Source · Prevention of Future Deaths

David Lyth

Ref: 2023-0233 Date: 7 Jul 2023 Coroner: Charlotte Keighley Area: Cheshire Responses identified: 2 / 1 View PDF

Repeated "rollaway" incidents with vehicles indicate a serious ongoing safety risk, suggesting that regular and periodic training for drivers on coupling and uncoupling procedures is inadequate.

Date 7 Jul 2023
56-day deadline 1 Sep 2023 est.
Responses identified 2 of 1
Accident at Work and Health and Safety related deaths

Coroner's concerns

AI summary
Repeated "rollaway" incidents with vehicles indicate a serious ongoing safety risk, suggesting that regular and periodic training for drivers on coupling and uncoupling procedures is inadequate.
View full coroner's concerns
(1) I received evidence that since 2020, there have been four rollaway incidents involving drivers working for 3D Trans Ltd:­
a. An incident causing damage to a fence between the 17th September 2020 and the 9th October 2020;
b. An incident leading to the death of Mr Lyth on the 30th November 2021;
c. An incident on the 15th November 2022;
d. An incident on the 12th June 2023. I acknowledge that these incidents involve different circumstances and that only one resulted in a fatality.

(2) I received evidence that following each of the incidents, refresher training was provided and various measures were put in place at the yard to physically prevent the vehicles or trailers rolling away. In addition to this, signage has been placed on the tractor and trailer units to serve as a reminder to drivers of the importance of securing the parking brakes on the tractor and trailer units. I have concerns regarding the provision of regular and periodic training for all drivers in respect of coupling and uncoupling procedures.

Responses

2 respondents
Health and Safety Executive Regulator / Inspectorate
22 Sep 2023 PDF
Action Taken

HSE states that they will engage with key stakeholders to remind them of the need to manage risk when coupling and uncoupling articulated vehicles. HSE has conducted a further inspection of 3D Trans Ltd and is satisfied with the measures the company has put in place regarding training, monitoring, and supervision. (AI summary)

View full response
Dear HM Coroner Keighley

PrevenƟon of Future Deaths Report - AŌer Inquest LYTH D A 30112021

Thank you for your letter and Regulation 28 report to prevent future deaths issued following the inquest into the death of David Lyth. You asked the Health and Safety Executive (HSE) to consider your concerns regarding the provision of regular and periodic training for all drivers in respect of coupling and uncoupling procedures. It may be helpful to provide some background: the general duty under the Health and Safety at Work etc. Act 1974 is to ensure employees health, safety and welfare at work. This legislation is not prescriptive but is goal setting. It is for the employer to consider the risks specific to their business and then take appropriate steps to control those risks. To assist employers with that process, HSE produces extensive free guidance on managing risk, some of which is industry specific. For example, HSE worked closely with the haulage industry and other regulators to investigate the reasons for unintended vehicle movement and subsequently produced specific guidance in 2013, please see safe-coupling-guide.pdf. This guidance provides practical advice for employers to help them manage the risks of coupling and uncoupling articulated vehicles. HSE produced further guidance on transport safety in 2014; this guidance is aimed at all industries and also provides practical measures for coupling and uncoupling, please see Workplace transport safety - A guide to workplace transport safety (hse.gov.uk)

2

As part of their consideration of risk in the business, employers should identify suitable risk controls and provide appropriate training and information to their employees to enable them to carry out their jobs safely, as well as an appropriate level of supervision/review to ensure that processes are followed consistently and that any issues are quickly identified and resolved. It is, for this reason, the employer’s responsibility to decide on the intervals for any refresher training. Whatever system the employer chooses to implement to manage risk, they should review it regularly to make sure it is up to date and still relevant. HSE continues to work closely with the industry in this area and we will engage with key stakeholders to remind them of the need to manage risk when coupling and uncoupling articulated vehicles. In relation to 3D Trans Ltd, HSE has conducted a further Inspection of the company since the inquest, and we are satisfied with the measures the company have put in place regarding training and monitoring and supervision for their drivers in respect of safe coupling and uncoupling procedures.
3D Trans Other
PDF
Action Taken

3D Trans has strengthened its training program to ensure that all drivers receive quarterly refresher training against the company's coupling and uncoupling procedure. This includes reviewing written procedures, watching a video, and completing a test. (AI summary)

View full response
Dear Coroner Re Regulation 18 Rojort t Prevent Graths We write wrlth rEference [0 your Rcgulation 28 report which was issued t? JD Trans Limited Lm connectlon with the rleath of Mr David Lyth *n J0 November 7071 We can conflrm that the company has now strengthened its training progrumme Lo ensure that Jll drvers rereive qujiLerly refresher trining Jpaingl the compuny'$ coupling ard uncouling ntaceclg T0 include FEVIEwIrg the writteri procerlures, watching & videj ard campleLing & Lest ta cnnfin Lhelf Wniderstanding These tecords will be teLbined by the company far 3 Mirimum ol [WQ Years We Wust that this amerdticnt I5 sufficient [D satisfy the (Epont Issued buL please do not hesitate tQ contact Us should VnU require any additional Information Kindest Regutds Director Mirector J0 Truns Lurrilted; Thomipson Aullulng; Shell Green Ind. Estote; Wdne} WYAB 0IZ Comkony R4n; 9231135 VAT: 231-041-IZ8 www ddtran Iimleiseuk

Report sections

Investigation and inquest
On 10 December 2021 I commenced an investigation into the death of David Alan LYTH aged 45. The investigation concluded at the end of the inquest on 27 June 2023. The conclusion of the inquest was that: On 30 November 2021 at 3D Trans Shell Green Industrial Estate, Widnes, David Alan Lyth became trapped between two trailers resulting in asphyxia. From the evidence presented the rollaway could only have occurred from neither the unit and the trailer brake not being applied.
Circumstances of the death
On the 30th November 2021 David Lyth had been working for 3D Trans Limited through a driving agency. That day he had complained of an issue with the air cables on his trailer and had been advised to collect a new trailer from the 3D Trans Limited yard. As he coupled up to a new trailer, the trailer started to roll back and he put his arms out to stop it and became trapped between two HGV trailers. When he was found, he was unresponsive and was taken to Whiston Hospital where his death was confirmed.
Copies sent to
3D Trans

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Report details

Reference
2023-0233
Date of report
7 July 2023
Coroner
Charlotte Keighley
Coroner area
Cheshire

Responses identified

Responses identified 2 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 Sep 2023 (estimated).

Sent to

3D Trans, Health and Safety Executive

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