Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0044, written 14 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Feb 2017 |
|---|---|
| Reference | 2017-0044 |
| Deceased | David Alexander |
| Coroner | Lydia Brown |
| Coroner area | Exeter and Greater Devon |
| Category | Accident at Work and Health and Safety 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.
for Exeter and Greater Devon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: J Head of Operations South West Health and Safety Executive 2 Riverside Bristol BS1 6EW CORONER | am Lydia Brown, Assistant Coroner for Exeter and Greater Devon 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. http://www.legistation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http:/Avww. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 17/02/2016 | commenced an investigation into the death of David lvor Alexander, 61 . The investigation concluded at the end of the inquest on 14 February 2017. The conclusion of the inquest was Cause of death - Chest Injuries Narrative conclusion — the Jury unanimously concluded that the death was accidental, with the gradient of the yard being a significant contributory factor. CIRCUMSTANCES OF THE DEATH David Alexander was an experienced lorry driver and mechanic, delivering animal feed to a farm. Whilst David was engaged in transferring the feed from the HGV articulated lorry by the method of bulk blowing, the transfer pipes blocked and had to be manually emptied and the farmer assisted with this. Unloading continued, solely under the control of David. The hydraulic ram was employed to lift the trailer to almost full height, the bulk blowing recommenced, but then almost immediately the trailer tipped over with an almost full load of 25 tonnes of feed, and landed on top of David, killing him instantly. On close inspection it was ascertained that the lift had taken place while the vehicle was parked on a small gradient of between 2.9 and 3.6 degrees. It was also identified that the bracket holding the base of the hydraulic ram had stress fractures that were not visible from a normal manual inspection, but one side of the bracket failed, either causing or as a consequence of the overturn. Evidence was heard that without the gradient, this catastrophic failure was unlikely to have occurred. 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. Room 226, Devon County Hall, Topsham Road, Exeter, EX2 4QL Tel 01392 383636 | Fax 01392383635 The MATTERS OF CONCERN are as follows. — (1) Evidence was taken during the inquest that overturns are not uncommon in this particular section of the industry, but are infrequently reported as there is no requirement to do so (2) The cause/s of overturn are not well understood or recognised as post event investigations are not carried out and there appears to be little knowledge or industry practise regarding regular inspections and/or replacement schedules in respect of the hydraulic ram brackets (3) There is little or no industry guidance available relating to this issue (4) It is not standard to fit new articulated lorries with inclinometers and they are not routinely, if ever, used on older vehicles notwithstanding that it is recognised that a very slight gradient of over 2 degrees can (at full extension of the hydraulic ram when fully loaded) cause overturn. This information does not appear to be widely recognised within the industry. Room 226, Devon County Hall, Topsham Road, Exeter, EX2 4QL Tel 01392 383636 | Fax 01392 383635 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty fo respond to this report within 56 days of the date of this report, namely by 12 April 2017. |, 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 my report to the Chief Coroner and to the following Interested Persons:- The family of David Alexander NWF Agriculture Limited | have also sent it to Agricultural Industries Confederation and the Farm Safety Partnership who may find it useful or of interest. | am 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 resperiSe by the Chief Coroner. Room 226, Deven County Hall, Topsham Read, Exeter, EX2 4QL Tel 01392 383636 | Fax 01392 383635
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.
DEVON FEED MILLS SURVEY OF DELIVERY ARRANGEMENTS - 2017 BACKGROUND This report was commissioned as a result of concerns raised by HM Coroner following an Inquest into the death of Mr David Alexander on 17 February 2016. Mr Alexander was killed when his vehicle overturned during a feed delivery to a farm; an alert was sent to the industry at that time. HSE further committed to undertake visits to feed mills in Devon to find out how far they were aware of the risk of vehicle overturn and to understand what steps they were taking to ensure that risk was managed. Prior to Mr Alexander’s death there was an industry-led initiative, which launched in 2013, to improve safety during feed deliveries. The Farm Safety Partnership (FSP) and Agricultural Industries Confederation (AIC) drew up guidance and continue to pursue this as a campaign. The AIC guide is reported to have been directly mailed, by the AIC and members of the FSP, to around fifty thousand farms that receive feed deliveries. The guide promotes dialogue between the farmer and delivery company to ensure that on-site conditions are known and the delivery can be planned. It explicitly raises the issue of slopes and raising vehicle bodies on sloping ground. This guidance was referred to during the Devon feed mills survey. THE SURVEY The HSE survey of Devon feed mills in 2017 involved an initial fact-finding visit to site by a non- warranted Visiting Officer followed up by a visit from an Inspector. In total, 7 sites were visited and the detailed findings are summarised below: e Businesses: the sites visited varied from small businesses to branches of large national organisations. e Awareness of the risk: All of the feed mills visited were aware of the incident resulting in the death of Mr Alexander and this appeared to have galvanised work being undertaken to address the risks from deliveries. All feed mills visited were aware of the industry guidance. e Type of deliveries: one of the seven businesses did not make any bulk/blower deliveries; the two largest organisations (nationals) were trialling non-tipping blower vehicles; the other sites were using a mixture of bulk blower and curtain sided vehicles for deliveries. e Site assessment: Typically, sales representatives made initial visits to new customer sites. However assessments of site conditions for deliveries were usually undertaken fater by either a transport/H&S manager (in larger organisations) or the delivery driver themselves, often using a check sheet provided by the company. e Sub-contracting: There was evidence of some sub-contracting of deliveries in smaller businesses. Large organisations and very small businesses did not use any sub-contract drivers. Where sub-contracting was part of the logistics chain, the sub-contract drivers were provided with the same type of information provided to the company’s own drivers. One area for future consideration, although beyond the scope of this survey, is third party supply businesses. Some feed mills were supplying to other businesses that were then running their own sales and delivery operations; these were typically small operators who would be responsible for making their own on-farm delivery arrangements. e Systems for tipping loads: Where tipping was taking place, arrangements ranged from the driver following an understood system of work to cameras being fitted to vehicle cabs so that tipping could be routinely monitored (this in one of the large companies). Another (large) company had fitted tipping sensors which cut off when any tipping above 2 4% degrees was detected. e Arrangements for dealing with blockages: Arrangements varied across sites from agreed systems, with drivers stopping deliveries if blockages could not be cleared, to no formalised systems. There was anecdotal evidence that blockages were more likely to occur where feed had been left in vehicles overnight. e Other matters of concern on site: Although not the focus of the visits, some other areas of concern were dealt with during visits including risks associated with work at height, exposure to dust and noise and risks from vehicle movements on sites. ° CONCLUSION Three feed mills were given advice on work at height issues by the Visiting Officer which they had actioned by the Inspector visit. One feed mill is now taking action on noise issues. One feed mill is taking action on workplace transport at the mill, to improve worker / vehicle segregation. (— One feed mill was given advice on respiratory protection. It was encouraging to see a move towards non-tipping vehicles in the larger organisations; these vehicles will negate the risk from the type of overturn seen in the incident that resulted in Mr Alexander’s death. In the meantime, where tipping vehicles are still in use the risk of overturn had been recognised by the feed mills and a variety of arrangements used to address it. Whilst there will always be variation in the way risk is controlled dependant on, for example, the size and nature of the business, there is scope for the industry to do more to encourage good practice among smaller businesses. This report will be shared with HSE’s national agricultural sector group to facilitate: e Discussion of findings with industry partners e = Intelligence-led future visits to the industry
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