Man killed and 6 injured by flying gas cylinders

A man was killed and six other injured by flying gas cylinders at a construction project.

The circumstances were:

• Crown House Technologies Ltd of Dartford, Kent, was principal contractor for a construction project.
• They engaged Kidde Fire Protection Services Ltd, of Slough, Berkshire, to supply and install fire suppression equipment at the new facility.  
• This work was carried out by Kidde Products Ltd, also from Slough.
• The three companies involved failed to recognise the significant risks involved in the project or to carry out an adequate risk assessment. 
• The principal contractor and the main contractors failed to co-ordinate the scheduled work activities or to co-operate meaningfully in light of the risks. 
• There had also been insufficient training and supervision.
• 80 cylinders, nearly two metres high and each weighing 142 kg,  were stored without their safety-critical protection caps and left without being properly secured in racks.
• Other trades involved in the construction project were also working next to these potentially unstable cylinders, unaware of the deadly risks involved.
• One or more of these cylinders was de-stabilised and probably fell over, causing its unprotected valve to shear off near the cylinder neck. 
• This released an uncontrolled jet of liquified argonite gas under high pressure, the force of which caused the cylinder to move, colliding with others. 
• These, in turn, were also knocked over and sustained similar damage.
• A chain reaction developed rapidly and for several minutes shocked and terrified workers desperately sought shelter as they endured a barrage of heavy cylinders rocketing around them. This continued until 66 of the 80 cylinders had been discharged. 
• Some of the cylinders travelled at estimated speeds of up to 170mph and developed sufficient energy to penetrate walls and ceiling voids, travelling into more remote parts of the building.
• The deceased was walking with a colleague when he was struck by one of the argonite gas cylinders as they were propelled alarmingly around the building. He suffered multiple injuries and died at the scene.
• Several other workers, including electricians working in the argonite store room, suffered injuries and long term effects 

  

Crown House Technologies Ltd  was fined £236,393 (inc. costs)

Kidde Fire Protection Services Ltd  was fined £224,696 (inc. costs).

Kidde Products Ltd. was also fined £224,696 (inc. costs)..

The HSE  Inspector  said:

"Mr Johnston had no control over the chain of events which led to his tragic death. He died while going about his business as a result of the shortcomings of others. It is only by chance that this incident did not cause further fatalities. There is little evidence that those involved were competent to undertake this work, or that safe systems of work were provided, or that there was suitable cooperation between the contractors involved. Employees of other companies were allowed to enter the argonite store while it was potentially unsafe to do so, and there is no evidence that anyone explained the risks to them, or acted effectively to control these risks. This incident was devastating for his family and yet it could have been avoided had there been effective planning, management, monitoring and coordination of the relevant activities. Health and safety is sometimes dismissed as an unnecessary burden on businesses but this tragic case clearly demonstrates its true importance to those at the 'sharp end' of the industry."

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."

Don't get caught out. Prepare a business continuity plan

Many companies pay lip service to disaster recovery plans. For a start, this is the wrong term; business continuity is a far more meaningful name, because it is more than thinking about fires or computer system major crashes. For example, what would happen if a key person was involved in a car crash. (This happened to me 30 years ago and people kept asking work questions from my hospital bedside.)

At an initial count, 25 to 30 scenarios need to be planned for to cover basic provisions, covering such topics as:

• People, eg what happens if key people are ill?
• Premises, eg fire
• Technology, eg what happens if key equipment breaks down?  What happens if the local phone system fails?
• Supplies, including key external services, eg what happens if a key supplier is unable to supply?
• Civil emergencies, including lack of accessibility to the site because of external factors such a major chemical spill on the industrial estate or accidents or flooding on access roads

Carry out a risk assessment, much as you would for health and safety, and assign scores for severity of the outcome and it's probability. Then, in descending order of risk:

1. Define steps to be taken to recover a situation.
2. Carry out step 1, plus where appropriate, define provisions to make such steps work. For example, with IT systems, not only is a back-up necessary, but it may be advisable to have an off-site back-up.
3. Carry out the above steps, plus make contact with appropriate organisations to organise the support they can provide and define how this may be organised.  For example, you may use another company to carry out operations which are unavailable because of the event.  Contact this company and arrange how this may be arranged, ie contact names and numbers. 
4. Carry out the above steps and, where appropriate, carry out a test of the plan.  This is typically essential where the provisions are technology-based.  For example, you need to test IT back-ups to confirm that they actually work.

 SSS can provide help with this. But whether or not you use outside help, it is essential that you do it.

Inadequate non-core operation results in fall through roof

Lack of a system for non-core operations was the underlying cause of a fall from height.
The circumstances were:

• An employee of  Paragon International Ltd., a vending machine supplier, was sent onto the roof to clean the guttering between two connected buildings. 
• No provisions were made to do the work safely, such as hiring a cherry-picker
• He was told he should try to stay away from the roof lights, but no practical steps were taken by the company to avoid this.
• The employee and another worker had to carry bags of debris to the top of the roof, walking on the metal sheets between the roof lights, so that it could be collected by a forklift truck.
• One of the men accidentally stepped onto a roof light and fell 6m into the accounts office below. He suffered bruising to his right side and leg, and injuries to his right hand and back.

Paragon International Ltd, was fined  £13,567 (inc. costs).

The HSE Inspector said:
"The worker was extremely lucky not to have been seriously injured or even killed when he fell through the roof light. If he had fallen further along the roof then he would have landed on the concrete warehouse floor. Paragon International knew the roof lights were fragile but he was simply told to try to avoid them, rather than any action being taken to keep him safe. The company should have carried out a proper assessment of the risks and then controlled them so that the work could be out safely. They could have used a cherry-picker, harnesses or safety netting, but none of these were chosen. An employee’s life was put at risk as a result."

SSS comment: This is a clear example of a failure to anticipate risks due to non-core operations. A company may have safe operations for its main business but fail to cope with something out of their normal expertise.  A simple permit to work system, which prompts a check of risks and how to control them is necessary for non-core operations.

Government plans to reduce work experience H&S requirements - full text

The Government is to simplify the health and safety requirements for businesses planning to offer work experience to school pupils as part of its crackdown on "burdensome" rules, it has announced.25 Jun 2013

New guidance issued by the Health and Safety Executive (HSE) states that young people should be treated in the same way as ordinary employees, and that businesses that have already performed a risk assessment with young people in mind do not need to repeat this assessment every time they take on a new student.

"Work experience is an important step in preparing young people for the world of work," said HSE chair Judith Hackitt. "Our revised guidance makes it clear – and easy – for employers and work experience organisers to understand what they need to do."

"There is no need for lots of paperwork or an over-cautious approach. Employers who are already managing the risks in their business effectively for employees are unlikely to need to do anything in addition for work experience. Schools and colleges just need to ask a few questions to ascertain that appropriate measures are in place," she said.

Alongside the new guidance, the Association of British Insurers has confirmed that work experience students will be treated as existing employees for the purposes of compulsory employers' liability insurance policies. Employers will also no longer have to carry out disclosure checks on staff supervising young people aged 16 or 17 on work experience.

The announcement is the latest in the Government's drive to cut down on unnecessary and over-burdensome health and safety regulation. Recent announcements have seen low-risk businesses taken out of the health and safety inspection regime, and proposals to remove around 800,000 self-employed people whose work poses no harm to others from health and safety regulation. From October this year, the law will also be changed so that businesses will no longer be liable for workplace accidents where they were not negligent.

The new guidance from the HSE in relation to work experience placements makes it clear that employers are "best placed to assess whether or not they need to do anything additional for a new young person joining them". Under health and safety law, work experience students become employees and should be treated no differently to other young people working for the employer, it says.

Employers should use their "existing arrangements" for the assessment and management of risks to young people, according to the guidance. For a business with five employees or fewer, written risk assessments are not required. Businesses that do not currently employ young people or that are taking on a work experience student for the first time should review their risk assessment before they start, but they do not need to repeat the assessment if a subsequent student is "of a broadly similar level of maturity and understanding" and has no additional needs.

Placements in "low-risk environments, such as offices or shops" should not require any additional preparatory work by the employer. Employers should "make arrangements to manage the risks" where the environment is less familiar to the student, according to the guidance. These arrangements could include induction, supervision, site familiarisation, protective equipment and control measures for specific high-risk factors, depending on the nature of the workplace, according to the guidance.

Schools, colleges and those organising placements are advised in the guidance to "simply ask sensible questions, in proportion to the level of risk", to satisfy themselves that the appropriate arrangements are in place. They should not be "second-guessing employers' risk assessments or requiring additional paperwork", according to the guidance.

Worker escapes death after 11m fall from cherry picker

Bradford Council was fined after a cherry picker overturned.

Bradford Council has admitted failing to adequately plan work at height following an incident where a worker fell from the cradle of a cherrypicker.

Two council workers were pruning dead branches in Bierley Hall Woods when the incident took place on 27 July last year. They parked the cherrypicker correctly on a compacted path in the woods and placed ground mats underneath the vehicle's stabiliser feet.

One of the workers then stood in the cradle as it was extended to 35 feet above the ground, so he could begin pruning the branches. As he rotated the boom arm and cradle anti-clockwise to move from tree to tree, the weight distribution of the machine changed and the cherrypicker overturned, causing him to fall 11 metres to the ground.

The 23-year-old suffered fractures to his spine, collarbone, pelvis and right leg, and also sustained internal injuries that required surgery. He was unable to return to work for more than five months and is no longer able to carry out tree work at height.

The HSE investigated the incident and found the council had supplied the wrong type of ground mats. As a result, when the vehicle's weight shifted, one of the stabiliser feet slid off a mat and sunk into the soft ground, causing the vehicle to overbalance.

The investigation also found the work hadn't been properly planned and the council had failed to train workers to carry out tree work on soft, sloping, or uneven ground.

HSE inspector David Welsh said: "The use of a vehicle-mounted cherrypicker for work at height needs to be properly planned and organised. The council failed to assess the risks of the tree-pruning work and provided unsuitable mats for the stabiliser feet, which led to an unsafe system of work being in operation.

"A cherrypicker is specialist lifting equipment for work at height and the council did not have a lifting plan in place for its general use for tree pruning, despite the dangers of using such lifting equipment being well-known."

City of Bradford Metropolitan Council appeared at Bradford Magistrates' Court on 25 June and pleaded guilty to breaching s2(1) of the HSWA 1974. It was fined £12,000 and ordered to pay £9623 in costs. - See more at: http://www.shponline.co.uk/home/in-court/full/worker-plunged-11-metres-from-overturning-cherrypicker#sthash.WORJpVJ5.dpuf

Bradford Council has admitted failing to adequately plan work at height following an incident where a worker fell from the cradle of a cherrypicker.

Two council workers were pruning dead branches in Bierley Hall Woods when the incident took place on 27 July last year. They parked the cherrypicker correctly on a compacted path in the woods and placed ground mats underneath the vehicle's stabiliser feet.

One of the workers then stood in the cradle as it was extended to 35 feet above the ground, so he could begin pruning the branches. As he rotated the boom arm and cradle anti-clockwise to move from tree to tree, the weight distribution of the machine changed and the cherrypicker overturned, causing him to fall 11 metres to the ground.

The 23-year-old suffered fractures to his spine, collarbone, pelvis and right leg, and also sustained internal injuries that required surgery. He was unable to return to work for more than five months and is no longer able to carry out tree work at height.

The HSE investigated the incident and found the council had supplied the wrong type of ground mats. As a result, when the vehicle's weight shifted, one of the stabiliser feet slid off a mat and sunk into the soft ground, causing the vehicle to overbalance.

The investigation also found the work hadn't been properly planned and the council had failed to train workers to carry out tree work on soft, sloping, or uneven ground.

HSE inspector David Welsh said: "The use of a vehicle-mounted cherrypicker for work at height needs to be properly planned and organised. The council failed to assess the risks of the tree-pruning work and provided unsuitable mats for the stabiliser feet, which led to an unsafe system of work being in operation.

"A cherrypicker is specialist lifting equipment for work at height and the council did not have a lifting plan in place for its general use for tree pruning, despite the dangers of using such lifting equipment being well-known."

City of Bradford Metropolitan Council appeared at Bradford Magistrates' Court on 25 June and pleaded guilty to breaching s2(1) of the HSWA 1974. It was fined £12,000 and ordered to pay £9623 in costs. - See more at: http://www.shponline.co.uk/home/in-court/full/worker-plunged-11-metres-from-overturning-cherrypicker#sthash.WORJpVJ5.dpuf

The circumstances were:

• Two tree workers set up the cherry picker correctly on a compacted path in the woods on 27 July 2012.
• The council had failed to properly plan and organise the safety aspects of the tree pruning work. 
• All the council workers who did tree work in off-road locations had never been trained to do the work in soft, sloping or uneven ground. All the training had been done in a depot yard.
• The stabilsier feet were set down on mats.
• No one had realised that the distance between the stabiliser feet was greater than the width of the path. 
• The wrong type of ground mats had been provided to the team to put underneath the machine's feet.
• One of the workers was working in the extended cradle among the tree tops. 
• As he rotated the boom arm and cradle anti-clockwise to move from tree to tree, the weight distribution of the machine changed.
• When the weight shifted, one of the vehicle's stabiliser feet had slid off a ground mat and then sunk into the soft ground at the side of the compacted path.  
• The unbalanced machine then toppled without warning.
• The worker plunged eleven metres from the cradle of a cherry picker.
• He suffered multiple injuries including fractures to his spine, collar bone, pelvis and right leg, plus internal injuries that required surgery

Bradford Council was fined  £21,623 (inc. costs) on 25th June 2013.

The HSE inspector said:
"A young man has suffered life-changing injuries as a result of a number of failures by Bradford Council but we could easily have been dealing with a fatal injury considering the distance of this worker's fall. The use of a vehicle-mounted cherry picker for work at height needs to be properly planned and organised. The Council failed to assess the risks of the tree pruning work and provided unsuitable mats for the stabiliser feet, which led to an unsafe system of work being in operation. A cherry picker is specialist lifting equipment for work at height and the council did not have a lifting plan in place for its general use for tree pruning, despite the dangers of using such lifting equipment being well known. Work at height remains one of the most significant causes of death and major injuries among workers. All such work must be carefully planned and workers need the correct equipment for each task and adequate supervision."

Bradford Council has admitted failing to adequately plan work at height following an incident where a worker fell from the cradle of a cherrypicker.

Two council workers were pruning dead branches in Bierley Hall Woods when the incident took place on 27 July last year. They parked the cherrypicker correctly on a compacted path in the woods and placed ground mats underneath the vehicle's stabiliser feet.

One of the workers then stood in the cradle as it was extended to 35 feet above the ground, so he could begin pruning the branches. As he rotated the boom arm and cradle anti-clockwise to move from tree to tree, the weight distribution of the machine changed and the cherrypicker overturned, causing him to fall 11 metres to the ground.

The 23-year-old suffered fractures to his spine, collarbone, pelvis and right leg, and also sustained internal injuries that required surgery. He was unable to return to work for more than five months and is no longer able to carry out tree work at height.

The HSE investigated the incident and found the council had supplied the wrong type of ground mats. As a result, when the vehicle's weight shifted, one of the stabiliser feet slid off a mat and sunk into the soft ground, causing the vehicle to overbalance.

The investigation also found the work hadn't been properly planned and the council had failed to train workers to carry out tree work on soft, sloping, or uneven ground.

HSE inspector David Welsh said: "The use of a vehicle-mounted cherrypicker for work at height needs to be properly planned and organised. The council failed to assess the risks of the tree-pruning work and provided unsuitable mats for the stabiliser feet, which led to an unsafe system of work being in operation.

"A cherrypicker is specialist lifting equipment for work at height and the council did not have a lifting plan in place for its general use for tree pruning, despite the dangers of using such lifting equipment being well-known."

City of Bradford Metropolitan Council appeared at Bradford Magistrates' Court on 25 June and pleaded guilty to breaching s2(1) of the HSWA 1974. It was fined £12,000 and ordered to pay £9623 in costs. - See more at: http://www.shponline.co.uk/home/in-court/full/worker-plunged-11-metres-from-overturning-cherrypicker#sthash.WORJpVJ5.dpuf

Bradford Council has admitted failing to adequately plan work at height following an incident where a worker fell from the cradle of a cherrypicker.

Two council workers were pruning dead branches in Bierley Hall Woods when the incident took place on 27 July last year. They parked the cherrypicker correctly on a compacted path in the woods and placed ground mats underneath the vehicle's stabiliser feet.

One of the workers then stood in the cradle as it was extended to 35 feet above the ground, so he could begin pruning the branches. As he rotated the boom arm and cradle anti-clockwise to move from tree to tree, the weight distribution of the machine changed and the cherrypicker overturned, causing him to fall 11 metres to the ground.

The 23-year-old suffered fractures to his spine, collarbone, pelvis and right leg, and also sustained internal injuries that required surgery. He was unable to return to work for more than five months and is no longer able to carry out tree work at height.

The HSE investigated the incident and found the council had supplied the wrong type of ground mats. As a result, when the vehicle's weight shifted, one of the stabiliser feet slid off a mat and sunk into the soft ground, causing the vehicle to overbalance.

The investigation also found the work hadn't been properly planned and the council had failed to train workers to carry out tree work on soft, sloping, or uneven ground.

HSE inspector David Welsh said: "The use of a vehicle-mounted cherrypicker for work at height needs to be properly planned and organised. The council failed to assess the risks of the tree-pruning work and provided unsuitable mats for the stabiliser feet, which led to an unsafe system of work being in operation.

"A cherrypicker is specialist lifting equipment for work at height and the council did not have a lifting plan in place for its general use for tree pruning, despite the dangers of using such lifting equipment being well-known."

City of Bradford Metropolitan Council appeared at Bradford Magistrates' Court on 25 June and pleaded guilty to breaching s2(1) of the HSWA 1974. It was fined £12,000 and ordered to pay £9623 in costs. - See more at: http://www.shponline.co.uk/home/in-court/full/worker-plunged-11-metres-from-overturning-cherrypicker#sthash.WORJpVJ5.dpuf

Worker's hand drawn into unguarded rollers on laminating machine

A Wellingborough firm has been fined for safety breaches after a worker’s hand was crushed in an unguarded laminating machine.

The circumstances were:
 

• The incident, on 20 January 2012 occurred at The Paper Pallet Company Ltd 
• The company uses recycled paper to make pallets
• A honeycomb laminating machine was unguarded at several points, not just where the incident occurred.
• The guarding over the gears and chains allowed access to dangerous moving parts.
• Some of the emergency stops did not work properly.
• The company had not carried out a risk assessment on the machine.
• There was no safe system of work for cleaning the gluing rollers or for the operation, use and maintenance of the line.
• An operator's right hand and forearm were drawn into gluing rollers of the machine.
• He has had four operations and extensive physiotherapy but it is unlikely he will ever regain full movement in his hand.

Following the incident, the company introduced a light guard system, which shuts down the line if anyone breaks the beam to approach dangerous moving parts.

The Paper Pallet Company was fined £30,877 (inc. costs).

The HSE inspector said:
"This is a very serious case of a company neglecting its duty to supervise and protect its employees from potentially dangerous machinery. Basic risk assessments weren’t carried out and Mr Taylor was not given suitable instruction in how to use the machine safely. Even his supervisor had not been given appropriate health and safety training to allow him to discharge his responsibilities adequately. The Paper Pallet Company Ltd has now introduced measures that will cut the power to the machinery if anyone approaches dangerous moving parts. It’s just a shame this did not happen before their employee suffered such severe injuries."