When Safe Systems Fail

In March 2024, a major UK food manufacturer, Baker & Baker Products UK Ltd, was handed a £400,000 fine after a horrific workplace accident left a member of staff seriously injured. The employee, Sharon Bramhall, lost her leg after being struck by a Mobile Elevating Work Platform (MEWP) while working a night shift. The details are tragic and, crucially, preventable.

The HSE investigation that followed found significant failings. Chief among them: a lack of a robust, enforced safe system of work for MEWP operations. The company had a policy in place that required trained MEWP operators to act as banksmen, those responsible for guiding vehicle movements. But on the night of the incident, that policy was not followed. The individual acting as a banksman hadn’t received the necessary training and didn’t hold the required operator licence. That lapse had devastating consequences.

This case highlights a truth that every business must face: having a health and safety policy isn’t enough. It’s not a tick-box exercise. Policies must be actively implemented, clearly communicated, and regularly reinforced through training and monitoring.

At Ranmoor Health and Safety, we often talk about the importance of creating a culture of safety not just compliance. The Baker & Baker case shows what happens when safety culture falters. It’s not about villainising businesses. It’s about learning from these incidents to make sure they don’t happen again.

What does a safe system of work really look like in this context?

Clear, documented procedures for MEWP usage that outline responsibilities at each stage.

Comprehensive training for all those involved — from the operator to the banksman and line managers.

Pre-operation checks  and formal sign-offs to ensure that safety systems are actually being used, not just assumed.

Regular audits of compliance with those procedures, especially in high-risk environments or shift-based operations.

The scale of the fine issued reflects the seriousness of the failings, but no amount of money can undo the impact on the worker involved. Her life has changed forever.

It’s worth noting that this incident occurred during a night shift. Lone working, shift work and lower supervisory presence out of hours all introduce additional risks and it’s vital these are accounted for in any safety planning.

The lesson is simple: systems are only as strong as their weakest link. It’s not enough to have policies we have to embed them, train them, and most importantly, live them. If your team needs support in reviewing or creating safe systems of work, especially for higher-risk operations like MEWPs, we can help.