Case Study: Systemic Safety Failure and Cultural Turnaround in Manufacturing

1. Background and Incident Summary

A major manufacturing plant experienced a catastrophic workplace accident resulting in a RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) reportable injury. A 22-year-old female employee sustained the loss of three fingers after her hand was drawn into the opposing rollers of a production machine.

The severity of the injury immediately triggered an investigation by the Health and Safety Executive (HSE). Recognising the gravity of the situation and the likelihood of significant legal and financial penalties, the company urgently engaged safety consultant, Tim Hassall, to lead an independent internal investigation and remediation strategy.

2. Investigation and Discovery of Systemic Failures

Tim Hassall’s thorough investigation quickly uncovered that the incident was not a one-off operational error but the result of a profound systemic failure within the company’s safety infrastructure and culture. The key failures discovered were:

Compliance and Documentation Deficiencies

• Language Barrier: Critical documentation, including primary Risk Assessments, were only available in German, despite the majority of the operational workforce communicating in English. This rendered the foundational safety documents unusable and non-compliant with UK legal requirements.
• Tick-Box Compliance: The Safety Verification Records (SVRs) or safety check sheets were fundamentally flawed. They were designed as simple tick-boxes, allowing operators to rapidly complete them without genuinely confirming safety conditions, turning safety checks into a worthless administrative exercise.

Procedural and Engineering Failures

• Safety Interlock Circumvention: The most critical finding was the deliberate and widespread practice of wiring out safety equipment and interlocks. This illegal modification was implemented by employees to allow swift access to the machine rollers to clear tangled products, a necessary step due to poor production process control. This direct override created the immediate hazard that led to the injury.
• Incorrect Work Practices: Operators were found to be using incorrect tools and equipment for routine tasks, such as cleaning printer heads, increasing the risk of hands entering the hazard zone.
• Missing or Inadequate Guarding: Several essential machine guards were found to be missing or were improperly installed, exposing dangerous moving parts to the operator.

3. Strategic Intervention and Remediation

Faced with overwhelming evidence of negligence and the impending financial and legal implications from the HSE, Tim Hassall implemented a comprehensive, three-pronged strategy focused on governance, compliance, and culture.

Phase 1: Immediate Compliance and Training

1. IOSH Managing Safely (MS) Training: Immediate deployment of accredited IOSH Managing Safely training for all managerial and supervisory staff. This ensured the company’s decision-makers understood their legal and moral responsibilities concerning workplace health and safety.
2. Full, Contextualised Risk Assessments: All machine and process risk assessments were re-written from scratch, fully translated into English, and developed in collaboration with floor staff to accurately reflect actual operational practices.

Phase 2: Procedural and Engineering Control

1. Robust Safe Systems of Work (SSOW): New SSOW were developed for all high-risk tasks, explicitly addressing the root cause of the interlock circumvention. This included mandated lock-out/tag-out procedures (LOTO) and the use of approved, long-handled tools for cleaning and clearing.
2. Engineering Integrity: A zero-tolerance policy was enforced regarding machine guarding. All missing guards were replaced, and the illegally wired-out safety interlocks were immediately rectified and subjected to routine integrity checks.

Phase 3: Cultural Change and Engagement

1. Creating a Safe Culture: Shift the internal mindset from viewing safety as an administrative burden to a core business value. This involved open communication and empowering employees to report hazards without fear of reprisal.
2. Engaged Workforce: Introduce joint worker-management safety committees and departmental safety champions to foster ownership and peer-to-peer accountability.