Recurring concern

Unsafe selection and execution of work methods exposing employees to hazards

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First reported 6 Jan 2014•Latest report 12 Feb 2025

Definition

What this concern includes

Includes recurring deficiencies in the selection, planning or execution of employee work methods where the report directly links the deficiency to unsafe working practices or exposure to hazards, including trial-and-error working, unsafe method changes and comparable unsafe execution practices.

Not included

  • Excludes failures belonging to a specifically named safety system, pathway or hazard where that wider issue provides the appropriate parent boundary.
  • Excludes generic training, supervision, safety-culture, documentation or communication deficiencies unless the report directly ties them to unsafe selection or execution of work methods.
  • Excludes hazards or unsafe conditions unrelated to how work methods are selected or executed, including pedestrian crossing, healthcare, internet-access and emergency-planning concerns.
  • Excludes a particular equipment, task or lifecycle failure when the report does not support a recurring unsafe work-method condition beyond that manifestation.
Reports
9

Distinct published reports

Individual concerns
13

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
11

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Blatchington Mill School1
Brighton and Hove City Council1
Frisbys Solicitors (legal representatives of John Wright's estate)1
Joseph Holt Limited1
Mac Skip Hire Limited1
Mineral Products Association1
National Rigging Advisory Group (NRAG)1
National Union of Rail, Maritime and Transport Workers1
Network Rail1
Office of Rail and Road1
Professional Lighting and Sound Association Limited1
Rail Accident Investigation Branch1
Recipient name withheld1
Unusual Rigging Limited1
Ward Bros (Malton) Limited1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Teesside and Hartlepool

    AI-generated summary

    Gary Lee JAMES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Gary Lee James died at James Cook University Hospital on 11 January 2019 from injuries sustained when metal frames fell on him while he was trying to move them at Ward Bros. The report identified concerns including inadequate risk assessment, training, equipment, supervision and first-aid provision, as well as failures to address employees’ safety concerns and unsafe working conditions.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Trial-and-error working practices exposing employees to hazards

    Wider context from the report

    “2. Workers undertaken on a trial-and-error basis, exposing employees to hazards. ”

    Source location

    Gary Lee JAMES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Pressure to continue tasks despite health and safety concerns and dangers

    Wider context from the report

    “8. A general approach of having to “get on with a task” in spite of health and safety concerns and dangers to employees. ”

    Source location

    Gary Lee JAMES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reviewed health and safety procedures and implemented improved risk assessments and safe systems of work across all activities.

    Verbatim wording from the response

    “On the wider subject of Ward Bros general health and safety procedures, risk assessments and safe systems of work were in place for all other activities. These had been drafted with the assistance of third parties with the appropriate expertise. Following the accident involving Mr James, Ward Bros conducted a full review of the existing health and safety procedures, in conjunction with third party experts. This resulted in improved risk assessments and systems of work which are reviewed on an annual basis. A training programme is in place which ensures employees receive regular training on the safe systems of work and updates are provided by way of toolbox talks and safety notices.”

    Source location

    Response from Ward Bros (Malton) Ltd
    Page 1 · response
    Published 14 February 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ceased the devanning operation and stopped undertaking further devanning work.

    Verbatim wording from the response

    “No further devanning has been undertaken by Ward Bros since the accident involving Gary James and we have no plans to become engaged in the process again in the future. For this reason, there is no risk of future deaths occurring at Ward Bros as a result of employees, or anyone else, devanning shipping containers.”

    Source location

    Response from Ward Bros (Malton) Ltd
    Page 1 · response
    Published 14 February 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ceasing devanning means there is no ongoing risk of deaths from employees or others undertaking that process.

    Verbatim wording from the response

    “No further devanning has been undertaken by Ward Bros since the accident involving Gary James and we have no plans to become engaged in the process again in the future. For this reason, there is no risk of future deaths occurring at Ward Bros as a result of employees, or anyone else, devanning shipping containers.”

    Source location

    Response from Ward Bros (Malton) Ltd
    Page 1 · response
    Published 14 February 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing and improved risk assessments, safe systems of work, training and expert support address safety concerns for other activities.

    Verbatim wording from the response

    “On the wider subject of Ward Bros general health and safety procedures, risk assessments and safe systems of work were in place for all other activities. These had been drafted with the assistance of third parties with the appropriate expertise. Following the accident involving Mr James, Ward Bros conducted a full review of the existing health and safety procedures, in conjunction with third party experts. This resulted in improved risk assessments and systems of work which are reviewed on an annual basis. A training programme is in place which ensures employees receive regular training on the safe systems of work and updates are provided by way of toolbox talks and safety notices.”

    Source location

    Response from Ward Bros (Malton) Ltd
    Page 1 · response
    Published 14 February 2025

    Open published response
  2. Buckinghamshire

    AI-generated summary

    Anthony William Rockall · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Anthony William Rockall died at John Radcliffe Hospital on 26 April 2022 from a head injury sustained when he fell from the tailgate of a truck during unloading at a reclamation yard. The pallet truck was longer than the tailgate, and concerns were raised about the unloading method, the weight on the tailgate, and the absence of subsequent reviews or changes to working practices, leaving risks of loads, equipment or individuals falling from the tailgate.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to review and change unloading working practices

    Wider context from the report

    “It was clear from the evidence that the pallet truck being utilised and the manner of unloading were incompatible with the truck being unloaded in that the pallet truck was longer than the tailgate of the truck and the method adopted required the pallet truck wheels to drop off the tailgate, grounding the load. There were also concerns expressed about the weight of the load, pallet truck and two individuals on the tailgate. Buckinghamshire Council evidence indicated a letter had been written to you on 27th September 2022 but your evidence was that this had never been received. The letter was described as informing you that you must review health and safety procedures at your premises, including the use of the pallet truck and the loading and unloading of client and casual workers’ vehicles. It was indicated you were also to assess the suitability of equipment for the task to be undertaken and to review who was permitted to use the equipment and when. Evidence at the Inquest was that there had been no review and no change of working practices since the incident involving Tony Rockall and that a pallet of bricks delivered on a truck such as was being used by Mr Rockall would be unloaded in exactly the same way now as then. It is clear that such practices could give rise to the toppling of a load, the pallet truck or an individual falling from a truck tailgate with the risk of fatal injuries arising. ”

    Source location

    Anthony William Rockall · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Bedfordshire and Luton

    AI-generated summary

    Russell Paul BOWRY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Russell Paul Bowry died after falling 11 metres through exposed roof material while working at height on a stage structure at Cardington Studios. The concerns included inadequate planning and supervision of work at height, insufficiently designed fall-protection systems, and unsafe working practices affecting self-employed riggers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unsafe working practices routinely occurring in rigging work

    Wider context from the report

    “(c) Unsafe working practices are routinely encountered by riggers in your industry and due to the structure of your industry – in which a small number of employers engage a large pool of self-employed riggers for individual jobs of short duration – riggers appear to have little influence over the fall protection or fall prevention measures that are put in place to keep them safe. ”

    Source location

    Russell Paul BOWRY · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  4. Brighton and Hove

    AI-generated summary

    David Alexander MOBS​​BY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David Alexander MOBS​​BY fell while working at Blatchington Mill School on 3 August 2018 and was found unconscious after working alone. The report raises concerns about inadequate health and safety arrangements for work at height, lack of training, supervision and risk assessment, and delays in providing CPR, including the absence of a first aider or designated person on site.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to plan work methods and equipment

    Wider context from the report

    “(1) Brighton and Hove City Council were “advising” Blatchington Mill School (BMS) on health and safety. They were apparently using a template which made no mention of work at height when considering the health and safety of the facilities (caretaking/cleaning) department at BMS. This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height. (2) Although Mr MOBS​​BY was employed either by Brighton and Hove City Council or BMS or a combination of the two, he was not monitored or instructed in his work. He was allowed to choose how, when and where he worked. Even though anyone who knew his job description or knew Mr MOBS​​BY was aware that he was using ladders and step ladders he was untrained with regard to working at height. • On the 3rd August 2018 he was unchallenged when he announced his work programme for the day. • His line manager’s did not instruct him with regard to the jobs he did, even though those jobs were considered to be unnecessary by the managers. • No methodology was explored when he announced his job for the day, there was no discussion about the equipment that he was going to use. • There was no risk assessment undertaken in respect of any of the jobs that he did. • He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day. • His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade. • He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly, from 0848 hrs until his fall at 1255 hrs having taken one forty minute break at 1100 hrs. • It seems clear that working at BMS formed a huge part of Mr MOBS​​BY’s life. He had been there for many years and was probably set in his ways and not amenable to being managed. • Those managing him were all relatively new to their managerial posts and yet none of them had received any management training. It was clear they had no idea how to deal with him. • They were not assisted by the fact that it was supposed to be the case that every employee was appraised annually. • There was no evidence at all to suggest that Mr MOBS​​BY had ever been appraised. I am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and I think the matters raised in it should have wider discussion throughout the Country. ”

    Source location

    David Alexander MOBS​​BY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. Manchester West

    AI-generated summary

    Elaine Horrocks · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Elaine Horrocks died after falling down cellar steps at the Rose Hill Tavern when a door was left ajar. The report identified an unsafe method of accessing the cellar and insufficient guarding of the cellar steps against accidental entry by the public.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unsafe method of work for travel to and from the cellar

    Wider context from the report

    “(1) There is an unsafe method of work in going to and from the cellar. ”

    Source location

    Elaine Horrocks · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  6. Rutland and North Leicestershire

    AI-generated summary

    Beverley Dorothy Upton · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Beverley Dorothy Upton, a heavy goods vehicle driver, died after being trapped between a loading shovel bucket and the side of her lorry while it was being loaded at work on 4 November 2015. Concerns included the method of loading, the lack of clear written and enforced rules requiring drivers to remain in their cabs and wear high-visibility clothing, and insufficient training and health and safety documentation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unsafe method of operating the CAT Loading Shovel to load lorries

    Wider context from the report

    “(1) The method of work employed at the time, in operating the CAT Loading Shovel to load lorries, put anyone in the vicinity at risk of injury or death ”

    Source location

    Beverley Dorothy Upton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  7. Norfolk

    AI-generated summary

    PETER JOHN BUCKLE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Peter John Buckle was injured at work when a post propping open a trailer tailgate slipped, causing the tailgate to fall. He was airlifted to Addenbrooke's Hospital and died later that day from his injuries. Concerns included the failure to reassess the risks when the original work method became unavailable and an apparent lack of a health and safety culture at ground level.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to reassess work methods when the existing method is no longer viable

    Wider context from the report

    “(1) Although a risk assessment was in place for the original method of carrying out the task (with the telehandler and grab), once this method was no longer viable a risk assessment was not carried out or considered prior to steps being taken with regard to the next method under consideration, namely to throw the rubbish over the side of the trailer; in that the trailer was reversed to the rubbish site, a telephone call was made to 2 other employees to assist and protective equipment was being obtained. This left Mr Buckle to assume the work was to be carried out in this way, whether or not the Site Manager was of the view the method of work was still under consideration. In any event this method of carrying out the work was blatantly unsafe. (2) The employees left at the site of the rubbish, decided on a third method of carrying out the work, without any thought for health and safety. Although health and safety induction training had been undertaken and managers had received further training, a health and safety culture was not apparent from the evidence, particularly at “ground level”. ”

    Source location

    PETER JOHN BUCKLE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to communicate and control whether a work method has been authorised

    Wider context from the report

    “(1) Although a risk assessment was in place for the original method of carrying out the task (with the telehandler and grab), once this method was no longer viable a risk assessment was not carried out or considered prior to steps being taken with regard to the next method under consideration, namely to throw the rubbish over the side of the trailer; in that the trailer was reversed to the rubbish site, a telephone call was made to 2 other employees to assist and protective equipment was being obtained. This left Mr Buckle to assume the work was to be carried out in this way, whether or not the Site Manager was of the view the method of work was still under consideration. In any event this method of carrying out the work was blatantly unsafe. (2) The employees left at the site of the rubbish, decided on a third method of carrying out the work, without any thought for health and safety. Although health and safety induction training had been undertaken and managers had received further training, a health and safety culture was not apparent from the evidence, particularly at “ground level”. ”

    Source location

    PETER JOHN BUCKLE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure that work methods are safe

    Wider context from the report

    “(1) Although a risk assessment was in place for the original method of carrying out the task (with the telehandler and grab), once this method was no longer viable a risk assessment was not carried out or considered prior to steps being taken with regard to the next method under consideration, namely to throw the rubbish over the side of the trailer; in that the trailer was reversed to the rubbish site, a telephone call was made to 2 other employees to assist and protective equipment was being obtained. This left Mr Buckle to assume the work was to be carried out in this way, whether or not the Site Manager was of the view the method of work was still under consideration. In any event this method of carrying out the work was blatantly unsafe. (2) The employees left at the site of the rubbish, decided on a third method of carrying out the work, without any thought for health and safety. Although health and safety induction training had been undertaken and managers had received further training, a health and safety culture was not apparent from the evidence, particularly at “ground level”. ”

    Source location

    PETER JOHN BUCKLE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure that employees select work methods with regard to health and safety

    Wider context from the report

    “(1) Although a risk assessment was in place for the original method of carrying out the task (with the telehandler and grab), once this method was no longer viable a risk assessment was not carried out or considered prior to steps being taken with regard to the next method under consideration, namely to throw the rubbish over the side of the trailer; in that the trailer was reversed to the rubbish site, a telephone call was made to 2 other employees to assist and protective equipment was being obtained. This left Mr Buckle to assume the work was to be carried out in this way, whether or not the Site Manager was of the view the method of work was still under consideration. In any event this method of carrying out the work was blatantly unsafe. (2) The employees left at the site of the rubbish, decided on a third method of carrying out the work, without any thought for health and safety. Although health and safety induction training had been undertaken and managers had received further training, a health and safety culture was not apparent from the evidence, particularly at “ground level”. ”

    Source location

    PETER JOHN BUCKLE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete behavioural safety training to improve decision-making when tasks or circumstances deviate from normal procedures.

    Verbatim wording from the response

    “Wayland Farms Limited has put in place new programmes to deal with health and safety since the accident. We refer to Page 2 of the Health & Safety Executive’s Fatal Incident Report dated 28th April 2015 in this regard (copy attached marked Exhibit “1”). A training program based around behavioural safety with the aim of improving the safety culture within Wayland Farms Ltd has been completed, this was a blend of theory and practice in both an engaging and thought-provoking way to enable smarter decisions and actions in relation to tasks and situations occurring that fall outside of what is expected to be the normal procedure or activity.”

    Source location

    2015-0425-Response
    Page 1 · response
    Published 3 November 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide further management and worker training emphasising communication of safety information from managers to workers.

    Verbatim wording from the response

    “This program called “stop and think” has been designed to help the worker understand the significance and importance of planning for key decisions’ when activities or procedures have a need to be amended due to a change in circumstance. The significant element of this program being the worker is asked to stop and contact their Unit Manager at the critical point; the decision and task planning is then carried out as a duel role with both levels of competence, the objective being to prevent the worker taking quick or hasty actions in an “act now, think later” way. Management”

    Source location

    2015-0425-Response
    Page 1 · response
    Published 3 November 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Confirm safety-critical communications in writing when they are delivered.

    Verbatim wording from the response

    “Written Documentation:”

    Source location

    2015-0425-Response
    Page 2 · response
    Published 3 November 2015

    Open published response
  8. Nottinghamshire

    AI-generated summary

    John Robert Wright · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Robert Wright, a Network Rail track maintenance worker, was struck by an oncoming train while working at Newark Northgate station on 22 January 2014 and died from his injuries on 31 January 2014. The concerns identified were the need for frequent reminders and training about vigilance, clearer briefings on train routes and safe working methods, and a balance between hearing protection and the ability to hear approaching trains.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to brief and enforce safe methods of work

    Wider context from the report

    “Despite its obviousness I am concerned that track side maintenance crew need frequent reminders/training as to the need to maintain vigilance at all times when working in the vicinity of lines along which trains can pass. When working in the vicinity of stations and/or points on the network where there are multiple lines, crews should be fully briefed as to the potential route of trains through stations or across any such lines, including, where reasonably practicable, consulting timetables; and safe methods of work are briefed and enforced. Further, I am concerned that there needs to be a balance struck between the ensuring that track side maintenance crews are provided with personal protective equipment such as hearing protection and an ability to hear oncoming locomotives/trains. ”

    Source location

    John Robert Wright · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  9. North and West Cumbria

    AI-generated summary

    Martin Geoffrey McGlasson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Martin Geoffrey McGlasson, a plant operative, died at the scene on 2 September 2011 after a nearly three-tonne concrete staircase he was slurrying fell onto and crushed him. The principal concerns were the unsupported method of working, debris and incorrect batten placement potentially causing instability, and a mismatch between the method used on the shop floor and the arrangements described in risk assessments. The report also identified that similar methods were widespread and that inexpensive safer alternatives were available.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Risk of fatal accidents from the widespread method of work

    Wider context from the report

    “(1) The Health and Safety Director for Thomas Armstrong Holdings Ltd gave evidence that the method of work undertaken by ACP prior to Mr McGlasson’s death is in widespread use throughout the industry. Thus a number of your members are at risk of deaths occurring in their establishments in similar circumstances to Mr McGlasson’s death, and presumably at risk of having Prohibition Notices served on them by the HSE. ”

    Source location

    Martin Geoffrey McGlasson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Cease storing and working on staircases standing on unrestrained stringer edges.

    Verbatim wording from the response

    “The Company has listed below the actions implemented in relation to the precast concrete stair manufacturing process. Actions that were implemented immediately post the fatal accident and prior to recommencement of the stair manufacturing process:-”

    Source location

    2014-0001-Response-by-DWF
    Page 3 · response
    Published 6 January 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Install a TOAST RACK support system with chock blocks to restrain stairs before crane release and dressing work.

    Verbatim wording from the response

    “The Company has listed below the actions implemented in relation to the precast concrete stair manufacturing process. Actions that were implemented immediately post the fatal accident and prior to recommencement of the stair manufacturing process:-”

    Source location

    2014-0001-Response-by-DWF
    Page 3 · response
    Published 6 January 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Cease manually tipping stairs from their stringer edges onto their soffits.

    Verbatim wording from the response

    “3. Immediate cessation of manually tipping stairs from their stringer stood edges to being laid flat on their soffit.”

    Source location

    2014-0001-Response-by-DWF
    Page 4 · response
    Published 6 January 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Install and use a TIPPING PIT to rotate stairs safely onto their soffits using overhead-crane lifting points and remote operator positioning.

    Verbatim wording from the response

    “4. Installation of a TIPPING PIT whereby all stairs are to be transported from the TOAST RACKS to the TIPPING PIT, using the overhead crane, and purpose lifting points on the top edge stringer of the precast stair, where the stair is then slowly lowered into the gravel TIPPING PIT allowing the stair to rotate safely onto its soffit. All operatives including the crane operator are stationed at a safe distance external to the TIPPING PIT.”

    Source location

    2014-0001-Response-by-DWF
    Page 4 · response
    Published 6 January 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise the risk assessment and draw up amended working procedures for supporting and turning precast stair units.

    Verbatim wording from the response

    “As a result of the death of Mr McGlasson and in light of the particular and unprecedented circumstance of the incident, other measures have also been taken, which include:”

    Source location

    2014-0001-Response-by-DWF
    Page 4 · response
    Published 6 January 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver toolbox talks, issue revised safety documents, consult operatives and supervisors, and adopt an agreed safe system for precast-stair manufacture.

    Verbatim wording from the response

    “6. A series of further TOOLBOX TALKS were also held involving all those concerned in the Management, Supervision & Manufacture of Precast Concrete Stairs reflecting the revised Risk Assessment & Safe Working Method and a copy of these documents were issued to all those noted above. Subsequent to issue to all general operatives and supervisors in the stair department, further consultation took place resulting in adoption of an agreed safe system of work in the manufacturing process of precast stairs, from mould preparation to completion.”

    Source location

    2014-0001-Response-by-DWF
    Page 4 · response
    Published 6 January 2014

    Open published response
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Data last updated 7 September 2026