January 2011

Examiners Report

NEBOSH National
Diploma in
Occupational Health
and Safety - Unit A
2011 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-A 1101 EXTERNAL DW/DA/REW

Examiners Report

NEBOSH NATIONAL DIPLOMA IN
OCCUPATIONAL HEALTH AND SAFETY


Unit A: Managing health and safety


JANUARY 2011




CONTENTS



Introduction 2



General comments 3



Comments on individual questions 4



2 EXTERNAL
Introduction





NEBOSH (The National Examination Board in Occupational Safety and Health) was formed in 1979 as
an independent examining board and awarding body with charitable status. We offer a comprehensive
range of globally-recognised, vocationally-related qualifications designed to meet the health, safety,
environmental and risk management needs of all places of work in both the private and public sectors.
Courses leading to NEBOSH qualifications attract over 25,000 candidates annually and are offered by
over 400 course providers in 65 countries around the world. Our qualifications are recognised by the
relevant professional membership bodies including the Institution of Occupational Safety and Health
(IOSH) and the International Institute of Risk and Safety Management (IIRSM).

NEBOSH is an awarding body to be recognised and regulated by the UK regulatory authorities:

The Office of the Qualifications and Examinations Regulator (Ofqual) in England
The Department for Children, Education, Lifelong Learning and Skills (DCELLS) in Wales
The Council for the Curriculum, Examinations and Assessment (CCEA) in Northern Ireland
The Scottish Qualifications Authority (SQA) in Scotland

NEBOSH follows the GCSE, GCE, VCE, GNVQ and AEA Code of Practice 2007/8 published by the
regulatory authorities in relation to examination setting and marking (available at the Ofqual website
www.ofqual.gov.uk). While not obliged to adhere to this code, NEBOSH regards it as best practice to
do so.

Candidates scripts are marked by a team of Examiners appointed by NEBOSH on the basis of their
qualifications and experience. The standard of the qualification is determined by NEBOSH, which is
overseen by the NEBOSH Council comprising nominees from, amongst others, the Health and Safety
Executive (HSE), the Confederation of British Industry (CBI), the Trades Union Congress (TUC) and
the Institution of Occupational Safety and Health (IOSH). Representatives of course providers, from
both the public and private sectors, are elected to the NEBOSH Council.

This report on the Examination provides information on the performance of candidates which it is
hoped will be useful to candidates and tutors in preparation for future examinations. It is intended to
be constructive and informative and to promote better understanding of the syllabus content and the
application of assessment criteria.

NEBOSH 2011


Any enquiries about this report publication should be addressed to:

NEBOSH
Dominus Way
Meridian Business Park
Leicester
LE10 1QW

Tel: 0116 263 4700
Fax: 0116 282 4000
Email: info@nebosh.org.uk
3 EXTERNAL
General comments





Many candidates are well prepared for this unit assessment and provide comprehensive and relevant
answers in response to the demands of the question paper. This includes the ability to demonstrate
understanding of knowledge by applying it to workplace situations.

There are always some candidates, however, who appear to be unprepared for the unit assessment
and who show both a lack of knowledge of the syllabus content and a lack of understanding of how
key concepts should be applied to workplace situations.

In order to meet the pass standard for this assessment, acquisition of knowledge and understanding
across the syllabus are prerequisites. However, candidates need to demonstrate their knowledge and
understanding in answering the questions set. Referral of candidates in this unit is invariably because
they are unable to write a full, well-informed answer to the question asked.

Some candidates find it difficult to relate their learning to the questions and as a result offer responses
reliant on recalled knowledge and conjecture and fail to demonstrate any degree of understanding.
Candidates should prepare themselves for this vocational examination by ensuring their
understanding, not rote-learning pre-prepared answers.


Common pitfalls

It is recognised that many candidates are well prepared for their assessments. However, recurrent
issues, as outlined below, continue to prevent some candidates reaching their full potential in the
assessment.

Many candidates fail to apply the basic principles of examination technique and for some
candidates this means the difference between a pass and a referral.

In some instances, candidates are failing because they do not attempt all the required
questions or are failing to provide complete answers. Candidates are advised to always
attempt an answer to a compulsory question, even when the mind goes blank. Applying basic
health and safety management principles can generate credit worthy points.

Some candidates fail to answer the question set and instead provide information that may be
relevant to the topic but is irrelevant to the question and cannot therefore be awarded marks.

Many candidates fail to apply the command words (also known as action verbs, eg describe,
outline, etc). Command words are the instructions that guide the candidate on the depth of
answer required. If, for instance, a question asks the candidate to describe something, then
few marks will be awarded to an answer that is an outline.

Some candidates fail to separate their answers into the different sub-sections of the questions.
These candidates could gain marks for the different sections if they clearly indicated which
part of the question they were answering (by using the numbering from the question in their
answer, for example). Structuring their answers to address the different parts of the question
can also help in logically drawing out the points to be made in response.

Candidates need to plan their time effectively. Some candidates fail to make good use of their
time and give excessive detail in some answers leaving insufficient time to address all of the
questions.

Candidates should also be aware that Examiners cannot award marks if handwriting is
illegible.
4 EXTERNAL
UNIT A Managing health and safety












Question 1 A large public limited company (plc) has recently experienced a fire and
explosion resulting in multiple fatalities and extensive environmental
damage.

(a) Outline a range of consequences that may affect the company
as a result of this incident. (5)

(b) As a result of the incident, shareholders in the company have
raised concerns about the risk management arrangements that
are in place and have called into question the Boards annual
statement that was provided as part of compliance with the
Turnbull/Financial Reporting Council guidelines on internal
control.

Explain the purpose of these guidelines and why they are
relevant to this type of incident. (5)


An obvious consequence of the incident described in the scenario would have been
the possibility of criminal prosecution by the relevant enforcing authority and the
initiation of civil actions for damages. There is a possibility that regulators would
subsequently have less trust in the organisation whilst licences could be lost or issued
with more stringent requirements. Candidates should then have referred to the costs,
both direct and indirect that would arise. Whilst certain costs would be covered by
insurance, there might in future be difficulty in obtaining similar insurance provision
and if this were possible, it would undoubtedly result in the payment of a much higher
premium. Costs involved in cleaning up after the accident would normally not be met
in an insurance claim and would fall directly to the company to finance. Further
consequences which might ultimately and indirectly prove costly include the effect on
the morale of the workforce with consequent difficulty in recruiting new staff; a failure
to supply a promised output; the loss of confidence among shareholders and investors;
and the loss of reputation amongst the companies clients and in its immediate
community. On the whole, this part of the question attracted answers to a reasonable
standard though some candidates concentrated solely on possible enforcement
actions to the exclusion of the other consequences that might affect the company.

In answer to part (b), candidates were expected to explain that the purpose of the
Turnbull/Financial Reporting Council guidelines on internal control is to ensure that
good risk management practice is in place in order to safeguard the organisations
assets and shareholders investments, to minimise losses and improve profitability and
to assist in compliance with legal obligations. Their relevance to the scenario
described in the question is that many of the risks they are designed to manage are
realised in such an incident such as those relating typically to health, safety and the
environment, business continuity, financial stability and customer relations and
following the guidelines should reduce considerably the probability of such an incident
occurring. There were but a few candidates who seemed to understand the guidelines
that emanated from the Turnbull report and of those that did, many were unable to
explain their relevance to the scenario described in the question.



Section A all questions compulsory
5 EXTERNAL

Question 2 Explain the domino and multi-causality theories of accident causation,
including their respective uses and possible limitations in accident
investigation and prevention. (10)


In explaining the domino theory of accident causation, candidates were expected to
include Heinrichs five step model and then to explain the development of that model
by Bird and Loftus where additionally management deficiencies are addressed. The
domino model may assist in the structuring of accident investigations, but, despite the
additional work carried out by Bird and Loftus, it does tend to be simplistic dealing with
a single chain of events that may restrict the search for multiple accident causes.
Additionally it is reactive rather than proactive and is therefore not useful in predicting
the likelihood of accidents whilst the Heinrich version in particular, encourages a focus
on immediate rather than underlying causes.

The key features of the theory of multi-causality include the recognition that accidents
have multiple causes and that these causes combine and react with each other in a
complex and random fashion. Additionally each contributory cause may have multiple
causes of its own. The value of the model in accident investigation and prevention is
that it encourages and emphasises the need for more in depth investigation to search
for multiple underlying failures and enables the likelihood of accidents to be predicted.
It also encourages the use of more systematic accident analysis techniques such as
fault tree and event tree analysis. However, it tends to be a complex process, is more
difficult to understand, requires more time and resources to identify the full causation
picture and there are practical difficulties in reaching a decision on the extent of an
investigation.

In general candidates seemed to be more familiar with the domino rather than the
multi-causality theory. If there was a weakness in the answers provided, it was a
failure on the part of some candidates to explain the uses and possible limitations of
the theories in accident investigation and prevention.



Question 3 A twin-engine aircraft crashed following the partial failure of one of its
engines. Although the aircraft could have landed safely on the one good
engine the pilot mistakenly shut down the good engine instead of the
failed engine. The aircraft was equipped with a new electronic instrument
display in which the traditional analogue gauges with mechanical pointers
had been replaced by less clear electronic readouts. Vibration levels for
each engine were displayed on two separate gauges in the instrument
cluster and investigation suggested that the pilot may have confused
which of the gauges related to which engine.

Outline design features of the aircraft display system which could help to
avoid similar or other errors in reading the instrumentation. (10)


Design features of the aircraft display system which could help to avoid confusion
resulting in errors in reading the instrumentation would initially involve separating the
instrumentation for each engine and locating them on the logical side in the instrument
cluster. The most important displays should be positioned more centrally and care
taken to ensure that they could easily be read from the pilot position while computer
displays should be designed to have the same clarity as traditional gauges.





6 EXTERNAL
Other design features would include the use of analogue gauges or electronic displays
to indicate change and the use of digital gauges to show precise values; marking
danger zones on analogue gauges using an appropriate colour; arranging for
analogue or electronic pointers to be in a similar position for normal circumstances;
providing audible or flashing warnings for safety critical conditions; minimising the
number of gauges and displays and ensuring that those provided are clearly labelled;
the provision of lighting for gauges and displays ensuring that the standard provided is
adequate to meet different cockpit conditions and that it avoids reflection and glare
from the instruments and finally and importantly ensuring the consistency of design
across aircraft.

There was a tendency amongst candidates not to answer the question that had been
set, with some referring to the design of the cockpit and the aircraft controls rather
than the instrument display system. Others discussed issues such as training and the
use of flight simulators which were not display design issues. Some recognised the
incident as the Kegworth air crash and dealt with wider issues relating to the incident
rather than answering the question as written.



Question 4 (a) Give the meaning of the term safety culture. (2)

(b) Outline a range of organisational issues that may act as barriers
to the improvement of the safety culture of an organisation. (8)


For part (a), an acceptable meaning of the term safety culture would have been the
shared attitudes, perceptions, beliefs, behaviour patterns and values that members of
an organisation have in the area of safety.

In answering part (b), candidates were expected to outline organisational issues that
could act as barriers to the improvement of the safety culture of an organisation such
as, for example, the lack of management commitment resulting in a lack of trust and
confidence in the management team by the employees; a failure to allocate adequate
resources to support improvement; the absence of effective means of communication
with employees to secure their involvement and ownership of safety issues; high staff
turnover making cultural improvement difficult to embed; a history of poor employment
relations; the existence of a blame culture and the lack of positive decision making by
management on the level of priority accorded to safety leading to uncertainty among
the workforce; the existence of a dominant pre-existing negative culture and the
effects of unsupportive peer pressure and workforce cultural issues such as language
barriers.

There were some good answers provided for both parts of this question, though some
candidates, who did not read it with sufficient care, discussed ways in which the
culture might be improved rather than the barriers that might prevent its improvement.
Others failed to gain maximum marks because they provided lists in answer to part (b)
rather than the required outline.











7 EXTERNAL


Question 5 (a) Describe the statutory procedures for making regulations under
the Health and Safety at Work etc Act 1974. (6)

(b) Outline the purpose and principles of cost-benefit analysis as it
applies to proposed regulations. (4)


Part (a) of the question required candidates to be familiar with section 15 of HASAW
where power to make Regulations is given to the Secretary of State with the proviso
that the subject matter of the Regulations should fall within those matters contained in
Schedule 3 to the Act. The procedure involves consultation by the Secretary of State
with HSE (though HSE may make a proposal to the Secretary) and with relevant
Government and other bodies. The proposals must lie before both Houses of
Parliament for 40 days and are passed if they are not voted against in either House. If
there is a vote against them, they are annulled. This is a fundamental aspect of health
and safety legislation, but a number of candidates had little knowledge of the relevant
statutory procedures, with some becoming confused between the procedures for
making Acts and Regulations and writing at length about green and white papers and
the various readings that would be necessary. A few candidates continue to refer to
the HSC as opposed to the HSE.

In answer to part (b), a good answer, and there were few of these, would have outline
that the purpose of cost-benefit analysis is to identify the overall value to society of
proposed Regulations by comparing the benefits which would arise with the costs of
implementing the Regulations. In carrying out the exercise, the costs and benefits are
both converted to a monetary value following established protocols for the costing of
benefits in terms of the prevention of death, damage injury and ill-health. Costs are
adjusted to allow for the different timescales over which costs and benefits may occur
or accrue and implementation costs are estimated. Finally the calculated monetary
values of costs and benefits are compared. Many candidates were unable to progress
beyond a general suggestion that the costs of implementing regulations could be
balanced against the benefits which would accrue to society. This was not enough to
gain the four marks available.



Question 6 Your company employs 900 people at a warehousing and distribution
site. Your site manager has asked for a set of summary information to be
provided each month for its executive meetings in order to monitor the
overall health and safety performance of the site.

Outline the possible contents of that set of information. (10)


This question required candidates to outline the contents of summary information to
be provided on a monthly basis for meetings of the company executive.. Both whole
site and departmental data would have been relevant. The contents might best have
been outlined under the general headings of reactive and proactive information.
Reactive information would deal with matters such as the number of lost time
accidents and near miss incidents with detail provided only on those that were serious
or potentially so; the current frequency or incident rates; the observed trends and
patterns; the level of ill-health and sickness absence; and other relevant reactive
information such as enforcement or civil actions taken and complaints received either
from the workforce or from clients and the community.





8 EXTERNAL
As for the proactive measures being taken by the company, the executive would need
to be given summary data on the monitoring exercises being carried out such as
audits, inspections and behavioural observations; information on any relevant
performance measures such as the number of risk assessments completed or
reviewed; progress made in reaching site or departmental safety targets; a summary
of the results of health surveillance and/or atmospheric sampling exercises and
benchmarking data to enable a comparison to be made with the performance of other
similar organisations.

Most answers to this question were to an acceptable standard but those candidates
who did not do so well had often ignored the fact that this was summary information
for senior executives and suggested contents which were far too detailed for the
purpose.







Question 7 A chemical reaction vessel is partially filled with a mixture of highly
flammable liquids. It is possible that the vessel headspace may contain a
concentration of vapour which, in the presence of sufficient oxygen, is
capable of being ignited. A powder is then automatically fed into this
vessel.

Adding the powder may sometimes cause an electrostatic spark to occur
with enough energy to ignite any flammable vapour. There is therefore
concern that there may be an ignition during addition of the powder.

To reduce the risk of ignition, an inert gas blanket system is used within
the vessel headspace designed to keep oxygen below levels required to
support combustion. In addition, a sensor system is used to monitor
vessel oxygen levels. Either system may fail. If the inert gas blanketing
system and the oxygen sensor fail simultaneously, oxygen levels can be
high enough to support combustion.

Probability and frequency data for this system are given below.

Failure type/event Probability
Vessel headspace contains concentration of vapour
capable of being ignited
0.5
Addition of powder produces spark with enough
energy to ignite vapour
0.8
Inert gas blanketing system fails 0.2 per year
Oxygen system sensor fails 0.1

(a) Draw a simple fault tree AND using the above data calculate the
frequency of an ignition. (16)

(b) Outline TWO plant or process modifications that you would
recommend to reduce the risk of an ignition in the vessel
headspace. (4)


In answering part (a) of the question, Examiners were expecting candidates to supply
a simple fault tree similar to that shown below and to calculate that the frequency of
ignition would be 0.008/yr or once in every 125 years.




Section B three from five questions to be attempted
9 EXTERNAL
While this was not a popular question, those candidates who had a good
understanding of the construction of a fault tree did well though there were a few
answers where gates were missing and calculations poor and incorrect whilst others
contained an event rather than a fault tree.


In answering part (b), candidates could have included an outline of any relevant
modifications that would reduce the risk of ignition in the vessel headspace. These
could have included replacing the powder feed with a slurry in a conducting liquid;
selecting and using materials with higher flashpoints to minimise the probability of a
flammable atmosphere; and redesigning the inert gas blanketing system to improve
reliability.



Question 8 A small company formulating a range of chemical products operates from
a site on which it employs about 50 staff. Although not falling within the
scope of the Control of Major Accident Hazards Regulations 1999, the
site poses a risk to employees, the neighbouring community and the
environment.

(a) Outline the types of emergency procedure that a site of this
nature may need to put in place in order to deal with incidents
affecting the safety of site personnel. (5)

(b) Identify the factors that should be considered during the
development of a major incident procedure AND outline the
arrangements that should be in place to ensure that such a
procedure is effective. (15)


The intention of part (a) of the question was to require candidates to address the types
of emergency the site might experience and the procedures that should be in place.
These would include, for example, procedures for dealing with chemical spillage and
/or release, fire evacuation and first aid treatment. Credit was also given for other
credible procedures such as those required for sabotage or bomb threats.


Ignition 0.008/yr
(once every 125 years)
&
Flammable vapours
0.5
Spark
0.8
Oxygen >limit
0.02
&
Blanketing
system fail
0.2/yr
O2 sensor
system fail
0.1
10 EXTERNAL
For part (b), better answers focussed first on the development of a plan and then on
the arrangements that should be in place to secure its effective implementation.
Factors that would need to be considered during the development of a major incident
procedure would be the level of the risk involved taking into account the nature of the
chemicals, the potential rates of release, the people affected and the environmental
issues involved; the existence of relevant guidance and standards and the availability
of internal and external emergency resources. Arrangements that could have been
identified include consultation with staff and external stakeholders such as emergency
services, local authorities and utilities on the development of the plan; the provision of
a control centre containing key information such as site plans, drainage plans and
chemical inventories together with communication facilities; the allocation of clear
responsibilities to individuals as part of the plan including arrangements for initiating
the procedure and for the call-out of key staff and support services; the provision of
equipment for communication between control parties in the event of an incident; the
provision of emergency equipment and personal protective equipment such as that
needed for spill containment, vapour suppression and fire control; consideration of the
information to be given to off-site residents and neighbours and arrangements for
liaison and communication with them; business continuity issues and press
management arrangements; and the provision of comprehensive training for site
personnel particularly those with key responsibilities with arrangements for periodic
practice and review of the laid down procedures.

This question was popular and generally well answered though some candidates
wrote in part (a) of the arrangements that should be made rather than outlining the
types of emergency procedure that should be in place whilst for part (b) others
described how an incident might be dealt with rather than the arrangements for
ensuring that the procedure introduced was effective.



Question 9 A manager in a manufacturing business calls out an engineer from their
equipment supplier to repair and reset a piece of production equipment.
After the repair there are difficulties in resetting the equipment. To help
resolve this, the manager removes a fixed guard from the equipment to
allow easier visibility and quicker adjustment. The engineer employed by
the equipment supplier is subsequently injured on a piece of moving
machinery that should have been protected by the guard.

(a) Outline possible breaches of the Health and Safety at Work etc
Act 1974. Your answer should include the company or individuals
who may have committed the breaches, the specific legal
requirements (including Section numbers) that have been
breached AND, in EACH case, reasons for the possible breach. (16)

(b) The manufacturing business is subsequently prosecuted under
Section 3 of the Health and Safety at Work etc Act and it
attempts to defend itself by blaming the acts of the manager
about which it knew nothing.

Explain, with legal reasons, whether this defence could be
successful. Make reference to case law where appropriate. (4)


A logical approach to answering part (a) of the question would have been to consider
the various sections of the Health and Safety at Work etc Act in turn and to decide
both whether they had been breached and by whom. There was, for example, a
breach by the manufacturing business of their general duty to their employees under
Section 2(1) in that they failed to ensure the safety of their employees by removing the
guard.

11 EXTERNAL
Additionally they could be said to be in breach of Section 2 (2)(a) since they failed to
provide safe plant and equipment to their employees. Similar duties lay also with the
equipment suppliers whose employee was injured whilst working on unguarded
machinery. The manufacturing business was also in breach of Sections 3 and 4 since,
by removing a guard, they did not conduct their undertaking in such a way as to
prevent non-employees from being exposed to risk and had control of premises in
which they provided unsafe equipment. It could be argued that the suppliers engineer
was in breach of Section 7 since he failed to take reasonable care for his own safety
by working on equipment with the guard removed whilst the manager of the
manufacturing business did not comply with his duty under Section 7 or 8 by removing
the guard and so interfering with something provided in the interests of safety.
Consideration would also have to be given to a possible breach of Section 36 by the
manager since, though the engineer worked on unguarded machinery, this was in fact
as a result of the managers deliberate action in removing the guard. Many candidates
failed to differentiate between the parties involved, often confusing the duties of the
manufacturer with those of the supplier and failing to identify what was breached, by
who and in what way..

In answering part (b), candidates were expected to refer to the decision in R v British
Steel PLC 1995 and that in R v Nelson Group Services (Maintenance) Ltd 1998 where
in the former the defence was not allowed on the grounds that it was based on the fact
that its senior management was not involved while in the latter, it was allowed on the
grounds that the employer had done all that was reasonably practicable. More
complete answers would also have referred to Regulation 21 of the MHSWR
regarding the provisions as to where the defence would not be allowed. Few
candidates seemed to understand what was required in answer to this part of the
question and there was little reference made to the relevant case law.



Question 10 An employee suffered a fractured skull when he fell three metres from
storage racking as he was loading cartons onto a pallet held on the forks
of a lift truck. A subsequent investigation found that the managers of the
company were aware that it was common practice for employees to be
lifted up on the forks of the vehicle and for them to climb up the outside of
the racking.

(a) Outline the legal actions that might be available to the injured
person in a claim for compensation AND the tests that would
have to be made for the actions to succeed. (14)

(b) Explain the meaning of general and special damages that may
be awarded in the event of a successful claim AND give
examples of the factors that are considered in calculating their
value. (6)


Part (a) of the question required candidates to outline how the torts of negligence and
breach of statutory duty could apply to the given scenario. They should have outlined
that, in order to succeed in an action for negligence, the claimant would need to
prove that a duty of care was owed to him, that this duty was breached, that his
injuries occurred as a result of the breach and that the type of injury was reasonably
foreseeable. Inclusion of these stages as they applied to the scenario was required
for instance, that the employer had not done everything that could reasonably be
expected to prevent a foreseeable accident in that a safe system of work had not
been provided. Marks were also available for reference to relevant case law such as
Wilsons & Clyde Coal v English (1938).




12 EXTERNAL
The claimant would also be able to pursue an action for a breach of statutory duty.
For this claim to succeed he would need to prove that he was within the class of
persons the statute was designed to protect (he was an employee acting in the
course of his employment); that his injury was of the type that the requirements of the
statute were intended to prevent; that a duty was placed on the defendant which he
had failed to meet and that the injury sustained was a direct result of this failure.
Additionally, he would have to counter any argument that the legislation involved did
not allow for civil action to be taken. Candidates needed to refer to the specific
statutes that had been breached and could give rise to the action namely the Work at
Height Regulations, MHSWR and PUWER. Marks were available for those
candidates who included references to relevant case law such as Corn v Weirs Glass
(Hanley) Ltd (1960). A few candidates were unable to differentiate between
negligence and breach of statutory duty whilst others made no reference to relevant
case law.

In answer to part (b), candidates should have explained that general damages, where
no exact sum is calculable, are based on estimated financial costs, such as loss of
future income in cases where there is partial or complete incapacity, sums awarded
for pain and suffering and those awarded for the reduction in the claimants quality of
life and amenity where account is taken of factors such as age, lack of mobility,
degree of disfigurement, inability to pursue sports, hobbies and other interests, and
diminished eligibility for social relationships.

Special damages may be awarded where the exact sum is calculable such as
itemised legal expenses, the loss of earnings prior to trial and the costs that have
accrued in making alterations to property as a direct result of a disability resulting
from the workplace accident.

This part of the question was not well answered with only a few candidates able to
explain the meaning of general and special damages. Some listed all possible
damages which might be awarded without attempting to classify them.



Question 11 (a) Outline the meaning of skill-based, rule-based AND
knowledge-based behaviour. (6)

(b) With reference to practical examples or actual incidents, explain
how EACH of these types of operating behaviour can give rise to
human error AND, in EACH case, explain how human error can
be prevented. (14)


In answering part (a) of the question, candidates should have outlined that skill-
based behaviour involves a low level, pre-programmed sequence of actions where
employees carry out routine operations, often as though they were on automatic pilot.

Rule-based behaviour involves actions based on recognising patterns or situations
and then selecting actions based on a learned set of rules. Finally, knowledge-based
behaviour is involved at the higher problem-solving level, when there are no set rules
and a decision on the appropriate action to be taken is based on knowledge of the
system. This part of the question was not well answered with few candidates able to
provide an adequate meaning of the different behaviours whilst some wrote about
types of error rather than behaviour.






13 EXTERNAL
For part (b), an explanation was required of how the three types of operating
behaviour might give rise to human error and how such errors could be prevented. In
the case of skill-based behaviour, errors may arise if a similar routine is incorrectly
selected, if there is interruption or inattention causing a stage in the operation to be
omitted or repeated or if checks are not carried out to verify that the correct routine
has been selected. Preventive measures would be directed at designing routines and
controls so that they are distinct from each other, using feedback signals to warn
when the wrong course of action is being taken, allowing adequate work breaks or job
rotation to maintain attention and introducing training, competence assessment and a
high level of supervision. Signals passed at danger on the railway may be a result of
skill-based errors.

As for rule-based behaviour, errors may occur where, for example, the diagnosis is
based only on previous experience or where sufficient training has not been given to
enable employees to make an accurate diagnosis, where there is a tendency to apply
the usual rule or solution even if it is inappropriate or where simply there is a failure to
remember the rule that should be applied. Preventive measures include clear
presentation of information, logical and easy to follow rule sets, systems designed to
highlight infrequent or unusual events and the provision of training and competence
assessment. Examples (if properly explained) could have included the Kegworth air
crash, Piper Alpha or Three Mile Island

In the case of knowledge-based behaviour errors will occur if there is a lack of
knowledge or inadequate understanding of the system, if there is insufficient time to
carry out a proper diagnosis and if the problem is not properly thought through or
evidence is ignored. Preventive measures would again involve training particularly in
risk and hazard assessment, the provision of adequate resources in terms of
information and time and the use of supervision and checking systems such as group
or peer review. Flixborough and Port Ramsgate provide examples of this type of error.
There were candidates who had difficulty in matching errors with the correct type of
behaviour whilst others were unable to explain how human error might be prevented.
Whilst examples and incidents were offered they were often connected with the wrong
type of behaviour. Examiners gained the impression that some candidates had little
real understanding of operating behaviour.


The National Examination
Board in Occupational
Safety and Health
Dominus Way
Meridian Business Park
Leicester LE19 1QW
telephone +44 (0)116 2634700
fax +44 (0)116 2824000
email info@nebosh.org.uk
www.nebosh.org.uk