SCENARIO

The design agency

$$Vault$$ is a design agency with ten employed workers, including the managing director $($MD$).$ Vault is situated in a building with a ground floor, an upper floor and a lower $($basement$)$ floor. The MD$$s office is located at the back of the ground floor. Also on the ground floor, there is an open$-$plan area where several workstations are set up$.$ In this open$-$plan area, there is a staircase that leads to both the upper floor and the lower floor. The lower floor consists of three rooms: a worker$$s rest area with a small kitchen; a toilet; and a printing room. There is a digital printing press $($DPP$)$ located in the printing room, which is used to create limited quantities of high$-$quality printed design work. The upper floor is an open$-$plan storage area, currently filled with cardboard boxes.

Vault was recently acquired by a competitor, and the new owners intend to introduce a formal health and safety management system. You have been hired as a health and safety consultant $($HSC$)$ to audit the current informal health and safety system. This is your first time carrying out an audit and you are not sure how detailed it needs to be$.$ While you do not know much about Vault, you are confident you can complete the audit perfectly.

The audit

You have arranged to be on site for one day to conduct the audit. It is raining when you arrive at $09\mathrm{.}00.$ You carefully walk up a worn, wooden ramp leading to the entrance, where a worker greets you at the door. You are distracted by loud music in the background. You notice a square patch of blue masking tape on the floor inside the entrance. You ask why it is there and you are told that there has been a hole underneath the tape for a long time.

You are then shown into the MD$$s office where the MD is on the telephone. The MD appears to be stressed as they gesture for you to sit down. The MD gives you a folder filled with health and safety documents. A preliminary check identifies some documents are missing, including the health and safety policy. You wait to talk to the MD$,$ but after ten minutes they are still on the telephone. You give the MD a note to inform them that you will start the audit and talk to them later. You leave the office and go to the open$-$plan area with the documents.

Worker Z invites you to sit at their workstation and gives you a conference chair from a nearby workstation. They mention that it is rare to get time to speak with the MD due to all of the MD$$s telephone meetings. You ask worker Z where the health and safety policy can be found. Worker Z apologises because they do not know what you are referring to$.$ Instead, they ask one of their colleagues to search for it on Vault$$s computer system.

Worker Z offers to show you the printing room. On the way they describe how everyone, including the MD$,$ was excited to use a DPP for the first time. Worker Z explains that Vault has reduced its dependency on printing companies after purchasing the DPP earlier this month from a stockist who only sells used machinery. You are impressed when you see the DPP and ask worker Z if they could show you the safe system of work $($SSOW$)$ document for using it$.$ Worker Z looks confused before handing you the DPP$$s instruction manual $($which was downloaded from the internet as the stockist did not have the original document$),$ which has untidy handwritten notes on it$.$

Worker Z tells you that these are the working instructions for the DPP$.$ They add that the MD has written on it $$safe system$.$ You notice that the notes only appear to simplify the language used in the instruction manual. You ask worker Z if they have been trained on how to use the DPP$.$ They unconfidently reply that they have been. Worker Z explains that the MD emailed everyone the day before the DPP was delivered. This email instructed everyone how to use the DPP based on an online version of the instruction manual and concluded that everyone will be able to use the DPP by themselves. This way the MD thought that everyone was trained before even seeing the DPP$.$ You ask worker Z if they felt the training was effective, but they give a vague reply.

At that moment something wet hits the top of your head. You look up and see a large area of mould on the ceiling and water leaking through the smoke alarm. You ask worker Z about this, and they hesitantly mention that the building has old pipework. They reassure you that the MD contacted the building owner two months ago. The MD said that they would contact the building owner again, as soon as they have time. Worker Z is confident that the building owner can fix it$,$ as they have done so several times before. You ask if the MD has contacted the building owner about the hole in the floor as well. Worker Z mutters that the MD does not tell the building owner about cosmetic issues like that.

When returning up the stairs you notice more blue masking tape on some of the step edging, which has started peeling off. You find a printed copy of the health and safety policy on worker Z$$s desk. The worker who found it jokingly tells you $$It was hidden in the computer system$.$ While reading the policy you notice a different organisation$$s name has occasionally been used instead of $$Vault$.$ You ask the workers nearby about this other name, but nobody has heard of it$.$ You search the Internet for this other organisation, and immediately find the health and safety policy on another organisation$$s website. You decide to ask the MD about this later, as their signature is on Vault$$s policy. You add the policy to the folder.

When reviewing the records, you notice that there have been several near misses on the stairs, but there are no investigation records. Also, there are no training records or emergency procedure documents. You ask the workers nearby if they have received any emergency procedure training.

Some of them vaguely remember seeing fire evacuation instructions in their induction packs. However, most workers cannot remember the details and have not revisited the information since then. You ask if they are aware of a written emergency procedure. Most of the workers are unaware of one, but one worker points towards the wall where coats are hanging. When you look behind the coats, you discover fire evacuation instructions printed on a faded sheet of paper attached to the wall.

The accident

You take a break to plan the rest of the audit. You consider talking to the MD now, but then get distracted as you start to review your notes. Towards the end of the day the smoke alarm suddenly sounds. You move quickly towards the main entrance nearby but are shocked to see everyone else ignoring the alarm. Worker Z sees that you are about to leave and calls out to you to ignore it$.$ Confused, you ask if this is a fire alarm test. They reply that the MD wants everyone to ignore the alarm. A different worker laughs, calling the sound $$the daily leak alarm$.$

At that moment, the MD rushes out of their office but they are still using their mobile telephone. It is the first time you have seen them since this morning, and you overhear them saying that they will stop the alarm sound permanently. The MD runs downstairs and within two minutes the alarm stops sounding. You hear the MD running back up the stairs, when there is a loud shout which came from the staircase area. You go to find out what has happened and find the MD sitting on a step. They are holding their mobile telephone in one hand and the battery from the smoke alarm in the other. There is a cut on the MD$$s forehead and their hands are grazed.

The MD asks you to get the first$-$aid kit from the kitchen. You shout for a first$-$aider and then go to collect the first$-$aid kit. You locate the first$-$aid kit on top of a wall$-$mounted cabinet, and you have to stand on the kitchen countertop to retrieve it$.$ Opening the first$-$aid kit, you find it is almost empty with only one dressing left.

You take the dressing to the MD to see if you can assist them. On the way, you notice that the blue masking tape you saw earlier on the steps, has completely peeled off. The edging of the step, below where the MD is seated, has separated from the step itself. Several workers have now gathered on the stairs, and some are panicking at the sight of blood on the MD$$s forehead. Worker Z mentions that the MD is not talking properly and asks what they should do$.$ You ask where the first$-$aider is$,$ but they reply that there is no first$-$aider. The MD$$s eyes have fixed and dilated pupils and they are unresponsive. Seeing this, you tell worker Z to call an ambulance. Worker Z and several other workers rush off to their desks to contact the emergency services. You stay with the MD until an ambulance arrives.

Task $5$: Evaluating safe systems of work;Why is Vault$$s safe system of work for the DPP insufficient? $(10)$ points

Note: You should support your answer, where applicable, using relevant

information from the scenario.