Select Committee on Public Accounts Minutes of Evidence


APPENDIX 3

Further supplementary memorandum submitted by the Royal Mint

QUESTION 78—FATAL ACCIDENT

  Your Committee asked for a very full note on the background to the accident, which sadly resulted in the death of Mr John Wynne on 28 June 2001.

BACKGROUND

  1.  An Ebner Bell Annealing furnace is situated at the east end of the Blank Production Department of the Royal Mint. It was manufactured and installed in 1998 by Ebner, a specialist furnace Company based in Austria. The fatality was caused by the bell annealing furnace being detached from the hook of the overhead crane whilst being transported from the storage to the working position. The furnace struck Mr Wynne causing fatal injuries.

  2.  The bell annealer consists of a base onto which coils and material are stacked vertically. An inner cover, which is lowered onto the base, encloses the stack. A heating bell measuring approximately four metres high and weighing approximately 6.5 tonnes is lowered over the inner cover and sealed onto the base. The inner cover and heating bell are lifted into position using a 7.5 tonne safe working load ("SWL"), 25 metre span, Morris electric overhead travelling ("EOT") crane. An operator using a remote radio control operates the crane from ground level.

  3.  The heating bell is fitted with a single lifting point consisting of a 65 millimetres diameter pin welded into cross members on top of the bell. The cross members also act as horizontal guides to lead the crane hook into engagement with the lifting point. The lifting point is equipped with a location indicator to show when the crane hook is correctly engaged on the pin.

  4.  The indicator consists of a horizontal hinged steel plate with a bell crank at right angles to the plate connected to a wire rope. The rope passes across the top and down the side of the bell to a red painted telltale weight acting in a vertical guide tube. When the point of the hook is passed over the lifting pin to the correct position it is directly under the free end of the hinged plate. As the hook is raised to engage with the pin, the point comes into contact with the free end of the hinged plate. The plate and bell crank rotate about the hinge pulling the wire rope horizontally and lifting the telltale weight so that it disappears from view into the guide tube.

THE INCIDENT

  5.  On 28 June 2001, the heating bell was being moved from its storage location using the EOT crane to position it over the inner cover on the furnace base. As the heating bell approached the furnace base, it became detached from the crane hook and fell approximately four metres to the floor, coming to rest on its side against a barrier at the side of the gangway in front of the furnace. Mr Wynne, who was not operating the crane, was struck and received fatal injuries.

  6.  An immediate investigation was undertaken, and a report prepared by the HM Specialist Inspector of Health & Safety.

  7.  When investigating the circumstances giving rise to the incident, it was possible to see the engagement of the hook clearly, but the indicator was not travelling its full length. This was caused by the hinged plate flap being distorted, but even so, and despite the user manual containing warnings to ensure that the hook engaged indicator shows that the crane hook is properly engaged, the operatives did not use the indicator.

  8.  It must be noted that there was a previous incident in September 2000 when the heating bell had become detached from the crane hook. The HSE agreed that the circumstances differed to those of the incident of June 2001. However, the HSE did conclude that the loss of control of a load such as the furnace was clearly an incident with potentially fatal consequences, and one which could reasonably have been expected to initiate a thorough assessment of the operation. They also concluded that whilst some investigation did take place, a suitable and efficient assessment of the risks posed by the operation was not made.

  9.  The report concluded that, if the lifting pin was properly engaged with the crane hook, it would not be possible for the heating bell to become detached. However, the probable explanation for this accident was that the crane hook was not properly engaged with the lifting pin of the heating bell. The heating bell was probably lifted with the lifting pin balancing on the point of the crane hook. The heating bell remained balanced on the hook while it was being transported from the storage to the working position and, when the crane hook was raised to the top hoist limit to lift the heating bell over the inner cover guide posts, the heating bell fell from the point of the crane hook, the guide bracket on the bottom of the heating bell struck the top of the inner cover, causing the bell to tilt sideways and then fall to the floor on its side coming to rest against the barrier on the other side of the gangway.

  10.  Numerous detailed discussions took place between the Project Engineers, Technical Services, the Health & Safety Department, and representatives of Ebner with regard to the operation of the furnace and the most appropriate and safe method of lifting it. However, it is accepted that the Mint did not formally record a suitable and sufficient risk assessment.

  11.  Furthermore, a number of personnel had received training (90% having achieved NVQ Level 2), and were highly experienced, not only in relation to lifting operations but also in relation to the operation of the Ebner furnace. Nevertheless, it is accepted that not all employees involved in the process can be shown from written records to have received sufficient instruction. It is also accepted that there was a need to improve the audit trail, such that documentary proof of the depth of job skills is readily available.

  12.  It is accepted that some operatives exhibited a lack of knowledge of the function of the location indicator and that, because it was used infrequently, there should have been time-based maintenance of the indicator.

  13.  There is no suggestion by the HSE that financial considerations played any part in the accident.

  14.  Indeed, there has been a significant investment in training and the health and safety structure prior to, and since, this tragic incident. Priority has been given to the areas now classified as a COMAH site.

  15.  The Mint co-operated fully with the HSE in the course of their investigation.

SUMMARY OF ACTIONS

  16.  Further steps were taken as follows:

  16.1  A full review of the operation of the Bell Annealer Furnace and Risk Assessment was undertaken and safe working procedures reviewed and up-dated.

  16.2  Those with responsibility for operating the Bell Annealer Furnace have undertaken Knowledge Competency Assessments.

  16.3  A Hazards & Operability Study ("HAZOP Study") has been undertaken in relation to the operation and maintenance of the Bell Annealer Furnace.

  16.4  The Blank Production Department has also undertaken a review of Risk Assessments throughout the Department.

  16.5  A Bell Annealing sub-group has been set up to review periodically the process to ensure that all issues and remedial actions identified have been implemented.

  16.6  In addition, a platform has been constructed around the annealing furnace area to assist the operators to visually confirm that the hoist is located correctly. This is the safest option because the location indicator is prone to damage despite regular maintenance.

  16.7  The HSE has confirmed that they are satisfied with the action taken.

GENERAL COMMENTS

  17.  Whilst the Treasury Officer of Accounts will be responding separately to the question of Crown Immunity generally, some of the specific comments below may aid a clearer understanding of the procedure in this case.

  17.1  Crown Immunity does not afford any protection from investigation by the HSE. Moreover, the Royal Mint asked the HSE to lead the investigation into this incident and ensured full co-operation by affording total access to all areas, employees and records.

  17.2  Crown Immunity does not grant any protection from prosecution for any Director or Manager. After a thorough investigation, initially by the Police and thereafter by the HSE, it was concluded that no individual should be the subject of a prosecution.

  17.3  The Mint invited the family of the employee, his union and their legal advisors to attend the Crown Censure Hearing so that there would not be any "behind closed doors" aspect to the investigation by the HSE and/or their findings.

  18.  Whilst understandably due to their grief, the family has refused the direct support of the Royal Mint's Welfare Department, they have received substantial financial support via the Mint. This immediate assistance will be supplemented by a Civil Claim which will undoubtedly be initiated and which the Mint will consider sympathetically.

  19.  This was a tragic accident for which the Royal Mint accepted responsibility at a very early stage. The circumstances surrounding the incident have been thoroughly investigated by the authorities and measures have been implemented to ensure there can be no repetition.

  20.  The Mint has a serious commitment to Health & Safety which is evidenced not only by the improvement in its accident record which has seen the number of accidents reduced year-on-year for the last four years but also by its increased resourcing of Health & Safety matters.

  21.  This commitment to resource in all aspects of Health & Safety, and the improvements to the accident record of the Royal Mint, are acknowledged by the HSE.

Gerald Sheehan

Chief Executive

The Royal Mint

27 November 2002


 
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