Dye house chemical release

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.

• Change of supplier and product: the stronger bleach needed a risk assessment before first use, and none was carried out.
• The new product reacts dangerously with the acid, which should have been found in the supplier's safety data sheet and used in the assessment.
• The safety data sheet was filed in purchasing and not passed to the kitchen, so those at risk had no information.
• Workers were not told about the new hazard, and the label was in a language many cannot read well.
• Workers were not trained in the new product, its dilution or what to avoid mixing it with.
• Storage was not reviewed, and the acid and bleach drums were found stored next to each other.
• Change of shifts to 12 hours without a risk assessment of fatigue and performance.
• The same number of workers was kept for longer shifts, with less rest for them to recover.
• The night supervisor now covers two floors, which reduces supervision.
• Maintenance at night was reduced to one fitter, which reduces the ability to fix faults such as the pump or the fan.
• Postponement of the pipework replacement is a change to the maintenance plan with no risk assessment.
• The changes were made by the PM for cost or output reasons, with no competent person asked to assess safety.
• Workers and their representatives were not consulted about the changes.
• Emergency procedures were not updated to cover the new chemical.
• There was no review of the changes after they were made, even after the first dizziness reports in month 1.
• The combined effect of several changes at once was not considered.

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.

• Examine the task with the workers who do it, since they know that the pump is often out of order and drums are poured by hand.
• Identify the hazards, such as incompatible chemicals, residue in tanks and splashes.
• Assess the risk and decide which controls are needed.
• Technical controls: a reliable transfer system, tank labelling and keeping acids and bleach in separate places.
• Technical controls: ventilation that works and gas detection with an alarm in reach.
• Procedural controls: a check that the tank is clean and empty before filling, signed by the operator.
• Procedural controls: a permit or checklist for non-routine tasks such as cleaning tanks.
• Behavioural controls: training, supervision and instruction in a language workers understand.
• Write the procedure down so that it is consistent and can be used for training.
• Provide suitable PPE as a last line of defence, with training in its use.
• Monitor by supervisors observing the task and by regular checks that the procedure is followed.
• Review the system after incidents or changes and when workers say it is not how the job is done.

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.

• Treat the incident as a high level investigation because of the serious injury and the number of people affected.
• Make the area safe, treat the injured and secure the scene before collecting evidence.
• Interview the affected workers, the fitter, the supervisor and the purchasing manager.
• Collect the safety data sheet, the purchase records, the training records and the shift patterns.
• Collect the maintenance records for the pump and the ventilation fan.
• Photograph the tank, the drums, the chained doors and the alarm button.
• Analyse the information to find immediate causes, such as mixing the two chemicals in one tank.
• Identify underlying causes, including the changes, 12 hour shifts and supervision.
• Identify measures to control the risks and make an action plan with dates and owners.
• Report as required by national law and tell the workers about the results.

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.

• Records are kept on paper by each supervisor and not collected centrally.
• Nobody reviews the records, so trends are not found.
• The records show repeated problems in the chemical kitchen at night, such as dizziness, eye irritation and fainting.
• Month 1 and month 5 incidents were not investigated and workers were sent home.
• Month 2: a leaking drum of the new bleach was used anyway, so a warning was missed.
• Month 4: acid and bleach drums stored together was a near miss with the same chemicals as the incident.
• Month 6: a ventilation fan stopped for two days and the repair was delayed, which increased the exposure.
• Actions recorded were weak, such as told to wear goggles or moved to another shelf, and did not deal with causes.
• No lost time injuries does not show the plant is safe, because it is a lagging indicator and can hide near misses and ill health.
• Some events were not reported at all, so the true level of risk is not known.
• Absence from dizziness and fainting is a sign of ill health that should be tracked.
• Near misses are free warnings, and Crescent did not use them.
• A mix of leading indicators such as inspections done and actions closed on time is needed.
• Results should be reviewed by managers and used in decisions on resources.

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.

• Organisational: 12 hour shifts with the same numbers of workers increase fatigue.
• Organisational: managers prioritise cost and output, which discourages careful working.
• Organisational: poor communication, because the data sheet stayed in purchasing.
• Organisational: reduced night maintenance and supervision.
• Job: a faulty transfer pump meant chemicals were poured by hand, which increases the chance of error.
• Job: instructions are in English, are kept in the supervisor's office and do not match how the job is done.
• Job: the tank was not cleaned and there was no check before filling.
• Job: the drum label was hard to read for many workers.
• Job: the night environment, with poor ventilation, may affect alertness.
• Individual: the worker was not trained on the new product, so lacked competence.
• Individual: fatigue after a long shift reduced attention.
• Individual: the worker may not have perceived the risk because the drums looked similar.

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.

• There was no emergency plan for a chemical release, so people did not know what to do.
• The alarm button was out of reach of the workers, so the alarm was delayed.
• The supervisor was on another floor and did not see the problem.
• It took about 12 minutes to turn off the fan that was drawing the gas into the hall, so nobody had the role or the knowledge.
• Two doors were chained, so escape routes were blocked.
• Workers evacuated by themselves, with no assembly point or roll call described.
• No drills had been carried out for chemical emergencies.
• Only one fitter was on duty at night, so help was limited.
• No first aid or trained person is mentioned for chemical exposures, and no eyewash or showers are described.
• There is no information about contact with the emergency services or sharing of the data sheet with them.
• Workers were not trained in the hazards of the new chemical.
• Emergency procedures should have been planned in advance and tested.

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): the ventilation fan failed for two days and the pump is often out of order, so equipment was not maintained.
• (a): doors were chained, which is an unsafe workplace condition.
• (a): acid and bleach were stored together and the chemical work method of pouring by hand was unsafe.
• (a): replacement of worn pipework was postponed for a year.
• (b): workers were not trained in the new bleach, and instructions are in English only.
• (b): workers say the instructions are not how the job is done, so the instruction was not suitable.
• (c): the night supervisor looks after two floors and was absent when the release happened.
• (c): drums were used after a leak with no checks, which shows weak supervision.
• (d): there is no emergency plan, the safety committee has not met for eight months and there is no worker representation.
• (d): the safety data sheet was not passed to the people who needed it.
• (e): goggles were suggested after eye irritation, but no suitable protection or training is described for the strong chemical.
• (f): the 12 hour shifts with the same workforce harm health and safety.
• (g): fainting and dizziness at the end of 12 hour shifts show that measures against fatigue were not taken.
• The GM's view that workers are paid to follow instructions ignores the employer's duties under R164.

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.

• Stop blaming workers and accept that management arrangements contributed to the incident.
• Provide resources for a reliable transfer system, a working ventilation fan and adequate maintenance at night.
• Appoint a senior person with responsibility for health and safety and define roles for supervisors.
• Restart the safety committee with worker representatives and meet regularly.
• Require a risk assessment and approval by a competent person before any change in chemicals, processes or shifts.
• Take part in safety tours and visit the night shift.
• Review incident records regularly and act on the trends.
• Set objectives, such as the number of near misses reported and actions closed on time.
• Review health and safety performance regularly, including 12 hour shift patterns.
• Communicate openly with workers about the incident and the changes made.

Marks counted: 0 of 10