Scenario:

Following a serious and well publicised accident, you have been newly recruited as a Health and
Safety Advisor at a bakery organisation. The organisation employs directors, shift managers,
maintenance engineers and bakery workers.

The organisation produces bread on a large scale using automated machinery. Ingredients are
mixed together to make a dough. The dough is placed in baking tins on a conveyer which travels
through an oven, baking the dough into bread. There are three large bread ovens at the bakery, as
well as other machinery used to prepare the dough. This is all housed in a large warehouse.
The bread baking ovens are long, metal-encased tunnels with a conveyor running through them.
The conveyor is made up of horizontal racking, bolted through metal plates at either end of the
conveyor chain. The conveyor is approximately 20 metres long and 3.3 metres wide
(approximately 66 x 11 feet), taking up virtually the whole of the width of the oven. The bread
dough is placed in tins that enter on one end of the conveyor, travel along the length of the oven
and exit at the opposite end.

Travelling at its fastest speed, the tins take 17 minutes to pass through the oven.

The directors do not believe that health and safety is a full-time job, but they hope that you will
improve the bakery’s health and safety performance, learn lessons from the recent serious
accident and, most importantly, improve the reputation of the organisation. They have told you
that there is no budget for health and safety, but if something is needed, you should present an
argument for how it will improve profit. You ask who the health and safety representatives are
within the organisation and are told that there are none with whom to raise specific safety issues.
However, if a machine needs to be fixed you should contact the maintenance engineer.

You also ask if any health and safety training is provided to staff and are advised that as far as
training is concerned, there is an induction for new starters within six weeks of joining the
organisation. New starters are then shown how to carry out their role by someone else in the
relevant department. You are told that quite a lot of people have received first-aid training, but it
was a long time ago and many of those trained have since left the organisation. Other than that,
there is not much in the way of training, because the directors feel it is wasting working time.
Finally, you ask where the health and safety documentation is kept but they say that they do not
know, and suggest you ask the shift manager on duty.
The duty shift manager is sitting at their desk surrounded by paperwork, looking stressed. You
introduce yourself and ask where the health and safety documentation is kept. The shift manager
pulls out a folder from a cupboard in the corner of the room and says that risk assessments are in
it. You find several completed risk assessments for the ovens and other machinery, but they are
very out of date. You ask to see the accident and near miss records, but the shift manager advises
that accidents do not happen often, so there is no need to keep a manual record. However, you
have heard from the other workers that accidents and near misses frequently occur, but that they
are not formally reported.

You ask where the inspection and maintenance documentation for the bakery machinery is kept
and are directed to the maintenance engineer. The maintenance engineer explains that they do not
keep a record of inspections and maintenance other than in their work diary, and that they can see
when a machine was last used from that diary. They have been doing the job for over 15 years
and ‘just know’ which machines have had work done to them. When they are working on a
machine, they check certain parts at the same time. They also remark that as the machines are
quite old, they frequently need parts replacing. The workers have been promised new machines a
few times, but these promises have not been kept.

The recent accident

As part of your remit to learn lessons from the recent serious accident, you decide to investigate
what happened. Your enquiries reveal that the accident occurred when the bakery was under
pressure to get an urgent order completed. You find out that the directors often allow workers to
cut corners

When it comes to safety measures, to enable them to get the job done as quickly as possible and
without costly delays. Workers are often individually blamed if target timelines are not reached.

This is how the accident happened. On a night shift, the conveyor racking collapsed into one of
the ovens stopping it from moving. The maintenance engineer, usually assigned to fix
breakdowns, only worked day shifts. Waiting for this engineer to come back on shift would have
caused significant downtime, and would have prevented the order from being completed on time.
Feeling under pressure, the shift manager on duty discussed the issue with their team to try to get
the oven back up and running. It was decided that a newly promoted maintenance engineer and
another young worker were assigned to enter the bread oven to retrieve the fallen racking
themselves. No-one on the night shift had ever been present when an oven had needed entering
before. The correct way to enter the oven for maintenance work would have been to remove the
side panels. However, this would have taken a long time, as specialist tools that they were
unfamiliar with, would have to be found and used.

The oven had only been switched off for two hours, but it was assumed that it was cool enough
to enter. The temperature gauges were not checked before entering. The two workers decided to
enter via the route the bread would take on the moving conveyor. They managed to get on the
conveyor through a small unguarded gap.

Once the workers had entered the oven, they soon realised it was too hot. They were unable to
get the attention of their colleagues outside of the oven but eventually managed to alert them by
shouting for help. Their colleagues tried to get them out of the oven, but they did not know how
to do this, or locate how far they were inside the oven. Everyone was frantically trying to help
but there seemed to be no-one in charge to take control of the situation. As a result of this, there
was a delay in getting them out. There was no way to reverse the conveyor belt, so the workers
had to forcibly pull off barriers and side panels to help them escape. Both workers who entered
the oven suffered serious burns. Workers at the scene were not first-aid trained but did their best
to help their colleagues. Unfortunately, both workers died from their injuries at the scene. The
workers who helped get them out were traumatised by what they had witnessed and had to take
extended periods off work to recover. There were also some workers who felt they could no
longer work at the bakery and resigned.

Following the accident, the bakery was closed for two weeks while an investigation took place.
The associated downtime caused many missed production deadlines and loss of contracts. The
organisation, the directors and duty shift manager were all prosecuted for breaches of health and
safety legislation. They pleaded guilty to all the counts against them. The organisation was fined

£350 000 and ordered to pay costs of £250 000. Since the accident, the bakery has lost bread
orders due to clients not wanting to be associated with them.

Task 1: Obligations Of Employers To Workers. (10 marks)

What employer obligations to workers are likely to have been contravened, leading to the
accident in this scenario? (10)

You only need to consider those obligations placed upon employers under
Recommendation 10 of International Labour Organisation R164 – Occupational Safety
and Health Recommendation,1981 (No. 164).
Note: You should support your answer, where applicable, using relevant information
from the scenario.

Task 2: Financial Arguments To Improve Health And Safety (10 marks)

Based on the scenario only, what financial arguments in relation to accidents, could you use
to convince the directors that health and safety needs to be improved?