Russell Paul BOWRY · Prevention of Future Deaths report

On Twenty-First March 2018 I commenced an Investigation into the death of Russell Paul BOWRY aged 52. The investigation concluded at the end of the inquest on Seventeenth October 2019.

The medical cause of death was found to be:

Ia Hypoxic Brain Injury
Ib Traumatic Cardiac Arrest
Ic Multi-Trauma

The Conclusion of the Jury at the end of the Inquest was a Narrative Conclusion –

Accident with the following contributory factors:
i) No written safe system of work
ii) Russell Bowry’s lanyard not being clipped on.

Russell Bowry’s death was confirmed at 04:21 on 16th March 2018 following his admission to Addenbrookes Hospital on 13th March 2018 after a fall from height. Russell was an experienced, NRC level 2 self-employed rigger who had been contracted by ELP Broadcast and Events Ltd (ELP) to work on the construction of the roof for a stage set at Cardington Studios – the Studios occupies the whole of Cardington Shed 2, a hangar built of steel lattice construction in the early 20ᵗʰ century to accommodate airships. The hangar is not windproof or watertight and ELP (who is a member of PLASA) had been contracted by the producer of a West End musical to provide a 32m wide x 16m long x 10m high windproof, rainproof, cuboid stage within the hangar.

To create the roof of the stage, ELP used an aluminium truss, of a kind which, I believe, is standard in your industry.

The truss had two x 32m sides and eight x 16m transverse sections. It was to be permanently installed, for a period of months, through attachment to the steel lattice and existing infrastructure of the hangar. It was assembled at floor level and its topsides were covered in rockwool, which in turn were covered with black plastic save for along the two long sides, where only the rockwool (and not the black plastic) was installed at ground level. The black plastic was omitted along these sides to permit the attachment of the hoisting equipment to the truss.

On 12 March 2018 ELP, assisted by NRC level 2 riggers including Russell, raised the said roof to a height of 9.5 metres on chain winch hoists and proceeded to attach it permanently to the steel lattice structure of the hangar. At the time of the fall, on the morning of 13 March 2018, Russell was working on the roof of the structure at a height of 11 metres. He was standing on one of the long sides of the truss attaching steel cables between the truss and the structure of the hangar. He was wearing a harness. Attached to the harness was a single lanyard. The lanyard was not attached to an anchor point. Almost immediately following a fall (with less serious consequences) of a fellow rigger, Russell fell a distance of 11m through the exposed rockwall material of the roof and sustained fatal injuries.

(a) Employers in your industry may believe that they can safely delegate to individual riggers the responsibility to plan work at height, supervise it and carry it out safely. Russell Bowry was an NRC level 2 rigger but he was working directly under ELP, whose employees had no NRC qualifications. There was no head rigger. ELP gave evidence that it was their expectation that experienced riggers could be relied upon to ensure their own safety. Yet the riggers from whom I heard, told me that they were not always clipped on;

(b) Employers in your industry may not realise they are responsible for designing the necessary safety features for work at height, including engaging the services of those who have the right skills to design such systems. Safe systems of work include ensuring that all clipping on points and safety features have the necessary impact requirements to hold a falling person and that the work can be done while the riggers are always clipped on or, that it is safe without clipping on;

(c) Unsafe working practices are routinely encountered by riggers in your industry and due to the structure of your industry – in which a small number of employers engage a large pool of self-employed riggers for individual jobs of short duration – riggers appear to have little influence over the fall protection or fall prevention measures that are put in place to keep them safe.