HSE Risk Assessment in Practice: Applied Scenarios

Risk Assessment and Management

Purpose

At Level 3, a learner identifies a hazard (e.g., “fumes”) and suggests PPE. At Level 7, you are presented with a situation where the risk assessment was done, the PPE was worn, and the permit was issued—yet the catastrophe still happened.

This worksheet provides four “Wicked Problems”—complex, high-stakes engineering scenarios where standard compliance failed. Your goal is to apply Forensic Analysis to identify the latent organizational failures.

Core Principles: The “Swiss Cheese” Model of Failure

Before engaging with the scenarios, recall Reason’s Model. Accidents in complex engineering systems are rarely caused by a single error. They require multiple layers of defense to fail simultaneously:

  • Organizational Influences: Budget cuts, culture.
  • Unsafe Supervision: Inadequate training, fatigue management.
  • Preconditions: “Rushing” to meet targets.
  • Unsafe Acts: The final trigger.

Your Task: Do not stop at the “Unsafe Act.” Dig deeper to find the “Organizational Influence.”

Scenario 1: Confined Space Fatality (Systemic Failure)

The Incident: A contract welder died from asphyxiation inside a pressure vessel during a scheduled turnaround.

  • The Paradox: A “Permit to Work” was issued. Atmospheric testing was conducted at 08:00 (showing 20.9% Oxygen). The welder entered at 10:00. The welder was wearing a rescue harness.
  • The Complication: The vessel was connected to a nitrogen purge line that was “tagged” as isolated but not physically disconnected (spaded). A valve leaked.

Level 7 Analysis Tasks:

  1. Critique the Permit System: Why is a signature on a piece of paper insufficient control for a fatal risk?
  2. Analyze the Isolation Strategy: Compare “Double Block and Bleed” vs. “Spading/Blinding.” Why did the engineer choose the less secure option? (Hint: Cost/Time pressure).
  3. Evaluate the Emergency Response: The rescue team took 20 minutes to deploy because the “Standby Man” had been assigned other duties. Discuss the legal liability of “resourcing conflicts.”

Scenario 2: Chronic MSD Litigation (Strategic Defense)

The Incident: Your engineering firm is facing a Class Action Lawsuit. Ten employees from the heavy assembly line have been diagnosed with debilitating spinal injuries.

  • The Paradox: The company has a “Manual Handling Policy” and provides annual “Safe Lifting Techniques” training. Every injured employee had signed a training register.
  • The Complication: The components weigh 23kg (legal limit is 25kg). However, the assembly rate was increased by 20% last year, requiring 30 lifts per hour.

Level 7 Analysis Tasks:

  1. Deconstruct the Defense: Why will the “We trained them” defense fail in court? (Reference: Ergonomics vs. Administrative Control).
  2. Cost-Benefit Critique: The Finance Director refused to buy a £50,000 vacuum lifter. Calculate the “False Economy” compared to the potential £1M+ litigation settlement.
  3. System Redesign: Propose an engineering solution that removes the human variable entirely.

Scenario 3: Process Safety Failure (Normalization of Deviation)

The Incident: A chemical reactor experienced a “thermal runaway,” venting toxic gas over a neighboring housing estate.

  • The Paradox: The reactor had a cooling jacket and a high-temperature alarm.
  • The Complication: Review of data logs shows the reactor had been running at 5°C above its design limit for six months to increase yield. Operators had silenced the “nuisance alarm” so often that it was taped over. Management knew yield was up but didn’t ask why.

Level 7 Analysis Tasks:

  1. Identify the “Normalization of Deviation”: How did an unsafe practice become the “standard operating procedure”?
  2. Management Culpability: Analyze the role of Senior Management. By rewarding high yield without auditing how it was achieved, did they encourage the accident?
  3. Governance Reform: Draft a “Process Safety Performance Indicator” (KPI) dashboard that would have flagged this risk before the explosion.

Scenario 4: Regulatory Prohibition Notice (Noise Control)

The Incident: The HSE has served a Prohibition Notice, shutting down your main stamping press due to noise levels of 105 dB(A).

  • The Paradox: All operators wear top-tier ear defenders (SNR 35dB).
  • The Complication: The HSE inspector cited the “Hierarchy of Control,” stating that PPE is a measure of last resort and the company failed to implement engineering controls because they were “too difficult.”

Level 7 Analysis Tasks:

  1. Legal Argument (ALARP): You must write a response to the HSE. Can you prove that acoustic enclosure (costing £200,000) is grossly disproportionate to the risk of hearing loss? (Likely answer: No. You must explain how you will fund and install it).
  2. Strategic Trade-off: The enclosure will reduce production speed by 10%. Justify this operational loss to the Board of Directors in terms of “License to Operate.”

Targeted Strategic Questions

  1. Synthesize: In all four scenarios, a “Risk Assessment” document existed. Why was it powerless to prevent the incident?
  2. Evaluate: How does “Production Pressure” act as a latent pathogen in safety critical systems?
  3. Justify: At what point does an “Engineering Failure” become a “Management Crime” (Corporate Manslaughter)?
  4. Critique: Why is the phrase “Operator Error” banned in High Reliability Organisations (HROs)?

Learner Task: Major Incident Investigation

Task Overview:

Select ONE of the four scenarios above. You have been appointed as the Lead Investigator reporting to the Board of Directors.

Deliverable:

Write a 3-Page “Root Cause & Strategic Remediation Report” (not a standard risk assessment form).

Structure:

  1. Executive Summary: The immediate impact (Human, Legal, Financial).
  2. Forensic Analysis:
    • Do not list hazards.
    • Map the Failure Path: Link the Management Decision (Latent Failure) →The Cultural Norm (Precondition) → The Incident.
  3. Legal Exposure Assessment:
    • Cite specific breaches of HSWA 1974, MHSWR 1999, or PUWER.
    • Estimate the probability of prosecution.
  4. Strategic Recommendations:
    • Short Term: Immediate stabilization.
    • Long Term: Systemic redesign (Engineering & Governance).
    • ALARP Justification: Defend the cost of your proposed solution.