Bottling plant amputation

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• The PTW was set up for work on the boiler room and roof only, so it does not cover maintenance on the lines, where moving machinery is a major hazard.
• In practice it is used only for hot work, so the system is not applied to the high risk task in the incident.
• The fitter was told verbally what to do and started work, with no written permit that set out the hazards and precautions.
• There was no lock out and tag out step, so the energy could not be isolated and proven safe before entry.
• Isolation depended on pressing the emergency stop, which stops the machine but is not a safe isolation.
• No competent person checked the work area or authorised work, because the supervisor was elsewhere.
• The permit system does not link with shift handover, so the next shift cannot know what work is in progress and what state the line is in.
• No time limit, sign off or hand back of the machine is described, which is needed for a PTW to be controlled.
• The system was designed years ago and has not been reviewed after the new machine and new layout.
• Employees were not trained in the PTW, and not told it applies to jam clearing and cleaning.
• Management did not check how the system was used, so poor practice became normal.
• There was no communication of the work to the operators and others on the line.

Marks counted: 0 of 12

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• Clearing a jam is a frequent task on the new machine, so staff are tempted to take shortcuts to avoid restarts.
• The task has no written procedure or isolation steps, so the fitter relied on habit.
• The fitter had worked six nights in a row and was probably tired, which reduces concentration at 03:10.
• The task was done alone, at night, with one supervisor for the whole plant, so there was no second person to check.
• The interlock had been defeated with tape, so the machine did not stop when the guard was opened.
• The access to the capping head for clearing jams was awkward or poorly designed, so reaching inside was needed.
• Production pressure and the bonus encouraged speed over the time needed to isolate the machine.
• The fitter had no clear information about the state of the machine because the handover was poor.
• Warning signs were in English only and may not have been understood by every worker.
• Rotating shifts weekly disturb sleep and body rhythm and increase errors.
• The lighting, noise or layout near the machine may have affected the task, and there was no work equipment designed for removing caps safely.

Marks counted: 0 of 10

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• Technical: fixed guards, or interlocked guards that cannot be easily defeated, such as coded or tamper resistant interlocks.
• Technical: a safe means of clearing jams without reaching inside, such as a jam clearing tool, an access hatch or an automatic reject system.
• Technical: fix the cause of the jams, such as checking cap quality and supplier, and adjusting the machine.
• Technical: a safe isolation device built in, such as lockable isolators on the machine.
• Technical: stored energy released or contained, for example by braking the capping head.
• Technical: emergency stops within reach, and a monitored fault display that shows the interlock status.
• Technical: place guards so that the operator can see the process without opening them.
• Technical: commissioning checks on the guards and interlocks before use, to prove they cannot be defeated easily.
• Administrative: written safe system of work for clearing jams, with lock out and tag out and verification of zero energy.
• Administrative: extend the PTW system to maintenance, cleaning and jam clearing on all lines.
• Administrative: training and instruction for operators and fitters on the new machine, in their language, with competence checks and refreshers.
• Administrative: translate or arrange the supplier manual and make warning signs multilingual and pictorial.
• Administrative: supervision and inspection that guards and interlocks are in place at the start of each shift, with a signed checklist.
• Administrative: a clear rule and disciplinary action for defeating safety devices, with an easy way to report faults.
• Administrative: improve shift handover with a written, signed log and a briefing on the state of each line.
• Administrative: staffing and working time rules, for example limits on consecutive nights, adequate cover on nights and fatigue checks.
• Administrative: remove the link between safety and the bonus, and set safety targets for managers.

Marks counted: 0 of 16

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• It was written eight years ago, before the new machine and the changes to the shift pattern.
• It does not name who is responsible for machinery safety, so duties are unclear.
• The previous PM wrote it, so it may not match the current structure, with the EM and the PM.
• After the incident and the prohibition notice, it must show how the findings will be built into the arrangements.
• Legal and standard requirements may have changed since it was written, and it must reflect the current ones.
• The policy should show real commitment from top management, and the practice at the plant, for example defeated interlocks, does not match it.
• The policy does not appear to cover contractors such as the machine supplier, or language and communication needs.
• Audit recommendations from four years ago should be reflected in the policy and its objectives.
• Worker representatives feel concerns are not acted on, so the arrangements for consultation need to be strengthened.
• A regular review is a good practice to keep it relevant, and it ensures the policy is communicated and signed by senior management.
• Changes such as introducing more automation and increasing output mean that its scope and aims should be updated.

Marks counted: 0 of 10

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• An audit is an independent check of the whole management system, so it can find weaknesses that day to day checks miss, such as the taped interlocks.
• It would show whether the 14 recommendations of four years ago were done, and why not.
• It gives an objective picture of compliance with law, standards and Crescent's own policy and procedures.
• It would test the PTW, isolation, training, handover and maintenance arrangements as they are really applied.
• It would help to set priorities and a plan for the improvements with the best effect on risk.
• It can show examples of good practice that can be shared across lines and shifts.
• It would show that management is serious about the improvement, which may help with the authority and the workers.
• It can support the case for money and resources, with evidence.
• It may help to reduce the risk of enforcement action, claims and insurance costs.
• It gives a baseline to compare with later audits to see progress.
• The interviews with workers on every shift would give an understanding of the culture and real practice.

Marks counted: 0 of 10

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• No risk assessment was done for the new machine before it started production.
• The need and the effect of the change on people, tasks and the work area were not planned, because the aim was output.
• Operators had 30 minutes of instruction and the fitters were not trained at all on the new machine.
• The supplier's manual is in a language nobody can read, so important instructions on use and maintenance were not available.
• Operating, cleaning, jam clearing and maintenance procedures were not updated.
• No commissioning check confirmed that the guards and interlocks were suitable and could not easily be defeated.
• The faster speed and frequent jams were not anticipated, and no controls such as a safe jam clearing method were planned.
• Workers and their representatives were not consulted before or after the change.
• No time was allowed for a trial period with monitoring and review once the machine was in use.
• The known interlock tampering was not dealt with after the machine started working.
• The PTW system, the staffing and the shift plan for maintenance were not adjusted for the new machine.
• Nobody was given the responsibility for the whole change and for checking that it was safe.

Marks counted: 0 of 12

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• Handover between shifts is verbal, and the log book is often not filled in, so nobody told the fitter that the interlock had been taped.
• The previous shift told him only that Line 2 was jamming, which is not enough information.
• Warning signs are in English only, though a third of workers speak and read other languages.
• The supplier's manual in a foreign language was not translated.
• Instructions to fitters were verbal, not written, so details were missed or changed.
• Supervisors knew about the taped interlocks and did not report or act, so important information stopped at the supervisor level.
• Worker concerns raised in the committee about the jams are noted and not acted upon, so there is no feedback.
• Management members rarely attend the committee, so communication up and down the organisation is weak.
• The night supervisor was away from the line and could not be reached quickly, so the fitter did not consult anyone.
• Operators did not tell the fitter or supervisor that the guard was defeated, perhaps because of the culture.
• There was no communication of the outcome of the audit to the workers.
• Emergency stop use and the work in progress were not communicated between the operator and the fitter.

Marks counted: 0 of 12

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• Fix a schedule of meetings that is kept, with dates for the year, and make attendance by management members expected and recorded.
• Ensure that the PM or another senior manager chairs, so decisions can be made on the spot.
• Agree and circulate an agenda in advance, which includes standing items such as incidents, near misses, audit actions and machine safety.
• Keep written minutes with actions, owners and deadlines, and review them at the start of each meeting.
• Include representatives from all shifts and areas, including nights, and hold meetings at times that suit them.
• Give representatives training, time in work hours and information, such as incident data.
• Provide interpreters or translation so that all members can take part.
• Report the outcome to all workers on notice boards, in briefings and in a language they understand.
• Give a formal response to concerns, such as the jams on Line 2, within a set time.
• Involve the committee in risk assessments, audits and the introduction of new equipment.
• Legal arguments: failure to comply risks prohibition notices, prosecution, fines and possible imprisonment of managers.
• Legal arguments: workers who lose a limb may claim compensation, and the authority has already issued a notice.
• Financial arguments: Line 2 is now stopped, so output and bonus are lost for more than the cost of a safe system.
• Financial arguments: the cost of the incident, such as sick pay, compensation, replacement staff and higher insurance.
• Financial arguments: fewer jams and stoppages mean better efficiency, so safety improvements can pay for themselves.
• Moral arguments: a worker has been disabled for life, and managers have a duty of care to everyone at the plant.
• Reputation arguments: customers and the public expect a responsible supplier, and a poor record may lose contracts.
• Staff arguments: a safer plant helps to recruit and keep skilled workers and improves morale.

Marks counted: 0 of 18