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This is an early version tool for searching recommendations across the whole database. When all inquiry recommendations are added the tool status will be changed to final. For now, just be aware there may be recommendations not yet uploaded.

You can filter by type of report and theme of inquiry as well as use the free text search which looks in the recommendations. Click apply to search and reset to start again.

The number of recommendations found will be displayed and each has a status box, a link to this site's page for the inquiry it comes from, and a page about just the recommendation.

The status box is in beta. Blue means not yet assessed. Red means the recommendation has not been adopted. Yellow partial adoption. Green full adoption and continued checking.

This is an early version tool for searching recommendations across the whole database. When all inquiry recommendations are added the tool status will be changed to final. For now, just be aware there may be recommendations not yet uploaded.

You can filter by type of report and theme of inquiry as well as use the free text search which looks in the recommendations. Click apply to search and reset to start again.

The number of recommendations found will be displayed and each has a status box, a link to this site's page for the inquiry it comes from, and a page about just the recommendation.

The status box is in beta. Blue means not yet assessed. Red means the recommendation has not been adopted. Yellow partial adoption. Green full adoption and continued checking.

Recommendations List

This is an early version tool for searching recommendations across the whole database. When all inquiry recommendations are added the tool status will be changed to final. For now, just be aware there may be recommendations not yet uploaded.

You can filter by type of report and theme of inquiry as well as use the free text search which looks in the recommendations. Click apply to search and reset to start again.

The number of recommendations found will be displayed and each has a status box, a link to this site's case study page; which details resources and more information about the incident, a page about just the recommendation, and a link to the official report.

The status box is in beta. Blue means not yet assessed. Red means the recommendation has not been adopted. Yellow partial adoption. Green full adoption and continued checking.

Filter by Themes

2696 items found

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Improve the process for communicating risks and associated controls in order to ensure risks and hazards are clearly understood by those responsible for managing and owning equipment operating risk;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Provide and mandate the use of a revised planning template for all training activities in order to ensure training activity is correctly planned and that appropriate risk mitigations are in place and correctly authorised;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Provide the Army with a mechanism to submit safety reports confidentially and anonymously in order to improve the Army reporting culture and encourage personnel to submit reports;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Analyse the suitability of the Defence Lessons Identified Management System and report the findings to the Deputy Chief of the General Staff in order to determine whether the system is fit for purpose;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Ensure that all UK Training Area Headquarters liaise with local Emergency Service Operations Centres annually in order to ensure that they are aware of all designated Emergency Rendezvous locations;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Improve the Army's Safety Occurrence Analysis process in order to ensure that lessons are identified and learnt from all safety occurrences;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Assure all High Mobility Truck Variant training documents in order to ensure coherence with the authoritative vehicle documentation;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Enhance safety training for all Army personnel in order to ensure safety policy and practices are understood at an appropriate level.

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Direct that officers selected for Reserve Regiment Executive Officer duties are post sub-unit command in order to ensure that adequate levels of experience are provided at all Reserve units;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Ensure that Training Estate users are made aware of the extent to which the Defence Infrastructure Organisation are assuring the Safe Place prior to each training activity in order to ensure that users are aware of the boundaries of risk ownership and safety provision

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Rewrite the High Mobility Truck Variant Safety and Environmental Case Report applying the correct colour-coding to the safety Claims and Arguments commensurate with the evidence available in order to clearly identify the level of evidence that has been reviewed to substantiate the claim and articulate the overall Safety Case confidence;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Ensure Reserve unit Training Warrant Officers are nominated as Defence Training Supervisors and should mandate the required Pre-Employment Training on associated Job Specifications and Assignment Orders in order to ensure that Reserve unit instructors are able to fulfil the role effectively;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Mandate an annual review of Armoured Vehicle Standing Orders in order to ensure that they remain coherent with other Defence policy;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Define the membership and attendance of Platform Safety and Environmental Panels in order to ensure appropriately qualified and competent individuals are empowered to comment on platform safety;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Introduce a harness cutter maintenance and inspection regime in order to assure that cutter blade condition remains appropriate through-life;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Mandate the recording of all vehicle maintenance on Joint Asset Management and Engineering Solutions, including weekly maintenance inspections in order to ensure an audit trail for all mandated maintenance activity;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Improve the Army Safety Occurrence Reporting System in order to make it easy to use for all involved;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Address the workforce requirement of the Training Standards Group in order to ensure that 2nd Party Assurance and Inspection activity is conducted;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Improve the door latches on all High Mobility Truck Variant vehicles in order to ensure crew members are protected during vehicle operations;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Ensure that all Armour Centre approved instructors receive the course convening briefing by the Training Standards Group in order to ensure that they have the knowledge required to conduct their duties;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Ensure that all unit Risk Assessments are available for review by all personnel and are reviewed by those with supervisory responsibilities prior to each activity in order to ensure that personnel are aware of the levels of risks and control measures to be put in place;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Assure that all Duty Holding activities are appropriately assessed and authorised in advance by Duty Holders in order to ensure that all associated risks to life are correctly scrutinised;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Update Armoured Vehicle Standing Orders to include guidance material on specific hazards associated with cross-country driving in order to assist commanders and drivers in identifying relevant hazards and associated control measures;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Provide vehicle tilt limitations to crews in order to enable them to remain within the safe operating envelope of all vehicles within their portfolio;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Conduct further vehicle trials in order to establish the maximum gradient limitations and determination of the safe operating envelope for High Mobility Truck Variant platforms;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Formally appoint a responsible person through a letter of delegation to manage and Chair all Platform Safety and Environmental Panels in order to ensure that equipment safety is appropriately managed across all Defence Lines of Development and that the as low as reasonably practicable and tolerable statement is endorsed on behalf of the Front Line Commands;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Establish an internal Army accident investigation capability in order to ensure that Army-wide lessons are learned from those accidents not investigated by the Defence Safety Authority;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Determine the requirement for audio protection and crew communications for all Armoured Vehicles in order to ensure appropriate hearing protection and internal communications;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Establish a certification process for new Land Environment Vehicles in order to ensure that vehicles introduced into military service meet defined safety standards.

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Establish and champion an appropriate Questioning Culture in the Army in order to ensure that safety related decisions are based upon facts rather than assumptions.

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Introduce an auditable record of those personnel who have completed the Bidding and Allocation Management System training in order to ensure users are competent to use the system;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Ensure that all Safety Occurrence Reports are adequately reviewed and lessons identified as part of the Annual Safety Case review during the Platform Safety and Environmental Panels in order to ensure that lessons are identified and learnt from all accidents.

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Establish a robust programme of safety audits for all areas under his/her jurisdiction in order to provide assurance to the Director General Defence Safety Authority that vehicle equipment management is being conducted safely.

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Introduce a formal Driving and Maintenance Instructor Continuing Professional Development programme for all Driving and Maintenance Instructors in order to ensure that instructors continue to develop their instructional skills;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Define the Roles and Responsibilities of Driving and Maintenance Instructors within Armoured Vehicle Standing Orders in order to take account of the lack of qualification of the student(s) in the vehicle;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Determine the provenance of the training limitation in order to ensure that it is within the safe operating envelope of the vehicle;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Ensure that there is effective transfer of Duty Holder owned risks in order to maintain appropriate levels of Duty Holding assurance at all times;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Include Just Culture training in all Command, Leadership and Management safety packages, including Safety Risk Management training in order to promote the use of a Just Culture to all Army personnel;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Revise Catterick Training Area Standing Orders For Training in order to ensure all vehicle related information is accurate and that the Out of Bounds areas are clearly defined;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Issue a change request to improve the Bidding and Allocation Management System User Interface in order to enhance the awareness of End Users when Management User changes are applied to bids;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Develop a policy for the management of personnel who sit outside of the anthropometric limitations of Armoured Vehicles in order to ensure the safety of crew members;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Ensure that 2nd Party Assurance of the Queen's Own Yeomanry training activity takes place as soon as practicable in order to provide assurance to the General Officer Commanding 1st (UK) Division that the Queen's Own Yeomanry training is being delivered in line with Land Warfare Centre direction;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Enhance the contents of Armoured Vehicle Standing Orders Chapter 2 to include practical safety advice to Armoured Vehicle operators in order to improve understanding and standardisation across the Armoured Vehicle fleet;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Revise the High Mobility Truck Variant Army Equipment Support Publications in order to ensure all hazards, operating limitations and safety envelopes are communicated to the End User;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Establish regulation and guidance on the safety clothing to be worn when operating open architecture vehicles in order to ensure crews are adequately protected;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Improve the follow-on procedures for all assurance activity in order to ensure findings are actioned in an appropriate and timely manner.

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Provide all Training Area Safety vehicles with appropriate and sufficient First Aid equipment including Automatic Emergency Defibrillators whilst deployed on the Training Areas in order to provide a more comprehensive first response capability;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Amend the Driving and Maintenance Instructors course and introduce the requirement for instructors to drive their chosen cross-country route on the day of the activity prior to conducting training in order to improve the safety of training delivery through Safe Place assurance.

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Update Army Command Standing Order 3228 in order to ensure that it is consistent with Joint Service Publication 822;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Rectify the disparity between Harness Cutter NATO Stock Numbers within the Land Environment in order to ensure that the correct equipment is fitted to all Armoured Vehicles;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Establish routine Hazard Identification meetings to include End User attendance for all Armoured Vehicles in order to understand and review the safety concerns of those who routinely operate Armoured Vehicles;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Ensure that Dynamic Risk Assessments are conducted by all supervisory personnel prior to activities taking place in order to ensure new hazards are assessed and associated controls are put in place to reduce risks to as low as reasonably practicable;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Introduce policy, procedures and training for commanders and instructors on the use of the left foot brake in order to mitigate the risk of driver error and associated vehicle accidents;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Set anthropometric limitations for the High Mobility Truck Variant fleet in order to ensure that crew members remain within the protected space offered by the Roll Over Protection System;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Establish a new Safety Information Management System in order to support Army safety learning;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Construct a Part 1 Safety Case for all High Mobility Truck Variant platforms in order to provide an auditable safety requirement against which the vehicles can be assessed;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Assure that all units conduct robust site-specific Risk Assessments for all training activity in order to ensure that training is conducted safely;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Conduct an assurance review of the Equipment Safety Matrix Improved to ensure that it is accurate in order to ensure Safety Cases are appropriately managed;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Improve the protection offered to crew members in all High Mobility Truck Variant vehicles taking into account the likelihood of roll over events, neck protection, helmet design and vehicle design in order to ensure that adequate protection is provided to vehicle occupants;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Direct that personnel selected for Reserve unit Training Warrant Officer positions are qualified and have experience in training delivery relevant to the unit's primary role in order to comply with Joint Service Publication 822;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

Review all JACKAL training in order to ensure that JACKAL training needs analysis, design, delivery and assurance is compliant with Joint Service training policy (JSP 822) and associated single Service training policy;

Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area

Defence

The newly established National Agency for Children and Families should have the following responsibilities: to assess, and advise the ministerial Children and Families Board about, the impact on children and families of proposed changes in policy; to scrutinise new legislation and guidance issued for this purpose; to advise on the implementation of the UN Convention on the Rights of the Child; to advise on setting nationally agreed outcomes for children and how they might best be achieved and monitored; to ensure that legislation and policy are implemented at a local level and are monitored through its regional office network; to report annually to Parliament on the quality and effectiveness of services to children and families, in particular on the safety of children.

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Ensure that the role of Reserve Units 1 & 2 are based on operational requirements. (Rec #1)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Review the command and control arrangements for Reserve Units 1 & 2. (Rec #2)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Ensure that the role of Reserve Units 1 & 2 is based on operational requirements. (Rec #3)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Include 'experience level' as an 'individual risk factor' in JSP 539. (Rec #4)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Enhance understanding and treatment of exertional heat illness among medical personnel. (Rec #5)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Improve access to military and civilian records for better medical reviews. (Rec #6)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Improve the readability of JSP 375. (Rec #7)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Conduct thermal burden testing on military uniforms. (Rec #8)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Review medical provision and governance for Reserve Units 1 & 2. (Rec #9)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Introduce physical fitness tests that reflect operational requirements. (Rec #10)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Ensure swim tests are completed before marches. (Rec #11)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Increase navigation and load carriage training. (Rec #12)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Establish effective monitoring criteria for training candidates. (Rec #13)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Adjust incentives to promote safe decision-making. (Rec #14)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Educate training teams on risks of motivating unrealistic objectives. (Rec #15)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Ensure proper command and control during endurance activities. (Rec #16)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Ensure candidates modify pace to manage thermal equilibrium. (Rec #17)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Educate teams on confirmation bias. (Rec #18)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Establish quick reaction capability with appropriate vehicles. (Rec #19)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Regularly review training safety culture. (Rec #20)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Ensure that the role of Reserve Units 1 & 2 are based on operational requirements. (Rec #21)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Review the command and control arrangements for Reserve Units 1 & 2. (Rec #22)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Ensure that the role of Reserve Units 1 & 2 is based on operational requirements. (Rec #23)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Include 'experience level' as an 'individual risk factor' in JSP 539. (Rec #24)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Enhance understanding and treatment of exertional heat illness among medical personnel. (Rec #25)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Improve access to military and civilian records for better medical reviews. (Rec #26)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Improve the readability of JSP 375. (Rec #27)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Conduct thermal burden testing on military uniforms. (Rec #28)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Review medical provision and governance for Reserve Units 1 & 2. (Rec #29)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Introduce physical fitness tests that reflect operational requirements. (Rec #30)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Ensure swim tests are completed before marches. (Rec #31)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Increase navigation and load carriage training. (Rec #32)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Establish effective monitoring criteria for training candidates. (Rec #33)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Adjust incentives to promote safe decision-making. (Rec #34)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Educate training teams on risks of motivating unrealistic objectives. (Rec #35)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Ensure proper command and control during endurance activities. (Rec #36)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Ensure candidates modify pace to manage thermal equilibrium. (Rec #37)

Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013

Defence

Educate teams on confirmation bias. (Rec #38)
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