The company has since introduced new systems to reduce the risk to workers from vehicles being driven onto the production line.
Mark Widnall, aged 59, from Coventry, was carrying out vehicle checks on the Land Rover line at Jaguar's Lode Lane plant in Solihull in the West Midlands on 8 February 2015 when the accident occurred.
Delivery driver Daniel Leahy was driving a Range Rover Sport vehicle onto the start of the production line, an event that normally happens 48 times an hour. As Leahy approached the line, he accidentally hit the accelerator, hitting the back of the last car he had parked and causing a four-car shunt.
Widnall, who was crossing the production line, was trapped between the second and third vehicles. He sustained severe injuries and his right leg was amputated above-the-knee. Two other employees also sustained minor injuries.
The Health and Safety Executive (HSE) investigation found that Widnall had been collecting the "build card" (a quality control record) for stamping from under the front windscreen wiper of the second vehicle when the shunt happened. Each worker on the line is required to stamp the card after completing a vehicle check.
The incident happened on a Sunday morning during an overtime shift. Lode Lane employs a rotating three-shift pattern and corresponding shift workers are usually asked to cover the overtime shift. However, on this occasion, the driver who normally moved vehicles up the line declined the opportunity to work overtime and Leahy substituted for him. The HSE found that Leahy was not familiar with the drive-on role and had not received training.
HSE inspector John Glynn told IOSH Magazine: "Jaguar Land Rover has a very detailed work element sheet that explains the safety procedures in the plant. Leahy had never seen that particular work element sheet, so the important part of it, like driving the car on, putting it in park and applying the electronic parking brake (EPB), he hadn't done specifically -¦ He was a driver and he has done a similar role to this in the plant but on the production line there was a specific set of instructions, which the company's own processes say drivers must be aware of, sign and receive training on, and he hadn't."
The HSE also found that the car maker had failed to separate the workers on the production line from the moving vehicles properly. In the Lode Lane plant, workers are required to leave several car lengths between themselves and the vehicles being driven onto the line.
"If they are all working at a steady pace, they should travel with the car down the production line," explained Glynn. "However, if they work a bit quicker than the cars being delivered, they will catch up with the vehicles as they are being delivered onto the line. There is tendency to work more quickly so they can work earlier on the cars. The advantage of that is that if they work on the cars as they are being delivered, it gives them an extra few minutes at lunchtime. It's called 'creep forward'. We heard evidence that that had happened on a few occasions and no evidence to show there had been any prevention of [creep forward] as it was at the time of the accident."
The HSE charged the company with breaching s 2 of the Health and Safety at Work Act. Jaguar Land Rover initially entered a "no indication of plea" at Birmingham Magistrates' Court on 10 June 2016, followed by a not guilty plea at Birmingham Crown Court on 15 July. The case was then listed at Birmingham Crown Court for an eight-day trial starting on 9 January 2017.
The court heard Leahy had not put the previous two vehicles in park mode as he should have. He assumed incorrectly that the vehicle's EPB system would engage when he turned off the engine and opened the door. Widnall said vehicles had been left on the line before without their parking brakes applied. However, the court heard that he would still have been hit had the vehicle been left in park.
"According to Widnall's statement, one of the drivers who would normally have done the drive-on had insisted that they didn't start work on the vehicle as he was delivering it and that they waited until he was parked up, put the handbrake on, got out of the vehicle and moved away," said Glynn.
Jaguar Land Rover's own risk assessment had identified a risk of crush, collision with an object or person while moving vehicles up the line. The manufacturer had imposed speed limits of 8 kph and reduced the vehicles' maximum speed to 32 kph in the final assembly (FA) 1 area, which is dedicated to Land Rover and Range Rover production. In addition, it had also trained drivers and other workers to beware of moving vehicles.
However, the court was also told that Jaguar Land Rover had not thought through the extent of the hazards, including the possibility that a driver could press the accelerator rather than the brake.
Had the company installed a buffer zone to prevent employees from working on vehicles near the line's entry point, it would have eliminated the risk. Training was also found to be inadequate.
In his sentencing remarks, Judge Philip Parker said that because Jaguar Land Rover had not truly identified the extent of the risk, the car manufacturer had never sought statistics on whether shunts occurred in other factories. While there had been no hard evidence of earlier accidents, there was at least one in the six months following the accident, though without serious consequences.
The judge assessed Jaguar Land Rover's culpability as medium because while the company had systems in place, they were insufficient and it had not fully considered the extent of the risk. The seriousness of the harm was a medium risk of level A (death, physical or mental impairment or significantly reduced life expectancy) or a high risk of level B (physical or mental impairment or a progressive, permanent or irreversible condition), placing the offence in harm category 2. The risk, he said, was to anyone working on the lines, and the s 2 breach was the cause of the actual harm.
Jaguar Land Rover's pre-tax profit of £1.5bn placed it significantly above the over-£50m threshold for a large organisation. The judge said the starting point for the fine was £600,000 (in the £300,000-£1.5m range).
However, Judge Parker referred to R v Thames Water Utilities and the Court of Appeal's suggestion that organisations which have offended negligently once or twice may face a substantial increase in fine levels. Jaguar Land Rover had two previous convictions.
In the first case, Jaguar Land Rover was fined £30,000 at Liverpool Crown Court for breaches at the company's factory in Halewood on Merseyside on 26 September 2011.
The second case, another incident at the Solihull plant in 2013, involved a 57-year-old maintenance electrician. The car manufacturer pleaded guilty to safety breaches after the worker was dragged into inadequately guarded machinery, suffering life-threatening crush injuries.
In sentencing, the judge said that he had to take the previous offences into account but in the context that Jaguar Land Rover's employees carry out millions of manoeuvres every day.
He also took into account the steps taken by the company to prevent a repeat of the accident, and the fact that the car manufacturer had sought to have an effective safety and health system in place. This included considering how it could conduct its operations in accordance with its duties under the Health and Safety at Work Act.
Jaguar Land Rover was fined £900,000 and ordered to pay £49,800 in costs.
The car maker has introduced a number of measures since the accident to improve safety procedures in the plant, including installing a buffer zone to prevent employees from working on vehicles close to the driver.
"Employees are now moved four vehicles down the track," Glynn explained, "and there is a physical barrier to stop them going further back towards the delivery point."
Jaguar Land Rover have also added a series of painted chevrons in the buffer zone to highlight the area as dangerous and installed permanent fencing along the production line to separate the vehicles from adjacent work areas in case vehicles are shunted off the line. The car maker has also introduced a new system of cameras and video screens so that drivers can clearly see the alignment of the vehicle with the conveyor.
Glynn added: "Before they had this system, the driver had to lean out the window to see the vehicle wheels line up. Range Rovers are big vehicles and it's a precision job to drive it on to the production line. It has to be done accurately."
