NEBOSH National Diploma in
Occupational Health and Safety
Unit A: Managing Health and Safety
Week 2 Workbook
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Contents
Homework Questions ...................................................................................................................................... 5
Day 1 ................................................................................................................................................................. 6
Day 2 ................................................................................................................................................................. 8
Day 3 .............................................................................................................................................................. 10
Day 4 .............................................................................................................................................................. 11
A7 The Assessment and Evaluation of Risk ........................................................................................... 13
Exercise 1 – Risk Ranking ........................................................................................................................ 14
Exercise 2 – Tolerability of Risk ............................................................................................................. 15
Nuclear Reactors ................................................................................................................................... 15
Plane Travel ............................................................................................................................................ 16
MMR Vaccine .......................................................................................................................................... 17
Smoking and Lung Cancer ................................................................................................................ 17
Exercise 3 HAZOP ...................................................................................................................................... 19
Classroom Questions ............................................................................................................................... 22
Additional Past Questions ...................................................................................................................... 24
A8 Risk control................................................................................................................................................. 29
Classroom Questions ............................................................................................................................... 30
Additional Past Questions ...................................................................................................................... 31
A9 Organisational Factors ........................................................................................................................... 33
Exercise 1 ...................................................................................................................................................... 34
Activity 1 – Control of Contractors ................................................................................................. 35
Activity 2 – Consultation and Communication .......................................................................... 36
Classroom Questions ........................................................................................................................... 37
A10 Human Factors ....................................................................................................................................... 39
Exercise 1 : X - Y Theory Questionnaire – Employee Preference.......................................... 40
Exercise 2 - Luchin’s Water Jar Problem ........................................................................................ 42
Luchin’s Water Jar – Solution........................................................................................................... 43
Exercise 3 – Human Factors and Human Failures ...................................................................... 45
Exercise 4– Human Failure Case Study .......................................................................................... 48
Exercise 5: Kegworth ........................................................................................................................... 49
Exercise 6 - Belbin’s Team Roles – Self Perception Inventory ............................................... 54
Classroom Questions ........................................................................................................................... 61
Additional Past Questions ................................................................................................................. 62
Classroom Questions - Examiners Feedback ........................................................................................ 65
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A7 Assessment and Evaluation of Risks ........................................................................................ 66
A8 Risk Control ...................................................................................................................................... 69
A9 Organisational Factors.................................................................................................................. 72
A10 Human Factors.............................................................................................................................. 75
Homework Questions - Examiners Feedback ....................................................................................... 78
Day 1 .............................................................................................................................................................. 79
Day 2 .............................................................................................................................................................. 84
Day 3 .............................................................................................................................................................. 88
Day 4 .............................................................................................................................................................. 92
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Homework Questions
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Day 1
1.
Outline the issues that should be considered when planning a health (10)
and safety inspection programme Information on the specific
workplace conditions or behaviours that might be covered in an
inspection is not required.
2.
An employer wishes to build a new gas compression installation to
provide energy for its manufacturing processes. An explosion in the
installation could affect the public and a nearby railway line. In view of
this the employer has been told that a qualitative risk assessment for
the new installation may not be adequate and that some aspects of the
risk require a quantitative risk assessment.
a)
Explain the terms ‘qualitative risk assessment’ AND ‘quantitative risk (5)
assessment’.
b) Identify the external sources of information and advice that the (5)
employer could refer to when deciding whether the risk from the new
installation is acceptable.
c)
A preliminary part of the risk assessment process is to be a hazard and
operability study.
(10)
Describe the principles and methodology of a hazard and operability
(HAZOP) study.
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Outline the use and limitations of fault tree analysis.
3.
(4)
A machine operator is required to reach between the tools of a vertical
hydraulic press between each cycle of the press. Under fault conditions,
the operator is at risk from a crushing injury due either (a) to the press
tool falling by gravity or (b) to an unplanned (powered) stroke of the
press. The expected frequencies of the failures that would lead to either
of these effects are given in the table below:
Failure type
a)
Frequency (per Effect
year)
Flexible hose failure
0.2
a
Detachment of press
tool
0.1
a
Electrical fault
0.1
b
Hydraulic valve
failure
0.05
a or b
Given that the operator is at risk for 20 per cent of the time that the (10)
machine is operating, construct and quantify a simple fault tree to
show the expected frequency of the top event (a crushing injury to the
operator’s hand).
b) If the press is one of ten such presses in a machine shop, state, with (4)
reasons, whether or not the level of risk calculated should be tolerated.
c)
Assuming that the nature of the task cannot be changed, explain how (2)
the fault tree might be used to prioritise remedial actions.
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Day 2
1.
a)
Outline the principles, application and limitations of Event Tree (6)
Analysis as a risk assessment technique.
A mainframe computer suite has a protective system to mitigate the
effects of fire. The system comprises a smoke detector connected by a
power supply to a mechanism for releasing extinguishing gas. It has
been estimated that a fire will occur once every five years (f=0.2/year).
Reliability data for the system components are as follows:
Component
Reliability
Detector
0.9
Power supply
0.99
Extinguishing gas release mechanism
0.95
b) Construct an event tree for the above scenario to calculate the (10)
frequency of an uncontrolled fire in the computer suite.
c)
2.
Suggest ways in which the reliability of the system could be improved.
(4)
A risk assessment has identified the need to introduce a safe system of
work for cleaning some moving machinery. The system proposed
would allow the machinery to be cleaned by the operator whilst it was
running at normal speed with the guards removed. This would present
a risk of injury from the moving parts. To reduce this risk it is proposed
that the cleaning is undertaken with a long-handled device which
would enable the operator’s hands to be kept away from the moving
parts.
a)
Outline the extent to which the proposed system of work meets the (5)
‘general principles of prevention’ referred to in Regulation 4 and
Schedule 1 of the Management of Health and Safety at Work
Regulations 1999. Your answer should refer to the specific ‘general
principles of prevention’ which are relevant to this scenario.
b) Outline the steps that an organisation should take to ensure the (5)
effective implementation of a new safe system of work, assuming that a
detailed risk assessment has already been undertaken.
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3.
The diagram below shows a section of process plant in which a raw
material is pumped continuously to a process from a storage tank. The
flow rate is controlled by an operator who adjusts the manual valve to
achieve the desired flow as shown on the flow gauge. If the flow is too
great a dangerous reaction may occur in the process. If there is
insufficient flow the product produced in the process will be defective
and will have to be discarded. Any contaminant in the raw material may
produce a dangerous reaction.
Apply the methodology of a hazard and operability (HAZOP) study to (20)
the process at point A on the diagram AND give the results of the study
in typical HAZOP format.
You are not required to produce a complete study. Consider only the
process parameter of ‘flow’ and apply no more than three guide words.
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Day 3
An organisation has decided to introduce a permit-to-work system for
maintenance and engineering work in an area used for the batch
manufacture of chemicals operating continuously over three shifts.
1.
Outline the key issues that will need to be addressed in introducing
(10)
and maintaining an effective system in such circumstances.
2.
a)
Outline reasons for establishing effective consultation arrangements (4)
with employees on health and safety matters in the workplace.
b) Outline a range of formal and informal consultation arrangements that (6)
may contribute to effective consultation on health and safety matters in
the workplace.
3
The refurbishment of an organisation’s offices will involve the services
of several different trades from a number of small local companies and
is to be completed while the building is occupied. An interior designer
specialising in commercial properties will manage the project, which
will last about three weeks and will require fewer than five persons to
be working on the refurbishment at any one time.
a)
Outline the criteria that should be used when selecting contractors to (6)
undertake their part of the project.
b) Outline the organisational measures that the project manager may (14)
need to consider in order to ensure the health and safety of office
personnel during the work. You are not required to consider the
specific risks associated with the work.
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Day 4
1.
2
A large warehousing and distribution facility uses contractors for many
of its plant and property maintenance activities. The number of
contractors’ employees on site at any one time is relatively small
(around 5% of the total workforce) but an analysis of the accident
statistics for the previous two years has shown that accidents to
contractor personnel, or arising from work undertaken by contractors,
account for 20% of the lost-time accidents on site.
(i)
Suggest reasons for the disproportionate number of accidents (6)
involving contract work.
(ii)
Describe the key organisational and procedural measures that should (14)
be in place to control the risks from contract work.
A manufacturing company is about to embark on a process of
organisational change that is intended to reduce costs and increase
productivity. As planned, the change will lead to a smaller workforce, a
flatter management structure, enlarged responsibilities for the
remaining staff, outsourcing of most maintenance tasks, increased use
of automated processes and the need for some employees to be multiskilled.
Review the elements of a strategy designed to ensure that the
company maintains its current high standards of health and safety, and
its positive health and safety culture, both during and after the change. (20)
3.
A fast-growing manufacturing company employs 150 people. Health
and safety standards at the company are poor as arrangements have
developed in an unplanned way without professional advice. The
company has managed to avoid any serious accidents and staff at all
levels do not seem particularly concerned. However two employees
have recently experienced near miss incidents and have complained
jointly to the Health and Safety Executive (HSE). A subsequent visit by
an HSE inspector in connection with the near-miss incidents has
resulted in the issue of three improvement notices.
The Managing Director wishes to dismiss the two employees whom he
has described as ‘troublemakers’.
(a) Explain the advice you would give the Managing Director with respect
to the proposed disciplinary action against the employees who have
complained.
(5)
(b) Outline the steps that could be taken to gain the support of the
workforce in improving the health and safety culture within the
company.
(15)
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A7 The Assessment and Evaluation of
Risk
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Exercise 1 – Risk Ranking
Identify the three issues you consider to be the highest risk and the three issues you
consider to be the lowest risk.
Explain the reasons for your choices.
Nuclear power
Alcohol
Swimming
Motor vehicles
Flying (private)
Contraceptives
Guns
Flying (commercial)
Skiing
Smoking
Police work
X - rays
Motorcycles
Pesticides
Football
Firefighting
Surgery
Trains
Large construction
Rock climbing
Food preservatives
Hunting
Bicycles
Food colourings
Spray cans
Electricity
Lawn mowers
Home equipment
Vaccinations
Antibiotics
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Exercise 2 – Tolerability of Risk
Consider the statistical data presented below, regarding the risk of death or serious
injury associated with:
•
Nuclear reactors;
•
Plane travel;
•
MMR inoculation; and
•
Smoking and lung cancer.
1. What is your opinion of the acceptability and tolerability of the associated risks?
2. What factors have influenced your opinion?
3. How do you feel your perception of the risk varies from that of the general
population?
4. If you feel your view point is different, what would account for the difference?
Nuclear Reactors
There have only been 2 major accidents (classified at level seven on the International
Nuclear and Radiological Event Scale - INES) in the history of civil nuclear power (over
13 000 accumulated reactor years of civil use from 1960 to present across 32 countries).
Location
Date Classification Notes
Fukushima, 2011
Japan
Level 7
Tsunami and possibly earthquake damage from
seismic activity beyond plant design. Long-term
effects unknown.
Chernobyl,
Ukraine
1986
Level 7
Explosion and fire in operational reactor, fallout over
thousands of square kilometres, 31 killed in the initial
incident, possible 4,000 cancer cases.
Kyshtym,
Russia
1957
Level 6
Explosion in waste tank leading to hundreds of cancer
cases, contamination over hundreds of km2.
Three Mile 1979
Island, NY
Level 5
Instrument fault leading to large-scale meltdown,
severe damage to reactor core.
Windscale,
UK
Level 5
Fire in operating reactor, release of contamination in
local area, possible 240 cancer cases.
1957
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Probabilistic risk assessments indicate the risk as follows:
•
1 full meltdown expected every 20000 years;
•
2 out of 3 meltdowns would yield no fatalities;
•
1 out of 5 would result in >1000 deaths;
•
1 out of 100 000 melt downs would result in > 50 000 deaths; and
•
The average expected fatalities from a meltdown would be 400.
In comparison air pollution from fossil fuel burning kills an estimated 10 000 people each
year.
Plane Travel
During 2003 there were a total of 106 casualties caused by aviation accidents in UK
airspace. Of these there were 21 fatalities.
89 casualties were caused by UK registered aircraft in UK airspace, of which 15 were
fatalities, and 17 were caused by foreign aircraft in UK airspace of which there were 6
fatalities.
From 1993 to 1996 US Carriers averaged 0.2 fatal accidents per 100 000 flight hours.
The odds of being involved in a fatal accident between 1985 and 2009 are as follows:
Odds of being on an airline flight
which results in at least one fatality
Odds of being killed on a single
airline flight
Top 25 airlines with the best accident
rates - 1 in 5.4 million
Top 25 airlines with the best accident
rates - 1 in 9.2 million
Bottom 25 with the worst accident rates
- 1 in 159,119
Bottom 25 with the worst accident rates
- 1 in 843,744
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MMR Vaccine
A comparison of the risks to children not vaccinated with those who are can be
summarised as
Effect
Risk from Diseases
Risk following 1st innoc.
Convulsions
1: 200
1:1000
Meningitis / encephalitis
1:200 to 1:5 000
1: 1000 000
Blood clotting disorders
1:3 000
1: 24 000
Anaphylaxis
0
1: 100 000 (egg allergy)
Death
1:8 000 / 1:10 000
0
The side effects of inoculation are acknowledged as:
•
Mild forms of any of the illnesses (Measles, mumps, rubella) 1:100; and
•
Serious side effects e.g. convulsions 1:1000.
Epidemiological research has not shown any significant risk of asthma, autism, GuillainBarre Syndrome or Crohnes disease.
Smoking and Lung Cancer
Smoking is estimated to be responsible for more than a quarter of cancer deaths in the UK,
that is, around 43 000 deaths in 2007.
Lung cancer is the 2nd most common cancer in the UK (after skin cancer) and around 86%
of lung cancer deaths in the UK are caused by tobacco smoking.
In the UK in 2008 40 800 people were diagnosed with lung cancer, and approximately35
260 people in the UK died from lung cancer.
The risk is dependent upon the amount smoked and duration of being a smoker, e.g. 20 a
day for 40 years is 8x higher risk than 40 a day for 20 years.
The risk decreases upon giving up though it takes approximately15 years for the risk to
return to the level of a non-smoker.
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Exercise 3 HAZOP
No petrol is being delivered to the delivery nozzle of the pump shown in the following
picture.
Complete the simplified HAZOP sheet for the deviation “No flow”
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Deviation
Safeguards
Guideword
Parameter
No
Flow
Cause
Consequence
(Existing
controls)
Action
(Additional controls)
Assume
there are no
existing
controls
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Deviation
Safeguards
Guideword
Parameter
No
Flow
Guideword
Cause
Consequence
(Existing
controls)
Action
(Additional controls)
Assume
there are no
existing
controls
Parameter
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Classroom Questions
1.
A chemical reaction vessel is partially filled with a mixture of highly
flammable liquids. It is possible that the vessel headspace may
contain a concentration of vapour which, in the presence of sufficient
oxygen, is capable of being ignited. A powder is then automatically
fed into this vessel.
Adding the powder may sometimes cause an electrostatic spark to
occur with enough energy to ignite any flammable vapour. There is
therefore concern that there may be an ignition during addition of the
powder.
To reduce the risk of ignition, an inert gas blanket system is used
within the vessel headspace designed to keep oxygen below levels
required to support combustion. In addition, a sensor system is used
to monitor vessel oxygen levels. Either system may fail. If the inert gas
blanketing system and the oxygen sensor fail simultaneously, oxygen
levels can be high enough to support combustion.
Probability and frequency data for this system are given below:
Failure type/event
Probability
Vessel headspace contains concentration of vapour
capable of being ignited
0.5
Addition of powder produces spark with enough
energy to ignite vapour
0.8
Inert gas blanketing system fails
0.2 per year
Oxygen system sensor fails
0.1
a)
Draw a simple fault tree AND using the above data calculate the (16)
frequency of an ignition.
b)
Describe, and justify, TWO plant OR process modifications that you (4)
would recommend to reduce the risk of an ignition in the vessel
headspace.
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2.
The frequency of pipe work failure in a large LPG storage facility is
estimated at once every one hundred years (f=0.01/year). Immediate
ignition of the released gas (probability, p=0.05) will result in a jet
flame. Otherwise, prevailing winds will normally carry any vapour
cloud off site across open countryside, where it will disperse safely.
However, under certain conditions (p=0.01), the cloud may drift to a
nearby industrial estate where ignition (p=0.5) will cause a vapour
cloud explosion or flash fire.
Using the data provided, construct an event tree to calculate the (20)
expected frequency of fire or explosion due to pipe work failure BOTH
on site AND on the industrial estate.
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Additional Past Questions
1.
For a range of internal and external information sources outline how (10)
each source contributes to hazard identification or risk assessment.
2.
An employer wishes to build a new gas compression installation to
provide energy for its manufacturing processes. An explosion in the
installation could affect the public and a nearby railway line. In view
of this the employer has been told that a qualitative risk assessment
for the new installation may not be adequate and that some aspects
of the risk require a quantitative risk assessment.
(a)
Explain the terms ‘qualitative risk assessment’ AND ‘quantitative risk (5)
assessment’.
(b)
Identify the external sources of information and advice that the (5)
employer could refer to when deciding whether the risk from the new
installation is acceptable.
(c)
A preliminary part of the risk assessment process is to be a hazard and (10)
operability study.
Describe the principles and methodology of a hazard and operability
(HAZOP) study.
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3.
A low pressure storage vessel is connected via pipework to a
manufacturing plant which could, in the event of malfunction,
generate a pressure great enough to rupture the vessel. To prevent
this, a pressure detector is installed in the low pressure storage
vessel. If pressure starts to rise above an acceptable level the
detector activates a valve control system. This in turn closes the
inlet valve to the vessel isolating it from excessive pressure. It has
been estimated that pressure great enough to rupture the low
pressure storage vessel would be generated once every four years
on average.
Reliability data for the system is given below:
(a)
(b)
(c)
Component
Reliability
Pressure detector
0.95
Valve control system
0.99
Inlet valve
0.8
Construct an event tree for the protective system described above
AND use it to calculate the frequency of a rupture of the low
pressure storage vessel.
(12)
It is proposed that, in addition to the protective system described
above, the low pressure storage vessel is also fitted with a suitable
pressure relief valve (reliability 0.9).
Assuming that the vessel would only rupture if both the protective
system and the pressure relief valve failed at the same time,
calculate the frequency of rupture of the low pressure storage
vessel in these circumstances.
(4)
Outline the issues that would need to be considered when
deciding whether both protective systems were needed on the low
pressure storage vessel.
(4)
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4.
A chemical reaction vessel is partially filled with a mixture of highly
flammable liquids. It is possible that the vessel headspace may
contain a concentration of vapour which, in the presence of
sufficient oxygen, is capable of being ignited. A powder is then
automatically fed into this vessel.
Adding the powder may sometimes cause an electrostatic spark to
occur with enough energy to ignite any flammable vapour. There is
therefore concern that there may be an ignition during addition of
the powder.
To reduce the risk of ignition, an inert gas blanket system is used
within the vessel headspace designed to keep oxygen below levels
required to support combustion. In addition, a sensor system is
used to monitor vessel oxygen levels. Either system may fail. If the
inert gas blanketing system and the oxygen sensor fail
simultaneously, oxygen levels can be high enough to support
combustion.
Probability and frequency data for this system are given below:
5.
Failure type/event
Probability
Vessel headspace contains
concentration of vapour
capable of being ignited
0.5
Addition of powder produces
spark with enough energy to
ignite vapour
0.8
Inert gas blanketing system fails
0.2 per year
Oxygen system sensor fails
0.1
(a)
Draw a simple fault tree AND using the above data calculate the (16)
frequency of an ignition.
(b)
Describe, with justification, TWO plant OR process modifications (4)
that you would recommend to reduce the risk of an ignition in the
vessel headspace
Outline the range of internal and external information sources that (20)
may be useful in the identification of hazards and the assessment
of risk. For each source, indicate the type of information available
and how it contributes to hazard identification or risk assessment.
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Explain the principles and methodology of a Hazard and (10)
Operability (HAZOP) study
6.
7.
(a)
Outline the use and limitations of fault tree analysis
(4)
A machine operator is required to reach between the tools of a
vertical hydraulic press between each cycle of the press. Under
fault conditions, the operator is at risk from a crushing injury due
either (a) to the press tool falling by gravity or (b) to an unplanned
(powered) stroke of the press. The expected frequencies of the
failures that would lead to either of these effects are given in the
table below:
8
Failure type
Frequency (per
year)
Effect
Flexible hose failure
0.2
a
Detachment of press 0.1
tool
a
Electrical fault
0.1
b
Hydraulic valve
failure
0.05
a or b
(b)
Given that the operator is at risk for 20 per cent of the time that the (10)
machine is operating, construct and quantify a simple fault tree to
show the expected frequency of the top event (a crushing injury to
the operator’s hand).
(c)
If the press is one of ten such presses in a machine shop, state, with (4)
reasons, whether or not the level of risk calculated should be
tolerated.
(d)
Assuming that the nature of the task cannot be changed, explain (2)
how the fault tree might be used to prioritise remedial actions.
A computer suite is protected from fire by a CO2 flood system. The
system comprises of components A (a detector), B (a switch) and C
(a release mechanism) installed in series.
It has been proposed that a new series system of a detector and a
switch, identical to A and B, are placed in parallel to the original
series components A and B, in order to improve the system
reliability.
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Calculate the improvement in reliability of the proposed new
system, given that the reliability of the components are:
Component A 95%
Component B 85%
Component C 97%
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(10)
A protective system comprises three components (A, B and C)
connected in series. It has been suggested that an identical system,
designed to cut in automatically in the event of failure by means of
a sensor and switch arrangement (D), should be placed in parallel
to the main system. The following data are available:
(a)
(b)
Component
Reliability
A
0.94
B
0.95
C
0.91
D
0.98
Using simple reliability theory, calculate the improvement in the
overall system reliability that the stand-by system would provide.
(10)
Identify the factors that should be taken into account in deciding
whether to go ahead with the proposed stand-by system.
(10)
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A8 Risk control
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Classroom Questions
1.
A risk management programme encompasses the following concepts:
a)
Risk avoidance
(2)
b)
Risk reduction
(3)
c)
Risk transfer
(3)
d)
Risk retention
(2)
Identify the key features of each of these concepts AND give an
appropriate example in each case.
2.
An organisation has decided to introduce a permit-to-work system for
maintenance and engineering work at a manufacturing plant which
operates continuously over three shifts.
a)
Outline the key issues that will need to be addressed in introducing (10)
and maintaining an effective permit-to-work system in these
circumstances.
A year after the introduction of the permit-to-work system an audit of
permit-to-work records shows that many permits-to-work have not
been completed correctly or have not been signed back.
b)
Outline possible reasons why the permit-to-work system is not being (10)
properly adhered to.
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Additional Past Questions
1.
2.
3.
A risk assessment has identified the need to introduce a safe
system of work for cleaning some moving machinery. The system
proposed would allow the machinery to be cleaned by the
operator whilst it was running at normal speed with the guards
removed. This would present a risk of injury from the moving parts.
To reduce this risk it is proposed that the cleaning is undertaken
with a long-handled device which would enable the operator’s
hands to be kept away from the moving parts.
(a)
Outline the extent to which the proposed system of work meets (5)
the ‘general principles of prevention’ referred to in Regulation 4
and Schedule 1 of the Management of Health and Safety at Work
Regulations 1999. Your answer should refer to the specific
‘general principles of prevention’ which are relevant to this.
(b)
Outline the steps that an organisation should take to ensure the (5)
effective implementation of a new safe system of work, assuming
that a detailed risk assessment has already been undertaken.
(a)
Outline the specific requirements for emergency planning and (6)
procedures in the Management of Health and Safety at Work
Regulations 1999.
(b)
Outline the types of information that the site should consider (4)
providing to the ambulance service.
(a)
An organisation has decided to introduce a permit-to-work system (10)
for maintenance and engineering work at a manufacturing plant
which operates continuously over three shifts.
Outline the key issues that will need to be addressed in
introducing and maintaining an effective permit-to-work system in
these circumstances.
(b)
A year after the introduction of the permit-to-work system an audit (10)
of permit-to-work records shows that many permits-to-work have
not been completed correctly or have not been signed back.
Outline possible reasons why the permit-to-work system is not
being properly adhered to.
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4.
(a)
A mixing vessel that contains solvent and product ingredients must (5)
be thoroughly cleaned every two days for process reasons.
Cleaning requires an operator to enter the vessel, for which a
permit-to-work is required. During a recent audit of permit records
it has been discovered that many permits have not been
completed correctly or have not been signed back.
Outline possible reasons why the permit system is not being
properly adhered to.
(b)
A sister company operating the same process has demonstrated (5)
that the vessel can be cleaned by installing fixed, high pressure
spray equipment inside the vessel which would eliminate the need
for vessel entry. You are keen to adopt this system for safety
reasons but the Board has requested a cost-benefit analysis of the
proposal.
Outline the principles
circumstances.
of
cost-benefit
analysis
in
such
(Detailed discussion of individual cost elements is not required).
5.
A maintenance worker was asphyxiated while working within an
emptied fuel storage tank.
A subsequent investigation found that the employee had been
operating without a permit-to-work, despite it being an
organisational requirement for this type of task.
6.
(a)
Explain why a permit-to-work system would be considered (3)
necessary in these circumstances.
(b)
Explain the possible reasons why the permit-to-work procedure (7)
was not followed on this occasion.
Outline the types of information that should be included in written (10)
safe systems of work. Details of any specific risk controls are not
required.
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A9 Organisational Factors
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Exercise 1
Astutis Childcare Trust (ACT) is a charitable foundation created approximately 100 years
ago to provide care for disadvantaged children in the south Wales coalfields.
Since the 1960s ACT has provided schooling, healthcare and social support for children
and young adults with a broad range of physical, psychological and emotional
difficulties.
The business is booming, all profits are ploughed back into the business to provide
additional facilities and ACT has acquired 2 residential units per year for the last 5 years.
The business plan is focused on maintaining this level of growth over the next 5 years.
ACT headquarters is situated in Cardiff. On site is a primary school caring for 70 children
aged 5 to 11; a residential care home offering respite care for up to 30 teenagers; and the
main offices which employs 50 administrative and professional support staff, a team of
10 social workers, and has a small training and conference facility which is due to be
extended to provide an additional revenue stream for the business.
ACT also operates:
•
25 other residential units varying from 4 to 20 beds across south Wales, the west
Midlands and south west England. These offer permanent homes and / or respite
care for children and young adults;
•
2 primary schools, (1 in Bristol, 1 in Monmouth) each looking after 50 children;
•
1 secondary school with 120 pupils at another location in Cardiff;
•
A tertiary facility providing a mix of traditional qualifications and life skills to prepare
young people for independent living; and
•
An “outward bounds” facility in Snowdonia with accommodation for 10 children +
carers and a range of outdoor activities.
Staff include: teachers / lecturers; carers; nurses; physiotherapists, occupational
therapists; speech therapists; social workers and educational psychologists.
Overall, approximately 40% of staff are trade union members (of 5 trade unions), though
the ratio varies from 0% to 90% in different units.
Carers work on shift; other staff are required to be “on-call”.
The importance of health and safety within the business has been recognised at board
level and a Director has been allocated responsibility for health and safety.
ACT does not employ a full time health and safety advisor and presently relies on the
services of a consultancy.
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Unit managers are expected to be trained to IOSH Managing Safely standard. 75% have
already been trained the remainder are programmed for training over the next two
years.
A recent health and safety audit made the following observations:
ACT is in the business of caring, it is evident that the wellbeing of the children and young
people in its care is its priority. Each person has their own personal care and educational
plans based upon their needs, delivered through a process of risk assessment.
Risk assessments of staff activities vary greatly in quality and quantity.
Although the building blocks of a management system are in place (HSG 65) ACT
struggles to capitalise on good works in parts of the business and often fails to share best
practise and learn from experience.
Staff in all units were keen to “do the right thing” but in 50% of the units visited lacked
awareness and understanding of legal requirements and best practise.
Activity 1 – Control of Contractors
ACT uses the services of many local contractors for a broad range of activities including:
window cleaning, gardening, handy-man activities and small construction works.
Appointments are made locally on an ad hoc basis, often relying on family, friends and
volunteers for recommendations, and often to actually deliver the service.
Works at head office are only awarded to screened contractors on ACTs select tender list.
The geographical spread of the units has made it impractical for them to appoint from
this list.
Advise ACT of necessary controls for the appointment of contractors and the
management of their activities on site.
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Activity 2 – Consultation and Communication
The last health and safety audit of ACT highlighted difficulties in sharing best practise
and learning from experience within the organisation.
ACT has recently received formal requests for the creation of a safety committee.
Make practical recommendations on how to improve consultation and communication
generally within the business and also how to ensure that statutory obligations to
consult are met.
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Classroom Questions
1.
2.
A large warehousing and distribution facility uses contractors for
many of its maintenance activities. Contractors make up
approximately 5% of the total workforce but an analysis of the
accident statistics for the previous two years has shown that accidents
to contractor personnel, or arising from work undertaken by
contractors, account for 20% of the lost-time accidents on site.
a)
Assuming that the accident statistics are correctly recorded, outline (6)
possible reasons for the disproportionate number of accidents
involving contract work.
b)
Describe the key organisational and procedural measures that should (14)
be in place to provide effective control of the risks from contract work.
Organisations are said to have both formal and informal structures (6)
and groups. Outline the difference between ‘formal’ AND ‘informal’ in
this context.
The HSE publication ‘Successful Health and Safety Management’ (6)
(HSG65) describes a model of safety management in which the
‘organising’ element requires control, co-operation, communication
and competence. Outline, using practical examples, what ‘cooperation’ means in this context.
Organisational change can, if not properly managed, promote a (8)
negative health and safety culture. Outline the reasons for this.
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A10 Human Factors
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Exercise 1 : X - Y Theory Questionnaire – Employee Preference
Score the
statements
5 = always, 4 = mostly, 3 = often, 2 = occasionally, 1 = rarely, 0 = never
1
I like to be involved and consulted by my boss about how I can best do my
job.
2
I want to learn skills outside of my immediate area of responsibility.
3
I like to work without interference from my boss, but be able to ask for help if
I need it.
4
I work best and most productively without pressure from my boss or the
threat of losing my job.
5
When I leave the company, I would like an ‘exit interview’ to give my views
on the organisation.
6
I like to be incentivised and praised for working hard and well.
7
I want to increase my responsibility.
8
I want to be trained to do new things.
9
I prefer to be friendly with my boss and the management.
10
I want to be able to discuss my concerns, worries or suggestions with my
boss or another manager.
11
I like to know what the company's aims and targets are.
12
I like to be told how the company is performing on a regular basis.
13
I like to be given opportunities to solve problems connected with my work.
14
I like to be told by my boss what is happening in the organisation.
15
I like to have regular meetings with my boss to discuss how I can improve
and develop.
Total Score
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60 – 75 Strongly prefers Y Theory Management (Effective long & short term)
45 - 59
Generally prefers Y Theory Management
16 - 44
Generally prefers X Theory Management
0 - 15
Strongly prefers X Theory Management (Autocratic leadership may be
effective in the short term but poor in the long term)
Most people prefer ‘Y-theory’ management.
These people are generally
uncomfortable in ‘X-theory’ situations and are unlikely to be productive, especially
long-term, and are likely to seek alternative situations.
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Exercise 2 - Luchin’s Water Jar Problem
In the figure, A, B and C represent three empty water jars, and the numbers represent the
capacity of each jar in centilitres. You have access to a tap, and your task is to use the jars
to measure out the exact amount of water in Column Four. You must use all three jars
on each problem.
Problem
Jar A
Jar B
Jar C
Amount
Required
1
21
127
3
100
2
14
163
25
99
3
18
43
10
5
4
9
42
6
21
5
20
59
4
31
6
14
36
8
6
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Luchin’s Water Jar – Solution
Problems one to five can be solved by using exactly the same method, as follows:
•
Fill jar B with water
•
Fill jar A from jar B
•
Fill jar C from jar B
•
Fill jar C from jar B
•
Leaves required amount in jar B
(i.e. B – A – (2C) = Amount required)
This method will also work for problem six although there is a simpler way of solving
problem six (see below).
Due to expectation it is highly unlikely that at this stage you will be looking for
alternative / simpler methods.
The phenomenon is also referred to as the inhibiting or "blinding" effect of the heuristic
set. (A heuristic is a “rule of thumb” used in problem solving).
For problem six:
•
Fill jar B with water
•
Fill jar A from jar B
•
Fill jar C from jar A
•
Leaves 6 in jar A
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Exercise 3 – Human Factors and Human Failures
For each of the following scenarios:
• Identify the human factors (i.e. individual / job / organisation) which contributed to
the accident; and
• Identify any human failures (violations or errors) that may have contributed to the
accident.
(1)
A process operator in a pharmaceutical company wanted to open a solvent
extraction column. He realised that fumes were liable to be emitted so he obtained
airline breathing apparatus. He then found that there was no convenient
connection to enable the hose to be connected to the piped air supply so he asked
a passing fitter to provide a suitable connection on the end of an existing filter unit
on a nearby line.
Although the works rules required a permit to work for such a job, the fitter
complied with the operators request without going through the permit procedure.
Upon donning the breathing apparatus the process operator immediately
collapsed – the connection had been made to a newly installed nitrogen line which
had not been marked because it had not been commissioned.
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(2)
A construction company was making structural alterations to a building. Some roof
work was required and although the main contractor had ordered scaffolding it had
not arrived by the time the roofing contractors arrived on site.
The contractor decided to carry on with the roof work despite the lack of
scaffolding. The work dislodged a coping stone at the edge of the roof which fell to
the street below seriously injuring a member of the public.
(3)
A plant manufactured oxygen and hydrogen by the electrolysis of water. As a result
of corrosion, hydrogen entered the oxygen line and there was an explosion.
The subsequent investigation revealed that although purity analysis of the gases
were required to be done every hour, operators were not undertaking the analysis
but were inserting figures from experience. Supervision was poor and the
operators were not aware of the criticality of the analysis in the safe operation of
the plant. Automatic monitoring facilities for shutting down the plant were
subsequently installed.
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(4)
A serious interruption to processing in a chemical plant was caused by an operator
selecting the wrong control from a set of identical panels. On one side of the room
the panels were arranged left to right and on the other side, right to left. The mirrorimage configuration was adopted because it makes the cabling installation easier.
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Exercise 4– Human Failure Case Study
For the scenario presented identify the contribution of human failures to the cause of the
event:
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Exercise 5: Kegworth
This case study sets out the events leading to the crash of a British Midland Airways
Boeing 737 on the western embankment of the M1 on 8 January 1989 resulting in 47
passengers losing their lives.
Identify and categorise the human factors, including human errors, associated with the
Kegworth air disaster.
Why did the captain shut down the wrong engine in an attempted emergency landing at
East Midlands Airport?
British Midland Airways Boeing 737 Series 400 took off from London Heathrow bound for
Belfast. It was the second leg of a double shuttle between the two airports.
Captain Kevin Hunt, the pilot in the M1 crash, was very experienced but had flown the
737 type that crashed for only 23 hours. His co-pilot had only 53 hours on the type. Each
had received only a day of classroom training on its instruments, known as the ‘glass
cockpit’.
‘Glass cockpits’ like the one on board the British Midland Boeing 737 that crashed at
Kegworth are of a design close to the cutting edge of aviation technology. The decision
to introduce them was a matter of economics.
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In an old cockpit, there are several hundred gauges feeding off many more sensors. In a
‘glass cockpit’ there are only the six cathode ray tubes, as in an ordinary television, and if
one fails the information displayed on it can be punched up on its neighbour. Repair is
achieved by unplugging the component and plugging in another. The system works
because all the sensors feed their information into three flight management computers,
each policing the other for mistakes.
They take responsibility for the information the pilot sees on his screen. The pilot’s
workload is cut because the computer will assess each problem for him.
The computers will also identity the nature of the fault and present the pilot with a
checklist of action to be taken.
Whilst six screens replaced up to 400 instruments, the information passing through those
screens is vast. In one column alone on a flight management display different messages,
the equivalent of three A4 pages in length, can flash up and each of those can be colourcoded to represent a different status.
The pilot, to understand what his aircraft is doing, must first understand what the
computer is doing. That flies in the face of basic airmanship.
Pilots’ comments reflect the dilemma. One said: “With old cockpits the workload was high,
but you were always aware of what’s going on. Things either worked or they didn’t. With the
computer you have to back-track to find the initial error before you can correct”.
Another commented: “With a flight management computer there is almost a sense of
disbelief. You ask, why is it doing that? Then you get sucked into an intellectual exercise of
trying to work out what is going on”.
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The co-pilot (first officer) was flying the aircraft. At 2005 hrs the aircraft was climbing
through 28,000 feet 20 nautical miles south-south-east of East Midlands Airport when
the aircraft began to shake and smoke fumes filled the flight deck.
The captain took control of the aircraft and immediately disengaged the autopilot.
Looking at the instruments he was unable to gain a clear indication of the problem.
His knowledge of the air conditioning system immediately led him to suspect No. 2
(Right) engine. The first officer when asked by the captain which engine is causing the
trouble replied “It’s the le...it’s the right one” to which the captain responded by “OK,
throttle it back”.
Having closed the throttle for No. 2 (Right) engine the smell and visual signs of smoke
abated. This convinced the captain he had selected the correct engine.
Previous 737 type aircraft had the air conditioning powered from the No. 2 (Right)
engine, however this newer 737 version had the air conditioning powered from both
engines.
The captain then reduced power on the No. 1 (Left) engine due to a slightly higher level
of vibration and fuel flow. This action progressively reduced the level of vibration to one
slightly higher than normal. The captain was even more convinced he had taken the
correct action.
Previous 737 type engine vibration gauge monitors had been largely ignored as they
were unreliable, however the newer ‘glass cockpit’ gauges were reliable, yet they did not
indicate a ‘red’ danger zone. The captain was not familiar with the Operations Manual
Bulletin (OMB) issued by Boeing in March 1988, which implicitly introduced the
procedure to be followed in the event of high engine vibration. It was mandatory for
captains to read the OMB. The first officer had also not read the OMB.
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Vibration monitors –
No ‘red zone’
No alert
If the captain and first officer had got it all wrong on the flight deck the three flight
attendants and some passengers had seen signs of fire from the No. 1 (Left) Engine.
This was described as ‘fire’, ‘torching’, or ‘sparks’. The captain had broadcast over the
cabin address system that there was a problem with the No. 2 (Right) Engine and they
could expect to land at East Midlands Airport in approximately 10 minutes.
The flight attendants were understandably puzzled by the captain’s reference to the
right engine. Some alert passengers had also been puzzled by the captain’s reference to
the right engine having seen the fire and sparks emitting from the left engine.
Shortly after shutting down No. 2 (right engine) the first officer had obtained clearance
for an emergency landing at East Midlands Airport. The landing phase is the most critical
phase of flight and the workload on the flight deck was intense. Approximately 2 to 4
nautical miles from touchdown at a height of 900 feet there was a sharp decrease in
power from No. 1 (left engine).
The cause of the accident was attributed to the flight crew shutting down No. 2 (Right)
engine after a fan blade had fractured in the No 1 (Left) engine. This engine
subsequently suffered a major loss of thrust due to secondary fan damage after power
had been increased during the final approach to East Midlands Airport.
Possibly, at this point it may have occurred to the captain his decision to shut down the
right engine had been a catastrophic mistake. He immediately called for the right
engine to be restarted but it was already too late. On the verge of a stall, the initial
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impact was on high ground just to the east of the M1 motorway. Passing through trees
the aircraft finally impacted on the lower part of the western (northbound) carriageway
of the motorway and the lower part of the western embankment.
Thirty nine passengers died in the accident and a further eight passengers died later
from their injuries. Of the remaining 79 passengers, 74 suffered serious injury.
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Exercise 6 - Belbin’s Team Roles – Self Perception Inventory
Instructions
Please distribute a total of 10 points for each section among the sentences that you
think best describe your behaviour. These points may be allocated among several
sentences, or in extreme cases they may be spread among all the sentences, or all 10
points given to one particular sentence. Please do not confer with anybody whilst doing
this exercise. The answers you give are confidential, but will feed into a theory of team
roles which may help to understand how and why you perform as you do in a team.
Try to relate your answers to the way you actually behave rather than how you would
prefer to behave.
Section One - What I believe I can contribute to a team:
10
I think I can quickly see and take advantage of new opportunities.
11
I can work well with a wide range of people.
12
Producing ideas is one of my natural assets.
13
My ability rests in being able to draw people out whenever I detect they
have something of value to contribute.
14
I can be relied upon to finish any task I undertake.
15
My technical knowledge and experience is usually my major asset
16
I am always ready to be blunt and outspoken to make the right things
happen .
17
I can usually tell whether a plan or idea will fit a particular situation.
18
I can offer a reasoned case for alternative courses of action without
introducing bias or prejudice.
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Section Two - If I have a possible shortcoming in teamwork it could be that:
20
I am not at ease unless meetings are well structured and controlled and
generally well conducted.
21
I am inclined to be too generous towards others who have a valid
viewpoint that has not been given a proper airing.
22
I am reluctant to contribute unless the subject deals with a field I know
well.
23
I have a tendency to talk a lot once the group gets onto new ideas.
24
My objective outlook makes it difficult for me to join in readily and
enthusiastically with colleagues.
25
I am sometimes seen as forceful and authoritarian if there is a need to get
something done.
26
I find it difficult to lead from the front, perhaps because I am over
responsive to the group atmosphere.
27
I am apt to get too caught up in ideas that occur to me and so lose track
of what is happening.
28
I tend to become preoccupied when I realise that loose ends have not
been tied up.
Section Three - When involved in a project with other people:
30
I have an aptitude for influencing people without pressurising them.
31
My general vigilance prevents careless mistakes and omissions being
made.
32
I am ready to press for action to make sure that the meeting does not
waster time or lose sight of the main objective.
33
I can be counted on to contribute something original.
34
I am always ready to back a good suggestion in the common interest.
35
I am keen to look for the latest in new ideas and developments.
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36
I try to maintain my sense of professionalism.
37
I believe others appreciate my capacity for cool judgement.
38
I can be relied upon to see that all essential work is organised.
Section Four - My characteristic approach to group work is:
40
I have a quiet interest in getting to know colleagues better.
41
I contribute when I know what I am talking about.
42
I am not reluctant to challenge the views of others or to hold a minority
view myself.
43
I can usually find a line of argument to refute unsound suggestions.
44
I think I have a talent for making things work once a plan has to be put
into operation.
45
I have a tendency to avoid the obvious and to come out with the
unexpected.
46
I bring a touch of perfectionism to any team job I undertake.
47
I am ready to make use of contacts outside the group itself.
48
While I am interested in all views, I have no hesitation in making up my
mind once a decision has to be made.
Section Five - I gain satisfaction in a job because:
50
I enjoy analysing situations and weighing up all the possible choices.
51
I am interested in finding practical solutions to problems.
52
I like to feel I am fostering good working relationships.
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53
I can have a strong influence on decisions.
54
I can meet new people who may have something new to offer.
55
I can get people to agree on a necessary course of action.
56
I feel in my element where I can give a task my full attention.
57
I like to find a field that stretches my imagination.
58
I feel I am using my special qualifications and training to my best
advantage.
Section Six - If I am suddenly given a difficult task with limited time and unfamiliar
people:
60
I like to read as much as I conveniently can on the subject.
61
I would feel like devising a solution of my own and then trying to sell it to
the group.
62
I would be ready to work with the person who showed the most positive
approach, however difficult s/he may be.
63
I would find some way of reducing the size of the task by establishing
what different individuals may best contribute.
64
My natural sense of urgency would help to ensure that we did not fall
behind schedule.
65
I believe I would keep cool and maintain my capacity to think straight.
66
IN spite of conflicting pressures I would press ahead with whatever
needed to be done.
67
I would be prepared to take the lead if I felt the group was making no
progress.
68
I would open up discussions with a view to stimulating new thoughts and
getting something moving.
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Section Seven - With reference to the problems to which I am subject in working in
groups:
70
I am subject to show my impatience with those who are obstructing
progress.
71
Others may criticise me for being too analytical and insufficiently
intuitive.
72
My desire to ensure that work is properly done can hold up proceedings.
73
I tend to get bored easily and rely on one or two stimulating members to
spark me off.
74
I find it difficult to get started unless the goals are clear.
75
I am sometimes poor at explaining and clarifying complex points that
occur to me.
76
I am conscious of demanding from others the things I cannot do myself.
77
I am inclined to feel I am wasting my time and would do better on my
own.
78
I hesitate to get my points across when I run up against real opposition.
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Belbin Team Roles Scoring Grid
Section
One
Two
Three
Four
Five
Six
Seven
IM
CO
SH
PL
RI
ME
TW
CF
SP
17
13
16
12
10
18
11
14
15
20
21
25
27
23
24
26
28
22
38
30
32
33
35
37
34
31
36
44
48
42
45
47
43
40
46
41
51
55
53
57
54
50
52
56
58
66
63
67
61
68
65
62
64
60
74
76
70
75
73
71
78
72
77
Totals
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Table of Norms – Belbin Team Roles
Low
Average
High
Very High
0-6
7 - 10
11 - 13
14 - 18
0-3
4-6
7-9
10 - 17
0-6
7 - 11
12 - 16
17 - 23
Monitor
Evaluator (ME)
0-5
6-9
10 - 12
13 - 19
Plant (PL)
0-4
5-8
9 - 12
13 - 29
0-6
7-9
10 - 11
12 - 21
Shaper (SH)
0-8
9 - 13
14 - 17
18 - 36
Team Worker
(TW)
0-8
9 - 12
13 - 16
17 - 25
Co-ordinator
(CO)
Completer
Finisher (CF)
Implementer
(IM)
Resource
Investigator
(RI)
Specialist (SP)
Average
Scores
8.8
5.5
10.0
8.2
7.3
7.8
11.6
10.9
6.8
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Classroom Questions
1.
(a)
Define the term 'ergonomics'.
(b)
Outline the effects of poor ergonomic design on health and (18)
safety, giving practical examples of how these effects can be
avoided.
(2)
2.
Outline how the design of displays and controls on work (10)
equipment can improve human reliability.
3.
Identify measures to improve human reliability in the (10)
workplace.
4.
Outline the factors to consider when devising rules and (10)
procedures at work in order to avoid the temptation of
employees to violate them.
5.
Outline both the individual and the organisational factors that (20)
are likely to influence the incidence of accidents due to human
error.
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Additional Past Questions
1
(a)
(b)
2
Outline the meaning and relevance of the following terms in the
context of controlling human error in the workplace:
i.
Ergonomics
(2)
ii.
Anthropometry
(2)
iii.
Task analysis
(2)
Excluding ergonomic issues, outline ways in which human (14)
reliability in the workplace may be improved. In your answer
consider ‘individual’, ‘job’ and ‘organisational’ issues.
Human failure was identified as a significant factor in an accident (10)
involving a crane. An employee was seriously injured when struck
by material being transported by the crane.
Outline the types of human failure which may have contributed to
the accident AND in EACH case give examples relevant to the
scenario to illustrate your answer.
3
A train driver has passed a stop signal resulting in a collision with
another train. Investigation of the incident concluded that the
driver had seen the signal gantry but had not perceived the
relevant signal correctly. There had been a number of previous
similar incidents at this signal gantry, although the driver was not
aware of this.
The driver concerned was inexperienced and had received no local
route training or information. The signal was hard to see being
partly obscured by a bridge on approach and affected by strong
sunlight. In addition, the arrangement of the lights on the signal
was a non-typical formation. The driver had approached the signal
with no expectation from previous signals that it would be on
‘stop’.
(a)
With reference to a relevant model of perception, Give practical (7)
reasons why the driver may not have perceived the signal correctly.
(b)
Outline the steps that could be taken to reduce the likelihood of a (13)
recurrence of this incident.
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4
Train drivers may spend long periods of time in the cab of a train (10)
and may be susceptible to loss of alertness. This can increase the
risk of human error.
Outline a range of measures that could reduce loss of alertness in
train drivers.
5
A poor organisational safety culture is said to lead to higher levels
of violation by employees.
(a)
Explain the meaning of the term ‘violation’ and the classification of (6)
violation as ‘routine’, ‘situational’ or ‘exceptional’
(b)
Outline the reasons why a poor safety culture might lead to higher
levels of violation by employees.
(4)
6
Outline the desirable design features of controls AND displays on a (20)
control panel for a complex industrial process aimed at reducing
the likelihood of human error.
7
Train drivers may spend long periods of time in the cab of a train
and may be susceptible to loss of alertness. This can increase the
risk of human error.
(a)
Describe, with examples, a range of factors which may influence
the degree of alertness of train drivers
(5)
(b)
Outline a range of practical measures that could reduce the risk of
lack of alertness in train drivers
(5)
8
9
A poor organisational safety culture is said to correlate with higher
levels of violation by employees.
(a)
Explain the meaning of the term ‘safety culture’ and briefly outline
the organisational characteristics of a positive safety culture.
(b)
Explain the meaning of ‘violation’ and the classification of violation (6)
as ‘routine’, ‘situational’ or ‘exceptional’.
(c)
Outline the reasons why a poor safety culture might lead to higher
levels of violation.
(6)
Outline the desirable design features of controls and displays on a
control panel for a complex industrial process aimed at reducing
the likelihood of human error.
(20)
(8)
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Classroom Questions - Examiners
Feedback
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A7 Assessment and Evaluation of Risks
1.
A chemical reaction vessel is partially filled with a mixture of highly
flammable liquids. It is possible that the vessel headspace may
contain a concentration of vapour which, in the presence of sufficient
oxygen, is capable of being ignited. A powder is then automatically
fed into this vessel.
Adding the powder may sometimes cause an electrostatic spark to
occur with enough energy to ignite any flammable vapour. There is
therefore concern that there may be an ignition during addition of the
powder.
To reduce the risk of ignition, an inert gas blanket system is used
within the vessel headspace designed to keep oxygen below levels
required to support combustion. In addition, a sensor system is used
to monitor vessel oxygen levels. Either system may fail. If the inert gas
blanketing system and the oxygen sensor fail simultaneously, oxygen
levels can be high enough to support combustion.
Probability and frequency data for this system are given below:
Failure type/event
Probability
Vessel headspace contains concentration of vapour
capable of being ignited
0.5
Addition of powder produces spark with enough
energy to ignite vapour
0.8
Inert gas blanketing system fails
0.2 per year
Oxygen system sensor fails
0.1
a)
Draw a simple fault tree AND using the above data calculate the (16)
frequency of an ignition.
b)
Describe, with justification, TWO plant OR process modifications that (4)
you would recommend to reduce the risk of an ignition in the vessel
headspace
In answering part (a) of the question, Examiners were expecting candidates to supply a
simple fault tree similar to that shown below and to calculate that the frequency of
ignition would be 0.008/yr or once in every 125 years. This was not a popular question,
but those candidates who had a good understanding of the construction of a fault tree
did well. There were some, however, who did not have this understanding, and
produced an event rather than a fault tree.
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In answering part (b), candidates could have included a description of any relevant
modifications as knowledge of the fire and explosion part of the syllabus was not
expected. Additional credit was given for selecting modifications which would make a
greater contribution to reducing the overall risk based on the probability data in the fault
tree. Modifications could have included replacing the powder feed with slurry in a
conducting liquid; selecting and using materials with higher flashpoints to minimise the
probability of a flammable atmosphere; and redesigning the nitrogen blanketing system
to improve reliability.
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2.
The frequency of pipe work failure in a large LPG storage facility is
estimated at once every one hundred years (f=0.01/year). Immediate
ignition of the released gas (probability, p=0.05) will result in a jet
flame. Otherwise, prevailing winds will normally carry any vapour
cloud off site across open countryside, where it will disperse safely.
However, under certain conditions (p=0.01), the cloud may drift to a
nearby industrial estate where ignition (p=0.5) will cause a vapour
cloud explosion or flash fire.
Using the data provided, construct an event tree to calculate the (20)
expected frequency of fire or explosion due to pipe work failure BOTH
on site AND on the industrial estate.
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A8 Risk Control
1.
A risk management programme encompasses the following concepts:
a)
Risk avoidance
(2)
b)
Risk reduction
(3)
c)
Risk transfer
(3)
d)
Risk retention
(2)
Identify the key features of each of these concepts and give an
appropriate example in each case.
Most candidates provided good answers to this question, although a number confused
the principles of risk avoidance and risk transfer. A number of candidates missed
opportunities for marks by failing to give examples Risk avoidance involves taking active
steps to avoid or eliminate risk for example discontinuing the process, avoiding the
activity, eliminating a hazardous substance.
Risk reduction involves evaluating the risks and developing risk reduction strategies,
requires the organisation to define an acceptable level of risk control to be achieved; this
could be by the use of safety/risk management systems or use of a hierarchy of control.
Risk Transfer involves transferring risk to other parties but paying a premium for this; for
example by the use of insurance; transfer of risk by use of contractors to undertake
certain works; use of third parties for business interruption recovery planning or
outsourcing the process.
Risk retention involves accepting a level of risk within the organisation along with a
decision to fund losses internally; it could involve risk retention with knowledge where
the risk has been recognised and evaluated; or risk retention without knowledge where
the risk has not been identified (obviously an unfavourable position for the organisation
to be in).
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2.
An organisation has decided to introduce a permit-to-work system for
maintenance and engineering work at a manufacturing plant which
operates continuously over three shifts.
a)
Outline the key issues that will need to be addressed in introducing (10)
and maintaining an effective permit-to-work system in these
circumstances.
A year after the introduction of the permit-to-work system an audit of
permit-to-work records shows that many permits-to-work have not
been completed correctly or have not been signed back.
b)
Outline possible reasons why the permit-to-work system is not being (10)
properly adhered to.
In answering part (a) of the question, key issues that could have been outlined include:
•
Arriving at a clear definition of the jobs and areas for which permits will be required;
•
Consideration of the operation of the system where contractors are involved;
•
Developing a permit to work procedure that defines how the system will operate;
•
Developing the permit format and multi-copy documentation system to encompass
issues such as job description, hazard identification, specification of risk control
measures, time limits and authorising, receiving and cancellation signatures and the
allocation of a unique reference number;
•
Arrangements for the return of permits and record keeping;
•
Arrangements for the display of multiple live permits;
•
Arrangements for communication between shifts;
•
Identification of the training needs for, and the delivery of training to, persons
authorising or receiving permits and those working in areas where permits may be
required;
•
Provision of supporting arrangements and equipment for safe working such as lockoff, isolation or gas testing facilities; and
•
Arrangements for routine monitoring and auditing the effectiveness of the system.
For part (b), possible reasons for the fact that there is not strict adherence to the permit
to work system include:
•
Permit issuers and receivers are not competent and have not been adequately
trained;
•
There is no routine monitoring or auditing of the system and the level of supervision
is poor;
•
There is a lack of perceived importance of the system with production seen as
having the greater importance and violations have become routine;
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•
The permit system is seen as too complex and cumbersome and difficult to
understand;
•
The potential hazards of maintenance and engineering work are not fully identified
or understood and the required controls are not fully understood by the permit
issuer;
•
The difficulties that arise in organising controls before the start of the work to be
carried out; and
•
A lack of effective communication between shifts and the person responsible for
issuing permits is not always available.
This was one of the better answered questions on the paper. It appeared that candidates
made good use of their experiences in their own workplaces though there were a few
who, for part (a), gave too much attention to the possible controls to be adopted for
particular permits rather than to the introduction of a permit to work system.
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A9 Organisational Factors
1.
A large warehousing and distribution facility uses contractors for
many of its maintenance activities. Contractors make up
approximately 5% of the total workforce but an analysis of the
accident statistics for the previous two years has shown that accidents
to contractor personnel, or arising from work undertaken by
contractors, account for 20% of the lost-time accidents on site.
a)
Assuming that the accident statistics are correctly recorded, outline (6)
possible reasons for the disproportionate number of accidents
involving contract work.
b)
Describe the key organisational and procedural measures that should (14)
be in place to provide effective control of the risks from contract work.
The first part of the question sought some possible reasons why there might be a
disproportionate number of accidents associated with work by contractors. Issues that
could have been covered include those related to the nature of the work – for instance;
•
Maintenance work might be more complex, higher risk, harder to control
satisfactorily and with fewer well-established work methods than other warehousing
and distribution activities;
•
A lack of established procedures and training for the management of third parties
including inadequate contractor selection and the provision of information from the
client to contract employees;
•
Poor planning and risk assessment and poor communication and coordination
between the parties affected by the contract work;
•
Inadequate supervision of contractor employees either by the client or by the
contractor; and
•
Staff turnover and a lack of contract worker competence and the effect of
contractual or financial pressures on the contractor.
The second part of the question required a description of the key organisational and
procedural measures required to minimise the risks associated with contract work.
Measures that could have been described include:
•
The selection of a competent contractor by obtaining evidence of past performance,
safety management arrangements, the adequacy of resources and risk control
proposals;
•
The provision of adequate information to the contractor prior to the work starting
on the nature of the work to be carried out and the known hazards and site safety
rules with an induction briefing to be given to all contract personnel before
admittance to site;
•
The preparation of job specific risk assessments and method statements and
arrangements for their co-ordination and review;
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•
The appointment of a client representative with contractor management
responsibility;
•
Arrangements for on-going communication; and
•
For active and reactive monitoring of performance and for job completion and hand
over including a safety performance review.
This was again a question which produced answers to a reasonable standard with for
part (b), many good and practical steps suggested to mitigate the problems identified.
If there was a weakness, it was that candidates concentrated on the competence and
performance of the contractors and ignored the part to be played by the client. There
were a few candidates who discussed the reasons for a poor accident reporting culture
even though it was clearly stated that the statistics were correctly recorded while others
lost marks for producing a series of bullet points for a question requiring an “outline” or
“describe” approach.
2.
Organisations are said to have both formal and informal structures (6)
and groups. Outline the difference between ‘formal’ AND ‘informal’ in
this context.
The HSE publication ‘Successful Health and Safety Management’ (6)
(HSG65) describes a model of safety management in which the
‘organising’ element requires control, co-operation, communication
and competence. Outline, using practical examples, what ‘cooperation’ means in this context.
Organisational change can, if not properly managed, promote a (8)
negative health and safety culture. Outline the reasons for this.
A formal structure or group is hierarchical, generally shown in an organisational chart
and characterised by defined responsibilities and agreed reporting lines, while an
informal structure is characterised by social and personal relationships, habitual and
related contacts and the presence of strong characters with personality and
communication skills that may exert personal influence.
In outlining the meaning of “co-operation” for part (b) of the question, candidates should
have referred to formal consultation arrangements such as those with safety
representatives, direct consultation with employees at team meetings and participation
in safety committee meetings and also to informal consultation on safety issues during
day to day discussions with employees.
“Co-operation” would also include the involvement of employees in safety processes
such as:
•
Carrying out risk assessments and developing systems of work;
•
Playing their part in incident investigations, inspections, audits and other
monitoring processes;
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•
Being encouraged to report hazards and “near miss” incidents; and
•
Being invited to become members of safety circles for problem solving.
Finally the provision of training and development would be an important factor in
maximising the involvement of employees in health and safety matters. Answers to this
part of the question were disappointing and many were directed towards control and
communication rather than to cooperation as required.
Examiners were concerned that some candidates at Diploma level showed little grasp of
the content of HSG65. Organisational change can, if not properly managed, promote a
negative health and safety culture for a number of reasons such as:
•
The profile of safety may not be maintained during the change and new job
responsibilities may not have fully covered safety issues;
•
Normal consultation mechanisms and routes may be disrupted;
•
Training in safety issues for new job-holders or for new responsibilities may not have
been completed;
•
The lack of adequate means of communication during the change may compromise
trust and poor consultation on change issues may have a negative effect on
cooperation and on other issues including safety;
•
There may be concern about job security which could encourage risk taking;
•
Redundancy processes or cost reduction measures may produce a perception that
the organisation is not concerned with personal well-being;
•
Experience or knowledge of risk controls may be lost with changes of personnel;
•
The safety implications of changes in personnel or numbers may not have been
properly assessed;
•
Extensive movement of personnel makes it harder to establish shared perceptions
and values;
•
A greater use of outsourcing without good control may result in lower safety
standards by contractors which may affect the perception of priorities; and
•
Last but not least the effects of natural resistance to change.
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A10 Human Factors
1.
(a)
Define the term 'ergonomics'.
(b)
Outline the effects of poor ergonomic design on health and safety, (18)
giving practical examples of how these effects can be avoided.
(2)
For part (a), there were inevitably a few answers that took a rather
restricted view of ergonomics but the majority correctly embraced
the notion of ergonomics as the study of the interaction between
workers and their work, in terms of the design of the workplace,
work equipment and work methods. Having recognised this, it
should have been apparent that the effects of poor ergonomic
design, for part (b), include almost the entire range of physical and
mental harm that can occur to persons at work. In particular,
candidates might have referred to physical harm in terms of
discomfort, fatigue, musculo-skeletal disorders and the results of
accidents, and to mental harm as evidenced by increased stress and
lack of motivation. Since ergonomics is also concerned with
reducing the probability of human error by system design,
candidates might also have appropriately mentioned catastrophic
failure as a possible effect of, for instance, poorly designed controls.
2.
Outline how the design of displays and controls on work equipment (10)
can improve human reliability.
3.
Identify measures to improve human reliability in the workplace.
(10)
Better candidates identified measures to improve human reliability
such as: ensuring the proper selection, training (induction, refresher,
etc) and supervision of employees; demonstrations by management
of their commitment to occupational health and safety; workplace
incentive schemes; carrying out ergonomic assessments of the
workplace and equipment used and improving the working
environment; introducing job rotation to counter monotony;
providing adequate rest breaks to reduce fatigue; and ensuring
good communication and consultation with the workforce.
Some candidates produced a checklist citing questions such as "Is
training provided?" or "Is the operative suitable for the task?".
Unfortunately, this did not address the question, which asked for
measures to improve human reliability.
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4.
Outline the factors to consider when devising rules and procedures (10)
at work in order to avoid the temptation of employees to violate
them.
This question was concerned with the factors to be addressed when
drawing up rules and procedures in order to minimize the possibility
of employees violating or ignoring them. The initial factor to be
considered is whether the rule or procedure is necessary, and is
perceived as necessary by all concerned, since a proliferation of rules
increases the temptation-to ignore them. That decided, it would
then be necessary to ensure that the purpose of the procedure is
clearly stated, that it is realistic, appropriate for the users and reflects
the task that is carried out, that it covers all hazards and includes the
necessary precautions for controlling those hazards, and that the
correct tools and equipment are actually available.
The way that a new rule or procedure is introduced is also very
important in avoiding future violations. For example, involving
employees in the preparation of rules or procedures, having a
system for feedback that includes suggestions on improvements,
training those involved in any new work methods, and reinforcing
the new rules and procedures with effective supervision (and the
visible support of senior management) will all reduce the likelihood
of violations, whether wilful or through misperception.
Additionally, the form in which the rule or procedure is presented to
employees should be addressed. If in a text format, the language
used should be familiar and the terminology consistent. The
instructions should flow in a logical sequence, be accurate, complete
and current, and be concise but with sufficient detail to ensure
clarity.
This question was not well answered. Many candidates saw it as a
general 'human factors' or 'human error' question rather than one
specifically addressing violations. Of these, some wrote at length on
just one or two factors (usually attitude and motivation) and
consequently their answers lacked any sort of breadth; others tried
to include everything they knew about human factors without ever
addressing the real issue of the question.
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5.
Outline both the individual and the organisational factors that are (20)
likely to influence the incidence of accidents due to human error.
The question required candidates to consider both the individual
and organisational factors that could influence the incidence of
accidents due to human error.
Most were able to outline a range of individual factors such as
competence, attitude, perception of risk, age and experience. Other
possible individual factors that were included only in better answers
were medical problems or conditions, personal problems, drink or
drug problems and mental capability.
Candidates performed less well when outlining organisational
factors. They could have covered a range of issues under such
general headings as management commitment and competence,
provision and level of training, selection procedures, workplace and
task design, work patterns, ability to learn from previous incidents
and environmental issues such as noise, ventilation, lighting and
temperature.
Some candidates did not read the question with sufficient care and
focused their responses in terms of how to avoid human error.
Therefore, while the selection of equipment is an influencing factor,
the question did not require a mass of detail in relation to the
specifics of control panel design.
Candidates familiar with the HSE guidance on human factors
("Reducing error and influencing behaviour" - HSG48) should have
achieved high marks on this question. Its value when dealing with
this area of the syllabus is emphasised.
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Homework Questions - Examiners
Feedback
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Day 1
Outline the issues that should be considered when planning a health (10)
and safety inspection programme Information on the specific
workplace conditions or behaviours that might be covered in an
inspection is not required.
1.
Candidates who structured their responses around the four key words of who, what,
where and when did best. This led them to outline factors such as:
•
The composition and competence of the inspection team;
•
The specific areas of the workplace to be inspected;
•
The frequency and timings of the inspections which may have to be more frequent
in higher risk areas with a decision being made as to whether the inspections would
take place at peak working times or during slow periods;
•
The method of carrying out the inspections and whether check lists should be
prepared and if so by whom;
•
The possible need to provide personal protective equipment for the inspection
team;
•
The involvement of the workforce with consultation on the proposed programme;
•
The need to obtain senior management support and commitment for the inspection
programme;
•
Consulting previous inspection reports and researching applicable legislation and
standards; and
•
Deciding on procedures to be followed after the inspection to ensure appropriate
remedial action is taken.
2
An employer wishes to build a new gas compression installation to
provide energy for its manufacturing processes. An explosion in the
installation could affect the public and a nearby railway line. In view of
this the employer has been told that a qualitative risk assessment for
the new installation may not be adequate and that some aspects of the
risk require a quantitative risk assessment.
a)
Explain the terms ‘qualitative risk assessment’ AND ‘quantitative risk (5)
assessment’.
b) Identify the external sources of information and advice that the (5)
employer could refer to when deciding whether the risk from the new
installation is acceptable.
c)
A preliminary part of the risk assessment process is to be a hazard and (10)
operability study.
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Describe the principles and methodology of a hazard and operability
(HAZOP) study.
In answering part (a) of the question, many candidates found difficulty in explaining the
terms qualitative and quantitative risk assessment. Qualitative risk assessment involves
the use of informed subjective judgements to arrive at a broad measure of risk.
Following a comprehensive identification of hazards, broad categories are used to
classify the likelihood of the hazards being realised and the severity of their
consequences. The categories may be descriptors or numbers. Most everyday risk
assessment is qualitative.
Quantitative risk assessment on the other hand is a numerical representation of the
actual frequency and/or probability of an event and its consequences. It often involves
comparison with specific criteria and is objective in identifying external sources of
information and advice for part (b), candidates could have referred to the tolerability
criteria set down in “Reducing Risks, Protecting People”.
Other sources of information may have included HSE or industry guidance which sets risk
control standards for the type of installation concerned, competent consultants with
relevant experience and other organisations with similar installations.
Insurers may also influence the risk tolerability decision by indicating their willingness or
otherwise to provide insurance. Candidates generally struggled to identify relevant
sources of information and very few referred to tolerability criteria
Part (c) sought to test candidates understanding of HAZOP studies. The purpose of a
HAZOP is to identify deviations from intended normal operation and is best used at the
design stage or when modifications are proposed for an existing installation. They were
expected to explain the need for a team approach with specialists from relevant
disciplines, a team leader and the need to define the scope of the study, breaking down
the process into elements, collecting data and information to support the study and
adopting a brainstorming approach.
Candidates should also have described that deviations are prompted by the use of guide
words which are applied to relevant process parameters such as temperature or flow and
marks were available for giving examples such as “no” (negation of the design intent),
“more” (quantitative increase), “as well as” (qualitative increase) and “other than”
(complete substitution). Better answers added that the study examines the possible
causes and consequences of each deviation, identifies possible corrective actions and is
documented and recorded.
Answers to this part of the question varied in quality. Few mentioned the use of guide
words but those who included a part of a typical HAZOP record form in their answer
generally obtained better marks
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3.
Outline the use and limitations of fault tree analysis.
(4)
A machine operator is required to reach between the tools of a vertical
hydraulic press between each cycle of the press. Under fault conditions,
the operator is at risk from a crushing injury due either (a) to the press
tool falling by gravity or (b) to an unplanned (powered) stroke of the
press. The expected frequencies of the failures that would lead to either
of these effects are given in the table below:
Failure type
Frequency (per
year)
Effect
Flexible hose failure
0.2
a
Detachment of press
tool
0.1
a
Electrical fault
0.1
b
Hydraulic valve
failure
0.05
a or b
Given that the operator is at risk for 20 per cent of the time that the (10)
machine is operating, construct and quantify a simple fault tree to
show the expected frequency of the top event (a crushing injury to the
operator’s hand).
If the press is one of ten such presses in a machine shop, state, with (4)
reasons, whether or not the level of risk calculated should be tolerated.
Assuming that the nature of the task cannot be changed, explain how (2)
the fault tree might be used to prioritise remedial actions.
This question was designed to test candidates’ understanding and application of fault
tree analysis. It was not a popular question but was generally well answered by those
who did attempt it. Candidates recognised that fault tree analysis is useful in analysing
accidents where there are multiple causes to an accident to calculate the probability of
the top event; it can be used to identify the most effective points of intervention in order
to reduce the probability of the top event occurring. On the negative side it is limited by
the requirement of skilled analysts to work the calculations out in complex situations and
its reliance on the accuracy and availability of failure data.
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(b)(i) Fault Tree
Part (b)(i) required the construction of a fault tree and its quantification using the data
presented. A significant number of candidates constructed an event tree rather than a
fault tree and so gained no marks.
Many of the remainder who attempted the construction made a reasonable attempt at a
fault tree consisting of four levels:
•
Crushing injury at the top;
•
Operator exposure and tool descent at the second level;
•
Type of tool descent (powered stroke or gravity fall) at the third; and
•
Component failures at the bottom. Those who achieved a reasonable construction
also tended to achieve good marks for quantification.
Part (ii) was seeking not just an opinion but some commentary on, or justification for, the
opinion in terms of the frequency of unexpected tool descent or operator injury. Those
candidates who did not give reasons for their opinions could not expect to gain high
marks.
Some reference was therefore needed to the likely disabling nature of the injury and to
such an event occurring once in about ten years (which was the estimated frequency).
Better candidates offered a risk level that might be considered to be more acceptable,
with some suggesting that if several of these presses were operating (perhaps within the
same factory), then a serious injury could be a regular occurrence.
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Part (iii) needed candidates to explain the general principles of using the probability data
in the fault tree so that priority is given to those actions that would give the greatest
reduction in the probability of the undesired events. For instance, gravity fall was
highlighted as the most likely event; therefore priority should be given to actions that
would prevent this.
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Day 2
1.
a)
Outline the principles, application and limitations of Event Tree (6)
Analysis as a risk assessment technique.
A mainframe computer suite has a protective system to mitigate the
effects of fire. The system comprises a smoke detector connected by a
power supply to a mechanism for releasing extinguishing gas. It has
been estimated that a fire will occur once every five years (f=0.2/year).
Reliability data for the system components are as follows:
Component
Reliability
Detector
0.9
Power supply
0.99
Extinguishing gas release mechanism
0.95
b) Construct an event tree for the above scenario to calculate the (10)
frequency of an uncontrolled fire in the computer suite.
c)
Suggest ways in which the reliability of the system could be improved.
(4)
Event Tree Analysis is based upon binary logic and is often used to estimate the
likelihood of success or failure of safety systems. It starts with the initiating event and
ends with the probability of a situation being controlled or not. It is limited by the lack of
knowledge of component reliability and other data and since it considers only two
possibilities – success or failure – it does not take into account partial downgrade (i.e.
limited success).
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For part (b), candidates were asked to construct an event tree for the scenario described
in the question. An acceptable answer would have been:
Marks were awarded for the general construction of the tree; for calculations of failure
rates from component reliability data; for calculation of system failure rate from
individual failure rates; for conversion of failure rate per year to failure every “X” years
which in this case was once in every thirty two years.
In answering part (c), candidates could have suggested ways such as choosing more
reliable components or using components in parallel. Credit was given for recognising
that the detector was the least reliable component and so would be a logical first choice
for such techniques. Installing a second independent but parallel system was also a way
of improving the reliability of the system.
This was not a popular question, but those who did attempt it generally achieved
reasonable marks though in some cases more detail was required on the principles,
applications and limitations of Event Tree Analysis. Some candidates confused event
trees and fault trees.
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2.
A risk assessment has identified the need to introduce a safe system of
work for cleaning some moving machinery. The system proposed
would allow the machinery to be cleaned by the operator whilst it was
running at normal speed with the guards removed. This would present
a risk of injury from the moving parts. To reduce this risk it is proposed
that the cleaning is undertaken with a long-handled device which
would enable the operator’s hands to be kept away from the moving
parts.
a)
Outline the extent to which the proposed system of work meets the (5)
‘general principles of prevention’ referred to in Regulation 4 and
Schedule 1 of the Management of Health and Safety at Work
Regulations 1999. Your answer should refer to the specific ‘general
principles of prevention’ which are relevant to this scenario.
b) Outline the steps that an organisation should take to ensure the (5)
effective implementation of a new safe system of work, assuming that a
detailed risk assessment has already been undertaken.
In answering part (a) of the question, candidates should have considered the general
principles of prevention listed in Schedule 1 of the Management of Health and Safety at
Work Regulations and outlined how far they had been met in the proposed system of
work for cleaning moving machinery as described in the given scenario. So for example,
the principle of giving priority to collective protective measures over individual
protective measures has clearly not been met in this scenario. As another example, the
principle of avoiding risks may not have been met in full but any statement of this
principle with a reasoned argument either way showing application of the principle
would have obtained credit.
Most candidates did not appear to be familiar with the general principles of prevention
and a significant number of candidates felt that these were simply a generic hierarchy of
control, which they are not. The majority of answers to this part were poor and it appears
to be an area of the syllabus that is not well understood despite it being a requirement of
the Management of Health and Safety at Work Regulations 1999.
For part (b), candidates were expected to outline the steps that an organisation should
take to ensure the effective implementation of a new safe system of work.
These would include:
•
Explaining the need for the safe system of work to the operators and involving them
in the drafting process;
•
Consulting the operators and others on the prepared draft;
•
Providing the necessary equipment and tools;
•
Training those involved in the new system and piloting its application under close
supervision; and
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•
Monitoring the use of the procedure and encouraging feedback and reviewing the
system of work after a specified period of time.
Answers to this part of the question were to a much better standard. Drafting and
consultation issues were well covered though some candidates did omit the need for
carrying out a review.
3.
The diagram below shows a section of process plant in which a raw
material is pumped continuously to a process from a storage tank. The
flow rate is controlled by an operator who adjusts the manual valve to
achieve the desired flow as shown on the flow gauge. If the flow is too
great a dangerous reaction may occur in the process. If there is
insufficient flow the product produced in the process will be defective
and will have to be discarded. Any contaminant in the raw material may
produce a dangerous reaction.
Apply the methodology of a hazard and operability (HAZOP) study to
the process at point A on the diagram AND give the results of the study
in typical HAZOP format.
(20)
You are not required to produce a complete study. Consider only the
process parameter of ‘flow’ and apply no more than three guide words.
In answer to this question, candidates were expected to apply the methodology of a
HAZOP study to the scenario described, to produce the results of the study in typical
HAZOP format and to consider only the process parameter of ‘flow’ and apply no more
than three guide words.
Marks were therefore available for first identifying the appropriate table headings such
as guide words, deviation, cause, consequence, safeguards (existing controls), and
actions (additional controls) and then the guide words, for example no, less, more, as
well as, other than and reverse.
A candidate who then opted to choose the guide word ‘less’ would have indicated that
the deviation would have been less flow, the cause - a defective pump or valve, a pipe
that was partly blocked or operator error, the consequence – a defective product, the
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existing controls – operator supervision, and possible additional controls could have
been – testing and maintaining the gauge and valve, automating the flow control, and
testing and maintaining the line.
A similar approach was required for each of the three guide words selected.
This was not a popular question but there were some good answers provided by
candidates who were aware of the tabular presentation format and applied it correctly to
the scenario described. Those who did not do so well did not produce the required
format or omitted some of the table headings whilst a few explained the principles of a
HAZOP study, which was not required.
Day 3
1.
An organisation has decided to introduce a permit-to-work system for
maintenance and engineering work in an area used for the batch
manufacture of chemicals operating continuously over three shifts.
Outline the key issues that will need to be addressed in introducing
and maintaining an effective system in such circumstances.
(10)
The question concerned the introduction and maintenance of an effective system and
was therefore organisational in nature. Many candidates recognised this and dealt with a
number of these issues but many focused on one specific element of operation (e.g. the
design of the permit) to the exclusion of others. Some candidates dwelt on issues such as
CoSHH risk assessments and job safety analysis rather than addressing the question as
written.
Key issues that could have been outlined include:
•
Defining the activities and areas for which a permit would be required;
•
Developing a PTW procedure that defines how the system will operate; and
•
Developing the permit format and multi-copy documentation system to encompass
issues such as job description, hazard identification, specification of risk control
measures, time limits and authorising, receiving and cancellation signatures.
Also relevant are:
•
Arrangements for the return of permits and record-keeping;
•
Arrangements for the co-ordination and display of multiple live permits;
•
Arrangements for communication between shifts (see the scenario);
•
Identification of training needs for, and delivery of training to, persons authorising or
receiving permits and those working in areas where permits may be required; and
•
Arrangements for contractors; provision of supporting arrangements and equipment
such as lock-off, isolation or gas testing facilities; and arrangements for routine
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monitoring and auditing the effectiveness of the system.
2.
a)
Outline reasons for establishing effective consultation arrangements (4)
with employees on health and safety matters in the workplace.
b) Outline a range of formal and informal consultation arrangements that (6)
may contribute to effective consultation on health and safety matters in
the workplace.
This question gave candidates the opportunity to demonstrate their knowledge of
consultation. In answer to part (a) most candidates were able to outline the statutory
requirement for consultation but did not expand on this to include: development of
ownership of safety measures amongst employees; improving perception about the
value and importance of health and safety; gaining the input of employee knowledge
to ensure more workable improvements and solutions; and encouraging the
submission of improvement ideas by employees.
Some candidates confused consultation with the provision of information while others
who mentioned the legal requirement unfortunately then referred to the wrong
statute.
Part (b) required candidates to outline a range of formal and informal arrangements
that could contribute to effective consultation. Marks were available for:
•
The establishment of safety committees;
•
Consultation with union-appointed safety representatives;
•
Consultation with elected representatives of employee safety;
•
Planned direct consultation at departmental meetings, team briefings or similar;
•
Consultation as part of accident/incident investigation or as part of risk
assessment;
•
Day to day informal consultation by supervisors with employees at the workplace;
•
Tool box talks;
•
Use of departmental/team meetings for ad-hoc consultation on safety issues;
•
Discussion as part of safety circles or improvement groups; and
•
Use of staff appraisals, questionnaires and suggestion schemes.
Some did not appear to appreciate the difference between formal and informal
consultation but nevertheless, managed to produce a good range of both. A few again
confused consultation with the provision of information and referred to the use of
posters and notice boards.
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3.
The refurbishment of an organisation’s offices will involve the services
of several different trades from a number of small local companies and
is to be completed while the building is occupied. An interior designer
specialising in commercial properties will manage the project, which
will last about three weeks and will require fewer than five persons to
be working on the refurbishment at any one time.
a)
Outline the criteria that should be used when selecting contractors to (6)
undertake their part of the project.
b) Outline the organisational measures that the project manager may (14)
need to consider in order to ensure the health and safety of office
personnel during the work. You are not required to consider the
specific risks associated with the work.
This was a reasonably popular question with answers to part (a) rather better than those
provided for part (b).
Candidates were able to outline a number of criteria to be considered in selecting a
competent contractor including, amongst others:
•
The contractor’s previous experience with the type of work;
•
The reputation of the contractor with previous or current clients;
•
The quality and content of the health and safety policy and risk assessments;
•
The level of training and qualifications of staff;
•
Accident/enforcement history;
•
Membership of relevant professional bodies;
•
Equipment maintenance and statutory examination records; and
•
The detailed proposals (e.g. method statements) for the work to be carried out.
The second part required an outline of the organisational measures that the project
manager might need to consider in order to ensure the health and safety of the office
personnel during the refurbishment work. There was a generous mark scheme for this
part of the question which offered a wide range of measures which could have been
cited by candidates.
These included:
•
Agreeing schedules and timescales with the contractors;
•
Induction issues such as the provision of relevant information on procedures for
signing in and out, accident reporting, means of escape and procedures to be
followed in the event of an emergency and on hazards in the building such as the
location of utilities and the presence of substances such as asbestos;
•
Arrangements for the staged delivery and storage of materials and the removal of
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waste; and
•
Arrangements for consultation between the individual contractors and the building
manager.
There would also be a need to ensure that the office employees were kept fully informed
of the timetable for and progress with the work and in particular of any parts of the
building to which access might be temporarily restricted.
Practical arrangements for monitoring the contractor’s health and safety performance
were also important Some candidates mistakenly took this to be a question on the CDM
Regulations whilst others concentrated on the physical controls to be put in place rather
than organisational measures.
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Day 4
1.
A large warehousing and distribution facility uses contractors for many
of its plant and property maintenance activities. The number of
contractors’ employees on site at any one time is relatively small
(around 5% of the total workforce) but an analysis of the accident
statistics for the previous two years has shown that accidents to
contractor personnel, or arising from work undertaken by contractors,
account for 20% of the lost-time accidents on site.
(a) Suggest reasons for the disproportionate number of accidents (6)
involving contract work.
(b) Describe the key organisational and procedural measures that should (14)
be in place to control the risks from contract work.
This question was the most popular of those in Section B and many candidates attained
reasonable marks. Part (a) of the question sought some logical observations on why
there might be a disproportionate number of accidents associated with work by
contractors. Issues that could have been covered include those related to the nature of
the work such as:
•
Maintenance work might be more complex, higher risk, harder to control
satisfactorily; and
•
Less well established work methods than other warehousing and distribution
activities.
Other considerations included:
•
Unclear responsibilities for controlling third parties;
•
A lack of training and procedures for third party management;
•
Poor planning and risk assessment;
•
Poor co-ordination and communication between the parties involved or affected;
•
Staff turnover;
•
Lack of contract worker competence;
•
Inadequate supervision; and
•
The effect of contractual or financial pressures.
Weaker answers tended to labour on data reliability issues, suggesting that accidents
involving contractors would be more likely to be reported and that the differences were
therefore not real. Such answers had really missed the clear intent of the question.
Part (b) of the question required a description of the key organisational and procedural
measures required to minimise the risks associated with contract work. Most candidates
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obtained some marks in this part but many looked at too few organisational elements to
obtain high marks.
Some candidates made very generic comments about safety management or vague
references to HSG65 but these were insufficiently specific to achieve marks. Nearly all
candidates dealt with the need for risk assessments and agreed systems of work but this
is only one part of a third party risk management process.
Additional measures that could have been described included:
•
The provision of adequate information to contractors on the nature of the work and
known hazards;
•
The selection of a competent contractor on the basis of evidence concerning skills
and competence;
•
Safety management arrangements, resources and risk control proposals; and
•
The appointment of a client representative with contractor management
responsibility; the provision of information on site rules and safety requirements; and
arrangements for the induction briefing of all contract employees.
Arrangements for coordinating, providing and reviewing risk assessments and method
statements are an important element of the control measures, as are supervision and
communication arrangements for all affected parties, monitoring (active and reactive)
arrangements, and procedures for completion, hand-over and review of safety
performance.
2
A manufacturing company is about to embark on a process of
organisational change that is intended to reduce costs and increase
productivity. As planned, the change will lead to a smaller workforce, a
flatter management structure, enlarged responsibilities for the
remaining staff, outsourcing of most maintenance tasks, increased use
of automated processes and the need for some employees to be multiskilled.
Review the elements of a strategy designed to ensure that the
company maintains its current high standards of health and safety, and
its positive health and safety culture, both during and after the change. (20)
This was a relatively unpopular question in which few candidates achieved good marks.
The question dealt with a subject that most safety professionals will have to deal with at
some stage in their careers – that of organisational change and its potential impact on
safety standards. The HSE has issued a number of good practice documents dealing
with this subject in recent years.
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There were some thoughtful and wide-ranging answers that achieved reasonable
marks but most answers were either too narrow – focused simply on risk assessment or
on the need for training, for example – or they were just summaries of the key concepts
in HSG65 without significant application to the scenario.
Strategy elements that could have been considered include:
•
A clear statement of safety objectives as part of the change process;
•
Allocation of senior management responsibilities for safety during the change;
•
Establishment of active and reactive safety performance measures for both during
and after the change;
•
A stated willingness to amend plans where there is evidence that safety may be
compromised;
•
Involvement of employees and their representatives in working groups dealing with
the change to utilise experience and encourage ownership; regular communication
of plans and progress to all employees; arrangements for risk assessment for all
planned process and human change (and for the involvement of employees in this);
•
Mapping of the proposed job skill and experience needs of the new structure (and
the involvement of employees in this);
•
The systematic assessment of development and training needs for individuals
(including arrangements to identify informal knowledge and experience that may
be lost and how to capture this);
•
Arrangements for managing the risks from the use of third parties for outsourcing
and assessing the competence of contractors;
•
Dealing with employee anxiety as sympathetically as possible through regular and
honest communication; and
•
A transparent approach to redundancy and help with job placement if needed.
Issues such as the provision of adequate time and resources for training and
implementation of the new arrangements, monitoring safety performance by agreed
measures during and after the change, and reviewing the change process and its safety
implications at intervals after the change were also relevant.
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3.
A fast-growing manufacturing company employs 150 people. Health
and safety standards at the company are poor as arrangements have
developed in an unplanned way without professional advice. The
company has managed to avoid any serious accidents and staff at all
levels do not seem particularly concerned. However two employees
have recently experienced near miss incidents and have complained
jointly to the Health and Safety Executive (HSE). A subsequent visit by
an HSE inspector in connection with the near-miss incidents has
resulted in the issue of three improvement notices.
The Managing Director wishes to dismiss the two employees whom he
has described as ‘troublemakers’.
(a) Explain the advice you would give the Managing Director with respect
to the proposed disciplinary action against the employees who have
complained.
(5)
(b) Outline the steps that could be taken to gain the support of the
workforce in improving the health and safety culture within the
company.
(15)
This question required application of employment law knowledge and a strategy for
changing the perception, involvement and ownership of employees on matters of health
and safety in their workplace.
For part (a) candidates should have recognised that this was a protected disclosure
under the Public Interest Disclosure Act 1998 though many of them could not name the
Act correctly or explain the real nature of the protection, despite many recognising that
an action at an Employment Tribunal, may result.
Other advice to the MD would have been to investigate why the employees felt the need
to refer the matter to the HSE, and to consider the possible root causes of their
complaints.
Part (b) required candidates to outline the steps that could be taken to gain the support
of the workforce in improving the health and safety culture within the company. Better
answers began by recognising the value of tools to help them understand current
employee perceptions such as informal discussions and safety climate questionnaires.
Methods of demonstrating the commitment of the business to the improvement of the
safety culture such as the development of a new policy, establishing a health and safety
committee, appointing a safety adviser, encouraging informal communication on health
and safety, investing in safety training for leaders and staff and emphasising through
communication and good example that safety had the same priority as production were
all measures that should have been identified.
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Steps to increase employee participation were also important and could have included
involvement in risk assessments, the development of safe systems of work, inspections,
incident investigation and team briefing sessions.
It would also be relevant to stress the importance that should be given to providing the
workforce with information on safety initiatives, to publicise the work of the safety
committee and to ensure that safety issues became a key part of routine reporting at all
levels.
In general, candidates did not take a broad enough approach to this part of the question
and there was possibly too much emphasis placed on the appointment of safety
representatives and the formation of a safety committee.
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