The circumstances were:
- There was a designated area of the assembly track where hydraulic fluids were pumped into the machine and steering and other systems operated to force the fluids through the system.
- The assembly sequence for the telescopic materials handler was changed, which led to the fitting of the front offside light and mirror arm being moved from a point when the hydraulics were not live, to a point when the hydraulics were live and functions such as steering were tested.
- On 3 June 2013 Roger Pearce was installing the vehicle’s offside light and mirror arm.
- This required him to crouch down.
- As a result of this, he could not be seen by a colleague testing the steering.
- When the steering was activated, he was crushed between a wheel and the bodywork.
- He fractured ten ribs; damaged the bones at the base of his spine, and injured his bladder and kidney. He was hospitalised for ten days and is still undergoing treatment. He has not been able to return to work.
“This was a serious incident with Mr Pearce sustaining injuries from which he has yet to recover. It was also a preventable incident. JCB had allowed the introduction of a serious hazard and failed to assess the risk from this change. The controls that were in place were inadequate and Mr Pearce suffered serious harm as a result. Since the incident, the fitting of the light and mirror arm has been moved back to earlier in the assembly sequence when the hydraulics are not operational. Other changes have included barriers around the assembly area and the introduction of a banksman to control personnel working within it. The risks associated with the manufacturing processes involving large pieces of powered equipment should be assessed to ensure that there are effective controls and safe work procedures to protect those involved in this work.”