SHERIFF COURT OF GLASGOW & STRATHKELVIN
UNDER THE FATAL ACCIDENTS AND
SUDDEN DEATHS INQUIRY (
DETERMINATION by
SHERIFF SEAN FRANCIS MURPHY,
Queen's Counsel,
In a
FATAL ACCIDENT INQUIRY
Into the death of
Dr. GRAHAM MELDRUM
The sheriff, on resuming consideration of the
evidence and submissions in the fatal
accident inquiry, DETERMINES:
In
terms of Section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (
That Dr. Graham Meldrum, born
In
terms of Section 6(1)(b) of the Fatal Accidents and Sudden Deaths Inquiry (
That the cause of Dr Meldrum's death was a head
injury consisting of depressed skull fractures with underlying associated brain
damage to either side of his head.
That this injury was sustained in an accident
at work. At the time of his death Dr
Meldrum was in the basket washing area of Allied Bakeries' premises operating a
Ratcliff Palfinger ("Ratcliff") RV1500LC column cantilever tail lift which was
attached to the rear of a Montracon semi-trailer box van, numbered 05739, which
was part of the Allied Bakeries vehicle fleet.
This type of tail lift had an extension portion which folded out from
the main section of the platform. Anti
luce plates were fitted to either side of the platform extension through which
retaining pins should have been deployed in order to secure the extension to
the arms of the tail lift when it was in the open position. These were defective so that the extension
could not be secured in that way on the lift in question. Dr
Meldrum was raising the tail lift with the platform opened out and the
extension deployed. As he did so the
platform began to move into its closed or stowage position. The extension folded forward suddenly from
its open towards its closed position with the result that the nearside
anti-luce plate attached to the extension struck Dr Meldrum on the right hand
side of his head, forcing the left hand side of his head at the temple against
a bayonet pin which projected from the tail lift column area and was part of
the stowage gear which secured the lift against the rear of the vehicle when
not in use. Death was instantaneous.
That the immediate causes of the accident were:
-
the sudden
and unexpected movement of the platform extension
-
the
defective state of the anti-luce plates and pins which meant that the extension
could not have been secured
-
the
raising of the lift with the platform and extension opened out while the cam
followers attached to the lift mechanism were deployed in the position which
caused the platform and extension to begin to fold into its stowage position
-
the position
of Dr Meldrum's head within the arc of the plate as the extension flipped over.
As the accident could not have occurred in the
absence of any one of the above factors I will consider each in turn in greater
detail.
The Movement of the Platform Extension
The folding extension was attached to the main
platform of the tail lift by a hinged section which contained within it torsion
bars to assist in the deployment and folding away of the extension. Immediately before the fatal episode Dr
Meldrum must have been pressing the operating button to raise the lift with the
platform deployed to its horizontal position and with the extension portion
also unfolded to the horizontal, i.e. in position for unloading the baskets
which were in the trailer. Folding flaps attached to the extension had also
been deployed to their operating position for use as loading ramps. The cam followers attached to the platform
were still in their horizontal position so that as the lift was raised they
engaged the cam at the rear of the trailer. This had the effect of moving the
platform and its related extension towards the vertical, i.e. towards the
position for stowage of the lift against the rear of the vehicle when the lift
was not in use and the vehicle was to be driven. Once
the platform reached an angle of about 55 degrees from the horizontal the
extension section and its attached ramps flipped over forwards in a sudden and
rapid movement towards the rear of the trailer. This movement caused the
nearside anti-luce plate to strike the right hand side of Dr Meldrum's head
forcing the left side of his head against the bayonet pin which projected from
the rear of the vehicle as part of the lift stowage equipment. The speed of this action was much greater
than that of the normal range of tail lift movements and would have taken less
than 1.2 seconds from the point at which the main section of the platform
reached the critical angle. It is a
reasonable inference that Dr Meldrum would not have expected the sudden and
rapid folding over of the platform extension to have occurred.
The Anti-Luce Fasteners
The extension portion of the tail lift when in
full working condition was fitted on each of its nearside and offside edges
with a metal plate which had a hole in its centre. When the extension was folded out these
plates rested on the support arms of the tail lift mechanism and the hole in
the plate passed over a small bracket or pin through which a retaining clip
passed; the clip would then be fastened into position so as to secure the
extension to the support arms of the mechanism.
These items collectively are known as anti-luce fasteners. On the tail lift in question the anti-luce
fasteners were defective on either side.
On the nearside the plate was still attached to the edge of the
extension but the locating pin and clip were missing, having apparently broken
off; on the offside the plate itself had broken off although the pin and clip
remained. In each case the damage had
occurred before the date of the accident without being repaired. Had the anti-luce fastener on either side been
operational and deployed by Dr Meldrum the extension portion of the lift platform
would have been retained against the support arm of the machinery with the
result that the accident would not have occurred because the sudden flipping
over of the extension could not have taken place when the tail lift was raised
even if the cam strikers were operating so as to cause the platform to begin to
fold against the rear of the trailer as it went up. Had the anti-luce fasteners been in working order
I consider that they would have been deployed by Dr Meldrum because the
platform extension would not have sat in its proper position without the
fasteners being engaged, since it would in part have been resting on them; and
because someone with his background and experience (in terms of his scientific
education, his commercial driving experience and his personal interest in
engineering) would have realised that they had an obvious function to retain
the extension in position.
The
The tail lift was fitted with a semi-automatic
cam closure system. This meant that when
the lift was to be deployed, cam followers which were in a vertical position on
either side of the tail lift when it was stowed against the rear of the trailer
would be in contact with a cam as the unit was lowered and would follow it
round to a horizontal position, allowing the platform to move out into the
horizontal, ready for use as a lift.
This position would be reached when the base of the platform was
approximately 400 mm above the ground.
In order for the platform to be raised and lowered for use in loading or
unloading the trailer it would be necessary to lower the platform further until
its base was about 50 mm above the ground, at which point the cam followers
would clear the cam and would be pushed into a vertical attitude under spring
loading. The system had been designed to
operate in this way so that the cam followers would automatically assume the
position necessary for the platform to be used as a lift. Once loading or unloading was complete the
platform should have been returned to a position on or just above ground
level. A lever situated on the nearside
edge of the platform was then to be used to lower the cam followers on both
sides into the horizontal and the operative was to raise the platform by
pushing the relevant button on the rear nearside of the trailer while holding
the lever in position with his other hand until the cam followers engaged with
the cam. Once they had done so, the
lever could be released and the cam followers would run against the profile of
the cam with the effect that as the platform unit was raised it would fold away
against the rear of the trailer. The
manual aspect of this part of the operation was designed to ensure that a
deliberate step was required to deploy the cam followers against the cam so
that the platform could not be raised with the cams engaged in such a way as to
fold the platform towards the rear of the vehicle by accident. The system was thus semi-automatic in that
the cam followers freed themselves from the cam automatically on deployment of
the lift but could only subsequently be re-engaged manually for stowage of the
lift. On the tail lift in question the
semi-automatic cam closure device was faulty in several respects on the day of
the accident. The spring loaders which
were designed to disengage the followers from the cam were broken, the linkage
designed to ensure that the nearside lever would raise both cam followers
together was fractured, and subsequent testing of the lift indicated that the
cam followers, once raised, would not sit at the correct angle. The most serious of these defects by far was
the failure of the spring mechanism designed to free the followers from the cam
automatically. The consequence of this
fault was that the followers would have to be raised manually into the vertical
position on either side before the platform could be used as a lift. This had not been done at the time of the
accident which had occurred while the platform was being raised by Dr
Meldrum. Consequently as he raised it
the platform began to fold in towards the rear of the trailer with the result
that the extension flipped over as described above.
Despite this, the extension section of the
platform would not have folded forward if one or more of the anti-luce
fasteners had been used to secure it. In
normal use, when the lift was to be stowed against the rear of the vehicle, the
platform extension and its attached flaps were to be folded away when the
platform was approximately 400 mm from the ground, and the extension itself was
secured to the main platform by means of a heavy-duty type of spring clip known
as a Salveson clip.
The Position of Dr Meldrum
It is
stating the obvious to say that the accident would not have occurred if Dr
Meldrum's head had been beyond the arc of the plate attached to the edge of the
platform extension at the material time.
However, that does not mean that his positioning was an operative cause
of the accident. The evidence indicated
that the tail lift was operated by a "push to run" system, which means that it
moved upwards for so long as the up button was being pressed or downwards for
so long as the down button was being pressed.
Once an operative ceased to press the button the lift would stop at once
in whatever position it had reached. It
was an electrically driven hydraulic system with two sets of operating buttons,
one placed externally at the rear nearside of the trailer, and one placed
within the trailer itself also to the rear nearside. At the time of the accident
Dr Meldrum was standing outside the trailer at the rear nearside and he was
found with his hand close to the external set of operating buttons. While the flip-over motion of the platform
extension was very rapid, the normal operating movements of the machinery were
gradual. Raising the lift platform from
its deployed to its stowage position by continuous application of pressure to
the button would take about 15 seconds.
Dr Meldrum's body was found in a position where his head was a safe
distance from the nearside arm of the machinery and he would have been in no
imminent danger of being struck by any part of it in the absence of the folding
over of the platform extension. The motion of the extension in flipping over
was described in evidence as counter-intuitive, in the sense that it was not a movement
which would have been expected by someone who was unfamiliar with the location
and condition of the torsion bars within the hinge, which were not visible in
normal operation. Therefore, while the
plate would not have struck Dr Meldrum if his head had been outwith its arc, no
criticism is attached to him because of that in the circumstances of this
accident.
In
terms of Section 6(1)(c) of the Fatal Accidents and Sudden Deaths (
That the maintenance by Allied Bakeries of the
anti-luce fastener plates and pins on the tail lift in a proper, serviceable
condition was a reasonable precaution whereby the accident which resulted in
the death might have been avoided.
That the maintenance by Allied Bakeries of the
semi-automatic cam closure device fitted to the tail lift in a proper,
serviceable condition was a reasonable precaution whereby the accident which
resulted in the death might have been avoided.
That the provision of adequate training by TNT
Logistics UK Ltd ("TNT") to Dr Meldrum in the use of this type of tail lift was
a reasonable precaution whereby the accident which resulted in the death might
have been avoided.
That the ensuring by duty managers at TNT that all
drivers, including agency drivers, were familiar with the operation of all
equipment they were required to use was a reasonable precaution whereby the
accident which resulted in the death might have been avoided.
In
terms of Section 6(1)(d) of the Fatal Accidents and Sudden Deaths Inquiry (
That the following defects in the system of
working operated by Allied Bakeries contributed to the accident resulting in
the death:
-
the
maintenance regime failed to keep pace with the level of depreciation of the
tail lift;
-
the
maintenance regime failed to ensure the safe upkeep of items of the tail lift equipment
with a safety aspect
That the following defects in the system of
working operated by TNT contributed to the accident resulting in the death:
-
the system
of driver evaluation and training failed to identify all requirements which
were placed upon drivers such as Dr Meldrum;
In
terms of Section 6(1)(e) of the Fatal Accidents and Sudden Deaths (
The facts relevant to the circumstances of the
death are set out in detail in the note below.
NOTE
The inquiry heard evidence on a total of twenty
three days between
The parties were represented by:
Ms Sultan, Procurator Fiscal Depute, for the
Crown
Ms Hay, solicitor, for Ceva Logistics UK Limited
(formerly TNT Logistics Ltd)
Mr Wade, solicitor, for Allied Grain Products
Limited
Mr Borland, advocate, for Ryder Limited
Mr Neilson, solicitor, for Colin Hutton Group
Limited
Mr Maillie, solicitor, for Zurich Risk
Services, and
Mr Caskie, advocate, for Ms Karen Thomson and
the family of the deceased.
I am grateful to each of them for their
assistance during the inquiry.
Background
Dr Graham Hamilton Meldrum was 40 at the time
of his death. He was unquestionably a
gifted and interesting person who contributed in a significant way to the
society in which he lived. At the outset
I wish to express sympathy to his partner, Ms Karen Thomson, to his daughter,
Heather, and to all of Dr Meldrum's
family over his very sad and untimely loss.
Dr Meldrum held a B.Sc. in chemistry from the
Suziline first placed Dr Meldrum with TNT on
The final matter to be considered in this
section is the issue of Dr Meldrum's employment status. A number of submissions were made about this
at the conclusion of the evidence in the inquiry. As was accepted, this is something of a side
issue because the question of responsibility for such areas as equipment
maintenance and training does not depend in the circumstances here upon Dr
Meldrum's employment status, and the issue of civil or criminal liability is
not a matter for this inquiry. He was
employed with Suziline Limited, a driving agency which has subsequently gone
out of business, in the sense that he was paid by them. However that agency's role was to offer his
services to companies which required suitably qualified drivers. By virtue of that arrangement those companies
assumed some of the features of an employer. .Suziline's standard application
form had a section which allowed the employee to record the types of vehicle
and equipment of which he had experience.
Dr Meldrum's form (Crown production number 6) contains a tick in the
section relating to tail lifts although it seems that his previous experience
lay with the underslung type. Details of the driver's licence and its
categories were also noted. Suziline did
not provide training to its drivers because it was an agency and its drivers
might be expected to operate a broad range of vehicle types during different
placements. Valentine Brown, the former
director of Suziline, confirmed that the agency had not provided training and
he indicated that efforts were made to provide appropriate drivers for
particular jobs. He also testified that
Dr Meldrum had contacted him for advice when he had concerns at a
placement. Mr Brown was a former HGV
driver himself and he regarded such contact from Dr Meldrum as a positive sign.
At the material time Dr Meldrum had been
provided by Suziline to TNT as an agency driver and his duties were conducted
in terms of the contract between TNT and Allied Bakeries by which the former
provided inter-bakery haulage services to the latter. His relationship with TNT displayed some of
the characteristics of an employee/employer relationship. The critical factor, however, is that he was
operating under the direction of TNT at the material time rather than that he
was a directly employed. As such they
had clear obligations towards him in terms of Section 3 of the Health and
Safety at Work etc Act 1974 ("the 1974 Act"), Regulation 3 of the Provision and
Use of Work Equipment Regulations 1998 ("PUWER"), and Regulation 3 of the Lifting Operations and Lifting
Equipment Regulations 1998 ("LOLER"). Allied
Bakeries certainly did not employ him in any meaningful sense but he was
operating equipment owned and maintained by them; therefore Allied Bakeries owed
obligations towards Dr Meldrum as a user of their equipment under the 1974 Act,
under Regulation 3 of LOLER and under Regulation 3 of PUWER.
Allied Bakeries and TNT each recognised their
responsibilities towards Dr Meldrum after the accident. Each admitted offences under Sections 3 and
33 of the 1974 Act, the details of which are set out in the complaint which
formed Ryder production number 52 at the inquiry.
Operating
Procedures.
At
The
Maintenance & Repair Regime
Allied Bakeries owned the fleet of vehicles
based at the
In practice Ryder had a daily presence at the
depot. Certain types of repair were
passed out by them to specialist sub-contractors. Fabrication work on trailers and their
equipment, including tail lifts, was passed out to the Colin Hutton Group
Limited ("Huttons") who had a mobile welding unit which could attend at the
depot when required. From time to time engineering repairs were required to
tail lift equipment and Ryder would pass that on to Johnston Engineering who
were tail lift specialists. Once items
raised in a DVCR had been dealt with, the repairer would note that on a copy of
the DVCR which would be returned to the duty controller. The evidence indicated that where a defect
had been reported but no such defect could be identified by the repair
mechanic, he should raise the matter with the controller to seek clarification;
where no defect could ultimately be traced, best practice was to note that
position on the DVCR before it was returned to the controller. Clarification was required from time to time
and that was understandable from the evidence heard in the inquiry. To give a single example, the cam followers,
which were metal levers which pivoted at one end, were referred to as "cam
followers" "cam strikers" "cams" "cam levers" "lifters" or "landing legs" by
various witnesses.
Although DVCR forms might be transmitted via
the TNT controller, there was never any doubt that the repairs were being
carried out for Allied Bakeries and on Allied Bakeries' vehicles. Where any significant question arose as to
whether something should be done to a vehicle or not, the Ryder mechanic would
seek instruction from Allied Bakeries staff and all Ryder invoices were sent to
Allied Bakeries.
Inspections were required periodically in terms
of the industry regulations. The Lifting
Operations and Lifting Equipment Regulations 1998 ("LOLER") ordained that a
thorough examination of tail lift equipment be carried out every six
months. Formerly these thorough
examinations were conducted by Ryder in terms of the maintenance contract, but
Allied Bakeries had decided to have this done independently, even before the
trailers were taken out of the contract with Ryder in 2004. The thorough
examinations of the lifting equipment required under the regulations were
carried out at the material period by Zurich Risk Services ("
In addition to the thorough examinations
required under the LOLER procedures, at the time of the accident each trailer
and tail lift in the fleet was given a maintenance inspection every six weeks
in the workshop at the Allied Bakeries depot in
Trailer
05739 before the Accident
Trailer 05739 and its associated cantilever
tail lift had been manufactured and supplied in 1996. It followed the general maintenance programme
as outlined above over the following years.
The last LOLER thorough examination of trailer 05739 before the accident
had taken place on
The trailer had been used on the day before the
accident,
The
Events of
On
Thereafter he was despatched to carry out a
second delivery run, this time using tractor unit registration number S860 WUK
attached to trailer 05739 which had the cantilever tail lift attached to
it. His employment history record
provided by TNT (Crown production number 5) shows that he had used the tractor
unit on two previous occasions and that he had towed the trailer once
before. It gives his departure time from
the
Thereafter Dr Meldrum went to
It is not possible to say with any degree of
certainty why he was raising the unit with the platform extended but with the
cam followers engaged.
The
Movement of the Platform Extension
This was described to the inquiry in detail by
Russell Breen, B.Sc., MIME, a Specialist Inspector for the Health and Safety
Executive ("HSE") of 17 years experience and a qualified mechanical
engineer. He had been shown the accident
scene by the police on the evening of
Each set
of tests had yielded the same results: if the platform was raised with the cam
strikers engaged and with the extension deployed but unsecured to the platform
arms, the extension would suddenly and violently fold forward towards its
stowage position and would strike the floor of the trailer or any baskets
within the rear of the trailer once the platform had reached an angle of
approximately 55 degrees from horizontal.
Assisted by the effect of the torsion springs within the hinge, this
movement took 1.2 seconds from the attainment of the necessary angle to the
point when the platform extension struck the back of the trailer. Mr Breen described this action of the
platform extension as "counter-intuitive".
In evidence he explained what was meant by this: one would expect the
platform to reach an angle "considerably greater" (transcript, Day 23, page 21) or "significantly more" (transcript, Day 23, page 23) than 55
degrees from horizontal before the extension wanted to flip forward. Once it did so, the action was very rapid as
well as unexpected with the result that Mr Breen thought "you would struggle to
get out of the way of it" (transcript,
Day 21, page 145).
None of the drivers who gave evidence could
provide any operational reason for raising the lift with the extension portion
deployed and the cam strikers set so as to fold into the stowage position. Mr Barsby, a semi-retired consultant and
former chief engineer from Ratcliff, testified that one of his colleagues had
told him that during discussions with Allied Bakeries over the design
specifications of the cantilever tail lifts it had been specified that the
units were to be capable of being stowed vertically against the rear of the
trailer with the platform extension folded out into its deployed position. It followed that one of the functions of the
anti-luce fasteners was to secure the platform extension at such a time. In his view the other functions of the
anti-luce fasteners were to prevent the flipping over of the platform extension
in the event of the lift being raised inadvertently with the cam strikers
deployed in the position which would cause the platform to fold into the rear
of the trailer; and to seat the extension correctly on deployment against the
effect of the torsion bars within its hinge which would tend to cause the
extension to bob up slightly from the horizontal on deployment. Insofar as it was suggested on behalf of
Allied Bakeries that I should disregard Mr Barsby's evidence of the design
specification, since he himself had not been a party to the negotiations, I see
no reason to reject that aspect of his evidence; in any event, it is a matter
equally within Allied Bakeries provenance and no evidence was led in
rebuttal. The safety aspect of the
anti-luce fasteners in preventing inadvertent flipping over of the extension
seems obvious although it is perhaps less so to an operator who has no
intention of raising the platform towards the stowage position with the
extension deployed.
In the event, two witnesses had seen a platform
extension flip over on earlier occasions.
James Thorpe, a commercial vehicle body repairer at Allied Bakeries' workshop
in Stockport, told the inquiry that he had seen it happen "a couple of times"
when an operator had forgotten to fold the extension away and had sought to
raise the lift into its stowage position.
He said that he had seen both drivers and mechanics do this (transcript, Day 5, pages 46-7). Mr Kane said that it could be done "very,
very easily" and that he had done it once by mistake (transcript, Day 1, page 116).
It was a frightening experience which had happened about the time that
he had started using it and he had not been warned about the danger of it (transcript, Day 1 page 187). It follows that the possibility of such an
occurrence was within the knowledge of Allied Bakeries.
The
Defective Anti-Luce Fasteners
The defective condition of each of the two
anti-luce fasteners on the tail lift was clearly to be seen in several of the
photographs within Crown production number 18.
On being shown these, Mr Barsby indicated that the plates visible in the
photographs were not the original ones supplied by Ratcliff but were later
replacements. That serves to indicate,
however, that the plates had been replaced as part of the maintenance regime at
some time before the accident.
The evidence indicated that the cantilever
column type of tail lift was particularly susceptible to accident damage. Since it stowed away against the rear of the
trailer impact damage was commonly caused by trailer units being reversed
against loading bays. The columns at
either side had to reach to a low level to allow the platform to deploy down to
ground level; consequently they commonly sustained damage by striking on to the
ground when a trailer was being driven over uneven ground or up or down an
incline. The depot at
The extension portion of the platform formed
one third of the total when extended.
The process of folding it out was assisted by the spring element of one
of the torsion bars within the hinge which joined it to the main section of the
platform. As it was extended the holes
in the plates attached to either side of the extension passed over the
fastening pins on the side arms of the main unit which were then fastened to
secure the extension in position. If the
fasteners and plates were fitted but not used, the plates would rest on the
pins so that the extension could not sit correctly in position. Most drivers seem to have regarded the
function of the anti-luce fasteners to be to retain the extension in position
against the bounce effect caused by a lively torsion bar; but once the bar had
lost its strength with age, the extension section would sit in the correct
position under its own weight.
Accordingly the anti-luce fasteners were not regarded as a
safety-related item by many users.
Mr Breen estimated that the anti-luce fasteners
on the tail lift had been defective for a period of "weeks, probably months,
rather than days" (Crown production 17, page 9). This was based on the degree of corrosion he
observed when he saw the unit just after the accident. While accepting that he was not a corrosion
engineer or a metallurgist, he had seen a great number of broken and corroded
items over his seventeen years as an inspector.
He estimated that the pins and plates were showing signs of medium-term,
or second stage, corrosion, that is older than a week or two but not yet very
old corrosion. This middle band was
particularly difficult to date accurately.
As indicated above, Mr McGuckien did not note
any defect with the anti-luce fasteners at the LOLER thorough examination of
the tail lift on
Mr Barsby and Mr Breen were each of the view
that the extension could not flip over if the anti-luce fasteners were engaged;
Mr Breen considered that the deployment of only one of the two fasteners would
have been sufficient. It follows that
the defect to each of the fasteners was a critical element in causing the
accident.
I was somewhat surprised that the safety aspect
of the anti-luce fasteners was lost on the drivers who gave evidence, even if
they had no operational need to fold the lift with the extension deployed. Even Mr Kane, who was described as
"pernickety" by his controller, did not report the damaged fasteners as
defective on the day before the accident.
He did not know why he did not do so, but added that the pins were never
used by drivers to secure the extension, which he referred to as the
"half-flap" (transcript, Day 1, page 66). There was at least a suggestion made on
behalf of Allied Bakeries in submissions that these defective fasteners might
have been noticed by Mr Rennie or Mr
Harvey when they were working on the tail lift on 11 July and that the former
might have brought them to the attention of an Allied Bakeries controller. However, the primary method of identifying
faults between formal periodic inspections or examinations lay with the drivers
in the regime operated by Allied Bakeries and it was the view of the drivers
towards these defects which was the critical element. Their position was shared by others who might
have been expected to think otherwise:
Mr Colin Manson, the former managing director of Johnston Engineering,
who was a tail-lift specialist and someone who carried out LOLER thorough
examinations, and Mr McGuckien both considered that faulty anti-luce fasteners
were to be classified as category (b) defects, that is not requiring immediate
repair and therefore not to be regarded a safety critical. Mr Rennie and Mr Harvey had carried out the
specific repairs which they had been detailed to do in terms of the DVCR.
The anti-luce fasteners had been designed into
the unit for a reason. The final word
with regard to this aspect of the inquiry lies with Mr Thorpe, who had this to
say (transcript, Day 4, pages 114-5):
"If somebody has put a pin there and a hole to fasten it down then they want it
fastened down". It is difficult to
escape the logic of that comment.
Unfortunately their significant safety aspect was not appreciated by the
drivers for the reason stated above.
The
Defective Semi-Automatic
Mr Thorpe testified that in 1997 he had been
instructed by his supervisor not to replace the springs which caused the cam
followers to deploy automatically into the vertical position once they were
broken. No explanation had been given to
him at the time but he thought it was because it took some time for the parts
to be obtained when the springs required to be replaced. Mr Barsby, of Ratcliff, described this
apparent policy of not maintaining the lift in the way in which the
manufacturer intended as "irresponsible" (transcript,
Day 19, page 135). Once he had been
briefed on the nature of the system as it had been designed to be used, Mr
Breen described the failure to maintain the equipment to design standards as
"unacceptable" (transcript, Day 23, pages
6-7).
Despite this there was evidence to indicate
that some of the semi-automatic cam closure systems were still being repaired
after that date. Specifically, the lift
in question had its springs replaced by Ryder in July 2004, while it was still
within their maintenance contract, to restore its semi-automatic
functioning. Alexander Tippell had
conducted the FTA examination of trailer 05739 in October 2004, when it was
about to come out of the Ryder contract. He testified that the semi-automatic
cam closure mechanism had been working at that time (transcript, Day 18, page 54).
However,
the drivers' evidence suggested that most of the semi-automatic cam closure
mechanisms were not operating normally for a period of years before the
accident. Despite conducting a number of
thorough examinations, Mr McGuckien had only learned about the semi-automatic
nature of the system a short time before the accident. It follows that the fact that he did not
report any defects in this aspect of the operation was because he did not know
to check it. He was aware that the lever
which lowered the cam followers was meant to operate upon them both
simultaneously and he had reported a failure in that respect as a category (b)
defect at thorough examination as indicated above.
The cantilever tail lift could be operated
safely if the cam followers were manually deployed, provided that the operator
knew how to do so correctly. This was
the way in which the unit was demonstrated in the video footage forming Crown
label number 1, and several witnesses had never seen them operate automatically.
The critical factor here is that the operator
had to know how the system was to be operated in order to use it safely. As described above, the semi-automatic system
was designed to make the lift deploy into the operating position automatically,
but to require manual input for storage, so that the lift could not be folded
up accidentally with the platform extension still deployed. However, for the cam followers to rise
automatically, the operator would have to know that he had to lower the lift
almost to ground level so that the cam followers would clear the cam when
pushed up by the springs. He could
deploy the extension section of the platform before that point had been
reached, which could cause the lift to fold if he then were to raise the unit
without first lowering it to free the cams.
Furthermore, although the tail lift could be safely operated despite
failure of the semi-automatic system if the cam followers were manually
deployed, an operator would need to know that that required to be done and how
to do it. In each of these respects the
issue of training is of first importance.
There was no evidence to indicate that Dr Meldrum had received any
training at all in the use of this type of tail lift.
Mr Kane, who had been driving for Allied
Bakeries for about five years by the time of the accident, said that he had
never seen the cam followers operate automatically. He indicated that he had deployed them
manually in the manner to be seen in Crown label number 1 when he had used the
trailer 05739 on the day before the accident, and he did not know at that time
that they were supposed to work automatically. It follows that the
semi-automatic system was not functioning on the day of the accident and that
it had probably not been working for some time beforehand.
In these circumstances the failure to maintain
the lift mechanism was a critical element in the accident because the semi-automatic
system was not functioning on the day in question. As a result of this, the cam followers did not
spring into the vertical but remained engaged with the cams so that the unit
began to fold in as it was raised. It
was this action, in conjunction with the defective anti-luce fasteners, which
caused the fatal flip-over of the extension section of the platform to occur.
The
Defective Maintenance Regime
Defects in the maintenance regime operated by
Allied Bakeries contributed to the causes of the accident because the defects
described above had not been identified and repaired at the time of the accident. While the date of occurrence of each defect
cannot be identified with certainty, I am satisfied that in each case the
defect had existed for some time prior to the date of the accident. No attempt was made on behalf of Allied
Bakeries to suggest otherwise.
In his report (Crown production number 17), Mr
Breen stated (at page8):
"6.1 The
tail lift was in poor condition with a number of broken, defective or missing
parts."
He concluded that the maintenance regime was
failing to keep pace with the deterioration to the tail lift as it approached
the end of its useful working life. It
is difficult to disagree with that opinion.
According to Allied Bakeries own records (the relevant report forms
Crown production number 9) it had been inspected in
On the day before the accident the tail lift in
question had been the subject of Mr Kane's DVCR and the defects noted thereon
had apparently all been repaired. The
lift had been seen by Mr Rennie and Mr Harvey who had repaired the various
parts of the vehicle, trailer and lift which they had been asked to
repair. Mr Harvey had gone further. He had replaced a bolt which secured one of
the cam followers to the shaft which ran between the two which he had noticed
was missing, despite that defect not appearing on the DVCR. He expected that repair to have made the
followers operate in tandem once more.
In fact they did not, because unknown to him there was also a fracture
in the shaft which linked them. All of
this simply underlines the central point about the difficulties in the
maintenance regime. The contracted repairers
and their sub-contractors concentrated on repairing items recorded on the
DVCRs, which is exactly what they were required to do. The DVCRs were completed by the drivers who
noticed obvious problems with the equipment they were using each day. It was a matter of chance if any driver
happened to have any degree of mechanical or engineering knowledge. The critical factor in this system was the
attitude of the driver to anything he observed in the equipment. If a driver failed to appreciate the significance
of any item, he might not report it as a defect. Thus it was that Mr Kane -
despite having accidentally experienced a flip-over of the extension portion of
the lift platform himself on one occasion - failed to appreciate that there was
a safety consideration attached to the use of the anti-luce fasteners so that
he did not report them as a defect on 11 July when they must obviously have
been defective. This situation is even more acute in the case of agency drivers
such as Dr Meldrum who are reasonably to be expected to have less familiarity
with vehicles and equipment than the regular drivers who use them more
often. Any regime which depends upon the
driver to recognise and report defects can only operate properly where all
drivers who use the machinery are familiar with its functions and, most
importantly of all, are able to recognise the parts of their equipment which
fulfil a safety function. This was
obviously not the case with the tail lift in question because drivers had lost
sight of the safety aspect of deploying the anti-luce fasteners so that they
had not been repaired.
With regard to the semi-automatic cam closure
mechanism, Mr Barsby said it had been designed to require a conscious effort to
be made to deploy the cam followers in the configuration required to fold the
tail lift away so that it could not be done inadvertently. The decision which had apparently been taken
not to renew the springs which operated the semi-automatic system was a failure
at a different level in the maintenance regime, because it reflected a systemic
failure at the level of management of the maintenance unit to appreciate the
proper and safe functioning of the equipment in the light of the explanation of
its true function and design intention.
A system of this sort requires not only that
all drivers are properly trained to recognise defects - and particularly
defects with a bearing on safety - but also that the message is constantly
reinforced at the level of operational management, to ensure that all drivers
continue to recognise the true nature of what they are facing so that the kind
of acceptance of the situation before them which had arisen in the case of the
two critical equipment defects in this case becomes unacceptable.
It was suggested at several points in the
evidence by Mr Caskie in cross-examination that aspects of the maintenance
regime were trimmed in an attempt to reduce costs. In rebuttal of that suggestion in his closing
submissions, Mr Wade suggested that problems had arisen because the safety
element of some components was not appreciated rather than because there had
been attempts to cut costs on the part of Allied Bakeries. I accept Mr Wade's position here. Alexander Tippell, an inspector with the FTA
of 26 years' experience, was satisfied with the standard of the
These failures of the maintenance regime as it
was actually operated by Allied Bakeries led directly to the specific failures
of the equipment detailed immediately above.
These issues are tied up closely with certain failures of training and
supervision in their bearing upon the causes of the accident.
The
Defective Training Regime
Dr Meldrum was clearly not familiar with the
tail lift equipment which he was required to use at the time of the accident
and had not been properly trained to use it safely. His work record with TNT (Crown production
number 5) showed that he had previously used a trailer fitted with a folding
cantilever tail lift of the same type on one occasion. This was on
There was a clear body of evidence about his
difficulties which indicate his lack of training. Asked about what he had said about the
cantilever lifts, his partner, Ms Karen Thomson, told the Inquiry that he had
indicated to her that there were things he was struggling with because he had
had to learn everything very quickly when he first started to use them, that he
had never used or even seen this type of tail lift before, and that they were
very old (transcript, Day 23, page 126).
Mr Corson described his obvious
difficulty in operating the lift earlier on the day of the accident and
indicated that he had formed the impression that Dr Meldrum had not known how
to use it, as indicated in detail above.
Finally, the evidence of the accident itself clearly suggests that he
cannot have been aware of the way in which the tail lift was about to
move. This body of evidence indicates
that Dr Meldrum had not been properly trained to use the type of lift he was expected
to use on
Anthony Donnachie was the TNT traffic
controller on the day when Dr Meldrum first arrived as an agency driver with
TNT at
The evidence further indicated that greater
induction and training time was given to TNT's own drivers than was the case
with agency drivers.
The evidence from Mr Barsby and others
indicated that the tail lift which featured in the accident was a model which
was specially built to a specification produced by Allied Bakeries and that no
other operative in
Mr Moore stated that if an agency driver was
required to use another type of vehicle with a different type of tail lift he
would either have to work out how to use it by himself or to ask someone else
to show him how to use it. Mr Kane said
that in his time as a driver with Allied Bakeries there had always been someone
he could ask if he came across something which he did not know how to use (transcript, Day 1, page 53). Mr Donnachie said that it would be up to the
driver to tell someone and to seek assistance if he did not know how to operate
a particular type of tail lift. Mike Norris, who was at the material time the
manager at TNT responsible for the Allied Bakeries contract, indicated that
where any TNT driver or agency driver encountered a piece of equipment with
which he was not familiar he would expect the driver to ask either the
controller or a competent TNT driver to show him how to use it. In his evidence Mr Norris placed the onus on
the agency driver to raise such concerns (transcript,
Day 6 page 13). I do not regard this
as a satisfactory state of affairs, in particular having regard to the type of
equipment which featured in this accident.
There are a number of very obvious reasons why an agency driver might
fail to raise a concern. He might not
appreciate that the equipment was different from that which he had previously
experienced, or he might be apprehensive about displaying a lack of familiarity
with it; he might be under pressure of time; he might be reluctant to appear
ill-informed or lacking in experience; there might not be anyone to hand who
could answer his needs in a satisfactory way; and he might not even recognise
the true nature of any difficulty before him. The tail lift in question was something
which drivers could not have experienced beforehand because it was effectively
unique to the Allied Bakeries' fleet. The
type of equipment fitted to each vehicle was within the knowledge of the
controller, as was the previous experience of each agency driver. In these
circumstances it would be a far safer approach for the controller or supervisor
to satisfy himself properly that any driver, but particularly an agency driver,
knew how to use the equipment which was being allocated to him. The onus has been put in the wrong place in
Mr Norris's approach.
No written guidance on the use of this type of
tail lift seems to have been issued to the drivers (agency or permanent) before
the accident. A detailed version was
produced by Allied Bakeries shortly after it, but by that time their cantilever
lifts were being put beyond use. The
operator's manual issued by Ratcliff was a generic one which was designed to
cover a range of cantilever lifts; it did not contain specific information
relating to the model supplied to Allied Bakeries' specification. None of the drivers who gave evidence spoke
of seeing such a document. In the circumstances of this accident, training
would have been of greater value than the provision of written guidance, albeit
the latter should have been available.
The training given to agency drivers such as Dr
Meldrum was deficient in that it was restricted to the use of the double-deck
style of trailer which had an underslung tail lift. It did not include training in the cantilever
type of tail lift which agency drivers were expected to use from time to time
as directed by a TNT controller.
Furthermore, the training system did not identify that as a defect
despite the fact that agency drivers could have had no realistic prospect of
having used such a type of lift before since it had been purpose-built for the Allied Bakeries
fleet. It is clear that the regular drivers
were able to operate the cantilever-style tail lift in such a way as to bypass
the problems created by the defective anti-luce fasteners and the defects to
the semi-automatic cam closure mechanism.
It is also clear that they had been doing so for a period of years
before the accident. Regrettably the
training offered to Dr Meldrum failed to pass on the knowledge of how to do
so. He was not trained in the use of the
type of lift which featured in the accident.
He was not trained in what to do if it failed in some way to operate
correctly. He was not shown how to use
it so as to overcome the difficulties created by the defective maintenance of
the critical components, as other drivers did.
These failures played a significant part in the accident.
Related
Issues: the role of the vehicle controller
Two questions became very significant as the
evidence to the inquiry progressed: that of identifying inexperience in an
agency driver; and that of transmitting information when equipment had been
modified or had altered in some way in its pattern of use. On the one hand it is relatively easy to
identify in broad terms areas of inexperience and to provide training accordingly. Each of the defects in the tail lift which
featured in the accident was something which need not have been dangerous to an
operator who knew how to bypass the problem.
Indeed the evidence strongly suggested that the faults were well known
and that adaptation had taken place so far as Allied Bakeries' and TNT's own
drivers were concerned.. The lift was
operated safely by drivers who knew how to compensate for the defects (even if
they did not appreciate that they were defects). Two major concerns arise: there appears to
have been no proper system for such knowledge to be transmitted among the
drivers; and there were clear defects in the procedure for assessing the
capabilities and experience of an agency driver such as Dr Meldrum. Mr Kane said that there was always someone to
ask when he came across a piece of equipment which he had not used before but
this is in no way a satisfactory system.
Such evidence as there was about the driver assessment and training
offered to Dr Meldrum as part of his induction by TNT indicated that he had
been assessed using a vehicle with an underslung tail lift. Equally while the evidence clearly indicates
that regular drivers such as Mr Kane knew how to by pass the defects in the
unit by operating the cam followers manually there is no evidence to suggest
that such knowledge was ever transmitted to an agency driver. It is not a
satisfactory answer for an operator such as TNT or Allied Bakeries to expect
the driver to ask for help when he comes across equipment with which he is not
familiar, for the reasons stated above in relation to where the onus should
lie. The only satisfactory response to
this problem is a system of working which places responsibility on the supervisor
who is detailing the work programme. He
allocates drivers to vehicles and to delivery runs; he knows which drivers are
in-house and which are agency; he knows which drivers are trained in which
areas; he knows which drivers have used each type of vehicle before; he knows
the features of each vehicle in the fleet; and if he does not know any of these
things he is in a position to find out without difficulty. The only safe system of working is one in
which drivers are allocated vehicles and equipment which they have been trained
to use and with which they are familiar.
The person best placed to ensure that happens is the supervisor, that is
the controller. The system must identify
to him when a driver (whether agency or employed) is using a particular vehicle
or equipment for the first time. The
system must then ensure that the driver concerned is seen to be able to use the
vehicle or equipment safely, the obvious way being to have his pre-run checks
supervised either by the supervisor, by the driving assessor, or by a senior
driver familiar with the equipment. Such
a system ought to establish that no-one leaves the depot without having
demonstrated competence in using safely the actual machinery he is being
expected to operate. In the case of Dr Meldrum
this did not happen. As an agency
driver, he was detailed to use equipment with which he was not familiar on
Other
Matters
On behalf of Allied Bakeries Mr Wade submitted
that the sticking noted by Mr Kane on 11 July, the problems observed by Mr
Corson on 12 July and the jamming described by Mr Breen when the tail lift was
tested on 13 July were all symptoms of the same fault which had occurred on
each of those occasions but which was said not to have happened when the
vehicle and its lift were being fixed by Mr Rennie and Mr Harvey on 11
July. This submission formed part of his
attack on the credibility of Mr Rennie. I was urged to consider that there had
been one defect which had occurred intermittently throughout the days mentioned.
I cannot accept that interpretation of the evidence. Mr Kane described a "sticking" on the
nearside which had occurred when he used the lift on two occasions. He said
that he could clear it by moving the lift up and down a few times. Mr Corson described a problem in lowering the
lift while it was in its stowed position.
He had seen Dr Meldrum attend to the stowage pins before he eventually
did manage to lower the unit. Neither Mr
Rennie nor Mr Harvey observed any sticking or jamming of the tail lift while
they were working on the vehicle despite raising and lowering it on a number of
occasions. Mr Breen found the lift to be
deploying to the point where the platform moved out to the horizontal but to be
jamming at that point, when it was about 400 mm from the ground. The unit jammed consistently at the same
point each time when it was tested.
These descriptions are at such variance with each other that I cannot
hold on a balance of probabilities that they refer to one recurring
difficulty. That being so, the sticking
or jamming issue has little weight in relation to Mr Rennie's credibility.
The occurrence of some form of sticking or
jamming at the time of the accident would obviously offer some explanation for
Dr Meldrum's actions in raising the lift with the platform deployed and the cam
followers engaged because he could well have been attempting to explore the
nature of any difficulty and attempting to cure it. However, since I cannot accept that the
evidence points to one fault occurring intermittently between 11 and 13 July
the issue becomes impossible to determine.
I accept the accounts of Mr Rennie and Mr Harvey that no sticking or
jamming was evident to either of them when they were working on the unit after
Mr Kane had returned it to the depot on 11 July. The nature of the fault observed by Mr Corson
around mid-day on 12 July does not lead to the conclusion that something must
have occurred when Dr Meldrum was back
at
In her submissions at the close of the Inquiry,
Ms Hay was critical of a perceived failure on the part of Allied Bakeries to
share information with TNT, for example about the decision not to replace the
springs in the semi-automatic cam closure system. I do not consider that this point is of major
significance in the circumstances of this accident. It is clear that on a day-to-day basis there
was considerable contact at driver-controller level. It is equally clear that both sets of drivers
must have been operating the lifts manually for a period of years and that
neither set of drivers had been systematically noting defective anti-luce fasteners
on their DVCRs. Vehicles were shared and
were used by each operator. The critical
failure with regard to the transmission of information was not in my view
between Allied Bakeries and TNT but between TNT and the agency driver, Dr Meldrum,
who was clearly left with insufficient guidance in the operation of a type of
lift which he was not likely ever to have experienced anywhere else and in
circumstances where TNT ought to have known that.
Conclusion
This horrible accident cannot be repeated
because in the immediate aftermath of Dr Meldrum's death Allied Bakeries had
all remaining tail lifts of this type which were still in service welded into
the closed position so that they could not be deployed for use as a lift
again. The type is now obsolete.
Mr Donnachie informed the Inquiry that since
the accident TNT's training procedures had been completely revised so that they
were now more detailed than they had been at the time of the accident and more
time was allowed for driver training.
However, the identification and maintenance of
safety-related items and the identification of training needs and the provision
of appropriate training remain live issues for all operators of industrial
machinery at all times.