On 30 September, employee George Falder was seen on CCTV footage at 2.45 pm. The autoclave door was shut and put into operation approximately an hour later. When the autoclave was subsequently checked at 6pm at the end of the shift, Mr Falder’s body was found. The autoclave was used to heat tyre beads – which strengthen tyres – to temperatures of up to 145oC. Not only is the heat intense, there is very limited oxygen within the autoclave when it is in operation. Medical experts at the inquest were of the view that Mr Falder was likely to have died within seconds of the autoclave being switched on.

The HSE’s investigation established that workers would often enter the autoclave to pick up fallen beads in between cycles, but that there were no procedures in place to prevent / restrict access to the autoclave, nor was there any system whereby the autoclave would be checked before the door was shut and the autoclave was switched on, by which stage any employee inside the autoclave would have no way of opening the door or stopping the operating cycle once it had begun. Improvement notices were served within days of the incident to address these deficiencies, which were rectified within the required 1 month period.

Pirelli pleaded guilty to a breach of s 2(1) HSWA and was fined £150k and ordered to pay costs of £46,706.