We spoke to Health and Safety Executive (HSE) inspector Andrew Johnson about a case where a one-tonne pallet of glass fell on a United Pallet Network (UK) Limited’s employee, causing life-changing injuries.
On 30 September 2016, Andrew Potts was working for United Pallet Network at its hub in Lichfield, Staffordshire, when a lorry containing a consignment of four pallets of glass arrived. The pallets had not been appropriately loaded or secured and fell out of the trailer onto the 58-year-old as he made attempts to adjust them. Andrew broke his neck in five places, in addition to suffering other injuries, and has been left permanently disabled.
We spoke to HSE inspector Andrew Johnson about this 'tragic and entirely avoidable accident'.
United Pallet Network (UPN) derives its name from the fact that a range of different haulage companies operate together and use this UPN site in Lichfield as a freight forwarding depot, according to Andrew.
'In this case it was a pallet of glass on a curtain-sided lorry that had come from the north and was heading to the south. The haulage lorry was dropping the load off at Lichfield, then a freight checker – in this case Andrew Potts – would scan the pallets before they were unloaded and loaded onto other lorries, then another haulage company from the south would pick up the load and deliver it.
'However, the pallet of glass hadn’t been stored on the trailer correctly. It wasn’t properly secured – there weren’t enough straps on the lorry and even the straps that were there wouldn’t have been sufficient to hold it in place. It shouldn’t have been on the road at all actually – it should never have left its original depot.
'The load had shifted in transit and when it arrived at UPN at around midnight, there was a bulge in the curtain because it was leaning on it. The lorry driver – who was a contracted driver more used to driving supermarket lorries which don’t require loading expertise in the same way – arrived on site and asked Andrew to help him deal with the shifted load.
'They tried different ways to fix the problem. Unfortunately, while Andrew was checking the pallet after having tried to move it, something broke and the pallet of glass fell on him.”
The investigation findings
'Every investigation I have been involved in, and probably almost every investigation HSE is involved in, feature incidents that could have been avoided, said Andrew.
'UPN had risk assessments, but if an accident has occurred it’s often because the risk assessment is very poor: it’s often either too basic, too generic or it hasn’t been communicated effectively. In this case, it was all three: it was too generic, it hadn’t been communicated, and it wasn’t specific to the different risks that could arise.
'Loading and unloading lorries is the bread and butter of what UPN does – it receives pallets on the back of lorry trailers. It therefore shouldn’t be unforeseeable that these things might shift in transit. It’s also not unforeseeable that haulage companies who transport these things might load them or secure them incorrectly.
'UPN did have nominal documentation that essentially told its workers to be careful, but the company didn’t specify exactly what needed to be done and it hadn’t provided proper instruction or training to staff to say what they needed to do. Some staff were not aware of written procedures for dealing with unsafe loads and could not recall receiving any instruction or training.
'They learned on the job, from others, or worked out for themselves what to do. In addition, there was no monitoring of any working practices, only auditing of vehicles as they came into the depot. There are lots of different complex scenarios that could happen when loads arrived, but UPN hadn’t appreciated that there needed to be recovery procedures to deal with any loads that had shifted in transit.
'At the HSE, we involved a mechanical engineering specialist to assist the investigation and his opinion was that recovery procedures were not adequate for complex scenarios that could occur from the receipt of unstable loads. Procedures weren’t understood or followed by the people who needed to know these things.
'It was essentially a case of staff working things out as they went. But you can’t just expect staff to figure it out as they go along or learn by experience when it’s something with the potential to be as high risk as this. We would expect employees to have much more definitive instructions.'
At Stafford Crown Court, more than six years after the incident occurred, United Pallet Network (UK) pleaded guilty to section 2(1) of the Health and Safety at Work Act. It was fined £94,667 and ordered to pay costs of £7,590.
'There are a number of things to take from this case. If your job is to load and unload lorries, you need to be absolutely sure that what you are doing is safe. There should be no ambiguity about how you achieve that: you should have clear instructions and training so that you feel confident that, even if there is a shifted load, you know how to deal with it,' Andrew added.
'The fact that there was a trial-and-error element to the way UPN staff went about this is very concerning. It has to be crystal clear what the risk is and what needs to be done to keep staff safe. If there is any uncertainty about anything, there should be a system in place where they can get guidance to deal with the problem correctly. They shouldn’t have to be making it up as they go along in such a high-risk environment.
'More broadly, the lesson to take is: get the basic and obvious things right first. If you’re a business who specialises in something specific, make sure you get everything to do with that specific element right first. Don’t think about trip hazards or all the nice easy wins that people often talk about in general health and safety. Think first and foremost about the actual specific health and safety risks that are particularly applicable to your business: what risks set you apart from everyone else? In this particular case, the key things were safe loading and lifting operations and workplace transport.
'When you don’t get the obvious things right in regard to your key undertakings, that’s when things can go catastrophically wrong. Perhaps people in businesses become blind to the obvious safety aspects on a day-to-day level, and maybe what they need is someone from outside to come in to look at those things and offer suggestions.
'So think about what it is that you actually do as a business and the risks in your business that make you different to other firms. On this occasion, UPN just didn’t get the basics right.'