Further supplementary memorandum submitted
by the Royal Mint
QUESTION 78FATAL 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.
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
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
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.
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
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.
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
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
16.7 The HSE has confirmed that they are
satisfied with the action taken.
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
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
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.
The Royal Mint
27 November 2002