Posted By RBW100
My reading of the situation is that the chap who shut the gate and started the machine had, by his own admission, forgotten that the IP was inside the machine. He had failed to perform the check that was required in the SSOW before starting the equipment.

I think the article is ambiguously worded. it says "While he was doing this, the interlocked gates were shut by Mr Lenton, to allow him to raise the height of the blanks." I took it to mean that Mr Lenton closed the doors to raise the blanks, forgetting that the IP was still inside.

As you say, I would have thought that a key interlock could have worked here, i.e. the machine would not run unless the gate was shut and a key was in a lock, that way the anyone entering the cage could take a key with them thereby knowing that the machine would not be started if they had the key.

My personal view is that the company should have shouldered some of the blame as I think more could be done to make the machine safer. However I also think that the prosecution of the worker should also have gone ahead. In my view there is not enough emphasis on people following instructions correctly.

RW

Posted By Raymond Rapp
Ron

Not yet read the article but on the prima facie evidence presented here it does seem unusual to prosecute an employee for what is clearly not a SSoW. Have the HSE forgot about Human Factors and over reliance on foreseeable human error?

It appears that the 'soft target' is still the first to be shot...

Ray

Posted By Tarquin Farquor
I would agree that on the information supplied I would have thought that the gates would have been locked 'open' to prevent accidental closure, surley this is more effective than relying on someone to check the area?

Information for the HSE regarding this incident is available at http://www.hse.gov.uk/press/2007/gnnwm24307.htm

TF

Posted By Robert K Lewis
Yes I rather think the words of the HSE spokesperson were somehow garbled here. However I think it is clear from the role titles of these two men that they were both trained, experienced and competent persons. A press setter is not an ordinary operative and should have known that interlocked gates should not be closed without prior checking concerning the machine status. Either he did not bother to check, or he did check and closed the gate regardless. Whatever the reason it was not something an employer would expect a competent person to do. Remembering that the HSE see behaviour and attitude as fundamental to competency.

Employers are permitted to use interlocks and I suspect that the lock out was overridden in some way hence the prosecution.

Bob

Posted By Ron Hunter
Taff2 -does it read to you as the employer having a SSoW then?

Posted By Tarquin Farquor
Ron ~ agreed.

Taff2 ~ we can only comment on the face value of the information provided. In my view the HSE, as issuing the press release, should (and maybe with hindsight they will) have provided a greater clarification of the prosecution and judgement, particularly following the Hatton Traffic Management case where they appeared to be set on pursuing something against the employer who had appeared to do everything 'reasonably practicable'. Yet in this case an employee (based on the information available in the release) has been prosecuted for something that I feel could be preventable fairly easily by locking the gates open. It could well be that the company is being prosecuted as well, that I could then understand, but this is not alluded to in the information given.

Regards,

TF

Posted By Tarquin Farquor
Taff2 ~ I don't think you are ruffling feathers, merely stating your point of view, adds to an informed debate. After all it would be a bit dull if we all agreed.

I agree with your sentiments and would apply them accordingly dependant on the situation. In this case my opinion is given on the information available. If further information comes to light my view may change.

So keep ruffling, I know I will.

Regards,

TF

Posted By Ron Hunter
Bob,

You are suggesting things that are nowhere in the text of either the SHP article or HSE text.

Bottom line of SSoW, sfarp,etc.:

What stops exactly the same thing happening again? Who's fault will that be? ANOTHER employee?

Hmmm.............

Posted By Tarquin Farquor
Bob,

You've made some good points there, particularly around the person likely to have been a competent person due to the nature of the work rather than a run of the mill employee, something that I had not considered.

If this is in fact the case then it would have been beneficial if the HSE had made clearer reference to that in the press release.

However, that said, in the light of what is reasonably practicable and sensible risk management, if the locking open of the gate is relatively easy to do and would have prevented this incident shouldn't it be done?

Yes, competent persons should work competently but as the works of ramussen etc have demonstrated slips, lapses etc come into play. Should an employer not reasonably guard against that?

Now that this incident has occurred should the SSOW (which was not that safe) be reviewed and the gate locked open to prevent this re-occurring?

Are there other aspects that come into play ie piece work?

Enjoying your forum contributions (past and present) as they add to an enjoyable and worthwhile debate.

TF

Posted By Martin Taylor
OK guys - issues here are:-

1) should employee be prosecuted
2) did employer have a safe system of work
3) should employer have been prosecuted

on 1) competent person must take responsibility for their actions - but why did they make the mistake (assume that the court was shown suitable evidence of his guilt).

on 2) it is very common in my experience (injection moulding machines) for the interlock gate to prevent access to machine when running (don't forget this is not a case where the door is shut and the machine started up - there were 2 actions - shut the door and press start button. The machine is very likely to have been manufactured to EN standards and operate as per those standards. The only element that I can see that could have been considered would have been some pressure mat system that detected the employee inside of the press - this would be my only addition to a safe system of work -

Key systems where the key is taken by the employee still rely upon people following a procedure (and often cause problems if the key gets lost.

Full isolation lock out and tag system may not be practicable on a machine undergoing setting

on 3) if the guarding on the machine complies with EN standards and is fully functional, the setter has been fully trained and assessed as competent then can the employer be expected to do more to be legally compliant?

Remember that the purpose of the prosecution is to punish poor employers and discourage bad practices - given the facts released do not indicate any shortcomings on the part of the employer why should they be prosecuted - also don't forget that the employer may be expected to lose any civil claim.

Also the concern about this setting a legal precedent - what is the precedent. Employer does everything reasonably practicable, employee makes a mistake. Although the outcome is unusual it is hardly a precedent.

I would like to see some comment from HSE on why the employer wasn't prosecuted (at the end of the day this isn't a judgement on the employer - the court have not been given the opportunity to judge them - there is nothing in the report to suggest that the magistrate commented on the fact that the employer wasn't prosecuted.

I think that this case is more interesting as a topic of human error - here is a machine and an operation that I will assume was well safeguarded (to industry standard) and a competent setter yet....... a serious accident has occurred - there will be thousands of similarly interlock guarded machines throughout industry - what more can we do to prevent human error of this type?????

a thought to ponder

Posted By Robert K Lewis
We might also, without detaled information to the contrary, hypothesise that the press setter was the person in control of the re-tooling. This is not altogether unlikely as he would be the person to start the procedure and the one to complete the final re-setting. He would thus probably hold the interlock key. Given this the onus is more strongly on him to ensure the lock out checks are undertaken before start up.

As to the IP surely he was in the position he should be with the panel locked out and on manual - all indicative of work being undertaken inside the guard area. There are no breaches here either of regulations or the SSoW.

Competent persons can be expected to behave competently, but employers need to demonstrate that they are monitoring this competence in order to rely on employee competence as a defence. On the facts presented, poor as they are, I think the right verdict was made.

Bob

Posted By jom
Ron,

I was about to ask if we know the verdict and penalty. You say it was a criminal conviction.

What does modern safety philosophy say about human errors? They WILL occur. It's not maybe.

What does modern safety philosophy say about systems? That they need to be designed to tolerate human error.

It is legitimate to ask why only this particular person was taken to court.

John.

Posted By Ron Hunter
Bob,

Or you could compare and contrast with a (typical) Improvement Notice on the HSE database, say IN 300204505.
There are no Notices against the employer in the case we are discussing.

Posted By jom
Where can the details of the case be viewed? Can you provide a URL, Ron?

John.

Posted By Ron Hunter
Enter the number as a search term:

http://www.hse.gov.uk/no...earch/simple/default.asp

Posted By Tarquin Farquor
Bob,

Thanks Bob, I would hope that that would be the case.

TF

Posted By Pete48
I find the comment attributed to the HSE investigating officer "In this case a THOUGHTLESS MOMENT (my caps) caused severe spinal injuries to a fellow worker." more than a little concerning.
Every nerve in my body is screaming that, if this is so, then the consequence of such a failure must dictate that other measures are sought to control the risk. Is that really not the case?
If simultaneous multiple entry of personnel to a danger area was a common occurrence, did they have multi-lock hasps or keys? Not totally fail safe, of course; but much more robust than relying on one person.
Did any risk assessment cover the human failure modes, that thoughtless moment which is so obviously predictable.
Exactly why did the HSE decide to prosecute a "thoughtless moment". Or is that merely the headline?
Surely there must be more to this case than has been reported thus far?
Confused of Tunbridge Wells (aka P48)

Posted By Pete48
Bob, indeed yes, those questions had passed my mind. I guess there must be an avenue to research the detail of the case, I admit to not knowing how or if one can do that.
It seems such an important case that it would be worthwhile to do so.
Any suggestions for me from anyone?

Thanks

Posted By Robert K Lewis
jom

Bearing in mind that this is an Australian case, if you read the report however, it is clear that very specific guidance is set out to deal with the situation that occurred. The guilty driver clearly knew the requirements as he described his actions totally in accordance with the rules, only problem was that this would have brought him to a halt before the collision point. He knew what he should do but clearly performed a different action. The magistrate was being kind methinks!!

Bob

Posted By Robert K Lewis
jom

My understanding from your post that you were questioning whether it was justice that the driver was prosecuted. It was this question of justice or not that I was responding to. The statement concerning erro and miscalculation for me were rather an understatement. Perhaps there is a greater parallel with the press setter case than we first realise?

Bob