PFD report

Kenneth Audsley · Prevention of Future Deaths report

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Issued 9 Sep 2021•West Yorkshire Eastern

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.

View original report
Concerns
6

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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. Insufficient oil in transformers creating a risk of hazardous gas accumulation during operation
  2. Failure of the manufacturer’s manual to warn against energising transformers without adequate oil
  3. Failure to recommend periodic transformer oil maintenance and replenishment
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.3

  1. Action

    Add pre-hire oil-check test sheets and carbon-monoxide warning notices to customer hire documentation.

    Stated by Hirst Electrical PHS (UK) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 17 September 2021.
  2. Action

    Prohibit employees from removing potentially energised transformer lids without adequate oil, and brief staff to stop this practice.

    Stated by Hirst Electrical PHS (UK) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 17 September 2021.
  3. Action

    Attach prominent oil-level and carbon-monoxide warning stickers to all transformers, instructing users not to energise without sufficient oil.

    Stated by Hirst Electrical PHS (UK) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 17 September 2021.

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

  1. Position

    The company considers its documented transformer safety changes sufficient to satisfy the notice and does not identify further necessary work.

    Stated by Hirst Electrical PHS (UK) Ltd.No action considered necessaryThe respondent said that no further action was needed.

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

Insufficient oil in transformers creating a risk of hazardous gas accumulation during operation

Wider context from the report

“(5) By virtue of these matters there exists the possibility that comparable transformers in service throughout the UK may contain insufficient oil to be operated safely and prevent an accumulation of potentially hazardous gases in the space thereby created. ”

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 of the manufacturer’s manual to warn against energising transformers without adequate oil

Wider context from the report

“(3) The manufacturer’s manual contained no warnings of the hazard which would be created if the transformer were to be energised without containing adequate oil for cooling and insulating purposes. ”

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 recommend periodic transformer oil maintenance and replenishment

Wider context from the report

“(4) The manufacturer did not recommend a periodic maintenance regime to confirm adequate oil remained in the transformer and have it replenished if necessary. ”

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 awareness of the risk of potentially lethal gas accumulation inside transformers

Wider context from the report

“(1) The risk that a potentially lethal gas could accumulate inside the transformer was not appreciated either amongst the electricians in this workplace or those involved with industrial transformers generally. ”

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 transformer warning signage requiring confirmation of adequate oil before use

Wider context from the report

“(2) There were no warning signs affixed to the transformer alerting users to the risk of using the transformer unless it had first been confirmed it contained adequate oil. ”

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 user awareness that inadequate transformer oil can cause overheating or fire

Wider context from the report

“(6) The risks identified could affect anyone (1) dismantling a transformer at the end of its life; (2) having cause to open a transformer for repair or maintenance purposes or (3) users who may be unaware that inadequate oil could cause a transformer to overheat or catch fire. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Add pre-hire oil-check test sheets and carbon-monoxide warning notices to customer hire documentation.

Verbatim wording from the response

“Finally, we have amended the documentation that is sent to our customers for all hires. This documentation includes:”

Source location

2021-0303-Response-from-Hirst-Electrical_Published
Page 3 · response
Published 17 September 2021

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

Prohibit employees from removing potentially energised transformer lids without adequate oil, and brief staff to stop this practice.

Verbatim wording from the response

“As a direct result of this we have as a business implanted a number of changes in our company’s working practices in an effort to prevent an incident of this nature ever being repeated.”

Source location

2021-0303-Response-from-Hirst-Electrical_Published
Page 1 · response
Published 17 September 2021

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

Attach prominent oil-level and carbon-monoxide warning stickers to all transformers, instructing users not to energise without sufficient oil.

Verbatim wording from the response

“Secondly, we have now attached stickers to all of our transformers as per your suggestion, providing a reminder to third-party operators not to energise transformers without first ensuring there is sufficient oil inside. Please see the images below.”

Source location

2021-0303-Response-from-Hirst-Electrical_Published
Page 1 · response
Published 17 September 2021

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 company considers its documented transformer safety changes sufficient to satisfy the notice and does not identify further necessary work.

Verbatim wording from the response

“We trust the aforementioned is sufficient action to satisfy the notice. However, if you believe there is more we can do then we welcome any further suggestions.”

Source location

2021-0303-Response-from-Hirst-Electrical_Published
Page 3 · response
Published 17 September 2021

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.1

  1. 1

    Enclose a copy of the referenced International Standard with customer hire documentation.

    Stated by Hirst Electrical PHS (UK) Ltd.Stated plannedThe respondent said that this action was planned when they made their response on 17 September 2021.

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

Enclose a copy of the referenced International Standard with customer hire documentation.

Verbatim wording from the response

“Finally, we have amended the documentation that is sent to our customers for all hires. This documentation includes:”

Source location

2021-0303-Response-from-Hirst-Electrical_Published
Page 3 · response
Published 17 September 2021

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