Effective Risk Management

Case Study One

A bakery company and three company directors were fined £373,000 after two workers died inside an oven. The men were carrying out  maintenance work when they became trapped inside the machine where temperatures were above 100C. They died from burns and heat exposure after being unable to escape.

There was no system of reversing the conveyor and no system of getting them out of the oven.

Two engineers died after maintenance on the bread oven went wrong in May 1998. The men were sent into the oven only two hours after it had been switched off. They climbed in through the bottom and onto a conveyor used to take the dough through the giant machine. All they were wearing for protection were all-in-one suits.

The oven was normally set to run at 260C. It had only been turned off for two hours and the centre was 100C when these two men went inside. No-one, it seemed, looked at the temperature gauge at the side of the oven which would have indicated it wasn't safe to go in. One engineer had taken a radio with him and after a few minutes inside sent a panicky message saying it was too hot.

They were trapped. There was no system of reversing the conveyor and no system of getting them out of the oven. It took 17 minutes - the time it took for the conveyor to pass through the oven - before other workers could help the men.

One engineer was brought out in "a state of collapse" and had extensive burns. The other was trapped inside the oven and had to be freed by the fire service. He had 80% burns to his body and died at the scene.

Responsibility

The Managing Director of the company which owns the bakery, admitted two charges of failing to provide a safe system of work. The Production Director pleaded guilty to a single count of the same offence. The Chief Engineer admitted one charge of failing to take reasonable care for others at work.

The Company were fined a total of £250,000 and ordered to pay costs of £175,000.

Joint investigation

The Managing Director was fined £20,000 and ordered to pay costs of £5,000. The Production Director was fined £1,000 and the Chief Engineer was fined £2,000 because of their financial means. They also escaped having to pay costs. The prosecution followed a joint investigation by the Health and Safety Executive and Leicestershire Police.

Speaking after the case, the Director General of the HSE said:

"This is an appalling case and naturally our sympathies are with the bereaved families. I hope that today's penalties will send the strongest message to employers throughout Great Britain that protecting the health and safety of workers is a vital task for directors and managers, not an administrative inconvenience."

The charges and fines were:

Charges

The Company contravened Section 2(1) of the Health and Safety at Work etc. Act 1974, failed to provide their employees that they did not ensure the safety of their employees at work with a safe system of work so far as was reasonably practicable.

The Company contravened Section 3(1) of the Health and Safety at Work etc. Act 1974, in that they did not conduct their undertaking in such a way as to ensure that persons not in their employment including the deceased were not exposed to dangers to their health and safety.

The Managing Director contravened Section 37 of the Health and Safety at Work etc. Act 1974 in that an offence committed by the company, namely failure in its duty under Section 2 (1) of the Health and Safety at Work etc. Act 1974 was carried out with his consent or connivance or was attributable to his neglect.

The Chief Engineer contravened Section 7 of the Health and Safety at Work etc. Act 1974 in that he failed to take reasonable care for the safety of other persons who were affected by his acts or omissions at work.

The Production Director, an employee contravened Section 37 of the Health and Safety at Work etc. Act 1974 in that an offence committed by the company, namely failure in its duty under Section 2 (1) of the Health and Safety at Work etc. Act 1974 was carried out with his consent or connivance or was attributable to his neglect.

Fine

The Company - £350,000 total fine for first four charges.

The Managing Director - £20,000

The Chief Engineer - £2,000

The Production Director - £1,000

In addition, the company was ordered to pay a total of £250,000 costs and Managing Director £5,000 costs.

Discussion

This case highlights the need to identify hazards, determine the risks and implement controls that will reduce the risks to an acceptable level.

Many companies carry out risk assessments for production activities, but fail to recognise the need to assess the risks from cleaning and maintenance activities which are significantly more likely to result in injury because of the nature of the work and the fact that in some cases safeguards are removed.

In this case, a risk assessment of the task would have identified that there were risks from heat as the task involved entry into an oven. There was also a risk from lack of breathable air and the oven would also have been classed as a confined space which would result in specific regulations applying.

When undertaking risk assessments, it is necessary first to identify the hazards present. Then quantify the level of risk based on any existing controls that are in place. If the level of risk is found to be too high, then additional control measures should be put in place.

Once additional controls have been identified and implemented, it is necessary to write a formal procedure that incorporates these control measures to ensure that the safest way of carrying out the task is documented. It is then necessary to provide training for those who will be carrying out the task to ensure that they know the hazards, risks and controls before doing the job.

The final step is to identify additional emergency procedures to ensure that if something does go wrong, action can be taken quickly and effectively to minimise the risk and extent of any injuries. For some tasks the hazards are obvious and the risk assessment process can be easily completed, however in other cases the hazards can be more difficult to identify and a structured assessment procedure can help with the process.

Summary

Writing out risk assessments and safe systems of work may seem to be a paper exercise that slows down the job, but this case study highlights the reasons why they are necessary. They can be used to minimise the likelihood of accidents occurring and help defend companies and their directors from prosecutions and compensation claims.

If this company had done risk assessments of the task before hand, they would most likely have identified the hazards and implemented strategies to control the risks. Two men could still be alive today, the company reputation would not be tarnished, it could have saved the company money in fines and compensation claims and it could have saved the directors money and a significant amount of stress.

The Management of Health and Safety at Work Regulations require employers to:

• Undertake risk assessments
• Have in place arrangements to cover health and safety
• Provide health surveillance
• Appoint one or more competent persons to provide health and safety advice and assistance
• Have procedures for serious or imminent danger and for danger areas
• Provide information for employees
• Co-operate and co-ordinate with other employees
• Ensure that employees are trained and competent to undertake their tasks

Failing to carry out these duties could not only result in accidents occurring and prosecutions by the HSE, but also individuals wishing to make compensation claims for injuries or ill health sustained at work can use any failure to comply with these regulations as a means of ensuring a successful claim can be made.

Further Information

For more details please call Mark Rastrick on 07966 174360 or simply email us at info@grmhs.co.uk and we will contact you.