Aaron Fretwell

PFD Report All Responded Ref: 2021-0331
Date of Report 5 October 2021
Coroner Kevin McLoughlin
Response Deadline ✓ from report 2 December 2021
All 1 response received · Deadline: 2 Dec 2021
Response Status
Responses 1 of 1
56-Day Deadline 2 Dec 2021
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner’s Concerns
1. No propping device was fitted to the trailer, which is understood to have been manufactured by Bailey Trailers Ltd in about 2002.
2. No warning signs were affixed to the trailer directing that the trailer body should be propped before anyone worked underneath it.
3. Trailers manufactured by 2002 should have complied with BS EN 1853: 1999 and/or the supply of machinery (Safety) Regulations 1992 which required a mechanical support to be installed to facilitate maintenance work to be carried out safely.
4. Evidence taken at the Inquest indicated that many types of agricultural trailers were in use without such propping devices or warning signs, which gives rise to concern that comparable accidents could occur in the future.
Responses
Bailey Trailers Ltd
21 Oct 2021
Response received
View full response
127344409.1\691479 1 RESPONSE BY BAILEY TRAILERS LIMITED TO THE REGULATION 28 REPORT TO PREVENT FUTURE FOLLOWING THE CONCLUSION OF THE INQUEST INTO THE DEATH OF AARON DARIE FRETWELL 21st October 2021 INTRODUCTION Bailey Trailers Limited (“the Company”) makes this response in respect of a regulation 28 report to prevent future deaths made on 5 October 2021 by the Senior Coroner for West Yorkshire (East), Kevin McLoughlin, following the conclusion of the inquest into the death of Aaron Fretwell on 1 October 2021 at Leeds Town Hall. In the regulation 28 report the circumstances of the death were stated to be, “On 2 February 2021, Aaron Darie James Fretwell was working on the family farm. In the course of replacing a worn ring on an agricultural trailer, he raised the trailer body and disconnected the hydraulic services. Whilst working under the trailer body, it descended, trapping him against the chassis, causing him to sustain crush injuries from which he died on 3 February 2021”. The trailer involved in the accident had been manufactured in approximately 2002 by the Company. The inquest concluded with a short-form conclusion of ‘accidental death’. In the regulation 28 report the Senior Coroner stated that many types of agricultural trailers are in use without propping devices or warning signs, which gives rise to concern that comparable accidents could occur in the future. In addition to the Company and the Chief Coroner, the regulation 28 report was sent to Mr Fretwell’s family, Inspector of the Health and Safety Executive, the National Institute of Agricultural Engineers and the British Agricultural and Garden Machinery Association. THE COMPANY’S RESPONSE The Company takes its health and safety responsibilities very seriously, has considered the Senior Coroner’s concerns and is responding accordingly. Firstly, the family who run the Company were deeply saddened to learn of the tragic accident involving one of their trailers and wish to convey their sincere condolences to Mr Fretwell’s family and friends. The Company is committed to supplying safe and compliant products to the market and to fulfilling its legal obligations under the Supply of Safety (Machinery) Regulations 2008 and the Health and Safety at Work Act 1974 (amongst others). The Company’s fundamental position is, and always had been, that all routine maintenance of trailers can and should be carried out with the body of the trailer in a lowered position. Where any work would require the body to be in a raised position, the Company recommends that the body be removed completely. This approach follows the hierarchy of controls for the management of risk by the taking of preventative measures in order of priority. The Company has designed the tipping trailers in a way which eliminates the need for maintenance to be carried out underneath a raised body which in itself would introduce potential risks which would need to be managed and reduced by engineering controls, i.e. by use of a prop. Notwithstanding that point, the Company can confirm that all of its tipping body models are now manufactured with body props as a standard feature as per paragraph 4.7.2 of BS EN 1853:2017 which states that “a mechanical support hinged to the trailer, in conformity with the requirements given in EN ISO 4254-1:2015, 4.11 shall be provided to secure the body in high position during maintenance operations”. The maximum weight of a tipper body is 4000kg of which approximately half is supported by the hinges. The prop therefore needs to be able to support 2000kg. Tests have been carried out on the Company’s tipping body models which demonstrated that the prop can support the entire 4000kg. Subsequent tests were carried out to 8000kg and these caused no deformation or damage to the prop, thereby demonstrating its strength. The general safety instructions within the Company’s revised Operation & Maintenance Manual for all tipping body trailers now states, “For normal maintenance and repairs it is not necessary to

127344409.1\691479 2 raise the body, the design of the trailer permits normal maintenance activities and adjustments to be undertaken without the need to raise the tipping body. In extraordinary circumstances where it may become necessary to raise the body, deploy the [mechanical body] support as described below”. The Manual reiterates the warning that users should “never work beneath the raised trailer body unless it is securely propped and supported”, and guidance is also given on how to deploy and stow the body support safely. Relevant safety decals (or signs) continue to be used to reinforce this point about not tipping the body unless absolutely necessary in the opinion of the user. Lastly, the Company has emailed its trade dealers (who sell to end users) to ask that they explain to their customers that the Company’s tipping trailers have been designed in a way which does not require the trailer to be raised for routine maintenance and adjustments but should they decide to do so, a prop has been fitted as a standard safety feature. 21 October 2021
Report Sections
Investigation and Inquest
On 5 October 2021, I commenced an investigation into the death of Aaron Darie James Fretwell, aged 19. The investigation concluded at the end of the Inquest on Friday 1 October. The conclusion of the Inquest was ‘Accidental Death’, with the following medical cause of death: 1a) Hypoxic Cerebral Encephalopathy 1b) Cerebellar Herniation
2) Lung Contusion
Circumstances of the Death
On 2 February 2021, Aaron Darie James Fretwell was working on the family far. In the curse of replacing a worn ring on an agricultural trailer, he raised the trailer body and disconnected the hydraulic services. Whilst working under the trailer body, it descended, tapping him against the chassis, causing him to sustain crush injuries from which he died on 3 February 2021.
Copies Sent To
, Health and Safety Executive
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.