CMBC Supply LimitedIncludes reports addressed to a minister or senior office-holder acting for this organisation.

Private and voluntary organisations · Private limited company

Pin Request correction

First report 5 Jul 2018•Latest report 5 Jul 2018

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from CMBC Supply Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: Chief Executive, Carlsberg Supply Co Ltd.

    Northamptonshire

    AI-generated summary

    David Chandler · 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

    David Chandler died at the scene on 9 November 2016 during work to remove a dormant compressor at the Carlsberg Brewery, following a high-pressure escape of gaseous ammonia. The concerns included reliance on an isolation from earlier work, inadequate review of the isolation standard, unclear responsibilities between organisations, and an incorrectly completed Permit To Work that did not refer to hazardous substances.

    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 CMBC Supply Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to establish clear responsibility for ensuring compressor isolation

    Wider context from the report

    “(1) The isolation for the 2014 work was still in place and does not appear to have been reviewed in the intervening period. The 2014 work was of a different nature and did not require physical removal of the whole compressor. There does not appear to have been any formal review of the appropriate isolation standard for the work in November 2016 to be performed safely. (2) Carlsberg contracted the work to Crowley Carbon who employed specialist refrigeration engineers. The evidence at the inquest suggested that Crowley Carbon and Carlsberg were each relying on the other to ensure that the compressor was safely isolated. (3) The Permit To Work (PTW) issued by Carlsberg to allow Speedrite to remove the compressor made reference to the 2014 PTW isolation, was completed incorrectly, and made no reference to hazardous substances. (4) Relying on the isolation from previous work on the compressor appears to have caused confusion as to the safe level of isolation necessary for work of a different nature two years later. ”
    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 CMBC Supply Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete the Permit To Work accurately with current isolation information

    Wider context from the report

    “(1) The isolation for the 2014 work was still in place and does not appear to have been reviewed in the intervening period. The 2014 work was of a different nature and did not require physical removal of the whole compressor. There does not appear to have been any formal review of the appropriate isolation standard for the work in November 2016 to be performed safely. (2) Carlsberg contracted the work to Crowley Carbon who employed specialist refrigeration engineers. The evidence at the inquest suggested that Crowley Carbon and Carlsberg were each relying on the other to ensure that the compressor was safely isolated. (3) The Permit To Work (PTW) issued by Carlsberg to allow Speedrite to remove the compressor made reference to the 2014 PTW isolation, was completed incorrectly, and made no reference to hazardous substances. (4) Relying on the isolation from previous work on the compressor appears to have caused confusion as to the safe level of isolation necessary for work of a different nature two years later. ”
    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 CMBC Supply Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify hazardous substances in the Permit To Work

    Wider context from the report

    “(1) The isolation for the 2014 work was still in place and does not appear to have been reviewed in the intervening period. The 2014 work was of a different nature and did not require physical removal of the whole compressor. There does not appear to have been any formal review of the appropriate isolation standard for the work in November 2016 to be performed safely. (2) Carlsberg contracted the work to Crowley Carbon who employed specialist refrigeration engineers. The evidence at the inquest suggested that Crowley Carbon and Carlsberg were each relying on the other to ensure that the compressor was safely isolated. (3) The Permit To Work (PTW) issued by Carlsberg to allow Speedrite to remove the compressor made reference to the 2014 PTW isolation, was completed incorrectly, and made no reference to hazardous substances. (4) Relying on the isolation from previous work on the compressor appears to have caused confusion as to the safe level of isolation necessary for work of a different nature two years later. ”
    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 CMBC Supply Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to review and determine the appropriate isolation standard for changed work

    Wider context from the report

    “(1) The isolation for the 2014 work was still in place and does not appear to have been reviewed in the intervening period. The 2014 work was of a different nature and did not require physical removal of the whole compressor. There does not appear to have been any formal review of the appropriate isolation standard for the work in November 2016 to be performed safely. (2) Carlsberg contracted the work to Crowley Carbon who employed specialist refrigeration engineers. The evidence at the inquest suggested that Crowley Carbon and Carlsberg were each relying on the other to ensure that the compressor was safely isolated. (3) The Permit To Work (PTW) issued by Carlsberg to allow Speedrite to remove the compressor made reference to the 2014 PTW isolation, was completed incorrectly, and made no reference to hazardous substances. (4) Relying on the isolation from previous work on the compressor appears to have caused confusion as to the safe level of isolation necessary for work of a different nature two years later. ”
    Open source report
Back to top

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026