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We speak to HSE inspector Dr Sara Lumley about a case where an aircraft engineer fell from a maintenance dock, causing life-changing injuries.
On 10 November 2019, Iain Mawson – an aircraft engineer employed by British Airways Maintenance Cardiff (BAMC) Ltd – fell from a maintenance dock at BAMC’s facility in Cardiff whilst inspecting the wing of a Boeing 747. Such was the extent of his injuries, including multiple skull fractures and a brain haemorrhage, Iain was placed into an induced coma for three weeks and has not returned to work since. We spoke to the Health and Safety Executive (HSE) inspector who investigated this case, Dr Sara Lumley, about what happened.
The incident
'This incident occurred during the maintenance of a Boeing 747. There were two tasks taking place at the time: one was to remove the boat fairings, which protect part of the mechanism of wing; the second was to fit wing flaps, which had been removed for maintenance,' said Sara.
'Engineers at BAMC were working off a platform about two metres high and had to remove the boat fairings from the wing, which left a gap of around a metre in the guardrail. They used safety barriers slotted into lugs either side to fill the gap in the guardrail. The team working on the plane then had to crane the flaps up to refit them. To do that, the team removed the safety barrier, otherwise part of the wing flap mechanism could hit the guardrail.
'Unfortunately, this was at 4pm on a winter’s evening, it was the end of the four-day shift and a new bay had opened up, so there was a lot going on. Workers stated there was a lot of pressure to get the job done. After the wing flaps were in place, the safety barrier was not refitted, but given the time of day it was dark and this was not easily visible.'
Iain and another aircraft engineer were about to do a duplicate inspection of the wing flaps to check that the flaps were correctly fitted and the plane was safe to fly. The other aircraft engineer was delayed, so Iain went up onto the platform alone to start his inspection. What happened next is unclear but an employee nearby heard something hit the ground and when they got closer they realised that Iain had fallen.
'The fall was only two metres, but people underestimate the effect of a fall from two metres. His injuries were very severe, so an ambulance was called and a doctor from the local air ambulance station came. They stabilised him and then Iain was transferred to Heath Hospital in Cardiff.”
The investigation
'The HSE received a phone call to say an aircraft engineer had been attended to by the air ambulance team at BAMC on 10 November. My principal inspector, Chant Nicholls, assigned the case to me, so a colleague and myself went out to visit the site straightaway. At the time, this was a potential fatality – Iain was in a coma in intensive care and desperately ill,' Sara explained.
'Knowing this makes the situation quite difficult. Our first thoughts are always with the injured person and their family, especially because the extent of Iain’s injuries were so severe and there was serious concern for his life. But as inspectors, we also have to go into his workplace where he has worked with colleagues for many years, knowing that we might have to speak to some of them. While we do have an investigation to do, it is obviously going to be incredibly sensitive. To see his colleagues so upset is distressing. No matter what has gone wrong in a company, people are still deeply affected by it.
'The first thing we always do when we go onto site is to introduce ourselves to senior management. We explain why we are there, how we will approach the investigation, and the potential outcomes in terms of enforcement, which could be from no action taken, to advice, to notices, to potential prosecution. We can’t predict the outcome at that stage because it depends on the evidence and the circumstances.
'We ask for key documents, such as risk assessments, safe systems of work, training and any documents that would indicate monitoring; in this case, were there any formal documented checks to show those safety barriers had been put back in place, because they are safety critical when working at height?
'We review the documents and then take statements from employees – that was particularly important in this case because when Iain had gone onto the platform, there was nobody else with him. So we tried to establish a timeline, what had happened, and if anybody had seen anything.'
The findings
'On the day we arrived on site, I served two improvement notices: one for the management of safety barriers and the other for the safe system of work for removing and replacing boat fairings to be reviewed and updated,' Sara said.
'I also served a prohibition notice to prevent the use of an unsafe removable wing docking in a different bay. A new wing docking had been brought into the company and there were gaps in the guardrail where BAMC had fitted temporary red and white plastic barriers, as you might see at roadworks. That is only a visual barrier that wouldn’t hold the weight of somebody. In other areas, tape had been put across gaps. In both cases the falls were quite significant, approximately five to six metres. Also, in the floor of the docking, there were holes that a body could go through. So I prohibited access within two metres of these exposed leading edges. BAMC remedied this very quickly.
'From our investigation into Iain’s incident, we found that there was a task-based risk assessment for both fitting and removing the boat fairings, and fitting and removing wing flaps. There were also safe systems of work. But none of those stated clearly how the removable safety barriers should be used, and whether they should be left in place.
'What we discovered was that different teams took different approaches to the task. Some removed the safety barriers to fit the wing flaps, some teams didn’t remove them to fit the wing flaps. To me, that indicated that although the risk assessment was there and it had been reviewed, nobody had really gone and watched this task being performed. There was a lack of analysis of the task and the risks involved: if anybody had gone and looked at those tasks happening, between two different teams, they would have realised very quickly that there were very different methods of work and that involved the safety barriers.
'This is particularly interesting because elsewhere in its business, British Airways has a great knowledge of safety-critical actions and monitoring. One of the things we found in the risk assessment was that it didn’t say the safety barriers should not be removed. However, in any safety-critical manual, it will tell you what you should do, and it will also tell you the key things that you shouldn’t do.
'There was also a lack of work at height training on the use of these removable platforms. Staff did have some work at height training but not for removable platforms or dockings.'
Further failings
At a follow up visit as part of the investigation, further breaches of work at height regulations were discovered which demonstrated that failings were widespread.
'After the incident BAMC took action to reduce the risks involved with this task. It was made clear that the safety barriers were not to be removed. Also for example, one of the concerns of the workers was that the barriers blended in visually with the platform – they were both aluminium. So, the barriers were subsequently painted bright yellow and that helped to show whether they were in place or not,' noted Sara.
'However, during a follow up visit, I had to serve a further improvement notice for a risk assessment of removable docking. Whilst there were task-based risk assessments, there was no risk assessment for the use of the actual platform. If a plane was dedocked, the platform was left with an exposed leading edge six or seven metres long and five or six metres high.'
Sentencing and lessons
On 6 January 2023 at Cardiff Magistrates’ Court, British Airways Maintenance Cardiff Ltd pleaded guilty to breaching section 2(1) of the Health and Safety at Work Act. It was fined £230,000 and ordered to pay costs of £21,623.
Sara said the lessons that IOSH members can take from this incident are very clear: “The Work at Height Regulations are very clear. Firstly it’s important to plan the work at height, especially where you have something that is of such a day-to-day nature that you have almost forgotten that it is working at height.
'Each task must be adequately analysed. It’s not a case of what you think is happening but what actually is happening? Watch people do their tasks and watch their use of the equipment. Don’t forget that while there are tasks to do with in terms of the job itself – in this case, on the aircraft – there are also tasks associated with the platforms, such as de-docking.
'One of the things people would argue is that nobody would go back up onto a platform when an aircraft has left, but we know people do – they might have left a tool up there, for example. It might be less likely, but always consider the potential for risk, the implications and what can be done.
'The guidance is very clear. The responsibility for health and safety lies with the duty holder. They are responsible to ensure they have adequately assessed risks and have looked at how they can prevent or control risks, especially working at height – there is the clear requirement to prevent work at height where possible, and if not, to control it. In this case there was lack of planning, lack of supervision and the actual practice was not safe.'
Two years ago, British Airways was fined £1.8m after a worker was crushed by a baggage trolley. Read the full story here.
