The intervention explored the RRMPOL CDM manufacturing sites arrangements for the management of asbestos containing materials (ACM’s).There are approximately 4000 deaths from asbestos related diseases in the UK each year. Of these people dying, 25% are tradesman such as builders, plumbers, carpenters and electricians. This equates to 20 tradesmen each week. Hence managing and working with ACMs is a priority nuclear site conventional health topic.
The intervention explored the manufacturing sites arrangements for the guarding of dangerous parts of machinery. There are approximately 12 deaths and 40,000 injuries each year across the UK following incidents where workers have been using machinery. Engineering machinery with dangerous moving parts is used on the site and hence this is a relevant conventional safety topic.
Aspects of the manufacturing sites welfare arrangements were examined following feedback from the site safety representatives during the intervention.
An update was sought in relation to progress against the manufacturing sites internal improvement plan following the May 2015 NOx gas incident. The NOx gas release was a result of trial pickling operations as part of new product development. This resulted in a higher than expected release of NOx gas into the operating area during processing within the Nitric acid tank and caused an overflow of Nitric acid onto a steam line which failed. There were no injuries as a result of the event following which the site produced a comprehensive improvement plan.
The key health and safety legislation applicable to the intervention is set out below:
The Control of Asbestos Regulations 2012: Approved Code of Practice and Guidance (CAR ACOP 2012), sets out the requirements for work with asbestos. Regulation 4 sets out the duty to manage asbestos in non -domestic premises and requires duty holders to identify the location and condition of asbestos and to manage the risk to prevent harm to anyone who works on buildings or to building occupants.
The Provision and Use of Work Equipment Regulations 1998 (PUWER 1998) sets out the requirements for machine guarding. Regulation 11 requires that employers should prevent access to dangerous parts of machinery.
The Workplace (Health, Safety and Welfare) Regulations 1992 (WHSW 1992) set out the welfare requirements for factories. Regulation 9 deals with cleanliness, Regulation 24 with facilities for changing clothing and Regulation 25 with facilities for rest and to eat meals.
The Management of Health and Safety at Work Regulations 1999 (MHSWR 1999) sets out the general frame work for health and safety arrangements, risk assessment and management and requires the site to have health and safety arrangements that are appropriate.
The manufacturing site contract the services of an asbestos survey company who act as a technical authority for asbestos and complete an annual management survey of site ACM. The survey company produce an asbestos register detailing relevant information such as ACM location, description and extent, damage, asbestos type and risk category. The register includes site drawings and photographs and gives an ACM material risk category and score along with a priority risk and a total risk score. The latest survey was completed in February 2016 and has identified that ACM material on site is generally in good condition.
The site have appointed in writing a Nominated Responsible Person (NRP) for asbestos who has completed a relevant duty holder training course run by the asbestos survey company. The NRP does not currently have a trained deputy but an individual has been identified and is due to attend the relevant training course later in 2016.
The NRP has access to the survey companies internet based ERisk system which holds the manufacturing site survey information. He provides an electronic copy of the survey to site line managers and production leads. The NRP is available to provide ACM information and advice to the site in relation to planned intrusive works and can liaise with the survey company in relation to asbestos removal work.
The site use licensed contractors for any work on ACM. Any such work is arranged through the survey company who use a number of licensed removal companies.
Rolls Royce has a corporate policy document for asbestos, Control Standard (HSE CS 14-00). This standard was introduced in August 2013 and sets out the expected approach to asbestos management. A supplement to the document sets out the information required within an asbestos register (HSE CS14-03).
The site has an Asbestos Management Plan (AMP) document which sets out the broad arrangements for the management of asbestos on the Raynesway site.
All staff working in areas with asbestos present are required to have completed an asbestos awareness eLearning training course.
The sites modification proposal form (MPF) and contractor control form TX 3030 both have questions in relation to the potential presence of asbestos.
Staff spoken to during the intervention all had a good understanding of the need to manage asbestos.
Rolls Royce introduced a new corporate H&S control standard for work equipment in August 2015 (HSE CS37). This document includes a requirement that all machinery has a machinery risk assessment and that suitable guards are in place. Full implementation is required by the end of 2017. The facility engineering manufacturing services manager has been appointed as the responsible person for HSE CS37. A new corporate risk assessment document is available and the site will need to either use this document or establish that existing machine risk assessments have considered all the relevant factors.
During 2014/15 Bureau Veritas (BV) were contracted to undertake assessments of machines within the sites Clean and Contact shops. The information provided by BV is currently under review by the responsible person to identify and prioritise any required improvements. This information will then feed into the revised risk assessment process.
Previous machine assessments carried out under the PUWER regulations are available within the maintenance department.
Operational risk assessments (carried out under the Management of Health and Safety at Work Regulations) are completed for individual machines. These focus on the tasks and processes undertaken on the machine and are carried out by local risk assessors and are signed off by a relevant manager. These assessments cover machine guarding arrangements and there is a cross over between them and the PUWER machine assessments.
Actual guarding standards were observed on a HME 55 Tonne mechanical power press with discussion taking place with both the press operator/guard inspector and the tool setter. The machine was not in use at the time of the intervention but had a combination of fixed and interlocked guards in place although the interlocked guard was not in normal production use. Daily guard checks were being recorded and both men had attended appropriate training for their roles. An operational risk assessment was in place for the machine with an annual review period identified. The local risk assessment (Ref CL0704) identified the guards present and the hazards. BV completes a thorough examination of the press every 6 months. Written codes of practise set out 12 monthly mechanical and electrical maintenance work instructions. The specific PUWER assessment was completed in 2008. The machine is due to be removed from site in Quarter 3 of 2016 and hence did not feature in the BV assessment work of 2014/15.
Guarding standards were observed on a Hydrotel milling machine. The machine was not in use at the time of the intervention but had an interlocked polycarbonate guard in place around the spindle. A telescopic probe was also in position at the spindle. A local risk assessment was in place (Ref CL0102) with a three yearly review period. The local assessment identified the guards present and identified additional control such as emergency stops, not wearing gloves and the need to wear eye protection. The specific PUWER assessment was completed in 2008 and the machine has been included in the more recent BV assessment with a number of recommendations being made. Written codes of practise set out 12 monthly mechanical and electrical maintenance work instructions.
The number of workers within the Clean shop has increased over the last 12 months with approximately 30 workers now on each of the three shifts. The current break room (mess room) kitchen facility has seating for only four workers. Another smaller kitchen located within the Clean shop has no seating area. Eating food within the work area is not ideal and should be discouraged. Plans are in place to create a new dedicated welfare area for workers that will include a kitchen, seating area and female changing rooms. This is to be located within the old business management suite which was vacated in November 2015 and is currently empty.
The site safety representatives expressed frustration that work to create the new welfare facility has not yet started. Management explained that delays were due to procurement procedures and that the project was now moving forward with completion due in the summer of 2016.
Concern was expressed by the safety representatives at the cleanliness of the existing kitchen facilities within the Clean shop. I inspected the Kitchen areas during the intervention to evaluate the situation.
The safety representatives raised concerns over laundry arrangements with problems being experienced with overalls replacement and laundering. Management explained that this matter had now been resolved with a new laundry provider due on site w/c 21st March to install new overall lockers.
The site has recorded good progress against their improvement plan following the pickle shop NOx event in May 2015.
The process chemist has completed a considerable amount of work in exploring the chemistry of the existing and trial core pickling process and checking/establishing safe work procedures.
Exposure monitoring has provided reassurance.
Pickle shop staff spoken to expressed satisfaction with the work done and control measures.
Priority: The site should review the overall priority it assigns to dealing with specific ACM material. This should involve consideration of the low, medium and high risk classifications given on the asbestos register and the links between the material risk, priority risk and total risk scores given compared to the requirements of HSE CS14-03 for ‘Action Priority’ determination.
Currently the asbestos register assigns a low, medium, high risk category based on an assessment of the ACM material condition only. This judgement is completed by the survey company and while the survey company also provide a separate priority risk score and total risk score these do not impact on the low, medium, high risk material classification given within the register. This approach does not meet the requirements of the Rolls Royce HSE CS14-03 document or good asbestos management practise which requires that an ‘Action Priority’ is determined based on consideration of both material condition and location factors (for example - vulnerability to disturbance).
The action priority score should result in either a low, medium or high risk category being assigned. This point recognises the fact that it does not automatically follow that those materials assigned the highest condition score will be the materials that should be given priority for remedial action.
Priority: The site should formally review the annual asbestos survey information and determine priorities. The sites Asbestos Management Plan (AMP) should reflect the treatment of ACM’s in line with their assigned action priorities following the formal review.
Provision of information to workers prior to work commencing: The site approach to ensuring that the asbestos register is checked prior to work starting on the fabric of the building lacks consistency and best practise is not effectively captured. A review should take place to include both projects and maintenance based activity. Clarity should be sought in particular in relation to the role of the NRP, who has direct access to the ERisk system and who is responsible for providing ACM register information to workers who may disturb an ACM prior to work starting.
Provision of information to workers prior to work commencing: ACM information in the general location of the contractor should be provided to them even if the planned work location does not include ACM. It is important that workers are aware of ACM that they may accidentally damage – for example during the movement of plant inside an area. Improved use of the detailed building drawings contained within the register would assist this process and could be provided as part of information exchange.
Priority: The fixed guard on the M225 press had slot openings which were found to be in need of minor alteration in order to comply with the safety reach distances set out in the relevant British Standard. It is acknowledged that this matter was actioned immediately following my visit. The issue of safety reach distances should be explored on any other machines with similar arrangements.
Risk assessment review and suitable maintenance: The two sampled PUWER machine assessments date from 2008 and together with the introduction of HSE CS 37 mean that the review of the BV assessments should be a site priority. While my inspection did not examine the BV report, the sample with the M203 machine indicates that it contains good recommendations based on technical standards and discussion with operators. This review work needs to be given sufficient focus and support to develop appropriate priority for any identified maintenance work.
Risk assessment review: The operational risk assessments and machine risk assessments should link together and they should reference each other. There was evidence on the machines sampled that the risk assessment process currently is not linking these two aspects together. The HSE CS37 process should be used to facilitate a joined up approach to risk assessment.
Priority: The cleanliness of the break room kitchen area within the clean shop was not to an acceptable standard during the intervention. The reasons for this should be explored and solutions developed. There should not be an over reliance on the contract cleaning staff and responsibility should be taken by those workers who use cooking equipment to clean after use. Management and safety representatives should work together to increase respect for such facilities.
The site are in the process of delivering plans for new welfare facilities for staff in the clean shop which will allow them to have food and drink away from the shop floor. However, this process has been delayed and more should have been done to provide temporary facilities. It is acknowledged that the site have now agreed to provide temporary welfare arrangements within the business management suite area until such time as work on the new welfare facility is started.
The new laundry arrangements should be monitored until such time as they have bedded in.
The site should review the small number of asset improvement plan items which are in danger of slipping against the original improvement plan dates.
There was a positive recognition by the site that the matters raised during the intervention merited their attention and action. The site was keen to complete the required improvements with some of the identified guarding issues being resolved immediately following the visit.
The EMM was considered and a letter to RRMPOL was identified as the appropriate mechanism to progress these matters. A follow up visit will be made in March 2017 to determine if required action has been taken. As it is necessary to address one or more shortcomings by giving formal instructions for remedial action to be taken this indicates that an overall CHS rating of ‘4 – below standard’ should be applied to the visit. Issues will be added to the ONR regulatory issues database for tracking purposes.