Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0213, written 22 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Apr 2024 |
|---|---|
| Reference | 2024-0213 |
| Deceased | David Carpenter |
| Coroner | Delroy Henry |
| Coroner area | Coventry and Warwickshire |
| 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: Prevention of Future Deaths Report Mr David John CARPENTER (died 19th January 2023) THIS REPORT IS BEING SENT TO: 1. 2. , Managing Director, Dennis Eagle Ltd , Engineering Director, Dennis Eagle Ltd 1. CORONER I am: Delroy Henry, Area Coroner, Coventry. Coventry Coroners Office, The Register Office, Manor House Drive, Coventry, CV1 2ND 2. CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, Schedule 5, paragraph 7 and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 3. INVESTIGATION and INQUEST On 19th January 2023 I commenced an investigation into the death of David John CARPENTER (aged 60 years). The investigation concluded at the end the inquest on 22nd April 2024 at Coventry Coroners Court. The conclusion of the death of Mr Carpenter was that death was “accident” a copy of which I attach to this report. 4. CIRCUMSTANCES OF THE DEATH Mr Carpenter was employed by Coventry City Council as a Refuse Collector. He was based at Whitley Depot, Coventry. His job involved collecting bins from the side of the road and taking them to a bin lorry/Rear Compaction Vehicle (RCV) to empty them. He worked as part of a team with another collector and a driver. The bin lorry involved in the incident was a Dennis Eagle lorry equipped with a Terberg ‘Omnideka’ automatic bin lift system. The Terberg bin lift system comprises two ‘lifting chairs’ which enable two household-sized waste bins to be emptied side by side. Each lifting chair has its own control panel located on the rear of the vehicle. The controls are used by bin crew to switch between different modes of use. The bin lift system can be operated in two modes (manual and/ or automatic) the two lifting chairs capable of operating independently of each other. CCTV cameras are fitted to these vehicles. Mr Carpenter was lifted into the rear hopper of this bin lorry when he activated the proximity start sensor and his coat became caught on the lifting chair comb tooth associated with the bin security switch. The machine through the automatic compaction cycle tragically causing Mr Carpenter fatal injuries. 5. CORONER’S CONCERNS During the inquest, the evidence and information revealed matters giving rise to a 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 them to you. The MATTER(S) OF CONCERN are as follows: i. ii. iii. iv. v. vi. The inquest explored issues such as the safety of the machinery (the bin lorry, in particular the bin lift system in automatic mode). The life span of this type of machinery i.e. Bin lorries is 8 – 12 years. There are thousands of bin lorries of this or similar design still in circulation in April 2024. The evidence was it is estimated 4 to 6 million residential bins are lifted every day by bin lorries provided by the manufacturers. It was/ is foreseeable that both workers (e.g. refuse collectors) and members of the public will approach the danger zone at the rear of the RCV. In the case of workers, for example, to remove debris/ detritus which occurs frequently on residential waste collection rounds. The circumstances of this inquest touching upon the death of David Carpenter in January 2023 accentuated this point. A risk of inadvertent whole-body lifting into the manufactures bin lorry hopper of a person in the danger zone carries with it a risk of death. Since the incident “new” machine designs [ as of January 2024] deal with some, but not all issues, as arose in the in the inquest e.g. differentiation between a bin and a person; warning signs easily visible to the public and reminding bin operatives; additional estops being more accessible from within the danger zone unlike the design in January 2023 in which transparent screens were adjacent to the bin lift controls and the emergency stop and thereby an obstacle to the accessibility of the emergency stop when an emergency arose with a person located within the danger zone; audible bleeps confirming the engagement and disengagement of automatic mode. The “new” machines however are very few when considered in totality of huge number of the manufactures RCV in circulation. vii. The availability of “modification software” (this software (amongst other functional changes) monitoring the RCV sensors [bin lost function] with the effect that a person may still be inadvertently lifted into to the hopper but the automatic compaction cycle now not engaging and thus some risk of death is reduced) in relation to vehicles of the same or similar specification to that in the inquest is at choice and cost to the user. viii. ix. x. xi. The cumulative effect being potentially important changes in the machinery in this hazardous working environment are inordinately slow, thus significant mechanical risks (best managed by the manufacturers) remain in April 2024 and compounded by the fact that the volume of work is high in this aspect of the waste industry i.e. millions of bin lifted daily. In addition there are example of issues which remain insufficiently considered/ actioned in relation to these ‘machines of suboptimal safety’ which include “sun glare on monitors” in the drivers cab which impact upon the ability of a driver to more clearly see the rear of the bin lorry and observe refuse collectors and thereby enhance safety in the hazardous job of refuse collection, mindful an emergency stop button is readily accessible in the drivers cab; clearly visible public warning signs about the danger zone remain deficient; the continued use of a Perspex/ transparent screen between the rear bin lift controls and the danger zone which amounts to an obstacle to a person activating the emergency stop in an emergency. There remains (now 15 months post Mr Carpenters death) thousands of machines of ‘sub optimal’ safety on UK roads. The bin lorry manufacturers with some 8- 10 thousand lorries (albeit not all at automatic mode RCVs) on UK streets. The evidence was customers are most, if not all Local Authorities in UK. The manufacturers sell to waste contractors who collect on behalf of Local Authorities and sell to hire company from who Local Authorities hire vehicles. The cumulative effect is such that a concern as to future deaths exists as of April 2024. 6. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you 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 17th June 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. 8. COPIES and PUBLICATION I have sent a copy of my report to the following: 1. HHJ Thomas Teague KC the Chief Coroner of England & Wales Chief Coroner's Office, 11th Floor Thomas More, Royal Courts of Justice, Strand, London, WC2A 2LL. chiefcoronersoffice@judiciary.gsi.gov.uk 2. David Carpenters family. 3. Coventry City Council. 4. Heath and Safety Executive 5. Waste Industry Safety and Health Forum I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. Date: 22nd April 2024
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.
REGULATION 28: PREVENTION OF FUTURE DEATHS
REPORT MADE ON 22 APRIL 2024 (REF: 2024-0213)
DENNIS EAGLE’S RESPONSE
14 June 2024
A Terberg Environmental company
Page 1 of 7
PFD Report (2024-0213): Dennis Eagle’s Response
Introduction
Dennis Eagle takes the safety of its customers, their communities and the wider public, very seriously. We
remain steadfast in our commitment to continue to provide compliant, safe and high-quality products and
services that not only meet but exceed industry standards, and we will continue to work closely and
collaboratively with our waste/automotive industry partners and the relevant regulators/standards
authorities, to highlight the importance of (and influence) safety in waste collection operations.
Dennis Eagle has been diligently and expeditiously working towards developing additional safety features
which comprehensively comply with the legislative requirements outlined in the Supply of Machinery Safety
Regulations 2008, and listening to the experience of the large base of customers that use our products.
Dennis Eagle are confident that all products have met the regulatory requirements in place at the time of
delivery, but recognise that our approach to reviewing safety related issues is a continuous process which
evolves based on real world experience and we therefore need to consider the Concern’s raised by Coventry
Coroner’s Office (as detailed below).
The improvements we have made to date ensure that Dennis Eagle products remain compliant and safe, but
also lead the way in setting the standard for safety in waste collection operations.
Coroner’s Concerns
The Coroner’s concerns contained in PFD Report (2024-0213) were focussed across four (4) main areas,
which included:
1. Warning signs about the operating zone at the rear of the vehicle, easily visible to the public and
reminding bin operatives.
2. Transparent screens between the rear bin-lift control panel and operating zone, impacting the
accessibility of the emergency stop when an emergency arose with a person located within the
operating zone.
3. Sun glare on monitors in the driver’s cab, impacting upon the driver’s ability to clearly see the rear
of the bin lorry and observe refuse collectors.
4. Availability of “modification software”, to disengage the automatic compaction cycle when certain
sensors are disengaged (i.e., when a bin container becomes detached).
Dennis Eagle welcomes these general observations and in this document, we address each of the Coroner’s
areas of concern by describing the steps already taken, measures being introduced now and/or any
considerations for the future.
In writing this response, we would like to again express our deepest condolences to David Carpenter’s family,
friends and colleagues.
A Terberg Environmental company
Page 2 of 7
PFD Report (2024-0213): Dennis Eagle’s Response
Coroner’s Concern: One (1)
Warning signs about the operating zone, easily visible to the public and reminding bin
operatives.
The purpose of the dust curtain is to reduce the likelihood of loose debris escaping from the rear of the bin
hopper. Since January 2024, “warning” varieties of the dust curtain (as pictured below) have been readily
available as a customisable option to all customers, which provide clear and distinct warning text and visuals
about the area being approached.
The “warning” variety dust curtain shall be offered for retrospective fitment on a free of charge basis to all
customers with existing products in service.
As of January 2024, all new “OmniDEKA” bin-lift mechanisms have additional safety features, including: (i)
a clearly-audible warning sound if an object is detected in the bin-lift operating zone that is not a bin (i.e.,
a person); and (ii) a number of additional safety decals (pictured below) around the bin-lift which warns
against hazardous and unauthorised use.
The additional safety decals shall be offered on a free of charge basis to all customers with existing products
in service.
These measures are designed to increase awareness of the bin-lift operating zones, and to warn against
improper or untrained use.
A Terberg Environmental company
Page 3 of 7
PFD Report (2024-0213): Dennis Eagle’s Response
Coroner’s Concern: Two (2)
Transparent screens between the rear bin-lift control panel and operating zone, impacting
the accessibility of the emergency stop when an emergency arose with a person located
within the operating zone.
The transparent screens located between the rear bin-lift control panel and bin-lift operating zone perform
a valuable function in protecting the rear bin-lift control panel from unintended activation and accidental
damage which can be commonly caused by loose, falling or large debris.
To aid the accessibility and use of the emergency stop in certain situations, we have developed a solution
to have the relevant, potentially obstructing, section of the transparent screen cut away or replaced (as
pictured below).
Section to
be removed
The transparent screen alteration or replacement shall be offered for retrospective fitment on a free of
charge basis to all customers with existing products in service.
On newer bin-lift mechanisms, additional emergency stops (as pictured below, in green) have been inserted
on top of the existing rear bin-lift control panel which are easily accessed or used in the event of an
emergency arising within the bin-lift operating zone or during the automatic bin-lift cycle. Note, these
additional emergency stops are not guarded by any transparent screen and are angled towards the bin-lift
operating zone.
These measures are designed to increase accessibility and to reduce the likelihood of unintended/accidental
damage and/or activation.
A Terberg Environmental company
Page 4 of 7
PFD Report (2024-0213): Dennis Eagle’s Response
Coroner’s Concern: Three (3)
Sun glare on monitors in the drivers cab, impacting upon the driver’s ability to clearly see
the rear of the bin lorry and observe refuse collectors.
As standard, all monitors inside the vehicle’s cab are now fitted with: (i) an adjustable arm/podium, which
allows for the monitor to be positioned away from sun glare; and (ii) a matt-finish screen, to decrease the
likelihood and impact of sun glare (where unavoidable).
To further increase visibility and provide additional protection against sun glare, we have developed a
solution (a shroud) to extend the cover provided to in-cab monitors (as pictured below).
The in-cab monitor shroud shall be offered for retrospective fitment on a free of charge basis to all
customers with existing products in service.
A Terberg Environmental company
Page 5 of 7
PFD Report (2024-0213): Dennis Eagle’s Response
Coroner’s Concern: Four (4)
Availability of “modification software”, to disengage the automatic compaction cycle
when certain sensors are disengaged (i.e., when a bin container becomes detached).
The “modification software” refers to a solution called “bin-lift compaction control upgrade” (BCCU), which
uses software to verify that a bin container remains present on the bin-lift chair during an emptying cycle.
This is completed by monitoring signals from: (i) the N1 (start) sensor, which detects the presence of a bin
container as it approaches the rear bin-lift mechanism and begins the automatic bin-lift cycle; and (ii) the
N6 (security) sensor detects when a bin container is engaged by the bin-lift comb/teeth (each, as pictured
below).
When a signal is lost from either the N1 or N6, a clear message is displayed on the diagnostic display system
located next to the bin-lift control panel and a new “container lost” function is activated, which: (i) stops
any active lifting cycle; (ii) turns off automatic mode; and (iii) interrupts the compaction request and places
the mechanism in manual mode until the system is reset.
In addition:
(1) when an operator switches from automatic mode to manual mode on either control panel (at either
side of the vehicle), both nearside and offside lifting chairs are placed into manual mode; and
(2) an additional timer has been introduced for deactivating the automatic mode if the bin-lift system
or vehicle has not been operated for a period of two (2) minutes (i.e., when the bin-lift has been
left unattended).
N6
N1
The BCCU solution shall be offered for retrospective fitment on a free of charge basis to all customers with
existing products in service.
This measure is designed to significantly reduce the likelihood of an unintended object (i.e., a person) from
being lifted by the rear bin-lift mechanism and subject to the compaction mechanism.
A Terberg Environmental company
Page 6 of 7
PFD Report (2024-0213): Dennis Eagle’s Response
ADDITIONAL ACTIVITIES
Customer Communication
In addition to fitting all above items as standard features on new refuse bodies and bin-lifts where
applicable, Dennis Eagle can confirm that the “warning” variety of the dust curtain, transparent screen
alteration or replacement, monitor shroud and BCCU software items shall be offered for retrospective
fitment on a free of charge basis to all customers with existing products in service.
This campaign will be communicated to all customers using the same process as established for other
“product campaign” activities previously completed by Dennis Eagle, i.e. contact with customer will be
repeatedly attempted in writing (up to three (3) times, on an escalating basis) with follow up telephone
calls being made to those customers who have not responded to earlier written recommendations, and
proactively targeting customers with larger fleets in order to expedite campaign completion.
We expect that this approach will help us to complete the rework activity as efficiently (and as practicably)
as possible, without undue delay or complication.
Dennis Eagle expect to start the customer communication process by the beginning of August 2024, once
the additional resources have been put in place to manage a campaign on this scale and conduct the rework
activities, together with procurement of all necessary components, as is standard with any large-scale
national product update campaign from a manufacturer.
Training and Manuals
Operator handbooks and associated training materials have been updated in line with the product updates
detailed within this document and shall be offered on a free of charge basis to all customers with existing
products in service.
Industry Developments
In addition to the product updates, Dennis Eagle are actively working with other waste/automotive industry
partners. This work includes:
•
the top three (3) manufacturers of refuse collection vehicles supplying the UK market (namely, Faun
Zoeller, Hillend and Terberg/Dennis Eagle) agreeing to share knowledge relating to industry practices
and the identification of risks associated with the operation of refuse collection vehicles. This is a major
development within the industry and will ensure that any new or unforeseen risks, which had not
previously been identified will be shared across the industry as soon as they become known, ensuring
that the key manufacturers can take appropriate action to mitigate the impact of these previously
unforeseen risks at the earliest opportunity. However, the case remains that all manufacturers are
reliant on proper near miss and incident reporting programmes at an operational level being
communicated to them to better, and in a timely manner, identify trends and concerns; and
• Dennis Eagle has direct representation on the British Standards Institution (BSi) working group to develop
UK standards for refuse collection equipment, in particular automatic bin-lift mechanisms. This group
is actively working on the introduction of standards aimed at improving operational safety, and one of
the key objectives for this standard is to introduce technology which is reliably able to distinguish
between a person and a refuse bin container, with the aim of preventing bin-lift operation when a
person is present within the operating zone.
A Terberg Environmental company
Page 7 of 7
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