Prevention of Future Deaths reports · 2014

Shaun Maslin

Regulation 28 report to prevent future deaths, reference 2014-0277, written 19 Jun 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report19 Jun 2014
Reference2014-0277
DeceasedShaun Maslin
CoronerRichard Travers
Coroner areaSurrey
CategoryAccident at Work and Health and Safety related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquests Touching the Death of Shaun MASLIN
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
 The Secretary of State for the Department of Business, Innovations
and Skills.
 The Chief Executive of the Energy and Utilities Skills (‘EUS’).
1 CORONER
Richard Travers HM Coroner for Surrey
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
3 INVESTIGATION and INQUEST
The inquest into Shaun Maslin’s death was opened on the 25th October
2011 and was resumed on 12th June 2014 with a jury. It was concluded on
18th June 2014.
The jury found that the cause of death was:
1a: Multiple Injuries, including spinal cord laceration at the base of
the brain.
They concluded with the short form conclusion:
Accidental Death.
4 CIRCUMSTANCES OF THE DEATH
On the morning of the 21st October 2011, Mr MASLIN was working with
his team of two men, on a gas main situated adjacent to the A30 between
the M25 and the Crooked Billet roundabout in Staines, Surrey. During the
course of the morning Mr Maslin proceeded to undertake a medium
pressure test on the part of the pipeline which crossed the river Colne, it
was known as the ‘River Crossing’. The works formed part of the NLGA
7600 project which was concerned with the replacement of the
RT4079 1
Twickenham medium pressure gas main. That project formed part of a
larger project being undertaken by the North London Gas Alliance which
was made up of National Grid Gas plc and Skanska plc. The Alliance had
subcontracted work to a company by the name of RBS Utilities and that
company had in turn sub‐contracted some of the work to Mr Maslin’s
company SM Plant Hire Ltd. The pressure test had not been authorised
under the NLGA’s Safe Control of Operations procedures and it was
conducted in a manner that did not comply with the NLGA’s practice
requirements. The jury concluded that, despite the above, there was
agreement that the pressure test should be undertaken. During the course
of the test and whilst the pipe was under pressure, the bracing which had
been fitted by Mr Maslin broke with the result that one of the one of the
end caps that had been fitted by Mr Maslin came away and struck Mr
Maslin causing him the injuries from which he subsequently died. He
was pronounced dead at the scene at about 12.00 hours that same day.
During the evidence it became apparent that Mr Maslin did not have the
necessary qualifications / competences to undertake this type of medium
pressure, but no one in the management chain were not aware of that.
Further, the evidence demonstrated that pressure testing a pipe at all
levels, including low and medium pressure, was in itself a very
dangerous task, particularly, if it was undertaken without proper safety
precautions being in place.
5 CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters that gave
rise to a concern that circumstances creating a risk of other deaths will
continue to exist in the future unless action is taken.
The MATTERS OF CONCERN are as follows: –
1. By reason of the dangers involved in pressure testing gas
pipelines, consideration should be given to making such tests the
subject of their own specific qualifications.
2. There is no national requirement for operatives within the gas
industry to be retrained and tested once they have obtained their
initial qualifications. Consideration should be given to imposing a
national requirement that all operatives in the gas industry be
subject to a five yearly review and re‐testing of their qualifications.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the Secretary of State for Justice has the power to take such
action.
RT4079 2
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 COPIES
I have sent a copy of this report to the Chief Coroner and the Interested
Persons in the Inquest, namely:
 Shaun Maslin’s Family –
 Irwin Mitchell
 National Grid Gas plc –
 Skanska UK plc – Kennedys Law
 RBS Utilities – , Beachcroft Solicitors
 Aviva on behalf of SM Plant Hire Ltd – ‐ DWF
 The Health and safety Executive –
9 Signed:
Richard Travers
DATED this 19th day of June 2014
RT4079 3

Responses

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.

Response from Respondent Not Named (PDF)
Surrey Coroner’s Court
Matter of Shaun MASLIN (Deceased)
Regulation 28 Report — Action to Prevent Future Deaths
Energy & Utility Skills Response

Background

Given the inherent risks associated with the transportation of gas across the whole of the UK,
the need for a competent workforce is clear and obvious to all. Established initially as a
National Training Organisation (NTO) in 1998, and subsequently licensed as a Sector Skills
Council when NTO’s were replaced in 2003, Energy & Utility Skills (EU Skills) has worked
collaboratively with employers to support this important objective.

Circumstances of the Specific Incident

The Coroner's report highlights the fact that the testing of medium pressure mains is a
potentially dangerous activity, and should always be undertaken by a competent person
following clear procedures. The industry does have well defined procedures for all such
activities which, if followed carefully, will mitigate all foreseeable risks for what is a standard
procedure for all newly installed gas mains.

Training and subsequent assessment of the competences needed to follow procedures and as
safely undertake pressure testing is essential, and for many years, gas workers have been fully
trained and assessed to complete these tasks. From the report it appears likely that this was
not carried out in this case, and so the actual competences held by EEN were not
recorded, or well known by those involved in the management of the project.

Competence Management

The gas industry involves a complex range of organisations ranging from the asset
infrastructure owners, large multi-utility contracting companies, smaller sub-contract
businesses and specialist engineers. Managing the competences needed across this diverse
industry in an effective way, requires a strategic industry standard approach that helps all
employers ensure that their personnel are properly trained in the first place, and then
maintain the necessary competences over time. Legislation, Codes of Practice and methods
of working do change on a fairly regular basis, sometimes due to improvements in technology,
and so a mechanism that facilitates the reinforcement of competence on a periodic basis is
likely to provide the most comprehensive solution.

This approach is recognised in many industries as a robust and cost effective solution and has
become the standard in industries where similar hazardous activities are carried out on a
regular basis. The Construction industry operates a comprehensive Skills Certification Scheme
(affiliated with the EU Skills scheme) and similar management system requirements are
standard in the Rail and Waste Management industries.

In respect of the Gas Distribution Network industry, much of the necessary framework already
exists to deliver a comprehensive approach that could relatively easily be expanded to
incorporate all of the requirements highlighted in the report.

Occupational Standards and Qualifications

A suite of gas industry National Occupational Standards (NOS) and vocational qualifications
derived from them, has existed since the introduction of NVQs in 1987. While these standards
and qualifications are updated on a regular basis to reflect changes in technology and working
practices, they offer only a partial solution to the creation and maintenance of a continually
competent workforce. Any perception that a qualification obtained many years ago, may
indicate competence forever, is clearly flawed. The establishment of initial competence, as
assessed against clear performance and knowledge criteria, must be re-assessed on a periodic
basis if competence is to be maintained on a sustainable basis. Since its creation, EU Skills has
developed a number of initiatives that facilitate this.

Existing Competence Management Solutions

EU Skills operates a comprehensive, internet based, register that enables employers to record
the skills, knowledge and authorisations of every operational worker, both directly employed
and operating under a contract. This register (EUSR — Energy and Utility Skills Register) is
recognised as a robust and effective mechanism and currently holds over 157000 records from
the Energy and Utility Sector. More information about EUSR and its operation may be found
on www.eusr.co.uk

EUSR operates as an industry voluntary basis and has no statutory mandate. However, despite
this, the number of employers using the EUSR continues to increase on an annual basis and
indicates that many employers value the register and its capability to help them manage the
competence of their, often mixed direct and indirect, employee workforce. Three types of
“scheme” are hosted on the EUSR register (i) Safety, Health and Environmental Awareness
(SHEA) across the range of specific industries both within the EU Skills sector and external to
it (ii) Job Role specific Competences that require the evidence of a recognised qualification,
and (iii) Permits and authorisations given by asset owners for individuals to carry out certain
tasks, or enter specific sites.

A recent enhancement of EUSR has been the introduction of a “Reference Scheme” for Gas
Distribution Network asset owners that facilitates the placement of a securely protected
“flag” on an individual’s record, should that individual operate in a manner that breaches
established safety procedures. This mechanism, developed in collaboration with National
Grid, is a radical and unique innovation and required significant careful planning to ensure
legal compliance and the support of the Information Commissioner.

Certain gas employers (those subject to the Gas (Safety) Installation and Use Regulations
1998) are required to be Gas Safe Registered and their employees subject to re-assessment
of their gas safety competences, on a five year cycle. While an external centre based
assessment model has operated for many years, a new Group Competence Scheme (GCS) has
recently been introduced that enables the employer, in line with their general obligations
under the Health and Safety at Work Act (H&SWA) to demonstrate the ongoing competence
of their workforce, via a robust management system that is externally audited and
certificated. The advantage of this approach is that it enables employers that operate across
a broader range of activities with some not covered by the Gas Safe Register requirements, to
incorporate all the necessary competence requirements within a single competence
management system. This GCS is fully aligned to the Gas Safe Register requirements and has
been supported by the industry Management Board that includes the HSE, Gas Safe Register
and UKAS Accredited Certification Bodies.

Comments on Actions to Prevent Future Deaths

Having been involved in the drive to improve and maintain skills and competence across the
energy and utility sector for many years the key issues may, in my opinion, be summarised as
follows...

The requirement for all employees to demonstrate initial competence to carry out job role
activities, by assessment against an industry standard is essential.

This achievement of Energy and Utility industry recognised competence should be registered
on the EUSR national database with an expiry date of no more than five years.

An assessment of continued competence, based on objective evidence against an industry
standard, should be carried out by the employer and used for re-registration upon the five
year expiry.

It should be mandatory for all energy and utility sector infrastructure asset owners to register
their workforce, both direct and indirect, on EUSR. Only when all workers are registered, can
the full benefits of, for example, the Referencing Scheme be realised across the industries.

Timescale

A comprehensive outcome, in line with the comments above, could be introduced very
quickly, given that most of the infrastructure and systems capability already exists. With many
of the employers involved (but not all) already embracing both EUSR and the concept of
increased “employer ownership of skills’, a move to a total registration and competence
management system is realistically achievable within two years.

Conclusion

Much of what is needed to prevent future incidents and deaths within the energy and utilities
sector is already in place, but operates without statutory backing. As a result, employer
participation is optional and creates gaps in the potential information that could be made
available to all employers and key agencies. Closing these gaps would reinforce the
effectiveness of the register, and offer a significant contribution to the management of
competence.

EU Skills remains committed to providing solutions that help employers meet their skills and
competence requirements, and would be happy to discuss the content of this response
further with the Coroner, the Department for Business and Skills or other stakeholders as
required.

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