An agricultural worker was crushed to death by the wheel of his vehicle when he made a fatal misjudgement while carrying out repairs.
Kevin Alderton squeezed between the wheel and chassis of his fertiliser-spreading tractor to adjust a screw, but had not switched the engine off. When he knocked a steering sensor fractionally out of position, the on-board computer automatically turned the wheel to realign it, crushing the 34-year-old against the machine.
An inquest jury yesterday returned a conclusion of accidental death, but a health and safety executive (HSE) investigation is still ongoing into Bunn Fertiliser, after it was served with an improvement notice for failing to ensure the safety of employees involved with the machinery.
The inquest led by Norfolk coroner Jacqueline Lake heard that the drivers of the spreading machines also carried out the majority of their maintenance and, though manufacturer support was available where necessary, they had received no formal qualification or training.
Team leader Colin Baxter and Mr Alderton, who had worked for the company for 21 and 16 years respectively, had made three attempts to repair a leaking oil seal on the Multidrive 6185 in the days leading up to the accident on February 8, 2013.
Mr Baxter said the maintenance training was 'in-house, self-taught', adding: 'It was what we had picked up as we went along. More experienced people would show people coming into the business.'
After a brief test drive, Mr Alderton said the problem had still not been resolved and attempted to tighten the loose screw alone, when he dislodged the sensor. He was discovered by a visiting lorry driver who saw him under the vehicle outside the workshop in Upgate Road, Seething, and then raised the alarm with Mr Baxter.
Mr Alderton, of Redlingfield Road, Eye, was pronounced dead at the scene and a post-mortem examination found the cause of death was traumatic asphyxia due to traumatic chest injuries.
Tony Frazier, chief engineer for Multidrive, said that it would have taken just a two-millimetre movement to the sensor to trigger a 10-degree movement of the wheels and that the engine would have had to be running for the wheels to have moved – something which was contrary to procedure.
HSE inspector Ivan Brooke, who carried out an investigation into Mr Alderton's death, said: 'The accident was directly caused when Kevin Alderton touched, moved or attempted to adjust the grub screw on the bottom coupling which caused the wheels to deflect inwards.'
Traces of cannabis-derived chemicals were found during Mr Alderton's post-mortem examination, though experts could not say how recently he had taken the cannabis or any possible effect it had had on him, while Mr Baxter said his colleague had been 'normal' on the morning of the accident.
The HSE issued Bunn Fertiliser with an improvement notice following the accident, saying there was 'insufficient information, instruction or training' to ensure the safety of those involved in machinery maintenance.
The inquest heard Mr Alderton had raised concerns over training in a 2010 appraisal, which compliance manager Dean Dunn said would have been addressed by his manager.
He said the team had more than 50 years of experience and could approach Multidrive directly for support.
In the wake of the accident, Bunn Fertiliser immediately suspended spreading operations and in-house maintenance across the 190-strong company and now sub-contracts the work out.
Following the inquest, Mr Alderton's family said they accepted the conclusion but declined to comment further until the HSE investigation had been completed.
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