12 Dec 2024 James Robert Michael ALDERMAN · Prevention of Future Deaths report West London
View report summary
Concerns raised 3 Lack of guidance on breastfeeding young babies in carriers/slings View source Risk of suffocation for young babies in carriers/slings View source Lack of safety and positioning information for young babies in carriers/slings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
James Robert Michael ALDERMAN · 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
Jimmy was being breastfed in a baby carrier worn by his mother when he collapsed after five minutes. He died three days later in hospital from accidental suffocation after his airway was occluded while he was not held in a safe position. The report identified insufficient information and guidance for parents about safe positioning of young babies in carriers or slings, particularly when breastfeeding, and raised concerns about the need for industry safety standards.
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. The report was sent to British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on breastfeeding young babies in carriers/slings
Wider context from the report “(1) There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings
(2) This notwithstanding a significant increase over recent years in the use of such equipment.
(3) The question of whether it is safe to breastfeed "hands free" is not addressed or referred to in the public domain or manufacturers literature.
(4) The NHS available literature provides no guidance or advice.
(5) The only current "tips" are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful
(6) Young babies are at risk of suffocation.
(7) Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Risk of suffocation for young babies in carriers/slings
Wider context from the report “(1) There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings
(2) This notwithstanding a significant increase over recent years in the use of such equipment.
(3) The question of whether it is safe to breastfeed "hands free" is not addressed or referred to in the public domain or manufacturers literature.
(4) The NHS available literature provides no guidance or advice.
(5) The only current "tips" are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful
(6) Young babies are at risk of suffocation.
(7) Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of safety and positioning information for young babies in carriers/slings
Wider context from the report “(1) There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings
(2) This notwithstanding a significant increase over recent years in the use of such equipment.
(3) The question of whether it is safe to breastfeed "hands free" is not addressed or referred to in the public domain or manufacturers literature.
(4) The NHS available literature provides no guidance or advice.
(5) The only current "tips" are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful
(6) Young babies are at risk of suffocation.
(7) Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.
” Open source report
6 Dec 2024 Champagauri Bhatt and Dipak Bhatt · Prevention of Future Deaths report North London
View report summary
Concerns raised 8 Inadequate information management for analysis and learning from white goods fires View source Failure by fire-investigating companies to notify authorities of investigation outcomes View source Lack of sharing of recall and replacement decision data and rationale for condensate pumps and RFI filters View source Moisture ingress into condensate pumps causing tracking faults, resistive heating and fire View source Failure of product risk assessments to account for occupants and their actions View source Lack of sharing of warranty replacement data for condensate pumps and RFI filters View source Failure to provide fire-durable identification plates on appliances View source Inadequate manufacturing standards for mains- and sub-mains-operated condensate pumps and RFI filters View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Champagauri Bhatt and Dipak Bhatt · 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 29 March 2023, a fire caused by an electrical fault in a tumble dryer led to inhalation injuries and the deaths of Champagauri and Dipak Bhatt. Concerns included moisture ingress into condensate pumps causing faults and fire, and the need for improved data sharing, product safety standards, fire investigation reporting, risk assessment, and appliance identification.
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. The report was sent to British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Inadequate information management for analysis and learning from white goods fires
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires .
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure by fire-investigating companies to notify authorities of investigation outcomes
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations .
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of sharing of recall and replacement decision data and rationale for condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Moisture ingress into condensate pumps causing tracking faults, resistive heating and fire
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire .
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure of product risk assessments to account for occupants and their actions
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates .
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of sharing of warranty replacement data for condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters .
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to provide fire-durable identification plates on appliances
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Inadequate manufacturing standards for mains- and sub-mains-operated condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards .
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” Open source report
Concerns raised 12 Limitations in applying the Small Commercial Vessel and Pilot Boat Code to high-speed passenger craft View source Lack of proper protection for passengers and crew from impact and vibration hazards View source Non-uniform risk management for high-speed rides View source Confusing and inconsistent requirements and guidance for small-craft operators View source Insufficient crewing for lookout and skipper workload control View source Delays in revising codes of practice for high-speed craft View source Loss of situational awareness during RIB operations View source Inadequate seating and collision-impact mitigation in RIBs View source Inadequate forward visibility from passenger-carrying RIBs View source Failure to ensure timely and comprehensive review of MAIB recommendations View source Unavailability of AIS capability for monitoring RIB operations View source Excessive piloting workload during high-speed RIB operations View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emily Jane LEWIS · 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
Emily Jane Lewis, aged 15, died at Southampton General Hospital on 22 August 2020 after the high-speed RIB on which she was a passenger collided with a buoy, projecting her into a handhold and causing fatal injuries. The principal concerns included the workload and situational awareness of a lone skipper, inadequate forward visibility and passenger protection, shortcomings in seating and handrail design, insufficient risk assessment and safety management, and confusing or inconsistent regulation of high-speed RIB experience rides.
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. The report was sent to British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Limitations in applying the Small Commercial Vessel and Pilot Boat Code to high-speed passenger craft
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of proper protection for passengers and crew from impact and vibration hazards
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Non-uniform risk management for high-speed rides
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides .
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Confusing and inconsistent requirements and guidance for small-craft operators
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Insufficient crewing for lookout and skipper workload control
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Delays in revising codes of practice for high-speed craft
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back : the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond . The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Loss of situational awareness during RIB operations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Inadequate seating and collision-impact mitigation in RIBs
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions , noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Inadequate forward visibility from passenger-carrying RIBs
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely and comprehensive review of MAIB recommendations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Unavailability of AIS capability for monitoring RIB operations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS) . There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Excessive piloting workload during high-speed RIB operations
Wider context from the report “In the course of the inquest I heard evidence of multiple issues in relation to in particular (a) the high workload of piloting a RIB at high speed, particularly in the vicinity of buoys and vessels (b) loss of situational awareness (c) the improvement in safety of having a second crew member thereby providing an additional lookout and reducing the skipper’s workload (d) forward visibility issues in RIBs complying with existing requisite safety standards when passengers are being carried (e) issues as to safe seating and the need to mitigate the effects of collisions, noting in particular the injuries suffered by Emily Lewis (f) the need for risk assessments and safety management systems to be meaningfully (g) limitations in applying the Small Commercial Vessel and Pilot Boat Code as annexed to MGN 280 (M)(Small Vessels in Commercial Use for Sport or Pleasure Workboats and Pilot Boats – Alternative Construction Standards) to high speed passenger craft operation (h) the potential benefits of an automatic identification system (AIS). There was also evidence concerning the way in which the revision of the codes of practice appears to have slipped back: the Maritime & Coastguard Agency now plan to go to consultation next year, then the RYA will respond. The MAIB describes current requirements and guidance for the operators of small craft as “confusing and inconsistent” and observe that there does not appear to be uniform approach to managing the risks associated with high speed rides.
In the foreword to the MAIB report into the index collision it is stated: “... passengers in small high speed craft are very vulnerable to impact and vibration injuries. In the last 15 years the MAIB has investigated numerous accidents involving high speed craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury and occasionally death.”
My concerns relate to:
a. Whether consideration should be given to licensing arrangements for port authorities and local authorities to achieve an early, uniform and comprehensive framework for the use of RIB craft on high speed experience rides, including crewing levels, manoeuvres, craft standards and risk assessments
b. Whether interim measures should be considered to manage risks of high-speed RIB experience rides
c. Whether the existing BS EWN ISO 11591 needs revision (or supplementing) to take into account the effect on forward visibility of passengers about RIB craft and whether any practicable retrospective steps can be identified to improve forward visibility on RIB craft
d. The need for consideration of seat and handrail design : as well as the injuries sustained by Emily Lewis I note the MAIB’s concerns about handholds for jockey seats
e. The need to consider whether there should be provision of AIS for RIB craft to facilitate monitoring of RIB craft operations and intervention in the event of unsafe practices being identified
f. The need to consider how timely and comprehensive review of MAIB recommendations can be achieved
” 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 Refer the Report to the relevant technical committee for consideration.
Verbatim wording from the response “8. In order to assist the Coroner, BSI has referred the Report to GME/33. The committee has explained:” Source location Response from British Standards Institution
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 Responsibility for the technical content and revision of the standard rests with the relevant technical committee, not the organisation.
Verbatim wording from the response “5. Each individual standard is the responsibility of one technical committee. It is the committee who is responsible for the technical content of the standard, not BSI. In this case the relevant standard (BS EN ISO 11591) is an international standard, developed by an international committee managed by the International Organization for Standardization (“ISO”) to which BSI contributes through a local (British) ‘mirror committee’. Such mirror committees consist primarily of experts who are independent of BSI, and who are often nominated by trade associations, professional bodies, research/scientific institutions, government or other entities. They have an independent chair and BSI provides a committee manager and other support including an editorial project manager for national standards.” Source location Response from British Standards Institution
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 Regulatory advice about forward visibility and craft safety falls outside the organisation’s role as a non-regulatory standards body.
Verbatim wording from the response “3. BSI’s role as the National Standards Body is to facilitate expert committees to achieve consensus on industry standards and best practice and to act as the publisher of standards.” Source location Response from British Standards Institution
Open published response
Concerns raised 2 Failure of window restrictor standards to address deliberate attempts to defeat restrictors View source Lack of reliable, up-to-date guidance on the limitations of window restrictor standards View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Terrence Roy Hubert Taylor · 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
Terrence Roy Hubert Taylor, an 82-year-old short-term resident of a residential care home, overcame a window restrictor, climbed out of a first-floor window and fell during the early hours of 11 December 2020, sustaining injuries from which he died. The principal concern was that current British Standards for window restrictors address accidental falls but not deliberate attempts to defeat them, and that this limitation and subsequent guidance on stronger restrictors were not generally known or understood by residential care home operators, manufacturers or suppliers.
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. The report was sent to British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure of window restrictor standards to address deliberate attempts to defeat restrictors
Wider context from the report “1. The concern relates to the guidance provided to operators of residential care homes in respect of window restrictors and the standard they are required to meet. The current standards have been developed to prevent accidental falling from windows. They do not deal with deliberate attempts to defeat the restrictor , which may well be the situation encountered residential care homes, as in fact occurred in this case. This limitation is not known or understood by operators of residential care homes.
2. In December 2013 the Department of Health published Health Building Note 00-10 Part D: Windows and associated hardware. That guidance was not directed to residential care home provides. The Guidance was updated following an earlier Coroner’s report to prevent future deaths addressed to the Chief Medical Officer. That Guidance Note provides that
“... window restrictors tested to current British Standards may be inadequate in preventing a determined effort to force a window open beyond 100mm ...”.
It also noted that:
“... The relevant tests for restrictors cited in BS EN 14351-1 and BS EN 13126-5 have been developed to prevent accidental falling from windows ... None of the British and European Standards deal with deliberate attempts to defeat the restrictor using impact forces , which may be the situation encountered in hospitals and care homes”.
3. The evidence was that this Guidance was not generally known or understood by operators of residential care homes or manufactures or suppliers of window restrictors.
4. In 2019 the Health and Safety Executive published Research Report RR1150 Review of Window Restrictors use in Health and Social Care. The outcome of that research was that in order to protect vulnerable people in health and social care premises:
“... it is suggested that window restrictors (and their fixings) are capable of withstanding push forces of at least 850N ...”.
5. Thus the HSE’s research suggests that window restrictors in health and social care premises should be able to withstand forces very much greater than that of the British Standards .
6. The evidence was that this research was not generally known or understood by operators of residential care homes or manufactures or suppliers of window restrictors.
7. Operators of care homes are likely to consider they are taking reasonable steps to secure windows by fitting restrictors that meet the British Standards, whereas the 2013 Department of Health Guidance and the 2019 Health and Safety Executive research indicates that is not so.
8. Action is required to ensure operators of care homes are provided with reliable, up to date guidance and to ensure that the limitations of the British Standard are widely known and understood by operators of residential care homes.
9. Action is required to review the British Standard relating to window restrictors to consider whether some different standard or qualification to the existing standard is required in respect of residential care homes and/or deliberate acts to disable window restrictors.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of reliable, up-to-date guidance on the limitations of window restrictor standards
Wider context from the report “1. The concern relates to the guidance provided to operators of residential care homes in respect of window restrictors and the standard they are required to meet. The current standards have been developed to prevent accidental falling from windows. They do not deal with deliberate attempts to defeat the restrictor, which may well be the situation encountered residential care homes, as in fact occurred in this case. This limitation is not known or understood by operators of residential care homes .
2. In December 2013 the Department of Health published Health Building Note 00-10 Part D: Windows and associated hardware. That guidance was not directed to residential care home provides . The Guidance was updated following an earlier Coroner’s report to prevent future deaths addressed to the Chief Medical Officer. That Guidance Note provides that
“... window restrictors tested to current British Standards may be inadequate in preventing a determined effort to force a window open beyond 100mm ...”.
It also noted that:
“... The relevant tests for restrictors cited in BS EN 14351-1 and BS EN 13126-5 have been developed to prevent accidental falling from windows ... None of the British and European Standards deal with deliberate attempts to defeat the restrictor using impact forces, which may be the situation encountered in hospitals and care homes”.
3. The evidence was that this Guidance was not generally known or understood by operators of residential care homes or manufactures or suppliers of window restrictors .
4. In 2019 the Health and Safety Executive published Research Report RR1150 Review of Window Restrictors use in Health and Social Care. The outcome of that research was that in order to protect vulnerable people in health and social care premises:
“... it is suggested that window restrictors (and their fixings) are capable of withstanding push forces of at least 850N ...”.
5. Thus the HSE’s research suggests that window restrictors in health and social care premises should be able to withstand forces very much greater than that of the British Standards.
6. The evidence was that this research was not generally known or understood by operators of residential care homes or manufactures or suppliers of window restrictors .
7. Operators of care homes are likely to consider they are taking reasonable steps to secure windows by fitting restrictors that meet the British Standards, whereas the 2013 Department of Health Guidance and the 2019 Health and Safety Executive research indicates that is not so.
8. Action is required to ensure operators of care homes are provided with reliable, up to date guidance and to ensure that the limitations of the British Standard are widely known and understood by operators of residential care homes.
9. Action is required to review the British Standard relating to window restrictors to consider whether some different standard or qualification to the existing standard is required in respect of residential care homes and/or deliberate acts to disable window restrictors.
” 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 Amend BS 6375-2 clause 5.3 to cover windows used in circumstances described by the Coroner’s report.
Verbatim wording from the response “Amendments to BS 6375-2” Source location Response from BSI
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 Discuss with CEN/TC 33 WG1 whether EN 14609 needs amendment to address restricted sliding sash windows.
Verbatim wording from the response “BS EN 14609, is referred to by BS EN 14351-1 as the test method to determine the load bearing capacity of safety devices, but it only covers casement windows not sash windows, clause 7 calls for the restrictors to be disengaged and figures A.1 to A.6 show the movement of the casement to be limited by a “block” stopping the movement of one corner. We will discuss the possible need to amend EN 14609” Source location Response from BSI
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 Introduce a BS 6375-2 annex specifying the test method for restricted sliding sash windows.
Verbatim wording from the response “As BS EN 14609 does not cover loads applied to restricted sliding sash windows we will need to introduce a new annex to BS 6375-2 describing the test method to be used for such windows.” Source location Response from BSI
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 Amend BS 6510 clause 12.2 to refer to BS 6375-2 clause 5.3 rather than the existing fixed load and duration.
Verbatim wording from the response “Steel-framed windows” Source location Response from BSI
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 glazing to withstand the 850 N point load and meet specified impact-resistance grades.
Verbatim wording from the response “If loads are to be applied to the casement or sash then it will be necessary to upgrade the glazing so it can withstand comparable loads. We therefore propose that the glazing should be able to support the 850 N point load (applied via the pad) but also be grade 1(B)1 or 1(C)1 when tested in accordance with BS EN 12600. This will reduce the risk of egress being achieved by breaking the glass.” Source location Response from BSI
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 Check whether the proposed BS 6375-2 amendment conflicts with existing European standards.
Verbatim wording from the response “The load bearing capacity of safety devices is an essential characteristic of windows (reference Table ZA.1) therefore, when such a device is fitted to a window the loadbearing capacity of the window, when tested in accordance with BS EN 14609, must be stated on the manufacturer’s declaration of performance in accordance with article 4 (2) of the assimilated EU Regulation 305/2011 (The Construction Products Regulation).” Source location Response from BSI
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 National requirements for window safety products are for the country where the products are used to establish.
Verbatim wording from the response “BS EN 14351-1, the European product standard for windows and external pedestrian doors, doesn’t, as appears in for example the HSE report RR1150, limit the load bearing capacity of a safety device to 350 N but instead sets 350 N as the minimum, or threshold, value for such devices. It would be for the EU member state, or country in which the product is used, to set the national requirements for such products.” Source location Response from BSI
Open published response
11 Jan 2023 Ashley Michel Bullard · Prevention of Future Deaths report West London
View report summary
Concerns raised 16 Excessive tolerated freeplay in 2-post vehicle lifts View source Failure to ensure engineers read and understand the lift manual View source Failure to keep lift inspection, maintenance and repair records View source Uncertainty about suitability of narrow vehicle lift points for frame contact pads View source Inconsistent communication of manual use and gear ring bolt responsibilities to lift owners View source Failure to maintain and verify required clearance around vehicle lifts View source Failure to require vehicle technicians to read the lift manual View source Failure to ensure lifts are maintained in accordance with manufacturer recommendations View source Lack of warnings about using outermost vehicle lift points View source Lack of clear gear ring bolt specifications in the installation and operation manual View source Failure to obtain confirmation that suppliers received all operational manuals View source Lack of consistent British Standards for tolerated freeplay in 2-post vehicle lifts View source Failure to ensure replacement of grade 4.8 gear ring bolts in existing lifts View source Lack of clear allocation of lift maintenance responsibilities View source Designation of unsafe outer vehicle lift points for 2-post lifts View source Lack of warnings about dangers of outermost lift points View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Ashley Michel Bullard · 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
Ashley Michel Bullard died after a Volvo S80 fell from a vehicle lift while he was working underneath it at Wheel Art Ltd. The lift’s freeplay and the alignment of its pads contributed to the pads moving from a structural part of the car to a non-structural part, causing the car to fall and fatally injure him. Concerns included inadequate maintenance, the use of unsuitable bolts, insufficient warnings and manuals, and risks associated with outer lift points and tolerated freeplay in two-post vehicle lifts.
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. The report was sent to British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Excessive tolerated freeplay in 2-post vehicle lifts
Wider context from the report “1. Evidence was given that it could be possible to reduce the degree of freeplay in the Bendpak 2-post vehicle lifts. Given lift points positioned close to the edge of the vehicle may be in danger of allowing lifting pads / frame contact pads on the Bendpak XPR9 2-post vehicle lift and possibly other similar 2-post lifts, to move from a position under the structure of the vehicle, to a non-structural part of the vehicle, with a risk of the car leaving the vehicle lift, it appears the level of tolerated freeplay creates a risk of injury or death to those operating the lift .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure engineers read and understand the lift manual
Wider context from the report “2. An experienced Liftmaster employee gave clear evidence that he did not read all of the installation and operating manual for the XPR9 lift , in spite of being said to have received refresher training from his employer less than 5 months before giving evidence. He said he was not required to read the manual when he was trained , even though he had also signed a letter confirming that he had in fact read the manuals for the XPR series. At the time of giving evidence, he was unaware of the torque table and the full extent of the lift maintenance requirements within the installation and operation manual, notwithstanding the fact that tightening of gear ring bolts was considered by all relevant witnesses, to be critical to the safety of the vehicle lift. That employee was said to be presently employed by Liftmaster and Liftmaster was said to presently install and service Bendpak lifts.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to keep lift inspection, maintenance and repair records
Wider context from the report “2. There was no evidence that Wheel Art Ltd ever kept records of inspections, maintenance, or repair of the Bendpak XPR9 lifts in accordance with the Bendpak XPR9 installation and operating manual. Again, whilst Wheel Art Ltd may now use different vehicle lifts, this concern is not focussed on the make or model of lift but on the maintenance of relevant records.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about suitability of narrow vehicle lift points for frame contact pads
Wider context from the report “2. It is unclear whether a narrow vehicle lift point is suitable for 2-post vehicle lifts using frame contact pads , or whether a better fitted lifting pad adaptor is available. Evidence was provided by an HSE expert engineer, that some form of slotted vehicle lift pad would be better suited when using a 2-post vehicle lift to raise a car by way of the narrow outer lift points that are more often used with vehicle jacks.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Inconsistent communication of manual use and gear ring bolt responsibilities to lift owners
Wider context from the report “1. There was little evidence of consistent practice amongst Liftmaster workers regarding informing the owners of vehicle lifts of the need to read the installation and operation manual , or in highlighting the important parts of the manual such as the need to tighten gear ring bolts. Liftmaster workers were not always aware that ‘the tightening a ‘safety-critical’ component such as gear ring bolts, were the customer’s responsibility, and hence that was not communicated to customers .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain and verify required clearance around vehicle lifts
Wider context from the report “3. Photographs suggested the clearances recommended by the manufacturer, between the lift posts and the nearest obstruction, were not maintained at the time of the incident. Those clearances were said to be 13 feet at the front of the lift, 11 feet at the rear of the lift, and 5 inches from the sides to the nearest wall. Photographs taken very shortly after the incident, disclose the presence of a different vehicle within just a few feet of the rear of the lift used by Ashley in a neighbouring XPR9 vehicle lift / lift bay. It is unclear to what degree the recommended clearance requirements within the manufacturer’s installation and operating manual were considered or adhered to at installation .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to require vehicle technicians to read the lift manual
Wider context from the report “1. There was no evidence that Wheel Art Ltd ever required vehicle technicians operating the Bendpak XPR9 lift, to read the installation and operating manual or to maintain the lift in accordance with the manufacturer’s recommendations. I am informed that Precision no longer owns any Bendpak XPR9 lifts, but instead uses Hoffman scissor lifts. This concern is not focussed on the make or model of lift but the use of lift operating manuals.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure lifts are maintained in accordance with manufacturer recommendations
Wider context from the report “1. There was no evidence that Wheel Art Ltd ever required vehicle technicians operating the Bendpak XPR9 lift, to read the installation and operating manual or to maintain the lift in accordance with the manufacturer’s recommendations . I am informed that Precision no longer owns any Bendpak XPR9 lifts, but instead uses Hoffman scissor lifts. This concern is not focussed on the make or model of lift but the use of lift operating manuals.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of warnings about using outermost vehicle lift points
Wider context from the report “3. There are no warnings on the Bendpak XPR9 2-post vehicle lift or in its installation and operation manual , that suggests caution or a prohibition on using a 2-post vehicle lift in conjunction with the outer most lift points on the underside of vehicles, that may be positioned on or near the sill or seam of the vehicle and often within a few inches from a non-structural part of the vehicle for lifting purposes.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of clear gear ring bolt specifications in the installation and operation manual
Wider context from the report “6. The specification of the grade and size and torque settings of gear ring bolts provided by Bendpak prior to installation was not sufficiently clear within Bendpak’s installation and operation manual , and appeared to cause confusion amongst engineers tasked with installing the lift and those required to service or maintain the lift.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain confirmation that suppliers received all operational manuals
Wider context from the report “4. At the point of providing suppliers / installers with the lift, Bendpak did not require any form of written confirmation of acknowledgement that suppliers received all manuals that Bendpak intended to provide, and considered important to the operation of the lift.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent British Standards for tolerated freeplay in 2-post vehicle lifts
Wider context from the report “1. There appear to be no British Standards for the safe, acceptable and/or tolerated degree of travel or length of travel in terms of freeplay in 2-post vehicle lifts in the UK . Whilst evidence was provided by the HSE that the industry body SAFed suggested an acceptable degree of freeplay is the diameter of the vehicle lift’s frame contact pad, it is noted that various 2-post vehicle lifts have different diameter pads, and hence there is no consistency in the amount of freeplay tolerated in 2-post vehicle lifts . It was also noted that the diameter of pad in the present case, at 130mm, could allow a frame contact pad, to move from a position underneath the structure of a vehicle, to a position under a non-structural part of the vehicle, which can cause the vehicle to leave the lift. An HSE engineer’s expert evidence was that it might be more sensible for tolerated freeplay to not exceed half the diameter of the frame contact pad.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure replacement of grade 4.8 gear ring bolts in existing lifts
Wider context from the report “5. There was no evidence as to whether all Bendpak XPR9 2-post vehicle lifts with grade 4.8 bolts had been recalled or whether grade 4.8 bolts had been replaced in all existing XPR9 lifts, nor any evidence as to what efforts had made to contact customers that might still have such lifts in operation , in order to replace grade 4.8 bolts in lifts manufactured after 01.01.2014.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of clear allocation of lift maintenance responsibilities
Wider context from the report “7. It is not clear within Bendpak’s installation and operation manual as to which components and bolts in particular, are the subsequent lift owner’s responsibility to maintain .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Designation of unsafe outer vehicle lift points for 2-post lifts
Wider context from the report “1. Volvo (and/or other manufacturers) appear to designate lift points towards the edge of vehicles , that are near, on, or outside the sill or seam of the underside of the vehicle. Lift points in a position so close to the edge of a vehicle frame, appear to be in danger of allowing frame contact pads on a Bendpak XPR9 2-post vehicle lift, and possibly other similar 2-post vehicle lifts, to move from a position under the structure of the vehicle, to a non-structural part of the vehicle, due to tolerated freeplay within the vehicle lift, leading to a risk of the car leaving the vehicle lift. Whilst multiple lift points are identified in manuals and/or on Autodata, no warning is given with regards to any danger of using 2-post vehicle lifts on the outer most lift points.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of warnings about dangers of outermost lift points
Wider context from the report “1. Volvo (and/or other manufacturers) appear to designate lift points towards the edge of vehicles, that are near, on, or outside the sill or seam of the underside of the vehicle. Lift points in a position so close to the edge of a vehicle frame, appear to be in danger of allowing frame contact pads on a Bendpak XPR9 2-post vehicle lift, and possibly other similar 2-post vehicle lifts, to move from a position under the structure of the vehicle, to a non-structural part of the vehicle, due to tolerated freeplay within the vehicle lift, leading to a risk of the car leaving the vehicle lift. Whilst multiple lift points are identified in manuals and/or on Autodata, no warning is given with regards to any danger of using 2-post vehicle lifts on the outer most lift points .
” Open source report
26 Apr 2022 Ashlie Timms · Prevention of Future Deaths report East London
View report summary
Concerns raised 7 Non-compliant fire alarms lacking automatic links to an Alarm Receiving Centre View source Lack of clear practical guidance for managing high-risk electrical devices in specialist housing View source Insufficient emphasis on British Standard recommendations for automatic fire alarm connections to Alarm Receiving Centres View source Incomplete fire safety audit processes View source Lack of clear guidance on fitting digital key-pad locks in specialist housing View source Failure of fire safety audits to accurately assess compliance View source Failure to ensure staff competence in fire evacuation procedures View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ashlie Timms · 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
Ashlie Timms, a 46-year-old woman living in supported accommodation, died on 20 April 2018 after a fire started when fabric materials came into contact with a portable fan heater. Staff delayed calling the emergency services, did not evacuate her, and the fire safety arrangements, alarm system, evacuation procedures and door lock were identified as concerns.
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. The report was sent to British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Non-compliant fire alarms lacking automatic links to an Alarm Receiving Centre
Wider context from the report “2. Fire Alarms in three units operated Sequence Care Group remain non-compliant with the 2013 British Standard Guidance , which recommends that they should have a link to an Alarm Receiving Centre (“ARC”) which automatically contacts the emergency services when a fire alarm is activated .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of clear practical guidance for managing high-risk electrical devices in specialist housing
Wider context from the report “4. No clear and practical guidance exists on how specialist housing operators should manage the use of high-risk electrical devices such as portable electric fan heaters .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Insufficient emphasis on British Standard recommendations for automatic fire alarm connections to Alarm Receiving Centres
Wider context from the report “6. Insufficient emphasis is placed upon recommendations contained within British Standards regarding automatic connections to ARCs in fire alarms fitted in specialist accommodation .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Incomplete fire safety audit processes
Wider context from the report “3. The London Fire Brigade conducted fire safety audits at the premises which assessed the unit as displaying the highest standard of fire safety compliance. These findings were found to be entirely incongruent with procedures, equipment and staff training in place before and at the time of the fire. The London Fire Brigade have reviewed and changed processes since 2018 but they remain incomplete .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on fitting digital key-pad locks in specialist housing
Wider context from the report “5. No clear guidance exists regarding the fitting of digital key-pad locks on doors in specialist housing .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure of fire safety audits to accurately assess compliance
Wider context from the report “3. The London Fire Brigade conducted fire safety audits at the premises which assessed the unit as displaying the highest standard of fire safety compliance . These findings were found to be entirely incongruent with procedures, equipment and staff training in place before and at the time of the fire . The London Fire Brigade have reviewed and changed processes since 2018 but they remain incomplete.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff competence in fire evacuation procedures
Wider context from the report “1. The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation . Despite reflection and remediation in policies, processes and training, multiple staff members who gave evidence to the inquest, remained unable to describe the proper action to take in the event of a fire alarm .
” 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 Consider strengthening standards commentary on zone plans, including their life-safety importance and potential non-conformity.
Verbatim wording from the response “2. While BS 5839-1 already details a need for users of the standard to check zones and confirm zone plans, it is proposed that commentary be added to 46.2 and/or 23.1 making the risk to life from a lack of a zone plan very clear. The text could also list the lack of a zone plan as a major non-conformity OR the lack of a zone plan immediately rendering the system non-compliant. This may include the absence of an ARC.” Source location Response from British Standards Institution
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 Consider recommending that users establish local fire-and-rescue-service policies for automatic fire-alarm responses and confirm premises coverage.
Verbatim wording from the response “3. Regarding ARC connections, the committee noted, many Fire & Rescue Service (FRS) are operating a nil-response policy to AFAs (AUTOMATIC FIRE ALARMS). The standard may include a recommendation the user to determine what the policy is for the local FRS and confirm whether the premises are included or exempt.” Source location Response from British Standards Institution
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 Fire detection installation and servicing issues should be examined by subcommittee FSH/12/1, which is responsible for the relevant standards.
Verbatim wording from the response “The committee experts believe the committees which should examine the issues more closely are:” Source location Response from British Standards Institution
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 Key-lock issues may be considered by subcommittee FSH/12/4 through a forthcoming amendment to BS 7273-4.
Verbatim wording from the response “Regarding the matter of key locks, it was agreed subcommittee FSH/12/4 may consider it as part of a forthcoming amendment to BS 7273-4. It may also be covered as part of the ongoing revision of BS 9991 via the inclusion of an informative note to the effect that “if electronic locking is provided on flat entrance doors of individual units of accommodation it should not be necessary or needed to install a code to exist the flat. Means of electric locking should be simple and easy to use (eg a simple lever handle). It is also important that residents understand how to use the electronic lock.”” Source location Response from British Standards Institution
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 Fire precaution issues should be examined by technical committee FSH/14, which is responsible for relevant building fire-safety standards.
Verbatim wording from the response “The committee experts believe the committees which should examine the issues more closely are:” Source location Response from British Standards Institution
Open published response
1 Apr 2022 Corrie McKeague · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 5 Failure of bin locks to prevent individuals entering bins View source Lack of automated recognition of unusually heavy bins View source Failure to provide and safety-check equipment for thorough and safe bin searches View source Failure of lorry viewing apertures to provide usable hopper visibility View source Failure of compaction processes to allow hopper inspection before compaction View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Corrie McKeague · 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
Corrie McKeague disappeared in Bury St Edmunds on 24 September 2016 after entering a commercial waste-bin area, and was later determined to have died in the back of a refuse lorry. The inquest identified concerns including ineffective bin locks and bin searches, lack of safe search equipment for drivers, and poor visibility through the lorry’s viewing window.
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. The report was sent to British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure of bin locks to prevent individuals entering bins
Wider context from the report “1. Ineffective bin locks.
The court heard that bin locks were designed to keep waste within the bin, keep inclement weather out, but were not designed to keep individuals out . The locks were described as not robust, and a determined or strong individual would get in . Due to their design the locks were also frequently broken .
Stronger locks (such as snap locks) had been considered, but due to the risk of entombing (an individual inadvertently becoming locked inside a bin) stronger locks had been discounted. However, the choir heard there are currently no stronger bin locks available which would allow an individual to open them from the inside should they become entombed in a bin.
There were 740 reported incidents of people in bins over a 6-year period (i.e. 10 per week), which are likely to be reduced if stronger locks are fitted.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of automated recognition of unusually heavy bins
Wider context from the report “2. Ineffective search of the bin.
Despite the lifting mechanism recording the weight of each bin every time it is lifted, there is no automated/digital system to recognise when a bin is significantly heavier than it usually is .
In this case the usual weight in the bin (based on an average of 13 previous collections) was approximately 15kgs. The bin weight recorded by the lifting mechanism on the dust cart was 116kgs. Such a significant difference in weight of a particular bin, is something that should be recognisable and should warrant a further check being completed .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to provide and safety-check equipment for thorough and safe bin searches
Wider context from the report “3. Any driver not having the means to search the bin thoroughly or safely .
The court heard that drivers are now told to use a ‘push stick’ to allow a more thorough search of the contents of a bin. This instruction was not in place at the time of this incident.
However, it was not clear from the evidence if the push stick is an identifiable piece of equipment on every vehicle , or if it is deemed as a piece of safety equipment, and therefore included in the daily safety checks of the vehicle .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure of lorry viewing apertures to provide usable hopper visibility
Wider context from the report “4. Poor visibility through the Perspex viewing window on the lorry
In relation to the poor visibility through the Perspex viewing aperture/window on the lorry two factors were identified:
Firstly, it is physically impossible to undertake a check of the hopper mechanism on the Biffa lorry as the viewing aperture window is too high for this to be achieved by an average height driver .
Secondly, on the six-year-old vehicle in question the Perspex had become opaque .
A Detective Constable who had watched the lifting process to provide evidence of its operation for the court, described the driver as standing on tiptoes to try a check the vehicle hopper, whilst peering around the wing of the lifting mechanism. When asked specifically about the viewing window the officer said it was too high to see through and opaque. The officer told the court the viewing aperture was ‘totally useless’ as a means of checking what was being loaded into the hopper .
Whilst viewing the hopper is impossible on the current vehicle, it renders the instruction for drivers to view the hopper prior to compaction (contained in the Biffa Operating Instructions for Trade Waste Vehicles) impossible to achieve.
In addition, the automatic nature of the compaction process, also makes adherence to the Operating Instructions impossible on some vehicles, as compaction starts immediately the bin is tipped.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure of compaction processes to allow hopper inspection before compaction
Wider context from the report “4. Poor visibility through the Perspex viewing window on the lorry
In relation to the poor visibility through the Perspex viewing aperture/window on the lorry two factors were identified:
Firstly, it is physically impossible to undertake a check of the hopper mechanism on the Biffa lorry as the viewing aperture window is too high for this to be achieved by an average height driver.
Secondly, on the six-year-old vehicle in question the Perspex had become opaque.
A Detective Constable who had watched the lifting process to provide evidence of its operation for the court, described the driver as standing on tiptoes to try a check the vehicle hopper, whilst peering around the wing of the lifting mechanism. When asked specifically about the viewing window the officer said it was too high to see through and opaque. The officer told the court the viewing aperture was ‘totally useless’ as a means of checking what was being loaded into the hopper.
Whilst viewing the hopper is impossible on the current vehicle, it renders the instruction for drivers to view the hopper prior to compaction (contained in the Biffa Operating Instructions for Trade Waste Vehicles) impossible to achieve.
In addition, the automatic nature of the compaction process, also makes adherence to the Operating Instructions impossible on some vehicles , as compaction starts immediately the bin is tipped .
” Open source report
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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 Experts do not accept that stronger locks would reduce deaths because containers may remain unlocked and the lock may not determine entry.
Verbatim wording from the response “32. Clearly this is not an isolated case. It is however not accepted by the experts that the number of deaths could be reduced if stronger locks are fitted. Bin crews and/or end users might leave the container unlocked. If a refuse vehicle broke down and therefore did not empty that container when scheduled, and the bin then became overfilled, an individual could easily empty a few bags onto the floor and enter the container. The lock would have served no bearing in that scenario.” Source location Response from BSI
Open published response
2 Apr 2020 Ava-May LITTLEBOY · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 4 Failure to require registration under an approved equipment inspection scheme View source Failure to require operators to use a recognised inspection process View source Failure to require notification of enforcing authorities when equipment is deemed unsafe to use View source Failure to categorise equipment defects and publicly record non-issued compliance declarations View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ava-May LITTLEBOY · 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
Ava-May LITTLEBOY, aged 3, died on 1 July 2018 after an inflatable trampoline exploded at Gorleston beach, throwing her into the air. The report raised concerns about the absence of required inspection and certification arrangements, the lack of publicly recorded information when equipment was unsafe, and the absence of a legal requirement to notify enforcing authorities or use a specified inspection scheme.
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. The report was sent to British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to require registration under an approved equipment inspection scheme
Wider context from the report “1. Evidence was heard that it is required a device will be inspected by an independent third party and,
provided it satisfies relevant requirements, it will be certified under the Amusement Device Inspection
Procedures Scheme (ADIPS) (or Pertexa Inflatable Play Equipment (PIPA) or another testing scheme or
method which demonstrates how such procedures equal or better the accepted best practice) as safe
to operate and a Declaration of Operational Compliance (DOC) will be issued. If the device is not
deemed fit to use, then the device is categorised according to the defect or concern raised which may
result in a DOC not being issued and the operator advised not to use the equipment until the defect has
been rectified.
The inflatable trampoline had been acquired in August/September 2017 and was inspected by an
independent company on 26 June 2018 (namely 4 days prior to the trampoline exploding). Concerns
were raised by the independent company with regard to no pre-use manufacturing paperwork being
available and that not all Tie Downs were being used. Evidence was heard that had the trampoline been
registered under ADIPS a Category A defect would apply, namely that the device is considered as being
of imminent danger to persons and that the device should not be used until those defects have been
rectified. As such, a DOC would not have been issued and it would have been clear that the trampoline
was not fit to be used.
However, as the trampoline had not been registered under ADIPS (or PIPA or an independent scheme),
the issues could not be categorised and it would not be recorded in any public domain that a DOC had
not been issued.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to require operators to use a recognised inspection process
Wider context from the report “3. The evidence also revealed that there is no legal requirement for an Operator to use either the ADIPS
or PIPA inspection process but can rely on an alternative form of scheme or method of their own
choosing to demonstrate the device is safe to use.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to require notification of enforcing authorities when equipment is deemed unsafe to use
Wider context from the report “2. Further, there is no requirement that the relevant enforcing authority, for instance Health and Safety
Executive or the Local Authority is informed that the equipment is deemed unsafe to use .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to categorise equipment defects and publicly record non-issued compliance declarations
Wider context from the report “1. Evidence was heard that it is required a device will be inspected by an independent third party and,
provided it satisfies relevant requirements, it will be certified under the Amusement Device Inspection
Procedures Scheme (ADIPS) (or Pertexa Inflatable Play Equipment (PIPA) or another testing scheme or
method which demonstrates how such procedures equal or better the accepted best practice) as safe
to operate and a Declaration of Operational Compliance (DOC) will be issued. If the device is not
deemed fit to use, then the device is categorised according to the defect or concern raised which may
result in a DOC not being issued and the operator advised not to use the equipment until the defect has
been rectified.
The inflatable trampoline had been acquired in August/September 2017 and was inspected by an
independent company on 26 June 2018 (namely 4 days prior to the trampoline exploding). Concerns
were raised by the independent company with regard to no pre-use manufacturing paperwork being
available and that not all Tie Downs were being used. Evidence was heard that had the trampoline been
registered under ADIPS a Category A defect would apply, namely that the device is considered as being
of imminent danger to persons and that the device should not be used until those defects have been
rectified. As such, a DOC would not have been issued and it would have been clear that the trampoline
was not fit to be used.
However, as the trampoline had not been registered under ADIPS (or PIPA or an independent scheme),
the issues could not be categorised and it would not be recorded in any public domain that a DOC had
not been issued .
” 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 Regulatory and enforcement action to prevent recurrence falls outside the functions and authority of a national standards body.
Verbatim wording from the response “4. BSI is not a regulatory body nor an enforcement authority. It is therefore unable to advise on regulatory matters, which are a matter for HM Government. Nor is it able to compel or monitor compliance with its standards, which are voluntary documents. As such, BSI is unfortunately not the right body to take action to prevent a reoccurrence of this tragic event. More detail on the role of BSI can be found below.” Source location 2020-0085-Response-from-British-Standards-Institution_Redacted
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 Voluntary standards cannot compel operators or create a compulsory certification scheme, so the organisation cannot undertake that responsive work.
Verbatim wording from the response “19. BSI is therefore not in a position to draft standards which would compel operators of machinery such as the trampoline in the Report.” Source location 2020-0085-Response-from-British-Standards-Institution_Redacted
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 Increased control of amusement devices and compulsory standards enforcement are matters for HM Government, regulatory authorities and the Health and Safety Executive.
Verbatim wording from the response “5. BSI does not consider that it is able to supplant the work of the Amusement Device Safety Council (ADSC), which functions in a similar fashion to BSI in the area of amusement park machinery. Instead, any question for increased control of devices such as that involved in the accident the subject of the Report is one for regulatory authorities and the Health and Safety Executive.” Source location 2020-0085-Response-from-British-Standards-Institution_Redacted
Open published response
22 Mar 2019 Bram Luke Radcliffe · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 3 Failure to ensure safe installation of fireplace surrounds View source Lack of a British Standard for fixing stone fireplace surrounds View source Exclusion of fire surround provision from Building Regulations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Bram Luke Radcliffe · 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 8 November 2017, two-year-old Bram Luke Radcliffe was found unresponsive after a marble fireplace surround detached from the wall and struck him. He was taken to hospital but died later that morning from his head injury. Evidence at the inquest indicated that the fireplace surround installation was substandard and dangerous, and raised concerns about the absence of a British Standard for fixing stone fireplace surrounds and their exclusion from building regulations.
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. The report was sent to British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure safe installation of fireplace surrounds
Wider context from the report “During the inquest I heard evidence to indicate that the installation of the fireplace surround was both substandard and dangerous , and that there is currently no British Standard for the fixing of stone fireplace surrounds only for the manufacture. I was informed that the provision of a fire surround is not ‘building work’ as defined by Regulation 3(1) of the Building Regulations 2010 (as amended), therefore would not be the subject to Building Regulations and subject to guidance provided by the manufacturer/supplier and good building practice.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of a British Standard for fixing stone fireplace surrounds
Wider context from the report “During the inquest I heard evidence to indicate that the installation of the fireplace surround was both substandard and dangerous, and that there is currently no British Standard for the fixing of stone fireplace surrounds only for the manufacture . I was informed that the provision of a fire surround is not ‘building work’ as defined by Regulation 3(1) of the Building Regulations 2010 (as amended), therefore would not be the subject to Building Regulations and subject to guidance provided by the manufacturer/supplier and good building practice.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Exclusion of fire surround provision from Building Regulations
Wider context from the report “During the inquest I heard evidence to indicate that the installation of the fireplace surround was both substandard and dangerous, and that there is currently no British Standard for the fixing of stone fireplace surrounds only for the manufacture. I was informed that the provision of a fire surround is not ‘building work’ as defined by Regulation 3(1) of the Building Regulations 2010 (as amended), therefore would not be the subject to Building Regulations and subject to guidance provided by the manufacturer/supplier and good building practice.
” Open source report
10 Nov 2014 Myra Goldman · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Failure to distribute gate weight between hinges View source Failure to use a proprietary method to prevent gate removal by lifting at the hinges View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Myra Goldman · 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
Myra Goldman died after a palisade gate fell on her. The Jury concluded that the gate fell because of fatigue of the lower right-hand hinged eye bolt and the configuration of the lugs and hinge pins; concerns were raised that this configuration placed most of the gate’s load on one hinge and that the relevant standard should be reviewed.
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. The report was sent to British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to distribute gate weight between hinges
Wider context from the report “The inversion of the upper hinge pin is not an uncommon practice and is intended to prevent a gate from being easily lifted off its hinges. BS 1722-12:2006 specification for steel palisade fences which states that ‘hinges shall be designed so that it is impossible to remove the gates by lifting at the hinges when they are in the shut and locked position’. The standard gives examples of hinge arrangements and does not specifically preclude this method.
In the opinion of HM Specialist Inspector (Mechanical Engineering) of the Health & Safety Executive who gave evidence at the Inquest ‘the common sense approach is to spread the load’ between hinges by orientating them the same way rather than putting the significant majority of the weight of the gate onto one hinge only and ‘to prevent the gate from being easily lifted off, a proprietary method should be used such as double – lug hinge or anti-theft collars or split pins’. The preference of HM Specialist Inspector was for the standard to be ‘changed’.
Any change can only be considered / implemented at a review meeting of the British Standards Institute.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to use a proprietary method to prevent gate removal by lifting at the hinges
Wider context from the report “The inversion of the upper hinge pin is not an uncommon practice and is intended to prevent a gate from being easily lifted off its hinges. BS 1722-12:2006 specification for steel palisade fences which states that ‘hinges shall be designed so that it is impossible to remove the gates by lifting at the hinges when they are in the shut and locked position’. The standard gives examples of hinge arrangements and does not specifically preclude this method.
In the opinion of HM Specialist Inspector (Mechanical Engineering) of the Health & Safety Executive who gave evidence at the Inquest ‘the common sense approach is to spread the load’ between hinges by orientating them the same way rather than putting the significant majority of the weight of the gate onto one hinge only and ‘to prevent the gate from being easily lifted off, a proprietary method should be used such as double – lug hinge or anti-theft collars or split pins’ . The preference of HM Specialist Inspector was for the standard to be ‘changed’.
Any change can only be considered / implemented at a review meeting of the British Standards Institute.
” 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 Forwarded the coroner’s letter to the responsible standards committee for inclusion in its review of BS 1722-12:2006.
Verbatim wording from the response “In this case, the committee of BS 1722-12:2006 recently accepted a proposal to review this Standard and the reviewed Standard is expected to be published in 2016. I have forwarded your letter to the chairman of the standing committee responsible for BS 1722-12:2006 to be included as part of their review. I have also asked the chairman to consider whether the proposed review of this Standard may be accelerated in light of the concerns you have raised.” Source location 2014-0490-Response-by-BSI
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 Asked the responsible standards committee chairman to consider accelerating the review of BS 1722-12:2006 in light of the safety concerns raised.
Verbatim wording from the response “In this case, the committee of BS 1722-12:2006 recently accepted a proposal to review this Standard and the reviewed Standard is expected to be published in 2016. I have forwarded your letter to the chairman of the standing committee responsible for BS 1722-12:2006 to be included as part of their review. I have also asked the chairman to consider whether the proposed review of this Standard may be accelerated in light of the concerns you have raised.” Source location 2014-0490-Response-by-BSI
Open published response
5 Nov 2014 Santosh Benjamin Muthiah · Prevention of Future Deaths report North London
View report summary
Concerns raised 10 Insufficient capacitor safety requirements to prevent hazards on failure View source Lack of requirements to isolate or protect refrigeration-appliance insulation from ignition View source Failure to identify appliance fire causes and appliance identifiers after fire damage View source Lack of second-hand market controls for recalled or safety-notice products View source Failure to routinely pass identified domestic appliance fire information to Trading Standards or manufacturers View source Underestimation of capacitor-related fire risk in Beko fridge-freezer risk assessment View source Inconsistent guidance on product risk notification and corrective action View source Lack of awareness of the safety notice for recalled Beko fridge-freezer models View source Inconsistent product safety risk assessments omitting or variably weighting serious injury factors View source Lack of requirements for less flammable or better-contained plastic materials in refrigeration appliances View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Santosh Benjamin Muthiah · 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
Santosh Benjamin Muthiah died after a fire spread through his home while he and his family were sleeping, with the medical cause recorded as cerebral anoxia due to inhalation of fire fumes. The report raised concerns about the identification and communication of appliance-fire information, risks from recalled and second-hand refrigeration appliances, product safety risk assessments, guidance and notification practices, and the construction and components of refrigeration appliances, including capacitors.
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. The report was sent to British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacitor safety requirements to prevent hazards on failure
Wider context from the report “24. I heard evidence for the LFB witnesses, in particular ████████, who gave evidence about the serious concerns they hold about the ongoing risk posed by capacitor failures resulting in fires. These concerns are twofold, relating generally to capacitors and the industry standards and in relation to Beko appliances.
25. Paragraph 24.8 of British Standard BS EN 60335-1:2012 ‘Household and similar electrical appliances; Safety; Part 1 - General requirements.’ applies to the type of capacitors used in refrigeration appliances. It states that they shall not cause a hazard in the event of failure.
26. This requirement is considered to be met by one or more of the following conditions:
a. The capacitors are of a class of safety protection P2 according to IEC 60252-1;
b. The capacitor is housed within a metallic or ceramic enclosure that will prevent the emission of flame or molten material resulting from failure of the capacitor;
c. The distance of separation of the outer surface of the capacitor to adjacent non-metallic parts exceeds 50mm;
d. Adjacent non-metallic parts within 50 mm of the outer surface of the capacitor withstand the needle-flame test of Annex E;
e. Adjacent non-metallic parts within 50 mm of the outer surface of the capacitor are classified as at least V-1 according to IEC 60695-11-10, provided that the test sample used for the classification was no thicker than the relevant part of the appliance.
27. I accept and agree with the concern raised by the LFB that the above requirement does not ensure that capacitors do not pose a hazard . This creates a risk to the safety of consumers.
28. The LFB FIT has experience of failures of P2 capacitors and failures leading to ignition of metal casing capacitors (contrary to a. and b. above).
29. Further, it is clear that the mechanisms of failure of a capacitor can bypass the required 50mm distance (contrary to c. above). Furthermore, in the case of a refrigeration appliance, the base of the compressor compartment is often two metal bars used for mounting components, leaving the floor surface exposed (for example a flammable carpet).
30. The LFB believes that the requirements regarding capacitors referred to in paragraph 50 above (citing paragraph 24.8 British Standard BS EN 60335-1 : 2012) are not robust enough to prevent capacitors from presenting a hazard , which creates a risk to the safety of consumers.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of requirements to isolate or protect refrigeration-appliance insulation from ignition
Wider context from the report “20. I heard evidence from the LFB witnesses who gave evidence concerning the inherent risks that refrigeration appliances present due to their construction. The polyurethane insulation material used in most refrigeration appliances represents a high fuel load, is highly flammable and when on fire burns to create dangerous gases.
21. There is no legal requirement or industry standard that this insulation material is isolated from or protected from ignition by a failure in another component within the appliance , which represent a risk of ignition, such as the compressor, capacitor or ancillary components. This represents a serious risk to the safety of consumers .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to identify appliance fire causes and appliance identifiers after fire damage
Wider context from the report “1. I heard evidence from various witnesses, including the LFB but also from Beko and ████████ formerly of Intertek, that there are often problems in identifying, not just the specific cause of an appliance fire, but even the manufacturer, model and serial number of the appliance in question due to the severity of the fire damage . This has a knock on effect on Fire & Rescue Services’ (“FRS’s”), Trading Standards (“TS”) and manufacturers’ ability to accurately identify a pattern or trend within fires from appliances which may evidence a specific manufacturing or component problem.
2. This creates a risk that the nature and extent of a potential problem with a particular manufacturer or particular appliance is not fully known and therefore underestimated with the consequence that the risk to the lives of consumers may also be underestimated.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of second-hand market controls for recalled or safety-notice products
Wider context from the report “8. I heard evidence from the LFB witnesses who gave some evidence that defective products on the second hand market pose a continuing risk to consumers.
9. There is no clear system in place to ensure that products subject to a safety notice or recall are not sold, unmodified, on the second hand market . By way of example, the LFB has recently identified several unmodified Beko fridge freezers which are subject to the safety notice, for sale in a second hand retailer. This lack of regulation or market surveillance of the second hand market poses a risk to consumers .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely pass identified domestic appliance fire information to Trading Standards or manufacturers
Wider context from the report “6. This is not the case routinely elsewhere in the country. There may be a variety of reasons for this, including the difficulty in identifying the appliances due to fire damage, and the more limited resources and expertise in the investigation of the causes of fires that other FRS’s have in contrast to the fortunate position of the LFB.
7. Whatever the reasons there is a risk in existence where such information that is gathered by FRS’s in relation to fires involving domestic electrical appliances (where the appliance can be identified) is not routinely passed to the appropriate TS Home or Primary Authority or indeed to the manufacturer . TS is taking decisions on whether to take any action in relation to a particular manufacturer or a particular appliance on less than all the available information. If they were provided with more accurate information about the incidences of appliance fires they would be in a better position to take action where necessary.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Underestimation of capacitor-related fire risk in Beko fridge-freezer risk assessment
Wider context from the report “31. I heard evidence from LFB witnesses who gave evidence of their concerns that serious failures in Beko Frost Free Fridge Freezers (“FFFF’s”) manufactured between 2000 and 2006 are continuing resulting in a serious risk to the safety of consumers. ████████ gave evidence of the numbers of fires which the LFB FIT have investigated to date, the appliance models and the causes of the fires. The LFB have written to Beko concerning these fires and the risk the appliances represent. This concern relates in large part to capacitor failures.
32. Although it is right to say that there was some evidence that there may be an “industry wide problem” i.e. that this risk is not specific to Beko, this alone does not address the risk which exists in Beko products and nor have the LFB been concerned enough in relation to the risk presented by other manufacturer’s products to write to any of them.
33. The LFB were provided with a risk assessment from Beko dated 26 April 2012 which states that the risk is “low” such that no action is necessary or proposed. The LFB is concerned that this underestimates the risk to the safety of consumers , particularly as Beko witnesses’ own evidence seemed to highlight that they consider the capacitor as a potential ignition source in fires .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Inconsistent guidance on product risk notification and corrective action
Wider context from the report “16. I heard from Beko witnesses and also, in particular, ████████ that there are inconsistencies between the EU Commission Guidance and the UK Trade Association Guidance on corrective action and the requirement to notify an enforcement authority .
17. The AMDEA guidance says that if the outcome of the risk assessment is that there is a “moderate” risk, the manufacturer is not required to notify TS but the BIS guidance says that a “moderate” risk outcome requires notification to TS.
18. Manufacturers therefore are in difficulty in consistently applying guidance and in carrying out their notification obligations where there is the requisite level of risk to consumers.
19. I accept the LFB submissions that such inconsistency creates a risk that TS not being notified and therefore action not being taken in circumstances when it arguably should be highlighting a risk to consumers.
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the safety notice for recalled Beko fridge-freezer models
Wider context from the report “10. I heard evidence from the LFB witnesses of their concerns that serious failures in Beko Frost Free Fridge Freezers (“FFFF’s”) manufactured between 2000 and 2006 are continuing resulting in a serious risk to the safety of consumers. ████████ gave evidence of the numbers of fires which the LFB FIT have investigated to date, the appliance models and the causes of the fires.
11. The LFB submits that there remains a risk in relation to the lack of or minimal awareness of the current safety notice in relation to these Beko models .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Inconsistent product safety risk assessments omitting or variably weighting serious injury factors
Wider context from the report “12. I heard a great deal of evidence concerning the process of risk assessment and the factors to be taken into account when considering the potential seriousness of injury and the likelihood of a risk eventuating.
13. It is the view of the LFB that the following matters should always be taken in to account when carrying out a product safety risk assessment:
a. Sleeping risk – i.e. the fact that a person is more vulnerable to the risks of fire when asleep;
b. The most serious consequence of a product failure i.e. in the case of fire, serious injury or death;
c. The potential long term physical impact on persons who have suffered burns injuries;
d. The possible psychological impact on persons who have suffered the trauma of a fire.
14. It was clear from the evidence that there have been and continue to be different approaches to risk assessment adopted . The evidence from ████████ and the evidence from the face of the Arcelik and Intertek Risk Assessments (in documentary form) made at the material times over a period of a number of years show that some of these factors are not taken into account and some may be taken into account to a variable degree .
15. Failing to take these factors into account expressly creates a risk that the seriousness of injury, and consequently, potentially the seriousness of the overall risk is underestimated .
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of requirements for less flammable or better-contained plastic materials in refrigeration appliances
Wider context from the report “23. The plastic materials which are used for filling, strengthening and insulating refrigeration appliances are highly flammable and increase the fuel load of these appliances posing a continuing risk to consumers . It is possible to use alternate, non-flammable or less flammable materials. It is also possible to better contain such combustible components or insulation. There is no such requirement at present which creates a risk to the safety of consumers .
” Open source report
27 May 2014 Gerardo Abadilla Tongobanua · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure of the LSA Code and ISO 15516 to specify the number, definition and performance of davit safety devices View source Lack of requirements to assess rescue boat lifting davits, winches and fall wires as a system View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Gerardo Abadilla Tongobanua · 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 7 February 2011, Gerardo Abadilla Tongobanua fell 29 metres during a fast rescue boat drill onboard the MV Tombarra while it was docked at Royal Portbury Dock, Bristol, after the fall wire snapped. The concerns identified were that the winch motor could overstress the fall wire and that the failed electronic switch did not stop the motor, while the relevant code and standard did not adequately specify system design or safety-device requirements.
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. The report was sent to British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Failure of the LSA Code and ISO 15516 to specify the number, definition and performance of davit safety devices
Wider context from the report “2. An electronic switch, fitted to the rescue boat davit onboard Tombarra, failed to operate and stop the winch motor. The LSA Code refers to ‘safety devices’ fitted to the davits which will automatically cut off the winch power to prevent overstressing of components. This is reflected in the international standard ISO 15516 “Ships and marine technology—launching appliances for davit-launched lifeboats”. However, neither the Code nor the standard specify the number, definition or performance of the ‘safety devices’ fitted. Consequently, manufacturers have little guidance in these areas compared to manufacturers of industrial machinery
” 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 British Standards Institution; that does not assign responsibility.
PFD Monitor interpretation Lack of requirements to assess rescue boat lifting davits, winches and fall wires as a system
Wider context from the report “1. The fall wire of MV Tombarra’s rescue boat failed because the winch electric motor was capable of easily overstressing the fall wire to the point of failure. There is currently no requirement within the Life-Saving Appliances (LSA) Code to consider design of the rescue boat lifting davit, winch and fall wire, as a ‘system’ when assessing the suitability of the forces and loads applied. The Code infers that ‘overstressing’ of the falls or davits could occur.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations