9 Sep 2021 Kenneth Audsley · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 6 Insufficient oil in transformers creating a risk of hazardous gas accumulation during operation View source Failure of the manufacturer’s manual to warn against energising transformers without adequate oil View source Failure to recommend periodic transformer oil maintenance and replenishment View source Lack of awareness of the risk of potentially lethal gas accumulation inside transformers View source Lack of transformer warning signage requiring confirmation of adequate oil before use View source Lack of user awareness that inadequate transformer oil can cause overheating or fire View source See 3 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Kenneth Audsley · 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
Kenneth Audsley, an experienced high-voltage electrical engineer aged 56, was overcome by carbon monoxide while investigating a fault inside an industrial transformer at work. The transformer contained substantially less oil than it should have, allowing carbon monoxide to accumulate. Concerns included insufficient awareness of the risk, a lack of warning signs and manufacturer warnings, no recommended periodic maintenance regime, and the possibility that other transformers could pose comparable risks.
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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 Hirst Electrical Plant Hire Services (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient oil in transformers creating a risk of hazardous gas accumulation during operation
Wider context from the report “(5) By virtue of these matters there exists the possibility that comparable transformers in service throughout the UK may contain insufficient oil to be operated safely and prevent an accumulation of potentially hazardous gases in the space thereby created .
” 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 Hirst Electrical Plant Hire Services (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the manufacturer’s manual to warn against energising transformers without adequate oil
Wider context from the report “(3) The manufacturer’s manual contained no warnings of the hazard which would be created if the transformer were to be energised without containing adequate oil for cooling and insulating 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 Hirst Electrical Plant Hire Services (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to recommend periodic transformer oil maintenance and replenishment
Wider context from the report “(4) The manufacturer did not recommend a periodic maintenance regime to confirm adequate oil remained in the transformer and have it replenished if 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 Hirst Electrical Plant Hire Services (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the risk of potentially lethal gas accumulation inside transformers
Wider context from the report “(1) The risk that a potentially lethal gas could accumulate inside the transformer was not appreciated either amongst the electricians in this workplace or those involved with industrial transformers generally .
” 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 Hirst Electrical Plant Hire Services (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of transformer warning signage requiring confirmation of adequate oil before use
Wider context from the report “(2) There were no warning signs affixed to the transformer alerting users to the risk of using the transformer unless it had first been confirmed it contained adequate oil .
” 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 Hirst Electrical Plant Hire Services (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of user awareness that inadequate transformer oil can cause overheating or fire
Wider context from the report “(6) The risks identified could affect anyone (1) dismantling a transformer at the end of its life; (2) having cause to open a transformer for repair or maintenance purposes or (3) users who may be unaware that inadequate oil could cause a transformer to overheat or catch fire .
” 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