Safety failures led to fatal explosion at Wiltshire factory

Since the mid-1980s, Chemring Countermeasures has manufactured decoy flares which British and NATO military aircraft deploy when targeted by missiles.

Swindon Magistrates Court heard on Thursday that inadequate staff training, supervision, and risk assessments at the Salisbury site, as well as failures to comply with its own health and safety policies, created circumstances that caused a deadly blast.

Since then, a new manager has taken charge, replaced the safety and operations directors, and carried out major changes to how the company handles explosive material.

The business pleaded guilty to failing to discharge its general health, safety and welfare duty to two employees.

WHAT HAPPENED

At 4.49pm in building 206 on August 10, 2018, Piotr Zukowski was nearing the end of his shift after the production of a third batch of a composite of magnesium, Teflon and Viton, a chemical which ignites flares.

Deposits of up to 5kg of MTV had built up inside the PressoFiltro mixing bowl during its use and, when he leaned his upper torso into the machine to replace the filter cloth, the solvent composition ignited due to metal-on-metal contact between his partly-aluminium dustpan and the material.

The blast sent the 29-year-old from Southampton outside the room and caused a pile of waste MTV stored in cleaning buckets in the corridor to ignite, which severely burned then-26-year-old Jake West from Pewsey.

WHAT WENT WRONG

Health and Safety Executive lead prosecutor Alan Hughes said that before the incident, “the defendant said that an ignition of MTV in the PressoFiltro was ‘not a credible event’.

“This fundamentally flawed assumption was written into the risk assessment policies, which did not reflect reality.

“Some operators had refused to work in the PressoFiltro. [Chemring] failed to address specific employee complaints about the level of cleanliness in the building and the build-up of matter.

“The defendant fell far short of its duty to ensure the health and safety of its employees [and] exposed a number of people to risk over a long period of time.”

Mr Hughes explained that no-one had acknowledged or assessed the safety risk of a build-up of MTV in the machine's sump that became increasingly sensitive as it was repeatedly wetted and dried during the cleaning process.

Keeping doors open during cleaning and temporarily leaving buckets of flammable waste material in the corridor were fire safety risks that went against the business’ policies and explosives licence agreement, but were “not regarded as violations” by some supervisors.

He added: “Some operators could not or did not follow the process instructions and devised their own ways of working due to omissions in the instructions.

“It instructs the operator to remove waste composition from the sump but does not say how. It does not say what to do if residual composition remains after cleaning is carried out.

“Underlying causes of previous incidents were not always recorded, so improvements could not be made to rectify them.”

A military helicopter throws out flares. Picture: Getty. (Image: Getty Images)

VICTIM’S MOTHER SPEAKS OF HER GRIEF

A statement from Piotr Zukowski’s mother read out in court said: “My life stopped on that day.

“I don’t know how I survived the next weeks, it was a nightmare.

“He went to work and never came back. I talked to him every Monday and now the phone is silent.

“I was going to visit him at his new home and he was going to start a family. He was happy and in love. Suddenly, he’s gone…. my lovable, wise, and supportive son.

“My life does not really exist. I go through another day for the sake of my other children. There is a gap in our hearts.

“The younger son has lost all motivation. It’s hard to tell a teenager that life is beautiful when this happens.

“My daughter became a shadow of herself and she can’t go to her brother’s grave, they were always together and could always count on each other.

“I’ve cried all my tears and have no hope. I try to have a life but I can’t overcome the sadness. It feels like I died with him.”

MAJOR IMPROVEMEMENTS MADE

Andy Hogben, managing director of Chemring Countermeasures' Salisbury site. (Image: LinkedIn)

Simon Antrobus KC, defending, said that Chemring’s managing director Andy Hogben - who was in court - expressed his and the company’s “unreserved apology” to Mr Zukowski’s family and to Mr West.

He added that Chemring “deals with risk on a daily basis as a vital part of the defence strategy in this country” and that the incident “was out of character with the way this company operates”.

Since then, the senior management team has changed and Mr Hogben has “embarked on a sustained and targeted improvement of the broader safety system”.

“Mistakes have been addressed and corrected by the new team to reduce risk.

“No-one has been harmed from an incident or ignition from that composition since. The court can be confident that the tragic evidence of this incident will not reoccur as a consequence of the defendant’s conduct.”

The company has invested heavily in automating processes so that personnel have as little contact with dangerous material as possible.

Building 206 is no longer used. Instead, an Alpha facility that only handled a relatively small amount of flare composition in 2018 has “grown massively at enormous cost to develop state-of-the-art technology” which has made Chemring “the only company of its nature in the world to carry out an automated process on this scale and nature”.

Everything is now more thoroughly monitored, staff and leadership training has improved along with regular refreshers, the company now only handles the smallest necessary amount of explosive material, and staff “feel empowered to identify concerns and stop processes if something does not feel right”.

Chemring Countermeasures in Salisbury. (Image: Google Maps)

THE SENTENCE

Chemring must pay a fine of £670,000 as well as £12,835.46 in court costs and £170 to fund victim services.

A spokesperson for the company said: “Chemring Countermeasures Ltd accepts full responsibility for the circumstances that led to the tragic incident on August 10, 2018, and pleaded guilty at the first available opportunity.

“It accepts the sentence that has been imposed and is grateful to the judge for recognising and taking into account the vast improvements to safety that have subsequently been made within the business and the significant co-operation shown in working with the Health and Safety Executive throughout its investigation.”