Mark Seward
PFD Report
Partially Responded
Ref: 2016-0136
Coroner's Concerns (AI summary)
A lack of clarity on pressure testing definitions and widespread non-compliance with work equipment regulations (PUWER) and HSE guidance across the industry posed significant safety risks.
View full coroner's concerns
(1) There was a lack of clarity as to what type of activity amounted to pressure testing.
(2) The degree of compliance with the Provision and Use of Work Equipment Regulations 1998 (PUWER) and guidance issued by the HSE such as GS4 was called into question, not only at AGD but more widely within the industry. Witnesses gave evidence that the poor practices followed at AGD were replicated elsewhere.
(2) The degree of compliance with the Provision and Use of Work Equipment Regulations 1998 (PUWER) and guidance issued by the HSE such as GS4 was called into question, not only at AGD but more widely within the industry. Witnesses gave evidence that the poor practices followed at AGD were replicated elsewhere.
Responses
Action Taken
The company has reminded staff about the health and safety policy, reviewed the site safety induction, and introduced a new traffic management plan. They have also invested in new health and safety software and appointed a new Safety Officer/Assistant Manager. (AI summary)
The company has reminded staff about the health and safety policy, reviewed the site safety induction, and introduced a new traffic management plan. They have also invested in new health and safety software and appointed a new Safety Officer/Assistant Manager. (AI summary)
View full response
IAGDJ AGD Equipment Limited Avonbrook House 198 Masons Road Stratford Enterprise Park Stratford-upon-Avon Warwickshire CV37 9LQ United Kingdom +44(0)1789 292227 f: +44(0)1789 268350 info@agd-equipment co.uk WWW . agd-equipment co.uk Response Report This report has been prepared in response to the Regulation 28 Report to prevent future deaths dated 5th April 2016 from David Clark Assistant Coroner. Please find below a detailed list of actions taken by AGD Equipment Limited since 27th May 2015 together with those that are work-in-progress at the present time. The company has a health and safety policy setting out the roles and responsibilities for all personnel including directors_ managers and employees. A copy of this policy is available both electronically on the computer and in a hard copy kept in the office, which is accessible to all employees_ A further copy of the policy is displayed on the health and safety notice board by the canteen and another copy is on display in the office reception area Following the Inquest all staff have been reminded about the health and safety policy and where it can be found. The AGD employees who gave evidence at the Inquest had actually been involved in drafting original policy and should therefore have been well aware of its contents. AGD continue to use the Site Safety PowerPoint induction given to all staff before start work. Following the Inquest AGD have reviewed the induction with specialist advice from the company's health and safety consultants_ The induction details the health and safety positions at the company and explains the health and safety hierarchy: AlI staff are given refresher training on these elements_ The company has a Health and Safety Committee with representatives from various areas of the business, as well as a representative from the company' s health and safety consultants. The Health and Safety Committee meet monthly to discuss on-going health and safety issues These health and safety meetings are fully minuted and the minutes are sent to the Board of Directors_ The minutes are reviewed during Board meetings where health and safety is top item on the Board Agenda The Health and Safety Committee has been in place for long time but again refresher information has been AGD Equipment Limited Directors: WH.Law (Chairman) RWLaw (Managing Director) EA Law R SPA Registered office as above Registered in England Company number 01275753 A subsidiary of AGD Holdings Limited Member the they key being
given to all staff to remind them of the existence of the Committee and its function Work is being undertaken to ensure Committee is a fully integrated and interactive part of the safety culture in the company_ AGD are working closely with the HSE to ensure that risk assessments and safe systems of work are in place. AGD are aiso working with the close assistance of company's health and safety consultants throughout this process to identify all risks, work duties and equipment; to ensure nothing is overlooked. Following the accident on 27th May 2015 the company reviewed all risk assessments_ COSHH assessments and safe systems of work. AGD's health and safety consultants were involved in this process and the Supervisory Team must access and use these documents when planning new tasks, or allocating work to personnel Having drawn up individual safe systems of work; toolbox talks were delivered to all employees likely to be involved in the relevant tasks to ensure that they understood the task and controls in place to work safely_ record is kept of these toolbox talks_ and they continue to be discussed by the Health and Safety Committee at monthly meetings to ensure a rolling programme of continuous improvement The company health and safety documents including policy_ risk assessments and safe systems of work along with relevant HSE Guidance are held electronically on servers and computers The company has also given the mobile engineers electronic tablets containing these documents for off-site reference A hard copy of all electronic documents is also held in folders located in the Service Department office. This was already the case at the time of the Inquest and was within knowledge of those employees who gave evidence because were part of the team directly involved in putting the documentation together. It is notknown why this information was not given to Coroner at the Inquest. Refresher training and awareness raising has been rolled out across all employees to remind them where all health and safety documents can be found. The company continue to use and update the comprehensive training matrix of skills and competencies for all employees_ This matrix details all health and safety training provided, or arranged by AGD; and is reviewed regularly at the Health and Safety Committee meetings Full minutes of the Health and Safety Committee meetings are not only passed to the Board but are also displayed on the health and safety notice board: The company is undertaking a full review of its safety management system to ensure that robust arrangements are in place for the future which covers (1) the company philosophy on safety; (2) the arrangements in place to plan and supervise work properly; Page 2 0f 3 the the the full the they the
(3) the arrangements in place to ensure all staff are skilled, trained and competent for the work undertake and (4) to ensure the monitoring arrangements are adequate and properly undertaken. Hand in hand with this review is new communications strategy to ensure all staff are aware of the system, its rules and their own responsibilities_ AGD have appointed new Safety OfficerIAssistant Manager with substantial experience in operational workshop health and safety: This new role has been recruited to ensure that working practices are up-to-date with current legislation and industry best practice To compliment this new role the company has altered the Paint Shop Supervisor role to the wider role of Workshops Supervisor so that the new Safety OfficerlAssistant Manager can concentrate on ensuring all health and safety rules controls and best practices are understood and fully implemented throughout the operational site for all employees and visiting suppliers. The company continue to outsource all pressure testing work and have no intention of ever bringing the work back in house A new traffic management plan has been introduced and fully implemented to improve safety in regards to all vehicle movements in and out of our facility. 10_ AGD have invested in a new health and safety software called Cognitia Safety and Compliance, which enables the company to manage all the health and safety documentation in one place The software holds all the risk assessments, safe systems of work, COSHH assessments, near misslaccident statistics , training certificates and occupational health medical certificates_ The software will be continually updated with the latest documents and certificates The office employees are currently receiving training on this software so that are able to use and refer to it on a daily basis 11_ Over the past twelve months AGD have spent in excess of E110,000 on safety, welfare and training: The company always have and always will invest in anything necessary to further ensure the safety of all employees, irrespective of any budget in place. Page 3 0f 3 they they
given to all staff to remind them of the existence of the Committee and its function Work is being undertaken to ensure Committee is a fully integrated and interactive part of the safety culture in the company_ AGD are working closely with the HSE to ensure that risk assessments and safe systems of work are in place. AGD are aiso working with the close assistance of company's health and safety consultants throughout this process to identify all risks, work duties and equipment; to ensure nothing is overlooked. Following the accident on 27th May 2015 the company reviewed all risk assessments_ COSHH assessments and safe systems of work. AGD's health and safety consultants were involved in this process and the Supervisory Team must access and use these documents when planning new tasks, or allocating work to personnel Having drawn up individual safe systems of work; toolbox talks were delivered to all employees likely to be involved in the relevant tasks to ensure that they understood the task and controls in place to work safely_ record is kept of these toolbox talks_ and they continue to be discussed by the Health and Safety Committee at monthly meetings to ensure a rolling programme of continuous improvement The company health and safety documents including policy_ risk assessments and safe systems of work along with relevant HSE Guidance are held electronically on servers and computers The company has also given the mobile engineers electronic tablets containing these documents for off-site reference A hard copy of all electronic documents is also held in folders located in the Service Department office. This was already the case at the time of the Inquest and was within knowledge of those employees who gave evidence because were part of the team directly involved in putting the documentation together. It is notknown why this information was not given to Coroner at the Inquest. Refresher training and awareness raising has been rolled out across all employees to remind them where all health and safety documents can be found. The company continue to use and update the comprehensive training matrix of skills and competencies for all employees_ This matrix details all health and safety training provided, or arranged by AGD; and is reviewed regularly at the Health and Safety Committee meetings Full minutes of the Health and Safety Committee meetings are not only passed to the Board but are also displayed on the health and safety notice board: The company is undertaking a full review of its safety management system to ensure that robust arrangements are in place for the future which covers (1) the company philosophy on safety; (2) the arrangements in place to plan and supervise work properly; Page 2 0f 3 the the the full the they the
(3) the arrangements in place to ensure all staff are skilled, trained and competent for the work undertake and (4) to ensure the monitoring arrangements are adequate and properly undertaken. Hand in hand with this review is new communications strategy to ensure all staff are aware of the system, its rules and their own responsibilities_ AGD have appointed new Safety OfficerIAssistant Manager with substantial experience in operational workshop health and safety: This new role has been recruited to ensure that working practices are up-to-date with current legislation and industry best practice To compliment this new role the company has altered the Paint Shop Supervisor role to the wider role of Workshops Supervisor so that the new Safety OfficerlAssistant Manager can concentrate on ensuring all health and safety rules controls and best practices are understood and fully implemented throughout the operational site for all employees and visiting suppliers. The company continue to outsource all pressure testing work and have no intention of ever bringing the work back in house A new traffic management plan has been introduced and fully implemented to improve safety in regards to all vehicle movements in and out of our facility. 10_ AGD have invested in a new health and safety software called Cognitia Safety and Compliance, which enables the company to manage all the health and safety documentation in one place The software holds all the risk assessments, safe systems of work, COSHH assessments, near misslaccident statistics , training certificates and occupational health medical certificates_ The software will be continually updated with the latest documents and certificates The office employees are currently receiving training on this software so that are able to use and refer to it on a daily basis 11_ Over the past twelve months AGD have spent in excess of E110,000 on safety, welfare and training: The company always have and always will invest in anything necessary to further ensure the safety of all employees, irrespective of any budget in place. Page 3 0f 3 they they
Sent To
- AGD Equipment Limited
- Construction Plant Hire Association
Response Status
Linked responses
1 of 2
56-Day Deadline
31 May 2016
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 28 May 2015, I commenced an investigation into the death of Mark Richard Seward, aged 49 years. The investigation concluded at the end of the jury inquest on 31 March 2016. The conclusion of the jury was that Mr Seward died from a head injury and that his death was the result of an accident.
Circumstances of the Death
Mr Seward was an experienced fitter, mechanic and engineer who had started work at AGD Equipment Limited (AGD) in Stratford-upon-Avon on 10 May 2015. On 27 May 2015, in the course of his employment, he was using a portable Enerpac pump to test a cylinder for an oil leak. At 11.19, the valve block on the cylinder fractured due to excessive pressure. The resulting explosion caused an ejection of metal and other debris at high speed. Mr Seward was crouching at close proximity to the cylinder. He was not wearing protective headware and was not shielded by a protective screen. He was struck by debris, resulting in a serious head injury. He was taken by air ambulance to University Hospital, Coventry, where he died at 14.35 the same day.
Action Should Be Taken
The particular circumstances which led to Mr Seward’s death are unlikely to recur at AGD because pressure testing is now sent off-site. However, my concerns relate more widely and include the proper understanding of pressure testing and the safe management of associated risks across the industry. Your organisation appears to be well-placed to assist with raising awareness of these concerns.
The action I am asking of you should include an explanation of the steps you are taking to raise awareness of the risks associated with pressure testing, and of how companies and individuals can gain access to guidance from the HSE.
I have written separately to the Managing Director of AGD.
The action I am asking of you should include an explanation of the steps you are taking to raise awareness of the risks associated with pressure testing, and of how companies and individuals can gain access to guidance from the HSE.
I have written separately to the Managing Director of AGD.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.