Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0022, written 16 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jan 2024 |
|---|---|
| Reference | 2024-0022 |
| Deceased | Charles Harper |
| Coroner | James Bennett |
| Coroner area | Birmingham and Solihull |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
1 2 3 4 5 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. President, The Pipeline Industries Guild. 2. Chair, British Drilling Association. CORONER I am James Bennett, H.M. Area Coroner for Birmingham and Solihull. 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. INVESTIGATION and INQUEST On 22 May 2023 I commenced an investigation into the death of Charles Harper. The investigation concluded at the end of the inquest on 11 January 2024. CIRCUMSTANCES OF THE DEATH Mr Harper was involved in horizontal directional drilling and associated works, forming part of the HS2 high-speed railway construction project on land known as Sublot 5 Site, Land North of Hollywell Brook, Middle Lane, Birmingham. On 27 April 2023 ducting made from rigid 180mm poly- ethylene coiled pipe was being dispensed from a coil trailer through a pre-drilled 100 meter hole. Mr Harper was stood sufficiently close to the trailer, that at the end of dispensing when the stored energy was released, it caused the unsecured tail end of the coiled pipe to spring and strike Mr Harper causing serious abdominal and chest injuries, and he died the following day. The coil trailer was supplied with a restraining clamp and strap. The operating manual for the coil trailer, and method statement and risk assessment for the work, all identified the risk of the tail end of coiled pipe springing as a consequence of stored energy, and that it should be secured to the trailer. No such securing mechanism was utilised on 27 April 2023 and this contributed to Mr Harper’s death. CORONER’S CONCERNS During the course of the investigation the evidence revealed matters of concern, as follows: 1. A material number of drilling and pipe dispensing companies have in the past, and continue, to dispense coiled pipe without the use of any method of securing the tail end of the pipe coil, contrary to trailer operating manual instructions. 2. The use of exclusion zones may be insufficient alone, and provide a false sense of security, to guard against the risk of a worker being struck by the tail end of a coiled pipe springing in an unpredictable way when stored energy is released at the final stage of dispensing. The trailer manufacturer in this case indicated – although their instructions make it clear the tail end of coiled pipe should always be secured to the trailer, and that clamps/straps were effective in preventing springing of the tail end of coiled pipe - an intention to do further testing around the forces generated when stored energy is released, the effectiveness of clamps and straps to restrain the tail end of coiled pipe, and consideration of cages being installed around trailers; This will take some time and will require collaboration with pipe coil manufacturers and pipe coil dispensers. The HSE indicated the facts will be considered by the relevant sector division who will decide what if any pro-active health and safety action to take; This will also take some time. It appears to me that a number of drilling/pipe dispensing companies who do not always seek to secure the tail end of pipe coil during dispending, are likely to be members of either The Pipeline Industries Guild and/or British Drilling Association. Both organisations explain on their respective websites an aim is to improve the health and safety of its members. Both organisations are likely to be in a position to take action to alert their members to the risk. In my opinion there is a risk that future deaths will occur unless action is taken, you are in a position to take preventative action, and therefore in the circumstances it is my statutory duty to report to you. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have 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 Tuesday 12 March 2024. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner of England & Wales, and to the following Interested Persons: 1. Harper Services Limited. 2. The Harper family. 3. Morrison Water Services Limited. 4. Balfour Beatty Vinci Joint Venture. 5. Steve Vick International Limited. 6. Aviva Insurance. 7. Health and Safety Executive. 8. West Midlands Police. I have also sent it to the following who may find it useful or of interest: 1. ATE (UK) Ltd (The evidence was that alongside Steve Vick Internation Limited they are the other major manufacturer of coil trailers). 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. Signature: 6 7 8 9 James Bennett H.M. Area Coroner, Birmingham and Solihull jurisdiction 16 January 2024
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.
British Drilling Association 55 Crown Street Brentwood Essex CM14 4BD 11 March 2024 The Birmingham and Solihull Coroner’s Court, Steakhouse Lane, Birmingham, B4 6BJ. For the attention of: Mr James Bennett (H.M. Area Coroner) Dear Coroner, We acknowledge receipt of your Regulation 28 report which was received by the British Drilling Association (BDA), on January 16, 2024. The BDA offers its condolences to all those affected by these events. The purpose and aims of the BDA are to improve health and safety and raise technical and training standards in the ground drilling industry. All work undertaken by BDA in preparing guidance notes, safety alerts and best practise documents is completed by its members on a voluntary basis. The Association is essentially administered through committees which determine the strategic direction and complete and undertake the work of the organisation. For clarity, the BDA currently does not have any members who undertake horizontal directional drilling which uses the equipment and pipework which appears to the subject of particular concern. The Association therefore lacks the expertise and experience needed to comment or provide specific guidance to members on either the events around Mr Harper's tragic death or the Coroner’s concerns as set out in Section 5 of his report. The BDA has however been working with Balfour Beatty Vinci Joint Venture and the Pipeline Industries Guild, to understand what action they have taken following the incident and to offer support to the proposed industry safety standard improvements. Whilst not in a position to provide specific guidance to members on the matters concerning the Coroner, the BDA will notify its members of this incident and share any safety alerts it receives via our Newsletter and on our website, to highlight the findings of the investigations and make them aware of the published information. Furthermore, the BDA will remind its members of the need to follow documented Safe Systems of Work (RAMS) in accordance with the Management of Health and Safety at Work Regulations 1999 and CDM Regulations 2015, and obligation to adhere to manufacturer instructions when utilising any work equipment in accordance with the Provision and Use of Work Equipment Regulations 1998. British Drilling Association 55 Crown Street Brentwood Essex CM14 4BD The above actions will be completed and distributed via our Newsletter and website by April 2024. Thank you for writing to the BDA. We trust that our response is considered appropriate and satisfactory, however should you have any further comments, questions or queries, please do not hesitate to contact us. We understand you will forward a copy of our letter to the Chief Coroner who may publish it in a complete, redacted or summary form, and confirm we would appreciate notification of such an intent. Yours sincerely For and on behalf of the British Drilling Association Chairman
The Birmingham and Solihull Coroner's Court Steelhouse Lane Birmingham B46BJ 7th March 2024 Dear Lynne, In relation to the PFD report, I can confirm that The Pipeline Industries Guild are undertaking the following actions: • March - following on from conversations with BBV and the sharing of lessons learned the attached note has been issued to all our members. • April - webinar to take place to discuss the lessons learned, safety measures to be implemented both with the trailers and on site and the impact this has had. For information all our webinars are recorded and promoted throughout the year via our YouTube channel. Webinar-HS2 Bickenhill-Coil Trailer Falality-Lessons Learn! • September - our quarterly online publication "In the Pipeline" which is issued to members and available via our website and social media platform will feature the lessons learned message & output from the webinar Gu,ld Internal measures: by ensuring safety moments are part of our standard agendas for all exec and board meetings continuing to raise safety awareness through our technical panels our awards will continue with the H&S commendation (which was awarded to LaySAFE - SAFE Coiled Pipe Installation in 2023) Please do not hesitate to contact me should you wish to clarify the above or require further information. Kind regards Executive Director The Pipeline Industries Guild Incorporated as a company ltm(ted by g1.:wantee and registered in Engiand no~ 25633-51 R'eg!st.z.red office; 15A Bioxham Mill 1 Barford.Road, Bloxham, Banb-ury1 0Xt5 4 FF
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