A death in the factory

A man lies bathed in blood on the factory floor. Beside him a team of first aiders, many close friends, frantically attempt to resuscitate their colleague but there is a problem. "We couldn't give him mouth to mouth because the accident had torn the bottom half of his face off," explains the site manager, who asked not to be named. The team perform chest compressions and thankfully the man's heart begins to beat again. He survived – but last year 27 other manufacturing workers did not. "Nobody believes it can happen to them," says the site manager. However, death or serious injury can strike on even the safest of shopfloors. "An operator using a crane failed to tie off two unneeded shackles out of the way," he explains. "Within seconds one of the loose shackles had snagged; when it slipped free, the shackle catapulted into the worker's head. The accident was the operator's fault, but that doesn't stop it being very painful [for everyone]. You can imagine the impact it had on our staff." Some workforces never fully recover, explains a health and safety manager at a paper mill where a worker was killed over a decade ago. The employee died instantly after stepping out unsighted into the path of a Volvo front loader truck, he explains. "The guy who was driving hasn't worked since. He was given counselling, but the shock and trauma of coming back to work was too much. I was a shift manager back then and I remember coming in that evening – you could sense it straight away." Eleven years on and the accident is still embedded in the psyche of the plant's workers, the manager adds. "A lot of the truck drivers even now will talk about it. They still drive with a monkey on their backs." But the story of the mill is one of triumph as well as tragedy. The fatality fuelled a complete overhaul of health and safety procedures on the factory floor. Physical barriers were introduced to areas where trucks operated near employees. Warning alarms and lights are activated when the vehicles approach and the site has adopted occupational safety and health standards from the US alongside UK regulation. "The accident had a big positive impact," says the health and safety manager. "People's awareness went up. There was an expectation that everyone on site took part in health and safety – we've seen great improvements in safety culture since." So much so, that the manufacturer picked up a safety accolade for its high standards. The success is down to closer collaboration with the shopfloor, he adds. "They're the people who have the most knowledge; they know the risks from doing the job. They might not know how good they are at risk assessment so it's up to management to give them that confidence." The need for management back-up over safety is reinforced by other manufacturers who've suffered severe accidents. "If someone turns around and says no because they feel unsafe, then they will be supported. That's the single biggest thing that's changed," one manager tells WM. But it shouldn't take a death or serious injury to create a proactive safety mindset. Manufacturers must view health and safety as the nucleus of operations rather than a bothersome distraction. The vast majority do, but in an industry well versed with continuous improvement, there is capacity to drive up standards further. Yet no matter how high your safety standards, it's impossible to banish the threat of accidents completely. "There wasn't horse play and it wasn't a behavioural thing," says a manufacturing manager, whose site was rocked by the tragic death of a maintenance worker. "It's one of the worst things to have happened in my working life," he says. "I've worked somewhere where a colleague had a heart attack at work but this was very different." The incident happened while an employee inspected a fault on an induction oven. Safety devices failed to cut power to the oven and the worker was killed by electrocution. "He was a young man having a laugh and a joke over a cup of coffee with his mates," says the manufacturing manager. "The next minute he goes out to a maintenance job and he never comes back." Many of the first aiders who arrived on the scene were so traumatised that they quit their posts. The employer, like all of those spoken to by WM, offered occupational health advice and counselling to grief-stricken colleagues. After the immediate human tragedy of the accident, the company faced up to expensive production downtime, media scrutiny and customer concerns. The easy option might have been to blame it all on the mechanical fault and stand by existing site safety procedures. However, the company was determined its safety response would go beyond ripping out the faulty oven, the manufacturing manager explains. The company has introduced environmental, health and safety information system reporting and most importantly empowered the shopfloor to drive up safety standards. "What I'm most proud of is our people," he says. "Rather than just identifying poor behaviour we now use near misses to spur reporting hazards at root cause. The health and safety manager can't be everywhere so you need all of your employees to take on that role." The site also keeps close ties with the deceased worker's family. "We're quite a local site and everybody knows the family," the site manager explains. A tree was planted at the factory in the worker's honour with family members attending a commemorative service each year. After the eulogies the wider manufacturing community might want to offer a short prayer: that we can counter such tragic deaths by giving everything to the health and safety cause and ensure no one else suffers the dreadful consequences of a death in the factory. The post accident investigation: what to expect WM talks to veteran HSE inspector Tim Galloway about how the regulator will respond to a fatal or serious injury occurrence at a manufacturing site It's hard to be in the best frame of mind in the aftermath of a fatality or serious accident. However, site managers would be wise to remain cordial when the HSE inspectorate calls. "It does help the company in front of the courts if we can say they cooperated fully with our enquiries," says Tim Galloway, HSE head of operations, London, and an inspector for more than 20 years. "I've encountered some hostility. Clearly in the immediate aftermath of an incident people are traumatised." Any factory suffering a major injury or employee fatality can expect a rapid visit from Galloway or his colleagues. "If it's a fatal or near fatal accident, then we get there as soon as we can," he explains. A team of two inspectors will join police at the accident scene. Their first priority is to gather evidence on what happened, according to Galloway. Inspectors will prohibit plant they believe is dangerous or want to use as evidence, he explains. Senior site staff can expect to be interviewed by HSE about the accident alongside eye witnesses. HSE will also gather company documents including emails about work processes, training records, maintenance records and risk assessments. The likely length of an HSE investigation is hard to quantify, according to Galloway. For serious accidents it's likely to include multiple site visits, he confirms. Those who have experienced the process describe it as draining and sometimes brutal. "When the HSE came in it was very stressful," one site manager told WM. "They're looking at systems from a very critical point of view. Under normal circumstances it might be collaborative, but not in the aftermath of a serious accident." Yet what HSE might proffer as professionalism to others feels like provocation. A factory manager says: "You've just been through something you wouldn't wish on anybody and these people come in behaving like you did it on purpose." When the HSE accident investigation concludes there are multiple potential outcomes. The regulator may take no further action where a worker has knowingly breached safety guidelines despite management's best efforts. However, manufacturers will be pressed on what steps they took to safeguard the worker, says Galloway. "It wouldn't be enough to say we sent them on a training course. We'd want to know what steps the supervisor took." HSE may rule the individual was at fault but the company could have done more to prevent the accident in terms of training or providing the right equipment. Manufacturers could be prosecuted by HSE in such circumstances if there is enough evidence and doing so is in the public interest, says Galloway. In other cases, the company may be found guilty of failing to ensure a safe working environment and be held directly responsible for the accident. The further you fall below industry expectations, the more likely prosecution, says Galloway. Where that safety breach is severe and has led to a fatality, charges could be made under corporate manslaughter. Fines where offences by the company caused a death will seldom be under £100,000, explains Galloway. Manufacturing managers can be imprisoned for life for gross negligence, he confirms. However, a more pertinent problem for the innocent is the cost in time and resource from fielding an investigation. Satisfying HSE enquiries can have a "massive impact on senior management" one manager told WM. The British Safety Industry Federation (BSIF) urges manufacturers to seek immediate professional help from solicitors. "Consider legal representation at the outset. Don't sit there with your fingers crossed that it won't go to court," advises Neal Stone of BSIF. Ultimately, though, prevention is better than cure. Galloway says: "Don't regard health and safety as a bolt on. It's your job as a production manager and is as much a part of manufacturing as quality or finance." first stop: first aid According to St John Ambulance, these are the first aid skills that everyone should know. The full unedited version can be downloaded at www.worksmanagement.co.uk Severe bleeding ? Apply direct pressure to the wound with a pad (eg, a clean cloth) or fingers until a sterile dressing is available ? Raise and support the injured limb if possible. Do not raise if you suspect the bone has been broken ? Lay the casualty down to treat for shock ? Bandage the pad or dressing firmly to control bleeding, dial 999 If someone is unconscious ? Check their airway is open and clear ? Tilt the head and lift the chin to open the airway ? Look along the chest, and listen and feel for breaths. If they are not breathing, their heart will stop. CPR must be started immediately ? If they are breathing normally and spinal injury is not suspected, put them in the recovery position. If someone is not breathing ? Tilt the head and lift the chin to open the airway ? Check for breaths for 10 seconds. If they are not breathing, their heart will stop. CPR must be started immediately ? Call 999 and if available, get an AED (automated external defibrillator) and follow the voice prompts. WM would like to thank the managers who had the courage to speak to us on this traumatic subject. We dedicate this article to the manufacturing workers who have lost their lives in active service.