HSE Crown Censure of MOD over death of cadet, 14

Date:

25 January 2013

The Ministry of Defence (MOD) has been censured today over safety failings that led to the death of a 14-year-old cadet.

Kaylee McIntosh died in August 2007 after becoming trapped beneath the boat she was in when it capsized on Loch Carnan in bad weather.

A Health and Safety Executive (HSE) investigation found a series of serious failings by Major George McCallum, who was leading the boating trip, compounded by systemic organisational failings by MOD Army.

General Sir Nick Parker attended today’s Crown Censure meeting and accepted the findings on behalf of the MOD, formally acknowledging there were health and safety failures.

The MOD cannot face prosecution in the same way as non-Government bodies. Crown Censures are agreed procedures applicable to Crown employers, including the MOD, in lieu of criminal proceedings.

HSE’s Director for Scotland and Northern England, David Snowball, who chaired the Censure said:

"The various investigations into the circumstances surrounding this tragic incident revealed a number of organisational failings by the MOD.

"HSE’s investigation has confirmed that primary failings during the activity amplified a number of significant underlying organisational failures. In particular, there was evidence of poor planning, leadership and execution of the exercise, coupled with inadequate oversight, procurement, monitoring and training arrangements. These all contributed to the events that took place.

"Together with the considerable failings of Major George McCallum, who was in charge of this activity and played a significant role in its planning, assessment and implementation, what should have been an enjoyable and exciting experience resulted in tragedy.

"The evidence brought to light by HSE’s investigation would be sufficient to provide a realistic prospect of conviction of the MOD in civilian courts. A Crown Censure is the maximum enforcement action that HSE can take and it serves to illustrate how seriously we take the failings that led to the death of Kaylee McIntosh." 

Kaylee McIntosh was part of a group from the 2nd Battalion of the Highlanders Army Cadet Force, taking part in the Annual Camp at South Uist.

On 3 August, Major George McCallum led an exercise to take some of the cadets by boat from the jetty at Loch Carnan to Loch Skipport where there was a training area.

Due to poor weather, the trip was abandoned part way through, but while trying to turn around, one of the boats capsized throwing everyone overboard. Kaylee was trapped beneath the boat for approximately two hours before she was noticed as missing.

Notes to editors

1. The Army Cadet Force (ACF) is a national voluntary youth organisation sponsored by the Ministry of Defence (MOD). It provides challenging military, adventure and community activities for boys and girls aged between 12 and 18 years. Although not part of the Army, it is closely linked and organised on military lines. Control of the ACF is effected by the MOD, Highland Reserve Forces and Cadet Association (HRFCA) and the Army Cadet Force (ACF).
2. A Crown Censure is the maximum sanction for a government body that HSE can bring. There is no financial penalty associated with Crown Censure, but once accepted is an official record of a failing to meet the standards set out in law.  More information can be found here: http://www.hse.gov.uk/enforce/enforcementguide/investigation/approving-enforcement.htm
3. The Crown Censure meeting was held on 25 January, with the formal record being agreed by all parties – this completes the censure process.
4. HSE has taken this decision now after considering all evidence, including that from the April 2010 FAI (Fatal Accident Inquiry) into Kaylee McIntosh’s death and the prosecution against Major George McCallum. The Crown Censure proceedings relate to the discharge of duties as an employer, under Section 2 and 3 of the Health and Safety at Work etc Act 1974 and Regulation 3(1) of the Management of Health and Safety at Work etc Act 1974.
5. The initial investigation into Kaylee McIntosh’s death was led by the Maritime Coastguard Agency (MCA), Marine Accident Investigation Branch (MAIB) and Northern Constabulary and later HSE in line with agreed national protocols regarding workplace fatalities. The Crown Office Procurator Fiscal Service brought charges, recommended by HSE, against Major George McCallum, a Cadet Executive Officer employed by the Highland Reserve Forces and Cadet Association (HRFCA), who admitted breaching Section 7(a) of the Health and Safety at Work etc Act 1974 and was fined £5,000 on 19 November 2012.
6. . Section 2(1) of the Health and Safety at Work etc Act 1974 requires: ‘every     employer to ensure, so far as is reasonably practicable, the health safety and welfare at work of all his employees’.
7. . Section 3(1)of the Health and Safety at Work etc Act 1974 requires  ‘employers to conduct their undertaking in such a way as to ensure, so far as is reasonably practicable, that persons who are not in their employment but who may be affected there by are not placed at risk to their health and safety’.
8. . Regulation 3(1) of the Management of Health and Safety at Work etc Act 1974 requires:‘an employer to make a suitable and sufficient risk assessment of (a) the risks to employees to which they are exposed while at work and (b) the risk to persons who are not employees to risks that arise from, or are connected with, the undertaking’.
9. Following its investigation, HSE concluded the following failures occurred on the day of the incident:
   
   Before the exercise
   • There was inadequate planning of the activity and so the potential risks were not fully considered
   • The Coxswain of the boat lacked the necessary proficiency to command the specific craft
   • The lifejackets provided to the cadets were inappropriate
   • Details about the proposed route had not been confirmed to all the main participants
   • The decision to add a general purpose machine gun in the bow lowered the freeboard on the craft
   • There was no safety officer nominated and no safety boat had been deployed
   • There was limited or inadequate instruction to the cadets and others on what to do in an emergency
   
   
   During the exercise:
   • The boat was operated in conditions potentially beyond its design capabilities
   • There was a failure to operate the self-bailers correctly
   • Key individuals could not communicate effectively with each other
   
   
   After the capsize:
   • Key individuals could not communicate effectively with emergency responders
   • There were inadequate arrangements to take a proper headcount and to confirm that all participants were safe.
   
   
   HSE also found the following systemic failures were apparent in the planning for the exercise:
   • It was unclear how the activity was actually authorised
   • Assault Troop Life Jackets could be sourced without any challenge about their intended use or buoyancy
   • Vessels could be gifted without any checks on their suitability or the availability of appropriate instruction material
   • There was no effective basis on which to demonstrate competency to use a gifted vessel within the terms of Army Guidance and Administrative Instructions
   • There was no clear basis on which to assess if the exercise leader was qualified to assume command
   • There was no dedicated Training Safety Adviser
   • There was no audit/inspection system of ACF practices at Battalion level.
   • There was no external verification of the Red Book test.
   
   
   
10. In Scotland the Crown Office and Procurator Fiscal Service has sole responsibility for the raising of criminal proceedings for breaches of health and safety legislation.

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