Click on the names below for further case details
FURTHER DETAILS OF DEATHS
Elizabeth Anne Bond
Elizabeth, an officer from RAF Cramwell, out on exercises, was climbing at Lockwood's Chimney, Clogwyn y Bustach, Nant Gwynant, Snowdonia, when she lost her footing and fell approximately 200ft. She died of multiple injuries.
The inquest was held at North West Wales Coroners Court in Bangor on 27 January 2005 and returned a verdict of 'Misadventure'.
The inquest heard that Elizabeth had failed to heed advice to clip herself to a sling around a boulder. After the inquest her mother, Anne Bond of Southport, said Elizabeth was terrified of heights.
'She had no experience of mountaineering. The RAF have already given me an apology and say they've put in place a new set of regulations. This was an accident that could have been prevented - those were the first words of the apology,' she said.
Coroner Dewi Pritchard-Jones said, 'Had she clipped to the tape, when she lost her footing she would have been hanging on the tape and been able to recover her footing. This is a preventable accident. The safety equipment was there but not used.
'I am certain Elizabeth Bond wasn't aware of the danger she was in. She felt she could cope adequately with the scramble that would finish off the activity.'
The inquest jury called for a review of the instructor-student ratio and of risk assessment. The Coroner said, 'I will convey those views to the RAF and Ministry of Defence.'
A Crown Censure hearing into Elizabeth's death took place in Cardiff in May 2006.
Crown Censure is an administrative process that Health and Safety Executive (HSE) follows in cases that cannot be heard in a court of law because the body involved has Crown immunity from prosecution*.
At the hearing the Ministry of Defence was censured under Section 2 (1) of the Health and Safety at Work etc. Act 1974 (the HSW Act), following an investigation into Elizabeth's death at the RAF's Resource and Initiative Training Centre (RITC), Fairbourne.
In summary, HSE contended that the RAF failed to carry out a suitable and sufficient assessment of the risk of falls from height presented by Lockwood's Chimney. In addition they failed to identify and implement effective control measures or carry out adequate monitoring, all of which are requirements of the MOD's Safe System of Training, as laid down in the MOD Health and Safety Handbook.
As a novice climber, Elizabeth should have been attached to a rope at all times on a climb of this difficulty and risk, but she was not. Inadequate levels of supervision and poor weather conditions significantly increased the risk of a fall.
As a result of these failures employees were exposed to a significant risk to their safety, and the RAF were considered to be in breach of Section 2 of the HSW Act, in that they failed to ensure, so far as was reasonably practicable, the safety of their employees.
From the evidence presented, HSE considers that there were repeated failings by several individuals on a number of different occasions. HSE concluded therefore that this constitutes a failure of the management system, and it is on this basis that the censure was brought against the RAF.
The RAF co-operated fully with HSE during the investigation and has taken remedial action in response to both this, and the findings of their own Board of Enquiry. This includes ceasing the use of Lockwood's Chimney by RITC Fairbourne, carrying out site-specific risk assessments for all activities and introducing random, no-notice inspections of the Centre to ensure standards are met.
HSE Inspector Sally Nicholson said after the censure, 'We are grateful to the RAF for their full co-operation during the investigation. We believe that there were significant failings, as outlined, which led to Flight Lieutenant Bond's death but are pleased to note the actions taken to reduce the risk of a similar occurrence.
'HSE acknowledges that it is important that the RAF provide realistic and challenging training, but this must be done without exposing employees to unreasonable risk.'
*Crown Censure hearings are closed meetings between HSE and the Crown body involved. At the hearing an HSE inspector presents evidence drawn from their investigation. The Crown body (in this case MoD) then give their evidence. For the censure to be confirmed, the Crown body must acknowledge that, but for Crown immunity, they would have been prosecuted for the alleged offence(s) and formally accept the censure.
James, who was from Blackpool, was working on sea salvage off Holyhead when he fell into the sea. His body was found nearly 17 days later.
The inquest was held on 3 July 2003 at the North West Wales Coroner's Court and returned a verdict of 'Accidental Death'.
Ieuan a farm worker died while feeding sheep from a trailer when it toppled into a 20 ft gravel pit and crushed him. Ieuan was standing on a trailer which slipped into the pit after a grassy overhang collapsed. The tractor driver could not see the lip of the pit, partly because the vehicles were surrounded by sheep. Both men and their two vehicles fell in. Ieuan suffered a fractured skull and major brain damage.
The inquest was held on 27 January 2005 at the North West Wales Coroner's Court and returned a verdict of 'Accidental Death'.
Coroner Dewi Pritchard Jones said, 'The tractor driver went too close to the edge of the pit, the edge crumbled and the wheel went over it. The tractor went to the bottom of the pit pulling the trailer behind it. It turned over and the coupling fractured due to the twisting of the tractor and trailer.
'Unfortunately Mr Hughes got crushed between the edge of the trailer and the ground.'
The coroner said the edge of the pit was 'very unstable'. He added, 'It must have been obvious that this was a danger to people working on that farm and in my view they would have been aware there was a soft edge.' But he said there was no legal need to fence off the gravel pit if gravel taken out is for the landowner's use - as in this case.
Ieuan, a farmer of Hengwrt Farm, Rhydy-main near Dolgellau, died when he became trapped underneath his overturned tractor. Ieuan was moving hay bales from a field to the farm when the tractor toppled over.
The inquest was held on 20 January 2004 at the North West Wales Coroner's Court and returned a verdict of 'Accidental Death'.
Gavin was killed after being thrown 20ft into the air when a tractor tyre he was pumping up exploded.
The inquest was held on 18 May 2005 at the North West Wales Coroner's Court in Caernarfon. The inquest jury returned a verdict of 'Misadventure'.
The Coroner Dewi Pritchard-Jones said the tyre which Gavin had been filling with air, 'flew off as if rocket propelled'. Mr Pritchard-Jones said Gavin was not aware of the potential danger and had not been trained for what he was doing. His employer David Pugh-Jones told the inquest he was not supposed to be repairing the wheel.
Miall Gwyn Roberts
Miall was driving a concrete lorry on a building site at Bala Enterprise Park. He was electrocuted by the lorry's hydraulic arm coming into contact with an overhead power line carrying at least 11,000 volts. The Principal Contractor for the site was R L Davies. Welsh Development Agency (WDA) was upgrading the site for a new unit to be used by Gwynedd Confectionery.
Another worker on the site, Darren Gittins received an electric shock but was uninjured.
Police, Health and Safety Executive and Scottish Power investigated how the pump came into contact with the cable.
The inquest was held on 2 September 2005 at the North West Wales Coroner's Court in Caernarfon and returned an 'Open' verdict.
In June 2007 at Mold Crown Court Permanent Flooring Ltd of Bagillt, Flintshire, pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc Act 1974 (HSW Act) for failing to ensure Miall's safety and to a charge under Section 2(1) of the HSW Act for putting Darren Gittins at risk. They were fined £6,000 and ordered to pay a contribution towards costs of £12,000.
R. L. Davies and Son Ltd of Llysfaen, Colwyn Bay, pleaded guilty to breaching Section 3(1) of the HSW Act in relation to the death of Mr Roberts and were fined £25,000. They were also ordered to pay costs of £15,814.54.
Judge Dafydd Hughes said the former Welsh Development Agency and Scottish Power had a responsibility and should have ensured that the power lines crossing the site were removed before work started.
The judge said if they had insisted on the cables being removed before work started then the tragedy would never have happened.
Speaking outside the court, Miall's mother Janice said, 'I am not very happy with the fines, I thought they might have been higher, but after saying that you cannot put a price on a life.'
HSE Inspector Chris Wilcox said, 'Each year there are around 1000 incidents involving electric shock at work, and about 30 of these have resulted in fatalities.
'In Wales alone, there have been several cases whereby construction workers and others have been severely injured or killed after coming into contact with high voltage electricity, so it is imperative that employers ensure their staff and contractors are protected by carrying out a full risk assessment of the site before work starts.
'Household voltages are enough to kill, but in this case the voltage involved was nearly 50 times greater. Overhead power lines can be switched off if the operators are given sufficient notice, but if this isn't possible, they should be consulted on safe systems of work.'
Speaking after the sentencing Elfyn Llwyd, Plaid Cymru MP for Meirionnydd Nant Conwy, said lessons should be learned from Miall's death. He said one contractor should look after all health and safety on a site. If one company was in charge then if there was a problem they would have to explain what went wrong
Mr Llwyd, Plaid's parliamentary leader, said the fact that responsibility had been shared was perhaps reflected in the fines being 'lower than would have been expected'.
'I feel that this whole area (of responsibility) should be looked at again,' he said. 'In fact Parliament is at the moment debating a Corporate Manslaughter Bill which could mean if someone dies because of serious negligence then the director of a company held responsible could face manslaughter charges.'
Ultimately one company or individual should be responsible for all health and safety rules being adhered to on a building site, he added. 'I don't think this would be too difficult to put into practice, if one company was in charge then if there was a problem they would have to explain what went wrong.'
Anthony was part of a 12-man team of specialist contractors dismantling parts of the works since November 2004. Anthony from Litherland, Liverpool, was hit by a telehandler, a specialised forklift truck, on the site of the former Great Lakes Chemical Plant at Amlwch on the island of Anglesey.
The site had been bought by American firm Canatxx who plan to use the site to convert liquid natural gas piped ashore from tankers moored off the North Wales coast. The plant known as Octel to local people had produced bromine-based chemicals for over 50 years before closing with a loss of 100 jobs in April 2004.
Investigations were undertaken by the Police and Health and Safety Executive into Anthony's death.
An inquest was held at North West Wales Coroner's Court in Caernarfon on 2 September 2005 when a jury returned an 'Open' verdict, after no evidence was put forward to explain how Anthony was struck by the machine.
The court heard that scuff marks found on the load carried by the fork-lift truck were not explained. The truck was carrying a load of oxy-acetylene cylinders on its front forks, restricting the driver's vision. It also emerged that the driver, Robert Stephen Kirby of Carr Lane, West Derby, Liverpool had not been trained to drive the truck.
Health and Safety Executive inspector, Christopher Wilcox said minimum guidelines for operating a fork-lift truck on building sites required a banksman to guide the driver but a banksman was not employed on the Great Lakes site and Mr Kirby said that was not practical.
Vehicle examiners found several defects on the truck and Health and Safety Executive officials ordered these to be rectified and drivers trained before the truck was allowed back into service.
Anthony's family said they had no comment to make about the verdict as they left the inquest. Representatives from Anthony's employers, J. Routledge and Sons, of Widnes, also left the hearing without making any comment.
A Health and Safety Executive official said a decision on whether to prosecute Mr Kirby had not yet been taken. He said, 'A file has been prepared and, in light of the inquest's findings, will be considered before a decision is reached.'
In November 2006 Anthony's employers J. Routledge & Sons Ltd of Widnes, Cheshire, were given a two year conditional discharge and a source linked to the company agreed to pay £10,000 costs at Wrexham Magistrates' Court, after pleading guilty to breaching Section 2 (1) of the Health and Safety at Work Act relating to an employers failure to protect the health and safety of its employees. The company has ceased trading since the incident.
HSE inspector Debbie John said, 'Telehandlers, a mobile plant commonly used by construction companies, are often involved in a number of fatal accidents and we want to bring this to the attention of the construction industry. If you use these types of plant, you need to know what the risks may be and how to check whether you might have a problem yourselves.
'The HSE would like to draw your attention to a specific risk with telehandlers which may occur when working on sites where a telehandler needs to be reversed, where it is moving forward with a load, or where there is poor pedestrian segregation, there is a risk, due to the driver's limited or obscured visibility, of people walking around the site being struck.
'A small investment in time and good working practices can often save a business a lot of time and money incurred as a result of injured workers or enforcement action.'
HSE's target is to reduce fatal and major workplace transport injuries by 10% by 2010 and while all fatal injuries are brought to the attention of HSE or local authorities, it is estimated that less than 50% of reportable injuries are actually reported.
'Reporting an incident does not necessarily result in enforcement action, but can often present an opportunity for employers to work with HSE and local authorities to learn lessons and improve working practices,' Debbie John added.
Aled, a builder and talented rugby player, died 12 days after he fractured his skull falling 25ft through a shed roof.
Aled was repairing asbestos roofing on top of a shed at Bwlchgwyn Farm, between Arthog and Fairbourne, when he fell through one of the sheets.
Aled been in an induced coma since the fall on April 9.
An inquest was due to be held at North West Wales Coroner's Court at Wrexham.