Staffordshire PEEL 2018
How effectively does the force reduce crime and keep people safe?
Staffordshire Police is good at reducing crime and keeping people safe. The force focuses on preventing crime, rather than just reacting to it.
Police officers and police and community support officers (PCSOs) work closely with different organisations and communities to tackle problems.
The force is good at investigating crime. However, it needs to improve its overall management and understanding of those suspected of criminal offences.
How effective is the force at preventing crime, tackling anti-social behaviour and keeping people safe?
This question was not subject to detailed inspection in 2018/19, and our judgment from the 2017 effectiveness inspection has been carried over. One area for improvement remained from that inspection.
- The force should routinely evaluate and share effective practice both internally and externally with relevant outside organisations. This will ensure its approach to preventing crime and anti-social behaviour (ASB) continuously improves.
During our fieldwork we reviewed the force’s progress on this area for improvement.
Since our last inspection the force has made good progress in the way it evaluates and shares good practice both internally and externally with partner organisations. The force works closely with different bodies and communities to tackle problems.
Through this unified approach it tries to identify and deal with the causes of crime and ASB, rather than responding to the symptoms. Local policing commanders regularly meet with community safety partnership leads to discuss new concerns.
This is complemented by local multi-agency problem-solving meetings where officers and staff discuss effective practice to agree shared actions. The force records problem-solving plans on its ‘citizen focus toolkit’. This is a database of effective practice which neighbourhood officers and staff can refer to. The force identifies key cases and uses them to promote learning. For example, officers have given presentations on using a community protection notice in response to fox hunting, and injunctions to tackle ASB by children.
This area for improvement is now completed.
How effective is the force at investigating crime and reducing re-offending?
Areas for improvement
- The force needs to improve its oversight and understanding of those wanted for criminal offences, ensuring they are both circulated on the Police National Computer and actively sought.
- The force should ensure that it is fully compliant with the Code of Practice for Victims of Crime with victim contact details consistently recorded and updated.
We set out our detailed findings below. These are the basis for our judgment of performance in this area.
Staffordshire Police has the right structures to deal with most of its investigative demand. To meet the needs of victims, calls for service and incidents are carefully assessed to ensure cases are investigated by the most appropriate team.
Strategic, tactical and operational meetings help the force move resources flexibly to make best use of staff skills.
Most investigations by Staffordshire Police are good quality. We reviewed a sample of 60 files, and then 12 more during our fieldwork. We found most investigations were conducted effectively, particularly for more serious crimes.
The force introduced a new policing model in July 2018. It restructured its investigation teams to create enough capacity and capability to cope with investigative demand.
The force has trained investigators working in frontline roles and in specialist investigation teams. This enables it to respond effectively to demand. The force has increased the number of officers in the investigations teams and created a specialist child protection and exploitation team.
There are enough skilled and experienced officers and staff to conduct investigations. Investigators’ caseloads are manageable. The investigations teams are staffed mainly by officers who are trained to the right level or are working towards their accreditation.
We heard from a cross-section of investigation and neighbourhood teams that the force’s crime allocation policy is effective. Officers are mainly allocated crimes that are right for their skills and ability.
The force gives officers and staff a clear framework to ensure investigations are allocated according to harm, crime type and the level of investigative skill needed.
It also considers whether crimes are part of a series or have local impact. The force holds a daily management meeting to review demand from calls for service and crimes and investigations reported over the last 24 hours. This ensures high-risk investigations are appropriately resourced. It also makes sure it promptly reviews the safeguarding needs of high-risk vulnerable victims.
Many of the force’s investigators have been trained to do Achieving Best Evidence (ABE) interviews. This means it is more likely that appropriately trained staff will interview victims and witnesses.
Since our last effectiveness inspection in 2017, the force has introduced three resolution centres to manage non-emergency incidents that officers don’t need to attend.
The force reviews and risk-assesses all cases to ensure they are right for this type of investigation. We reviewed sample cases investigated this way and found that they were allocated appropriately and were effectively managed.
Officers have a good understanding of the importance of gathering evidence at an early stage of an investigation. Frontline officers we spoke with made the most of opportunities to gather evidence in the ‘golden hour’. This is the hour immediately after a crime has been committed.
If officers can gather evidence during the golden hour, they are more likely to get evidence they might not later. Officers showed good understanding of the requirements of forensic preservation (keeping evidence intact). They said they were given enough time to achieve this at crime scenes.
We saw examples of comprehensive handovers to investigators, which included results of initial enquiries such as CCTV location, house-to-house calls and suspect enquiries.
The force uses investigation plans. These range in complexity according to the type of crime officers are investigating. Most of the investigation plans included a summary of the case and a list of proposed work.
Oversight of investigations by supervisors has improved. In most cases we found evidence of supervisors providing good focus and direction. In specialist units and the criminal investigation department, recorded supervision was more active and informative. For example, supervisors made direct enquiries on investigations.
The force has also made progress following the Code of Practice for Victims of Crime (VCop). We found most crime victims get a good service. The force has effective processes in place and good supervision to make sure victims are kept updated on progress with their investigation.
We found that officers contact victims regularly and record this contact on crime files. Investigators recorded the number and nature of the contact as agreed with victims. However, the force knows it has more to do to be fully compliant with the VCoP. For example, data shows that the force only offers victim personal statements (VPSs) in around 70 percent of cases. To increase the number of VPSs completed the force has plans to introduce a web-based portal. This will enable victims to write their own statements in their own time. The force expects this to improve quality and satisfaction levels.
Over the last 12 months, the force has achieved investigative results broadly equal to that of other forces. In the 12 months to 30 June 2019, 8.9 percent of recorded crimes led to a charge, compared with the England and Wales rate of 7.7 percent. However, in 20.3 percent of cases, a suspect was identified but the victim(s) didn’t support police action. This is higher than the England and Wales rate of 18 percent.
In our 2017 effectiveness report, we said that the force should take action to understand the reasons victims don’t support police action in a high proportion of the crimes it investigates. This year we found that the force has worked hard to understand this. The force has reviewed cases to understand the reasons for the victims’ decisions and to ensure it is recording results accurately.
The force is working to improve its effectiveness in investigation quality, victim and witness services, and the results it achieves. The force has a service effectiveness board (SEB) which reviews investigation processes from first contact to outcome.
It uses a three-step format: contact, solve and prevent. The force gives information and guidance to operational officers, including case studies. This initiative has focused on frontline officers and staff to improve their knowledge and effectively deal with incidents from the start.
The force has focused on identifying and preserving evidence and producing proportionate investigation plans based on assessing the victim’s needs and the level of risk. Using body-worn video (BWV) improves evidence collection to better support prosecutions. All frontline operational officers are given it.
An important part of the force’s investigations is managing suspects who are avoiding prosecution, or people identified as suspects but who have not yet been arrested or interviewed.
In our 2017 effectiveness inspection, we said that Staffordshire Police needed to improve its oversight and understanding of people wanted for criminal offences. Our report said the force should ensure suspects’ names are shared through the Police National Computer (PNC) – and that they were being looked for.
We found the process for making investigative enquiries to find people wanted on warrant on the PNC still needs improvement.
There is also no consistent approach to recording enquiries made to find offenders. The force is aware of this problem and was reviewing it during our inspection. However, locally, the force has an effective process to manage people who fail to appear on bail, people named as having committed a crime and suspects identified through forensic evidence.
The force co-ordinates enquiries to find high-risk offenders through effective daily management meetings chaired by senior officers. Investigators have a good understanding of the need to make appropriate enquiries to try and trace offenders. Officers and staff were focused on finding and arresting them.
Officers regularly consult Immigration Enforcement to manage arrested foreign nationals. They work effectively with ACRO and Immigration Enforcement to get relevant information about overseas convictions.
The force has protocols with Immigration Enforcement to carry out checks and review options for removing or deporting people who have committed serious crimes or who are a threat to communities. To prepare for Brexit, the force provided training to officers and staff on the use of new tools to manage offenders from EU countries.
Changes to police bail as a result of the Policing and Crime Act 2017 have resulted in many suspects being released under investigation (RUI) from police custody.
We found the force is using the new bail legislation. Investigators use it to manage offenders – imposing bail conditions in appropriate cases to keep the public safe.
The force monitors and records how it uses RUI. It regularly reviews cases to ensure it is used appropriately. The force has a policy directing supervisors to review all RUI cases at 28 days to ensure there is an investigative direction and all necessary actions are taken.
An inspector needs to authorise RUI, and sergeants are encouraged to be proactive and involved in deciding if bail or RUI is the right action. Custody sergeants have a dedicated email inbox to get updates from officers about ongoing investigations and how this may affect charge/bail/RUI decisions.
The force needs to improve how it records the reasons for RUI decisions to ensure it is being used effectively. The force is aware of this and has given training to all custody staff to ensure bail options are considered when safeguarding is needed.
We found that officers with responsibility for investigations have a good understanding of their disclosure obligations. Many of those we spoke with have had formal training. Twenty-five disclosure practitioner champions support colleagues through advice and guidance where they need it. Performance monitoring is done in line with national requirements. The force gives one-to-one sessions to support those who need to improve.
This ensures investigators apply disclosure rules effectively when they compile criminal case files. The force has an effective process to ensure investigators complete disclosure schedules to a good standard. Supervisors, together with the force’s criminal justice department, check the quality of the files before the force submits them to the Crown Prosecution Service.
The force reviewed its justice services in 2017. In response, it created two local prosecution hubs and a centralised support unit. This made justice services more accessible to frontline officers and staff. It enables early intervention in all cases so that only those that need a Crown Prosecution review are sent to the Crown Prosecution Service. It also means out-of-court disposals (outcomes that don’t need to go through the courts – like cautions) are used where it is right to do so.
Staffordshire Police performs well on case file quality. Its case files have a low number of errors compared to other forces. For example, in January 2019, Staffordshire had the lowest error rate of all 43 forces in England and Wales (as measured by the national file quality assessment). It continues to maintain relatively low error rates each month.Summary for question 2
How effective is the force at protecting those who are vulnerable from harm, and supporting victims?
Areas for improvement
- The force should implement the necessary processes to share information with schools in relation to children affected by domestic abuse incidents, to ensure information is shared as quickly and effectively as possible.
We set out our detailed findings below. These are the basis for our judgment of performance in this area.
Understanding and identifying vulnerability
The force has a clear definition of vulnerability with effective processes to protect vulnerable people. The force’s approach is to intervene early to reduce harm, focusing on safeguarding people at risk.
The force’s policies and guidance give clear, unambiguous guidance and direction for safeguarding children, young people and adults. The force works closely with local authorities and other partners to interpret information. This helps it to understand where harm is concentrated and the types of exploitation happening in local communities.
The force uses a data performance ‘dashboard’ to identify patterns of crime, repeat victims and vulnerable people in communities. This enables the force to effectively brief officers and staff locally to focus on protecting people at risk of harm.
The force’s early intervention strategy focuses on identifying root causes of vulnerability. This includes domestic abuse, mental health, substance misuse and child neglect. The force’s vulnerability strategy is reinforced by an internal force media campaign, ‘See beyond the obvious’.
Officers and staff we spoke to during the inspection showed a good understanding of the nature and scale of vulnerability. The force has provided vulnerability and mental health training to all frontline and public-facing staff and supervisors, including police officers, PCSOs and call handlers.
It has invested in training and continuing professional development (CPD) for officers in its public protection team. Also, the force has developed a comprehensive vulnerability toolkit available on both the force intranet and mobile devices. This gives officers and staff examples of good practice, guidance and information on where they can access appropriate services.
To improve its understanding of vulnerability, the force has started a three-year study partnership with an MSc student. This is so it can learn from victims’ experiences and use the information to improve the services it provides.
The force works closely with partner bodies, such as adult social services, children’s services and voluntary organisations, to understand community threats and risk. When it identifies vulnerability, the force is good at sharing information about its nature and scale.
Each local policing area in Staffordshire has a harm reduction hub. This is a team that offers multi-agency co-ordination and joint activities to keep vulnerable people safe.
The force has a range of meetings where it considers performance and service delivery to support people in the community with complex needs. Together with local partner organisations, each local harm reduction hub holds a weekly vulnerability meeting. This identifies the people most at risk of becoming victims of crime or ASB. Actions are agreed through the meetings, and services provided to support them.
We found the force encourages officers and staff to use their curiosity to investigate and uncover vulnerability and hidden harm. For example, trafficking of vulnerable people who are forced to work without pay or made to work against their will.
Officers and staff work well with partner bodies to take steps to uncover hidden harm. At local vulnerability meetings, agencies share information to identify risk. They agree joint actions and ensure appropriate agencies are involved to address issues early.
The force also hosts and organises a monthly multi-agency modern slavery and human trafficking tactical group. The group identifies new threats and shares intelligence. It makes assessments with partner bodies and gets involved early to deal with these threats. This helps safeguard vulnerable people who might be at risk of exploitation.
Staffordshire Police is good at identifying vulnerable people when they first contact the police. This includes identifying repeat victims, victims of domestic abuse and people who live with mental ill health. Call handlers respond to calls quickly and follow a structured risk assessment process to ensure they respond to incidents consistently.
All call handlers have been trained in the national risk assessment tool known as THRIVE. In the sample of calls we listened to, we found operators applied it well. The force’s IT systems allow it to identify cases involving vulnerable people easily, using markers. But the system doesn’t automatically identify repeat victims, including victims of domestic abuse. Instead, call handlers must search force systems manually.
Additional information is available to help call handlers assess a person’s vulnerability through an application called ‘active intelligence’. This system enables call handlers to examine previous calls, revealing any problems or increasing vulnerability. We found that call handlers have a good understanding of the needs of vulnerable people with mental health problems. To make sure callers get the right service, call handlers can get advice and assistance by phone from community psychiatric nurses through a mental health triage scheme.
We found officers who attend incidents are good at identifying risks to victims and consistently identify risks to other vulnerable people in households. This includes recording details of children who live in the household, no matter where they were when the incident took place.
Responding to incidents
The force responds to incidents involving vulnerable people promptly, to keep them safe. To ensure the control room maintains call-handling performance when there are a lot of incoming calls, multi-skilled staff move flexibly between different roles.
During our visit to the force control room, calls were answered efficiently. Call handlers apply their training and use THRIVE well. They identify each caller’s needs to make sure they fully assess risks and offer safeguarding advice over the phone to reduce risk of further harm.
When officers attend an incident, they can get information on their mobile devices and regular updates from control room staff. This makes them aware of the vulnerable people and risks they might find when they arrive.
Our effectiveness inspection in 2017 identified the force needed to improve its services to vulnerable people, particularly domestic abuse victims, when officers weren’t able to attend or when attendance was delayed. This included re-assessing the risks victims face, so safeguarding support could be prioritised.
We are pleased to report that this area for improvement has been addressed by the force. All deployments are now monitored, and a daily performance report provides updates on incidents. Response times to immediate and priority incidents are monitored by the force incident manager. There is an effective triage process to reassess the risks to victims so that appropriate safeguarding can be put in place.
The force has a good understanding of the nature and scale of vulnerability caused by mental ill health, developed with partner organisations. The force and its partner bodies work together to identify and intervene early in times of crisis. Over the last 12 months the number of people detained in custody under section 136 of the Mental Health Act has reduced considerably.
In partnership with the mental health trust, the force has an on-street mental health triage scheme in the north of the county. Officers work alongside a mental health professional and respond to people suffering an acute mental health episode.
Triage is not available 24/7. But the force has identified when it is most needed: between 4.00pm and 2.00am. Outside these hours, officers can contact mental health practitioners for advice over the phone.
There is no on-street mental health triage in the south of the county. However the Staffordshire police, fire and crime commissioner has secured funding and aims to commission services in the south.
The force has appointed a PCSO as a dedicated early intervention officer in each local policing area. These staff have received enhanced training and co-ordinate a multi-agency response to support people who make repeat calls – many have mental health problems.
The force effectively protects victims of domestic abuse and prioritises attendance at these incidents. In the 12 months to 31 March 2019, officers attended 80 percent of domestic abuse incidents as an emergency or priority call.
The force responds to less than 6 percent of domestic abuse cases by telephone.
It is one of five forces in England and Wales taking part in a pilot to trial telephone-based first responses to domestic abuse cases where an immediate or priority response isn’t required.
The pilot isn’t meant to replace officers being sent out, or to resolve calls. The force will still send out officers when required, at a timescale reflecting the risk of threat and harm. The pilot is currently being evaluated.
In all incidents involving domestic abuse, officers use a standardised risk assessment tool – the domestic abuse incident log (DIAL) – to assess and record risk. This includes recording details of children who live in the household. Officers and staff clearly understand their responsibility to identify children and make referrals about them to other agencies for assessment and support.
Every day, officers and staff working in the multi-agency safeguarding hub (MASH) review all high-risk and any standard risk domestic abuse incidents escalated by harm reduction hubs, and put urgent safeguarding actions in place.
Staffordshire Police has one MASH for the county. The force plays a leading role in the MASH. It works with a range of partner bodies, including education, probation, health and children’s services to share information and ensure safeguarding arrangements are there for vulnerable people.
The force doesn’t comply with the requirements of Operation Encompass. That operation requires that schools be told before 9.00am when a child or young person has been involved or exposed to a domestic abuse incident the previous evening. However, the force has found a technical solution. Its new NICHE records management system (which will be implemented in April 2020) will automatically notify schools.
We reported in 2017 that the force needed to improve its understanding of a number of falling performance indicators. These included arrest and charging rates for domestic abuse cases, and the high proportion of cases categorised as ‘evidential difficulties’.
The force has made a considerable effort to understand the issues and completed an internal audit of 100 cases. However, current systems don’t allow it to effectively single out the data needed to make an accurate assessment. Its new NICHE system will allow the force to find and analyse data more accurately.
Although this area for improvement is now closed, we will review this aspect of force performance in the future.
Supporting vulnerable victims
The force has effective, well-developed relationships with outside partner organisations like the NHS trust and local authorities. These help it support vulnerable people and address victims’ needs. The force has established processes enabling it to analyse data and exchange information about vulnerable people with other safeguarding organisations.
The force exchanges information through different contact points including the knowledge hub, MASH, the mental health triage, and harm reduction hubs based in local policing teams.
Neighbourhood teams are involved in the ongoing safeguarding of vulnerable victims. This includes children at risk of sexual exploitation, people with poor mental health and repeat victims of domestic abuse.
Regular meetings, led by the local policing commander, examine crime and ASB in the area. In the meetings they also cover people missing from home and cases where intervention is needed to protect a child. These meetings ensure the force uses appropriate tactics and the right interventions.
Multi-agency risk assessment conference (MARAC) processes in Staffordshire are effective. All high-risk domestic abuse cases are referred to the MARAC. The force produces plans to support victims with other agencies.
Over the next 12 months the force will be restructuring MARAC arrangements from one central meeting to one held in each local policing area. This will allow relevant local service providers to attend and work more closely with the harm reduction hubs, co-ordinating actions to protect high-risk victims. The force piloted this approach in two areas (Tamworth and Newcastle). The first evaluations have been positive.
In cases where prosecution is not possible or practical, Staffordshire Police makes appropriate use of legal powers to protect victims of domestic abuse. This includes domestic violence prevention notices (DVPNs) and orders (DVPOs).
Each DVPO is included on the daily briefing so frontline officers and staff can actively manage the order and enforce breaches when appropriate. In the 12 months to 31 March 2019, the force applied for 168 DVPOs. Of these, 159 were authorised, and offenders breached 46. In the same period, 201 applications for DVPNs were made, 196 were authorised and 6 were breached.
The force has a clear commitment to the Domestic Violence Disclosure Scheme, sometimes called Clare’s Law.
It uses the legislation well to protect potential victims of domestic abuse. Force data shows the number of ‘right to know’ and ‘right to ask’ applications are increasing.
In the 12 months to 31 March 2019, there were 122 applications to the ‘right to know’ scheme and the force made 96 disclosures. There were also 133 applications to the ‘right to ask’ scheme and the force made 53 disclosures.
The force has clear processes to manage pre-charge bail in domestic abuse cases, and safeguard victims. Custody sergeants have been trained in new bail legislation. Before offenders are released from custody, the force reviews the risks presented by them and safeguarding is put in place for the victim.
The force regularly seeks and uses feedback from vulnerable victims and other users to improve its services. It carries out surveys of domestic abuse victims, including whether the victim supports a prosecution.
However, the force has found the current survey only gives an indication of victim satisfaction – and limited details of their experience. To change this, the force will develop a survey similar to Merseyside Police’s. It hopes this will provide more detail and so improve its understanding.
To complement surveys, the force seeks feedback from victims of domestic abuse through partner organisations. It has used this feedback to review and adjust the services it provides. For example, the force, with partner organisations, is in the process of introducing a domestic abuse perpetrator programme. It developed this following victim feedback that some people didn’t want to end their relationship. They wanted the perpetrator to change their behaviour.
In our 2017 effectiveness report, we said the force should ensure that risks posed by registered sex offenders are managed effectively. The force has addressed this and now uses a risk-based approach to prioritise any backlog of visits or assessments.
This has been effective in reducing build-ups and ensures offenders who present the highest level of risk get appropriate supervision. At the time of our inspection we found minimal delays in assessments and visits. The force does monthly workload reviews. These include information on outstanding visits and assessments. All visits to offenders are unannounced unless three consecutive attempts have been unsuccessful. This means offenders have less opportunity to hide incriminating items or behaviour.
Officers and staff from the sexual offender management unit (SOMU) work flexibly across relevant locations to increase their understanding of local issues. Low, medium and some high-risk cases are the subject of joint visits by SOMU and trained neighbourhood staff. This improves the exchange of knowledge and intelligence between teams and means offenders are managed more effectively.
The force makes good use of additional or ancillary powers, such as sexual harm prevention orders (SHPOs). In the 12 months to the end of March 2019, the force issued 86 SHPOs. There were 21 recorded breaches.
The force’s approach to identifying people who share indecent images of children online is effective. It takes a proactive approach to reducing this threat. The specialist child protection and exploitation team has the capacity and capability to proactively identify and deal with offenders who share indecent images of children.
During our inspection we found there was a backlog of 93 cases awaiting further investigation. However, we found sufficient measures to mitigate risk and the backlog was being managed effectively.Summary for question 3
How effective is the force at tackling serious and organised crime?
This question was not subject to detailed inspection in 2018/19, and our judgment from the 2017 effectiveness inspection has been carried over.
How effective are the force’s specialist capabilities?
Understanding the threat and responding to it
The force has an adequate understanding of the potential harm facing the public. Its APSTRA conforms to the requirements of the code and the College of Policing guidance. The APSTRA is published annually and is accompanied by a register of risks and other observations. The designated chief officer reviews the register frequently to maintain the right levels of armed capability and capacity.
Last year we identified one area where the force’s APSTRA could be improved. It did not include details of how rapidly its armed response vehicles (ARVs) respond to incidents. This is important to determine whether the force has enough armed officers to meet operational demands.
The most recent APSTRA still does not include this detail, although we are aware work is currently going on to include it. This work is expected to be completed and included within the APSTRA shortly. The force should ensure this is the case and we will be monitoring this closely.
All armed officers in England and Wales are trained to national standards. There are different standards for each role that armed officers perform. Most armed incidents in Staffordshire are attended by officers trained to an ARV standard. However, incidents sometimes occur that require the skills and specialist capabilities of more highly trained officers.
We found that Staffordshire Police has limited access to specialist firearms capabilities. This reduces its ability to manage incidents that require additional skills. It means that ARV officers sometimes have to attend and resolve incidents to reduce risks and protect the public without the full capacity and capability to do so safely. For high-risk and complex armed incidents to be resolved safely, it is important that the skills and capabilities of officers match the threats they face. Staffordshire Police recognises the limitations of its current specialist firearms provision. The force is considering how it can improve access to specialist capabilities, whether by increasing the skills of existing officers, or providing this capability in collaboration with other forces in the region. Staffordshire Police is exploring the available options so that it can be assured of access to appropriately trained and equipped officers. The force should resolve this situation as a matter of urgency.
Working with others
It is important that effective joint working arrangements are in place between neighbouring forces. Armed criminals and terrorists have no respect for county boundaries. Therefore, armed officers must be prepared to deploy flexibly in the knowledge that they can work seamlessly with officers in other forces. It is also important that any one force can call on support from surrounding forces in times of heightened threat.
Staffordshire Police provides standalone arrangements. We are, however, satisfied the force continues to work closely with other forces in the region to minimise the risk of developing isolated practices and procedures.
We also examined how well prepared forces are to respond to threats and risks. Armed officers in Staffordshire Police are trained in tactics that take account of the types of recent terrorist attacks. Also, Staffordshire Police has an important role in designing training exercises with other organisations that simulate these types of attack. We found that these training exercises are reviewed carefully so that learning points are identified, and improvements are made for the future.
As well as debriefing training exercises, we also found that Staffordshire Police reviews the outcome of all firearms incidents that officers attend. This helps ensure that best practice or areas for improvement are identified. We found that this knowledge is used to improve training and operational procedures.Summary for question 5