Inadequate isolation procedure causes death in furnace
An accident at AETC Ltd., occurred because of inadequate isolation procedures which allowed a powered valve to close.
The circumstances were:
Graham Britten, a maintenance fitter, was carrying out maintenance in a vacuum casting furnace on 4 November 2009.
The furnace comprises two chambers separated by the large sliding isolation valve.
AETC Ltd did not have an effective isolation procedure for maintenance work on the furnace.
AETC Ltd had failed to adequately train and supervise maintenance staff.
The furnace control systems, intended to protect operators when carrying out routine cleaning within the furnace chambers, were inadequate and exposed them to unnecessary risk.
Mr Britten had gone to the furnace with a colleague to fix a fault after the main isolation valve had become jammed part-way while closing.
Mr Britten was standing on the rising table within the lower furnace chamber inspecting the valve when it suddenly closed, causing fatal head injuries.
AETC Ltd was fined £377,500 (inc. costs). In sentencing, Judge T Bayliss QC said:
"At the time of the accident there was no robust system in place to ensure safety during maintenance. It was left to the discretion of the fitters. It was, I’m sorry to say, a shambles."
The HSE Inspector said:
"There were two issues here. Firstly, the furnace operators routinely climbed into the furnace to clean, thinking that when the furnace doors were open the valve could not move. This was not the case and they were continually at risk. Secondly, there was no safe system for maintenance work. There were no isolation procedures and, as a result, the fitters developed their own methods of working. The maintenance work that Mr Britten was carrying out was not unforeseen and the jamming of the isolation valve was a recurring problem which ATEC knew about. When the valve jammed, air pressure continued to build up in the cylinder that drives the valve such that, when the jam was cleared, the stored energy caused the valve to close rapidly with tragic consequences. Safe isolation procedures with training, supervision and monitoring would have prevented Mr Britten’s needless death."