Source · Prevention of Future Deaths

Afolabi Ojerinde

Ref: 2025-0060 Date: 3 Feb 2025 Coroner: Zak Golombeck Area: Manchester City Responses identified: 2 / 4 View PDF

Petrol stations lack adequate controls and guidance to ensure compliance with regulations regarding dispensing petrol, failing to prevent unsafe access to fuel.

Date 3 Feb 2025
56-day deadline 31 Mar 2025 est.
Responses identified 2 of 4
Suicide (from 2015)

Coroner's concerns

AI summary
Petrol stations lack adequate controls and guidance to ensure compliance with regulations regarding dispensing petrol, failing to prevent unsafe access to fuel.
View full coroner's concerns
I am concerned about the safety of petrol stations and how they do not ensure compliance with Regulation 12 of the Petroleum (Consolidation) Regulations 2014. When comparing this to petrol stations, ensuring that the individual is: seeking to dispense petrol into a motor vehicle or motor boat; seeking to dispense petrol into a suitable portable container; over the age of 16. The evidence at the Inquest from the companies that operated the site and provided security accepted that the guidance available for petrol stations do not and cannot ensure compliance with the 2014 Regulations.

Responses

2 respondents
Energy Institute Petroleum Enforcement Liaison Group Association for Petroleum and Exp
3 Feb 2025 PDF
Action Planned

EI, APEA, and PELG state that they will continue to review publications and update them where applicable. Additional work to develop a best practice guide for unmanned petrol filling stations is being undertaken by industry with the support of PELG. (AI summary)

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Dear Mr Golombeck Further to the recent Regulation 28 of 3rd February 2025, this response is submitted on behalf of Energy Institute (EI), Association for Petroleum and Explosives Administration (APEA) and Petroleum Enforcement Liaison Group (PELG). Firstly, all three organisations wish to pass on their sincere condolences to the family of Mr Ojerinde following these sad events. EI The Energy Institute (EI) is the leading chartered professional membership body supporting individuals and organisations across the energy industry. With a combined membership of over 14 000 individuals and 300 companies in 100 countries, it provides an independent focal point for the energy community and a powerful voice to engage business and industry, government, academia and the public internationally. As a Royal Charter organisation, the EI offers professional recognition and sustains personal career development through the accreditation and delivery of training courses, conferences and publications and networking opportunities. It also runs a highly valued technical work programme, comprising original independent research and investigations, and the provision of EI technical publications to provide the international industry with information and guidance on key current and future issues. APEA The APEA is a UK based organisation with worldwide membership. It draws membership from those in the retail petroleum industry who are involved with the design, construction and operation of filling stations. The membership includes regulators from national and local government authorities, oil companies, equipment manufacturers, suppliers, service and installation organisations and contractors. The APEA was founded in 1958 and has the same objectives as today:
• The advancement of scientific and technical knowledge
• The supply and interchange of information
• Uniformity of standards interpretation and application

The APEA is consulted by governments and standards authorities in this specialist field. It also runs training courses, provides technical advice and holds an annual conference. PELG PELG was set with the aim to facilitate appropriate and consistent enforcement by Petroleum Licensing Authorities (PLAs) through the dissemination of advice, guidance and good practice. Under the sponsorship of the Health and Safety Executive (HSE) in Great Britain, PELG was set up to devise guidance and provide advice to PLAs and licensees on the Petroleum (Consolidation) Act 1928 and to produce circulars (PETELs). Later, the role was broadened to provide a platform for revisions to legislation and played a key part in the devising and implementation of the Dangerous Substances and Explosive Atmospheres Regulations (DSEAR) in Great Britain in 2002, and subsequently the Petroleum (Consolidation) Regulations (PCR) that came into force in Great Britain on 1st October 2014. PCR repealed the Petroleum (Consolidation) Act 1928 and introduced a certification regime to replace petrol licencing and

separate notification of keeper arrangements. The authorities allocated to enforce PCR are referred to in the Regulations as Petroleum Enforcement Authorities (PEAs).

Aims and objectives The aim of PELG is to facilitate appropriate and consistent enforcement by PEAs and compliance by petrol dispensing premises operators through the dissemination of advice, guidance and good practice. PELG has six objectives; namely to:
• Discuss the need for advice and guidance (including on technical issues where there is a need for a consensus view among PEAs and HSE); to commission and agree such advice and disseminate it to PEAs and make it available to operators of petrol dispensing premises.
• Assess the implications for enforcement of new developments in technology, industry practice and procedures.
• Liaise effectively with HSE, PEA’s, National Fire Chiefs Council, Environmental Agencies and the associations representing the retail petroleum industry on matters within its remit.
• Assist in finding solutions to general problems that might otherwise incur costly and time- consuming appeals.
• Ensure the principles of the Regulators' Code, as issued by BEIS is being followed.
• Advise PEAs on compliance with the National Local Authority Enforcement Code.

Comment All incidents within the sector are taken extremely seriously and reviewed to ensure guidance and regulations remain fit for purpose. Following the incident and subsequent Section 28, the group have reviewed both the EI(IP)/APEA’s Guide the “Design, Construction, Modification, Maintenance and Decommissioning of Filling Stations” (The “Blue Book”) and EI/PELG Guide “Petrol Filling Stations Guidance on managing the risks of fire and explosion” (The Red Guide), paying particular attention to the following sections of each publication;

Blue Book including hyperlink Section 7.6 – Control Systems Annex X – Safety Signs and Safety Information Notices. Red Guide including hyperlink Section 5 – Managing The Risk Section 6.4 – Operating and Emergency Procedures Section 7.3 – Dispensing Control Measures highlighting Section 7.3.8 – Sites operating in Unmanned Mode and Section 7.3.12 – Assessing The Risks

Annex A – CCTV Surveillance Annex C – Training It should be noted the guidance in place is goal setting, illustrating the fundamental principles for site operators to achieve across a spectrum of fuelling formats, with guidance to support this, however it remains for site operators to risk assess and implement appropriate control measures at premises deemed suitable to operate in such a way. Please note additional work in relation to the operation of petrol filling stations on an unmanned basis is being undertaken by industry with the support of PELG to develop a best practice guide to further support operators beyond the standard guidance in place.

Conclusions Having completed the review, whilst the incident has caused obvious concern, it is felt that both publications remain comprehensive and fit for purpose. All three responding organisations and the various Trade Associations and manufacturers who they represent, remain keen to work closely with operators to ensure that risks are assessed and mitigated against to ensure incidents such as these are kept to a minimum. Please rest assured that APEA, EI and PELG will continue to ensure that publications are reviewed on a periodic basis and updated where applicable.

Best regards

Secretariat

For and on behalf of Energy Institute, Petroleum Enforcement Liaison Group and Association for Petroleum and Explosives Administration

9th April 2025
HSE on behalf of DWP Regulator / Inspectorate
15 Jul 2025 PDF
Action Taken

HSE notes that Tesco and the Energy Institute on behalf of PELG have carried out detailed reviews of their systems and guidance which they believe now address the issues raised by this incident. (AI summary)

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Dear Mr Golombeck Inquest into the death of Afolabi Oluwafemi OJERINDE (Deceased) – Regulation 28 report Health and Safety at Work etc. Act 1974 Your letter of 25th April 2025 to the Secretary of State for Work and Pensions enclosing your Regulation 28 report (dated 3rd February 2025) has been passed to me for reply. I work in the Health and Safety Executive’s (HSE) Engagement and Policy Division which has the policy lead in relation to these regulations and the interface with Petroleum Enforcement Authorities (PEAs) via the Petroleum Enforcement Liaison Group (PELG). I note your report was sent to a number of bodies with an interest in this issue. This response will address matters that are within HSE’s areas of responsibility as the policy lead for the Regulations, and highlight where matters are more appropriately addressed by other organisations. My comments are based on my discussions with stakeholders and sight of relevant documents, together with my experience as a health and safety professional. I would make the following observations – Legal framework  The specific legislation governing the operation of petrol stations in Great Britain is the Petroleum Consolidation Regulations 2014. The key point to note here is that whilst HSE has the policy ownership for PCR, HSE is not the enforcing authority and PCR identifies PEAs in the Regulations which is consolidate in our enforcing authority guidance: Appendix 1: Health and Safety (Enforcing Authority) Regulations 1998: A-Z guide to allocation.

2  Other relevant legislation includes the Dangerous Substances and Explosive Atmospheres Regulations 2002 (DSEAR) which the PEAs enforce, the Health and Safety at Work etc. Act 1974 and the Management of Health and Safety at Work Regulations 1999 which local authorities enforce.  Suicides in the workplace are not reportable under RIDDOR (the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013). The regulations only require the duty holder / person in control of a workplace to report a death from a workplace accident (See Suicide prevention - HSE.)  Health and safety law is goal setting rather than prescriptive i.e. it sets out the standards that are to be achieved, not how this is to be done. Regulations may be supported by Approved Codes of Practice (ACOP) and / or sector or industry specific guidance. A common requirement is for duty holders to assess the risks created by their undertaking. In the case of PCR, the detailed industry guidance is contained in - o ‘Petrol filling stations - guidance on managing the risks of fire and explosion’ (the Red Guide), published by the Energy Institute. Sections 5, 6.4 and 7.3 address risk assessment and section 8 includes guidance on unattended self-service and unmanned sites; and o ‘Design, Construction, Modification, Maintenance and Decommissioning of Filling Stations’ (the Blue Book produced by the Association for Petroleum and Explosives Administration - APEA) Matters of concern You raise concerns about the safety of unmanned petrol stations and whether they ensure compliance with Regulation 12 of the Petroleum (Consolidation) Regulations 2014. i.e. those dispensing petrol are over the age of 16, and that petrol is dispensed only into a motor vehicle, motor boat or a suitable portable container. Whilst this is undoubtedly a tragic incident, a person taking their life in this way is a rare event. It is also very difficult to control against – provided a person is over 16 and dispenses petrol into an approved container, there is nothing to stop them buying the petrol and then subsequently using it to set themselves on fire in the same way as Mr Ojerinde. The policy intent of the Petroleum Consolidations Regulations is to ensure that both manned and unmanned petrol stations are equally safe for use by members of the public. Operators must assess the risks and put in place suitable and sufficient measures to ensure risks are adequately controlled and there is significant guidance, as detailed above, to assist the operators in this respect. As stated above, there is no obligation to consider suicide risks in their assessment or control measures. However, as with all risk assessments, these must be reviewed periodically, particularly after an incident to make sure they reflect the physical workplace and current systems and working practices. Where deficiencies are identified they should be rectified or mitigated as appropriate. I understand that Tesco and the Energy Institute on behalf of PELG have carried out detailed reviews of the their systems and guidance which they believe now address the

3 issues raised by this incident. Greater Manchester Fire & Rescue Service can advise further on the specific changes made.

Report sections

Investigation and inquest
On 05 September 2023 I commenced an investigation into the death of Afolabi Oluwafemi OJERINDE aged 48. The investigation concluded at the end of the inquest on 29 January 2025. The conclusion of the inquest was that: The deceased, who suffered from a psychotic illness, attended an petrol station on 4th September 2023 where he was able to pay for and dispense petrol into a plastic water bottle. He then ignited the petrol and placed himself in the fire. The deceased died on 5th September 2023 at Wythenshawe Hospital from the effect of injuries sustained during the incident on 4th September 2023.
Circumstances of the death
The Deceased attended an petrol station. After paying at the pump with a credit/debit card, was able to dispense petrol into a plastic bottle (not a suitable portable container) . It was confirmed in evidence that the petrol station is not continuously watched, and that for a person attending without a vehicle, an alarm would only be raised after minutes. Such control measures did not, therefore, have any bearing on the Deceased being able to dispense petrol in contravention of Regulation 12 of the Petroleum (Consolidation) Regulations 2014. The Deceased proceeded to ignite the petrol and place himself in the fire. He subsequently died of his injuries.

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Report details

Reference
2025-0060
Date of report
3 February 2025
Coroner
Zak Golombeck
Coroner area
Manchester City

Responses identified

Responses identified 2 of 4
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 31 Mar 2025 (estimated).

Sent to

Association for Petroleum and Explosives Administration
Department for Work and Pensions
Energy Institute
Petroleum Enforcement Liaison Group

Part of a series

2 reports
2024-0338 All responses identified

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