David Ivor Alexander · Prevention of Future Deaths report

On 17/02/2016 I commenced an investigation into the death of David Ivor Alexander, 61 . The investigation concluded at the end of the inquest on 14 February 2017. The conclusion of the inquest was

Cause of death - Chest Injuries

Narrative conclusion – the Jury unanimously concluded that the death was accidental, with the gradient of the lorry being a significant contributory factor.

David Alexander was an experienced lorry driver and mechanic, delivering animal feed to a farm. Whilst David was engaged in transferring the feed from the HGV articulated lorry by the method of bulk blowing, the transfer pipes blocked and had to be manually emptied and the farmer assisted with this. Unloading continued, solely under the control of David. The hydraulic ram was employed to lift the trailer to almost full height, the bulk blowing recommenced, but then almost immediately the trailer tipped over with an almost full load of 25 tonnes of feed, and landed on top of David, killing him instantly.

On close inspection it was ascertained that the lift had taken place while the vehicle was parked on a small gradient of between 2.9 and 3.6 degrees. It was also identified that the bracket holding the base of the hydraulic ram had stress fractures that were not visible from a normal manual inspection, but one side of the bracket failed, either causing or as a consequence of the overturn. Evidence was heard that without the gradient, this catastrophic failure was unlikely to have occurred.

(1) Evidence was taken during the inquest that overturns are not uncommon in this particular section of the industry, but are infrequently reported as there is no requirement to do so

(2) The cause/s of overturn are not well understood or recognised as post event investigations are not carried out and there appears to be little knowledge or industry practise regarding regular inspections and/or replacement schedules in respect of the hydraulic ram brackets

(3) There is little or no industry guidance available relating to this issue

(4) It is not standard to fit new articulated lorries with inclinometers and they are not routinely, if ever, used on older vehicles notwithstanding that it is recognised that a very slight gradient of over 2 degrees can (at full extension of the hydraulic ram when fully loaded) cause overturn. This information does not appear to be widely recognised within the industry.