We spoke to HSE inspector Rose Leese-Weller about how failures in the earliest stages of planning a catering equipment cleaning facility’s shopfloor ultimately led to a worker fatality.
On 8 January 2018, a worker at Pan Glo (UK) Ltd’s premises in Skelmersdale, Lancashire – previously known as Cleanbake Ltd – fell into a tank of water heated to 76°C, suffering 37% burns. Despite being pulled from the tank by a colleague almost immediately and then being transferred to hospital, the gentleman died from his injuries a week later. In an exclusive interview, Health and Safety Executive inspector Rose Leese-Weller explained to IOSH magazine exactly what happened.
‘Pan Glo cleans and restores industrial-sized baking tins that are used to make loaves of bread. The baking tins are loaded into large cages and these are moved by crane along a process that involves a series of 14 huge tanks that are 10 or 12 feet deep, each filled with different substances. These substances ranging from a caustic soda mix to water at different temperatures, with the tins having so many hours in each tank before being moved onto the next,’ Rose said.
‘In order to keep the heat in the process, the company has fitted lids to the tanks. These lids are hydraulically operated and made out of a steel frame with aluminium sheets pop rivetted into the frame. It was custom and practice for individuals working for Pan Glo to go onto the tops of the lids to gain access to the backs of the tanks, where all the components involved in the operation of the hydraulic lids were found. Workers had to go over the top of the lids because there was limited space between the back of the tanks and the wall.
‘A couple of days before the incident, part of the counter-balance for lifting the tanks had been removed and the counter balance weights had been left on top of one of the lids of the tanks. The gentleman who died thought he would do a good deed. He moved an empty cage over one of the tanks, walked along the frame of the tank holding onto this cage, and put the weights into the cage. He then walked back. But just before he was about to step off the frame of the lid onto the catwalk in front of the tank, he put his foot on the aluminium part of the lid and it gave way.
‘He fell up to his chest into the tank with water heated up to 76°C. A workmate was on the catwalk, so he grabbed the gentlemen and pulled him out of the tank. They then hosed him down and took him to hospital. He was in the burns unit but sadly he died a week later from heart failure caused by the burns.’
‘The incident happened on 8 January 2018 and the HSE received the report about it on 9 January. I went to site that same day. Obviously, everybody on site was very shocked. For me, it was a case of taking initial photographs and undertaking the initial stages of any investigation. We also served a Prohibition Notice immediately,’ explained Rose.
‘Over the course of the investigation I found that there were no risk assessments for maintenance procedures and there were no safe systems of work for maintenance procedures. Health and safety wasn’t very effective at all. The health and safety manager had been at that site for only week and there had been no previous health and safety manager, so there was no formalised health and safety system. They had had consultants in offering advice at times, but nothing with any great effect.
‘That meant there was very little in the way of documentation to help with the investigation. I picked up what documents there were and I also picked up CCTV footage, which was very useful but very difficult to watch. We were able to see the gentleman walking along the lid, we could see the lid give way, and we knew that that same man died because of those injuries. Initially we did this as a joint investigation with the police and even they were left shocked by the footage.’
Rose’s investigation found that there were a number of failings that contributed to this incident involving spectrum of areas, including planning, equipment, management and safety culture. For example, on the equipment side of things, the structure of the lids was completely unsuitable.
‘Because of the caustic soda fumes, what happened was, what our specialist described as a ‘galvanic reaction’. It’s basically like a battery where the steel consumes some of the aluminium that was pop-riveted next to it and corroded it,’ she said.
‘But even before that, the fact the tanks had been placed in such a way where it was impossible to access most of their crucial working parts without climbing over the lids was a significant failing. What should have happened before the tanks were even placed on site, the company should have considered necessary maintenance from the very start. Had the hydraulics and heat pipes been placed at the front of the tanks, there would have been no need for workers to go over the tops of the tanks to get access to the rear. That should have thought of from the beginning when they were planning the process.
‘There was also the issue of communication. None of the Pan Glo employees knew that the tank lid frames were made out of steel but that the tank lid inserts were made out of aluminium. Most of the employees I spoke to were very shocked when I told them because they all knew that they couldn’t use aluminium in that environment, because it was caustic. However, the director at the time who left before the accident didn’t communicate that with the employees – and that’s so basic.’
At Preston Magistrates’ Court on 18 October 2022, Pan Glo (UK) Ltd pleaded guilty to breaching section 2(1) of the Health and Safety at Work Act. The company was fined £200,000 and ordered to pay costs of £14,597.
‘About a year before the incident happened, Cleanbake Ltd had been part of a buyout, so Pan Glo (UK) Ltd is part of a larger American company. Pan Glo had a single UK director who left about four months before the accident, which meant that most of the directors were based in America. However, after the incident, the company bought the unit next door, so that they could knock a hole in the wall, allowing workers access to the rear of the tanks to do necessary maintenance without needing to climb over them,’ Rose said.
‘One of the saddest parts of this story is that, before Christmas 2017 someone looked at the process and said, we really need a manufactured walkway to go over the top of the tanks. When the incident happened, the walkway had been ordered and it was actually delivered after the accident.’
WHAT CAN IOSH MEMBERS LEARN FROM THIS CASE?
‘Health and safety should be part of a holistic approach to business. Think about your process. You might have raw materials coming in – whether they are powders, substances hazardous to health, or things like steel. Then you have the manufacturing process itself. And then you have the product going out. In each of those areas you need risk assessments,’ noted Rose.
‘But equally, when you have machinery, you need to think about what maintenance you require, because that’s what keeps you running: if your machines break down, you’ve got no business, and if you are served with a Prohibition Notice, your business has to stop. How are you going to maintain your process? What happens if something goes wrong and you need to access the machinery around the back, or gain entry into the machine? Or what if it needs cleaning? How are your staff going to be able to enter into that machine and is it going to be safe?
‘What I often advise people when they are moving to new premises or planning to put new equipment in, is just to simply chalk it all out. Chalk out the machinery and plant; check that you can get your forklift trucks round and there is sufficient space. Just put chalk marks on the floor – it’s very basic but very few people do it.’