April 2021

SCENARIO

You are the health and safety advisor for a large supermarket store that employs 80 permanent
workers. The workforce is comprised of workers, day and night shift managers and a store manager.
The store manager’s working hours overlap the two shifts. The store is just 1 of 400 under the same
ownership. The store manager is mainly concerned with keeping shelves fully stocked with goods to
meet customer demand and ambitious sales targets. When not in their office, they spend the rest of
their time walking up and down the goods aisles checking for empty shelves. This supermarket was
listed in the top 10 for sales last year and the store manager wants to do even better this year. They
have told shift managers that they do not care how it is done, but the supermarket must be in the top
5 this year for everyone to receive their bonus.

As a result of high demand leading up to a very busy national holiday period, 20 additional temporary
workers have been recruited. Before starting work, the temporary workers have a very brief induction
consisting of a 2-minute video explaining the company values. However, there are no written job
descriptions and limited instruction or training about how to do the work. There is very limited
supervision. There are also no written training records for these workers. The temporary workers
are unaware of the company health and safety policy or how to report any issues, defects, or
problems to their shift manager. They are immediately put to work in busy areas where they are
needed most, such as shelf-stacking and transporting empty cardboard boxes to a storage area for
compacting. They are told not to operate the compactor as it is dangerous and has been the subject
of a previous enforcement visit.

As part of the supermarket’s drive to be more environmentally responsible, they have a large
compactor (baling) machine. This is used to compact waste cardboard packaging so that it takes up
much less space when it is stored and transported. The compactor comprises of three sections,
arranged vertically. At the top is an enclosed hydraulic ram. In the centre is an opening, at about
chest height, through which the cardboard is fed; the opening is guarded by a safety gate. At the
bottom, resting on the ground, is a chamber, in which the cardboard is compacted by the hydraulic
ram; the contents of the chamber can be accessed through a safety door on the front of the machine.
Under normal circumstances, the authorised operator manually opens the safety gate and feeds
waste cardboard into the machine through the opening, which then falls into the chamber below.

When the chamber is full, the authorised operator closes the safety gate across the opening above
and starts the compactor using control buttons on the side of the machine. This causes the vertical
hydraulic ram to move down, compacting the cardboard into bales in the chamber, before returning
back up to its starting position. An alarm sounds to indicate the process is finished. The authorised
operator then opens the chamber’s safety door, binds the bale of cardboard with wire and moves it
onto pallets, where it is stored for eventual pick-up by a recycling contractor. The gate and door are
fitted with a safety protection device that means, in normal circumstances, the hydraulic ram cannot
operate unless both are closed.

Some months ago, the store manager had arranged for the compactor installer to train shift
managers and experienced workers on the use of the compactor. You then help the trained workers
to complete a compactor risk assessment. The plan was, that following on from the risk assessment,
the day shift supervisor would develop a safe operating procedure (SOP) for the machine. However,
this supervisor retired and left the organisation before the SOP was completed and authorised. As a
result, some workers did not fully understand the SOP and often sought clarification from the day
shift or night shift manager. This was viewed as a complaint by the respective shift manager.
Whenever workers raised any safety concern, the response was usually the threat of discipline in the
form of formal warnings, loss of bonus, or dismissal and replacement by other ‘more willing’ workers.

At the beginning of the day shift, the shift manager was told that the compactor’s safety protection
device had stopped working. The compactor continued to operate even when the safety gate was
open. The shift manager tried to telephone the installation company for most of the day and only got
an answer towards the end of the shift. The installation company told them that they could not send
an engineer to fix it for at least 24 hours. This was relayed to the store manager who told workers in
the compactor area only not to use the machine until it had been fixed, but took no other action to
prevent its use. Neither the store manager, nor the day shift manager re-visited the compactor area
of the supermarket. At shift handover, the day shift manager simply told the night shift manager that
the compactor was ‘faulty’, and it would be fixed the next day.

At the beginning of the night shift, an experienced worker and a young temporary worker took a large
pile of waste cardboard boxes to the compactor. Although warning signs specified ‘authorised
workers only to use this compactor’, the experienced worker loaded the compactor with the
cardboard and then told the temporary worker to operate the controls on the compactor. After a short
while, the machine stopped with the hydraulic ram down on top of some compacted cardboard. The
experienced worker saw that the compactor was jammed (as it often did) and so immediately opened
the safety gate and reached inside to try and clear the jam. The compactor re-started suddenly,
crushing the worker’s hand. The temporary worker called the emergency services directly, as they
did not know what else to do. There was no first-aider working on shift at the time of the accident.
The injured worker was immediately taken to hospital and required amputation of their lower arm.
The temporary worker was distressed and advised to go home. As soon as the night shift manager
found out about the accident, they telephoned the store manager. The store manager told them to
do nothing and said that they would start an investigation the following morning, and that this was no
reason to delay fixing the faulty compactor as already arranged.

The following morning you are asked to carry out an accident investigation by the store manager.
You have been warned not to spend too much time on it so that the store can go back to normal as
quickly as possible to hit those sales targets. You strongly disagree with this attitude and argue that
it is a serious accident and needs to be investigated properly. You ask the store manager why the
investigation has been left until now and they reply that you are responsible for such health and
safety matters, so it is your job and not theirs. You inform the store manager that, due to the injuries
sustained, the accident needs to be reported to the enforcement authorities as soon as possible.
The supermarket store should also expect another visit from the enforcement authority. You also
inform the store manager that the injured worker is likely to claim for compensation. As a result, a
court case is likely and the supermarket will need a lawyer. This is the latest claim of many such
claims over the years by workers at this supermarket.
Task 1: Workers’ responsibilities in the workplace

1 The injured worker, and their fellow worker, may have contravened some of
their responsibilities as workers within International Labour Organisation
Convention C155 – Occupational Safety and Health Convention, 1981
(No.155) Article 19 and associated Recommendation R164 – Occupational
Safety and Health Recommendation, 1981 (No.164) recommendation 16.

Comment on the extent to which Article 19 of C155 and recommendation 16

of R164 may have been contravened. (10)
Note: You should support your answer, where applicable, using relevant
information from the scenario.

Task 2: Influencing health and safety culture

2 To improve health and safety performance in the supermarket, you know that
you need to positively influence health and safety culture.

What appear to be the negative indicators of health and safety culture at the
supermarket? (20)
Note: You should support your answer, where applicable, using relevant
information from the scenario.

Task 3: Health and safety management roles and responsibilities

3 Comment on the effectiveness of roles and responsibilities in relation to health

and safety management in the supermarket. (10)
Note: You should support your answer, where applicable, using relevant
information from the scenario.

Task 4: Accident investigation and recommendations

4 (a) Why should the scene of the accident have been secured? (5)

(b) Based on the scenario only, what training would you recommend the
supermarket arranges for the different types of workers to minimise the
probability of a repeat accident? (15)

Task 5: Determining individual human factors that negatively influence behaviour

5 What individual human factors might have negatively influenced the behaviour
of the injured worker? (10)
Note: You should support your answer, where applicable, using relevant
information from the scenario.
Task 6: Showing how the faulty compactor exposed workers to greater risk

6 With the compactor’s safety protection device not working, the workers were
exposed to significantly greater risk. A good visual way of demonstrating and
understanding this is to draw a risk matrix like the one shown below.

(a) Assuming that you are teaching someone who has never seen this kind
of risk matrix before
(i) show how the matrix can be used to confirm that the risk level was
acceptable when the compactor risk assessment was initially
carried out. (5)
(ii) show how the matrix can be used to confirm that the risk level
changed significantly with the safety protection device not working. (5)
Note: Show calculations and support the calculations using information,
where applicable, from the scenario.

(b) What additional administrative control measures could the supermarket

put in place to prevent a repeat of this accident with the compactor? (10)
Note: You should support your answer, where applicable, using relevant
information from the scenario.

Task 7: Financial arguments for the store manager to improve health and safety

7 Based on the scenario only, what financial arguments could you use to
convince the store manager that health and safety needs to be improved? (10)
 Answer (April 2021)
Task 1: Workers’ responsibilities in the workplace

Question 1
The following information from the scenario, portrays that the injured worker and his
fellow worker had contravened the Article 19 of C155 and recommendation 16 of R164.

Workers, while performing their work, co-operate in the fulfilment by their obligations
placed upon them”. But from the scenario, the workers had ignored the warning signs
specified “authorised workers only to use this compactor”.

Representatives of workers in the undertaking co-operate with the employer in the field of
occupational safety and health. From the scenario, the experienced worker failed to co-
operate with the employer by instructing the inexperienced temporary worker to operate
the controls of the compactor.

Representatives of workers may consult their organisation on measures by taken by

them to secure occupational safety and health. There is no evidence in the scenario that,
neither the experienced worker and nor the temporary worker had consulted any of the
employer representatives before operating the compactor machine.

Workers and their representatives in the undertaking are given appropriate training in
occupational safety and health. The temporary workers have been given only a brief
induction consisting of a 2-minute video. There is no written job descriptions and limited
instruction or training about how to do the work.

A worker reports forthwith to his immediate supervisor any situation which he has
reasonable justification to believe presents an imminent and danger to his life or health.
The experienced worker did not inform his immediate supervisor about the machine
defect and had taken shortcut by opening the safety gate, reached inside to try and clear
the jam.

The following information from the scenario, portrays that the injured worker and his
fellow worker had contravened the Recommendation 16 of R164 statements,

Takes reasonable care for their own safety and that of other persons who may be
affected by their acts or omissions at work – In this scenario, the experienced workers put
the life of temporary worker in danger by reached inside the compactor to try and clear
the jam. The compactor re-started suddenly, crushing the worker‟s hand.

Comply with instructions given for their own safety and health and those of others and
with safety and health procedures – The safety instruction specified as “authorised
workers only” was not complied by both the workers.

Use safety devices and protective equipment correctly and do not render them
inoperative. – Here, night shift manager informed that the compactor was „faulty‟, and it
would be fixed the next day, but the experienced worker, At the beginning of the night
shift, had bypassed the safety device,

Report any situation which they have the reason to believe could present a hazard and
which they cannot themselves correct – In the scenario, the experienced worker failed to
report to his supervisor when the compactor machine stopped due to malfunction.

Task 2: Influencing health and safety culture

Question 2

Here, several negative health and safety indicators observed in the supermarket.

 The management had told the shift managers that they do not care how it is done
to become Top 5 this year – This shows the lack of management commitment
towards health and safety of the workplace.
 Many court cases and claims for compensation against the supermarket by the
workers, showing the previous poor history of accidents in the workplace.
 Likely chance of penalties, by the enforcement authorities, for the legal health and
safety violations at the supermarket.
 Safe Operating Procedure (SOP) for the compactor machine was not developed
and authorized.
 Whenever workers raised any safety concern, the shift managers response was
usually the threat of discipline in the form of formal warnings, loss of bonus, or
dismissal and replacement by other “more willing” workers.
 Store manager took no proper action to prevent the use of compactor machine
when he was informed about the fault in compactor‟s safety protection device.
 Inadequate HSE induction training for new employees. There are no written job
descriptions and limited instruction or training about how to do the work & whom
to report, in case of emergencies.
 Inadequate supervision at the workplace.
 The temporary workers are unaware of the company health and safety policy.
 The temporary workers are unaware on how to report any issues, defects, or
problems to their shift managers.
 No proper written handover procedure between day shift manager and night shift
manager about the existing hazards in the workplace.
 Lack of Safety Priorities, the safety may fails in many areas, the baling machine
does not have proper guarding. the injury will happen on machine with lack of
safety aspects. hydraulic ram are need to close properly and emergency safety
button on machine not fixed.
 Unsafe behaviour of injured and temporary worker, who had ignored the safety
warning sign “authorised workers only to use this compactor”.
 Unauthorized worker (young temporary worker) had been allowed to operate the
compactor.
 Poor maintenance of machineries due to which the hydraulic ram of the compactor
was often jammed.
 Absence of proper training and awareness of the experienced worker, due to which
he opened the safety gate when the machine is in operation.
 Absence of first aider in the night shift.
 Poor safety attitude of store manager who had instructed to delay the accident
investigation process.
 Store manager found to warn the Health and Safety Advisor on not to spend too
much time on accident investigation, reflecting negative safety culture.
 Blaming culture in the supermarket where the store manager said that the Health
and Safety Advisor is solely responsible for health and safety matters.
 Lack of monitoring system, the management and the site manager has failed to
inspect the workplace. And they cannot take any risk assessment on the
workplace, and they failed to identify the workplace .
 High accident rate, the injured worker is likely to claim for compensation. This is
the latest claim of many such claims over the years by workers at this
supermarket.
Task 3: Health and safety management roles and responsibilities

Question 3
Overall effectiveness of roles and responsibilities are found to be very poor.

Poor health and safety management found to be reflected in every level of the
supermarket.

Store Manager:
The roles and responsibilities in relation to the health and safety management for
Store Manager is ineffective because of the below reasons.

 He was not caring about Health & Safety of his supermarket and
concentrating only on becoming Top 5 in sales this year.
 The Health and Safety Policy of the supermarket was not effectively
communicated.
 No evidence of safety performance goals was established. (Only goals for
productivity were established)
 Insufficient resources allocated for health and safety.

Shift Manager
The roles and responsibilities in relation to the health and safety management for
Shift Managers is ineffective because of the below reasons.

 They did not ensure adequate supervision in the workplace.

 They did not ensure adequate induction training, written job descriptions,
adequate instructions to carry out the job for new workers.
 The shift managers did not participate in the accident investigation
process.
 The shift managers did not allow any workers to raise safety concerns at
workplace; They consider the safety concerns as complaint and threaten
the workmen in the form of formal warnings, loss of bonus etc.,

Experienced & Temporary workers

The roles and responsibilities in relation to the health and safety management for
workers is ineffective because of the below reasons.

 They did not take reasonable care for their own safety or their fellow
workmen when operating the faulty compactor.
 The safety warning sign of “authorised person only” was ignored.
 The safety instructions were not complied.
 The safety device (safety gate) was bypassed by the experienced worker
without consulting his immediate supervisor.
 The experienced worker did not report to his supervisor when the
compactor got jammed.

All of this information in the scenario indicates the ineffectiveness of roles and
responsibilities in relation to health and safety management at all levels of supermarket.

Task 4: Accident investigation and recommendations

Question 4 (a)

Any accident scene needs to be secured because,

1. Secure the scene as soon as possible to prevent it being altered.
 2. To identify the real causes of the accident.
3. One of the first and most important actions to take is to secure the location of the
incident. The decision to secure the scene of the incident may best be made by
local (management) personnel.
4. Securing the scene may be done even before the formal decision to investigate is
taken.
5. To preserve the evidence of the scene, Securing the scene of the incident is
important to make sure that (material) evidence is not moved or removed, which
can easily happen after an incident.
6. To prevent other people from entering the accident spot and disturbing the
evidence
7. To preserve the evidence of the scene

Question 4 (b)
The health & safety trainings, which I would recommend the supermarket for different
types of workers to minimise the probability of repeated accident, are.
 IOSH Health and Safety Leadership and commitment training for Store Managers &
Shift Managers as well as workers.
 Effective Safety induction training, Proper safety induction training for new
(temporary workers), it's important that we incorporate safety into their induction
to the supermarket – before they start their job.
 Daily Tool Box Talk Training to all workforce before starting the activities.
 Compactor‟s Safety Protection Device Importance training
 Safety Protection Device Importance needs to be communicate to all workforce.
 Compactor safety awareness training for shift managers and experienced workers
 Third party compactor operator training by the compactor installer for authorised
compactor operators.
 Risk Assessment training for all store manager, shift managers and workmen
 Compactor Safe Operating Procedure (SOP) training for authorised users of the
compactor machine.
 Emergency response training and reporting protocols for new workers.
 Manual Handling training for new & experienced workers involved in shelf-stacking
and transporting empty cardboard boxes to a storage area.
 Accident Investigation training for store manager, shift managers and workmen
 HSE Legal requirements training for Store Managers & Shift Managers.
 Behaviour based safety training for all employees.
 Health and Safety Policy communication training.
 Health and Safety Roles and Responsibilities training for all employees.
 Frequent Health and Safety Trainings on general Health and Safety subjects for
general safety awareness for all employees.

Task 5: Determining individual human factors that negatively influence

behaviour

Question 5
Based on the information from the scenario, the individual human factors which could
have negatively influenced the behaviour of injured worker are,
 Poor safety attitude towards safety of the store manager
 Only production motive of the store manager and shift managers.
 Poor supervision by the supervisors or store manager or shift managers.
 Due to lack of Competence, experienced worker saw that the compactor was
jammed (as it often did) and so immediately opened the safety gate and reached
 inside to try and clear the jam. The compactor re-started suddenly, crushing the
worker‟s hand.
 Poor Skills, Injured worker had a poor Skills about compactor‟s safety protection
device. Skill level inadequate for the task performed
 Poor Attitude, Injured worker had a poor Attitude about compactor‟s safety
protection device and SOP.
 Working with inexperienced and untrained temporary workers
 Threat of disciplinary action by the shift managers in case any safety concern was
raised.
 Poor response to complaints by the compactor installation company
 Lack of competency and SOP training to perform the job.
 The experienced worker and experience might have led him to take it so simple to
operate this machine.(Over familiarisation)
 Poor communication between shift managers
 Over confidence of experienced worker to ignore the warning signs.
 Poor perception of risk by the worker.

Task 6: Showing how the faulty compactor exposed workers to greater risk

Question 6 (a) (i)

The risk assessment matrix helps to quantify the risk level determine the risk categories
are Low, Medium, and High.

Risk = Likelihood x Severity

Likelihood – Probability of accident to happens.

Severity – Extent of injury or property damage if the accident happens.

Which means, Likelihood = 1 (Very Unlikely); Severity = 2 (first aid injury)

Risk = 1 x 2 = 2

So, in this case, the risk level will be “low risk”. confirmed that the risk level was
acceptable when the compactor risk assessment was initially carried out.

According to the information given in scenario, Compactor machine was equipped with
safety gate, safety alarm and automatic switches. All these control come under
engineering control. Workers were given instruction and training about safe use of
compactor and only authorized person was allowed to use that machine. These were
administrative control measure. Both these factors combined together to form likelihood
of the accident to rating 1 (very unlikely) so the risk, at that time, was in acceptable (low)
range

While in case of any accident, it will require first aid injury, soothe severity will be in
rating2 (first aid injury)

Question 6 (a) (ii)

As mentioned in the previous answer,

Risk = Likelihood x Severity

Likelihood – Probability of accident to happens.

Severity – Extent of injury or property damage if the accident happens.
 According to the information given in scenario, When the compactor safety protection
device was NOT working, there is high chance of hydraulic ram coming down and hitting
the operator, when the safety gate was open.So, both the severity is high and the
likelihood of hydraulic ram coming down will be increased.

Which means, Likelihood = 3 (Very likely); Severity = 3 (Major Injury)

Risk = 3 x 3 = 9

So, in this case, the risk level will be “High”. confirmed that the risk level changed
significantly with the safety protection device not working.

Question 6 (b)
I would suggest the following additional administrative control measures for the
supermarket to prevent a repeat of this accident.
 Safe system of work: This is a formal procedure which defines a method of working
that eliminates hazards or minimises the risks associated with the large
supermarket. Conduct Large compactor (baling) machine Safety & Safety
Protection Device Importance training for store manager, shift managers,
temporary worker and experienced workers.Comply the Safe Operating
Procedure (SOP) for the machine.
 Reduce exposure: In this, large supermarket, an worker who spends all day
working on Large compactor (baling) machinery with hazardous moving parts is
more likely to suffer injury than an worker who only spends one hour of their
working day exposed to the same hazard. So Reduce exposure duration, the less
time and the lower frequently, the better.
 There should be a proper Permit to work system (PTW). According to the scenario,
experienced person assigned controlling of machine action to unskilled worker,
which may be the cause of accident. No one should be allowed to run any
equipment unless a permit to work issued by higher authorities. In this way all the
workers doing specific tasks will be under documentation.
 A detailed safety induction training can be developed, which emphasise about the
adherence to Health and Safety rules at the supermarket.
 Written job descriptions with specific Health and Safety roles & responsibilities can
be developed and communicated to all levels of the organisation.
 Health and Safety policy of the supermarket can be communicated to all employees
and displayed at prominent locations of the supermarket.
 A proper reporting procedure can be developed to report in case of any defect/
issues / problems at workplace.
 Safe Operating Procedure (SOP) can be developed and authorised for the
compactor machine.
 A Safety incentive program can de developed and implemented at supermarket, for
encouraging the workers to report / raise safety concerns at their workplace.
 A proper shift handover safety inspection checklist can be developed and
implemented in which the relieving shift manager will inform all the existing
hazards in the workplace.
 Competent and continuous supervision can be ensured especially at highly
hazardous locations.
 Appropriate disciplinary procedure can be developed to reprimand the employees
who found to violate the developed safety procedures and existing safety rules at
workplace.
 A trained and experienced first aider can be immediately deployed for both shifts.
Task 7: Financial arguments for the store manager to improve health and
safety

Question 7

I would use the following financial arguments to convince the store manager to improve
health and safety.

I would make convince & Financial arguments for the store manager like, Accidents and
ill health result in various direct and indirect cost. Some of the cost can be insured
against and most cannot be insured. To prevent such financial losses and damage to the
profitability of an organization it is required to manage health and safety to avoid
accidents and ill health.

Accidents and ill-health are costly. These costs may be calculably arising directly from
the accident, such as sick pay, repairs to damaged equipment, fines, and legal fees, or
more difficult to assign a monetary value to such as lost orders and business interruption.
In practice, the costs that are more difficult to calculate are often substantially more than
those that are easier to assess.

All employers are required to have certain types of insurance against accidents, ill-health
or other problems, such as:

 Employers‟ liability;
 Public liability;
 Motor vehicle;

These insurances will cover some of the costs of accidents and ill-health, e.g.
compensation claims from employees and damage to motor vehicles. However, many of
the costs cannot be insured against, such as:

 Product and material;

 Lost production;
 Legal costs in defending civil claims, prosecutions or enforcement;
 Overtime and other temporary labor costs to replace the injured;
 Time spent investigating the accident and other administration costs (including
supervisor‟s time);
 Fines from criminal;
 Loss of highly trained and/or experienced;
 Effects on employee morale and the resulting reduction in
 Bad publicity leading to loss of contract I will explain to the Store Manager that the
direct cost of any accident will be only like a “Tip of the Iceberg” and the actual
cost are far higher.

I will make him understand that spending on improving Health and Safety is not expense,
but it is an investment to prevent future accidents.
December 2021
SCENARIO

Following a serious and well publicised accident, you have been newly recruited as a Health and
Safety Advisor at a bakery organisation. The organisation employs directors, shift managers,
maintenance engineers and bakery workers.

The organisation produces bread on a large scale using automated machinery. Ingredients are
mixed together to make a dough. The dough is placed in baking tins on a conveyer which travels
through an oven, baking the dough into bread. There are three large bread ovens at the bakery, as
well as other machinery used to prepare the dough. This is all housed in a large warehouse.

The bread baking ovens are long, metal-encased tunnels with a conveyor running through them. The
conveyor is made up of horizontal racking, bolted through metal plates at either end of the conveyor
chain. The conveyor is approximately 20 metres long and 3.3 metres wide (approximately 66 x 11
feet), taking up virtually the whole of the width of the oven. The bread dough is placed in tins that
enter on one end of the conveyor, travel along the length of the oven and exit at the opposite end.
Travelling at its fastest speed, the tins take 17 minutes to pass through the oven.

The directors do not believe that health and safety is a full-time job, but they hope that you will
improve the bakery’s health and safety performance, learn lessons from the recent serious accident
and, most importantly, improve the reputation of the organisation. They have told you that there is no
budget for health and safety, but if something is needed, you should present an argument for how it
will improve profit. You ask who the health and safety representatives are within the organisation
and are told that there are none with whom to raise specific safety issues. However, if a machine
needs to be fixed you should contact the maintenance engineer.

You also ask if any health and safety training is provided to staff and are advised that as far as
training is concerned, there is an induction for new starters within six weeks of joining the
organisation. New starters are then shown how to carry out their role by someone else in the
relevant department. You are told that quite a lot of people have received first-aid training, but it was
a long time ago and many of those trained have since left the organisation. Other than that, there is
not much in the way of training, because the directors feel it is wasting working time. Finally, you ask
where the health and safety documentation is kept but they say that they do not know, and suggest
you ask the shift manager on duty.

The duty shift manager is sitting at their desk surrounded by paperwork, looking stressed. You
introduce yourself and ask where the health and safety documentation is kept. The shift manager
pulls out a folder from a cupboard in the corner of the room and says that risk assessments are in it.
You find several completed risk assessments for the ovens and other machinery, but they are very
out of date. You ask to see the accident and near miss records, but the shift manager advises that
accidents do not happen often, so there is no need to keep a manual record. However, you have
heard from the other workers that accidents and near misses frequently occur, but that they are not
formally reported.

You ask where the inspection and maintenance documentation for the bakery machinery is kept and
are directed to the maintenance engineer. The maintenance engineer explains that they do not keep
a record of inspections and maintenance other than in their work diary, and that they can see when a
machine was last used from that diary. They have been doing the job for over 15 years and ‘just
know’ which machines have had work done to them. When they are working on a machine, they
check certain parts at the same time. They also remark that as the machines are quite old, they
frequently need parts replacing. The workers have been promised new machines a few times, but
these promises have not been kept.

The recent accident

As part of your remit to learn lessons from the recent serious accident, you decide to investigate what
happened. Your enquiries reveal that the accident occurred when the bakery was under pressure to
get an urgent order completed. You find out that the directors often allow workers to cut corners
when it comes to safety measures, to enable them to get the job done as quickly as possible and
without costly delays. Workers are often individually blamed if target timelines are not reached.

This is how the accident happened. On a night shift, the conveyor racking collapsed into one of the
ovens stopping it from moving. The maintenance engineer, usually assigned to fix breakdowns, only
worked day shifts. Waiting for this engineer to come back on shift would have caused significant
downtime, and would have prevented the order from being completed on time. Feeling under
pressure, the shift manager on duty discussed the issue with their team to try to get the oven back up
and running. It was decided that a newly promoted maintenance engineer and another young worker
were assigned to enter the bread oven to retrieve the fallen racking themselves. No-one on the night
shift had ever been present when an oven had needed entering before. The correct way to enter the
oven for maintenance work would have been to remove the side panels. However, this would have
taken a long time, as specialist tools that they were unfamiliar with, would have to be found and used.

The oven had only been switched off for two hours, but it was assumed that it was cool enough to
enter. The temperature gauges were not checked before entering. The two workers decided to enter
via the route the bread would take on the moving conveyor. They managed to get on the conveyor
through a small unguarded gap.

Once the workers had entered the oven, they soon realised it was too hot. They were unable to get
the attention of their colleagues outside of the oven, but eventually managed to alert them by
shouting for help. Their colleagues tried to get them out of the oven, but they did not know how to do
this, or locate how far they were inside the oven. Everyone was frantically trying to help but there
seemed to be no-one in charge to take control of the situation. As a result of this, there was a delay
in getting them out. There was no way to reverse the conveyor belt, so the workers had to forcibly
pull off barriers and side panels to help them escape. Both workers who entered the oven suffered
serious burns. Workers at the scene were not first-aid trained but did their best to help their
colleagues. Unfortunately, both workers died from their injuries at the scene. The workers who
helped get them out were traumatised by what they had witnessed and had to take extended periods
off work to recover. There were also some workers who felt they could no longer work at the bakery
and resigned.

Following the accident, the bakery was closed for two weeks while an investigation took place. The
associated downtime caused many missed production deadlines and loss of contracts. The
organisation, the directors and duty shift manager were all prosecuted for breaches of health and
safety legislation. They pleaded guilty to all the counts against them. The organisation was fined
£350 000 and ordered to pay costs of £250 000. Since the accident, the bakery has lost bread orders
due to clients not wanting to be associated with them.
Task 1: Obligations of employers to workers

1 What employer obligations to workers are likely to have been contravened,

leading to the accident in this scenario? (10)

You only need to consider those obligations placed upon employers under
Recommendation 10 of International Labour Organisation R164 -
Occupational Safety and Health Recommendation,1981 (No. 164).
Note: You should support your answer, where applicable, using relevant
information from the scenario.

Task 2: Influencing health and safety culture

2 To improve health and safety performance in the organisation, you know that
you need to influence health and safety culture.

What appear to be the negative indicators of health and safety culture at the
bakery? (15)
Note: You should support your answer, where applicable, using relevant
information from the scenario.

Task 3: Financial arguments to improve health and safety

3 Based on the scenario only, what financial arguments in relation to accidents,

could you use to convince the directors that health and safety needs to be
improved? (10)

Task 4: Investigating incidents

4 You advise the directors that the organisation should carry out some health and
safety performance monitoring.

Comment on the reactive (lagging) monitoring measures that could be put in

place by the organisation. (10)
Note: You should support your answer, where applicable, using relevant
information from the scenario.

Task 5: Prioritising health and safety issues

5 You have decided to form a health and safety committee to help improve health
and safety at the organisation.

Based on the scenario only, identify TEN health and safety issues that the
committee should prioritise at their first meeting. (10)
Task 6: Training recommendations

6 Based on the scenario only, what training should the bakery arrange for the
different types of workers, to make a repeat of the recent accident less likely? (10)

Task 7: Emergency procedures

7 (a) Why do emergency procedures need to be developed? (5)

(b) What could have contributed to the failure of the emergency

arrangements when dealing with the recent accident? (15)
Note: You should support your answers, where applicable, using relevant
information from the scenario.

Task 8: Setting suitable health and safety targets

8 You propose a health and safety target to help improve health and safety
management system performance. You formulate the target action table
below.

Target Actions required Who is Timeframe

responsible for actions
Reduce recorded Monitor accident Top management 12 months
accidents by 50% statistics on a
monthly basis

Train workers on
accident reporting

Comment on the suitability of the target action table in helping to improve

health and safety management system performance. (15)
Answer (December 2021)
Task 1: Obligations of employers to workers

Question 1
The employer obligation to workers are unlikely to have been contravened leading to the
accident are
 Use of safe method:-in the scenario it is evident that there was no permit to work
system.
 Provide adequate supervision at work place:- in scenario there was no
supervisor when the young worker and maintenance engineer entered the oven.
 Eliminate physical and mental fatigue: - in the scenario we can see that due to
high work pressure and work load the young worker and maintenance engineer
entered the oven for maintenance in absence of main maintenance engineer.
 Provide appropriate training and instruction: - the workers were not given
proper training. The workers entered the oven in a wrong way.
 Lack of worker technical knowledge:-the management didn’t provide any toolbox
talk to workers. They don’t know how use specific tool for opening side panel of
oven.
 Provide and maintain safe work place:-in the scenario it is evident that the
machines in the work place were too old and no safe system for working.
 No first aider: - during accident there were no first aider to provide first aid to
workers. The management didn’t provide training to workers.
 Absence of competent worker: - a young worker (vulnerable person) and less
experienced maintenance engineer was assigned for maintenance.
 Absence of safety officer: - management didn’t give importance for health and
safety so no safety officer was appointed.
 Emergency procedures: - works were unaware of emergency procedures. There
was no emergency procedure for taking out the worker trapped inside oven.

Task 2: Influencing health and safety culture

Question 2
Negative indicators for health and safety in the bakery are:-
 The directors have a negative attitude towards safety. They don’t believe that
safety is a full time job.
 Absence of safety officer is a negative indicator. The management is not
concerned about workers safety.
 Absence of accident reporting system. The shift engineer told that no accident5s
occurs at work place but the workers told me that accidents happens frequently,
this accident were not reputed formally.
 Workers were blamed by managers when goals are not achieved. Shows the
blame culture in the organisation.
 Major accident occurred cause death of 2 workers which can be used as a
negative indicator.
 Lack of proper training: - the workers were not given proper training for using the
specific tool for opening the side panel of oven.
 High worker absence and turnover: - after the accident many workers leaved the
bakery.
 Using young worker for maintenance job. Young workers are classified as
vulnerable persons. Which is a negative indicator for health and safety.
 Lack of maintenance: - the machines in the bakery were too old not maintained
properly.
 No permit to work system:- permit was not given to workers before maintenance
of oven.
 No proper leadership: - the management is nit concerned about workers safety
 they are running behind profits.
 There were no written policy for health and safety in the bakery. Which is
negative indicator for health and safety.
 High workload was given to workers. To continue the production in bakery the
young worker and maintenance engineer were pressured to enter the oven for
maintenance.
 After the accident enforcement actions were taken by the enforcement authority
which is a negative indicator for health and safety.
 Absence of first aid provision. No first aids were given to injured workers and
workers had lack of training in giving first aid.

Task 3: Financial arguments to improve health and safety

Question 3
Following financial arguments can be used to convince the directors that health and
safety needs to be improved.
 After the accident the bakery has to be closed for 2 weeks which interrupts the
business. Which delay in full filling the orders.
 Reduction in staff morale when frequent accident occurred which cause reduction
in staff morale. This cause reduction productivity and efficiency of workers.
 Recruitment cost of new safety officer after the accident. After the accident
new safety officer was appointed.
 After the accident the bakery was forced to fined by enforcement authority as
part of legal actions,
 Legal cost has to be paid as compensation to affected worker.
 After the accident company’s reputation and good had effected badly. Which
may face difficulties in getting new orders and loosing existing customers.
 After the accident the public image and reputation god damaged. Which will
affects the sales of bakery in future.
 Difficulties in new recruitments and retaking staff. Many staff reassigned from
the bakery because off accident.
 Cost to be paid for the repair/ replacement of damaged oven. During the
accident the oven was broken to take the workers out.
 Productions were lost during the investigation procedures to overcome the lost
production the current worker may have to do overtime. So the cost of paying
over time can be avoided.
All this costs can be avoided if the bakery had a good health and safety culture.

Task 4: Investigating incidents

Question 4
The following reactive monitoring measures can be used in the bakery.
 The post-mortem report of died worker died at accident by investing this data we
can know how the worker died. If it due to heat in the oven or hit by any
mechanical parts in oven.
 The accident investigation report can be used for reacting monitoring. By looking
through this data we can understood the root cause of accident.
 The enforcements actions taken by enforcement agency due to accidents can be
considered as a reactive monitoring data.
 Maintenance report data can be considered as reactive monitoring data. By
looking to this last maintenance date of machine are known.
 Complaints records from workers can be used as a reactive monitoring data. By
investigating this data we can know workers difficulties in worksite.
  Number of civil claims against the organisation also can be used as a reactive
monitoring data.
 Cost of accidents can be used as a reactive data. By looking to this data previous
repair cost to equipments can be known.
 Near miss reports can be used as a reactive monitoring data. Before a major
accident to happen there will be so many near misses.
 Permits to work system records also can be used a reactive monitoring data. By
looking to this data we can know if there was permit to work was given for
maintenance machines.
 Dangerous occurrences in workplace can also be considered as a reactive
monitoring data.

Task 5: Prioritising health and safety issues

Question 5
To improve the health and safety culture of the organisation following things must be
done immediately.
 Appoint a health and safety officer in the bakery. If there is a safety officer
accidents will be less.
 Provide proper awareness and training to worker. During last incident the worker
doesn’t know how to use specific tools to open the side panel of oven.
 Appoint competent worker for maintenance worker. During last incident a young
worker and less experienced maintenance engineer was appointed for
maintenance work.
 There should be proper leadership by the management. The management is
not concerned about workers safety. The management is only focused on
production.
 The organisation should develop a proper health and safety policy. And copies
of this should be given to all workers.
 Develop a permit to work system in work place. So that the safety officer will
check the work place and evaluate the risk before giving permit to work
 Develop emergency procedures. In the last accident workers don’t know how to
take out the trapped workers in the oven.
 Replace the old machine with new machines that has emergency stop switches.
 Give flexible work loads to workers. The management is giving high workloads and
work stress to workers.
 Provide proper personal protective equipments for workers. No PPE was given
to young worker and maintenance engineer before entering to oven.
 Provide proper supervision for maintenance work. During last accident there
were no supervisor and any workers present when the two workers entered the
oven.

Task 6: Training recommendations

Question 6
The training should the bakery arrange for different type of workers are,
 Provide first aid training to workers so that workers can give first aid when
needed.
 Provide all workers training on emergency procedures so that the workers will
know what to do in emergency situation.
 Provide proper safety awareness training for directors. So that they will improve
the health and safety culture of the organisation.
 Provide proper training for young workers so that they can do their work in a safe
 manner.
 Provide workers training on permit to work system. There was no permit to work
system in the company. If provided they will use it for maintenance.
 Provide proper training on supervision. During accident there was no supervisor.
 Provide proper training for using tools. During the last accident the workers were
unaware for using specific tool for opening side panel of the oven.
 Provide training on incident reporting. So that reporting skills will be improved. In
the bakery workers were only reporting incidents verbally.
 The training must be given to maintenance engineer so that they can do their
work in a safe system of way.
 Provide training on incident and accident investigation so that the workers will
investigate in the incident right way and root cause of incidents will be known and
preventive measures can be taken.

Task 7: Emergency procedures

Question 7 (a)
The main objective of emergency procedure are
 To reduce the injuries and protect people in the emergency area.
 Here in the scenario there was no emergency procedure for taking out the worker
from the oven.
 If there is proper emergency procedure the anxiety level of workers will be reduced
because the worker will feel more confident when there is structured plan to
respond in emergency situation.
 Emergency procedures will reduce the damages to buildings, stocks, and
equipments.
 To protect the environment and community. By proper emergency procedure the
damage to environment can be reduced.

Question 7 (b)
The reasons that contributed to the failure of emergency arrangement in the last accident
are,
 There was no emergency plan to rescue the worker from the oven.
 No proper training and mock drill were not conducted on emergency situation.
 There was no emergency alarm system that has to be used during an emergency
situation occurs. The trapped worker in the oven was shouting for help.
 The management didn’t assign the responsible person to deal in emergency
situation like this.
 No procedures were given to workers when an emergency alarm was given
 The emergency procedures in the bakery were outdated.
 No proper procedure on giving first aid to injured worker. From the scenario it is
clear that no first was given to injured worker.
 There was no emergency switch to stop machines. The machines were too old and
outdated.
 No supervision by higher officials when an emergency situation arises.
 No proper work to permit system was given to workers. Before giving permit the
safety officer will check the work place and will instruction on when an emergency
occurs.
 Regular maintenance of machines were not conducted.
 When worker entered the oven there was no worker at outside to communicate
when an emergency situation arise.
 The management didn’t give importance to health and safety.
Task 8: Setting suitable health and safety targets

Question 8
The target table given in the scenario can be evaluated by using SMART
(smart means specific, measurable, achievable, reasonable, time bond)

 Specific: - Target mentioned here was to reduce accident the amount of accidents
by 50% in 12 months. So the target is specific in nature.
 Measurable:- here the target can be measurable by measuring the accident rates
before and after implementation of the task.
 Achievable and reasonable: - the targets are not achievable and reasonable.

The action monitor accident statics on a monthly basis is not reasonable and
achievable because
 In the scenario it is clear that management is not giving priority to safety.
 No proper leadership by management. The director din’t even considers safety
as a full time job.
 No recourses allocation for doing safety measures.
 There is no accident reporting, incident reporting, and accident investigating
system.
 The managements give over wok pressure to workers and blame them if this is
not completed.
In the current scenario achieving this goal is not applicable

The action train workers on accident reporting is not reasonable and achievable
 The management is not investigating events so the workers will think that there is
no use of reporting procedure.
 There is a blame culture in the organisation. So workers may feel they will be
blamed if they reported the events

 Time bond: - within the given time limit this task can be completed if management
is only ready.

 This targets can be only achieved if appropriate workplace is provided

 The leadership qualities needed to be improved. Work load given to the workers
must be realistic.

 Blame culture to be removed

 Appoint a competent maintenance engineer at night shifts.

 Management should give more importance to safety. And they must also provide
proper resources for safety.

 Proper trainings had to be given to workers

Based on the evidence presented above i can clearly tell that the target plan is not
reasonable and achievable.
The plan does not follow smart.
FEBRUARY 2022
SCENARIO (for information)

A car showroom for an international car sales organisation is situated on an industrial estate on the
outskirts of a town. The showroom mainly sells new cars but occasionally sells used ones. Car
sales are driven by ambitious targets. If these targets are met, the sales force receive large financial
bonuses. The Managing Director (MD) reports to the regional, national, and international Boards and
delegates the responsibility for meeting sales targets to the Head of Sales (HoS).

The indoor showroom is a single storey building, with an open plan design. The centre of the
showroom displays four examples of the new cars for sale. Towards the back of the showroom are
three desks where the sales team talk with customers. To the right of the desk areas are two
separate offices. One office is occupied by the HoS, and one by the MD. Next to these offices is a
waiting area that includes a drinks dispensing machine, a few tables and chairs (for information
displays, customer seating, etc) and a television. Various new and used cars are parked in neat
rows around most of the outside of the showroom building. Also outside, near the entrance, there
are twelve dedicated parking bays for visiting customers, vehicles for test driving and vehicles being
prepared for handover to customers.

The HoS has 10 years‟ service at the showroom. They are driven by car sales, usually at the
expense of safety. This attitude is shared by the leadership team and the Sales Supervisor. The
Sales Supervisor has 5 years‟ service and has a strong influence on those reporting to them,
including a very impressionable 17-year-old sales apprentice. The sales team all get along very well
and are given a great deal of freedom to do what they like; what matters most is getting the job done
and achieving the sales targets. As a result, most of the sales team take chances for the greater
good of the team and to maximise bonuses. The sales apprentice, in an attempt to „fit in‟, thinks it is
humorous to use the fire extinguisher to wake up the Sales Supervisor who is sleeping during their
break. The Sales Supervisor sees the comical side and puts the fire extinguisher back.

The remaining member of the sales team is a senior salesperson. They have worked at the
showroom for a long time. They are more cautious than the others and have safety concerns.
One of these concerns is about the lack of attention paid during the movement of vehicles. Although
there are signs saying, „do not use mobile phones while in vehicles‟, the senior salesperson has
observed near misses due to „rushing‟ the job, the apprentice using their phone while driving, and
speeding in the car park in an attempt to „show off‟. They think some of this is due to a lack of
training and supervision, having witnessed a very short induction with the apprentice. There have
been other, similar, events in the past, some involving minor injuries. But there is no record of any of
these near misses or injuries.

In the last 12 years, only one fire-related incident has been recorded. This was a false alarm, where
a child had read the instructions on one of numerous fire call points that read „Break glass, press
here‟, so that is exactly what the child did! The Sales Supervisor had assumed the role of fire
marshal, and although untrained, escorted visitors and workers to the assigned assembly point
nominated in the written emergency procedure. Not even the workers really knew what they were
doing, as such events do not happen very often, and no one can remember ever practicing the
emergency procedure.

The senior salesperson talks, in confidence, to the Sales Supervisor about these safety concerns.
Surprisingly, the Sales Supervisor replies that management feel that overall fire risk is low and there
is no need for frequent fire drills. The senior salesperson is confused and highlights that petrol
vehicles are in the showroom, and emphasises the compliance obligations to inform, check, learn
and improve through such drills. They finish the conversation by pointing out that all the fire action
notices around the building are not just there for the benefit of visitors, but to help protect people and
to satisfy insurers too. Despite these personal concerns, the senior salesperson still feels a lot of
pressure to fit in with the rest of the group, and not worry about the unsafe working that has become
common practice.

The MD is somewhat detached from the day-to-day practical operations because of attendance at
various off-site exhibitions, national and international conferences, and frequent online meetings. As
IG1_IGC1-0010-ENG-OBE-QP-V1 Feb22 © NEBOSH 2022 page 1 of 5
a result, they delegate the daily „running‟ of showroom to the sales team and any health and safety
responsibilities to the HoS. However, the HoS has not had any specific health and safety training to
fulfil this role. Although the senior salesperson has bravely raised the fire evacuation testing safety
issue with the MD in the past, the MD sees no reason to challenge unsafe behaviours and interfere
with a successful team if it is meeting the sales targets. However, they do accept that there have
been some lucky escapes from incidents that could have been more serious. But nothing bad has
happened so far, so why worry? The senior salesperson respectfully suggests a different view that
profits and bonuses can be wiped out easily by the large costs associated with even one workplace
accident. In addition, the unwelcome attention of enforcement agencies and the media. The senior
salesperson‟s view is that is just a matter of time before a serious accident happens.

That same day, in the late afternoon, the Sales Supervisor asks the apprentice to move a car from
the car park to a hardstanding location right in front of the entrance, ready for customer collection.
The apprentice locates the car, as instructed. As they move the car to the required location, they
answer a call on their mobile phone, and stop the car in front of the showroom. While simultaneously
raising the mobile phone to their ear with one hand and exiting the vehicle, they trip over the seatbelt
which has not quite fully retracted. They stretch out their other arm to cushion the fall onto the
concrete hardstanding. The apprentice hastily gets up, looks around in embarrassment to see if
anyone is looking, and acts as if nothing has happened. However, the Sales Supervisor witnessed
the seemingly harmless-looking incident. Later, the two of them have a conversation in the rest area
about the incident. The Sales Supervisor promises to spare the apprentice embarrassment by
saying “It is a matter for you, and you alone; as long as you don‟t say a word to anyone else, neither
will I”.

The following day, the apprentice arrives at work with a plaster cast on their wrist. Their wrist had
swollen and become tender and painful. They had gone to hospital and had an X-ray that confirmed
a small fracture of the wrist. The plaster cast allows limited movement of the fingers. The Sales
Supervisor talks to the apprentice and advises them to say that they fell off a bike at home should
anyone ask. The apprentice agrees and does not see this as a problem. They are put on light duties
until further notice. The senior salesperson is suspicious, and later takes the apprentice aside and
informs them about the implications of accidents at work.

IG1_IGC1-0010-ENG-OBE-QP-V1 Feb22 © NEBOSH 2022 page 2 of 5

Task 1: The influence of peers

1 Comment on the influence of peers on health and safety at the car showroom. (10)
Note: You should support your answer, where applicable, using relevant
information from the scenario.

Task 2: Emergency procedures

2 (a) What are the positive points about fire safety arrangements at the car
showroom? (5)

(b) What are the negative points about fire safety arrangements at the car
showroom? (10)

(c) Why is it important to practice emergency procedures? (5)

Task 3: Accident reporting

3 Within a workplace there are formal procedures for reporting accidents.

(a) Comment on the Sales Supervisor‟s approach to reporting the

apprentice‟s accident? (5)

(b) How should the apprentice‟s accident be reported by the employer? (5)

Task 4: The legal reasons for health and safety management

4 What are the legal reasons why health and safety should be managed at the
car showroom? (10)

Task 5: Workers’ responsibilities in the workplace

5 It is likely that the injured apprentice may have contravened some of their
responsibilities as a worker within International Labour Organisation
Convention C155 – Occupational Safety and Health Convention, 1981
(No.155) Article 19 and associated Recommendation R164 – Occupational
Safety and Health Recommendation, 1981 (No.164) recommendation 16.

Comment on the extent to which Article 19 of C155 and recommendation 16

of R164 may have been contravened. (10)
Note: You should support your answer, where applicable, using relevant
information from the scenario.

IG1_IGC1-0010-ENG-OBE-QP-V1 Feb22 © NEBOSH 2022 page 3 of 5

Task 6: Near misses

6 It is often a matter of chance that a near miss turns into an accident.

How could investigation of the previous near misses have helped prevent this
accident? (10)
Note: You should support your answer, where applicable, using relevant
information from the scenario.

Task 7: Health and safety culture

7 What appear to be the negative indicators of health and safety culture at the
car showroom? (20)
Note: You should support your answer, where applicable, using relevant
information from the scenario.

Task 8: Health and safety management roles and responsibilities

8 It is important that everyone in the organisation knows their health and safety
roles and responsibilities.

Comment on the effectiveness of roles and responsibilities in relation to health

and safety management in the car showroom. (10)
Note: You should focus on roles and responsibilities and not the health and
safety management system.
Note: You should support your answer, where applicable, using relevant
information from the scenario.

IG1_IGC1-0010-ENG-OBE-QP-V1 Feb22 © NEBOSH 2022 page 4 of 5

ANSWER (FEBRUARY 2022)
Task 1: The influence of peers

Question 1
It is commonly seen that adolescents, especially males, tend to deviate away from their
parental influence and move on and get influenced greatly by their peers/co-workers.
Research studies have shown that peer influence is one of the dominant factors leading
the young people to get involved in risky behaviours and actions.

Overall, the influence of peers on health and safety at the car showroom is quite
negative. The scenario states the most influential person in the group as Sales
Supervisor and he had the ability to make other follow his norms and thought processes.
The negative aspect of the peer group pressure could actually been seen on how
vulnerable category, a 17 year old apprentice was dealt with. Inspite of knowing they
are more prone to accidents and injuries, they were given full freedom to do what they
like, with the prime motive being the achievement of sales target. The concept of “Profit
over safety” was planted into the young worker minds due to the negative peer group
influence of the Sales Supervisor, which he imbibed from HoS and MD.

There is a strong urge for new or young workers to “fit-in” the group by displaying similar
traits or attitude of the group members. A perfect example would the horseplay carried
out at the workplace, as we see young apprentice using fire-extinguisher to wake up
sleeping Sales Supervisor during the break and he brushing it aside lightly. If there was a
positive peer influence, he would have given a strict warning not to repeat it, explaining
the risks associated with such rough games.

Another negative impact of peer influence is witnessed during the conceal of the
accident occurred, where Sales Supervisor influence the young apprentice to keep
quiet about the accident and tells him to not to report it, which further lowers the safety
culture of the organisation due to the under-reporting of incidents. He is encouraging
the young apprentice to tell lies and hide facts.

Also, the negative peer influence is seen clearly when senior salesperson tries to point
out the unsafe conditions such as movement of vehicles and mock drills. He is given
negative safety pressure by making him change his perception of risk and also to think
that there is no need of frequent fire drills. The pressure to fit in the group is so high
that he is forced to think in negative attitude and not to worry about the unsafe conditions.

So, in conclusion, due to the above mentioned reasons and evidences, the peer group
influence on Health and Safety matters in the car showroom is very negative.

Task 2: Emergency procedures

Question 2 (a)
The following are positive aspects of fire safety arrangements at the car showroom-

Nominated responsibility of fire marshal- The Sales supervisor, although untrained,

was nominated the role of fire marshal and he escorted the visitors and workers to the
assembly point.

Provision of raising a fire alarm – Numerous manual call points for fire alarm provided
to alert workers and other people to start emergency evacuation procedures.
Answer sheet IG1_IGC1-0010-ENG-OBE-V1 Feb22 © NEBOSH 2022 page 1 of 9
Provision of firefighting equipment- The scenario states the presence and availability
of fire extinguishers to put off fire and deal the spread of fire promptly.

Procedures to be followed developed – On hearing the alarm, the workers and visitors
proceeded to the assembly point as per the written emergency plan.

Written instructions and notices– The manual call point for fire alarm had clear
instructions to be followed like “Break glass and press here”

Question 2 (b)
The following are the negative points about fire safety arrangements at the car showroom

Failure to foresee emergency situations – The sales supervisor failed to foresee

emergency situation, like fire breakout, that can happen at workplace while working with
fuel like petrol and source of ignition nearby.

Inappropriate design of the workplace – The scenario tells that car showroom had
open design plan, and any organisation with change of fire risks ideally need to go for
compartmentalisation design plan and fire partitions.

Failure to give fire emergency training and information- To deal with critical situations
in an appropriate and sensible manner, workers should be trained and instructed on how
to follow procedures. In scenario, sales supervisor, who played the role of fire marshal
was untrained and therefore did not know the actual procedures or duties to be fulfilled
during a fire breakout.

Failure to conduct drills– Mock drills or rehearsals of critical events would have
enabled workers to familiarize them with speedy procedures of emergency response plan
and do it under minimum time without any delay. In the car workshop, the workers were
confused and they could not remember the correct procedures.

Lack of fire safety risk assessment – The car showroom failed to conduct a special risk
assessment on fire hazards and review and update periodically to identify potential
threats to the organisation.

Non-segregation of fuel and ignition source – The presence of petrol vehicles in the
showroom with presence of sparks and usage of mobile phones around it are quite
dangerous.

Lack of fire detectors – Even though the organisation has got firefighting and fire alarm
raising provisions, it has not installed fire detectors and other devices. UK fire alarm
regulations require that all organisations require to have an appropriate fire detection
system, which may include fire alarms, smoke alarms and sprinkler systems.

Question 2 (c)
The organisation needs to practice emergency procedures due to the various reasons –
 For bringing the event under control promptly and reduce its severity/effects on
people, equipment, materials, machines and properties.
 Employees can test and evaluate their personal skills, as well as the
effectiveness of the organization’s emergency procedures or protocols, and also
identifies gaps in emergency response procedures.
 For meeting compliance obligations, ILO guidelines on safety measures and
hence preventing enforcement actions and subsequent fines /penalties.

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  Saves lives and prevents property damage -Mock drill helps employee too react
quickly and safely as soon as during emergency crisis without much delay.
 For allocating necessary resources and for providing adequate training and
mock drills to reduce the severity of the injury and other adverse results.

Task 3: Accident reporting

Question 3 (a)
The Sales Supervision approach on reporting accident in which young apprentice got
injured was very unprofessional and was in total violation with the formal system of
accident reporting.
He failed to report the accident to the higher authorities in the company like HoS and
MD, also other relevant bodies like enforcement authority, insurance company, local
regulatory bodies,etc.
He also did not record the accident and maintain an internal accident report containing
all the relevant details related to the accident like date, time, injury detail, victim details,
activity carried out, violations of rules, etc
Another unethical behaviour was his exertion of negative peer influence to conceal the
incident without anyone knowing and give false statements.

Question 3 (b)
All workplace related accidents needs to be reported by the employer as per the
legal/statutory requirements of the state or country. As per RIDDOR (Reporting of
Injuries, Diseases and Dangerous Occurrences Regulations 2013), it informs local
authorities, regulatory bodies, enforcement authorities about the accident, so that they
can identify when the risks arises and see if it needs any kind of investigation.
ILO code of practice on the recording and notification of occupational accidents and
diseases stats that employer needs to report the incident to
- the relevant enforcement body (e.g. labour inspectorate)
- the insurance company
- ststistics producing company
- or any other relevant bodies.
Notification should be made along with accident report form containing details such as
name and employee details of the victim, details of the employer, activity of the
enterprise, number of workers, type of injury, date and time, action leading to injury, shift
timing, work process and equipment involved at the time of accident.

Task 4: The legal reasons for health and safety management

Question 4
The legal reasons for managing health and safety at the car showroom are as follows:
As per ILO C155, Article 16, employer has certain duties to fulfil a part of law
requirements such as provision of safe workplace, equipment, training, supervision,
personal protective equipment, ensuring various risks are reduced as far as reasonably
practicable and protecting the worker lives. Failure to achieve these minimum standards
leads to enforcement actions or prosecution before court.
Legal reasons are based on compliance obligations and to avoid various punitive,
preventive and compensatory damages to the car showroom and they are the following:

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 - Enforcement notices issued by labour inspectors or other enforcement
authorities in forms of improvement notices or prohibition notices, following any
violations in legal obligations of the employer.
- Fines/Penalties, by the criminal court for the breach of legal duties and causing
adverse events at the workplace from the employer’s side.
- Also, imprisonment of the individuals of the company can also happen if
proved, it was fault or failure to fulfil duties from their side.
- Sometimes, the organisation can get their licence removed to continue any kind
of business operations.
- Worker compensation or civil claims as declared by the court to compensate
for the pain and suffering the victim and his dependants had to go through
because of the accidents and injuries. Insurance premiums also increase with
the high rate of accidents.
- Some incidents could attract media attention as mentioned in the scenario, and
result in reputation damage of the company.
- Shut down of the organisation can also happen depending upon the severity of
the adverse event and catastrophic effect of it.
So, in order to prevent all these actions, health and safety needs to be implemented.

Task 5: Workers’ responsibilities in the workplace

Question 5

As per ILO, C155, article 19 and R164, article 16, several responsibilities of the workers
were found to be contravened at the car showroom and they are the following:
 Ensure own safety and co-workers’ safety also
This responsibility of the employee was seen to be fully contravened by the young
apprentice who indulged in unsafe behaviour in form of rash driving and playing
pranks with fire extinguishers on other employees.
 Comply with safety instructions
This responsibility was also fully contravened by the apprentice as inspite of
having instructions like “Don’t use mobile phone while driving “, they were
frequently seen to be violating the safety rules.
 Use of safety devices and protective equipment correctly
The major cause of the accident was due to the seatbelt not retracted fully and
hence the young worker once again contravened this responsibility too.
 Report any kind of unsafe condition or hazardous potential threat
This responsibility is likely to have been contravened by the young worker as the
scenario states most of the sales team takes chances to maximise bonus at the
expense of safety.
 Report any work related injury and accidents
This fully contravened by the young worker as he does not report the accident
and tries to cover up the incident on the influence of the negative peer pressure.
 Responsibility to attain adequate safety information
The young worker has no interest in seeking information on any kind of safety
related matters and is more focused on making money like other team members.
 Sufficient amount of training
The responsibility to seek and undergo training at the workplace is partially
contravened as even though they are given induction training, it is very short and
insufficient.
 Involvement in worker consultation

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 Scenario gives no information of worker consultation where the safety issues are
discussed and solutions sought by the young worker.
 Reporting any imminent dangers to life and leave workplace
This is also contravened as there were many frequent narrow escapes due to
safety lapses, but the young worker was hardly bothered and had no hesitance in
continuing work at the organisation.

Task 6: Near misses

Question 6
Near misses, according to Frank .E.Bird, 1969, have the potential to turn into accidents if
not investigated properly. According to the Bird’s accident triangle, even though, not all,
atleast some could turn into life threatening events later at the workplace.
The investigation of the previous near misses could have helped to prevent the accident
in the following ways:
 Prevent recurrence – Near Miss investigation will help the car showroom to
identify ineffective existing control measures, which when rectified and additional
control measures implemented, can help in preventing the incident from repeating
again. In scenario, there were frequent near misses occurring.
 To identify root cause- Near miss investigation will reveal the immediate and
root causes, wherein the root causes are directly linked to the management
failures of the organisation. For example, in the car showroom, a few
management failures were lack of training and supervision.
 For compliance obligations- Investigation also ensure whether organisation is
complying with all local and international statutory requirements.
 To learn lessons – Investigation helps in understanding what went wrong and
rectify it next time and for future projects, including ineffective work procedures,
unsafe acts from the employees.
 Staff Morale- Investigation of near misses enhances the morale of the
employees, makes them better motivated to follow safety protocols and
procedures.
 Worker involvement and consultation- Since workers are consulted and asked
questions during the investigation procedures, they are more involved in the
decision making process, which is a major requirement of ISO 45001 standard.
 Spreads safety awareness – The senior managers in the scenario have less
awareness and knowledge on the importance of safety, and investigation will
reveal how small minute violations can lead to catastrophic events.
 To take disciplinary actions- young worker were given too much freedom and
they frequently demonstrated unsafe behaviours like using mobile phones at the
site. Investigation will help to identify the people violating and give some
disciplinary action as a warning no to repeat it.
 Updation of Risk Assessment – Investigation of near misses will help in update
and review of risk assessment carried out at the workplace.
 To discover near miss trends- Which can be a source of lagging indicator and a
part of reactive monitoring system.

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Task 7: Health and safety culture

Question 7
The following are the negative safety culture indicators at the car showroom:
 Profit over safety – The organisation gives more priority to profit generation
rather than safety, where their entire focus is on achieving sales target and getting
the financial bonus.
 Existence of unsafe behaviour – Inspite of signs prohibiting the use of mobile
phones while operating vehicles, the young worker is seen to be using his phone
while operating the vehicle, which is not taken seriously by the supervisor or
manager and dealt accordingly.
 Lack of disciplinary actions- Workers who violate safety rules are not given any
sort of punishments and therefore they have no fear when violating safety
protocols at the car showroom.
 Negative peer influence- Managing Director, HoS, Sales Supervisor all had
negative attitude towards safety and the attitude of placing more importance to
financial gain over safety was passed onto other workers as well, especially
young worker.
 No dedicated H&S professional – Instead of appointing a competent safety
professional at the showroom, HoS was given the responsibility of safety matters,
who had no training or awareness to carry out the roles and responsibilities.
 Lack of training - Even though the Sales Supervisor had assumed the role of the
fire marshal, he had no training provided to fulfil the duties of the nominated
responsibility. Moreover, new workers given only a small short induction training
prior to joining.
 Frequent near misses – The organisation had a few lucky escapes from the
incidents which could have been serious and sadly nothing was investigated and
root cause found out to prevent recurrence.
 Ignoring vulnerable category – Young worker who was 17 yrs old was not
prohibited from doing risky tasks and no supervision or mentors were provided to
see if they are carrying out their job in a safe manner.
 Horseplay – Another negative safety culture observed at the workplace was
indulgence in rough games or pranks. In scenario, young apprentice misused fire
extinguisher for fun and the supervisor just brushed it aside lightly without telling
him the adverse consequences.
 No mock drills – As part of emergency preparedness, periodic mock drills are
necessary and this was missing at the car showroom. Hence workers were all
confused and could not remember anything properly.
 Passive response of the management – The management felt that overall fire
risk is low and there is no need for frequent fire drills, wherein they actually had
some potential threats like operation of petrol vehicles.
 Under-reporting of the incidents- Even though near misses and other incidents
had happened, there were no records of such reporting at the car showroom.
 Poor commitment from the management- MD was detached from the
operations and he was mainly focused on attending meetings and other events,
and he gave the running of the showroom to sales team.
 Over workload – It was seen in the scenario that sales supervisor was sleeping
due to the break time, which leads to the fact that there was too much work and
excessive fatigue amongst workers.
 Lack of supervision- There was no supervision given for young worker at the
time of accident, where he was left alone all by himself to do the task.
 Lack of safety awareness – HoS and MD thinks that since there no serious

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 adverse event happened till now, why waste time after investigating near misses,
which is a negative indicator.
 False witness statement – The supervisor and young apprentice cook up story
and give wrong statement to cover up the actual incident.
 Inadequate manpower – Multiple roles were given to workers and running of the
showroom handed over to the sales team.
 Lack of consultation – Other profit and bonuses, no worker consultation were
carried out at the workplace.

Task 8: Health and safety management roles and responsibilities

Question 8
. The effectiveness of roles and responsibilities in relation to health and safety
management in the car showroom can be summarized as below:
Director/Senior Manager
In respect with Health and safety at the car showroom, the effectiveness of the roles and
responsibilities of Managing Director and HoS were found to be somewhat
unsatisfactorily executed.
To begin with there was no mention of an effective HSE policy or safety aims/objectives
for the organisation. The leadership and commitment form their side for safety was
almost nil as they majorly focussed on making profit generations and achieving sales
target. Safety was a less priority amongst them and they transferred this concept to other
employees as well.
Allocation of resources were also inadequate especially as manpower, there was no
dedicated health and safety professional. They also imposed multiple roles on the
employees and lacked a clear mentioning of employee roles as well. There was no
involvement from their side in the operational matters, focused mainly on attending
meetings online. Also taking disciplinary actions against violators and imposing proper
safety rules and regulations were also missing from their side.

Mid level / Supervisor

The sales supervisor has also failed to execute his roles and responsibilities at the car
showroom. He failed to be responsible and take authority over the area under his control.
Even he witnessed several unsafe behaviours from workers and several near misses,
there was no initiation from his side to carry out investigation or review or update risk
assessments. He failed to implement safe working procedures and allowed horseplay or
pranks to be carried out at the cost of safety.
He did not provide adequate level of supervision while young worker undertook risky
tasks and also did not provide adequate information on the implications of unsafe acts.
He further failed to make sure new workers are adequately given induction training prior
to joining. Also, consultation with worker not carried out and also no proper
documentation maintained, for example, incident reports.
Workers
Primarily two workers were seen at the showroom, a senior sales person and a young 17
yrs old apprentice. While the senior experienced fulfilled a partial execution of his roles
and responsibilities, the young worker totally neglected his responsibilities.
The senior sales person is more vigilant than others and he points out unsafe acts and
unsafe conditions as a part of his roles and responsibilities. He also informs the
supervisor and other the consequences of safety violations and how it could affect the
business.
The young worker has completely contravened all his responsibilities by failing into the
negative peer influence of other workers and fulfils no such worker responsibility, like
ensuring own and other safety, following safety rules, using safety equipment properly,

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and reporting work related accidents.

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