PFD report

Mr Benjamin Hugh Wylie · Prevention of Future Deaths report

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Issued 14 Nov 2016•Berkshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
9

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
2

Described in responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised9

  1. Unavailability of a quick-reference condensed operator manual
  2. Inadequate training in correct track-greasing procedures
  3. Lack of permanent warning signage beside the grease nipple
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Issue a detailed Safety Alert addressing grease-nipple component suitability, protective plates, damaged-component reuse and training for track tensioning.

    Stated by Health and Safety ExecutiveStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2016.
  2. Action

    Issue a general Safety Alert on the circumstances of the incident to relevant industry users.

    Stated by Health and Safety ExecutiveStated completedThe respondent said that this action was complete when they made their response on 14 November 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Machinery law does not generally require warnings directly on machine parts, except to prevent incorrect fitting or illustrate rotation.

    Stated by Health and Safety ExecutiveDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Unavailability of a quick-reference condensed operator manual

Wider context from the report

“(6) It was heard that the manual for the SR70 piling rig machine is always kept in the cab of the machine for use by the operator. This was described as a 350 page manual. No quick reference condensed version of key matters is available. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate training in correct track-greasing procedures

Wider context from the report

“(8) The evidence suggested that certain piling rig workers were not following the correct procedures for greasing the tracks suggesting that there was a training issue that needed to be addressed and possibly incorporated into the manual. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of permanent warning signage beside the grease nipple

Wider context from the report

“(1) In the course of the evidence at the Inquest it was acknowledged that the risk of grease being expelled from the grease nipple at high pressure was recognised. No permanent warning plate or sign was attached to the machine beside the grease nipple. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to issue existing users a warning bulletin about grease nipple failure risks

Wider context from the report

“(5) It is understood that no warning bulletin has been issued to existing users of the relevant piling rig machines warning of the risk of the grease nipple failure and potential consequences. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of the manual to prohibit repairs or modifications to failed parts

Wider context from the report

“(7) The manual does not contain a warning to always replace failed parts on piling rigs with new units. There is no statement that repairs or modifications to failed parts should not be carried out. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Existing machines requiring removal of the metal plate for track greasing

Wider context from the report

“(4) The Jury heard that, in the ordinary course of use of the machine, were covered by a metal plate. However, this had to be removed in order to carry out the greasing of the tracks. Evidence was given that new machines allow greasing of the tracks with the plate in place but there are a number of existing machines in use which do not have that adaptation. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of pressure release valves within the grease nipple unit

Wider context from the report

“(3) The evidence also given was that other piling rig manufacturers install pressure release values within the grease nipple unit that prevents pressure building up to the force that struck Ben Wylie. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Grease nipple orientation facing the greasing operator

Wider context from the report

“(2) The grease nipple(s) of which there is one on each side of the machine was orientated on the SR70 machine so that it was perpendicular to, rather than parallel to, the tracks. This meant that the nipple faced out towards the greasing operator. Evidence suggested that other manufacturers have the grease nipple orientated parallel to the tracks. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of the manual to require replacement of failed parts with new units

Wider context from the report

“(7) The manual does not contain a warning to always replace failed parts on piling rigs with new units. There is no statement that repairs or modifications to failed parts should not be carried out. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Issue a detailed Safety Alert addressing grease-nipple component suitability, protective plates, damaged-component reuse and training for track tensioning.

Verbatim wording from the response

“body. However, the opinion of its relevant Specialist Inspector of Mechanical Engineering is that the critical issue is to ensure that the parts specified are suitable for expected operating pressures so as to ensure failure is prevented, so far as is reasonably practicable. HSE intends to address this issue in a further Safety Alert to be issued to industry, which is currently in draft form.”

Source location

2016-0407-Response-by-HSE
Page 2 · response
Published 14 November 2016

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

Issue a general Safety Alert on the circumstances of the incident to relevant industry users.

Verbatim wording from the response

“In 2015 HSE issued a general Safety Alert relating to the circumstances of the incident which led to Mr Wylie’s death. HSE is aware that Soilmec (UK) Ltd have issued two Safety Alerts relevant to the incident which occurred with one of their machines. Following conclusion of the Inquest HSE has been preparing a more detailed Safety Alert, taking account of further evidence and the results of component testing which became available after the issue of its first general Safety Alert. The new Safety Alert is due to be published shortly. It is aimed at a broad audience which will include those working in the piling industry, but also those working in other industries where the use of tracked plant is commonplace. Please let me know whether you would like me to send you a copy of the Safety Alert when it is issued.”

Source location

2016-0407-Response-by-HSE
Page 2 · response
Published 14 November 2016

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

Machinery law does not generally require warnings directly on machine parts, except to prevent incorrect fitting or illustrate rotation.

Verbatim wording from the response

“HSE notes that other respondents have stated that a warning sticker/plate will be affixed to machines adjacent to track tensioning grease nipples in the future. The legislation which machine manufacturers are required to comply with when designing, manufacturing and supplying machinery for use at work, the Supply of Machinery (Safety) Regulations 2008 (SMR) require that risks be eliminated by design wherever possible. Where the designer considers that residual risks exist that cannot be designed out, the Regulations state that necessary warnings must be provided. This allows the manufacturer to choose whether to place warnings that will be needed less frequently in the operation and maintenance manual and/or to affix a warning to the machine part itself.”

Source location

2016-0407-Response-by-HSE
Page 1 · response
Published 14 November 2016

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

The wording of the machine manual is for the manufacturer to determine, subject to its legal obligation to provide safe operating information.

Verbatim wording from the response

“The legal requirement under SMSR is for manufacturers to provide “the information necessary to operate it [ie the machine] safely, such as instructions.””

Source location

2016-0407-Response-by-HSE
Page 2 · response
Published 14 November 2016

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

Employers and contractors must determine required competence and ensure workers are properly trained for machinery maintenance operations.

Verbatim wording from the response

“There are several legal requirements on employers and contractors to ensure that those who operate or maintain machinery used on construction sites or elsewhere are properly trained and competent to carry out both scheduled and unplanned maintenance operations. Those with duties under health and”

Source location

2016-0407-Response-by-HSE
Page 2 · response
Published 14 November 2016

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

No research is planned into grease nipple assembly designs because additional devices may introduce risks and other risk-reduction means are preferable.

Verbatim wording from the response

“The opinion of HSE’s relevant Specialist Inspector of Mechanical Engineering is that if a valve, designed to dissipate pressures well below component failure design pressures, were fitted within the grease nipple assembly, failure of an undamaged grease nipple would be very unlikely. However, HSE notes the differing opinions of the members of the FPS regarding the possibility of other risks being created through the fitting of such devices. When designing machinery, especially where it will be operating in harsh environments, one consideration would be to minimise the number of small devices which could fail or be incorrectly adjusted or replaced. Eliminating or reducing associated risks by other means would generally be preferable. HSE has no plans to conduct research into the designs of grease nipple assemblies.”

Source location

2016-0407-Response-by-HSE
Page 2 · response
Published 14 November 2016

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
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Data last updated 7 September 2026