Kenneth Audsley
9 Sept 2021 · Coroner Kevin McLoughlin · West Yorkshire (East)
The coroner's concerns
1. potentially lethal gas accumulation inside transformer
“The risk that a potentially lethal gas could accumulate inside the transformer was not appreciated either amongst the electricians in this workplace or those involved with industrial transformers generally.”
2. lack of warning signs on transformer
“There were no warning signs affixed to the transformer alerting users to the risk of using the transformer unless it had first been confirmed it contained adequate oil.”
3. missing manufacturer warnings about oil deficiency
“The manufacturer's manual contained no warnings of the hazard which would be created if the transformer were to be energised without containing adequate oil for cooling and insulating purposes.”
4. absence of periodic oil maintenance recommendations
“The manufacturer did not recommend a periodic maintenance regime to confirm adequate oil remained in the transformer and have it replenished if necessary.”
5. insufficient oil in comparable transformers causing hazardous gas accumulation
“By virtue of these matters there exists the possibility that comparable transformers in service throughout the UK may contain insufficient oil to be operated safely and prevent an accumulation of potentially hazardous gases in the space thereby created.”
6. risk to individuals during transformer dismantling repair or use
“The risks identified could affect anyone (1) dismantling a transformer at the end of its life; (2) having cause to open a transformer for repair or maintenance purposes or (3) users who maybe unaware that inadequate oil could cause a transformer to overheat or catch fire.”