SCENARIO
The warehouse
You are a newly-hired warehouse worker for the distribution organisation Miller-Oslo (MO). You work in one of their small warehouses with 14 other workers, including the warehouse manager (WM) and two supervisors. Goods weighing up to 1000kg are stored in sealed crates or stacked on pallets and then stretch wrapped. These are then stored on racking until required for shipment by distribution vehicles. There are two loading bays at the back of the warehouse, with floor ramps allowing goods to be loaded onto the vehicles by forklift trucks (FLTs). There is a small kitchen, rest area, toilets for workers, and two side offices - the larger office is the WM’s.
Entrance to the warehouse is by ID card access. There is an intercom system to ring for non-card holders. Visitors who are expected will be escorted while inside the building, and unexpected visitors are denied entrance. On your first day of employment the supervisor on duty gives you a quick tour of the building to start your induction. They make sure you know where the fire exits are before rushing you into the smaller office. Inside, you are seated in front of an old television (TV). Next to the TV is a collection of VHS video cassettes labelled: ‘Induction Part 1’; ‘Part 2 - Fire Safety’; ‘Part 3 - Manual Handling’; and ‘Part 4 - What to Do in an Emergency’. The supervisor leaves you alone while you watch the videos.
The videos appear to apply to all MO warehouses. You learn from the ‘What to do in an emergency’ video that the first-aid box is in reception. You think back to the tour of the building and do not remember seeing a reception area or first-aid box. You learn that personal pagers should be turned off during working hours, and that all accidents or near misses should be reported to your health and safety officer. The video happily states that the health and safety officer will teach you ‘everything you need to know’ about health and safety after the induction ends, and your specific warehouse’s health and safety policies and procedures.
The supervisor returns four hours later when you have finished watching the videos. They have a box of high visibility vests, hard hats and gloves, that you sort through to find your closest size. With the induction training complete, they give you an ID card then take you back into the warehouse for your job training. You cannot see any painted traffic lines on the ground separating the pedestrian path and FLT routes, as shown in the videos, so you ask the supervisor if the videos were incorrect. They sigh and tell you that the lines have needed repainting for a long time. You ask who the health and safety officer is and learn that the warehouse has been trying to hire someone for that position “for years”
Over the next week you are taught your job tasks by the other workers and become friendly with them. They teach you a few methods to save time, but they are not sure if these methods are causing overloading of the racking closest to the loading bay. Later that day you hear the WM shouting at an FLT driver for taking too long to load an order onto a delivery vehicle. The WM gives the FLT driver an immediate verbal warning for causing delays. You overhear the WM muttering that they will not let their reputation of keeping the warehouse ahead of schedule be ruined. The workers nearby whisper “avoid the WM because they only come out of their office when angry”. They also mention that this driver has not even been given time off to complete their FLT training.
The crash
Later that day, as you pass a loading bay you see an FLT speeding around the corner towards you. The driver notices you, panics and desperately tries to change direction. This driver is the one who was shouted at earlier. You jump back onto the loading bay ramp to avoid the FLT. You slip and twist your ankle. You fall to the ground screaming and your ankle swells painfully. The driver swerves the FLT away from the ramp, but the vehicle begins to tilt. They try to recover the situation but within seconds the FLT topples sideways into the nearby racking. The racking collapses and an avalanche of metal and pallets buries the driver.
A week later, after the warehouse has reopened, the workers call a meeting. You are on sick leave for your injured ankle but decide to attend. When you arrive, you hear shouting from the smaller office. The shouting does not stop as you enter, and you see all of the workers are there, except the FLT driver. Several people are having a loud argument with the WM. The WM notices you sitting down and resting your leg in an ankle brace on a chair. They sneer and point out that this meeting cannot be so important if the FLT driver cannot be ‘bothered’ to show up. The room goes silent. Everyone is horrified by the WM’s comments. One of the workers informs the WM that the FLT driver is in hospital. As a result of the accident they are in a coma and have a crushed skull. The WM finally stops arguing.
Your colleagues demand change. This was the worst accident so far and “cannot be ignored this time”. Eventually the WM reveals that MO are hiring a health and safety consultant to make recommendations for improvements. The WM then starts arguing again, blaming the FLT driver entirely for the accident. They claim this meeting is an excuse for everyone not to work and that they will never allow a worker-demanded meeting again
The health and safety consultant (HSC)
The HSC arrives two days later. They spend the first day talking with the WM and looking through paperwork. The next day the HSC gathers the workers and supervisors together, deliberately excluding the WM. They introduce themself, then explain that they will speak to everyone as a group to better understand the warehouse and workforce. They will also speak to everyone individually but assure them that conversations will be confidential.
The two supervisors welcome the HSC because “management might finally listen”. Everyone had been complaining about time pressure and safety concerns for months. They were ignored, so they stopped trying to talk to the WM about it. One of the supervisors says that they are meant to be taking a NEBOSH qualification on behalf of the warehouse, but they have repeatedly been refused time off to study. Another worker furiously recalls that the traffic route lines were meant to be repainted yearly, but the WM always cancelled it because the work would “cause delays”.
Task 6: Understanding how previous accident investigation prevents future accidents
How could an investigation of the previous accidents have helped to prevent this accident?
Note: You should support your answer, where applicable, using relevant information from the scenario.
Solution
Investigating previous accidents is a crucial part of
proactive safety management and can significantly contribute to preventing
future accidents, including the one thAat occurred in the scenario. Here's how
an investigation of previous accidents could have helped prevent the scenario's
accident:
- Identifying Root Causes:Previous
accident investigations could have identified common underlying causes or
trends, such as inadequate training, equipment issues, or organizational
factors contributing to accidents. Recognizing these root causes allows
for targeted preventive actions.
- Implementing Corrective
Actions:Based on the findings of previous accident investigations,
corrective actions could have been implemented to address specific safety
deficiencies. For example, if a past accident revealed a lack of proper
training, measures could have been taken to improve training programs.
- Learning from Mistakes:Previous
accidents offer valuable lessons that can be shared across the
organization. Learning from past mistakes and near misses can raise
awareness about potential risks and encourage a proactive safety mindset
among employees.
- Continuous Improvement:Investigations
of previous accidents can foster a culture of continuous improvement.
Recognizing areas where safety can be enhanced allows organizations to
continually refine safety practices and policies.
- Enhanced Training and
Awareness:The results of previous investigations can be used to
develop more effective training programs and safety awareness initiatives.
Workers can be educated about the specific risks and hazards that led to
past accidents.
- Increased Reporting and
Hazard Awareness:When employees see that accident investigations lead
to positive changes, they may become more inclined to report hazards and
near misses. This can help identify potential issues before they result in
accidents.
- Reassessing
Organizational Culture:Investigating past accidents can also shed
light on aspects of the organizational culture that may have contributed
to safety lapses. If there is a pattern of pressure to prioritize
productivity over safety, for example, this can be addressed through
cultural changes.
- Enhanced Safety
Policies and Procedures:Past accidents can highlight weaknesses in
existing safety policies and procedures. This can lead to the revision and
improvement of these documents to better protect employees.
- Reducing Reoccurrence
of Similar Incidents:Understanding how previous accidents occurred can
help organizations implement preventive measures specifically designed to
reduce the risk of similar incidents. This could include equipment
upgrades, process changes, or additional safety protocols.
- Building Trust and Open
Communication:
11 Conducting thorough and transparent accident
investigations can build trust between management and employees. This trust is
essential for open communication about safety concerns and a willingness to
report issues.
12. Early Detection of Patterns and Trends:
Through a thorough analysis of
past accidents, organizations can detect patterns and trends related to
specific hazards, processes, or work conditions. This early detection allows
for targeted interventions to prevent recurring incidents.
13. Identification of Systemic Issues:
Accidents are often symptoms of
deeper systemic issues within an organization. Investigating previous accidents
can reveal systemic problems in safety management, culture, or policies that
need to be addressed holistically.
14. Improved Incident Reporting and
Documentation:
Learning from past accidents can
lead to improvements in incident reporting and documentation procedures.
Clearer and more standardized reporting processes can help identify risks more
effectively.
15. Validation of Safety Protocols:
Accident investigations can
validate the effectiveness of existing safety protocols and procedures. If past
accidents occurred despite adherence to established protocols, this may signal
a need for updates or modifications to improve safety measures.
16. Identification of Training Needs:
Past accidents can highlight
areas where additional training or skill development is required. This
information can inform the development of targeted training programs to address
specific safety gaps.
17. Enhanced Emergency Response Plans:
Investigation findings can lead
to improvements in emergency response plans. Insights from past accidents can
help organizations better prepare for similar incidents, reducing the severity
of their impact.
18. Strengthening Safety Leadership:
Learning from previous accidents
can encourage safety leaders and managers to take a more proactive role in
safety management. It can also motivate them to provide the necessary resources
and support to enhance safety.
19. Employee Engagement and Ownership:
Involving employees in accident
investigations and sharing the findings with them can empower them to take
ownership of safety. This can lead to more vigilant and safety-conscious
behaviors among the workforce.
20. Enhanced Hazard Identification & risk
Management
Insights gained from past accidents can improve hazard
identification processes. Employees can become more adept at recognizing
potential hazards, leading to proactive hazard mitigation. Past accidents can be integrated into an organization's risk
management processes. This allows for a more comprehensive approach to
identifying, assessing, and mitigating risks.
21. Benchmarking with Industry Best Practices:
Comparing investigation findings with industry best practices allows organizations to benchmark their safety performance. This can highlight areas where they may be falling behind and inspire improvements.
Documented Learning and Knowledge Sharing:
The lessons learned from accident
investigations can be documented and shared within the organization. This
knowledge sharing ensures that safety insights are not lost over time and can
benefit future employees.
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