Source · Prevention of Future Deaths

Karl Mitchell

Ref: 2023-0168 Date: 22 May 2023 Coroner: Peter Harrowing Area: Avon Responses identified: 1 / 3 View PDF

Many older lorry-mounted cranes with dangerous stabiliser designs remain in use, posing a crush injury risk as safety modifications are not universally applied. There is an urgent need to disseminate safety learning and modification awareness throughout the industry.

Date 22 May 2023

56-day deadline 10 Jul 2023

Responses identified 1 of 3

Accident at Work and Health and Safety related deaths Other related deaths

Coroner's concerns

AI summary

View full coroner's concerns

(I) There are a large number of these lorry mounted cranes with such stabiliser beams and rotating legs in use by companies of all sizes and for a variety of uses within the industry.

(2) Whilst manufacturers have taken steps to modify the design of the stabiliser beams and rotating legs so as to ensure the risk of such crush injuries can be avoided in the future such modifications will only apply to new vehicles and those where the owner I operator of the vehicle becomes aware of possibility of modifications being available.

(3) Vehicles without being modified will continue to be used throughout the industry and thereby such vehicles will continue to pose a risk of crush injuries occurring to the operator.

(4) Action needs to be taken to disseminate the learning from this tragic incident throughout the industry so that operators of such vehicles are aware that safety modifications may be available for their vehicle and in any event operators need to be made aware of the risk of crushing so as to ensure safe operation at all times.

Responses

1 respondent

Department for Transport Central Government

8 Aug 2023 PDF

Action Planned

The Office of the Traffic Commissioner will assist in providing the HSE's safety notice relating to swing-up stabilisers to lorry operators, once it is published. (AI summary)

View full response

Dear Dr Harrowing,

Thank you for your email of 23 May, enclosing your Regulation 28 Report dated 22 May to Prevent Future Deaths. This relates to the inquest into the death of Karl Mitchell on 25 September 2021, from injuries sustained when operating the lorry mounted stabiliser beam and swing up hydraulic stabilising legs.

I am sorry to hear of the tragic death of Karl Mitchell, for which I offer my sincere condolences to his family and friends.

The Department sets the requirements that vehicles must meet to ensure they can be driven safely on the roads. However, the Department does not set requirements for machinery which is primarily intended for use when the vehicle is stationary, other than to ensure it doesn’t interfere with the safe operation of the vehicle itself.

The Head of Traffic Commissioner Policy has been in contact with the Health and Safety Executive (HSE), who has informed them that the underlying harmonised standard has been reviewed and is being updated. HSE intends to publish a safety notice relating to swing-up stabilisers on their website. Once informed of HSE’s publication of the safety notice, the Office of the Traffic Commissioner will assist in providing this notice to lorry operators.

I trust that this action addresses the concern that you have raised and will go some way towards preventing such deaths in future.

From the Secretary of State The Rt Hon Mark Harper MP

Great Minster House 33 Horseferry Road London SW1P 4DR

Report sections

Investigation and inquest

On 29th September 2021 I commenced an investigation into the death of Mr. Karl Mitchell age 50 years. The investigation concluded at the end of the inquest on 23rd March 2023. The conclusion was that the medical cause of death was l(a) Cerebral oedema; 1 (b) Hypoxic brain injury; 1 (c) Traumatic crush injury to chest, and the conclusion of the jury as to the death was 'Accident'

Circumstances of the death

The Deceased was a lorry driver with Titan Containers Limited a company who provided shipping type containers to various sites which were then used for storage and as temporary site facilities. The containers were loaded and off loaded using a lorry mounted crane. The lorry used by the Deceased was fitted with a hydraulic stabiliser beam and swing-up (rotating) hydraulic stabilising leg at each corner. These were deployed during the loading and off loading procedure so as to stabilise the vehicle whilst the crane was in use. On 23rd September 2021 the Deceased was delivering a container to a local primary school for the purposes of temporary storage during building works. The Deceased successfully off loaded the container and was in the process of retracting the nearside front stabiliser beam when he was crushed by the swing up (rotating) leg causing him to suffer a cardiac arrest. The fire and rescue services attended and he was released using the 'jaws of life'. He was attended by paramedics and conveyed to hospital where he died on 25th September 2021 as a result of his injuries. On this particular vehicle the control panel for the stabiliser beams and legs was mounted on the front nearside of the vehicle adjacent to the lorry mounted crane. In order to stow, in this case, the nearside stabiliser beam for road use it is necessary to rotate the swing up leg through 180° from the downward position to the vertical position. This enables the beam and leg to be stowed behind the cab of the vehicle when it is being driven on the road. Whilst carrying out this procedure the operator, in this case the Deceased, stands at the control panel with their back to retracting beam and leg. The swing up leg on the nearside when rotating upwards rotates in anticlockwise direction. Therefore the leg rotates directly behind the operator standing at the control panel. Whilst carrying out this procedure the Deceased was unaware that the swing up leg had not rotated fully to the upright position but was at an angle of approximately 80° from the downwards position. Therefore as the beam continued to be retracted the swing up leg crushed the Deceased against the control panel. Whilst further retraction of the beam could be stopped the hydraulic pressure remained trapping the Deceased and causing crush injuries.

Action should be taken

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th July 2023. I, the coroner, may extend the period. Your 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. COPIES and PUBLICATION

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Report details

Reference: 2023-0168
Date of report: 22 May 2023
Coroner: Peter Harrowing
Coroner area: Avon

Responses identified

Responses identified 1 of 3

2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Jul 2023.

Sent to

Department for Transport

Health and Safety Executive

Titan Containers Limited

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.