Recycling plant baler crush 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.

• A risk assessment is a careful look at what could cause harm so that a decision can be made about the precautions that are needed.
• Noor has no risk assessment for the baler or the conveyor, although they are the most dangerous machines on the site, so the hazards were not identified.
• The only assessments were written by a previous manager and cover other areas, so the assessments are out of date and do not cover the work being done.
• The assessment should begin by identifying the hazards, such as the crushing ram, the moving conveyor, entry into the hopper, noise, dust and forklift trucks.
• It should identify who may be harmed, including operators, agency workers, maintenance fitters, cleaners and visitors.
• It should evaluate the risk, by considering the likelihood of harm and its severity, and existing controls such as the interlocked gate and whether they work.
• The near miss in month 1 and the cable tie in month 2 show a high likelihood of serious harm that was known and not acted on.
• It should identify new controls, using the hierarchy of control, for example a fixed guard, a lock-out system and a remote way of clearing jams.
• The findings should be recorded, as the law requires once an employer has more than a set number of employees, and should be communicated to the workers and the supervisors.
• The assessment should be done by a competent person who knows the machine, with the involvement of the operators who use it.
• It should be reviewed regularly and after any incident or change, such as a change of machine or of staff.
• Because the order of work and the number of agency workers change, the assessment should be practical for the real way that the work is done on each shift.

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.

• The hazard is crushing and entanglement by the ram, which has great force and cannot be stopped by a person once it starts.
• Where possible, access to the hopper should be prevented by a fixed guard, so that nobody can reach the danger zone.
• Where an interlocked guard is suitable, its complete safety system must prevent access to hazardous movement and unsafe restart. Validate stopping performance, access time and the control system; opening a guard cannot be assumed to stop a ram instantaneously.
• The interlock should be designed so that it is difficult to defeat, for example with coded or tamper-resistant switches, and not stopped by pressure from the material.
• The faulty switches should have been replaced in good time, and the maintenance budget and spare parts should be sufficient.
• Have competent specialists design jam-clearing that avoids dangerous access where practicable, with verified energy control and suitable access arrangements. Do not assume an improvised long tool makes work near moving machinery safe.
• Before any necessary authorised access, control and verify all dangerous energy and possible movement, including stored hydraulic or pneumatic energy, under a competent isolation/lock-off procedure. An electrical stop alone is insufficient.
• A permit to work or a controlled procedure for entry should state the checks needed and who authorises the entry.
• Emergency stop devices should be within easy reach, tested regularly and not tied up.
• The floor around the machine should have clear markings, exclusion zones and barriers so that pedestrians and forklift trucks keep away.
• Only trained and authorised workers should operate and clear the machine, and signs should show the rules.
• Supervisors should check that the controls are used, and the machine should be inspected and maintained to a planned schedule.

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.

• Health and safety culture is the shared attitudes, values and behaviour in an organisation about safety.
• Output targets and bonuses linked to production only, with no safety measure, show that production is put ahead of safety.
• Supervisors saw the cable ties and the reaching into the hopper and gave a verbal warning or no action, which shows that rule-breaking is accepted.
• Reports of problems, such as the cable ties and the tied up emergency stop cord, were recorded and nobody acted, so workers learn that reporting has no effect.
• There are no accident or near miss figures on display, and an injury to an agency worker was not recorded in the accident book, which shows poor reporting.
• The safety officer has other duties, safety meetings are not held regularly and temporary supervisors are untrained, which shows low commitment.
• Directors and managers should show leadership by setting clear policy, visiting the work areas and acting when they see unsafe behaviour.
• Safety performance should be included in the targets and bonuses of managers and supervisors.
• Managers should encourage reporting by acting on every report and giving feedback, with a fair approach that does not blame individuals.
• Workers should be consulted and involved in risk assessments and in setting safe methods, and training should be provided in a language that they understand.

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.

• Agency workers are often young or new to the work, are less familiar with the site and may be less willing to raise concerns, so they are at higher risk, and Noor has the same duty to them as to its own employees.
• Noor should agree with Swift in writing who is responsible for what, including training, protective equipment and supervision.
• Noor should tell Swift the nature of the work and the hazards before the worker arrives, and should not ask for workers at the last minute without time to prepare.
• Induction should be given before work begins and should cover the site layout, hazards, emergency arrangements, rules and the person to report to.
• Induction should be in a language that the worker understands, using pictures, demonstrations and written instructions as well as talks.
• Job specific training should be given before a worker uses or works near the baler or the conveyor, and the worker should be shown the controls and the stop buttons.
• Workers should receive protective equipment such as safety footwear, gloves, hearing protection and high visibility clothing on the first day, not the following week.
• Agency workers should not be allowed to do high risk tasks, such as clearing the baler hopper, until they are trained and authorised.
• Competent supervision should be provided for new workers, and supervisors need to be trained for the role, since the temporary supervisors at Noor were not.
• A named person at Noor should be responsible for the agency workers on each shift and should check that they understand the rules.
• Training should be recorded and checked, and the information should be kept up to date.
• Workers should be told how to report hazards and injuries, and the supervisors should know that they must record every accident, including the cut hand in month 4.
• Noor should include agency workers in consultation, safety talks and risk assessments.
• Noor should review the record of Swift and the performance of the agency workers, and should choose the agency by its safety standards and not only by its cost.

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.

• Monitoring measures health and safety performance and shows whether the controls are working.
• Active monitoring takes place before things go wrong, for example inspections of the baler, checks on the interlock, and audits of the permit and isolation system.
• Supervisors should check each shift that the guard, the gate switch and the emergency stop work, and that nobody has defeated a safety device.
• Planned preventive maintenance of guards and switches should be checked against a schedule, and the results recorded.
• Active monitoring should also include checking training records, induction, and the condition of protective equipment.
• Reactive monitoring takes place after an event, for example by recording and investigating accidents, near misses, ill health and complaints.
• Noor did not record the agency worker's cut hand, and the near misses and cable tie reports were not followed up, so it lost the chance to learn.
• Measures such as the number of near misses reported, the number of defeated interlocks found and the percentage of inspections done give early warning.
• Lagging measures such as injuries, days lost and enforcement notices show past failures, and are not enough alone.
• The results should be reported to senior management at regular intervals, so that they can decide on action and resources.
• Findings should be used to correct faults promptly, with a person named for each action and a date for it to be done.
• The system should be audited and reviewed, using the findings to improve the policy and the arrangements.

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.

• The purpose of an investigation is to find out what happened and why, in order to prevent it happening again, and not to blame an individual.
• The scene should be made safe and the baler isolated and preserved, with the interlock, the cable tie and the controls left as they were.
• The authorities should be notified where the law requires it, as it does for a fatal incident, and the family should be supported.
• Evidence should be gathered by photographs, measurements, the log books, the training and induction records, and the maintenance records.
• Witnesses, including the supervisor, the forklift driver and the people who tied the switch, should be interviewed separately and promptly.
• The investigation should be done by a team that includes a manager, a worker representative and a competent person, who are independent of the people involved.
• The immediate causes include the baler not being isolated, the interlock being defeated by a cable tie, the worker entering the hopper and the forklift driver pressing restart.
• Underlying causes include the lack of a risk assessment and of a safe system for clearing jams, and the lack of lock-out equipment.
• Further underlying causes include pressure to meet the target, supervisors who accepted rule-breaking, and untrained supervisors and workers.
• Organisational causes include the poor policy, the lack of monitoring and the failure to follow up the near misses recorded in the log.
• The causes should be set out in a clear chain, so that the investigation can show the failures at each level.
• Recommendations should be specific, with the person responsible and a date, using the hierarchy of control.
• The findings and actions should be shared with all workers and with Swift, and the actions should be checked until they are completed.
• The risk assessment and the policy should be reviewed in the light of the findings.

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.

• Noor should assess the emergencies that could occur, including serious injury, fire, collapse of stacked bales and dust, and plan for them.
• A written emergency procedure should say who does what, and it should cover day, night and weekend working, since the incident was on a Saturday.
• Emergency stop devices should be within reach of workers, tested regularly, and clearly marked.
• An alarm should be audible and visible everywhere on the site, including in the yard when the machines are running.
• Escape routes and assembly points should be marked, kept clear and used in regular drills, which have not been held at Noor.
• The numbers of the emergency services and the address of the site should be displayed near the telephones, and not kept in a drawer.
• A first aid needs assessment should consider the number of workers, the hazards, the distance to the hospital and the shift pattern.
• Because there are heavy machines and a hospital 25 minutes away, Noor needs trained first aiders on every shift, including nights and weekends.
• First aid boxes should be placed near the high risk areas and kept stocked, and the first aiders should be trained with the skills for crush injuries and bleeding.
• A trained person should meet the ambulance at the gate and guide it to the casualty, to save time.
• Rescue arrangements should say how a trapped person can be freed safely, for example by lockout of the baler and a way of reversing the ram.
• Workers, including agency workers, should be told about the emergency arrangements at induction and should know their role.
• Serious incidents should be reported to the authorities, and any injury should be recorded.
• The arrangements should be reviewed after drills and after incidents, and the drills should include night and weekend shifts.

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 worker died at work, and everyone has a right to go home safely, whatever their contract or employer.
• Moral: the family has lost its earnings and a loved one, and colleagues who saw the incident may suffer lasting distress.
• Moral: Noor has a duty of care to agency workers as well as to its own employees, and these workers are often the most vulnerable.
• Legal: employers have a duty to provide safe machinery, safe systems of work, information, instruction, training and supervision, and Noor failed on all of these.
• Legal: the authorities can investigate, issue improvement or prohibition notices, and bring prosecutions, with fines or imprisonment for those responsible, including managers.
• Legal: a civil claim for compensation may be made by the family, and the plant may lose its licence or contracts.
• Legal: legislation usually requires the risk assessment and the maintenance of guards to be in place, and a bypassed interlock is a clear breach of the law.
• Financial: the direct costs include fines, legal fees, compensation, higher insurance premiums, damage to the machine and the cost of repair.
• Financial: the indirect costs include lost production while the plant is stopped for investigation, the cost of replacing and training workers, and investigation time.
• Financial: paper mills and other customers may stop buying from a plant with a fatal accident, so Noor may lose business and its reputation.
• Financial: workers' morale may fall, absence may rise and it may be harder to recruit, which increases costs.
• The cost of the controls, such as new interlocks, lock-out equipment and training, is small compared with the loss from the incident.

Practice points counted: 0 of 12