PFD report

Andrew Terrance John Lownes · Prevention of Future Deaths report

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Issued 13 Mar 2017•Inner West London

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.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Report evidence summary

Concerns raised2

  1. Lack of unloading instructions identifying the function and route of load-securing bands
    Part of recurring concern: Unsafe loading and unloading of heavy vehicle loads
  2. Failure to keep tall, heavy, narrow-based GCWUs secured at all times
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 unloading instructions identifying the function and route of load-securing bands

Wider context from the report

“1. The consignment of GCWUs which arrived on site from a factory in Switzerland was not accompanied by written unloading instructions, despite: • Containing two GCWUs each weighing around 600kg • The narrow nature of GCWUs -- which meant they were likely to fall if not adequately secured to the transport stillage at all times. • The relatively complex nature of the banding arrangements which secured the GCWUs to the transport stillage, involving some bands which were around the individual GCWU alone, others which lashed a particular GCWU to the stillage and others which sought to bind the entire consignment. Some of the bands lay positioned on top of other bands which served a different purpose. The entire load was shrink wrapped which added to the difficulty of identifying the function and route of a particular band around the load. In consequence, it was not obvious to those unloading the consignment which band served which purpose. This gave rise to a risk that in the course of unloading a band might be cut inadvertently resulting in the fall of a heavy GCWU. Workers in the vicinity could be in a position of jeopardy, as was the case here. Evidence was taken from an expert witness who had considerable experience in construction site management. He said when he examined an identical consignment after the tragedy it took him over an hour to work out the function of the multiple bands placed on the consignment. 2. Although not relevant to the Inquest into Mr Lownes’ death, it is pertinent in my judgment, to refer to another Inquest which I conducted in Leeds in 2009 involving the death of Alan Fletcher, a man aged 59 who sustained fatal crush injuries whilst unloading a container of GCWUs in Leeds. Although that incident involved goods shipped in a container from the UAE rather than on a stillage, there are common features between the two cases: ➢ The absence of unloading instructions ➢ Tall, heavy, narrow based items which have the potential to cause harm if not secured at all times. ”

Is this part of a recurring concern?

Yes — Unsafe loading and unloading of heavy vehicle loads.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to keep tall, heavy, narrow-based GCWUs secured at all times

Wider context from the report

“1. The consignment of GCWUs which arrived on site from a factory in Switzerland was not accompanied by written unloading instructions, despite: • Containing two GCWUs each weighing around 600kg • The narrow nature of GCWUs -- which meant they were likely to fall if not adequately secured to the transport stillage at all times. • The relatively complex nature of the banding arrangements which secured the GCWUs to the transport stillage, involving some bands which were around the individual GCWU alone, others which lashed a particular GCWU to the stillage and others which sought to bind the entire consignment. Some of the bands lay positioned on top of other bands which served a different purpose. The entire load was shrink wrapped which added to the difficulty of identifying the function and route of a particular band around the load. In consequence, it was not obvious to those unloading the consignment which band served which purpose. This gave rise to a risk that in the course of unloading a band might be cut inadvertently resulting in the fall of a heavy GCWU. Workers in the vicinity could be in a position of jeopardy, as was the case here. Evidence was taken from an expert witness who had considerable experience in construction site management. He said when he examined an identical consignment after the tragedy it took him over an hour to work out the function of the multiple bands placed on the consignment. 2. Although not relevant to the Inquest into Mr Lownes’ death, it is pertinent in my judgment, to refer to another Inquest which I conducted in Leeds in 2009 involving the death of Alan Fletcher, a man aged 59 who sustained fatal crush injuries whilst unloading a container of GCWUs in Leeds. Although that incident involved goods shipped in a container from the UAE rather than on a stillage, there are common features between the two cases: ➢ The absence of unloading instructions ➢ Tall, heavy, narrow based items which have the potential to cause harm if not secured at all times. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

No official response is included in the current published snapshot.