22 Oct 2015 Richard LACO · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure of method statements, risk assessments and lift plans to address changed landing-fitting processes View source Insufficient process understanding among personnel responsible for planning and approving landing-fitting work View source Unavailability of an appropriate plan for basement landing fitting View source Failure to specify the correct landing orientation for tag-line tilting View source Failure to include stop instructions for unsuccessful positive fixings during landing fitting View source Failure to identify the need for a task-specific landing-fitting plan during drafting and approval View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 7
Action
Stop lifting when circumstances, environmental changes or attachment deviations compromise the operation, then assess and approve lift-plan modifications before resuming.
Stated plannedThe respondent said that this action was planned when they made their response on 22 October 2015. View source
Action
Require qualified appointed persons to plan lifting operations using CMF’s native lift-plan procedure.
Stated plannedThe respondent said that this action was planned when they made their response on 22 October 2015. View source
Action
Submit lifting plans, temporary-works requirements and relevant design considerations to the Principal Contractor for approval before lifting.
Stated plannedThe respondent said that this action was planned when they made their response on 22 October 2015. View source
Action
Use purpose-designed lifting holes or bespoke lifting carriages, identified during design with advice from the appointed person.
Stated plannedThe respondent said that this action was planned when they made their response on 22 October 2015. View source
Action
Implement an alternative landing-lifting method using bolted lifting frames, anchored lifting eyes, chains, separate winches and an additional slab opening.
Stated completedThe respondent said that this action was complete when they made their response on 22 October 2015. View source
Action
Require appointed persons to brief lift teams on approved plans, temporary works, design considerations and individual responsibilities.
Stated plannedThe respondent said that this action was planned when they made their response on 22 October 2015. View source
Action
Require appointed-person re-briefings after lift-supervisor absence and whenever a lift plan remains in force for more than 90 days.
Stated plannedThe respondent said that this action was planned when they made their response on 22 October 2015. View source See 4 more actions
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AI-generated summary
Richard LACO · 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
Richard Laco died on a building site at the Francis Crick Institute when a landing fell on him while it was being tilted into place. The fitting process used a different methodology from earlier landings, but the method statement, risk assessment and lift plan did not describe the process or provide key safety instructions. The report also raised concerns about inadequate understanding of the planning and approval requirements among some site witnesses.
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 C.M.F. Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of method statements, risk assessments and lift plans to address changed landing-fitting processes
Wider context from the report “1. The fitting of the two below ground landings in core D of the development at the Francis Crick Institute utilised a different methodology to the landings already fitted in cores A and F. The shape of the landings was trapezoid rather than rectangular; and they were lowered vertically to ground level and then later raised & tilted to pass the side fins; rather than simply being lowered from the top directly into place.
However, no part of the method statement, risk assessment or lift plan recognised that .
There was no description of the different process ; there was no instruction to stop the procedure if positive fixings (i.e. feeding the slings through eye bolts) could not be achieved; and there was no indication that the wide rather than the narrow end of the landing should be tilted down with the tag lines.
The need for such a plan was not identified by CMF in drafting the planning documents, nor by LOR in checking and approving them.
” 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 C.M.F. Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient process understanding among personnel responsible for planning and approving landing-fitting work
Wider context from the report “2. Not only was there no appropriate plan in place for the fitting of the two basement landings in core D, at inquest nearly two years after the event, some site witnesses did not appear to see the need for such a plan.
Some witnesses did not appear familiar with basic terminology, despite still holding a pivotal role in planning/approving the plans for such processes, and gave evidence that did not demonstrate clarity of understanding of the processes .
” 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 C.M.F. Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an appropriate plan for basement landing fitting
Wider context from the report “2. Not only was there no appropriate plan in place for the fitting of the two basement landings in core D, at inquest nearly two years after the event, some site witnesses did not appear to see the need for such a plan.
Some witnesses did not appear familiar with basic terminology, despite still holding a pivotal role in planning/approving the plans for such processes, and gave evidence that did not demonstrate clarity of understanding of the processes.
” 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 C.M.F. Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to specify the correct landing orientation for tag-line tilting
Wider context from the report “1. The fitting of the two below ground landings in core D of the development at the Francis Crick Institute utilised a different methodology to the landings already fitted in cores A and F. The shape of the landings was trapezoid rather than rectangular; and they were lowered vertically to ground level and then later raised & tilted to pass the side fins; rather than simply being lowered from the top directly into place.
However, no part of the method statement, risk assessment or lift plan recognised that.
There was no description of the different process; there was no instruction to stop the procedure if positive fixings (i.e. feeding the slings through eye bolts) could not be achieved; and there was no indication that the wide rather than the narrow end of the landing should be tilted down with the tag lines .
The need for such a plan was not identified by CMF in drafting the planning documents, nor by LOR in checking and approving them.
” 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 C.M.F. Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to include stop instructions for unsuccessful positive fixings during landing fitting
Wider context from the report “1. The fitting of the two below ground landings in core D of the development at the Francis Crick Institute utilised a different methodology to the landings already fitted in cores A and F. The shape of the landings was trapezoid rather than rectangular; and they were lowered vertically to ground level and then later raised & tilted to pass the side fins; rather than simply being lowered from the top directly into place.
However, no part of the method statement, risk assessment or lift plan recognised that.
There was no description of the different process; there was no instruction to stop the procedure if positive fixings (i.e. feeding the slings through eye bolts) could not be achieved; and there was no indication that the wide rather than the narrow end of the landing should be tilted down with the tag lines.
The need for such a plan was not identified by CMF in drafting the planning documents, nor by LOR in checking and approving them.
” 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 C.M.F. Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the need for a task-specific landing-fitting plan during drafting and approval
Wider context from the report “1. The fitting of the two below ground landings in core D of the development at the Francis Crick Institute utilised a different methodology to the landings already fitted in cores A and F. The shape of the landings was trapezoid rather than rectangular; and they were lowered vertically to ground level and then later raised & tilted to pass the side fins; rather than simply being lowered from the top directly into place.
However, no part of the method statement, risk assessment or lift plan recognised that.
There was no description of the different process; there was no instruction to stop the procedure if positive fixings (i.e. feeding the slings through eye bolts) could not be achieved; and there was no indication that the wide rather than the narrow end of the landing should be tilted down with the tag lines.
The need for such a plan was not identified by CMF in drafting the planning documents, nor by LOR in checking and approving them .
” 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 Stop lifting when circumstances, environmental changes or attachment deviations compromise the operation, then assess and approve lift-plan modifications before resuming.
Verbatim wording from the response “6. If at any stage the lifting operation becomes compromised by unforeseen circumstances or changes to the local environment, lifting will cease as soon as it is safe to do so. The appointed person will then assess the changes and implement the modification within the lift plan before lifting resumes. Similarly the slinger signaller must not deviate from using the prescribed attachments or accessories defined in the lift plan and schedule of common lifts. Any deviation will cause lifting to cease until the approved person has assessed the implications.” Source location Richard-Laco-Response2
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 Require qualified appointed persons to plan lifting operations using CMF’s native lift-plan procedure.
Verbatim wording from the response “2. The lifting operations are to be planned by a qualified appointed person for lifting and not by site managers who may not have formal qualifications for lifting operations despite having extensive experience of lifting. A lift plan is to be completed using the CMF native lift plan procedure to ensure consistency and content.” Source location Richard-Laco-Response2
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 Submit lifting plans, temporary-works requirements and relevant design considerations to the Principal Contractor for approval before lifting.
Verbatim wording from the response “3. Lifting plans together with any temporary works requirement or relevant design considerations are to be submitted to and approved by the Principal Contractor for projects before lifting commences.” Source location Richard-Laco-Response2
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 Use purpose-designed lifting holes or bespoke lifting carriages, identified during design with advice from the appointed person.
Verbatim wording from the response “1. All members to be lifted will either have adequately sized holes that allow for the fixing of positive anchorages for lifting accessories or for alternative bespoke lifting carriages. These will be identified during the design stage and advice obtained from the appointed person.” Source location Richard-Laco-Response2
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 Implement an alternative landing-lifting method using bolted lifting frames, anchored lifting eyes, chains, separate winches and an additional slab opening.
Verbatim wording from the response “Following the incident and after intensive investigations into best practice for an alternative method of lifting, it was determined to proceed with a lift plan that involved tilting the landing past the fin plates. An additional lifting frame was designed to be fixed to the landing with bolts that would facilitate the use of lifting eyes. The use of slings for lifting was substituted by chains attached to the lifting eyes. A second winch was introduced and another hole made in the slab so the tilt of the landing could be carried out by raising and lowering of separate winches rather than taglines. The trapezoidal landings above the ground floor slab were installed in accordance with the original lift plan methodology as this was still considered to be the best practice although the use of slings was again substituted for chains attached to directly anchored lifting eyes.” Source location Richard-Laco-Response2
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 Require appointed persons to brief lift teams on approved plans, temporary works, design considerations and individual responsibilities.
Verbatim wording from the response “4. All approved lifting plans will be explained to the lift team by the appointed person to ensure everyone in the lift team understands and that all members of the lift team are fully conversant with their respective duties or responsibilities. This is also to include any temporary work associated with the lift and/or important design considerations.” Source location Richard-Laco-Response2
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 Require appointed-person re-briefings after lift-supervisor absence and whenever a lift plan remains in force for more than 90 days.
Verbatim wording from the response “5. After delegation of the lift plan to the lift supervisor, absence of this person through illness or other reason will require a re-briefing by the appointed person to ensure replacement and entire lift team are briefed before lifting resumes. In any event if the lift plan is in force for more than 90 days, a re-briefing of the lift team will be a requirement.” Source location Richard-Laco-Response2
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The irregular landing shape was not sufficiently significant to require changing the lifting plan, and factory trials raised no concerns.
Verbatim wording from the response “The Project Lifting Plan produced by CMF on 25th May 2013 for lifts within the cores was revised on the 22nd August 2013 (Revision C) to include photographs of trial lifts conducted by CMF at its factory. The revisions were made in anticipation of lifts to be conducted within Cores F and D. The lifting plan in this revised format was intended for use in Core D, despite the irregular shape of the landings on one side of the core. The shape of the landing was not considered by CMF to be of sufficient significance to necessitate a change to the lift plan.” Source location Richard-Laco-Response2
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations