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March 19, 2008

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Failure to learn lessons ends in fatality and GBP 250,000 penalty

A Corus worker died after being struck on the head by a piece of machinery, in an incident whose potential had been previously noted. but not acted upon.

Corus UK Ltd, trading as Corus Packaging Plus, was fined £250,000 at Swansea Crown Court on 19 February following an investigation into the death of Francis Coles at the Trostre Tin Plate works in Llanelli on 4 January 2003. The company had pleaded guilty last November at Llanelli magistrates’ court to breaching s2(1) of the HSWA 1974 and reg. 11 of the Provision and Use of Work Equipment Regulations 1998.

The incident occurred while Mr Coles was working on a five-stand mill, where five pairs of rollers squeeze and stretch steel strips to make them thinner. Gaps between each set of rollers allow workers to walk through to the back of the machinery. Mr Coles was assisting in a roll change and was walking through a gap between one of the sets when a deflector plate descended, striking him on the head.

HSE inspector Alan Strawbridge told SHP that the deflector plate had a facility for pins and bolts to protect against such incidents, but the frequency with which workers had to walk through the gaps meant that while some employees used them, others did not. Moreover, the practice was never properly managed or checked.

The system of work involved the use of an automated controller programme, which checks that it is safe for a deflector plate to descend. However, a manual control switch was also used for certain jobs.

Strawbridge said it seemed likely that someone inadvertently or deliberately operated the switch to lower the plate. He added that the switch was “very loose, and you could turn the switch with very little force”.

A deflector plate also struck an individual in an incident in 1997. Although quite different to the incident involving Mr Coles, an internal investigation carried out by Corus failed to alert it to the existence of a potential problem. In 2002, several months prior to the fatal incident, minutes from a health and safety meeting recorded the need for a risk assessment to be carried out to make the inter-stand areas safer, but this was never acted upon.

Following the incident, the HSE issued Corus with a Prohibition Notice, which it complied with by installing interlocking gates to the inter-stand areas, so no one could physically enter the area unless all the parts were locked.

In mitigation, Corus said it was the first major accident that had taken place on the site, and that it had previously held a good health and safety record. Sentencing the company, the judge also accepted there was no suggestion that it had been looking to take shortcuts to make profit.

Strawbridge said: “The key messages to get across are that, firstly, on safe systems of work — unless they are enforced and policed, then they don’t really exist. The second point is that when accidents do happen, you have to take the full opportunity to investigate them and learn all the lessons.”

Corus said in a statement to SHP: “Since the accident we have been determined to learn from the tragedy, and, following the detailed and thorough investigations into the incident, we have taken steps to ensure that a similar incident can never happen again. This has reinforced our approach to health and safety, which is paramount to everything we do.”

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