Scenario With Notes and Detailed Answer
Scenario With Notes and Detailed Answer
You are a co-ordinator for a behavioural safety audit (BSA) programme at a food manufacturing site.
Behavioural safety is just one of a range of approaches that senior managers want to introduce to the site to
change the organisation and improve health and safety. 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 health and safety
behaviours on site.
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 notice some issues that require
further consideration.
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 was erected for the job.
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 working surface with oil.
You discover that the work carried out by the contractor was done under the authority of a permit-to-work
(PTW). 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 permit
was issued to cover the period 09:00 - 17:00 that day. The contractor also told you that they were not
provided with any slip-resistant footwear, and only a hard hat was mentioned as part of control measures.
Question: What employer obligations are likely to have been contravened, leading to the contractor’s accident
in this scenario?
(10 Marks)
Answer:
1. Provide and maintain safe workplace - The workplace was unsafe due to oil leakage on the scaffolding
platform, leading to a slip hazard.
2. Provide adequate supervision of worksite - No supervisor was present during the work; last seen only d
induction.
3. Eliminate physical & mental fatigue - The PTW issuer was overloaded with work (75 permits daily), red
attention to safety details.
4. Use safe work methods - No physical check of the worksite was done before issuing the permit-to-work
5. Organization nature of the activity - The contractor was not experienced in food manufacturing industry
specific hazards.
6. Provide adequate PPE - Slip-resistant footwear was not provided to the worker; only a hard hat was
recommended.
7. Worker technical knowledge - The worker lacked technical familiarity with the food manufacturing site
procedures.
8. Ensure working procedure - Although work hours were defined, rest breaks were not properly commun
increasing fatigue risk.
9. Proper Incident Investigation - Accident dismissed as human error without proper investigation, missing
learning opportunities.
10. Risk Assessment - No prior risk assessment was conducted for the oil leakage hazard on elevated pla
11. Communication of Hazards - Workers were not informed about the risks from oil leaks while working a
heights.
12. Site Housekeeping Standards - Poor housekeeping allowed oil to accumulate and created hazardous
conditions.
13. Inadequate Monitoring - Regular checks were missing, allowing unsafe conditions to remain unnoticed
14. Contractor Familiarisation with Site - Contractor was inadequately familiarised with the site-specific
risks and emergency procedures.
15. Overloaded Permit Issuers - PTW issuers being overloaded compromised the effectiveness of permit
measures.
16. Failure to Update Safety Systems - Despite past incidents, the safety systems and preventive actions
not updated accordingly.