Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0245, written 29 Aug 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Aug 2017 |
|---|---|
| Reference | 2017-0245 |
| Deceased | Shaun Carter |
| Coroner | Caroline Saunders |
| Coroner area | Gloucestershire |
| 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.
H M Assistant Coroner for Gloucestershire Caroline Saunders REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Tonic Construction Ltd 2. Health and Safety executive PY CORONER | am Caroline Saunders, H M Assistant Coroner for Gloucestershire. x] CORONER’S LEGAL POWERS ! make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and | aie 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On the 7" June, the senior coroner commenced an investigation into the death of Shaun Carter. The investigation concluded at the end of the inquest oni9" July 2017. The conclusion of the inquest was a narrative conclusion, The medical cause of death was: 1a) Blunt Head Trauma. CIRCUMSTANCES OF THE DEATH Shaun Carter was employed by Tonic Construction and on 31°! May 2016 he was engaged in removing spoil to a spoil heap at a construction site in Cirencester. Evidence demonstrated that Shaun drove his dumper truck up the spoil heap, however at the top the truck went over the edge. Shaun jumped from the dumper truck but was struck by it during the fall. He suffered catastrophic injuries and was pronounced dead at the scene. | SORDRERS 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. The MATTERS OF CONCERN are as follows. — 1. At the inquest there was evidence that the risks associated with the use of dumper trucks was recognised and that risk assessments and method statements were written which reflected these risks. However the safety procedures were not followed, not seen by all relevant personnel (some of whom could net read) and the practice jn this regard was not audited. 2. At the inquest it was confirmed that there was no Process in place to ensure that spoil heaps were managed safely, nor any guidelines issued by the HSE in this regard. This has been addressed by Tonic Construction in relation te the sites it manages, but there are still no industry standards relating to the management of spoil heaps. 3. Dumper trucks are designed to ensure that drivers are protected, even if the dumper trucks topple over. However the inherent open nature of trucks can nonetheless make the driver feeling vulnerable and despite the instructions which require the driver to Gloucestershire Coroner's Court, Carinium Avenue, Barnwood, Gloucester, GL4 3D) Tel 01452 305661 | Fax 01452 412618 T- remain seated during an incident, statistics indicate (as in this case) that the naturai reaction of drivers is to jump from the truck. 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. Tonic Construction Ltd In relation to point (1) above, | have heard of the changes that have been made in practice however | should like reassurance regarding the safety culture and the processes for auditing that practices are known by all and adhered to. Health and Safety Executive In relation to Point (2) above. At the inquest | heard evidence from | HSE investigator that there is scope for guidelines to be extended by the HSE and circulated throughout the industry which is dedicated to the construction, management and inspection of spoil heaps. Health and Safety Executive In relation to Point (3) above. | should like to be informed whether the HSE is issuing any guidelines to the industry to consider whether the design of dumper trucks should be explored, which takes account af the natural human response in an accident, to jump from a failing truck. | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 4pm on 25" October 2017. 1, 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 foliowing Interested Persons (1) The family of Shaun Carter a tam also under a duty ta 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 response by the Chief Coroner. Dated 29" August 2017 Signature Chowol Qe Caroline Saunders H M Assistant Coroner for Gloucestershire Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gtourester, GL4 30) Tel 01452 305661 | Fax 01452 412618
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.
Health and Safety Executive Construction Division Ray Cooke Construction Sector Mrs C Saunders 9 Quinton Business Park HM Assistant Coroner Ridgeway Gloucestershire Coroner's Court Birmingham Corinium Avenue B32 1AL Barnwood Tel: 020 3028 1754 Gloucester GL4 3DJ ray cooke@hse.gov.uk Date 13 October 2017 boise Bean Construction Sector Head of Unit Simon Longbottom Dear Mrs Saunders The Coroners and Justice Act 2009, Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 Regulation 28 report touching the death of Mr Shaun Carter lam the Head of the Construction Sector Safety Team at HSE and am replying on behalf of HSE to your Regulation 28 letter of 29th August 2017 arising from the inquest concerning Mr Shaun Carter deceased. Your letter raises two matters of concern requiring a response from HSE. | set these out below together with our response: 1. At the inquest it was confirmed that there was no process in place to ensure that spoil heaps were managed safely, nor any guidelines issued by HSE in this regard. This has been addressed by Tonic Construction in relation to the sites it manages, but there are still no industry standards relating to the management of spoil heaps. At the inquest | heard evidence from Sue Adseit, HSE investigator that there is scope for guidelines to be extended by the HSE and circulated throughout the industry which is dedicated fo the construction, management and inspection of spoil heaps. There were several fatal accidents involving forward tipping dumpers during 2016 and HSE was instrumental in helping the construction industry (including Tonic Construction) set up a working group to take forward safety improvements connected with the design and use of dumper trucks and the design of spoil heaps. | attend that group on behalf of HSE. The group is co-chaired by the Construction Plant-hire Association and Civil Engineering Contractors Association. The group comprises construction contractors, hire companies, owners of forward tipping dumpers, manufacturers, client organisations and industry federations as well as HSE. The actions from that group include promoting an emphasis on training, not just of operators but also of supervisors and those who design construction sites so they understand the safety issues raised by the construction of spoil heaps and can where possible reduce or eliminate the use of them and otherwise tightly control the use of them. HSE will publicise the changes via its e-news bulletin which is well subscribed to within the construction industry, and provide links to the industry pages on our website. Other specific actions the group is taking are included below. The Construction Plant-hire Association (CPA) is producing updated guidance on the safe use of forward tipping dumpers. HSE has been involved in commenting on this. This work is nearing completion and the guidance will be available free to download from the CPA website. The guidance will include information for operators that should improve awareness and knowledge by including detail explaining why issues are important rather than just saying something should be done; guidance to managers and designers for planning and supervision of forward tipping dumpers on sites; and a case study annex using a real example. HSE will provide a link from its website to this guidance. The Civil Engineers Contractors Association (CECA) is providing pages on its website dedicated to forward tipping dumpers and providing links to other information to be a central source of information and to co-ordinate future activities. It is hoped these pages will be launched in about a month. Again, HSE will provide a link from its website to this. One of the aims of the new CECA webpages will be to encourage organisations to sign up to the key safety principles for the use of forward tipping dumpers. These are full all-round vision, improved stability, training, competence, tight control of spoil heaps, exclusion zones to separate people from plant, and selection of the correct plant for the task/ site. Also, Construction Plant Certification Scheme (CPCS), the main plant training scheme for operators of machinery are revising the training specifications for forward tipping dumper truck operators and are looking at how they might build in criteria on operator behaviours to complement the current training and assessment. The Strategic Forum for Plant Safety Group (SFPSG) is to produce good practice guidance on forward tipping dumpers. | also attend this group on behalf of HSE. This guidance will be available to download free of charge and will be hosted on the CPA website (CPA chair that group). | will also be assisting CPA with an addition to its guidance on ground conditions to include advice on unconsolidated spoil heaps, and this will again be under the auspices of the SFPSG. This guidance will also be available to download free of charge from the CPA website HSE has started a review and revision of its HSG144 guidance on safe use of vehicles on construction sites. We are considering what specific advice we can provide to help improve safety in the use of forward tipping dumper trucks and include signposting to other guidance published by CPA and CECA. This should be completed next year. 2. Dumper trucks are designed to ensure that drivers are protected, even if the dumper trucks topple over. However, the inherent open nature of trucks can nonetheless make the driver feel vulnerable and despite the instructions which require the driver to remain seated during an accident, Statistics indicate (as in this case) that the natural reaction of drivers is to jump from the truck. In relation to this | should like to be informed whether HSE is issiting any guidelines to the industry to consider whether the design of dumper trucks should be explored which takes account of the natural human response in an accident to jump from a falling truck. A manufacturers’ sub-group of the working group has been considering potential dumper truck design improvements identified by the users/hire companies/clients. These result from a survey of Civil Engineers Contractors Association members which suggested improvements that are most important or critical to safety. The manufacturers will be meeting again, under the leadership of the Construction Equipment Association, to work through specific improvements that can be made. HSE will also be involved. Examining the feasibility / desirability of the fitting of cabs as standard will take some time. There is currently no standard or set test criteria for determining the design of any cab and the level of impact it should take. Design changes need to be considered carefully and done correctly so that they do not introduce other unforeseen hazards. However, in the meantime other improvements will be included such as being unable to drive the dumper if the seatbelt is undone, and an audible warning if the operator undoes the seatbelt. These are already available from manufacturers but frequently purchasers decide to buy them without. This has highlighted the need for improved awareness and understanding of the issues and the actions listed under 1 are all designed to achieve this. In conclusion HSE will continue to work with and contribute, to support and publicise the positive and constructive steps the construction industry is taking on this important issue. Yours sincerely Ray Cooke _Head of Construction Sector Safety
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