Richard Laco

COMPLETE

LAING O'ROURKE

Coroner ME Hassell

Senior Coroner

Inner North London

St Pancras Coroner’s Court
Camley Street

London N1C 4PP

9 December 2015

Dear Madam,
INQUEST CONCERNING THE DEATH OF RICHARD LACO ON 6 NOVEMBER 2013

| write this letter in response to the Prevention of Future Deaths (“PFD”) report issued on 22 October
2015. In the PFD report, reference was made to the planning of two lifts of staircase landings at
basement level in Core D at the Francis Crick Institute (“the Crick”) by the specialist contractor, CMF
Limited (“CMF”), and the review of those lifts by the principal contractor, Laing O’Rourke. This letter
addresses the concerns raised and sets out the actions that have been taken by Laing O’Rourke since
the accident.

First and foremost, Laing O’Rourke would like to make clear from the outset that nothing said in this
letter should be taken as in any way diminishing our distress at the death of Richard Laco in the
incident on 6 November 2013. It is our paramount objective to formulate and implement a safe work
place for all. Laing O’Rourke deeply regrets the incident in which Mr Laco lost his life. Such incidents
serve to strengthen our resolve to maintain a safe working environment for everyone on our projects.
The Directors insist that safety is at the forefront of the business. To that end, Laing O'Rourke launched
Mission Zero in October 2010, a campaign which built on previous initiatives with the ultimate aim of
eliminating all work related accidents from our operations by 2020.

The Core D basement lifts at the Crick

CMF was employed by Laing O’Rourke to be the architectural metalwork subcontractors at the Crick.
CMF had the responsibility for designing, planning and executing its works, including the lifting of
landings and staircases in the cores. CMF and their Appointed Person for Lifting were responsible for
producing relevant risk assessments and method statements for its works and a Lift Plan for its lifting
operations. In accordance with Laing O’Rourke’s Construction Phase Health, Safety and Environmental
Plan for the Crick, CMF’s Risk Assessment and Method Statement (“RAMS”) for the staircase works
was reviewed by the Laing O’Rourke Package Manager, Andy Fright, whilst CMF’s lift plan was initially
issued to Andy Fright, who referred it to the Laing O’Rourke Appointed Person for Lifting at the Crick,
Mike Mungroosingh. Paul Hughes took over from Mike Mungroosingh as Laing O’Rourke’s Appointed
Person for lifting on 25 July 2013 and reviewed revisions B and C of the CMF Lift Plan.

As the Package Manager Andy Fright’s responsibilities included checking that CMF’s documentation
was complete and correct. This included ensuring that the scope of works was correct, that it was
properly defined and that the sequence of works was correct. Andy Fright also checked to see how
the work interfaced with other trades on site and checked that the CMF employees had the
satisfactory competence, certificates and qualifications for the work. He also looked at the equipment
CMF would use, the resources available on site and any emergency provisions necessary to complete
work. He ensured that the client’s quality specification for the landings and staircases had been met.

Bridge Place, Anchor Boulevard, Admirals Park, Crossways, Dartford, Kent, DA2 6SN
tel: +44 (0)1322 296200 fax: +44 (0)1322 296262 web: www.laingorourke.com

LAING OROURKE

As part of his Package Manager function, Andy Fright referred specialist documentation involving
CMF’s lifting operations to the Appointed Person for Lifting at Laing O’Rourke to review.

As will be appreciated, giving evidence can be difficult, particularly in the context of an inquest. This
is not a forum which employees of Laing O’Rourke are used to, but the witnesses called at the hearing
endeavoured to assist and were transparently straightforward. Laing O’Rourke trains its employees
rigorously and is confident that its people have suitable skills and expertise for their respective roles.

The CMF Lift Plan, as reviewed by Laing O’Rourke’s Appointed Person for Lifting, utilised positive lifting
attachments on landings and staircases when installing these sections into the stair cores.
Photographs in the CMF Lift Plan, added at Laing O’Rourke’s request, showed that landings would be
stropped through eye bolts, which are positively fixed to the landing and choked. Staircase sections
were fixed with a lifting jig. These sections, once positively attached, would be installed into the stair
cores using a block and tackle to manipulate into place onto the fin plates in the case of landings, or
onto the installed landings in the case of the stair flight sections. The use of positive lifting attachments
provides for a safe system of work when a load is lifted up and manipulated into place above the
ground regardless of any variation in the shape of the component.

Paul Hughes, Laing O’Rourke’s specialist Appointed Person for Lifting, asked CMF to add some
clarifications to its Lift Plan in August 2013. He asked that CMF uprate its winch to 2 tonnes to increase
the factor of safety. In particular, at the request of Paul Hughes, photographs were added to the Lift
Plan Rev C demonstrating the positive lifting attachments and the chain block/block and tackle for
adjusting the position of the staircases and the landings for their installation in cores A to F. As he
made clear at the inquest, Paul Hughes’s view, supported by Mark Shearon (HM Inspector Health &
Safety Executive), was that the lift plan is a working document and the use of photographs improves
the understanding of the crew when briefing them on the work.

Laing O’Rourke approved the CMF Lift Plan on the basis that positive lifting attachments would be
used for the lifting and installation of the landings (and staircases). As stated by Paul Hughes at the
inquest, if CMF felt that it needed to deviate from the lift plan in force, for any reason, during the
installation of landings or staircase sections, the lifting operation should have stopped immediately
and further planning undertaken. Although the PFD report states that “there was no instruction to
stop the procedure if positive fixings...could not be achieved”, Laing O’Rourke had only approved CMF’s
lifts on the basis that positive lifting attachments were in use as had been the case in all the previous
stair cores. No approval has ever been given by Laing O’Rourke to CMF to lift without positive lifting
attachments.

Laing O’Rourke was not told about CMF’s departure from the agreed safe system of work. No approval
was given to CMF by Laing O’Rourke to deviate from the agreed lift plan. If the principles in the lift
plan could not be complied with by CMF, then the plan needed to be re-addressed, re-written and re-
submitted to Laing O’Rourke. This was anticipated by CMF’s lift plan itself, which at page 16 of
Revision C states, “This document must be regularly reviewed by the CMF site team/AP”, that is the
CMF Appointed Person for lifting, “and as required the LOR appointed person. Should any changes be
required WORKS WILL NOT BE CONTINUED UNTIL APPROVAL OF ALL AUTHORISED PERSONS IS
OBTAINED IN WRITING. THIS DOCUMENT WILL REQUIRE UPDATING TO REFLECT ANY CHANGES
AGREED TO”.

As stated by Paul Hughes, the absence of a positive lifting connection is a stop point; when lifting units
and manipulating a load in the air rotating into place, there must be a positive lifting connection in
order to ensure safe lifting. This principle remains the same with all lifts and shapes.

With hindsight, as the landings in the basement of core D were a different shape and were to be lifted
upwards past the fin plates, before being lowered downwards onto the fin plates in the core, CMF
should have considered an additional note in the plan for this lift. It is relevant, however, that the
principle behind the method of lifting agreed by Laing O’Rourke in November 2013 required positive
lifting attachments to be applied to a load lifted into the air and manipulated into place. This approved
method provided a safe system of work, notwithstanding that, with hindsight, additional clarifications
could have been, and eventually were, made to the plan by CMF, to account for the shape of the
landing and the upward lift. The design of the lifting method and lift plan was the specialist
contractor’s responsibility. As the principal contractor Laing O’Rourke ensured that any such plan was
safe by insisting on the use of the positive attachments.

Action taken by Laing O’Rourke following the accident to prevent future deaths

On 8 November 2013 the Laing O’Rourke Project Leader at the Crick, Bob Williams, circulated an email
reminder that, following the Project Director Jonathan Abbott’s team talk, all packages were to
undergo a full review of all method statements and lifting plans to ensure that they were current and
reflected the actual install methods. This email also indicated that all Contractor Managing Directors
were required to visit the site, in order to undertake a personal presentation to their respective teams
on what was required of them at the Crick. All lift plans were suspended until they had been again
reviewed and approved by Laing O'Rourke. A briefing of the accident and a health and safety briefing
were conducted on 11 November 2013. Work recommenced at the Crick on 11 November 2013, save
for the fact that core D remained closed for the official investigation.

In November 2013 Laing O’Rourke requested that CMF provide a detailed RAMS for the removal of
the damaged landings in core D. Laing O’Rourke stressed to CMF that all landings and staircases must
be rigged with positive lifting attachments. In December 2013 CMF started work on the revised RAMS
and Lift Plan for the remaining stair installation, as well as testing its positive lifting attachments.
Approval was granted by the HSE for the removal of the damaged landings from core D on 17 January
2014. On 23 January 2014 CMF were instructed to undertake a safe start workshop and to explain
their method of installation for the next phase.

The revised CMF Lift Plan, dated 9 April 2014, is tailored for the installation in the basement in core D
and has been reviewed by the HSE. This revised plan again requires positive lifting attachments to be
rigged to the steel landings and the staircases. The basement landings and stairs under the ground
floor slab in core D were successfully installed by CMF in May 2014.

Following this tragic accident Laing O’Rourke and the client have insisted on even greater use of health
and safety measures. The CDM (Construction Design and Management) Co-ordinator has been
required to be on site twice a month instead of once a month since 6 December 2013. On 21 January
2014 Dean Pettinger of Laing O’Rourke was appointed as an additional Appointed Person for Lifting
and was specifically directed to focus on all lifts carried out by CMF, even though all those lifts were
the primary responsibility of CMF.

As an additional safeguard, Laing O’Rourke now requires that lifting activity within a RAMS, is formally
signed off on the RAMS and Lift Plan by the Laing O’Rourke Appointed Person for lifting. The same
formal acknowledgement is now required by the Laing O’Rourke Temporary Works Co-ordinator, for
any temporary works. Authorisation from the appropriate specialist person has always been required

during the review process, for example, where the contractor’s work involves lifting. However, this
step has now been committed to writing and the specialist person’s acceptance, whether it is the
Temporary Works Co-Ordinator or the Appointed Person for Lifting, is evidenced on the
documentation. A Safety Alert was issued to all Laing O’ Rourke workplaces, through both the
Management and Health and Safety functions, for implementation on 28 November 2013 emphasising
the requirement that lifting operations on a project must include the sign off by the Laing O’Rourke
Appointed Person for Lifting as set out on the Revised Method Statement Approval Sheet T6-D. This
Safety Alert emphasises that all contractors’ Lifting Plans written by specialist contractors, such as
CMF, must, as well as having been risk assessed, planned and approved by the sub-contractor’s
Appointed Person for Lifting, be approved in writing by the Laing O'Rourke Appointed Person for
Lifting.

Furthermore, each project team is now required to review activities carrying increased risk on a
monthly basis and schedule a ‘Planned vs Actual’ assessment for these activities. As part of the
‘Planned vs Actual’ assessment a manager will review the accepted method statement for an activity
on a more formal basis and will then review with the team carrying out the work whether there has
been any change in circumstance which may have an impact on the plan, or whether improvements
could be made to the method in order to make the operation safer.

As stated above, Laing O'Rourke strives to learn lessons from continuous review of all its operations
and, especially, from distressing incidents involving personal injury. Many steps have been taken at
the Crick designed to ensure that tasks are subjected to heightened scrutiny and control to minimise
the risk that safety considerations could be overlooked in planning and executing work on the site.

Laing O'Rourke reiterates its deep regret at the death of Richard Laco in this accident. The company
takes this fatal accident very seriously and personally, and is driven to re-double its efforts to maintain

a safe working environment throughout its operations.

Yours faithfully,

Vo

Managing Director UK & Europe

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CMF Ltd
Central Way, Feltham,
Middlesex TW14 0X}

Our Ref: TMB/tk

Ms M E Hassell

Senior Coroner

Inner North London

St. Pancras Coroners Court

Kemley Street

London N1C 4PP 14 December 2015

Dear Ms Hassell

Prevention of Future Death Report — Richard Laco
Response from CMF Limited

CME Limited is in receipt of the prevention of Future Death Report dated 22
October 2015. CMF Limited is required to respond to you by 21% December 2015.
The company has considered the matters of concern raised in the report and
responds as follows:

The Project Lifting Plan produced by CMF on 25" May 2013 for lifts within the cores
was revised on the 22"? August 2013 (Revision C) to include photographs of trial lifts
conducted by CMF at its factory. The revisions were made in anticipation of lifts to
be conducted within Cores F and D. The lifting plan in this revised format was
intended for use in Core D, despite the irregular shape of the landings on one side of
the core. The shape of the landing was not considered by CMF to be of sufficient
significance to necessitate a change to the lift plan.

Further factory trials on the level balance of the trapezoidal shaped landings carried
out prior to commencing the installations in Core D had not raised any concerns that
change to the lifting plan was necessary.

The additional lifting procedure of re-slinging the landing at the bottom of Core D
and lifting landings into position with a winch through a hole in the ground level slab
above was similar to the methods contained in the lift plan revisions for the top
sections of Core A and F that had utilised almost identical procedures.

The method avoided the need for any operative to be underneath the load other
than final bolting once the landing had been positioned over the supporting fin
plates.

Continued............ Tel: 020 8844 0940

Fax: 020 8751 5793
www.cmf.co.uk

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Ms M E Hassell 14" December 2015
Post Incident Method

Following the incident and after intensive investigations into best practice for an
alternative method of lifting, it was determined to proceed with a lift plan that
involved tilting the landing past the fin plates. An additional lifting frame was
designed to be fixed to the landing with bolts that would facilitate the use of lifting
eyes. The use of slings for lifting was substituted by chains attached to the lifting
eyes. A second winch was introduced and another hole made in the slab so the tilt
of the landing could be carried out by raising and lowering of separate winches
rather than taglines. “The trapezoidal landings above the ground floor slab were
installed in accordance with the original lift plan methodology as this was still
considered to be the best practice although the use of slings was again substituted
for chains attached to directly anchored lifting eyes.

Future Methods for Site Lifting

1. All members to be lifted will either have adequately sized holes that allow for
the fixing of positive anchorages for lifting accessories or for alternative
bespoke lifting carriages. These will be identified during the design stage and
advice obtained from the appointed person.

2. The lifting operations are to be planned by a qualified appointed person for
lifting and not by site managers who may not have formal qualifications for
lifting operations despite having extensive experience of lifting. A lift plan is
to be completed using the CMF native lift plan procedure to ensure
consistency and content.

3. Lifting plans together with any temporary works requirement or relevant
design considerations are to be submitted to and approved by the Principal
Contractor for projects before lifting commences.

4. All approved lifting plans will be explained to the lift team by the appointed
person to ensure the plan is fully understood and that all members of the lift
team are fully conversant with their respective duties or responsibilities. This
is also to include any temporary work associated with the lift and/or important
design considerations.

5. After delegation of the lift plan to the lift supervisor, absence of this person
through illness or other reason will require a re-briefing by the appointed
person to the replacement and entire lift team before lifting resumes. In any
event if the lift plan is in force for more than 90 days, a re-briefing of the lift
team will be a requirement.

Continued............

Ms M E Hassell 14 December 2015
6. If at any stage the lifting operation becomes compromised by unforeseen

as it is safe to do so. The appointed person will then assess the changes and
implement the modification within the lift plan before lifting resumes.
Similarly the slinger signaller must not deviate from using the prescribed
attachments and accessories defined in the lift plan and schedule of common
lifts. Any deviation will cause lifting to cease until the approved person has
assessed the implications.

T hope this addresses your concerns in relation to CMF Limited. If you require any
further information please do not hesitate to contact me.

Yours sincergly

CMF LIMITED