R (Bodycote HIPP Ltd) v HM Coroner for Herefordshire
| Jurisdiction | England & Wales |
| Judge | MR JUSTICE BLAKE |
| Judgment Date | 14 January 2008 |
| Neutral Citation | [2008] EWHC 164 (Admin) |
| Docket Number | CO/3670/2006 |
| Court | Queen's Bench Division (Administrative Court) |
| Date | 14 January 2008 |
[2008] EWHC 164 (Admin)
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
THE ADMINISTRATIVE COURT
Royal Courts of Justice
Strand
London WC2A 2LL
Mr Justice Blake
CO/3670/2006
Mr Tim Horlock QC (instructed by Higgs & Sons) appeared on behalf of the Claimant
The Defendant did not appear and was not represented
(Approved by the Court)
On 2nd February 2006, following a short inquest that had begun on 30th January 2006, a jury, summoned by Her Majesty's Coroner by the County of Herefordshire, returned an inquisition on the deaths of two men that occurred within the district of the coroner. They returned, as part of that inquisition, verdicts of unlawful killing on both of them. By this application the claimant company seeks to quash those verdicts, permission to bring these proceedings having previously been granted by Collins J on 22nd August 2006.
The brief facts can be summarised as follows.
On Monday, 14th June 2004, the two men who died were found dead on the landing of a pit operated by the claimant company in Hereford in connection with their commercial activities. The activities included hot isostatic processing that was carried on on metal components in order to strengthen them. The process involved the introduction of argon gas under pressure into a machine called “the Press” which is located in a pit in the company's premises at Hereford, those premises being part of a UK company which is itself part of a broader international company concerned with such production of matters.
Because the industrial process uses argon gas very serious health and safety issues arise. From the evidence that was adduced before the Coroner, it is plain that argon gas is a gas that is significantly heavier than air and will sink if released into the atmosphere. If you use a procedure whereby argon gas escapes into a confined pit then that gas will drive out the oxygen content of healthy air and reduce it below the 21 per cent proportion of oxygen to air necessary for life. A percentage of only 16 per cent oxygen in the air would, according to the expert evidence, present serious risk to life and could result in a normal person without any previous health ailments becoming unconscious within minutes and dead within minutes after that.
The perils of working in an environment where this gas may be present were further underlined at the inquest because argon is colourless, odourless and tasteless, which means that someone who is being exposed to it is not aware, without more, that he or she is being exposed to it.
The two men who died were first, Stuart Jordan, who was an experienced employee of the claimant company and was the site or works manager of the company at the particular premises and had been for some years. He was the most senior person employed by the company present on the site on a regular basis, although would answer to the directors of the company for the performance of his duties. As indicated, he had worked for the company for some years, had apparently been trained in the perils of working with argon gas, although it appears that no precise record of the precise content of his training had come to light in the form of documentation before the inquest. However his full job description demonstrates that his responsibilities included implementation of the company's health and safety procedures at the site.
The second man who died was Richard Clarkson. He was employed as the works engineer at the site. He was junior to Mr Jordan in terms of his responsibilities, and would have taken instructions from him; but he also would necessarily have been aware that argon gas is dangerous, and his own job description included an obligation to carefully monitor safety procedures.
The precise circumstances of the deaths were considered by the jury and, in the light of the order that this court is proposing to make pursuant to this application, they will have to be re-examined by a future jury and in those circumstances the least said the better, having regard to the fact that there will be a fresh inquest. Nevertheless, to set the matter in context, it appears that both men, possibly one after another, went down into the pit on 14th June to investigate something that was going wrong with the procedure. Their unconscious bodies were seen shortly after. Emergency services were called, they were found to be dead. What caused them to go down into the pit was not immediately apparent. However, it appears that on the previous day there had been an attempt to process metal machinery in the press but there was insufficient argon to complete the process. There appears to have been a leak from argon under pressure from the press into the pit and then a number of factors may have contributed to the events which tragically resulted in the deaths of these two men.
First, it seems that a fan that ought to have spread gases and cleared them was not working and had not been working since the two months previously following a power cut in April 2004.
Secondly, it seems that the machinery that should alert anyone contemplating going into the pit by means of an oxygen reading, and an audio alarm if oxygen fell below 19 per cent consistency in the air, had been overridden, so that the alarm did not sound.
Thirdly, there was a body of evidence called before the Coroner and the jury to indicate that persistent practice at the particular site had been that the audio alarm was frequently overridden by a number of employees, not limited to those in a supervisory capacity; and that many employees, including members of the reception staff, had gone into the pit without all the prior procedures to check that it was safe for them to do so and that they were doing so for a legitimate and authorised reason.
Fourthly, the jury were directed that there was no evidence that these two men were intending to harm themselves by going into the pit, and their verdict indicated they were not satisfied that there was any such explanation. In which case it is likely that neither of them was aware of the potentially fatal consequences of their entry down there. That must mean that one or other or neither of them had checked visual monitor of the oxygen level that was properly functioning even though the alarm was not.
Fifthly, it appears that neither were carrying personal oxygen monitor or any other form of equipment that would have enabled them to be alert to the presence of argon gas down there.
Sixthly, it appears that the logs that should be kept restricting access and the means by which...
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...this particular submission to which I refer, but do not repeat. In my view, it is only necessary to refer to R (Bodycote HIP Ltd) ~v~ HM Coroner for Herefordshire (2008) EWHC 164 Admin in which Blake J. considered what verdicts might be returned if the inquisition were quashed. When conside......
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