PFD report

David Alan LYTH · Prevention of Future Deaths report

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Issued 7 Jul 2023•Cheshire

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
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

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

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Concerns raised1

  1. Lack of regular and periodic training for all drivers in coupling and uncoupling procedures
    Part of recurring concern: Unsafe tractor and trailer coupling systems
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

    Strengthen driver training with quarterly coupling and uncoupling refreshers, procedure review, video learning, comprehension tests, and two-year record retention.

    Stated by 3D Trans LimitedStated completedThe respondent said that this action was complete when they made their response on 10 July 2023.
  2. Action

    Produce and provide cross-industry workplace transport guidance covering practical coupling and uncoupling safety measures.

    Stated by Health and Safety ExecutiveStated completedThe respondent said that this action was complete when they made their response on 10 July 2023.
  3. Action

    Produce and provide industry-specific guidance on managing coupling and uncoupling risks for articulated vehicles.

    Stated by Health and Safety ExecutiveStated completedThe respondent said that this action was complete when they made their response on 10 July 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The strengthened quarterly driver training programme is considered sufficient to address the report, so no additional action is proposed.

    Stated by 3D Trans LimitedNo 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

Lack of regular and periodic training for all drivers in coupling and uncoupling procedures

Wider context from the report

“(1) I received evidence that since 2020, there have been four rollaway incidents involving drivers working for 3D Trans Ltd:- a. An incident causing damage to a fence between the 17th September 2020 and the 9th October 2020; b. An incident leading to the death of Mr Lyth on the 30th November 2021; c. An incident on the 15th November 2022; d. An incident on the 12th June 2023. I acknowledge that these incidents involve different circumstances and that only one resulted in a fatality. (2) I received evidence that following each of the incidents, refresher training was provided and various measures were put in place at the yard to physically prevent the vehicles or trailers rolling away. In addition to this, signage has been placed on the tractor and trailer units to serve as a reminder to drivers of the importance of securing the parking brakes on the tractor and trailer units. I have concerns regarding the provision of regular and periodic training for all drivers in respect of coupling and uncoupling procedures. ”

Is this part of a recurring concern?

Yes — Unsafe tractor and trailer coupling systems.

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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

Strengthen driver training with quarterly coupling and uncoupling refreshers, procedure review, video learning, comprehension tests, and two-year record retention.

Verbatim wording from the response

“We can confirm that the company has now strengthened its training programme to ensure that all drivers receive quarterly refresher training against the company's coupling and uncoupling procedure, to include reviewing the written procedures, watching a video and completing a test to confirm their understanding. These records will be retained by the company for a minimum of two years.”

Source location

Response from 3D Trans
Page 1 · response
Published 10 July 2023

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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

Produce and provide cross-industry workplace transport guidance covering practical coupling and uncoupling safety measures.

Verbatim wording from the response

“HSE produced further guidance on transport safety in 2014; this guidance is aimed at all industries and also provides practical measures for coupling and uncoupling, please see Workplace transport safety - A guide to workplace transport safety (hse.gov.uk)”

Source location

Response from HSE
Page 1 · response
Published 10 July 2023

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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

Produce and provide industry-specific guidance on managing coupling and uncoupling risks for articulated vehicles.

Verbatim wording from the response

“To assist employers with that process, HSE produces extensive free guidance on managing risk, some of which is industry specific. For example, HSE worked closely with the haulage industry and other regulators to investigate the reasons for unintended vehicle movement and subsequently produced specific guidance in 2013, please see safe-coupling-guide.pdf. This guidance provides practical advice for employers to help them manage the risks of coupling and uncoupling articulated vehicles.”

Source location

Response from HSE
Page 1 · response
Published 10 July 2023

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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 strengthened quarterly driver training programme is considered sufficient to address the report, so no additional action is proposed.

Verbatim wording from the response

“We can confirm that the company has now strengthened its training programme to ensure that all drivers receive quarterly refresher training against the company's coupling and uncoupling procedure, to include reviewing the written procedures, watching a video and completing a test to confirm their understanding. These records will be retained by the company for a minimum of two years.”

Source location

Response from 3D Trans
Page 1 · response
Published 10 July 2023

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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

Employers are responsible for deciding refresher-training intervals based on risks specific to their businesses.

Verbatim wording from the response

“As part of their consideration of risk in the business, employers should identify suitable risk controls and provide appropriate training and information to their employees to enable them to carry out their jobs safely, as well as an appropriate level of supervision/review to ensure that processes are followed consistently and that any issues are quickly identified and resolved. It is, for this reason, the employer’s responsibility to decide on the intervals for any refresher training. Whatever system the employer chooses to implement to manage risk, they should review it regularly to make sure it is up to date and still relevant.”

Source location

Response from HSE
Page 2 · response
Published 10 July 2023

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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 training, monitoring and supervision measures for 3D Trans drivers are considered sufficient for safe coupling and uncoupling.

Verbatim wording from the response

“In relation to 3D Trans Ltd, HSE has conducted a further Inspection of the company since the inquest, and we are satisfied with the measures the company have put in place regarding training and monitoring and supervision for their drivers in respect of safe coupling and uncoupling procedures.”

Source location

Response from HSE
Page 2 · response
Published 10 July 2023

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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

    Maintain industry collaboration and engage key stakeholders to reinforce risk management during articulated-vehicle coupling and uncoupling.

    Stated by Health and Safety ExecutiveStated in progressThe respondent said that this action was in progress when they made their response on 10 July 2023.

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

Maintain industry collaboration and engage key stakeholders to reinforce risk management during articulated-vehicle coupling and uncoupling.

Verbatim wording from the response

“HSE continues to work closely with the industry in this area and we will engage with key stakeholders to remind them of the need to manage risk when coupling and uncoupling articulated vehicles.”

Source location

Response from HSE
Page 2 · response
Published 10 July 2023

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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