Fatal Accident - A Case Study
November 27th 2003

Today’s Case Study
•	Graeme Barrie 
–	biography
•	Caledonian Brewery
–	background
•	The Accident
•	The Aftermath
•	The Court Case.
Graeme Barrie
•	…….. - 1994		Motor Trade
•	1994 - 1995		Bar Manager
•	1995 - 1996		Disc Jockey
•	1996 - 2001		Sales Representative, 					Caledonian Brewery
•	2001 - 2003		Health & Safety Officer					Caledonian Brewery
•	2003 - 			Sales Executive, CHSS. 
Caledonian Brewery
•	Opened in 1869
•	Management buyout 1987
–	Owned by board, MD and Production Manager (MD’s son)
•	Major fire 1994 - Maltings destroyed
•	Major fire 1998 - Brewhouse gutted.
Caledonian Brewery
•	1999 - £6m brewing contract won
•	2000 - Turnover c. £12m
•	37 staff
–	16 production and packaging
–	8 sales
–	1 engineer
–	8 office
–	4 directors.
The Accident
	The following details are taken directly from the records taken at the time
	The purpose of this case study is to highlight the effect on a business a serious accident can have
	There are details some may find disturbing.
The Accident - Feb 23, 2001
	07.15hrs	The accident occurs, FLT driver is trapped under the roll-over bar on the left side of the toppled FLT.  CB staff try in vane to lift FLT by hand, and by using second FLT, each time they try, driver started to scream, thinking they were making it worse, staff try repeatedly from different angles.
The Accident - Feb 23, 2001
	07.20hrs	Fire Brigade arrive and successfully lift FLT with lifting bag.  Ambulance crew arrive and call for Medic One.  Paramedics work on driver for twenty-five minutes before attempting to transport him to A&E.  Police start investigation.
–	10 pints of fluids at scene.
The Accident - Feb 23, 2001
	08.10hrs	Police given personnel file
	08.30hrs 	HSE informed of accident.  FLT lying on the ground, at right angles to lorry, forks under the bed of the trailer by six inches.  If the FLT was brought upright, where the wheels are lying, the forks do not line up with the lift, which was scattered.
The Accident - Feb 23, 2001
	09.00hrs	GB appointed HSO
	09.30hrs	HSE arrive to investigate
»	business suspended
	09.45hrs	Police Inspector slips on ice
	10.30hrs	HSE inspector issues detaining notice for various documents including “copy of operator training record” (FLT driver).
The Accident - Feb 23, 2001
	11.00hrs	Owners of the damaged FLT contacted, they start making their way to brewery

	11.35hrs	HSE inspector issues Prohibition Notice prohibiting us from using FLT’s for loading and unloading of goods in the loading yard

	11.45hrs	HSE see security video to establish time of accident. 
The Accident - Feb 23, 2001
	Whilst not showing the actual accident, the video did show quite clearly the unloading was in progress.  After four lifts have been moved, and having been out of the picture completely, the front end of the lorry appears in the picture from the right, followed seconds later by rolling kegs.  
The Accident - Feb 23, 2001
	11.48am	Having seen video, HSE call Traffic Police back with the Vehicle Inspector
	11.50hrs	HSE inspector issues Notice of Taking Possession for CCTV tape showing area near accident at 07.15
	12.00hrs	HSE ask us to arrange for risk assessment to be carried out on the lifting the FLT for impounding.

The Aftermath
•	Fork lift driver dies, lunchtime 8/3/01
•	News withheld until 16.30
–	Colleagues had left for the day
–	Announcement on six o’clock news
•	Telesales department try to tell staff before news program
•	Brewery closed for funeral, 15th March.
Injured FLT Driver

Consultant’s report

Court Case preparation
•	Paperwork taken into possession
•	Video of accident created
•	Procurator Fiscal site visit
•	Accounts examined
•	More staff interviews.
Court Case
•	14 charges
–	Company
–	Managing Director
–	Production Manager
•	Lawyers plead to one charge for Company
•	Sheriff part blames lorry driver
•	£10,000 fine.
Conclusions
•	The slope was a major factor in the sequence of events – if the slope had not been there, the truck would not have had to move 

•	The HSE have measured the incline to be in the range of 5-9 degrees, the FLTs are design tested to 3.4 degrees.
Conclusions
•	the staff did not wear their seat belt whilst in the FLT
•	staff were seen wandering around in the CCTV video in the FLT area
•	inadequate supervision
•	no written procedure
•	no formal risk assessments
•	wheels of lorry were not chocked.
Conclusions
•	We failed to provide a safe system of work

•	The FLT driver was not to blame, he was simply on his way in to collect a lift, he was correctly lined up – but he did not have his seat belt on.
Remedial Action
•	Tarmac loading area
•	Lighting
•	Interlocks
•	Asbestos removal
•	PPE
•	Training
•	Fire alarm.
Final Thought...
	An average company, doing an average job, on an average day - they had an average accident
	Someone didn’t get to go home at the end of their shift
	Someone left a wife and three kids
	We don’t pay people enough to make this sacrifice.

Thank you for your time

Any questions?