We spoke to HSE inspector Pippa Trimble about how a lorry driver’s fatal fall resulted in an almost half-million-pound fine.
On 23 April 2018, Christopher Barnes – a 69-year-old lorry driver working for Devereux Developments Ltd – delivered doors to a site in Gloucestershire.
After arriving on site, Christopher opened the curtain doors to his trailer and released the load-securing straps. However, some of the straps – which were suspended from the roof of the trailer – were tangled. Christopher’s attempts to free them from ground level were unsuccessful, so he climbed onto the trailer’s cargo bed and then onto the load itself to try again. Unfortunately, he stepped backwards off the load and fell 2.3 metres onto the concrete floor of the yard below. Christopher was taken to hospital but sadly passed away from his injuries the following day.
Pippa Trimble, one of the HSE inspectors involved in this fatal incident, explained to us what happened and what should have been done to avoid it occurring.
The investigation
'HSE was notified about the incident on 25 April, the day after Christopher died,' Pippa said.
'In this investigation colleagues from across HSE worked together to progress the investigation and gather evidence. HSE staff in Bristol attended the Wiltshire site – where the doors were initially loaded onto the trailer by Christopher earlier that morning – to gather information about the load. Inspectors from Newcastle visited Devereux Developments Ltd who are based in the north-east to obtain documents, such as risk assessments and safe systems of work, and also to take statements from fellow drivers. My Birmingham team visited the incident site in Gloucestershire and took statements from witnesses.
'The first priority in any investigation is to identify ongoing risk and take appropriate enforcement action to ensure that risk is managed. To achieve this, we rapidly gathered all evidence – including risk assessments, safe systems of work and training records – to identify any failings in the company’s undertaking, any material breaches of health and safety law, and to ensure that these were rectified.'
The findings
The HSE’s focus on preventing ongoing risk was well-founded and an Improvement Notice was served early in the investigation on Devereux Developments Ltd in August 2018. The Improvement Notice identified the company had failed to make a suitable and sufficient assessment of the risks to employees, particularly when working at height on trailer beds during loading/unloading operations.
Due to the lack of prohibitions and systems in relation to working on trailer beds or climbing on loads whilst unloading, employees were forced to devise their own systems to unload deliveries.
'Devereux Developments Ltd acted and complied with that notice – it reviewed all its safe systems of work and its risk assessments in relation to work at height on trailer beds and implemented control measures as a result,' Pippa said.
'In addition to the Improvement Notice, the HSE’s investigation revealed that Devereux Developments didn’t identify the possibility that out-of-reach straps could become tangled and it hadn’t set out procedures to deal with that.
'The investigation also identified that Devereux Developments had not implemented a management system that provided suitable and sufficient instruction and training to their drivers. An example is there was no system in place to ensure a record was kept when documents or updates were given to drivers, and there was no formal method to check a driver’s compliance with safety procedures.'
The prosecution
'In terms of the decision to prosecute, that was taken by the investigating team and the Principal Inspector,' Pippa said.
'We follow the same principles as the CPS, and whether a prosecution is likely is reviewed throughout the investigation. We also follow our Enforcement Management Model – the EMM – which identified that the breach was significant enough for there to be a prosecution, as well as applying the principles of our Enforcement Policy Statement in making the decision.'
At Cheltenham Magistrates’ Court on 28 June 2022, Devereux Developments pleaded guilty to breaching section 2(1) of the Health and Safety at Work Act. the company was fined £480,000 and ordered to pay costs of £12,053. Devereux is appealing the sentence.
What should have happened
Pippa said what should have happened in this incident is quite straightforward.
'There should have been a clear and thorough risk assessment that clearly assessed all the risk relating to working at height, particularly working on a trailer and working on loads. That would have then identified the necessary control measures, which weren’t implemented in this instance.
'There should have been an absolute prohibition of working on the trailer load or the deck area without suitable measures in place. As a result, that would have enabled Devereux to draft a clear safe system of work, which would have set out exactly what drivers should do, particularly when dealing with tangled straps on loads.
'Practical control measures to free tangled straps could have also been implemented, such as the use of a telescopic pole, which can untangle straps from ground level. Some Devereux drivers do have them but it appeared one was not available to Christopher in this incident. The safe system of work that the company has put in place after the incident now requires all drivers to use these telescopic poles.'
Key learnings for IOSH members
'I think this case will resonate with a lot of IOSH members, particularly where they have colleagues working off-site,' Pippa said.
'There is obviously a difficulty with remote working but, in my opinion, it’s crucial to make sure that training is suitable, and that it reflects the current safe systems of work and the current risk assessments. If there is any update, that related training needs to be distributed to all employees and a record of that should be kept.
'Having proactive management and competency checks is important, too. One finding from this case was that there was no formal method to check a driver’s compliance with safety procedures, the approach was reactive. If there was an incident, the safety manager would visit with that driver, but there was nothing proactive in place.
'However, the key learning here is to ensure that instructions and the safe systems of work that are provided are clear in terms of the relevance to risk assessments. IOSH members need to clearly and thoroughly assess in a suitable and sufficient risk assessment all of the potential risks. That suitable and sufficient risk assessment is important to identify the risks, and it forms a solid foundation for recognising the required control measures and devising safe systems of work which are not vague and open to interpretation.'
