Andrew Lownes

Evidence taken during the inquest gave rise to a concern, in my opinion, that future deaths will occur unless action is taken. In such circumstances it is my statutory duty to report the matter to you as an organisation which may have the power to take action: The consignment of GCWUs which arrived on site from a factory in Switzerland was not accompanied by written unloading instructions, despite: Containing two GCWUs each weighing around 600kg The narrow nature of GCWUs which meant were likely to fall if not adequately secured to the transport stillage at all times_ The relatively complex nature of the banding arrangements which secured the GCWUs to the transport stillage, involving some bands which were around the individual GCWU alone, others which lashed a particular GCWU to the stillage and others which sought to bind the entire consignment; Some of the bands lay positioned on top of other bands which served a different purpose: The entire load was shrink wrapped which added to the difficulty of identifying the function and route of a particular band around the load they

In consequence, it was not obvious to those unloading the consignment which band served which purpose. This gave rise to a risk that in the course of unloading a band might be cut inadvertently resulting in the fall of a heavy GCWU. Workers in the vicinity could be in a position of jeopardy, as was the case here. Evidence was taken from an expert witness who had considerable experience in construction site management; He said when he examined an identical consignment after the tragedy it took him over an hour to work out the function of the multiple bands placed on the consignment: Although not relevant to the Inquest into Mr Lownes' death; it is pertinent in my judgment; to refer to another Inquest which conducted in Leeds in 2009 involving the death of Alan Fletcher, a man aged 59 who sustained fatal crush injuries whilst unloading a container of GCWUs in Leeds Although that incident involved shipped in a container from the UAE rather than on a stillage, there are common features between the two cases: The absence of unloading instructions Tall, heavy; narrow based items which have the potential to cause harm if not secured at all times_