Steel rolling mill pusher 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 permit to work is a formal written system that controls high risk non-routine work, such as repairs in a dangerous area, by setting out the work and the precautions before it starts.
• Before the repair a competent person should identify the hazards, which here include a moving hydraulic pusher, stored hydraulic pressure and heat from the furnace.
• The pusher should have been stopped and isolated from its electrical and hydraulic power, so that it could not move.
• Secure isolation against reconnection under a competent lock-off system, with personal control where required and clearly defined authorised removal and hand-back procedures. A tag alone does not physically prevent restart.
• Stored hydraulic pressure should have been released and any part that could move or fall should have been blocked.
• A competent person should verify all required isolations and absence/control of hazardous energy before access, using a safe defined procedure. A generic attempt to start equipment is not a complete verification method and must not expose anyone to movement.
• The permit should state the location, the work to be done, the hazards, the precautions and the protective equipment required.
• It should also state the time that it is valid for, and the names of the issuer and the person who will do the work.
• The permit should be issued by an authorised person and accepted by the fitter, who signs to show that he understands the precautions.
• A sign should be put on the control panel and the operator should be told, so that the operator knows not to start the pusher.
• The permit should be handed over properly at a change of shift, and the lock should be removed and the permit closed only when the work has been finished and the area checked.
• At Zameen nothing was in place, because there was no permit system and no lock-out equipment, and supervisors and fitters each thought that isolation was the other's job.

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.

• Alpha was chosen because its price was a third lower than the others, but competence should be the main factor and not price.
• Zameen should have checked Alpha's health and safety policy, accident record and insurance before choosing it.
• Zameen should have asked for the qualifications and training of the fitters, including their experience of hydraulic systems like the pusher.
• Zameen should have asked for a risk assessment and a method statement for the work and checked them.
• Zameen should have given Alpha information about the hazards of the site, such as the furnace, the pusher, the 12 hour shifts and the other work going on.
• Every contractor should receive an induction, covering the layout, the emergency arrangements and the site rules, and not just a day on site.
• The work should have been planned together with the mill, including when it would be done, in which area, and how it would affect production.
• The work should have been controlled by a permit to work and isolation of the pusher.
• A named person at Zameen should have been given the job of supervising the work and of acting as the contact for the contractor.
• Zameen should have monitored the work on site and had the authority to stop it if it was not safe.
• Both employers share a workplace, so they have to co-operate and tell each other and their workers about the risks that their work creates.
• After the job Zameen should review Alpha's performance and use the result when it makes decisions about contractors in the future.

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.

• Organisational: the monthly output targets and the bonus of the PM put production before safety.
• Organisational: the cut in the maintenance budget and the view that stoppages are costly give a message that speed is more important than precautions.
• Organisational: 12 hour shifts and overtime cause fatigue, and the operator had been at work for 11 hours.
• Organisational: poor communication, because the fitter was not told about the shift pattern and the operator was not told that the fitter was at the pusher.
• Organisational: supervision was weak, as nobody was named to look after the contractor and the supervisor only told the fitter to be quick.
• Job: the control panel had no cover and no lock, so it was easy to start the pusher by mistake.
• Job: the trip bar had been removed, so a safety device that could have stopped the pusher had gone.
• Job: poor lighting, noise and faded signs make hazards harder to see and communication harder.
• Job: the operator could not see the fitter from the control panel, so a task that was done by two people had no way of checking.
• Individual: the fitter was new to the mill and had no induction, so he did not know the hazards or the rules.
• Individual: the operator was tired and under pressure to finish the stoppage, which affects attention and judgement.
• Individual: earlier mistakes with the pusher had gone without action, so the habit of not following rules could have become normal to the workers.

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 policy has a statement of intent that says what the organisation wants to achieve, an organisation section that says who is responsible for what, and arrangements that say how it will be done.
• The policy of Zameen is only a general statement, so it does not say who has to do what, and nobody owns isolation.
• It was written six years ago and not reviewed, so it does not reflect the changes in work since then.
• Directors should set the direction, provide resources such as maintenance money and competent staff, and review performance.
• Managers, such as the PM and the maintenance manager, should put the policy into practice by planning, setting up safe systems and making sure that people follow them.
• Supervisors should see that work is done safely, that permits are in force and that workers are not hurried.
• Workers should follow the rules, use equipment as instructed, report hazards and not put others at risk.
• A competent person should advise the mill, but the safety officer of Zameen has other duties, so the time and the authority are not enough.
• The policy should be communicated to all workers and contractors, which was not done.
• The mill should check that the policy works through monitoring, and review it after a serious incident like this one.

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.

• Active (before the event) monitoring checks that the controls are in place and working, and reactive (after the event) monitoring looks at incidents and near misses.
• Planned inspections of the furnace area, the pusher and the control panels should be made by managers and supervisors with a checklist.
• The inspection should check guards, trip devices, covers, lighting, signs and isolation equipment.
• Audits should check the whole system, for example whether permits are issued and closed properly and whether contractors are controlled.
• Sampling of permits, observations of workers at work and talks with them show whether the procedures are followed in practice.
• Leading indicators, for example the number of inspections done, the actions closed on time and the training completed, show how well the system is working.
• Lagging indicators, such as injuries, near misses and lost time, show what has gone wrong.
• At Zameen the log shows two near misses with the pusher that were noted but not reviewed or acted on, so reactive monitoring did not work.
• The trip bar was removed and nobody noticed, which suggests that there were no inspections of the safety devices.
• The maintenance log shows work without isolation or a hot work check, and nobody reviewed it.
• Reports should be made to the management, who should compare them with targets and with earlier periods to look for trends.
• Quarterly safety meetings, with supervisors rarely present, do not give a regular way of reviewing the results.
• Workers should be consulted and encouraged to report hazards and near misses without blame.
• Findings should lead to actions with owners and dates, and the actions should be followed up and checked.

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 first step is to make the scene safe, give first aid, and preserve evidence by isolating the pusher and recording its state.
• A team should lead the investigation, with a manager, a supervisor, a worker representative and the safety officer, and with someone independent of the area.
• Information should be collected by photographs, measurements of the area and the position of the controls.
• Witnesses should be interviewed, which includes the operator, the supervisor who sent the fitter, the colleague who found him and the security guard.
• Documents should be reviewed, such as the contractor selection papers, the maintenance and shift logs, the policy, the risk assessments and the training records.
• The immediate cause is that the pusher moved while the fitter was in it, because it was not isolated.
• The underlying causes include the absence of a permit and lock-out system, the removed trip bar and the uncovered panel.
• The root causes are management failures, such as production pressure, cuts in maintenance, poor contractor control and the lack of monitoring.
• The team should look at human factors such as fatigue and communication, and not stop at blaming the fitter.
• The team should recommend actions to remove the causes, in the order of the hierarchy of control.
• Each action should have a person responsible, a date and a way to check that it was done.
• A report should be written and the results shared with the workers, contractors and directors.
• Under the law of the country the serious injury may need to be reported to the authority, and the mill should check what is required.
• Benefits include preventing a repeat, showing workers that safety matters, meeting legal duties and reducing future costs.

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 emergency plan was written for day working, so it does not cover the night shift when the incident happened.
• There was only one trained first aider, on the day shift, and the guard who gave first aid at night held a certificate that had expired.
• The mill should have enough trained first aiders on every shift, based on the number of workers and the risks, and fully stocked first aid boxes.
• No one nearby knew how to stop the pusher quickly, so emergency stops should be marked and workers trained to use them.
• The fitter was found by a colleague who had to shout for help, so the mill should have a reliable way to raise the alarm, such as telephones or radios.
• An ambulance was called and came after 50 minutes, so the mill should have an agreement with the ambulance service and a plan for what to do in that time.
• The hospital is 30 minutes away, so the mill should consider a vehicle that is ready and a person trained to drive it, and a way to send a person with the casualty.
• Rescue from machines needs equipment and training, so that a trapped person can be freed safely without causing more harm.
• A person should be named to take charge, to call the emergency services and to meet them at the gate.
• The plan should cover other emergencies as well, such as fire, a spill of hot metal or a hydraulic oil fire near the furnace.
• The plan should include evacuation routes, assembly points and a way to account for people, including contractors.
• Drills should be held on all shifts, and none was held in two years.
• New workers and contractors should be told what to do in an emergency in their induction.
• The plan should be reviewed after the incident and after any change, with lessons used to improve it.

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: the fitter lost an arm because of failures in the system, and people have a right to go home safely.
• Moral: workers and their families suffer pain, loss of income and long-term disability, and the mill has a duty of care to everyone who works there, contractors as well.
• Moral: the incident can harm the confidence of the workers and may reduce morale in the mill.
• Legal: the employer has a duty to provide safe equipment, safe systems of work, information, training and supervision.
• Legal: the authorities can inspect, issue notices to improve or to stop work and prosecute the company and its managers.
• Legal: the injured fitter, or his employer, may bring a civil claim for compensation against Zameen.
• Legal: the managers who set production before safety may be held personally responsible.
• Financial direct costs: medical care, compensation, fines and the cost of repairing or replacing damaged equipment.
• Financial direct costs: loss of output during the investigation and if the authority stops work on the pusher.
• Financial indirect costs: time spent on the investigation, replacing and training staff, and disruption to other workers.
• Financial indirect costs: damage to the reputation of the mill with customers and with contractors, who may be less willing to work there.
• Insurance premiums may rise, and not all costs are insured, so the mill will pay part of them itself. The cost of improving the system is small compared with these costs.

Practice points counted: 0 of 12