Source · Prevention of Future Deaths

Tony Williams

Ref: 2024-0385 Date: 18 Jul 2024 Coroner: Jacqueline Devonish Area: Cheshire Responses identified: 1 / 1 View PDF

There were no clear images in the guidance or support materials produced by HSE to assist drivers who load and unload bales, and the accident would not have occurred if Mr Williams had not unloaded with the overhang facing downhill.

Date 18 Jul 2024
56-day deadline 12 Sep 2024 est.
Responses identified 1 of 1
Accident at Work and Health and Safety related deaths

Coroner's concerns

AI summary
There were no clear images in the guidance or support materials produced by HSE to assist drivers who load and unload bales, and the accident would not have occurred if Mr Williams had not unloaded with the overhang facing downhill.
View full coroner's concerns
The configurations for safely loading bales widthways, on a slope of 4.5 degrees and utilising crisscross strapping were considered in evidence. HSE produced laser measurements and images identifying the centre of gravity and risks associated with unloading overhanging bales on a slope when the most rearward bales are loaded widthways. HSE concluded that the accident would not have occurred if Mr Williams had not unloaded with the overhang facing downhill. It became apparent that there were no clear images in the guidance or support materials produced by HSE to assist drivers who load and unload bales.

Responses

1 respondent
Health and Safety Executive Regulator / Inspectorate
6 Sep 2024 PDF
Noted

The HSE states that current guidance on safe stacking, loading, and unloading of bales is sufficient and does not require further images or supporting material, but they will keep the report on record for consideration when it is next reviewed. (AI summary)

View full response
Dear HM Senior Coroner Devonish PREVENTION OF FUTURE DEATHS REPORT – TONY WILLIAMS Thank you for your email and attached Regulation 28 “Report to prevent future deaths” dated 18/07/2024. The report outlines matters of concern arising from the inquest into the death of Mr Tony Williams. Mr Williams was killed while unloading bales from a trailer at in Cheshire on 2nd December
2020. I am the Health and Safety Executive’s (HSE) Head of Operations covering the area of Great Britain (GB) in which the incident occurred. In providing this response I have consulted with the team that sets HSE operational policy in relation to safe work with bales, and the team responsible for HSE operational policy in relation to transport.

You raise the following MATTERS OF CONCERN in your report:

It became apparent that there were no clear images in the guidance or support materials produced by HSE to assist drivers who load and unload bales”.

Background HSE recognise that unstable loads present a serious risk of harm. Vehicle loading, unloading and load securing cross over two areas of legislation: road traffic, which is enforced by the Driver & Vehicle Standards Agency (DVSA) and police forces, and workplace safety which is enforced by HSE and local authorities. In this response, although I have made reference to some DVSA guidance, I will address the workplace safety aspect as other agencies are better placed to address any concerns regarding how material is transported by road.

Your concerns for HSE to address Health and safety legislation is goal setting in its nature, rather than prescriptive. The Health and Safety at Work etc. Act 1974 and Regulations made under it require employers to assess the risk from work operations, including working with bales, and provide control measures to reduce these risks, so far as is reasonably practicable.

2 To assist employers and provide a framework for compliance with the law, HSE produce guidance for industry to follow. In relation to working with bales in agriculture, HSE produced publication INDG125(rev
3) “Safe working with bales in agriculture” which is available free from our website at:

HSE publications, such as “Farmwise” and “What a good farm looks like” (both available free from the HSE website), INDG125 is HSE’s primary guidance document for the safe loading and stacking of bales. In addressing your concerns, this reply will focus predominantly on INDG125.

Bales and the trailers on which they are transported, may be of a range of shapes and sizes. INDG125 must therefore contain sufficient information to be useful to duty holders such that they can plan for safe operation of activities, but also be broad and flexible enough to reflect the variations. The guidance therefore sets out the principles that should be adopted rather than be prescriptive for specific situations.

In relation to the safe stacking of bales, the principles are set out on pages 2, 3 and 4 of the guidance supported by Figures 1, 2 and 3. In considering the concerns raised in your report we have concluded that there is sufficient information, by way of both images and supporting material, to allow duty holders to plan their stacking operations safely and that the current guidance is satisfactory.

In relation to the safe loading and unloading of bales, the principles are set out throughout the guidance document but specifically on pages 6 and 7. We acknowledge the absence of images in this section however, having considered the concerns raised in your report we have concluded that there is sufficient information that will allow duty holders to plan and carry out the loading and unloading of bales safely and that the current guidance is satisfactory.

Guidance on the safe loading and unloading of vehicles is also provided in HSE publication HSG136, A Guide to Workplace Transport. Although it does not specifically reference bales, the publication sets out employers’ responsibilities under health & safety legislation and provides guidance on key safety issues which also includes managing vehicle movements on sites, work at height, and coupling and uncoupling articulated vehicles. It too takes a broad and flexible approach due to the complexity and variety of the many different transport operations in GB and is available free from the HSE website at

Other enforcing authorities and industry associations HSE also works closely with other enforcing authorities and industry associations to support them in producing their own industry-specific detailed guidance.

This includes work undertaken with the DVSA and trade associations on the production of on-road guidance for drivers and operators. In recognising that loads come in a variety of shapes and sizes, as do the vehicles transporting them, the DVSA guidance is also generally not prescriptive but sets out the general principles of load securing and advice to help vehicle operators and drivers comply with the law.

The current version of this guidance can be found at https://www.gov.uk/government/publications/load- securing-vehicle-operator-guidance/load-securing-vehicle-operator-guidance. An updated version is due to be published in autumn 2024 which will contain advice that bales should be properly supported by the vehicle or trailer load bed.

Further queries or comments on the DVSA guidance are best directed to the DVSA.

In conclusion Having carefully considered the content of your report and your concern around a lack of information HSE provides we have concluded that the guidance currently available in relation to the safe stacking, loading and unloading of bales is sufficient and does not currently require further images or supporting material. HSE legislation is goal setting and not prescriptive. As such HSE guidance documents adopt a broad and flexible approach that will allow duty holders to plan and safely undertake work activities for a wide range of situations.

3

However we keep HSE guidance, including INDG125, under periodic review and we will keep your report on record for consideration when it is next reviewed.

Report sections

Investigation and inquest
On 10 December 2020 I commenced an investigation into the death of Tony WILLIAMS aged 45. The investigation concluded at the end of the inquest on 15 July 2024. The conclusion of the inquest was that the death was a Misadventure.
Circumstances of the death
On 2 December 2020, Tony Williams, an HGV driver for , was delivering bales of hay to in Cheshire. Thirty-three hay bales were loaded onto the 45ft HGV at in Suffolk by the farm director in the presence of Mr Williams, who was experienced in the strapping and loading of Hesston bales. Three bales were loaded width ways, the opposite direction to the rest of the bales, on the back end of the vehicle. On the journey from Suffolk, somewhere along the route an ANPR camera had caught an image of hay overhanging the back of the vehicle. When arriving at , with the assistance of a banksman, Mr Williams reversed down a public domain road with a known slope comparable to a wheelchair ramp. Mr Williams was witnessed by a Farmhand unstrapping the load when the three width ways bales fell from the back. Two of which fell on top of Mr Williams. The Farmhand who witnessed the unstrapping, removed the bales from Mr Williams with his telehandler and administered CPR with guidance from the ambulance service operator. When the ambulance arrived advanced life saving measures were administered to no avail. He was pronounced dead at the scene at 11:01 hours.

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Report details

Reference
2024-0385
Date of report
18 July 2024
Coroner
Jacqueline Devonish
Coroner area
Cheshire

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Sep 2024 (estimated).

Sent to

Health and Safety Executive

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