Inquiry into death of Dunbar man from wind turbine fall told of test change delay

Basilio Brazao, 19, known as ‘Basil’, died after he hit his head on the third-from-the-bottom rung of the ladder inside the 230ft-tall turbine at the Earlsburn Wind Farm near Fintry, Stirling.

A fatal accident inquiry heard that in 2003, nearly four years before Mr Brazao’s death in May 2007, the Health and Safety Executive commissioned research which identified concerns about the European Standard under which the “fixed rail vertical fall arrest system”, which Mr Brazao was using, was made.

Tests suggested that a climber falling backwards could interfere with the system’s “slider”, preventing it from properly braking.

In 2004, the HSE published two safety warnings and a “national annexe” was added to the European Standard in Britain, recommending the changes.

The inquiry, held at at Stirling Sheriff Court this June, heard that after Mr Brazao’s death, the HSE lodged an action alerting the European Commission to concerns about the device he had been using, which was manufactured by the German company HACA Leitern, and purchased in Germany.

The European Union only revised the testing standard for the HACA and similar devices last month.

Sheriff William Gilchrist, in a 14-page judgement issued on Monday, said: “There is no suggestion the manufacturers, HACA, had not designed the system to meet the requirements of the [relevant] European Standard.

“However, there was evidence to the effect that the testing required by the European Standard was deficient, because it did not test for foreseeable scenarios, including, in particular, a fall-back test.

“Shortly before the Fatal Accident Inquiry began, a revised European Standard was approved by the EU, due to come into force in September 2014. The revised standard includes the requirement to undertake a fallback test.

“It is clear that the [old] European Standard was deficient.” The inquiry heard that Mr Brazao, a Portuguese South African living in Dunbar, had begun to descend the ladder after working in the ‘nacelle’ area of the turbine, near the top.

‘Bite marks’ on the ladder’s safety rail showed the the HACA device had tried to arrest his 57.72-metre fall, beginning just 2.02 metres from the top platform, but there were no significant bite marks below 40 metres.

It is thought he may have fallen feet first initially, and then turned upside down after tangling with the ladder, then plunging head-first, with his back to the ladder, towards the ground.

Sheriff Gilchrist ruled: “The slider failed to arrest his fall, either because of the deceased’s interaction with the ladder, resulting in him applying a horizontal pressure away from the ladder when the HACA slider was trying to bite onto the safety rail, or the brake cams may have been released from the safety rail as the deceased bounced backwards.” The inquiry heard that Mr Brazao was using a ladder to access the top of turbine, as it was not fitted with an internal lift.

Turbine manufacturer Nordex, one of the firms involved on the site, were fined £26,000 at Stirling Sheriff Court in March 2012 after admitting breaching health and safety rules by not having lifts, but it was accepted that their failure was not “causually connected” to Mr Brazao’s death.

Sheriff Gilchirst said: “It was accepted by all parties that had a lift been fitted for the use of Mr Brazao and others, it would have been a reasonable precaution whereby the accident resulting in his death might have been avoided.” The inquiry heard that Mr Brazao was found by colleagues in a pool of blood. He was apparently conscious, still wearing his safety harness, which was clipped to the fall arrest device, and his uncle, who also worked at the site, was giving him mouth-to-mouth.

A plant operator called 999 and asked for an air ambulance, but when it arrived paremedics found he was not breathing, had no pulse, and a defibrillator found he was flatlining.