Recurring concern

Unsafe planning and control of lifting operations

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First reported 22 Oct 2015•Latest report 24 Nov 2020

Definition

What this concern includes

Includes failures in the dedicated lifting-operation process, including identifying the actual lifting method, preparing and agreeing a suitable lift plan or risk assessment, specifying load orientation and handling instructions, defining stop conditions and required supervision, and ensuring the plan is approved and communicated before work begins.

Not included

  • Excludes generic work-method, training, communication or safety-management deficiencies where no lifting-operation planning or control failure is identified.
  • Excludes equipment design, maintenance or inspection failures where the lifting operation's planning and control process is not deficient.
  • Excludes failures in loading or transport operations that do not involve lifting operations or their dedicated safety controls.
  • Excludes implementation failures occurring after a complete, approved and communicated lifting plan has been established, unless the plan or its control arrangements were themselves inadequate.
Reports
2

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2015–2020

First to latest report issue date

Stated actions
8

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.

C.M.F. Limited1
Laing O'Rourke1
PCR Steel Ltd1
Recipient name withheld1
SE Galvanisers Ltd1

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. Essex

    AI-generated summary

    Christopher Sparks · 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 4 April 2019, Christopher Sparks, a HGV driver, was struck by a falling steel balcony frame while he was on the trailer bed during loading. The concerns included the absence of an approved safe loading and lifting plan, a banksman, a clearly marked driver area, and suitable equipment for moving and loading the products.

    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 an approved and agreed loading and lifting plan

    Wider context from the report

    “(1) Ahead of the incident, there was no approved, safe loading and lifting plan in place and agreed between the two firms ”

    Source location

    Christopher Sparks · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Richard LACO · 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

    Richard Laco died on a building site at the Francis Crick Institute when a landing fell on him while it was being tilted into place. The fitting process used a different methodology from earlier landings, but the method statement, risk assessment and lift plan did not describe the process or provide key safety instructions. The report also raised concerns about inadequate understanding of the planning and approval requirements among some site witnesses.

    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 of method statements, risk assessments and lift plans to address changed landing-fitting processes

    Wider context from the report

    “1. The fitting of the two below ground landings in core D of the development at the Francis Crick Institute utilised a different methodology to the landings already fitted in cores A and F. The shape of the landings was trapezoid rather than rectangular; and they were lowered vertically to ground level and then later raised & tilted to pass the side fins; rather than simply being lowered from the top directly into place. However, no part of the method statement, risk assessment or lift plan recognised that. There was no description of the different process; there was no instruction to stop the procedure if positive fixings (i.e. feeding the slings through eye bolts) could not be achieved; and there was no indication that the wide rather than the narrow end of the landing should be tilted down with the tag lines. The need for such a plan was not identified by CMF in drafting the planning documents, nor by LOR in checking and approving them. ”

    Source location

    Richard LACO · 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

    Failure to specify the correct landing orientation for tag-line tilting

    Wider context from the report

    “1. The fitting of the two below ground landings in core D of the development at the Francis Crick Institute utilised a different methodology to the landings already fitted in cores A and F. The shape of the landings was trapezoid rather than rectangular; and they were lowered vertically to ground level and then later raised & tilted to pass the side fins; rather than simply being lowered from the top directly into place. However, no part of the method statement, risk assessment or lift plan recognised that. There was no description of the different process; there was no instruction to stop the procedure if positive fixings (i.e. feeding the slings through eye bolts) could not be achieved; and there was no indication that the wide rather than the narrow end of the landing should be tilted down with the tag lines. The need for such a plan was not identified by CMF in drafting the planning documents, nor by LOR in checking and approving them. ”

    Source location

    Richard LACO · 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

    Failure to include stop instructions for unsuccessful positive fixings during landing fitting

    Wider context from the report

    “1. The fitting of the two below ground landings in core D of the development at the Francis Crick Institute utilised a different methodology to the landings already fitted in cores A and F. The shape of the landings was trapezoid rather than rectangular; and they were lowered vertically to ground level and then later raised & tilted to pass the side fins; rather than simply being lowered from the top directly into place. However, no part of the method statement, risk assessment or lift plan recognised that. There was no description of the different process; there was no instruction to stop the procedure if positive fixings (i.e. feeding the slings through eye bolts) could not be achieved; and there was no indication that the wide rather than the narrow end of the landing should be tilted down with the tag lines. The need for such a plan was not identified by CMF in drafting the planning documents, nor by LOR in checking and approving them. ”

    Source location

    Richard LACO · 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

    Review all package method statements and lifting plans, suspend lifting plans pending review, and reapprove them before work recommences.

    Verbatim wording from the response

    “On 8 November 2013 the Laing O’Rourke Project Leader at the Crick, Bob Williams, circulated an email reminder that, following the Project Director Jonathan Abbott’s team talk, all packages were to undergo a full review of all method statements and lifting plans to ensure that they were current and reflected the actual install methods. This email also indicated that all Contractor Managing Directors were required to visit the site, in order to undertake a personal presentation to their respective teams on what was required of them at the Crick. All lift plans were suspended until they had been again reviewed and approved by Laing O’Rourke. A briefing of the accident and a health and safety briefing were conducted on 11 November 2013. Work recommenced at the Crick on 11 November 2013, save for the fact that core D remained closed for the official investigation.”

    Source location

    Richard-Laco-Response
    Page 3 · response
    Published 22 October 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

    Require monthly review of higher-risk activities and Planned-versus-Actual assessments against accepted methods.

    Verbatim wording from the response

    “Furthermore, each project team is now required to review activities carrying increased risk on a monthly basis and schedule a ‘Planned vs Actual’ assessment for these activities. As part of the ‘Planned vs Actual’ assessment a manager will review the accepted method statement for an activity on a more formal basis and will then review with the team carrying out the work whether there has been any change in circumstance which may have an impact on the plan, or whether improvements could be made to the method in order to make the operation safer.”

    Source location

    Richard-Laco-Response
    Page 4 · response
    Published 22 October 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

    Use purpose-designed lifting holes or bespoke lifting carriages, identified during design with advice from the appointed person.

    Verbatim wording from the response

    “1. All members to be lifted will either have adequately sized holes that allow for the fixing of positive anchorages for lifting accessories or for alternative bespoke lifting carriages. These will be identified during the design stage and advice obtained from the appointed person.”

    Source location

    Richard-Laco-Response2
    Page 2 · response
    Published 22 October 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

    Require qualified appointed persons to plan lifting operations using CMF’s native lift-plan procedure.

    Verbatim wording from the response

    “2. The lifting operations are to be planned by a qualified appointed person for lifting and not by site managers who may not have formal qualifications for lifting operations despite having extensive experience of lifting. A lift plan is to be completed using the CMF native lift plan procedure to ensure consistency and content.”

    Source location

    Richard-Laco-Response2
    Page 2 · response
    Published 22 October 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

    Submit lifting plans, temporary-works requirements and relevant design considerations to the Principal Contractor for approval before lifting.

    Verbatim wording from the response

    “3. Lifting plans together with any temporary works requirement or relevant design considerations are to be submitted to and approved by the Principal Contractor for projects before lifting commences.”

    Source location

    Richard-Laco-Response2
    Page 2 · response
    Published 22 October 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

    Implement an alternative landing-lifting method using bolted lifting frames, anchored lifting eyes, chains, separate winches and an additional slab opening.

    Verbatim wording from the response

    “Following the incident and after intensive investigations into best practice for an alternative method of lifting, it was determined to proceed with a lift plan that involved tilting the landing past the fin plates. An additional lifting frame was designed to be fixed to the landing with bolts that would facilitate the use of lifting eyes. The use of slings for lifting was substituted by chains attached to the lifting eyes. A second winch was introduced and another hole made in the slab so the tilt of the landing could be carried out by raising and lowering of separate winches rather than taglines. The trapezoidal landings above the ground floor slab were installed in accordance with the original lift plan methodology as this was still considered to be the best practice although the use of slings was again substituted for chains attached to directly anchored lifting eyes.”

    Source location

    Richard-Laco-Response2
    Page 2 · response
    Published 22 October 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

    Require positive lifting attachments for landings and staircases and request detailed RAMS for removing damaged landings.

    Verbatim wording from the response

    “In November 2013 Laing O’Rourke requested that CMF provide a detailed RAMS for the removal of the damaged landings in core D. Laing O’Rourke stressed to CMF that all landings and staircases must be rigged with positive lifting attachments. In December 2013 CMF started work on the revised RAMS and Lift Plan for the remaining stair installation, as well as testing its positive lifting attachments. Approval was granted by the HSE for the removal of the damaged landings from core D on 17 January 2014. On 23 January 2014 CMF were instructed to undertake a safe start workshop and to explain their method of installation for the next phase.”

    Source location

    Richard-Laco-Response
    Page 3 · response
    Published 22 October 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

    Stop lifting when circumstances, environmental changes or attachment deviations compromise the operation, then assess and approve lift-plan modifications before resuming.

    Verbatim wording from the response

    “6. If at any stage the lifting operation becomes compromised by unforeseen circumstances or changes to the local environment, lifting will cease as soon as it is safe to do so. The appointed person will then assess the changes and implement the modification within the lift plan before lifting resumes. Similarly the slinger signaller must not deviate from using the prescribed attachments or accessories defined in the lift plan and schedule of common lifts. Any deviation will cause lifting to cease until the approved person has assessed the implications.”

    Source location

    Richard-Laco-Response2
    Page 3 · response
    Published 22 October 2015

    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

    Responsibility for designing and planning the specialist lifting method and lift plan rested with the specialist contractor.

    Verbatim wording from the response

    “With hindsight, as the landings in the basement of core D were a different shape and were to be lifted upwards past the fin plates, before being lowered downwards onto the fin plates in the core, CMF should have considered an additional note in the plan for this lift. It is relevant, however, that the principle behind the method of lifting agreed by Laing O’Rourke in November 2013 required positive lifting attachments to be applied to a load lifted into the air and manipulated into place. This approved method provided a safe system of work, notwithstanding that, with hindsight, additional clarifications could have been, and eventually were, made to the plan by CMF, to account for the shape of the landing and the upward lift. The design of the lifting method and lift plan was the specialist contractor’s responsibility.”

    Source location

    Richard-Laco-Response
    Page 3 · response
    Published 22 October 2015

    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

    The irregular landing shape was not sufficiently significant to require changing the lifting plan, and factory trials raised no concerns.

    Verbatim wording from the response

    “The Project Lifting Plan produced by CMF on 25th May 2013 for lifts within the cores was revised on the 22nd August 2013 (Revision C) to include photographs of trial lifts conducted by CMF at its factory. The revisions were made in anticipation of lifts to be conducted within Cores F and D. The lifting plan in this revised format was intended for use in Core D, despite the irregular shape of the landings on one side of the core. The shape of the landing was not considered by CMF to be of sufficient significance to necessitate a change to the lift plan.”

    Source location

    Richard-Laco-Response2
    Page 1 · response
    Published 22 October 2015

    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

    The approved lift plan required positive attachments, and any inability to comply required lifting to stop and the plan to be reconsidered.

    Verbatim wording from the response

    “Laing O’Rourke approved the CMF Lift Plan on the basis that positive lifting attachments would be used for the lifting and installation of the landings (and staircases). As stated by Paul Hughes at the inquest, if CMF felt that it needed to deviate from the lift plan in force, for any reason, during the installation of landings or staircase sections, the lifting operation should have stopped immediately and further planning undertaken. Although the PFD report states that “there was no instruction to stop the procedure if positive fixings...could not be achieved”, Laing O’Rourke had only approved CMF’s lifts on the basis that positive lifting attachments were in use as had been the case in all the previous stair cores. No approval has ever been given by Laing O’Rourke to CMF to lift without positive lifting attachments.”

    Source location

    Richard-Laco-Response
    Page 2 · response
    Published 22 October 2015

    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

    Requiring positive lifting attachments was considered sufficient to ensure a safe system for lifting and manipulating the loads.

    Verbatim wording from the response

    “As stated by Paul Hughes, the absence of a positive lifting connection is a stop point; when lifting units and manipulating a load in the air rotating into place, there must be a positive lifting connection in order to ensure safe lifting. This principle remains the same with all lifts and shapes.”

    Source location

    Richard-Laco-Response
    Page 3 · response
    Published 22 October 2015

    Open published response
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Data last updated 7 September 2026