Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0094, written 19 Mar 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Mar 2019 |
|---|---|
| Reference | 2019-0094 |
| Deceased | Mark Parry |
| Coroner | Heath Westerman |
| Coroner area | Cheshire |
| Category | Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. HM Acting Chief Executive of Health and Safety
1
CORONER
I am Heath Westerman, Assistant Coroner, for the Coroner area of Cheshire.
2
CORONER’S LEGAL POWERS
I 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.
3
INVESTIGATION and INQUEST
On 8th March 2017 an investigation was commenced into the death of Mark Keith
PARRY dob 14th March 1980. The investigation concluded at the end of the inquest on
18th March 2019. The conclusion of the inquest jury was that the deceased had died
whilst undertaking repairs on a heavy goods vehicle when he was struck on the head by
a piston from an exploding airspring which led to brainstem (duret) haemorrhage. The
jury determined that the deceased had died by accident.
CIRCUMSTANCES OF THE DEATH
4
Mark Keith Parry was a specialist heavy goods vehicle mechanic. On 21st February
2017 he was called out to a broken down heavy goods vehicle in Nantwich. He identified
the cause of the breakdown as a broken trailing arm on axle 3, the rear most axle on the
trailer unit. He crawled underneath the trailer unit in order to strap the trailing arm on
axle 3 to axle 2 so that the HGV could be driven to a yard for repair. He exhausted the
air supply out of the airbag to axle 3 but had not done so with the air supply to the airbag
on axle 2. Whilst the strap was attached to axle 3 and axle 2 it was not secured tight as
the ratchet clasp used to do that was open leaving the strap lose and baggy. Mr Parry
was getting out from underneath the trailer unit using his legs first, his upper body and
head being raised between axle 3 and axle 2, when an explosion occurred and the
bellow from axle 2 was ejected and struck Mr Parry on the back of his head. He was
transferred by air ambulance to the Royal Stoke University Hospital where he died on
2nd March 2017 from the unsurvivable head injuries received.
5
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.
The MATTERS OF CONCERN are as follows.
Guidance
That there are no published guidelines by the Health and Safety Executive to mechanics
and those companies that employ mechanics on how to work with or approach working
with Air Suspensions on Heavy Goods Vehicles. The value of such guidance is that it
would signpost strategies and risks attached to such work.
1
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 14th May 2019. I, 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons;
.
I 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 response by the Chief
Coroner.
9
19th March 2019 Heath Westerman
Assistant Coroner, Cheshire
2
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.
24 4 HSE Health and Safety Executive Cheshire Coroner's Office West Annexe Town Hall Sankey Street Warrington Cheshire WAI 1UH Reference Engagement and Policy Division BP6301 Alnwick House Benton Park view Newcastle Upon Tyne NE98 1YX httpy/www.hse.gov.uk/ HWIJM/14927/CR P| For the attention of Heath Westerman, Assistant Coroner, Cheshire Date 13 May 2019 Dear Mr Westerman REGULATION 28 REPORT FOLLOWING INQUEST OF MARK PARRY Your letter of 20 March 2019 to Dr David Snowball, HSE’s Acting Chief Executive, has been passed to me to reply, as the sector lead for the motor vehicle repair industry. Your Regulation 28 report raises a concern that there are no published guidelines on how to approach work on air suspension systems on heavy goods vehicles. | have reviewed our current guidance and identified that we have two documents relating to work on air suspensions systems, however these refer specifically to buses and coaches. They are PM85 Safe recovery (and repair) of buses and coaches fitted with air suspension htto:/Awww.hse.gov.uk/pubns/pm85.pdt and paragraphs 175-178 and 212-213 of HSG261 Health and Safety in motor vehicle repair and associated industries http//www.hse.gov.uk/pubns/priced/hsg26 1 pdt The guidance highlights the risk from the collapse of vehicles supported using air suspension and of fragments being ejected from the bellows at high speed. However, it does not identify control measures in relation to ejection or relate to vehicles other than buses and coaches. HSE therefore plan to issue a safety alert, identifying the required control measures and emphasising the risks are present on all vehicle types with air suspension systems. As you can appreciate, this will take some time, as it will require consultation with industry; | hope this will be finalised by August 2019. The safety alert will be published on the HSE website and publicised through trade associations and e- bulletins. Longer term, | will amend PM85 to address control measures in relation to ejection; and will review whether this guidance can be renamed to relate to all large vehicles with air suspension systems. | hope to complete this by the end of March 2020. HSG261 is also being updated and revised and the content relating to air suspension systems will be reviewed, though this a longer term project. Yours sincerely HM Inspector of Health & Safety
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