After having been seen at about 9.30 p.m. on the evening of 27 June 1985, it was noticed by Central Control room Operator Griffiths that the deceased Paul Alexander CRAWFORD did not respond to his call . This absence was reported to Shift Foreman POLKINGHORNE. A search was instituted. At about 11.20 p.m. the body of the deceased was located in the collection chamber of No. 3 Pump Box.
There is no evidence to suggest that the deceased was attempting to clear blocked sprays although he may have attempted to do so. In such an attempt, it would be necessary for the deceased to extend his body beyond the safety or hand rail. We are unable to determine the cause of the fall.
CAUSE OF DEATH: Drowning by falling into the collection chamber.
Recommendations
THE RECOMMENDATIONS OF THE REVIEWERS ARE AS FOLLOWS:
(1) To prevent work being performed on inspection ladders by any person, all inspection ladders be removed or replaced with proper work ladders where necessary.
(2) All safety hand rails be modified to suit access by work ladders and all lower rails be replaced or installed where necessary up to normal safety standards'.
(3) New types of demountable water sprays be installed to aid clearing of blocked sprays from ground level. Use of fresh water is an avenue available to minimise future blockages of sprays
(4) All old sprays and all old disused water pipes be removed.