Source · Prevention of Future Deaths

Ashley Holden

Ref: 2020-0096 Date: 17 Apr 2020 Coroner: Paul Smith Area: Lincolnshire 2 responses identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner noted inconsistent and incomplete guidance documents regarding the safe stacking, unstacking, and loading of bales in agriculture. This lack of definitive instruction creates a risk of unsafe practices leading to future fatalities.

Date 17 Apr 2020
56-day deadline 13 Jul 2020 est. estimated from the Judiciary.uk publication date
Responses identified 2 of 2
Accident at Work and Health and Safety related deaths Other related deaths

Coroner's concerns

AI summary
The coroner noted inconsistent and incomplete guidance documents regarding the safe stacking, unstacking, and loading of bales in agriculture. This lack of definitive instruction creates a risk of unsafe practices leading to future fatalities.
View full coroner's concerns
_ received evidence that; Fatalities from falling bales are an acknowledged risk within agriculture with a number of fatalities annually
2. There are two specific guidance documents available to the public which are relevant to this issue; Department of Transport Code of Practice, "Safety Loads on Vehicles" (2002) Health and Safety Executive (HSE), "Safe Working With Bales in Agriculture' (2012) The two pieces of guidance are not consistent in the approaches that suggest and indeed the later guidance does not reference the earlier guidance. There is no definitive guidance provided to the industry in relation to the stacking or unstacking of bales, Or in relation to the loading and strapping of loaded trailers in a manner which takes account of the different sizes and composition of bales, andlor different trailer sizes and configurations The absence of specific guidance on this issue creates a risk of the development of unapproved and potentially unsafe individual practices, with the consequential risk of future deaths The provision of definitive guidance would be welcomed by those working within agriculture. ACTION SHOULD BE TAKEN In my opinion action should be taken t0 prevent future deaths and believe you ANDIOR your organisation has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report, namely by 10 July 2020. !, the Area 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:

Responses

2 respondents

Health Safety England

Letter dated 3 Jul 2020 PDF
AI-classified response stance Noted
AI-generated response summary

• The Health and Safety Executive (HSE) stated it works closely with the Driver & Vehicle Standards Agency (DVSA) and police forces to provide guidance and training on vehicle loading and load securing. • HSE confirmed it monitors and adapts its guidance, including INDG125, in light of incidents and modern farming practices. • HSE indicated it would take the coroner's comments into account at the next review of INDG125 and consider whether improvements could be made.

View full response
Dear Mr Smith Inquest into the death of Ashley Mark Holden - Regul~tion 28 report. Thank you for your letter dated 20 April 2020 to Inspector ......and the associated Regulation 28 report dated 17 April 2020. I lead a team th~ operational policy in relation to the agriculture sector and this includes safe use and stacking of bales in farm work. Vehicle loading 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. As such, HSE works closely with DVSA, the police, Highways England, and the Office of the Traffic Commissioner to ensure that guidance is available to vehicle operators and drivers to help them comply with their duties on the road and in the workplace (e.g. farm or factory). I understand you have sent a similar letter and report to the Department for Transport (DfT). HSE recognise that unstable loads present a serious risk of harm during loading and unloading. In 2013 we worked with DVSA to introduce a new enforcement approach for vehicle loading, and produce updated on-road guidance on load securing for vehicle operators, which was published in 2015. We continue to work closely with DVSA and police forces, providing training on vehicle loading for frontline personnel alongside specialist technical support. We also provide loading and load securing advice through wider forums to the agricultural sector. The risk of fatal and serious injury when working with bales in agriculture is well known and guidance has been in place in various forms for decades. Recently, between 2014 and 2019, 6 people were killed by falling bales. We continue to monitor and adapt our guidance in light of

incidents and modern farming practices. For example, INDG125(rev3) was revised in 2012 to provide updated guidance to the industry on safe working practices, including the safe loading and unloading of bales. The DfT guidance Code of Practice: Safety of loads on vehicles is already referenced in INDG125 under the 'Find out More' section of the leaflet on page 10. We are grateful for your comments and we will take then into account at the next review. The overarching legal framework in place for workplace safety includes the Health and Safety at Work etc. Act 1974 and this applies to work with bales. The Act, and Regulations made under the Act, require employers to assess the risk from work operations, including loading activities, and provide control measures to reduce these risks, so far as is reasonably practicable. Of relevance to loading are the Lifting Operations and Lifting Equipment Regulations 1998 (LOLER) which set out what duty holders involved in any lifting operation must do to comply with the law. Every lifting operation is different, but the heart of LOLER requires all lifting work to be properly planned and organised. When handling and loading bales, control measures would normally include the following:
• Planning the configuration of the load and the loading operation. The configuration of the load will vary depending on a number of factors including but not limited to the type of vehicle, the type of bale and the nu.mber of bales.
• Using a competent person who is able to stack bales safely. The competent person should understand the risks when loading bales, including that bales shift when they get compressed and settle.
• Using suitable lifting machinery to load bales. The machinery should be operated by a trained and competent person.
• Keeping pedestrians and all other people out of the way during loading.
• Not overloading the trailer.
• Not stacking bales beyond the edge of the trailer.
• Only allowing securing of the load to take place after the load has been assessed by a competent person as being stable. The guidance contained in INDG125 is intentionally broad and sets out the principles of safe loading that meet the Act and LOLER. It has never been our intention to cover every possible configuration but the combination of suitable and sufficient assessment, planning and use of competent people allows for loads of many types to be loaded and transported safely within a robust legal framework. The duty rests on employers and those in control of the loading operations to identify risks associated with the loading operation, implement effective controls to ensure the safety of persons who may be affected, and keep these controls under review. We keep guidance, including INDG125, under periodic re-evaluation. When INDG125 is next reviewed we will consider whether improvements can be made.

Department for Transport

Central Government
Letter dated 7 Jul 2020 PDF
AI-classified response stance Action Planned
AI-generated response summary

• The Driver and Vehicle Standards Agency (DVSA) will update the 'Load Securing - Vehicle Operators Guidance' with assistance from the Health & Safety Executive (HSE). • The Department for Transport (DfT) Code of Practice, 'Safety Loads on Vehicles' (2002), will be amended to ensure effective cross-referencing. • DfT will work with other organisations, including DVSA and HSE, to promote safe working practices during loading and unloading operations.

View full response
Dear Mr Smith, I am writing in response to the 'Regulation 28' report issued on 17 April 2020. I am replying as the Minister responsible for this issue. On behalf of the Department for Transport (DfT), I would like to take this opportunity to acknowledge the concerns you have raised regarding the tragic incident which resulted in the death of Mr Ashley Mark Holden on 10 November 2018. In preparing this response my officials have consulted with the following:
• Driver and Vehicle Standards Agency (DVSA)
• Health & Safety Executive (HSE) Your report outlined a number of concerns relating to guidance for the safe loading and unloading of bales and the consistency of existing HSE and DfT guidance, which you considered to be insufficiently detailed to avoid the occurrence of unapproved and potentially unsafe working practices. I understand you have sent a similar letter and report to HSE. The report you have written offers clear scope for my department to take a lead in reviewing previous DVSA guidance, whilst working with HSE to reach a consistent approach to future guidelines. There are two relevant and specific guidance documents available to the public, which you have reviewed and noted as being inconsistent in their approach. You have also highlighted that the most recently published guidance does not currently make proper reference to the earlier guidance.

We propose:
• That DVSA updates the 'Load Securing - Vehicle Operators Guidance' which was last reviewed with HSE in 2015. HSE has agreed in principle to assist DVSA in updating this guidance which was already proposed at the start of this year. Having considered the approaches that could be taken, we have identified that a generic approach to safe loading principles, rather than very specific information covering each size of bale and trailer, is considered to be most practical. A comprehensive table seeking to cover every permutation of trailer and bale would be overly complex and may confuse. However, the updated guidance will look at the key principles for the safe loading and transport of bales.
• To amend the DfT Code of Practice, 'Safety Loads on Vehicles' (2002) to ensure both are cross referenced effectively. Whilst HSE leaflet INDG125 already references the DfT guidance on page 10 titled Find out mor~ ­

. consider whether improvements can be made to INDG125 when it is next under periodic re-evaluation.
• DfT will work with other organisations including, where appropriate, the DVSA and HSE to promote safe working practices during loading and unloading operations. We note that HSE does and will continue to engage with the agricultural industry to promote safe practice over a variety of topics, including safe working with bales. I hope you find these proposals helpful and are assured that the Department and its agencies are taking appropriate action to respond to your concerns. BARONESS VERE OF NORBITON

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Report details

Reference
2020-0096
Date of report
17 April 2020
Coroner
Paul Smith
Coroner area
Lincolnshire

Responses identified

Responses identified 2 of 2
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 13 Jul 2020 (estimated from the Judiciary.uk publication date).

Sent to

Department for Transport
Health and Safety Executive

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