Siemens Plc has pleaded guilty to breaching s 33(1)(c) of the Health and Safety at Work Act after a self-employed contractor died at its Train Care Facility in west London.
Technician Ian Parker, 58, was fatally crushed when a 650kg traction motor he was preparing for removal from an electric Desiro 360/2 train, which operates on the Heathrow Express, fell on him. He died at the scene.
The investigation
The Office of Rail and Road (ORR) investigated the incident at Siemens Train Care Facility located at 203 Old Oak Common Lane, White City, which at the time was run by Siemens Rail Systems, a division of Siemens, but is currently operated by a separate company, Siemens Mobility Ltd.
The ORR found that the self-employed technician was working as part of a team of contractors that made up the facility’s Heavy Overhaul Team.
On 13 June 2017, the team was tasked with removing several traction motors for routine refurbishment from electrically powered trains. A crane was to be used to lift the traction motors.
Each 650kg motor was connected to the train’s bogie frame by four mounting bolts and mounting sleeves held them in place. In addition, there were two safety plates below the motor to prevent it falling if the mounting bolts both failed.
The ORR investigation found that the mounting bolts, the mounting sleeves and the safety plates should not have been removed until after the crane had taken the motor’s weight.
At some point in the lead up to the incident, the self-employed contractor removed the mounting bolts, the mounting sleeves and the safety plates before the motor had been properly supported by the crane. He was in an inspection pit underneath the motor when it fell.
ORR inspectors were unable to determine when the technician removed the bolts, but noted that it is highly likely they were removed immediately before the accident and not in the right sequence.
Training and procedures
The investigation determined that the task was not unusually specific or complex. However, it was hazardous work and required technical skill.
The members of the Heavy Overhaul Team were qualified to remove the traction motor, the ORR reported.
However, as Umar Ali, ORR principal inspector told IOSH magazine, the White City depot didn’t routinely do traction motor removals. The work was normally undertaken at Siemens’ Northampton site.
‘On this occasion, they were asked to do the work for Northampton because they didn’t have capacity to do it,’ Umar said.
‘While this team was made up of experienced overhaul engineers, the motor removal jobs were not that common. The removal sequence is very specific and the Acton Overhaul Team didn’t get this right.’
Siemens operated a defined working procedure for the task, including the correct sequence for removing the traction motor, which was contained in its Vehicle Maintenance Instructions (VMI). Each team member could access the instructions on the company’s computer system.
The ORR noted that the VMI was underpinned by a hazard risk assessment, which identified various task risks, such as crush hazards and the use of lifting equipment.
However, the regulator pointed to defects in the task planning, which included a failure to carry out an appropriate task-specific risk assessment and a lack of clear allocation of responsibility for supervising the task on this occasion.
In the sentencing remarks, the rail regulator noted that had Ian ‘been subject to appropriate supervision to ensure that he followed the procedure set out in the VMI as required, he would have been able to remove the traction motor safely’.
The ORR also concluded that the Heavy Overhaul Team and the crane operator were not competent to undertake the hazardous work because neither party had any previous experience of undertaking this work, nor had they been given specific training.
The investigation concluded that both task-specific training and assessment were required to undertake this work. In addition, the crane operator ‘required specific information, instruction and training on the removal of traction motors’.
The ORR also concluded that the Safety Critical Assessments which the Heavy Overhaul Team had undertaken were ‘generic and unsuitable as a standalone assessment to measure the team’s, or an individual’s, competence for the task’.
In undertaking the work, the Heavy Overhaul Team had also relied on a generic rather than specific lifting plan.
Umar told IOSH magazine that there had been an accident at Siemens’ Neville Hill depot in Leeds the week before the tragedy that involved a lifting operation.
‘They had identified the need for a proper briefing, lifting plans and supervision, and to advise other depots of this incident,’ he said. ‘Part of that was to get the supervisors to sign the lifting plan and unfortunately it didn’t happen on this occasion.’
Prosecution, sentencing and learnings
Siemens Plc admitted breaching section 33(1)(c) of the Health and Safety at Work Act at the first opportunity at Westminster Magistrates’ Court.
Her Honour Judge Dhir KC sentenced the company at the Central Criminal Court in central London last month. She fined the business £1.4 million and ordered it to pay £99,284.84 in costs.
Although the parties agreed that the case fell within the medium culpability category, the ORR said it fell in the upper end and therefore proposed that high culpability should be considered.
In the sentencing remarks, the ORR suggested that Siemens ‘fell far short of the appropriate standard by failing to put in place measures which are recognised standards in the industry and/or failing to make appropriate changes following a prior incident exposing risks to health and safety’.
The regulator contended that Siemens’ culpability should be increased by two factors. The first was the absence of adequate supervision. The second was that the Heavy Overhaul Team and the crane’s operator were not competent to carry out the tasks. Siemens, however, did not accept that the team was not competent to undertake the task.
Judge Dhir KC did not hear any oral evidence from expert witnesses on this disputed issue. She told the court: ‘I cannot be sure that the defendant’s offence included, in addition to failing adequately to supervise the [Heavy] Overhaul Team, giving the task of removing the motors to a team who were not competent to perform it.’
She added that even if she accepted ORR’s contention on this issue, it ‘would have made no material difference to the sentence which I am about to impose’.
Considering all the matters, the judge did not consider Siemens’ failings amounted to falling in the high culpability category in the guideline.
In terms of the seriousness of harm risked, she set it at the highest level. She then turned to the likelihood of harm and told the court that her sentencing would reflect the likelihood of Level A harm arising.
Taking into considering that, at the time of the accident Siemens employed around 950 people at 13 train care facilities across the UK to maintain train fleets for seven train operators and the fact that ‘there was no evidence before me of any previous (or subsequent) accident at any of those facilities involved Level A harm’, the judge concluded that the level of harm arising was low.
This, she added, placed the harm in category 3. However, she had to consider two other factors. The first was whether the offence was a significant cause of actual harm and the second was whether it exposed a number of workers or members of the public to the risk of harm.
Judge Dhir KC told the court that three other members of the Heavy Overhaul Team and a few others went into the inspection pit to try to assist the technician at a time when there was a second traction motor above the pit which had also had its mounting bolts removed.
Taking these factors into account, she moved the offence up to harm category 2.
The judge said that Siemens was a very large organisation with a turnover of £524.5 million in the year to 30 September 2021.
Taking into account an amended schedule with updated profits and losses for 2019-2022, she referenced two previous cases involving the sentencing of very large organisations and proposed £2.4 million as a starting point.
She said that this figure was ‘proportionate to the defendant’s means and sufficiently large to constitute appropriate punishment and to bring home to management and shareholders the need for regulatory compliance’.
Siemens had two previous convictions both in its wind power division, one of which had resulted in a fatality. However, it had no previous convictions in its rail operation.
Judge Dhir KC then took into consideration Siemens’ mitigating factors. It had accepted responsibility for its failings at the earliest opportunity, had taken voluntary steps to remedy the problems identified and now had effective health and safety procedures in place (see box below).
Taking these points into consideration, she reduced the fine to £2.1 million and told the court that no further adjustment was required in relation to the fine’s proportionality. However, she did reduce the fine by a third to reflect Siemens’ guilty plea at the first opportunity.
Siemens took steps to remedy the deficiencies found. After the accident, the company addressed:
1. Communication
Siemens briefed technical staff at the Acton Depot
2. Management
Siemens reviewed, re-issued their lifting plan and implemented a permit to work (PTW) system for lifting operations using slings and chains.
3. Supervision
The duty supervisor (responsible for any particular technical team) is the signatory on the lifting plan/PTW and therefore determines whether the lift is planned properly, and can take place.
(Xhead) Health and safety procedures
In a report to the coroner to assist in his consideration of the preparation of a Prevention of Future Deaths Report under Regulation 28 of the Coroners (Investigations) Regulations 2013, Siemens provided details of the steps that it had taken since June 2017 to improve its procedures. These included:
(i) Enhancements made to the management system document to ensure that the responsibilities of all staff, and specifically for holders of key positions, are clearly explained.
(ii) A revised matrix was developed, and implemented, to structure technical training and inform competence management.
(iii)A skills development programme was implemented to ensure that those appointed as supervisors had both the technical and non-technical skills necessary to fulfil the role successfully.
(iv)Whereas prior to the incident tasks were conducted in line with the VMI, with more detailed ‘how’ information and risk assessments and parts lists etc. provided in separate documents, now all relevant information is incorporated into a single document which includes illustrations to aid understanding and clarity.
(v)Staff have been consulted to ensure that the task documents reflect work tasks ‘as done in practice’, and that key safety information is highlighted. Although it is to the company’s credit that such steps have now been taken, they could easily have been taken prior to the incident and would have controlled risks from maintenance activities more effectively. They therefore lend support to the conclusion that prior to the incident, the company did not do all that was reasonably practicable to comply with its duties under section 3 of the HSWA.
