Gary Webster
2 Mar 2020 · Coroner Kevin McLoughlin · West Yorkshire (East)
The coroner's concerns
1. approaching hazardous turbulent water without risk assessment
“To retrieve the gas cylinder the two men approached a hazardous area of turbulent water, without a formal risk assessment having taken place or a aS = method statement approved”
2. failure to appreciate hazards by senior engineer and manager
“the failure of the Senior Engineer and Manager involved to appreciate the hazards involved”
3. inadequate risk assessment before task execution
“require a suitable and sufficient assessment of the risks involved before proceeding”
4. lack of alternative method evaluation for safety
“consider whether alternative methods of accomplishing the task might reduce or eliminate the risks to their safety”
5. potential future fatality from inadequate planning
“another death may occur in the organisations named due to inadequate planning procedures”
6. unauthorised untrained operation of safety boat
“the safety boat was being operated at the time of the incident by a worker who was neither authorised nor trained”