Alan Dimbleby
PFD Report
Partially Responded
Ref: 2016-0120
Coroner's Concerns (AI summary)
Self-propelled sprayers lack operator seat restraints, risking operators being thrown from the vehicle if it overturns. HSE guidance may inappropriately suggest these restraints are not needed for this vehicle type.
View full coroner's concerns
During the course of the inquest the evidence revealed matters that gave rise to concerns that circumstances creating a risk of other deaths will continue to exist in the future unless action is taken.
Operator Seat Restraint
1. Consideration should be given to fitting operator seat restraints to self-‐‑propelled sprayers. The cabin of the vehicle was such that it would have provided adequate protection to Mr Dimbleby had he not been thrown out of the vehicle. However, without appropriate operator seat restraints there is a serious risk that the operator will be thrown from the vehicle should it overturn and, as such, a safe cabin does not provide adequate protection.
2. Consideration should be given to removing self-‐‑propelled sprayers from the class of vehicles in respect of which the HSE guidance suggests that operator seat restraints may not be needed or are inappropriate [Agriculture Information Sheet 37 (revision1)].
Operator Seat Restraint
1. Consideration should be given to fitting operator seat restraints to self-‐‑propelled sprayers. The cabin of the vehicle was such that it would have provided adequate protection to Mr Dimbleby had he not been thrown out of the vehicle. However, without appropriate operator seat restraints there is a serious risk that the operator will be thrown from the vehicle should it overturn and, as such, a safe cabin does not provide adequate protection.
2. Consideration should be given to removing self-‐‑propelled sprayers from the class of vehicles in respect of which the HSE guidance suggests that operator seat restraints may not be needed or are inappropriate [Agriculture Information Sheet 37 (revision1)].
Responses
Action Taken
Bateman Engineering has changed the design of their cabs to include seat restraints, and now fits them on all vehicles before they leave the workshop. (AI summary)
Bateman Engineering has changed the design of their cabs to include seat restraints, and now fits them on all vehicles before they leave the workshop. (AI summary)
View full response
Dear Sir , write in response to the prevention of future deaths report issued following the Inquest into the death of Alan Dimbleby. As understand your report, it requests that consideration should be given to fitting operator seat restraints to self-propelled sprayers. As set out in my statement provided for the Inquest, there is no requirement for sprayers to have seat restraints. We have always focussed on making the cab enclosure as safe and secure as possible so that the driver is protected irrespective of whether are wearing a seat restraint_ In the report you acknowledge that the cabin of the sprayer was still intact and generally undamaged following the accident_ However , since became aware of the circumstances of Mr Dimbleby's accident, have changed the design of the cabs to include seat restraints and no vehicle leaves our workshop without oe being fitted_ that you find the action taken to be adequate and am happy to discuss matters further with you if you think that would be helpful:
Action Planned
HSE will raise the issue of seat restraints on self-propelled sprayers at the next appropriate meeting for consideration in future revisions of applicable standards and will consider revising guidance to better inform the choice of vehicle when working on slopes. (AI summary)
HSE will raise the issue of seat restraints on self-propelled sprayers at the next appropriate meeting for consideration in future revisions of applicable standards and will consider revising guidance to better inform the choice of vehicle when working on slopes. (AI summary)
View full response
Dear Mr Travers Re: Mr Alan Dimbleby (deceased) Regulation 28 Report to Prevent Future Deaths Thank you for your letter of the 23 March regarding Alan Dimbleby's tragic death on 23
2015. You asked me to consider two issues: (a) whether; operator seat restraints should be fitted to self-propelled sprayers; and (b) whether HSE guidance Agricultural Information Sheet 37 requires revision to remove self-propelled sprayers from the class of vehicles where operator seat restraints may not be needed or may not be appropriate: On the first issue, the use of seat restraints has to be considered in conjunction with the design of the machine_ If seat restraint is to be effective in an overturn situation it must be in conjunction with a roll over protective structure (ROPS): A_ ROPS is protective structure intended to provide the operator with protective zone to reduce the risk of injury: Vehicles fitted with ROPS are fitted with seat restraints so that the operator remains within the protective zone. In 2009 the relevant standard was revised and required seat belt anchorage points if the sprayer was fitted with ROPS. However the standard, which was most recently revised in 2013, allows the manufacturer to choose how to reduce the risk Of an overturn, or to mitigate the likelihood of injury in an overturn and ROPS is only one of the options July
available Not all sprayers manufactured now, or in the past, will have ROPS cab. Where non-ROPS cab is present which is particularly likely on older machines, the fitting and wearing of seat restraints is not recommended as it can increase the risk of injury in the event of a roll over, non-ROPS cab is not designed to, nor will it have been tested to demonstrate that it can withstand the forces to which it is exposed during a roll over. Consequently, in an overturn the structure is likely to deform, and penetrate the zone occupied by the restrained driver resulting in a risk of serious personal injury: Additionally, on older machines regardless of whether or not have ROPs fitted, there may not be any suitable anchorage points for seat restraints and fitting them may be unfeasible_ The to preventing an overturn on sloping ground is for employers to assess the work, including travel to and from the site in question, to select the right equipment for the conditions, to ensure the work is planned so that it can be carried out safely and to ensure that the operator is trained and competent for the task Where a risk of overturning has been identified as significant, one of the means by which this can be reduced is to specify a machine fitted with ROPS and operator restraint_ HSE's guidance about overturning vehicles' gives range of practical considerations that the employer needs to consider when planning the work. Overall we cannot advocate policy that all self-propelled sprayers be fitted with seat restraints HSE works with the relevant British Standards (BSI) and European Standards (CEN) committees on agricultural machinery safety, and we will raise this issue at the next appropriate meeting for the consideration in future revisions of applicable standards_ On your second point; concerning HSE guidance on the use of seat restraints? similar constraints apply to how far this can be changed. Our guidance has to apply to the full range of self-propelled work equipment (including those fitted with ROPS and those not fitted with ROPS). It gives advice on the steps that should be taken to comply with health and safety legislation: The guidance is not intended to be comprehensive, and does not cover every possible configuration of self-propelled work equipment: specifically we cannot recommend the use of seat restraints for a vehicle that is not also fitted with ROPS for the reasons given above_ We do nonetheless keep all of our guidance under review and at the next opportunity we will consider whether the wording can be revised to better inform the choice of vehicle when working on slopes_ In your report (Section 6) you state that HSE is in a position to draw these concerns to the appropriate authority in Portugal who has the power to take action: We do not understand the reference to Portugal which does not appear to have any relevance to this incident: Therefore, we do not intend to take this action. http Ilww.hse gov uklagricultureltopics/machinerylfarm-vehicles-2.htm 2 AIS 37 Operator seat restraints for tractors and mobile work equipment in agriculture and forestry they key the Very
2015. You asked me to consider two issues: (a) whether; operator seat restraints should be fitted to self-propelled sprayers; and (b) whether HSE guidance Agricultural Information Sheet 37 requires revision to remove self-propelled sprayers from the class of vehicles where operator seat restraints may not be needed or may not be appropriate: On the first issue, the use of seat restraints has to be considered in conjunction with the design of the machine_ If seat restraint is to be effective in an overturn situation it must be in conjunction with a roll over protective structure (ROPS): A_ ROPS is protective structure intended to provide the operator with protective zone to reduce the risk of injury: Vehicles fitted with ROPS are fitted with seat restraints so that the operator remains within the protective zone. In 2009 the relevant standard was revised and required seat belt anchorage points if the sprayer was fitted with ROPS. However the standard, which was most recently revised in 2013, allows the manufacturer to choose how to reduce the risk Of an overturn, or to mitigate the likelihood of injury in an overturn and ROPS is only one of the options July
available Not all sprayers manufactured now, or in the past, will have ROPS cab. Where non-ROPS cab is present which is particularly likely on older machines, the fitting and wearing of seat restraints is not recommended as it can increase the risk of injury in the event of a roll over, non-ROPS cab is not designed to, nor will it have been tested to demonstrate that it can withstand the forces to which it is exposed during a roll over. Consequently, in an overturn the structure is likely to deform, and penetrate the zone occupied by the restrained driver resulting in a risk of serious personal injury: Additionally, on older machines regardless of whether or not have ROPs fitted, there may not be any suitable anchorage points for seat restraints and fitting them may be unfeasible_ The to preventing an overturn on sloping ground is for employers to assess the work, including travel to and from the site in question, to select the right equipment for the conditions, to ensure the work is planned so that it can be carried out safely and to ensure that the operator is trained and competent for the task Where a risk of overturning has been identified as significant, one of the means by which this can be reduced is to specify a machine fitted with ROPS and operator restraint_ HSE's guidance about overturning vehicles' gives range of practical considerations that the employer needs to consider when planning the work. Overall we cannot advocate policy that all self-propelled sprayers be fitted with seat restraints HSE works with the relevant British Standards (BSI) and European Standards (CEN) committees on agricultural machinery safety, and we will raise this issue at the next appropriate meeting for the consideration in future revisions of applicable standards_ On your second point; concerning HSE guidance on the use of seat restraints? similar constraints apply to how far this can be changed. Our guidance has to apply to the full range of self-propelled work equipment (including those fitted with ROPS and those not fitted with ROPS). It gives advice on the steps that should be taken to comply with health and safety legislation: The guidance is not intended to be comprehensive, and does not cover every possible configuration of self-propelled work equipment: specifically we cannot recommend the use of seat restraints for a vehicle that is not also fitted with ROPS for the reasons given above_ We do nonetheless keep all of our guidance under review and at the next opportunity we will consider whether the wording can be revised to better inform the choice of vehicle when working on slopes_ In your report (Section 6) you state that HSE is in a position to draw these concerns to the appropriate authority in Portugal who has the power to take action: We do not understand the reference to Portugal which does not appear to have any relevance to this incident: Therefore, we do not intend to take this action. http Ilww.hse gov uklagricultureltopics/machinerylfarm-vehicles-2.htm 2 AIS 37 Operator seat restraints for tractors and mobile work equipment in agriculture and forestry they key the Very
Sent To
- Health and Safety Executive
Response Status
Linked responses
2 of 3
56-Day Deadline
18 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
The inquest into the death of Mr Dimbleby was opened on the 4th August 2015 and was resumed on the 22nd March 2016 with a jury and concluded the following day, 23rd March 2016.
The jury found the cause of death to have been:
1a. Hypoxic Brain Injury 1b. Cardiac Arrest 1c.Traumatic Fracture of Cervical Veterbrae
They concluded with a short form conclusion of ‘Accidental Death’.
The jury found the cause of death to have been:
1a. Hypoxic Brain Injury 1b. Cardiac Arrest 1c.Traumatic Fracture of Cervical Veterbrae
They concluded with a short form conclusion of ‘Accidental Death’.
Circumstances of the Death
On the 23rd July 2015, Mr Dimbleby, a very experienced crop sprayer, was spraying areas of cover at Warren Barn Farm, Woldingham, Surrey. He was driving his usual vehicle a Bateman RB35 self-‐‑propelled sprayer with which he was very familiar. The land was undulating and in parts very steep. As Mr Dimbleby was making his way from the second area of cover to the third area, the sprayer became unstable and rolled down the incline. Mr Dimbleby was thrown from the cabin and died as a result of Rtdoc/02512-2015/Reg28/23-3-2016 injuries that were sustained when he was struck by the rolling vehicle. The cabin of the vehicle was still intact and generally undamaged, but there was no form of operator seat restraint. The jury found that the gradient of the slope on which he was working together with the absence of a seatbelt made a material contribution to his death.
Copies Sent To
I have sent a copy of this report to the following
1. Dr Richard Judge, Chief Executive HSE
2. Bateman Engineering Ltd
4. DAC Beachcroft Claims Ltd (
5. The Chief Coroner
Signed
Richard Travers
DATED this 23rd March 2016
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.