It’s easy to get caught up in the numbers when it comes to HSE prosecutions and there have been many large fines this year. But behind every case is a human story. In this article, we look at the people affected, unpack what happened in each prosecution, and highlight the practical lessons organisations can take from them. We’ll finish with some clear steps you can start taking now to strengthen your own processes and prevent similar incidents.
Case 1
Cambridgeshire County Council, Guided Busway
Cambridgeshire County Council ran its Guided Busway for more than 10 years without key safety measures such as adequate lighting, appropriate speed limits, physical separation between buses and pedestrians/cyclists, or clear warning signage.
Despite a fatality in 2015 and serious incidents that followed, the council did not carry out its first risk assessment until 2016 (which was inadequate) and chose to appeal HSE enforcement action rather than act promptly. Three people – Jennifer Taylor, Steve Moir and Kathleen Pitts – were killed in separate incidents, and two young cyclists sustained serious and life-changing injuries.
Jennifer Taylor, 81, was killed after stepping off a bus at a designated but unlit crossing on a dark November evening. By the time she was visible to the driver, travelling at the then-permitted 56mph, it was too late to stop. Her family describe her as deeply loved and hope that the lessons from her death will lead to lasting safety improvements.
Three years later, keen cyclist, youth football coach and school governor Steve Moir, 50, lost control on the narrow, shared path alongside the busway, his wheel catching a raised kerb and throwing him into the path of a bus travelling at 56mph. His family say his death has left a “big hole” in their lives that cannot be filled, robbing them of a loving, funny man with a real zest for life.
In October 2021, 52-year-old Kathleen Pitts was struck and killed while walking along the pathway beside the busway, even after the local speed limit had been reduced to 30mph following Steve’s death. Her death was followed just weeks later by another devastating collision in which a 16-year-old cyclist suffered life-changing injuries at a designated crossing.
Practical lessons we can learn from this:
- Do a thorough risk assessment before opening, and keep it live. A major public transport system operated for years with no risk assessment and then an inadequate one. Any new infrastructure or system that interfaces with the public should have a formal risk assessment before go-live, and scheduled reviews whenever incidents, near misses or usage patterns change.
- Don’t wait for tragedy to act on warning signs. A fatality in 2015, serious incidents and HSE enforcement notices should have triggered urgent redesign and controls. Organisations need clear triggers, for example a serious incident, enforcement action, repeated near misses, that automatically prompt a formal review and action plan.
- Design for the real behaviour of users, not ideal behaviour. Basic controls such as lighting, physical separation, speed limits and clear signage were missing or inadequate. When members of the public, cyclists or vulnerable users are involved it should be taken into account that people might be tired, distracted or unfamiliar with the layout or using the space in ways you didn’t originally intend.
Case 2
British Airways, falls from televators at Heathrow
British Airways was prosecuted after two baggage handlers fell from height while unloading aircraft at Heathrow Terminal 5, suffering serious head and back injuries.
The HSE found that modifications to televator platforms had created gaps between guardrails and the aircraft fuselage, and that platforms were sometimes not fully extended, leaving unprotected edges workers could fall through.
These risks were reasonably foreseeable and had not been adequately controlled, despite previous HSE visits and an ongoing retrofit programme for guardrails.
Practical lessons we can learn from this:
- Reassess risks whenever you modify equipment or processes. Extending televator platforms changed the gap between guardrails and the aircraft, creating a new fall risk that wasn’t properly controlled. Any engineering change, however small, should trigger a fresh risk assessment and, where needed, redesign of guards, barriers and procedures.
- Work at height basics still apply in complex environments. Continuous edge protection or an equivalent safe system was missing at the front of platforms.
- Treat remedial programmes as urgent when life-changing risk is present. A retrofit programme for guardrails was underway but not completed when serious incidents occurred. Once you know a piece of equipment can put workers at risk, completing corrective actions quickly should be treated as critical.
- Design procedures that work under real pressure. Baggage handling is dynamic and time-pressured, so controls must be simple, obvious and hard to bypass. There should be clear set-up checks, visual indicators and active supervision.
Case 3
Industrial Chemicals Ltd, uncontrolled acid releases
At Industrial Chemicals Ltd’s West Thurrock site, two major uncontrolled releases of highly corrosive acids occurred in 2020 due to poorly installed, inspected and maintained pipework and valves.
In January, around 300,000 litres of hydrochloric acid escaped, forming a hydrogen chloride gas cloud that spread over nearby towns, forcing school closures and public health warnings.
In August of the same year a sulphuric acid leak continued for days because a safety valve failed to operate and manual isolation was not possible. Investigations by HSE and the Environment Agency revealed long-standing deficiencies in maintenance, inspection and containment arrangements at the site.
Practical lessons we can learn from this:
- Put robust inspection and maintenance around safety-critical assets. Corroded and poorly maintained pipework and valves were the cause of both acid releases. At high-hazard sites, pipework, valves and containment systems need planned, recorded inspection and maintenance regimes.
- Treat minor leaks as precursors and act fast. There were smaller pipe failures before the major loss of containment. Organisations should treat repeat leaks or small releases as red flags that demand root-cause analysis and system-wide fixes.
- Test that emergency valves and isolation systems actually work. The sulphuric acid leak continued because a manual valve designed to control leaks couldn’t be operated. Safety-critical devices need periodic functional and there should be clear emergency procedures for isolating processes quickly.
Case 4
Biffa Waste Services, pedestrian struck by reversing skip wagon
At Biffa’s Bradford waste transfer station, 57-year-old sort line operative James Tabiri was struck from behind and fatally crushed by the rear wheels of a reversing skip wagon as he walked towards the site office.
CCTV showed that unsafe shortcuts around pedestrian routes had become normalised on site, turning a routine walk across the yard into a fatal journey.
Practical lessons we can learn from this
- Design pedestrian–vehicle segregation that is both effective and respected. Segregated routes existed but were routinely bypassed, with people climbing over barriers. If your layout forces people to choose between “the long safe way” and “the quick risky way”, many will choose the latter. Routes need to be convenient, clearly marked and supported by physical controls that genuinely keep people and vehicles apart.
- Monitor real behaviour, not just paperwork. CCTV showed unsafe practices had become normal on site. Regular workplace transport observations, CCTV reviews and supervisor walk-arounds should be built into monitoring, with clear follow-up when standards slip.
- Make supervision and challenge part of the control system. A casual attitude to rules had developed because unsafe behaviour went unchallenged. Supervisors must understand that enforcing traffic management rules is a core part of their job, not an optional extra.
- Never be complacent about reversing. Nearly a quarter of workplace transport deaths happen during reversing. Organisations should always ask: can we eliminate or reduce reversing with one-way systems, turning circles or designated turning areas, and where reversing is unavoidable, are we using the right mix of banksmen, technology (cameras, sensors) and strict procedures?
Case 5
Tata Steel, contractor crushed in conveyor system
Contractor and father-of-three Justin Day, 44, was crushed to death inside a conveyor system at Tata’s Port Talbot steelworks when a live section of machinery restarted as he entered to investigate a hydraulic leak.
His family, who were waiting for him at his youngest son’s school rugby match when they received the call, say his death has “shattered” their world and left them as “shadows” of their former selves.
Practical lessons we can learn from this:
- Apply full isolation and lockout/tagout for maintenance – every time. Parts of the conveyor were still live while work was being done elsewhere on the system. A robust isolation and lockout/tagout (LOTO) procedure should ensure all relevant energy sources and sections are safely isolated and verified before anyone enters danger zones.
- Use permits-to-work and clear communication for complex jobs. Multiple teams were working on different levels of the conveyor without a single, controlled view of the job.
- A permit-to-work system that defines the scope, isolations, authorised personnel and hand-back process can prevent people entering machinery that others believe is still live.
- Guard dangerous parts so people cannot enter them by mistake. Access to dangerous moving parts should be physically prevented by fixed guards, interlocks and safe access routes. Sensors alone are not a safeguard if they can trigger hazardous movement when someone is in the wrong place.
- Manage contractors’ safety as if they were your own employees. Contractors must be fully integrated into your isolation, permit and machinery safety arrangements. That means proper inductions, clear roles and responsibilities, and ensuring they feel able to question isolations or stop work if something doesn’t look right.
How organisations can start making changes now
- Make risk assessment a living process. Assess new systems before they go live and build in regular reviews whenever you change equipment, layouts or see incident / near-miss trends emerging.
- Treat early warning signs as triggers. Serious incidents, repeat near misses, equipment failures or regulator concerns should automatically prompt a structured review and time-bound action plan.
- Close the gap between paperwork and reality. Procedures, risk assessments and traffic plans only work if they’re followed. Use routine monitoring, site walks and open reporting to spot shortcuts and intervene early.
- Tighten control of high-risk activities. Put clear structure around maintenance, work at height, workplace transport and hazardous substances using guarding, segregation, LOTO, permits-to-work and planned maintenance as standard.
- Ensure leadership visibly owns safety. Resource maintenance properly, back supervisors enforcing safe systems, respond positively to regulator feedback and be willing to stop or adapt work when risks aren’t controlled.
You can then tailor these generic lessons to your own sectors and link them to whatever digital systems, audits or training programmes you want to highlight as practical ways to turn learning from 2025’s fines into meaningful change.
