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
Responses linked to these 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 Bmm Jv 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 Bmm Jv 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 Bmm Jv 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 Bmm Jv 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 Bmm Jv 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 Bmm Jv 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 Bmm Jv 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 Share the Report with other designers on future weir projects.
Verbatim wording from the response “I trust that the information supplied above satisfies your request for information. BMM JV will ensure the Report is shared with other designers in future weir projects.” Source location 2020-0049-Response-from-BMM-JV-Limited_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 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
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 ARUP retained responsibility for the Weir’s operational design and asset-maintenance strategy.
Verbatim wording from the response “BMM JV were appointed as Principal Designer under the CDM Regulations 2015 in June 2015. BMM JV’s role as Principal Designer included ensuring risks had been controlled by design. ARUP bore responsibility for the design of the operation of the Weir and the strategy for maintenance of the asset. BMM JV was provided with a health and safety file as part of its appointment which included an Operation and Maintenance Part 3 FAS Maintenance and Repair Strategy prepared by ARUP.” Source location 2020-0049-Response-from-BMM-JV-Limited_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 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
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations