Person killed by dichloromethane fumes

A worker has died after inhaling dichloromethane fumes.
The circumstances were:

• Colin Pocock was using an industrial paint and varnish remover to strip a resin coating from a bath in the bathroom of  a housing association property in Wandsworth on 16 June 2009.
• The stripping agent contained dichloromethane, also known as methylene chloride, a carcinogenic toxic chemical. 
• Fumes rapidly built up in the confined space and he died at the scene as a result of over exposure.

The HSE investigation found:

• There was insufficient natural ventilation in the bathroom. 
• Mr Pocock's employer, Multicrest Ltd, a franchisee of Renubath Services Ltd, should have provided mechanical ventilation equipment to compensate.
• Written documentation from Multicrest stated that work of this nature should only be done in well ventilated areas, but no equipment was provided to employees. 
• Managers were unaware of how work needed to be done in bathrooms and failed to provide adequate safe working arrangements.

Multicrest Ltd., was fined £81,286 (inc. costs).

The HSE inspector said:
"This is a shocking death resulting from totally inadequate ventilation in the enclosed bathroom space in which Colin Pocock had to operate. The risks associated with stripping agents containing dichloromethane are well known, yet he was exposed to lethal fumes with virtually no protection. Mechanical ventilation equipment is often a necessity, but all he had to rely on was a small open window, a basic mask and pot luck. The use of substances that create toxic fumes must only be used where the fumes cannot build up and affect people, and the work must be properly planned and supervised - none of which happened on this occasion."


The sentencing at Southwark Crown Court follows an earlier prosecution of Renubath Services Ltd, Multicrest's franchising company, for identical failings linked to inadequate ventilation arrangements.

Source: HSE LSE/13

Inadequate segregation causes death

European Metal Recycling Limited was fined £370,00 (inc. costs) following the death or a worker  because of a failing to properly segregate people and moving vehicles.

The circumstances were:

• Linas Mataitis was a temporary worker.
• He was working near a large shredding machine that had been powered down for essential annual maintenance, with surrounding safety zones and interlocking gates opened up to allow worker and vehicle access.
• Linas was one of a team of workers using hand shovels to scrape and clear dirt near conveyors feeding the shredder, which they placed into piles for colleagues using machines to clear.
• On the morning of 18 July there were three vehicles operating alongside the team on foot; a bobcat, a mini excavator and a wheeled loading shovel. 
• The smaller machines were being used to fill the bucket of the loading shovel, which then drove away to be emptied.
• The loading shovel was being driven by a partly trained operator who may have been unauthorised to use it.
• Although EMR had a documented procedure for clearing dirt from around the conveyors, which mentioned the use of a bobcat, it did not cover the shutdown operation when the safety gates were open, when more vehicles were operating nearby and when there was increased pedestrian movement.
• The loading shovel was returning to be refilled for a fourth time when it struck Linas and crushed him against a conveyor support.

An HSE investigation found that:

• There were inadequate arrangements for safely managing the movement of people and machinery.
  
• The company had confusing and conflicting records of who was trained and authorised, highlighting failings to properly manage and audit training and supervision.

Source: HSE 20/5/13 LSE/13

Tynedale Roadstone fined £27000 after amputation

A worker suffered horrific injuries and had to have his arm amputated when he fell into dangerous machinery in an asphalt production plant.
The circumstances were:

• John Wyatt was employed by Tynedale Roadstone Limited and had been carrying out an inspection of the conveyor area
• Mr Wyatt had gained access to the conveyor area to carry out an inspection, 
• Safety gates to the plant had been fitted with locks to restrict access these had been disabled
• He slipped and fell forward and was caught up in the snub pulley roller and the conveyor belt.

The HSE's investigation concluded that:

• There were no suitable risk assessments, 
• There were inadequate safe systems of work 
• There was a lack of information and instruction for employees.

 The HSE inspector  said:"Mr Wyatt’s horrific injuries should not and need not have happened. This incident was easily preventable had Tynedale Roadstone carried out an adequate risk assessment of their equipment and properly supervised their employees. Plant of this type is recognised in the industry as being high risk, which is why they are so heavily guarded with trapped key systems. Safety devices are installed on machinery with dangerous moving parts to protect those who work with them. Companies have a legal duty of care to ensure they are properly fitted and working effectively at all times. Disabling or switching off safety devices puts workers at unnecessary risk and is simply not acceptable. HSE will not hesitate to take enforcement action in cases such as this."

Unguarded or poorly guarded machinery is the cause of many injuries in workplaces across the country. Latest figures revealed eight workers were killed and more than 1,000 were seriously injured as a result of contact with the dangerous moving parts of machines.

BAe Systems fined £350,000 following death

BAE Systems  were fined £350,000 (inc. costs) following a death on an employeed in a press.

The circumstances were:

• Gary Whiting was part of a 4-man team carrying out a routine service of a large metal press, a machine the size of a two-bedroom house.
  
• The press was one of only a handful in the country and used to make Hawk jet trainer components.
  
• It was serviced around four times a year and all the maintenance team were experienced workers.
• Two men were working at one end of the machine and two at the opposite end. Neither pair could properly see the other.
  
• Mr Whiting and his colleague were working with one of the two trays that fed into either end of the press.
  
• The other team was testing the tray bed and press frame at the other side.
  
• Mr Whiting entered the machine to remove a piece of equipment.
  
• At the same time, one of his colleagues at the far end started the full test cycle of the press frame.
  
• The 45-square-metre frame descended, trapping and crushing Mr Whiting who died later that day. 

The HSE found that:

• There were serious safety failings of BAE Systems (Operations) Ltd at its plant in Saltgrounds Road, Brough.
  
• There were a series of flaws in safety practices during maintenance of the metal press, some of which had existed for many years.
  
• There were no suitable assessment of the risks associated with the test process.
  
• There was a lack of engineering control measures to prevent entry by workers to dangerous parts of the machine during testing or to stop the machine if anyone did enter a danger zone.

The HSE Inspector said:"This was an entirely preventable tragedy that devastated Mr Whiting’s wife, Jackie, his two children and his wider family. They have shown admirable resilience during what has been a protracted and, at times painful, process. The dangers of maintenance work on these types of machines are well- known yet BAE Systems Ltd failed to identify those risks and its serious failings led to this tragedy. Although the press machine had been serviced regularly, it was done in the same unacceptable way and it is surprising there had not been an earlier incident. The guarding was inadequate and there were no key safety systems, no light guards or interlocks on the doors of the machine; nothing that would have either prevented entry to dangerous parts or stopped the machine if entry was made. In addition, there were no instructions, either written or verbal, given by BAE to workers about how to carry out the testing process safely. This incident should serve as a reminder to companies to ensure that dangerous parts of their machines are identified and measures taken to properly protect their workers. No company should put its employees at unnecessary risk."

The accident occurred over 4 years ago.

Source: HSE 21/5/13  Y&H/105/13

Company and director fined after a fatal fall

Michael Febrey a director of a concrete structures firm has been ordered to pay a total of £25,000 (inc costs) and Carillion Construction Ltd, was fined £182,500 (inc.costs)
after a worker died following a fall from height at a Swansea building site.

The circumstances were:

• The deceased was contracted by Febrey Ltd to work as a scaffolder at the site in Swansea.
• He was dismantling a scaffold ladder access platform ahead of the installation of a roof and staircase on the fourth floor when he fell around 19 metres to the ground, narrowly missing a carpenter working directly below.

The HSE found that

• Febrey Ltd had inadequate and ineffective health and safety management arrangements
• There was little or no communication, information and instruction provided to its workforce.
• The management team on site was not adequately trained in health and safety, despite repeated warnings by its health and safety consultants. This led to persistent and systematic failures to control risks at the site.
• Mr Febrey was aware of the failings within his company - his workforce had raised concerns about the site – yet he failed to take responsibility for the company’s failings which allowed this culture to continue.
• Carillion Construction Ltd failed to ensure the safety of its employees and those under its control. 
• Carillion, as principal contractor at the site, was made aware of and had detected many failings in the safety management of Febrey Ltd. However, it failed to gain improvement from the company.

Carillion Construction Ltd, was fined £182,500 (inc.costs)
Febrey Ltd, of Burcott Road, Bristol, which when into liquidation shortly after the incident fined a token amount of £85, which - had it still been solvent and able to pay - would have been in the region of £250,000.

The HSE Inspector  said:
"Febrey Ltd did not manage health and safety. I can only echo the sentencing remarks made by Judge Thomas, that: ‘…there was a lack of proper and adequate expertise, training and direct responsibility for matters of health and safety. The personnel, the time, the resources and the will were all lacking to address the reoccurring problems of people working unsafely at height as necessary. Disregard for basic safety measures were left unchallenged. No one took ownership of the issue. In such an atmosphere, not only the inexperienced and the vulnerable, but the experienced like Mr Samuel, can become sloppy and complacent. It was against that background and in that culture that the accident happened. This culture was allowed to continue without proper managerial intervention and for that reason Mr Febrey, as the managing director, must bear a portion of direct responsibility. There was a void in the company’s organisation, which Mr Febrey must have recognised, but did not rectify. Carillion Ltd. had a duty to plan, manage and monitor the work. Febrey’s failing were all too apparent, moreover Carillion were aware of it. Judge Thomas said: ‘Ultimately, what they did not do was stop it - they did not do enough, they did not achieve the desired necessary result. Nagging and warning are one thing- positive, effective action is another. Carillion should have taken robust steps to remedy a situation which they were perfectly aware of.’ Falls from height are still the biggest killer in the construction industry and this is the tragic reality of what can happen when adequate arrangements are not in place to manage health and safety. Mr Samuel was a young man who had a lot to live for. His children and family will have to live with his loss for the rest of their lives. It is heartbreaking that his untimely death could so easily have been prevented."

Source: HSE 13 May 2013

Leg broken in several places by forklift truck

The Swan Mill Paper Company Ltd., of Swanley, have been prosecuted after a worker at its warehouse was injured after being crushed between a forklift truck and a pallet of paper goods.

The circumstances were:

• The injured person was in an aisle in the warehouse taking tickets off pallets that were filled with paper goods. 
• The pallets were then to be put on racks at either side of the aisle. 
• A colleague using a forklift truck to stack the pallets on the right hand side of the same aisle, reversed and backed into the worker, crushing him between the truck and the pallet.
• He suffered three breaks in his right ankle as well as two fractures to his left leg

The HSE:

• Found that the accident could have been avoided if simple safety precautions had been taken
• Prosecuted  Swan Mill Paper Company who were fined £8,000 (inc. costs)

The HSE Inspector said: "The incident was entirely preventable. Swan Mill Paper Company failed to make sure that there was a safe vehicle and pedestrian system of work in place within their warehouse. Such a measure would have prevented vehicles being able to access areas where workers on foot were moving around. Such a system was entirely possible without any detriment to the work being done. Due to the clear dangers of pedestrians and vehicles interacting in the same areas, companies need to ensure, as much as they can, that workers on foot and forklift trucks on the move are properly separated. The incident at Swan Mill Paper Company was in a fairly narrow aisle with restricted visibility. The risk of a collision between a moving forklift and a warehouse operative while both are working in the same location is significant and should have been obvious to the company."

Source: HSE 7th May 2013 LSE/96/13

2 health and safety bills in the Queen's Speech

In the Queen's Speech today, there were two bills which affect health and safety:

Mesothelioma Bill
This bill is designed to help people who suffer from Mesothelioma as a result of exposure to asbestos. It establishes a payment scheme for those people who cannot trace their employer or their employer's insurance company, where the employer was responsible for the asbestos exposure. Anyone diagnosed with mesothelioma from 25 July 2012 will be able to make a claim. The bill will be funded by a levy on insurance companies, and it will apply to the whole of the UK.

Draft Deregulation Bill
This draft bill lays out how the government intends to reduce the amount of regulation with which businesses, individuals and public bodies have to comply. Measures include exempting from health-and-safety legislation people who are self-employed and whose work poses no risk of harm to other people.

Part of leg may need to be amputated following crush by 1.5 tonnes of tin plates

David Wain suffered serious injuries when a 1.5 tonne pallet of tin plates fell onto his right lower leg and foot when he was employed by Emballator UK Ltd.

The circumstances were:

• The incident occurred on 6 February 2012 at the Emballator UK Ltd  factory in Tyersal, Bradford, which manufactures tin cans.
• A fault had developed on the usual, modern, pallet turner, which is used to turn bulk tin plate.
• Mr Wain, a coating assistant at the plant, had been told to use an older machine to turn the bulk tin plate
• He had no experience of using the older machine and a colleague gave him a demonstration of how to use it and how to load the pallets for turning.
• Mr Wain used a forklift truck to pick up a pallet of plates, loaded the machine the way he had been told - wedging the load using empty pallets - and switched it on. 
• Moments later, after the machine turned 180 degrees, he saw the plates and pallets moving. 
• He tried to get out of the way but the full load of metal plates spilled out of the machine in a weighty waterfall, trapping his foot against the floor.

Part of Mr Wain’s big toe was severed and the sole of his foot was split. Surgeons managed to reattach the next two toes and he needed plates put into his ankle and screws into his lower leg. He was informed earlier this year by the hospital that his foot and lower leg may need to be amputated.
The HSE found that:

• Emballator UK Ltd had failed to provide both safe equipment and a safe system of work. 
• There was no clamping mechanism to retain the pallet of metal plates within the rotating machine
• There was no guarding to keep operators from the machine during turning.
• The firm had not identified the risks involved with using the older machine, and in particular the risk of the plates falling out. 
• Mr Wain was not supervised whilst he used the machine for the first time. 
• No checks were made that he understood the risks and the precautions to take.

Emballator was fined £15,769 (inc. costs).

The HSE Inspector said:
"Everyone has the right to come home from work safe and well. But David Wain suffered life-changing injuries in an incident that was preventable. Emballator UK Ltd failed in their duties to provide a suitable machine for turning pallets and a safe method of operation that Mr Wain could use. Manually securing the load in an open box by means of wedges or empty pallets is not a sufficiently reliable method of securing the load. A proper examination of the risks would have shown that there was a danger of the load shifting and falling from the machine, during or after turning. A simple clamping mechanism would have secured it, and was indeed applied to the newer machine. It is also essential that checks are made by managers to ensure operators are trained and competent to use the machines they provide, understand the risks and associated precautions to take."

Source: HSE 1 May 2013 Y&H/93/13