Recurring concern

Unsafe progression of safety-critical activity training

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First reported 15 Nov 2016•Latest report 28 Jul 2023

Definition

What this concern includes

Includes failures in progression, sequencing or acceleration of explicitly safety-critical activity training where participants may be advanced before they are adequately prepared or capable, including the anchor’s inappropriate acceleration of dive training for a high-ranking naval visit and comparable parachute-training progression concerns.

Not included

Excludes ordinary educational or recreational training where the activity is not safety-critical.
Excludes deficiencies in training content, equipment, supervision or assessment when progression itself is not the shared unsafe condition.
Excludes operational failures during the activity after training progression was appropriately determined.
Excludes generic staffing, organisational-pressure or leadership concerns that do not directly affect progression of safety-critical activity training.

Reports: 2
Individual concerns: 2
Date range: 2016–2023
Stated actions: 5

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

British Skydiving1

Ministry of Defence1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

28 Jul2023
Dorset
Concerns raised1
1. Inappropriate acceleration of safety-critical dive training for a high-ranking naval visit
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Cascade an Urgent Safety Notice to training authorities and providers requiring safety-critical training to remain progressive and protected from inappropriate acceleration.
  Stated by Ministry of DefenceStated completed
2. Action
  Obtain assurance from Training Providers that the direction on protecting safety-critical training is understood and will be followed.
  Stated by Ministry of DefenceStated completed
3. Action
  Formally review JSP 822 and JSP 375 to incorporate requirements for safe, progressive training and management of changes to training time, content, or resources.
  Stated by Ministry of DefenceStated planned
AI-generated summary

BENJAMIN DAVID MCQUEEN · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Benjamin McQueen drowned on 14 November 2018 during a military diving exercise in Portland Harbour, Dorset, after experiencing complications during the dive and being recovered unconscious from the seabed. The concerns included the lack of a spare breathing-apparatus cylinder for the stand-by diver, accelerated safety-critical training, the absence of a dedicated defibrillator, and inconsistent minimum safety-pressure guidance for breathing apparatus.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inappropriate acceleration of safety-critical dive training for a high-ranking naval visit
Wider context from the report
“(2) The progression of the dive training in which Ben was engaged was safety-critical. The progression of training was accelerated for several reasons, one of which was a visit by a high-ranking naval officer. The concern of the instructing staff was to polish the drills ahead of that visit and to take the pressure off the dive students by allowing them to practise the dive with relevant equipment ahead of the visit. This acceleration of safety-critical training in part because of such a visit was not appropriate. ”
Source location
BENJAMIN DAVID MCQUEEN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Cascade an Urgent Safety Notice to training authorities and providers requiring safety-critical training to remain progressive and protected from inappropriate acceleration.

Verbatim wording from the response
“MOD Response. The DDS is committed to taking a systemic approach to reviewing and updating the safety policy documents and renewing the management of Health and Safety in Defence. An Urgent Safety Notice has been cascaded across all Training Requirements Authorities and Training Delivery Authorities, to ensure that all Training Providers are clear on the requirement to protect our Service Personnel. The Defence Safety Authority as an independent regulator, investigator and assurer for Health, Safety and Environmental Protection (HS&EP) will continue to safeguard and uphold the message within the Urgent Safety Notice.”

Source location
Response from Ministry of Defence
Page 3 · response
Published 10 August 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Obtain assurance from Training Providers that the direction on protecting safety-critical training is understood and will be followed.

Verbatim wording from the response
“To achieve this, all Training Activity Owners with responsibility for safety critical training have sought assurance from their Training Providers that this direction is understood and will be adhered to. Further, with continued direction and guidance from Talent Skills Learning and Development (TSLD) and DDS, both training policy (JSP 822) and health and safety policy (JSP 375) will undergo a formal review with updates to encapsulate this narrative and its application within training, to ensure enduring and coherent policy going forward.”

Source location
Response from Ministry of Defence
Page 3 · response
Published 10 August 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Formally review JSP 822 and JSP 375 to incorporate requirements for safe, progressive training and management of changes to training time, content, or resources.

Verbatim wording from the response
“To achieve this, all Training Activity Owners with responsibility for safety critical training have sought assurance from their Training Providers that this direction is understood and will be adhered to. Further, with continued direction and guidance from Talent Skills Learning and Development (TSLD) and DDS, both training policy (JSP 822) and health and safety policy (JSP 375) will undergo a formal review with updates to encapsulate this narrative and its application within training, to ensure enduring and coherent policy going forward.”

Source location
Response from Ministry of Defence
Page 3 · response
Published 10 August 2023
Open published response
15 Nov2016
County Durham and Darlington
Concerns raised1
1. Potential progression beyond parachutists’ abilities without sufficient regard to time between jumps
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Make a formal written risk assessment for non-tandem students with non-standard body morphology, disabilities or other special needs.
  Stated by British SkydivingStated planned
2. Action
  Give special consideration to wind-tunnel training before skydiving, including training with equipment and heading control while back-to-earth.
  Stated by British SkydivingStated planned
Respondent positions 2
1. Position
  The student was not progressed beyond her abilities for the planned skydive.
  Stated by British SkydivingDisputes the concern
1. Position
  The interval between the student's previous jump and Peterlee jump was not considered a major factor in the accident.
  Stated by British SkydivingDisputes the concern
AI-generated summary

Pamela Gower · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Pamela Gower, who had achondroplasia and was a keen parachutist, died after entering a high-speed spin during a level 6 parachute jump and sustaining fatal injuries on impact with the ground. A concern was raised about whether she had been progressed beyond her abilities, particularly in light of the time between her later jumps; this question remained under active consideration by the BPA.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Potential progression beyond parachutists’ abilities without sufficient regard to time between jumps
Wider context from the report
“1. The BPA board of enquiry raised a question as to whether the deceased was progressed beyond her abilities, taking into account the time period between her later jumps. Evidence from the Chief Instructor and owner of the parachute club in question was that the training given to the deceased met all Parachute Association rules and moreover exceeded them. He did not believe that there was any difficulty caused in this case arising from the time periods between her jumps nor that the deceased was progressed beyond her abilities. Notwithstanding this evidence, the BPA Chief Operating Officer remained of the view that the question raised in the report was still a valid one and one which was being actively considered by the BPA. In the circumstances, I have no doubt that the threshold for this report is being met and I am under an obligation to make this report. ”
Source location
Pamela Gower · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Make a formal written risk assessment for non-tandem students with non-standard body morphology, disabilities or other special needs.

Verbatim wording from the response
“For (non-tandem) skydive students who have non-standard body morphology (such as caused, for example, restricted growth), disabilities or other special needs:”

Source location
2016-0446-Response-by-Bristish-Parachute-Association
Page 5 · response
Published 12 February 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Give special consideration to wind-tunnel training before skydiving, including training with equipment and heading control while back-to-earth.

Verbatim wording from the response
“For (non-tandem) skydive students who have non-standard body morphology (such as caused, for example, restricted growth), disabilities or other special needs:”

Source location
2016-0446-Response-by-Bristish-Parachute-Association
Page 5 · response
Published 12 February 2017
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The student was not progressed beyond her abilities for the planned skydive.

Verbatim wording from the response
“There has been some debate about whether or not the length of time between the deceased’s last jump in Spain and her first jump at Peterlee was appropriate. Given that an assessment was made in the wind tunnel as well as the fact that she completed her level five / check out dive without any issues, the Panel do not believe that this was a major factor in her inability to recover from a back to earth position on her final jump.”

Source location
2016-0446-Response-by-Bristish-Parachute-Association
Page 4 · response
Published 12 February 2017
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The interval between the student's previous jump and Peterlee jump was not considered a major factor in the accident.

Verbatim wording from the response
“There has been some debate about whether or not the length of time between the deceased’s last jump in Spain and her first jump at Peterlee was appropriate. Given that an assessment was made in the wind tunnel as well as the fact that she completed her level five / check out dive without any issues, the Panel do not believe that this was a major factor in her inability to recover from a back to earth position on her final jump.”

Source location
2016-0446-Response-by-Bristish-Parachute-Association
Page 4 · response
Published 12 February 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Inappropriate acceleration of safety-critical dive training for a high-ranking naval visit

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Potential progression beyond parachutists’ abilities without sufficient regard to time between jumps

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 3

Actions described in response 2

Respondent positions 2