NEBOSH Open Book Examination

Answers
Task 1: Workers not meeting their obligations

1. Ignoring supervisor instructions: Workers in Factory 1 became reluctant to communicate

with the production manager, affecting their participation in safety discussions.
2. Failure to follow safety protocols: Worker X neglected the proper use of the paper
guillotine, leading to the accident.
3. Unsafe practices: Workers did not report or rectify unsafe conditions, such as the exposed
start button on the guillotine.
4. Risky shortcuts: Worker X rushed through tasks due to fear of supervisor reprimand,
neglecting safety measures.
5. Inadequate training adherence: Workers signed off on pre-ticked checklists without
properly verifying equipment safety.
6. Neglecting personal protection: Despite complaints about vibration-related ill-health,
workers continued using outdated stapling guns without ensuring safer alternatives.
7. Failure to report issues: Workers failed to escalate issues like faulty lighting and water
leaks impacting machinery visibility and safety.
8. Disregard for SSOW: Worker X and others did not ensure compliance with the safe system
of work, bypassing critical training and checklist adherence.
9. Neglect of internal communication: Workers did not effectively communicate safety
concerns across different departments.
10. Lack of participation in inspections: Workers failed to actively participate in inspections,
making it difficult to identify and mitigate risks.
11. Disengagement from safety culture: Workers' disengagement shows a breakdown in the
organisational safety culture.
12. No feedback on safety incidents: Workers neglected to provide feedback on past
incidents, limiting the opportunity for learning.
13. Insufficient use of protective equipment: Workers did not consistently use available
personal protective equipment, increasing risks.
14. Limited compliance with procedures: Workers often neglected compliance with
standard operating procedures due to a lack of motivation.
15. Overlooking hazard reporting systems: Workers failed to use established hazard
reporting systems to address potential risks.
16. Miscommunication during training: Training was rushed, leading to a lack of
understanding, which contributed to failure in safety adherence.
Task 2: Policy implementation

1. Failure to prevent accidents: The company had multiple incidents, including forklift
collisions and a severe finger amputation, indicating a failure to prevent accidents.
2. Inadequate accident investigation: The supervisor did not assist in the paper guillotine
investigation, and the risk assessments were outdated, showing a lack of proper
investigation processes.
3. Unsafe working conditions: Factory 2 had unsafe conditions, such as water-damaged
ceilings, rusting machinery, and a crumbling ramp.
4. Failure to maintain safe equipment: The guillotine's missing safety guard and outdated
stapling guns indicate a failure to provide safe plant and equipment.
5. Neglect of legal requirements: The investigation by the Health and Safety Authority
suggests that the company was not meeting its legal obligations.
6. Inadequate consultation: Workers were disengaged from health and safety discussions
due to management ignoring their concerns.
7. Failure to allocate resources: The MD repeatedly rejected essential safety improvements
due to cost concerns, limiting resources for safety enhancements.
8. Lack of supervisor training: Supervisors, especially in Factory 2, were not adequately
involved in enforcing safety protocols or ensuring equipment safety.
9. Disengagement from workers: Management failed to engage workers meaningfully in
discussions about health and safety standards.
10. Inconsistent application of safety measures: Measures taken in Factory 1 were not
consistently applied in Factory 2.
11. Limited investment in safety technology: Management consistently refused to invest in
improved safety technologies, such as non-compressed air stapling guns.
12. Inadequate hazard identification: The lack of updated risk assessments shows the
company failed to identify and mitigate emerging risks.
13. Lack of corrective actions: Corrective actions following incidents were not properly
enforced, allowing hazards to persist.
14. Inconsistent equipment maintenance: Equipment, especially in Factory 2, was poorly
maintained, as evidenced by rust and water damage.
15. Failure to formalise procedures: The health and safety policy was present but poorly
implemented, showing a lack of follow-through on safety procedures.
16. Management indifference: Management showed indifference to safety
recommendations, undermining efforts to improve safety.
17. Neglect of temporary workers: The company did not take adequate steps to ensure the
safety of agency workers.
18. Reactive rather than proactive safety approach: The company's approach was largely
reactive, dealing with issues after incidents occurred rather than preventing them.
19. Lack of cross-factory safety standardisation: Standards in Factory 1 and Factory 2 were
inconsistent, with Factory 2 having poorer safety conditions.
Task 3: Worker involvement

1. Reinstate Health and Safety Committee: Reviving the committee would allow for regular
meetings and worker participation in safety improvements.
2. Encourage open communication: Management should actively listen to workers'
concerns, addressing the perception that their input is ignored.
3. Worker-led inspections: Involve workers in daily inspections alongside supervisors to
identify and rectify hazards early.
4. Provide safety incentives: Reward workers for reporting hazards or suggesting safety
improvements to foster engagement.
5. Improve training sessions: Conduct thorough, language-inclusive training for all workers,
ensuring they understand procedures and can provide feedback.
6. Develop a feedback loop: Establish a system where workers can see the impact of their
safety suggestions, ensuring their concerns are acted upon.
7. Increase union collaboration: Engage safety representatives to lead initiatives and
mediate between management and workers on safety matters.
8. Allocate sufficient time for safety checks: Give workers ample time during shifts to
complete safety tasks without rushing, promoting thoroughness.
9. Implement worker surveys: Regular surveys can help gather opinions on health and
safety standards and areas for improvement.
10. Improve supervisor-worker relationships: Encourage supervisors to have more open
discussions with workers about safety concerns.
11. Foster a safety-first culture: Promote a culture that prioritises safety over speed or
productivity, engaging workers in this shift.
12. Provide clear communication channels: Workers should have access to clear channels to
report safety issues or ideas for improvement.
13. Conduct joint safety audits: Involve workers in joint safety audits with management to
give them ownership of safety standards.
14. Offer anonymous reporting: Allow workers to report safety issues anonymously to
encourage more candid feedback.
15. Increase transparency: Management should be transparent about safety decisions and
actions taken in response to worker concerns.
16. Host regular safety workshops: Run workshops where workers can learn about safety
procedures and give their input on improving them.

Task 4: Individual factors influencing the accident

1. Language barriers: Worker X’s limited proficiency in the local language made
understanding instructions and safety procedures difficult.
2. Inadequate training: The rushed training session contributed to Worker X’s lack of
preparedness to safely operate the guillotine.
3. Fear of reprimand: Worker X was pressured to work faster due to previous warnings,
compromising their focus on safety.
4. Stress and fatigue: Worker X’s discomfort and stress from trying to avoid further
reprimands influenced their unsafe behavior.
5. Poor visibility: The cluttered work area and inadequate lighting worsened the worker’s
ability to operate the machine safely.
6. Lack of familiarity: As a new employee, Worker X had not yet developed a strong routine
or comfort with the machine's operations.
7. Physical strain: Worker X described leaning uncomfortably over the machine, likely
affecting their ability to work safely.
8. Overconfidence in checklist: Worker X relied on the pre-ticked checklist without fully
verifying the safety of the machine.
9. Unclear instructions: The rushed training meant that Worker X did not have a clear
understanding of proper operation.
10. Stress from unfamiliar environment: The unfamiliar environment likely increased
Worker X's stress, contributing to mistakes.
11. Perceived pressure from peers: Worker X may have felt pressure from colleagues to
perform faster, leading to unsafe actions.
12. Miscommunication between workers: There may have been miscommunication
between Worker X and other workers due to language barriers.
13. Physical exhaustion: Worker X's physical strain may have increased their likelihood of
mistakes, especially late in the shift.
14. Inadequate rest: Worker X might not have had enough rest between tasks, increasing
the chance of accidents.
15. Lack of feedback on performance: Worker X may not have received adequate feedback
during the training process, leading to errors.
16. Insufficient focus on safety: Worker X’s primary concern was completing the task
quickly, rather than focusing on safety.

Task 5: Risk assessment

(a) Positive aspects (9 Marks) Points: 13

1. Regular use of external consultants: The company employed an external health

and safety consultant to assess risks.

2. Daily factory inspections: The production manager performed daily inspections in

Factory 1, discussing risks with workers.

3. Corrective actions: The PM attempted to implement corrective actions based on

risk assessments, indicating a proactive approach.

4. Formal documentation: Risk assessments were formally documented, even if

incomplete.
 5. Some worker involvement: Workers were initially involved in risk discussions
during daily inspections.

6. Management structure: Factory 1 had a clear management structure with defined

health and safety roles.

7. Health and safety policy in place: The company had a health and safety policy
signed by the MD, albeit not fully effective.

8. SSOW for the guillotine: There was a documented safe system of work for the
paper guillotine.

(b) ask 5(b): Negative aspects (15 Marks)

1. Outdated risk assessments: The most recent risk assessment was two years old,
making it irrelevant to current conditions.
2. Incomplete risk coverage: The assessments only covered production activities
and excluded critical equipment like the guillotine.
3. Rejected safety improvements: The MD repeatedly rejected safety
improvements, such as purchasing non-compressed air stapling guns and new
safety guards.
4. Supervisory neglect: The PM did not visit Factory 2, leaving safety management
to production supervisors with no follow-up.
5. Lack of follow-up on corrective actions: Although the PM attempted to
implement corrective actions, management often ignored these recommendations.
6. No worker input on risk assessments: Workers were not actively consulted or
involved in the risk assessment process, especially in Factory 2.
7. Inconsistent safety standards: Factory 2’s poor conditions, including the
crumbling ramp and rusted machinery, were not addressed in risk assessments.
8. Failure to update assessments after incidents: The risk assessment was not
updated after the paper guillotine incident or following the Health and Safety
Authority's intervention.
9. Neglect of equipment hazards: Key equipment hazards, like the missing guard
on the guillotine, were not identified in assessments.
10. Ignoring environmental factors: Water leaks damaging the reels and machinery
were not factored into the assessments, despite visible effects.
11. Unaddressed ergonomic issues: Worker complaints about pain and numbness
from stapling guns were not considered in risk assessments.
12. Incomplete pre-use checks: The paper guillotine’s pre-use checklist was
inadequate, and workers were given pre-ticked checklists to bypass safety
protocols.
13. Inadequate machine-specific risk assessments: The assessments were generic
and did not consider the specific risks associated with operating dangerous
machinery like the guillotine.
14. Lack of training considerations: Risk assessments did not account for the
inadequate training provided, especially for new workers like Worker X.
 15. No assessment of language barriers: Worker X's limited understanding of the
local language and its impact on safety was not factored into assessments.
16. Poor consultation with workers: Workers in Factory 2 were not consulted about
the risks, despite their complaints about equipment safety and workplace
conditions.
17. Failure to assess temporary workers' risks: Agency workers, like Worker X,
were not adequately considered in risk assessments, despite being more
vulnerable to hazards.
18. Over-reliance on external consultants: The company relied on external
consultants for risk assessments, but these were neither updated nor followed up
properly by internal management.
19. Inadequate hazard identification process: The risk assessments failed to
identify obvious hazards, such as the exposed start button on the guillotine and
water damage affecting lighting and machinery.

Task 6: Reactive monitoring measures (14 Marks)

Points: 18

1. Accident records: Review records of accidents, such as the forklift truck collision
and paper guillotine accident.

2. Near-miss reports: Collect near-miss reports, especially in high-risk areas like

Factory 2.

3. Sickness and absence records: Monitor worker absenteeism due to work-related

injuries, such as those from stapling guns.

4. Civil claims data: Analyze civil claims related to vibration-related injuries for
insights into workplace hazards.

5. First-aid treatment logs: Check records of incidents that required first-aid, such as
the treatment provided to Worker X after the guillotine accident.

6. Incident trends: Identify trends in workplace accidents, focusing on patterns of

incidents like those involving agency workers.

7. Compensation claims: Evaluate the number of compensation claims submitted due

to workplace injuries or ill-health.

8. Machine stoppages: Track instances where machines, like the paper guillotine,
were stopped due to safety concerns.

9. Enforcement notices: Review notices issued by external bodies, like the Health and
Safety Authority's prohibition on the guillotine.
 10. Inspection reports: Examine external and internal health and safety inspection
reports for compliance failures.

11. Feedback from workers: Collect worker feedback on unsafe conditions through
surveys or health and safety committees.

12. Failure of safety controls: Track data on equipment malfunctions or failures, such
as the missing safety guard on the guillotine.

13. Workplace audits: Use audit data to identify deficiencies in safety practices across
both factories.

14. Health surveillance data: Assess health surveillance reports to monitor long-term
health conditions like vibration-related illnesses.

15. Lost workdays: Count the number of workdays lost due to injuries or illnesses
linked to work activities.

16. Prosecution records: Document any legal actions or prosecutions, such as the one
involving the MD and the Health and Safety Authority.

17. Training attendance: Review records of worker attendance at safety training

sessions, like those for the guillotine.

18. Equipment maintenance logs: Analyze logs of equipment maintenance and

repairs, especially for critical machines like the guillotine.

Task 7: Underlying causes of the paper guillotine accident (11 Marks)

Points: 15

1. Inadequate training: Worker X received rushed training from another worker, not
a qualified trainer.

2. Missing safety guard: The paper guillotine lacked a critical safety guard, directly
leading to the accident.

3. Exposed start button: The start button on the guillotine was exposed, allowing for
accidental activation.

4. Faulty equipment maintenance: Poor maintenance practices allowed the

guillotine to remain in use despite safety concerns.

5. Poor workplace layout: The cluttered work area made it difficult for Worker X to
safely operate the machine.

6. Lack of supervision: The supervisor did not properly oversee Worker X or ensure
the safety of the guillotine.
 7. Pressure to work faster: Worker X was pressured by the supervisor to increase
work speed, compromising safety.

8. Inadequate risk assessment: The guillotine was not specifically included in risk
assessments, overlooking critical hazards.

9. Insufficient checks: Worker X was given a pre-ticked checklist and did not conduct
proper safety checks.

10. Neglect of complaints: Workers had previously complained about issues like faulty
lighting, but no corrective action was taken.

11. Water damage: Leaking water affected the nearby lighting and possibly other
aspects of safety around the machine.

12. Poor communication: Worker X’s limited understanding of the local language may
have prevented them from fully understanding safety instructions.

13. Management negligence: The MD’s refusal to invest in safety improvements

contributed to the hazardous conditions.

14. Unsafe system of work: The existing safe system of work for the guillotine was not
properly enforced or followed.

15. Lack of follow-up on audits: Previous inspections or risk assessments did not
address or prevent the safety failures leading to the accident.

Let me know if you need further adjustments or additional details for these tasks.