Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0096, written 17 Apr 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Apr 2020 |
|---|---|
| Reference | 2020-0096 |
| Deceased | Ashley Holden |
| Coroner | Paul Smith |
| Coroner area | Lincolnshire |
| Category | Other related deaths · Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
HM CORONER Lincolnshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Department of Transport 2. Health and Safety Executive | CORONER | am Paul Duncan Smith, Area Coroner, for the Coroner area of Lincolnshire, 4 Lindum Road, Lincoin, LN2 1NN CORONER’S LEGAL POWERS | 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 19 November 2018 | commenced an investigation into the death of Ashley Mark Holden, aged 27. The investigation concluded at the end of the inquest on 11 December 2019. The conclusion of the inquest was that Mr Holden died as a result of an accident, the medical cause of death being: la. Head Injury CIRCUMSTANCES OF THE DEATH 1. On 10 November 2018 Ashley Holden was employed as an HGV driver. He was instructed by his employer to visit Staples Farm, Main Road, Stickney. Boston to collect a quantity of straw bales. 2. Although his employment had not commenced until 7 November 2018 he had visited that farm on previous occasions and had collected a similar load of bales without incident. 3. On 10 November, as previously, the trailer was loaded for him by farm operatives and the bales were loaded in accordance with the normal pattern. 4. The trailer had an extendable bar fitted to the rear which lengthened the trailer bed by approximately two feet. After the trailer had been fully loaded, Mr Holden noted that the bales, as loaded, were overhanging the trailer bed. He requested that a number of bales be removed from the rearmost section of the trailer as he wished to check that the bar was fully extended. 5. The farm operative removed a total of 9 bales from the very rear of the trailer, following which Mr Holden and the operative confirmed that the bar was fully extended. It was pulled out by an additional couple of inches only. 6. As that occurred, two of the remaining bales, being unstable, fell from the trailer, one of them striking Mr Holden and forcing his head onto the extended trailer bar where he sustained fatal injury. 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. — | received evidence that; 1. Fatalities from falling bales are an acknowledged risk within agriculture with a number of fatalities annually. 2. There are two specific guidance documents available to the public which are relevant to this issue; e Department of Transport Code of Practice, “Safety Loads on Vehicles” (2002) e Health and Safety Executive (HSE), “Safe Working With Bales in Agriculture” (2012) 3. The two pieces of guidance are not consistent in the approaches that they suggest and indeed the later guidance does not reference the earlier guidance. 4. There is no definitive guidance provided to the industry in relation to the stacking or unstacking of bales, or in relation to the loading and strapping of loaded trailers in a manner which takes account of the different sizes and composition of bales, and/or different trailer sizes and configurations. 5. The absence of specific guidance on this issue creates a risk of the development of unapproved and potentially unsafe individual practices, with the consequential risk of future deaths. 6. The provision of definitive guidance would be welcomed by those working within agriculture. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND/OR your organisation has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10 July 2020. |, the Area 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 I have senta ~ of ~ _ to the Chief Coroner and to the following Interested Persons Thorley Brothers Ltd Health and Safety Executive | 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. Dated this 17th day of April 2020 avers, Ce Paul D Smith Area Coroner Lincolnshire
2 responses 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.
• Department for Transport Paul Smith HM Area Coroner 4 Lindum Road Lincoln Lincolnshire LN2 1NN Dear Mr Smith, Baroness Vere of Norbiton Minister for Roads, Buses and Places Great Minster House 33 Horseferry Road London SW1P4DR Tel : 0300 E-Mail : dft.gov.uk Web site: www.gov.uk/dft Our Ref: Your Ref: 7 July 2020 I am writing in response to the 'Regulation 28' report issued on 17 April 2020. I am replying as the Minister responsible for this issue. On behalf of the Department for Transport (DfT), I would like to take this opportunity to acknowledge the concerns you have raised regarding the tragic incident which resulted in the death of Mr Ashley Mark Holden on 10 November 2018. In preparing this response my officials have consulted with the following: • Driver and Vehicle Standards Agency (DVSA) • Health & Safety Executive (HSE) Your report outlined a number of concerns relating to guidance for the safe loading and unloading of bales and the consistency of existing HSE and DfT guidance, which you considered to be insufficiently detailed to avoid the occurrence of unapproved and potentially unsafe working practices. I understand you have sent a similar letter and report to HSE. The report you have written offers clear scope for my department to take a lead in reviewing previous DVSA guidance, whilst working with HSE to reach a consistent approach to future guidelines. There are two relevant and specific guidance documents available to the public, which you have reviewed and noted as being inconsistent in their approach. You have also highlighted that the most recently published guidance does not currently make proper reference to the earlier guidance. We propose: • That DVSA updates the 'Load Securing - Vehicle Operators Guidance' which was last reviewed with HSE in 2015. HSE has agreed in principle to assist DVSA in updating this guidance which was already proposed at the start of this year. Having considered the approaches that could be taken, we have identified that a generic approach to safe loading principles, rather than very specific information covering each size of bale and trailer, is considered to be most practical. A comprehensive table seeking to cover every permutation of trailer and bale would be overly complex and may confuse. However, the updated guidance will look at the key principles for the safe loading and transport of bales. • To amend the DfT Code of Practice, 'Safety Loads on Vehicles' (2002) to ensure both are cross referenced effectively. Whilst HSE leaflet INDG125 already references the DfT guidance on page 10 titled Find out mor~ - https://www.hse.qov.uk/pubns/indg125.pdf, we note that HSE intends to . consider whether improvements can be made to INDG125 when it is next under periodic re-evaluation. • DfT will work with other organisations including, where appropriate, the DVSA and HSE to promote safe working practices during loading and unloading operations. We note that HSE does and will continue to engage with the agricultural industry to promote safe practice over a variety of topics, including safe working with bales. I hope you find these proposals helpful and are assured that the Department and its agencies are taking appropriate action to respond to your concerns. BARONESS VERE OF NORBITON
Health and Safety Executive Engagement & Policy Division Agriculture, Vulnerable workers, Waste & Recycling Unit Hornbeam House Electra Way Crewe CW1 6GJ Tel : 020 - §)hse.gov.uk http://www.hse.qov.uk/ Head of Unit HSE Paul Smith HM Area Coroner for Lincolnshire Lincoln Coroners' Court & Office 4 Lindum Road Lincoln Lincolnshire LN2 1NN 3rd July 2020 Your Reference: 02848-2018 Dear Mr Smith Inquest into the death of Ashley Mark Holden - Regul~tion 28 report. Thank you for your letter dated 20 April 2020 to Inspector . . . . . . and the associated operational policy in Regulation 28 report dated 17 April 2020. I lead a team th~ relation to the agriculture sector and this includes safe use and stacking of bales in farm work. Vehicle loading and load securing cross over two areas of legislation: road traffic which is enforced by the Driver & Vehicle Standards Agency (DVSA) and police forces, and workplace safety which is enforced by HSE and local authorities. As such, HSE works closely with DVSA, the police, Highways England, and the Office of the Traffic Commissioner to ensure that guidance is available to vehicle operators and drivers to help them comply with their duties on the road and in the workplace (e.g. farm or factory). I understand you have sent a similar letter and report to the Department for Transport (DfT). HSE recognise that unstable loads present a serious risk of harm during loading and unloading. In 2013 we worked with DVSA to introduce a new enforcement approach for vehicle loading, and produce updated on-road guidance on load securing for vehicle operators, which was published in 2015. We continue to work closely with DVSA and police forces, providing training on vehicle loading for frontline personnel alongside specialist technical support. We also provide loading and load securing advice through wider forums to the agricultural sector. The risk of fatal and serious injury when working with bales in agriculture is well known and guidance has been in place in various forms for decades. Recently, between 2014 and 2019, 6 people were killed by falling bales. We continue to monitor and adapt our guidance in light of incidents and modern farming practices. For example, INDG125(rev3) was revised in 2012 to provide updated guidance to the industry on safe working practices, including the safe loading and unloading of bales. The DfT guidance Code of Practice : Safety of loads on vehicles is already referenced in INDG125 under the 'Find out More' section of the leaflet on page 10. We are grateful for your comments and we will take then into account at the next review. The overarching legal framework in place for workplace safety includes the Health and Safety at Work etc. Act 1974 and this applies to work with bales. The Act, and Regulations made under the Act, require employers to assess the risk from work operations, including loading activities, and provide control measures to reduce these risks, so far as is reasonably practicable. Of relevance to loading are the Lifting Operations and Lifting Equipment Regulations 1998 (LOLER) which set out what duty holders involved in any lifting operation must do to comply with the law. Every lifting operation is different, but the heart of LOLER requires all lifting work to be properly planned and organised. When handling and loading bales, control measures would normally include the following: • Planning the configuration of the load and the loading operation. The configuration of the load will vary depending on a number of factors including but not limited to the type of vehicle, the type of bale and the nu.mber of bales. • Using a competent person who is able to stack bales safely. The competent person should understand the risks when loading bales, including that bales shift when they get compressed and settle. • Using suitable lifting machinery to load bales. The machinery should be operated by a trained and competent person. • Keeping pedestrians and all other people out of the way during loading. • Not overloading the trailer. • Not stacking bales beyond the edge of the trailer. • Only allowing securing of the load to take place after the load has been assessed by a competent person as being stable. The guidance contained in INDG125 is intentionally broad and sets out the principles of safe loading that meet the Act and LOLER. It has never been our intention to cover every possible configuration but the combination of suitable and sufficient assessment, planning and use of competent people allows for loads of many types to be loaded and transported safely within a robust legal framework. The duty rests on employers and those in control of the loading operations to identify risks associated with the loading operation, implement effective controls to ensure the safety of persons who may be affected, and keep these controls under review. We keep guidance, including INDG125, under periodic re-evaluation. When INDG125 is next reviewed we will consider whether improvements can be made. Yours sincerely Acting Head of Health, Engagement, Livestock and Pesticides Agriculture Sector 2
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