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Fatal Accident Inquiry into the Death of James Alexander Fraser, Sheriff Graeme Napier, Kirkwall Sheriff Court, 10th June 2011


In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that James Alexander Fraser (DOB 20.08.64) died at Gorn Farm, Rendall, Orkney between 3.30 pm and 5 pm on 3rd January 2011. In terms of s.6(1)(b), the cause of death was traumatic asphyxia as a result of chest compression. Formal determinations were made under s.6(1)(c)(d) and(e).

Mr Fraser was a self-employed farmer. On the day of his death he was carrying out maintenance work on a round baler. The baler was equipped with 2 separate safety devices to prevent the tailgate dropping down unintentionally. Firstly the baler's tailgate was operated by two hydraulic ‘rams' which were controlled by an isolation valve. Secondly, the baler had a hinged mechanical support known as a 'scotch' which acted as a physical barrier preventing the tailgate from lowering if the isolation valve failed.
While Mr Fraser was working under the tailgate the isolation valve disengaged and the tailgate lowered unexpectedly. As Mr Fraser had not used a scotch he became trapped in the lowered tailgate and was asphyxiated. Mr Fraser was discovered by his son Gavin at around 5pm. It was clear that Mr Fraser was already dead at that time.

Under s.6(1)(c) the sheriff found that the accident would not have occurred if Mr Fraser had used a scotch on the baler. Under s.6(1)(d) the sheriff identified that the main defect in the system of work was Mr Fraser's failure to carry out a risk assessment for the planned maintenance operation. Had he done so he would have been able to take steps to avoid the accident. Under s.6(1)(e) the sheriff noted two facts that were relevant to the death. First, the deceased was working in cramped conditions which increased the potential for accidents. Second, the Health and Safety Executive have issued guidance that is relevant to the deceased's area of work and these are available free of charge.