. Gapped posts and insufficient
SQEP erode the systems in place to identify
safety concerns and hampers improvement.
DPHC operates a whole force approach with
57% of all posts being civilian liability.
Although there have been improvements in
overall military staffing within DPHC,
shortfalls remain. The latest data from DPHC
reveals that military staffing has increased with
post gapping reduced from 10% last year to
9%222. However, specific professional cadres
continued to experience shortfalls across all
three single Services.223 Despite the partial
success of short-term mitigating strategies and
the use of a civilian workforce forum in providing
a focussed approach to improving the
recruitment process in several areas, challenges
remain within recruiting and retaining the civilian
workforce with staffing unchanged at 80%
across the full breadth of disciplines.224

those TLBs holding the risk, but robust 2PA is a
key contributor to patient and staff safety. In
addition to the lack of assurance evident in JFC
of the provision of Host Nation healthcare
provision for personnel at our overseas bases,
there have been examples of weaknesses in
medical assurance during Force Generation
activities. During Ex SAIF SAREEA 3 it was
identified that there is no formal handover or
verification of the medical standards required for
the exercise prior to deployment from the Force
Generating HQ227 to PJHQ, and therefore only
limited assurance could be given that all
personnel had been appropriately prepared prior
to arrival at the exercise. Reassuringly, this
shortfall was discovered during internal
assurance activity, but it highlights that some
basic but major weaknesses remain in
maintenance of adequate standards of
preparation in the joint environment.
•
Infrastructure. Infrastructure firmly
remains as one of the top three issues which
threaten healthcare delivery and patient safety
within Defence.228 Highlighted by the CQC
repeatedly229 since 2009 and by the newly
formed DMSR last year230, the safety and
suitability of MTF infrastructure was one of
the poorer performing areas in compliance
with the relevant essential standard. These
concerns were not isolated incidents but

•
Organisational Change. The DMS has
experienced significant organisational change
over the past 12-18 months.225 The far-reaching
implications of this led to friction and turbulence
at multiple levels in structures, manning and
leadership. This created challenges in
addressing recognised safety concerns and
maintaining momentum at a time when the DMS
is managing multiple change programmes such
as CORTISONE, Defence Healthcare Delivery
Optimisation and Future Healthcare in Europe.
•
2PA. Pressure to maintain delivery of
clinical services across DPHC has been at the
expense of effective 2PA. Insufficient SQEP
and the lack of a formal training pathway to
develop the necessary governance and
assurance competences are a recognised issue
that is implicitly tolerated by the TLBs.226 How
long this can or should be tolerated lies with

222

226

223

227

Navy Comd 9.1%; Army Comd 11.5%; Air Comd 6.9%.
Navy Comd reported a 44% shortfall of Dental Hygienists. The
Army reported shortfalls in Consultants in Occupational Medicine
(25%). Shortfalls of Primary Healthcare Nurses were reported by
Navy Comd and the Army (both 24%). Shortfalls of Mental Health
Nurses were reported by both the Army and Air Comd (20% and
19% respectively).
224
Medical Officers within Minor Injury Assessment Centres (75%
gapped), Radiographers (59% gapped), Dental Hygienists (42%
gapped), Social Workers (35% gapped), Psychiatrists (34%
gapped).
225
Including the move of the Inspector General’s team to form the
DMSR in the DSA in December 2017.

non-compliance with the mandated 2-yearly cycle of 2PA visits.
Army, Navy or Air Comds.
228
The Healthcare Commission, Defence Medical Services: A
review of the clinical governance of the Defence Medical Services
in the UK and Overseas, dated March 2009.
229
CQC, Defence Medical Services: A review of compliance with
the essential standards of quality and safety, dated June 2012 and
CQC, CQC’s inspection programme of Defence Medical Services
Annual report for Year 2 (2018/19), dated July 2019.
230
MOD, Defence Safety Authority Annual Assurance Report April
2017 – March 2018, dated 26 October 2018, Section 3.7.

3-23

 reflected examples across the Defence Estate,
citing common issues such as damp, insufficient
space, poor ergonomics, lack of sound-proofing
and inadequate arrangements for handwashing
and protecting privacy and dignity. The CQC
also noted that many MTFs were not purposebuilt to deliver primary care.231 This situation
reflects chronic underinvestment in
healthcare facilities by the MOD, perpetuating
a culture of acceptance by DMS staff where risk
has been tolerated and access to clinical
services becomes seen as a priority over safety.
It is recognised, however, that the ownership of,
and responsibility for, the infrastructure in which
many MTFs operate is complex and often multiagency in nature. Consequently, the amount of
direct leverage that the DMS has varies. A
recent agreement with JFC to prioritise
infrastructure work where CQC identify noncompliance232 represents a positive step
forward, and one that the other TLBs would be
encouraged to follow. In addition, the Regulator
will continue to work with TLBs and the CQC to
help inform the prioritisation of work.

will require the active intervention of DMS to
maintain adequate mitigation of the recognised
risks to safety.
•
Review of Service Personnel
Suicides. The DMSR-led review of Service
Personnel (SP) suicides published last year236
made a number of recommendations on what
measures could be taken to reduce suicide in
Service Personnel. Responsibility for delivering
the recommendations through the Suicide
Prevention Working Group (SPWG) has been
passed to Chief of Defence Personnel. During
this reporting period the SPWG asked the
DMSR to complete a thematic review of
unexpected deaths from October 2016 to
December 2018 using ASER as a source,
additional information from TLBs and crossreferenced with lessons identified by Defence
Statistics in 2016. The DMSR found that the
same trends identified in the previous reviews
continued to be reported, raising concerns that
lessons had not been learned or have had
insufficient time to generate an effect. The
SPWG accepted these findings and, with the
continuing support of the DMSR, is reviewing
their action plans accordingly.

•
Medical Systems (Med IS). Automated
Significant Event Reports (ASERs) are the
primary method used across the DMS for patient
safety event reporting. Alongside clinical
administration, issues with Med IS are a major
reason for event reporting, specifically within
DPHC and PJHQ. The initial findings of a Tiger
Team233 formed to investigate the causes of this
reporting found that whilst the functionality of the
existing Med IS234 was generally fit for purpose
with no reported evidence of a direct patient
safety issue or harm identified, routine issues of
poor network speed, instability and poor
system reliability did pose a potential235 risk
to patient safety. Replacement of the existing
Med IS remains a priority. The Cabinet Office
approval of the Business Case for the previously
delayed replacement (Programme
CORTISONE) in November 2018 is therefore
welcomed. Until Programme CORTISONE
enters service it is expected that Med IS will
remain a major reason for ASER reporting and

Summary - LIMITED
There are well-defined safety structures and
processes in operations across the Medical
Services’ community to allow risks to be
identified; however, a lack of capacity is
compromising their ability manage those
risks effectively. Basic lessons are not
being shared across Defence’s healthcare
delivery, which is hindering organisational
learning. Shortfalls in staff and the
challenge of building and retaining SQEP
continue to have a detrimental impact on
the TLBs’ delivery of effective 2PA, a key
safeguard in maintaining patient
safety. This when combined with areas of
inadequate healthcare infrastructure and
unreliable and outdated Med IS means
DMS remain at LIMITED safety assurance.

231

eg in 2011 the CQC visited a primary care rehabilitation facility
in an old building which was once a gym. Many observations
made regarding infection control had not been resolved when reinspected in January 2019 (only one sink in the whole facility had
hot water, the sink in the staff area was blocked, no patient toilets
or showering facilities, and insufficient Med IS for the 7 clinicians).
232
CQC issues are treated and prioritised as non-compliance with
statute.
233
In response to the BMA Armed Forces Committee’s concerns
raised in May 2018 regarding the Defence Medical Information

Capability Programme (DMICP), the SG directed that a Tiger
Team (TT) be created.
234
The Defence Medical Information Capability Programme
(DMICP).
235
There have been no examples reported of this having had a
direct impact on patient safety or having caused actual harm.
236
DSA, Defence Safety Authority Focused Review of Suicides
among Armed Forces Personnel – Final Report, dated 14 August
2018.

3-24

 DSA Maturity
assurance

Figure 4-1

4.1

Context

Regulator Maturity Levels

A core function of the DSA is to provide a single
independent focus for the regulation, assurance and
investigation of Health, Safety & Environmental
Protection (HS&EP) in Defence by bringing together
the Defence Safety Regulators for the seven distinct
regulated domains and functions, along with the
Defence Accident Investigation Branch (DAIB), the
Defence Safety Policy & Assurance (DSPA) Team
and other stakeholders. These Defence regulated
domains and functional areas have evolved
independently alongside their statutory peers237 for
many years and have developed different approaches
and cultures. The DSA, as a body independent of the
command chain, is uniquely placed to identify crosscutting issues and best practice, improve and simplify
regulation, strive for parity across domains and
highlight their relative importance to the Department.
To assess the maturity of the DSA and its regulators
since its formation in 2015, this report uses the same
Defence Internal Audit-derived assessment grades as
it does for the regulated domains. The definition of
regulator maturity associated with each grade is
shown at Figure 4-2.

237

Full:
Regulator has robust, effective regulations &
processes.
Sufficient SQEP to deliver the full range of regulatory
& risk-based assurance functions and have capacity to
innovate. 3PA delivered is robust across all areas.
Substantial:
Regulator has effective regulations & processes but
may have minor weaknesses.
Sufficient SQEP to deliver all essential regulatory &
assurance functions. 3PA delivered is effective across
all areas that are subject to audit.
Limited:
Regulator has effective regulations & processes but
may have some major weaknesses/deficiencies.
May have SQEP deficiencies which necessitate
prioritisation of outputs. 3PA delivered is supportive
where audited.
No Capability:
Regulator has ineffective regulations & processes or
several major weaknesses.
Insufficient SQEP to deliver essential functions.
3PA ineffective and unreliable.

Figure 4-2

eg the Health & Safety Executive (HSE), Civil Aviation Authority (CAA), Maritime & Coastguard Agency (MCA), Care Quality Commission
(CQC), Vehicle & Operator Standards Agency (VOSA), Air Accidents Investigation Branch (AAIB), etc.

4-1

 feedback from the mutual recognition programme
has provided a further element of independent
assurance of how the MAA is performing in
relation to its international military peer group.
This year the application of RBA continued to
bed-in across the MAA and has started to
produce dividends.241 Whilst improvements in
overall MAA workforce numbers and Suitably
Qualified & Experience People (SQEP) in certain
areas have been seen, there remain some key
shortfalls in certain niche and emergent areas.242
Therefore, based on improvements in SQEP in
some areas of the MAA, the robust nature of its
regulatory publications and the continuing
maturity of its RBA model means that the
assessment of regulator maturity for the MAA
can be raised to SUBSTANTIAL maturity.

In order to qualify the DSA’s assessment of
assurance in each domain it is necessary to
understand the capability and maturity of the
regulating body. This considers the contribution
Regulators make towards their Regulated
Communities through the quality and
effectiveness of the 3PA they provide. It also
includes the maturity of their regulations, their
application of Risk-based Assurance (RBA), their
alignment with the principles of the Regulators’
Code238, their relationship with their statutory
peers, whether they have sufficient SQEP to
deliver their full range of roles, their ability to
discharge those roles effectively and their
capacity to innovate.239 Overall, the DSA is
assessed as having LIMITED maturity. The
assessed maturity level of each of the Regulators
and the DSA’s overall investigative and policy
capability is summarised in Figure 4-1 and
described in the rest of this section.

4.2

4.3

Defence Maritime Regulator (DMR)

This year the DMR has restructured to a leaner
organisational model comprising Policy &
Legislation, Analysis & Plans and Inspectorate
sections, supported by four Duly Authorised
Organisations (DAOs)243 in order to deliver the
full complement of regulator functions. In parallel
it has fully reviewed and up-issued its Regulation
Set and Defence Codes of Practice (D-CoP)244
following consultation with stakeholders. The
Naval Authority Group Certification Rules and the
Warships in Harbour Rules publications were
also reviewed and issued earlier this year, with
work ongoing to review guidance for use of Red
White and Blue Ensigns, Sea Trials and
Automation in the Maritime Sector. Whilst
investigations into the diving fatalities which
occurred in March and November 2018 continue,
these tragic accidents have rightly caused the
DMR and diving operators in the TLBs to
question the validity of their current assurance
practices. Subsequently the Defence Diving
Standards Team (DDST)245 has conducted a full
certification programme of military diving units
and audits of Client Responsible
Organisations246. In addition, the DMR remains
engaged with its DAOs on the outcome of these
investigations, supporting reviews of training the

Military Aviation Authority (MAA)

Following the 2017 MAA External Audit Panel240
findings the focus this year has been
reinvigorating the MAA’s internal quality
assurance activity to ensure compliance with
relevant standards and policies. Additionally,
there has been considerable international
engagement during the year in support of the
mutual recognition programme with Germany,
US forces and Australia. As well as helping to
eliminate unnecessary certification activity, the

Department for Business Innovation and Skills, Regulators’
Code, April 2014.
239
In assessing DAIB and DSPA maturity ‘regulations’ is substituted
with ‘policy’.
240
MAA External Audit Panel 2017 (MEAP17) comprising
independent auditors external to MOD reported that the MAA
‘continues to exercise a very positive impact on Air Safety’,
https://www.gov.uk/government/publications/military-aviationauthority-maa-external-audit-panel-meap-report-2017.
241
The establishment of the MAA’s Assurance Co-ordination Cell
(ACC) has delivered a more holistic view across the MAA branches
238

enabling a far richer risk picture across all elements of the Defence
Air Environment (DAE).
242
eg safety-critical software, Artificial Intelligence and battery
power expertise; fast-jet and Remotely Piloted Aircraft experience.
243
The Naval Authority Group (NAG), Defence Diving Standards
Team (DDST), Capt Port Operations and FOST Operational Sea
Training Team.
244
DSA, DSA02-DMR – Defence Maritime Regulations for Health,
Safety and Environmental Protection, published 1 January 2019.
245
as a DMR DAO.
246
organisations that commission commercial diving for Defence.

4-2

 portfolio of diving guidance publications.
Interactions with statutory regulators continue to
be constructive and effective with the full support
from the MCA, HSE and Environment Agency for
the new regulatory set. Despite significant staff
churn in this period247, DMR has still been able to
deliver its responsibilities to Defence. Based on
the robust and effective review of its regulatory
set, its restructuring and maintenance of
sufficient competent staff to meet the full
requirements of the audit programme, these
developments in DMR’s regulatory maturity
warrant an improved assessment of
SUBSTANTIAL maturity.

4.5
Defence Fire Safety Regulator
(DFSR)
Risk Based Fire Safety Audits are the key
nationally recognised approach for fire safety
regulators to sample compliance on selected
premises. Audits are primarily focused on
premises used for sleeping but also where the
opportunity presents itself wider audits of other
types of premises in use across the TLBs are
conducted. The DFSR was able to conduct a
higher level of RBA this year due to a
commensurate drop in regulatory consultation on
building works in some of the regions.253
However, this welcome increase in audit tempo is
not expected to endure. Therefore, in order to
develop further audit capacity, generate a larger
data set by which to inform better analysis and to
drive improvements in quality and consistency,
the DFSR has initiated an internal review of
Standard Operating Procedures (SOPs),
supporting processes and Enforcement Action
tracking to ensure it has robust management
system.

4.4
Defence Land Safety Regulator
(DLSR)
This year has seen the DLSR continue to mature
within all its regulated areas. The ATSR248 has
now completed its initial development and is able
to fulfil its role in the inspection and licensing of
all Defence AT Centres. The restructuring within
the MTSR249 has enabled better use of the
resource available and the FGSR250 continues to
work with the TLBs and DIO to develop robust
solutions to the legacy of significant infrastructure
safety risks. Finally, while the LSSR251 has
developed a greater understanding of its safety
risks, it has also confirmed that LSSR lacks the
resource to fully carry out its regulatory
responsibilities, particularly in the conduct of
adequate 3PA and the certification of land
vehicles.

Recruitment, an ageing demographic and
retention of SQEP have all been issues testing
the sustained delivery of fire safety assurance
across all areas of Defence. DFSR, DFR, Navy
Comd and Air Comd254 are all competing with an
increase in private sector demand for fire
professionals which has out-stripped national
capacity, partly as a consequence of the Grenfell
tragedy and organisations reviewing their fire
safety arrangements. Notably the ability of the
private sector to recompense at market rates has
made it difficult for Defence to compete. So,
despite the temporary improvement in RBA, the
outflow in SQEP and the sustainment of an
adequate competent regulatory capability, DFSR
remains at LIMITED maturity.

Whilst the rebalancing of existing DSA resource
in the last year has provided some respite, the
capacity and capability to address this assurance
and certification gap in a timely manner is still
lacking. This may require a more innovative
approach; something that will be tackled as part
of the DSA’s strategic objectives over the coming
year.252 Although DLSR has shown some
improvement across all of its AOR as resource
uplifts enacted over the last two years have taken
effect, the continued shortfalls in its LSSR
capability dictate that DLSR remains at LIMITED
maturity.

4.6
Defence Ordnance, Munitions and
Explosives Safety Regulator (DOSR)
The DOSR continues to deliver well established
support to its Regulated Community and is
assessed as having SUBSTANTIAL maturity.
The regulatory framework it maintains has been
recently reviewed and re-issued in a more
accessible format for its stakeholders’ daily

DSA, ‘Setting the Standard, The Defence Safety Authority
Strategic Plan 2019-2025’, published 26 May 2019.
253
The Duty to Consult process as directed by 2017DIN06-23, Duty
to consult with the Defence Fire Safety Regular. Reduction in
notifiable works seen in the North, Central and overseas regions.
254
Each of these organisations employ professional fire fighters.

247

252

~70% of staff changed over in 2018/19 which necessitated an
intensive period of training and upskilling.
248
Adventurous Training Safety Regulator.
249
Movement and Transport Safety Regulator.
250
Fuel and Gas Safety Regulator.
251
Land Systems Safety Regulator.

4-3

 operations.255 By adopting a proactive approach
to recruitment and actively maintaining the
competence of its staff, DOSR has maintained
sufficient SQEP to deliver all of its regulatory and
assurance functions whilst continuing to exploit
the strong bonds it has made with its statutory
peers and military allies towards improvements in
commonality and interoperability.256

The DMSR team is currently fully staffed for its
IOC which has been the delivery of 3PA primarily
in DPHC265 which remains reliant on the CQC
continuing to undertake inspections on the
Regulator’s behalf. A further uplift in staff will be
required for the DMSR to achieve FOC and
deliver its full span of regulatory functions to the
scale necessary for its Regulated Community,
such as a full review of applicable DEDs and
expanding 3PA activity into the single Services
and in our overseas and operational
environments. Therefore, on the basis that the
DMSR remains at IOC it is assessed as having
LIMITED maturity.

Following the discovery of issues around the 2PA
of OME257 acquisition (see Section 3.6.3) there is
a clear need to expedite work to conclude the
DOSR’s organisational separation from those
conducting internal OME assurance within
DE&S.258 This should include options for
establishing robust 3rd Party certification259 and
ranges and explosives licensing activities with
TLBs. 260 These changes have the potential to
enhance the existing OME assurance model for a
small uplift in resource and are therefore
currently under investigation.

4.8
Defence Nuclear Safety Regulator
(DNSR)
The DNSR’s maturity is assessed at Annex B.

4.9
Defence Accident Investigation
Branch (DAIB)

4.7
Defence Medical Services
Regulator (DMSR)

The DAIB delivers a core, independent
investigative function for Defence and is a key
enabler to informing TLBs and Regulators of the
root causes of significant safety incidents
involving Defence personnel and equipment.
The DAIB is fully staffed with trained
investigators, some with considerable experience
in accident investigation. However, it is
recognised that the experience gained is a
function of the number of accidents and incidents
to which investigators deploy. When
compounded by the high churn rates of military
personnel, retention of these investigative skills is
a key challenge. The DAIB is therefore working
with the single Services workforce planners to
consider extending the existing appointment
lengths for military staff.

Having stood up the DMSR on 1 December
2017, progress on delivering the organisational
separation necessary from the Joint Medical
Group (JMG) to allow the DMSR to achieve its
FOC261 has been slower than planned due to
staff churn and reduced capacity in both the
DMSR and JMG. This work has since been reenergised, with a set of transitional principles and
deliverables agreed to provide the foundation for
development beyond its current IOC.262 This will
include confirming the DMSR’s scope of
responsibility263 and ‘right sizing’ the team.
DMSR Regulations to cover the MOD’s
disapplication from the Health and Social Care
Act 2008 (Regulated Activity) 2015 (H&SCA)
Regulations264 have been produced and
published. In addition, an exemption and
appeals process has also been developed.

In terms of investigative capability, the DAIB is
most mature in the aviation domain, with
investigators from all three Services (both
operators and engineers) and all are based at the

255

evidence from the current 2nd Party processes in place within DE&S
for assurance.
260
TLBs currently self-authorise their own ranges and license their
own explosive facilities.
261
Full Operating Capability.
262
Initial Operating Capability.
263
DMSR Stakeholder Committee Mar 19 confirmed Vets and
Military Working Animals should not be in scope for DMSR but
covered by the Army Inspector and participation in the Royal
College of Veterinary Surgeons Practice Standards Scheme.
264
DSA, DSA02 Healthcare Regulatory Policy and Healthcare
Regulations, dated 21 December 2018.
https://www.gov.uk/government/publications/healthcare-regulatorypolicy-and-healthcare-regulations-dsa02
265
Defence Primary Healthcare.

DSA, DSA 02 Defence Ordnance, Munitions and Explosives
(OME) Regulations, version 1.0, dated 4 June 2019 and DSA, DSA
03.OME Defence Code of Practice (DCOP) and Guidance Notes for
OME Acquisition, dated April 2019
256
The DOSR Policy, Regulations & Guidance Team (PRG)
continues to work closely with the NATO Munitions Safety &
Information Analysis Centre to align better NATO standards and
methodology with UK practices.
257
Ordnance, Munitions and Explosives.
258
Currently the Defence Ordnance Safety Group (DOSG), a team
within DE&S, provides safety advice, assurance and certification of
Defence’s OME systems.
259
Currently DOSR does not provide 3rd Party certification of
weapon systems (including lasers) and relies heavily on the

4-4

 same site. Whilst historical reasons have
resulted in the Land domain investigators being
currently split across two sites (Andover and
Bristol)266 this arrangement has been suboptimal. Consequently, the DAIB is exploring
options to co-locate and improve its operating
efficiency. However, the DAIB’s major capability
gap is the lack of a specialist maritime
investigative capability. Although required to
investigate accidents and serious incidents
across the three principal operating domains, the
DAIB continue to have no dedicated maritime
SQEP and rely heavily on secondment or support
from external Subject Matter Experts. Work is
ongoing on how to resolve this shortfall;
therefore, the DAIB is assessed as having
LIMITED maturity.

produced to assist Head Office in establishing an
HS&EP policy unit within the Department and
split strategic policy matters from those
supporting Regulation.269 As a result, DSA’s
assurance of general policy compliance and
occupational H&S remains limited; therefore,
DSPA has been assessed as having LIMITED
maturity.

4.11

DSA Maturity – Other factors

4.11.1 External Audit of the DSA. At a House
of Commons Defence Committee (HCDC)
hearing in 2015 the Department committed to
conduct an external audit of the quality of the
DSA’s work to demonstrate its effectiveness as
an organisation.270 The external audit took place
between September and November 2018. Led
by Rear Admiral (Retd) Dr Chris Parry, a former
Director of DOC271, the audit team included a
Principal Inspector from the HSE and the Deputy
Chief Inspector of the Office of ‘Nuclear
Regulation (ONR) and submitted their report to
the SofS on 19 November 2018.272 The audit
concluded that the DSA:

4.10 Defence Safety Policy & Assurance
Team (DSPA)
As a result of the shortfall in the DSA’s
assurance capabilities identified in DSA’s
2016/17 AAR267, the DSA HQ has been
restructured to establish a (limited) capability to
assure the Department’s compliance against the
full scope of the SofS’s HS&EP policies,
particularly compliance with legislation governed
by statutory regulators.268 The initial phase of
this activity has been a programme of baselining
assessments of TLB Safety and Environmental
Management Systems (SEMS) and compliance
with SofS HS&EP policy statements. The
majority of TLBs were benchmarked by the
assurance team during the reporting period and
an overview of the findings is at Section 5.4. The
core of the DSPA team’s work has continued to
transition the disparate range of safety-related
Joint Service Publications (JSPs) into the DSA01
set of high-level safety policies. Significant levels
of obsolescent information are being reworked
and whilst staff churn and recruitment challenges
have reduced the pace of this change, progress
has been made. DSPA also supports internal
governance, RBA coordination and promotion of
good-practices between regulators. In addition, a
number of policy think-pieces have been

•
has, since its formation, substantially
transformed attitudes and galvanised action
within Defence with regard to risk and safety;273
•
should remain independent and
accountable directly to the SofS;
•
still has a way to go before it can provide
SofS with the strategic level assurance across all
HS&EP;
•
should become more strategic in its
approach, more output focussed and more
forward looking.
For the MOD as a whole, the audit suggested
that improvements needed to be made in toplevel governance and agreements, with a
pressing need for realistic metrics and an
analytical capability by which safety assurance
could be measured and vulnerabilities identified.
In addition, the audit report made 65
recommendations towards further improving the

DAIB’s Land domain investigators were formed from the Army’s
Land Accident Investigation Team (LAIT) in Andover and DE&S’s
Serious Equipment Failure Investigation Team (SEFIT) in Bristol.
267
MOD, Defence Safety Authority Annual Assurance Report April
2016 – March 2017, 31 October 2017, para 13.
268
eg Health and Safety Executive, Maritime and Coastguard
Agency, Food Standards Agency.
269
This was an outcome of the Head Office review of safety
governance in Defence (see Section 5.4).
266

270

House of Commons Defence Committee, Beyond endurance?
Military exercises and the duty of care: Government Response to
the Committee’s Third Report of Session 2015–16, published on 24
April 2016,
https://publications.parliament.uk/pa/cm201617/cmselect/cmdfence/
525/52504.htm
271
Defence Operational Capability.
272
Parry, Report and Findings from the 2018 External Audit of the
Defence Safety Authority, dated 19 November 2018.
273
Environmental Protection was out-with the Audit’s scope.

4-5

 effectiveness of the DSA and governance of
safety in Defence. These recommendations
have been reviewed by the DSA and have been
taken forward into the DSA’s Strategic Plan for
2019-2025274 in parallel with the Defence Safety
and Environment Committee’s work on
recommendations from Head Office’s
subsequent review of safety governance (see
Section 5-4).

Environment (Principles and Governance) Bill
and has continued to develop an understanding
of the complex legislative landscape that EP has
become. The DSA has also routinely reviewed
Cabinet Office correspondence requests of which
>50% were on EP matters, as well as
participated in the ‘European Conference for
Defence and the Environment’ and in
EUDEFNET281 to ensure awareness of upcoming
European legislation that could impact Defence
activities. In order to provide central coordination
and coherence to the assurance of EP across the
Department, the DSA has set an explicit
objective in its strategy282 to develop a Defencewide oversight of EP issues and to grow this
awareness across DSA and Head Office in the
coming years.

4.11.2 Analysis & Plans Capability. As the
Analysis and Plans capability of each Regulator
has continued to mature275, it has provided each
with the ability to better direct RBA, improve the
effectiveness of their engagement with their
Regulated Communities and allow resource to be
focused proportionately to the level of concern or
likely impact to Defence.276 As a consequence
this has generated headroom for some
Regulators to reinvigorate their periodic reviews
of regulations so that they remain relevant and
effective and strengthen their understanding and
engagement on emerging legislation.

Summary – LIMITED
The DSA has continued to mature as a
constructive and effective safety Regulator
for Defence activities. Decisions taken
previously to restructure the DSA, improve
the analysis capability of Regulators and
enhance the quality of regulation,
assurance, enforcement and investigation
have all begun to deliver effect. The gains
in terms of consistent sustainable RBA are
going in the right direction, and the majority
of recommendations made by the External
Audit are within the DSA’s gift to address.
However, some step-change improvements
such as the certification of Land and OME
systems will need the co-operation and
consent of both Head Office and some of
the TLBs to move forward. The
effectiveness and value added by the DSA
is reliant upon the delivery of robust selfassurance by TLBs and, in the future, by the
approach to HS&EP-risk management
taken by the newly formed Defence Safety
& Environment Committee.

4.11.3 Environmental Protection (EP).
Previous DSA AARs277 highlighted the limited
capabilities the DSA had to assure Defence’s
compliance with EP regulation and policy. The
requirement and scope of EP assurance varies
across the regulated domains. Where EP
regulation and policy is mature in the Defence
regulated space278, DSA assurance is generally
good in those pockets of EP regulated activity.
However, beyond the assurance provided by
individual Regulators the DSA does not provide
consistent or coordinated oversight nor does it
currently assure compliance with statutory EP.
EP policy spans a number of areas in Defence,
from that set by the DSA as regulation279, land
and estates policy set by FMC(Infra)280 and wider
government policy on climate change and
sustainability. Central coordination therefore has
the potential to add value to EP management
and compliance in Defence.
This year DSA has provided support to DEFRA’s
development of UK legislation on the
DSA, ‘Setting the Standard, The Defence Safety Authority
Strategic Plan 2019-2025’, published 26 May 2019.
275
Bar DMSR who, as our newest regulator, has yet to establish an
analysis and plans capability.
276
The 3rd principle of the Regulators’ Code, Department for
Business Innovation and Skills, Regulators’ Code, April 2014.
277
MOD, Defence Safety Authority Annual Assurance Report April
2016 – March 2017, dated 31 October 2017 and MOD, Defence
Safety Authority Annual Assurance Report April 2017 – March
2018, dated 26 October 2018, Section 2.5.3.
278
eg maritime activities and MACR.
274

279

Joint Service Publication 418, Management of Environmental
Protection in Defence, version 1 dated December 2014.
280
Finance & Military Capability (Infrastructure) is a section within
MOD Head Office that oversees Defence’s Infrastructure
programme, policy, funding and strategic balance of investment
activity for the Defence Estate. Joint Service Publication 850:
Infrastructure and Estate Policy, version 1 dated October 2018.
281
The European Defence Network, an informal, expert-led group
comprising of environmental focal points and specialists from
Ministries of Defence (MODs) of EU Member States.
282
DSA, ‘Setting the Standard, The Defence Safety Authority
Strategic Plan 2019-2025’, published 26 May 2019.

4-6

 Analysis and Recommendations

Figure 5-1

5.1

to improve the Department’s governance of
safety, inform HS&EP-conscious decision making
within Head Office and set the necessary
conditions to allow senior risk owners to more
effectively manage the broad and complex
activities in Defence to minimise harm to our
people, our capabilities and the environment.284
Whilst the recommendations were challenging,
they were also universally welcomed as a
catalyst to corral and refocus the excellent
‘safety-minded’ work which continues across the
Department on a daily basis. The following
sections review progress made towards these
key recommendations.

What’s Changed?

The safety assurance assessments of the
Regulators for each domain set out in Section 3,
supported by submissions from the TLBs, are
summarised in Figure 5-1. The overall
assessment for Defence of LIMITED Safety
Assurance is unchanged from last year.
However, it comes with a greater level of
confidence as the overall maturity and capability
of the Defence Safety Regulators has increased,
as described in Section 4, improving the value
and confidence of the 3PA they provide.
Since the definition of Limited Safety Assurance
implies significant weaknesses in control
systems, it is important that Defence understands
what these are and considers carefully whether
they are acceptable. This understanding should
inform Balance of Investment (BOI) decisions by
Senior Duty Holders (SDHs) and senior risk
owners283 and, in turn, should be informed by the
appetite of the SofS and the Defence Board for
better safety assurance. Last year’s DSA Annual
Assurance Report (AAR) made a number of
recommendations to the SofS on pragmatic ways
283

5.2

Brexit

5.2.1 Assessing the Safety Risk. The DSA
has continued to refresh its assessment of the
potential Safety and Environmental challenges to
Defence as a result of the UK’s withdrawal from
the EU. The aim of this has been to assure Head
Office and the Regulated Communities of the
DSA’s understanding of the implications of Brexit
for Defence Safety and determine whether there
is more that the Department should be doing.
284

through the governance of the Perm Sec-led DSEC.

MOD, Defence Safety Authority Annual Assurance Report April
2017 – March 2018, 26 October 2018, Annex C.

5-1

 •
Delivery of medical services to EUbased personnel.
Prudent planning within the Department and
continued close integration on safety matters
across government and with civilian regulators
and public bodies has considerably mitigated the
impact these changes could have on Defence
outputs. The DSA remains engaged with its
statutory peers and the MOD’s EU Exit Team as
Brexit planning develops.

Working with each DSA Regulator, the MOD EU
Exit Team and statutory regulators in Other
Government Departments (OGDs) this
assessment gauged levels of engagement
across regulated domains, sought to identify any
specific risks and considered if there was any
need for change to Defence Safety policy or
regulations. Following cross-government
direction, the DSA was also asked to consider
the implications of a ‘No Deal’ Brexit as part of
wider contingency planning.

5.3
The Modernising Defence
Programme (MDP)
5.3.1 MDP Outcome. The National Security
and Capability Review (NSCR)292 concluded that
the world has become more uncertain and
volatile since 2015. The resulting MDP293 which
comprised four work-streams294 has led to a
revised Defence Operating Model (DOM) and a
Defence Purpose295 which is built upon the
foundations of:

5.2.2 Conclusion. The DSA’s updated
assessment concluded that for the areas that
Defence regulates there was no current need to
materially change285 defence safety
regulation.286 However, for safety-related
matters regulated by statutory regulators287,
Defence would need to amend its processes in
the same way as the general public or UK
Industry in order to accommodate changes to
safety-related UK law which arise from the EU
(Withdrawal) Act 2018288 These include:
•

•
Mobilise defence to make the most of
what it already has, making the current force
more lethal and better able to protect UK
security. The Department plans to invest to
improve the readiness and availability of a range
of key defence platforms, including: major
warships, our attack submarines and helicopters
and reprioritise within the current defence
programme to increase weapon stockpiles and
spares and to improve the combat effectiveness
of capabilities already in service.

Driving in non-NATO EU countries289;

•
Changes in reporting from EU-regulated
statutory bodies (eg MHRA290, ECHA291, EU
Commission) to UK regulatory bodies;

•
Modernise defence and the Armed
Forces to deliver national and international
security more smartly and effectively, adapting
how it operates, becoming more innovative and
better at exploiting the opportunities offered by
modern technology to ensure our forces retain
strategic military advantage. The Department
intends to invest in a range of new ‘Spearhead’

•
Contracting civilian air, maritime and
road haulage services particularly where it
involves EU registered crew, vessels or trailers;

285

293

There may be administrative changes necessary to refer to the
EU (Withdrawal) Act 2018 in lieu of EU Regulation.
286
MOD, Defence Safety Authority Annual Assurance Report April
2017 – March 2018, 26 October 2018, Recommendation 1.
287
Where Defence does not have a DED, it is required to comply
with the applicable UK law and is regulated by the respective
statutory regulator (eg Health & Safety Executive, Vehicle &
Operator Services Agency, Environment Agency, etc).
288
and any subsequent secondary legislation.
289
Five EU member states are not NATO members: Austria,
Finland, Ireland, Malta, and Sweden; therefore driver licensing does
not come under the NATO Status of Forces Agreement 1955.
290
Medicines and Healthcare products Regulatory Agency.
291
European Chemicals Agency.
292
https://www.gov.uk/government/publications/national-securitycapability-review-nscr .

MOD, Mobilising, Modernising & Transforming Defence
A report on the Modernising Defence Programme, published 18
December 2018
https://assets.publishing.service.gov.uk/government/uploads/syste
m/uploads/attachment_data/file/765879/ModernisingDefenceProgra
mme_report_2018_FINAL.pdf
294
MDP workstreams: Workstream 1 – MOD Operating Model,
Workstream 2 – Efficiency and business modernisation,
Workstream 3 – Commercial and industrial approach, Workstream
4 – Defence policy, outputs and military capability.
295
The Defence Purpose describes in a simple way what Defence
does for the country and the direction for the whole organisation to
help those working in Defence understand their objectives and how
their work contributes. The Defence Purpose is to ‘protect the
people of the UK, prevent conflict, be ready to fight our enemies.
We are prepared for the present, fit for the future’.

5-2

 innovation programmes to apply cutting-edge
technologies to contemporary challenges whilst
integrating more fully the newer domains of
cyberspace and space.

disproportionate level of effort and investment to
remain ALARP and tolerable. However, as
poorly managed Change across the Department
has previously been highlighted as a pan-domain
threat to safety297, the impetus lies with SROs on
ensuring the key tenets of MDP are managed
effectively and consider safety throughout. This
further emphasises the value of properly
considered Organisational Safety Assessments
(OSAs)298 in providing SROs with a structured
method of determining the impact of Change on
safety outcomes. The formation of the Head
Office HS&EP Directorate now provides the
opportunity for senior management oversight and
assurance that programme outcomes are both
Safe to Operate and can Operate Safely both in
isolation and when integrated with wider MOD,
cross-government and coalition systems. This
also presents Head Office with an opportunity to
test its revised Defence Operating Model (DOM)
against ‘live’ programmes in order to further
assure itself that the DOM is fit-for-purpose.

•
Transform the way the Department does
business to maintain momentum on
strengthening and modernising defence. This
will include implementing a number of changes to
how the MOD is organised and is operating, such
as strengthening our Head Office and
accelerating transformation of the Defence
Equipment and Support organisation.
5.3.2 Consideration of Safety. By ensuring
safety is an integral consideration of Change,
whether it is driven by activity in the Mobilise,
Modernise or Transform space, the MOD can
protect its operational capability from
unnecessary losses, ensure the safety of its
personnel and maintain its professional
reputation through compliance with applicable
legislation. The MDP has the potential to
rationalise the large portfolio296 of Organisational
and Equipment change programmes and deliver
consequential safety benefits, such as retiring
those ageing capabilities which require a

Recommendation 1: Head Office should
assure itself that the revised Defence
Operating Model and governance
arrangements provide sufficient
consideration of safety during its oversight
of change initiatives.

5.4

Head Office Governance of Safety

5.4.1 Requirement. The Department’s Chief
Operating Officer (COO), as ‘safety risk owner’
for the Defence Board, commissioned a review to
determine the optimal role for Head Office in
relation to HS&EP, and how that role should be
discharged. This was against a backdrop of
growing concern reflected in the DSA’s Annual
Assurance Report 2017-18299 and by the
Improvement Notice served on the Perm Sec in
April 2018 which suggested that there was a
critical shortfall in Head Office governance and
resourcing, highlighted by an almost complete
absence of staff in Head Office to deal with
HS&EP matters as they arise. The Review was
conducted between September and November
2018 and reported to the COO on 18 December
2018.300

296

298

The Defence Equipment Plan alone equated to £180Bn out to
2026/27. MOD, Defence Equipment Plan 2017, 31 January 2018.
297
MOD, Defence Safety Authority Annual Assurance Report April
2017 – March 2018, 26 October 2018, Sect 5.4.2.

DSA01.2, Chapter 7, Assessment of Organisational Change on
Health, Safety and Environmental Protection, issued 8 July 2018.
299
ibid, Recommendations 3 & 4.
300
MOD, Review into the MOD Head Office Governance of Health,
Safety and Environmental Protection, dated 18 December 2018.

5-3

 •
the DSA would also support the new
Head Office policy unit in work to clarify the
DSA’s wider policy and assurance remit;

5.4.2 Findings. The Review found that MOD
Head Office was unsighted on overall HS&EP
performance across Defence, unclear about its
responsibilities and had neither the processes
nor personnel to discharge its governance and
other responsibilities. However, it stressed that

•
sustained, and highly visible top-level
leadership will be required if we are to embed the
right HS&EP culture.

‘many people in the MOD – at all levels and in
all the Defence Organisations – take safety
extremely seriously, drawing on a great deal
of expertise and experience. And it seems
clear that some areas are centres of
excellence. Guidance and instructions
abound. However, it was remarked to us
several times that HS&EP within Defence is
often delivered despite and not because of
our organisation and processes. The role of
Head Office was notable by its absence.’

The ExCo303 agreed with the general thrust of the
recommendations and stressed that work to take
the findings forward should not compromise
existing safety arrangements and should
contribute towards satisfying the extant
Improvement Notice.304
5.4.3 Progress. Following endorsement by the
ExCo an interim Director of Head Office HS&EP
(D HS&EP) was appointed in 28 February 2019
and the inaugural DSEC was held on 24 April
2019. The DSEC subsequently approved the
formation of nine workstreams305 and a
supporting DSEC Working Group to carry
forward the recommendations of the Safety
Governance Review, the DSA External Audit and
the findings of the DSA’s AAR. Work has
commenced in a number of the workstreams306
with specialist expertise being drawn in from
across the Department including the DSA. In
addition, new holding to account mechanisms307
between Head Office and the TLBs have safetygovernance embedded within its structure and
safety is now a standing agenda item in the
quarterly senior review meetings. Considerable
progress has now been made on a number of
fronts and reflects the positive steps Head Office
has taken to address the recommendations of
the Governance Review and establish the
required frameworks to improve the visibility of
safety-related risks.

The Review made 27 recommendations, some of
which aligned or overlapped with the
recommendations of the External Audit of the
DSA301 (see Section 4.11). Key findings were
that:
•
ownership of HS&EP policy should
ultimately rest with the Head Office and
arrangements should be made to effect this as
quickly as possible;
•
a Director-level led policy unit be created,
with an interim appointment as soon as possible,
to support senior Head Office staff in handling
the immediate issues and transition;
•
the Perm Sec should chair a 4* Defence
Safety and Environment Committee (DSEC)302,
with membership to include: the Service Chiefs,
Commander JFC, the COO, the Director General
Nuclear and the Chief Executives of DIO and
DE&S and Director General DSA;

5.5
Safety and Environmental
Protection Management Systems (SEMS)
Baselining

•
the DSA should retain responsibility for
safety-related Service Inquiries and continue its
role as Defence regulator, enforcer and assurer;

5.5.1 SEMS Baselining Activity. Following
agreement by the former Defence Safety
Committee, the DSA commenced a programme
of baselining assessments of TLB SEMS308 and
their means of complying with the SofS HS&EP

301

Parry, Report and Findings from the 2018 External Audit of the
Defence Safety Authority, dated 19 November 2018.
302
replacing the previous 3* Defence Safety Committee.
303
The MOD’s Executive Committee, chaired by the Perm Sec.
304
In April 2018 DG DSA served an Improvement Notice on the
Department for a lack of safety governance for Defence.
305
DSEC Workstreams: 1 – Top Level Leadership; 2 – Risk; 3 –
Management Information; 4 - Engagement; 5 - Delineation of Policy
and Assurance Responsibilities; 6 – EP Policy and Assurance; 7 –
Functional Leadership Strategy; 8 - Implementation of

Recommendations made by Head Office and Parry Reviews and
DSA AAR; 9 – Organisational Design.
306
Top Level Leadership, Management Information and Risk were
agreed as high priority enabling tasks.
307
The MOD’s quarterly Performance and Risk Review governance
process.
308
DSA01.2, Chapter 2, Requirement for Safety and Environmental
Management Systems in Defence, version 1.1, dated 26 June
2018.

5-4

 policy statement.309 During this reporting period
the Defence Safety and Policy Assurance
(DSPA) team conducted seven baseline reviews
with TLB staff310 and took feedback on the DSA
publications programme and ways of improving
Defence safety policy. A further three reviews are
planned for 2019311 prior to the commencement
of a formal audit programme.

categorised as pan-domain313, assurance and
domain-specific threats.314 Each of the domainspecific threats have already been covered: Mid
Air Collision (MAC) at Section 3.2.3; Fuel & Gas
Infrastructure (FGI) at Section 3.4.3; and Fire
Safety Management at Section 3.5.3. In addition,
the lead finding last year regarding Head Office’s
governance of Safety has already been
discussed at Section 5.4. The remaining pandomain threats are covered below. In addition,
numerous reports and observations of
deficiencies in the fabric of the Defence Estate
which could pose a threat to the safety of
personnel and the environment has been
considered worthy of particular note for the
SofS/Defence Board and senior risk owners.

5.5.2 Findings. Whilst there were no common
themes identified from the baselining activity,
each TLB displayed an intent to capture the
means by which it exercised its safety
responsibilities as an organisation. The level to
which this was achieved was found to vary, with
some TLBs focusing on Defence regulation and
others focusing more on statutory occupational
HS&EP compliance. The benchmarking also
was an opportunity to explore how far each
SEMS extended into an organisation, and
whether there were gaps or areas of Defence
activity that had been left out. Various views
were given on how each TLB interacted with
Head Office in the reporting and, where
necessary, escalation of HS&EP risks. The
introduction of new Head Office governance
frameworks such as the quarterly Performance
and Risk Reviews (PRRs) were seen as a
positive step forward; however, uncertainty still
lay in how this process would be formalized and
documented. Subsequently this opportunity for
Head Office to clarify safety risk mechanisms and
capture them in Defence policy was seized by
the newly formed DSEC and is to be addressed
through an explicit workstream (see Section 5.4).

5.6

5.6.1 Effects of Change. Change, whether
business change or that driven by capability
development or transformation, has the potential
to adversely impact safety if not managed
correctly. There has been growing evidence that
the requirement for SROs315 to generate and
consider OSAs has been gaining traction,316 with
OSAs now mandated within the SofS’s HS&EP
policy statement.317 The positive engagement
initially witnessed from SROs, spanning many
TLBs, has placed Defence in a considerably
better informed and prepared position than
previous years. However, the quality of OSAs
has remained unwelcomingly variable and some
have been noted as having been produced in
retrospect, more as a demonstration of policy
compliance, and missing the added value an
OSA brings to good change management. In
order to support TLBs in the preparation of OSAs
and to demonstrate examples of OSAs adding
real value to change programmes, the DSA will
continue to promote its ‘train the trainer’
initiatives318 in 2019/20 and plans to review and

‘Significant’ Safety Threats

The previous DSA AAR312 highlighted 7
significant threats to maintaining safety in
Defence, many of which have endured from
previous assurance reports. These were

309

MOD, Health, Safety and Environmental Protection in Defence:
Policy Statement by the Secretary of State for Defence, dated 20
June 2018.
310
Baseline reviews of Air Comd, Navy Comd, Army HQ, Defence
Equipment & Support (DE&S), Defence Nuclear Organisation
(DNO), Head Office & Commissioning Services (HOCS) and
Defence Electronics & Components Agency (DECA) SEMS were
conducted.
311
Joint Force Command (JFC), Defence Science & Technology
Laboratory (Dstl) and the Defence Infrastructure Organisation
(DIO).
312
MOD, Defence Safety Authority Annual Assurance Report April
2017 – March 2018, 26 October 2018, Section 5.4.
313
Head Office governance of safety, effects of Change and lack of
SQEP.
314
either due to the societal/reputational impact (mass casualty
accident (mid-air collision with civil airliner, seismic protection of
MOD buildings)), national or political relevance (fire safety

(Grenfell), drones (Gatwick)) or threats which are considered
cumulatively significant beyond existing TLB risk reporting (fuel/gas
infrastructure accident (Buncefield, Singapore harbour).
315
Each major equipment or business change programme has a
Senior Responsible Owner appointed by the Perm Sec.
316
DSA01.1, Defence Policy for Health, Safety and Environmental
Protection, v1.0, August 2016 sets the requirement to conduct an
OSA; whereas, DSA01.2, Chapter 7, Assessment of Organisational
Change on Health, Safety and Environmental Protection, issued 8
July 2018 details the necessary content and approach.
317
MOD, Health, Safety and Environmental Protection in Defence:
Policy Statement by the Secretary of State for Defence, dated 20
June 2018.
318
MOD, Defence Safety Authority Annual Assurance Report April
2017 – March 2018, dated 26 October 2018, Recommendation 5:
‘The DSA to propose a training package on OSAs for inclusion in
Head Office-run SRO training’.

5-5

 share the lessons from previous OSA reviews
and feedback from OSA workshops.319
5.6.2 Insufficient SQEP. A lack of sufficient
SQEP has been an enduring Defence-wide
concern for the last 14 years.320 Numerous
Service and TLB-led initiatives over the years
have attempted to treat this perennial issue with
varied success. In the Maritime domain Royal
Navy initiatives to generate and sustain SQEP in
the longer term are beginning to deliver tangible
results321; whereas, across Aviation the
resourcing of Air Safety SQEP remains patchy.
Improving numbers of SQEP within our Medical
Services are encouraging; however, significant
shortfalls remain in some key specialisations.
SQEP in Defence’s Ordnance, Munitions &
Explosives cadre is currently adequate but lacks
resilience, and our Fire Safety experts are
competing with a strong external market driven
by the outcomes of the Grenfell Tower Inquiry.
On a positive note, evidence this year has shown
that TLBs have, in general, a clearer focus on
understanding and managing risks from
insufficient SQEP. Visibility has also improved
centrally with critical workforce shortfalls being
routinely reported to Head Office and reviewed
within the new Departmental governance
arrangements.322 Regulators have further
reported that SQEP shortfalls are increasingly
being driven by personnel lacking experience
rather than qualifications which, as a necessary
transitory phase in the road to recovering
competence in an organisation, further underpins
a slow but improving situation. The Chief of
Defence Personnel (CDP) continues to develop
measures323 which Single Services can and have
chosen to enact.324 However, faced with a
dynamic external employment market, which is
presently buoyant for many of the niche skills
held by some of the Department’s key personnel,
these individual measures may not be sufficiently
scalable or enduring to attract and, more
importantly, retain the expertise we need.
Several of the Department’s external agencies
have exercised the greater flexibility they were

granted to set their own remuneration and
grading frameworks to address such concerns.325
Head Office may wish to consider where these
increased freedoms were successful and
whether they could address the more difficult
SQEP shortfalls that have challenged Defence.
Recommendation 2: The Defence Board,
through the DSEC, should consider whether
some of the renumeration and grading
freedoms exercised by MOD’s external
agencies could be utilised to address the
Department’s more difficult SQEP
recruitment and retention challenges.
5.6.3 Inadequate 2PA. The conduct and
analysis of 2PA has previously been inconsistent
across Defence through weaknesses in
organisational structure, processes and
workforce allocation. Previous concerns in the

319

322

This will contribute towards ongoing work to include the scrutiny
of OSAs as part of the assurance process in JSP 655 and SRO
mandates. See MOD, Defence Safety Authority Annual Assurance
Report April 2017 – March 2018, dated 26 October 2018,
Recommendation 6.
320
Insufficient SQEP has featured as a concern in each MOD
annual safety report since 2005.
321
The Navy Command Engineer Manpower Recovery Programme
and the Navy Command Junior Engineer Officer Manning Recovery
Programme.

MOD internal Quarterly Performance and Risk Reviews.
Options such as recruitment initiatives (golden handshakes,
recruitment bounties), financial retention incentives and financial
rewards aligned to attaining professional qualifications.
324
In August 2018 the RAF introduced a financial award for
engineers achieving external validation from a Professional
Engineering Institute.
325
eg DE&S (through their Transformation Programme), the UK
Hydrographic Office and Dstl.
323

5-6

 Land and Maritime domains had been subject to
focussed action by both Army and Navy
Commands (Comds), with demonstrable
improvements in both the governance and
conduct of 2PA. In Navy Comd the quality and
visibility of assurance evidence has improved,
and in Army Comd the frameworks to assure
safety have been reinforced within the Army’s
overall governance and assurance policies.326
This demonstrates the benefits of investing time,
personnel and resource into 2PA and giving
commanders (and risk owners) confidence in the
safety underpinning the routine and high-risk
activities they undertake. Where that senior
investment or prioritisation is lacking, so is the
confidence. Poor or insufficient 2PA does not
mean that the activities or equipment in question
are unsafe. It just means that it is difficult to
prove that it is safe327 and, particularly where it is
assurance that a piece of equipment is Safe to
Operate, it begins to undermine any subsequent
safety argument stating that it is Operated
Safely.328 2PA is a critical safeguard in the
layered assurance model Defence relies upon to
minimise unnecessary harm to our people and
should warrant the necessary attention and
priority that affords. Those areas of Defence
lacking in effective 2PA should be encouraged to
examine why that is the case and, through the
broader Defence community, be supported in
advice and guidance on ways to successfully turn
it around.

impacts the morale of our people who have to
work in those buildings which have lacked care
or investment330; it diverts the attention and
resource of Heads of Establishment (HoE) to
actively manage facilities that are not fit for
purpose; it threatens the safety of our people
who live and sleep in accommodation that has
lacked adequate maintenance or repair of fire
protection systems331; and it threatens the safety
and environment of those working in and around
our FGI. In particular, the projected £8.5Bn
shortfall in overall infrastructure funding
estimated by the National Audit Office (NAO)
illustrates the ‘huge challenge’332 and complexity
of maintaining the Defence Estate. Recovery
requires not only long-term financial planning and
the capacity of the construction and facilities
management sector, but the prioritisation and will
of Defence to treat these issues in a taut fiscal
climate, where it must compete against the
operational necessity to mobilise and
modernise our military capabilities. Investment
last year into a 10-year programme of mandatory
inspection, maintenance and repair333 of the
Department’s UK fuels infrastructure
demonstrated the immediate and positive impact
this has on infrastructure compliance, noting that
funding for the overseas fuels estate is less
mature. At the beginning of this reporting period
infrastructure funding and prioritisation was
transferred back to user TLBs from the Defence
Infrastructure Organisation (DIO) under the
Defence Infrastructure Model Review (DIMR).
TLBs have widely welcomed this transfer, as has
the DIO, with many reporting that having the
ability to direct and prioritise maintenance and
repair activity has allowed them to expend their

Recommendation 3: The DSEC should
share amongst their members exemplars of
initiatives or strategies which have been
successful in improving the governance,
resourcing and delivery of effective 2PA
within TLBs.
5.6.4 Defence Infrastructure. As reported last
year, the Department had recognised that there
was a significant risk329 that the poor condition of
the estate would affect defence capability. The
chronic effects of a declining estate have the
potential to impact safety in a number of ways. It

Army Command Standing Order 9001 – The Army Policy for
Audit & Inspection and Army Command Standing Order 3216 – The
Army’s Safety and Environmental Management System.
327
eg an inability to assure Host Nation healthcare provision for
personnel at our overseas bases (see Section 3.7.3).
328
eg a lack of assurance of weapon safety cases (see Section
3.6.3.)
329
NAO, Delivering the Defence Estate, HC782 2016-17, 15
November 2016.
326

330

eg chronic building deficiencies engendering a culture of
acceptance of sub-standard facilities by medical staff.
331
eg unwanted fire alarm activations eroding building occupants’
responses to and confidence in fire protection systems. See DSA,
Fire Safety Review: Defence Single Living Accommodation,
DFSR/18/001/Report dated 14 August 2018.
332
NAO, Delivering the Defence Estate.
333
Noting there are legal requirements for inspection, maintenance
and serviceability of FGI for which the Department is not exempt.

5-7

 allocated funding more effectively. However, this
new model has still to be tested against pan-TLB
infrastructure issues.

5.7

Safety Think-pieces

The purpose of these think-pieces is to highlight
topics or themes that the DSA has observed
which the Department may wish to consider or
investigate further at a strategic or collective
level. They do not reflect specific safety or
environmental risks or threats, but instead they
aim to challenge thinking.
supporting these statistics varies considerably
whether in the operational, trained or training
environment, and that the Department has set
the improved capture and analysis of
Management Information (MI) as a priority
workstream for the DSEC.339 However, despite a
lack of meaningful MI it is still recognised that
safety-related injuries and ill-health have a
tangible impact on the delivery of Defence
outputs, on the well-being and morale of our
personnel and on bearing avoidable costs on the
Department.340 There is, therefore, an
opportunity now for Defence to consider how it
can restore equal focus341 on preventing harm to
our people as it currently does so well towards
preventing fatalities, and how this could be
supported by the outputs of the various DSEC
workstreams.

5.7.1 Risk to Life (RtL) versus harm. Since
the recommendations of the Nimrod Review by
Lord Justice Haddon-Cave334 were accepted and
implemented, the focus of Defence and the
regulatory and policy frameworks it
commissioned have been appropriately aimed at
reducing the Risk to Life (RtL) from Defence’s
particularly complex, challenging and high
consequence activities to As Low As is
Reasonably Practicable (ALARP) and with a
tolerable level of residual risk. Having started in
aviation, the policy of Duty Holding was rolled out
across Defence in order to provide enhanced
oversight and management of those high-risk
activities.335 Considering that there has been a
reducing trend in safety-related fatalities over the
last ten years (see Section 2.2.3, Figure 2-3) it is
posited that this policy has contributed in some
part towards this outcome. However, contrary to
that trend, Defence Statistics reported that the
rate of injury and ill-health for UK Armed Forces
personnel had ‘significantly increased’336
uniformly over the last five years even when
considering the perennial issue of late reporting
(see Section 2.2.3, Figure 2-5).337 Whilst part of
this increase could be attributed to improved
reporting (through improvements in safety culture
or a reduction in deployed operations338) it could
also reasonably be put that the current policies
and measures to reduce injuries within our
workforce are, at best, merely supressing injury
rates rather than reducing them. It is accepted
that the quality of the underpinning data

Recommendation 4: The Defence Board,
through the DSEC, should consider whether
the current measures to minimise injury and
harm to Defence personnel are adequate.
5.7.2 Complacency versus SQEP. Even with
sufficient, appropriate and even the best
available SQEP, errors are made and incidents
occur. However, the findings of recent DAIB
deployments and the outcomes of several
Service Inquiries now suggest that the risk of
avoidable accidents being caused by
complacency (errors made by those we would
deem the most competent) may be comparable

334

337

Haddon-Cave, The Nimrod Review: An independent review into
the broader issues surrounding the loss of the RAF Nimrod MR2
Aircraft XV230 in Afghanistan in 2006, HC1025, published 28
October 2009, https://www.gov.uk/government/publications/thenimrod-review
335
DSA01.2 Chapter 3, Duty Holding, version 1.1 dated May 2018.
336
MOD, Deaths in the UK Regular Armed Forces: Annual
Summary and Trends over Time 1 January 2009 to 31 December
2018, published 28 March 2019.

Late reporting and data corrections accounted for an additional
11% increase in reporting in 2016/17. Error bars have been added
to illustrate this historical variation.
338
It is recognised that there is a lesser propensity to report minor
injuries on operations or in deployed environments where the
means to report are more limited or onerous.
339
see Section 5.4.3.
340
through compensation, the recruitment and training of
replacement staff or replacement of equipment.
341
eg in its prominence, leadership, resource allocation and
departmental policy.

5-8

 to those who lack the required levels of
qualification and experience. Too often we have
been surprised that such an experienced crew,
team, unit, tradesman or operator could make
such poor judgements as to risk or cause harm
when they really should not. Routinely these
events can be attributed to a Failure-to-Follow
process, a concern shared by many TLBs and
risk owners. The standard mechanisms for
treating these events such as reviewing
procedures, re-education and increased
supervision are generally less effective when
dealing with ‘high calibre/highly specialised’
personnel. Credibility, peer review and senior
leadership have a greater role to play. Based on
recent events this may be an opportunity for
Head Office to provide a Defence-wide focus to
this avoidable threat and consider how the
Department can apply these levers in order to
maintain the very standards and behaviours that
are needed to operate safely, whilst concurrently
striving to improve Defence’s overall Safety
Culture.342

have been successfully implemented over the
last 13 years, including the latest joint MTSR346,
police, ambulance, fire and rescue services
‘Survive the Drive’ campaign whose innovative
approach and initial feedback saw it recognised
by a commendation from the Vice-Chief of the
Defence Staff (VCDS). Under statutory
legislation the Department’s Duty of Care (DoC)
as an employer covers ‘work-related’ safety.347
However, the recognised348 boundary of this DoC
is narrow and equates to ~6% of the overall LTA
fatalities in the last four years. The deaths and
serious injuries which result from all LTAs impact
not only the injured themselves, but their families,
colleagues and the operational effectiveness of
our Forces. Previously Head Office has
monitored and centrally acted upon LTA trends
beyond statutory requirements at a Departmental
level; however, this was some ten years ago.349
Since then road safety activities have continued
to be discussed and coordinated between TLBs
at a working level350 but without the mandate or
centralised resource to drive Defence-wide policy
or training requirements beyond on-duty
activities.351 At present, alongside Defence-wide
campaigns such as ‘Survive the Drive’ and ‘Grim
Reaper’, there are a number of local and TLB-led

Recommendation 5: The Defence Board,
through the DSEC, should consider whether
complacency poses an increasing threat to
safety and what measures could, if
required, mitigate that threat.
5.7.3 Land Transport Accidents (LTAs) beyond duty. LTAs343 involving Armed Forces
personnel who are on duty and which result in a
fatality, serious injury or significant loss in
capability are subject to the same statutory
investigative requirements as any other accident
category.344 Whilst LTA fatalities have
progressively dropped over the last 35 years
(Figure 5-1), LTAs on and off duty remain one of
the top three causes of fatality for Armed Forces
personnel.345 Numerous road safety initiatives

342

348

An overview of safety culture is provided at DSA01.2 Chapter 5,
Safety Culture, version 1.0 dated May 2018.
343
This category is broader than Road Traffic Accidents in that it
includes accidents involving any mode of land transportation
whether on or off a public highway.
344
Section 343 of the Armed Forces Act 2006 and Joint Service
Publication 832, Guide to Service Inquiries, Issue 1, October 2008.
345
The top 3 causes of Armed Forces fatalities are suicide, cancer
and land transport accidents. Source: MOD, Deaths in the UK
Regular Armed Forces: Annual Summary and Trends over Time 1
January 2009 to 31 December 2018, published 28 March 2019.
346
Movement and Transport Safety Regulator, a section of the
Defence Land Safety Regulator.
347
Health and Safety at Work etc. Act 1974, Part 1, Section 2
General duties of employers to their employees & Section 3
General duties of employers and self-employed to persons other
than their employees.

Generally recognised as occurring either: on Defence premises,
on duty or involving Defence equipment. Off duty LTAs are
normally considered outside this statutory DoC except where work
arrangements may be a major contributory cause (eg work induced
fatigue).
349
Overall LTA fatalities and trends were last formally reported by
Head Office in the Defence Environment and Safety Board’s annual
report for 2009. Source: MOD, Safety, Environmental and
Sustainable Development Report 2009, dated 25 October 2010.
350
Through the Defence Road Safety Working Group under the
oversight of the DSA’s Movement and Transport Safety Regulator.
351
The Defence Road Safety Working Group is non-executive, has
no assigned funding and is attended by non-budget or risk owners.
Any actions or initiatives are taken and funded by individual TLBs,
and any required regulatory or policy changes are made by the
Regulator.

5-9

 initiatives and training opportunities for
personnel.352 With the formation of the DSEC
and the establishment of a Head Office HS&EP
directorate, Defence may wish to consider
elevating the central governance and tracking of
all LTAs to a higher level.353 Moreover, it may
wish to study, in a similar manner as Transport
for London (TfL) has in its ‘Safe Behaviours’
element of its Vision Zero action plan354, whether
the central coordination and funding of such
initiatives could ensure that the same
opportunities for education, awareness and
training are available and accessible to all
Defence personnel, regardless of location, trade

or organisation with the aim to reduce overall
LTA rates even further.
Recommendation 6: The DSEC should
elevate the governance and tracking of
Land Transport Accidents for all Defence
personnel and directly affected third parties
to a higher level and consider whether
Head Office-led coordination and funding
could further reduce fatality rates.

UK Regular Armed Forces LTA Fatality Rates355

Figure 5-1

352

Ranging from local funding of personnel attending external road
safety initiatives such as Bikesafe to role-specific defensive driver
training for certain personnel deploying to overseas locations.
353
to a senior executive level in Defence which could provide both a
mandate and resource to the supporting working groups. It should
also consider expanding its data capture and analysis to include

civil servants and third parties (eg members of the public) involved
in Defence LTAs.
354
TfL, Vision Zero action plan, published July 2018. Source:
http://content.tfl.gov.uk/vision-zero-action-plan.pdf
355
Source: MOD, Deaths in the UK Regular Armed Forces: Annual
Summary and Trends over Time 1 January 2009 to 31 December
2018, published 28 March 2019.

5-10

 Summary
6.1

Key Findings and Assessments

•
There were two safety-related fatalities356 of Defence personnel and two members of the public
died as a result of Defence activity357 between 1 April 2018 and 31 March 2019 (Section 2.2.2).
•

There were 13,683 reported injuries358, an 11% increase on the preceding year359 (Section 2.2.3).

•
Improvements in safety assurance have been made across all domains, bar Medical Services
(Section 3.7.3) which has shown no change and Ordnance, Munitions & Explosives (OME) which has
shown a partial reduction in assurance (Section 3.6.3) but remains at SUBSTANTIAL.
•
Evidence suggests that the previous decline in Fire Safety assurance across Defence has been
arrested, with indications of small but measurable improvement (Section 3.5.3).
•
There is evidence of some general improvements in the delivery of 2nd Party Assurance (2PA).
However, there are still specific areas of weakness resulting from a lack of investment or prioritisation
which undermine confidence in the overall assurance of some equipment or services (Section 5.6.3).
•
Overall safety assurance for Defence has marginally but measurably improved since last year but
remains at LIMITED360 due to some remaining major weaknesses in safety systems361 (Section 5.1).
•
The Aviation, Maritime and OME domains have been assessed by their Regulators as having
overall SUBSTANTIAL safety assurance; however, a minority of TLBs operating within these domains
remain at LIMITED (Section 5.1).
•
Concerns over the material state of Defence Infrastructure (Section 5.6.4) and a lack of sufficient
competent personnel (Section 5.6.2) are consistent safety themes reported by TLBs over the period of
this report.
•
Good progress has been made by Head Office as it begins to address the findings of the Review
of Head Office Governance of Health Safety and Environmental Protection in Defence and the
Improvement Notice.

6.2

TLB Safety Assurance

Figure 6-1

356

Diving accident in Portland Harbour and Jackal accident in Catterick. For context, there were 61 Armed Forces fatalities in FY18/19.
Two Land Transport Accidents: MAN SV versus civilian pickup truck (Belize, 7 May 2018) and MAN SV versus motorcyclist (East Yorkshire,
24 Aug 18). Both remain under police investigation.
358
Defence injury and ill-health statistics are published annually in September meaning, for the purposes of the AAR, they lag all other reporting
by ~6 months.
359
Against reported injuries at this stage in FY16/17. Data quality issues and late reporting may alter the final figure.
360
Using DIA criteria safety assurance is assessed as Full, Substantial (minor weaknesses), Limited (major weaknesses) or No Assurance.
361
eg TLB Safety & Environmental Management Systems, Head Office strategic balance of investment processes, Acquisition Safety, etc.
357

6-1

 Although this AAR is based on assessments by
each regulated domain rather than by TLB,
Figure 6-1 reflects a synthesis of the overall
levels of assurance in each domain as assessed
for each major TLB, showing the changes from
last year’s corresponding assessments. This
relates only to those activities regulated by the
DSA, but the baselining of TLB Safety and
Environmental Management Systems (SEMS)
which commenced this year is the first step
towards being able to provide an overall
assessment of each TLBs demonstrated level of
safety assurance.362

6.3

complacency in key areas and, if so, how we
should deal with it. The third asks whether the
Department currently pays enough attention to
the prevention of Land Transport Accidents, both
on and off duty, which are one of the biggest
killers of our people, or whether there is more we
could do centrally to focus attention and action.
My final recommendation is the need for Defence
to further improve its Safety Culture. It is
extremely important that the momentum
generated in the last year to improve safety
assurance in each of the regulated domains is
maintained and that the attention being given to
further improving the Safety Culture of each TLB
is sustained at all levels.363 It is imperative that
the workstreams established by Head Office to
re-establish its governance of HS&EP in Defence
are fully supported, particularly as we define the
Functional Leadership Strategy for HS&EP.364
This Functional Leadership Strategy will be
fundamental to improving our Safety Culture and
its development should be prioritised by the
Department.

Recommendations

Although my overall assessment of HS&EP in
Defence remains at LIMITED ASSURANCE this
AAR also acknowledges the progress made in
many areas. While many of the more serious
shortcomings highlighted in last year’s AAR are
being addressed, with much progress made,
there are still areas for further improvement.
Based on the analysis and expert opinion of my
Defence Safety Regulators I have made 7
recommendations in this report (reproduced in
Annex C) for topics and themes that the
Department, through its newly formed Defence
Safety and Environment Committee (DSEC),
may wish to focus upon. These are broader in
nature than the specific recommendations made
in last year’s AAR, but they still challenge how
we as a department currently view safety. Three
relate to the enduring threats to HS&EP posed by
change, shortage of SQEP and inadequate selfassurance by TLBs. These areas should remain
under close scrutiny by the DSEC. Three further
recommendations focus on new areas of
potential concern. The first recognises the
extensive effort that has gone into specifically
managing Risks to Life (RtL) through enhanced
risk management using the duty holding
principles and governing frameworks, but
questions whether this has been at the expense
of reducing the overall levels of harm to our
people and the environment, and whether there
is more we could do in this area. The second,
based on a range of incidents in recent years
where some of our most qualified and
experienced personnel have made unnecessary
mistakes, asks whether we have a problem with

Recommendation 7: Head Office should
prioritise the formation of a Functional
Leadership Strategy for HS&EP which aims
to improve the Department’s Safety Culture.
As the DSA continues to mature and enact the
recommendations of its own External Audit
through its Strategic Plan, it will fully support
Head Office and the TLBs, through the DSEC, in
taking forward the recommendations of the Head
Office review of safety governance. In particular,
as an independent and specialist organisation it
will stand ready to advise, assist and assure the
Department’s work to minimise the impact it has
on the environment, minimise the harm it causes
to our people and grow a positive and enduring
Safety Culture.

6.4

Conclusion

With the positive steps taken in restoring Head
Office governance and the growing focus on
HS&EP within each of the TLBs, there are a wide
range of initiatives, actions and frameworks being
established, rejuvenated or, in some areas,
developed to higher levels of maturity and

362

364

Whether the overall assessment of TLB safety assurance is
conducted by the Head Office HS&EP Directorate or is an
independent assessment by the DSA is yet to be decided.
363
Several TLBs have set explicit objectives to improve Safety
Culture within their annual Command (business) Plans.

DSEC Workstream 7: Functional Leadership Strategy. The
purpose of this workstream is to clarify who is the HS&EP functional
‘owner’, identify any issues arising from the shift from the
Department’s ‘Defence Authority’ framework to Functional
Leadership and develop a HS&EP functional strategy and plan.

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 effectiveness. While many of the complex and
significant HS&EP risks facing Defence today will
endure for many years to come, confidence that
those risks have been correctly identified, are
well understood and are being appropriately
managed is improving. However, to maintain this
positive momentum, there is a need to have a
central focus in order to channel those efforts
efficiently and effectively. Therefore, with the
DSEC as the governing body365, greater
emphasis needs to be placed on developing and
fostering a good Safety Culture across Defence.
Every action, change or improvement taken
needs to answer the questions ‘Does it
promote a positive Safety Culture?’ Only by
consistently demonstrating those just, reporting,
learning, questioning and flexible behaviours will
HS&EP awareness become fully rooted in our
thinking.

Air Marshal Sue Gray CB OBE FREng
Director General
Defence Safety Authority

365

The DSEC Terms of Reference include the requirement to
‘…improve safety culture and performance within Defence’.

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Annex A
Safety-Related Inquiries and Investigations April 2018 – March 2019
New and ongoing Defence Safety Service Inquiries: April 2018 – March 2019
31 January 2019

Jackal Vehicle Accident, Catterick Driver Training Area. An SI was convened on 13
February 2019 into the circumstances surrounding the death of a soldier following the rollover of a Jackal High Mobility Tactical Vehicle. The SI is ongoing.

14 November 2018

Diving Fatality, Portland Harbour. An SI was convened on 28 November 2018 into the
circumstances surrounding a death during combat swimmer diving training in Portland
Harbour.

26 March 2018

Diving Fatality National Diving and Activity Centre (NDAC). A Navy Comd led SI was
convened on 26 April 2018 into the circumstances surrounding the underwater death of a
soldier during Army Diver training at the NDAC, Chepstow. The SI report was published
on 31 July 2019.366

20 March 2018

Hawk T1. An SI was convened in March 2018 to investigate the crash of a Hawk T1 (Tail
No XX204) from the Royal Air Force Aerobatic Team at RAF Valley that resulted in the
death of the rear seat occupant and injury to the flying pilot. The aircraft was damaged
beyond economic repair. The SI is due to report in October 2019.

31 January 2018

Al Asad Airbase, Iraq. An SI was convened in February 2018 to investigate the
circumstances surrounding the death of an Army Officer who died after being struck by a
vehicle in Al Asad Airbase, Al Anbar Province, Iraq. The SI is due to report in October
2019.

25 August 2017

Hercules C130. Hercules C-130J CMk4 (Tail No ZH873) was conducting a night cargo
delivery mission to a natural surface landing strip. The aircraft landed hard and was
damaged. The SI report was published on 21 May 2019. 367

14 June 2017

Royal Tank Regiment, Challenger 2 (CR2) live firing accident. A CR2 suffered an
internal explosion whilst conducting a live firing exercise at Castlemartin ranges,
Pembrokeshire. All 4 crew members were injured to varying degrees. Unfortunately, 2 of
the crew members later died from their injuries. The report was published on 26 July
2018.368

24 March 2017

Watchkeeper 043. Watchkeeper (Tail No WK043) crashed into the sea in Cardigan Bay
to the north of West Wales Airport. The Unmanned Air Vehicle (UAV) was being flown by
a mixed Army, UTacS, Thales crew under a Military Flight Test Permit for the purpose of
conducting an Army student conversion sortie. The SI report was published on 11 April
2019.369

3 February 2017

Watchkeeper 042. Watchkeeper (Tail No WK042) crashed into the sea in Cardigan Bay
to the north of West Wales Airport. The UAV was being flown by a mixed UTacS, 370
Thales crew under a Military Flight Test Permit for the purpose of conducting a de-icing
equipment trial. The SI report was published on 11 April 2019. 371

366

https://www.gov.uk/government/publications/service-inquiry-into-the-fatal-diving-incident-at-the-national-diving-and-activity-centre
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/803287/20190517HERC_ZH873_SI_Redacted_RT_Final-O.pdf
368
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/727954/20180823Challenger_SI_Castlemartin_Redacted_RT.pdf
369
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/792953/20190402WK043_SI_Final_Report-_Redacted__RT-OS.pdf
370
UAV Tactical Air Systems Ltd.
371
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/792947/20190402WK042_SI_Final_Report-_Redacted__RT-OS.pdf
367

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 New and ongoing Defence Safety Service Inquiries: April 2018 – March 2019
2 January 2017

Camp Taji. A soldier from 2 LANCS suffered a fatal gunshot wound whilst inside his room
in the accommodation block at Camp Taji, Iraq. An SI was convened in January 2017 but
was paused to allow an associated Court Martial to be conducted. The Court Martial has
since concluded and the SI is expected to be published in late 2019.

1 November 2016

RAF Tain. Whilst part of the waiting detail prior to a night live firing sniper shoot, a soldier
from 3 RIFLES received a fatal gunshot wound. An SI was convened on 12 January 2017
after further information was received from the Police regarding the nature of the death.
This report was published on 9 August 2018. 372

9 August 2016

Griffin. A Griffin helicopter (ZJ241) operated by the Defence Helicopter Flying School,
RAF Valley, experienced severe vibration after landing near Yr Aran, Snowdonia. During
the subsequent shutdown the aircraft caught fire. The crew evacuated safely but the
aircraft was rapidly consumed by the fire and sustained Category 5 damage. The SI
report was published on 16 August 2018. 373

New and ongoing Non-Statutory Inquiries: April 2018 – March 2019
Luge Accident. A RAF Senior Aircraftsman (SAC) was injured on 29 January 2018 during the RAF Bobsleigh,
Skeleton and Luge Association (BSLA) Novice Ice Championships at Innsbruck Olympia Eiskanal, Austria. The
SAC was a Novice Luge athlete and suffered a serious head injury. The inquiry report was published on 13
September 2018.374
Glock 17 General Service Pistol. Following a recent spate of accidents, all of which were the result of an
unintended discharge involving the Glock pistol, DG DSA directed that a Non-Statutory Inquiry (NSI) be
conducted into the Glock pistol and the safety issues surrounding its use. The NSI concluded that there was no
evidence to indicate that any technical failure of the weapon contributed to any of the accidents and made a
number of recommendations to enhance weapons safety across Defence.
Foxhound Fire. On 13 June 2018 a Foxhound Light Protected Patrol Vehicle (LPPV) caught fire whilst
transiting to Salisbury Plain Training Area; there were no injuries. A DAIB-led NSI was instigated to determine
the cause of the fire and to review other related fire incidents and wider Foxhound LPPV safety governance
arrangements. The NSI concluded that repairs carried out in the 2 weeks before the fire had not been done
satisfactorily, partly due to the use of inexperienced tradesmen and partly due to the lack of effective
supervision. The investigation was unable to determine the source of the fire; however, it was considered very
likely that it was caused by an electrical short circuit as a result of the poor routing of an electrical harness and
was fuelled by the leak of transfer gearbox oil into the hull. Additionally, the lack of an Automatic Fire
Suppression System in the V-Hull of the Foxhound, which had been recommended following earlier fires, meant
that the fire could not be easily fought. The NSI made several recommendations aimed at reducing the
likelihood of reoccurrence of a vehicle fire and to the broader organisational and safety governance
arrangements.

372

http/www.gov.uk/government/publications/service-inquiry-report-into-the-death-of-a-soldier-participating-in-a-night-live-firing-sniper-cadre-atraf-tain-range-field-firing-area-on-1-november.
373
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/733515/Griffin_Final_Report_-_RT.pdf.
374
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/739452/20180910Luge_NSI_Report_FINAL_REDACTED_RT.pdf

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 Watchkeeper 050 Crash. On 13 June 2018 Watchkeeper 050 (WK050) crashed following an unsuccessful
attempt to land during an Army Captaincy Development Flight. A DAIB-led NSI was instigated and concluded
that Ground Control Station crew had lost Situational Awareness (SA) whilst the Air Vehicle (AV) was attempting
to land, choosing to manually abort the landing and remotely cut the engines which subsequently resulted in the
AV crashing. The investigation was able to confirm that the AV system was fully serviceable at the time of the
accident and that it had automatically initiated a go-around following its failed approach 4 seconds prior to the
crew manually intervening. Unfortunately, had no action been taken by the crew the AV would have completed
its automatic go-around from which it could have been commanded to conduct a further approach. The NSI
subsequently made 13 Safety Recommendations with the aim of reducing the likelihood of reoccurrence of this
type of accident.
Warrior Fire. On 13 July 2018 a Warrior Armoured Fighting Vehicle (AFV) operated by the Range Safety and
Control Group (RSCG) at British Army Training Unit Suffield (BATUS) caught fire and was subsequently deemed
a total loss; no personnel were injured. A DAIB-led NSI was instigated to determine the cause of the incident,
review previous fires on Warrior AFVs and determine the extent to which recommendations from previous
investigations had been implemented. The investigation was unable to determine conclusively the source of the
fire; however, based on witness statements and analysis, it was considered very likely that the fire started in the
area of the battery compartment. The NSI made a number of recommendations aimed at reducing the likelihood
of reoccurrence and the severity of the fires on the Warrior AFV.
Dauphin AS365N3 Wire-strike. On 20 September 2018 a Dauphin AS365N3 helicopter struck electrical
distribution wires near Rollestone Camp on Salisbury Plain Training Area. There were no injuries; however, it
was agreed that the incident warranted an NSI by the Defence Accident Investigation Branch (DAIB). The NSI
panel concluded that there were no technical issues with the aircraft and that the incident was due to Human
Factors.

Civilian Fatalities involving Defence Activity: April 2018 – March 2019
MAN SUPPORT VEHICLE (MAN SV) Collision - Belize. On 7 May 2018 there was a collision between a MAN
SV and 2 civilian vehicles in Belize while the MAN SV was conducting a routine non-tactical resupply in support
of Ex MAYAN STORM. The driver of one of the civilian vehicles died from his injuries and the Defence
personnel received superficial injuries. The collision is subject to an ongoing Belizean Civil Police and the Royal
Military Police investigations.
MAN SV Collision – North Dalton, Yorkshire. On 24 August 2018 there was a collision between a MAN SV
and a civilian motorcyclist while the MAN SV was conducting Packet/Convoy Commander training as part of a 3vehicle packet. When faced with an oncoming civilian HGV on a narrow track the packet positioned itself to
allow the civilian HGV to pass. In doing so the rear vehicle of the packet reversed onto a verge and collided with
a civilian motorcyclist who, unbeknownst to the MAN SV driver, had pulled into a blind spot behind his vehicle.
The motorcyclist regrettably died of his injuries. The collision is subject to an ongoing civil Police investigation.

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Annex 
Defence Nuclear Domain Assurance (Limited Distribution)

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Annex C
Report Recommendations
Recommendation 1:

Head Office should assure itself that the revised Defence Operating Model and
governance arrangements provide sufficient consideration of safety during its
oversight of change initiatives.

Recommendation 2:

The Defence Board, through the DSEC, should consider whether some of the
remuneration and grading freedoms exercised by MOD’s external agencies could be
utilised to address the Department’s more difficult SQEP recruitment and retention
challenges.

Recommendation 3:

The DSEC should share amongst their members exemplars of initiatives or strategies
which have been successful in improving the governance, resourcing and delivery of
effective 2PA within TLBs.

Recommendation 4:

The Defence Board, through the DSEC, should consider whether the current
measures to minimise injury and harm to Defence personnel are adequate.

Recommendation 5:

The Defence Board, through the DSEC, should consider whether complacency poses
an increasing threat to safety and what measures could, if required, mitigate that
threat.

Recommendation 6:

The DSEC should elevate the governance and tracking of Land Transport Accidents
for all Defence personnel and directly affected third parties to a higher level and
consider whether Head Office-led coordination and funding could further reduce
fatality rates.

Recommendation 7:

Head Office should prioritise the formation of a Functional Leadership Strategy for
HS&EP which aims to improve the Department’s Safety Culture.

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Notes:

All images are licensed under the under the terms of the Open Government Licence v3.0 except those stated below:
p 3-22, bottom right. Image by Sergeant A Baskerville RLC © Crown copyright 2011
p 5-6. Image by Petty Officer Airman (Photography) O Cooban © Crown copyright 2016

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