18 June 2019
Gas Services (Jersey) Ltd (Gas Services) was fined £20,000 plus £2,000 costs after pleading guilty to a breach of the Health and Safety at Work (Jersey) Law, 1989. The case arose from unsafe work carried out to four gas-fired boilers that resulted in residents and staff at L’Hermitage Care Home being exposed to carbon monoxide gas.
Gas Services was sub-contracted to service and repair gas appliances at the L’Hermitage Care Home, including four gas-fired condensing boilers used to supply heat and hot water to the home. On Friday 9 March 2018, an employee of Gas Services arrived at the care home. He was to repair boiler number 3, which had been out of service for an extended period of time, before servicing all four boilers. He was also due to carry out inspection and servicing of other gas appliances at L’Hermitage and its sister facility, Beaumont Villa.
On the Friday afternoon, the gas engineer completed the repair of boiler number 3 and serviced all four boilers at L’Hermitage. However, he failed to carry out the appropriate checks to ensure that the boilers were operating safely before he left the premises, primarily because his gas analyser, used to measure gases (including carbon monoxide) produced by combustion, was not working.
During the course of that evening, Saturday and Sunday staff and residents on the first floor of the home fell ill, complaining of headaches, dizziness, nausea and breathing difficulties. Fortunately due to the staff’s diligence, carbon monoxide poisoning was suspected and immediate action taken to ventilate the area and the Jersey Gas emergency services contacted. Combustion checks of the four boilers carried out on the Sunday evening identified that all were combusting poorly, with the level of carbon monoxide produced by boiler number 3 above the reading scale of the gas analyser. All of the boilers were immediately shut down.
An examination of the four flues, one per boiler, the following day identified that a section of the flue fitted to boiler number 3 had come apart in the roof space. Although it is not possible to determine when this damage had occurred, the breach in the flue allowed the high level of carbon monoxide gas produced by the poorly combusting boiler to penetrate the first floor of the home, exposing staff and residents. The fact remains, however, that the boiler should not have been producing poisonous levels of carbon monoxide in the first place.
During the prosecution the Court agreed that there were serious failings on behalf of Gas Services and its conduct fell far below the appropriate standard. The Court stated that working with gas appliances requires a high level of care and skill to be exercised, having regard to the potentially fatal risk of harm.
The gas engineer employed by the company, although Gas Safe registered to work on domestic gas appliance, had no accredited qualifications to work on commercial installations, such as the boilers at L’Hermitage. The Court commented that although he may have gained experience while working on commercial installations, the standard of his work on this occasion and the poor judgements he made whilst carrying out the work called into question his competence to undertake the work in the first place.
Instead of carrying out the basic, but fundamental, industry standard checks to ensure safe combustion on the boilers, ie combustion gas analysis, the gas engineer simply looked at the flame picture to ascertain how well the boilers were combusting. The subsequent series of events demonstrates very clearly how ineffective this is in identifying even dangerous levels of carbon monoxide. He also failed to carry out the appropriate checks of the flue, in line with industry standards, to ensure its integrity.
When sentencing the company to a total fine and costs of £22,000, the Court made it very clear that this was directly related to the financial position of the company, and an acceptance that any higher fine would carry the risk of bankrupting the company. The company was given 18 months to pay.
Note
Following this prosecution there have been calls for stricter controls to be introduced regarding the competence of those working with gas. The Health and Safety Inspectorate is currently considering this matter and is likely to seek wider views in due course.
gov.je