David Chandler

Carlsberg UK

Dr Philip Barlow
HM Assistant Coroner
Coroner's Office Constabulary Block

Grisberg

UK

Carlsberg Supply Company UK Limited
Jacobsen House
140 Bridge Street

Carlsberg Supply Company UK Limited. Registered Office: 140 Bridge Street, Northampton, NN1 1PZ. Registered in England and Wales No. 8626420. VAT Reg No. GB 679 0058 12

1 Angel Square Northampton

Angel Street NNI1 1PZ

Northampton

NN1 1ED Tel +44 (0) 1604 668866

Fax +44 (0) 1604 234444
www.carlsberg.co.uk

28" August 2018

Dear Dr Barlow

inquest touching the death of David Chandler
Regulation 28 Report to Prevent Future Deaths

| am responding on behalf of Carlsberg Supply Company UK Limited ("“Car/sberg") to your Regulation 28
Report dated 5 July 2018.

| confirm that | am duly authorised to respond on behalf of Carlsberg.
Carlsberg’s response is as follows:

1) The isolation for the 2014 work was still in place and does not appear to have been reviewed in
the intervening period. The 2014 work was of a different nature and did not require physical
removal of the whole compressor. There does not appear to have been any formal review of the
appropriate isolation standard for the work in November 2016 to be performed safely.

It is agreed that the work carried out in 2014 was of a different nature to that carried out in 2016. In
2014 only the compressor unit was removed. The oil separator (to which the discharge pipework
remained connected at all times) remained in situ. The 2014 isolations on both the discharge and
suction sides of the compressor were effective throughout those works. The isolations remained in
place in readiness for a return to service of the compressor unit which had undergone refurbishment.

Those isolations remained in situ between 2014 and 2016. However, even if the isolations had failed in
some way, which they did not, ammonia would not have escaped to atmosphere because the ammonia
system was closed. In other words, even if one of the isolations failed, ammonia would have
progressed into the compressor unit only rather than to the atmosphere.

During the course of 2016 Crowley Carbon Limited (Crowley Carbon), a specialist energy efficiency
company with expertise in industrial ammonia refrigeration plant systems, conducted an energy
efficiency study and concluded that Carlsberg could make significant improvements. Carlsberg
accepted Crowley Carbon’s recommendations and appointed them as Principal Contractor and Principal
Designer (within the meaning of the Construction Design and Management Regulations 2015) for the
project.

Crowley Carbon’s recommendations, referred to above, involved the removal of the compressor unit
and the oil separator (the Works). Crowley Carbon was responsible for the planning, management and
monitoring of the Works. As Principal Designer, Crowley Carbon was also responsible for preparing and
modifying designs so as to eliminate, reduce or control foreseeable risks that may have arisen during
the Works. Crowley Carbon signed to acknowledge its acceptance of its appointment to those roles.
Therefore, Crowley Carbon had a responsibility for ensuring that the risks posed by the presence of

LNO12 (01/14)

ammonia at the site were adequately controlled and that the isolations were adequate for the purposes
of the Works.

Crowley Carbon conducted numerous site visits to enable it to plan the Works.
At all material times, Crowley Carbon:-

(a) was aware of the nature of the isolations performed in 2014 (i.e. that they were not ‘double
block and bleed’ type isolations);

{b) was aware of the likely presence of ammonia in the pipework behind those isolations;

(c) had access to the relevant Piping and Instrumentation Diagrams which identified the locations
of potential isolation points; and

(d) had access to the Permit to Work relating to the isolations in 2014.

Since the incident the isolation policy and procedures across Carlsberg have been reviewed using the
HSE guidance document entitled “The safe isolation of plant and equipment” (HSG253). The policy and
procedures now in place require any isolation to be risk assessed and implemented in accordance with
HSG253._ For each isolation, there is a defined procedure to enable trained individuals to apply an
isolation suitable to protect against the hazardous energy source. All relevant personnel have received
refresher training.

As noted above, the isolations implemented in 2014 were effective between that date and the Works
(in that they did not allow ammonia to pass). Nevertheless, Carlsberg has implemented a system to
ensure that long-term isolations are reviewed in accordance with HSG253. It has implemented a colour
co-ordinated ‘Lock-Off and Tag Out’ procedure so that long-term isolations are easily distinguished
from short-term isolations. Carlsberg has also introduced a long-term isolation register, which is
reviewed on a quarterly basis and re-validated by the Head of Engineering.

(2) Carlsberg contracted the work to Crowley Carbon who employed specialist refrigeration engineers.
The evidence at the inquest suggested that Crowley Carbon and Carlsberg were each relying on the
other to ensure that the compressor was safely isolated.

As noted above, Crowley Carbon had been appointed as both Principal Contractor and Principal
Designer. Carlsberg was relying on Crowley Carbon to ensure that the isolation was adequate having
regard to the nature of the Works.

Since the incident, and to ensure appropriate communication ahead of any future engineering work,
Carlsberg has enhanced its suite of documentation concerning the provision of pre-construction
information to relevant parties. This documentation was and is specific to each project and will identify
the hazards relevant to the works being undertaken. As part of this communication the responsibility
for isolations is clearly defined. To ensure all parties understand the role that they are assigned specific
to CDM15 Carlsberg continues to require those parties to sign a “client brief checklist”.

Carlsberg requires all potential Principal Contractors and Principal Designers to adequately demonstrate
competency in undertaking said duties and any companies not approved under the safe contractor
scheme for these critical roles are not invited to tender.

Although Crowley Carbon was aware of the nature of the isolation in place, the enhancement of the
isolation standards now in place (as detailed in the response to point 1 above) ensures that the
appropriate standard for isolation is applied irrespective of who is responsible for it.

(3) The Permit To Work (PTW) issued by Carlsberg to allow Speedrite to remove the compressor made
reference to the 2014 PTW isolation, was completed incorrectly, and made no reference to hazardous
substances.

Carlsberg has reviewed the PTW system and has concluded that it is fit for purpose. The Health and
Safety Executive attended the site on the 15 August 2017. The permit system was reviewed during that
visit and it made no recommendations for improvement.

The referencing of one permit to another is an acceptable practice within the PTW system. Post
incident practice would ensure that any previous isolations were verified against the enhanced isolation
procedure referred to in response to point 1. In these circumstances, an appropriate level of isolation
will be implemented at all times.

Since the incident, Carlsberg has reviewed the competence of individuals with responsibility for
completing PTWs. To further enhance competency, specific HSG253 training was conducted post
incident.

(4) Relying on the isolation from previous work on the compressor appears to have caused confusion
as to the safe level of isolation necessary for work of a different nature two years later.

We do not accept that there was confusion caused by the permit issued in respect of either the 2014 or
2016 works. Crowley Carbon was aware of the nature of the isolation performed in 2014. The
evidence clearly demonstrated that Crowley Carbon personnel were fully aware of the presence of
ammonia in the discharge pipework beyond the isolation on the discharge side of the compressor unit.
See the response to point 1 above. Carlsberg expected the work to be planned, managed and
monitored by Crowley Carbon so as to control those risks. See the response to point 2 above.

| believe that the above addresses all issues raised in your report.

Yours sincerely

Head of Legal