18 Dec 2025 JOHN HENRY OATES known as HARRY OATES · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 5 Low hanging lines resulting from phase-to-phase faults View source Manufacturing of porcelain tension disc insulators failing to prevent voids in cement fill View source Porcelain tension disc insulators with asymmetrical pins increasing internal stresses View source Lack of automatic detection of low hanging lines View source Locations with porcelain tension disc insulators above equipment where a conductor could be suspended after disc failure View source See 2 more concerns
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AI-generated summary
JOHN HENRY OATES known as HARRY OATES · 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
Harry Oates died instantly on 27 October 2023 after contacting an energised low-hanging 11kV conductor while on a training run in a field. The conductor had been released after the simultaneous failure of two porcelain insulators containing voids in their cement fill, and there was no automatic detection of the low-hanging line at the time. The principal concerns were the previously unknown defects in widely used insulators, the potential for phase-to-phase faults to create low-hanging lines, and the existence of other locations with similar configurations and risks.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Electricity Networks Association; that does not assign responsibility.
PFD Monitor interpretation Low hanging lines resulting from phase-to-phase faults
Wider context from the report “5. A phase-to-phase fault can lead to a low hanging line. This was not known prior to Harry’s death.
6. There will be locations across the UK which have the combination of porcelain tension disc insulators situated above equipment (such as an ASL) on which a conductor could be suspended in the event of disc failure.
” 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 Electricity Networks Association; that does not assign responsibility.
PFD Monitor interpretation Manufacturing of porcelain tension disc insulators failing to prevent voids in cement fill
Wider context from the report “1. The cement fill within the porcelain tension disc insulators was found to contain voids in 73% of the insulators tested . These voids were introduced during the manufacturing process . The industry was unaware of these voids until discovered during ENWL’s investigation. Porcelain tension disc insulators are used widely throughout the electricity industry – and other industries.
2. Some of the discs tested were also found to have asymmetrical pins which increased the internal stresses on the insulators.
3. Either voids alone or in combination with an asymmetrical pin create a means by which electric current can pass across the voids and lead to failure of an insulator.
” 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 Electricity Networks Association; that does not assign responsibility.
PFD Monitor interpretation Porcelain tension disc insulators with asymmetrical pins increasing internal stresses
Wider context from the report “1. The cement fill within the porcelain tension disc insulators was found to contain voids in 73% of the insulators tested. These voids were introduced during the manufacturing process. The industry was unaware of these voids until discovered during ENWL’s investigation. Porcelain tension disc insulators are used widely throughout the electricity industry – and other industries.
2. Some of the discs tested were also found to have asymmetrical pins which increased the internal stresses on the insulators.
3. Either voids alone or in combination with an asymmetrical pin create a means by which electric current can pass across the voids and lead to failure of an insulator.
” 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 Electricity Networks Association; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic detection of low hanging lines
Wider context from the report “7. Although at the time of the incident, there was no automatic means of detecting a low hanging line , technology now exists that can detect both these factors and which narrows the area in which the low hanging line is situated – Linesight.
8. It has also been determined that Linesight can detect that an insulator may be subject to internal stresses.
” 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 Electricity Networks Association; that does not assign responsibility.
PFD Monitor interpretation Locations with porcelain tension disc insulators above equipment where a conductor could be suspended after disc failure
Wider context from the report “5. A phase-to-phase fault can lead to a low hanging line. This was not known prior to Harry’s death.
6. There will be locations across the UK which have the combination of porcelain tension disc insulators situated above equipment (such as an ASL) on which a conductor could be suspended in the event of disc failure.
” 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 Review relevant ENA SHE standards in light of information shared from the incident.
Verbatim wording from the response “Objective 1: Review and improve where necessary, Safety, Health and Environment (SHE) industry standards and public safety risk assessment
ENA and its members will:” Source location Response from Electricity Networks Association
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an Engineering Technical Report documenting asset failure evidence and relevant emerging failure mechanisms for member-company risk assessment.
Verbatim wording from the response “- Develop an Engineering Technical Report (ETR) to collate and document engineering evidence on asset failure modes relevant to this incident, consolidating findings from SP ENW and concerns identified in your report, and incorporate learning from wider industry experiences. It will also capture and review other relevant or emerging failure mechanisms, providing a reference resource for ENA member companies.” Source location Response from Electricity Networks Association
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue promoting engineering-standard improvements and awareness of innovative monitoring and detection technologies.
Verbatim wording from the response “Broader objectives
ENA will continue to promote improvements in engineering standards and raise awareness of available and emerging innovative monitoring and detection technologies, including those referenced in your report. ENA member companies will assess the effectiveness of these solutions and share current and emerging good” Source location Response from Electricity Networks Association
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop supplementary guidance and risk-assessment criteria for automatically reclosed overhead lines with potentially low-hanging conductors.
Verbatim wording from the response “- Develop supplementary guidance to address the risk relating to overhead lines that have automatically reclosed where a low hanging conductor may exist but has not been reported or been detected. The guidance will establish a risk assessment criteria for member companies to consider, informed by industry best known and available practices. This should inform and strengthen existing ways of working and support appropriate interventions such as risk-targeted inspections or patrols, asset location data, enhanced monitoring, and other appropriate or technical solutions to proportionately mitigate foreseeable risk.” Source location Response from Electricity Networks Association
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Member companies are responsible for reviewing their public safety risk assessments and determining proportionate interventions or investment actions.
Verbatim wording from the response “This additional guidance will support ENA member companies in reviewing and updating their own individual associated public safety risk assessments, which each company has committed to undertake and continue to review periodically.” Source location Response from Electricity Networks Association
Open published response
4 Nov 2022 Levi Louis Alleyne · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 5 Lack of Standard Operating Procedure instructions to contact the local DNO during electrical hazards View source Fragmented DNO emergency contact arrangements across ambulance service boundaries View source Delays to life-saving treatment due to uncertainty about whether OHPLs remain live View source Unavailability and poor accessibility of correct DNO emergency numbers to ambulance control centre operators View source Risk to bystanders and emergency services from approaching patients near live OHPLs View source See 2 more concerns
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AI-generated summary
Levi Louis Alleyne · 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
Levi Louis Alleyne, a grab lorry delivery driver, died by electrocution at a building site after raising his lorry’s crane arm beneath overhead power lines. CPR was delayed because it was unclear whether the electricity remained live, and the ambulance control operator had no procedure or readily accessible emergency contact information for the relevant electricity network operator. The report identifies risks of delayed life-saving treatment or people approaching live electrical hazards and notes that similar mitigating procedures may not be adopted across England and Wales.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Electricity Networks Association; that does not assign responsibility.
PFD Monitor interpretation Lack of Standard Operating Procedure instructions to contact the local DNO during electrical hazards
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off . There is no such instruction in the national Standard Operating Procedure .
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” 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 Electricity Networks Association; that does not assign responsibility.
PFD Monitor interpretation Fragmented DNO emergency contact arrangements across ambulance service boundaries
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact . There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries . Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand . The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO .
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” 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 Electricity Networks Association; that does not assign responsibility.
PFD Monitor interpretation Delays to life-saving treatment due to uncertainty about whether OHPLs remain live
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live . There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live ,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” 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 Electricity Networks Association; that does not assign responsibility.
PFD Monitor interpretation Unavailability and poor accessibility of correct DNO emergency numbers to ambulance control centre operators
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes . The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known .
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” 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 Electricity Networks Association; that does not assign responsibility.
PFD Monitor interpretation Risk to bystanders and emergency services from approaching patients near live OHPLs
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live .
” 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 Promote overhead-powerline safety guidance, risk assessment requirements, and the 105 reporting number through the Public Safety Committee.
Verbatim wording from the response “ENA continues to promote awareness of the dangers associated with electricity networks with third parties and members of the public through its Public Safety Committee (‘PSC’) which includes the Health and Safety Executive (‘HSE’). This includes promoting:” Source location Response from Energy Networks Association
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess potential changes or improvements to public communications promoting awareness of dangers associated with electricity assets.
Verbatim wording from the response “Finally, we will also undertake an assessment of any changes or improvements that can be made to how we communicate with the public to promote the awareness of the dangers associated with electricity assets in the public domain.” Source location Response from Energy Networks Association
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the safety leaflet for emergency services in response to the concerns identified in the report.
Verbatim wording from the response “Referencing the concerns set out in your report, ENA will also review and update accordingly its safety leaflet entitled - Safety advice for the Emergency Services. Again, this will be completed by 31st January 2023 at the latest and I will write to let you know when it has been done.” Source location Response from Energy Networks Association
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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 Complete a review with each DNO and TNO confirming effective annual communication of regional network boundaries to local emergency services.
Verbatim wording from the response “ENA has asked each DNO and TNO to check and confirm that suitable and effective arrangements are in place to regularly communicate on an annual basis, their overall network boundaries at a regional level or equivalent with their local emergency services. This will help maintain awareness of the appropriate DNO and TNO to be contacted in the event of an emergency involving overhead powerlines (OHPLs).” Source location Response from Energy Networks Association
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations