Talk given by George Stewart
TUC/CCA Conference, 8 July 2002 on
 “Law Enforcement and Corporate Accountability”

I am the father of Paul Stewart. Paul was just 23-years old when, on 8th September 1999, along with 3 other men, he fell 25 metres to his death. The other men who died were Andrew Rogers, aged 40, Jeffrey Williams, aged 42 and Ronald Hill aged 39. 

At the time my son Paul was working for Kvaerner (Cleveland Bridge) Ltd. This company was in a joint venture with another company called Costain Ltd who had been awarded the contract to undertake major construction work on the Avonmouth Bridge.

The four men died after strong winds blew the gantry off the end of the rail, sending the workers plunging 25 metres to the Ground.

Type of Person
I would just like to start by saying a few words about my son. Paul was a very loving and doting family man who was devoted to his children. All he ever wanted out of life was to work for his family, but unfortunately as he had not been out of his apprenticeship for long he found it difficult to find work, so when the chance came to work for Kvaerner he jumped at it. This was his first job in the construction industry, so he relied on the experience of his supervisors to keep him on the right lines. Unfortunately he was too trusting and he was too polite to argue when he was asked to do any job allocated to him.

He was also very safety conscious person. In fact prior to his death he had complained on several occasions to his mother about the lack of interest in safety by certain members of the management team on site. I myself had worked in the construction industry for 41 years prior to Paul’s death – and in fact had helped Paul get a job with Kvaerner.

Today I want to say a few words about what happened in the few years after my son’s death and why I am dissatisfied with some of the decisions taken by the Crown Prosecution Service, the Health and Safety Executive and the Coroner. 

The Police Investigation and the Crown Prosecution Service
The first thing that happened was a police investigation. The police undertook what I understand to have been a thorough investigation into the circumstances surrounding the deaths. 

The police were investigating to see whether there was evidence of manslaughter. In fact, during their investigation, they arrested 7 men and interviewed them under caution. However all the people were released without charge. After some time we were informed that the Crown Prosecution Service had decided there was insufficient evidence to prosecute any individual for manslaughter. As a result no company could be prosecuted for manslaughter

This was a very difficult time for my wife and me. I was not Paul’s next of kin.  The police and Health and Safety Executive were therefore only willing to provide me with limited information about the circumstances of Paul’s death.  

My gut feeling was that there must have been sufficient evidence for such a prosecution, but I did not have access to the evidence and therefore could not challenge their decision.  Nor could I afford to instruct a solicitor to advise me whether the decision by the Crown Prosecution Service could be challenged

The Health and Safety Executive’s decision to prosecute
The Health and Safety Executive then told us that it would be prosecuting both Kvaerner and Costain Ltd for health and safety offences. However I could not understand why the Health and Safety Executive was not charging any individual managers or indeed directors - responsible for the site - for these deaths. As charges had already been laid against the two companies, the Health and Safety Executive was not willing to provide any detailed reasons why it had decided against prosecuting any individuals. 

The Inquest
I hoped – now that the Crown Prosecution Service had decided not to prosecute for manslaughter - that there would be an inquest at which I would hear live evidence, question witnesses, and get some clear understanding of how my son came to his death. 

An Inquest would also have provided me and the other families with an opportunity to try and get an “unlawful killing” verdict. Such a verdict would have meant that the case would have been referred back to the Crown Prosecution Service so that it could re-consider its decision not to prosecute for manslaughter

However the coroner refused to hold an inquest before the prosecution. This is highly unusual – since it is common practice for coroners to hold inquests before the Health and Safety Executive makes its decision to prosecute.

The failure to hold an inquest in this case – before the prosecution – meant that I had to wait until the Health and Safety Executive prosecution was presented in court, before I could find out how my son and the other 3 men died.

The Health and Safety Executive prosecution
This took place at Bristol Crown Court on 29th November 2001.  The companies pleaded guilty to health and safety offences – so no witnesses were called to give evidence.  The Health and Safety Executive summarised its case against the companies and the companies then offered its plea of mitigation before sentencing occurred.  

One must remember that these were not small and under funded companies but multi national companies who had received a total of £650 million of public money by the government to carry out the work.  In the opening statements the Health and Safety Executive stated that:

“The seriousness of the case lies not only in the number of health and safety breaches committed by the company but that fact that the dangerous working practices of the company not only put the lives of the workmen at risk but other workers on site, residents in the vicinity of the bridge, road and rail users at risk”

I only have time to set out some of the failings identified by the Health and Safety Executive.

• 	In relation to training workers for gantry work, the Health and Safety Executive stated that:
-	In 1996 a company called Technitube provided induction training to three men.  At the time of the tragedy only one of these men was still on site and he was not involved in the gantry work;
-	After Technitube had finished providing training, future training was provided by  individuals who themselves had not been trained;
-	No management, engineers and safety representatives ever received training – nor did the individual nominated as the gantry supervisor
-	there was no training manual produced or circulated to gantry operators;
-	my son and the other three men who died had not received any training;
-	A risk assessment had identified the need for a permit type system to ensure that only those trained could work on the gantry.  This was not implemented.
One engineer highlighted the problems about training and the fact that the gantries were being operated unsafely in a memo to the company, yet no new measures were implemented. His team was subsequently disbanded and the engineer left the site shortly afterwards. Kvaerner sent an instruction from head office that the gantries should be moved only when a supervisor was present to control the operation, however the management on site chose to ignore this letter and allowed the men to carry on as usual.

• 	In relation to the Monitoring of the movement of gantries, the Health and Safety Executive stated:
-	No one was monitoring whether the gantries were being moved correctly;
-	supervisors did not know how to move gantries correctly because they themselves had not been trained;
-	Supervisors and safety representatives never went on to the gantries when it was being moved.
Costain’s resident safety officer identified and reported this to management – yet his
report was not acted upon. 

• 	In relation to the Company’s failure to measure wind speeds before moving the gantries, the Health and Safety Executive stated:
-	workers had to make their own assessment of whether or not it was too windy to move the gantries;
-	there was a fixed weather station on site which had been broken some time before the incident;
-	On the day of the tragedy, the weather forecast had identified the potential for high winds, increasing during the day – yet no readings were taken.
Enquires had earlier been made to find out what would be the cost for a daily met office reading  - however Head Office would not sanction such expense

•	In relation to the type of gantry used, the Health and Safety Executive  stated that:
“An additional and major risk was deliberately introduced by the defendants, that of operating across discontinuance runway beams - that of the trolleys coming off the end of the runway beams. What made the situation even more dangerous was that the beams were not fitted with positive stop ends to prevent trolleys from falling off. “ 

•	The Health and Safety Executive also had found evidence of previous derailments and near misses that were known to the company
(a)	6 months before my son died there was a partial derailment when two workers nearly died when the trolley they were working on dropped off the end of the runway beams.  The matter was raised at a meeting – a memo issued – however no physical measures were taken to ensure that this could never happen again. A week later when the Health and Safety Executive visited the site –there is no record of this incident being raised.  
(b)	A supervisor erector saw an unoccupied Tip gantry being moved uphill simply by the wind for about 5 meters.
(c)	A week before my son’s death an inspection and audit was carried out on the gantries by another company.  Numerous defects of the gantry were identified but nothing was done to rectify these prior to the incident.  

In relation to these, the Health and Safety Executive stated in court:

“There were a number of incidents set out above which should have acted as warnings, in particular the incident involving partial derailment, which came very close to producing an identical accident 6 months earlier. “

The Health and Safety Executive concluded

 “It can properly and fairly be said that this was an accident waiting to happen.  There was nothing unusual or unforeseeable about the combination of events that led to the collapse of the gantry”. 

“The lack of safety in design and construction from start, and the failure to react to incidents prior to the fatal accident, is evidence of blindness to basic health and safety principles of truly staggering proportions.”

What I have set out above is just the some of the failures on the part of the companies. What unfolded in court was simply shocking beyond belief. I simply could not understand why the Health and Safety Executive did not prosecute any individual managers for health and safety offences. In court the Health and Safety Executive stated: 

“Although there are a number of individuals within the two companies who are at fault, there is no single directing mind sufficient to allow a charge of corporate manslaughter and any charges against individuals under the Health and Safety at Work Act would simply divert attention from the primary responsibility of the companies for there persistent and blatant breaches of duty under the Act”. 

This in my view was not a sufficient response.

The Inquest
I should just add one thing. After the prosecution, I assumed that we would at least be having an inquest. This would have allowed us to hear people give evidence in public and for me and other families to questions witnesses about what happened. However the coroner who refused to hold an inquest before the prosecution, has now refused to hold the inquest after it.

Conclusion
Although, the companies were sentenced to £500,000 each, I am not satisfied that proper accountability has taken place. For these companies, the fines are not large – a small percentage of what they earned for their work on the bridge and no individual managers responsible for the failures of training, operating procedures have been brought to account.