Container terminal night shift collision

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: the bonus for container moves and the league table put speed before safety.
• Organisational: the TM's view that stopping a machine costs money sets the priorities for managers.
• Organisational: banksmen were removed at night to save wages, which is a resource decision.
• Organisational: 24 hour working with long shifts causes fatigue, and the driver was in his tenth hour.
• Organisational: poor communication, shown by the layout change being announced only a few days before and by an induction that did not cover it.
• Job: the lasher's work was moved into the stacking area, so a task on foot is done where machines reverse.
• Job: poor lighting at night and dark overalls make workers hard to see.
• Job: reach stackers give the driver a poor view to the rear, and reversing without a guide makes the task harder.
• Job: shared radios that are often out of battery make communication unreliable.
• Individual: the lasher was an agency worker on his third night and was not trained in the new layout.
• Individual: the driver was tired and under pressure to catch up on moves, which affects attention and risk perception.
• Peer influence: new drivers copy experienced drivers who reverse without a banksman, and workers who report problems are called slow.

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 only assessment is five years old and has never been reviewed, so it does not reflect the current yard and night working.
• It rates the risk of pedestrians being struck as low, although vehicles and people share the same area, so the rating is wrong for the current layout.
• It is general and does not deal with the specific task of lashing in the stacking area.
• No assessment was made when the layout changed and night working began.
• Workers were not consulted, although they know how the work is really done.
• Existing controls such as the banksman at night and hi-visibility clothing were not assessed and were not working.
• A suitable and sufficient assessment identifies the significant hazards and who is at risk, including agency workers and visitors.
• It should use the five steps: identify hazards and who is at risk, assess the risk, control the risks, record the findings and review.
• The risk rating should use the likelihood of harm and its probable severity, and take account of existing controls.
• Controls should follow the hierarchy: eliminate the pedestrian and vehicle contact by separating routes, then engineering controls such as lighting and cameras, then administrative controls, then PPE.
• The findings should be recorded and communicated to the workers, and the assessment reviewed after changes and incidents.
• Residual risk should be considered after the controls to decide whether it is acceptable.

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 move to 24 hour working was a change that introduced night work, fatigue and low light, and it was made without a risk assessment.
• The new yard layout removed the pedestrian walkway, which removed an existing control.
• Moving the lashers' place of work into the stacking area created contact between people on foot and reversing machines.
• Lighting was not improved, so existing controls became less effective in the dark.
• Emergency procedures were not changed for night working, so first aid cover and ambulance access were not suitable.
• The shift managers were told only a few days before, so there was no time to plan, train or consult.
• Workers were not consulted or told how the changes would affect them.
• A risk assessment should have been carried out before each change, by competent people.
• The assessment should have led to controls such as segregated walkways, better lighting, banksmen at night and hi-visibility clothing.
• Workers and contractors should have been communicated with and trained before the change began.
• Emergency procedures should have been amended to cover night shifts.
• The change should have been phased and the work areas segregated until the controls were in place.
• The effect of the change should have been reviewed during and after it, using inspections and near miss reports.
• Several changes were made at the same time, and their combined effect was not considered.

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.

• Inspections are monthly, always in daylight and use a one page checklist, so they do not see night shift conditions.
• Months 2 and 5 inspections recorded no problems although near misses were being recorded at night, which shows the inspections were not effective.
• Month 1 and month 4 near misses between machines and people were recorded with no action, or weak action such as telling the driver to be careful.
• Month 3 slip in the dark was treated as first aid only and no cause such as lighting was considered.
• Month 6 reversing without a banksman was not recorded as an incident, which shows under-reporting.
• Nobody reviews the log or looks for trends, so repeated warnings were missed.
• Workers are discouraged from reporting near misses because they are called slow, so the data is incomplete.
• Improvement: carry out inspections on all shifts, including nights, by competent people using a suitable checklist.
• Improvement: involve workers and supervisors in inspections and safety tours, and include senior managers.
• Improvement: use leading indicators such as inspections completed, near misses reported and actions closed on time, as well as injury rates.
• Improvement: review the log regularly and act on trends and repeat entries.
• Improvement: encourage reporting by acting on reports and not blaming people.

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.

• A trained first aider is provided on the day shifts only, so there was no first aid cover at 02:15.
• The ambulance gate was locked at night and the key was held far away, so the ambulance was delayed by 25 minutes.
• The medical centre is 20 minutes away, so first aid on site is even more important.
• The emergency plan was written for day working and was not changed for night shifts.
• No drill has been held for a casualty in the yard, so people did not know what to do.
• Shared radios with low batteries delayed the call for help.
• Improvement: provide trained first aiders and equipment on every shift, based on the number of people, the distance to help and the hazards.
• Improvement: make sure that gates used by emergency services are open or can be opened quickly at all times, and tell the services the plan.
• Improvement: give each supervisor a reliable radio or phone, test them and keep them charged.
• Improvement: hold drills for night shifts, including a casualty in the stacking area, and correct any weaknesses found.

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.

• Treat the incident as a high level investigation because of the serious injury and the potential for a fatality.
• Give medical care and make the area safe as immediate actions, and secure the reach stacker and the scene.
• Report the incident to the authority in line with national law.
• Form a team that includes a competent investigator, a manager, a worker representative and someone who knows reach stackers.
• Gather information: statements from the lasher if possible, the driver, the colleague who called for help and the shift manager.
• Collect documents: the risk assessment, the incident log, the inspection records, training and induction records and the shift rosters.
• Collect physical evidence: photographs, measurements of the visibility from the driver's seat, lighting levels and CCTV if available.
• Immediate causes: the machine reversing without a guide, a worker on foot in the reversing zone and poor visibility.
• Underlying causes: the unmanaged change, the removal of banksmen and walkways, and the out of date risk assessment.
• Underlying causes: the bonus system and league table, driver fatigue and the weak induction.
• Identify risk control measures and set up an action plan with owners and dates.
• Check that the actions are completed and share the lessons with workers.

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.

• Analyse the task of lashing, including where lashers walk, with the lashers who do the job.
• Identify the hazards, such as moving machines, reversing vehicles, poor lighting and falls, and who is at risk.
• Technical controls: separate walkways and designated crossing points for people on foot.
• Technical controls: better lighting, cameras and proximity warning devices on reach stackers.
• Procedural controls: banksmen on every shift for reversing, and a rule that no pedestrian enters a stack area while a machine is working.
• Procedural controls: a permit or work plan for lashing in the stack areas, agreed with the crane and stacker controllers.
• Behavioural controls: induction in the layout and the rules, in a language that workers understand.
• Behavioural controls: supervision on the night shift and a culture in which anyone can stop a job without penalty.
• Provide hi-visibility clothing and a working radio to each lasher, as the last line of defence.
• Write the procedure down so that it is consistent and can be used for training.
• Instruct and train drivers and lashers in the procedure.
• Monitor by supervisors observing the work on all shifts, and by checks that the controls are in place.
• Review the system after incidents, near misses and changes, and when workers say it does not work.
• Set measures such as the number of banksman covered reversing movements and near miss reports to see if the system works.

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.

• Accept that management arrangements contributed to the collision and stop blaming the injured worker.
• Review the bonus and the league table so that they do not reward speed over safety.
• Provide the resources for banksmen on every shift, lighting, radios and first aid cover at night.
• Define roles and responsibilities for safety on every shift, including a named person for yard traffic.
• Appoint a senior person with specific responsibility for health and safety.
• Appoint competent people, inside or outside the terminal, to help it meet its duties.
• Require a risk assessment and approval by a competent person before any change in layout or working hours.
• Take part in night safety tours and inspections so that workers see commitment.
• Consult workers, including agency workers, on risks and changes, and include workers in safety meetings.
• Improve communication and induction, including the languages spoken by workers.
• Encourage near miss reporting by acting on reports and making sure that nobody loses a bonus for stopping work.
• Set objectives for safety, such as the percentage of reversing movements guided by a banksman.
• Review health and safety performance regularly, including the incident log, and act on the findings.
• Share the lessons from the incident with all shifts and contractors.

Marks counted: 0 of 14