Hefty Fine For Carlsberg After Fatality

Global brewing giant Carlsberg has been fined £3 million after a contractor died and another was seriously injured following an ammonia gas leak at one of its breweries. 

Carlsberg incident

In November 2016, Carlsberg was in the process of upgrading the refrigeration system – a key element of the brewing process – at its main UK brewery in Northampton. 

On 9 November 2016, part of the work being done involved the removal of the refrigeration system’s old compressor. It was during the removal of the compressor that there was an uncontrolled release of ammonia gas, which killed David Chandler and seriously injured David Beak. It also resulted in another 20 people requiring medical assistance, including some of members of the emergency rescue team. 

The HSE was notified of the incident the same day and immediately began a joint investigation alongside the police. 


The investigation was initially under the work-related death protocol because Mr Chandler died a as a result of the ammonia release. When somebody dies, the police initially lead investigation and HSE support. Subsequently, if the police are satisfied there are no grounds for gross negligence manslaughter or corporate manslaughter it comes to the HSE as the lead regulator and they assume primacy. 

Although the investigation was quite complex, the reasons for the incident were actually quite simple and it essentially came down to inadequate isolation. 

In this case, both Carlsberg and Crowley Carbon had a duty to ensure the correct level of isolation was in place ahead of the intrusive work being undertaken. HSE’s investigation concluded that the standard of isolation in relation to that compressor was a single valve non-proved isolation, which is the lowest standard of isolation. The standard that should have been in place was positive isolation, which is the highest standard of isolation. There is industry guidance on isolations for these kinds of systems – it’s freely available – and it should have been followed. 

Key Learnings

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Projects involving multiple contractors always require ‘effective management arrangements for planning, managing and monitoring risks to the health and safety of those who will be affected by that work’. 

In this incident, it was only really two duty holders working together because Crowley Carbon was the principal designer and the principal contractor. It wasn’t a complicated or difficult arrangement. 

This incident was entirely preventable – all Carlsberg and Crowley Carbon had to do look at the risk of ammonia gas and identify the correct standard of isolation required for this type of system. Had they done that, David Chandler would not have lost his life. 

If you have any questions relating to this or any health and safety concerns, I’d be more than happy to have a discussion.

Information relating to managing risk and risk assessments at work can be found here.

Another article on health and safety news is available here.

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Steve Kilburn
Steve Kilburn
I initially trained as an industrial chemist working in a variety of manufacturing environments eventually moving into quality management which grew to encompass environmental and occupational health and safety management systems. I hold a Masters Degree in Health and Safety law and Environmental Law and a Post Graduate Certificate in Sustainable Waste Management and I am a Graduate Level Member of the Institution of Occupational Safety and Health (IOSH). In my spare time I enjoy reading, my favourite author is Stephen King, and listening to music, generally from the late 70’s, 80’s and 90’s.
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