Exami ner s Repor t

NEBOSH Nat i onal Di pl oma i n

Occupat i onal Heal t h and Saf et y

Januar y 2006 exami nat i ons













UNIT A

2006 NEBOSH, Dominus Way, Meridian Business Park, Leicester LE19 1QW
tel: 0116 263 4700 fax: 0116 282 4000 email: info@nebosh.org.uk website: www.nebosh.org.uk

The National Examination Board in Occupational Safety and Health is a registered charity, number 1010444

T(s):exrpts/D/D-0106 GP/RJ /PM/J S/RCC/REW



UNIT A Managing health and safety


General comments
This was the third Unit A examination paper of the re-formed NEBOSH Diploma and the questions set were
taken from the syllabus material published in the Diploma Guide. 358 papers were submitted for
examination.

To be successful in this part of the examination process, candidates need to be prepared to deliver and
apply a level of knowledge commensurate with the Diploma award. As always, there were some excellent
answers with maximum or near maximum marks being achieved on most questions by a small number of
candidates, but not necessarily the same candidates on each occasion. Where candidates achieved low
marks overall, this was generally for at least one of the following three reasons. Firstly, candidates were not
always armed with the degree of understanding and detail required at this level. This was particularly
evident in many of the answers provided to Questions 5 and 8 for example. Candidates setting out on a
course of study for the level 6 Diploma need to ask themselves whether they have provided for the
necessary preparation, revision and examination question practice that is important for maximising their
chances of success in the examination; this is a very different level of examination from the NEBOSH
National General Certificate. Secondly, many candidates achieved less than their possible potential through
focusing on only a limited range of issues on a question that had scope for a broader range to be tackled.
Questions 1 (a) provided numerous examples of this. Examination question practice, with feedback provided
by training providers, together with the use of answer plans (on Section B questions in particular) are
important elements in trying to maximise marks. Thirdly, candidates wasted much time and lost many
opportunities for marks by failing to read the question carefully, not relating their answers to the question
asked or the scenario set, and providing information that was not asked for or required. This was a particular
issue for scenario questions such as Questions 7(c) and 11.








Section A all questions compulsory

Question 1 The Management of Health and Safety at Work Regulations 1999 requires that
employers appoint a Health and Safety Assistant.

(a) List the key legal requirements that must be satisfied by the employer
when making such an appointment. (5)

(b) Outline the key elements of the strategic role of the health and safety
professional with respect to the employers current health and safety
management system. (5)


Examiners expected candidates to find this question simple to answer, as it is assumed that
candidates are aspiring to become practising health and safety professionals. A number of
candidates made reference to HASAWA even though the question clearly referred to The
Management of Health and Safety at Work Regulations 1999. The key to answering the
question well was knowledge of Regulation 7 of MHSWR. Most candidates identified
competence as a key requirement but then failed to go any further by identifying
appointment of one or more persons, arrangements for cooperation if 2 or more; numbers
and time available sufficient for size, risk and risk distribution; information on health and
safety issues provided to external appointees; preference for internal appointment;
information on temporary workers; or exemptions for partnerships where one partner is
sufficiently competent.




NEBOSH 2006 2 Unit A - J anuary 2006
The second part of the question was reasonably well answered, although candidates who
reproduced HSG(65) without relating it to the role of the health and safety professional did
not gain high marks. Candidates who read the question carefully and focused on the
strategic role gave good answers which included elements such as: formulating and
developing elements of the health and safety management system; developing and agreeing
plans for improvement including short and long-term targets; involvement in reactive
monitoring such as reporting and accident investigation; involvement in proactive monitoring
such as inspections and audits; developing/agreeing plans to improve safety culture;
organising and participating in review arrangements; developing/agreeing a suitable safety
policy statement; managing relationships with enforcing bodies; advising senior
managers/Board on strategic safety issues; and co-ordination and support issues of a health
and safety department.



Question 2 A risk management programme encompasses the following concepts:

(i) risk avoidance; (2)

(ii) risk reduction; (3)

(iii) risk transfer; (3)

(iv) risk retention. (2)

Identify the key features of each of these concepts and give an appropriate
example in each case.


Most candidates provided good answers to this question, although a number confused the
principles of risk avoidance and risk transfer. A number of candidates missed opportunities
for marks by failing to give examples.

Risk avoidance involves taking active steps to avoid or eliminate risk for example
discontinuing the process, avoiding the activity, eliminating a hazardous substance.

Risk reduction involves evaluating the risks and developing risk reduction strategies,
requires the organisation to define an acceptable level of risk control to be achieved; this
could be by the use of safety/risk management systems or use of a hierarchy of control.

Risk Transfer involves transferring risk to other parties but paying a premium for this; for
example by the use of insurance; transfer of risk by use of contractors to undertake certain
works; use of third parties for business interruption recovery planning or outsourcing the
process.

Risk retention involves accepting a level of risk within the organisation along with a decision
to fund losses internally; it could involve risk retention with knowledge where the risk has
been recognised and evaluated; or risk retention without knowledge where the risk has not
been identified (obviously an unfavourable position for the organisation to be in).



Question 3 (a) Outline the main defences available to a defendant in a civil case who is
being sued in an action for the tort of negligence. (6)

(b) Outline factors which will be considered in determining the level of
damages paid to a successful claimant. (4)


Most candidates answered this question well, although it should be noted that answers
which comprise of simple lists are not acceptable at this level. The main defences that could
have been covered are: that no duty was owed by the defendant to the claimant; that
although there was a duty there, it was not breached (to gain marks her, candidates are
expected to make reference to foreseeability and reasonableness); the damages may not be
as a result of the breach; the damage may be too remote; volenti non fit injuria; the type of
damage may not have been foreseeable; contributory negligence.
NEBOSH 2006 3 Unit A - J anuary 2006

Many factors are taken into consideration in determining the level of damages, the most
obvious being the degree of disability; the loss of earnings and/or opportunities; and the pain
and suffering. Other factors that could be considered are: medical costs and expenses; the
cost of special adaptations; the cost of care; loss of amenity; and contributory negligence
might result in a reduction of damages awarded.



Question 4 An advertising campaign was used to promote improvement in safety standards
within a particular organisation. During the period of the campaign the rate of
reported accidents significantly increased, and the campaign was deemed to be
a failure.

(a) Suggest, with reasons, why the rate of reported accidents may have been
a poor measure of the campaigns effectiveness. (2)

(b) Describe four proactive (active) measures which might have been used to
measure the organisations health and safety performance. (8)


The first part of the question was reasonably well answered with candidates correctly
identifying that a reason why the number of reported accidents had increased was because
they may have previously been under-reported. Unfortunately, some candidates stopped at
that point, which did not fulfil the requirement for an explanation. Marks were available for
explaining that raised awareness may have led to previously unreported accidents now
being reported, but that, in the absence of other data, it is almost impossible to tell whether
or not the increase is real. Better answers suggested why accidents may have been
previously under-reported.

Although some very good answers were given to part (b), candidates failing to achieve good
marks in this part of the question did not describe the methods of measuring in sufficient
detail. Many answers identified good methods of improving safety within an organisation
such as increased consultation, toolbox talks, risk assessment, training etc without
identifying the need to count the number done to use them as a year-on-year indicator.
These were means of improving safety, not measuring it. Proactive measures that could
have been considered include: safety audits; safety tours, workplace inspections; safety
sampling; safety surveys; environmental monitoring and health surveillance safety climate
measures; various types of behavioural safety measurements; benchmarking; or, as
discussed measuring of any health and safety performance against set targets.



Question 5 Human failure was identified as a significant factor in an accident involving a
crane. A contractors employee was seriously injured when struck by material
being transported by the crane.

Outline the types of human error which may have contributed to the accident.
Refer to relevant examples based on the scenario to illustrate your answer. (10)


Examiners expected candidates to outline skill based errors, mistakes, and violations.
These could have occurred in the given scenario.

Skill based errors could be: slips of action where a familiar task or action was carried out as
planned such as operating the wrong switch/controls; or lapse of memory where a step was
missed in the action sequence due to memory, for instance commencing the lifting operation
out of sequence when other workers were not prepared

Mistakes are errors of judgement which could be: rule based ie application of the wrong
rule, such as lifting instead of lowering, or crossing the path of the lifting operation; or
knowledge based such as: an unfamiliar situation, no rules, wrong conclusion formed for
instance the first time the crane driver had undertaken that particular lifting operation, wrong
height of lift, or it could involve the injured person being unaware that the lifting operation
was taking place.
NEBOSH 2006 4 Unit A - J anuary 2006

Although HSG 48 defines violations as human failings rather than human error, the
Examiners decided to accept violations in answer to this question. Violations involve rule
breaking, ie a deliberate failure to follow rules (eg not sounding siren when lifting operation
taking place, or intentionally walking close to lifting operation). Better responses went on to
cover the subdivisions of routine, situational, and exceptional violations with suitable
examples. Reference to model systems such as HSG 48 or Rassmussen gained marks.

Some candidates provided examples from well known situations such as flying a plane
rather than applying their understanding to the scenario as required by the question; others
described factors that may affect the likelihood of the error occurring again not required by
the question. This demonstrates that even at this level some candidates do not read the
questions carefully, wasting time on answers that cannot gain marks.



Question 6 Explain with reference to case law, the meaning of the terms practicable and
reasonably practicable as they apply to health and safety legislation. (10)


The ability to distinguish between the terms practicable and reasonably practicable is
fundamental to an understanding of health and safety law. Good answers were those that
were backed up with appropriate reference to case law and regulations that illustrated the
use of the terms. Candidates should bear in mind that the actual circumstances of a case
are normally less important than the basis of the decision (the ratio decidendi).

Most candidates were able to explain that though practicable was not an absolute duty, it
was of a higher standard than that of reasonably practicable This means that there must be
compliance with the duty as far as technical and practical feasibility allows, with no reference
to cost. Reasonably practicable requirements as those where a balance is made between
risk and cost (in terms of money, time and trouble) and which are met when the cost of
further control is grossly disproportionate to any reduction in risk. Reference was made to
cases such as Adsett v. K&L Steelfounders and Engineers Ltd (1953), Marshall v Gotham
[1954] and Edwards v National Coal Board [1949] in order to demonstrate the principles
involved.








Section B three from five questions to be attempted

Question 7 A forklift truck is used to move palletised goods in a large distribution
warehouse. On one particular occasion the truck skidded on a patch of oil. As a
consequence the truck collided with an unaccompanied visitor and crushed the
visitors leg.

(a) State, with reasons, why the accident should be investigated. (4)

(b) Outline the actions which should be followed in order to collect evidence
for an investigation of the accident. Assume that the initial responses of
reporting and securing the scene of the accident have been carried out. (8)

(c) Describe factors which should be considered in analysis of the
information gathered in the evidence collection. (8)


This question was a popular choice with candidates, not unexpectedly considering most
Health and Safety Practitioners are involved in accident investigation at some time in their
careers.




NEBOSH 2006 5 Unit A - J anuary 2006
Although some candidates wanted to use the exercise as an opportunity to apportion blame
they should note that the apportionment of blame for the sake of it can damage the
organisations safety culture. They should also note that there are many other reasons for
investigating accidents and most candidates were able to identify reasons such as to identify
its causes (immediate and underlying), to prevent a recurrence, to assess compliance with
legal requirements, to demonstrate managements commitment to health and safety and to
obtain information and evidence for use in the event of any subsequent civil claim. Few,
however, mentioned that the investigation could provide useful information for the costing of
accidents and in identifying trends.

Part (b) was generally well answered with responses set out in a realistic chronological
order: starting with taking photographs, sketches and measuring relevant parts of the
accident scene before anything is disturbed, obtaining any CCTV footage available; then
moving on to examining the condition of the fork lift truck; determining its speed at the time
of the accident; the loads carried, the safe working load of the truck and any forward visibility
issues with the load in place; the reasons for the oil spillage; emergency spillage procedures
in place and the reasons why they were not followed on this occasion; the failure to follow
laid down operating procedures; the competence of the fork lift truck driver and examining
the workplace to determine any contributing environmental factors such as the condition of
the floor and the standard of lighting; interviewing relevant persons such as the visitor
(where this is possible), the reception personnel (to identify working practices against any
written visitor procedures).

Part (c) was not so well answered. It is not sufficient to merely collect data and put it into a
report, it must be analysed and examined objectively before inclusion in an official accident
report (which may be used in a subsequent legal action). Good answers considered: job
factors such as the attention needed for task, any distractions that may have contributed to
the accident, whether any procedures were inadequate and the time available to carry out
the job; human factors such as competence of the driver and whether there was any
evidence of fatigue and/or stress; organisation factors such as work pressure, availability of
sufficient resources, quality of supervision and the general health and safety culture within
the warehouse; and finally whether plant and equipment factors such as the forklift truck
controls or layout of workplace or signage (too much, too little) could have contributed to the
accident. Credit was also given for describing factors which related to the reliability and
quality of evidence.

A number of candidates assumed that the visitor was unauthorised, which was not stated in
the question and spent time focusing on duties to trespassers.



Question 8 A fast-growing manufacturing company now employs 150 people. Health and
safety standards at the company are not good, as arrangements have
developed without professional advice in an unplanned way during the time of
rapid growth. The company has, though, managed to avoid any serious
accidents and, in the main, staff at all levels do not seem particularly concerned.

Two employees, however, have recently experienced two separate near-miss
incidents and have complained jointly to the Health and Safety Executive. A
subsequent visit by an HSE inspector has resulted in the issue of three
improvement notices. The Managing Director wishes to dismiss the employees
(whom he has described as troublemakers) even though he accepts that their
concerns were probably justified.

(a) State the advice you would give the Managing Director with respect to the
proposed disciplinary action to the employees who have complained and
give supporting reasons. (5)

(b) Outline the steps that should be taken to gain the support of the
workforce to improve the health and safety culture within the company. (15)


This was a popular question that required application of employment law knowledge and a
strategy for changing the perception, involvement and ownership of employees on matters of
health and safety in their workplace.
NEBOSH 2006 6 Unit A - J anuary 2006

The first part of the question produced a few good answers but many answers were unclear
and incorrect. About half of the candidates recognised that this was a protected disclosure
under the Public Interest Disclosure Act 1998 (see Element A7 of the Diploma Guide)
though unfortunately, many of them could not name the Act or explain the real nature of the
protection, despite many recognising that an action at an Employment Tribunal may result.
Some candidates had the mistaken belief that employees were protected from dismissal
simply by complying with Section 7 of the HSW Act 1974. A number recognised the
negative cultural implications of disciplining the two employees and the need to recognise
the root causes of employee concerns.

Part (b) required candidates to identify the components of a strategy to improve employee
support for and perception of health and safety issues within the workplace. Many
candidates performed reasonably well on this part although as is often the case, a significant
minority felt that reciting the key elements of HSG 65 was the solution to all problems.
Better answers began by recognising the value of using tools to help them understand
current employee perceptions such as informal discussions and safety climate
questionnaires. Methods of demonstrating the commitment of the business to good safety
management such as the development of a new policy and arrangements for health and
safety; the introduction of new consultative arrangements and training programmes and the
behaviour and communication techniques, targets, reporting, resourcing and priorities
relating to health and safety issues adopted by senior and line managers were all
reasonable issues to explore. Steps to increase employee participation were also important
and could have included involvement in risk assessments, the development of safe systems
of work, inspections, incident investigation and team briefing sessions.



Question 9 (a) Outline the use and limitations of fault tree analysis. (4)

(b) A machine operator is required to reach between the tools of a vertical
hydraulic press between each cycle of the press. Under fault conditions,
the operator is at risk from a crushing injury due either (a) to the press
tool falling by gravity or (b) to an unplanned (powered) stroke of the
press. The expected frequencies of the failures that would lead to either
of these effects are given in the table below:

Failure type Frequency (per year) Effect
Flexible hose failure 0.2 a
Detachment of press
tool
0.1 a
Electrical fault 0.1 b
Hydraulic valve failure 0.05 a or b

(i) Given that the operator is at risk for 20 per cent of the time that the
machine is operating, construct and quantify a simple fault tree to
show the expected frequency of the top event (a crushing injury to
the operators hand). (10)

(ii) If the press is one of ten such presses in a machine shop, state,
with reasons, whether or not the level of risk calculated should be
tolerated. (4)

(iii) Assuming that the nature of the task cannot be changed, explain
how the fault tree might be used to prioritise remedial actions. (2)


This question was designed to test candidates understanding and application of fault tree
analysis. It was not a popular question but was generally well answered by those who did
attempt it. Candidates recognised that fault tree analysis is useful in analysing accidents
where there are multiple causes to an accident to calculate the probability of the top event; it
can be used to identify the most effective points of intervention in order to reduce the
probability of the top event occurring. On the negative side it is limited by the requirement of
skilled analysts to work the calculations out in complex situations and its reliance on the
accuracy and availability of failure data.
NEBOSH 2006 7 Unit A - J anuary 2006
(b) (i) Fault tree


&
CRUSHING
INJURY
Operator
exposed
Tool comes down as
result of failure
Powered
stroke
Gravity
fall
P = 0.2
f = 0.2 x 0.5 = 0.1/yr
or 1 in 10 years
f = 0.15 + 0.35
= 0.5/yr
f = 0.05 + 0.2 + 0.1
= 0.35/yr
f = 0.05 + 0.1
= 0.15/yr
f = 0.05 /yr f = 0.1 /yr f = 0.05 /yr f = 0.2 /yr f = 0.1 /yr
Valve
failure
Valve
failure
Hose
failure
Detach-
ment of
tool
Elect-
rical
fault


Part (b)(i) required the construction of a fault tree and its quantification using the data
presented. A significant number of candidates constructed an event tree rather than a fault
tree and so gained no marks. Many of the remainder who attempted the construction made
a reasonable attempt at a fault tree consisting of four levels: crushing injury at the top;
operator exposure and tool descent at the second level; type of tool descent (powered
stroke or gravity fall) at the third; and component failures at the bottom. Those who
achieved a reasonable construction also tended to achieve good marks for quantification.

Part (ii) was seeking not just an opinion but some commentary on, or justification for, the
opinion in terms of the frequency of unexpected tool descent or operator injury. Those
candidates who did not give reasons for their opinions could not expect to gain high marks.
Some reference was therefore needed to the likely disabling nature of the injury and to such
an event occurring once in about ten years (which was the estimated frequency). Better
candidates offered a risk level that might be considered to be more acceptable, with some
suggesting that if several of these presses were operating (perhaps within the same factory),
then a serious injury could be a regular occurrence.

Part (iii) needed candidates to explain the general principles of using the probability data in
the fault tree so that priority is given to those actions that would give the greatest reduction
in the probability of the undesired events. For instance, gravity fall was highlighted as the
most likely event, therefore priority should be given to actions that would prevent this.





























NEBOSH 2006 8 Unit A - J anuary 2006

Question 10 Atom Chemicals Ltd engaged the services of an industrial cleaning company,
Becom Cleaners Ltd, to clean their chemical processing vessel using Atom
Chemicals own electrical cleaning equipment. The production supervisor of
Atom Chemicals issued a permit-to-work for Becom Cleaners to undertake the
work. The vessel cleaning operation involved the use of flammable solvents
and the Becom Cleaners employee was badly burned whilst using the electrical
equipment.

Identify and explain the possible breaches of the Health and Safety at Work etc
Act 1974 and the Management of Health and Safety at Work Regulations 1999
by:

(a) Atom Chemicals. (8)

(b) Becom Cleaners. (6)

(c) Individuals. (2)

Make reference to relevant case law and explain the relevance in this case. (4)


This was not a popular question even though it concerned two significant pieces of health
and safety legislation. Candidates who did well on this question identified the following
possible breaches of HSWA by Atom Chemicals: s3(1) regarding undertaking and so far as
is reasonably practicable; s4 as occupier and controller of non-domestic premises, regarding
provision of plant s2 in relation to the risk to its own employees, s2(1), s2(2)(c); Under
MHSWR Reg 3 risk assessment; Reg 5 effective safety management arrangements; Reg 11
cooperation and coordination; Reg 12 instructions / information for workers in host
employers undertakings.

Possible breaches by Becom Cleaners were under HSWA s2(1) and s2(2) (a)-(e) duties to
employees; HSWA s3(1) putting Atom Chemicals employees at risk; Under MHSWR Reg 3
risk assessment; Reg 5 effective safety management arrangements; Reg 11 cooperation
and coordination; Reg 10 Information to employees on hazards/controls; Reg 13
competence and training of employees.

Possible breaches by individuals in consideration of the duties of employees under HSWA
s7 and MHSW Reg 14; with consideration of the permit issuer: HSWA s7, MHSW Reg 14
and HSWA s36.

Relevant case law correctly included by candidates was: R v Associated Octel Co Ltd (1996)
4 All ER 846; R v Swan Hunter Shipbuilders Ltd and Another (1982) 1 All ER 264.

Answers which included breaches under COSHH, DSEAR and PUWER did not attract
marks as the question specifically asked for possible breaches under the Health and Safety
at Work etc Act 1974 and the Management of Health and Safety at Work Regulations 1999.



Question 11 A new chemical plant which falls within the scope of the Control of Major
Accidents and Hazards (COMAH) Regulations 1999 is being planned. The
manufacturing process will involve toxic and flammable substances. The plant
is near to a residential area.

Identify the issues to be considered in the development of an emergency plan to
minimize the consequences of any major incident. (20)


This was a reasonably popular question with many candidates giving answers which
identified a sufficient number of relevant points related to the emergency plan. Some poor
answers discussed producing a MAPP and describing measures to control and manage the
risk rather than the emergency measures to mitigate the consequences of an emergency.

NEBOSH 2006 9 Unit A - J anuary 2006

Good answers recognised the role of key individuals in the planning stage with effective
communication and practising of the plan. Issues that candidates successfully identified
were: to consider the quantities involved; to provide information to local authority as part of
the planning requirements; possible causes of a major incident; estimating the likely extent
of damage; staff and equipment call-out arrangements; resources needed to deal with
incident; how the alarm will be raised both on-site and in the neighbourhood; evacuation or
shelter arrangements on and off-site; training of staff in emergency plan; action to minimize
extent such as shutting off services; search and rescue arrangements; notification of
emergency services; co-ordination with emergency services; control and management on
site including clear allocation of responsibilities for emergencies during all shifts and out of
working hours; communication with community; emergency plan testing arrangements;
control of spillage/pollution; toxicity/flammability and any possible additive effects; clean
up/decontamination; dealing with the media; consultation with emergency services / third
parties / stakeholders; establishing control centres; and ensuring the availability of
information / site plans / inventory etc.
NEBOSH 2006 10 Unit A - J anuary 2006