2 Mar 2020 Gary Dean Webster · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 7 Failure to verify competence for operating the safety boat and its outboard motor View source Failure to appreciate hazards of inherently hazardous tasks View source Failure to design safe debris-removal arrangements for weir maintenance View source Lack of suitable and sufficient risk assessment before hazardous tasks View source Failure to enforce permit controls and verify operator credentials View source Failure to consider lower-risk methods for hazardous tasks View source Failure to approve method statements for hazardous tasks View source See 4 more concerns
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bam Nuttall Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to verify competence for operating the safety boat and its outboard motor
Wider context from the report “(2) A permissioning system was in operation at the site which restricted the operation of the safety boat to identified persons who had been trained and authorised.
Despite this, the safety boat was being operated at the time of the incident by a worker who was neither authorised nor trained. He had operated the boat on previous occasions but had no experience of doing so in the turbulent water conditions encountered. Whilst he was controlling the boat it became engulfed with water cascading over the weir and overturned.
A second aspect of this concern relates to Gary Webster who was expected by the Works Manager to be operating the safety boat and hence can be inferred to be expressly authorised to do so.
He was qualified and had many years’ experience operating large boats. It was assumed that by virtue of qualifications obtained elsewhere on other vessels that he could be taken to be competent to operate a small craft such as this safety boat . The evidence taken at the Inquest indicated he was not competent to operate the boat’s outboard motor .
These factors indicate that the permissioning system was ineffective on 30/10/17. The concern here is that unless a permit system is enforced, with appropriate checks made for verity credentials, a further death may occur if individuals are allowed to stray beyond the boundaries of their competence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bam Nuttall Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to appreciate hazards of inherently 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bam Nuttall Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to design safe debris-removal arrangements for weir maintenance
Wider context from the report “(3) It was a known phenomenon that flotsam and debris would float down the River Aire, pass over the weir gates on occasions and then remain in the vicinity of the swirling water at the foot of the 2.6m cascade at the weir gates. Such debris may create the potential for monitoring devices near the weir gates to be damaged or cause environmental harm.
Such a phenomenon should have been foreseen at the time the weir installation was designed. If it was deemed necessary for debris to be removed then a safe working platform should have been incorporated into the design in order that the task of retrieving offending items could be accomplished without workers being exposed to hazardous of working in close proximity to turbulent water . Alternatively, a procedure should have been devised to enable debris to be freed by the operation of the steel weir gates or underlying neoprene bladders .
The concern here is that shortcomings in the designs of this nature may expose workers to potentially fatal risks in the course of future maintenance tasks .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bam Nuttall Limited; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bam Nuttall Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to enforce permit controls and verify operator credentials
Wider context from the report “(2) A permissioning system was in operation at the site which restricted the operation of the safety boat to identified persons who had been trained and authorised.
Despite this, the safety boat was being operated at the time of the incident by a worker who was neither authorised nor trained. He had operated the boat on previous occasions but had no experience of doing so in the turbulent water conditions encountered. Whilst he was controlling the boat it became engulfed with water cascading over the weir and overturned.
A second aspect of this concern relates to Gary Webster who was expected by the Works Manager to be operating the safety boat and hence can be inferred to be expressly authorised to do so.
He was qualified and had many years’ experience operating large boats. It was assumed that by virtue of qualifications obtained elsewhere on other vessels that he could be taken to be competent to operate a small craft such as this safety boat. The evidence taken at the Inquest indicated he was not competent to operate the boat’s outboard motor.
These factors indicate that the permissioning system was ineffective on 30/10/17. The concern here is that unless a permit system is enforced, with appropriate checks made for verity credentials , a further death may occur if individuals are allowed to stray beyond the boundaries of their competence .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bam Nuttall Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to consider lower-risk methods for 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bam Nuttall Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to approve method statements for 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.
” Open source report
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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 SG16 working-over-water guidance, train relevant employees and contractors, and prohibit entry into high-risk weir areas.
Verbatim wording from the response “Since the incident, BAM Nuttall has consolidated its processes and procedures in respect of working over or near water in its guidance document “SG16”. This guidance has been trained out to all relevant BAM Nuttall employees and contractors. The basic principle is to ensure zonal working is implemented on sites such that high risk areas are classed as prohibited entry. I can confirm that the area under operating weir would be classed as a prohibited area using this system. As such, workers will not ever be permitted to enter the area.” Source location 2020-0049-Response-from-BAM-Nuttall-Ltd_Redacted
Open published response
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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 Ban debris-clearing activity in front of water curtains across BAM sites.
Verbatim wording from the response “Immediately following the incident, BAM Nuttall considered whether the activity of clearing out debris from the area in front of the curtain of water was a necessary task at Knostrop Weir. It was concluded that the debris was a cosmetic eyesore, but posed no risk of damaging Knostrop Weir. As such, the activity was not a required activity and was subsequently banned on both the local site and all BAM sites. We determined after a further review that the activity could not occur at any other BAM Nuttall site; this learning has been recorded to ensure corporate learning in the future.” Source location 2020-0049-Response-from-BAM-Nuttall-Ltd_Redacted
Open published response
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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
Open published response
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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 design of the weir installation was outside the respondent’s involvement, so it could not comment further on that matter.
Verbatim wording from the response “BAM Nuttall was not involved in the design of the weir installation. As such, I am unable to comment on this further, except to confirm that BAM Nuttall will ensure that the Coroner’s Report to Prevent Future Deaths is shared at the earliest opportunity with any designers of weirs in projects for which BAM Nuttall is acting as Principal Contractor.” Source location 2020-0049-Response-from-BAM-Nuttall-Ltd_Redacted
Open published response
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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 qualification records, supervision and site rules are considered sufficient to identify and control competent equipment operators.
Verbatim wording from the response “All Site Operatives and contractors are reminded of the site rule that they may only operate equipment that they hold the appropriate qualifications and competence to do so. This is enforced through supervision and disciplining at site level.” Source location 2020-0049-Response-from-BAM-Nuttall-Ltd_Redacted
Open published response
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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 worker’s qualifications were considered suitable, and no additional qualification was considered industry standard or necessary.
Verbatim wording from the response “In respect of the Coroner’s second concern around qualifications, the Coroner heard conflicting evidence about whether Gary Webster had previously operated the boat involved in the incident. BAM Nuttall is unable to reconcile that evidence. However, I can confirm that in my opinion, Mr Webster’s qualifications were suitable for his role on site and it would not be industry standard to ask for any additional qualification.” Source location 2020-0049-Response-from-BAM-Nuttall-Ltd_Redacted
Open published response
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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 claim that the site worker operated the boat while untrained or unauthorised is disputed.
Verbatim wording from the response “In respect of the site worker who was not competent to operate the boat, I can confirm BAM Nuttall operates a strict policy of disciplining individuals if they operate equipment when they are not competent to do so. In some cases this would result in instant dismissal. In this instance, whilst the operative himself stated he had previously operated the boat, this is disputed and would have been put to him as untrue if he had attended the inquest in accordance with his witness summons. Were it the case that the operative was found to be operating the dory boat without being qualified and authorised to do so, he would have been guilty of gross misconduct and would have been disciplined immediately. There is a clear prohibition on untrained operators using pieces of equipment which they are not authorised to work.” Source location 2020-0049-Response-from-BAM-Nuttall-Ltd_Redacted
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations