Garment factory fire

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.

• Obligation (a): the rear exit was padlocked, the main stair corridor was blocked, and the smoke detector was disconnected, so the workplace was not kept as safe as reasonably practicable.
• Obligation (a): unguarded drive belts and daisy chained extension leads on the stitching floors are unsafe equipment and unsafe use of electricity.
• Obligation (a): the boiler was last examined three years ago and a steam hose has leaked for weeks, so equipment was not maintained.
• Obligation (a): fire extinguishers were not checked for three years, so they may not have worked, and lint was allowed to build up around machines and light fittings.
• Obligation (b): new operators get one morning shown by a neighbour, with no formal training on machines, hazards or fire.
• Obligation (b): no evacuation drill was ever held, so nobody had been trained in what to do or where to go.
• Obligation (c): supervisors did not check that escape routes were clear or that the padlocked door could be opened, and the guard with the only key left his post.
• Obligation (c): nobody supervised housekeeping or equipment condition, since lint, blocked corridors and leaking steam were left for weeks.
• Obligation (d): there was no organised arrangement for safety: no safety officer until now, no committee, written reporting or named person for fire, and the MD visits only twice a month.
• Obligation (e): no heat protection for pressing workers and no cut resistant gloves for cutters, which must be supplied at no cost to the worker.
• Obligation (f): 13 hour days, six days a week, with one 30 minute break, as a regular pattern in busy periods, harm safety and health.
• Obligation (g): long hours, piece rate pressure and overtime to 23:00 probably caused fatigue, which slows reaction in an emergency.
• Obligation (h), keeping up with technical knowledge: the false alarms from the detector were treated by switching it off instead of finding the lint problem.
• The cost of safety measures was put behind output and orders, and the workers' complaints were ignored, which shows the obligations were not treated as a priority.

Marks counted: 0 of 15

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 evacuation drill had ever been held, so workers did not know how to react or how long it would take to leave.
• The rear exit door was padlocked and the only key was held by a guard who was away from his post, so a main escape route was unavailable for about 10 minutes.
• The corridor at the top of the main stair was blocked by stacked fabric and cartons, so the other escape route was also unusable.
• The alarm was a hand bell at reception that could not be heard over machines or on three floors, so there was no effective warning.
• The smoke detector in the level 3 store had been disconnected, so there was no early warning of the fire.
• Fire extinguishers were last checked three years ago and nobody was trained to use them, so early firefighting was unlikely to work.
• There was no evacuation plan with an assembly point, fire wardens or roll call, so nobody knew who was still inside.
• Workers jumped from a window, which shows that safe routes were not available and risk of further injury.
• The evening overtime shift had less supervision, which reduced the number of people able to direct an evacuation.
• The lane beside the building was blocked by parked motorcycles, so the fire brigade was delayed by 25 minutes.
• There was one first aid box and no trained first aider on the shift, so 14 injured workers had no first aid help.
• The PM assumed that workers knew the way out, so no emergency plan was written or communicated.

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.

• It was done by the PM alone, who has had no training in risk assessment, so competence is in doubt.
• It is four years old and has no review date, although the factory has since changed in size, stock and working hours.
• Hazard identification is poor: lint, old light fittings, extension leads, the hand bell alarm and the disconnected detector are not mentioned.
• The people at risk are listed only as workers, with no mention of night overtime staff, visitors, new operators or people who might need help to escape.
• The existing controls are vague, for example careful use and staff are experienced, and say nothing about who does what or how often.
• The only fire control for a store of fabric is a no smoking sign, which does not address ignition or fire spread.
• The escape row lists two staircases but does not consider that one is padlocked and the other blocked.
• Every risk is rated low with no explanation, which is not credible for a store full of flammable material in a building with 220 people.
• No further action is shown for any hazard, so there is no plan, owner or deadline for improvement.
• There is no signature, so nobody has taken responsibility for it.
• There is no sign that workers or supervisors were consulted, though they know where lint builds up and which exits are used.
• The assessment does not consider emergency procedures such as an alarm, assembly point and drills.
• The steam boiler and leaking hose are assessed with the words staff are experienced, which is not a control measure.
• It was filed and not communicated to workers, so it did not lead to any change on the floor.

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.

• Set up a joint health and safety committee with elected worker representatives, meeting regularly with written minutes and agreed actions.
• Give representatives time in work hours, training and access to managers.
• Consult workers before changes such as new layouts, machines or overtime patterns.
• Involve operators and supervisors in risk assessments and inspections, as they know where lint builds up and which doors are used.
• Introduce a simple route for reporting hazards and near misses, including a written or anonymous option, rather than word of mouth.
• Protect workers from reprisal, because those who complain are now told others are waiting for their jobs.
• Give feedback on what was done about each report, for example on a notice board.
• Involve workers in evacuation drills and ask for their ideas afterwards.
• Hold short briefings in the workers' own language at the start of shifts.
• Management should walk the floor regularly and listen to workers, since managers now rarely do.
• Include workers in incident investigations, so lessons are accepted and used.
• Recognise good reporting, so that raising a concern is seen as helpful.

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.

• The MD visits twice a month and appears to leave safety to the PM, so there is no visible leadership.
• Output and export orders are put first, shown by overtime to 23:00 and the piece rate system.
• Workers who complain are told that others are waiting for their jobs, so fear stops reporting.
• Complaints go to the PM by word of mouth and are not recorded or followed up.
• The detector was disconnected instead of its cause being dealt with, which shows that shortcuts are accepted.
• Locked exits and blocked corridors were allowed to continue, so managers and supervisors tolerate unsafe conditions.
• No drill has ever been held, and the PM assumes workers know the way out, which shows complacency.
• Equipment was not maintained or checked for years, showing that spending on safety is avoided.
• Operators are trained only by one morning with a neighbour, so safety is not treated as a skill.
• The MD blames the PM and the PM blames the workers, so nobody accepts responsibility.
• Basic protection such as gloves is not supplied, which tells workers that their safety has low value.
• Nobody challenges unsafe behaviour, which suggests unsafe habits have become normal.

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.

• Daily checks by supervisors that exits are unlocked and corridors and stairs are clear, with a signed checklist.
• Regular workplace inspections by management and worker representatives, with actions tracked until closed.
• Weekly test of the fire alarm and detectors, with records.
• Regular checks and servicing of fire extinguishers, with tags and records.
• Timed evacuation drills, with notes on delays, blocked routes and head counts.
• Checks on electrical leads, plugs and light fittings and on lint build up around machines.
• Examination and maintenance records for the boiler and steam pipework and a check on leak reports.
• Checking that operators have received machine and safety training and that records are kept.
• Counting hazard and near miss reports and the share of actions closed on time.
• Monitoring hours worked and rest breaks, to find fatigue risks.
• Safety tours and observation of work practices such as use of guards and protective equipment.
• Periodic audits of the safety management system against the policy.
• Short worker surveys on how safe they feel and whether they would report a concern.

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.

• Make the scene safe, care for casualties and notify the authorities and the insurer, as required by law.
• Preserve the scene and evidence with photographs, sketches and measurements before anything is cleared.
• Secure physical evidence such as the light fitting, burnt fabric, detector, bell, padlock and key.
• Select a competent investigation team led by someone independent of the production line, with worker representatives.
• Take statements early and separately from the injured, the guard, supervisors, stitching operators and the PM.
• Collect CCTV or gate records if they exist, and the timeline of alarm, evacuation and arrival of the fire brigade.
• Review documents: risk assessment, maintenance, inspection and training records, hours worked and the overtime list.
• Establish the immediate cause of ignition and spread, for example the lint covered fitting and stored fabric.
• Identify underlying causes such as blocked routes, a disabled detector and no drills.
• Identify root causes in management arrangements, such as no inspection system, no named responsibility and output pressure.
• Look at earlier warning signs such as the false alarms and the unsafe conditions that workers had complained about.
• Use a structured method such as a timeline or asking why repeatedly, and avoid stopping at blaming the workers.
• Write recommendations with an owner, deadline and cost for each action.
• Share findings with workers and managers and include lessons in training.
• Follow up to check that the actions have been done and are working, and review the risk assessment.
• Consider support for injured workers and the family of the worker who died.

Marks counted: 0 of 15

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.

• Compensation and legal claims from the injured workers and from the family of the worker who died.
• Fines, legal costs and the cost of complying with notices from the labour inspector.
• Wages paid to workers while the factory is closed for three weeks.
• Lost production and late delivery penalties on orders in progress.
• Loss of the main export buyer and other customers, and damage to the reputation of the business.
• Damaged machines and equipment, which the insurance does not cover.
• Cost of recruiting and training replacements for injured workers and those who do not return.
• Sick pay and medical treatment costs for the 14 hospitalised workers.
• Management time spent on the investigation, the inspector and the insurer.
• Higher insurance premiums in future, if cover is available.
• Counselling and support for distressed workers.
• Falling morale and higher absence and staff turnover, which cut productivity.

Marks counted: 0 of 12