David Chandler · Prevention of Future Deaths report

On 16 November the coroner commenced an investigation into the death of David Chandler, age 45. The investigation concluded at the end of the inquest on 2 July 2018. The conclusion of the inquest was accidental death and the medical cause of death was inhalation of ammonia.

On 9 November 2016 David Chandler was subcontracted to work at the Carlsberg Brewery in Northampton. He was employed by Speedrite NE as an engineer and was assisting with the removal of a dormant compressor unit. The compressor unit had not been used since previous work in 2014. At the time of the incident the compressor was isolated from the high pressure ammonia system on the discharge side using a single proved isolation. While Mr Chandler was assisting with the work a high pressure escape of gaseous ammonia occurred. Mr Chandler’s three co-workers managed to escape but Mr Chandler died at the scene.

(1) The isolation for the 2014 work was still in place and does not appear to have been reviewed in the intervening period. The 2014 work was of a different nature and did not require physical removal of the whole compressor. There does not appear to have been any formal review of the appropriate isolation standard for the work in November 2016 to be performed safely.

(2) Carlsberg contracted the work to Crowley Carbon who employed specialist refrigeration engineers. The evidence at the inquest suggested that Crowley Carbon and Carlsberg were each relying on the other to ensure that the compressor was safely isolated.

(3) The Permit To Work (PTW) issued by Carlsberg to allow Speedrite to remove the compressor made reference to the 2014 PTW isolation, was completed incorrectly, and made no reference to hazardous substances.

(4) Relying on the isolation from previous work on the compressor appears to have caused confusion as to the safe level of isolation necessary for work of a different nature two years later.