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1. What management failures could have contributed to the accident?
UNIT NG1 / IG1
NEBOSH International General Certificate in Occupational Health and Safety
OPEN BOOK EXAMINATION
SCENARIO Dough Delight is a family-owned bakery that was established 60 years ago. It specialises in producing fresh bread for small, independent cafés. The bakery site features a factory, a small canteen, and welfare facilities for all workers. The factory operates 24 hours a day, seven days a week.
Six months ago, Dough Delight installed new, automated machinery in the factory to improve production standards. As a result of the increase in efficiency of the new machinery, several workers were made redundant. Despite this, there is still a small, dedicated workforce on site. This workforce has a peer group that includes a newly-appointed manager, shift managers, maintenance engineers, and factory workers.
The shift managers are responsible for putting together the factory workers’ monthly rota. The factory workers are contracted to work 12-hour shifts, four days a week, followed by three days off.
Two months ago, a factory worker told the manager that they are pregnant, and submitted all of the necessary documentation. Due to their pregnancy, the worker was also concerned about their current shift patterns, so provided a medical certificate requesting exemption from night shifts. The manager instructed them to continue with their usual duties and hours, emphasising the importance of taking regular breaks, and encouraging the expectant mother to share any additional concerns.
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The bread-making process The automated bread-making process starts in the mixing area, where all of the ingredients are combined to form a dough. The dough is then divided into pieces, placed on a conveyor belt, and sent to the prover (a controlled environment designed to allow the dough to rise before baking). After proving, the dough is shaped and placed into tins, ready for baking. Once baked, the bread is left to cool to prevent condensation before packing. Finally, the bread is sliced and packaged.
Increased production Following the installation of the new machinery, there has been an increase in bread production orders from new independent cafés. Shift managers have noticed that additional manual intervention from the factory workers is now required to correct any errors or reset machinery. They also want the factory workers to perform quality checks, both during the production process and after the bread is baked, to help ensure that the automated process is running smoothly.
As a result of the increased workload, factory workers have complained. Because of this, for the first time, five young factory workers were hired one month ago during a busy, seasonal period. On their first day, a shift manager (SM) provided them with a handbook and gave them a brief tour of the factory. Given their inexperience, each young worker was paired with a factory worker to job shadow and observe for the remainder of the day. After this initial day, the young workers were then expected to perform tasks independently.
The accident At 02:00 on a busy, rainy morning, the factory workers on shift included the expectant mother and some of the young workers. The expectant mother was working in the packaging area. The floor in this area was cluttered with empty boxes and plastic packaging. The floor was particularly dirty from mud and water tracked indoors by workers. One of the young workers arrived late and was immediately given the task of tidying up and mopping the floor in the packaging area by the SM. Eager to impress the SM, they began mopping the floor quickly and showing off in front of the expectant mother. They thought it would be humorous to slide across a section of the freshly mopped floor. When they were nearly finished, the SM called them away to assist with another task. In a rush, the young worker forgot to display a wet floor sign and tidy up the boxes and plastic packaging, as instructed. Meanwhile, as the expectant mother was leaving the packaging area, they tripped over a box, slipped and fell on the recently mopped floor.
Two minutes later, factory workers A and B were walking past the packaging area and heard someone screaming, “Somebody please help me!” They ran towards the screaming voice and found the expectant mother lying on the floor. Worker A telephoned the SM to call them to the scene.
Worker A then asked Worker B to quickly find a first-aider, while they stayed with the expectant mother and tried to calm them down.
After a short while, Worker B returned to the scene of the accident with the SM, who carried a chair and some water. The SM had already called for an ambulance on their mobile phone. Worker A asked about the first-aider’s whereabouts, and the SM responded that they were not working that day. Worker A sighed and shook their head. While waiting for the ambulance, the SM helped the expectant mother onto the chair and offered them a drink of water. Meanwhile, other factory workers started to gather in the doorway of the packaging area to see what was going on.
The ambulance arrived within 20 minutes and the ambulance crew had to ask these factory workers to move away from the doorway so that they could access the area. After an initial assessment by the ambulance crew, the expectant mother was taken to the hospital for further checks.
Later that day, the SM received a call from the hospital with news that the expectant mother had only sustained minor injuries and would make a full recovery. The expectant mother chose not to return to work for the remainder of their pregnancy.
After the accident The following day, the SM met with the manager to discuss the accident. They told the manager that the outcome could have been much more severe, and that they would begin gathering information for an accident investigation. The SM also recommended hiring a health and safety officer to review the current health and safety policies and procedures at Dough Delight. The manager reluctantly agreed.
A month later, a part-time health and safety officer (HSO) was hired. On their first day, the SM gave the HSO a tour of the factory. During the tour, the HSO noticed a young worker mopping the floor and asked the SM, “Will the worker put up a wet floor sign once they have finished cleaning the area?” The SM replied, “I hope so, as that contributed to a previous accident.” The HSO then asked, “What accident? What happened? Is it recorded in the accident book?” The SM said that the accident was not recorded in the accident book and then explained what had happened. The HSO was not impressed.
The SM then left the HSO to review the current health and safety policies and procedures. The SM provided the HSO with several documents, including the health and safety policy, risk assessments, accident book, maintenance reports, and training records. Upon reviewing the health and safety policy, the HSO noticed that it was dated 2021 and signed by a previous manager. They then examined the risk assessments; these had not been reviewed for two years and seemed to be very generic.
After observing the young worker mopping the floor, the HSO became curious about the types of training provided. They reviewed the organisation’s job training records and discovered that these were dated up to 2023. There were no health and safety training records available.
Later that day, the HSO met with the manager to discuss their concerns about the documentation. The HSO asked the manager why there was no specific risk assessment completed for the expectant mother involved in the accident. The HSO added that there was a record of a previous risk assessment completed for another expectant mother. The manager responded, “I am not aware of any previous records as that was before I started, and I have not had the time to complete a new, specific, risk assessment.” The manager told the HSO that they did have a meeting with the expectant mother. During that meeting, the manager advised the expectant mother that they should limit the time that they spent standing, to perform some of their tasks seated, and to avoid lifting heavy items.
The HSO then commented that, after reviewing all the documentation and records, “the only records that seem to be up to date are the maintenance reports.” The manager responded, “Well, without regular machinery maintenance, we would have poor-quality produce, which would lead to low sales.”
Since the meeting between the HSO and the manager, a new workplace inspection programme has been implemented.
1
What management failures could have contributed to the accident? Note: You should support your answer using relevant information from the scenario.
(16)
2
Under clause 6.1.2.1 of ISO 45001:2018, organisations should consider making necessary adaptations to the needs and capabilities of workers.
How effectively did the manager respond after the expectant mother informed them of their pregnancy? Note: Your answer must be based on the scenario only.
(6)
3
Why might Dough Delights’ health and safety policy require a review? Note: You should support your answer, where applicable, using relevant information from the scenario.
(9)
4
What are the legal reasons for managing health and safety?
(10)
5
How effectively did members of the workforce immediately manage the accident? Note: Your answer must be based on the scenario only.
(14)
6
What would be the benefits of worker and employer involvement in workplace health and safety consultation at Dough Delight?Note: You should support your answer, where applicable, using relevant information from the scenario.
(12)
7
How could carrying out health and safety inspections before the accident have benefitted Dough Delight?
(14)
Note: You should support your answer, where applicable, using relevant information from the scenario.
8
Comment on the influence of peers at Dough Delight.
(7)
Note: You should support your answer, where applicable, using relevant information from the scenario.
9
Why should a special case risk assessment for young workers be completed at Dough Delight?
(12)
Note: You should support your answer, where applicable, using relevant information from the scenario.
End of assessment
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