Recurring concern

Unsafe progression of safety-critical activity training

First to latest report 15 Nov 2016 — 28 Jul 2023

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
5

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.

What is 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 and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Dorset

    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

  2. County Durham and Darlington

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026