Cement works shutdown incident

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.

• Contractors were chosen on the lowest quote, so price counted for more than competence or safety.
• Delta's safety record and insurance have not been checked since the first year, so pre-selection checks were not repeated.
• There was no check of Delta's competence for work such as preheater tower repairs.
• Delta's induction was 15 minutes, given by a security officer rather than a competent person, and it was in English although many workers speak another language.
• The induction did not cover the site hazards, the emergency arrangements or how to report problems.
• Eastgate did not coordinate the shutdown work between contractors and its own staff in a planned way.
• The HoM refused a site safety contact for Delta, so there was no supervision or liaison on safety.
• Contractors were paid a bonus for finishing early, which encouraged shortcuts.
• Contractor workers did not report injuries or near misses, so nobody monitored their safety performance.
• Contractors were not asked for method statements or risk assessments for high risk tasks.
• Eastgate relied on the contractor's own management and did not monitor them while they worked.
• Contractor workers were moved to other tasks and left working alone at height, which was not controlled by Eastgate.

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.

• P-114: the same person signed as issuer and acceptor, so there was no independent check that the precautions were in place.
• P-114 and P-118: gas test not recorded, or recorded before the permit was issued, so the atmosphere was not shown to be safe at the time of entry.
• The single gas detector is often needed elsewhere, so testing before entry is not reliably done.
• P-124 was signed on day 7 afternoon for use on the night shift, so conditions could have changed before the work started.
• Supervisors signed several permits at the start of a shift to save time, which means they were not assessing each job.
• P-124: the isolation box was ticked but the isolation point is not named and was not checked, which shows isolation was not verified.
• Electrical isolation used tags only, with no locks, so a switch could be switched on by someone who did not see the tag.
• P-126: a permit signed in blank for three days gives authority without the specific work, place and time being defined.
• No inspection of the scaffold by a competent person was recorded, so a precaution needed for the work was missing.
• P-114, P-126 and P-121 were not closed or have no closing time, so the system does not show that the work was completed and the area made safe.
• Nobody reviewed the permit register, so these faults were not found by the management.
• The permit forms were used as paperwork, with ticked boxes but no check that the precautions were physically in place.
• There is no sign of coordination between permits for work in the same area, such as hot work and entry to a duct.
• Time pressure from the shutdown bonus encouraged supervisors to shorten the permit process.

Marks counted: 0 of 14

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.

• Analyse the task: identify the hazards such as hot material, work at height, gases and isolation of the feed.
• Involve the people who do the job, because they know how blockages are really cleared.
• Assess the risk and write the procedure down so that it is consistent and can be used in training.
• Technical controls such as a safe way to dislodge material from the ground or from a protected position.
• Isolation of the feed system with locks and verification that it is off.
• Procedural controls such as a permit to work with named isolation points.
• Protective clothing and equipment suited to hot material, as the last line of defence.
• No lone working on the platform, with a second person present and a rescue arrangement ready.
• Instruct and train the people in the system and check that they understand it.
• Monitor the system by supervision and checks, and review it after any incident or near miss.

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.

• Check that the injured worker has medical care and that the family and the contractor are told.
• Make the area safe and prevent further harm, for example by securing the cyclone and the platform.
• Preserve the scene, including the inspection door, the permit and the isolation points, until evidence is gathered.
• Report the incident to the enforcement agency in line with national law.
• Do not restart the kiln until the investigation has found out how the hot material was released.
• Gather information: take statements from the injured worker, the colleague who raised the alarm and the supervisor who signed the permit.
• Collect documents: permit P-124, the permit register, training records, method statements and the emergency plan.
• Take photographs and measurements of the platform, the door and the blockage.
• Identify immediate causes such as opening the door with material built up behind it and working alone.
• Underlying causes could include production pressure and bonuses, signed permits in advance, and unverified isolation.
• Other underlying causes: weak contractor control, no rescue plan, lack of supervision and no safety meetings.
• Set an action plan with owners and dates, and check that actions are completed.

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.

• The emergency plan is six years old and was written for normal operations, so it does not cover the shutdown.
• The siren cannot be heard over grinders and compressors, so the warning may not reach everyone.
• There is no rescue plan or equipment for the preheater tower, so it took 25 minutes to bring the casualty down.
• Rescue from height has never been tested or practised.
• The nurse works only on the day shift, so there was no first aid on the night shift when 150 contractors were on site.
• The first aid box on the platform was empty, so no checks were made on first aid supplies.
• The hospital is 40 minutes away and the access road was partly closed, so the ambulance was delayed.
• There was no plan for alternative access for the emergency services during the road closure.
• Contractors were not told the emergency arrangements in a language they understand.
• No drills have been carried out, so people did not know what to do or who to call.
• First aid provision did not take account of the shift pattern, the number of people and the remoteness of the site.
• No communication method such as radios was provided, which might have helped the colleague raise the alarm quickly.

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.

• Organisational: a bonus for finishing the shutdown early encouraged speed over safety.
• Organisational: the PM's view that extra days are money thrown away set the priorities for managers.
• Organisational: contractors fear dismissal, which stops reporting and hides problems.
• Organisational: safety meetings stopped three months ago, so there was no consultation.
• Organisational: long shifts and night work increase fatigue.
• Organisational: communication is poor, with an induction in a language many workers do not speak well.
• Job: the task of clearing a blockage involves hot material and work at height at night, with poor access and lighting at 02:30.
• Job: a permit that was signed the afternoon before did not describe the conditions at the time of the job.
• Job: the procedure for the task was not clear, and the equipment to clear the blockage safely was not provided.
• Job: the worker was alone, which removed the chance of a second check.
• Individual: the worker was a contractor with limited induction and may not have had the competence for this task.
• Individual: the worker may have been tired and under pressure to finish, which affects risk perception.
• Individual: workers see rules as being for the auditors, which is an attitude formed by what managers do.
• Peer influence: staff who stop a job to ask a question are told that the schedule cannot slip, so new workers learn to carry on.

Marks counted: 0 of 14

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.

• Carry out daily inspections of work areas by competent people using checklists, with named people responsible for actions.
• Check each permit in the field to see that the precautions are in place, for example that locks are fitted and the gas test is recorded.
• Audit the permit register every shift for blank, pre-signed or unclosed permits.
• Have a safety tour with the PM and contractor supervisors so that leaders are seen to take part.
• Sample the air and gas in vessels as a check on the atmosphere, using enough detectors.
• Leading indicator: the percentage of permits that pass a field check.
• Leading indicator: the number of safety tours and inspections completed against plan.
• Leading indicator: the percentage of contractor workers who have completed a suitable induction.
• Leading indicator: the number of near misses reported, which shows the reporting culture.
• Leading indicator: the proportion of corrective actions closed on time.
• Encourage contractors to report problems without fear of dismissal.
• Use both leading and lagging measures, and review the results with management.

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.

• Plan: carry out a risk assessment of the whole shutdown, not only individual tasks.
• Plan: set objectives for the shutdown such as zero permit faults found in audit.
• Plan: select contractors on competence and safety record as well as price, and recheck them each year.
• Plan: update the emergency plan to cover the shutdown and test rescue from height.
• Do: provide an induction in a suitable language and communicate the rules.
• Do: provide resources such as locks for isolation, gas detectors and a night shift first aider.
• Do: assign roles, for example a site safety contact for each contractor and a permit coordinator.
• Check: monitor by inspections, audits of the permit system and the investigation of near misses.
• Check: record and report all incidents, including those involving contractors.
• Act: review results after the shutdown, update the procedures and share the learning.
• Top management should stop linking bonuses to speed alone, and include safety measures in them.
• Top management should appoint a senior person with responsibility for the shutdown safety.
• Top management should visit the work areas and take part in safety tours.
• Top management should respond to the incident by reviewing the system, not blaming the worker.

Marks counted: 0 of 14