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Engagement & Policy Division

Stuart P G Fisher Health & Safety Executive
HM Senior Coroner — County of Lincolnshire a Reus?

4 Lindum Road Berane

Lincoln

LN2 1NN Tel: 0203 028 1782

http://www.hse.gov.uk/

Date: 8' January 2019

Dear Sir,

HEALTH AND SAFETY AT WORK ETC ACT 1974

REGULATION 28 REPORT TO PREVENT FURTHER DEATHS; IN RESPECT OF THE INQUEST
TOUCHING ON THE DEATH OF PETER JOHN LETT

| refer to your report in respect of the above which was forwarded to me to provide a response. |
understand that the inquest concluded that Mr LETT’s death was “accidental death” due to multiple injuries.
Mr LETT was assisting at Heckington Windmill, Sleaford in his capacity as a volunteer. His clothing
became entangled in the crankshaft of a Ruston Hornsby stationary engine situated in a shed adjacent to
the windmill.

The inquest identified a matter of concern, namely, that it considered there to be a dearth of Health &
Safety Executive (HSE) Guidance in respect of historic and heritage equipment, (much of which is
unguarded and potentially extremely dangerous). The inquest called for clear guidance to be produced by
the HSE to seek to prevent future deaths.

The death of Mr LETT was the subject of an investigation by North Kesteven District Council (local
Authority) who are the relevant regulator of Health & Safety legislation in respect of the Windmill and the
activities being undertaken on site. In this instance the Local Authority Inspectors were supported by
Michael Raynor CEng MiMechE MAPM, HM Specialist Inspector (HSE Mechanical Engineering), who
provided technical support and opinion. | understand that Mr Raynor's report was available to the inquest.
The report identifies that the machine involved in the incident was a “vintage” Ruxton & Hornsby single
cylinder “heavy oil’ engine which had been installed recently at the site to provide drive for other machinery
within the windmill when the sails were not rotating.

The duty under the above Act to ensure that the risks associated with the operation and use of the
machinery on site were controlled by the Heckington Windmill Trust extended to both the volunteers
assisting on site and the public visiting the attraction. | understand that the investigation identified that the
machinery was not suitably guarded at the time of the incident and as such the Local Authority served an
Improvement Notice on the Trust requiring them to control the risks associated with the operation of the
engine. The revised safeguards implemented to comply with the notice included the fitting of relevant
guards to prevent access to the dangerous parts of the machinery including the rotating shaft which Mr
LETT’s clothing had become entangled in.

The Health and Safety Executive has produced a wide range of guidance relevant to the guarding of
machinery. This is freely available to download from the HSE website. The machinery guarding homepage
signposts readers to a wide range of additional information including specific guidance on the requirements
for dangerous parts of machinery to be guarded to comply with the Provision & Use of Work Equipment

Regulations (PUWER) 1998. The Approved Code of Practice to these Regulations is aimed at employers,
dutyholders and anyone who has responsibility for the safe use of work equipment. If dutyholders follow the
practical advice within the Code they will comply with the law. Although written for the 1998 Regulations the
Code reflects and updates previous guidance in respect of machinery guarding including those relevant to
vintage machinery. additionally, more detailed information on specific guarding requirements and solutions
is available within PD 5304:2014 “Guidance on Safe Use of Machinery” produced by BSI Standards. This
includes guidance on the guarding of rotating shafts with projections on them as was relevant in this case.
Although the machinery in this case was vintage, it had been newly installed. The requirements of PUWER
are relevant to this installation and all vintage or heritage machinery.

The HSE recognises the challenges associated with safeguarding heritage machinery, particularly the need
to strike the balance between ensuring the machinery is safe yet does not detract from the authentic
representation of any historical exhibit. In some cases, the machines at heritage attractions are no longer in
general use and whilst specific guidance for these may not be available PUWER sets out a default position
of assessing the risks from first principles. Dutyholders should then implement measures and develop safe
operating procedures in accordance with the outlined hierarchy of controls to ensure the machinery is
safeguarded as far as is practicable. This may include the fabrication and installation of bespoke guards. (|
understand that in this case the guarded fitted subsequently included fitting Perspex panels to control the
risks yet still allow the public to see the operating exhibit).

In this instance the Windmill is operated and controlled by the Heckington Windmill Trust who although is
an employer is primarily an organisation run by volunteers. We recognise that voluntary organisations and
volunteers play an increasingly important part of society in Great Britain and their activities underpin and
support a significant proportion of the delivery of services and leisure activities. Health and safety
legislation applies to the activities of volunteers and in particular the safety of the public, however this may
not be fully understood by those involved. As such, the HSE acknowledge the need to engage with
voluntary organisations and volunteers and ensure they have a better understanding of their duties and are
better signposted to relevant guidance to ensure that they understand their duties and can comply with the
requirements of the law. The lead on volunteers has been incorporated into the HSE Public Services
Sector. The current work plan seeks to improve and expand the specific HSE web pages which focus on
voluntary activity and work with relevant stakeholders to develop further guidance and support networks for
voluntary organisations including assisting them in finding bespoke guarding and risk control solutions to
include heritage machinery.

| trust that this provides you with the necessary reassurance that there are relevant standards and
guidance setting out the duty and the approach to machinery safeguarding solutions to include historic
equipment. As | have identified the HSE are actively working to improve the signposting to risk control
solutions and support for organisations such as the Heckington Windmill Trust.

HM Principal Inspector of Health & Safety
Head of Public Administration, Education & Volunteers (PAEV) Sector