Examiners’ Report NEBOS NEBOSH H level 4 Diplom Dipl oma a January 2005 2005 examinatio examinatio n
The NEBOSH level 4 Diploma was launched in August 2004. Since only Unit A of the Diploma was examined at the first sitting in January 2005, this Report represents only part of what will be available from later sittings when all three Units will be examined. examined. As such, the Report Report wil l not be published formally as a priced publication but copies will be supplied free of charge, and for a limited period, to accredited centres. It may be copied freely freely for provisi on to st udents and tutors.
NEBOSH, Dominus Way, Meridian Business Park, Leicester LE19 1QW tel: 0116 263 4700
fax: 0116 282 4000
email:
[email protected]
website: www.nebosh.org.uk
The National Examination Board in Occupational Safety and Health is a registered charity, number 1010444 T(s):exrpts/D/2005jan
RCC/GP/0405/xxx
UNIT A – Managin g health and safety
General comments This was the first examination paper for the new NEBOSH level 4 Diploma and the questions set were based centrally on the published syllabus. As the first sitting of the new award, an examination was offered for Unit A only. 358 candidates sat the examination. There were some examples of excellent answers amongst the scripts but very many were disappointing. In particular, there was a worrying number of candidates who submitted answers that were little more than NEBOSH Certificate level and yet others who struggled to apply their knowledge to a scenario or case study and responded by putting down all they could think of in the relevant subject area without actually addressing the question. The paper is designed to test the breadth and depth of candidates’ knowledge and understanding in selected areas of the level 4 Diploma syllabus. To be successful in this part of the assessment process, candidates need to be prepared to deliver and apply a level of knowledge that is commensurate with the content and learning outcomes detailed in the syllabus. However, many answers achieved only low marks and generally did so for at least one of three reasons. Firstly, candidates were not always prepared with the degree of understanding and detail required at Diploma level. This echoes some of the comments made above about Certificate level answers and lack of knowledge was evident in many of the answers provided – for example, those to Questions 2 and 4. Candidates setting out on a course of study for the level 4 Diploma need to ask themselves whether they have allowed 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 compared with the NEBOSH National General Certificate. Secondly, many candidates achieved less than their possible potential through focusing on only a limited range of issues in a question that had scope for a broader range to be tackled. Questions 7 and 8 provided many examples of such answers. Practice in answering examination questions, and taking account of the advice and guidance of tutors on how to plan answers and how to address the breadth and depth required, are important elements in trying to maximise marks. Thirdly, a failure to read the question carefully, to relate the answer clearly to the question asked (or to the scenario set) and/or to provide only the information that actually answers the question caused much wasted time for candidates. This was a particular cause for concern in scenario questions, such as Questions 5, 10 and 11.
Section A – all questions compulsory Question 1
Outline the organisational and task design factors that might promote routine violations by employees.
(10)
Element A6 and, to a lesser extent, Element A5 of the syllabus contain the material that is relevant to this question. The question specifically sought information on both organisational and task design factors although many candidates focused on either one or the other. Some restricted their answers entirely to issues of safety culture, some of which were clearly relevant but much more was required. A number of answers referred to HSG48 and, while many of these responses were relevant, some simply focused on the classification of error, or provided much detail on the different types of violation, rather than concentrating on the factors that might make routine violations more likely. 1
In terms of organisational factors, employees are more likely to violate laid-down procedures if those procedures are difficult to understand or are (or are perceived to be) dated, irrelevant, unnecessary, restrictive or excessive. Other factors include: a lack of relevant supervision, enforcement and/or monitoring; inadequate training, consultation and/or communication; inappropriate peer pressure or cultural norms that see other priorities as more important; the negative effects of incentive or reward schemes; and issues relating to work overload and lack of resources. Task design factors could have included any of the ergonomic issues relating to: environmental factors (which may affect comfort or effort required); the design of controls, equipment, software and PPE (which may have postural, fatigue or ease of use implications); and the reliability or accuracy of instrumentation or alarms (which may affect the willingness to trust and to act on appropriate data or warnings). Candidates should have provided some detail on each of these in order to show why employees might be tempted not to follow procedures, often for reasons that are quite understandable, even though unacceptable, in the circumstances.
Question 2
With reference to relevant cases, explain the legal difficulties that have arisen in trying to secure convictions for corporate manslaughter and how the proposed new offence of corporate killing would overcome such difficulties.
(10)
Corporate manslaughter remains a topical issue within the safety profession and a number of proposals for legislative action to deal with the difficulties of securing conviction have been discussed since the Law Commission’s Report in 1996. The subject, together with relevant case law, is contained within Element A7 of the syllabus. Given the currency of this issue, the answers to this question were extremely disappointing. Candidates should have been able to explain that the legal hurdles to achieving a conviction for corporate manslaughter include the need to identify gross negligence in an individual acting at ‘controlling mind’ level within an organisation. Organisations with large and diffuse management structures make this task particularly difficult and cumulative management failings alone do not meet the specific legal criteria. The proposals for an offence of corporate killing do not require the identification of an individual in this way. They simply require the identification of management arrangements falling far below those that should be reasonably expected and which resulted in death. Marks were available for illustrating the explanation with relevant cases and, in this respect, details of the three cases listed in the syllabus could have been provided. There were clearly some serious misunderstandings about the nature of corporate manslaughter, with very many candidates convinced that s.36 and/or s.37 of the HSW Act represented the relevant law here. The principles of corporate manslaughter and corporate killing were frequently mixed together and the relevant case law was often not understood. Despite the inclusion of the word ‘corporate’ in the two terms, many candidates did not understand that they are corporate offences (ie ones committed by an organisation) as opposed to an offence by an individual.
Question 3
State the objectives and outline the methodology of Failure Mode and Effects Analysis (FMEA), giving an example of a typical safety application.
(10)
Some excellent answers were provided to this question with a number of candidates achieving maximum marks. Unfortunately, such candidates were in the minority and most achieved only modest or poor marks.
2
Many candidates clearly did not understand at all what FMEA is, and there were many others who confused FMEA with fault tree or event tree analysis. The question required a simple statement of objectives and an outline of the methodology. The latter could have included: identifying the component parts of a system, the failure modes of each component and the possible causes; identifying the effects of component failure on the whole system; assessing the probability of failure; identifying existing means of failure detection; allocating risk priority codes based on severity and probability; identifying actions to reduce risk to a tolerable level; and documenting in the conventional tabular format. Any suitable example of process plant, equipment or machinery with safety-critical implications would have been appropriate to obtain the credit for a ‘typical safety application’, although some were rather too vague in this respect.
Question 4
(a)
(b)
Outline the difficulties that organisations face in trying to ascertain the true costs of accidents and incidents.
(5)
Explain briefly how compliance with the philosophy advocated in the Institute of Chartered Accountants’ guidance document on ‘Internal Control’ (The Turnbull Report) would support good safety management in an organisation.
(5)
Many candidates answered the first part of this question by listing the costs of accidents and, in some cases, classifying them into insured/uninsured costs or direct/ indirect costs. However, this was not asked for. Rather, the question required candidates to identify the difficulties that organisations face in ascertaining the true costs of accidents and incidents and many candidates either did not do this or focused on just one relevant issue such as reporting difficulties. Answers could have included the difficulty in defining the scope and minimum level of incident to be costed, problems of under-reporting or recording, understanding the full scope of costs associated with an accident or incident, and obtaining realistic cost figures for more subtle cost elements such as loss of productivity or goodwill. The time and resources required to collect data and to undertake the costing, and the long time delay associated with some costs such as compensation, are also potential difficulties. The second part of the question was very poorly answered with only a tiny minority of candidates giving anything like a reasonable answer. Most candidates appeared to know nothing about the Turnbull Report even though it is clearly identified as a syllabus requirement in Element A1. This is an issue for course providers to address. Suitable explanations would have included a brief summary of the purpose of, and risk management philosophy inherent in, the Turnbull Report together with a summary of the key elements of the Report that would support good safety management. These include clear policy and commitment, risk evaluation through a process of risk assessment, management processes that control risk to an acceptable level, monitoring arrangements, clear communication and reporting arrangements, a process of internal audit, an annual Board level review of risk controls and a statement to shareholders on outcomes. Such issues should have been familiar territory.
Question 5
A secretary was injured by her chair when the adjustment mechanism, which used gas under pressure, exploded due to a manufacturing fault. With reference to case law where appropriate, provide notes to explain the civil and criminal law implications of this accident.
(10)
Elements A8 and A9 of the syllabus contain the relevant content for this question. There were a few excellent answers with candidates gaining maximum marks but unfortunately these were, again, very much the exception. Answers to this question demonstrated widespread confusion between civil and criminal law and, in many cases, a failure to understand the principles of each. It is particularly disappointing to see candidates making observations such as “the employer could bring a prosecution against the supplier” or “the injured employee will sue the employer under section 2 of the Health and Safety at Work Act”. 3
Many candidates focused their criminal law explanation entirely around employer duties under the HSW Act, section 2, and PUWER. These may be peripherally relevant but, since it was a manufacturing fault, it is quite reasonable to speculate that it may not have been reasonably practicable for the employer to be aware of the fault. In this respect, the manufacturer’s duties under section 6 of the HSW Act should have formed the significant part of the criminal aspects. In terms of the civil law, most candidates focused on the employer’s common law duty of care to employees, often with simplistic regurgitation of the tests for negligence. Again, although this may have some relevance, the Employer’s Liability (Defective Equipment) Act 1969 would be a much more likely route for a successful action in this case and should have received particular attention – but it was ignored by many candidates and misunderstood by others (with some candidates suggesting that the provisions of EL(DE)A allow the employer, or the employee, to sue the manufacturer). The manufacturer’s liability to the end user under the rules of negligence was also worth noting. The use of inappropriate or irrelevant case law was also fairly widespread suggesting that real understanding of the legal points associated with specific case law is weak for many candidates.
Question 6
An organisation has decided to introduce a permit-to-work system for maintenance and engineering work in an area used for the batch manufacture of chemicals operating continuously over three shifts. Outline the key issues that will need to be addressed in introducing and maintaining an effective system in such circumstances.
(10)
This question dealt with permit-to-work systems and was founded on the content of Element A4 of the syllabus. The question concerned the introduction and maintenance of an effective system and was therefore organisational in nature. Many candidates recognised this and dealt with a number of these issues but many focused on one specific element of operation (eg the design of the permit) to the exclusion of others. Some candidates dwelt on issues such as COSHH risk assessments and job safety analysis rather than addressing the question as written. Key issues that could have been outlined include: defining the activities and areas for which a permit would be required; developing a PTW procedure that defines how the system will operate; and developing the permit format and multi-copy documentation system to encompass issues such as job description, hazard identification, specification of risk control measures, time limits and authorising, receiving and cancellation signatures. Also relevant are: arrangements for the return of permits and record-keeping; arrangements for the co-ordination and display of multiple live permits; arrangements for communication between shifts (see the scenario); identification of training needs for, and delivery of training to, persons authorising or receiving permits and those working in areas where permits may be required; arrangements for contractors; provision of supporting arrangements and equipment such as lock-off, isolation or gas testing facilities; and arrangements for routine monitoring and auditing the effectiveness of the system.
4
Section B – three from five questions to be attempted
Question 7
A large warehousing and distribution facility uses contractors for many of its plant and property maintenance activities. The number of contractors’ employees on site at any one time is relatively small (around 5% of the total workforce) but an analysis of the accident statistics for the previous two years has shown that accidents to contractor personnel, or arising from work undertaken by contractors, account for 20% of the lost-time accidents on site. (i)
(ii)
Suggest reasons for the disproportionate number of accidents involving contract work.
(6)
Describe the key organisational and procedural measures that should be in place to control the risks from contract work.
(14)
This question was the most popular of those in Section B and many candidates attained reasonable marks. The first part of the question sought some logical observations on why there might be a disproportionate number of accidents associated with work by contractors. Issues that could have been covered include those related to the nature of the work – for instance, maintenance work might be more complex, higher risk, harder to control satisfactorily and with less wellestablished work methods than other warehousing and distribution activities. Unclear responsibilities for controlling third parties and a lack of training and procedures for third party management, poor planning and risk assessment, and poor co-ordination and communication between the parties involved or affected could also be relevant issues. Staff turnover, lack of contract worker competence, inadequate supervision and the effect of contractual or financial pressures may also be contributory factors. Weaker answers tended to labour on data reliability issues, suggesting that accidents involving contractors would be more likely to be reported and that the differences were therefore not real. Such answers had really missed the clear intent of the question. The second part of the question required a description of the key organisational and procedural measures required to minimise the risks associated with contract work. Most candidates obtained some marks in this part but many looked at too few organisational elements to obtain high marks. Some candidates made very generic comments about safety management or vague references to HSG65 but these were insufficiently specific to achieve marks. Nearly all candidates dealt with the need for risk assessments and agreed systems of work but this is only one part of a third party risk management process. Additional measures that could have been described include: the provision of adequate information to contractors on the nature of the work and known hazards; the selection of a competent contractor on the basis of evidence concerning skills and competence; safety management arrangements, resources and risk control proposals; the appointment of a client representative with contractor management responsibility; the provision of information on site rules and safety requirements; and arrangements for the induction briefing of all contract employees. Arrangements for co-ordinating, providing and reviewing risk assessments and method statements are an important element of the control measures, as are supervision and communication arrangements for all affected parties, monitoring (active and reactive) arrangements, and procedures for completion, hand-over and review of safety performance.
5
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. Following a visit from the Health and Safety Executive, the company has been asked to provide details of its procedures for dealing with a range of emergencies. (i)
(ii)
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. Describe the arrangements that should be in place in order to demonstrate an effective major incident procedure.
(5) (15)
This was also a popular question and many candidates again achieved reasonable marks. In fact, this question attracted the highest mean mark of all questions in this section. The subject matter is contained in Element A4 of the syllabus. Part (i) of the question invited candidates to consider, and then outline, the common types of emergency procedure that a site of the type described in the scenario may require. Local chemical spillage/release procedures are important on a site of this nature, as are fire evacuation, first-aid treatment and major incident procedures. Credit was also given for other credible procedures, such as those required for sabotage or bomb threats. In part (ii), many candidates provided reasonable answers with the main failings relating to the provision of only a limited number of arrangements or to provide, as some did, a very generic answer often referenced vaguely to HSG65. Arrangements that could have been described include: the initial identification of major incident risks; consultation with internal (staff, contractors) and external (emergency services, local authorities) stakeholders on the development of a plan; development of clear responsibilities as part of the plan; arrangements for initiating the procedure and for the call-out of key staff and support services; provision of a control centre and standby with key information and communication facilities; provision of equipment for communication between control parties in the event of an incident; provision of emergency equipment and PPE, such as that needed for spill control, suppression, etc; arrangements for communication with off-site residents and neighbours; press management arrangements; business continuity issues; and arrangements for regular practice, periodic review and, of course, comprehensive training of staff with key responsibilities and all other site personnel.
Question 9
In relation to Community law within the European Union: (i)
distinguish between EC directives and EC regulations
(ii)
outline the process for making EC legal instruments concerning health and safety matters
(iii)
describe the key functions of the European Court of Justice.
(4) (10) (6)
This was the least popular question in Section B. A number of candidates who attempted it gained reasonable marks overall and there were a few excellent answers; but many more did not provide the level of understanding and detail required to meet this part of Element A7 of the syllabus.
6
Part (i) of the question was answered reasonably well with most candidates recognising the fundamental difference between EC Directives and Regulations in terms of their effect on member states. Better candidates recognised that Directives have to be implemented through national legislation by a particular date. Part (ii) of the question, however, was generally poorly answered with many candidates unable to identify, or confusing, the main players in the process such as the European Commission, Parliament and Council of Ministers. The relevant procedure is the codecision procedure and marks were available for explaining the key elements of the three readings that can form part of that procedure. It was not necessary to include all of the procedural detail at each reading to obtain maximum marks. For example, for the first stage of the procedure it was sufficient to explain that the Commission makes a proposal on which the Parliament and the Economic and Social Committee give opinions and on which Council deliberates. Following this, Council may adopt a common position by qualified majority voting, which it communicates to the Parliament. Explanation by way of annotated flowchart was fine if enough detail was provided. It was particularly disappointing to find a small number of candidates talking about Green and White Papers and Royal Assent. Most candidates understood the broad role of the European Court of Justice and many were able to explain some of the direct actions (eg against a member state for failure to fulfil obligations under EC law) that the Court would hear. Only a few candidates explained the process of preliminary rulings on matters of EC law, which is an important part of the Court’s role in evolving the body of EC law; even fewer recognised the entitlement of parties to a preliminary ruling from the ECJ when there is a hearing in the final national court of appeal. Some candidates seemed to have a vague, mistaken notion of the ECJ itself as some sort of final appeal court for cases heard nationally, whether or not EC law is involved.
Question 10
The following table shows the numbers of lost-time accidents to employees for two hospitals situated in the same locality. Hospital A is a longestablished NHS general hospital employing 2,500 staff, whereas Hospital B, which opened in 1998, is a private hospital employing 300 staff.
(i)
(ii)
(iii)
Year
Hospit al A
Hospit al B
2000 2001 2002 2003
75 69 82 78
4 7 6 5
Assuming that the numbers of employees have remained constant over the period, calculate the annual lost-time accident incidence rates for the two hospitals and draw general conclusions from the results.
(4)
Identify possible limitations with the data that might make direct comparisons on safety performance unreliable.
(4)
Suggest reasons for an actual difference in safety performance between the two hospitals.
(12)
Element A3 contains the syllabus material for this question, which was not especially popular, possibly due to the need for calculations, albeit quite simple ones, in part (i). The first part of the question involved the calculation of accident incidence rates for the two hospitals and the large majority of candidates were able to do this and achieve good marks. For some, the choice of multiplier (eg 1,000 employees) appeared to cause some difficulty but, providing it was stated, this was not a critical issue. From the figures, most candidates correctly concluded that incidence rates in Hospital A were higher, and often significantly higher, than those in Hospital B. Candidates who chose to provide reasons for the differences at this point had evidently not read to the end of the question, and seemed not to have noticed that this part was worth just four marks. 7
In part (ii), candidates needed to recognise some of the limitations of this type of reactive data and apply them to the scenario. Essentially, this part of the question was looking for reasons why the figures produced in part (i) might not be directly comparable. Marks could have been achieved, for example, by recognising that the hospitals may have different definitions of a lost-time accident or that reporting rates, or propensity to take time off following an accident, may vary between the hospitals for socio-economic or cultural reasons. In addition, the extent of contractor use may differ (the figures relate solely to employees) and no account appears to have been taken of overtime or part-time employees – ie the figures relate to actual numbers of employees and not to a full-time equivalence. Also, no account is taken of injury severity in the data, which could be a key parameter in making a valid comparison. Most candidates recognised one or two of these issues, largely related to reporting rates, but very few identified three or four. Part (iii) was concerned with possible reasons for an actual difference in safety performance between the hospitals and issues relevant to the part (ii) answer were therefore not relevant to this part. A number of candidates confused the two parts. There were many possible and credible reasons for differences in safety performance within the scenario given and it was not necessary or desirable to invent detailed, fictitious scenarios to create more reasons. Possible reasons would centre around either inherent risk levels or the adequacy of risk management arrangements. They could have included: the nature of the hospital activities (for instance, the presence or absence of an accident and emergency department with its attendant problems of unplanned admissions, potentially difficult or intoxicated patients and increased patient movement and handling); the age of the hospitals with the newer hospital potentially having better designed and more modern equipment, and premises that have incorporated more modern standards of safety and environmental control into their design; the older hospital having a larger, more complex workforce to manage and possibly being less able to compete for well-trained and experienced staff in the local marketplace; and risk assessment and safety management processes that may differ between the hospitals, with the newer hospital being able to develop systems from scratch when it started in 1998 and not having to cope with historical or out-of-date practices and a larger, more complex workforce and range of risks. Most candidates discussed at least one or two of the above issues but many looked at too narrow a range to obtain high marks in this part.
Question 11
A manufacturing company is about to embark on a process of organisational change that is intended to reduce costs and increase productivity. As planned, the change will lead to a smaller workforce, a flatter management structure, enlarged responsibilities for the remaining staff, outsourcing of most maintenance tasks, increased use of automated processes and the need for some employees to be multi-skilled. Review the elements of a strategy designed to ensure that the company maintains its current high standards of health and safety, and its positive health and safety culture, both during and after the change.
(20)
This was a relatively unpopular question in which few candidates achieved good marks. Founded on Element A5 of the syllabus, the question dealt with a subject that most safety professionals will have to deal with at some stage in their careers – that of organisational change and its potential impact on safety standards. The HSE has issued a number of good practice documents dealing with this subject in recent years. There were some thoughtful and wide-ranging answers that achieved reasonable marks but most answers were either too narrow – focused simply on risk assessment or on the need for training, for example – or they were just summaries of the key concepts in HSG65 without significant application to the scenario.
8
Strategy elements that could have been considered include: a clear statement of safety objectives as part of the change process; allocation of senior management responsibilities for safety during the change; establishment of active and reactive safety performance measures for both during and after the change; a stated willingness to amend plans where there is evidence that safety may be compromised; involvement of employees and their representatives in working groups dealing with the change to utilise experience and encourage ownership; regular communication of plans and progress to all employees; arrangements for risk assessment for all planned process and human change (and for the involvement of employees in this); mapping of the proposed job skill and experience needs of the new structure (and the involvement of employees in this); the systematic assessment of development and training needs for individuals (including arrangements to identify informal knowledge and experience that may be lost and how to capture this); arrangements for managing the risks from the use of third parties for outsourcing and assessing the competence of contractors; dealing with employee anxiety as sympathetically as possible through regular and honest communication; and a transparent approach to redundancy and help with job placement if needed. Issues such as the provision of adequate time and resources for training and implementation of the new arrangements, monitoring safety performance by agreed measures during and after the change, and reviewing the change process and its safety implications at intervals after the change were also relevant.
Examination statistic s
NEBOSH level 4 Diplo ma, January 2005 examin ation
Unit A Number of examination candidates
358
Number (percentage) of passes in the examination
136 (38%)
Number of students submitting an assignment
348
Number (percentage) of passes in the assignment
164 (47%)
Number of eligible candidates
342
Number (percentage) of Unit passes * =
Unit B *
Unit C *
93 (27%)
examinations for Units B and C were not offered at this sitting ‘eligible candidates’ are those who became eligible for a Unit Certificate by submitting an assignment and sitting the examination.
9
