HSE inspector Gethyn Jones explains the failings that led to the death of a contractor and the lessons for industry.
On 25 September 2019, Justin Day, 44, was carrying out maintenance work on a conveyor system at Tata Steel’s Port Talbot site. An employee of MII Engineering Ltd, Justin successfully replaced a faulty lift cylinder. But when he later returned to the machinery, unaware it had not been fully re-isolated, a sensor triggered the system. The conveyor activated and fatally crushed him.
We spoke to HSE inspector Gethyn Jones about how this tragic incident unfolded – and what can be learned.
The incident
‘Justin worked on a large conveyor system in the hot mill quench area that transports large steel coils at Tata’s Port Talbot steelworks,’ explained Gethyn. ‘The conveyor system is operated by light sensors and goes through a 90-degree angle. To allow that to happen there is a machine called a coil tilter. This is situated in the middle of two conveyors placed at 90 degrees to each other. Using a metal beam and cylinder, a coil is lifted from the first conveyor and placed on the coil tilter, a second beam from the opposite conveyor moves under the coil, lifts it and then lowers it onto the outbound conveyor for further processing. This continuous process moves the coils through 90 degrees. ‘This machine runs every single day, it’s fairly slow moving, and it’s been there for a long time. Although there were some barriers in place to demarcate the area the equipment was in, these were easily bypassed by means of a gate and there was no effective guarding to prevent access to the dangerous parts of the machine. ‘On the day of the incident, one of the lift cylinders on the first conveyor was faulty and needed replacing. Tata Steel had a four-hour maintenance window scheduled. They hadn’t planned to replace the cylinder because they didn’t have enough time but then, the planned shutdown was extended to a five-hour maintenance window, and the decision was made to try to get this job done. ‘While Tata Steel does have its own employees, they also use a company called MII Engineering Ltd to come in and do the maintenance work. Because it’s Tata Steel’s equipment, Tata Steel signed off a fluid power permit to ensure that none of the equipment could operate. On the day, the permit covered three isolations to allow the cylinder to be replaced: one isolation for the ‘in’ conveyor, one for the coil tilter, and one for the ‘out’ conveyor. None of the equipment could move. Everything was safe and signed off.
This was an automated piece of equipment that allowed full body access; with obvious dangerous moving parts that could cause harm, but the dangerous parts were unguarded
‘Justin was the supervisor for MII Engineering Ltd. He was an experienced man who had worked in the steelworks for a number of years. He knew the area and how the equipment worked. Along with his team, they went in and undertook the work to replace the faulty cylinder. Once they had finished, all the contractors left the area and then signed off the permit. That is part of the safety system – the permit can’t be signed off until everybody has left. ‘Justin and his colleagues had gone back to a part of the site called the boudoir where they could relax while Tata removed all the isolations to recommission the machinery. However, during that process, Tata realised that the new cylinder was leaking hydraulic fluid. ‘Tata put a call out on the radio for Justin to return. However, Justin didn’t hear the call because he was outside moving a vehicle. Instead, his colleague, Carl Williams, returned to the machine to repair the leak. When Justin returned to the boudoir, he was told there had been a call for him and there was a problem with one of the cylinders. He headed straight back to machinery. ‘At this point it’s important to know that the conveyors are on one floor of the steelworks, but most of the machinery that controls the conveyor’s movement is actually on the floor below in a basement area. Justin arrived back to the quench area, he was on the top floor and walked to the edge of the coil tilter, he stood there for a few seconds and would have been able to see Carl and Tata staff working in the machinery below him. ‘He stood there for about 12 seconds – we think he was trying to communicate with the men below. I believe he was trying to determine the extent of the problem and probably looking for some reassurance that the issue wasn’t serious. The men below didn’t see him and wouldn’t have been able to hear him, so he decided to get down into the coil tilter – there’s a large gap where the beams drive in and out – to get closer to the men below. ‘Justin didn’t realise that Tata hadn’t re-isolated all the equipment as they had in the morning; they had only isolated the discrete part they were working on to repair the leak. When Justin got into the coil tilter, a light sensor that runs across the top was triggered. This activated the coil tilter and one of the beams was driven into place, crushing Justin to death.’
The investigation
‘I was able to make it to the site quite quickly and the scene was incredibly upsetting. There were immediate questions about how this could happen’, said Gethyn. ‘Because this was a workplace fatality, the police had primacy for the investigation and took statements from all the witnesses who had been present at the time. Once they had ruled out any prospect of a corporate manslaughter charge, we took over the investigation under the work-related death protocol. ‘The incident happened on 25 September 2019, and we took over primacy in March 2020. We had initially assessed the machinery and determined it was unguarded and unsafe to use. ‘I also assessed relevant documentation such as risk assessments, safe systems of work, isolation policies and procedures, and maintenance logs. We took all of that information away as part of the investigation. I also investigated the level of training, skills, knowledge and competence demonstrated by key individuals to help me understand the decision-making process that led to the incident.’
The findings
‘One of the key things for me was that this was an automated piece of equipment that allowed full body access; with obvious dangerous moving parts that could cause harm, but the dangerous parts were unguarded,’ Gethyn said. ‘The first thing I did was prohibit the use of the machine and I also served an Improvement Notice to ensure it was guarded properly. It should have been guarded from the first day it was installed but it had never been properly risk assessed so I don’t think the risk the machine posed had ever been fully appreciated. ‘When it comes to maintenance, there is often the argument that guarding is removed to allow the work to be completed, so it wouldn’t protect you anyway. There is a very clear requirement under Regulation 11 of PUWER 1998 to prevent access to any dangerous part of machinery or to stop the movement of any dangerous part of machinery before any part of a person enters a danger zone. Therefore, if you have a dangerous piece of equipment with moving parts that should be guarded, when the guarding is removed, you have to take other measures to make it safe, such as secure isolation.
Tata Steel UK has ten previous convictions for 17 health and safety offences
‘In this case, the reason the equipment wasn’t fully isolated was because there hadn’t been any guarding to remove. The isolation process therefore wasn’t triggered. The machine had always posed a risk to anybody who came into contact with it, but it was the maintenance activity that put Justin right in the middle of the danger zone. ‘So, the machine had never been properly risk assessed. Had it been it would have been guarded from day one. To allow the permit to be signed off after the initial maintenance process, all the guarding would have had to be replaced, and when Justin returned it would have been impossible for him to climb into the machine. ‘In terms of the need for effective isolation, Tata Steel called Justin back to the machine to help repair a fault. It was then incumbent on Tata to make sure the whole work area was safe. Unfortunately, there were no visual clues in the area to indicate if the machinery was isolated or not and Justin could see people working underneath the machine on the floor below. I believe that Justin, knowing exactly how the machinery operated, was convinced that all the previous isolations had been reinstated.’
The prosecution
At Swansea Crown Court on 31 July 2025, Tata Steel (UK) Ltd, of Grosvenor Place, London, pleaded guilty to breaching sections 2(1) and 3(1) of the Health and Safety at Work Act. The company was fined £1.5 million and ordered to pay £26,318 in costs.
What should have happened?
‘This dangerous machine should have been guarded from day one,’ Gethyn said. ‘If it had been guarded, irrespective of the maintenance activity, if you remove guarding, you still have to ensure the machinery is safe and an effective way to do this is to securely isolate. Either way, whether guarded or isolated, it would have been safe. ‘The problem in this case was, because it had never been guarded, it didn’t trigger any further thought about the need to reinstate all the previous isolations rather than just isolate the single discrete piece of equipment that needed to be repaired.’
What can IOSH members learn from this?
Prosecution counsel, Nuhu Gobir, told the court that Tata Steel UK has ten previous convictions for 17 health and safety offences. In fact, only two years ago IOSH Magazine spoke to Gethyn about another Tata Steel prosecution also involving the Port Talbot works, where a contractor suffered a permanent brain injury.
So what can be done about organisations that repeatedly find themselves involved in health and safety issues?
‘For companies where there are repeat offences, the thing we need to impress is the importance of developing an effective health and safety culture that needs to be driven from the very top. All businesses have a statutory duty to ensure the health and safety and it comes down to senior leaders within the business taking responsibility and being committed to effecting change. I sincerely hope that with regards to this case, the necessary lessons have been learned.
‘In the case of Justin’s death, this was a failure to implement health and safety basics. The need to undertake suitable and sufficient risk assessments and ensure dangerous machinery is guarded is a fundamental of good health and safety management. Furthermore, the need to securely isolate machinery when guarding is removed to allow maintenance is not a complicated concept, which is well understood throughout industry. There is simply no excuse that such obvious controls were not in place. ‘It should not be forgotten that Justin was an experienced man who knew the work area and the equipment. But even so, a failure to implement effective practical controls put his life in danger. If the basics had just been done right, this incident would never have occurred, and Justin’s family would not have had to deal with the tragic consequences of losing a much-loved family man.’
Source – IOSH
