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Error on trial

Open-access content Tuesday 20th June 2017
Authors
Bridget Leathley

Error-on-trial

In most other areas of endeavour we learn from triumphs, but in safety the focus is often on disaster. We are knowledgeable enough to realise that we cannot simply blame the end user, but we still try to unpick long, causal chains of errors -- of end users, of senior management, of designers -- seeing human error as something to be designed, managed or reinforced out of an organisation.

Some approaches focus on the end-user errors, whether deliberate violations or mistakes. Behaviour-based safety approaches, for example, assume that the systems have been fixed, and that persuading people to wear their personal protective equipment and complete their checklists should be the focus of effort. Other approaches concentrate on organisational faults -- which still amount to human errors, just further up the management chain. Critics of Herbert Heinrich's 1930s methods often forget that his "fault" domino did not refer just to the human errors of front-line workers. Heinrich's use of the phrases "unsafe design or construction" and "hazardous arrangement" suggests he was well aware of the role of errors in design and management.

Error definitions

Classical definitions

"A generic term to encompass all those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to the intervention of some chance agency." (Reason, 1990).
Although Lisanne Bainbridge and Charles Perrow challenged the idea that human error could be identified and eliminated in complex modern systems, their writing does not appear to challenge accepted definitions.

Cynical definitions

Jens Rasmussen points the blame clearly at the designers of the equipment and tasks with his definition of human error as "instances of man-machine or man-task misfits". In the second edition of Man-made Disasters, authors Barry Turner and Nick Pidgeon suggest human error is "a convenient justification for the rather different social process of blame allocation".

New views

In Safety I and Safety II (Aldgate, 2014), Erik Hollnagel surrounds the words "human error" with quotes, preferring to consider "performance variation". In an earlier publication he defines human error as "one explanation out of several possible for an observed performance" (1983).
Sidney Dekker's Field Guide to Human Error (CRC Press, 2014) defines his new view of human error as "a judgement that we make after the fact; information about how people have learned to cope (successfully or not) with the complexities and contradictions of real work. Elsewhere, he has stated "there is no such thing as human error".

James Reason's "Swiss cheese" model shows holes (failings) in layers of protection at the managerial level, which let an accident trajectory through these "slices" so, when the end user performs an unsafe act, an accident occurs.

Through multiple books, Sidney Dekker has tried to persuade organisations to move away from seeing human error as the fault (culpable or otherwise) of the individual to a symptom of problems in the organisation.

As well as the arguments over whose errors are of most concern -- end users', management's, designers', or planners' -- there have been debates over how best to eliminate mistakes. Early approaches considered "error prone" people (see Error proneness box below) could be weeded out of the workplace. Other efforts have focused on training, human factors, reinforcement or punishment.

Human factors expert Jens Rasmussen and Reason are well known for their efforts to categorise human error (see Error definitions box). By categorising an error, it is argued, you are better able to prevent it. Training reduces skill-based errors, checklists improve the use of rules, and a better understanding of the system and of the potential for mistakes reduces the likelihood of knowledge-based faults. But whomever they blamed, and however they thought it could be solved, there has been a consensus that human error is something to be identified and eliminated.

Sense of inevitability?

Even as Rasmussen and Reason were categorising human errors, Barry Turner had already warned of the flaws in this approach. Having explored many of the management errors that resulted in major incidents such as the Aberfan coal slide in Wales, which killed 116 children and 28 adults in 1966, Turner wrote in the book Man-made Disasters (Butterworth Heinemann, 1977):

"However comforting the promise of an infinite tidiness [-¦] there are limits on our ability to reduce uncertainty, to master all of the open-ended and perverse qualities of our environment, and upon our ability to prevent disaster. If we start by recognising that instability lies at the heart of the world, then we may come to realise that the optimism and the assertion of certainty which enables life to create and spread order cannot completely overcome this instability."

In other words, even if we try to understand the chains of errors that "cause" accidents, disasters will still happen. Turner also emphasised how organisations could have an amplifying effect on individual human errors, making things worse rather than better.

We are not consistent, and it is that inconsistency -- or variability -- that has led to progress

Categorising human error

Jens Rasmussen's 1982 paper Human Errors: a taxonomy for describing human malfunction in industrial installations, in the Journal of Occupational Accidents defined three categories of human performance that could be subject to errors:
  • Skill-based: more or less subconscious routines, with performance controlled by stored patterns of behaviour -- an experienced driver does not need to think consciously about changing gear and using the clutch at the same time, for example. Errors are related to variability.
  • Rule-based: performance in familiar situations controlled by stored rules. Typical errors include wrong classification of the situation or the failure to recognise the need to apply a particular set of rules.
  • Knowledge-based: required in unfamiliar situations for which actions must be determined from an analysis and a decision based on knowledge of the functional, physical properties of the system and the priority of various goals. Error mechanisms can be defined only in relation to the goal of the task.
James Reason adopted these performance categories to define skill-based slips (substituting one step for another), skill-based lapses (forgetting a step), rule-based mistakes (choosing the wrong rules) and knowledge-based mistakes (making the wrong decisions).
Reason added a further category of human failures in the form of violations, which could be subdivided into routine, situational and exceptional. By 1997 Reason had developed a "culpability decision tree" which had nine possible outcomes, with decreasing culpability from "malevolent damage" to "blameless error".

In 1983 psychologist Lisanne Bainbridge warned of the "ironies of automation": the more we automate processes, the less capable people become to cope with problems when they occur. The less frequently we have to intervene to make a system work, the less knowledge we have of how it works (leading to more knowledge-based mistakes).

In 1984, Yale sociologist Charles Perrow published Normal Accidents (Princeton), in which he argued that our socio-technical environments are now so complex that accidents are inevitable. And yet, despite these often-cited works we continue as though we can identify all hazards, proceduralise all necessary controls, audit the procedures, and that accidents will only occur if people (whether frontline or management) make errors or choose to violate codes.

Safety too

There is an alternative way to look at behaviour that is labelled "human error" (see Error proneness box below). Perhaps errors are not a problem to be solved, but an innate attribute of human performance that is essential to learning and development. As a leading proponent of this idea, safety academic Erik Hollnagel has attempted to redefine safety. If old safety (or Safety I) is the absence of accidents, or "a condition where the number of things that go wrong is acceptably small", the study of safety will cover those things that go wrong, which inevitably leads to a focus on errors.

Safety II, by contrast, is where as many things as possible go right, and should lead to a focus on desirable outcomes, and encourage more of that. Safety I has an assumption that error-free procedures can be written, and that variability can and should be eliminated; Safety II sees variability in human performance as indispensable.

This is not a new idea. In 1982 Rasmussen explained: "Human variability is an important ingredient in adaptation and learning, and the ability to adapt to peculiarities in system performance and optimise interaction is the very reason for having people in a system."

He went on to suggest that the way to optimise performance was to provide people with opportunities for trial-and-error experiments, with human error considered as an unsuccessful experiment. In some situations, we can experiment because we have the time and resources to reverse the effect if it is not what we wanted. Say an area of floor has been identified as being particularly slippery, so a new method of cleaning is proposed. After the new method is adopted, if the problem remains, other methods can be tried. Complex systems such as flight decks and air traffic control do not allow for trial and error, so people are trained using simulators, which allow for unsuccessful experiments without the unacceptable consequences normally associated with them.

Rasmussen does not claim to have originated the idea that the variability that can lead to disaster or to triumph is the same thing, crediting the philosopher and physicist Ernst Mach in 1905: "Knowledge and error flow from the same mental sources; only success can tell the one from the other."

Rasmussen also identified the problem that Hollnagel tackles: that human errors are identified after the fact, only when a system performs unsatisfactorily. But where Rasmussen's solution to this was ergonomics and human factors -- design the machines and tasks to fit the way people act and think -- understanding Hollnagel's Safety II requires us to stop talking about errors, and instead talk about variability.

Positive variability

Error proneness?

Academics and practitioners have argued about the extent to which human error is the cause of accidents and have proposed different theories about the cause of error itself. In the 1920s, a study of drivers found an uneven distribution of injuries, and suggested the term "accident prone" to describe a personality type. Herbert Heinrich's domino theory of accident causation reflected this attitude, suggesting that users' faults were due to their "social environment and ancestry". In Human Safety and Risk Management (CRC Press, 2006), Ian Glendon et al list some personality characteristics that have been linked to safety behaviour:
  • Aggression predisposes people to be unwilling to endure inconvenience and frustration which they might associate with taking safety precautions, obeying speed limits or wearing personal protective equipment.
  • Anxiety can result in more obsessive checking of actions and a lower tolerance for danger; this can be positive in increasing caution but negative in interrupting the smooth flow of routine actions.
  • Extroversion might lead individuals to seek out sensation, including risk. Extroverts are regarded as less able with high vigilance and easy tasks, and less able to cope with sleep deprivation. In some studies, extroverts had more injuries and more vehicle crashes than introverts.
  • Introversion has been found to make people less able to cope with noisy, stressful environments, or demanding situations requiring attention on multiple tasks.
  • Impulsiveness can make people respond faster but less accurately than those with low impulsivity, though when task requirements are complex high impulsives can be slower.
Such findings are often the result of a single study, and each personality trait has strengths as well as weaknesses. Glendon et al conclude: "No personality trait for accident proneness has ever been isolated and it is unlikely to be worth looking for."

If we had always followed the procedures provided by those before us, we would still be carving our own tools, cooking on an open fire and riding horses, albeit with written procedures for the storage of sharp flints, the avoidance of burns, and controls for zoonoses -- diseases that can be transmitted to humans from animals. Humans are innovative -- we think of better ways of doing things, we try them, and if they work we carry on doing them. We are not consistent, and it is that inconsistency -- or variability -- that has led to progress.

The same behaviour that "caused" an accident today was the behaviour that yesterday got the job done successfully and quickly. The can-do attitude that won the contract is the same one that leads to an accident because of driving when tired; the culture that landed the first people on the moon was the same one that led managers to override the advice of engineers to launch the Challenger Space Shuttle on a day that was close to freezing in 1986.

In the short term it might be possible to specify how someone should climb a particular ladder safely to clean a particular window. A different window might need a different approach -- and we don't want to prevent someone finding a better way to clean the window that doesn't involve a ladder.

As the Loughborough University researchers in IOSH's OSH in a Changing World research programme found (bit.ly/2ri574Q), workarounds and dynamic risk assessments are recognised by many as acceptable forms of adapting existing procedures or, in some cases, creating procedures on the spot. Each time a business sends a vehicle out on the road, the driver is expected to adapt their focus to the circumstances. For more complicated systems it is even more important that we have people who can think through the options and determine the best approaches. The more complex our systems become, the greater is the need for "performance adjustments" without which, Hollnagel argues, "anything but the most trivial activity would be impossible".

Whereas Reason's accident trajectory was a straight line, suggesting a predictable linear sequence of events, Hollnagel talks of "non-linear emergent outcomes". Small amounts of variability in lots of places in the system (in people and in technical elements) affect each other in unpredictable ways to produce an undesirable effect. Trying to control the variability of each person and each technical component is practically impossible, and in any case undesirable -- since you would lose the benefits along with the disadvantages.

Returning to Turner's 1978 hypothesis that organisations amplify individual errors, Hollnagel's ideas challenge us to see how we can build resilient organisations instead, ones that can monitor conditions and adjust quickly to sustain operations and safety. He points out that this approach has the benefit of making organisations better able to respond to business opportunities as well as to safety threats.

Another outcome of considering human variability as something of value is that, rather than investigating just accidents or even near-misses, we should put more effort into talking to people about what they do when the outcomes are positive. Asking people how they avoided an accident, or how they prevented a problem escalating might be more revealing than waiting for accident.

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Dacorum Borough Council has been fined £100,000 for failing to protect its employees from hand-arm vibration syndrome (HAVS) after seven cases were reported to the Health and Safety Executive (HSE) over a single year.
Open-access content
Image credit: web_nz_shutterstock_513260500

 MSDs causing more than a quarter of DALYs lost in NZ

Wednesday 21st August 2019
Musculoskeletal harm now accounts for 27 per cent of all work-related disability-adjusted life years (DALYs) lost in New Zealand, according to a report from the country’s health and safety regulator, WorkSafe. A DALY is defined by the World Health Organization as one lost “healthy” life year.
Open-access content

Latest from Manufacturing and engineering

EcoOnline webinar

 Expert analysis of HSE stats in manufacturing

In this webinar, we will take a closer look at what the new stats mean compared to previous years with a focus on the topics of chemical management, permit to work and EHS in the manufacturing industry. Book your free place now and earn CPD points, too.
Open-access content
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 Exclusive interview: why Nestlé was fined £800,000 for repeat incidents

Wednesday 23rd November 2022
IOSH magazine spoke to HSE inspector Bill Gilroy about a serious accident at a Nestlé factory in Newcastle – an almost carbon copy of a previous incident at another of the confectionary firm’s factories.
Open-access content
web_New-cars-at-factory_credit_iStock-1320492982.jpg

 G4S: Vehicle for change

Friday 27th May 2022
The switch to electric vehicles is changing the risk landscape for car manufacturers. We found out how G4S is protecting assembly line workers and its first responders
Open-access content

Latest from Mining and quarrying

HSE stats lowest on record

 HSE stats reveal lowest fatality rate on record

Friday 3rd July 2020
A total of 111 individuals lost their lives at work in the 12 months ending 31 March 2020, the lowest ever recorded number of workplace fatal accidents.
Open-access content

 Irish drive to cut quarry deaths

Thursday 12th September 2019
The Irish Health and Safety Authority (HSA) has this week launched an inspection blitz on quarries with a focus on the most common causes of fatal injury. 
Open-access content
Image credit: web_nz_shutterstock_513260500

 MSDs causing more than a quarter of DALYs lost in NZ

Wednesday 21st August 2019
Musculoskeletal harm now accounts for 27 per cent of all work-related disability-adjusted life years (DALYs) lost in New Zealand, according to a report from the country’s health and safety regulator, WorkSafe. A DALY is defined by the World Health Organization as one lost “healthy” life year.
Open-access content

Latest from Third sector

HSE stats lowest on record

 HSE stats reveal lowest fatality rate on record

Friday 3rd July 2020
A total of 111 individuals lost their lives at work in the 12 months ending 31 March 2020, the lowest ever recorded number of workplace fatal accidents.
Open-access content
Image credit: web_traffic-warden_iStock-139960986.

 Union launches guide to protect gig economy workers

Friday 13th September 2019
The public service union Unison has published a new guide for its health and safety representatives to explain how the gig economy has affected its members and what support they can provide.
Open-access content
Image credit: web_nz_shutterstock_513260500

 MSDs causing more than a quarter of DALYs lost in NZ

Wednesday 21st August 2019
Musculoskeletal harm now accounts for 27 per cent of all work-related disability-adjusted life years (DALYs) lost in New Zealand, according to a report from the country’s health and safety regulator, WorkSafe. A DALY is defined by the World Health Organization as one lost “healthy” life year.
Open-access content

Latest from Transport and logistics

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 Life-changing one tonne load fall results in £95,000 fine

Monday 13th March 2023
We spoke to Health and Safety Executive (HSE) inspector Andrew Johnson about a case where a one-tonne pallet of glass fell on a United Pallet Network (UK) Limited’s employee, causing life-changing injuries.
Open-access content
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 Siemens to pay £1.4m for train technician’s fatal crush

Tuesday 7th March 2023
Siemens Plc has pleaded guilty to breaching s 33(1)(c) of the Health and Safety at Work Act after a self-employed contractor died at its Train Care Facility in west London.
Open-access content
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 Logistics giant Eddie Stobart’s £133k fine for exposing port staff to asbestos

Friday 2nd December 2022
Eddie Stobart has been fined £133,000 for a number of failures that resulted in staff at its rail and container freight port in Widnes, Cheshire being exposed to asbestos.
Open-access content

Latest from Accident reduction

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 Gig workers and safety standards

Wednesday 4th January 2023
As gig working becomes more commonplace, how can OSH professionals ensure that safety standards are maintained for every worker in their care?
Open-access content
tfiy

 Common sense: a flawed concept?

Wednesday 4th January 2023
While it is a phrase familiar to many, for OSH professionals it is a fundamentally flawed concept. We explore why – and find out how to ensure evidence-based approaches are used.
Open-access content
dx

 Predictive analytics

Tuesday 1st November 2022
Using predictive analytics can arm OSH professionals with a powerful tool to expose critical risks and, potentially, avert future fatalities and injuries.
Open-access content

Latest from Compliance

Web workers mask

 Top 10 tips for unlocking the 'new normal'

Tuesday 12th October 2021
Whether returning to work feels like the 'baby steps' suggested by UK prime minister Boris Johnson or a huge and daunting task, easing of the lockdown has now begun.
Open-access content
Man-getting-vaccinated_iStock-1251663430

 No jab, no job: health and safety versus civil liberties

Thursday 11th March 2021
No jab, no job – easy to say but a minefield to navigate. As the NHS programme rolls impressively on, thoughts turn to how useful vaccine protection might be.
Open-access content
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 AI in OSH: the smart move

Monday 1st March 2021
AI will leave its mark on every aspect of our lives, but is this cause for alarm or celebration? The tech may keep workers safe, but is it a danger to privacy and consent?
Open-access content

Latest from Human factors

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 The impact of burnout

Thursday 2nd March 2023
Burnout, moral injury and moral distress are bubbling up in the workplace. But how are these concepts connected?
Open-access content
rt

 Talking shop: four-day week

Tuesday 1st November 2022
A four-day week is being trialled in the UK. What long-term health and safety implications could be created by its adoption in the workplace? Four industry leaders offer their thoughts.
Open-access content
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 Remote working's ethical dilemmas

Thursday 1st September 2022
The rapid shift to remote working has presented employers with new workplace ethical dilemmas.
Open-access content

Latest from Employee involvement

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 Top tips for better health and safety training

Thursday 19th January 2023
Nick Wilson, director of health and safety services at WorkNest, has more than 20 years of training experience, working with individuals from the top to bottom of organisations. Here he explains the steps you can take to improve the effectiveness of training and increased employee engagement when delivering courses.
Open-access content
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 How to be a problem solver

Wednesday 4th January 2023
We find out what soft skills are needed to overcome – or prevent – OSH issues in the workplace.
Open-access content
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 The ups and downs of building a safety culture

Thursday 1st September 2022
Beliefs in and attitudes towards safety underpin OSH culture and, ultimately, performance. How do we build a safety culture and how might it change?
Open-access content

Latest from Management systems

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 Newcastle City Council fined £280k for failing to remove rotten willow tree that crushed six-year-old school girl

Monday 16th January 2023
Newcastle City Council has accepted responsibility for failing to properly manage the risk of a decayed willow tree that collapsed in strong winds and struck several children while they were playing at Gosforth Park First School in Newcastle upon Tyne during the lunchbreak.
Open-access content
web_Catastophe_PSD_800x500

 Book review: Catastrophe and Systemic Change

Friday 6th August 2021
This excellent book by Gill Kernick shines a light on all those undercurrents and how, as you read this, they may even be undermining your safety management system.
Open-access content
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 EU-OSHA's prevention measures to counter prolonged sitting risks

Wednesday 28th July 2021
A European Agency for Safety and Health at Work (EU-OSHA) report exploring the health risks associated with prolonged static sitting at work has outlined a range of measures that employers should include in a prevention strategy to enhance employee protection.
Open-access content

Latest from Performance/results

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 ‘OSH-washing’ safety data

Thursday 2nd March 2023
As greenwashing continues to undermine progress on sustainability, we explore whether ‘OSH-washing’ is an equally concerning issue.
Open-access content
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 ROPE theory

Wednesday 2nd November 2022
In the first part of this two-part series, Paul Verrico CMIOSH and Sarah Valentine set out a new safety theory that uses a ‘story’ to illustrate the need for rest, observation, planning and empowerment (ROPE).
Open-access content
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 PIRC warns safety risks go unreported in workplace safety disclosures review of PLCs

Tuesday 7th June 2022
Companies are deliberately choosing not to report all of their safety breaches and fines, so risks to safety are not being picked up by shareholders and other stakeholders, a review of workforce safety disclosures from publicly listed companies (PLCs) has found.
Open-access content

Latest from Regulation/enforcement

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 A reasonable balance to strike

Friday 24th March 2023
Safety interventions should be practicable and cost-effective, but too much of an imbalance towards safety does not make economic sense for employers, argues Geoff Vaughan, who suggests ‘gross disproportion’ provides a practical limit.
Open-access content
web_Jeremy-hunt-holding-dispatch-box_credit_Fred-Duval_shutterstock_2275701011.png

 Spring budget and occupational health

Friday 17th March 2023
Richard Jones CFIOSH, comments on the occupational health aspects of the Chancellor Jeremy Hunt's first budget statement.
Open-access content
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 Health and safety regulations at risk under draft law

Monday 13th March 2023
A proposed new law aims to revoke EU-derived legislation, including life-saving protections, by December 2023, unless specifically kept or replaced – Richard Jones CFIOSH explains how OSH practitioners can get involved.
Open-access content

Latest from Safe systems of work

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 Penalties mount for vehicle parts maker on OSHA’s ‘severe violator enforcement programme’

Wednesday 10th August 2022
The US Department of Labor has presented an Ohio-based vehicle parts manufacturer on its ‘severe violator enforcement programme’ with a fine of $480,240 (approx. £373,000) after inspectors found it had continually exposed workers to multiple machine hazards
Open-access content
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 Dyson lands £1.2m fine after worker escapes more serious injuries

Friday 5th August 2022
Dyson Technologies has been handed a £1.2 million fine after a worker at its Wiltshire site narrowly escaped being crushed by a 1.5 tonne milling machine.
Open-access content
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 Talking shop: hand dominance

Friday 1st July 2022
How should organisations consider left-handedness in their safety management systems? Four industry leaders offer their thoughts.
Open-access content

Latest from Leadership

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 Interview: Nicole Rinaldi

Thursday 21st April 2022
Nicole Rinaldi became director of professional services at IOSH in October 2021. Here, she looks back over her first few months and towards an exciting future for the OSH profession.
Open-access content
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 Ignoring your brain can endanger your safety

Tuesday 15th March 2022
User guide to your brain
Open-access content
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 From safety champion to future leader

Wednesday 1st September 2021
IOSH Future Leader Jessica Sales explains her journey from lab quality control apprentice to QHSE manager with global commercial real estate services and investment company, CBRE. 
Open-access content

Latest from Personal protective equipment

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 Worker unfairly dismissed after ‘cursory’ risk assessment banned crucifix necklace

Friday 22nd July 2022
A factory worker who was sacked after refusing to remove his crucifix necklace has won his unfair dismissal case on appeal after a judge agreed the employer’s risk assessment had been 'cursory'.
Open-access content
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 The dangers of forestry

Wednesday 4th May 2022
Winter storms and slashed budgets combined with a lack of skills and awareness are leading to needless deaths in forestry and arboriculture.
Open-access content
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 Care worker who threatened to report employer for Covid PPE breach wins constructive dismissal case

Monday 11th April 2022
A care home worker who joked about reporting his employer to the Care Quality Commission (CQC) for not enforcing the wearing of facemasks at the height of the pandemic has won his claim for constructive unfair dismissal.
Open-access content

Latest from Slips and trips

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  Morrisons’ £3.5m fine is ‘a warning to all employers’, says council

Friday 24th March 2023
Morrisons supermarket has been fined £3.5 million for failing to ensure the health and safety of an epileptic employee who died after falling from a shop stairway.
Open-access content
ft

 Judge dismisses John Lewis car park injury appeal

Wednesday 4th January 2023
A man who tripped in a parking bay argued that the retailer owed him a duty of care.
Open-access content
web_escalator_credit_iStock-1308544430

 Escalator safety: raising the game

Monday 22nd November 2021
An award-winning engineer and a former head of safety at John Lewis discuss the dangers of making assumptions about the causes of escalator accidents, and how best to encourage safe behaviour among members of the public.
Open-access content

Latest from Bridget Leathley

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 Back on course

Tuesday 7th July 2020
We talk to training providers about how they have adapted essential courses to cope with social distancing, including a rapid switch to virtual classrooms.
Open-access content
Lexicon: Z

 Z is for Zeigarnik

Friday 24th April 2020
We round off the alphabet by considering how to use the Russian psychologist's work in OSH
Open-access content
Y is for Yerkes-Dodson

 Y is for Yerkes-Dodson

Thursday 2nd April 2020
The strength of the stimulus as the experimental variable, with performance as the result.
Open-access content
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