This report was carried out to evaluate the

accident case study that is related to the

relevant legislation and safety systems
relevant to the Safety Technology elements
where applicable and suggest the
recommendation for better improvement
Accident
Case Study
Evaluation
Barnet bread company fined
after man dies from fall
Nurhafiza Hasin
13043064
John Elward

pg. 1

Contents

1.0 Introduction of the incident .............................................................................................................. 2
2.0 Case review ....................................................................................................................................... 3
3.0 Decision/recommendation ............................................................................................................... 8
4.0 Summary/Conclusion ........................................................................................................................ 9
5.0 References ...................................................................................................................................... 10
6.0 Legislation ....................................................................................................................................... 11
7.0 Appendices......................................................................................................................................12



















pg. 2


Barnet bread company fined after man dies from fall

1.0 Introduction of the incident

As reported in HSEs news (2011) a bread company based at Barnet in Greater
London named Ovenpride Wholesale Ltds Finchley Road bakery has been
prosecuted and fined by the Health and Safety Executive (HSE) after cause a fatal
accident where an employee fell from a ladder in 2009.
The site manager of the bakery Amjad Mahmood, was gave an order to casual
handyman Rocco Carofalo for build the shelving in the storeroom. The accident happen
in the morning of 22 April 2009, Carofalo had stood on a stepladder while construct the
shelves using the tools and material that provided by Ovenpride. However, the
stepladder view to be in very poor condition, and cause an accident to Carofalo, he was
found lying on the floor bleeding from a severe head wound, with the stepladder beside
him at the noon. On 23 June, as a result of his injuries, he died.
The tragic incident happen was easily preventable. The Ovenpride and the manager
had responsible for fail to provide a safe system of work. They should have carried out a
risk assessment, planned and organize the work to be carried out in a safe manners.

Companys name Ovenpride Wholesale Ltds Finchley Road Bakery
Offender Ovenpride Wholesale Ltds Finchley Road bakery
Amjad Mahmood
Victim Rocco Carofalo
Enforcing Authority Health and Safety Executive (HSE)






pg. 3

2.0 Case review

Stones reported in Employers Liability Insurance News (2011), two Inspectors
from HSE inspected the scene after the incident and issued a Prohibition Notice to stop
any work at height because of the unsuitability of all access equipment. A stepladder
was in poor condition, was taken from the bakery by HSE inspectors.
The City of London Magistrates' Court heard that the Ovenpride Wholesale Ltd,
of Empire Way, Brent pleaded guilty to breaching Section 2(1) Health & Safety at Work
etc Act 1974. It was fined total of 1. Ovenprides fine reflects the fact that the firm is
now in liquidation.
The site manager, Amjad Mahmood, age 57, from Donnington Road, Brent
pleaded guilty to also breaching Section 2(1) of the Health & Safety at Work etc Act
1974. He was fined a total of 300 and ordered to pay costs of 200.
In Section 2(1) of Health and Safety at Work etc. Act 1974 stated that:
General duties of employers to their employees.
(1) It shall be the duty of every employer to ensure, so far as is reasonably
practicable, the health, safety and welfare at work of all his employees

The incident happened because lack of precaution that taken regarding to the
safety system in the bakery. The manager should create regulations among safety and
health in his company to prevent work-related death, injury and ill health on workplace.
Here is the legislation that can apply in the workplace to avoid this occurrence might
happen.

1) The City of London Magistrates' Court
The virtual Courts enable the defendant to appear in a magistrates court for a
first hearing over a video link while still physically located in the police station
where they are charged. Case papers are shared electronically and this provides
swifter justice by enabling a hearing to take place within hours of charge.
(www.justice.gov.uk, 2013)



pg. 4

2) Health and Safety at Work etc. Act 1974
General duties of employers to their employees.
General duties of employers and self-employed to persons other than their
employees.
General duties of employees at work

3) The Work at Height Regulations 2005
According to The Work at Height Regulations 2005, it is require duty holders to
ensure:
all work at height is properly planned and organised
all work at height takes account of weather conditions that could endanger
health and safety
those involved in work at height are trained and competent
the place where work at height is done is safe
equipment for work at height is appropriately inspected
the risks from fragile surfaces are properly controlled
the risks from falling objects are properly controlled.

4) Health and safety in construction HSG150
Step-ladders provide a free-standing means of access, but they require careful
use. They are not designed for any degree of side loading and are relatively
easily overturned. Avoid over-reaching. People have been killed getting down
from workplaces such as loft spaces when they have stepped onto the top step
of a step-ladder which has then overturned. The top step of a step-ladder should
not be worked from unless it has been designed for this purpose.

5) Management of Health & Safety at Work Regulations (MHSWR)

Undertake the risk assessments



pg. 5

Safety Technology Elements

1) Assessing suitable personal protective equipment (PPE) at work

As stated in HSE website (2014) PPE is the equipment that will protect the user
regarding health and safety risks at work. The Ovenpride Wholesale Ltd can
apply the PPE approach to the workers. For example, it can include items such
as safety helmets and hard hats, gloves, eye protection, high-visibility clothing,
safety footwear and safety harnesses.

For head hazards
It can cause an impact from falling or flying objects, risk of head bumping, hair
entanglement. The employee can wear an option such as range of helmets, hard
hats and bump caps

For hands and arms
It can cause hazards such as abrasion, temperature extremes, cuts and
punctures, impact, chemicals, electric shock, skin infection, disease or
contamination. The user should wear gloves, gauntlets, mitts, wrist-cuffs,
armlets. It is recommended to avoid gloves when operating machines such as
bench drills where the gloves could get caught.

For feet and legs
Hazards might occur for example wet, electrostatic build-up, slipping, cuts and
punctures, falling objects, metal and chemical splash, abrasion. The user should
wear safety boots and shoes with protective toe caps and penetration-resistant
mid-sole, gaiters, leggings, spats.

2) Ladder safety

As mentioned in HSE Ladder Safety (2014), it is eligible to use a ladder or
stepladder:
In one position for a maximum of 30 minutes
Use for light work where they are not suitable for heavy work. If a task
involves a worker carrying more than 10 kg or a bucket of something up
the ladder or steps it will need to be justified by a detailed manual handling
assessment
Where a handhold is available on the ladder or stepladder
Do not overreach. Keep belt buckle inside the stiles and both feet on the
same rung.

pg. 6




When working on stepladders, avoid work that imposes a side loading,
such as side-on drilling through solid materials for example bricks or
concrete, by having the steps facing the work activity.





You should also avoid holding items when climbing (for example by using
tool belts)
Sources : www.hse.gov.uk/pubns/indg402.pdf.
Sources : www.hse.gov.uk/pubns/indg402.pdf.


pg. 7

Establish the ladder or stepladder is in a safe condition before using it. As a
guide, only use ladders or stepladders that:
Have no visible defects. They should have a pre-use check each working
day
Have a current detailed visual inspection.
Have been maintained and stored in accordance with the manufacturers
instructions.
Do not use the top two steps of a stepladder, unless a suitable handrail is
available on the stepladder (see Figure 11)
Do not use the top three steps of swing-back or double-sided stepladders, where
a step forms the very top of the stepladder (see Figure 12)



The ladder should be pre-use checked and inspected in accordance with the
manufacturers instructions. The ladder feet has to prevent from wobble and be in
good repair means it not loose, missing, splitting, excessive worn, secure and
clean. The feet should have a contact with the ground.



Sources : www.hse.gov.uk/pubns/indg402.pdf.

pg. 8

3) Maintenance of tools and equipment
Ladders are easy tool to use but if they are not maintained properly, they can
be unsafe. The employers should maintain the neglected ladders frequently.
Before using a ladder, it should be inspected to make sure it is in good
condition.

A pre check ladder starts from the top to down. Users should looking for any
loose steps and rungs. The rungs have to be sturdy, clean, and not slippery
from grease or oil. The upright ladder legs should be strong and free of
cracks, splits, and bent edges. The ladders braces should be solid. Nails,
screws, bolts or other fasteners should be tight. Finally, the ladder feet should
be examined and the non-slip base should be in good repair
(www.statefundca.com/safety, 2013)


3.0 Decision/recommendation


Risk Assessment

Risk assessment is the process to identified hazard and assessed for a given
situation, for example a workplace or a work activity. The purpose of the risk
assessment is to indicate the hazard that need to be controlled and prevent
from become worst.
There are five steps when conducting the risk assessment:

i. Identify the hazards
The hazard from the case had be identify that the company fail to
provide a safe system of work and poor condition of step ladder cause
an death accident to handyman named Rocco Carofalo.

ii. Decide who might be harmed and how
A casual handyman at Ovenpride's Finchley Rd Bakery, Rocco
Carofalo working on the shelves using tools and materials provided by
Ovenpride and found lying on the floor bleeding from a severe head
wound.


pg. 9

iii. Evaluate the risks and decide on precaution
Risks of using poor condition of materials and tools, proper risk
assessment and maintenance from the employers should be taken to
prevent any incident might happen.

iv. Record findings and implement them

v. Review assessment and update if necessary


The sample of risk assessment and policy template to be attached in the
appendices from Health and Safety Executive website.

4.0 Summary/Conclusion

From the case that had been review before, it was concluded that the
breach of duty by employers and fatal accident cause to the workers because
lack of proper inspection of tools and equipment. Aims to reduce work-related
death, injury and ill health, according to the legislation, Health and Safety
Executive enforcing authority accused Mr Mahmood and his company, were both
fined over the incident which should by law be covered with employers liability
insurance.
I would recommend the risk assessment to the company and provide
appropriate safe work system at workplace. Use suitable Personal Protection
Equipment while conducting any task of work and proper maintenance of tools
and equipment. The benefits for the workers can make healthier and safer
working conditions whilst the employers, it is beneficial to increased productivity
among the organization.






pg. 10

5.0 References

Available at: http://www.she.ltd.uk/how-can-we-help-you (Accessed: 24 January
2014)
Available at: http://www.thsp.co.uk/news/health-and-safety-in-the-
workplace/death-fall-fine-for-barnet-bread-firm.html (Accessed: 22 January 2014)
Available at:
http://www.statefundca.com/safety/safetymeeting/SafetyMeetingArticle.aspx?Arti
cleID=67 (Accessed: 22 January 2014)
Falls from height, Available at: www.hse.gov.uk/falls/index.htm (Accessed: 22
January 2014)
Heath, Employers Liability Insurance, News (2011) Available at:
http://www.johnheath.com/news/barnet-bread-firm-fined-over-employee-
death/(Accessed: 22 January 2014)
Health and Safety Executive (2011) Available at:
http://www.hse.gov.uk/press/2011/coi-ldn-2017.htm (Accessed: 22 January
2014)
Health and Safety at Work etc. Act 1974 Available at:
http://www.legislation.gov.uk/ukpga/1974/37/section/2(Accessed: 28 January
2014)
Personal Protective Equipment, Available at:
www.hse.gov.uk/pubns/indg174.htm. (Accessed: 22 January 2014)
Stones (2011) Available at: http://www.foodmanufacture.co.uk/People/Bread-
company-fined-1-after-fatal-fall-accident
The City of London Magistrates' Court, Available at:
http://www.justice.gov.uk/legal-aid/areas-of-work/crime/magistrates-courts 20
June 2013(Accessed: 22 January 2014)





pg. 11

6.0 Legislation

The Work at Height Regulations 2005
The Work at Height Regulations 2005 (as amended)
Provision and Use of Work Equipment Regulations 1998 Construction (Health,
Safety and Welfare) Regulations 1996
Safe use of work equipment Provision and use of Work Equipment Regulations
1998 Approved Code of Practice and guidance
Health and safety in construction HSG150 (Second edition) HSE Books 2001
ISBN 0 7176 2106 5
















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pg. 13