Prevention of Future Deaths reports · 2016

Ben Collins

Regulation 28 report to prevent future deaths, reference 2016 – 0282, written 10 Aug 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report10 Aug 2016
Reference2016 – 0282
DeceasedBen Collins
CoronerSimon Wickens
Coroner areaSurrey
CategoryAccident at Work and Health and Safety related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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.

IN THE SURREY CORONER’S COURT

The Inquests Touching the Death of Ben Andrew Collins
A Regulation 28 Report — Action to Prevent Future Deaths

THIS REPORT IS BEING SENT TO:

e Digsafe Suction Excavations Ltd
e Health and Safety Executive

1 | CORONER
Simon Wickens HM Area 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 the death of Ben Andrew Collins was opened on the 4"
August 2015 and was resumed on the 26" July 2016 before a jury. It was
concluded on 1* August 2016.

The cause of death was:
la. Positional Asphyxia
2. Fractured Ribs and Femur

The conclusion of the jury was; Accidental Death

4 | CIRCUMSTANCES OF THE DEATH

On the 27" July 2015 Mr Collins was using a Suction Excavation Machine
on behalf of his employer Digsafe Suction Excavations Ltd in order to
excavate a trench beside the M3 Motorway. Whilst excavating, Mr
Collins was seen on CCTV to enter the trench whilst the suction machine
was directly above him, take off the machine’s control panel from around
his waist and drop it onto the ground beside the trench before bending
down into the trench. On dropping the control panel the suction machine

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began to descend and trapped Mr Collins in the trench. The Court heard
evidence that the control panel was faulty in that involuntary downward
movement of the excavator could be engaged unintentionally due to
wear and tear of the joystick.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed that upon finding
Mr Collins in the trench, those present had no knowledge of how to
operate the Suction Excavator in order to release Mr Collins. Digsafe
Excavations Ltd provided one person with knowledge of how to operate
the excavator with an expectation that a second man would be provided
by whosoever contracted with them. That person however would not
know how to operate the Suction Excavator in an emergency or be fully
trained in its use. Further there is no HSE guidance covering;

a) the use of a Suction Excavation machine,

b) training for such use,

c) the provision of a fully trained second man,

d) the regularity of servicing of control panels.

MATTER OF CONCERN:

Digsafe Suction Excavation Ltd give consideration to the provision of a
second man by them at each excavation who is fully trained in the
operation of the Suction Excavator and associated equipment such as an
air-lance.

The HSE give consideration to the provisions of guidance regarding
training and the use of suction excavation equipment including a
recommendation for the provision of a second man fully trained to use
the Suction Excavator and associated equipment, regular servicing of
remote controllers together with the proper documentation of such.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I
believe that the people listed in paragraph one above have the power to
take such action.

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

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taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.

8 | COPIES

Ihave sent a copy of this report to the following:
1. Digsafe Suction Excavation Ltd.
2. Health and Safety Executive

1
5. Mway Communications Ltd
6. The Chief Coroner

~

Signed:

Simon Wickens

DATED this 10" August 2016

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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 Hse (PDF)
THE INQUEST TOUCHING THE DEATH OF BEN COLLINS — ACTION TO PREVENT
FUTURE DEATHS

Ben Collins tragically died on the 27 July 2015 following a work accident involving a suction
and vacuum excavator.

The inquest concluded on 1 August 2016 with the jury returning a verdict of accidental death.
Following the hearing HM Coroner served a Regulation 28 report on the HSE requiring
written response to the following areas of concern: ;

‘[That] the HSE give consideration to the provision of guidance regarding training and the
use of suction excavation equipment including a recommendation for the provision of a
second man fully trained to use the Suction Excavator and associated equipment, regular
servicing of remote controllers together with the proper documentation of such.’

HSE responds to the Regulation 28 report as follows:

GUIDANCE — HSE publishes a wide range of health and safety guidance written for use by
industry and interested parties. For more technical or targeted guidance HSE now finds that
itis more effective to assist industry trade bodies to write their own guidance. This allows
the guidance to be more relevant and specific to users, easier to keep up to date and to
access. The HSE has been working closely with the Construction Plant-hire Association
(CPA) to improve standards regarding the use of suction excavators. The CPA has formed a
Suction and Vacuum Excavator interest group, which comprises of representatives from the
HSE, manufacturers, users and hire companies. The main thrust of the group is to produce
guidance. At the time of writing this has reached the stage of a second draft which is out for

consultation within the group.

Their next meeting is in mid-October and they hope to have the guidance published in early
2017 (no specific date has been set and the timescale is dependent on the goodwill of
industry participants who contribute in their spare time). The guidance will be available to
download free of charge from the CPA website and will be reviewed and updated as this

niche industry develops.

The second draft includes sections on training, the use of a second person, maintenance
and examples of daily and weekly checks and inspection records.

THE USE OF A SECOND PERSON - The draft guidance states “In principal, excavation
with a suction and vacuum excavator should be considered a two —person operation unless
the risk assessment allows for single person operation for the particular task. Each new
activity must be risk assessed before single person operation can be authorised.” The
default position in the current draft of the guidance is therefore two person operation but with
the rider to allow single person operation for extremely simple work.

The second person is defined in the draft guidance as: “ personnel trained to have machine
operating skills used to support the excavating activity and the principal operator, and can
take charge in emergency situations.” The draft guidance outlines the areas of training and
or familiarisation that should be undertaken, which includes emergency- stop procedures

and locations of emergency — stop controls, and re activation of the machine following
emergency stop control activation.

MAINTENANCE - the draft guidance states that: “the function of all controls and safety
devices should be checked by the suction and vacuum excavator operator for correct —
working before the excavator commences. The remote control units should be checked to
ensure sufficient battery power is available for the intended operations, clean, free from
damage and the operation of the emergency stop button and any other isolating devices .
must be checked for operational function.” HSE will also recommend to the CPA that the
text should stress that remote control units contain sensitive electronic devices and that any
damage or malfunction noted means the unit should not be used until it has been repaired.

The guidance also covers routine inspection and maintenance that should be aligned to
manufacturer's requirements. :

TRAINING - The Construction Industry Training Board (CITB) has set up a voluntary national
training course for suction and vacuum excavator operators. This includes both a practical
and theory test. The practical test will be led by an assessor who is independent of the
trainer. Successful candidates will obtain a Construction Industry Training Board (CITB)

accredited qualification.

As with most examined CITB courses there will be an option for operators who were trained

in-house and are suitably experienced to bypass the CITB training course and achieve

qualification by undertaking the written and practical test. The pass mark for CITB assessed

courses and the method of testing is designed to assist those with literacy problems whilst

maintaining the pass criteria at a suitably high level i.e. all candidates need to demonstrate a
_high level of knowledge and understanding to achieve a pass mark.

-At the time of writing, this course and the assessment scheme is being launched. Once
established this should, subject to duty holders implementing effective management
arrangements, exclude untrained operators from the market and within a period estimated
to be approx. 2 years will result in a near fully trained suction and vacuum workforce. This
time period is necessary to enable a backlog of current in-house trained operators to pass

through the new system.

It is the HSE’s opinion that the new guidance, once published; and the new accredited
training scheme, once established, will cover the key points raised by the HM Coroner.

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