Question 4(b)You explain to the board of directors that the accident has not resulted from a single cause, but instead from a combination of failures. Comment on the likely active failures that led to the fall from height accident. Note:You sh

Question 4(b)You explain to the board of directors that the accident has not resulted from a single cause, but instead from a combination of failures.

Comment on the likely active failures that led to the fall from height accident.

Note:You should support your answer, where applicable, using supporting document 1 and relevant information from the scenario.

(Please give a minimum 15 bullet points)


Packagenics is a medium-sized organisation occupying a two-story office building located just outside a large city. The organisation has grown significantly over the last eight years; worker numbers have increased from 60 to 125. The office can accommodate up to 100 workers. All workers are office-based, apart from 10 workers who work remotely.

Regular meetings with customers and visitors are also held at the office. At the front of the office building is a car park that has 45 parking spaces. Once the car park is full, workers and visitors are expected to park their vehicles on the roads near the offices. The car park surface has cracks and potholes, and there are some old, unused garages at one end.

The chief executive officer (CEO) and board of directors have agreed to extend the office building on some unused land next to the existing office. They also plan to repair and re-surface the car park and increase the number of parking spaces by demolishing the unused garages.

You have been Packagenics’ facilities manager for the last three years, and the board of directors have recently extended your duties to managing health and safety. They believe this will allow them to concentrate on the management of the business. Although you have no formal health and safety qualifications, you have been in similar roles for the past 10 years. You also have some experience of managing health and safety in other organisations. You have requested to attend a health and safety course, but this has been declined.


As part of the building and car park extension project you are expected to select and manage the contractors on site. You have never managed or sourced contractors, so you begin by reading through the organisation’s contractor policy. The policy includes a ‘contractor approval process’ and a list of contact numbers for local contractors already approved. You discuss the project requirements over the telephone with various contractors, and shortlist four that are the most suitable from this list.

You prepare a specification that covers the scope of the work. The four reputable contractors you shortlisted are invited to submit a proposal and quotation for the work. As part of this, you also ask all contractors to supply a copy of their health and safety policy.

You arrange for each of the contractors to visit the site. Over the course of a week, all four contractors visit the site and assess the required work, then discuss any details with you. They provide you with their health and safety policy, a list of references and insurance details. Shortly afterwards, they all provide you with a proposal and quotation, including their risk assessment and method statement (RAMS). After comparing prices and documentation, you select two of these specialist contractors; one contractor for the office extension and a different contractor for the car park extension. You draft a proposal and present this to the board of directors two days later.

During the Board meeting, the CEO advises that their friend’s organisation, Elite Construction Ltd (ECL), should also be considered for the building and car park extension project.

The CEO tells the Board that during a recent golf game with their friend, who is ECL’s managing director (MD), the extension project was discussed. The MD mentioned that they personally have three years’ experience in refurbishing buildings. The MD also told the CEO that they always act as the site manager (SM) on jobs to help ensure good standards are maintained. The MD went on to say how they have managed health and safety issues on other projects. They also said that ECL are a member of the contractor safety accreditation scheme, and their last refurbishment job was completed 18 months ago. When concluding the conversation, the MD told the CEO that a discount would be applied to the project. All of this impressed the CEO, who concluded that ECL were the best organisation for the building and car park extension project.

The CEO recommends to the Board that ECL are appointed. Although ECL has yet to visit the site to view the scope of the work required, the CEO’s recommendations are accepted by the Board.

Reluctantly, you take the details of ECL so that you can obtain their health and safety documentation. The Board is keen to get the new facility operational as soon as possible and want the project to be completed quickly.

A week later you receive ECL’s health and safety policy and a discounted quotation. You decide to telephone them to discuss the project further and invite them to look around the site. You speak to the SM and ask what experience ECL has with car park extension work; the SM tells you that they have a certificate in health and safety so there is nothing to worry about. They assure you it is not a hard job as it is only a question of adding tarmac. “How hard can it be?”they ask you. They go on to say they have many talented and trained workers, plus a 17-year-old, enthusiastic apprentice who has just started working for them. The apprentice has experience in gardening, and the SM thinks that they will be a quick learner. The SM requests photographs of the office, the unused land and the existing car park. These will be sent by email. You ask them to visit the site, but they tell you they are busy on another job.

A few days later you receive a risk assessment and a method statement by email. When reviewing the information, you notice that both documents are based on the previous job that ECL completed 18 months ago. Trusting the CEO’s judgment you accept the quotation and draft a contract for the project.

The project

It is a hot day and the project has started. A construction phase plan has been devised for the whole project. ECL has promised to complete the project within four months. The car park extension will be the last part to be completed. All office workers will work remotely during the project.

ECL have provided the majority of the plant and equipment (including a circular saw), which they have purchased to reduce their long-term costs. The apprentice has been using the circular saw on their own to cut through pipes to help re-lay a drainage system. During this activity, you question the SM to determine if the apprentice has received appropriate training. The SM tells you “They watch and learn; most workers have been trained this way. It’s the best type of training, and the apprentice will learn faster this way”.

You continue to oversee the work daily and update the board of directors on the progress.

The accident

It is the end of the working day, and two of ECL’s workers (worker A and worker B) are directed to carry out work on the roof joists. Access is from a corridor on the second floor of the new extension. The workers have been told to complete the job by the end of the following day. The apprentice is observing the task.

It is worker A’s birthday. While working they discussed how much they enjoyed the food and wine at a nearby restaurant during their lunch break. Both workers were assembling a tower scaffold provided by the SM. Once assembled the workers realised that it was too wide to be positioned in the work area correctly. As a result, worker A had an idea. They said, “Let’s use the boards from the tower scaffold and position them between the roof joists to make a work platform. It’s late and I need to get home as I’m having a family birthday dinner”. Feeling hot and tired, worker B (who was also keen to go home) agreed. They had done this on a previous job and therefore did not see a problem with it.

The apprentice who was watching their co-workers was concerned. They find you and the SM outside to tell you what is happening. The SM’s response is “They are old enough to make sure they don’t fall; we just need to move on with the job. We have deadlines, and this is the only tower scaffold we have”. Surprised by this response the apprentice returns to the job site. As they return, they see worker A, who is outside getting some fresh air. At this point in time, worker B had gained access to the work area, via the external supporting scaffolding, without fall arrest equipment. After completing the task, worker B stepped from the roof onto the platform, when the board broke. They had fallen five metres to the ground below, sustaining a head injury, rendering them unconscious; when worker A and the apprentice found them.

At this point you are still talking to the SM outside; the apprentice runs to you to tell you what has happened. You hear the SM say quietly to themselves “not another accident that’s a worker’s fault”.

You call an ambulance straight away from your mobile phone, and stay with the injured worker. The worker is taken to hospital. You are informed later that the worker died because of their injuries.

You carry out some independent research about ECL and find that an enforcement notice was issued to them during their last job. Workers were found to be working on a flat roof that had no edge protection available to prevent a fall. Nothing was done to rectify the unsafe working conditions, and ECL was later prosecuted for non-compliance with the notice. You also discover that certification to the contractor safety accreditation scheme had expired, as ECL failed to provide requested information at renewal.

The board of directors are worried about the outcome from any investigation, and how this may affect potential contracts. One of the Board members has read about the ‘5 Whys’ analysis and they tell the rest of the Board that this approach would be a quick and cost-effective process to prove that the accident was the SM’s fault. The rest of the Board say that they have not heard of this, but think it is a good idea. Therefore, the Board arrange to meet off site to carry out the ‘5 Whys’. You tell them it is important to interview the other workers involved first, but they say it is not necessary as they already know the cause.

You then speak to the SM and tell them that the Board are going to do a ‘5 Whys’ to prove it was the SM’s fault. The SM says that it was not their fault, it was the worker who was at fault. They also do not want the accident reported to the enforcement authority.