PFD report

Mark Richard Seward · Prevention of Future Deaths report

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Issued 5 Apr 2016•Warwickshire

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
6

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
15

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

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

Concerns raised6

  1. Failure of managers and staff to access computer-based health and safety material
    Part of recurring concern: Unreliable staff access to and understanding of safety-critical guidance
  2. Lack of clarity about activities constituting pressure testing
  3. Unavailability of clear operating instructions for the Enerpac pump
    Part of recurring concern: Failure to ensure clear and followed instructions for safe equipment use
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.9

  1. Action

    Develop a communications strategy explaining the safety management system, its rules and staff responsibilities.

    Stated by Agd Equipment LimitedStated in progressThe respondent said that this action was in progress when they made their response on 5 April 2016.
  2. Action

    Appoint a Safety Officer/Assistant Manager with operational workshop safety experience.

    Stated by Agd Equipment LimitedStated completedThe respondent said that this action was complete when they made their response on 5 April 2016.
  3. Action

    Remind all staff about the health and safety policy and where to access it.

    Stated by Agd Equipment LimitedStated completedThe respondent said that this action was complete when they made their response on 5 April 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Health and safety documents were available electronically and in hard copy, contrary to any premise that the company lacked accessible documentation.

    Stated by Agd Equipment LimitedDisputes 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

Failure of managers and staff to access computer-based health and safety material

Wider context from the report

“(4) AGD managers and staff had not accessed computer-based material relating to health and safety issues. ”

Is this part of a recurring concern?

Yes — Unreliable staff access to and understanding of safety-critical guidance.

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 clarity about activities constituting pressure testing

Wider context from the report

“(1) There was a lack of clarity as to what type of activity amounted to pressure testing. ”

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

Unavailability of clear operating instructions for the Enerpac pump

Wider context from the report

“(3) No instruction manual had been provided to AGD to give clear instruction on how the Enerpac pump should be used. ”

Is this part of a recurring concern?

Yes — Failure to ensure clear and followed instructions for safe equipment use.

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 a specific risk assessment or method statement for the work

Wider context from the report

“(2) There was no specific risk assessment or method statement for the type of work being carried out by Mr Seward. ”

Is this part of a recurring concern?

Yes — Failure to assess risks before hazardous work tasks.

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 compliance with PUWER and HSE pressure-testing guidance across the industry

Wider context from the report

“(2) The degree of compliance with the Provision and Use of Work Equipment Regulations 1998 (PUWER) and guidance issued by the HSE such as GS4 was called into question, not only at AGD but more widely within the industry. Witnesses gave evidence that the poor practices followed at AGD were replicated elsewhere. ”

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 clear strategic and operational responsibility for health and safety issues

Wider context from the report

“(1) It was unclear who had responsibility for Health and Safety issues at AGD at a strategic (ie. Board) level and operationally. ”

Is this part of a recurring concern?

Yes — Unclear accountability for health and safety controls.

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

Develop a communications strategy explaining the safety management system, its rules and staff responsibilities.

Verbatim wording from the response

“(3) the arrangements in place to ensure all staff are skilled, trained and competent for the work they undertake; and (4) to ensure the monitoring arrangements are adequate and properly undertaken. Hand in hand with this review is a new communications strategy to ensure all staff are aware of the system, its rules and their own responsibilities.”

Source location

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Page 3 · response
Published 5 April 2016

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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

Appoint a Safety Officer/Assistant Manager with operational workshop safety experience.

Verbatim wording from the response

“7. AGD have appointed a new Safety Officer/Assistant Manager with substantial experience in operational workshop health and safety. This new role has been recruited to ensure that working practices are up-to-date with current legislation and industry best practice. To compliment this new role, the company has altered the Paint Shop Supervisor role to the wider role of Workshops Supervisor so that the new Safety Officer/Assistant Manager can concentrate on ensuring all health and safety rules, controls and best practices are understood and fully implemented throughout the operational site for all employees and visiting suppliers.”

Source location

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Page 3 · response
Published 5 April 2016

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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

Remind all staff about the health and safety policy and where to access it.

Verbatim wording from the response

“1. The company has a health and safety policy setting out the roles and responsibilities for all personnel including directors, managers and employees. A copy of this policy is available both electronically on the computer and in a hard copy kept in the office, which is accessible to all employees. A further copy of the policy is displayed on the health and safety notice board by the canteen and another copy is on display in the office reception area.”

Source location

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Page 1 · response
Published 5 April 2016

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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

Expand the Paint Shop Supervisor role to Workshops Supervisor to support implementation of site-wide safety rules and controls.

Verbatim wording from the response

“7. AGD have appointed a new Safety Officer/Assistant Manager with substantial experience in operational workshop health and safety. This new role has been recruited to ensure that working practices are up-to-date with current legislation and industry best practice. To compliment this new role, the company has altered the Paint Shop Supervisor role to the wider role of Workshops Supervisor so that the new Safety Officer/Assistant Manager can concentrate on ensuring all health and safety rules, controls and best practices are understood and fully implemented throughout the operational site for all employees and visiting suppliers.”

Source location

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Page 3 · response
Published 5 April 2016

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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 risk assessments, COSHH assessments and safe systems of work following the accident.

Verbatim wording from the response

“Following the accident on 27th May 2015 the company reviewed all risk assessments, COSHH assessments and safe systems of work. AGD’s health and safety consultants were involved in this process and the Supervisory Team must access and use these documents when planning new tasks, or allocating work to personnel.”

Source location

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Page 2 · response
Published 5 April 2016

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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

Work with the HSE and health and safety consultants to establish comprehensive risk assessments and safe systems of work.

Verbatim wording from the response

“4. AGD are working closely with the HSE to ensure that risk assessments and safe systems of work are in place. AGD are also working with the close assistance of the company’s health and safety consultants throughout this process to identify all risks, work duties and equipment, to ensure nothing is overlooked.”

Source location

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Page 2 · response
Published 5 April 2016

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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 the site safety induction with specialist advice and provide refresher training on safety roles and hierarchy.

Verbatim wording from the response

“2. AGD continue to use the Site Safety PowerPoint induction given to all staff before they start work. Following the Inquest, AGD have reviewed the induction with specialist advice from the company’s health and safety consultants. The induction details the key health and safety positions at the company and explains the health and safety hierarchy. All staff are being given refresher training on these elements.”

Source location

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Page 1 · response
Published 5 April 2016

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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

Develop task-specific safe systems of work and deliver toolbox talks to relevant employees, maintaining records and discussing them through the safety committee.

Verbatim wording from the response

“Having drawn up individual safe systems of work, toolbox talks were delivered to all employees likely to be involved in the relevant tasks to ensure that they understood the task and the controls in place to work safely. A full record is kept of these toolbox talks, and they continue to be discussed by the Health and Safety Committee at monthly meetings to ensure a rolling programme of continuous improvement.”

Source location

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Page 2 · response
Published 5 April 2016

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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

Roll out refresher training and awareness raising so employees know where to find health and safety documents.

Verbatim wording from the response

“The company health and safety documents including the policy, risk assessments and safe systems of work along with relevant HSE Guidance are held electronically on servers and computers. The company has also given the mobile engineers electronic tablets containing these documents for off-site reference. A hard copy of all electronic documents is also held in folders located in the Service Department office. This was already the case at the time of the Inquest and was within knowledge of those employees who gave evidence because they were part of the team directly involved in putting the documentation together. It is not known why this information was not given to the Coroner at the Inquest. Refresher training and awareness raising has been rolled out across all employees to remind them where all health and safety documents can be found.”

Source location

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Page 2 · response
Published 5 April 2016

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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

Health and safety documents were available electronically and in hard copy, contrary to any premise that the company lacked accessible documentation.

Verbatim wording from the response

“The company health and safety documents including the policy, risk assessments and safe systems of work along with relevant HSE Guidance are held electronically on servers and computers. The company has also given the mobile engineers electronic tablets containing these documents for off-site reference. A hard copy of all electronic documents is also held in folders located in the Service Department office. This was already the case at the time of the Inquest and was within knowledge of those employees who gave evidence because they were part of the team directly involved in putting the documentation together. It is not known why this information was not given to the Coroner at the Inquest. Refresher training and awareness raising has been rolled out across all employees to remind them where all health and safety documents can be found.”

Source location

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Page 2 · response
Published 5 April 2016

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. 1

    Introduce and fully implement a traffic management plan for vehicle movements at the facility.

    Stated by Agd Equipment LimitedStated completedThe respondent said that this action was complete when they made their response on 5 April 2016.
  2. 2

    Continue updating and regularly reviewing the employee training and competency matrix.

    Stated by Agd Equipment LimitedStated in progressThe respondent said that this action was in progress when they made their response on 5 April 2016.
  3. 3

    Train office employees to use and refer to the Cognitia safety software daily.

    Stated by Agd Equipment LimitedStated in progressThe respondent said that this action was in progress when they made their response on 5 April 2016.
  4. 4

    Remind staff about the Health and Safety Committee and undertake work to integrate it into the company safety culture.

    Stated by Agd Equipment LimitedStated in progressThe respondent said that this action was in progress when they made their response on 5 April 2016.
  5. 5

    Implement Cognitia Safety and Compliance software to centralise safety documentation and records.

    Stated by Agd Equipment LimitedStated completedThe respondent said that this action was complete when they made their response on 5 April 2016.
  6. 6

    Undertake a full review of the safety management system covering safety philosophy, work planning, competence and monitoring arrangements.

    Stated by Agd Equipment LimitedStated in progressThe respondent said that this action was in progress when they made their response on 5 April 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Pressure testing will continue to be outsourced, with no intention of bringing the work back in-house.

    Stated by Agd Equipment LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Introduce and fully implement a traffic management plan for vehicle movements at the facility.

Verbatim wording from the response

“9. A new traffic management plan has been introduced and fully implemented to improve safety in regards to all vehicle movements in and out of our facility.”

Source location

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Page 3 · response
Published 5 April 2016

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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

Continue updating and regularly reviewing the employee training and competency matrix.

Verbatim wording from the response

“5. The company continue to use and update the comprehensive training matrix of skills and competencies for all employees. This matrix details all health and safety training provided, or arranged by AGD, and is reviewed regularly at the Health and Safety Committee meetings. Full minutes of the Health and Safety Committee meetings are not only passed to the Board but are also displayed on the health and safety notice board.”

Source location

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Page 2 · response
Published 5 April 2016

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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

Train office employees to use and refer to the Cognitia safety software daily.

Verbatim wording from the response

“10. AGD have invested in a new health and safety software called Cognitia Safety and Compliance, which enables the company to manage all the health and safety documentation in one place. The software holds all the risk assessments, safe systems of work, COSHH assessments, near miss/accident statistics, training certificates and occupational health medical certificates. The software will be continually updated with the latest documents and certificates. The office employees are currently receiving training on this software so that they are able to use and refer to it on a daily basis.”

Source location

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Page 3 · response
Published 5 April 2016

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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

Remind staff about the Health and Safety Committee and undertake work to integrate it into the company safety culture.

Verbatim wording from the response

“3. The company has a Health and Safety Committee with representatives from various areas of the business, as well as a representative from the company’s health and safety consultants. The Health and Safety Committee meet monthly to discuss on-going health and safety issues. These health and safety meetings are fully minuted and the minutes are sent to the Board of Directors. The minutes are reviewed during Board meetings where health and safety is a top item on the Board Agenda. The Health and Safety Committee has been in place for a long time but again refresher information has been”

Source location

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Page 1 · response
Published 5 April 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

Implement Cognitia Safety and Compliance software to centralise safety documentation and records.

Verbatim wording from the response

“10. AGD have invested in a new health and safety software called Cognitia Safety and Compliance, which enables the company to manage all the health and safety documentation in one place. The software holds all the risk assessments, safe systems of work, COSHH assessments, near miss/accident statistics, training certificates and occupational health medical certificates. The software will be continually updated with the latest documents and certificates. The office employees are currently receiving training on this software so that they are able to use and refer to it on a daily basis.”

Source location

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Page 3 · response
Published 5 April 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

Undertake a full review of the safety management system covering safety philosophy, work planning, competence and monitoring arrangements.

Verbatim wording from the response

“6. The company is undertaking a full review of its safety management system to ensure that robust arrangements are in place for the future which covers (1) the company philosophy on safety; (2) the arrangements in place to plan and supervise work properly;”

Source location

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Page 2 · response
Published 5 April 2016

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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

Pressure testing will continue to be outsourced, with no intention of bringing the work back in-house.

Verbatim wording from the response

“8. The company continue to outsource all pressure testing work and have no intention of ever bringing the work back in house.”

Source location

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Page 3 · response
Published 5 April 2016

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

Data last updated 7 September 2026