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Safety, Health, Environmental & Quality Bulletin No 683

01 August 2019

Multiple Levels of Defence

We have recently had a potential incident report where it was identified that we didn’t have a COSHH
assessment for a product we were about to use on a new project.

During the initial project planning the need for two new chemicals was identified, and the Material
Safety Data Sheets (MSDS) for both were obtained, but only one was sent for evaluation, the other
forgotten about.

During training of crews, a crew identified that they where missing the COSHH assessment. The
COSHH assessment was then generated before the product was used.

This incident shows the need for multiple checks in
safety systems, as we all make mistakes and things
can be missed. This is often referred to as the
Swiss Cheese model, as each layer of defence has
holes, but each additional layer reduces the chance
of a holes aligning.

Often it can be seen as a waste of time having to
keep carrying out checks that somebody else is also
checking, but this incident shows the need for these
checks, and that they work.

When you are carrying out checks, audits or inspections, be aware of why you are doing so, its not just a
paperwork exercise, or to comply with some law or rule, you are doing it to make sure nobody else has
missed something that could injure you. If you don’t complete the check/inspection, or just tick boxes
without thought, then you are removing a layer of cheese from the defences.

We are all a product of learning. Every skill we have; everything we know; everything we believe and everything we do has
been learned throughout the course of our lives. Some of us learn best by studying graphs and charts, some through visual
presentations, and some by reading detailed text books. It is important that we receive information in a format that works for
us as individuals! That’s why at Xmo Strata we use a variety of communication platforms such as bulletins, newsletters,
videos etc. However, if you feel there is a better way for us to share health and safety information, please let us know.
Ultimately, your safety is in your hands – but we will do all we can to keep you well informed!