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A poor organisational safety culture is said to lead to higher levels of violation by
(a) Give the meaning of the term violation AND outline the classification of violation as
routine, situational or exceptional. (6)
(b) Outline why a poor safety culture might lead to higher levels of violation by employees.
(a) Give the meaning of the term violation AND outline the classification of violation as
routine, situational or exceptional. (6)

Violations are deliberate deviations from the rules or a procedure and can be
divided into three types: situational, routine and exceptional.

Most violations are motivated by a desire to carry out the job despite prevailing
constraints, and very rarely are they motivated by wilful acts of sabotage or

Routine violations occur when Breaking Rules become a way of working within a
group due the desire to take short cuts and the workers perception maybe that the
rules are too restrictive or the rules no longer apply , this could be due to lack of
enforcing the rule.

Situational Violations- Breaking Rules due to the pressure from the job such a time
pressure, insufficient staff for the work load and the right equipment not being

Exceptional Violations- These rarely happen only when something goes wrong. To
solve the problem employees believe you that a rule has to be broken. It is falsely
believed by the employees that the benefits outweigh the risk.

(b) Outline why a poor safety culture might lead to higher levels of violation by
employees. (4)

- It is worth mentioning that a safety culture is based on the common beliefs and
perceptions of workers which are built up over time by the decisions and behaviours of
management and their fellow workers.


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- A shared perception that safety is not important could lead to individuals violating
rules because they have a different perception of what is important.
- They may be influenced by peer pressure. They wish to be accepted by their peers, so
will behave in a similar way, even if this means violating rules.
- General perception that rules are not important.
- Production is considered the most important part of the job.
Explain the principles and methodology of a Hazard and Operability (HAZOP) Study. (10)
- Purpose is to identify deviations from intended normal operation.
- Team approach
- Includes specialists from a variety of functions and disciplines (engineers, process
specialists, chemists etc.)
- Team leader skilled in HAZOP process
- HAZOP used at design and modification stages
- Scope of the study clearly defined
- Process is broken down into elements
- Collection of data, drawings, specifications, layout etc.
- Uses a brainstorming approach
- Deviations against process parameters are prompted by the use of guide words. Give
examples of the guide words (MORE, LESS, AS WELL AS etc.) and parameters (flow,
pressure, level, temperature etc.)
- It is an explain question, so marks are available for examples. So you could give an
example of a deviation against a process parameter. e.g. If transferring hydrocarbons from
one tank to another, MORE flow, which could lead to overflow. An overflow would lead to
MORE level, and possible increase in pressure/venting etc.
- HAZOP will examine the causes and consequences of each deviation. Again, give some
examples to illustrate what you are saying.

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- Creates an action plan.

- Findings are recorded in a report.
The principles of a Hazard and Operability (HAZOP) study are to systematically question
every part of either a new system during the design phase or an existing system by a
multidisciplinary team to identify potential hazards and operability problems that may be
caused by deviations from the design intent of the plant being studied. An essential
process in a HAZOP for questioning and systematic analysis is the use of keywords to focus
the attention of the team upon deviations and their possible causes. Adequate controls can
then be identified depending on the outcome of the study.
The methodology of a HAZOP study firstly involves selecting a multidisciplinary team, this
should include persons familiar with the plant or system to be studied, design engineers
and other specialists. A team leader should be selected and this person should be an
experienced specialist from works management or a specially trained consultant.
A full description or overview of the plant is to be made in order to maintain an overview of
the whole process so that parts of the system are not left out.
Once this is done, a section of the plant is selected and all applicable primary words
(Deviations) are identified. Primary words are typically process orientated words that could
consist of words like: Flow, Pressure, Etc.
After the primary keywords are identified, secondary keywords are used to identify possible
causes to the deviation and the possible consequences are linked to them.
All current and design safeguards are then identified and should shortcomings be found,
actions are formulated to improve current or introduce new safeguards and the study is
then redone.
The results are recorded in a table for traceability and tracking.
A forklift truck is used to move loaded pallets in a large distribution warehouse. On one
particular occasion the truck has skidded on a patch of oil. As a consequence the truck
collided with an unaccompanied visitor and crushed the visitor's leg.
a) Give reasons why the accident should be investigated. (4)

We investigate accidents to identify the causes, both immediate, underlying and the
root causes.

- The goal is to prevent recurrence of the accident.


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- We need to determine whether we are complying with legal requirements or not.

- It is an implied legal requirement to investigate accidents. To comply with the

general duties of C155 it is necessary to investigate accidents.

- Investigations demonstrate management's commitment and can restore worker

morale and reassure them that their safety is important.

- The information collected can be used to determine liability, so a decision can be

made whether to settle or defend civil claims.

- The cost of the accident can be calculated, and this will help demonstrate the cost
benefits of implementing the recommendations.

- Investigations will help identify trends which can then lead to reallocation of
priorities and resources to problem areas.

- The investigation will discover the causes, and reveal deficiencies in risk
assessments and safe systems of work.

b) Assume that the initial responses of reporting and securing the scene of the accident
have been carried out. Outline the steps which should be followed in order to collect
evidence for an investigation of the accident. (8)

- Taking photographs, make sketches, and take measurements of the scene before
anything is disturbed.

- Obtaining CCTV footage of the incident if available.

- Examine the condition of the forklift and determine its speed at the time of the

- Check whether the load being carried was safe, within the SWL of the FLT, and check
any possible visibility issues caused by the load.

- Find out the reasons for the oil spillage. Check what emergency spillage procedures
are in place, and find out why these were not followed.

- Check the competence of the FLT driver, when they were last trained, and also any
issues with their health surveillance (eyesight etc.).

- Check possible environmental factors like lighting issues causing poor visibility or
glare, noise which could be a possible distraction, or overprotection of hearing
protection, condition of the floor and whether this is inherently slippery.

- Interview witnesses, the driver, reception workers, and even the visitor.

- Obtain the procedures for how visitors are controlled, find out why the visitor was

c) The investigation reveals there have been previous skidding incidents which had not
been reported and the company therefore decides to introduce formal system for
reporting 'near-miss' incidents. Outline the factors that should be considered when
developing and implementing such a system. (8)


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- Clearly defining "near-miss" so everyone knows what should be reported and what
should not.
- Consulting with employees and representatives on the proposed system and how it
should work, and how to best achieve the desired result.
- Arranging for training to be delivered to all employees, providing supplementary
information and publicity to remind them.
- Keep the reporting method simple, and the forms easy to understand. Clarity of reporting
formats e.g. online, paper etc. Location of forms.
- Clear reporting lines i.e. who should they be reported to.
- Introduce and practise a no blame culture. No penalties for reporting a near miss or
being involved in one.
- Ensure there is a system in place to investigate the near misses e.g. clear responsibilities
on who does the investigation, ensure they have the time/skills/resources to investigate,
and management is committed to fixing the root causes.
- Report findings of investigations back to the person who reported the near miss
- Collect the data and use it to identify trends. Monitor and review this on a regular basis.

Train drivers may spend long periods of time in the cab of a train and may be susceptible
to loss of alertness. This can increase the risk of human error.
a) Describe, with examples, a range of factors which may influence the degree of alertness
of train drivers. (5)
Generally there are 3 things which will affect alertness in train drivers:

- Fatigue

- Health

- Environment


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If you structure your answer around these 3 things, then you can't go far wrong.
Here are the points I would make in part a) Please note I have NOT described these

- Drivers could be fatigued due to the design of shift systems and the rotations
(moving from days to nights and back to days again etc.).

- Insufficient recovery periods between shifts. Not enough sleep.

- Shifts are excessively long, with possibly inadequate breaks.

- The driver may have non work activities between shifts which prevents him from
sleeping, possibly maybe a family/baby/2nd job/hobbies etc.

- Alertness can be reduced due to medical conditions (insomnia, epilepsy, diabetes,

strokes, heart attacks).

- The driver may have taken alcohol, or drugs. They may be on medication which
makes them drowsy.

- They may be distracted by thinking about personal issues and problems, or be

distracted by a stressful situation (financial, domestic, legal, employment etc.)

- Temperature too warm, not enough ventilation, makes them drowsy.

- Too much noise, can be distracting. Mobile telephones.

- Uncomfortable seating in the cabin, too much time stretching and shifting position.
People whose bodies are aching will be distracted by the aches.

- Driving repeatedly on the same route, especially for long periods, will make you less
alert. Those of us who drive cars on long highways/motorways regularly have
experienced this! If the new driver is new then actually they will be MORE alert. They
lack experience and may be a little nervous taking the train out for the first time alone.

- Spending long periods of time alone increases the likelihood of being distracted by
our own thoughts. While constant interaction with colleagues is not desirable either,
occasional interactions will keep the driver engaged with his duties.


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b) Outline a range of practical measures that could reduce the risk of lack of alertness in
train drivers. (5)
- Introduction of a shift system, with rules on the maximum shift lengths (12 hours being a
maximum), provision of regular breaks, and sufficient recovery times between shifts. Pay
special attention to night shifts where alertness is lower.
- Ensure sufficient transition time between moving from day to night shifts, and night to
day shifts. Usually at least 48 to 72 hours.
- Pre-employment medical examinations to check for any existing health conditions which
may affect alertness, eye sight tests, general fitness health etc. Regular health screening
throughout employment.
- Alcohol and substance use policy, with provision for random testing. Rules on medication
and encouraging drivers to report the prescription of medication which may affect at no
- Design of the cabin:
- Air conditioning to keep it at a comfortable temperature. Not so warm they get drowsy,
not so cold they get distracted.
- Noise insulated cabin to reduce the amount of noise.
- Adjustable seating, enough space to move.
- Finally, variations in the routes they drive, to ensure they do not get bored or
complacent. Variety also helps people stay alert.

a) Explain how accident data can be used to improve health and safety performance, within an
organisation. (6)

Here is what I would include in an answer:

- I'd say that the data will identify problem areas, both geographically and also in terms of activities,
departments, and possibly even defective parts of the management system. This then allows us to
introduce positive changes to fix the problems.
- The data allows us to prioritise resource allocation. We may focus our resources in the problem areas,
such as extra time, people, money, equipment etc.
- The data can be used to benchmark departments and sites against each other, and even benchmark the
whole organisation against other similar organisations. That way we can identify high performers and


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learn how they have achieved these levels of performance so the learning can be shared across the
- The data will identify trends in accidents i.e. common causes, common areas, common types of incident.
Again this helps us focus our efforts.
- These trends can be communicated to the workforce so that their awareness of risky situations and
activities is improved.
- The data can be used in consultation / committee meetings with the workforce so conversations/decisions
can be had/made which are based on fact.
- The data will enable calculation of accident costs, which provides a strong argument for an increase in
H&S resources.
- Finally the data will help identify new targets for H&S improvement. If you have a trend of accidents in
an area, then you can set a target for a lower rate of accidents.

b) Outline TWO active monitoring methods that can be used when assessing an organisation's
health and safety performance. (4)
In part b) most students were able to get at least two marks for identifying two types of active monitoring. A
small minority of students did not seem to know what is meant by active monitoring so I suggest they study
this part of the course materials. Where most students went at least a little bit wrong is in the outline of the
active monitoring. Most were too vague for a Diploma candidate to get the two marks.
Here are possible types of active monitoring you could outline:
- Inspections: a regular/scheduled activity. It identifies existing conditions, such as observations of work,
physical conditions of the workplace/equipment, and the behaviour of people, and compares these to an agreed
- Audits: comprehensive examination of all aspects of an organisation's performance against the objectives
stated in the organisation's policies and procedures. Can be internal or external.
- Health surveillance: health screening using techniques such as audiometry, blood tests, and eyesight tests.
- Safety survey: questionnaire that focuses on a particular activity/risk and seeks to evaluate workers' attitudes
towards this.
- Safety tour: unscheduled workplace check on specific issues. Often done by a senior manager and used to
informally discuss H&S with workers and listen to any concerns they have.
a) Give the meaning of the term 'motivation'. (2)
Motivation is the driving force behind the way a person acts... (Only a few people got this).
... In order to achieve a goal. (Most people got this).

b) Outline how an organisation can motivate workers to adopt safe working practices. (8)
- Ensuring there is a positive health and safety culture, and eliminating any blame culture.
- Setting realistic H&S objectives and targets. It is demotivating if your targets are unrealistic.


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- Involve workers in H&S issues and decisions, consult with them, and set up a H&S committee with a good
mixture of worker and management representation.
- Having clear H&S responsibilities.
- Havinga good reward and recognition structure for H&S achievements. Most students got this one.
- Monitoring H&S performance.
- Provide training, information and instruction on the consequences of not behaving safely.
- Demonstrate management commitment, provide resources, and a safe place of work.
- Managers lead by example.
- Supervisors and managers actively monitor and provide appropriate feedback and coaching their workers
about their performance.
- Provide adequate welfare facilities. This does not directly motivate, but not having these is demotivating.
An organisation is proposing to move from a health and safety management system based on the ILO's ILOOSH 2001 model to one that aligns itself with OHSAS 18001.
Outline the possible advantages AND disadvantages of such a change. (10)

- 18001 can be externally certified whereas ILO OSH 2001 cannot. This means that it can be
independently verified.
- The certification can be used for publicity and commercial purposes. Many potential clients may have
18001 as a condition for doing business. Therefore it may increase sales.
- 18001 is readily integrated with 9001 and 14001 so the new system may be more easily understood
and implemented with those standards already in place.
- Improved employee morale since the organisation is demonstrating sufficient concern to invest in what
is a complex and costly system.
- More prescriptive in its requirements, therefore much easier to audit against this standard, and also
much easier to benchmark against other organisations who have 18001.
- ILO OSH 2001 has no formal approach to continual improvement. Therefore 18001 will force the
organisation to always strive for improvement and document it.
- It is possible, but not certain, to get reduced insurance premiums upon certification.


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- The additional ongoing cost of external certification.
- There is a cost in time and disruption of changing systems, including changes to documentation,
additional training, and the potential for mistakes to be made during the transition process.
- Some people may be resistant to change and may not see the need for the new system.
- It could be perceived as bureaucratic and overly complex for small businesses.
- The additional bureaucracy in itself is a downside.
Identify content that could be included in an accident reporting training course for all employees within an
organisation. (10)
I would suggest the following structure of the course:
- Definition of accident / near miss and examples of what should be reported.
- Legal requirements under local legislation, it's implied under ILO C155 and R164 and also the ILO Codes of
Practice on the Reporting and Notification of Accidents.
- Benefits of reporting i.e. identification of root causes, prevention of recurrence, learning lessons.
- Costs of accidents to the organisation and the individual. Highlight the importance of preventing recurrence.
- What format: paper report form? Online? Intranet form? Location of paper forms?
- Whom to send the report to.
- The overall reporting procedure. Who does what. How this then triggers accident investigation and possibly a
review of risk assessments.
- How to fill in the form. Information required.
- Consequences of not reporting. Recurrence. Disciplinary consequences.
- Identity of first aiders (often report accidents on behalf of people).
- Emphasise the no blame culture. No penalties against individuals who report accidents.
- Emphasise management commitment to accident reporting.


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a) Outline why it is important to involve workers in the development of safe systems of work. (5)
Part a)
- Workers have practical knowledge of the work activity and environment which managers and H&S
specialists often do not have. Most students got this.
- Workers also will have a better understanding of what systems of work will be effective in practice. i.e. what
is practical and what would actually work.
- Involving employees demonstrates serious management commitment to H&S.
- It also raises the profile of H&S. Employees getting involved in H&S instead of it merely being imposed by
- If the employees are involved in developing a SSOW then they will develop a sense of ownership. i.e. it is
"their" SSOW.
- This is turn makes them much more likely to use it and follow it it in future. They may even self police it
amongst themselves and with new starters. A surprising number of students did not get these last two points.

b) Outline why it is important for safe systems of work to be in writing. (5)

Part b)
- Written information is usually much clearer than verbal.
- Everyone who reads it receives the same message.
- A complex task will require a written SSOW because people will need to check it more than once.
- In many cases the task is so complex that the SSOW almost becomes a checklist, being referred to throughout
the activity so that the correct sequence of actions is followed.
- You would use it in an audit, checking that the way the task is being performed is how it is supposed to be
performed according to the written document.
- It is useful to defend compensation claims and prosecutions to prove you have a SSOW.
- Further to this, legal compliance. ILO C155 requires SSOW as does maybe your local legislation. To prove
you have them it is useful if they are written.
- H&S management systems (and QA systems) will require SSOW to be written.

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Unit A
A low pressure storage vessel is connected via pipework to a manufacturing plant that could, in the event of
malfunction, generate a pressure great enough to rupture the vessel. To prevent this, a pressure detector is
installed in the low pressure storage vessel. If pressure starts to rise above an acceptable level the detector
activates a valve control system. This in turn closes the inlet valve to the vessel isolating it from excessive
pressure. It has been estimated that pressure great enough to rupture the low pressure storage vessel would be
generated once every four years on average (ie 0.25 failures per year).
Figures for the probability of successful operation of the system components are given below:
Pressure detector: 0.95
Valve control system: 0.99
Inlet valve: 0.8
Construct an event tree for the protective system described above AND use it to calculate the overall
probability of rupture storage vessel caused by the failure of the protective system. (10)
Every single student got the correct result to this question, which is fantastic.
However, not every single student would have got 10 out of 10. Some missed very easy opportunities to
demonstrate further knowledge in showing their workings out, as a result they will have limited themselves to
8 or 9 marks only (only? still very good!).
Here is what the Tree should look like approximately.


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Most of the workings out have been shown. But there is something missing. We also need to show how to
calculate the failures of each component. I know that this is obvious, but there is a mark for showing this.
Failure of the detector: 1 - 0.95 = 0.05
Failure of the valve control system: 1 - 0.99 = 0.01
Failure of the valve: 1 - 0.8 = 0.2
To get the result you add up all of the failures:
F1 + F2 + F3 = 0.047025 + 0.002375 + 0.0125 = 0. 0619
To express this in years: 1 divided by 0.0619 = 1 event every 16.15 years.
You would still get marks for rounding up or down, so results saying 16 years would normally be acceptable
provided you've demonstrated your understanding with the workings out.
Remember though, it is good to check that your result is correct by adding all of the numbers together.
0.0619 + 0.1881 + 0.75 = 1
That is a good sign my answer is right. Well done everyone on getting a great result!
Outline content that could be included in an accident reporting training course for all workers within an
organisation. (10)
1. Firstly you need to ensure workers have a clear understanding and definition of what an accident is
and the reasons why it is important to report all accidents, even minor accidents and near misses that
could have lead to a serious accident.
2. Ensure they are aware of the benefits of reporting accidents, that it will benefit everyone if the root
causes can be established and future accidents prevented. There should be emphasis on the no
blame so that workers will not be scared to report accidents for fear of retribution or getting into
3. Provide information on the procedure for accident reporting whether it will be by phone call, email or
on a form that they need to fill in and submit. Who they should report too, usually their direct
supervisor but also additional people to inform if he is not available like the Health and Safety
representative. If forms are to be filled in, ensure the workers where to find the forms, know what
information should be filled in on the form and where it should be submitted.
4. The workers need to be informed of the emergency telephone numbers to phone in the event of a
serious accident or fire outbreak. The telephone numbers should be posted on signs around the
workplace and can also be printed on the back of their access cards for instance. They need to know
what details to give to the call taker like the address of the accident, people involved and any
important information that the rescue team might need like a chemical spill etc
5. Workers should have access and knowledge of the Emergency response procedures for their
department so they can know exactly what to do in an emergency and who to report to or phone.


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6. Inform workers of the consequences of failing to report an accident but focus on what the event will
cause and not on any punishment or blame for it.
(Include below listed topics) Wills advice

Definition of accident/near miss

Explanation of the legal requirements on accident reporting. External reporting requirements
Commitment of management to accident reporting
Benefits of reporting, opportunities to learn lessons
Lack of blame culture, purpose is to identify causes, not blame.
The links to risk assessment reviews
The report will be used to start an investigation.
The methods of reporting/format i.e. paper form, online etc.
Whom report to
Internal reporting requirements i.e. company policy
The reporting procedure
How to fill in the form
Consequences of not reporting

a) Give the meaning of 'safety culture'. (2)
It is the combined outlook of all workers, supervisors and managers in the company regarding the
importance of Health and Safety. It is their shared beliefs, perceptions, behaviour and attitude to working
safely. It has become the norm of behaviour for every member of the organisation.

b) Outline a range of organisational issues that may act as barriers to the improvement of the safety culture of
an organisation. (8)

The lack of involvement and commitment for senior management and them not leading by
example. This shows the workforce that management does not value health and safety in the
organisation or that they place other factors like production ahead of health and safety. A lack of
management commitment will lead to the workforce not trusting them.
The lack of resources allocated to Health and Safety seeing as it is expensive to implement control of
hazards in the workplace.
The history of a poor health and safety culture in the organisation leading workers to believe that
working unsafely is the norm and a history of poor employee / industrial relationships.
No appointment of a Health and Safety advisor, committee or regular toolbox safety talks, safety tours
or workplace inspections. This means that Health and safety issues are not monitored and that hazards
are not identified.
A lack of consultation with the workforce. Consulting with the workforce can lead to hazard
identification and the workers can share their knowledge and expertise in work processes to reduce the
risk of injuries or loss.
The lack of Health and Safety policies, standard operating procedures, safe systems of work and job
specific safety analysis with the implementation of permit to work systems for hazardous jobs.
High staff turnover that leads to loss of competent and knowledgable workers especially if they were
involved in health and safety rolls. It also compromises the ability of workers to form relationships
and commit to the culture together.


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No procedures in place to deal with organisational changes leading to insecurity and fear of the
workforce for losing their jobs or redundancy. The channels of reporting of health and safety issues
may also be lost during the change process or the importance of health and safety not uphold during
this time. Redundancy processes may lead workers to believe that the organisation does not value it
Loss of bonuses or incentives or a reduction in salary will cause workforce to become negative to all
aspects of the organisation including Health and safety.

Incentive or bonus schemes could have the opposite effect by creating competition to finish a job
quicker thereby leading to the worker taking chances or cutting corners with increased hazards and
Cultural differences, language barriers and social differences leading to workers not being able to
form a combined outlook for health and safety issues.
Failing to appoint safety representatives and employee representatives with the result that the workers
concerns and complaints are not carried over to management and they are not resolved.
Having a blame culture in the organisation that will cause workers to be scared of reporting health and
safety issues for fear that they will be blamed for it.

June 10 2015 Completed


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