NEBOSH IGC 3 February 2021 Solved Paper

NEBOSH IGC 3 February 2021 SCENARIO

You are a coordinator for a behavioral safety audit (BSA) program at a food manufacturing site. Behavioral safety is just one of a range of approaches that senior managers want to introduce to the site to change the organization and improve health and safety. Successful implementation of the BSA program is one of the occupational health and safety objectives for the whole site.  Each BSA involves a trained observer who observes site workers, including contractors, carrying out a task.  The observer looks for both safe and unsafe behavior, as well as noting the general workplace conditions at the time. There is a follow-up conversation between the site worker and observer, usually immediately after the observation.  In this conversation, observers give praise to site workers on observed safe behavior as well as considered verbal feedback on unsafe behavior. The idea is to encourage safe behavior and, if site workers are behaving unsafely, try to establish why they behave in that way and discuss what can be done to change it.

Your job is to co-ordinate the activities of ten trained observers across the site, one of whom is a young apprentice, and one an expectant mother with a child due in six months. The observers are workers who have volunteered to actively monitor their respective manufacturing departments. They use a checklist of critical behaviors that were identified from studying past accidents and incidents in the organization. The checklist is common to all departments to carry out daily BSAs. As co-ordinator, you collect the completed checklists daily, collate and evaluate data, and conduct weekly feedback meetings with workers in each department. All the associated forms, checklists, and procedures are carefully version-controlled.

You report to a supervisor who is not convinced of the value of the BSA program. This same attitude is also shared by some of the other long-serving middle managers. You know that the introduction of the BSA program will need careful management if it is to be accepted by your supervisor and the other managers. However, you do have the support of at least one member of the site senior management team, nominated as the site behavioral safety Champion. They have already provided resources for you to develop behavioral safety awareness training and ensured all 150 staff attended. Separate financial support was also provided for carrying out observer training for the ten volunteers. This included special communication facilities for an observer with hearing difficulties.

Your supervisor talks to you about an accident that occurred two weeks ago, where a contractor suffered a knee injury. The contractor works for a national contracting maintenance company and was brought on-site to do a specific job. The supervisor thinks the accident is an obvious case of ‘human error’ that is not worth the time to investigate further. Your supervisor hands you the accident report to read and suggests that any reasonable person would come to the same conclusion.

Reading the report, you note that the injured contractor was rescued by the site’s emergency response team, taken to hospital, and was off work for a week. Your supervisor thinks that most accidents are unavoidable and that people are to blame because they behave unsafely. You disagree and argue that blaming individuals is a mistake and demoralizes the workforce. It is a core value of the BSA program that the root cause of unsafe behavior is often management failures, and these must be determined so that lessons can be learned. Your supervisor asks you to investigate the accident further, confident that it will prove that it was all down to human error.

When the injured contractor is well enough to return to work, you arrange a meeting and ask some questions. Although the contractor has a lot of experience in contracting work, including involvement in permit-to-work systems at other sites, this was the first time they had worked at this food manufacturing site. You ask how the injury occurred. They reply that while adjusting a piece of equipment alone, they slipped on a working platform, made of scaffolding poles (tubes) and scaffold boards, that were erected by the contractor.

When you ask the contractor how they feel about being injured at work the reply really surprises you. They say: ‘It is accepted as part of our job, unsupervised, we live with the risks and accept the consequences, without complaint’. You respond by explaining that their employer and the food manufacturing site where they are working have a joint responsibility to care for them. The contractor confirms that, before starting the job, they had received specific induction training and job-specific

information from the site supervisor, although that was the last time that they saw them on that day. You also ask about the safety of the work environment and they indicate it appeared to be fine. You visit the accident scene and observe that oil, used by a site maintenance technician to lubricate equipment above the working area, has leaked onto the working platform below and coated the boards.

You discover that the work carried out by the contractor was done under the authority of a permit-to-work (PTW). So, you also decide to investigate how the permit system operated on that day. You ask the contractor about the sequence of events on the day of the accident. They recall that a job instruction was received, then the contractor walked to the site office where PTWs was written and issued. The contractor, trained in the responsibilities of what accepting a permit meant, presented a job description note to the manufacturing site’s PTW issuer and a brief discussion took place. They appeared to be extremely busy, and the contractor overheard them say that they were issuing up to 75 PTWs a day!

The site’s permit issuer talked with the contractor about the exact nature of the job and clarified understanding of the hazards and risks for the proposed task. The task appeared to be a low-risk one to the permit issuer, and because of this and a high workload, they did not physically check the area where the task was due to take place. The self-duplicating PTW forms were duly completed and authorized, including relevant signatures. One copy was retained by the contractor, one copy was put on display at the job site, and one was kept as a record in the site office. The permit was issued to cover the period 09:00 – 17:00 that day. The contractor also told you that the permit issuer talked about associated control measures, including isolation of equipment before starting work and the wearing of head protection while working on equipment.

Your investigation concludes that there were many organizational management failures and only one identified human error. One of your recommendations is to review the original risk assessment for the maintenance of equipment above the working area, at the scene of the accident.

Task 1: Behavioural safety audits and the use of checklists

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Task 2: Explaining to the contractor the obligations of employers to workers

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Task 3: Determining root causes of the accident

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Task 4: Assessing the permit-to-work system arrangements

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Task 5: Effectively managing contractors during work

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Task 6: Influencing health and safety culture

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Task 7: Understanding arrangements in ISO 45001: 2018 (Plan, Do, Check, Act)

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Task 8: Assessing the application of risk assessment at the manufacturing site

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