Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0120, written 23 Mar 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Mar 2016 |
|---|---|
| Reference | 2016-0120 |
| Deceased | Alan Dimbleby |
| Coroner | Richard Travers |
| Coroner area | Surrey |
| Category | Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 Alan George DIMBLEBY A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: • Dr Richard Judge, Chief Executive HSE • Bateman Engineering Ltd 1 CORONER Richard Travers HM Senior 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 Mr Dimbleby was opened on the 4th August 2015 and was resumed on the 22nd March 2016 with a jury and concluded the following day, 23rd March 2016. The jury found the cause of death to have been: 1a. Hypoxic Brain Injury 1b. Cardiac Arrest 1c.Traumatic Fracture of Cervical Veterbrae They concluded with a short form conclusion of ‘Accidental Death’. 4 CIRCUMSTANCES OF THE DEATH On the 23rd July 2015, Mr Dimbleby, a very experienced crop sprayer, was spraying areas of cover at Warren Barn Farm, Woldingham, Surrey. He was driving his usual vehicle a Bateman RB35 self-‐‑propelled sprayer with which he was very familiar. The land was undulating and in parts very steep. As Mr Dimbleby was making his way from the second area of cover to the third area, the sprayer became unstable and rolled down the incline. Mr Dimbleby was thrown from the cabin and died as a result of Rtdoc/02512-2015/Reg28/23-3-2016 1 injuries that were sustained when he was struck by the rolling vehicle. The cabin of the vehicle was still intact and generally undamaged, but there was no form of operator seat restraint. The jury found that the gradient of the slope on which he was working together with the absence of a seatbelt made a material contribution to his death. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters that gave rise to concerns that circumstances creating a risk of other deaths will continue to exist in the future unless action is taken. The MATTERS OF CONCERN are: Operator Seat Restraint 1. Consideration should be given to fitting operator seat restraints to self-‐‑propelled sprayers. The cabin of the vehicle was such that it would have provided adequate protection to Mr Dimbleby had he not been thrown out of the vehicle. However, without appropriate operator seat restraints there is a serious risk that the operator will be thrown from the vehicle should it overturn and, as such, a safe cabin does not provide adequate protection. 2. Consideration should be given to removing self-‐‑propelled sprayers from the class of vehicles in respect of which the HSE guidance suggests that operator seat restraints may not be needed or are inappropriate [Agriculture Information Sheet 37 (revision1)]. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the persons listed in paragraph one above are in a position to draw these concerns to the appropriate authority in Portugal who has the power to take such action. 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. Rtdoc/02512-2015/Reg28/23-3-2016 2 8 COPIES I have sent a copy of this report to the following: 1. Dr Richard Judge, Chief Executive HSE 2. 3. 4. DAC Beachcroft Claims Ltd ( 5. The Chief Coroner (Mr Dimbleby’s widow) Bateman Engineering Ltd Signed: Richard Travers DATED this 23rd March 2016 Rtdoc/02512-2015/Reg28/23-3-2016 3
2 responses 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.
BYCOTT, CHULMLEIGH, NORTH DEVON. EX18 7DS. H.M. Coroner for Surrey ry to HM Coroner = Surrey 25 April 2016 Dear Sir, | write in response to the prevention of future deaths report issued following the Inquest into the death of Alan Dimbleby. As | understand your report, it requests that consideration should be given to fitting operator seat restraints to self-propelled sprayers. As | set out in my statement provided for the inquest, there is no requirement for sprayers to have seat restraints. We have always focussed on making the cab enclosure as safe and secure as possible so that the driver is protected irrespective of whether they are wearing a seat restraint. In the report you acknowledge that the cabin of the sprayer was still intact and generally undamaged following the accident. However, since | became aware of the circumstances of Mr Dimbleby’s accident, | have changed the design of the cabs to include seat restraints and no vehicle leaves our workshop without one being fitted. | hope that you find the action taken to be adequate and | am happy to discuss matters further with you if you think that would be helpful. Yours sincerely, PO Company Reg. No, 1497923 England VAT No. 321 1848 85
Chief Executive
Dr Richard Judge
Redgrave Court
Mr R Travers Merton Road
HM Coroner for Surrey Bootle
HM Coroner's Court Merseyside L20 7HS
Station Approach
Woking Tel: 0151 951 5766
Surrey Fax: 0151 951 3932
GU22 7AP
http://www.hse.gov.uk/
Date: 29 June 2016
Our ref: CE-87-16
Your ref: Rtdoc/02512-2015/Reg28/23-3-2016
Dear Mr Travers
Re: Mr Alan Dimbleby (deceased) Regulation 28 Report to Prevent
Future Deaths
Thank you for your letter of the 23 March regarding Alan Dimbleby’s tragic
death on 23 July 2015.
You asked me to consider two issues:
{a) whether; operator seat restraints should be fitted to self-propelled
sprayers; and
(b) whether HSE guidance Agricultural Information Sheet 37 requires
revision to remove self-propelled sprayers from the class of vehicles
where operator seat restraints may not be needed or may not be
appropriate.
On the first issue, the use of seat restraints has to be considered in
conjunction with the design of the machine. If a seat restraint is to be
effective in an overturn situation it must be in conjunction with a roll over
protective structure (ROPS). A ROPS is a protective structure intended to
provide the operator with a protective zone to reduce the risk of injury.
Vehicles fitted with ROPS are fitted with seat restraints so that the operator
remains within the protective zone. In 2009 the relevant standard was revised
and required seat belt anchorage points if the sprayer was fitted with ROPS.
However the standard, which was most recently revised in 2013, allows the
manufacturer to choose how to reduce the risk of an overturn, or to mitigate
the likelihood of injury in an overturn and ROPS is only one of the options
available. Not all sprayers manufactured now, or in the past, will have a
ROPS cab.
Where a non-ROPS cab is present, which is particularly likely on older
machines, the fitting and wearing of seat restraints is not recommended as it
can increase the risk of injury in the event of a roll over. A non-ROPS cab is
not designed to, nor will it have been tested to demonstrate that it can,
withstand the forces to which it is exposed during a roll over. Consequently,
in an overturn, the structure is likely to deform, and penetrate the zone
occupied by the restrained driver resulting in a risk of serious personal injury.
Additionally, on older machines regardless of whether or not they have ROPs
fitted, there may not be any suitable anchorage points for seat restraints and
fitting them may be unfeasible.
The key to preventing an overturn on sloping ground is for employers to
assess the work, including travel to and from the site in question, to select the
right equipment for the conditions, to ensure the work is planned so that it can
be carried out safely and to ensure that the operator is trained and competent
for the task. Where a risk of overturning has been identified as significant,
one of the means by which this can be reduced is to specify a machine fitted
with ROPS and operator restraint. HSE’s guidance about overturning
vehicles! gives a range of practical considerations that the employer needs to
consider when planning the work. Overall we cannot advocate a policy that
all self-propelled sprayers be fitted with seat restraints.
HSE works with the relevant British Standards (BSI) and European Standards
(CEN) committees on agricultural machinery safety, and we will raise this
issue at the next appropriate meeting for the consideration in future revisions
of the applicable standards.
On your second point, concerning HSE guidance on the use of seat
restraints’, similar constraints apply to how far this can be changed. Our
guidance has to apply to the full range of self-propelled work equipment
(including those fitted with ROPS and those not fitted with ROPS). It gives
advice on the steps that should be taken to comply with health and safety
legislation. The guidance is not intended to be comprehensive, and does not
cover every possible configuration of self-propelled work equipment. Very
specifically we cannot recommend the use of seat restraints for a vehicle that
is not also fitted with a ROPS for the reasons given above. We do
nonetheless keep all of our guidance under review and at the next opportunity
we will consider whether the wording can be revised to better inform the
choice of vehicle when working on slopes.
In your report (Section 6) you state that HSE is in a position to draw these
concerns to the appropriate authority in Portugal who has the power to take
action. We do not understand the reference to Portugal which does not
appear to have any relevance to this incident. Therefore, we do not intend to
take this action.
1 http-/www.hse.gov. uk/agriculture/topics/machinery/farm-vehicles-2.htm
? AIS 37 Operator seat restraints for tractors and mobile work equipment in agriculture and forestry
Yours sincerely
(an fee
Dr Richard Judge
Chief Executive
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