Corporate manslaughter analysis

On January 26, 2013, Paul Bowers, a contractor working for a CAV Aerospace subsidiary based at warehouse premises within Cambridge Airport, was crushed to death by several tonnes of aircraft-grade aluminium. 

During a trial at The Old Bailey the jury were told how the premises in which Paul worked in was over-crowded with aircraft grade aluminium ‘stringers’ which formed skeletal structures inside aircrafts for large parts such as wings.

This was an issue which was raised by Cambridge managers to senior management within the parent company, CAV Aerospace, several times over years due to it being unsafe, however no action was ever taken.

On the day of Paul’s death, he and a colleague were working in the warehouse when a stack of stringers weighing several tonnes collapsed, landing on top of Paul and crushing him.

The jury heard how Paul was in a walkway which should have been a completely clear area, however it was being used to store extra stock material. Either side of the walkway the stacks of stringers were above maximum safe heights.

Had the walkway been clear when the stringers fell on Paul, medics believe he would not have suffered fatal injuries.

Health and Safety Executive Inspector, Graham Tompkins, said: “The CAV Aerospace board did not act on requests from their local managers or an independent health and safety consultant’s advice that a new stacking system was needed, as well as reducing the amount of metal billets stored, before someone got hurt.”

Ruth Waring FCILT, MD of Labyrinth Logistics Consulting and founder of the Logistics Safety Circle said: “Some of the aspects of this case indicate the need for improved communication between different sections of businesses. Others can learn lessons from this case in relation to supplier and contractor management, as well as internal communications between subsidiaries in the same group. Often it is unclear which part of the business is responsible for taking action, and – where responsibilities are not well defined – it is easy for the parties involved to take insufficient action.

To prevent this type of incident happening in a complex supply chain Ruth recommends:

– Identify at a group and subsidiary level which parts of the business are responsible for what, including risk assessments, safe systems of work, writing staff handbooks, carrying out staff, agency and contractor inductions and providing ongoing training and appointing local safety champions.

– Ensure that risk assessments and near misses / safety concerns are documented and, crucially, that action plans are owned within the element of the business which can implement change at local level and truly understands the hazards and risks involved.

– Ensure that those taking ownership for safety action plans (who is going to do what, by when?) have sufficient budget allocated to make the changes they need, or at least have a defined escalation procedure for asking for justifiable funds to make changes to improve safety (remember, money, time, trouble, effort and sacrifice should always equal the risk and hazard on the risk scales).

– Always remember that going higher up the hierarchy of risk reduction (in this case, removing the stacks from the walkways and reducing the height) is preferable to attempting to deal with a dangerous situation through information, instruction and training and/or PPE.

Justin O’Sullivan, SEMA approved rack inspector at Storage Equipment Experts added: “Any fatality in the warehousing industry is tragic. However, it is especially saddening to hear HSE say that the death was “entirely preventable”.

“This death was caused by failing to meet some of the most basic warehousing safety requirements. Knowing how to stack your materials and how to keep your walkways clear are two of the most basic elements of storage management. Neither HSE nor any private health and safety organisation in the UK are unclear about this. Clear walkways and safe stacking are not grey areas; they are black and white.

“HSE recommends a two level approach to maintaining a safe warehouse. The first is a regular check by managers or staff in a logbook. The second is an annual check by a certified racking professional. What has been revealed at the court hearing is that CAV Aerospace ignored both managers’ and safety inspectors’ advice on the safety of their warehouse. For any company to ignore such obvious warning signs, especially a company with the money and resources that CAV Aerospace have, is completely unforgivable.

“Hopefully, this sad story will make businesses like CAV Aerospace realise that the words and warnings of safety inspectors et al are not uttered to slow down productivity, but to ensure that every worker is as safe as possible.”