Andrew Coates
PFD Report
All Responded
Ref: 2016-0025
All 1 response received
· Deadline: 24 Mar 2016
Coroner's Concerns (AI summary)
An unsuitable wooden shed was licensed for fireworks storage, containing other combustibles and having deficient licensing that failed to specify types or designate a specific site, exacerbated by sketchy inspection records.
View full coroner's concerns
The Fireworks Store at Larch Cottage was, in 2008, licenced under the terms Of the Manufacture and Storage of Explosives Regulations 2005. premises had been subject to a Registration since 2004. It is questionable as to whether what amounted to a wooden shed comprised within a vehicle garage was a suitable structure for a firework store particularly one licenced for 1000 kq my The
Evidence was given that the store contained a large amount of other material some of it combustible and access could only be made to the store via an adjoining compartment containing two petrol driven machines. It seemed that this state of affairs had obtained for a number of years, notwithstanding apparently compliant inspections In addition the licence granted was deficient in that it effectively licenced the entire property instead of designating a specific site The licence did not specify the type of firework or explosive to be stored: The effect was to give authority to store explosives of any type up to a net explosive quantity of 1000 kg: The records of inspections were sketchy: The construction and none firework content of the store at the least exacerbated ensuing fire.
Evidence was given that the store contained a large amount of other material some of it combustible and access could only be made to the store via an adjoining compartment containing two petrol driven machines. It seemed that this state of affairs had obtained for a number of years, notwithstanding apparently compliant inspections In addition the licence granted was deficient in that it effectively licenced the entire property instead of designating a specific site The licence did not specify the type of firework or explosive to be stored: The effect was to give authority to store explosives of any type up to a net explosive quantity of 1000 kg: The records of inspections were sketchy: The construction and none firework content of the store at the least exacerbated ensuing fire.
Responses
Action Taken
Cumbria County Council has provided training to Trading Standards Officers on firework storage, reviewed quality assurance procedures (incorporating minor amendments), and audited large firework stores, rectifying an issue with separation distances. (AI summary)
Cumbria County Council has provided training to Trading Standards Officers on firework storage, reviewed quality assurance procedures (incorporating minor amendments), and audited large firework stores, rectifying an issue with separation distances. (AI summary)
View full response
Dear Mr Roberts Coroners (Investigations) Regulations 2013 Regulation 28 Report to Prevent Future Deaths Regarding the Late Polly Connor and Andrew Coates write with reference to your Regulation 28 letter dated January 2016,in respect of the storage of fireworks at Larch Cottage, Ecclerigg, Windermere. Please accept this letter and Cumbria County Council's letter of the 241 March 2016 as the Council's complete response to you Regulation 28 letter. Within your letter you raised concerns and recommended that the Council should "fully and carefully review the decision making and inspection process of explosive stores in the county. This is to include the manner of construction and content of the structures and the scope of licences' Our letter dated the 24" of March 2016, detailed the actions taken to that date, however due to the flooding in Cumbria in December 2015 we had been unable to arrange for the external audit of our processes and licensed stores. It was agreed that Cumbria County Council would take the following action by the 31s August 2016: Ensure that all officers who are conducting firework licencing inspections will receive training on the requirements of the Explosives Regulations 2014, and will specifically examine storage requirements_ Conduct an external review of Quality Assurance procedures: Extemally validate the large firework stores in Cumbria, so that expert opinion on the construction, suitability and compliance with the regulations could be sought: Review of existing licences by external expert: In our letter dated 24th March 2016, we advised you that the HSE were t0 conduct the external audit of our processes and licensed stores. The HSFE were subsequently unable to conduct the audit: Therefore Cumbria County Council; contracted an independent exnert; to validate the firework stores licensing and review the Council's licenses and procedures is the Lead Officer for Explosives Serving the people of Cumbria Apprenticeships cumbria:gov.uk Gocd for our Business 27h
for the Chartered Standards Institute , and is a Fellow of the Association for Petroleum and Explosive Administration with over 25 years experience. can confirm that the following actions have undertaken to address your concerns: Training on 17 June 2016 provided training to all operational Trading Standards Officers and fireworks administrators in respect of The Explosives Regulations 2014, This training specifically covered the storage of fireworks and construction of firework stores, separation distances, hazard types of fireworks and licensing requirements_ Quality Assurance Procedures and Review of Existing Licenses reviewed (he fireworks quality assurance procedures and work instructions implemented by Cumbria Trading Standards. He identified some minor amendments to the procedures in his report, which have now been incorporated into the Council's procedures and practices_ Firework Store review also conducted an audit of the large Cumbrian fireworks stores and their associated licenses. In respect of the mandatory legal requirements he identified one issue over the quantity and then the subsequent separation distances specified in one licence This has now been rectified. There were also some issues identified with the best practice requirements which the businesses determine how comply with these requirements. Compliance of these issues has been agreed with the businesses concemed. am pleased to advise you that Cumbria County Council has addressed the issues which were identified in report; and the licensing procedures and Firework Stores in Cumbria were complainant with the Explosive Regulations 2014. The Council has also provided additional training for all staff involved in firework licensing: hope that the independent report ad our interim response dated March 2016 provides you with reassurance that Cumbria County Council is now fully meeting its statutory responsibilities under the Explosive Regulations 2014, as the enforcing and licensing authority: Should you wish to discuss the content of letter or attached report further, please do not hesitate to contact me_
for the Chartered Standards Institute , and is a Fellow of the Association for Petroleum and Explosive Administration with over 25 years experience. can confirm that the following actions have undertaken to address your concerns: Training on 17 June 2016 provided training to all operational Trading Standards Officers and fireworks administrators in respect of The Explosives Regulations 2014, This training specifically covered the storage of fireworks and construction of firework stores, separation distances, hazard types of fireworks and licensing requirements_ Quality Assurance Procedures and Review of Existing Licenses reviewed (he fireworks quality assurance procedures and work instructions implemented by Cumbria Trading Standards. He identified some minor amendments to the procedures in his report, which have now been incorporated into the Council's procedures and practices_ Firework Store review also conducted an audit of the large Cumbrian fireworks stores and their associated licenses. In respect of the mandatory legal requirements he identified one issue over the quantity and then the subsequent separation distances specified in one licence This has now been rectified. There were also some issues identified with the best practice requirements which the businesses determine how comply with these requirements. Compliance of these issues has been agreed with the businesses concemed. am pleased to advise you that Cumbria County Council has addressed the issues which were identified in report; and the licensing procedures and Firework Stores in Cumbria were complainant with the Explosive Regulations 2014. The Council has also provided additional training for all staff involved in firework licensing: hope that the independent report ad our interim response dated March 2016 provides you with reassurance that Cumbria County Council is now fully meeting its statutory responsibilities under the Explosive Regulations 2014, as the enforcing and licensing authority: Should you wish to discuss the content of letter or attached report further, please do not hesitate to contact me_
Sent To
- Cumbria County Council
Response Status
Linked responses
1 of 1
56-Day Deadline
24 Mar 2016
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
Report Sections
Investigation and Inquest
On 5"h September 2014 an investigation was commenced into the death of Andrew William Telford Coates aged 41 years. The investigation concluded at the end of the inquest on 22nd January 2016. The conclusion of the inquest was: Cause: 1a) Effects of Explosion and Fire Conclusion: Accidental death
Circumstances of the Death
On the 30" August 2014 between the hours of 15.00 and 15.30 at Larch Cottage; Ecclerigg; Windermere, Cumbria in an outbuilding known as the Fireworks Store located on the property, an unexplained explosion rendered Andrew William Telford Coates unable to exit the Fireworks Store. Fire consumed the building: This resulted in a fatal level of carbon monoxide inhalation:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action: In the light of the evidence from the Inquest; to fully and carefully review the decision making and inspection process of explosive stores in the county. This to include the manner of construction and content of the structures, and the scope of the licences granted. Your RESPONSE You are under a duty t0 respond to this report within 56 days of the date of this report;, namely by 25ih March 2016. I, the coroner , may extend the period: 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_
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Require fire engineer calculations for fire spread and evacuation
Grenfell Tower Inquiry
Fire risk assessment failures
Fire risk, vulnerable smokers
Require external wall information for fire services
Grenfell Tower Inquiry
Fire risk assessment failures
Train fire personnel on external wall fire risks
Grenfell Tower Inquiry
Fire risk assessment failures
Require evacuation plans for high-rise buildings
Grenfell Tower Inquiry
Fire risk assessment failures
Require compliant flat entrance doors where unsafe cladding exists
Grenfell Tower Inquiry
Fire risk assessment failures
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.