Richard King and Roland Michael Duffell

In the light of my foregoing conclusions, I now offer the following recommendations:- • there are a number of matters which I would like to see considered as a matter of urgency by the committee responsible for British Standards in relation to flame cutting and welding equipment and hoses carrying both oxygen and flammable gases, namely;- • the elimination of circumstances wherein the creation of a notch between two hoses can trap molten metal particles, to eliminate the risk of those trapped particles burning their way through the outer surfaces of the hoses causing either an immediate fire, or oxygen enrichment or, worst of all, a leakage of unburnt gases into atmosphere with potentially explosive effect on ignition - patently there is a particular risk with oxy-acetylene equipment, especially if use is made of oxygen and acetylene hoses which are manufactured in such a way as to be permanently joined together; • the adequacy of the thermal resistance qualities of the hoses used for the conveyance of oxygen and flammable gases; • the adequacy, in the circumstances disclosed in the evidence, of the test for the thermal resistance qualities of such hoses; • what steps can be taken for the easier identification and distinction between propane and acetylene hoses given the proximity in the colour spectrum of their present outer coating colours, especially given the availability now of luminous colours; also what markings about the flammable nature of the contents of the hoses should be marked on the outer coatings; and • whether and how best pressure gauges can be incorporated as standard into equipment used in connection with welding, flame cutting, grinding and allied processes; • Consideration requires to be given as to whether there is a need for further regulation, whether by amendment of the Confined Spaces Regulations, 1997, or otherwise, or, at any rate, by amendment of the Approved Code of Practice, to take account of the following:- o whether persons should be permitted to enter or carry out work in a confined space without an adequate means of instant communications with a responsible person outwith the confined space first being established; o whether persons should be permitted to enter or carry out work in a confined space where flammable gases and/or oxygen is present without a safe and sufficient means of regulating the supply of all such gases to the confined space by a remote start system operated outwith the confined space so that supplies of any particular gas or gases to the confined space are only live when the gas is required for flame cutting, pre-heating or other related processes, and the supplies are not otherwise live; o whether persons should be permitted to enter or carry out work in a confined space where flammable or toxic gases and/or oxygen are or may be present without the presence of suitable and sufficient atmospheric monitoring equipment and a person sufficiently trained in its use so that the presence of any unsafe condition, including oxygen deficiency or enrichment or the presence of toxic or unburnt flammable gases, can be detected; o whether persons should be permitted to enter or carry out work in a confined space where flammable or toxic gases and/or oxygen are or may be present without the presence of a suitable and sufficient supply of fire extinguishers; o whether persons should be permitted to enter or carry out work in a confined space where flammable or toxic gases and/or oxygen are or may be present without the presence of an adequate supply of emergency respiratory equipment of the type known as BA escape sets, in the use of which such persons as enter the confined space should be adequately trained; o whether, at least so far as concerns planned works, as opposed to those which may arise on an emergency basis, no work involving any hot process such as flame cutting, welding or grinding should take place in a confined space without the works being controlled by an effective and properly operated permit to work system; o whether, prior to any person being permitted to act as either an Issuing Authority or Performing Authority under a permit to work system, that person should be required to pass a written test of competence in the particular system and in the importance generally of permit to work systems; and o whether at all times when a permit to work system is in operation a copy of the permit should be exhibited at the site of the work being carried out under it; • Those who operate permit to work systems should consider:- o the adequacy of their cross-referencing systems; o whether when it comes to deciding upon appropriate precautions, instead of using a "tick box" approach, there should be a requirement to specify what each precaution should consist of e.g there should be 3 fire extinguishers each of the dry foam type located within the confines of the confined space; o whether there are any circumstances in which revalidation should be permitted; and o whether communication of information from manager to manager, supervisor to supervisor and tradesman to tradesman at shift changeovers is adequate or requires to be formalised. • Whether, more generally, there is a need for the relevant authorities to consider:- o whether only tradesmen holding appropriate certificates of competence should be allowed to - o carry out hot works (welding, flame cutting, grinding and allied processes) at all or, at any rate, in a confined space; o be permitted to install equipment for such processes; o be permitted to maintain and repair equipment for such processes o be the only persons permitted to carry out any function in relation to the operation of any portable gas bottle or cylinder and the connection or disconnection of hoses or other equipment thereto; o supervise the performance of hot works in a confined space; and o prepare a risk assessment for the performance of hot works in a confined space; o how to address the problem of the safety of temporary workers especially in the building and construction industries where the work site is constantly changing and the absence of a settled workforce with some prospect of continuity of employment contributes to the present lack of safety among such workers; o how to improve the quality of supervision, with particular regard to safety, of temporary workers; and o whether there is a need for statutory provision to enable local fire services to have access for familiarisation exercises to ships or other marine installations in dock, whether for repair, upgrading or otherwise, for a period in excess of seven days. I hope all of the foregoing will serve to encourage urgent consideration of revisals necessary at the various levels I have striven to identify to prevent further unnecessary loss of life.