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The Little Book of Health and Safety Horrors Part 16: Recycling, refuse collection, road traffic

RECYCLING

Gas cylinder explosion death

In June 2009 Tony Johnson was working at Walter Heselwood Ltd’s site in Sheffield. A pressurised gas cylinder was put through a shearing machine. It exploded and a large section struck Mr Johnson on the head. He suffered fatal injuries.  The company had no effective health and safety management system in place. It had failed to adequately assess the risks involved with processing different types of scrap material. It had also failed to put in place a range of measures to reduce risks. A spokesperson for the HSE is reported to have commented after the case that companies processing different materials should have good documented systems to ensure that materials such as pressurised cylinders are sorted and dealt with correctly.

Serious ash burns

In December 2009 an agency worker was cleaning ash from a filtration hopper at a Veolia Environmental Services site in Deptford. He prodded the ash with a rod in an attempt to clear a blockage. The ash fell onto him and he suffered 17 per cent burns to his body. He was hospitalised for a month. The worker, who wishes to remain anonymous, was from Eastern Europe. He spoke little English and had not been properly instructed on working practices at the site. Veolia had not followed its own policies and procedures for the management of dangerous tasks. This put a vulnerable worker at risk by failing to provide him with adequate information or supervision.

 

Collapse of waste material: worker asphyxiated

In August 2014 Neville Watson, an employee of New Earth Solutions Group Ltd, was driving a loading shovel near a pile of waste material which was eight metres high. He had connected a shredder to the vehicle. The pile collapsed on him and he died from asphyxiation. The company had failed to undertake and prepare risk assessments or safe systems of work for the creation and management of stockpiles of waste. It had also failed to provide adequate training. An HSE inspector commented after the case that the company had failed to ensure that the deceased was supervised by a worker trained in the task he was carrying out. He had never previously carried out that task.

Excavator fall death

In July 2012 Lindsay Campbell was working in the bucket of an excavator at South Coast Skips Ltd’s site in Arundel. He was running an electric cable to power a waste screening machine. The bucket was lifted nine metres from the ground when the hydraulic pressure dropped, the bucket tipped forward and Campbell fell nine metres to the concrete floor. He suffered fatal injuries. An HSE inspector is reported to have made the following comments after the case: nobody should ever be lifted in the bucket of an excavator. Neither the bucket nor the excavator have the necessary safety devices nor fail safe devices which would prevent a person falling. The company did not have in place the training and supervision and especially the health and safety culture that ensures that nobody would consider undertaking such an obviously unsafe act such as this.

Dumper truck death

Ben Sewell, an employee of Dittisham Recycling Centre Ltd, was working at its site in Dittisham, South Devon. He was driving a dumper truck to move oversized material. He drove the truck along a dirt track down a steeply sided valley. He was not wearing a seat belt. He was found lying at the side of the track a few metres from the truck. He had suffered fatal injuries.The HSE discovered a series of safety failings with vehicles at the site. Tipping operations were unsafe and some of the roadways were inadequately protected.The deceased had not been adequately trained.

An HSE inspector commented that dumper trucks are inherently unstable and dangerous machines to operate. The company had not enforced the necessary rules to make sure that they were driven safely, including the full and proper use of seat lap belts.

Reversing vehicle death

In April 2016 a 76-year old female employee of  Savanna Rags International Ltd, a clothing and textile recycling company, was walking from a weighbridge to a smoking shelter in the company’s yard during her afternoon break. She was struck by the rear of a reversing delivery vehicle and suffered fatal injuries. The company had failed to make a suitable and sufficient assessment of risks arising from vehicle movement. It was custom and practice for vehicles to reverse from the weighbridge. This was used by workers to access the company’s factory. There were no measures in place to adequately segregate pedestrians from moving vehicles and no safe system of work in place to ensure that vehicles could manoeuvre safely

 

REFUSE COLLECTION

Crushing death

In May 2014 a refuse collection vehicle was being refurbished at John Fowler and Son (Blacksmiths and Welders) Ltd’s site in Chorley. An operative using the controls within the cab of the vehicle closed the tailgate on a worker. He suffered fatal crushing injuries. The vehicle was supplied with controls for raising and lowering the tailgate which were designed so that a one-metre gap should be left when it was closed. The safety limit switch was jammed, so that the tailgate could be completely closed. There had been a poor system of work and an inadequate risk assessment. Veolia ES Sheffield Ltd had failed in its inspection regime, which would have identified and corrected the fault with the safety limit switch.

 

ROAD TRAFFIC

Collision with traffic signs: multiple injuries

Carillon AM Government Ltd was responsible for placing a series of road signs warning of the closure of a junction on the A12 near Saxmundham. The roadworks ahead signs should have been placed at intervals of 800, 400 and 200 metres ahead of the closure. In fact, the first indication was less than 200 metres before the road closure on the 50 mph stretch of the road. Glyn Turner was driving his motorcycle south along the road when he collided with the traffic signs. He suffered multiple injuries and is now paralysed. A spokesperson for the HSE is reported to have commented after the case that roadworks provide increased risk in what is already a very hazardous environment. Anyone doing work on our roads must take great care to warn road users in good time what to expect on the road ahead.

 

Death on pedestrian crossing

In May 2009 Mary Whiting, a passenger at Luton Airport, was crushed by a 26 tonne milk lorry as she used a pedestrian crossing between a terminal building and a passenger drop-off zone. The crossing, designed by C-T Aviation Solutions Ltd and situated on private land leased by the airport operators, was badly positioned and did not conform to regulations which apply to public roads. London Luton Airport Operations Limited was responsible for maintaining the roads, parking enforcement and signage at the airport. The company was served with an improvement notice after the death of Mrs Whiting, which required chamges to be made related to the safety of pedestrians and vehicles.


The Little Book of Health and Safety Horrors Part 15: mines, poisoning, police, prisons

MINES

 

Death of coal miner in roof fall

In September 2011 Gerry Gibson was working at Kellingley colliery. He was killed when 15 tonnes of rock, which formed a section of roof, collapsed as a powered roof support was being operated. Six days previously, a similar roof fall had occurred. UK Coal Managers (now Juniper (No3 Ltd) had been aware of the earlier fall. No investigation had been carried out and insufficient precautions had been taken to prevent a recurrence. The company had not improved its system of monitoring roof supports to ensure that warning signs of ground movement would be quickly picked up.

Costs were not awarded so as not to jeopardise potential payments to the Miners’ Pensioners’ coal allowance scheme, a major creditor of UK Coal. An HSE inspector commented after the case that the HSE had prosecuted despite the company being in administration. There was significant public interest in a very serious offence and the company’s standard of managing health and safety was far below what was required.

Deaths of mineworkers

In June 2006 Trevor Steeples was killed at Daw Mill colliery near Coventry, operated by UK Coal Mining, when he was exposed to high levels of methane. In August 2008 Paul Hunt was killed at the same colliery when he fell from an inadequately maintained underground transporter into the path of a moving train. In January 2007 Anthony Garrigan was killed at the same colliery as he worked with colleagues to install rockbolts to keep a tunnel support wall in position. he was crushed to death when more than 100 tonnes of inadequately supported coal and stone fell on him. The tunnel had previously collapsed and UK Coal should have supplied a safer system of support. In November 2007 Paul Milner died at Welback colliery in Nottinghamshire. He was installing extra roof supports in order to salvage equipment from a coal face which had ceased production. Milner was crushed to death under 90 tonnes of rock when the roof collapsed. A suitable code of practice had been agreed to provide a safe system of work. This code was not properly implemented by UK Coal.

 

POISONING

In 2008 B was employed as a storeman by a Scottish local authority. He was responsible for supplying gardeners with weedkiller containing paraquat. The weedkiller was stored in a locked container. B was a keyholder. He put some weedkiller into mineral water bottles to take home for use in his own garden. On the way home he stopped at a club. The bag containing the bottles became mixed up with bags belonging to F. F drank the paraquat and died.

 

 

 

 

POLICE

Firearms death

In June 2008 PC Ian Terry was engaged in a firearms training session at a disused warehouse in Manchester. He was role playing an armed criminal. The training session involved practising to apprehend armed criminals from a car.  Terry was killed by a colleague using a shotgun. He suffered fatal chest injuries. The officer responsible for the course, referred to as F to protect his identity, ran a course with a lethal combination of factors including the use of live ammunition in an aggressive scenario.

 

PRISONS

Prison suicide: Crown Censure

The National Offender Management Service (NOMS) has been subjected to a formal Crown Censure by the Health and Safety Executive, following the death of a prisoner. In September 2006 Daniel Rooney was a prisoner at HMP Bullingdon. He was observed in the act of attempting to hang himself. He was identifed as being at risk of self-harm and was moved to a safer cell. Later that day, Rooney hanged himself with a ligature made from his bedding and suspended from a shower rail support bracket. The bracket should not have been strong enough to support the ligature. Examination of the safer cell found a number of points where ligatures could be attached.

The provisions of the Health and Safety at Work etc Act 1974 apply to Crown bodies, but Crown immunity means that such bodies are excluded from statutory enforcement, including prosecution and penalties.


The Little Book of Health and Safety Horrors Part 14: Lawnmowers, Lifts and Local authorities

LAWNMOWERS

Serious hand injury

In March 2014 an employee of  New Charter Housing Trust was using a ride-on mower with a grass box attached. The chute to the grass box became blocked because the grass was long and wet. The worker reached into the chute to clear a blockage, His hand came into contact with a rotating metal fan. He suffered serious injuries. He had not received training on how to use the mower and did not know that the fan continued to rotate for 30 seconds after the machine’s engine was switched off.

Strimmer chain death

In February 2010 Tony Robinson, a self-employed contractor, was using a chainsaw to cut back overgrown vegetation at Ramsden Dock in Barrow. He had been hired to help clear undergrowth at the site during the construction of the new Waterfront business park. A chain attachment had been fitted to a strimmer so that it could be used for more heavy duty work. The chain, spinning at 300 mph, became detached and struck him on the back of the neck. He suffered fatal injuries. The HSE investigation of the incident found that the work had not been planned or carried out safely. ThreeShires Ltd had not properly considered the risks of using the attachment and had allowed the deceased to work close to where the strimmer was being operated.

The HSE issued a Safety Alert following the incident, which warned that there was a risk of death or serious injury from the use of the chain attachment. It served a prohibition notice on the sole importer of the attachments into the UK. The attachment is now banned throughout Europe.

Hand caught in blades

In August 2011 a maintenance worker, who wishes to remain anonymous, employed by Clear Channel UK Ltd, an outdoor advertising company, was working at a billboard site in Bath Road, Bristol. He tried to clear a blockage from a petrol-powered mower which he was operating. He thought that the mower had been turned off. As he tried to remove the blockage, the mower’s blade started to rotate. His thumb was almost severed and his fingers were severely injured. A 14 hour surgical procedure was needed to reattach his thumb and repair the damaged fingers. A safety feature which cuts out the engine of the mower and stops the blades rotating was not working properly. Clear Channel did not have an effective reporting and maintenance system for reporting faults in equipment. It had allowed a lawnmower which was not in good repair or efficient working order to be used by its employees.

 

LIFTS

Lift crushing death: stately home operator fined

Arthur Mellar, a butler, was killed in July 2014 when a luggage lift descended on him. The luggage lift was being used to lift guests’ bags from the ground to the second floor of the house of the Burghley House stately home in Stamford, operated by Burghley House Preservation Trust Ltd.  A bag became jammed and the lift stopped. Mellar tried to free the bag when the lift descended and crushed him, causing fatal injuries.The lift had not been fitted with a slack rope detector. An assessment of the lift would have shown that the lift should have been thoroughly examined and tested. A competent lift engineer would have identified defects with the lift.

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Lift shaft fall death

In January 2011 work was being carried out on the decommissioning of a lift shaft in a building being converted into flats in the Victoria area of London. The chain supporting the lift car broke while two men were working on it. The car fell six storeys to the bottom of the shaft. One worker was wearing a safety harness and was seriously injured. The other was not wearing a safety harness and was killed. Planning and management of the project was inadequate in relation to work at height and the lift decommissioning work.

Lift shaft fall death

Craig Jones, a resident of Marsden House in Bolton, was trapped in a lift at the premises and was unable to raise the alarm. He attempted to self-rescue by forcing the lift doors open and sliding out onto the floor below. He slipped and fell five storeys down the lift shaft, suffering fatal injuries.Warwick Estates Property Management Ltd, as management company of the building, had failed to take suitable and sufficient steps to prevent the deceased from self-rescuing. An HSE inspector commented after the case that the problems with the lift were well-known. Those who manage lifts have a responsibility to ensure that if people are trapped they have a way to raise the alarm and are not in a position to try to rescue themselves.

Lift shaft fall: serious injuries

In March 2012 Terry Moore, an experienced lift engineer, was working on a lift shaft at Rosie Maternity Hospital in Cambridge. He was working on the top floor of a three-storey annex which was under construction. He fell into the shaft and fell nine metres to the foot of the shaft and suffered multiple fractures. The guard rails placed across the entrance to the shaft were 908 mm high. This did not meet the regulatory requirement that barriers must be at least 950mm above the edge from which a person is liable to fall. It could not be proved that the height discrepancy was a causative factor in the fall, but it was a serious safety failing.

 

LOCAL AUTHORITIES

Council road sweeper collision: death of motorcyclist

In September 2010  a council road sweeper lorry was cleaning a dual-lane slip road. Derek McCulloch, a motorcyclist, drove into the back of the sweeper. He suffered fatal injuries. The sweeper was travelling at 4 mph and there was a bend in the road which probably prevented the deceased from seeing the vehicle. The sweeper had flashing beacons and a large arrow on its back indicating that vehicles should pass. There should have been significantly more controls in place for sweeping a road of this type. There was no road-specific risk assessment in place but a generic one covering all road sweeping carried out by the council.

Dishwasher fluid

In May 2011 East Sussex County Council was fined following an incident in which a man died and five others were seriously injured when they drank dishwasher fluid.

A group of persons from the St Nicholas Centre in Lewes, a day care facility for adults with learning difficulties run by the council, were taken to Plumpton Agricultural College to use the sports facilities.

They were given a drink which had been prepared at the day centre and brought to the sports hall. This should have been orange squash but actually contained sodium hydroxide, a cleaning chemical.

The six who drank the fluid started vomiting blood and fitting. Colin Woods, who had Down’s Syndrome, died 17 months after drinking the chemical. Five others suffered burns to their mouths, throats and stomachs. Most had to undergo repeated surgery.

Three will never be able to swallow normally again.

East Sussex County Council had failed to ensure that the fluid was safely stored away. It was left on the side in an unlocked kitchen. The chemical was marked as corrosive but it was similar in appearance to that of orange squash.

Surviving service users at the day centre were too traumatised by the incident to be interviewed about who had mixed the drink.

A spokesperson for the HSE is reported to have made the following comments:

  • This was one of the worst incidents which he had investigated in all his time as a health and safety inspector.
  • It was impossible to adequately imagine the suffering and terror that the victims must have felt as the tragedy unfolded.
  • The terrible thing was that the incident and its horrific consequences could so easily have been prevented by simply locking away the container of sodium hydroxide.
  • Mr Woods had died a slow, painful and unnecessary death and others had suffered terrible and preventable injuries, some painful and permanent, because the council had failed in its responsibility to take proper care of them. It was imperative that authorities properly protected vulnerable people in their care.

 

Mobility scooter death from reversing lorry

In July 2008 Derrick Baines, aged 76, was returning to his home in Langold, Nottinghamshire, on his mobility scooter when he was struck by a reversing bin lorry. He suffered fatal multiple injuries. The lorry was on a missed bin collection. It had a one-man crew. The fatal incident could have been prevented if there had been a reversing assistant at the back of the vehicle. The driver became aware that something was wrong when he noticed shopping spilled in the road behind his vehicle.

An HSE inspector commented after the case that if the local authority had staffed the vehicle appropriately, Baines would probably still be alive today. Very large vehicles such as the one involved in the incident have a number of blind spots. It was impractical to expect a lone driver to reverse safely without the aid of a colleague walking behind to check that the route was clear. These vehicles are fitted with flashing lights and a reversing warning system, but the council needed to take into consideration that the system was not adequate. Another worker should have been present and could have prevented this needless loss of life.


The Little Book of Health and Safety Horrors Part 13: Industry

INDUSTRY

Foundry death from grinder

Stuart Stead, an employee of  H.I. Quality Steel Castings Ltd, was using a hand-held grinder to work on a casting at the company’s foundry in Doncaster. The disc fitted to the machine exploded and sent fragments across his workbay. A shard struck him in the mouth. He suffered fatal injuries. The disc was nine inches in diameter despite the fact that the grinder had a maximum tool diameter of two inches unless guarded. It was attached to the grinder by using a non-proprietary tool. The disk was rated for 6650 rpm but was running at 12,000 rpm. The grinder had no guard. The excessive speed of the grinder, coupled with the added load caused by the non-standard attachment, had put stresses on the disc beyond its capacity.

The HSE’s investigation had discovered a number of previous incidents when discs had flown off grinders. None of these had been mentioned in monthly minutes of the company’s health and safety meetings. Despite some initial training in abrasive wheels, employees did not understand rotation speeds of machines versus discs and had free access to a number of grinders and discs. This contributed to the prevalence of unsafe combinations.

Severed hand

In March 2016 a worker at Pipework Engineering Services Ltd was operating a foot pedal saw. His hand came into contact with the saw’s rotating blade. He suffered a severed hand and wrist which required surgical intervention to reattach. The company had failed to install the machine correctly and in accordance with the manufacturer’s instructions. This meant that it could be operated from a position which took the operator very close to the blade.

 

Death of steelworker in blast furnace

In April 2006 Kevin Downey was working a night shift at Tata Steel’s Port Talbot plant. He went to the cast house at the site to inspect the slag pool of a blast furnace which was due to close for maintenance. He fell into the open section of a channel containing slag at 1500 degrees Celsius. The company had a reporting system which showed a significant number of near misses where steam had led to dangerous situations.It was common practice to operate the furnace with channels left uncovered without taking additional precautions to prevent workers from falling in.

 

Severe head injuries in pneumatic metal press

In August 2011 Wayne Hill, a maintenance engineer, was working at H & E Knowles (Lye) Limited’s site. He was repairing a pneumatic metal press when it unexpectedly started working and crushed his head. He suffered severe head injuries including a fractured nose and jaw and lacerations. He needed extensive reconstructive surgery. The press takes a sheet of metal and forms it into a wheelbarrow body. It should not have been able to operate if the door was open. The machine had a faulty interlocking guard which meant that it did not detect that the door was open. The machine had been designed and built by the company 25 years ago. There were no technical drawings or other documentation and an adequate risk assessment had never been carried out. The machine broke down regularly and maintenance staff repaired it with no instructions.

 

Factory death: overturned vehicle

In April 2008 Martin McMenemy, an employee of O. Turner Insulation Ltd and Clegg Food Projects Ltd, was working on the construction of a food processing plant in Leicester. He was driving a scissor lift to install wall and ceiling panels. The vehicle overturned when it went into an uncovered pit. McMenemy suffered fatal head injuries. O.Turner and Clegg Food Projects Ltd, the principal contractor for the project, had failed to take precautions to cover the hole. The incident could have been prevented if the pit had been covered with a metal plate or cordoned off.

 

Flammable solvent fire: worker severely burned

In November 2014 an employee of HMG Paints Ltd  was using a highly flammable solvent to clean the floor of a spray booth at the company’s premises in Manchester. He complained about the difficulty of removing dried paint and was allowed to buy an industrial floor scrubber to carry out the work. The electric motor of the scrubber ignited a cloud of vapour which had built up in the booth. The worker suffered 26 per cent burns.The planning for cleaning floors with solvent had failed to recognise the hazard and level of risk associated with the use of highly flammable solvents to clean floors. The worker who was injured had not been trained to clean floors and was not adequately supervised.

 

Distillery fire: employee severely burned

In November 2012 ethyl acetate, a highly flammable liquid, was being moved from a bulk storage tank to an intermediate container at Alcohol Ltd’s warehouse.The liquid ignited. An employee was engulfed in flames and suffered twenty per cent burns to his head, neck and hands. The fire destroyed the warehouse and damaged nearby cars and houses.The HSE investigation found that the most likely cause of the fire was a discharge of static electricity generated by the transfer of the liquid.There was poor management of pipework and associated valves and a failure to completely inspect the equipment or monitor the systems of work.

 

Severed arm in conveyor belt

An employee of the company was making adjustments to a misaligned conveyor belt at  Concrete Fabrications Ltd’s site in Henbury, Bristol. He had to adjust tensioning rods which were inside the machine’s guards. He tried, with a hammer, to remove material which had built up on a rod. The hammer was dragged into the rotating machinery with his arm. The arm was torn off  between the shoulder and the elbow.The company should have had adequate guards on dangerous parts of the machinery. Clear procedures should exist regarding maintenance and adjustments of machinery and arrangements should be in place to ensure that machinery is not run without the necessary guarding in place, and that clear isolation and lock off procedures exist. A sufficient risk assessment would have identified the risks associated with tracking conveyor belts and identified appropriate control measures.

 

Death of worker in crude oil fire

In June 2010 a fire broke out at Total UK Ltd’s Lindsey Oil Refinery in Immingham. The fire was caused by an uncontrolled release of crude oil. Robert Greenacre, a contracted fitter, was working below a distillation column which contained hot crude oil. They opened equipment, which released crude oil. It ignited and Greenacre was killed.

Operators of major accident hazard establishments must have in place a functioning system of risk assessment for all work where hazardous substances could be released. Operators should always try to eliminate risk through hazard avoidance. In many circumstances this can be achieved by carrying out the work during shut-down conditions. Where this is not practicable, the highest achievable levels of isolation to industry standards are required.If Total had followed well established principles of risk assessment the major fire and the death could have been avoided.

Oil burns

Harvey Hopwood, employed by PAS (Grantham) Ltd  as health and safety manager, was overseeing the jet washing of an oil storage tank at the company’s site in Easton, Lincolnshire.He climbed between the guard rails of a gantry at the top of the tank to check progress. He knocked a pipe which came away and released oil with a temperature of more than 160 degrees Celsius. The oil spread over his upper body, causing 10 per cent burns.The company had failed to carry out a risk assessment for the cleaning operation. It had done the work first and written the risk assessment retrospectively.

 

Multiple burn injuries from casting machine

In May 2009 Stephen Bond-Lewis, a foundryman employed by Special Metals Wiggin Ltd, was removing waste material from a metal casting machine at the company’s premises in Hereford.Part of the machine which weighed 964 kg and had a temperature of between 100 and 250 degrees centigrade, became detached, fell forward and pinned Bond-Lewis against a storage bin. He suffered severe burns to 25 per cent of his body and crush injuries.The method used to remove ingot moulds from the casting machine was unsafe. It involved the use of overhead cranes to pull the moulds free. This damaged the bolts and their fixing points. The fixing bolts on a large number of casting machines were in poor repair. This had not been noticed or put right. This, together with the company’s failure to have a proper maintenance programme in place, resulted in the mechanical failure of the machine.

 

Explosion injuries: both legs amputated

In December 2011 Clive Dainty, an employee of Filtration Service Engineering Ltd, was pressure testing a vessel. The vessel exploded and struck Dainty. He had to have both legs amputated, suffered head injuries and now has restricted movement in his arms.The vessel was being tested because of concerns about the quality of the welding. The company decided to use compressed air instead of water. The pressure built up to such an extent that the vessel exploded. An assessment of the risks involved in pneumatic pressure testing should have identified that air was not a suitable testing medium. The test could have been carried out by simply filling the vessel with water.

 

Chemical burns

Two employees of PSL Worldwide Projects Ltd were cleaning a pipe system at its site in Cramlington. They were using sodium hydroxide granules through a hose as a cleaning agent. The sodium hydroxide reacted with water in the system. This caused the liquid to heat up and build pressure in the hose. It detached and sprayed the workers with the solution. One worker suffered life-threatening burns. The other sustained severe burns. The work had not been adequately assessed by the company. The equipment provided was not suitable and the company failed to provide adequate personal protective equipment for the work.

Caustic burns

Mark Mclean, an employee of Princes Ltd, was working at the company’s site in Bradford in July 2013. A hose carrying a caustic substance spilt. He was sprayed with caustic solution and suffered chemical burns to the left side of his face and arms and temporary blindness. There was no evidence that the company had taken preventative measures.

Incidents at lead smelting works

In August 2009 a worker at a lead smelting works was transporting molten lead slag with a temperature of more than 800 degrees Celsius on a forklift truck. The container holding the molten metal fell off the truck. The liquid was spilt on the ground and ran into a drain.

When it came into contact with water, the liquid lead exploded and blew heavy drain covers several metres into the air. The employee fell onto the molten metal. He suffered severe burns to his face, arms, chest, back and left foot.

In May 2010 an employee of Key Engineering was investigating a fault on an overhead travelling crane. He was positioned on the crane gantry. As the crane ran along the tracks, he rested his right arm on top of the crane’s control panel. When it neared the end of the bay, the clearance between the control panel and a roof beam narrowed to a few millimetres. His arm was trapped and he suffered severe crush injuries.

 

Molten steel burns

In April 2013 Kevin Watts, a trainee crane driver employed by Tata Steel Ltd, and two workmates, escaped from the top of a crane when a ladle containing 300 tonnes of molten metal dislodged and spilled. They had been operating an electric overhead crane which carried the ladle. One of the hooks on the ladle was not working properly. The metal caught fire and reached the cab of the crane. Watts suffered severe burns on his head and forearms. His colleagues suffered less serious burns. The crane’s camera system had not been operating properly for some time. This had been reported on near-miss and pre-use checks but had not been remedied. Lighting, which employees stated was poor, cut out completely during the incident. Training documents were ambiguous and instructions had not been communicated

.An HSE inspector made the following comments after the case:

Given the potential consequences of a ladle of holding 300 tonnes of molten metal spilling its load onto the floor, control measures should be watertight. The incident could have been avoided if safety measures, which were introduced after the incident, had been in place at the time.

Scalding injuries

In October 2011 two employees of Meadow Foods Ltd were cleaning a tank at the company’s site in Chester. The cleaning process involved a complex series of valve changes. There were no written instructions or diagrams on how this should be done. One of the employees opened a valve. Compressed air which had built up was released, forcing out hot water with a temperature of 70 degrees Celsius. Both workers were severely scalded. The company had carried out a risk assessment for the cleaning process but had failed to identify basic risks, for example burns from hot water.

Drum explosion: life-threatening injuries

In August 2012 Andrew Foster, an employee of  Highway Care Ltd, was using a plasma cutter to cut up a drum which had previously contained a flammable substance. The drum exploded in his face, causing severe and complex head and brain injuries. He has permanently lost vision in his right eye and has very limited vision in his left eye. The company had failed to ensure the health and safety of its employees. An HSE inspector commented after the case that if a welding torch or plasma cutter is used on a tank or drum which has contained a flammable substance, it can explode. It only takes a small amount of residue to create a potentially flammable atmosphere.

Fall of worker into pulping machine

In July 2014 a worker was carrying out maintenance work at a paper mill in Manchester. He was tightening coupling bolts with a torque wrench. The wrench slipped and the worker fell backwards from an unprotected edge into a paper pulping machine. He managed to swim in darkness to a ledge at the side of the pulper. He suffered fractures to his left foot. Valmet Ltd, the company which provided all the mill’s machinery, had carried out a risk assessment but did not identify the fall from height risk. An HSE inspector commented after the case that it was pure luck that the pulper blades were not working when the worker fell.

Leg amputation

In January 2014 Jodie Cormack, a short-term contract worker, climbed onto a production line conveyor belt to clear potatoes into an auger in-feed for soup production. Operators used a ladder to access the conveyor belt and used a squeegee to push vegetables into the auger. Cormack slipped into the auger and suffered an amputated left leg. Baxters Food Group had failed to make a suitable and sufficient assessment of the risks to which workers were exposed when they were clearing vegetables from the conveyor belt. It had also failed to provide and maintain a safe system of work. The company had failed to provide necessary information, instruction, training and supervision to ensure the health and safety of employees.

Industrial blender death

In January 2011 George Major, an employee of Rettenmaier UK Manufacturing Ltd, was working at its site in Mansfield. He was helping to clear a blockage from an industrial blender in which shredded paper was mixed with bitumen and oil before being pressed into pellets for reinforcing asphalt mixes for use in road surfaces. Major was dragged into the blender and suffered fatal injuries. The guard had been removed from the blender and it had not been isolated and locked off from the electricity supply. The production line at the site was computer controlled with control screens on two floors. There was no control screen on the same floor as the blender. There was no written system of work or instructions for isolation, no manuals or written instructions, no proper training and no risk assessments.

Worker sprayed with molten metal

In March 2012 a furnace operative, who wishes to remain anonymous, was working at Tata Steel UK Ltd’s  plant in Rotherham. A control system fault caused 25 tons of molten metal to spill from a furnace. The worker began to hose the spill with water to cool it, following standard practice. When the water made contact, there was a large explosion and the worker was showered with molten metal. He suffered life-threatening injuries and needed numerous skin grafts and reconstructive surgery. The HSE investigation identified serious safety failings by Tata in recognising and dealing with risks which resulted in workers being exposed to unnecessary danger. The company had no procedures for dealing with spillages of molten metal, no assessment of the dangers and risks and no safe system of work in place. It had become normal practice for workers to hose water onto spills. The water is trapped under the surface of the molten metal and rapidly turns to steam vapour causing a sudden rise in pressure and a massive explosion. This risk is well known within the industry.The company had no procedures for dealing with spillages. Employees used hoses to cool the metal. This was very dangerous but the scale of the risk was not recognised by workers who had received no information or instruction on what to do.

Death from crushing injuries

Christopher Williams, a maintenance supervisor employed by Morgan Technical Ceramics Ltd at its Wrexham premises, was moving a power press which was stored in a shipping container. As he was moving the press, which weighed half a tonne, on a pallet truck, it toppled over and struck him, causing fatal injuries. The lifting operation had been unsafe. The

An HSE inspector is reported to have commented after the case that thirty per cent of fatal accidents in manufacturing in Britain involve the fall of a heavy item. It was important that everyone involved in maintenance understood the risks, and that lifts were properly planned by a competent person.

Severed hand in lathe

In February 2012 Gavin Nobes was working at Marshall Brass’s site in Heckingham, Norfolk. He was polishing a brass clock face bezel on a lathe. The bezel snagged on a polishing wheel and drew his hand and arm into the machine. His left hand was severed and had to be reattached. The polishing lathe was not suitable for polishing the bezel because there was a high risk of snagging. The firm was prosecuted for failing to arrange an alternative method of polishing the bezel or adapting the machine or work system so that the work could be safely done.

Acid burns

In December 2011 three employees of Polimeri Europa UK Ltd were working on a roadway at the company’s site in Southampton. Pipework situated close to them split and sprayed them with sulphuric acid. A jet of sulphuric acid was sent 20 metres high. The workers suffered acid burns to their faces. The company had a plan to inspect its pipework systems in 2008 but initial target dates had been missed. Priority had been given to pipework carrying other hazardous substances. The company had failed to make sure that its pipework, much of it over 50 years old, was in a safe condition. Corrosion had been allowed to take hold of the section of the pipe which carried the acid. The company would have been well aware of the legal requirement to ensure integrity of the sulphuric acid pipework, But it had failed to do so for many years.

Unguarded power hammer: crushed hand

In March 2011 the employee, who wishes to remain anonymous, was using a 10-tonne power hammer at Johnson Mathey plc’s site in Royston, Hertfordshire. He was using the machine to crush waste pieces of metal when he caught his left hand under the automatic hammer. Two of his fingers were severed. The hammer was unguarded. It had regularly been used without a guard.

 

Crane death

In May 2011 Wilfred Williams was carrying out maintenance on an overhead travelling crane at C Brown & Sons (Steel) Ltd’s site in Dudley. He was working six and a half metres from the ground. he stepped from the gantry where he was working, to the rail of an adjacent crane and sat down. The crane was moved by an operator who had not seen him. He was crushed against an upright stanchion and suffered fatal injuries. Williams and a colleague had accessed the cranes via a cherry picker. Williams was not wearing a harness, there was no fall protection, nor a safe system of work at height. No measures had been taken by the company to isolate the other cranes in the bay where work was taking place, nor in the adjacent bay.

 

Severed arm in circular saw

In February 2012 Brian Morris, an employee of Stagecraft Display Ltd, was working at the company’s factory in Powys. He had finished sawing for the day and was cleaning sawdust from below a circular saw. He stopped the machine and reached into the machine as it was still running. The moving blade caught the arm of his jacket, severing his right arm. Although the saw was fitted with an interlock which stopped it when it was accessed, it took more than 30 seconds for it to stop completely. Three months before the incident, a machine maintenance engineer inspected the saw and told a manager that it should be taken out of service or fitted with a brake which would stop it more quickly. An HSE inspector is reported to have commented after the case that saws cause the most injuries in the woodworking industry. Power-operated circular saws are dangerous machines which have caused many serious incidents.

Severed finger in blending machine

In March 2010 an employee of Bee Health Ltd was working at the company’s factory in Bridlington, East Yorkshire. He was using a ribbon blender to mix product ingredients. He did not know that a fixed guard below the machine had been removed with a valve which required a new part. Another employee had taken the valve from the blender to clean it. He found that the valve needed a new part, so he did not reattach it. The blender continued to be used with a plastic bag below it to collect the product. The first employee attempted to make a hole in the plastic bag. His fingers were caught in the rotating blades. He suffered an amputation of the index finger of his right hand and severe cuts and nerve damage to the middle finger.

Manufacturing employment resulted in 21 % of fatalities at work in 2010/11. There were a total of 27 fatal injuries in the manufacturing sector. In the same year, there were 17,599 reported non-fatal injuries and an estimated 27,000 self-reported injuries.

 

Fall into molten metal pit

In May 2010 an employee of Copper Alloys Ltd, who wishes to remain anonymous, was working in the company’s foundry. He was using a long-handled tool to scrape impurities from the top of a freshly poured casting when he tripped and fell into an unfenced gap between the metal mould and the five-feet deep pit in which the mould was sited. The molten metal in the mould had a temperature of more than 900 degrees Celsius. The worker used the tool to try to stop himself falling into the pit. He landed on the edge of the mould. His arm was immersed in the molten metal. His upper legs were burned on the impurities which he had scraped from the mould. The worker suffered severe burns to his arm and upper legs. He needed skin grafts and continues to undergo physiotherapy for restricted movement in his arm and legs. He has been unable to return to work. The HSE investigation concluded that there was no guard railing around the edge of     the mould pit and that Copper Alloys had failed to recognise the risk of workers falling into the pit.

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Chemical burns

In February 2015 Keith Brown, an employee of Poligrat (UK) Ltd, an electropolishing company,  was told to dispose of waste cleaning materials at the company’s site in Aldershot. The disposal method involved pouring caustic granules into an intermediate bulk container (IBC) to neutralise acids in the container.An exothermic reaction caused the container to become unstable. It erupted over Brown. He suffered alkaline burns to his eyes.The activity, and the substances used in it, had not been suitably or sufficiently risk assessed.

An HSE inspector commented after the case that the use of an IBC as a reaction vessel had been wholly inappropriate. IBCs were designed for storage and not as chemical reactors. Other safer and reasonably practicable options were available, for example using a waste management company to remove and safely dispose of the chemicals.

Death in carding machine

In February 2012 Nasir Hussain gained access to a blocked carding machine which formed part of a production line at Felt Supplies Ltd’s site in Dewsbury. He overrode the safety system using a key to unlock one of the production line’s gates. He stood on top of the carding machine to use a metal bar to clear the blockage. The line was still running. His clothing became entangled and he was pulled into the machine. He suffered fatal injuries. The use of a spare key to access running machinery was custom and practice. Despite the HSE issuing a prohibition notice, this unsafe practice was allowed to continue following the fatal accident.

Amputated hand in carding machine

In March 2016 an employee of The Stuffing Plant Ltd, a soft toy filling company, was attempting to clear a blockage in a carding machine. The machine had a flange attachment for connecting pipework to supply loose fibre to a toy filling machine. The flange and pipework were left off to allow the machine to discharge into a wooden enclosure. A spiked roller inside the discharge chute was unguarded and accessible during the machine’s operation. The employee had entered the wooden enclosure and was clearing a blockage from the discharge chute. The spiked roller dragged him into the machine. He suffered severing of most of his fingers and his hand was amputated from the wrist because of the seriousness of his injuries.

Compressed air hose: eye injury

In July 2012 an employee of Faltec Europe Ltd, who does not wish to be identified, was working at the company’s premises on Tyneside. He was carrying out maintenance work on a paint fume filter. He isolated a compressed air hose at its connection point and disconnected it. He did not know that the hose had to be vented before it was disconnected. The hose whipped and struck him in the face, striking his eye and fracturing his cheekbone. He has permanently lost the sight in his right eye. Faltec had failed to provide the worker with adequate information, instruction or training on the equipment which he was using.

Saw blade: serious hand injuries

In February 2012 an employee of Envirowales Ltd, who wishes to remain anonymous, was working at Jamestown Industries’ lead recycling plant in Ebbw Vale. He was operating a saw to cut lengths of lead into smaller, more manageable pieces. The employee tried to dislodge a piece of lead which had become jammed, in the belief that the saw blade was fully retracted and out of reach. His right hand made contact with the blade of the saw, severing his third finger. He also suffered severe injuries to the tendons of his hand. The employee had not been supervised at the time of the incident and there was no experienced operator working with him. Training had been provided but it was not adequate to ensure that all workers understood the risks when the saw was retracted, or the procedure for removing jammed material. Neither company had provided the necessary measures to prevent access to the dangerous parts of the saw. They had also failed to supervise inexperienced employees or to ensure that the injured employee had understood every aspect of the operation.

Furnace valve death

In November 2009 Graham Britten, an employee of AETC Ltd, was carrying out maintenance work in a vacuum casting furnace at the company’s site in Leeds. The main isolation valve closed suddenly and trapped his head, causing fatal injuries. The deceased had gone to a furnace to deal with a fault after the main isolation valve had become jammed. He was inspecting the valve when it closed. AETC did not have an effective isolation procedure for maintenance work on the furnace, had failed to act on repeated recommendations from their health and safety manager and had failed to adequately train and supervise maintenance staff. The lack of a consistent, monitored isolation policy resulted in there being no effective procedures in place to prevent Britten from entering the furnace without first isolating the equipment and releasing stored energy.The furnace control systems, intended to protect operators when carrying out routine cleaning work, were inadequate and exposed workers to unnecessary risk.

Life-threatening crush injuries

A maintenance electrician employed by Jaguar Land Rover Ltd  was working at its site in Solihull. He was investigating a production line stoppage and he approached a gap in the perimeter guarding of a conveyor. He was struck by an empty vehicle body carrier and was dragged through the gap into a restricted processing area. He suffered multiple fractures and lung punctures.The gap was unguarded until HSE enforcement required the provision of

.An HSE inspector is reported to have commented after the hearing that the incident had been entirely preventable. Although the gap in the perimeter guarding was minimally sized to allow empty carriers into the restricted area, it also allowed access to dangerous moving parts within the production process while in itself creating a crush hazard with the moving conveyor

Steelworks death

In April 2008 Kristian Lee Norris was working for Vesuvius UK Ltd at a steelworks in Redcar. He was re-lining a furnace. He was struck on the head by a metal bar which fell from a lift ten metres above him. He suffered fatal injuries. Adequate precautions were not in place to control the risks from falling tools or other materials. These failings were known to Vesuvius and to Tata Steel (the owner of the steelworks) but they allowed work to continue.

 

Unguarded machinery death

In December 2008 John Smith, an employee of Railcare Ltd, was killed when he suffered head injuries while working at an axle lathe with an unguarded chuck.The lathe was 25 years old at the date of the incident. Smith was using it to clean and polish sets of wheels from railway vehicles. He came into contact with the unguarded chuck and suffered fatal head injuries.

The subsequent HSE investigation found that the company had failed to carry out a suitable and sufficient risk assessment of the risks to employees when using the lathe to clean wheels. It had failed to implement a safe system of work and had also failed to provide adequate information, instruction, training and supervision on the use of the lathe.

Crane fatality

In December 2008 Michael Tilley, an employee of Parker Plant Ltd, a quarrying plant and equipment manufacturer, was working at the company’s site in Leicester. He and a colleague were using an overhead crane to load sections of structural steelwork into a shipping container. The steel structures were 9 metres long and weighed 1.5 tonnes. They would not fit into the container and the two workers were told to place one section on top of each other on the ground.  As they released the lifting chains from the load, the top section fell onto Tilley’s head. He suffered fatal injuries. The two men had been working from an incorrect diagram. This showed that the structures would fit on top of each other, but in fact this was impossible. Also, the structures were not strapped together. This meant that the load was unstable and likely to fall unexpectedly. The work had not been properly planned or supervised and the lifting equipment was defective. Tilley and his colleague had not been provided with information on the size, weight or centre of gravity of the load. This would have enabled them to sling the load correctly. Further, they had not been given adequate training on how to manage such a complex lifting operation.

 

Cement explosion

In January 2008 Peter Reynolds, an employee of Cemex, was treating waste cement dust in a bypass dust plant at the company’s works in Rugby. He was clearing a blockage in the plant’s mixer when a violent explosion of dust and steam occurred. The force of the explosion blew Reynolds through the side of a building onto a road 10 metres below. He suffered fatal injuries. Cemex had recognised the potential for blockages to cause explosions as steam pressure built up within the mixer but it had failed to take action to prevent blockages.The company had also failed to review its risk assessment after an incident in May 2006 when an explosion in the same machine bent a metal-cladded external wall.

Cemex was fined £200,000 plus £172,000 costs for a breach of section 2, HSW Act, for failing to ensure the health and safety of employees.

The company’s protection against the buildup of pressure was for the plant to be continuously vented when processing waste cement dust. The vents frequently blocked, and the blockages caused steam to build up to a high pressure. Cemex could have made a number of changes to the mixer to reduce the flow of dust and improve the venting and cooling systems, or it could have devised a new system of work. No action was taken. Workers were expected to operate this dangerous piece of machinery.

 

Foundry death

Stuart Stead, an employee of H.I. Quality Steel Castings Ltd, was using a hand-held grinder to work on a casting at the company’s foundry in Doncaster. The disc fitted to the machine exploded and sent fragments across his workbay. A shard struck him in the mouth. He suffered fatal injuries. The disc was nine inches in diameter despite the fact that the grinder had a maximum tool diameter of two inches unless guarded. It was attached to the grinder by using a non-proprietary tool. The disk was rated for 6650 rpm but was running at 12,000 rpm. The grinder had no guard.  The excessive speed of the grinder, coupled with the added load caused by the non-standard attachment, had put stresses on the disc beyond its capacity. The HSE’s investigation had discovered a number of previous incidents when discs had flown off grinders. None of these had been mentioned in monthly minutes of the company’s health and safety meetings. Despite some initial training in abrasive wheels, employees did not understand rotation speeds of machines versus discs and had free access to a number of grinders and discs. This contributed to the prevalence of unsafe combinations.

Death from electrocution

In March 2009 Jake Herring, a trainee design engineer, was carrying out electrical testing work at Grundfos Pumps Ltd’s factory in Windsor. He was working unsupervised while he tested a live electrical control panel. There was no formal training plan for Herring to undertake electrical testing. He came into contact with a live 3 phase electrical system and was killed. At the time of the incident he was working unsupervised outside the designated electrical test area. The company had not adequately risk assessed the testing of live electrical panels to identify a safe system of work. It had failed to provide suitable training and supervision.

Death by crushing: £20,000 fine

Martin Rice, an employee of The Stone Company UK Ltd, was working at the company’s site near Chelmsford. he was unloading a delivery of manufactured stone and placing it on storage A-frames in a warehouse.As he lowered a bundle of slabs which weighed three tonnes, the bundle fell on him and crushed him against the side of building. He suffered fatal injuries. The A-frames were poorly sited and were not appropriate within the confines of the warehouse.

Printing machine crushing death

In April 2012 a 23-year old agency worker from Lithuania was working in Gordon Leach t/a RGE Engineering Company’s print room. She entered the machine to apply thinners to the ink. The machine started. Her head was crushed between the printing pads and the printing table of the machine. She suffered fatal injuries. The machine had no effective guarding system.

Unguarded tyre shredding machine: amputated arm

In November 2013 Nathan Johnson was working at Cartwright Projects Ltd’s premises in Ashford, Kent. He was feeding tyres by hand into a tyre shredding machine. The machine failed to grip a tyre properly on its metal teeth. Johnson’s sleeve was entangled in the metal teeth and his arm was dragged into the machine. He lost his right forearm up to the elbow. Mark Anton Arabaje, the sole director of the company, had removed the metal bucket guard from the machine. This allowed easy access to the metal teeth.

Steel company: serious burn injuries

In August 2013 an in-house contractor was fitting a valve to an oxygen pipe carrying pure oxygen at Sheffield Forgemasters Engineering Ltd. He was carrying out checks when the pipe exploded. He suffered severe third-degree burns and was kept in a coma for several weeks.The oxygen pipe had been fitted with unsuitable parts. No action had been taken to take control of pipelines or to implement training or levels of responsibility for the management of the work.

Worker dragged through a CD-sized gap in machine

Compass Engineering Ltd and Kaltenbach Ltd, a machine supply company, were fined at Sheffield Crown Court in July 2011 after a worker was seriously injured when he was dragged through a gap in a machine. The gap was no wider than a CD case.

In December 2008 Matthew Lowe, an employee of Compass, was working at the company’s site in Barnsley. He looked into the machine’s outlet point to check a line of work. Lowe was caught on a conveyor used to move heavy steel beams. He was dragged through a 125mm opening between a moving measuring head and a wall. Lowe suffered serious injuries including a ruptured stomach and bowel, a fractured spine, both hips, his right arm, several ribs and a fractured pelvis. He has lasting physical and psychological damage. There was no guarding in place to protect Lowe from dangerous moving parts. This was a serious safety failing for both Compass and for Kaltenbach, which had supplied the machine. Both companies were responsible for ensuring that adequate guarding was in place. Although the machine belonged to Compass, Kaltenbach had installed the equipment and signed it off as being fit and ready for use. Lowe was inexperienced in operating the machinery after he had been moved from a different line at the premises because of a lull in his regular workload. The lack of guarding was the decisive factor.

An HSE inspector commented that it was remarkable that Lowe had survived. If appropriate guarding had been in place, the incident would never have happened. The prosecution would live long in the memory because of the shocking details. He hoped that it served as a reminder to those involved in the manufacturing, processing and supply of machinery of the need to prevent access to dangerous parts.

Lowe is reported to have made the following comments after the case:

  • What mattered most was that the industry learned from his experience. His life had changed forever and no matter how well he recovered from his physical injuries, he would still have the psychological impact of the accident hanging over him.
  • He hoped that his case highlighted the dangers posed by not following health and safety regulations. It would not put his life back to how it was before the incident, but at least it might prevent others suffering in the future.
  • Too many people are needlessly killed and injured in accidents at work. If hearing his story made them think twice about safety, and about the daily risks which they faced in the workplace, then he would be happy.

 

Meal blending machine

Norman Porter, who had only been working at J Murray & Son Ltd for eight weeks, died after he became entangled in moving parts of a meal blending machine. The investigation revealed that the company had removed safety panels from the top of the mixer to allow raw ingredients to be added more easily. This had the undesired effect of exposing the dangerous moving parts of the machine, which the company failed to identify and correct. The investigation also revealed that the blender was operated without the safety guards for approximately three years.

 

Steelworks fatalities: Corus (UK) Ltd

Corus (UK) Ltd, the steelmaking company, was fined £170,000 in April 2007 after a worker was killed by a falling crane.

In July 2003 Shane Eastwood, an employee of Corus, was working at the company’s site in Rotherham. He was working on machinery in an engineering workshop under an overhead crane. The crane’s hoist block, which weighed 260 kg, fell seven metres onto Eastwood, causing fatal injuries.

A limit switch, which was designed to cut power to the crane if its block was hoisted too far, and which was safety-critical, had failed. As a result, the hoist rope snapped and the block fell.

The accident had been entirely avoidable. Corus had failed to properly maintain the limit switch. The switch was defective and had progressively failed.

This was reported to have been the ninth time in five years that Corus has been fined for health and safety offences.

 

Corus was also fined £1.3million at Swansea Crown Court on December 15, 2006, for health and safety offences relating to fatalities at its Port Talbot plant.

In November 2001 a blast furnace exploded at the plant. The explosion lifted the top half of the furnace two feet into the air and resulted in molten metal falling on workers. Three were killed, twelve suffered serious burn injuries and five others were injured. The explosion was caused by water leaking into the white hot centre of the furnace, which had been in operation for 47 years. Some of the injured, and those who witnessed the incident, were still receiving psychological treatment five years after the explosion.

The Crown Court Judge criticised the company’s casual attitude to safety. During a two-day hearing, evidence was given of a catalogue of errors which resulted in the explosion. These included years of recommendations by senior employees at the plant, relating to the furnace, which were ignored.

In 1993 a decision was taken to prolong the life of the blast furnace. A committee was set up to discuss and report on the furnace four times a year. The committee made a series of recommendations, none of which were acted upon.

One example was a recommendation to carry out a comparative study into the benefits of electrical and diesel pumps. The failure of a succession of electrical pumps, which circulated cooling water to the furnace, resulted in the explosion. The furnace had suffered many pump failures before the explosion.

The power plant log for the period before the incident showed that an electrical transformer had been damaged by rain and needed repair. A plan to repair it was the start of events which eventually caused the incident. The transformer had to be partially isolated before repairs were carried out. This meant that the current to a furnace pump was transferred to another transformer. This operation needed monitoring to ensure that voltage remained constant.

The team of employees working on the furnace on the day before the explosion was not told about the repair work. When the current was transferred, the voltage in the transformer dropped. This caused a pump to trip and an auxiliary pump, which then came into operation, also tripped. The result of this was that water to cool the system ceased to circulate and approximately 50 tons leaked into the furnace. Employees  who were sent to deal with the leak thought that it had been repaired. In fact, the water remained in the furnace. It reacted with the molten metal in the furnace and caused the explosion when the metal core was reheated on the next day.

Corus pleaded guilty to breaches of health and safety law. Defending counsel stated that this did not mean that the company acknowledged that it had foreseen that lives would be at risk. Modern blast furnaces went back to the Victorian era. There were no records of similar explosions having happened. The inquest into the deaths had recorded verdicts of accidental death. An internal report issued  by Corus at the time of the inquest had concluded that the explosion was neither foreseen nor foreseeable.

Senior management responsible for the furnace had met to discuss problems with it one hour before the explosion. The risk of a discharge, but not an explosion, had been discussed at the meeting.

The families of the victims of the explosion were reported to have made the following comments:

  • They were disgusted and shocked at the outcome.
  • It was quite unbelievable that the company should have been fined such a meagre sum.
  • Corus should have been fined up to the maximum allowable. A large fine would have ensured that other companies sat up and listened and understood the consequences of not doing enough for health and safety.
  • The judge had stated that Corus had made £143 million this year after tax, so what they had been ordered to pay was a pinprick.

 

Molten metal spray

In September 2014 an employee of Gemini Corrosion Services Ltd was killed when he was sprayed with molten aluminium. He came into contact with a rotating pipe being spray coated with molten aluminium by a thermal spray application machine used to spray a coating into steel drill pipes used in the oil industry. The company had failed to ensure that the machine was adequately guarded or that adequate measures were in place to prevent access by any worker to dangerous parts of machinery.

Crushing injuries

In February 2014 Richard Blake, a welder and fabricator employed by Point Engineering (Hull) Ltd, was preparing a marine hutch and frame for inspection, using a sling and overhead crane to move it to a vertical position so that it could be stamped with an approval mark by a surveyor. The frame, which weighed more than 500kg, fell onto him, trapping his pelvis and legs. He suffered a shattered pelvis and fractured hip. The surveyor narrowly escaped injury. The work had not been correctly planned and assessed.

Death from mooring rope

Paul Houghton, a worker at Diverse Ventures, a Portsmouth shipbuilding and repair company, was killed in 2012 when he was struck by a mooring rope. The rope was being used to pull the jib of a small crane back into position. The rope broke under tension. He was standing in the danger area of the operation. There was no management of safety and no suitable and sufficient risk assessment.

Death in waste shredder

In July 2013 Karlis Pavasars, an agency worker working for Mid-UK Recycling Ltd at its site near Ancaster, was cleaning a conveyor. The recycling line started and Pavasars was drawn onto the conveyor, through a trammel and into an industrial waste shredder. He suffered fatal injuries. The fixed gate which fenced off the area and prevented access to the conveyor had been removed several weeks before the incident. This meant that workers could freely gain access to the area. Management knew that the gate was not in place.

Death of worker: £3.8 million fines

In July 2014 Richard Reddish, an employee of Explore Manufacturing Company Ltd, was working in the finishing area of the company’s site in Worksop, Nottinghamshire. He was working from a mobile elevating work platform to remove lifting attachments from a concrete panel which weighed 11 tonnes and which was stored on a transport pallet. The panel toppled and struck the platform. He was thrown from the platform and struck by a concrete panel. He suffered fatal injuries. The pallets had been supplied by Select Plant Hire Company Ltd. The frame used to secure the panel to the pallet was not properly connected. A locking pin had not been inserted and there was no pre-checking system. The pallets were in a poor and defective condition. Large freestanding concrete panels were stored in the finishing area instead of being secured in storage racks. There was a lack of adequate planning

Fatal forklift incident

In July  2014 a worker employed by Vacu-Lug Traction Tyres Ltd was transporting tyres with a forklift at the company’s site in Grantham, Lincolnshire. The truck ran over a loose tyre. The worker, who was not wearing a seat belt, was crushed between the truck and the ground. He suffered fatal injuries. There was no company policy in place instructing workers to wear seat belts when operating forklift trucks. If the tyres had been securely stored, this would have prevented them from rolling onto the roadway and would have reduced the risk of the vehicle overturning.

 

LAWNMOWERS

Serious hand injury

In March 2014 an employee of  New Charter Housing Trust was using a ride-on mower with a grass box attached. The chute to the grass box became blocked because the grass was long and wet. The worker reached into the chute to clear a blockage, His hand came into contact with a rotating metal fan. He suffered serious injuries. He had not received training on how to use the mower and did not know that the fan continued to rotate for 30 seconds after the machine’s engine was switched off.

Strimmer chain death

In February 2010 Tony Robinson, a self-employed contractor, was using a chainsaw to cut back overgrown vegetation at Ramsden Dock in Barrow. He had been hired to help clear undergrowth at the site during the construction of the new Waterfront business park. A chain attachment had been fitted to a strimmer so that it could be used for more heavy duty work. The chain, spinning at 300 mph, became detached and struck him on the back of the neck. He suffered fatal injuries. The HSE investigation of the incident found that the work had not been planned or carried out safely. ThreeShires Ltd had not properly considered the risks of using the attachment and had allowed the deceased to work close to where the strimmer was being operated.

The HSE issued a Safety Alert following the incident, which warned that there was a risk of death or serious injury from the use of the chain attachment. It served a prohibition notice on the sole importer of the attachments into the UK. The attachment is now banned throughout Europe.

Hand caught in blades

In August 2011 a maintenance worker, who wishes to remain anonymous, employed by Clear Channel UK Ltd, an outdoor advertising company, was working at a billboard site in Bath Road, Bristol. He tried to clear a blockage from a petrol-powered mower which he was operating. He thought that the mower had been turned off. As he tried to remove the blockage, the mower’s blade started to rotate. His thumb was almost severed and his fingers were severely injured. A 14 hour surgical procedure was needed to reattach his thumb and repair the damaged fingers. A safety feature which cuts out the engine of the mower and stops the blades rotating was not working properly. Clear Channel did not have an effective reporting and maintenance system for reporting faults in equipment. It had allowed a lawnmower which was not in good repair or efficient working order to be used by its employees.


The Little Book of Health and Safety Horrors: hazardous substances and hospitals

HAZARDOUS SUBSTANCES

Release of toxic substances

In November 2011 methyl iodide, a highly toxic substance which can affect the central nervous system, was released into the atmosphere at Archimica Chemicals Ltd and Euticals Ltd’s site in Flintshire, because of poorly written procedures. In February 2012 an agency worker was exposed to the same substance because he was provided with inadequate respiratory protection. In June and July 2012 a worker was exposed to the same substance after having been given inadequate decontamination training. In July 2012 a worker suffered severe and permanent injuries following exposure to the same substance, having been issued with poorly fitting respiratory protection. In November 2012 three workers were exposed to dichloromethane, a hazardous substance with potentially fatal effects, when a process vessel overflowed. Both companies are now in liquidation and it is reported that the site is being decommissioned.

Drugs exposure at veterinary practice

Employees of  Davies Veterinary Services Ltd in Bedfordshire, which included a total of 125 vets, nurses and support staff, were exposed to harmful drugs over a four-year period. The fume cabinet used for animal chemotherapy drug preparation was not used in the way for which it was designed. The employees were potentially exposed to substances which are harmful to human health and can cause cancer. A dangerous occurrence was reported to the HSE in 2011 by one of the vets who believed that the fume cabinet was unsuitable. There was no system of work in place to prevent or reduce the risk of exposure to employees. There had been no maintenance of the fume cupboard for many years. Cleaning procedures were inadequate.Employees had not been given any safety training in the use of the fume cupboard. There was inadequate personal protective equipment and no monitoring systems. From July 2007 until September 2011 workers at the practice could have been exposed to the drugs.

 

HOSPITALS

Death of patient from drowning

Mansoor Elahi was an inpatient at Birch Hill Hospital, operated by Pennine Care NHS Foundation Trust . On September 5 2013 he was taking part in a prearranged rafted canoeing activity provided by an outdoor activities centre in partnership with the Trust. He removed his buoyancy aid and jumped into the water to commit suicide. The Trust had failed to carry out a risk assessment for the property or to adequately assess the deceased’s suitability to attend. His actions had been entirely foreseeable because he had tried to enter the water on a previous occasion. If the Trust had carried out a suitable assessment it would not have allowed a vulnerable person the opportunity to end his life.

Death of patient in fall

Adam Withers was detained as a patient at Epsom Hospital, run by Surrey and Borders NHS Foundation Trust/ In May 2014 he was in the hospital courtyard with his mother. He climbed over a conservatory roof and up a 130-foot industrial chimney. He fell and suffered fatal injuries. There had been a series of failures to ensure the proper management of risk associated with absconding patients. There was insufficient communication between employees and inadequate systems to ensure that the risks identified were addressed and remedied. An HSE inspector commented after the case that if the Trust had carried out a suitable assessment and made the appropriate changes they would not have allowed a vulnerable person the opportunity to end his life.

Hospital window death fall

In June 2010 Robin Blowes was admitted to a hospital operated by Southend University Hospital NHS Foundation Trust  for surgery. He developed signs of confusion and was moved to a side room. He fell nine metres through a window which was fitted only with a single restrictor and suffered fatal injuries.The hospital’s arrangements for managing the risk of patients falling from windows were inadequate. The window of the deceased’s room was fitted only with a single angle bracket restrictor which was bent to one side, allowing the window to be fully opened. Since 1989, guidance has been in place which states that windows in hospitals where there are vulnerable patients should be restricted to a maximum opening of ten centimetres to prevent falls.

 

In–patient fall death 

Mark Scott-Green was an in-patient at Royal United Hospital Bath. He became confused and vulnerable. The NHS Foundation Trust authorised a Deprivation of Liberty Safeguard. This authorised the forcible return of patients to their rooms for treatment in their best interests. In November 2012 hospital security returned Scott-Green to his second-floor room. He fell from his window and was found dead in the hospital courtyard. The window was fitted with one restrictor. It was large enough to flex . the gap was larger than the recommended 100mm standard. Other windows at the hospital were not adequately restricted. The HSE issued an improvement notice to ensure that all restrictors were suitable and prevented the windows opening more than 100mm. A safety alert had been issued by the Department of Health to all NHS Trusts informing them of the risk of relying on one window restrictor.

Death of patient from drowning

In September 2014 Joan Darnell, aged 78, was admitted to a specialist dementia ward in a hospital operated by the Norfolk and Suffolk NHS Foundation Trust. In October she was reported missing and was found face-down in a bath full of water. She had dies from drowning. The Trust did not have adequate policies or procedures in place for managing patient safety. It had failed to complete an appropriate risk assessment for the deceased and to take steps to prevent vulnerable patients having unsupervised access to bathrooms. Nor did it have adequate systems and arrangements in place to ensure that patients under its care on the ward were effectively monitored.

Death of patient from drowning

In September 2014 Joan Darnell, aged 78, was admitted to a specialist dementia ward in a hospital operated by the Norfolk and Suffolk NHS Foundation Trust. In October she was reported missing and was found face-down in a bath full of water. She had dies from drowning. The Trust did not have adequate policies or procedures in place for managing patient safety. It had failed to complete an appropriate risk assessment for the deceased and to take steps to prevent vulnerable patients having unsupervised access to bathrooms. Nor did it have adequate systems and arrangements in place to ensure that patients under its care on the ward were effectively monitored.

Death of psychiatric patient

In August 2010 Gary Niven, a patient with a history of depression, hanged himself in the A&E department of Crosshouse Hospital in Kilmarnock. He died a few days later. The risk of psychiatric patients being left alone was identified by NHS Ayrshire and Arran. It had procedures for staff to follow but these were not followed for Mr Niven. Mr Niven had been taken by ambulance to the hospital after saying he was feeling suicidal and had already attempted to hang himself. He was taken to a room where the doors were always left open so that he could be observed. A charge nurse noticed that the doors were closed and Mr Niven was found inside, having made a ligature from the arm of his jumper.

Scaffolding fall

W Hughes and Son Ltd was engaged to replace a roof in the Royal Preston Hospital. It installed scaffolding to reach the roof but failed to fence off the steps leading to the scaffold. A 17 year old mental health patient climbed the scaffolding. She fell six metres and suffered a fractured spine and pelvis.  An HSE inspector is reported to have commented after the case that construction firms have a legal duty to make sure that construction sites are secure and clearly signed.

Deaths of patients: Mid Staffordshire Hospital Trust

The HSE investigated the deaths of four patients between 2005 and 2014 at Cannock and Stafford hospitals. Three of the patients suffered fatal flaws and a fourth suffered a severe anaphylactic reaction after being given penicillin despite having informed the hospital on several occasions that she was allergic to it. The HSE investigated the Trust in accordance with its policy to investigate deaths in the health sector where there was evidence that standards had not been met because of a systematic failure in management systems. The Trust failed to follow a number of its own policies in relation to handing over information, completing records, carrying out falls risk assessments and the monitoring of care plans.

Bacteria exposure

In January 2011 a test vial containing a strain of multi-resistant TB bacteria smashed when it fell to the ground while being handled. Four employees risked exposure but none suffered adverse effects. The Royal Brompton and Harefield NHS Foundation Trust should have developed and implemented a safe system of work to prevent such an incident. It should also have better implemented appropriate and adequate control measures, and ensured that staff  were suitably trained. In 2002 the HSE had issued an enforcement notice for the same laboratory facility for failing to ensure that it was sealable for disinfection. Critical control measures, including the laboratory sealability and filters, were not examined, monitored, tested or maintained.

 

Hospital window fall

In September 2011 a patient in a ward at West Suffolk Hospital climbed up to a bay window in an attempt to escape. She fell three metres to the ground below and suffered a broken vertebra and a punctured lung. The hospital’s arrangements for managing the risk of patients falling from windows were inadequate. There was no window restrictor fitted to the window. A survey conducted by the Trust after the incident identified a number of issues with window restrictions. Guidance has been available since 1989 which states that windows in hospitals where there are vulnerable patients should be restricted to a maximum opening of ten centimetres to prevent falls.

 

Death of patient in fall

Adam Withers was detained as a patient at Epsom Hospital. In May 2014 he was in the hospital courtyard with his mother. He climbed over a conservatory roof and up a 130-foot industrial chimney. He fell and suffered fatal injuries. There had been a series of failures to ensure the proper management of risk associated with absconding patients. There was insufficient communication between employees and inadequate systems to ensure that the risks identified were addressed and remedied.

Death of patient in hoist

In April 2012 John Biggadike, a patient at The Pilgrim Hospital in Lincoln, died from internal injuries after falling onto an exposed metal post on a standing aid hoist which staff were using to support him. The kneepad on the hoist had been incorrectly removed. This left the metal post exposed. The United Lincolnshire Hospitals NHS Trust did not have systems for training and monitoring the way in which staff used the hoist. Unsafe practices had developed. A spokesperson for the HSE is reported to have commented after the case that if staff had received effective training and monitoring in the use of the hoist, the death could have been avoided.

Death of diabetic

Gillian Astbury, a 66 year old Type 1 diabetic, died from diabetic ketoacidosis at Stafford Hospital in April 2011 because of failures to implement basic handover procedures and to ensure essential record keeping. Staff at the hospital did not follow or even sometimes look at medical notes which stated that Ms Astbury needed insulin, regular blood tests and a special diet. The system for communicating patient needs at staff handovers was inconsistent. Record keeping and monitoring of patient care plans were far below acceptable standards. Mistakes were made at up to eight shift changes and 11 drugs rounds. The failure to administer insulin was the direct cause of Ms Astbury’s death.

Mid Staffordshire NHS Foundation Trust has been the subject of two major inquiries into events at Stafford Hospital between 2005 and 2009.

Death of nil-by-mouth patient

In December 2013 James South was admitted to Raigmore Hospital suffering from a number of complaints. He was treated with naso-gastric feeding. A label stating that he was to be Nil by Mouth was placed at the head of his bed. South died following the lunchtime meal which was served to him. He was found to have mashed potato on his face and inside the mask which he had been wearing. The Highland Health Board had failed in its duty to ensure the health, safety and welfare of those not in its employment and had not taken all reasonable steps to ensure that risks to patients with special dietary requirements were managed.

NHS Hospital Trust fined after series of deaths

Between June 2011 and November 2012 five elderly patients died while being cared for in hospitals run by the Shrewsbury and Telford Hospital NHS Trust.  Mohan Singh, aged 74, was admitted to the Princess Royal Hospital in Telford. It was recommended that he had bed watch. He fell to the floor and suffered fatal injuries. Eileen Thomson, aged 81, suffered three falls in the hospital, She died in May 2012. Edna Evans, aged 92, suffered a fall in the hospital. She died in October 2012. The post mortem found that the injury which she suffered in the fall contributed to her death. Ada Clarke, aged 91, died in October 2012 after falling out of bed in the hospital. Gerald Morris, aged 72, fell in the Royal Shrewsbury Hospital, He suffered a fractured hip and died in November 2012. Fall prevention measures, including close supervision of those in a confused mental state, were not properly applied. This was made worse by poor consideration and communication surrounding measures to protect against falls.


The Little Book of Health and Safety Horrors Part 11: Garages and Gas

GARAGES

Garage pit fall: serious injuries

The injured customer’s car was parked in front of a vehicle inspection pit. Farhad Mashinchi, the garage owner, was showing the customer a part fitted under the bonnet when the customer fell into the pit. He suffered multiple injuries. Mashinchi had allowed a member of the public into the garage with an open pit without suitable and sufficient precautions to prevent a fall. Putting a barrier around the pit would have prevented the fall.

Burns from oil drum

A mechanic employed by Kankku Ltd, a garage company, was badly burned while trying to cut the top off an empty oil drum.The remaining oil inside the drum caught fire and caused an explosion. The mechanic suffered burns to his hands and arms. Tops were cut from empty oil drums once every three months for the storage of scrap metal. The company failed to consider the risk of the propane torch creating and igniting a vapour from the small amount of oil remaining in the drums.

 

GAS

Carbon monoxide poisoning

Mehboob and Suraiya Bobat, landlords of a house in Bolton, were fined after tenants suffered carbon monoxide poisoning.

A man, his wife and their four-month old child were taken to hospital, suffering symptoms which included headaches, palpitations and breathing difficulties. They were treated for high levels of carbon monoxide poisoning. The HSE investigation found that four gas appliances at the house were unsafe, and the landlords had failed to arrange an annual gas safety check. A gas-powered water heater in the kitchen of the house should only have been used for five minutes at a time because it did not have a flue. It had emitted high levels of carbon monoxide. The heater and a gas heater in a bedroom were classified as immediately dangerous by a gas engineer.

Dangerous gas work: risk of carbon monoxide poisoning

In November 2010 Newport City Council contracted a home improvement company to carry out loft conversion work at a property in Bettws, Newport, South Wales. The householder had agreed to modifications of her property, with a grant from the local authority, to accommodate foster children. The work included moving a boiler into the loft and replacing a gas fire flue. The householder complained that the boiler was leaking and was not working properly. She arranged for an inspection by an independent engineer. The engineer discovered that the boiler was leaking and that the pressure relief valve had not been connected. He advised the householder not to use the equipment. A Gas Safe officer found that the boiler had not been correctly fitted and that the gas fire flue had been capped below the level of the loft. This allowed carbon monoxide gas into the loft, and was classified as immediately dangerous. Newport City Council had not checked the competence of the contractor and had not monitored its work. It had not followed its own procedures for choosing contractors. A spokesperson for the HSE is reported to have commented after the case that the shoddy and careless work by the contractors could have cost a family with young children their lives. Anyone carrying out work on or near a flue should get advice from a Gas Safe registered engineer before starting work.

Illegal gas work: prison sentence

Neil Simon McKimm carried out gas work including the servicing of boilers. He used the alias of a legitimate gas engineer to deceive his customers. He repeatedly falsely pretended to be a legitimate Gas Safe engineer and falsely signed official records in the name of a legitimate gas engineer. He was sentenced to 18 months imprisonment in May 2016. An HSE inspector commented after the case that the HSE would robustly pursue those who broke the law.


The Little Book of Health and Safety Horrors Part 10: Fisheries

FISHERIES

Death of diver

Graeme Mackie placed an advert online offering his services as a trainee shellfish diver. John MacNeil engaged him to collect shellfish from his boat in the River Forth Estuary. Mackie drowned in his first dive. He was not wearing any Buoyancy Control Device.MacNeil failed to have any standby diver on hand in case of emergencies and he was not able to give immediate assistance.

The HSE Principal Inspector (Diving) made the following comments:

  • The dive resulted in tragic consequences which could have been avoided if MacNeil had planned the activity properly and employed the correct size dive team made up of competent divers.
  • Diving is a high hazard activity, bit if it is conducted properly, in accordance with the regulations and guidance, the risks can be managed.
  • The minimum team size normally required when diving for shellfish is three qualified divers – a supervisor, a working diver and a standby diver. Additional people may be required to operate the boat and to assist in an emergency.

 

Deaths of cockle pickers

In August 2006 a gangmaster in charge of Chinese migrant cockle pickers was sentenced to 14 years’ imprisonment on 21 counts of manslaughter. The facts, in summary, were that 23 Chinese migrant workers died after a group of 35 cockle pickers were cut off by the tide after dark in February 2004. Twenty-one bodies were later recovered.

The gangmaster – Lin Liang Ren – was also convicted of perverting the course of justice and facilitating illegal immigrants to work in the United Kingdom. His girlfriend, Zhao Xiao Qing, was sentenced to two years and nine months imprisonment for perverting the course of justice and facilitating. His cousin, Lin Mu Yong, received a sentence of four years and nine months imprisonment for helping cocklers to break immigration laws.

Crushing death

In October 2013 Tomas Suchy, an employee of Interfish Ltd, was clearing a fallen stack of frozen fish boxes at the company’s site in Plymouth. He was killed when a stack of frozen fish boxes fell onto him. There was no safe system of work or instruction to works as to how the stacks should be stored. There was no written procedure for dealing with falls of stock.


The Little Book of Health and Safety Horrors Part 9: Farms

FARMS

Leg amputation

In July 2014 an employee of Clynderwen and Cardiganshire Farmers Ltd entered a wheat silo to clear a blockage. The rotating auger in the silo pulled him into the silo. His clothing was caught and he was pulled further into the silo. He suffered serious lacerations to his leg, which was later amputated. There was inadequate instruction and training on the electrical and mechanical isolation of the auger. The auger was not adequately isolated. The company was fined £10,000 plus £1300 costs.

Eight-year old farm boy: leg amputation

In October 2015 an eight-year old boy was sitting on the back of an all-terrain vehicle on his parents’ farm in Kirkbean, Scotland. The vehicle was being used to cut grass. The boy fell from the vehicle and suffered serious leg injuries. The leg was amputated below the knee. The driver of the vehicle had not been trained in its use and the company which operated the farm had allowed the boy to ride on it on previous occasions. The company which operated the farm was fined £10,000. It had taken no action to ensure that the boy was kept separate from the farm’s business activities.

Three-year old farm boy seriously injured

Four members of a farming family were fined in May 2015following an incident in which a three-year old boy was injured. In September 2013 a three year old boy climbed onto the first floor of a barn at a farm in Derbyshire. His foot was drawn into an auger. He suffered deep lacerations which needed plastic surgery. The auger was being used by the family to move grain around. It was guarded but the guard was not designed for the dimensions of a child.

Death from barbed wire

In February 2015 Adrian Pickett was contracted to carry out hedge cutting for James Headland at a farm. Pickett was using a rotary flail hedge cutter. A piece of barbed wire shot from the machine. It struck Headland in the neck, causing fatal injuries. Pickett had failed to ensure his own safety and that of others by following a safe system of work. His maintenance of the equipment and correct use of guards for the work activity were also faulty. He was sentenced to 80 hours of community service and ordered to pay £6500 costs.

Tractor death

In July 2009 Thomas Phizacklea, an employee of Stuart Webster, was working at a farm in South Lakeland. He was found dead under the wheel of a tractor. The tractor was 27 years old. It was in poor condition. The handbrake did not function. The most likely explanation for the fatality was that Phizacklea had left the tractor running in neutral without the handbrake on as he got out of the cab to walk around the vehicle. His body was found trapped between the front offside wheel of the tractor and a mound of earth. Webster had a legal duty to ensure that work could be carried out safely on his farm. He should have kept up the maintenance of the tractor  or taken it of use altogether .He was fined £20,000 plus £29,000 costs.

 

Dumper truck death

William Friend and Robert Plume, directors of Wedgewood Buildings Ltd were given suspended prison sentences in December 2014 following the death of a worker when a dumper truck overturned. The company was contracted to expand a pond on a farm near Tiverton, Devon .Daniel Whiston was driving a dumper truck to move spoil around the site. The truck overturned and crushed Whiston, causing fatal injuries. The deceased had been given 30 minutes training by a colleague who had not been trained to teach other workers and was not competent to supervise him. The dumper truck had a number of serious defects. These included steering failure and defective brakes. No sufficient risk assessments had been undertaken for the work and there was no safe system of work.

Death of migrant worker by electrocution

In July 2006 Gerard Faltynowski, a Polish migrant worker, was helping to build a polytunnel in a field near Blairgowrie in Scotland. The polytunnel was placed below three overhead power lines carrying 11,000 volts. Faltynowski had slotted thirteen poles, each one half a metre in length, and was carrying them vertically. The pole touched the cables. He was killed instantly.

Severed fingers and thumb

In February 2014 an assistant farm manager was operating a firewood processing machine which comprised a circular saw, log splitter and conveyor.  In the course of splitting a log, his left hand became caught between the log and the splitting wedge. All the fingers and thumb of his left hand were severed. The machine had recently been supplied. It did not comply with the relevant British standard and was not safe to use.

Pheasant shoot: all-terrain vehicle death

In October 2013 James Gaffney was driving an all-terrain vehicle to collect dead game following a pheasant shoot on the Urra sporting and farming estate in North Yorkshire.He was not wearing a seatbelt. The vehicle overturned and he suffered fatal head injuries. No-one had used the seatbelt on the vehicle because they had not been instructed to do so.

Tractor death

In June 2009 Kim Webb, aged 26, was working on a farm near North Cadbury in Somerset. She was driving a tractor on a sloping field. The tractor had no seat belt, cab or roll over bar. Ms Webb was checking cattle in a number of fields. The tractor rolled over twice and crushed Ms Webb, causing fatal injuries. The tractor had no rollover protection. Brake pedals on the tractor could not be linked together. This made it unsuitable for road driving. There was a lack of suitable and sufficient risk assessments for the type of work being carried out. There was no safe system of work for the tasks which employees were required to carry out using the tractor. No effective training had been provided. There had been a failure of management control, oversight and supervision in relation to use of the tractor. Ms Webb’s supervisor had no formal training qualifications to instruct her in the use of the tractor. The company had allowed the tractor to be used without a roll bar and had failed to monitor the use of the tractor in a sloping field.

Drowning in grain bin

In July 2014 Arthur Mason, an employee of a farm company, was cleaning inside grain bins at a farm run by the company. He stood directly on the stored grain. He was wearing a harness with a fall-arrest lanyard which was secured to a fixed ladder inside the bin.He began to sink into the grain and the forces involved caused the lanyard to unravel and extend. He became engulfed in the grain and died from drowning.The employing company had failed to adequately identify and manage the risks associated with cleaning grain stores. There was no safe system of work and no-one had been trained in how to complete the work safely.

Machine death

In May 2009 George Stokes, a farmer, was preparing a McHale square bale wrapping machine for the grass cutting season. He was found dead, slumped over the machine.The machine’s safety trip bar had not been designed to stop the rotating baling arms in sufficient time. This meant that anyone who activated the safety trip bar was at risk of being struck.

The failure of the trip bar to stop the rotating bale wrapping arms to stop meant that Stokes had suffered fatal head injuries.

 

Fatal fall from height

David William McVey employed William Sproat, a casual worker, in August 2012 to repair a storm damaged shed roof on a farm.McVey and Sproat accessed the roof using ladders. Sproat fell 18 feet through the roof to the concrete floor below. He suffered fatal injuries.Neither man was wearing a safety harness. There was no edge protection and McVey had taken no measure to prevent or mitigate a fall from height.

Farm explosion death

In May 2010 Peter James, an employee of Cantelo Nurseries Ltd,, was working at a nursery on a farm near Taunton. He was told to unbolt a hatch cover from a pressurised tank used to heat greenhouses. There was still pressure in the system. A release of pressure sent the hatch cover flying. It struck James, causing fatal injuries. Three other workers suffered serious injuries. The work had not been properly planned, workers had not been properly trained or supervised, and one of them spoke very little English and found it difficult to understand instructions. The hatch should not have been removed until all the pressure had been safely released from the system.

Trampling incident

In June 2013 Emma Smith was walking on a public footpath at a farm near Helston in Cornwall. She was trampled by cows belonging to Jonathan Bryant. She suffered life-threatening injuries including punctured lungs and multiple fractures.The path was well-used by local people. Bryant had not assessed the risk to walkers by putting cows with calves in the field adjoining the path.

Death and injury from cows

In May 2013 Mike Porter and his brother John were walking with dogs  on a pubic footpath through a field near Bradford on Avon. Cows with calves were grazing in the field. The animals belonged to Brian Godwin.Mike Porter died from crush injuries caused by cattle trampling him. His brother suffered multiple rib fractures, a punctured lung and general contusions.Godwin had not taken reasonable precautions to protect members of the public walking on footpaths through his fields, from his cattle.The incident was the fourth in five years involving injuries to members of the public caused by Godwin’s cattle.

Straw bales crushing injuries

A 20-year old veterinary student was on a work placement at RL Matson& Sons’ stud farm in Shropshire. She was collecting hay for horses’ troughs when she was struck by four falling straw bales which weighed more than 1.2 tonnes. The student suffered multiple crushing injuries including a fractured pelvis and ankle. The bales had to be removed using a telehandler. The incident could have been prevented if the bales had been properly stacked without risk of collapse.  HSE records show that since 2000, 18 deaths have resulted from being struck by falling bales.

Death from drowning

In September 2011 Luke Yardy drowned when he fell from a boat while trying to retrieve the carcase of a bird from a lake in Cambridgeshire.Yardy had been engaged by a farming partnership to undertake pest and predator control. He was not supplied with a life jacket nor had he receive any training in the use of boats.His brother attempted to rescue Yardy but he also drowned.

All-terrain vehicle head injuries

The fiancée of a director of a farming company lost control of an all-terrain vehicle (ATV) at one of the company’s farms in mid-Devon. The ATV crashed and rolled and threw her to the road. She was not wearing a helmet and suffered life-changing head injuries. The company failed to report the incident. The ATV was described by a police vehicle examiner as being in a dangerous and unroadworthy condition with longstanding defects to its brakes and steering.The woman had been given no formal training in the use of an ATV and no helmet was available for her.

Potato crusher hand injuries

In June 2009 a casual worker, who wished to remain anonymous, was helping Timothy Dean, a farmer, with the potato harvest. A potato crusher, designed and built by Grimme (UK) Ltd, had been fitted to a potato harvester. The crusher was frequently blocked with stones. Workers signalled the harvester driver to isolate power on the machine while they reached into the crusher to clear the blockage.The casual worker reached into the machine, thinking that the power had been isolated. It had not. His hand was caught in the machinery. He suffered three severed tendons in his right hand. Grimme had supplied the crusher to Dean. Defects were found in the machine. There was no safety guard to stop people from accessing the dangerous moving parts and no instruction manual had been provided. Dean had not properly assessed the risks entailed in the work and did not have a safe system of work for the farm workers.

 

Arm amputation in potato grading machine

In November 2013 Marek Walisewski, a Polish worker, was cleaning the rollers of a potato grading machine at a farm in Staffordshire. The farm was operated by WB Daw & Son.His duties included operating, cleaning and clearing blockages on the machine. He sat down under the rollers to clean them while they were moving, using a long screwdriver. The rollers drew his left arm into the machine. The crush injuries resulted in his arm having to be amputated. Unsafe work systems were being used which involved cleaning and clearing blockages from the rollers while they were rotating under power.The company had failed to give clear instructions to workers and failed to monitor their activities.

Grain bin asphyxiation

In August 2014 Zach Dean Fox, aged 19, was working at Seamore Farming’s farm in Hawick. He was trying to clear a blockage in a large metal container used for grain storage. The blockage was in an exit space at the bottom of the bin which still contained a quantity of grain. He became immersed in free-flowing grain and died from asphyxiation. The system of work in place to clear blockages in the bin was inherently unsafe.


The Little Book of Health and Safety Horrors Part 8: Electrocution

 

ELECTROCUTION

Death from electrocution

In June 2010 Bradley Watts,  a 21-year old subcontractor, was lagging pipes in the loft space of  Natures Way Foods premises in Chichester. He came into contact with a 240 volt live electrical cable and was killed.The live cable was part of an old system which had been removed by the company in 2008. It was not identified in any way. Its existence and nature was not known to the company.The company had plenty of opportunity to deal with redundant cables. It had always assumed that they were not live.  If the old cabling had been removed in a systematic and controlled way, or if subsequent checks of the loft space had identified examples of poor practice, the death of Watts could have been avoided.

 

Death from electrocution

In March 2009 Jake Herring, a trainee design engineer, was carrying out electrical testing work at Grundfos Pumps Ltd’s factory in Windsor. He was working unsupervised while he tested a live electrical control panel.There was no formal training plan for Herring to undertake electrical testing. He came into contact with a live 3 phase electrical system and was killed. At the time of the incident he was working unsupervised outside the designated electrical test area.The company had not adequately risk assessed the testing of live electrical panels to identify a safe system of work. It had failed to provide suitable training and supervision.

Electrical explosion death

In May 2008 John Higgins, an employee of UK Power Networks (Operations) Ltd, was working at an electrical substation in Chelmsford. He was working on a transformer tap charger which was a device for manually adjusting voltage ratios. The tap charger exploded. Higgins suffered fatal injuries. The explosion caused a fire and blacked out a large part of Chelmsford. The company had failed to properly assess work with tap changers and to devise procedures for the work. It had also failed to adequately train employees. A spokesperson for the HSE is reported to have commented that Higgins’ death illustrated how dangerous work on or near electrical distribution networks could be, and how imperative it was that employers, large or small, ensured that all activities involving high voltage equipment were properly assessed and that safe systems of work were put in place.

 

Serious burn injuries

In May 2015 a worker was trying to replace a traffic light pole in central Gloucester. He came into contact with a live underground cable. He suffered an electric shock and severe burn injuries to his hands, arms, stomach, face, legs and chest. This was the first time that a group of workers including the victim had worked on an Amey LG Ltd project. Amey had not provided adequate information on the location of underground services. The company’s supervision of the work was inadequate and it had not properly managed the risks from the underground services.

Runner electrocuted

In July 2012 James Kew was running on land in Essex when he came into contact with a high voltage cable. He was electrocuted. The cable was 1.5 metres above the ground. It straddled a well-used footpath. Parts of a porcelain insulator had disintegrated on a wooden pole which supported the cable. The cable should have been 5.5 metres above the ground. Members of the public had reported the matter to UK Power Networks (Operations) Ltd. The company should have immediately de-energised that part of the network. It did not do so and dispatched a technician to the scene. Mr Kew was killed before the technician arrived. UKPN had failed to fully assess the risk posed to members of the public. A spokesperson for the HSE is reported to have made the following comments after the case:

  • Witnesses to the incident had suffered severe trauma and stress-related illness.
  • Distribution network operators have an absolute duty to ensure that they do everything reasonably practicable to ensure the health and safety of members of the public who may be put at risk by the operation of their undertakings.
  • The risks posed by high voltage conductors which descend below the safe statutory height is entirely foreseeable.
  • Network operators must have robust procedures in place that facilitate dynamic risk assessment and the immediate implementation of effective risk control measures to protect the public.

Worker electrocuted

In January 2015 BAM Construction Ltd was constructing a railway operating centre in Basingstoke. BAM appointed Shoreland Projects Ltd as groundworks contractor for the project. Work began to install lampposts on the site entrance road. One of the lampposts touched 11kv overhead power lines as it was being lifted into position by an excavator. Mark Bradley was electrocuted. He suffered multiple life-changing injuries including severe burns to his neck. There had been a failure to properly identify the presence of the overhead power lines and to appropriately plan the work. No suitable control measures were in place to prevent contact with the overhead power lines.

Death by electrocution

In October 2010 Martin Walton was working at a data centre in Hounslow, Middlesex. He was working on a power distribution unit when his forehead made contact with the 415 volt live terminals of a unit. Balfour Beatty Engineering Services Ltd  had been contracted to carry out infrastructure works at the site. Norland Managed Services Ltd was contracted to provide mechanical and electrical maintenance and had control of the site. The underlying cause of the fatality was a succession of failures which indicated the complete breakdown of Balfour Beatty’s management of health and safety in relation to the project. Norland was responsible for the management of the impact of the construction project on the operational infrastructure under their control. It issued a permit to work to Walton, allowing him to reroute the existing site power supply through a new distribution unit, in the knowledge that it had the potential to receive a power supply from a source not under their control and without confirming that the other supply was isolated.


The Little Book of Health and Safety Horrors Part 7: day care, diving, docks

DAY CARE

Choking death

In April 2012 Alison Evans, a 34-year old severely disabled woman, was attending an adult day care centre in Leeds. Ms Evans had not developed a rotary chew, the circular motion which allows food to be ground down for swallowing. Tracey Ann Gilboy, a support worker, allowed a sweet to be given to Ms Evans. She choked and later died in hospital. Gilboy had failed to take reasonable care for the safety of Ms Evans in a way which set in motion a chain of events which resulted in her death.

Death from drowning

Nikki Deaney was a care worker at Springwood Day Centre. She was supposed to be providing one-to-one supervision for Majid Akhtar during a group trip to a reservoir. She lost sight of Majid who died from drowning when he suffered an epileptic seizure when he fell into the water. Deaney had spent a significant amount of time on her mobile phone instead of giving her full attention to Majid while walking him around the reservoir.

 

DIVING

Death of diver: prison sentence for boat skipper

In March 2011 James Irvine was scuba diving from Guthrie Melville’s boat in Largo Bay on the River Forth estuary. He descended as normal but failed to surface. His body was found and recovered the next day. Melville had failed to assess the risks to Irvine and to provide appropriate supervision, equipment including a means of communication and essential safety gear. He had also failed to ensure that there were enough competent people to take part in the diving project and failed to have a standby diver in place to provide assistance to Irvine in the event of a reasonably foreseeable emergency. Since April 2005 Melville had shown the same lack of regard to essential health and safety regulations and had exposed a number of other divers to serious risk.

Melville was sentenced to nine months imprisonment.

The HSE’s Principal Inspector of Diving commented that diving was a high hazard activity. If it was conducted properly, in accordance with regulations and guidance, the risks could be managed. The minimum team size normally required when diving for shellfish was three: a supervisor, a working diver and a standby diver. Additional people might be required to operate the boat and to assist in an emergency.

Simple measures taken to ensure that a diver in trouble could communicate to the supervisor and that the diver was marked by a line and float, or by a line to an attendant on the dive boat, maximised the chance of a successful outcome to an emergency.

 

DOCKS

Dock worker seriously injured in capstan

In June 2014 a three-man team was securing an ocean-going vessel’s heavy mooring ropes at an Essex maritime terminal. The fingers of the left hand of one of the workers became caught between the rotating drum of a powered capstan and a heaving line. His left arm was dragged into the capstan and wrapped tightly around the rotating drum. He suffered multiple fractures, nerve and ligament damage. C.RO Ports Limited had failed to suitably identify and control risk associated with the use of powered capstans at the port. The system of work adopted was unsafe. Arrangements for the instruction, training and supervision of workers using the equipment were inadequate, as were those for the audit and monitoring of safety. The company had failed to heed warnings raised by workers before the incident. The HSE served an improvement notice on the company requiring it to suitable identify relevant hazards and to control risk in accordance with legislation.

An HSE inspector is reported to have commented after the case that all capstans feature dangerous rotating components. Capstans are difficult to guard, so it is vital that all workers must be made to stand well away from the danger zone while they are in use.

Worker decapitated

In 1998 Simon Jones was sent by an employment agency to work at Shoreham docks. He was employed by Euromin. Jones’ work involved the unloading of bags of cobblestones from the hold of a ship. The system for this involved workers standing near an open grab bucket attached to a crane. The lever in the driver’s cab for closing the bucket was very sensitive. When it was operated, the bucket closed in one second. Jones was decapitated when the grab bucket closed on him.

The Health and Safety Executive (HSE) and the police investigated the killing. The HSE issued improvement and prohibition notices and decided to prosecute Euromin for statutory offences. The Director of Public Prosecutions decided not to prosecute the company for negligent manslaughter. This decision was challenged in the High Court on behalf of Jones’ family.

The decision of the High Court was as follows:

  • The DPP’s decision not to prosecute would be quashed.
  • The DPP had been wrong in applying a test of subjective culpability rather than objective liability for the dangerous system of work.

The test for negligent manslaughter was objective. Negligence would be criminal if, on an objective basis, the defendant showed a failure to advert to a serious risk going beyond mere inadvertence in respect of an obvious and important matter which the defendant’s duty demanded he should address