Source · Prevention of Future Deaths

Alan Dimbleby

Ref: 2016-0120 Date: 23 Mar 2016 Coroner: Richard Travers Area: Surrey Responses identified: 2 / 3 View PDF

Self-propelled sprayers lack operator seat restraints, risking operators being thrown from the vehicle if it overturns. HSE guidance may inappropriately suggest these restraints are not needed for this vehicle type.

Date 23 Mar 2016
56-day deadline 18 May 2016 est.
Responses identified 2 of 3
Accident at Work and Health and Safety related deaths

Coroner's concerns

AI summary
Self-propelled sprayers lack operator seat restraints, risking operators being thrown from the vehicle if it overturns. HSE guidance may inappropriately suggest these restraints are not needed for this vehicle type.
View full coroner's concerns
During  the  course  of  the  inquest  the  evidence  revealed  matters  that  gave   rise  to  concerns  that  circumstances  creating  a  risk  of  other  deaths  will   continue  to  exist  in  the  future  unless  action  is  taken.  

Operator  Seat  Restraint    
1. Consideration  should  be  given  to  fitting  operator  seat  restraints   to  self-­‐‑propelled  sprayers.  The  cabin  of  the  vehicle  was  such   that  it  would  have  provided  adequate  protection  to  Mr   Dimbleby  had  he  not  been  thrown  out  of  the  vehicle.  However,   without  appropriate  operator  seat  restraints  there  is  a  serious   risk  that  the  operator  will  be  thrown  from  the  vehicle  should  it   overturn  and,  as  such,  a  safe  cabin  does  not  provide  adequate   protection.  
2. Consideration  should  be  given  to  removing  self-­‐‑propelled   sprayers  from  the  class  of  vehicles  in  respect  of  which  the  HSE   guidance  suggests  that  operator  seat  restraints  may  not  be   needed  or  are  inappropriate  [Agriculture  Information  Sheet  37   (revision1)].

Responses

2 respondents
Bateman Engineering Ltd
25 Apr 2016 PDF
Action Taken

Bateman Engineering has changed the design of their cabs to include seat restraints, and now fits them on all vehicles before they leave the workshop. (AI summary)

View full response
Dear Sir , write in response to the prevention of future deaths report issued following the Inquest into the death of Alan Dimbleby. As understand your report, it requests that consideration should be given to fitting operator seat restraints to self-propelled sprayers. As set out in my statement provided for the Inquest, there is no requirement for sprayers to have seat restraints. We have always focussed on making the cab enclosure as safe and secure as possible so that the driver is protected irrespective of whether are wearing a seat restraint_ In the report you acknowledge that the cabin of the sprayer was still intact and generally undamaged following the accident_ However , since became aware of the circumstances of Mr Dimbleby's accident, have changed the design of the cabs to include seat restraints and no vehicle leaves our workshop without oe being fitted_ that you find the action taken to be adequate and am happy to discuss matters further with you if you think that would be helpful:
Alan DIMBLEBY
29 Jun 2016 PDF
Action Planned

HSE will raise the issue of seat restraints on self-propelled sprayers at the next appropriate meeting for consideration in future revisions of applicable standards and will consider revising guidance to better inform the choice of vehicle when working on slopes. (AI summary)

View full response
Dear Mr Travers Re: Mr Alan Dimbleby (deceased) Regulation 28 Report to Prevent Future Deaths Thank you for your letter of the 23 March regarding Alan Dimbleby's tragic death on 23
2015. You asked me to consider two issues: (a) whether; operator seat restraints should be fitted to self-propelled sprayers; and (b) whether HSE guidance Agricultural Information Sheet 37 requires revision to remove self-propelled sprayers from the class of vehicles where operator seat restraints may not be needed or may not be appropriate: On the first issue, the use of seat restraints has to be considered in conjunction with the design of the machine_ If seat restraint is to be effective in an overturn situation it must be in conjunction with a roll over protective structure (ROPS): A_ ROPS is protective structure intended to provide the operator with protective zone to reduce the risk of injury: Vehicles fitted with ROPS are fitted with seat restraints so that the operator remains within the protective zone. In 2009 the relevant standard was revised and required seat belt anchorage points if the sprayer was fitted with ROPS. However the standard, which was most recently revised in 2013, allows the manufacturer to choose how to reduce the risk Of an overturn, or to mitigate the likelihood of injury in an overturn and ROPS is only one of the options July

available Not all sprayers manufactured now, or in the past, will have ROPS cab. Where non-ROPS cab is present which is particularly likely on older machines, the fitting and wearing of seat restraints is not recommended as it can increase the risk of injury in the event of a roll over, non-ROPS cab is not designed to, nor will it have been tested to demonstrate that it can withstand the forces to which it is exposed during a roll over. Consequently, in an overturn the structure is likely to deform, and penetrate the zone occupied by the restrained driver resulting in a risk of serious personal injury: Additionally, on older machines regardless of whether or not have ROPs fitted, there may not be any suitable anchorage points for seat restraints and fitting them may be unfeasible_ The to preventing an overturn on sloping ground is for employers to assess the work, including travel to and from the site in question, to select the right equipment for the conditions, to ensure the work is planned so that it can be carried out safely and to ensure that the operator is trained and competent for the task Where a risk of overturning has been identified as significant, one of the means by which this can be reduced is to specify a machine fitted with ROPS and operator restraint_ HSE's guidance about overturning vehicles' gives range of practical considerations that the employer needs to consider when planning the work. Overall we cannot advocate policy that all self-propelled sprayers be fitted with seat restraints HSE works with the relevant British Standards (BSI) and European Standards (CEN) committees on agricultural machinery safety, and we will raise this issue at the next appropriate meeting for the consideration in future revisions of applicable standards_ On your second point; concerning HSE guidance on the use of seat restraints? similar constraints apply to how far this can be changed. Our guidance has to apply to the full range of self-propelled work equipment (including those fitted with ROPS and those not fitted with ROPS). It gives advice on the steps that should be taken to comply with health and safety legislation: The guidance is not intended to be comprehensive, and does not cover every possible configuration of self-propelled work equipment: specifically we cannot recommend the use of seat restraints for a vehicle that is not also fitted with ROPS for the reasons given above_ We do nonetheless keep all of our guidance under review and at the next opportunity we will consider whether the wording can be revised to better inform the choice of vehicle when working on slopes_ In your report (Section 6) you state that HSE is in a position to draw these concerns to the appropriate authority in Portugal who has the power to take action: We do not understand the reference to Portugal which does not appear to have any relevance to this incident: Therefore, we do not intend to take this action. http Ilww.hse gov uklagricultureltopics/machinerylfarm-vehicles-2.htm 2 AIS 37 Operator seat restraints for tractors and mobile work equipment in agriculture and forestry they key the Very

Report sections

Investigation and inquest
The  inquest  into  the  death  of  Mr  Dimbleby  was  opened  on  the  4th  August   2015  and  was  resumed  on  the  22nd  March  2016  with  a  jury  and  concluded   the  following  day,  23rd  March  2016.  

The  jury  found  the  cause  of  death  to  have  been:  

1a.  Hypoxic  Brain  Injury   1b.  Cardiac  Arrest   1c.Traumatic  Fracture  of  Cervical  Veterbrae  

They  concluded  with  a  short  form  conclusion  of  ‘Accidental  Death’.
Circumstances of the death
On  the  23rd  July  2015,  Mr  Dimbleby,  a  very  experienced  crop  sprayer,  was   spraying  areas  of  cover  at  Warren  Barn  Farm,  Woldingham,  Surrey.  He   was  driving  his  usual  vehicle  a  Bateman  RB35  self-­‐‑propelled  sprayer  with   which  he  was  very  familiar.  The  land  was  undulating  and  in  parts  very   steep.  As  Mr  Dimbleby  was  making  his  way  from  the  second  area  of   cover  to  the  third  area,  the  sprayer  became  unstable  and  rolled  down  the   incline.  Mr  Dimbleby  was  thrown  from  the  cabin  and  died  as  a  result  of   Rtdoc/02512-2015/Reg28/23-3-2016 injuries  that  were  sustained  when  he  was  struck  by  the  rolling  vehicle.   The  cabin  of  the  vehicle  was  still  intact  and  generally  undamaged,  but   there  was  no  form  of  operator  seat  restraint.  The  jury  found  that  the   gradient  of  the  slope  on  which  he  was  working  together  with  the  absence   of  a  seatbelt  made  a  material  contribution  to  his  death.
Copies sent to
I  have  sent  a  copy  of  this  report  to  the  following1. Dr  Richard  Judge,  Chief  Executive  HSE2.  Bateman  Engineering  Ltd4. DAC  Beachcroft  Claims  Ltd  (5. The  Chief  CoronerSignedRichard TraversDATED  this  23rd  March  2016

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Report details

Reference
2016-0120
Date of report
23 March 2016
Coroner
Richard Travers
Coroner area
Surrey

Responses identified

Responses identified 2 of 3
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 18 May 2016 (estimated).

Sent to

Bateman Engineering Ltd
Health and Safety Executive
the appropriate authority in Portugal

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