Matthew Wilmot
PFD Report
All Responded
Ref: 2018-0107
All 2 responses received
· Deadline: 12 Aug 2018
Coroner's Concerns (AI summary)
Risk assessments for path closures are inadequate for unique routes without alternative access, leading pedestrians to disregard barriers and use hazardous excavations.
View full coroner's concerns
The accident happened on a path which had been excavated to find a stop cock. The excavation had been abandoned as a Deep Excavation Team was required. The path was closed by placing sign at each end of the stating that the path was closed. The hole and were fenced off by using a metal railed fence which was alongside the path and plastic yellow barriers which were secured to the metal fence_ A risk assessment had taken place The evidence was that the risk assessment was in line with the Red Book and Industry Standards. The Red Book encourages a risk assessment based on the locality , footfall, etcetera My concern is that not enough consideration was given to the nature of the path. To all intents and purposes there are two types of paths_ The most common is the path that runs parallel to a highway: If that path is closed, the pedestrian can be guided around the excavation or told to cross the It is unlikely that the pedestrian would walk through barriered area in such circumstances as that would be slower than walking around it. The second type of path is one that is unique in its journey A to B ie there is no road to the side This particular path lead from the road to row' of houses, which were not accessible by road_ The alternative route (which was not signposted) was metres away; meaning diversion of about 300 metres. The path was not located in an area of risk_ However, my concern is that route that is unique is always at risk as pedestrians will want to travel the shortest route_ This is backed up by the evidence in the Inquest which recorded 9 pedestrians (including the deceased) travelling through the closed path in the hours before the deceased was found The excavators took photographs of the site just before left it. Looking at those photographs, would have risked walking the closed My concern is that there is not enough emphasis within the risk assessment process that a route that is unique has different risks to that is parallel. Senior Coroner; The Court House; Woburn Street: AMPTHILL, Bedfordshire: MK+5 ZHX Tel 0300-30u-6559 Fax 0300-300-8267 path spoil road . from they down path, path
ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and 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 29 June 2018. 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_
ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and 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 29 June 2018. 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_
Responses
Action Taken
M&S Water Services has amended its team briefing to include a procedure for operatives to escalate concerns about "unique" locations to a supervisor, who will then decide on appropriate control measures. The briefing will be mandatory for new operatives and refreshed for existing operatives every six months. (AI summary)
M&S Water Services has amended its team briefing to include a procedure for operatives to escalate concerns about "unique" locations to a supervisor, who will then decide on appropriate control measures. The briefing will be mandatory for new operatives and refreshed for existing operatives every six months. (AI summary)
View full response
Dear Sirs Deceased Matthew James Wilmot Date of Incident 28 May 2017 We write in response to the Regulation 28 Report dated 17 April 2018 We note the concern is that there was not enough emphasis within the risk assessment process that a unique route has different risks to a path that is parallel It is further noted that the Coroner was satisfied that the evidence given at the Inquest was that the risk assessment undertaken by M&S for the excavation outside 280 Devon Road was in line with the Red Book and Industry Standards During the course of the Inquest evidence was given in relation to exhibit 'TH2' . The document was the Team Briefing given following the accident involving Mr Wilmot The briefing followed a review of the risk to the general public regarding open excavations. It stated: Please take into consideration the following specifics before leaving an open hole: Would you expect high footfall in the area e.g:: school, public house, hospital, GP Surgery Is the job likely to be ongoing e.g:: due to Engineering difficulties Have you any reason to suspect that a MOP might move our barriers, take into consideration surrounding houses etc. If you have to provide the public with an alterative route is it realistic and easy to negotiate? We must be compliant but we must also be realistic in our expectations. Cane R CHAS Water Constructionline Krenarnd Safe [M HoioFn Registered Qifice: Unit 6, Kigh Town Enterprise Centre: York Street: Lulon; Bedfardishire, LU2 OHA Registtation No: 6218970. VaT No. 694 9134 90 Director: M,J Harkin: Director & Co, Secrefary; KH Harkin V:Ww"m##xn Manx Ncv Moms (WXS) Pitbing Vramanc 7e4 4 Flsle: w-etinis LajI cwlak-nn3 PPsv ~S!g:onw "13<1"g Res: : ~
If any of the above is a concern then please consider all or some of the following: Consider storing the spoil elsewhere to enable us to keep the footpath open Consider plating the excavation Consider the need for Heras Fencing If you need advice then contact your supervisor It is submitted that the additional guidance given to operatives within three days of the accident on 28 May 2017 should assuage the concern regarding unique sites and whether or not there is sufficient focus in the risk assessment process on the likelihood of the public using the alternative route. It will be appreciated that on the Devon Road site the Mes operatives were required to complete the Amey Utility Services Limited risk assessment template Given that no two sites are the same; the Company is wary of being too prescriptive in respect of the guidance given to operatives: Therefore, in order to address the specific concern of the Coroner the Company has amended point 4 of the briefing to read as follows - If a footway closure road closure alternative pedestrian route is is it suitable will pedestrians follow it? If the assessment is that they will not; please contact your supervisor for advice The intent is to provide a procedure for operatives to escalate any concerns in relation to 'unique' locations to a supervisor and for the supervisor to then make the final decision on the appropriate control measures to be put in place. As such; the procedure will ensure supervisory involvement in relation to assessments of all 'unique' locations: The briefing will be a mandatory part of the induction process for new operatives and will be refreshed for all existing operatives at six month intervals It is important to stress that M&S does not fulfil the role of the Job Initiator or Job Planner The evidence of Amey (paragraph 4.5 of statement dated 14"h December 2017) was that the Job Planner reviews the job for any special requirements based on the Job Initiators comments. The process involves a visit to the site by the Customer Services Technician: To this extent there is also the opportunity within the planning permitting process to identify 'unique' locations As was highlighted the Inquest hearing; the Company is committed to going above and beyond existing Industry Standards / guidance in relation to Street Works: additional processes now put in place are part of the commitment to continuous improvement
If any of the above is a concern then please consider all or some of the following: Consider storing the spoil elsewhere to enable us to keep the footpath open Consider plating the excavation Consider the need for Heras Fencing If you need advice then contact your supervisor It is submitted that the additional guidance given to operatives within three days of the accident on 28 May 2017 should assuage the concern regarding unique sites and whether or not there is sufficient focus in the risk assessment process on the likelihood of the public using the alternative route. It will be appreciated that on the Devon Road site the Mes operatives were required to complete the Amey Utility Services Limited risk assessment template Given that no two sites are the same; the Company is wary of being too prescriptive in respect of the guidance given to operatives: Therefore, in order to address the specific concern of the Coroner the Company has amended point 4 of the briefing to read as follows - If a footway closure road closure alternative pedestrian route is is it suitable will pedestrians follow it? If the assessment is that they will not; please contact your supervisor for advice The intent is to provide a procedure for operatives to escalate any concerns in relation to 'unique' locations to a supervisor and for the supervisor to then make the final decision on the appropriate control measures to be put in place. As such; the procedure will ensure supervisory involvement in relation to assessments of all 'unique' locations: The briefing will be a mandatory part of the induction process for new operatives and will be refreshed for all existing operatives at six month intervals It is important to stress that M&S does not fulfil the role of the Job Initiator or Job Planner The evidence of Amey (paragraph 4.5 of statement dated 14"h December 2017) was that the Job Planner reviews the job for any special requirements based on the Job Initiators comments. The process involves a visit to the site by the Customer Services Technician: To this extent there is also the opportunity within the planning permitting process to identify 'unique' locations As was highlighted the Inquest hearing; the Company is committed to going above and beyond existing Industry Standards / guidance in relation to Street Works: additional processes now put in place are part of the commitment to continuous improvement
Action Taken
B & D Civil Engineering reports that M&S will amend its team briefing to emphasize assessing suitability of alternative pedestrian routes and escalating concerns to supervisors. The revised briefing will be mandatory for new operatives and refreshed for existing operatives every six months. (AI summary)
B & D Civil Engineering reports that M&S will amend its team briefing to emphasize assessing suitability of alternative pedestrian routes and escalating concerns to supervisors. The revised briefing will be mandatory for new operatives and refreshed for existing operatives every six months. (AI summary)
View full response
Dear Sirs Our client: B & D Civil Engineering Limited Deceased: Mr Matthew James Wilmot Date of incident: 28 May 2017 We write on behalf of our client, B & D Civil Engineering Limited in response to the Regulation 28 Report dated 17 April 2018 We note the concern is that there was not enough emphasis within the risk assessment process that a route that does not run parallel to highway has different risks to that is parallel to highway. It is further noted that the Coroner was satisfied that the evidence given at Inquest was that the risk assessment undertaken in connection to the excavation outside 280 Devon Road was in line with the Red Book and Industry Standards and the path was not located in an area of risk During the course of the Inquest, evidence was heard in respect of the contract/responsibility matrix including evidence that B & D provided labour, plant ad equipment pursuant to a subcontract: Inquest considered the relevant risk assessment and method statement: In addition, evidence was heard in relation to exhibit TH2, a Team Briefing given following the accident involving Mr Wilmot Briefing followed a review of the risk to the general public regarding open excavations and it briefed attendees to take into consideration certain specifics before leaving a open hole: The specifics together with the proposed steps to be taken are recorded in the copy Briefing annexed hereto. Briefing attended by B & D operatives emphasised focus on risks connected to an open hole and the likelihood of the public an alternative route. It will be appreciated that on the Devon Road site the operatives were required to complete the Amey Utility Services Limited risk assessment template_ Nev w O-owua:Ncuse 30*]6 Mcc-nert Sttee {onccn ECn 0994 neepsi6a 0z0 220 S200 020 7320580] 'Mt e tsawec#% Plts Marus 14jr Ic)aling' D;lllle"s m Iltus Linitc"d, cuniprini incOrracr/ En;lndl _ Wale" Rez Ntx 0941584 Rezislnrl olfice: krcphs Wall, Hannaner Walk Lawis IS}4AR, Pl"xus Laru: Limiler/ is uhurisrl rulerl !h Sowieilr; Rzualion Autherity (SR Na 0J6520) #hxx profustiumai rksen Ie jcsd #e cLOA uk lisc of din*tors Add Ich-dinlors #hoJI" is ;itabie #i the olirce- Fhc tanignaltd ctICC As5x ixfe d parinau' ( ` lireclar rrirlty = Icrin Mmnc[ sec*i,fari piner ~r indlitlai dinrlor ol Ph"xus |.J1 ! iinifed.r an emukucr consuluni cjunaleni r scnior 'sthuraling id inelule"s non-slicitors ,nd nctrtani Lw Limnife"ri is # Multi-njtiaru Pccha regui:uled b The _ SleIeneAd Siauda Nx jugi#hoss' profassion:i rukstnkacussy M #I j S(H E-LK 70*3 W path The The The using S ma Nu;
P L EX U $ Our client is advised that in order to address the specific concern of the Coroner M & S will amend point 4 of the Briefing to read, "If a footway closure/road closure/alternative pedestrian route is setup, is it suitable/will pedestrians follow it? If the assessment is that they will not, please contact your supervisor for advice The procedure enables operatives to escalate any concerns for the supervisor to make the final decision on the appropriate control measures to be in place Our client is advised the revised Briefing will be a mandatory part of the induction process for any new operatives supplied by B & D and existing operatives will be briefed and refreshed at six-month intervals.
P L EX U $ Our client is advised that in order to address the specific concern of the Coroner M & S will amend point 4 of the Briefing to read, "If a footway closure/road closure/alternative pedestrian route is setup, is it suitable/will pedestrians follow it? If the assessment is that they will not, please contact your supervisor for advice The procedure enables operatives to escalate any concerns for the supervisor to make the final decision on the appropriate control measures to be in place Our client is advised the revised Briefing will be a mandatory part of the induction process for any new operatives supplied by B & D and existing operatives will be briefed and refreshed at six-month intervals.
Sent To
- B & D Civil Engineering Limited
- M & S Water Services
Response Status
Linked responses
2 of 2
56-Day Deadline
12 Aug 2018
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.