Accident Case Study 2017 Fork Lift Truck Accident - High Risk Manufacturing Company Introduction You are employed as a Group Safety Adviser to a high risk manufacturing company which has several depots for production, storage, transport, etc. of chemicals. The company was a small family concern until it was bought by a conglomerate two years ago. Since then there have been many changes affecting both staff and working practices. The company is driven by the production and sales departments. They are driving a strategy to economically double production, storage and logistics of hazardous agents. There is friction within the management structure. You are trying to update safety policy and to introduce a safety management system; the Human Resources Manager is trying to implement a series of job descriptions and an appraisal system. Against you both are the Production Manager and the Sales Manager, who see your dual efforts as an unwarranted intrusion into profit making. Until now, there has been a relatively good accident record with only minor injuries being reported. Accident Background Documents An accident involving injury to an employee by a rider-operated lift truck has just occurred. You have heard from sources within the company that some internal activists are trying to exploit the accident. They claim it is an example of exploitative management as to why it happened. Feelings are running high and the local media are taking an interest in the case. The accident of the company’s chemical storage and light maintenance repair depots which is accountable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR). As Group Safety Adviser it is your responsibility to conduct the required investigation and to inform the appropriate enforcing authority with details. You have been asked by Senior Management to obtain more information regarding the accident; to assess its possible future impact on the company, and to produce a report. You have assembled the following documents: 1. Statement made by the lift truck driver. 2. Notes of questions to, and answers from, the victim. 3. A recent maintenance report on the lift truck. 4. Accident report form and sketch produced by the supervisor. New Safety Strategy With the new strategy to grow the business, you have also been asked to advise upon the course of action regarding the demolition of existing warehouse infrastructures for construction of a larger Long Term store (see drawing). A policy to ensure the safe demolition and construction needs to be developed for this work so that the safety elements of this work can be managed internally with the main contractor who will be appointed. The plan, in principle, is to double the volume of production and storage of hazardous agents, and decisions need to be made about hazardous agent siting and storage; safety assessments and control strategies. Legal notifications may also have to be considered. The hazardous agents of interest relate to ammonium nitrate and sodium chlorate in addition to oxidizing agents and acids. Ensuring legal compliance is important. Case Study Exercise As Group Safety Adviser you are concerned with acting and giving advice on the following aspects of the accident and planning for the new warehouse: • Identifying the immediate and underlying/root causes of the accident • Prevention of further injury to employees; • Meeting the requirements of RIDDOR, COMAH and CDM notifications or reporting (if required) • Compliance with the Health & Safety at Work etc Act 1974 and Regulations etc, including any consideration for future potential compliance with Control of Major Accident Hazards Regulations & Construction and Design Regulations • Reducing potential for compensation claims and liaising with insurers. • Developing safe construction and demolition policy for the work proposed • Advising on the legal implications of hazardous agent volume increases • Preparing an Action Plan designed to minimise the likelihood of a similar accident occurring again and for the safety considerations of the proposed warehouse redevelopment Statement of Mr. L T Driver 20th November 2016 11.30 I was asked by the supervisor of the Repair Department to go to bay 5 to pick up a gearbox for removal to the ready-use store. When I got to bay 5, the two trainees had just loaded the gearbox onto a pallet. I picked up the pallet with the fork lift and set off to the ready-use store. As I was approaching the entrance to the store I saw somebody walk out from behind the shelving. I braked hard and tried to stop. The gearbox flew off the pallet and hit him on the legs. I then skid into the old shelving supports that have never looked like they could hold a child up. I’m not surprised it gave way but with it, three IBC containers of sodium peroxide were crushed and leaked out onto the ground. At the same time, I could see then that it was Alan Jones from the repair shop that had been hit by the gearbox - he had shouted and fallen to the ground. I ran to the store supervisor’s office to get help. I then ran back to Alan and waited for help to arrive. I couldn’t do anything as I don’t know about first aid. There was an awful smell of peroxide. The store supervisor came along after a couple of minutes and said the ambulance was on its way. He asked Alan a few questions about what he was doing there in the long-term store. The ambulance arrived after about fifteen minutes. The store supervisor organized the cleanup of the spill as our eyes were watering. I haven’t moved the fork lift or the gearbox since the accident. Notes of Questions to and Answers from Alan Jones 20th November 11.00 QUESTION: Why were you in the long term store? ANSWER: I went to the ready-use store to check on the make and number of a gearbox ordered earlier by phone. There was nobody in the ready use store so I went into the long term store to look for the store man. QUESTION: Can you remember what happened? ANSWER: I walked into the store past some electricians. I called out for the store man but nobody answered. I walked on to search through the bays for him. I walked round the end of the first set of shelving and the fork lift was right there. I never had a chance. I felt my legs hit and I suppose I passed out. The next thing I remember was you and Len, the driver, bending over me asking if I was alright. QUESTION: Didn’t you hear the fork lift coming? ANSWER: No, I was still wearing ear defenders as I’d come from production. I’m so used to them I forget to take them off. QUESTION: Didn’t you see any signs or lights? ANSWER: Not that I can remember. Extract from Maintenance Report on the Lift Truck 5th May 2016 Steering Steering control Steering mechanism/system Wheel bearings Wheel alignment Brakes Controls Condition of service brake Condition of parking brake Service brake performance Parking brake performance Lighting Equipment Front and rear lamps Headlamps Stop lamps Flashing warning lamp Tyres and Wheels Tyre type Tyre condition OK Checked and adjusted OK Checked and adjusted OK Bled system, renewed front o/s pipe Adjusted and greased ratchet OK OK New bulb front n/s OK OK Loose connection temporary repair OK Front tyres renewed SEX: Male ACCIDENT REPORT FORM NAME: Alan Jones ADDRESS: 6 North Street Ambridge Borsetshire AGE: 38 POSITION: Mechanic DATE OF ACCIDENT: 20-11-16 TIME: 1050 PERSON MAKING REPORT: R Johnson Stores Supervisor. NATURE OF INJURY: Injury to legs from collision with loaded fork lift truck. Taken to hospital. DESCRIPTION OF ACCIDENT: Mr Jones walked into the long-term store which is prohibited to unauthorised persons. He failed to hear the truck or to see its warning light. He walked around a blind corner and the fork lift truck hit him. CAUSE OF ACCIDENT: Entering a prohibited space. RECOMMENDED ACTION: Bigger warning signs.