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Examiners' Report

NEBOSH National Diploma in Occupational Health and Safety January 2006 examinations

UNIT A

© 2006 NEBOSH, Dominus Way, Meridian Business Park, Leicester LE19 1QW

tel: 0116 263 4700 fax: 0116 282 4000 email: [email protected] website: www.nebosh.org.uk

The National Examination Board in Occupational Safety and Health is a registered charity, number 1010444

T(s):exrpts/D/D-0106 GP/RJ/PM/JS/RCC/REW

UNIT A ­ Managing health and safety

General comments

This was the third Unit A examination paper of the re-formed NEBOSH Diploma and the questions set were taken from the syllabus material published in the Diploma Guide. 358 papers were submitted for examination. To be successful in this part of the examination process, candidates need to be prepared to deliver and apply a level of knowledge commensurate with the Diploma award. As always, there were some excellent answers with maximum or near maximum marks being achieved on most questions by a small number of candidates, but not necessarily the same candidates on each occasion. Where candidates achieved low marks overall, this was generally for at least one of the following three reasons. Firstly, candidates were not always armed with the degree of understanding and detail required at this level. This was particularly evident in many of the answers provided to Questions 5 and 8 for example. Candidates setting out on a course of study for the level 6 Diploma need to ask themselves whether they have provided for the necessary preparation, revision and examination question practice that is important for maximising their chances of success in the examination; this is a very different level of examination from the NEBOSH National General Certificate. Secondly, many candidates achieved less than their possible potential through focusing on only a limited range of issues on a question that had scope for a broader range to be tackled. Questions 1 (a) provided numerous examples of this. Examination question practice, with feedback provided by training providers, together with the use of answer plans (on Section B questions in particular) are important elements in trying to maximise marks. Thirdly, candidates wasted much time and lost many opportunities for marks by failing to read the question carefully, not relating their answers to the question asked or the scenario set, and providing information that was not asked for or required. This was a particular issue for scenario questions such as Questions 7(c) and 11.

Section A ­ all questions compulsory

Question 1

The Management of Health and Safety at Work Regulations 1999 requires that employers appoint a Health and Safety Assistant. (a) List the key legal requirements that must be satisfied by the employer when making such an appointment. Outline the key elements of the strategic role of the health and safety professional with respect to the employer's current health and safety management system.

(5)

(b)

(5)

Examiners expected candidates to find this question simple to answer, as it is assumed that candidates are aspiring to become practising health and safety professionals. A number of candidates made reference to HASAWA even though the question clearly referred to The Management of Health and Safety at Work Regulations 1999. The key to answering the question well was knowledge of Regulation 7 of MHSWR. Most candidates identified competence as a key requirement but then failed to go any further by identifying appointment of one or more persons, arrangements for cooperation if 2 or more; numbers and time available sufficient for size, risk and risk distribution; information on health and safety issues provided to external appointees; preference for internal appointment; information on temporary workers; or exemptions for partnerships where one partner is sufficiently competent.

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The second part of the question was reasonably well answered, although candidates who reproduced HSG(65) without relating it to the role of the health and safety professional did not gain high marks. Candidates who read the question carefully and focused on the strategic role gave good answers which included elements such as: formulating and developing elements of the health and safety management system; developing and agreeing plans for improvement including short and long-term targets; involvement in reactive monitoring such as reporting and accident investigation; involvement in proactive monitoring such as inspections and audits; developing/agreeing plans to improve safety culture; organising and participating in review arrangements; developing/agreeing a suitable safety policy statement; managing relationships with enforcing bodies; advising senior managers/Board on strategic safety issues; and co-ordination and support issues of a health and safety department.

Question 2

A risk management programme encompasses the following concepts: (i) (ii) (iii) (iv) risk avoidance; risk reduction; risk transfer; risk retention. (2) (3) (3) (2)

Identify the key features of each of these concepts and give an appropriate example in each case. Most candidates provided good answers to this question, although a number confused the principles of risk avoidance and risk transfer. A number of candidates missed opportunities for marks by failing to give examples. Risk avoidance involves taking active steps to avoid or eliminate risk for example discontinuing the process, avoiding the activity, eliminating a hazardous substance. Risk reduction involves evaluating the risks and developing risk reduction strategies, requires the organisation to define an acceptable level of risk control to be achieved; this could be by the use of safety/risk management systems or use of a hierarchy of control. Risk Transfer involves transferring risk to other parties but paying a premium for this; for example by the use of insurance; transfer of risk by use of contractors to undertake certain works; use of third parties for business interruption recovery planning or outsourcing the process. Risk retention involves accepting a level of risk within the organisation along with a decision to fund losses internally; it could involve risk retention with knowledge where the risk has been recognised and evaluated; or risk retention without knowledge where the risk has not been identified (obviously an unfavourable position for the organisation to be in).

Question 3

(a)

Outline the main defences available to a defendant in a civil case who is being sued in an action for the tort of negligence. Outline factors which will be considered in determining the level of damages paid to a successful claimant.

(6)

(b)

(4)

Most candidates answered this question well, although it should be noted that answers which comprise of simple lists are not acceptable at this level. The main defences that could have been covered are: that no duty was owed by the defendant to the claimant; that although there was a duty there, it was not breached (to gain marks her, candidates are expected to make reference to foreseeability and reasonableness); the damages may not be as a result of the breach; the damage may be too remote; volenti non fit injuria; the type of damage may not have been foreseeable; contributory negligence. © NEBOSH 2006 3 Unit A - January 2006

Many factors are taken into consideration in determining the level of damages, the most obvious being the degree of disability; the loss of earnings and/or opportunities; and the pain and suffering. Other factors that could be considered are: medical costs and expenses; the cost of special adaptations; the cost of care; loss of amenity; and contributory negligence might result in a reduction of damages awarded.

Question 4

An advertising campaign was used to promote improvement in safety standards within a particular organisation. During the period of the campaign the rate of reported accidents significantly increased, and the campaign was deemed to be a failure. (a) Suggest, with reasons, why the rate of reported accidents may have been a poor measure of the campaign's effectiveness. Describe four proactive (active) measures which might have been used to measure the organisation's health and safety performance.

(2)

(b)

(8)

The first part of the question was reasonably well answered with candidates correctly identifying that a reason why the number of reported accidents had increased was because they may have previously been under-reported. Unfortunately, some candidates stopped at that point, which did not fulfil the requirement for an explanation. Marks were available for explaining that raised awareness may have led to previously unreported accidents now being reported, but that, in the absence of other data, it is almost impossible to tell whether or not the increase is `real'. Better answers suggested why accidents may have been previously under-reported. Although some very good answers were given to part (b), candidates failing to achieve good marks in this part of the question did not describe the methods of measuring in sufficient detail. Many answers identified good methods of improving safety within an organisation such as increased consultation, toolbox talks, risk assessment, training etc without identifying the need to count the number done to use them as a year-on-year indicator. These were means of improving safety, not measuring it. Proactive measures that could have been considered include: safety audits; safety tours, workplace inspections; safety sampling; safety surveys; environmental monitoring and health surveillance safety climate measures; various types of behavioural safety measurements; benchmarking; or, as discussed measuring of any health and safety performance against set targets.

Question 5

Human failure was identified as a significant factor in an accident involving a crane. A contractor's employee was seriously injured when struck by material being transported by the crane. Outline the types of human error which may have contributed to the accident. Refer to relevant examples based on the scenario to illustrate your answer.

(10)

Examiners expected candidates to outline skill based errors, mistakes, and violations. These could have occurred in the given scenario. Skill based errors could be: slips of action where a familiar task or action was carried out as planned such as operating the wrong switch/controls; or lapse of memory where a step was missed in the action sequence due to memory, for instance commencing the lifting operation out of sequence when other workers were not prepared Mistakes are errors of judgement which could be: rule based ie application of the wrong rule, such as lifting instead of lowering, or crossing the path of the lifting operation; or knowledge based such as: an unfamiliar situation, no rules, wrong conclusion formed for instance the first time the crane driver had undertaken that particular lifting operation, wrong height of lift, or it could involve the injured person being unaware that the lifting operation was taking place. © NEBOSH 2006 4 Unit A - January 2006

Although HSG 48 defines violations as human failings rather than human error, the Examiners decided to accept violations in answer to this question. Violations involve rule breaking, ie a deliberate failure to follow rules (eg not sounding siren when lifting operation taking place, or intentionally walking close to lifting operation). Better responses went on to cover the subdivisions of routine, situational, and exceptional violations with suitable examples. Reference to model systems such as HSG 48 or Rassmussen gained marks. Some candidates provided examples from well known situations such as flying a plane rather than applying their understanding to the scenario as required by the question; others described factors that may affect the likelihood of the error occurring ­ again not required by the question. This demonstrates that even at this level some candidates do not read the questions carefully, wasting time on answers that cannot gain marks.

Question 6

Explain with reference to case law, the meaning of the terms `practicable' and `reasonably practicable' as they apply to health and safety legislation.

(10)

The ability to distinguish between the terms `practicable' and `reasonably practicable' is fundamental to an understanding of health and safety law. Good answers were those that were backed up with appropriate reference to case law and regulations that illustrated the use of the terms. Candidates should bear in mind that the actual circumstances of a case are normally less important than the basis of the decision (the ratio decidendi). Most candidates were able to explain that though `practicable' was not an absolute duty, it was of a higher standard than that of `reasonably practicable' This means that there must be compliance with the duty as far as technical and practical feasibility allows, with no reference to cost. `Reasonably practicable' requirements as those where a balance is made between risk and cost (in terms of money, time and trouble) and which are met when the cost of further control is grossly disproportionate to any reduction in risk. Reference was made to cases such as Adsett v. K&L Steelfounders and Engineers Ltd (1953), Marshall v Gotham [1954] and Edwards v National Coal Board [1949] in order to demonstrate the principles involved.

Section B ­ three from five questions to be attempted

Question 7

A forklift truck is used to move palletised goods in a large distribution warehouse. On one particular occasion the truck skidded on a patch of oil. As a consequence the truck collided with an unaccompanied visitor and crushed the visitor's leg. (a) (b) State, with reasons, why the accident should be investigated. Outline the actions which should be followed in order to collect evidence for an investigation of the accident. Assume that the initial responses of reporting and securing the scene of the accident have been carried out. Describe factors which should be considered in analysis of the information gathered in the evidence collection. (4)

(8)

(c)

(8)

This question was a popular choice with candidates, not unexpectedly considering most Health and Safety Practitioners are involved in accident investigation at some time in their careers.

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Although some candidates wanted to use the exercise as an opportunity to apportion blame they should note that the apportionment of blame for the sake of it can damage the organisation's safety culture. They should also note that there are many other reasons for investigating accidents and most candidates were able to identify reasons such as to identify its causes (immediate and underlying), to prevent a recurrence, to assess compliance with legal requirements, to demonstrate management's commitment to health and safety and to obtain information and evidence for use in the event of any subsequent civil claim. Few, however, mentioned that the investigation could provide useful information for the costing of accidents and in identifying trends. Part (b) was generally well answered with responses set out in a realistic chronological order: starting with taking photographs, sketches and measuring relevant parts of the accident scene before anything is disturbed, obtaining any CCTV footage available; then moving on to examining the condition of the fork lift truck; determining its speed at the time of the accident; the loads carried, the safe working load of the truck and any forward visibility issues with the load in place; the reasons for the oil spillage; emergency spillage procedures in place and the reasons why they were not followed on this occasion; the failure to follow laid down operating procedures; the competence of the fork lift truck driver and examining the workplace to determine any contributing environmental factors such as the condition of the floor and the standard of lighting; interviewing relevant persons such as the visitor (where this is possible), the reception personnel (to identify working practices against any written visitor procedures). Part (c) was not so well answered. It is not sufficient to merely collect data and put it into a report, it must be analysed and examined objectively before inclusion in an official accident report (which may be used in a subsequent legal action). Good answers considered: job factors such as the attention needed for task, any distractions that may have contributed to the accident, whether any procedures were inadequate and the time available to carry out the job; human factors such as competence of the driver and whether there was any evidence of fatigue and/or stress; organisation factors such as work pressure, availability of sufficient resources, quality of supervision and the general health and safety culture within the warehouse; and finally whether plant and equipment factors such as the forklift truck controls or layout of workplace or signage (too much, too little) could have contributed to the accident. Credit was also given for describing factors which related to the reliability and quality of evidence. A number of candidates assumed that the visitor was unauthorised, which was not stated in the question and spent time focusing on duties to trespassers.

Question 8

A fast-growing manufacturing company now employs 150 people. Health and safety standards at the company are not good, as arrangements have developed without professional advice in an unplanned way during the time of rapid growth. The company has, though, managed to avoid any serious accidents and, in the main, staff at all levels do not seem particularly concerned. Two employees, however, have recently experienced two separate near-miss incidents and have complained jointly to the Health and Safety Executive. A subsequent visit by an HSE inspector has resulted in the issue of three improvement notices. The Managing Director wishes to dismiss the employees (whom he has described as `troublemakers') even though he accepts that their concerns were probably justified. (a) State the advice you would give the Managing Director with respect to the proposed disciplinary action to the employees who have complained and give supporting reasons. Outline the steps that should be taken to gain the support of the workforce to improve the health and safety culture within the company.

(5) (15)

(b)

This was a popular question that required application of employment law knowledge and a strategy for changing the perception, involvement and ownership of employees on matters of health and safety in their workplace. © NEBOSH 2006 6 Unit A - January 2006

The first part of the question produced a few good answers but many answers were unclear and incorrect. About half of the candidates recognised that this was a protected disclosure under the Public Interest Disclosure Act 1998 (see Element A7 of the Diploma Guide) though unfortunately, many of them could not name the Act or explain the real nature of the protection, despite many recognising that an action at an Employment Tribunal may result. Some candidates had the mistaken belief that employees were protected from dismissal simply by complying with Section 7 of the HSW Act 1974. A number recognised the negative cultural implications of disciplining the two employees and the need to recognise the root causes of employee concerns. Part (b) required candidates to identify the components of a strategy to improve employee support for and perception of health and safety issues within the workplace. Many candidates performed reasonably well on this part although as is often the case, a significant minority felt that reciting the key elements of HSG 65 was the solution to all problems. Better answers began by recognising the value of using tools to help them understand current employee perceptions such as informal discussions and safety climate questionnaires. Methods of demonstrating the commitment of the business to good safety management such as the development of a new policy and arrangements for health and safety; the introduction of new consultative arrangements and training programmes and the behaviour and communication techniques, targets, reporting, resourcing and priorities relating to health and safety issues adopted by senior and line managers were all reasonable issues to explore. Steps to increase employee participation were also important and could have included involvement in risk assessments, the development of safe systems of work, inspections, incident investigation and team briefing sessions.

Question 9

(a) (b)

Outline the use and limitations of fault tree analysis. A machine operator is required to reach between the tools of a vertical hydraulic press between each cycle of the press. Under fault conditions, the operator is at risk from a crushing injury due either (a) to the press tool falling by gravity or (b) to an unplanned (powered) stroke of the press. The expected frequencies of the failures that would lead to either of these effects are given in the table below: Failure type Flexible hose failure Detachment of press tool Electrical fault Hydraulic valve failure (i) Frequency (per year) 0.2 0.1 0.1 0.05 Effect a a b a or b

(4)

Given that the operator is at risk for 20 per cent of the time that the machine is operating, construct and quantify a simple fault tree to show the expected frequency of the top event (a crushing injury to the operator's hand). If the press is one of ten such presses in a machine shop, state, with reasons, whether or not the level of risk calculated should be tolerated. Assuming that the nature of the task cannot be changed, explain how the fault tree might be used to prioritise remedial actions.

(10)

(ii)

(4) (2)

(iii)

This question was designed to test candidates' understanding and application of fault tree analysis. It was not a popular question but was generally well answered by those who did attempt it. Candidates recognised that fault tree analysis is useful in analysing accidents where there are multiple causes to an accident to calculate the probability of the top event; it can be used to identify the most effective points of intervention in order to reduce the probability of the top event occurring. On the negative side it is limited by the requirement of skilled analysts to work the calculations out in complex situations and its reliance on the accuracy and availability of failure data. © NEBOSH 2006 7 Unit A - January 2006

(b) (i)

Fault tree

CRUSHING INJURY

f = 0.2 x 0.5 = 0.1/yr or 1 in 10 years

&

P = 0.2 Operator exposed Powered stroke

Tool comes down as result of failure

f = 0.15 + 0.35 = 0.5/yr

Gravity fall

f = 0.05 + 0.2 + 0.1 = 0.35/yr

f = 0.05 + 0.1 = 0.15/yr

Valve failure

f = 0.05 /yr

Electrical fault

f = 0.1 /yr

Valve failure

f = 0.05 /yr

Hose failure

f = 0.2 /yr

Detachment of tool

f = 0.1 /yr

Part (b)(i) required the construction of a fault tree and its quantification using the data presented. A significant number of candidates constructed an event tree rather than a fault tree and so gained no marks. Many of the remainder who attempted the construction made a reasonable attempt at a fault tree consisting of four levels: crushing injury at the top; operator exposure and tool descent at the second level; type of tool descent (powered stroke or gravity fall) at the third; and component failures at the bottom. Those who achieved a reasonable construction also tended to achieve good marks for quantification. Part (ii) was seeking not just an opinion but some commentary on, or justification for, the opinion in terms of the frequency of unexpected tool descent or operator injury. Those candidates who did not give reasons for their opinions could not expect to gain high marks. Some reference was therefore needed to the likely disabling nature of the injury and to such an event occurring once in about ten years (which was the estimated frequency). Better candidates offered a risk level that might be considered to be more acceptable, with some suggesting that if several of these presses were operating (perhaps within the same factory), then a serious injury could be a regular occurrence. Part (iii) needed candidates to explain the general principles of using the probability data in the fault tree so that priority is given to those actions that would give the greatest reduction in the probability of the undesired events. For instance, gravity fall was highlighted as the most likely event, therefore priority should be given to actions that would prevent this.

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Unit A - January 2006

Question 10

Atom Chemicals Ltd engaged the services of an industrial cleaning company, Becom Cleaners Ltd, to clean their chemical processing vessel using Atom Chemicals' own electrical cleaning equipment. The production supervisor of Atom Chemicals issued a permit-to-work for Becom Cleaners to undertake the work. The vessel cleaning operation involved the use of flammable solvents and the Becom Cleaners' employee was badly burned whilst using the electrical equipment. Identify and explain the possible breaches of the Health and Safety at Work etc Act 1974 and the Management of Health and Safety at Work Regulations 1999 by: (a) (b) (c) Atom Chemicals. Becom Cleaners. Individuals. (8) (6) (2) (4)

Make reference to relevant case law and explain the relevance in this case.

This was not a popular question even though it concerned two significant pieces of health and safety legislation. Candidates who did well on this question identified the following possible breaches of HSWA by Atom Chemicals: s3(1) regarding `undertaking' and so far as is reasonably practicable; s4 as occupier and controller of non-domestic premises, regarding provision of plant -- s2 in relation to the risk to its own employees, s2(1), s2(2)(c); Under MHSWR Reg 3 risk assessment; Reg 5 effective safety management arrangements; Reg 11 cooperation and coordination; Reg 12 instructions / information for workers in host employers undertakings. Possible breaches by Becom Cleaners were under HSWA s2(1) and s2(2) (a)-(e) ­ duties to employees; HSWA s3(1) putting Atom Chemical's employees at risk; Under MHSWR Reg 3 risk assessment; Reg 5 effective safety management arrangements; Reg 11 cooperation and coordination; Reg 10 Information to employees on hazards/controls; Reg 13 competence and training of employees. Possible breaches by individuals in consideration of the duties of employees under HSWA s7 and MHSW Reg 14; with consideration of the permit issuer: HSWA s7, MHSW Reg 14 and HSWA s36. Relevant case law correctly included by candidates was: R v Associated Octel Co Ltd (1996) 4 All ER 846; R v Swan Hunter Shipbuilders Ltd and Another (1982) 1 All ER 264. Answers which included breaches under COSHH, DSEAR and PUWER did not attract marks as the question specifically asked for possible breaches under the Health and Safety at Work etc Act 1974 and the Management of Health and Safety at Work Regulations 1999.

Question 11

A new chemical plant which falls within the scope of the Control of Major Accidents and Hazards (COMAH) Regulations 1999 is being planned. The manufacturing process will involve toxic and flammable substances. The plant is near to a residential area. Identify the issues to be considered in the development of an emergency plan to minimize the consequences of any major incident.

(20)

This was a reasonably popular question with many candidates giving answers which identified a sufficient number of relevant points related to the emergency plan. Some poor answers discussed producing a MAPP and describing measures to control and manage the risk rather than the emergency measures to mitigate the consequences of an emergency.

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Unit A - January 2006

Good answers recognised the role of key individuals in the planning stage with effective communication and practising of the plan. Issues that candidates successfully identified were: to consider the quantities involved; to provide information to local authority as part of the planning requirements; possible causes of a major incident; estimating the likely extent of damage; staff and equipment call-out arrangements; resources needed to deal with incident; how the alarm will be raised both on-site and in the neighbourhood; evacuation or shelter arrangements on and off-site; training of staff in emergency plan; action to minimize extent such as shutting off services; search and rescue arrangements; notification of emergency services; co-ordination with emergency services; control and management on site including clear allocation of responsibilities for emergencies during all shifts and out of working hours; communication with community; emergency plan testing arrangements; control of spillage/pollution; toxicity/flammability and any possible additive effects; clean up/decontamination; dealing with the media; consultation with emergency services / third parties / stakeholders; establishing control centres; and ensuring the availability of information / site plans / inventory etc.

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Unit A - January 2006

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