Pirelli Tyres has been prosecuted by the HSE after an investigation found the company did not have a system in place to make sure the autoclave was checked before it was switched on.

Carlisle Crown Court heard that the man was last seen alive on CCTV footage at around 2.45pm during a Sunday shift. Just over an hour later, a colleague shut the door on the five-metre long industrial autoclave and began the operating cycle. The 48-year-old’s body was found inside just after 6pm.

The court was told the heavy, circular pressure-door on the autoclave could not be opened from the inside, and there was no way for anyone inside the machine to stop the cycle once it had begun.

The industrial autoclave was used to heat rubber tyre beads. During its operation, steam would be piped into the vessel under pressure, creating a deadly atmosphere containing little or no oxygen.

The HSE investigation found that, on some occasions, employees including the deceased man had entered the autoclave to pick up fallen beads when the pressure-door was open between cycles.

However, despite this practice taking place, Pirelli had failed to identify the autoclave as a confined space posing a serious risk. There were therefore no measures in place, such as instructions or signs, to prevent access to the autoclave.

There was also no system for checking the autoclave before the door was shut and the operating cycle was started.

Pirelli Tyres Ltd was fined £150,000 and ordered to pay £46,706 in prosecution costs after pleading guilty to a breach of the Health and Safety at Work etc. Act 1974.

After the case the HSE inspector commented that this tragic death has had a devastating impact on his family and friends.

The HSE concluded his colleague had no way of knowing anyone was inside when he switched on the machine because the company did not have systems in place to stop this from happening. Had Pirelli undertaken a comprehensive risk assessment they should have been able to identify the risk posed by workers entering the autoclave.

If this was identified then steps could have been taken to either have prevented access, or made sure that the autoclave was properly checked each time before the door was closed and the operating cycle started.

If such simple steps had been taken then this man’s death might have been avoided.

As we tell our clients, risk assessment is about looking at what really goes on in their workplace and not looking at just what they believe should be happening. Perhaps it’s time to have a relook at yours!