Peter Buckle
PFD Report
All Responded
Ref: 2015-0425
All 1 response received
· Deadline: 29 Dec 2015
Coroner's Concerns (AI summary)
An unsafe work method was adopted without a risk assessment, and a strong health and safety culture was absent among employees despite training.
View full coroner's concerns
In the circumstances it is my statutory to report to you: _ (1) Although a risk assessment was in place for the original method of carrying out the task (with the telehandler and grab) , once this method was no longer viable a risk assessment was not carried out or considered prior to steps being taken with regard to the next method under consideration, namely to throw the rubbish over the side of the trailer; in that the trailer was reversed to the rubbish telephone call was made to 2 other employees to assist and protective equipment was being obtained_ This left Mr Buckle to assume the work was (o be carried out in this way, Whether or not (he Site Manager was of the view the method of work was still under consideration In any event this method of carrying out the work was blatantly unsafe (2)_The employees lelt at the site of the rubbish_decided on a third method of carrying day safety "Stop duty sile, out the work, without any thought for health and safety: Although health and safety induction training had been undertaken and managers had received further (raining, a health and safety culture was not apparent from (he evidence , particularly at "ground level"
Responses
Action Taken
Wayland Farms implemented new health and safety programs including a behavioral safety training program ('stop and think'), and will provide further training with external consultant input. They acknowledge the need for disciplinary action for breaches, greater written documentation, and are undertaking measures on a continual improvement basis. (AI summary)
Wayland Farms implemented new health and safety programs including a behavioral safety training program ('stop and think'), and will provide further training with external consultant input. They acknowledge the need for disciplinary action for breaches, greater written documentation, and are undertaking measures on a continual improvement basis. (AI summary)
View full response
Dear Ms Lake Mr Peter Buckle (deceased) v Wayland Farms Ltd We write further to Regulation 28: Report to Prevent Future Deaths dated 3rd November 2015. In relation to your concerns detailed ir the Report we confirm that since Mr Buckle' s accident the following measures have been irplemented: Programmes; Wayland Farms Limited has put in place new programmes to deal with health and safety since the accldent; refer to Page 2 of the Health & Safety Executive's Fatal Incident Report dated 28th Aprll 2015 in this regard (copy attached marked Exhibit "1") A training program based around behavioural safety wlth the aim of improving the safety culture withln Wayland Farms Ltd has been completed, this was a blend of theory and practice in both an engaging and thought- provoking way to enable smarter decislons and actions in relation to tasks ad situations occurring that fall outslde of what is expected to be the normal procedure or activity. This program called 'stop and think" has been designed to help the worker understand the signlficance and importance of planning for decisions' when activities or procedures have a need to be amended due to a change In circumstance significant element of this program the worker is asked to stop and contact their Unit Manager at the crltlcal point; the decision and task planning is then carried out a5 a duel role with both levels of competence, the objective to prevent the worker taklng qulck or hasty actions in an "act nOw, think later' way. Management Registered in England No: 6727508 New We key The being being
Wayland Farms Llmlted Little Melton Food Park Little Melton Norwich Norfolk NR9 3NP WAYLAND Tel 01603 813830 FARMS IIT Fax 01603 812091 further training ensuring that there is an emphasis on the necessity for communication cascading from the manager to the workers. Iraining: The Solicitors on behalf of Wayland Farms Ltd, Robin Simon LLP, have also offered to speak to the directors and managers in addition to trainlng being provided by Wayland Farms Health & Safety and Environmental Manager. It is believed that a external person speaking to the directors and managers will assist in emphasising and ensuring that manager understand their responsibilities, following which the managers can then reiterate and enforce health and safety issues with employees_ Disciplinary Action: Wayland Farms Ltd acknowledges that disciplinary action needs to be taken where there Is a breach of health and safety procedures: Written Documentation: Wayland Farms Ltd acknowledge that there needs to be greater written documentation in relation to safety communications, and risk assessments regardIng what happens when things change in the course of the work being undertaken: Wayland Farms Ltd plan to take steps that safety critical communications are confirmed in writing as and when carried out_ Plan of Actlon/Further Re-Iteration: It is apparent that the measures referred to above are being undertaken on a continual improvement basis with enhanced focus since the Claimant's accident: With regards to enforcement and the associated training, It Is anticipated that operational directors will have received the legislation update and guidance pertaining to this during the last 2 weeks in January 2016, A new Health and Safety Audit just been completed and a trial completed in December 2015. The new Audit incorporates staff interviews to validate the knowledge and understanding of the information, instruction, training and supervision provided by Wayland Farms Ltd_ The new Audlt will be carried out per unit annually, and will incorporate 1O% of staff being Interviewed. Registerad in England No; 6727508 has
Wayland Farms Llmited Little Melton Food Park Litlle Mellon Norwich Noriolk NR9 3NP WAYAND Tel 01603 813830 EARMSITT Fax 016803 812091 If you have queries please do not hesitate to contact us.
Wayland Farms Llmlted Little Melton Food Park Little Melton Norwich Norfolk NR9 3NP WAYLAND Tel 01603 813830 FARMS IIT Fax 01603 812091 further training ensuring that there is an emphasis on the necessity for communication cascading from the manager to the workers. Iraining: The Solicitors on behalf of Wayland Farms Ltd, Robin Simon LLP, have also offered to speak to the directors and managers in addition to trainlng being provided by Wayland Farms Health & Safety and Environmental Manager. It is believed that a external person speaking to the directors and managers will assist in emphasising and ensuring that manager understand their responsibilities, following which the managers can then reiterate and enforce health and safety issues with employees_ Disciplinary Action: Wayland Farms Ltd acknowledges that disciplinary action needs to be taken where there Is a breach of health and safety procedures: Written Documentation: Wayland Farms Ltd acknowledge that there needs to be greater written documentation in relation to safety communications, and risk assessments regardIng what happens when things change in the course of the work being undertaken: Wayland Farms Ltd plan to take steps that safety critical communications are confirmed in writing as and when carried out_ Plan of Actlon/Further Re-Iteration: It is apparent that the measures referred to above are being undertaken on a continual improvement basis with enhanced focus since the Claimant's accident: With regards to enforcement and the associated training, It Is anticipated that operational directors will have received the legislation update and guidance pertaining to this during the last 2 weeks in January 2016, A new Health and Safety Audit just been completed and a trial completed in December 2015. The new Audit incorporates staff interviews to validate the knowledge and understanding of the information, instruction, training and supervision provided by Wayland Farms Ltd_ The new Audlt will be carried out per unit annually, and will incorporate 1O% of staff being Interviewed. Registerad in England No; 6727508 has
Wayland Farms Llmited Little Melton Food Park Litlle Mellon Norwich Noriolk NR9 3NP WAYAND Tel 01603 813830 EARMSITT Fax 016803 812091 If you have queries please do not hesitate to contact us.
Sent To
- Wayland Farms Limited
Response Status
Linked responses
1 of 1
56-Day Deadline
29 Dec 2015
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 26 March 2015 commenced an investigation into the death of PETER JOHN BUCKLE, AGED 67 YEARS_ The investigation concluded at the end of (he inquest on 29 OCTOBER 2015. The conclusion of the inquest was Medical Cause of Death: 1a) Traumatic Subarachnoid Haemorrhage b) Hinge fracture of skull Conclusion: Misadventure,
Circumstances of the Death
On 24 March 2015, whilst at work, Mr Buckle was instructed to load rubbish onto his trailer: The telehandler was not working so it was suggested Ihe rubbish was to be Ihrown into the trailer by hand: It was then felt the sides of the trailer were too high: was decided to prop open the tailgate with a post A post was propped against the tailgate but it slipped causing the tailgate to fall resulling in injury to Mr Buckle. He was airlifted to Addenbrooke's Hospital where he died later (hat from his injuries. Health and procedures were in place at the time of the incident and since the incident a and Think" campaign which had been identified earlier; has been put in place_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation has lhe power to take such action
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Amend GLOS to allow claimants oral submissions at panel hearings
Post Office Horizon Inquiry
Care risk assessment failures
Post Office to engage in negotiations during HSSA appeal period
Post Office Horizon Inquiry
Care risk assessment failures
Require multidimensional risk assessments throughout operations
Jermaine Baker Inquiry
Care risk assessment failures
Amend firearms authorisation forms for risk assessment and tipping points
Jermaine Baker Inquiry
Care risk assessment failures
Draw up maternity risk assessment protocol
Morecambe Bay Investigation
Care risk assessment failures
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.