Gary Webster

Date:28.04.20 

Your reference: 

Our reference: 

Tel: 

Inquest touching the death of Gary Dean Webster – response to Regulation 28 Report 

Dear Sir 

As you are aware, I gave evidence at the resumed inquest touching the death of Gary Dean Webster and 
wanted to formally respond on behalf of BAM Nuttall Limited (“BAM Nuttall”) to the Regulation 28 Report 
to Prevent Future Deaths dated 2 March 2020.   

I begin this letter by reiterating both my deepest sympathy and condolences, and those of BAM Nuttall, to 
Mr Webster’s family. 

The conclusion of the inquest was that the medical cause of death was as a result of cold water 
immersion which led to cardiac arrest and later multiple organ failure.  The Jury returned a narrative 
conclusion. 

Following the inquest, you raised three discrete concerns in your Regulation 28 Report, and invited BAM 
Nuttall to respond.  I have answered each of these areas in turn: 

1.  Risk Assessment 

The Coroner identified the following concerns: 

the failure of the Senior Engineer and Manager involved to appreciate the hazards involved 
require a suitable and sufficient assessment of the risks involved before proceeding 

1. 
2. 
3.  consider whether alternative methods of accomplishing the task might reduce or eliminate the 

risks to their safety 

The Coroner heard evidence that a dynamic, point of work risk assessment was carried out by the site 
foreman immediately prior to Gary entering the weir on the Dory boat.  It is accepted by BAM Nuttall that 
this was not a formal written risk assessment and was not supported by a method statement to carry out 
the work activity, unlike all of the very carefully planned and executed tasks on site that day – the inquest 
heard about the dive plan and the maintenance to the bladders which were being undertaken and for 
which in line with BAM Nuttall’s procedures, trained and competent engineers carried out detailed written 
risk assessments, with input from the site foreman and other site workers.  

There have been some changes in personnel in the two and half years since Gary’s death. Refresher 
training has either already been provided or has been scheduled to be provided to all of those who are in 
roles where they might be expected to undertake risk assessments to ensure the high levels of 
competence expected by BAM Nuttall remains current and front of mind, as part of BAM Nuttall’s ongoing 
training provision.  Separately, BAM Nuttall’s dedicated health and safety team has again circulated 
information relating to the incident to the wider business, highlighting the need for carrying out risk 
assessments when undertaking new or unfamiliar work activities.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
  
 Immediately following the incident, BAM Nuttall considered whether the activity of clearing out debris from 
the area in front of the curtain of water was a necessary task at Knostrop Weir.   It was concluded that the 
debris was a cosmetic eyesore, but posed no risk of damaging Knostrop weir.  As such, the activity was 
not a required activity and was subsequently banned on both the local site and all BAM sites. We 
determined after a further review that the activity could not occur at any other BAM Nuttall site; this 
learning has been recorded to ensure corporate learning in the future.  

Since the incident, BAM Nuttall has consolidated its processes and procedures in respect of working over 
or near water in its guidance document “SG16”.  This guidance has been trained out to all relevant BAM 
Nuttall employees and contractors.  The basic principle is to ensure zonal working is implemented on sites 
such that high risk areas are classed as prohibited entry.  I can confirm that the area under an operating 
weir would be classed as a prohibited area using this system.  As such, workers will not ever be permitted 
to enter the area.  

2.  Qualifications 

The Coroner raised two concerns relating to qualifications.  The first was in relation to one site worker who 
was not trained to operate the boat involved in the incident and the second related to Gary Webster’s own 
qualifications.  

In respect of the site worker who was not competent to operate the boat, I can confirm BAM Nuttall 
operates a strict policy of disciplining individuals if they operate equipment when they are not competent 
to do so.  In some cases this would result in instant dismissal.  In this instance, whilst the operative 
himself stated he had previously operated the boat, this is disputed and would have been put to him as 
untrue if he had attended the inquest in accordance with his witness summons.  Were it the case that the 
operative was found to be operating the dory boat without being qualified and authorised to do so, he 
would have been guilty of gross misconduct and would have been disciplined immediately.  There is a 
clear prohibition on untrained operators using pieces of equipment which they are not authorised to work. 
All Site Operatives and contractors are reminded of the site rule that they may only operate equipment 
that they hold the appropriate qualifications and competence to do so.  This is enforced through 
supervision and disciplining at site level. 

In relation to permitting, there is no one stop shop as an industry standard. There is no “permitting” 
system mandated in any ACOP or guidance note.  Site operatives either hold a “ticket” for a particular 
piece of equipment, or they do not.  If they hold a ticket and can demonstrate they are competent under 
the supervision of a site foreman, then they are deemed competent to operate that equipment on site.  
This is recorded and managed at site level.    

Gary Webster’s qualifications were checked at the outset of his commencing work at Knostrop Weir.  
BAM Nuttall believe Gary was a competent boatmaster with significant experience of working on water.  
Gary Webster’s experience was respected on site; he was known to identify and rectify issues with 
methods of work and the evidence given at the inquest, including by his family, was known to refuse to 
work if he felt the method was not suitable.   

In respect of the Coroner’s second concern around qualifications, the Coroner heard conflicting evidence 
about whether Gary Webster had previously operated the boat involved in the incident.  BAM Nuttall is 
unable to reconcile that evidence.  However, I can confirm that in my opinion, Mr Webster’s qualifications 
were suitable for his role on site and it would not be industry standard to ask for any additional 
qualification.  

The site foreman and site supervisors are aware of and keep a record of which operatives are competent 
to operate which machinery and equipment.  In this case, the instruction to operate the boat was given to 
Mr Webster, who as set out above, was competent to operate it.  It is not clear how an additional physical 
marker (such as a different colour hard hat) would assist in identifying a competent individual and indeed 
on a complex site with many pieces of specialist equipment it may even cause confusion to site workers.  

 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 3.  Design of the weir installation 

BAM Nuttall was not involved in the design of the weir installation.  As such, I am unable to comment on 
this further, except to confirm that BAM Nuttall will ensure that the Coroner’s Report to Prevent Future 
Deaths is shared at the earliest opportunity with any designers of weirs in projects for which BAM Nuttall 
is acting as Principal Contractor.  

BAM Nuttall is committed to the ongoing training of its workforce, as well as the ongoing development of 
ever safer systems of work.  To that end, the business has carefully considered the concerns raised by 
the Coroner and is satisfied that similar circumstances cannot arise again.  

Yours sincerely 

Director, Health and Safety 
BAM Nuttall ltd

bmmiv

M
_ M

nuttall BARSOHAD

Mr Kevin McLoughlin

Senior Coroner for West Yorkshire (East}

HM Coroners Office
71 Northgate
Wakefield

WF1 3BS

By email: hmcoroner@wakefield, gov.uk

EMM UV Limited
Registered in England and Wales
Company number 08584962
Registered Office. St James House,
Knoll Road, Camberley, Surrey,
GUIS 3xW

Case No 11568

27 Apri] 2020

Dear Mr McLoughiin,

Regulation 28 Report to Prevent Future Deaths following the inquest touching upon the
death of Mr Gary Dean Webster

{am writing to you on behalf of BMM JV Limited (BMM JV) to respond to the concerns raised by
your investigation into the circumstances surrounding the tragic death of Mr Webster. { wish to
extend my deepest sympathy and condalences to Mr Webster's family on behalf of BMM JV.

BMM JV is an incorporated joint venture between BAM Nuttall Limited (BAM Nuttall) and Mott
MacDonald Limited (Mott MacDonald). BMM JV was incorporated in June 2013 for the purposes
of tendering for projects like the Leeds Flood Alleviation Scheme. BMM JV entered into the
contract in September 2014. BMM JV were appointed as Principal Designer to the project in June
2015.

On behalf of BMM JV, BAM Nuttall delivered the construction aspects of the project and Mott
MacDonald delivered design aspects in relation to elements of the Knostrop Weir's installation.
The Weir design had been determined by ARUP prior to BMM JV’s appointment. Mott
MacDonald's design role, on behalf of BMM JV, was confined to the design of the concrete
foundation and wall elements of the Weir.

[have sought to address your concerns, to the extent that | am able, in turn:

t. Risk Assessment

| understand that BAM Nuttall have responded to the Regulation 28 Report (the Report)
separately and addressed you in respect of matters concerning site operations.

BMM JV was not involved in the construction or site operations.
2. Qualifications

| understand that BAM Nuttall have responded to the Report separately and addressed
you in respect of matters concerning site operations.

BMM JV was not involved in the consiruction or site operations.
3. Design of the Weir installation

The Weir design had been determined between ARUP and Leeds City Council before
BMM JV's appointment in September 2014.

bmmijv
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[Page 20f 3

ARUP, in its role as Designer (under the Construction (Design and Management)
Regutations 2007), had undertaken the hydraulic modelling of the river and Weir, as well
as the selection of the form of the Weir.

Leeds City Council tendered and contracted with specialist supplier, Dyrhoff, te design,
manufacture and supply all the component parts of the moveable Weir, prior to BMM JV
coming on board,

The extent of Mott MacDonald's design role, on behalf of BMM JV, was specifically in
relation to the design of the concrete foundation and concrete wall elements of the Weir
and to accommodate process and equipment defined by ARUP. These aspects of the
design were unchanged by BMM JV's own contribution to the design of the concrete
foundation.

Information relating te the pre-construction phase plan (PCPP) was prepared by ARUP
prior to BMM JV's appointment. The PCPP was included as part of the tender
documentation sent by Leeds City Council to BMM JV. The pre-construction phase of
the project was essentially complete by the time of BMM JV's appointment on the project
in September 2014.

BMM JV were appainted as Principal Designer under the CDM Regulations 2015 in June
2075. BMM JV's role as Principal Designer included ensuring risks had been controlled
by design. ARUP bore responsibility for the design of the operation of the Weir and the
strategy for maintenance of the asset. BMM JV was provided with a health and safety
file as part of its appointment which included an Operation and Maintenance Part 3 FAS
Maintenance and Repair Strategy prepared by ARUP.

ARUP's design allowed for the isolation of the Weir for maintenance purposes as set out
in ARUP's Operation and Maintenance Strategy (paragraph 4.3, page 18).

| trust that the information supplied above satisfies your request for information. BMM JV will
ensure the Report is shared with other designers in future weir projects.

Yours sincerely,

Y
a

Company Secretary

BMM JV Limited