Part 3:
What happens when training management goes wrong
Sadly, there is no shortage of incidents of inadequate or undocumented training causing serious harm and in some cases, death. Take a look at two cases below which involved training deficiencies:
Case 1
A waste management company (Rainbow Waste Management) had to pay out over £200,000 in fines and costs following the death of a 24-year old worker in June 2013. The victim had been driving a motorised loading shovel from outside the cab and had reversed the vehicle with the bucket raised. The bucket dropped onto the victim, and he died from severe crush injuries to his head.
If you're a driver, you probably had many driving lessons, took a test, and now have a document to prove you can own and drive a car. In the workplace, there are many other activities, including operating complex machinery, which should be subject to a similar recorded process.
At the time of the inquest, the director of Rainbow Waste Management claimed that staff were fully trained on the company's health and safety procedures and that the victim had been put through a full training program on how to operate the vehicle.
However, when it came to the court case, Rainbow was unable to demonstrate that thorough training had taken place. If training had been provided, the HSE evidence suggested it hadn’t been understood, as by watching CCTV they found over two hundred examples of unsafe working practices in the ten days leading to the accident.
Case 2
In the second prosecution a 29-year-old worker was filling gas cylinders from a high-pressure filling system. The cylinders were produced by a small company in Lancashire for sale to restaurants and pubs which use them for dispensing drinks.
A risk assessment of a task such as this would show that an essential control is to carry out comprehensive pre-fill cylinder checks, to make sure there is no fluid left in the cylinder and that there are no cracks in the cylinder walls.
The HSE states that the worker had not received “adequate training or instruction” on how to do these checks. Whether they had been shown on the job or not, the lessons had clearly not been learnt, and the employer could present no training records in its defense.
The outcome was an explosion, leading the young man to have one leg amputated below the knee.
The employer was fined £40,000, plus nearly £6,000 in costs. For a small firm with total assets of less than £1 million, a significant sum to find.
Don’t forget about forgetting!
An often-overlooked element of employee training is that skills become forgotten over time. We naturally fall into habits or our own way of doing things and can sometimes become blind to hazards in environments we are familiar with. Skills can also diminish through lack of use.
Let’s take a hypothetical situation where a new paper company employee has received training and been signed off as competent on the use of small trolleys and larger roll-cages as manual handling aids.
For several weeks the employee is successfully using the small trolleys, but one day they are required to use a large roll cage. The employee is unaware that the roll cage is damaged and becomes difficult to move with heavy cargo. After much pushing and pulling the roll cage falls and injures the employee.
The learning and forgetting curve (see below) demonstrates how when we first start learning, we quickly become more knowledgeable or more skillful. Over time it becomes more difficult to take new information in, and we need a break (the top of the blue curve). Then we start to forget, quickly at first, then more slowly as time goes on. The green line shows the minimum we need to know to do something safely and effectively – we overlearn initially because we will forget.
If we refresh the knowledge before we have forgotten too much, we can cause our efficiency to peak again (the purple curves). The more often we do that, the less likely we are to lose our competence. The red line shows the day of the accident - for our employee, the purple curves show that repeated use of the smaller trolley meant that on the day of the accident she was still competent. The blue line shows where she was with the roll cage.
To decide how often to re-train you need to consider the tasks people do, the competency needed – and the consequence if it goes wrong.