Recurring concern

Failure to assess risks before hazardous work tasks

First to latest report 19 Jun 2014 — 2 Mar 2020

Reports that mention this concern
6
Times this concern has been raised
6
Stated actions linked to this concern
7

What this concern includes

Includes failures of task-specific risk assessment before hazardous work, including missing assessments, assessments that fail to identify relevant hazards, and failures to use the assessment to determine safer methods or alternatives.

What is not included
  • Excludes generic safety culture, training, supervision or documentation deficiencies unless they directly constitute a failure of the task-risk-assessment process.
  • Excludes equipment-suitability assessments where no broader task-risk-assessment failure is identified.
  • Excludes failures in the execution of work after an adequate task-risk assessment has been completed.
  • Excludes clinical, care, environmental or other risk assessments that are not specifically assessments of hazardous work tasks.

Reports and published responses 6 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West Yorkshire Eastern

    AI-generated summary

    Gary Dean Webster · 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 Dean Webster died after a boat capsized while he was attempting to retrieve a propane gas cylinder from turbulent water at a weir. He was immersed for approximately 15 minutes, suffered cardiac arrest and multi-organ failure, and died in hospital. The principal concerns were the absence of a suitable risk assessment and approved method statement, ineffective permissioning and competence checks for safety-boat operation, and design shortcomings that exposed workers to hazardous water during debris-retrieval tasks.

    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

    Lack of suitable and sufficient risk assessment before hazardous tasks

    Wider context from the report

    “(1) To retrieve the gas cylinder the two men approached a hazardous area of turbulent water, without a formal risk assessment having taken place or a method statement approved. The two men involved had not undertaken this task before. It required them to approach a hazardous area of turbulent water. Despite this they were permitted to proceed without a risk assessment being undertaken or a method statement being approved. The task was merely delegated to them and they were left to devise a method for themselves. The concerns arising from this are (1) the failure of the Senior Engineer and Manager involved to appreciate the hazards involved (2) require a suitable and sufficient assessment of the risks involved before proceeding and (3) consider whether alternative methods of accomplishing the task might reduce or eliminate the risks to their safety. Such an approach to inherently hazardous tasks gives rise to the risk that another death may occur in the organisations named due to inadequate planning procedures. ”

    Source location

    Gary Dean Webster · 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

    Provide refresher risk-assessment training to personnel expected to undertake risk assessments.

    Verbatim wording from the response

    “There have been some changes in personnel in the two and half years since Gary’s death. Refresher training has either already been provided or has been scheduled to be provided to all of those who are in roles where they might be expected to undertake risk assessments to ensure the high levels of competence expected by BAM Nuttall remains current and front of mind, as part of BAM Nuttall’s ongoing training provision. Separately, BAM Nuttall’s dedicated health and safety team has again circulated information relating to the incident to the wider business, highlighting the need for carrying out risk assessments when undertaking new or unfamiliar work activities.”

    Source location

    2020-0049-Response-from-BAM-Nuttall-Ltd_Redacted
    Page 1 · response
    Published 10 March 2020

    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

    Construction and site-operation concerns fall outside BMM JV’s involvement and therefore are not addressed by BMM JV.

    Verbatim wording from the response

    “I understand that BAM Nuttall have responded to the Regulation 28 Report (the Report) separately and addressed you in respect of matters concerning site operations.”

    Source location

    2020-0049-Response-from-BMM-JV-Limited_Redacted
    Page 1 · response
    Published 10 March 2020

    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

    BAM Nuttall is responsible for responding to concerns concerning construction and site operations.

    Verbatim wording from the response

    “I understand that BAM Nuttall have responded to the Regulation 28 Report (the Report) separately and addressed you in respect of matters concerning site operations.”

    Source location

    2020-0049-Response-from-BMM-JV-Limited_Redacted
    Page 1 · response
    Published 10 March 2020

    Open published response

  2. 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 undertake risk assessments for work tasks

    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

  3. Warwickshire

    AI-generated summary

    Mark Richard Seward · 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

    Mark Richard Seward died after a pressurised cylinder fractured during workplace testing, ejecting debris that caused a serious head injury. Concerns included unclear definitions of pressure testing and questioned compliance with PUWER and HSE guidance, with evidence that poor practices were replicated elsewhere in the industry.

    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

    Lack of a specific risk assessment or method statement for the work

    Wider context from the report

    “(2) There was no specific risk assessment or method statement for the type of work being carried out by Mr Seward. ”

    Source location

    Mark Richard Seward · 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

    Work with the HSE and health and safety consultants to establish comprehensive risk assessments and safe systems of work.

    Verbatim wording from the response

    “4. AGD are working closely with the HSE to ensure that risk assessments and safe systems of work are in place. AGD are also working with the close assistance of the company’s health and safety consultants throughout this process to identify all risks, work duties and equipment, to ensure nothing is overlooked.”

    Source location

    SEWARD-Response
    Page 2 · response
    Published 5 April 2016

    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

    Review risk assessments, COSHH assessments and safe systems of work following the accident.

    Verbatim wording from the response

    “Following the accident on 27th May 2015 the company reviewed all risk assessments, COSHH assessments and safe systems of work. AGD’s health and safety consultants were involved in this process and the Supervisory Team must access and use these documents when planning new tasks, or allocating work to personnel.”

    Source location

    SEWARD-Response
    Page 2 · response
    Published 5 April 2016

    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

    Develop task-specific safe systems of work and deliver toolbox talks to relevant employees, maintaining records and discussing them through the safety committee.

    Verbatim wording from the response

    “Having drawn up individual safe systems of work, toolbox talks were delivered to all employees likely to be involved in the relevant tasks to ensure that they understood the task and the controls in place to work safely. A full record is kept of these toolbox talks, and they continue to be discussed by the Health and Safety Committee at monthly meetings to ensure a rolling programme of continuous improvement.”

    Source location

    SEWARD-Response
    Page 2 · response
    Published 5 April 2016

    Open published response

  4. Norfolk

    AI-generated summary

    ARTHUR CAXTON MASON · 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

    On 9 July 2014, Arthur Caxton Mason, aged 21, died after being buried beneath moving grain while cleaning inside a grain bin at Hall Farm. The principal concerns were inadequate staff training in risk assessment, failure to recognise hazards in grain-bin cleaning procedures, and the absence of an emergency plan for hazardous areas on the farm.

    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 identify risks in farm task risk assessments

    Wider context from the report

    “(2) It was unclear from the evidence that staff involved in carrying out Risk Assessments recognised the risks of carrying out various tasks on the farm. The current document "Procedure for Cleaning out Grain Bins" does not recognise any risks or hazards in carrying out the tasks and it was not clear from the evidence a Risk Assessment is in place for this new procedure, introduced following and as a result of Mr Mason’s death. ”

    Source location

    ARTHUR CAXTON MASON · 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 and update the grain-store risk assessment and method statement for the revised cleaning method.

    Verbatim wording from the response

    “With regards to the specific grain store building, a new risk assessment has been done along with a method statement. It is now more detailed and addresses the risks of the new method of work. A copy is attached. This now addresses the risks that are present in the new cleaning method and the appropriate method of work for cleaning the bins. This document was updated as a result of a visit from the HSE, after the Inquest. A version of this updated document will also be sent independently to the HSE and it will also be subject to further review by Cope Safety Management Ltd (see below).”

    Source location

    2016-0128-Response-by-Maurice-Mason-Ltd
    Page 2 · response
    Published 1 April 2016

    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

    Commission CSML to review and amend health-and-safety policies, risk assessments, safe systems, emergency plans and the employee handbook.

    Verbatim wording from the response

    “In order to address the Coroner’s concerns and to address safety issues across MML, the Company has instructed Cope Safety Management Ltd (CSML) (qualifications attached) to review and amend:-”

    Source location

    2016-0128-Response-by-Maurice-Mason-Ltd
    Page 2 · response
    Published 1 April 2016

    Open published response

  5. 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 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

  6. West Somerset

    AI-generated summary

    Names not published · 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

    Seven people died when 34 vehicles collided in thick fog on the M5 motorway near Taunton on 4 November 2011; 51 others were injured. The concerns related to preventing vehicles entering areas of severely reduced visibility, detecting and warning of fog, and managing risks from firework displays that may increase fog or smoke near highways.

    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 assess humidity and wind conditions immediately before firework displays

    Wider context from the report

    ““B” To consider whether or not risks arising from firework displays being held in periods of very high humidity can be greatly reduced if the City and Guild’s courses for Firers and Senior Firers (being the only persons able to conduct a firework display using class IV fireworks) had instruction in realising when such risks arose. AND before operating any display Firers had prepared :- (i) a risk assessment which took account of the topography of the area, nearby watercourses, prevailing wind conditions, identifying highways and all other matters relevant for the safety of the users thereof onlookers and nearby residents. (ii) Assessed the humidity, wind direction and speed immediately before the display, (iii) Positioned lookouts to see if any smoke or fog was approaching a highway or railway line in the immediate vicinity. (iv) Had immediate access to a communication link to the emergency services and (v) Be able to stop the display immediately if an emergency arises AND to consider whether Firers and Senior Firers should be licensed by law for periods of five year AND whether Local Licensing Authorities shall advise persons holding firework displays of the risks referred to herein. ”

    Source location

    Names not published · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026