When simply popping into a bar for a drink after work can change your life forever
What happened?
The beer lines (pipes between barrel and pump) were being cleaned at a bar in Leeds, and the task was being carried out during normal opening times. The chemical being used for this task was sodium hydroxide, a highly corrosive chemical.
The only control measure in place was the beer badge on the pump was turned round to face the staff to indicate that the beer was not available. A new member of staff was working at the bar. He did not know the ‘rule’ about the beer badge being turned around, and turned it back to face the customers.
A customer asked to taste the pale ale, called ‘Sunbeam’ and a similar colour to the chemical, and the member of staff served him the drink to taste.
The drink wasn’t pale ale, but sodium hydroxide. The customer suffered ‘exquisite pain’, was taken to hospital with severe internal injuries, placed in an induced coma, and eventually had surgery to remove his oesophagus.
Legal Outcome
The bar and its owner were fined £25,000 plus £18,000 costs.
What can we learn from what happened?
This case represents an astonishing series of bad decisions, that when taken individually were bad enough, but when taken collectively led to a major, life-changing accident.
The starting point when assessing any risk is identifying the hazard, and considering whether it can be eliminated, and if not, reduced. To clean beer lines effectively you need some kind of chemical agent to kill off the nasty bugs that may accumulate in a beer line, and sodium hydroxide is commonly used, but you only need a trace, not use it neat.
Then when there is any potential for someone to be exposed to a hazard, ways of keeping that hazard away from people must be considered. To carry out the task was bad enough, but to only rely on turning the beer badge around was unforgivable.
Then the over-reliance on human controls needs to be minimised. In this case, the lad behind the bar was too inexperienced to know what the beer badge rule was all about, so the poorly thought through control became completely redundant.
That the customer asked for a taster rather than a half or full pint was unfortunate, and had he not done so then surely both he and the lad behind the bar would have spotted the difference between cool, inviting pale ale and a corrosive chemical. But he didn’t, and a terrible accident happened to someone who a few seconds earlier had simply popped into the bar for a drink after work.
Source of Information
SHP In-Court