Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0303, written 9 Sep 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Sep 2021 |
|---|---|
| Reference | 2021-0303 |
| Deceased | Kenneth Audsley |
| Coroner | Kevin McLoughlin |
| Coroner area | West Yorkshire (East) |
| 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. Hirst Electrical Plant Hire Services UK Limited, Unit 3, Mallard Industrial Estate, Horbury Junction, Wakefield, WF4 5QH. 1 CORONER I am Kevin McLoughlin, Senior Coroner, for the Coroner area of West Yorkshire (East). 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 22nd June 2020 I commenced an investigation into the death of Kenneth Audsley, aged 56. The investigation concluded at the end of the Inquest on Wednesday 8th September 2021. The conclusion of the Inquest was Accidental Death due to Carbon Monoxide Poisoning in the course of his work. 4 CIRCUMSTANCES OF THE DEATH Kenneth Audsley, aged 56 was an experienced high voltage electrical engineer. On Friday 19th June 2020 he was investigating a fault on a large industrial transformer at his place of work when he was overcome by carbon monoxide which had accumulated inside the transformer. The transformer should have been filled with 2500 litres of oil but in fact held only approximately 170 litres of oil. The carbon monoxide had collected in the space which should have occupied by the oil. The timescale and circumstances in which the oil was lost and the carbon monoxide gas collected in its place have not been established. 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:- (1) The risk that a potentially lethal gas could accumulate inside the transformer was not appreciated either amongst the electricians in this workplace or those involved with industrial transformers generally. (2) There were no warning signs affixed to the transformer alerting users to the risk of using the transformer unless it had first been confirmed it contained adequate oil. (3) The manufacturer’s manual contained no warnings of the hazard which would be created if the transformer were to be energised without containing adequate oil for cooling and insulating purposes. (4) The manufacturer did not recommend a periodic maintenance regime to confirm adequate oil remained in the transformer and have it replenished if necessary. 1 (5) By virtue of these matters there exists the possibility that comparable transformers in service throughout the UK may contain insufficient oil to be operated safely and prevent an accumulation of potentially hazardous gases in the space thereby created. (6) The risks identified could affect anyone (1) dismantling a transformer at the end of its life; (2) having cause to open a transformer for repair or maintenance purposes or (3) users who maybe unaware that inadequate oil could cause a transformer to overheat or catch fire. 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 Thursday 4th November 2021. 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:- (1) The family of Kenneth Audsley (2) The Health and Safety Executive, FAO I have also sent it to the following who may find it useful or of interest: (1) Loadgen Limited, FAO (2) (3) RF Winder Electrical Limited, Belgrave Works, Town Street, Leeds (4) The Institution of Occupational Safety and Health (IOSH) (5) West Yorkshire Police, FAO DC , Power 2 Connect 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 Dated: Thursday 9th September 2021 Signed: KEVIN McLOUGHLIN Senior Coroner West Yorkshire (E) 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.
IRST www.hirstelectrical.co.uk 25 October 2021 HMCoroner Mr. K Mcloughlin Wakefield Coroner Re Regulation 28 Notice, Mr. Kenneth Audsley Dear Coroner, We write to you with reference to your Regulation 28 notice issued to us in respected of Mr. Kenneth Audsley's death. As a direct result of this we have as a business implanted a number of changes in our company's working practices in an effort to prevent an incident of this nature ever being repeated. We remain deeply shocked and saddened by the loss of our friend and colleague, Kenny, and wholly support the notion to inform the industry to prevent recurrence of such a tragedy. We are aware that our solicitor, , has contacted you with a list of third parties that we deal with within our daily duties to assist with this process. We would also like to take this opportunity to demonstrate changes we have made in support of the notice. Firstly, the company' s employees are now prohibited from removing the lid of any transformer which is suspected to have been energised without adequate oil in place. All staff dealing with transformers have been briefed on the risks posed by removing a transformer lid in such circumstances, and indeed have been instructed to stop this practice. Rather, in the event that a transformer is returned in a condition leading us to suspect that it may have been incorrectly energised without sufficient oil in place, then steps will be taken to deliver this back to the manufacturer, Winders, to undertake the necessary repairs. Winders were party to the Regulation 28 report issued and also assisted with the HSE' s investigation, and therefore are now also aware of the potential risks posed by Carbon Monoxide to be able to respond appropriately to this. Secondly, we have now attached stickers to all of our transformers as per your suggestion, providing a reminder to third-party operators not to energise transformers without first ensuring there is sufficient oil inside. Please see the images below . The notices have been placed in obvious locations on the transformers. The first pair of labels have been sighted on one of the transformer covers which an engineer will necessarily have to remove in order to fit a set of cables before the transformer can be operated . . Unit 3 Mallard Industrial Park, Horbuty Junction, Wakefield, WF4 5QH Tel: 01924 -261611 Fax: 0870 706 1222 Web Site - www.hirstelectrical.co.uk Email - enquiries(alhirstelectrical.co.uk R ' steredO ,.-,: 12GmnheudRoad, Huddm/ield, WutYorkshire. Enghnd, HDI 4ENCo. RegNo: 350214-1- VAT No: 69873,658 :Z0036JB/DT 4.2.lnnO Jan:ZOJO Lcttcrb:-1 Continuation IRST www.hirstelectrical.co.uk The second label has been placed next to the oil sight glass. This shows a further arrow to indicate the oil level. The user is instructed not to energise if the oil level is below that point. ~ -··.r•-, -- 1250D Lastly a sticker has been placed near to the breather line again, giving simple instruction to the end user. VALVE TO BE CLOSED FORTRANSPOR VALVE TO BE OPENED BEFORE ._____ E""'!!:NERGISATIO_N..,..""""~r:-,-.,.. Unit 3 Mallard Industrial Park, Horbury Junction, Wakefield, WF4 5QH Tel: 01924 - 261611 Fax: 0870 706 1222 Web Site - www.hirstclectrical.co.uk Email - enquiries(g, hirstelectrical.co.uk •i,tmdO 1c,: 12 Grunh,adRoad, H11ddm-/ield, West York.J-hire, Engh11d, HDI 4ENCo. Reg No: 35021-/./- l 7AT No: 698735658 4.2.1 R..0 JIIQlQJI) l.Jhcad IRST www.hirstelectrical.co.uk Finally, we have amended the documentation that is sent to our customers for all hires. This documentation includes- • A test sheet showing the readings of the equipment at the point of hire. This confirms that the oil has been checked and it indicates that all pre hire checks have been done (copy enclosed). • We will also enclose a copy of the International Standard referred to by in her testimony to yourself. • A warning notice, indicating the potential presence of Carbon Monoxide, should the transformer be energised without sufficient oil inside. (Copy on the next page). We trust the aforementioned is sufficient action to satisfy the notice. However, if you believe there is more we can do then we welcome any further suggestions. Yours sincerely Managing Director Hirst Electrical PHS (UK) Ltd. Unit 3 Mallard Industrial Park, Horbury Junction, Wakefield, WF4 5QH Tel: 01924 - 261611 Fax: 0870 706 1222 .... ~,... ·--··· ...._ .. ...._._,.., Web Site - www.hirstelectrical.co.uk Email - em,1uiries@ hirstelectrical.co.uk Re istmdO ice: 12 Grecnh,adRoad, H11dders/ield, West Yorkshire, Engla11d, HDI 4EN Co. Reg No: 35021+1 VAT No: 69873f6i8 20036311/DT 4.1..l ~,.o J.n2010 Lcn~rticad
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