Recurring concern

Inadequate safety controls for high-risk machinery work

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First reported 30 Apr 2018•Latest report 26 Jun 2025

Definition

What this concern includes

Includes failures of controls specifically dedicated to safe high-risk machinery work, including hazard identification, risk assessment, safe systems of work, worker competence, supervision and controls for machinery operated near electrical equipment or other serious hazards.

Not included

  • Excludes generic workplace safety or risk-assessment deficiencies where high-risk machinery work is not the material safety condition.
  • Excludes machinery maintenance, electrical-equipment maintenance and equipment defects where the operational safety controls for high-risk machinery work are not deficient.
  • Excludes work-at-height, lifting, vehicle-operation and other named hazard systems when those systems provide the more specific supported boundary.
  • Excludes incidents or injuries where no continuing failure in high-risk machinery safety controls is identified.
Reports
6

Distinct published reports

Individual concerns
9

A report can raise multiple concerns

Date range
2018–2025

First to latest report issue date

Stated actions
5

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.

Recipient name withheld2
BAE Systems plc1
D D Dodds and Son Ltd1
Department for Transport1
Haulage Contractors Ltd1
Health and Safety Executive1
Kenny And Murphy Limited1
Lincs Firwood Co Ltd1
Ministry of Defence1
Office of Rail and Road1
Treanor Pujol 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. Somerset

    AI-generated summary

    Michael Ernest Kerslake · 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

    Michael Ernest Kerslake sustained fatal injuries while using a petrol-driven brush cutter with a metal blade near an electricity pylon at Colley Lane Industrial Estate on 7 September 2023. The principal concern was that no risk assessment warned workers about the risks of using machinery near electrical equipment, and no such assessment remained in place.

    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 risk assessment warning workers about the risks of using machinery near electrical equipment

    Wider context from the report

    “1. There was no risk assessment in place warning workers on the estate of the risks of using machinery in the vicinity of electrical equipment. 2. Kenny & Murphy no longer own the estate in question but they own other sites. 3. It remains the case that no risk assessment as described above is in place. ”

    Source location

    Michael Ernest Kerslake · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Further safety work at the sold incident site cannot be undertaken because the respondent has no influence over its tenants.

    Verbatim wording from the response

    “Kenny & Murphy Ltd sold the incident site together with the main part of the Estate in March, 2024 and so have no influence over those tenants. Kenny & Murphy Ltd currently own one site at Bridgwater and a 50% interest in two sites at Southampton. We have undertaken an assessment on all three sites and submit that they differ from the incident site as they only have one tenant per site and there are no shared areas outside of their individual control and responsibility. None of the sites has any H Pole within its boundary or any transformer to handle incoming electricity at the same 11000v level. However, I have taken steps to discuss with the tenants the concerns raised by yourself regarding working safely around electricity and have also provided the tenants with the NGED "Stay Away Stay Safe!" leaflet and a copy of the HSE Electricity at Work Safe Working Practice document HSG85.”

    Source location

    Response from Kenny & Murphy Ltd
    Page 1 · response
    Published 14 July 2025

    Open published response

  2. Inner South London

    AI-generated summary

    Mr Christian Kwame Tuvi · 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

    Mr Christian Kwame Tuvi, an escalator cleaner aged 44, died at Waterloo Station after the traveller moved while he was in a gap, causing blunt force trauma to the chest. The jury identified inadequate briefing, failure to complete a site-specific risk assessment, failure to give an audible warning, and failures concerning the inching pendant and compliance with the method statement. The report also raised continuing concerns about unresolved responsibility for training and competence to operate the travellator during cleaning.

    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 cleaners against an agreed competence standard for inching

    Wider context from the report

    “The ORR informed the coroner that in 2020 an improvement notice was served on Cleshar Cleaners, requiring them to provide a safe system of work for communicating the movement of the conveyor which does not rely solely on verbal communication. Cleshar has appealed the Improvement Notice and the Employment Tribunal have stayed the notice until 2024. Although the improvement notice is under appeal Cleshar has made some changes to improve their safe system of work. These included a padlock for the operative to place on the nearest isolator switch before entering the gap, pressing the stop button in, KONE discussing with Cleshar where the gap is to be left prior to handing over control of the machine and the risk assessment and method statement now identify the need for a middle person to relay messages. The improvements that Cleshar made have allowed them to resume the deep clean of Waterloo moving walkway. However, the TfL familiarisation training for working in a plant room no longer provides inching as part of the course. TfL expects their contractors to provide inching training for their operatives. Without the evidence of competence to inch the machine the isolation/inching function remains with KONE as a temporary solution. It is unclear why this cannot be a permanent solution. I heard from witnesses that it would be safer for engineers, who are present during deep cleans, to operate the movements of the traveller, but I was told that it would lead to a lack of clarity as to who was in charge. This seems not to be insoluble given different contractors with different employees is a norm on building sites working safely under HSE rules across the country. More likely there are undisclosed issues perhaps related to assumption of responsibility for risk or financial considerations which explain the resistance. The inquest heard that prior to the accident, cleaners would attend a TfL training course with a signed form which TfL observed was a certificate of competence to inch and operate the controls of the traveller. But the issuing manager and cleaners thought that the TfL course provided that training. The withdrawal of that training and the inability to find another training facility, has led to the cleaners not being trained and so not permitted to operate the travellator. Cleshar Cleaners management have not in the past assessed their cleaners for competence to inch and there is no agreed standard of competence. Concerns were expressed in the inquest that most of the cleaners did not have English as their first language and that the risk assessment method statement was a huge technical document, with which the cleaners were not familiar and they all required training in the whole method of work, and not just the person in charge. MY CONCERN and reason for reporting this matter to the minister and not just the regulator and contractors, is that nearly four years have passed and there remains an impasse between the organizations as to whom should train whom, and the competence required to operate the travellator whilst it is being cleaned. It seems that TfL has the power to produce a resolution, but is leaving matters to others to resolve. It is hard not to conclude that there is corporate reluctance to assume risk for an important public service. The regulatory bodies and contractors in the supply chain have allowed this matter to remain unresolved for an unacceptable length of time and there may be a system failure in the allocation of responsibilities and powers in the process of contracting for cleaning escalators. ”

    Source location

    Mr Christian Kwame Tuvi · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Formal transport safety intervention is the Office of Rail and Road’s responsibility as the independent rail safety regulator.

    Verbatim wording from the response

    “As you will be aware, my Department has limited powers to intervene formally in transport safety matters, which are the responsibility of the Office of Rail and Road in its capacity as the independent Rail Safety Regulator. Furthermore, my Department does not have powers to intervene in London Underground Limited’s day-to-day operations or processes, for which it is separately accountable to the London Mayor as a subsidiary of TfL.”

    Source location

    Response from Department for Transport
    Page 1 · response
    Published 18 July 2023

    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

    Day-to-day London Underground operations and processes fall outside departmental powers and are accountable to the London Mayor through TfL.

    Verbatim wording from the response

    “As you will be aware, my Department has limited powers to intervene formally in transport safety matters, which are the responsibility of the Office of Rail and Road in its capacity as the independent Rail Safety Regulator. Furthermore, my Department does not have powers to intervene in London Underground Limited’s day-to-day operations or processes, for which it is separately accountable to the London Mayor as a subsidiary of TfL.”

    Source location

    Response from Department for Transport
    Page 1 · response
    Published 18 July 2023

    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

    Current arrangements, with competent KONE engineers undertaking all inching activities, are considered a clear and safe response to the training concern.

    Verbatim wording from the response

    “In light of the report, we have discussed the training of inching activities with KONE. KONE has informed us that, having considered the relevant work arrangements, they have decided, in consultation with Cleshar Contract Services Ltd (Cleshar), to continue permanently with the current temporary working arrangements i.e. KONE engineers will undertake all inching activities on LU’s moving walks and escalators, which they are contracted to maintain and clean, so Cleshar operatives can clean the machines. KONE engineers are assessed and deemed competent against the National Vocational Qualification (NVQ) Level 3 for escalator maintenance which includes inching. KONE consider that this is a clear and safe way forward to ensure that they meet their responsibility for the cleaning of these assets.”

    Source location

    Response from Transport for London
    Page 1 · response
    Published 18 July 2023

    Open published response

  3. Norfolk

    AI-generated summary

    Zachariah Nathaniel RICHARDSON · 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

    Zachariah Nathaniel Richardson, aged 18, suffered fatal injuries after being found trapped between a forklift truck and a wall while working alone at a site. Concerns included his limited experience and recent forklift training, overdue examinations and defective or defeated safety devices on the forklift trucks, and wider shortcomings in health and safety systems and competence.

    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

    Poor perception of risks associated with high-risk machinery

    Wider context from the report

    “3. Evidence was heard at the inquest that a Health and Safety Consultant visited the sites at Lincs Firewood and Dodds and Son in October and November 2020, following Mr Richardson’s death. The Consultant found there was little understanding of the importance of health and safety because there were no systems in place although working on high risk machinery. The perception of risk was found to be “poor” and “no one had taken the time or understood the importance to become competent in health and safety prior to the incident” ”

    Source location

    Zachariah Nathaniel RICHARDSON · 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

    Lack of health and safety management systems for high-risk machinery

    Wider context from the report

    “3. Evidence was heard at the inquest that a Health and Safety Consultant visited the sites at Lincs Firewood and Dodds and Son in October and November 2020, following Mr Richardson’s death. The Consultant found there was little understanding of the importance of health and safety because there were no systems in place although working on high risk machinery. The perception of risk was found to be “poor” and “no one had taken the time or understood the importance to become competent in health and safety prior to the incident” ”

    Source location

    Zachariah Nathaniel RICHARDSON · 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

    Implement task-specific risk assessments, employee briefings, toolbox talks and annual or change-triggered reviews of control measures.

    Verbatim wording from the response

    “Risk Assessment and Toolbox Talks”

    Source location

    Response from DAC Beachcroft
    Page 4 · response
    Published 7 October 2022

    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

    Strengthen employee induction by requiring review and signed acknowledgement of relevant safety documentation, including risk assessments.

    Verbatim wording from the response

    “• The employee induction process has been made more robust and includes a review of all relevant safety documentation, including risk assessments”

    Source location

    Response from DAC Beachcroft
    Page 4 · response
    Published 7 October 2022

    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 role-specific health and safety training modules covering operational hazards, emergency procedures, reporting and LOLER compliance.

    Verbatim wording from the response

    “Health and Safety Training”

    Source location

    Response from DAC Beachcroft
    Page 5 · response
    Published 7 October 2022

    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

    Maintain external health and safety consultancy providing audits, recommendations, management documentation, legislative updates, training and specialist support.

    Verbatim wording from the response

    “External Assistance”

    Source location

    Response from DAC Beachcroft
    Page 3 · response
    Published 7 October 2022

    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

    Appoint a full-time Health and Safety Coordinator and fund IOSH Managing Safely certification and related health and safety training.

    Verbatim wording from the response

    “Internal”

    Source location

    Response from DAC Beachcroft
    Page 3 · response
    Published 7 October 2022

    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

    Health and safety management risks are addressed through external consultancy, a dedicated coordinator, risk assessments, audits and reviewed control measures.

    Verbatim wording from the response

    “External Assistance”

    Source location

    Response from DAC Beachcroft
    Page 3 · response
    Published 7 October 2022

    Open published response

  4. North Wales (East and Central)

    AI-generated summary

    Austin Allen Ellsum THOMAS · 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

    Austin Allen Ellsum THOMAS died after being struck by a Volvo shovel loader truck while walking on the factory floor at a paper mill on 6 February 2017. The concerns identified were the potential distraction caused by music played at high volume in heavy machinery and the absence of random drug testing for employees operating heavy machinery, particularly drivers.

    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 control high-volume music use while operating heavy machinery

    Wider context from the report

    “(1) I heard evidence from an expert vehicle examiner who upon examination of the volvo shovel loader truck involved in the fatal accident found a CD in the CD compartment within the drivers cab of the truck. This CD player allowed CD’s to be played to a volume level of 32. I heard no evidence as to when the CD was last listened to however, I am concerned that there exists an inbuilt facility for drivers to listen to music at high levels when operating heavy machinery in a confined space such as the warehouse. Whilst I heard evidence that a new radio communication system would cut out any music playing in the truck cab I am concerned that the levels of volume are such that they could provide a distraction for a driver. I also heard evidence that whilst instances of pedestrians and vehicles moving on the factory floor at the same time had been significantly reduced, it had not been eliminated altogether. The combination of a driver being distracted listening to music in a contained environment where heavy machinery is being operated presents a risk of future deaths. Whilst neither the existence of the CD player nor the playing of any CD was involved in this inquest, having raised the concern at the end of the inquest, no policy or working rules or regulations relating to the listening of music and or CD’s whilst operating machinery for employees at the paper mill factory or any factory owned and operated by Downtons or UPM was brought to my attention. I make it clear that this issue played no part in the inquest of the deceased. (2) The inquest heard evidence as to the levels of cannabis in the blood of the driver of the shovel loader truck some 7 hours after the fatal incident. No evidence was available as to the levels of cannabis in the drivers system at the time of the fatal incident. The inquest heard evidence from the driver himself as to his cannabis use which included an admission that he had smoked cannabis on his own evidence the night before commencing an early shift the following day. The inquest also heard evidence that the drivers admitted use of cannabis was not consistent with the levels detected in his blood. I have been provided with a drugs policy from the factory operator which provides for drug testing on a ‘show cause’ basis only. There is no policy in relation to random testing particularly for drivers operating heavy machinery. Given the evidence heard at the inquest I am concerned that an employee may use drugs without the knowledge of his employer and continue to operate heavy machinery creating a risk of future deaths. I note that the policy I have been provided with does not appear to have been reviewed or updated following the incident resulting in the death of Mr Thomas in February 2017. ”

    Source location

    Austin Allen Ellsum THOMAS · 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

    Lack of policy governing music and CD use while operating machinery

    Wider context from the report

    “(1) I heard evidence from an expert vehicle examiner who upon examination of the volvo shovel loader truck involved in the fatal accident found a CD in the CD compartment within the drivers cab of the truck. This CD player allowed CD’s to be played to a volume level of 32. I heard no evidence as to when the CD was last listened to however, I am concerned that there exists an inbuilt facility for drivers to listen to music at high levels when operating heavy machinery in a confined space such as the warehouse. Whilst I heard evidence that a new radio communication system would cut out any music playing in the truck cab I am concerned that the levels of volume are such that they could provide a distraction for a driver. I also heard evidence that whilst instances of pedestrians and vehicles moving on the factory floor at the same time had been significantly reduced, it had not been eliminated altogether. The combination of a driver being distracted listening to music in a contained environment where heavy machinery is being operated presents a risk of future deaths. Whilst neither the existence of the CD player nor the playing of any CD was involved in this inquest, having raised the concern at the end of the inquest, no policy or working rules or regulations relating to the listening of music and or CD’s whilst operating machinery for employees at the paper mill factory or any factory owned and operated by Downtons or UPM was brought to my attention. I make it clear that this issue played no part in the inquest of the deceased. (2) The inquest heard evidence as to the levels of cannabis in the blood of the driver of the shovel loader truck some 7 hours after the fatal incident. No evidence was available as to the levels of cannabis in the drivers system at the time of the fatal incident. The inquest heard evidence from the driver himself as to his cannabis use which included an admission that he had smoked cannabis on his own evidence the night before commencing an early shift the following day. The inquest also heard evidence that the drivers admitted use of cannabis was not consistent with the levels detected in his blood. I have been provided with a drugs policy from the factory operator which provides for drug testing on a ‘show cause’ basis only. There is no policy in relation to random testing particularly for drivers operating heavy machinery. Given the evidence heard at the inquest I am concerned that an employee may use drugs without the knowledge of his employer and continue to operate heavy machinery creating a risk of future deaths. I note that the policy I have been provided with does not appear to have been reviewed or updated following the incident resulting in the death of Mr Thomas in February 2017. ”

    Source location

    Austin Allen Ellsum THOMAS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Birmingham and Solihull

    AI-generated summary

    Matthew Karl Hatfield and Darren Paul Neilson · 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

    Cpls Matthew Karl Hatfield and Darren Paul Neilson died after a Challenger 2 tank fired while its BVA assembly was absent, causing hot pressurised gases to enter the turret, the breech block to explode and a subsequent fire. The substantive concerns included unclear use and meaning of the Prove The Gun drill, inadequate information about tank status available to the Range Conducting Officer, and insufficient risk assessment of the gun’s ability to fire without the BVA assembly.

    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 actively consider drills when assessing risk and identifying hazards during manufacture

    Wider context from the report

    “3. ████████ from the HSE confirmed that had applied advanced or developed risk assessment techniques when undertaken then it would have been identified in the design and manufacture of the gun that it could fire without the BVA assembly present when undertaking the TVEDU red drill. BAE and the MOD should look at their process to ensure that their risk assessments are suitable and importantly that drills are actively considered when assessing risk and identifying hazards during manufacture. ”

    Source location

    Matthew Karl Hatfield and Darren Paul Neilson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 MoD is responsible for the specific content of army drills, although those drills would be considered in any design process.

    Verbatim wording from the response

    “We can also confirm that any such design or assessment of design would take account of the foreseeable use of the armament in practice, which would incorporate the army drills for training and operations. The specific content of those drills is obviously a matter for the MoD but they would be considered as part of any design process. However as explained above, such a gun designed today in accordance with the relevant Standard should not be able to fire at all if a component of the obturation system is missing.”

    Source location

    2018-0231-Response-by-BAE-Systems
    Page 2 · response
    Published 23 September 2018

    Open published response

  6. West Yorkshire Eastern

    AI-generated summary

    Matthew Luke Fulleylove · 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

    Matthew Luke Fulleylove, aged 30, sustained a fatal head injury on 5 June 2014 when his head became trapped between two heavy industrial machines passing on adjacent rail tracks during the production of large concrete beams. Concerns were raised about the restricted working space, the small gap between the machines, continued machinery passes, and the incomplete implementation of recommended safety measures.

    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

    Relaxation of the stringent system of work for machinery passing

    Wider context from the report

    “(2) A Witness told the Inquest that heavy industrial machines of the type involved in this fatality do still pass each other on tracks 11 and 12 despite criticisms voiced by an Expert Engineer in relation to the small gap between them coupled with the fact that some of the remedial safety measures advocated by the Expert Engineer have not been implemented. In fairness, it recognised that a Director of Treanor Pujol Limited did attempt to explain that the incidence of ‘machinery passes’ is now much reduced and some protective measures have been implemented, together with greater levels of suspension and training. Nonetheless, concern remains that any relaxation in the stringent system of work advocated by the Expert Engineer may give rise to a repetition of the circumstances which brought about the fatality on 05/06/2014. ”

    Source location

    Matthew Luke Fulleylove · 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 implement advocated remedial safety measures for machinery passing

    Wider context from the report

    “(2) A Witness told the Inquest that heavy industrial machines of the type involved in this fatality do still pass each other on tracks 11 and 12 despite criticisms voiced by an Expert Engineer in relation to the small gap between them coupled with the fact that some of the remedial safety measures advocated by the Expert Engineer have not been implemented. In fairness, it recognised that a Director of Treanor Pujol Limited did attempt to explain that the incidence of ‘machinery passes’ is now much reduced and some protective measures have been implemented, together with greater levels of suspension and training. Nonetheless, concern remains that any relaxation in the stringent system of work advocated by the Expert Engineer may give rise to a repetition of the circumstances which brought about the fatality on 05/06/2014. ”

    Source location

    Matthew Luke Fulleylove · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026