This is an HTML version of an attachment to the Freedom of Information request 'DESB Annual Reports 06-07, 07-08, 08-09'.


 
 
Ministry of Defence 
 
 
 
 
 
 
 
MINISTRY OF DEFENCE 
 
DEFENCE ENVIRONMENT AND SAFETY BOARD 
 
SAFETY, ENVIRONMENT AND SCIENTIFIC RISK  
 
REPORT 2007 
 
 
20080301_DESB Report Calendar Year 2007_final.doc 

 
CONTENTS 
 
 Page 
 
 
Executive Summary 

 
 
Introduction 

 
 
Progress made against Risks 

 
 
Discussion of Other Risks 
14 
 
 
Performance 
16 
 
 
Assurance Summary 
18 
 
 
Priorities for 2008 
19 
 
 
 
 
 
Annexes: 
 
 
A. Scientific 
Risk 
 
B. 
Crown Censures, Improvement Notices, Prohibitions and Pollution 
Incidents - 2007 
 
C. Audit 
Programme 
 
 

20080301_DESB Report Calendar Year 2007_final.doc 

EXECUTIVE SUMMARY 
 
1. 
There is no major change to the most significant Safety and 
Environment risks to Defence shown in the 2006 DESB Report.  At TLB level 
and below and within the Trading Fund Agencies, action plans have led to 
some encouraging improvements in a number of areas of concern which have, 
in turn, uncovered other areas where action is required.  Note that 
Sustainable Development is no longer covered in this report. 
 
2. 
There has been improvement across the Department in demonstrating 
leadership and commitment to Safety and Environmental Protection (S&EP) 
but the risk to reputation and to compliance, particularly in light of the 
forthcoming Corporate Manslaughter legislation, still remains significant. 
 
3. 
Several areas of work are having a positive influence on improving the 
ability to measure and monitor our performance in S&EP management.  
However, a lack of leading performance indicators and independent evidence 
means that a clear picture of assurance does not emerge.  Although End-to-
End assurance will produce improvement, this is not yet in place throughout 
the Department. 
 
4. 
There has been a 13% fall in fatalities attributable to Road Traffic 
Accidents (RTAs) in 2007.  The bulk of this problem is in the Army who have 
undertaken the most noteworthy activities towards reductions in this area.  
RTAs, both on and off duty, remain a significant cause for concern. 
 
5. 
The impact of organisational change on safety management 
arrangements, including problems with recruitment, retention and career 
development of Suitably Qualified and Experienced Personnel (SQEP), is 
being felt to varying degrees across the Department.  This remains a cause 
for concern and there has been little improvement. 
 
6. 
Failure to assess and manage land contamination has the potential to 
impact on defence activities through reducing the availability of training areas, 
limiting development of the estate, reducing disposal receipts and diversion of 
funding to meet statutory clean-up obligations.  In order to clarify the extent of 
any problems and to enable costed solutions to be found DE has initiated a 
data collection exercise. 
 
7. 
The condition of some parts of the MOD estate continues to give cause 
for concern with the potential to impact on operational capability as well as to 
cause environmental contamination; specifically, the condition of the 
explosives and fuel storage facilities are highlighted.  Inevitably, there are 
associated cost impacts.  There has been little improvement on last year. 
 
8. 
Many contributors continue to express concerns over the failure to 
learn and communicate lessons from accidents/incidents, leading sometimes 
to a repetition.  Introduction of the new Incident Recording and Information 
System Project (IRIS) in Jan 08 will help, but as yet there is no significant 
improvement in this risk from last year. 

20080301_DESB Report Calendar Year 2007_final.doc 

 
9. 
There have been major efforts, in particular by DE, to improve the 
implementation of Control, Coordination, Communication and Cooperation 
(4Cs) policy with contractors.  However, the position remains inconsistent 
across the estate as demonstrated by audit results, and the current overall 
assessment is that there is only limited compliance.. 
 
10. 
The MOD Aviation Regulatory and Safety Board (MARSB) continue to 
report that aircraft and their crews (particularly helicopters) are at risk in high 
tempo operational theatres due to pressures arising from the enduring nature 
of these tasks and the level of resources available to support them.  The delay 
to the provision of Collision Warning Systems (CWS) and lack of wire strike 
protection for helicopters also continue to provide significant risk. 
 
11. 
The quality of reports from duty holders and Functional Safety Boards 
(FSBs) continues to improve, though clarity over roles and responsibilities of 
FSBs remains a challenge to the provision of effective assurance.  The receipt 
of 2 Crown Censures in 2007, reflecting incidents in 2003 and 2004, along 
with the requirement for improved interfaces and End-to-End assurance, 
highlights deficiencies which we are starting to put right.  We are becoming 
more aware of what we have to do in terms of understanding the extent of the 
risks but the heightened awareness, reflected in better reporting of accidents 
and incidents, has produced an apparent worsening in performance in some 
areas. 
 
12. 
The lack of sufficient evidence on which to base the assessment of 
assurance is itself a weakness.  Providing an overall assurance assessment 
is, therefore, particularly difficult this year.  Actions are in hand to make 
improvements in many areas of concern but at the present time the DESB 
assess that management of S&EP is at Significant Weakness. 
 
13. 
For its priorities in 2008, the DESB: 
 
a.  
Agreed that an assurance strategy should be produced to 
clearly articulate the relationship between Functional Safety Boards 
and TLBs, reporting requirements for the DESB, and principles of End 
to End assurance. 
 
b. 
Agreed that the following should be mandated across the 
Department: coherent procedures for sharing lessons learned from 
accidents and incidents; communication of good practice; and, accident 
investigation by appropriately trained personnel. 
 
c. 
Agreed that existing work underway in DE&S, under the Safety 
Improvement Working Group, should seek to clarify safety interfaces 
between DE&S and FLCs/PJHQ.  Once identified, the necessary 
processes should be put in place, as appropriate, by FSBs and TLBs. 
 

20080301_DESB Report Calendar Year 2007_final.doc 

d. 
Agreed that, resource requirements for S&EP should be 
coordinated to enable identification and incorporation in the Planning 
Round. 
 
e. 
Agreed that a framework for performance measurement should 
be developed, particularly including leading Key Performance 
Indicators. 
 
f. 
Agreed that the use of IRIS should be mandated across the 
Department, with exceptions to be agreed by DS&C only where it can 
be demonstrated that they provide more effective and appropriate 
measures. 
 
g. 
Agreed that DS&C should initiate follow on work from the DMCS 
report on Major Hazard Accident Response Arrangements, including 
improvements in independent scrutiny. 
 
h. 
Agreed that the benefits of development programmes for SQEP, 
covering recruiting, training and career management, should be 
examined. 
  
i. 
Agreed the proposed audit programme, designed to contribute 
towards verification of the effectiveness of management processes in 
place for safety and environmental protection.  A functional audit on the 
impact of organisational change on safety management (including 
Streamlining) should be included. 
 
j. 
Agreed that DS&C should conduct a review of top level safety 
governance. 
 
It is intended that these priorities should be incorporated into a DESB action 
plan, and the DESB be updated on progress at 6 monthly intervals.

20080301_DESB Report Calendar Year 2007_final.doc 

link to page 6 INTRODUCTION
 
1. 
The DESB Annual Report covering calendar year 2007 provides 
assurance on the extent to which the Department is achieving effective Safety 
and Environmental Protection (S&EP).  Areas of specific concern are 
highlighted by identifying common themes and risks.  It encompasses 
contributions from the Duty Holders responsible for implementing safety and 
environmental policy and standards, and from the Chairs of the Functional 
Safety Boards (FSBs).  These contributions form an audit trail for the 
conclusions in this report, which itself necessarily includes only limited detail.  
 
2. 
Reporting is risk-based, with the risks discussed and agreed by a Risk 
Tracking Group (RTG) consisting of stakeholder representatives from the 
Duty Holders (including Trading Fund Agencies), FSBs, and Scientific Risk. 
The RTG has met three times in the past year, developing and refining the 
risk evaluation process to allow a better analysis of the risks.  
 
3. 
Organisational changes in the past year have led to slight revisions to 
the list of contributors to this report.  The report from Defence Equipment & 
Support (DE&S) replaces previous inputs from Defence Logistics 
Organisation (DLO) and the Defence Procurement Agency (DPA); the report 
from MOD Aviation Regulatory and Safety Board (MARSB) replaces previous 
inputs from the Defence Air Safety Board (DASB). 
 
4. 
Contributors have set out in detail the following for their area: Risks; 
Performance (including Fatalities, Trends in Accidents and Incidents, Pollution 
Incidents, Crown Censures, Improvement and Prohibition Notices received 
and implementation of Environmental Management Systems (EMS)); 
Progress and Successes; and, Audit Findings.  The reports conclude with an 
assurance assessment for each area and set out priorities for the coming year.  
These reports are available at: Duty Holder/FSB inputs 2007.   
 
5. 
Duty Holders, in their role as risk owners, have a responsibility to 
address risks relevant to their area.  Departmental issues formed from the 
aggregation of TLB risks have the potential to lack critical detail.  However, 
the most significant risks/issues to Defence objectives, assessed through the 
RTG process, are as follows: 
 
•  Leadership/Commitment to S&EP 
•  S&EP management systems weaknesses 
•  Road Traffic Accidents 
•  Lack of suitably qualified and experienced personnel 
• Land 
contamination 
• Infrastructure 
•  Failure to learn from accidents/incidents 
•  Poor implementation of 4Cs1 policy 
•  Increased operational pressures resulting in air accidents 
 
                                                 
1 Control, Coordination, Communication and Cooperation. 

20080301_DESB Report Calendar Year 2007_final.doc 

6. 
Complexity precludes a consolidated ‘traffic light’ depiction of each 
risk/issue, therefore a narrative indication of change against last year is made 
in this report.  An assurance assessment for the Department is given, with a 
recommendation of priorities for DESB action in 2008. 
 
 

PROGRESS MADE AGAINST RISKS/ISSUES
 
•  Leadership/Commitment to Safety & Environmental Protection 
 
7. 
There has been much good work across the Department in this area 
which shows major improvement on last year.  However, the risk to reputation 
and to compliance, particularly in the light of the forthcoming Corporate 
Manslaughter legislation, still remains significant.  Successes and actions vary 
across the Department; examples include: 
 
a. 
During 2006 the creation of the single naval TLB and the 
Transformation programme of 2007 provided an opportunity to revisit 
safety and environment (S&E) management process across the naval 
service using Lean methodology.  This resulted in the creation of the 
Fleet Operating Authority and greater senior management oversight 
through Deputy Commander-in-Chief Fleet’s monthly Fleet Delivery 
Group.  The Navy Board have participated in a safety workshop. 
 
b. 
Senior Army Boards have this year undertaken safety training 
conducted by CESO(A) and a major review has been carried out into 
the degree of compliance with H&S law, prompted by the introduction 
of the Corporate Manslaughter and Corporate Homicide Act 2007.  
CESO(A) reports on safety performance now at every 4* and 3* 
Command Board each quarter.   
 
c. 
Air Command has been briefed at both 4* and 3* Board level on 
the implications of the Corporate Manslaughter legislation.  This has 
resulted in a review by the 3* Command Delivery Group of the 
organisation and arrangements for safety management across Air 
Command.  As a consequence, strengthened arrangements are now 
being put in place for Board-level oversight and direction of safety, 
environmental protection and sustainable development (SHEP&SD), 
including an overarching reporting framework across all the functional 
safety areas, with a quarterly review by the Command Delivery 
Group.  The Command Board, supported by both the Command 
Delivery Group and the Air Audit Committee, will review safety 
performance and assurance biannually.  An Aviation Safety 
Management Plan has been endorsed by CinC; and a similar, 
complementary plan covering off the detailed arrangements for (ground) 
safety, environmental protection and sustainable development will be 
developed in due course. Senior officers’ Directives are being 
amended to reflect their responsibilities for SHEP&SD accordingly 
 

20080301_DESB Report Calendar Year 2007_final.doc 

link to page 8 link to page 8 d. 
CJO Directives now include safety responsibilities.  This is a first 
and key step in establishing safety assurance in operational areas. 
 
8. 
Other areas have also taken the initiative to brief their management 
boards and senior staff.  Furthermore, briefings are to take place in early 2008 
to individual Defence Board members as well as the Board itself in April 08, in 
order to demonstrably reinforce leadership in health and safety at that level. 
 
•  Safety & EP Management Systems Weaknesses 
 
9. 
Although there have been significant efforts to improve S&EP 
management systems, this work has itself exposed further areas of concern 
such as interfaces between FSBs and TLBs.  Other areas of concern include:  
 
a. 
the Defence Ordnance Safety Board (DOSB) reports concern 
that existing arrangements are unable to provide adequate safety 
assurance of ordnance/explosives deployed on operations,  Concerns 
emerged last year regarding OME safety on operations, largely centred 
on Op HERRICK and relating to multinational munitions storage and 
handling safety.  They included the reporting and handling of munitions 
incidents, especially during extended operations away from bases, and 
the issue of and compliance with limited safety clearances for UOR 
systems and some munitions natures.  In order to identify and mitigate 
these potential risks, PJHQ has become a full DOSB member and 
implemented its own munitions safety board; 
 
b. 
Concern that Urgent Operational Requirements (UORs) have 
not always covered the requirement for training, potentially impacting 
on operational safety.   
 
The Strategic Gap Analysis2 identified high level organisation and 
arrangements and performance monitoring as two key areas of system 
weakness.  Examples of work to address these is outlined in the following 2 
paragraphs. 
   
10. 2nd PUS endorsement of the paper on Strategic Organisation and 
Arrangements for Safety Across Defence 3 has prompted changes in the role 
of the FSBs.   An example is that, because of these influences, the thrust of 
the Ship Safety Board’s (SSB) assurance activities has changed from a focus 
on IPTs to an End-to-End focus on the integration of functions across the 
maritime domain.  That said, it is of concern that End-to-End assurance is not 
yet in place throughout the Department.  Work is underway to produce an 
assurance strategy by Spring 08, which will clarify the relationship between 
FSBs and TLBs. This is a key priority for 2008.  
 
11. 
Dstl report accident potential as well as actual occurrences, thereby 
increasing their “near miss” reporting, and DE&S have set up a Safety 
                                                 
2 DESB P(07)2 
3 D/VCDS&2PUS/9/4/1 LM dated 2 Apr 07, Strategic Organisation and Arrangements for 
Safety Across Defence. 

20080301_DESB Report Calendar Year 2007_final.doc 

link to page 9 link to page 9 link to page 9 Improvement Working Group to look at strategic lessons from recent major 
accident Boards of Inquiry.  These activities, together with other action within 
TLBs/TFAs, have had a positive influence on improving our ability to measure 
and monitor the performance of S&EP management systems.  Nevertheless, 
more needs to be done to develop leading performance indicators, and this 
will form a key priority for 2008. 
 
•  Road Traffic Accidents (RTAs) 
 
12. Data4 for Service deaths attributable to RTAs in 2007 shows a 13% fall, 
from 61 in 2006 to 53 in 2007.  However, RTAs remain a significant cause for 
concern.  DESB members should note that the bulk of this problem is in the 
Army who have undertaken the most noteworthy activities towards reductions 
in this area.  Data for 2006 (shown in Table 1, below) shows that RTAs 
accounted for 32% of all Service deaths, compared to 33% the previous year. 
 
Table 1. Summary of Defence Road Traffic Accident Statistics 20065
 
 
2005 
2006 

5 Yr 

Change 
Average 
Change 
Road Traffic Accidents 
7,781 
6,918 
-11.1% 
8,032 
-4.59% 
RTA rate per 100K miles 
2.36 
2.51 
+6.35% 
2.28 
+1.3% 
Fatalities On-Duty 
11 

-18.19% 
13 
0% 
Fatalities Off-Duty 
41 
52 
+26.83% 
47 
+2.17% 
On-Duty Injuries Serious 
58 
47 
-18.97% 
66 
-5.72% 
On-Duty Injuries Slight 
471 
396 
-15.93% 
595 
-10.26% 
Actual Costs of Insurance 
£12.95M £10.9M -15.83% 
£10.79M 
+6.72% 
Claims 
Estimated Cost of MOD 
£4.88M £4.92M 
+0.82% 
£5.55M 
-0.54% 
Vehicle Repairs 
Estimated Total Losses6
£142.80M 
£126.56M 
-11.37% 
£130.78M 
+4.19M 
 
 
13. 
Aside from Defence Road Management Committees, HQ Land has 
continued to actively pursue solutions to reduce RTAs, including targeted 
radio and TV advertisements, and road safety campaigns throughout the year. 
A major campaign has been launched by CESO(A) to raise the awareness of 
soldiers returning from Ops.  A series of TV and radio commercials were 
recorded in Summer 2007 and broadcast on BFBS TV and radio to troops in 
the final weeks of their op tours to raise awareness of the fact that British 
troops are twice as likely to die on the road as civilians.  During 
Decompression, a hard-hitting DVD drama depicts a soldier returning from 
R&R and eventually being killed in an RTA (“The Grim Reaper”) and a series 
of posters, constantly refreshed to keep the campaign alive on return to 
barracks.    
                                                 
4 Source: Defence Movement Transport Policy Division. 
5 JSP 485 Edition 2006. 
6 Estimated losses are calculated using a formula developed on behalf of the Health and 
Safety Executive.  These recognise that the true accident costs are between 8 and 36 times 
the known costs.  To avoid exaggeration, these losses are calculated by multiplying known 
insurance claims and estimated repair cost by a factor of 8.  Therefore, this should be seen as 
the minimum level of loss to the defence budget. 

20080301_DESB Report Calendar Year 2007_final.doc 

link to page 10  
14. 
The campaigns have been widely acclaimed, but it is too early to see 
significant changes.  In addition, a Motor Insurance package is being 
developed to incentivise good driving but dis-incentivise poor driving.  Further 
campaigns are planned for 2008, subject to funding. 
 
•  Lack of Suitably Qualified and Experienced Personnel 
 
15. 
The impact of organisational change on safety management 
arrangements, including retention of Suitably Qualified and Experienced 
Personnel (SQEP), is being felt to varying degrees across the Department 
and there has been little improvement in this area from last year.  The 
Secretary of State’s Policy Statement7 requires assessments to be carried out 
prior to any significant organisational change to confirm that environmental 
and safety management is not degraded.  However, change initiatives across 
the Department continue to compete with necessary consolidation activity for 
scarce safety SQEP resource. 
 
16. 
Reports this year reflect concerns and include work towards mitigation 
by the Army, the Defence Nuclear Environment and Safety Board (DNESB), 
DE&S and the DOSB. 
 
a. 
The progress of the Corporate Manslaughter and Corporate 
Homicide Act 2007 through parliament prompted the Army to 
undertake a review of safety compliance.  A major uplift in resources 
for safety management (Safety Advisers in Arms & Services 
Directorates, at formation level and in 87 units) has been endorsed by 
CinC Land personally for implementation in 2008 at a cost of £6.1M. 
 
b. 
DNESB report that the continued availability of sufficient nuclear 
suitably qualified and experienced personnel (NSQEP), both for MOD 
itself and for defence contractors, is one of the greatest challenges to 
the sustainable future of the defence nuclear programmes in the 
medium term.  At present MOD has an underbearing of nearly 10% of 
civilian NSQEP posts.  But there have been some encouraging 
developments in 2007.  DE&S corporately has recognised that 
upskilling is key to its future success, which has provided a welcome 
framework.  Director General Submarines (DGSM) has refined his 
analysis of the demand and supply of NSQEP staff, both safety 
professionals and engineers.  Most importantly, he has gained 
corporate funding and approval for the annual recruitment of 22 
graduates and 22 technicians (advanced modern apprenticeships) and 
for their initial nuclear training, and, further, for a training margin of 6 
posts to allow mid career development.  
 
c. 
To assist Directors General in the recently formed DE&S to 
manage safety and environmental issues within their new clusters, and 
to support the Chiefs of Materiel in their task, the S&EP Directorate has 
                                                 
7 Safety, Health and Environmental Protection in the Ministry of Defence, dated 19 Dec 06. 
10 
20080301_DESB Report Calendar Year 2007_final.doc 

introduced a team of qualified Safety and Environmental Liaison 
Officers, to provide a corporate focus within the clusters and help drive 
improvement. 
 
d. 
The DOSB report inadequate assurance of Ordnance, 
Explosives and Munitions (OME) competence.  The requirement to 
ensure there are sufficient personnel entering the MoD OME 
community, including at the lowest local industrial levels, is the subject 
of work within the DE&S and needs to remain dynamic in the context of 
evolutions within DSDA.  Work to map current MoD OME 
competencies to National Occupational Standards is also ongoing, to 
ensure that MoD personnel, particularly in the industrial grades, are 
appropriately qualified, as well as experienced. 
 
18. 
The DESB feel that the challenge of recruiting, training and managing 
SQEP might be better delivered through the formalisation of a development 
programme.  Priorities for action in 2008 will include a functional audit on the 
impact of organisational change (including Streamlining) on safety 
management. 
 
•  Land Contamination 
 
19. 
Failure to assess and manage land contamination has the potential to 
impact on defence activities through reducing the availability of training areas, 
limiting development of the estate, reducing disposal receipts and diversion of 
funding to meet statutory clean-up obligations.  Land quality assessments 
carried out to date have not identified the wide spread presence of 
contamination on the defence estate.  However, in order to give greater 
assurance on this point, DE has initiated a data collection exercise to clarify 
the extent of any problems and to enable costed solutions to be found. 
 
20. 
There are some specific issues that may lead to calls upon defence 
resources: 
 
a. 
Contamination from the use of ordnance on the training estate:  
Work in North America has identified potential environmental risks from 
OME used in training.  An initial scoping study carried out by DE DTE 
indicates that the risk is very low, but further investigations will be 
carried out to provide greater assurance.  
  
b. 
Disposal of ammunition and pyrotechnics within general waste:  
DE DTE has had a number of incidents where ammunition and 
pyrotechnics have been disposed of as general waste.  No serious 
incident has occurred to date but there is a risk of injury to contractors.  
A successful pilot project for waste separation has been carried out at 
Otterburn and the lessons are being rolled out to other ranges.  
 
c. 
Unexploded Ordnance (UXO):  UXO presents a significant risk 
of injury to trainees, contractors, tenants and members of the public.  
Risk assessment and mitigation measures are in place but the limited 
11 
20080301_DESB Report Calendar Year 2007_final.doc 

availability of EOD resources is a handicap and may lead to restrictions 
on access to and use of parts of the defence estate. 
 
d. 
Chemical Warfare (CW) agent legacy:  Residual traces of (CW) 
agent have been found on sites formerly used for CW agent storage 
and disposal at the end of WWII.  DE has initiated Project Cleansweep 
to quantify the risks:  46 sites have been identified for investigation, of 
which 33 are no longer under MOD control. 
 
•  Infrastructure 
 
21. 
There have been initiatives in this area but, to date, insufficient 
mitigation action to change the level of risk from last year.  DESB members 
expressed concern that the condition of some aspects of the MOD estate, 
notably fuel and explosive storage facilities, has the potential to impact on 
operational capability.  There is, inevitably, a cost impact. 
 
22. 
The DOSB reports on mitigation actions designed to address further 
deterioration in the explosives estate. The project to provide a Compliant 
Explosives Facility (North) (CEF(N)) is unlikely to reach the IAB by Spring 08, 
as the option study is still being populated, and is now planned for Oct 08.  
Funding has been agreed at £124 M although allocations in year may change 
due to resourcing pressures across MOD.  This could compress the build 
programme but is not expected to delay the project beyond its 2014 
completion date. 
 
23. Following 
identification of the poor condition of Longtown/Eastriggs, DE 
conducted a further assessment of the remainder of the OME estate, the 
findings of which have yet to be fully assessed and costed.  It is likely that 
further investment will be required in sites such as Kineton in order to ensure 
OME safety and to safeguard operational capability in the medium term. 
 
24. 
The Army again reports concern that failure to maintain sea defences 
at Lydd could lead to the reduction in size or loss of a major training facility. 
The Environment Agency are preparing a consultation document as part of 
the Coastline Management Plan that proposes the current forward line of sea 
defence at Lydd Ranges should be maintained.  Other than possible 
objections relating to potential damage of the site (which has multiple 
designations) as a result of the work undertaken, this proposal is likely to gain 
local approval as it will provide protection for the Romney Marshes.  The 
possibility that MOD might be invited to contribute to the cost of the forward 
defence strategy cannot be ruled out. The situation will be kept under review 
 
•  Failure to Learn from Accidents/Incidents 
 
25. 
Contributors continue to express concerns over the failure to learn and 
communicate lessons from accidents/incidents, leading sometimes to a 
repetition.  More needs to be done, particularly in the light of Crown Censures 
and the Corporate Manslaughter and Corporate Homicide Act 2007, to ensure 
lessons are learnt from accidents/incidents and from good practice in specific 
12 
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link to page 13 areas of the Department.  Furthermore, inputs indicate concern over the 
robustness and consistency of accident investigation processes, particularly in 
their ability to identify root causes. Work to address this will form a priority for 
2008. 
 
26. 
As of Jan 08, the Incident Recording and Information System Project 
(IRIS) has replaced the Ministry of Defence’s ageing accident and incident 
recording and claims handling databases, CHASP and RAPID respectively.  
IRIS will significantly enhance the Department’s ability to record, learn and 
share data and knowledge, and will enable claims handling to be directly 
linked to the causal event record and follow-up investigation.  IRIS will collect 
data on direct costs of accidents/incidents and indirect costs (such as 
equipment losses, recovery and repair, retraining and medical treatment) 
which are often less clear but no less a threat to defence capability.  The 
DESB agreed that the use of IRIS should be mandated across the 
Department, with exceptions to be agreed by DS&C only where it can be 
proven that these provide more effective and appropriate measures 
 
•  Poor Implementation of 4Cs Policy  
 
27. 
There have been major efforts to improve the implementation of 4Cs 
policy. DE has been at the forefront of this improvement programme, with 
delivery of awareness events to over 550 MOD personnel and contractors.  
Nevertheless, overall, the position remains inconsistent across the estate as 
demonstrated by variable audit conclusions, and the current overall 
assessment is that there is only limited compliance.  A further series of 
workshops, focussed on individual TLBs, will be rolled out through 2008.   
.  
•  Increased Operational Pressures Resulting in Air Accidents 
 
28. 
MARSB continue to report that aircraft and their crews are at risk in 
high tempo operational theatres due to pressures arising from the enduring 
nature of these tasks and the level of resources available to support them.  
Higher accident rates8 would inevitably lead to the loss of high value aviation 
assets, affecting operational capability.  The recommendations from an in-
depth study into helicopter accidents on operations are being addressed – 
there is a strong read-across to fixed wing ops and the DESB should note that 
the findings point to a requirement for a re-examination of the level of 
resources required. 
 
29. 
The provision of Collision Warning Systems (CWS) has suffered delays 
for technical and financial reasons and the MARSB considers it important that, 
both for functional and presentational perspectives, this capability should be 
put in place as soon as possible.  In addition, despite increased training, wire 
strikes continue to present a significant hazard to helicopter crews with 
                                                 
8 The headline aircraft accident rate, measured as a 3 year rolling average of accidents 
causing damage either not repairable on site (or using the equipment/facilities on site), 
beyond economic repair, or the aircraft is missing, has increased from 0.16 to 0.18 per 10,000 
flying hours. 
13 
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link to page 14 link to page 14 link to page 14 resultant impact on this scarce resource; investigations into wire strike 
protection for military helicopters is ongoing. 
 
 
 
DISCUSSION OF OTHER RISKS 
 
Scientific Risk 
 
30. 
Key risks identified by Science Innovation and Technology (SIT) to 
Safety, Health and Environmental Management are shown at Annex A. 
 
 
Low Probability/High Consequence Risks 
 
31. 
The complexity of the Department’s business activities can itself 
present a hazard, and care needs to be taken to identify any accumulation of 
reductions in control measures which could lead to increased risk.  In general, 
the DNESB, MARSB and the DOSB provide assurance that high 
consequence risks, such as those associated with nuclear safety, explosives 
and fuel safety and aviation safety are being well managed.  However, there 
is no room for complacency, and infrastructure, especially for fuel and 
explosives storage sites, must be adequately resourced.  Furthermore, 
rigorous scrutiny and oversight of our management of high consequence risks 
must continue to develop, and the management system would benefit from 
benchmarking and independent challenge in some areas. 
 
 
32. 
A recent DMCS report9 included the following recommendations: to 
introduce independent scrutiny of all investigations into major accidents 
across all the major hazard environments; to introduce a safety improvement 
plan for the Defence Board (DB); and, to compare MACR10 against COMAH11 
Regulations.  Clearly, risk assurance processes in place for these areas need 
to be of the very best and follow on work from this report will be initiated by 
DS&C. 
 
 
High Probability/Low Consequence Risks 
 
33. 
Figures provided by Claims for low consequence risks (Falls, Trips and 
Slips) show a summary of the numbers for Service and civilian personnel in 
Figure 1 (below).  The trend shows a slow decline from a peak in 2002. 
 
 
 
 
                                                 
9 A Review of Major Hazard Accident Response Arrangements in the Ministry of Defence, dated 25 
Jan 08. 
10 Major Accident Control Regulations (MACR). 
11 Control of Major Accident Hazards (COMAH). 
14 
20080301_DESB Report Calendar Year 2007_final.doc 

Figure 1.  Summary of Department-wide figures for Falls, Trips and Slips  
 
Falls, Trips & Slips in the MOD
450
400
350
300
All Falls/Trips & Slips
250
Falls
200
Trips & Slips
150
100
50
0
2000
2001
2002
2003
2004
2005
2006
 
 
34. 
The cost to the Department of these low consequence risks, in terms of 
compensation paid, continues to rise and is summarised in Figure 2 (below). 
 
Figure 2.  Summary of the cost of Department-wide Falls, Trips and Slips 
 
The Cost of Falls, Trips & Slips in the MOD
£10,000,000
£9,000,000
£8,000,000
£7,000,000
£6,000,000
All Falls/Trips & Slips
£5,000,000
Falls
£4,000,000
Trips & Slips
£3,000,000
£2,000,000
£1,000,000
£0
2000
2001
2002
2003
2004
2005
2006
 
 
35. 
The financial cost is only part of the burden to the MOD as data for 
associated absence has not been readily available.  DS&C will investigate 
whether HRMS can be used to capture the cost of absence in the case of 
civilians.  To help reduce the incidence of such low consequence accidents, 
particularly amongst civilian personnel, MOD ran its own version of the HSE’s 
‘Watch Your Step’ from August to October in 2007. Service personnel and 
contractors are also important audiences and were targeted where 
appropriate and practicable to do so. The campaign ran alongside the other 
current HSE campaigns such as ‘falls from vehicles’ and ‘lighten the load’, 
and TLBs were advised that they may find it helpful to incorporate messages 
15 
20080301_DESB Report Calendar Year 2007_final.doc 

link to page 16 from the falls from ‘vehicles’ campaign if it helps to reach their intended 
audience. 
 
Crown Censures 
 
36. 
Two Crown Censures were taken by the Department in 2007, reflecting 
Health & Safety incidents in 2003 and 2004.   A summary, together with 
Improvement and Prohibition Notices, is at Annex B. 
 
Pollution Incidents 
 
37. 
No Environment Agency Enforcement Notices were received this year.  
A summary of pollution incidents is included at Annex B. 
 
 
PERFORMANCE 
 
Fatalities 
 
38. 
Data from DASA up to the end of 200712 for injury-related, on-duty 
fatalities is shown in Figure 3 (below).  Also shown below are a breakdown of 
these fatalities on deployed operations (Figure 4) and excluding deployed 
operations (Figure 5).  All Figures include RTAs.  (Note: the graphs show 3 
year averages, not annual figures.) 
 
Figure 3: Number of injury-related deaths, on-duty, excluding suicide 
and open verdicts (3 year moving average) 
 
80
70
ths 60
a
50
 de
40
r of
30
be
20
um
10
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
3 year moving average
Tri-Service
Naval Service
Army
RAF
 
 
Note that data for Figure 3 includes 86 combat deaths in 2007, whereas for 
Figures 4 and 5 only data for non-combat deaths is used. 
 
                                                 
12 Data for 2007 has not yet been validated.  The fully validated data will be available from 31 
Mar 07 when DASA publish the National Statistic release ‘Deaths in the UK Regular Armed 
Forces, 2007’. 
16 
20080301_DESB Report Calendar Year 2007_final.doc 

link to page 17 Figure 4: Number of non-combat deaths, on duty, on deployed 
operations (3 year moving average) 
 
14
12
ths
10
 de
8
r of
6
be
4
um
N

2
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
3 year moving average
Tri-Service
Naval Service
Army
RAF
 
 
The general upward trend in Figure 4 is due to a variety of causes, including 
the Nimrod crash in 2006. 
 
Figure 5: Number of deaths, on duty, excluding operational deployments 
(3 year moving average) 
 
35
30
s
25
eat
20
f d
 o 
15
er
10
m
u
N

5
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
3 year moving average
Tri-Service
Naval Service
Army
RAF
 
 
The number of on-duty deaths outside of operational deployments, although 
now less than the 1999 figure, remains steady.  
 
Suicides 
 
39. The 
number13 of suicides and open verdicts recorded for Regular 
Service personnel in 2007 was 3, although a total of a further 10 are awaiting 
                                                 
13 Source: DASA. 
17 
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link to page 18 link to page 18 link to page 18 verdict.  If confirmed, this figure would represent a slight reduction from the 4 
recorded in 2006. 
 
 
ASSURANCE SUMMARY 
 
40. 
Quality of reports from duty holders and FSBs continues to improve 
with clarity over roles and responsibilities of FSBs remaining the biggest 
challenge to the provision of effective assurance.  Progress has been made in 
defining the requirement of ‘independent, evidence-based end-to-end 
assurance’ but more work is required on an over-arching assurance strategy. 
 
41. 
The DESB noted that impact that media interest can have on safety 
matters.  The issuing of two Crown Censures on MOD by the Health & Safety 
Executive in Mar 07, and latterly the publication in Dec 07of the Board of 
Inquiry into the loss of Nimrod MR2 XV230, caused the Board of DE&S to 
reconsider and revisit its assessment of risk in 2007.  The effect of these 
events, reinforced by the findings of the Buncefield Standards Task Group 
report14, the Baker Report15 and confirmation of the details of creation of a 
criminal offence of Corporate Manslaughter, has been to sensitise the DE&S 
Board to the necessity of validation of policy and verification of its 
implementation.   Robust and independent assurance is required, delivering 
value through challenge where possible. 
 
42. 
The majority of contributors report Substantial Assurance of effective 
management of health and safety risks, and compliance with health and 
safety management systems.  Environmental management remains less well 
developed in most areas.  However, it is clear that visibility of safety and 
environmental issues at senior management level has improved over the past 
12 months.  Furthermore, across the Department there is greater awareness 
and understanding of the extent of the risks.  But the result of this heightened 
awareness, particularly in the area of accident reporting, is reflected in an 
apparent worsening in performance in some areas. 
 
43. 
Providing an overall Assurance assessment has proved particularly 
difficult this year.  Improved awareness is bringing to the fore a number of 
areas of systemic weakness (detailed in this year’s report) which are manifest 
in some areas more than others.  Following discussions, the decision was 
right on the cusp between Minor and Significant Weakness and the DESB has 
agreed16 that, overall, the management of S&EP is at: 
 
SIGNIFICANT WEAKNESS 
 
 
44. 
Annex C sets out the audit programme for the next 3 years. 
                                                 
14 HSE Report: 12th October 2006 
15 BP U.S. Refineries Independent Safety Review Panel (the “Baker Report”) January 2007. 
16 Satisfactory – Performance on Target; Minor Weakness – Small Variation from Target; 
Significant Weakness – Significant Variation from Target; Critical Weakness – Major Variation 
from Target. 
18 
20080301_DESB Report Calendar Year 2007_final.doc 

PRIORITIES FOR 2008 
 
45. 
For its priorities in 2008, the DESB: 
 
a.  
Agreed that an assurance strategy should be produced to 
clearly articulate the relationship between Functional Safety Boards 
and TLBs, reporting requirements for the DESB, and principles of End 
to End assurance. 
 
b. 
Agreed that the following should be mandated across the 
Department: coherent procedures for sharing lessons learned from 
accidents and incidents; communication of good practice; and, accident 
investigation by appropriately trained personnel. 
 
c. 
Agreed that existing work underway in DE&S, under the Safety 
Improvement Working Group, should seek to clarify safety interfaces 
between DE&S and FLCs/PJHQ.  Once identified, the necessary 
processes should be put in place, as appropriate, by FSBs and TLBs. 
 
d. 
Agreed that, resource requirements for S&EP should be 
coordinated to enable identification and incorporation in the Planning 
Round. 
 
e. 
Agreed that a framework for performance measurement should 
be developed, particularly including leading Key Performance 
Indicators. 
 
f. 
Agreed that the use of IRIS should be mandated across the 
Department, with exceptions to be agreed by DS&C only where it can 
be demonstrated that they provide more effective and appropriate 
measures. 
 
g. 
Agreed that DS&C should initiate follow on work from the DMCS 
report on Major Hazard Accident Response Arrangements, including 
improvements in independent scrutiny. 
 
h. 
Agreed that the benefits of development programmes for SQEP, 
covering recruiting, training and career management, should be 
examined. 
  
i. 
Agreed the proposed audit programme, designed to contribute 
towards verification of the effectiveness of management processes in 
place for safety and environmental protection.  A functional audit on the 
impact of organisational change on safety management (including 
Streamlining) should be included. 
 
j. 
Agreed that DS&C should conduct a review of top level safety 
governance. 
 
19 
20080301_DESB Report Calendar Year 2007_final.doc 

It is intended that these priorities should be incorporated into a DESB action 
plan, and the DESB be updated on progress at 6 monthly intervals.
20 
20080301_DESB Report Calendar Year 2007_final.doc 

 
Annex A to 
DESB Report 2007 
 
 
SCIENTIFIC RISK 
 
1. 
Scientific Risks highlighted to the DESB by the Scientific Risk 
Management Team from SIT are set out below. 
 
2. Tungsten 
Alloys.   
 
a. 
The major ongoing risk relates to the use of tungsten alloy 
munitions in penetrating weapons.  Tiny fragments of one particular 
alloy caused aggressive cancers in rats with 100% incidence and 
mortality.  DU had no significant effect on the same rats.  Embedded 
fragments can be expected in significant numbers of individuals after a 
land battle between armoured units (such weapons are generally only 
used against armour).  Such fragments are impractical, probably 
impossible, to remove. 
 
b. 
Although one other alloy does not show the effect, the big 
uncertainty at present relates to which other similar alloys would 
perform in the same manner.  At our urging, DE&S is testing an 
alternative to the one munition that would have used the identical alloy 
in the short term.  A similar alloy is used in GOALKEEPER (although 
the risk of exposure is substantially lower).  Of most immediate concern 
is a related alloy which will be used in the RARDEN cannon on current 
plans.  It is almost certainly too late to avoid any deployment at all if 
capability is to be maintained.  We are recommending that an 
alternative is developed and tested now.  The decision to commit to 
manufacture the new formulation can then be made once this work is 
complete, by which time it should be clearer whether the change is 
necessary.  This course of action would however require DE&S to find 
additional funds for development now. 
 
c. 
The overall research programme in this area is well-linked with 
the US programme and should help inform which alloys are a problem 
as well as how to treat injured personnel should such alloys be used 
against us.  The US has recommended that their programmes do not 
use the specific alloy in future. 
 
3. Nanotechnology.  A key growing concern is that knowledge of the 
potential toxicology of nanomaterials is not keeping pace with advances in the 
field of nanotechnology.  We have been tracking this for some years, and 
have commissioned some work that has led DSTL to develop their capability 
to address key enabling factors (e.g. containment of experimental particles, 
risk assessments) required to support future assessments.  However the field 
is enormous (and varied; not all applications will be of concern).  IPTs need to 
understand that there may need to invest more in understanding safety and 
A - 1 
20080301_DESB Report Calendar Year 2007_final.doc 

toxicology if they are developing applications based on nanotechnology and 
that the techniques for safety assessment could be ground-breaking (and 
hence slower and more expensive than usual). 
 
4. Wind 
farms.  Although the UK was one of the first Nations to identify 
the potential risk to Defence interests from windfarms and DE Safeguarding 
have coordinated a variety of studies into their effect on Air Traffic and Air 
Defence radars and seismic stations, there has recently been additional 
strong pressure for a large expansion in UK windfarms which could prejudice 
our systems.   We are pleased to note the planned operational analysis study 
that should further increase the strength of our analytical position, and past 
trials have identified some key issues, however at present there is no 
technical solution to the problem, and procedural solutions (e.g. choice of 
location) are limited.  This is work against the known problems, but there 
remains the risk of unexpected extra problems.  It would seem that substantial 
extra work will be required to address this issue and the DESB may wish to 
support this.  The generic concern about ‘encroachment’ from environmental 
legislation and related constraints (such as the issues with sonars highlighted 
last year) remains valid and SIT will assist D S&C in their planned work on all 
encroachments. 
 
5. 
The scientific risk team will continue to track these and similar issues. 
 
A - 2 
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link to page 23 link to page 23 link to page 23  
Annex B to 
DESB Report 2007 
 
CROWN CENSURES, IMPROVEMENT NOTICES, PROHIBITIONS AND 
POLLUTION INCIDENTS - 2007 
 
Crown Censures1
 
1. 
Two Crown Censures were served on the Ministry of Defence in 2007 
regarding incidents that occurred at Teesport in 2003 and Albemarle Barracks 
in 2004.  Each incident resulted in the death of a serviceman.   
 
a. 
May 2003.  Whilst commanding the unloading of armoured 
vehicles from a semi low loader a second vehicle rolled and crushed a 
soldier between the two. He later died in hospital from his injuries. 
 
b. 
May 2004.  After washing a Multi Launch Rocket System (MRLS) 
vehicle a soldier went to dry his clothes on the exhaust vent. The 
MRLS was put into high revs and as the power engaged the vehicle 
lurched forward rapidly and unexpectedly collided with a forklift truck. 
The soldier was trapped between the towing bracket of the forklift and 
a load basked on the MRLS. He later died in hospital from his injuries. 
 
2. 
By the time the Censures were issued, the identified failings had been 
addressed and procedures and processes revised.  Lessons learnt from the 
investigation of these incidents by MOD and HSE have been incorporated into 
current working practices to avoid similar occurrences. The actions taken by 
MOD were agreed by the HSE as sufficient to prevent a reoccurrence and 
improve general safety. 
 
Crown Improvement Notices2
 
3. 
One Crown Improvement Notice was served during this period: on 
Landmarc (DTE), issued on 4 Jul 07. 
 
Crown Prohibitions3
 
4. 
No Crown Prohibitions were reported during this period. 
 
5. 
However, Defence Fuels Group, as independent Fuels Licensing 
Authority, served an extra-ordinary Prohibition Notice on King’s Lines Fuel 
Depot (KLFD), Gibraltar.  When the Prohibition Notice was served, the 
Command had already taken the decision to cease all operations at KLFD 
and also stop both MOD personnel and/or contractors from accessing or 
                                                 
1 An administrative procedure, whereby HSE may summon a Crown employer to be censured 
for a breach of the Health and Safety at Work Act, or a subordinate regulation, which, but for 
Crown Immunity, would have led to prosecution with a realistic prospect of a conviction. 
2 Served by HSE when it is assessed that relevant statutory provisions are being contravened. 
3 Served by HSE when it is assessed that an activity will give rise to the risk of serious injury. 
B - 1 
20080301_DESB Report Calendar Year 2007_final.doc 

link to page 24 link to page 24 carrying out routine operations at the fuel installation.  The contractor is still 
undertaking those activities required to minimise the risk from the de-fuelled 
depot. 
 
Enforcement Notices4
 
6. 
Two Environment Agency (EA) Enforcement Notices were served 
during this period, both on Air Command against RAF Marham: 
 
a. 
Emissions from the Paint Facility not permitted.  The Unit did not 
hold a LAPC permit for VOC emissions.  Although a permit has now 
been granted by the Local Authority, at a cost of £2500 and £1k annual 
subsistence charge, the station disputes whether it was a legal 
requirement and CESO(RAF) are now advising.   
 
b. 
Discharge Consent for Station Sewage Treatment Works 
exceeded.  Although a consent has been issued, it is a Project 
Aquatrine responsibility and hence was passed to the Aquatrine 
Service Provider, C2C. 
 
Pollution Incidents5
 
7. 
FLEET reported the following pollution incidents: 
 
a. Marine 
Forty-six discharges were reported in breach of 
MARPOL Regulations, compared with 39 in 2006, an increase in 
accident rate of 18%. However, the total volume of pollutants was only 
4061 litres compared with 13,247 litres reported for the same period in 
2006.The spillage of F76 fuel fell to 772 litres from 897 litres in 2006, 
excluding the 2 large spillages of 9,200 litres last year. The 2 largest 
separate spillages were 1000 litres of hydraulic oil from a defective 
cooler on HMS ILLUSTRIOUS and 1000 litres of sewage on HMS 
KENT because of an incorrect system line-up. There has been a 58% 
increase in the number of reported release of Montreal Protocol gases 
to 54; of these 51 were attributable to equipment failure. 
 
b. Land   
There have 18 Tier 1 incidents and 3 Tier 2 
incidents during the reporting period, one of which was a release of raw 
sewage at RNAS YEOVILTON and has been investigated by the 
Environment Agency, because of shortcomings identified in the service 
provider’s management system. 
                                                 
4 The purpose of enforcement is to: ensure that duty holders take action to deal immediately 
with risks; promote and achieve sustained compliance with the law; ensure that duty holders 
who breach health and safety requirements, and directors or managers who fail in their 
responsibilities, are held to account. 
JSP 317 Definitions
TIER 1: Where the clean up is entirely within the unit’s capability. 
TIER 2: The clean up requires assistance from another Service unit, or from an external 
organisation. 
TIER 3: A Catastrophic Incident requiring major external assistance. 
 
B - 2 
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8. 
The Army recorded 45 environmental incidents this year attributable to 
Army activity.  None were considered to be in the major category. There were 
37 Tier 1, and 8 Tier 2 incidents.  Six of the Tier 2 incidents occurred in 
UKSC(G) where assistance by the DFS raised the category from Tier 1 to Tier 
2. 
 
9. 
Air Command reported 105 Tier 1, 13 Tier 2 and zero Tier 3 pollution 
incidents.  It should be noted that 23% of total spills reported were as a result 
of aircraft venting.  Other pollution incidents/issues: 
 
a. 
A pollution incident occurred at RAF Brize Norton when an Oil 
Interceptor on a neighbouring scrap yard failed.  Although the Station 
was not at fault, it fell to them to manage and fund the remediation 
works which are still on-going. 
 
b. 
Although CESO(RAF) has written to Station’s reiterating the 
requirement, under JSP 317, for all spills to be reported to DFG, it is 
thought that many spills are still not being reported.  RAF Stations have 
ordered enough fuel absorbents to clean up approx 10 times the 
volume of fuel that has been reported in Spill Reps.  
 
10. 
CJO reported the following 3 pollution incidents in 2007 (compared to 2 
in 2006, though they resulted in a smaller cumulative discharge), all occurred 
in the Falklands Islands Base (FIB):  
 
a. 
1 x 200ltrs estimated uncontrolled fuel loss over 4 week period 
from main AVTR over land pipeline by Main Gate.  Small pin prick hole in 
underground pipe work identified and repaired.  Area dammed and PCA 
used to remove fuel until repair completed. 
 
b. 
1 x 1000ltrs estimated uncontrolled fuel release of F76 to rear of 
PSD pump room.  Gasket seal failed on isolation valve joint.  Quick 
reaction by PSD staff reduced environmental impact.  90% of fuel 
recovered area already on contaminated ground register and monitored. 
 
c. 
5 x <30ltrs in volume total.  Minor spillages of vehicle/aircraft 
hydraulic oil.  No trends identified. 
 
11. 
DE&S reported 64 Tier 1, 11 Tier 2 and zero Tier 3 spillages. 
 
 
 
B - 3 
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link to page 26 link to page 26 link to page 26  
Annex C to 
DESB Report 2007 
 
AUDIT PROGRAMME 
 
TLB/TFA Audits. 
 
 
 
 
FY 08/09 
FY 09/10 
FY 10/11 
 
DSG1
Dstl DE&S 
DE&S2
FLEET Air 
Command 
CJO3
CTLB Met 
Office 
LAND DE 
 
SIT  
 
UKHO  
 
 
This S&EP programme reflects revised working arrangements of combined 
audits with Security Risk Management and Business Continuity. 
 
Functional Audits in FY08/09. 
 
•  Best Practice Review of Accident Investigation. 
 
•  Impact of Organisational Change on Safety Management, including 
recruitment, management and retention of SQEPs. 
 
Follow-up Reviews in FY 08/09 
 
•  DE&S (6 month Review). 
 
•  ABRO/DARA (6 month Review). 
 
•  Met Office (6 month Review). 
 
•  Air Command (6 month Review). 
 
 
                                                 
1 Formerly ABRO/DARA. 
2 Slipped from 07/08. 
3 The scope of this audit will seek to include systems for safety in operational areas. 
C - 1 
20080301_DESB Report Calendar Year 2007_final.doc