Poultry plant ammonia 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.

• A risk assessment finds what could cause harm, who may be harmed and what precautions are needed, so that risks can be controlled.
• The assessments at Fresh Valley are seven years old and do not cover manual handling, repetitive work or the refrigeration plant, so the main hazards were not identified.
• Ammonia is toxic and corrosive, and a release can burn the eyes, skin and lungs and can kill. Liquid ammonia under pressure is also very cold.
• Repetitive cutting and packing at a fast rate, with awkward postures, can cause pain and injury to the hands, wrists and shoulders.
• Wet floors, knives, moving line equipment, cold rooms, noise and work in the roof space are further hazards.
• The assessment should identify who is at risk, including line workers, agency workers, fitters, contractors and people who cannot get out of a cold room.
• It should evaluate the likelihood and the severity of harm, together with the controls that exist, such as the detectors, which were not working.
• The warnings in the log, such as the smell of ammonia in month 1 and the corroded pipe in month 2, showed that the risk was known and should have led to a review.
• The assessment should be done by a competent person, with help from the workers who do the jobs, and should consider the effect of raising the line speed.
• It should apply the hierarchy of control, for example by changing the design of the task, using a safer refrigeration system and limiting the speed of the line.
• The significant findings should be recorded and an action plan with owners and dates should be made.
• The assessment should be reviewed after changes, after incidents and near misses, and at planned intervals.

Practice points 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.

• Keep the refrigeration plant in good condition with planned inspection and maintenance of the pipes, valves and joints, and replace corroded parts instead of patching them.
• Keep the amount of ammonia as low as practicable, and consider a system that uses less of it or a safer refrigerant.
• Fit ammonia detectors in the plant room, the roof space and the areas where gas could collect, and test and calibrate them regularly.
• Link the alarm to a place that is always staffed and to a siren and flashing lights in all parts of the plant, with an automatic shut-down of the plant at a set level.
• Repair any fault in the detectors at once, and do not run the plant without working detectors, or have a tested alternative.
• Keep the plant room secure, with the door closed and signs, and with access only for trained and authorised people.
• Label the valves and pipes, and keep up to date drawings and an operating manual in the plant room.
• Have emergency shut-off valves that can be reached from a safe place outside the plant room.
• Provide ventilation of the plant room that works in an emergency, and a safe way of venting the gas away from people.
• Provide breathing apparatus and suits for trained emergency staff, and emergency eyewash and showers near the plant.
• Use competent contractors who are selected for their experience of ammonia plant, and who work under the permit system.
• Check the controls with regular audits and tests, and keep records.

Practice points 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 permit to work is a formal written system that controls dangerous work, so that it begins only when the hazards have been assessed and the precautions put in place.
• There was no permit for work on the ammonia system, and the fitter was sent to the roof without any check of the system or of the precautions.
• The system was not isolated, so liquid ammonia was still in the pipe under pressure when the valve was loosened.
• The permit should state the task, the place, the hazards, the isolation, the protective equipment, the time limit and the emergency arrangements.
• The permit should be issued by a trained and authorised person who has seen the site of the work and has checked that the precautions are in place.
• Competent refrigeration personnel should establish and verify the required energy/material isolation and management of residual pressure and ammonia before opening the system, using a designed safe method. Do not release ammonia into the workplace as an improvised depressurisation step.
• Assess roof-space access, supervision, communication and emergency/rescue needs for the task. A second person does not by itself make high-risk maintenance safe; the required competent resources and controls must be established before work.
• Schedule high-risk maintenance when adequate competent supervision, isolation and emergency arrangements can be provided. Night work is not universally prohibited, and calling a task an emergency does not remove the need for effective controls.
• Maintenance should be planned and not only done when something fails, with schedules and records.
• Contractors should be chosen for their competence and safety record, and not only for the cost, and should provide risk assessments and method statements.
• Fresh Valley should give contractors information about the hazards of the site, the permit system and the emergency arrangements, before they begin.
• The fitter and others should be told that they have the authority to stop and refuse work that is unsafe.
• Fresh Valley should supervise contractors and check the quality of their work, and hold meetings with them to share information.
• The permit system should be monitored by audits, and breaches should be dealt with.

Practice points 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.

• The bonus and the target to raise the line speed show that output is put before health and safety.
• There are no figures for accidents and ill health, and the pain of the workers was not entered in the accident book, so reporting is poor.
• Earlier warnings, such as the smell of ammonia and the corroded pipe, were not investigated or acted on.
• The safety policy names only the owner, and the duties of the safety officer were given to the EM, who has a conflict of interest.
• Workers who stop the line are shouted at and lose bonus, so they do not feel able to raise concerns.
• Senior managers should set a clear policy that safety comes first, name the people who are responsible and give them the resources.
• They should review the line speed and the bonus so that they do not encourage unsafe work, and include safety in the targets.
• They should appoint a competent safety adviser who is independent of production.
• They should be visible on the shop floor, listen to workers and act on what they hear.
• They should consult workers and agency workers on safety and set up a way of reporting problems without a penalty.

Practice points 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.

• Employers must give workers the information, instruction and training needed to work safely, matched to the risks of the work.
• Induction should be given before work starts, and should cover the hazards of the plant, the rules, the alarm, the exits, the muster point and who to report to.
• The induction should be in the languages that workers speak, with pictures and demonstrations, and agency workers should receive it in the same way as employees.
• All workers should be told about the hazard of ammonia, its smell, the signs of exposure and what to do if they smell it, such as moving away to a safe place upwind.
• Line workers should be trained in safe work methods for cutting and packing, including posture, breaks and how to report pain early.
• Maintenance staff should be trained in the ammonia system, the permit system, isolation and the use of breathing apparatus.
• Supervisors need training in their role, including how to supervise agency workers, how to respond to reports and why they must never discourage workers from stopping the line.
• Fresh Valley should agree in writing with Quick who is responsible for training and protective equipment, and should give notice of its need for workers.
• Refresher training should be given at intervals and after changes and incidents.
• Training should be recorded, and its effect checked by observation and questions.
• Communication can be improved with pictures and signs in several languages, regular short safety talks at the line, and a simple way of reporting hazards.
• Workers on the line should be involved in safety meetings and in risk assessments, since they know the work best.

Practice points 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.

• An emergency plan should be based on the risk assessment and cover a release of ammonia, a fire and people trapped in a cold room.
• The plan should name people with roles, such as the incident controller, the emergency team, the first aiders and the person who calls the emergency services.
• The alarm should be heard and understood in all parts of the plant, including the roof space and the cold rooms, with lights as well as sirens.
• In the incident the detectors did not alarm and the siren was not heard everywhere, so people did not know what to do.
• Exit routes should be marked, lit and kept clear, with ways out from the cold rooms that can be opened from the inside.
• The muster point should be upwind of any likely release and away from the plant room, and not in the car park next to it.
• Workers should be told to move away from the gas, upwind and to higher ground, and not towards the plant room.
• A roll call at the muster point should account for everyone, including agency workers and contractors.
• Drills should be held at intervals and used to improve the plan, and there had been none for three years.
• An emergency team should be trained and equipped with breathing apparatus and suits, and be available on every shift.
• First aid should match the risk, with trained first aiders on every shift, eye wash, oxygen and a plan for treating burns and breathing problems.
• The emergency services should know about the ammonia, the plan of the site and where the plant is, and should take part in exercises.
• There should be a plan for the transport of casualties to hospital and the care of those who are exposed.
• After an emergency the site should be made safe, evidence preserved and the plan reviewed, and workers offered support.

Practice points 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.

• The aim of an investigation is to find the causes so that a repeat can be prevented, not to find a person to blame.
• The first step is to give care to the injured, make the scene safe and call the emergency services, and then preserve the evidence, such as the valve and the pipe.
• Information should be collected from the scene, photographs, the log, maintenance and training records, the permits and statements from witnesses.
• The team should include a manager, a supervisor and a worker representative, with the right competence, and may need outside experts.
• Witnesses should be interviewed soon, separately and with care, and in a language that they understand.
• The team should build a timeline and look for immediate, underlying and root causes.
• Immediate cause: the fitter loosened a valve on a pipe that had not been isolated, and liquid ammonia sprayed out.
• Immediate cause: the detectors were out of order, so there was no alarm, and the siren was not heard everywhere.
• Immediate cause: workers ran in the wrong direction because there was no evacuation plan or training, and two could not get out of a cold room.
• Underlying cause: there was no permit or isolation system for work on the ammonia plant and no planned maintenance, so a corroded pipe was patched and left.
• Underlying cause: the faults in the detectors were not repaired, and earlier warnings were not acted on.
• Underlying cause: poor training and induction of agency workers and contractors and no drills.
• Root causes include a poor safety culture, where output was put first, unclear responsibilities and no competent safety adviser.
• The team should make recommendations with an action plan with owners and dates, report the incident as the law requires and share the lessons with the workers.

Practice points 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.

• Moral: a fitter died and eleven workers were injured, two of them seriously, and nobody should be harmed by their work.
• Moral: the families have lost income and a loved one, and the workers who were trapped or injured may suffer for a long time.
• Moral: the pain of workers on the line is a harm that can be prevented, and the plant has a duty of care to agency workers as well as to employees.
• Legal: employers must provide safe plant, safe systems of work, information, instruction, training and supervision, and must assess the risks.
• Legal: the failures at Fresh Valley, such as the lack of a permit, the broken detectors and no drills, are likely to be breaches of these duties.
• Legal: the authority may issue a notice or prosecute, and managers and directors may be personally liable.
• Legal: injured workers and families may bring a claim for compensation.
• Financial: the direct costs include damage to the plant, the loss of product, the repair of the pipes and the cost of the investigation.
• Financial: the plant may be closed for a long time, with loss of production and income, and penalties under the supermarket contract.
• Financial: fines, compensation and higher insurance can be large, and the loss of customers and reputation can be difficult to recover.
• Financial: workers with injuries from repetitive work lead to sickness absence and the cost of replacing staff, so better design pays for itself.
• Reputation: supermarkets check the safety record of their suppliers, and a fatal incident may lead to the loss of the contract.

Practice points counted: 0 of 12