Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0001, written 6 Jan 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jan 2014 |
|---|---|
| Reference | 2014-0001 |
| Deceased | Martin McGlasson |
| Coroner | Robert Chapman |
| Coroner area | Cumbria (North & West) |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Martin Clarke, Chief Executive, British Precast Concrete Federation. CORONER | am Robert Chapman, Assistant Coroner, for the Coroner Area of North and West Cumbria CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 12" September 2011 | commenced an investigation into the death of Martin Geoffrey McGlasson, aged 37. The investigation concluded at the end of the Inquest before a Jury on 20" December 2013. The conclusion of the inquest was: The Cause of death was: 1.a. Multiple Injuries The Conclusion of the jury was: Mr McGlasson died as a result of an accident CIRCUMSTANCES OF THE DEATH Mr McGlasson was a plant operative employed by ACP Concrete Limited, part of Thomas Armstrong Holdings Limited, in Workington, Cumbria. On the 2™ September 2011 he was slurrying a concrete staircase that had, that morning, been removed from a mould. The staircase had been transported by another operative by overhead crane and placed on its edge on two wooden battens on the floor. The staircase was not supported by the crane, or by other means whilst Mr McGlasson worked on it. He had slurried the back of the staircase and had started on the stairs side when the staircase fell on him, crushing predominantly his chest. The staircase was removed by use of the crane but it was clear that he was dead at the scene. The stairs weighed almost 3 tonnes. No one witnessed the accident. The evidence was that the system of work, which had been in operation for 23 years without incident, was that: 1. After removal from the mould by overhead crane the staircase was set down on two or more battens (depending on the size of the staircase and any landings it had); 2. The operator would “sweep” the floor with the battens to ensure that they had no debris underneath, before setting the staircase down; 3. He would also seek to place the batten under the widest part of the stair to ensure maximum stability; 4. The operator would take the tension off the crane and then take hold of the top of the staircase and attempt to move, or rock it, it to check its stability. If he was concerned that it was unstable he would lift it and move the battens or the staircase; 5. Once satisfied as to stability he would remove the chains and leave the Staircase, unsupported, to be slurried. 6. After the slurrying process had been completed the staircase was “rocked over” onto the forks of a forklift truck and then removed to the storage yard. The evidence at the Inquest was that the method of work was followed on the day of Mr McGlasson's death. The work area was busy and the operative moved the staircase to what was considered to be an unusual place, in front of the joiners bench. During the police and HSE investigation there was evidence of debris at the scene, such as small offcuts of plywood, screws etc, that may possibly have been under one or more of the wooden battens. It appears that the battens had been placed under the staircase at almost the narrowest part of the stairs rather than the widest part. A specialist HSE Inspector gave evidence at the Inquest to the effect that in normal circumstances substantial effort, in excess of the power of one man, would be needed to push or pull over a staircase if placed properly on the wooden battens. However in this case the most likely explanation for the overturn was that there was debris under the battens. There was clearly concern why this instability was not felt by the operative when he put down the stairs, or Mr McGlasson as he was slurrying, and no explanation was forthcoming. There had been, in 2003, a short attempt to change the method of work to ensure that the staircase was supported by the crane during slurrying. This was found to be impracticable, and was abandoned. They returned to the former method of work, as described above, and that remained in use until Mr McGlasson's death. However the Risk Assessments for several subsequent years and up until the death, which had been prepared by the Health and Safety Department at Thomas Armstrong Holdings Ltd showed that the method of work in operation was that the stairs were supported by the crane. There appears to have been no recognition by the managers, health and safety department or the supervisors of the difference in what was actually happening on the shop floor to what was said in the Risk Assessments. Following Mr McGlasson's death the HSE immediately served a Prohibition Notice on ACP Concrete limited. Within a few days they had put in place a new method of work so that'a “toast rack” was installed in front of each mould. These are steel pillars which slide into the floor and which support the staircases, which are also chocked, during the course of slurrying. The evidence at the Inquest was that the cost involved in building the “toast rack” was small, and its use has not appreciably affected the speed of the process. They do not make fewer stairs as a result of the new method of work. Coincidentally there had been another accident at the ACP works on the morning of Mr McGlasson’s death. A 17 year old had been rocking a small staircase onto the forks of a fork lift truck when the staircase rocked back at him and pinned his against the front of the mould. Fortunately a bolt sticking out from the front of the mould had prevented the staircase crushing his legs. As a result of this accident ACP Concrete have devised a method of overturning stairs after slurrying that does not involve men rocking the stairs onto the forks. They now transport the staircases by crane to a sloping gravel pit. Again the cost of installing the gravel pit was small and it has made no appreciable difference to the rate of production. Not surprisingly the evidence at the Inquest was that the new method of work was much safer in that it eliminated the risk of injury or death in slurrying or finishing the staircase and then subsequently handling it. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) The Health and Safety Director for Thomas Armstrong Holdings Ltd gave evidence that the method of work undertaken by ACP prior to Mr McGlasson’s death is in widespread use throughout the industry. Thus a number of your members are at risk of deaths occurring in their establishments in similar circumstances to Mr McGlasson’s death, and presumably at risk of having Prohibition Notices served on them by the HSE. Whilst the method operated had not apparently previously caused any accidents at ACP Concrete, evidence was given of an accident at Bison Concrete Products in 2002 involving the death of Mr David Jenkins. | understand that whilst it involved the overturning of a staircase, it occurred in a storage yard in a “domino effect”. (3) The method of preventing an accident as occurred to Mr McGlasson by installing a “toast rack” and gravel pit are inexpensive and do not affect production (4) The risk of an accident occurring should be weighed in the balance with the potential injuries (which in this case are likely to be fatal or serious), and the cost involved in preventing such injuries (which in this case are very small). There cannot be any serious argument about affecting production. Care should be taken to ensure that Risk Assessments or their contents are disseminated or explained to the staff actually operating the process to ensure that what is being done on the ground is reflected in the Risk Assessment, and proper care given to then assess the actual risk. (2 — (5 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe that the British Precast Concrete Federation has the power to advise your members to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 3 March 2014. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of report to the Chief Coroner and to the following Interested Persons: ACP Concrete Limited and their solicitors f ACP Concrete and his solicitors | sO the Health and Safety Executive. | have also sent it to the following who may find it useful or of interest: The Cumbria Constabulary lam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 6th January 2014 Signed: UL ‘
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
DWF LLP 1 Scott Place 2 Hardman Street Manchester M3 3AA DX 14313 Manchester T 03333 20 22 20 F 03333 20 44 40 www.dwf.co.uk Your Ref: RC/SS/I/3/861/11 Mr Chapman Our Ref: JVC/N50024/29882 HM Coroner ; Please quote 5 D & E Lakeland Business Park this when Lamplugh Road replying —_ Cockermouth Date: 30 April 2014 Cumbria CA13 0QT Please ask for: Ext: By Post and By Email: Beal hmcoroner.northwest@cumbria.gov.uk Direct Fax: Dear Mr Chapman, MR MARTIN MCGLASSON (DECEASED) INQUEST 17 TO 20 DECEMBER 2013 RESPONSE TO REGULATION 28 REPORT We write in reference to your Regulation 28 Report dated 6 January 2014 and further to our letter of response dated 3 March 2014. To set the background, during the Inquest the evidence was that the system of work adopted by the Company which had been in operation for 23 years without incident was that: 1.After removal from the mould by overhead crane the staircase was set down on two or more battens (depending on the size of the staircase and any landings it had); 2. The operator would “sweep” the floor with the battens to ensure that they had no debris underneath, before setting the staircase down; 3. He would also seek to place the batten under the widest part of the stair to ensure maximum stability; 4. The operator would take the tension off the crane and then take hold of the top of the Staircase and attempt to move, or rock it, to check its Stability. If he was concerned that it was unstable he would lift it and move the battens or the staircase; 5. Once satisfied as to Stability he would remove the chains and leave the staircase unsupported, to be slurried. 6. After the Slurrying process had been completed the staircase was “rocked over” onto the forks of a forklift truck and then removed to the storage yard. This system of work was an industry wide practice. As a result of the Inquest your Report Provided that we respond with actions we have taken which will help prevent future deaths (our actions being taken after advice and guidance being received from the British Precast Federation “BPCF). URMIN50024/29882/958 7666-40, Auth Your Report set out that we provide a written response by Monday 3 March 2014. We wrote to you on 3 March 2014 to request an extension of time for the Company to formally respond to the Regulation 28 letter. This was to allow us time to evaluate the British Precast Federation [BPCF] guidance which wasn’t available at that point in time and make any additional and necessary changes to the Company's internal Procedures and manufacturing process. We understand the British Precast wrote to you on 28 February 2014 Stating that it was taking its instruction very seriously and set out the actions it had already taken and a timetable for action. The British Precast and its members confirmed they had already:- 1. Formally consulted and discussed with their product group the Precast Flooring 2 Formally consulted and discussed with their product group the Structural Precast 3. Visited ACP Concrete and the factory where the accident occurred to see the remedial 4. Had extensive internal discussion regarding how to promote improved Safety across the whole industry and beyond their membership. The proposed timetable of their action, including actions completed was confirmed as follows:- 1. Consult and discuss with relevant Parts of British Precast by 14 March including a meeting of our Health and Safety Steering Committee on 4 March and the next SHAD to be held on 11 March at Aggregate Industries, Hulland Ward factory, Derbyshire 2. Checking with Bison Concrete Products and past management for any related lessons from the death of Mr. Jenkins by 12 March. 3. Develop Proposed best practice by end March 2014 4. Hold a consultation period on proposed best Practice with HSE, within membership and also with manufacturers that are not members 5. Issue best Practice guidance on May 1* at our AGM and conference PRECAST2014, By way of background information British Precast is the trade association for UK concrete Product producers operating permanent or long-term temporary manufacturing facilities. They have over 70 manufacturing members accounting for 70% of industry output. The British Precast target is to create a zero harm workplace for all. We can confi anaging Director of the Co i (Group HS Director) and Finance Director, met with SO of the Britis recast Concrete Federation. We can confirm that the circumstances Surrounding Mr McGlasson’s death, the subsequent investigation and the Inquest were discussed. ee... ae. the British Prec. Federation visit Company premises at Workington. During this visit iain and el URMIN50024/29882/9587666-1 viewed and assessed the procedures and systems in place relating to the manufacture of Precast stairs and in particular the restraining systems employed when Stairs were stood on their stringer edges. Subsequent to this meeting EE o1s0 attended a BPCF safety meeting on 12 March 2014. This meeting had been called in relation to improving safety of the Prestressing process where the British Precast have a task group working with the HSE. Part of the agenda of this meeting Specifically related to the Stability of stairs during their manufacture Process and therefore was an Opportunity to address the issues of stair safety The BPCF has now evaluated all the evidence and has developed best practice guidance on Safe factory finishing of precast concrete stairs. This guidance has been developed in consultation with:- - The specialist Product groups of British Precast — the Precast Flooring Federation and the Architectural and Structural Precast Association - The wider membership of British Precast - Non-members of British Precast as best they were able to do - The Health and Safety Executive The Company received draft copy of the BPCF Members Briefing Document No 11/2014 which sets out the best Practice guidance. We can confirm that the Company has reviewed the briefing document and agreed to the implementation of its Comments and guidelines. We can confirm the best Practice guidance is as follows:- A risk assessment and safe system of work should be developed, communicated and agreed with all relevant Staff. It is industry best practice to avoid placing stairs on their edge unless needed. If placing on edge is required then standard practice is:- - To support by craneage. - To support by a restraint system (e. g. toast rack type system) A copy of the Members Briefing No: 11/2014 which shall be formally circulated by the BPCF on 1 May 2014 is enclosed. The Company has listed below the actions implemented in relation to the precast concrete stair manufacturing process. Actions that were implemented immediately post the fatal accident and prior to recommencement of the stair manufacturing process:- 1. Immediate cessation of the practice of storing and working on staircases standing on their stringer edges without any means of restraint. The British Precast Guidance No: 11/2014 Specifically states that “it is industry best practice to avoid Placing stairs on their edge unless needed”. 2. Installation of the TOAST RACK stair Support system, whereby the stairs are placed on their stringer edge between upright steel posts, including the placement of chock blocks for further Stability before being released from the crane hooks and having subsequent URM/N50024/29882/9587666-1 dressing works applied. The British Precast Guidance 11/2014 specifically refers to a toast rack type system as a Suitable restraint system. The guidance States that “/f placing on edge is required then standard practice is: - To support by craneage. - To support by a restraint system (e.g. toast rack type system) 3. Immediate cessation of manually tipping stairs from their stringer stood edges to being laid flat on their soffit. Installation of a TIPPING PIT whereby all stairs are to be transported from the TOAST RACKS to the TIPPING PIT, using the overhead crane, and purpose lifting points on the top edge Stringer of the Precast stair, where the stair is then slowly lowered into the gravel TIPPING PIT allowing the stair to rotate safely onto its Soffit. All operatives including the crane operator are stationed at a Safe distance external to the TIPPING PIT. As a result of the death of Mr McGlasson and in light of the Particular and unprecedented circumstance of the incident, other measures have also been taken, which include: In consultation with the Precast Stair Department Operatives & Supervisors, the Risk Assessment was revised, and amended working procedures were drawn up to reflect the changes in working practices agreed including the Support and Turning of precast Stair units as detailed above. A series of further TOOLBOX TALKS were also held involving all those concerned in the Management, Supervision & Manufacture of Precast Concrete Stairs reflecting the revised Risk Assessment & Safe Working Method and a copy of these documents were issued to all those noted above. Subsequent to issue to all general Operatives and Supervisors in the stair department, further Consultation took place resulting in adoption of an agreed safe system of work in the manufacturing process of Precast stairs, from mould preparation to completion. In common with the company’s other Processes, working Practices in the staircase department remain under constant review, and the Company carried out a full formal review of all company practices and Procedures, as well as and including a full formal review of all Management, Supervisors & General Operatives training including those relative to Health & Safety Management and Awareness. The Process of review and consultation on safe systems of work, was rolled out to the Production processes relating to all other Products manufactured by ACP at the Production facilities at Lakes Road Workington, Risehow, Maryport & Trafford Park Manchester, resulting in agreed Safe systems of works being adopted. URMINS0024/29882/9587666, 1 These were introduced through a series of internal training toolbox talks, using the newly adopted Risk Assessment & Method Statement as the basis. The Company also employed the services of external training providers for the training of supervisors and meeting shall include the three named representatives and two me management team. The nominated m bers of the management team are’ the Production Manager a the Group Health and Safety Director. If they are not available another mem er of the management team would be invited to participate. 10. The company wants to raise awareness of current Safety standards set by the Company to prevent accidents and have introduced new Procedures to achieve this. This involves a new starter review through which the Company will monitor, assess, instruct and train new employees. It is intended that every week at the supervisors meeting, safety issues are to be discussed including any accidents that have occurred. The stated aim of the Company is the prevention of any re-occurrence of accidents. Yours faithfully MN LLP URMIN50024/29882/9587666-1
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