Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0162, written 10 May 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 May 2017 |
|---|---|
| Reference | 2017-0162 |
| Deceased | Peter Richardson |
| Coroner | Simon Wickens |
| Coroner area | Surrey |
| Category | Other 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
__________________________________________________________
The Inquests Touching the Death of Peter William RICHARDSON
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
• Penny Mordaunt, MP, Minister of State for Disabled People,
Health and Work, (1)
• Safety Assessment Federation - SAFed (2)
• The Garage Equipment Association - GEA (3)
• Health and Safety Executive - HSE (4)
• HSB Engineering Insurance Services Limited - HSB (5)
•
• West End Garage -WEG (7)
• Liftmaster Ltd (8)
(6)
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 Peter William Richardson was opened on
the 4th December 2015 and was resumed on the 24th April 2017 before a
jury. It was concluded on 2nd May 2017.
The cause of death was:
1a. Head Injuries
The conclusion of the jury was; Accidental Death
4 CIRCUMSTANCES OF THE DEATH
On the 27th September 2015 Mr Richardson was using a Bendpak Two-
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Post vehicle lift on behalf of his employer, West End Garage in order to
work underneath a car. Whilst under the car, Mr Richardson was seen on
CCTV to be fitting an under-shield. He was towards the rear of the
vehicle when the car became dislodged from the lift and fell. The Car fell
onto Mr Richardson causing head injuries that were fatal.
The Court heard evidence that the Lift Arm locking mechanisms were
either not working at all or were not working as intended so as to allow
movement or ‘play’ at the time of the incident. The responsibility for
maintaining the lift rested with the operator who received instruction on
the lift in 2012 at the point it was fitted, but not subsequently. Instruction
manuals relating to this specific lift do not assist with tolerance levels or
torque settings for safety critical elements.
The Court heard that under-shields on the Mercedes CLK and other cars
present a clearance problem when lifted on two-post lifts as the size of
the pad means it can extend onto the under-shield hampering its
removal. The Court was told other items such as pieces of wood are
often placed on top of the lifting pads in order to gain the clearance that
is needed. It was said in evidence that anything placed upon the pad
may be held securely by the weight of the vehicle, but could create
further instability. Mr Richardson had used rubber blocks from another
model of lift on top of the lifting pads at the time of the incident.
5 CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise
to concern and 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.
During the course of the inquest the evidence revealed that:
a) No formal guidance exists as to safe tolerances of safety critical
elements of two-post lifts. The Court heard from two HSE
witnesses and a ‘Thorough examiner’ who examined the lift for the
purposes of complying with LOLER 1988, who gave differing
views on what was a safe tolerance or ‘play’ for an extended lift
arm. Further, it was accepted this was an issue of concern to the
HSE, but as yet remained to be dealt with.
b) The supplier of the Bendpak Lift in the UK, Liftmaster, do not
supply guidance as to the required torque for safety critical
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elements of their two-post lifts and neither do they provide
guidance on safe tolerance levels.
c) Safe tolerance should be considered at a LOLER ‘Thorough
Examination’ however there is no guidance to be followed and
there is no requirement for such tolerance levels to be recorded
and as such the levels are not available to any subsequent
examiner.
d) Mr Richardson who operated the lift only received training on the
specific lift at the point it was installed in 2012. All other users
were subsequently trained by him in its use, which was not
recorded and all users of the lift were expected to maintain the lift
properly.
e) It is a known practice for a variety of different objects (for example
a piece of wood) to be placed on top of the lift pads between the
pad and the vehicle when it is lifted in order to provide clearance
and to assist with difficult jobs such as removing a car under-
shield.
MATTERS OF CONCERN ARE:
That consideration be given by (1), (2), (3) and (4) [please see paragraph 1 above] to:
1) Issuing guidance as to safe tolerance levels of safety critical elements on
two-post lifts.
2) Implementing a system of recording tolerance and torque levels of all
safety critical elements during a ‘Thorough Examination’ of a vehicle lift.
3) Implementing a system for recording such levels for comparison at
subsequent examinations.
4) Either advising the industry that the practice of placing foreign objects
between the two-post lift pads and the vehicle to provide the necessary
clearance should not continue, or advising the industry how to provide
such clearance safely when, for example, removing a car under-shield on
a Two-post lift.
5) Implementing a system to ensure and to record that those operating a lift
have been appropriately trained in its use and its maintenance and that
they are periodically retrained.
That consideration be given by (8) to -
1) Providing appropriate and safe torque levels and tolerance levels of safety
critical elements on Bendpak two-post lifts and others supplied.
That consideration be given by (5) and (6) to -
1) Implementing a system of recording tolerance and torque levels of all
safety critical elements during a ‘Thorough Examination’ of a vehicle lift.
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2) Implementing a system for recording such levels for comparison at
subsequent examinations.
That consideration be given by (7) to -
1)
2)
3)
4)
Ensuring any member of staff operating a vehicle lift has received
sufficient and appropriate training in the use thereof.
Ensuring each vehicle lift is checked on a daily basis by an
appropriately experienced/trained member of staff and that all such
checks are adequately recorded in writing.
Ensuring all vehicle lift manuals are available to lift operators at all
times whilst at work.
Ensuring all vehicle lift operators use the pads made specifically for
the lift being used and are instructed not to use any other object
between the lift’s pads and the vehicle.)
6 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.
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 following:
1. Penny Mordaunt, MP. Minister for Disabled People, Health and
Work
2. Health and Safety Executive - HSE
3. Safety Assessment Federation - SAFed
4. The Garage Equipment Association - GEA
5. West End Garage - WEG
6. HSB Engineering Insurance Service Ltd - HSB
7.
8. Liftmaster Ltd
9.
10. The Chief Coroner
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I am also under a duty to send the Chief Coroner a copy of your
response.
The Chief Coroner may publish this report and / or the responses in a
complete or redacted or summary form. Further, 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 response by
the Chief Coroner.
Signed:
Simon Wickens
DATED this 10th May 2016
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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.
Engagement and Policy Division James Atexander Farnhill Mr S Wickens . H.M. Coroner for Surrey Health and Safety Executive . Redgrave Court Station Approach Merton Road Woking Boole Surrey Liverpool L20 7HS GU22 7AP Tel: 020 3028 3129 alex.farnhill@hse.gov.uk 30 August 2017 Dear Mr Wickens, Ref: Mr Peter William RICHARDSON (Deceased): Regulation 28 Report In response to our letter dated 17 July 2017, you asked if we could consider further the evidence given HSE inspectors at the Inquest and the issues they raised with current guidance. We have discussed the concerns further in relation to the thorough examination of two post ramps of this type and note the following. The HSE intends to issue additional guidance concerning the inspection of two post ramps by thorough examiners to highlight the risks in relation to this type of lifting equipment. This will be covered in HSE Operational Guidance, which will be brought to the attention of the various stakeholder groups, namely the inspection industry and will also be publically available on the HSE website. The focus of this guidance will be to ensure that during thorough examinations, the examiner checks the main arm does not move inadvertently when the locking mechanism is engaged and checks that the lateral movement, of the fully extended arm’s sliding elements, does not exceed the limit set by the version of BS EN 1493 in force at the time of the lift’s manufacture. This is in addition to the measures already set out in the letter of the 17" July. | hope this reply is helpful. Yours sincerely HM Inspector of Health and Safety
HM Coroner for Surrey HM Coroners Court Station Approach Woking Surrey GU22 7AP Dear Ms Church Re- Mr Peter William RICHARDSON (Deceased) Regulation 28 Report to Prevent Future Deaths Further to your correspondence dated 15'" May 2017 containing the Report to Prevent Future Deaths (PFD), please find the response below for both HSB Engineering Insurance Services Ltd (HSB) an with respect to the points raised in the report. Following the recommendations made during the inquest, HSB issued a technical document on the 3 May 2017 to its engineering surveyors which instructed them to record the pad wear (tolerance) on the report of thorough examination for two post vehicle lifting tables, as suggested in the PFD report. With respect to checking the torque settings, this procedure would normally be considered a maintenance activity and therefore not within the scope of a thorough examination. We have however considered as to whether : assessing the torque settings should now be included in the scope of a thorough examination and we feel this should be a consideration for all inspection bodies. As such we are working with SAFed, to establish a common approach who in turn are liaising with the HSE to ensure consistency throughout the industry. Therefore the method used by HSB for assessing the pad wear still aligns with that detailed in the HSE SIM 03/2010/02. We would also like to take this opportunity to inform you that Mr Hayward has now left HSB’s employment and has a new position which does not involve the thorough examination of motor vehicle lifting tables. ania Munich RE = 05 July 2017 Gareth Bendelow Chief Engineer/Technical Director HSB Engineering Insurance Tel.: +44 (0)845 345 5510 Fax: +44 (0)845 345 5610 Our Ref: GB/AL HSB Engineering insurance Services Limited Chancery Place 50 Brown Street Manchester M2 2JT www. hsbeil.com Registered in England and Wales: 03010292 Registered office: New London House 6 London Street London EC3R 7LP HSB Engineering Insurance Page 2 05 July 2017 Gareth Bendelow Chief Engineer/Technical Director HSB Engineering Insurance We trust this now concludes both HSB and Mr Hayward’s individual actions Tel.: +44 (0)845 345 5510 with the exception of those now aligned with SAFed. i Yours sincerely fF ttiCS Technical Director ae For and on behalf of HSB Engineering Insurance Services Limited
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