Oral evidence: Beyond endurance? Military exercises and the duty of care, HC 598Wednesday 25 November 2015

Oral evidence, 25 November 2015.

Witnesses

Air Marshal Richard Garwood CB CBE DFC RAF, Director General, Defence Safety Authority, Air Marshal Paul Evans CB RAF, Surgeon General, Major General Christopher Tickell CBE, Army Recruiting and Training Division, Air Commodore Warren James CBE RAF, Head of Training, Education, Skills, Recruiting and Resettlement, and Major General Simon Brooks-Ward CVO OBE TD VR, Deputy Commander Field Army, gave evidence.

Chair

Good morning. May I ask you to individually identify yourselves and your areas of responsibility and expertise? Air Commodore, could we start with you?

Air Commodore James

Yes, hello. I am Air Commodore Warren James. I am head of Training, Education, Skills, Recruiting and Resettlement—it is a policy branch—for Chief of Defence people in the Ministry of Defence. I have a previous background in training.

Major General Brooks-Ward

Major General Simon Brooks-Ward. I am Deputy Commander of the Field Army and the Senior Army Reservist.

Air Marshal Garwood

Air Marshal Dick Garwood., Director General of the Defence Safety Authority at the MoD.

Air Marshal Evans

Air Marshal Paul Evans, Surgeon General.

Major General Tickell

Major General Chris Tickell, General Officer Commanding of the Army’s Recruiting and Training Division, so I am responsible for all Army training, individual and collective.

Chair

At the beginning of the session, I emphasised that we are looking particularly at the health and safety of service personnel during training, exercise and selection events and whether effective processes exist for capturing lessons from accidents and deaths that have occurred during such events. We are not looking at individual cases. I wanted to reiterate that before we start.

Mr Gray

Air Marshal Garwood, may I start with a general question about the relationship between the MoD and the HSE? That comes under a general agreement, which is signed, I think I’m right in saying, by the second permanent under-secretary and the chief executive of the HSE. Should there not be a military co-signatory to that?

Air Marshal Garwood

It has historically been the permanent under-secretary, because he has been the Department’s senior official for safety, and of course, he sits on the Defence Board. In terms of good safety governance, we need an official at the highest level of Defence, so it really needs to be a Defence Board member. The document that you refer to is one that details the administrative relationship and responsibilities between the HSE and the Ministry of Defence, so it is probably not an appropriate vehicle—

Mr Gray

I recognise that, but would it not be sensible to have military sign-off? It is the military who are potentially taking these risks in training. Would it not be sensible to have military involvement alongside the permanent secretary?

Air Marshal Garwood

I think quite the reverse. I think it is healthy to have the permanent under-secretary hold the military to account in that respect. Indeed, the permanent under-secretary takes part in the holding-to-account sessions of the TLBs and the commands, of which, as head of the Defence Safety Authority, I feed him information on a monthly basis to challenge the single services. So I believe that there is an element of health in having the PUS as head of safety and therefore logically signing off that document.

Mr Gray

Moving on to the figures that we requested and have been given about individual deaths in the three services during training, and particularly arduous training, may I ask you just a couple of questions? First of all, there is no breakdown between Regular training and Reserve—incidentally, I want to declare an interest. Major General, you may not remember this, but last time we met, we were manoeuvring a 25-pounder on the Salisbury plain. We were both gunners in the HAC together.

Major General Brooks-Ward

Good reminder—I remember.

Mr Gray

So this might be one for you. Can these figures reasonably be broken down between the Reserves and the Regular forces?

Major General Tickell

From the Army’s point of view, of the 88, 17 were Reservists.

Mr Gray

Right. It would be quite useful perhaps, in that case, to have them broken down in terms of units as well, in the same way as you have done for the Regular forces. Perhaps that is something that you could provide in the other two services as well. In terms of the Army, you have given us a very good breakdown with regard to individual regiments and corps. It might be helpful to know which of them were Regulars and which were Reserves, so we can see if any pattern emerges. One thing you have not included in the figures—I would be interested to know whether you feel that this could usefully be done—is information for specialist military units, except for those who are sharp-eyed and see words such as Hereford cropping up and can read between the lines. But by and large, you have not given us any particular breakdown with regard to specialist military units. Would that not be possible?

Air Marshal Garwood

I gather that is being worked on this morning, so I suggest that comes to you in a written response. Of course, it will need to look at the definition of which type of activity is conducted by the specialist military units, but I was told this morning that that work will follow to the Committee.

Mr Gray

That would be helpful, thank you. Sticking with specialist military units, and bearing in mind that we do not discuss some of these things in too much detail, there are parts of arduous training for specialist military units that are more arduous than for the ordinary services. Should there be a separate joint service publication for that particular type of training? At the moment, it comes under the same JSP as ordinary training. Should we not have a specialist JSP for that kind of extreme, arduous training?

Air Marshal Garwood

I believe there should be one document covering all, which indeed there is. As you rightly say, training has varying degrees of severity. In that case, it comes down to the risk assessment done by commanders, who should look at the type of activity and put mitigation in place accordingly. If you have arduous training conducted by a specialist military unit, you are clearly pushing people a lot further than you would, for instance, on an Air Training Corps or Army Cadet hike. The risk assessment would therefore look at better mitigation. If, for instance, you are sending people over the top of a mountain range, you would not rely on mobile phone coverage; you would use proper radios and have proper medical cover, et cetera. For me, it is down to the risk assessments, stemming from the common document. I can see no reason why, in the total force concept, we would have a series of documents especially for Reserves. I think that would probably work against.

Mr Gray

Not Reserves. I am talking about specialists.

Air Commodore James

Yes, the design of the training policy covers Reserves and Regulars, regardless of whether it is a specialist military unit. What changes is how the course is designed for that particular cohort. Your framework documents actually allow for the ability to do that and then introduce more robust training, with an increased risk appetite and the increased risk mitigation that goes with it—you tailor accordingly. The JSP enables anything across that range.

Mr Gray

Let us do this from a different angle. Of all the things we do in all three Armed Services in terms of training, what are the most dangerous?

Air Marshal Garwood

I can give you the type of activity that would most likely result in a death.

Mr Gray

Not all 121, but I would be interested to know what sorts of things they were doing.

Air Marshal Garwood

Around 31% of those deaths happen in MT-style accidents, not necessarily from driving but from vehicle crushings, et cetera. Probably one of the most hazardous activities is around our vehicles.

Mr Gray

But in arduous training—the sort of thing that we are looking at—what are the kinds of things that would be viewed as being the most hazardous?

Major General Tickell

It is fair to say that adventurous training, if you look at the statistics, is self-evidently dangerous, but it is governed by exactly the same processes and policy as anything else.

Mr Gray

So of 121 perhaps 30% have been vehicle crushings and other MT driving accidents. What sort of percentage would be adventurous training?

Major General Tickell

From the Army perspective, 15 out of the 88.

Mr Gray

That is roughly—

Major General Tickell

17%.

Mr Gray

Okay. So we are roughly more than half with the MT and adventurous training, and 40%-odd are therefore other forms of training. Of that 40%-odd, which bits are the most dangerous? Leaving aside vehicles crushings, vehicle accidents and adventurous training, which we can understand, of the balance—arduous training for war fighting—what are the most dangerous bits?

Major General Tickell

Again, from the Army perspective, there were nine deaths from live firing. I can go through them all.

Mr Gray

Accidents on the range?

Major General Tickell

Accidents on the range, et cetera, but there is a pretty wide spread, from an individual drowning through to parachuting accidents and other activities. There is nothing really beyond the specific areas I described.

Mr Gray

Sticking with that, I have one last question. You might find this one difficult to answer. The variety of deaths that you describe came about as a result of a wide variety of different errors, some by the individual concerned and some no doubt by sub-unit commanders. How many of them would you say are culpable in systemic terms? How many of them would you say—we are going to discount what you say, because you are probably being defensive—could be culpable against the system, as it were? How many of them could have been avoided if the system had been different? That might be another way of looking at it.

Major General Tickell

If I may, I can talk about what has gone on in the division since I have been in command, which is just over two years. Inevitably, there have been a number of incidents, although happily very few. Every incident is investigated, as you know, and we may want to go into that in more detail in due course. That investigation will apportion blame if that is applicable. What I can say is that during my time, I have removed one independent sub-unit commander from command as a result of a safety incident. I will not go into any more detail, but we have done that. Of course, at a lower level in terms of failing to deliver the requisite duty of care to our trainees, whether it be in phase 1 initial training or phase 2 training, there are occasional incidents and absolutely people are removed from command if they are culpable. The mechanisms are absolutely there, but clearly you have to weigh up whether people have wantonly disregarded the policy or whether human factors have played their part. That is, as you would understand, what we need to do.

Air Marshal Garwood

I think it would be fair to say that, historically, the accountability was less well defined. This came out of the Nimrod review, as part of which we put into place the duty holder concept, which I am sure you will come to later, but that is relatively new. In aviation across all three services you can date this back to about 2011, and in the rest of our activity, it is dated around—the JSP certainly came out in November 2013.

Mr Gray

We are coming back to duty holding in a moment.

Air Marshal Garwood

Yes. That is how we now define the true accountability for injury or death—through the duty holder concept, which is new.

Mr Gray

Can I just ask you, Major General, second to last, about arduous training? Of the 121, how many of those deaths would be attributable to arduous exercises or training?

Major General Tickell

Forgive me, but it slightly depends on what your definition of arduous is, and in what context.

Mr Gray

We do not want to go into any individual cases, but in terms of either initial training of new recruits or—in my old regiment, going back 30 or 40 years, which Major General Brooks-Ward and I were in together, our bit was the soft bit, but the hard bit used to go out on difficult, tough training exercises. The gun troop did not, but the other half of our regiment did. We took it easy, didn’t we, Simon?

Major General Brooks-Ward

I could not possibly comment.

Mr Gray

But you know the kind of thing I mean. Without going into too much detail, to what degree is arduous training or exercise dangerous? To what degree should we be doing something about making them less dangerous?

Major General Tickell

I think absolutely all the systems in place make it less dangerous, because there is this dynamic risk assessment process in play. Once you have absolutely nailed the risk assessment before an activity happens, there is a requirement to dynamically risk assess during that activity. Therefore that means that it is beholden on the commander, the DDH—duty delivery holder—to reduce the risk if he feels that either the training audience or the environmental conditions are taking it outwith the boundaries that are safe. That absolutely plays into the duty holder construct, which we now enjoy.

Mr Gray

So heat and cold, and that kind of thing?

Major General Tickell

Yes. I can give you examples from within my division as to how we play environmental conditions and, frankly, the start state of the training audience in order to play tunes with what our output standard will be. That is what I expect my commanders to do, and as the ODH—official duty holder—for what goes on in my division, that is what I am responsible for, ultimately to CGS, to make sure that we are governing it in a safe way.

Mr Gray

Finally, Surgeon General, do you think there are the correct medical supplies and safeguards in place in these arduous training exercises to minimise risks and to ensure that where incidents occur, they are sorted out as quickly and as well as they possibly can be? You are going to say yes, but I want you to try to avoid just saying yes.

Air Marshal Evans

I would say yes. I think the policy is right and I think I would look at that in two ways in terms of medical policy. One would be the preliminary medicals or assessments that are done to see that individuals are fit to do whatever level of training is proposed. That will differ according to the level, depending on—arduous is the word used before. That is one component and I am very content that that is sound. One would expect that to be followed in any exercise format that is taking place. The other area is more specifically environmental things: obviously heat is one, cold is another and noise is another. These elements are all things that are covered very well in policy. I do not know whether as part of the Committee you have seen JSP 539, but that is a very comprehensive document that covers, from both the commander’s and the medical officer’s perspective, the sort of questions that one should be asking in order to formulate that risk assessment that was mentioned earlier.

Mr Gray

I am confident that our learned advisers have seen JSP 539, but I have to admit that I personally have not.

Air Marshal Evans

It is quite a refreshing read. Of course, I read it again in the last 48 hours and it is quite detailed.

Mr Gray

I apologise, because I have to go and see the Moderator of the Church of Scotland, who is taking a service. So I am leaving now—forgive me.

Chair

That is fine. Before we move on to the duty holder concept, Can I come back to you, Air Marshal Evans? We talk a lot about the duty of the people who are setting up the exercises and the risk assessments undertaken across the military. What about the duty of the individual—is that spelt out anywhere in terms of their need to protect themselves? For example, if they are given water because they are expected to keep themselves hydrated, and their duty to report illness or feeling unwell or areas of pain. Is that set out anywhere? How much is that emphasised—the individual’s personal responsibility as opposed to the military’s overarching responsibility?

Air Marshal Evans

I think it is, obviously depending on the circumstance, but if we talk about heat and cold there is quite clear instruction given as part of the pre-briefing for the commanders to indicate to individuals, first, that they should be fit and report any sudden change in fitness. Obviously, as I said earlier on, medicals may be done several months before an activity is taken, and in certain circumstances that is quite acceptable, but clearly if you have flu or other illnesses, these may predispose to some of the conditions that we are considering here. So it is quite important that, in that pre-briefing, individuals are given every encouragement to come forward and, indeed, in some situations they have to self-declare that they are still fully fit before they undertake the activity.

Chair

How long before the exercise does that pre-briefing take place? Is that the same day, the day before or a week or two months before?

Air Marshal Evans

It varies, depending on the exercise. My colleagues here will give you a more definitive answer to that.

Major General Tickell

If a unit or sub-unit is deploying to Kenya, for instance, the pre-briefings will happen well in advance, but that does not mean that there will not be a refresher all the way through up until the moment they deploy and then when they do deploy, because if you are suffering from a heat or cold injury, actually the individual may not be the best person to spot it and, therefore, again you are beholden on the chain of command taking that duty of care interest in the individual. I know you are not suggesting otherwise, but it is absolutely a meshing of both the individual’s responsibilities as well as our collective responsibilities through the chain of command.

Chair

Major General Tickell, why are there more Army deaths in individual training rather than collective training? As a layperson, I would have thought that collective training was more complex.

Major General Tickell

I think it is more complex, but if you look at the population that go through individual training versus collective training, last year within my organisation we trained upwards of 60,000 individuals through an individual training course and collectively we trained 20,000. So many more are going though individual training courses than are going through collective training courses; ergo, there is that disproportion in terms of the numbers.

Chair

Thank you. Richard Benyon is going to look at the duty holder concept.

Richard Benyon

Before I do that, may I seek to see whether there has been a culture change? Going back to my own experience in the 1980s, the relationship between a platoon commander and a platoon sergeant, and the relationship between a company commander and a company sergeant-major, would have been that the commissioned officer plans and had overall responsibility for the welfare of the men, but things such as health and safety were considered to be pretty much an admin role and were dealt with by the platoon sergeant, or by the CQMS and the company sergeant-major. I suppose what I am really looking for you to say is that that has changed and there is now a universal responsibility for commanders at every level to—I am sure you are going to say yes again—

Major General Tickell

I will answer it from the Army perspective. I think the cultural change has been huge, to be quite honest. I took over this job just prior to the construct coming in, and it has been really interesting how the sea change even in that relatively short space of time—just over two years—has meant how fundamentally different we are at approaching those activities. That is not to say that we were laissez-faire about them before, but the fact that, from the Army’s perspective, it has reinforced the chain of command’s responsibility absolutely holds people’s feet to the fire. So, again, as the two-star ODH within the training world, that means I take a very close interest in my delivery duty holders, who are—

Richard Benyon

It trickles down, does it?

Major General Tickell

Absolutely. I know intimately all the two-star risks that I am holding, and I take a very close interest in them because I am ultimately responsible and accountable if something goes wrong. And I know that my commanding officers, who fundamentally are the DDHs, take that duty very seriously—frankly, for exactly the reasons we’re here this morning—because we know, and rightly, that we will be held to account if things go wrong.

Richard Benyon

Moving on to the duty holder concept, the MoD’s written evidence talks about a key outcome of the Haddon-Cave report being “the need to clearly identify and mark out the senior duty holders that have both the authority and legal responsibility with respect to the operation of military equipment”. Is the multi-service nature of joint organisations able to follow the duty holder concept? I can understand it in terms of a unit, but where there is a joint service activity how does it work?

Air Marshal Garwood

Absolutely. It works in the same way. There are exactly three levels of duty holder—senior duty holder, operating duty holder and delivery duty holder—and they are well defined, and those simple principles apply in any joint organisation. An example would be the Joint Helicopter Command. If we look at support helicopters within the command, the Chief of the Air Staff is the senior duty holder. If we look at the operating duty holder, that is a two-star Army officer currently—the commander of Joint Helicopter Command. And if we go down to the delivery level, out on the stations, that, in terms of the support helicopters, would normally be a Royal Air Force group captain. This works well with those three levels and can either be coincident with the chain of command or outwith the chain of command.

Major General Tickell

I have joint units in my organisation and, as the Air Marshal said, the ODH/DDH construct is exactly the same.

Air Marshal Garwood

I think it would be fair to say, however, that there are degrees of maturity in this regard across all three services. In aviation the duty holder construct has been around since early 2011, so it is very mature and very well defined, and people clearly understand their role. It’s far, far newer in the land domain, where it has come in over the last year or so, so to be fair it’s still settling down. But we are seeing a real cultural change. Basically, if the two-star is interested in safety, then people around him and below him are interested in safety, and we are seeing that. It is an approximate figure, but we are assessing, certainly in aviation, that those operating duty holders at two-star level are probably putting up to about 25% of their time into the duty holding role and concept. In aviation I would define it as the jewel in the crown of safety.

Richard Benyon

May I ask General Brooks-Ward whether there is any added challenge for a Reserve unit, compared with a Regular unit? The Regular unit will be getting up to do soldiering every day of the week, and the Reserve unit will be doing it for some of the week or some of the month. Are you able to seamlessly spread the culture and the responsibility of duty holders across both types of unit?

Major General Brooks-Ward

As far as the Reserves are concerned, we adhere to it, because of the time factor as well. There is a policy that goes down from GOC RTD to the units, and it is well-enforced. We are now integrated and have the same standards, the same training platforms and so on. That in a way dictates that we are exactly the same as our Regular counterparts. We are fully tuned into what GOC RTD is talking about in terms of duty holding.

Major General Tickell

If I may add, we do training in Kenya—forgive me for using Kenya again as an example; I could use Canada—where we integrate Regular and Reserve. Going back to the dynamic risk assessment piece, it is about understanding the start state of the individual soldiers, be they Regular or Reserve, and tempering the training to take account of where they are in their training progression, as well as the environmental factors. The construct and the theory of the policy is exactly right in terms of taking into account different standards at different times.

Major General Brooks-Ward

It is honest. It is an honest system.

Richard Benyon

That is very reassuring. This next question is for anyone who wishes to answer it. I am trying to get my head around the letters issued to operating duty holders and delivery duty holders. Should they include a description of the action that could be taken against them if they do not comply with the requirements set out?

Air Marshal Garwood

If I can take that one, the letters absolutely should not set that out, because we cannot predict the level of severity in a failing, ranging from death through injury. What is crystal clear in those letters—they are all individually hand-crafted, often by the Chiefs of Staff—is that the senior duty holder is holding his operating duty holders personally accountable and responsible for the activity within their area of operations. That is not delegable; you cannot start passing out that accountability to blame someone below you. We are now crystal clear, but it would be wrong to try to put a sanction up front against a situation where we do not know what will happen.

Richard Benyon

Do we have a copy? I am looking at the Clerks. We do. Okay. That will be helpful. Could you compare the duty holder concept in two different joint organisations, such as the Joint Helicopter Command and the specialist military units group? Is one stronger than the other? If so, why? Do they have a parity of severity, if you like?

Air Marshal Garwood

They are identical, but I go back to my point about the maturity in various areas. Taking the Joint Helicopter Command, the duty holder construct, the three levels, the letters, the behaviours and the culture are all very mature. There is no doubt about that. This has been rolled out later to land. Indeed, the Royal Navy are still doing some final understanding of what they would expect at the delivery level. There are lesser degrees of maturity away from the aviation domain, where this came to fruition. As part of the defence safety regulatory review that we are conducting now, which will go to the Defence Board early next year, we are doing what is called re-enshrining the duty holder concept. We are looking at the whole concept to make sure that outside aviation this is fit for purpose, which I believe it is. However, one size will not fit all. An example would be the numbers of duty holders we are talking about. If we go to aviation, there are three senior duty holders, five operating duty holders and 27 delivery duty holders. That is clear. If you go into the land domain, the Army has around 600 delivery duty holders. So we need to look at how the letters are promulgated, if that is the answer, and how this is handled at that level, because they are not quite the same.

Richard Benyon

Thank you. Can you give me an example of where commanders fulfil their responsibility to reduce risk to as low as reasonably practical—the concept of ALARP?

Major General Tickell

The collective training environment is probably a reasonable example, because it is related to heat as well, whether it is our training in Canada, Kenya or other locations. Often the ambient temperature in those locations is above the guidelines within the JSP. In theory that means that we would be doing very little training, which is clearly counter-intuitive. We therefore have to go through a process whereby we drive down the risk to the ALARP standard. It is not just about heat, because when you are talking about heat and people are having to operate in body armour and helmets, because they are live firing, you are then combining the challenge of policy constraints in terms of live firing—articulated in something called Pamphlet 21—with constraints about heat. The requirement is then for us to look at what is in the JSP and adjust it, and adjust it so much that I as the two-star ODH am prepared to sign off that waiver. The way we adjust it, in theory, is that you have two-hours work, one-hour rest. We reverse that to one-hour work, two-hours rest. We stop in the middle of live firing and allow soldiers to ventilate—that is, take their helmet and body armour off in order to cool down. That is all after the acclimatisation process, which takes quite a lot of time anyway. That and a number of other measures allow us to conduct live firing at an ALARP standard. There is clearly still a risk, which is why it sits with me rather than the commander in Kenya or Canada or wherever it happens to be. As a consequence of that activity, we then sent out a multidisciplinary team to all those locations to make recommendations back into the JSP, in order to amend it. While the JSP is continually amended, from my parochial point of view those amendments are about to come out in print early in the new year, I think. They will allow me not to be holding the two-star risk, because I will be operating within the policy, if that makes sense.

Richard Benyon

Are there any special provisions in the duty holder concept for junior entrants aged 16 to 17 and a half?

Major General Tickell

No, the provisions are the same, because if you go back to the safe system of training and risk assessment, part of it is understanding the audience—in this case, they are younger—and then adjusting what we do, but there is no different mechanism for them.

Richard Benyon

I think you have answered part of my next question, which is around the role of the duty holder concept for individual and collective training. Does it include any responsibility for specialist military units?

Major General Tickell

I have no responsibility for specialist military units, in terms of how you are describing it.

Richard Benyon

You have not?

Major General Tickell

No, because they are part of the Joint Forces Command, not part of the Army.

Richard Benyon

So how would we find out about how they adopt the duty holder concept?

Air Marshal Garwood

The Joint Forces Command has the same three-level structure. The commander of Joint Forces Command is senior duty holder. A specialist military unit will have a two-star director, who is the operating duty holder. In the field, you will have a commanding officer, who is the delivery duty holder. Again, it is exactly the same.

Richard Benyon

Air Marshal Evans, as Surgeon General, what role do you play in the duty holder concept within the MoD and Armed Forces?

Air Marshal Evans

That needs a slight explanation. Although I am the senior duty holder for my own HLB, as the senior responsible officer for Headley Court, it is my Defence Safety Authority role that is more relevant. That is my responsibility for the overall delivery of healthcare in the firm base and in the operational deployable space. My job is to assure commanders that that system is working as effectively as possible.

Richard Benyon

Are there any training activities where you have had concerns that the policy, or its application, is not where it should be?

Air Marshal Evans

Our medical reporting system is very much about significant event reporting, and the encouragement of medics on the grounds to report incidents. That allows my Inspector General’s team to look at individual cases, but also at trends, if they are relevant to a particular exercise or operation. If we go back to Afghanistan for a minute, that was certainly a very attuned process, whereby we were looking very quickly and very directly at incidents and trying to make improvements where we felt that was necessary. It was creating a feedback cycle and feeding back into the system fairly effectively.

Richard Benyon

That is the key point: feeding back into the system. If you were noticing a trend, you would be talking to your colleagues, such as Air Marshal Garwood and others.

Air Marshal Evans

Absolutely. We do that regularly.

Air Marshal Garwood

From a Defence Safety Authority point of view—again, this goes back to the duty holding concept—we would describe the Surgeon General as the “duty holder facing”. He would provide policy support, assistance and advice to the duty holder on their duty of care responsibility, but that responsibility, in terms of a death or an injury, does not chop across the Surgeon General; it remains with the nominated duty holder. The Surgeon General, in that instance, would be duty holder facing. It is the same within the DE&S. There are many people in the DE&S who are duty holder facing towards the aviation duty holders and the land equipment duty holders.

Chair

Air Marshal Evans, can I come back to you on the issue of individual responsibility, and the responsibility of the duty holder, and those working under them, regarding risk assessment? One piece of evidence we received suggested that there is a tension between the individual doing the reporting, who could have adverse things happening to them as part of the exercise—for example, they could have wet feet—which could result in longer-term damage to their capability to continue, and the need to man up. How do you balance that? You talked about significant events reporting. We might actually not be talking about a significant event, but the long-term consequences—trench foot, for example—could be very serious. How do you balance a situation where a problem is highlighted that could have serious consequences, and the need to continue the exercise? Where is that balance?

Air Marshal Evans

I think you have to create a culture where you get a level of responsibility from the individual, so that they are confident enough to report against a training background that, as you have heard, could be very arduous, including where they are keen to complete the course as best they can—if it is a selection course, for example. You have to create a culture where that happens. Colleagues have described—I will not go over it—the change that has happened in the last two or three years, with the introduction of the duty holder concept. Very clear guidelines are passed down, ultimately, to the commanders in the field, who are responsible for risk assessment to manage their people correctly. That is what I would expect. An important shift has got to happen so that individuals are confident enough to come forward and say, in your case, “Yes, I have trench foot. My feet are wet, and I think I am getting a problem.” Clearly, as you know, the sooner medical help is given, the better the outcome. That is part of the culture. You say that in many circumstances, by coming forward early, you minimise risk and potential long-term damage, which could ultimately be the pass or fail of their staying at the level of activity they are in, whether it is in the military or another field of activity. Creating a culture in which people are confident about coming forward with an injury or an illness is really important.

Major General Tickell

Our philosophy, to use a rather dull phrase, is to train in, rather than select out. That is the mantra we use in the Army and in the other services as well. It is absolutely in our interest to get everybody to pass whatever course it is, because it is a waste of individual time and, frankly, collective resources for them not to pass it. I know that when I first joined the Army, that was not necessarily the culture. There was a rather different approach to arduous training courses—or any course, for that matter. From me down to the most junior NCO, the whole purpose of what we do is to get people through the training engine to success, as opposed to the opposite. It is beholden on the individual, but it is absolutely beholden on the training staff to have a duty of care to the individual, to make sure he or she can continue to get to the end state.

Chair

Thank you. Let us move on to Johnny Mercer.

Johnny Mercer

This is to all of you. Are you aware of anyone having faced disciplinary or administrative action as a consequence of a failure in the design, delivery or supervision of training?

Air Marshal Garwood

Yes, absolutely.

Johnny Mercer

Could you give us any sort of sanitised—

Air Marshal Garwood

From a Defence Safety Authority point of view, we distance ourselves from blame. If we spot criminal activity or a service offence, we hand that to the command chain. It is very important that people talk to us without fear of retribution. There are many well-publicised events that are in the open press. One this week is the beasting of the soldier. You have got the Puma at Catterick, when one of the pilots received a suspended prison sentence. You have got the case of Kaylee McIntosh, which resulted in a Crown censure of the MoD.

Johnny Mercer

When you last came before this Committee, we had a conversation about whether or not a commander had lost their job. At the time, you said the answer was no, you were not aware.

Air Marshal Garwood

I said I was not aware from the date that we set the Defence Safety Authority up, which was 1 April 2015. Clearly, in response to your question I have looked at a couple of articles in the newspapers. They were the ones that first came to mind. We have also reported service offences to the chain of command regarding our aviation activity, including the case of the Red Arrows, which involved several people, and the case of the Lynx in Afghanistan, which was reported to the command chain as a potential service offence. To emphasise, we then hand those cases over.

Johnny Mercer

That is not your job; I understand that. Out of 125 deaths since 2001, we have still not seen a single civilian prosecution. Is that correct?

Air Marshal Garwood

I do not have those figures. You mentioned the 131 deaths, but we should remember that—off the top of my head—about 30 of those were from natural causes in training.

Johnny Mercer

Absolutely, but there are very clear cases where an incident has happened, a report has been picked up, action has not subsequently been taken and further individuals have died. If that were to happen in a civilian company, there would be prosecutions.

Air Marshal Garwood

Yes, but it is also quite complex. It depends on magnitude and their involvement. For instance, we clearly have the service justice system, but if the severity is less, then this failing, or shortcoming, let us say, could be reported in someone’s annual report.

Johnny Mercer

Forgive me, but insertion into an annual report—is that fair if someone has lost their life due to negligence?

Air Marshal Garwood

No, sorry; I am talking about all issues here, not just loss of life. No, obviously that is absolutely not appropriate, but for a minor failing—and it could be a minor failing—that is one end of the scale. The other end of the scale, clearly, is to go to a criminal or service prosecution. I do not have further examples, and I cannot answer your question about those 131. I suggest that you write to the MoD.

Johnny Mercer

The answer is none. We have just had the Service Prosecuting Authority in here, and the answer is that none of those have resulted in a civilian prosecution. Seven have resulted in service sanctions, but none has resulted in a prosecution.

Air Marshal Garwood

I should also add—I have made the point a couple of times—that the duty holder construct came out of our failings in Nimrod and now gives us a better way of holding people to account. There is now clarity there.

Johnny Mercer

When did that come in? Two years ago?

Air Marshal Garwood

In aviation, across all three services, it came in in 2011, and in the Navy, other than aviation, probably about a year later. Land, the Army, was the last. I saw the op order recently; it was February 2014.

Johnny Mercer

February 2014. And what specifically precipitated that coming in? What were the identified shortfalls that led to that concept being brought in?

Air Marshal Garwood

I will look at it the other way: the success in aviation across all three services made it logical for the MoD to roll out the duty holder construct into all the other domains, which it has done; that is why they follow on from aviation.

Johnny Mercer

So, by extension, was there a slight vacuum of accountability at an individual level within the Army, which is what we are particularly looking at here, before 2014?

Air Marshal Garwood

I would not call it a vacuum, but I think that accountability would have been held at multiple levels across a command chain, potentially a five-deep command chain. That responsibility would have lain in there and been less clear, and the people in that command chain would not have had that personal accountability letter placed on them by their chief. The clarity is now there.

Major General Tickell

I was a commanding officer in 2003 to 2005, clearly before this construct came in, and I knew absolutely that I was responsible and accountable when I took my regiment out training. I expected to be held accountable if I got it wrong, but this construct has absolutely tightened it up so that it is—I will not say watertight; mistakes do happen, but it is much better now, from my perspective, than it was before. There is no question about that.

Johnny Mercer

Just to clarify that last point, you are aware of individuals being formally removed from post, or losing their job, as a result of health and safety breaches?

Major General Tickell

Since I have been in command, yes, I am.

Johnny Mercer

Are you concerned by the ratio of Regular to Reservist deaths in any of the three services?

Major General Tickell

I can answer from the Army’s perspective and General Simon may take over. If you split down the statistics, I think we have had something like 18 Reservist deaths. I think nine were from natural causes, three were from the Brecon incident, one was in Afghanistan, and that takes you to about five.

Johnny Mercer

In percentage terms, that is about right, is it?

Major General Tickell

It is about right; ergo, while every death is self-evidently an absolute tragedy, no, I do not think that there is a disparity.

Major General Brooks-Ward

I agree.

Johnny Mercer

The MoD says that neither the Army nor the RAF take any specific additional measures to ensure the health and safety of Reservists on training and selection exercises. Given that Reservists generally carry out far less training than their Regular counterparts, why are there not specific policy provisions to account for the different start states of Reservists before arduous training?

Air Commodore James

There are in policy. This comes back to the point that my colleagues made earlier. You will design your policy around the cohort that you are going to. The reason why there is no difference is that they are treating the whole force as the same whole force, but the start state will be different for Reservists, so you will design that course start state for them if they need more pre-training. The feedback may say that there must be pre-training prior to the main training, and it will be done in that design phase, so the Reservist might get a different course and treatment, but the policy that governs it would be identical, and that would be true for junior soldiers and Cadets. It is not the policy that covers it that is not doing that; it is the design of that cohort. In essence, it is being aware of who you are designing the guidance for.

Johnny Mercer

If you were asking Regulars and Reservists to achieve the same standard, is there not a mandatory build-up process that you would require Reservists to do, so that you, under the duty holder concept, have the confidence that these individuals have had the correct training to enable you to ask them to achieve the standard?

Air Commodore James

Yes. As part of the design of that course, it would do exactly that.

Chair

A number of witnesses want to come in on that. Major-General Tickell, did you want to?

Major General Tickell

I think we are all going to say the same thing. It is about whether it is the individual space or the collective space. We are doing more and more integrated training now. If I look at some of the weapons courses that we run at Brecon now, we have Reservists doing them alongside their Regular counterparts. There are different issues. There is the start standard, in terms of their familiarity with the weapons system, whatever it happens to be, as well as their physical fitness and all the rest of it. All that is assessed on day one, and we then regulate the training, all being well, to get the Reservists to the same output standard, but ultimately if he or she is not going to get there, they are not going to get there. That is what dynamic risk assessment is all about.

Johnny Mercer

Is there therefore a different stream that a Reservist would go through? If all attendees turned up on day one, and some passed the CFT and some did not, and you took them forward, would there be a different stream for Reservists to go through to get that build-up training?

Major General Tickell

We would adjust the training and give the individual remedial training, if it was going to be worthwhile over a relatively short period. Clearly, they will turn up for a two-week module in the context of a wider Regular course. If someone is physically unable to pass something like a CFT, he or she is probably not going to be able to do it within two weeks, ergo it is not worth it. But you could identify a training deficiency when that individual finishes. If he or she is competent in that weapons system, he or she will get the pass, but there will be a training deficiency that will go back to the unit, and the unit will have make good on that over time.

Johnny Mercer

Is there any follow-through to make sure that that particular sub-unit brings up that training deficiency?

Major General Tickell

That qualification will not be put into JPA until the training deficiency has been met.

Johnny Mercer

And who assesses that?

Chair

May I ask Major Brooks-Ward to come in? I can see him twitching and wanting to respond.

Major General Brooks-Ward

Not really. My colleague is doing very well on our behalf. You must bear in mind that the constraint is time; we are looking at the same standards, but it may take longer to get there. You cannot lie on JPA; the time of fudging facts and figures has gone. We understand what the training delta is—the deficiency of our Reservists, if there is any.

Johnny Mercer

On a broader point to finish, the first question from James Gray was to you, Air Marshal Garwood, about the permanent under-secretary holding the military arm to account, as we essentially do in any democracy. Do you feel—this is to all of you—that there is a general problem with accountability, or is that something that just doesn’t exist? It is very clear today that the systems in place now are pretty good. The duty holder concept has been proved to work across aviation and has now been put across to the other services and that is great. We have seen before in this Committee and in other Committees instances of quite serious neglect by individuals who are responsible for the planning and delivery of training. So, without a single civilian prosecution, do you think that accountability is really happening?

Air Marshal Garwood

It would be wrong of me to sit here and say that there have not been failings, because we all know there have been failings over the years. That is unquestionable. We have heard and seen and studied the coroner’s reports on these and there have been failings. I do believe the culture has changed. I think the measures that you have articulated that we have now put in place will actually really home in on those that are accountable. For example, if there is an accident in a land domain now—certainly if there is a fatality—my very first phone call is to that operating duty holder, which is often GOC 1 or GOC 3 Div. That is my first call and we discuss with him what type of investigation will be going on. So I do think we have seen a cultural change. Some of this has come from external sources—no question. I have seen up to a two-star officer having to give account of himself in a coroner’s court. Our commanders and people responsible are now being called into those situations, which probably would not have happened 10 years ago. I think society expects more from us; and I hope we are living up to that. I think since Sir Charles Haddon-Cave’s Nimrod report we now have far better processes in place. Clearly, we all sign up to the fact that every death is a deep tragedy, but when you look at the statistics for deaths in training and on exercises and take out natural causes, and consider that over 15 years that is six and a half or seven a year. Per 100,000, the military is on my reckoning on a par, in terms of deaths, with the waste disposal industry. We are at half the rate for agriculture and farming. I would like to see some credit for where the MoD has taken this, and how seriously it takes it. Maybe the figures that we have heard this morning—and every one is a tragedy and we must make sure we drive those figures down—

Johnny Mercer

Absolutely, and I guess of the two things that we are focused on—we come back to this question of prosecuting people. It is not about hanging people out to dry. It is about making sure lessons have been learned. For example, we have a very clear case of an individual dying on a course that I was on, and recommendations from that not being put in place, and then three more people dying. What we are looking to do is to make sure things like that do not happen, and secondly that the deterrent is there—for individuals to take responsibility for that individual.

Air Marshal Garwood

I can assure you now, the mechanism is in place; those recommendations would be taken seriously and, in the case of death, each recommendation, of which there may be many—I think in aviation in the last five years we have had something like 600 recommendations. I personally sign each one of those off when I have the evidence that is presented to me at a board we do every six months. I can absolutely assure you that process is now in place. Perhaps it was not in the past.

Chair

During the evidence that we had from Mr Cayley we were told that everything that went for prosecution came through him, but that things might go for administrative action. Does anyone have any overall monitoring responsibility for those cases of injury or incidents that would go through administrative action, to see what has in fact been dealt with at that level? Is anyone monitoring that?

Air Marshal Garwood

I am sure the single services certainly will be, because that is casework that will be directed their way. It is certainly not done at Defence Safety Authority level—not for the admin action. We look after the safety recommendations, absolutely, but as I said earlier, we do distance ourselves from the admin action, so it will be the single services.

Chair

Mr Cayley also said to us that where there was a decision to prosecute or not, he would have conversations with the family in relation to the prosecution. Again, this might be something that goes back to the individual services. At administrative action level, is that conversation also taking place, do you know?

Air Marshal Garwood

With the families?

Chair

Yes.

Air Marshal Garwood

I don’t know. I would be surprised if it was, but I don’t know.

Chair

Major General Tickell, has the operation of the office of duty holder meant that the exercises that you are able to undertake have reduced the effectiveness and quality of training? Do you have any concerns that the health and safety legislation is limiting your capacity to train and to provide a realistic experience for the personnel that you are training?

Major General Tickell

The short answer is no. The policy is there and it keeps us within the guidelines, but if you go back to the dynamic risk assessment et cetera, you can absolutely play tunes within that policy to make sure that if the training audience is of a certain standard—a high standard—you can make it as demanding as they need. If you talk to any soldiers when they come out of Kenya or Canada, they will certainly feel as though they have had a good time.

Chair

So it is not less arduous; it is just that the overarching responsibility for monitoring—

Major General Tickell

There is a better construct in place.

Chair

Thank you very much; that is extremely helpful. Is it harder to ensure that Reservists report illness and injury prior to starting training events? Is that something that you are aware of? Because they are so keen—they have actually got there and they want to do this training—is it likely that they will not report?

Major General Tickell

Well, they are responsible for self-declaring, so yes, we are beholden on the individual saying that he or she is carrying whatever injury it is or whatever, but I think it’s pretty difficult to hide an injury or illness for more than a few hours. I think very quickly the training staff understand the limitations of the individual.

Chair

Air Marshal Garwood, what mechanisms and matrixes do you have for ensuring that the recommendations of coroners’ reports, service inquiries and police investigations are actually implemented?

Air Marshal Garwood

This is a process we have much improved since 1 April this year. For a fatality now, we will conduct a service inquiry. One has not always been conducted in the past. Often the service inquiry in the past was convened and then it sat back and waited for various other reports. I believe and have decided that we can run parallel investigations, because we are only interested in safety and preventing recurrence and so we have to get in quickly and look at this. We now run parallel safety investigations that are extensive and can last up to a year, many of them, where there is any complexity. The recommendations in that report—it is not staffed by anyone outside the Defence Safety Authority, so when I have that report complete, I sign it off and present it to the Secretary of State. It is not staffed in the MoD or the single service commands, so my word is final on that. The newly formed Defence Accident Investigation Branch was formed on 1 October. Those recommendations will be tracked. They always have been for aviation; they will now be tracked for all deaths across the service and they will be signed off individually by me when they are ready. That is at the high level. We then have the non-statutory inquiry, maybe for a lesser issue—maybe a life-changing injury, but not a death. If they are led by the accident investigation branch, they will follow the same process in monitoring. If they are led by the commands—we often delegate this down into the commands, to, say, a duty holder, or the command chain rather than the duty holder—then their lessons would go into their own lesson management system: NLIMS, DLIMS, ASIMS. Those are all information management systems that look after those lessons accounts. As we further grow this branch, I would like to take in all of those lessons, even at the lower level, as one central lessons bank. We are now looking at how we could have an IT system that could handle all of that, but the important ones I look after. The coroner would write a rule 28 letter to the Secretary of State. The recommendations that the coroners put forward will be broken out into the duty holder and front-line command areas and dealt with and tracked at that level. Again, I would eventually like to track those centrally. The only ones we do not handle are the police ones, because the police are not doing a safety investigation; they are doing a criminal, judicial investigation, and that is something that the Defence Safety Authority do not deal with at all. So we would not track that type of recommendation, and we would not expect the police to come out with key safety recommendations. Clearly, if they found one, they would come and tell us and we would track it, but routinely they have a different part of the parallel investigation. From 1 April we have revised this process. It is much better, much tighter, and, most importantly, it will provide lessons across all of the front-line commands. Perhaps in the past we were guilty of one single service investigating one event, and perhaps those lessons were not disseminated as widely across the other areas. I can assure you we now have a very good system in place.

Chair

The system you outline is suitably lengthy and arduous as you try to collect and examine all the issues.

Air Marshal Garwood

Yes.

Chair

Do you keep the families of the deceased involved as the process evolves?

Air Marshal Garwood

Yes. I see that as a key priority. We will have an event and convene the service inquiry, which is the legal convening when I bring the president and his team—there are three of them—in front of me. One of the very early things that I ask the president to do is to make contact with the families—if they wish to have contact—to explain his process. Normally they are very receptive. Normally the president will go and brief the family on the service inquiry process. At some point, as the inquiry progresses, we will give an update to the families and then, when the inquiry is finished, we will provide the families with an unredacted copy of the report, which is hand delivered by the visiting officer and is followed by a briefing from the president. We find it is best to let them read it with the visiting officer and then the president to come in and answer their questions. Then we respond to all manner of asks from the family. Recent examples have been to view wreckage, to have photographs of the wreckage, and to acquire elements of flying clothing that were used. So we respond to that. Although my role is not that of the visiting officer, as that care is with the single service command, I do see that I have a key role as the investigator—the independent investigator; we make that point—in making sure the family is looked after.

Chair

One of my colleagues needs to go, so I want to ask two questions very quickly, and I would be grateful if you could give brief answers. If you want to follow it up with written evidence afterwards, that is fine. Air Marshal Garwood and Air Marshal Evans, Child Soldiers International has told us that recent data have demonstrated that junior entry recruits are twice as likely to be medically discharged with training-induced injuries as standard entry recruits. Does military training put junior entrants, whose bodies are still developing, at undue risk of harm? Please answer very briefly and then, if you wish to, follow up with additional comments.

Major General Tickell

I am responsible for the junior entry. In the training year 2014-15, 2.62% of our junior entry were discharged through muscular skeletal injuries. In the senior entry, it was 3.2%. I do not recognise the statistics that CSI is providing but I am happy to get into more detail if somebody could give that to me.

Chair

Air Marshal Garwood, you are happy with that?

Air Marshal Garwood

indicated assent.

Chair

Finally, Air Marshal Garwood, how will you measure the success of the duty holder concept and the Defence Safety Authority? Do you have parameters to measure success and are you aware that you will be reviewing progress?

Air Marshal Garwood

We are, but it is hard for me to answer. We have the defence safety regulatory review, which is going on now and reports just before Christmas. That will look at our measures of effectiveness. Currently we don’t have—we can work on the HSE statistics, many of which have been put on the table here today, and we can make comparators to where our fatality rate and major injury rate sit. Indeed, we pass that to the Defence Board every month but it is a fairly coarse measure. It is an area I would like to develop and will be part of our review in the new year.

Chair

Thank you. In that case, I thank you all for your evidence, and for the changes you are making and implementing. Oral evidence: Beyond endurance? Military exercises and the duty of care, HC 598 31