PFD report

Paul Anthony Daniels · Prevention of Future Deaths report

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Issued 2 Jan 2018•Manchester South

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
3

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
8

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 raised3

  1. Lack of immediately available support for tree surgeons
  2. Ineffective communication between groundsmen and tree surgeons
  3. Failure to provide an aerial-work-qualified groundsman for tree surgeons
    Part of recurring concern: Unsafe work-at-height operations
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.5

  1. Action

    Ensure lessons from the incident are considered when AFAG 401 and AFAG 402 are next reviewed.

    Stated by Health and Safety ExecutiveStated plannedThe respondent said that this action was planned when they made their response on 7 March 2018.
  2. Action

    Promulgate incident learning and reinforce adherence to relevant tree-work safety guidance through AFAG committee members and their organisations.

    Stated by Health and Safety ExecutiveStated plannedThe respondent said that this action was planned when they made their response on 7 March 2018.
  3. Action

    Continue rigorously implementing emergency-rescue requirements in areas under Forestry Commission control.

    Stated by Forestry Commission EnglandStated plannedThe respondent said that this action was planned when they made their response on 7 March 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The absence of evidence about compliance with supervision, auditing and proficiency requirements prevents further comment on those measures.

    Stated by The Arboricultural AssociationUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 immediately available support for tree surgeons

Wider context from the report

“1. There were two tree surgeons climbing with one groundsman between them. The ratio of 2:1 meant that the tree surgeons did not have someone supporting them and available immediately at all times; ”

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

Ineffective communication between groundsmen and tree surgeons

Wider context from the report

“3. Communication between the groundsman and tree surgeons was via shouting and hand signals. This was difficult given the density of the trees being cut and the height that the tree surgeons were working at. ”

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 provide an aerial-work-qualified groundsman for tree surgeons

Wider context from the report

“2. The groundsman supporting the tree surgeons was not qualified for aerial work. This meant that should the tree surgeon have required assistance whilst in the trees the groundsman could not have gone to their help; ”

Is this part of a recurring concern?

Yes — Unsafe work-at-height operations.

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

Ensure lessons from the incident are considered when AFAG 401 and AFAG 402 are next reviewed.

Verbatim wording from the response

“In addition as a matter of routine AFAG and its members keep guidance under review to ensure that lessons learned through incidents are reflected in the guidance and we will ensure that these points are again considered when these specific leaflets are next reviewed.”

Source location

2018-0003-Response-by-HSE
Page 2 · response
Published 7 March 2018

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

Promulgate incident learning and reinforce adherence to relevant tree-work safety guidance through AFAG committee members and their organisations.

Verbatim wording from the response

“AFAG next meets as a committee on 8 May 2018 and I will take this opportunity to promulgate the key learning points from this incident via the committee members. The range of organisations represented on the committee should enable the message, through their respective memberships, to have a wide reach throughout the industry. I will ask that members underline the importance of all people involved in this type of work adhering to the standards set out in the guidance and highlight the concerns raised in your letter.”

Source location

2018-0003-Response-by-HSE
Page 2 · response
Published 7 March 2018

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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 rigorously implementing emergency-rescue requirements in areas under Forestry Commission control.

Verbatim wording from the response

“I would also like to confirm the AFAG guidance and current best practice requires a risk assessment to be carried out to establish the emergency procedures, methods of communications and sufficient competent resources to effect a rescue without delay.”

Source location

2018-0003-Response-by-Forestry-Commission
Page 2 · response
Published 7 March 2018

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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 emergency procedures with in-house arborists against AFAG guidance 401 and 402.

Verbatim wording from the response

“• Reviewing the emergency procedures against AFAG guidance 401 & 402 with our in-house arborists;”

Source location

2018-0003-Response-by-Forestry-Commission
Page 1 · response
Published 7 March 2018

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

Re-brief employees supervising arboricultural contracts on key AFAG guidance requirements.

Verbatim wording from the response

“• Re-briefing employees, who supervise arboricultural contracts, on the key requirements of this guidance;”

Source location

2018-0003-Response-by-Forestry-Commission
Page 1 · response
Published 7 March 2018

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 absence of evidence about compliance with supervision, auditing and proficiency requirements prevents further comment on those measures.

Verbatim wording from the response

“Reducing the risk of future deaths from human error in this respect revolves around supervision, auditing and the measurement of operator proficiency.”

Source location

2018-0003-Response-by-Arboricultural-Assocation_Redacted
Page 1 · response
Published 7 March 2018

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

Existing AFAG guidance adequately addresses tree-climber ratios, aerial-rescue training and communication requirements for legal compliance.

Verbatim wording from the response

“These three matters are addressed in long standing guidance produced by AFAG and effectively set out the standards expected to ensure legal compliance in this type of work.”

Source location

2018-0003-Response-by-HSE
Page 1 · response
Published 7 March 2018

Open published response

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.3

  1. 1

    Publish and disseminate a safety bulletin summarising the events and reinforcing correct methods, training, preparation and planning to members, partner organisations and the wider arboricultural audience.

    Stated by The Arboricultural AssociationStated plannedThe respondent said that this action was planned when they made their response on 7 March 2018.
  2. 2

    Complete the supervisor training-module update and include the incident in its scheme of work.

    Stated by Forestry Commission EnglandStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
  3. 3

    Circulate the Arboricultural Association safety bulletin to relevant staff.

    Stated by Forestry Commission EnglandStated plannedThe respondent said that this action was planned when they made their response on 7 March 2018.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Adequate aerial rescue provision would not have prevented this type of accident or prevented the fall from height.

    Stated by The Arboricultural AssociationDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Industry-wide arboriculture standards and practitioner communication largely fall outside the Forestry Commission’s minor role.

    Stated by Forestry Commission EnglandOutside remitThe respondent said that this matter was outside its role or authority.

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

Publish and disseminate a safety bulletin summarising the events and reinforcing correct methods, training, preparation and planning to members, partner organisations and the wider arboricultural audience.

Verbatim wording from the response

“1. Publish a summary of the events (as described in your regulation 28 notice) to our membership via a safety bulletin notice (copy attached). This will be done electronically to our 2500 plus members. We will circulate this safety bulletin to relevant partner organisations namely the ICF and ISA. This will be completed by the end of February 2018.”

Source location

2018-0003-Response-by-Arboricultural-Assocation_Redacted
Page 1 · response
Published 7 March 2018

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

Complete the supervisor training-module update and include the incident in its scheme of work.

Verbatim wording from the response

“• Completing the process of updating the training module we offer for our supervisors regarding arboricultural contracts and we will ensure that the incident is covered within the scheme of work for this module.”

Source location

2018-0003-Response-by-Forestry-Commission
Page 1 · response
Published 7 March 2018

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

Circulate the Arboricultural Association safety bulletin to relevant staff.

Verbatim wording from the response

“• Circulating the Arboricultural Association safety bulletin regarding this matter;”

Source location

2018-0003-Response-by-Forestry-Commission
Page 1 · response
Published 7 March 2018

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

Adequate aerial rescue provision would not have prevented this type of accident or prevented the fall from height.

Verbatim wording from the response

“Whilst having these measures in place will help to reduce risks that aerial tree workers are exposed to, the measures relating to adequate aerial rescue provision would not have prevented this type of accident in these circumstances.”

Source location

2018-0003-Response-by-Arboricultural-Assocation_Redacted
Page 1 · response
Published 7 March 2018

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

Industry-wide arboriculture standards and practitioner communication largely fall outside the Forestry Commission’s minor role.

Verbatim wording from the response

“The Forestry Commission has only a very minor role in the arboriculture industry and we do not have any great involvement in the setting of standards within the industry or communication with practitioners in the industry, which means that your opinion that we could take action to prevent further deaths may have been misplaced.”

Source location

2018-0003-Response-by-Forestry-Commission
Page 1 · response
Published 7 March 2018

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

Data last updated 7 September 2026