Images courtesy of the HSE
On 18 July 2017, a section of the rear wall of Citadel Church in Splott, Cardiff fell on scaffolder Jeff Plevey, instantly killing him. We spoke to Liam Osborne, the HSE’s lead investigator on this case, to find out how such a tragic incident came about.
The derelict church was undergoing demolition at the time, specifically because that very same rear wall had been identified in a report as unstable and ‘in danger of imminent collapse’. Earlier this month, after an 11-week trial, Cardiff Crown Court sentenced four men involved with the demolition to suspended prison sentences, with four firms involved receiving combined fines of more than £340,000. But how could a known and obvious risk have been ignored, and eventually resulted in a man’s death?
The incident
'Citadel Church was undergoing hand demolition and scaffolding had been placed around the church to allow that to happen. Some of the back wall had been partly demolished and a couple of days earlier, the entire roof had been taken down,' Liam said.
'Three scaffolders were disassembling scaffolding from the rear wall. This wall was made of thick stone and it towered above them, but suddenly it collapsed. Two of the scaffolders ran for their lives with the rubble landing around them. Unfortunately one scaffolder, Jeffrey Plevey, was trapped in the corner of the scaffolding and a large section of masonry fell on him, killing him instantly and burying him under the rubble.
'The HSE was alerted by South Wales Police soon after the incident happened. Although this was a police-led investigation, a small team of us from HSE worked to support South Wales Police’s Major Crime Investigation Team, alongside a number of other organisations.'
The first organisation that needed to take immediate action was Network Rail. Citadel Church was positioned next to the main Paddington to Swansea railway line and rubble from the collapse had fallen down onto the track.
'Luckily it didn’t cause any derailments but two trains in particular had to be flagged down by workers from Network Rail and construction company Carillon, who were working on a nearby road bridge and ran down the railway line to alert a high-speed train and a commuter train that were approaching,' said Liam.
The team from HSE worked with council building control, specialist fire and rescue teams, and obviously the police.
'We brought in a structural engineering expert immediately, who then took the lead in liaising with police and fire and rescue at the scene. Jeff’s body had to be recovered and our specialist worked with the rescue teams to recover him in a safe and dignified fashion,' Liam explained.
'Then the on-site investigation commenced. That lasted about two weeks and we worked with a new demolition contractor who had been brought on site to start examining the debris and rubble to determine what condition the building had been in, what work had been done, and how it had been done. At the same time, they also made the building safe to allow the railway lines and neighbouring roads to reopen, and also to allow people living in the house next door to return home.'
Chain of responsibility
Possibly even more difficult than the on-site investigation were the steps police and the HSE had to take to identify exactly who was responsible for failing to take the necessary measures to prevent Jeff's death.
'It was quite difficult to investigate on account of the number of different entities and duty holders that were involved. It’s often like that in construction, where it’s very rare just to get one organisation or one company that takes on all of the work – often you have a lot of separate teams that come together. So it took a lot of time and a painstaking level of detail to collect so many different documents, photographs, designs and emails, and then forensically go through all of them, to piece together not just what had happened but how decisions were made, what action was taken or – more relevant in this case – what action wasn’t taken,' Liam said.
'There were many failings, but the most significant were the most basic, which included a failure to plan correctly. They had had a lot of time to plan, but the work hadn’t been thought through properly. That included setting up the initial organisation on site with established roles and responsibilities, and getting people in at the right time to give the right level of advice. There were a lot of problems with the ways the organisations involved had carried out risk assessments. Key things had been overlooked, and because they’d been overlooked, they then hadn’t been properly managed.
'Also, there was a lot of information about the instability of the church in a report that Network Rail had previously commissioned and shared with the building’s owner. The building’s owner then supplied that information to some of the parties involved in this incident, but that information wasn’t then shared onwards to all of the different duty holders. Because of that, a lot of people weren’t aware of the pre-existing instability of the rear wall in particular – which was the reason why the building was being demolished in the first place. The rear wall was actually already known about as being in danger of ‘imminent collapse’.
'The prosecution case was that it was hard to understand how that information, crucial as it was, had not been treated with the seriousness it required.'
The outcome
The fact that so many parties had a hand in these failings is reflected in the outcome of the case heard at Cardiff Crown Court.
Keith Young, the demolition contractor, was found guilty of failing to take necessary steps to ensure a structure does not collapse when carrying out construction work contrary to Construction (Design and Management) Regulations and the Health and Safety at Work Act. He received a 45-week sentence suspended for 18 months with an order to pay costs of £66,000.
Stewart Swain, director of Swain Scaffolding Ltd, was found guilty of failure to discharge a duty. He received a 39-week sentence suspended for 15 months with an order to pay costs of £25,000.
Swain’s business, Swain Scaffolding Ltd, was also convicted of failure to discharge a duty and was fined £120,000 with costs of £25,000.
Philip Thomas, director of South Wales Safety Consultancy Ltd, pleaded guilty to failure to discharge a duty and received a 36-week sentence suspended for 15 months with an order to pay costs of £20,000.
Thomas’s business, South Wales Safety Consultancy Ltd, also pleaded guilty to failure to discharge a duty and was fined £97,500 with £17,500 costs.
Richard Dean, director of NJP Consultant Engineers Ltd, pleaded guilty to failure to discharge a duty and received a 35-week sentence suspended for 15 months with an order to pay costs of £20,000.
Dean’s business, NJP Consultant Engineers Ltd, also pleaded guilty to failure to discharge a duty and was fined £93,300 with £6,700 costs.
Finally, Strongs Partnership Ltd pleaded guilty to failure to discharge a duty and was fined £33,500 with £17,500 in costs.
'Because this was a police-led investigation, prosecution decisions were made by the Crown Prosecution Service (CPS). Obviously, HSE was part of the investigation team, so we worked with the police and the CPS to help them arrive at the decisions that they did make,' Liam said.
'It was very clear following the analysis of all of the documents and emails that the directors of the companies involved were also the actual people on site making the decisions, or not making the required decisions, or giving poor advice. Quite why they failed to act as they should have done is something we never really had a satisfactory answer to.'
That frustration was echoed in the closing remarks by the judge, Mrs Justice Jefford: 'If any one of these companies and individuals had raised a red flag or even a concern about the performance of the others, Mr Plevey’s death could have been avoided. The familiarity and informality with which these parties all proceeded led to neglect. I am left with the firm impression that no-one said anything because they just assumed that everything was fine and because no-one said any differently. What happened on this site exemplifies what can happen and the tragedy that can occur if that sort of approach is taken to health and safety on construction sites. It is to be hoped that lessons will be learned not only by these defendants but by the industry generally.'
What can we learn?
'There are so many things to take from this case, but it’s probably most important to go back to basics,' Liam said.
- Effective sharing of information, dealing with things as they happen, and making sure you don’t look the other way are key learnings.
- If something looks obviously dangerous, it probably is obviously dangerous.
- Form a well-managed and well-resourced team from the outset.
- Plan as much as possible, as early as possible
- Competence is key. Use the skills of the right people in at the right time – that cannot be emphasised enough.
When dealing with known structural stability, or if maintaining stability is a risk during demolition, focus on using ‘remote’ or machine demolition techniques, rather than opting for hand-demolition. In effect, ensure that people are removed from the potential zone of collapse, even if that means securing highway or railway closures and decanting people from neighbouring properties.
