DWF
Action Taken
Lightwater Quarries Ltd has implemented a newly adopted Risk Assessment & Method Statement as the basis for training, Turning Circle awareness and management, changes in lifting from the crane, safety talks, newly employed services of external training providers and has created a Safety Committee in order to improve and raise standards of health and safety at work. (AI summary)
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Dear Mr Chapman; MR MARTIN MCGLASSON (DECEASED) INQUEST 17 TO 20 DECEMBER 2013 RESPONSE TO REGULATION 28 REPORT Weewrite in reference to your Regulation 28 Report dated 6 letter of response dated 3 March 2014. January 2014 and further to our To set the background, the Inquest the evidence was that the by the Company which had been in operation for 23 system of work adopted years without incident was that: baAfter removal from the mould by overhead crane the staircase battens (depending on the size of the staircase was set down on two or more 2 The operator would "sweep" and any landings it had); underneath, before the with the battens to ensure that had no debris the staircase down; 3 Heiwould also seek to place the batten under the widest stability; part of the stair to ensure maximum stathes operator would take the tension off the crane ad then staircase and attempt to move, or rock it, to check its take hold of the top of the unstable he would lift it and move the battens stability. If he was concerned that it was
5. Once satisfied or the staircase; as to stability he would remove the chains and leave the unsupported, to be slurried. staircase frkfter the slurrying process had been completed the staircase forks of a forklift truck and then removed to was "rocked over' onto the the storage yard. This system of work was an industry wide practice_ As a result of the Inquest your Report provided that which will prevent future we respond with actions we have taken received from the British deaths (our actions taken after advice and guidance Precast Federation "BPCF) ~in 'iWi F"llit|ue<:.4 4 " x7: 'me :ATtd " ""a '"p' " ,40k1 DWann#u:Nm MnikU; Vinl t4 m1um0E: F0ft; n| {4" | ""rURMIN50024/29882/ {Whce. Sott Htort Inuri 8trul. Muklkne M+A 19587666-dorseri mt regulaterd Ey Me Solititors ReguluoMAutunA Nwvr ! ['m441srh %- fnju m;uS Aulhorised regulaled' by Ihe: Fiaricinl Corill # Aullwcrity {nualerl pracIlce by Ihie Law Society cl Scollar! (Eujisteuex} TMyr ISO) 'NHJ1 P O(JK Cerlili ale No | RO A(Nar2# icn | = [ 6 41a1 Place Our during floor they setting help being being Pmc- and
dwf Your Report set out that we provide a written response by Monday 3 March 2014. wrote to You on 3 March 2014 to request respond to the Regulation 28 letter. This afo extension of time for the Company to formally Federation [BPCF] guidance which was to allow us time to evaluate British Precast additional and necessarya changescto therComvalable at that point in time and make process the Company's internal procedures any and manufacturing We understand the British Precast wrote to its instruction seriously and you On 28 February 2014 stating that it was action set out the actions it had already taken and timetable for The British Precast and its members confirmed had already - Formally consulted and discussed Federation, whose members with their product group Precast 2 Formally consulted and manufacture stairs. Associationowtioecmenbefiscuased with their product group the Structural Precast 3 Visited ACP Concrete manufacture stairs and the where the accident measures installed. occurred to see the remedial Had extensive internal discussion whole and beyond their eegacding how to promote improved safety across the membership. The proposed timetable of their action, including actions completed was confirmed as follows: Consult and discuss with relevant meeting of our Health and Safetyr parts of British Precast by 14 March including to be held on 11 March at Committee on March and the next SHAD 2 Checkicg; Ofh Bisrctoncreeregaducid asidea sHulland Ward faciorndereysnire from the death of Mr. Jenkins Productscand past management forany relavediTessons 3 Develop proposed by 12 March. Hold best practice by end March 2014 a consultation period on proposed best also with manufacturers that are not practice with HSE, within membership and 5, Issue best practice guidance members on May 1 at our AGM and conference PRECAST2014, By way of background information British product producers operating permanent IDrecest is the trade association for UK concrete have over 70 manufacturing members Or long-term temporary manufacturing facilities Precast target is to create a zero harrer accounting for 70% of output. The British workplace for all. We can confirm that_ Director) and Managing Director of the of the British Finance Director; met with (Group HS surrounding Mr McGlasson crdeatFedeeation We can confirm that the discussed. death, the subsequent investigation and tthe (nquestances Inquest were Company premises ad of the British Precast Concreta Federation Workington. this visit visited the and URMN5O024/29882/9587666-1 We the very taking they the Flooring factory industry Steering They industry Compan During
viewed and assessed the procedures and precast stairs ad in particular the systems in place relating to the manufacture of their edges_ restraining systems employed when staies mwerefacooc on Subsequent to this meeting
2014. This had been called falso attended a BPCF safety meeting on 12 March where the British Precast have in relation to improving safety of prestressing process meeting specifically related task group working with the HSE Part of the therefore to the stability of stairs their agenda of this was an opportunity to address the issues Of stair manufacture process and She BPCF hasnow evaluated all the evidence safe finishing of precast and has developed best practice guidance on consultation with: - concrete stairs. This guidance has been developed in TheAspecialist product groups of British Precast the Architectural and Structural Precast the Precast Federation and The wider membership of Btitash? PeecsSAssociation Non-members of British Precast as bess The Health and were able to do Executive Seite Company received draft copy of the BPCF Members sets out the best practice guidance. We Document No 11/2014 which document and agreed to the cant-confirm that the Company has reviewed the implementation of its comments ana guidelines. We can confirm the best practice guidance is as follows:- A risk assessment and safe system of with all relevant staff. It is industry workcshould be developed, communicated and agreed needed. If placing on edge is benepracticeato avoid placing stairs on theircedge aglesd required then standard practice is: - To support by craneage_ To support by a restraint system (e.g: toast rack type system) A copy of the Members No: 11/2014 2014 is enclosed_ which shall be formally circulated by the BPCF on The Company has listed below the actions stair manufacturing process Actions implemented in relation to the precast concrete accident and prior to recommencement that were implemented immediately post the fata of the stair manufacturing process: _ Immediate cessation of the practice of their edges without storing and on staircases standing on 11/2014 specifically any means of restraint The British Precast Guidance their estates that "it is industry best practice to avoed No: edge unless needed". stairs on 2 Installation of the TOAST RACK stair their stringer edge between support system; whereby the stairs are placed on for further stability before upright steel posts, the placement of chock blocks released the crane hooks and having subsequent URMN50024/29882/9587666-1 stringer meeting the during safety factory Flooring they Safety Briefing briefing Briefing May working stringer placing including being from
dwf dressing works applied. The British Precast toast rack type system as suitable Guidance 11/2014 specifically refers to placing on edge is required then stantare stracticsystem: The guidance states that "If practice To support by craneage. To support by a restraint system (e.g: toast_ rack type system) 3 Immediate cessation of manually Iaid flat on their soffit tipping stairs their stood edges to Installation of a TIPPING PIT RACKS fo teaTIPPINGG PPT; wsiegebheauverirs are t9 be transported the TOAST the top edge stringer of the using overhead and purpose points gravel TIPPING PIT nrecast stair, where the stair is then slowfy on rallowing the stair to rotate Gafely lowered into the the crane operator are stationed onto its soffit, AlI operatives PIT. at a safe distance external to the TIPPING As result of the death of Mr unprecedented circumseance %f Ie incGesson and in light of the particular and which include: incident; other measures havenelsoabeenl taken
5. In consultation with the Precast Stair Assessment was revised ranasareaidedeporkirent Operatives & Supervisors, the Risk the in practices iorking procedures were drawnOp teeflesk stair units as detailed above. agreed the Support and of precast A series of further TOOLBOX the Managemener SupervisOr TAarufaere also held all those revised Risk & Manufacture of Precast Concrete concerned in issued Assessment & Safe Working Method and Stairs reflecting the to all those noted above: a copy of these documents were supervisors in hestaioteeparovent Sutseg eonsui to all general operatives of an agreed safe further consultation took place and system of work in the manufacturing in adoption mould preparation to completion. process of precast stairs, from In common with the department remaithencer ponytartheverocndese working practices in the staircase review oi all company peacticestadericedand the Company carried out a full formal review of all Management; procedures, as well as and including a full formal relative to Health & Siapevesors & General Operativesntraining consultation on safe Sayetersaragement and Awareness: The procegsi lureviewhane to all of work, was rolled out to and Road cherzproducts manufactured by ACP aothe production processes safe Verrington Risehow; Maryporcturedafford Park production facilities at Lakes systems of works adopted Manchester, resulting in agreed 8_ full review of all training refresher training, new iraningcareditatioate was carried out and where applicable included and updated methods specifically relating to Health and Safety were actioned, This awareness and management URMN5O024/29882/9587666-1 is: - from stringer being from the crane, lifting including changes working including Turning involving issue resulting Safety including relating the being training training
These were introduced through a series of internal training newly adopted Risk Assessment & Method toolbox the employed the services of external Statement as the basis The Compangalse managers on health and training providers for the training of supervpsory ad of Occupational Safetyrand afetlth aregesis ancbmanagement including the Institution General Certificate in [LO.SH] & obtaining certification of the International Occupational Health and Safety [NEB.Oaio The Company has created Safety Committee in of health and safety at work The aim order to improve and raise standards can approach their respective of tforming the committee is 5o that employees representative can then representatives with issues and suggestions, Whictyehe intended that the Committee to the meetings and promote to the committee It is shall include hold a meeting every 4 6 weeks. The attendees at this the three named representatives and two management team. The nominated members of members ofthe the Production Manager and the management team arel are not available another Group Health and Safety Director: participate member of the management team would be invited to
10. The company wants to raise awareness of Company to prevent accidents and have current safety standards set by the This involves a new starter review introduced new procedures to achieve thise instruct and train new employees. throughewhich the Company will monitor;eassess, meeting, safety issues are to be It is intended that week at the supervisors discussed any accidents that have occurred. The stated aim of the Company is the prevention of any re-occurrence of accidents. faithfully DWF LLP URMN50024/29882/9587666-1 talks, using safety bring meeting the they every including Yours
5. Once satisfied or the staircase; as to stability he would remove the chains and leave the unsupported, to be slurried. staircase frkfter the slurrying process had been completed the staircase forks of a forklift truck and then removed to was "rocked over' onto the the storage yard. This system of work was an industry wide practice_ As a result of the Inquest your Report provided that which will prevent future we respond with actions we have taken received from the British deaths (our actions taken after advice and guidance Precast Federation "BPCF) ~in 'iWi F"llit|ue<:.4 4 " x7: 'me :ATtd " ""a '"p' " ,40k1 DWann#u:Nm MnikU; Vinl t4 m1um0E: F0ft; n| {4" | ""rURMIN50024/29882/ {Whce. Sott Htort Inuri 8trul. Muklkne M+A 19587666-dorseri mt regulaterd Ey Me Solititors ReguluoMAutunA Nwvr ! ['m441srh %- fnju m;uS Aulhorised regulaled' by Ihe: Fiaricinl Corill # Aullwcrity {nualerl pracIlce by Ihie Law Society cl Scollar! (Eujisteuex} TMyr ISO) 'NHJ1 P O(JK Cerlili ale No | RO A(Nar2# icn | = [ 6 41a1 Place Our during floor they setting help being being Pmc- and
dwf Your Report set out that we provide a written response by Monday 3 March 2014. wrote to You on 3 March 2014 to request respond to the Regulation 28 letter. This afo extension of time for the Company to formally Federation [BPCF] guidance which was to allow us time to evaluate British Precast additional and necessarya changescto therComvalable at that point in time and make process the Company's internal procedures any and manufacturing We understand the British Precast wrote to its instruction seriously and you On 28 February 2014 stating that it was action set out the actions it had already taken and timetable for The British Precast and its members confirmed had already - Formally consulted and discussed Federation, whose members with their product group Precast 2 Formally consulted and manufacture stairs. Associationowtioecmenbefiscuased with their product group the Structural Precast 3 Visited ACP Concrete manufacture stairs and the where the accident measures installed. occurred to see the remedial Had extensive internal discussion whole and beyond their eegacding how to promote improved safety across the membership. The proposed timetable of their action, including actions completed was confirmed as follows: Consult and discuss with relevant meeting of our Health and Safetyr parts of British Precast by 14 March including to be held on 11 March at Committee on March and the next SHAD 2 Checkicg; Ofh Bisrctoncreeregaducid asidea sHulland Ward faciorndereysnire from the death of Mr. Jenkins Productscand past management forany relavediTessons 3 Develop proposed by 12 March. Hold best practice by end March 2014 a consultation period on proposed best also with manufacturers that are not practice with HSE, within membership and 5, Issue best practice guidance members on May 1 at our AGM and conference PRECAST2014, By way of background information British product producers operating permanent IDrecest is the trade association for UK concrete have over 70 manufacturing members Or long-term temporary manufacturing facilities Precast target is to create a zero harrer accounting for 70% of output. The British workplace for all. We can confirm that_ Director) and Managing Director of the of the British Finance Director; met with (Group HS surrounding Mr McGlasson crdeatFedeeation We can confirm that the discussed. death, the subsequent investigation and tthe (nquestances Inquest were Company premises ad of the British Precast Concreta Federation Workington. this visit visited the and URMN5O024/29882/9587666-1 We the very taking they the Flooring factory industry Steering They industry Compan During
viewed and assessed the procedures and precast stairs ad in particular the systems in place relating to the manufacture of their edges_ restraining systems employed when staies mwerefacooc on Subsequent to this meeting
2014. This had been called falso attended a BPCF safety meeting on 12 March where the British Precast have in relation to improving safety of prestressing process meeting specifically related task group working with the HSE Part of the therefore to the stability of stairs their agenda of this was an opportunity to address the issues Of stair manufacture process and She BPCF hasnow evaluated all the evidence safe finishing of precast and has developed best practice guidance on consultation with: - concrete stairs. This guidance has been developed in TheAspecialist product groups of British Precast the Architectural and Structural Precast the Precast Federation and The wider membership of Btitash? PeecsSAssociation Non-members of British Precast as bess The Health and were able to do Executive Seite Company received draft copy of the BPCF Members sets out the best practice guidance. We Document No 11/2014 which document and agreed to the cant-confirm that the Company has reviewed the implementation of its comments ana guidelines. We can confirm the best practice guidance is as follows:- A risk assessment and safe system of with all relevant staff. It is industry workcshould be developed, communicated and agreed needed. If placing on edge is benepracticeato avoid placing stairs on theircedge aglesd required then standard practice is: - To support by craneage_ To support by a restraint system (e.g: toast rack type system) A copy of the Members No: 11/2014 2014 is enclosed_ which shall be formally circulated by the BPCF on The Company has listed below the actions stair manufacturing process Actions implemented in relation to the precast concrete accident and prior to recommencement that were implemented immediately post the fata of the stair manufacturing process: _ Immediate cessation of the practice of their edges without storing and on staircases standing on 11/2014 specifically any means of restraint The British Precast Guidance their estates that "it is industry best practice to avoed No: edge unless needed". stairs on 2 Installation of the TOAST RACK stair their stringer edge between support system; whereby the stairs are placed on for further stability before upright steel posts, the placement of chock blocks released the crane hooks and having subsequent URMN50024/29882/9587666-1 stringer meeting the during safety factory Flooring they Safety Briefing briefing Briefing May working stringer placing including being from
dwf dressing works applied. The British Precast toast rack type system as suitable Guidance 11/2014 specifically refers to placing on edge is required then stantare stracticsystem: The guidance states that "If practice To support by craneage. To support by a restraint system (e.g: toast_ rack type system) 3 Immediate cessation of manually Iaid flat on their soffit tipping stairs their stood edges to Installation of a TIPPING PIT RACKS fo teaTIPPINGG PPT; wsiegebheauverirs are t9 be transported the TOAST the top edge stringer of the using overhead and purpose points gravel TIPPING PIT nrecast stair, where the stair is then slowfy on rallowing the stair to rotate Gafely lowered into the the crane operator are stationed onto its soffit, AlI operatives PIT. at a safe distance external to the TIPPING As result of the death of Mr unprecedented circumseance %f Ie incGesson and in light of the particular and which include: incident; other measures havenelsoabeenl taken
5. In consultation with the Precast Stair Assessment was revised ranasareaidedeporkirent Operatives & Supervisors, the Risk the in practices iorking procedures were drawnOp teeflesk stair units as detailed above. agreed the Support and of precast A series of further TOOLBOX the Managemener SupervisOr TAarufaere also held all those revised Risk & Manufacture of Precast Concrete concerned in issued Assessment & Safe Working Method and Stairs reflecting the to all those noted above: a copy of these documents were supervisors in hestaioteeparovent Sutseg eonsui to all general operatives of an agreed safe further consultation took place and system of work in the manufacturing in adoption mould preparation to completion. process of precast stairs, from In common with the department remaithencer ponytartheverocndese working practices in the staircase review oi all company peacticestadericedand the Company carried out a full formal review of all Management; procedures, as well as and including a full formal relative to Health & Siapevesors & General Operativesntraining consultation on safe Sayetersaragement and Awareness: The procegsi lureviewhane to all of work, was rolled out to and Road cherzproducts manufactured by ACP aothe production processes safe Verrington Risehow; Maryporcturedafford Park production facilities at Lakes systems of works adopted Manchester, resulting in agreed 8_ full review of all training refresher training, new iraningcareditatioate was carried out and where applicable included and updated methods specifically relating to Health and Safety were actioned, This awareness and management URMN5O024/29882/9587666-1 is: - from stringer being from the crane, lifting including changes working including Turning involving issue resulting Safety including relating the being training training
These were introduced through a series of internal training newly adopted Risk Assessment & Method toolbox the employed the services of external Statement as the basis The Compangalse managers on health and training providers for the training of supervpsory ad of Occupational Safetyrand afetlth aregesis ancbmanagement including the Institution General Certificate in [LO.SH] & obtaining certification of the International Occupational Health and Safety [NEB.Oaio The Company has created Safety Committee in of health and safety at work The aim order to improve and raise standards can approach their respective of tforming the committee is 5o that employees representative can then representatives with issues and suggestions, Whictyehe intended that the Committee to the meetings and promote to the committee It is shall include hold a meeting every 4 6 weeks. The attendees at this the three named representatives and two management team. The nominated members of members ofthe the Production Manager and the management team arel are not available another Group Health and Safety Director: participate member of the management team would be invited to
10. The company wants to raise awareness of Company to prevent accidents and have current safety standards set by the This involves a new starter review introduced new procedures to achieve thise instruct and train new employees. throughewhich the Company will monitor;eassess, meeting, safety issues are to be It is intended that week at the supervisors discussed any accidents that have occurred. The stated aim of the Company is the prevention of any re-occurrence of accidents. faithfully DWF LLP URMN50024/29882/9587666-1 talks, using safety bring meeting the they every including Yours