Bakery Scenario

Following a serious and well publicised accident, you have been newly recruited as a Health and Safety Advisor at a bakery organisation. The organisation employs directors, shift managers, maintenance engineers and bakery workers.

The organisation produces bread on a large scale using automated machinery. Ingredients are
mixed together to make a dough. The dough is placed in baking tins on a conveyer which travels through an oven, baking the dough into bread. There are three large bread ovens at the bakery, as well as other machinery used to prepare the dough. This is all housed in a large warehouse.

The bread baking ovens are long, metal-encased tunnels with a conveyor running through them. The conveyor is made up of horizontal racking, bolted through metal plates at either end of the conveyor chain. The conveyor is approximately 20 metres long and 3.3 metres wide (approximately 66 x 11 feet), taking up virtually the whole of the width of the oven. The bread dough is placed in tins that enter on one end of the conveyor, travel along the length of the oven and exit at the opposite end. Travelling at its fastest speed, the tins take 17 minutes to pass through the oven.

The directors do not believe that health and safety is a full-time job, but they hope that you will improve the bakery’s health and safety performance, learn lessons from the recent serious accident and, most importantly, improve the reputation of the organisation. They have told you that there is no budget for health and safety, but if something is needed, you should present an argument for how it will improve profit. You ask who the health and safety representatives are within the organisation and are told that there are none with whom to raise specific safety issues. However, if a machine needs to be fixed you should contact the maintenance engineer.

You also ask if any health and safety training is provided to staff and are advised that as far as
training is concerned, there is an induction for new starters within six weeks of joining the
organisation. New starters are then shown how to carry out their role by someone else in the
relevant department. You are told that quite a lot of people have received first-aid training, but it was a long time ago and many of those trained have since left the organisation. Other than that, there is not much in the way of training, because the directors feel it is wasting working time. Finally, you ask where the health and safety documentation is kept but they say that they do not know, and suggest you ask the shift manager on duty.

The duty shift manager is sitting at their desk surrounded by paperwork, looking stressed. You
introduce yourself and ask where the health and safety documentation is kept. The shift manager pulls out a folder from a cupboard in the corner of the room and says that risk assessments are in it. You find several completed risk assessments for the ovens and other machinery, but they are very out of date. You ask to see the accident and near miss records, but the shift manager advises that accidents do not happen often, so there is no need to keep a manual record. However, you have heard from the other workers that accidents and near misses frequently occur, but that they are not formally reported.

You ask where the inspection and maintenance documentation for the bakery machinery is kept and are directed to the maintenance engineer. The maintenance engineer explains that they do not keep a record of inspections and maintenance other than in their work diary, and that they can see when a machine was last used from that diary. They have been doing the job for over 15 years and ‘just know’ which machines have had work done to them. When they are working on a machine, they check certain parts at the same time. They also remark that as the machines are quite old, they frequently need parts replacing. The workers have been promised new machines a few times, but these promises have not been kept.

The recent accident

As part of your remit to learn lessons from the recent serious accident, you decide to investigate what happened. Your enquiries reveal that the accident occurred when the bakery was under pressure to get an urgent order completed. You find out that the directors often allow workers to cut corners when it comes to safety measures, to enable them to get the job done as quickly as possible and without costly delays. Workers are often individually blamed if target timelines are not reached.

This is how the accident happened. On a night shift, the conveyor racking collapsed into one of the ovens stopping it from moving. The maintenance engineer, usually assigned to fix breakdowns, only worked day shifts. Waiting for this engineer to come back on shift would have caused significant downtime, and would have prevented the order from being completed on time. Feeling under pressure, the shift manager on duty discussed the issue with their team to try to get the oven back up and running. It was decided that a newly promoted maintenance engineer and another young worker were assigned to enter the bread oven to retrieve the fallen racking themselves. No-one on the night shift had ever been present when an oven had needed entering before. The correct way to enter the oven for maintenance work would have been to remove the side panels. However, this would have
taken a long time, as specialist tools that they were unfamiliar with, would have to be found and used.

The oven had only been switched off for two hours, but it was assumed that it was cool enough to enter. The temperature gauges were not checked before entering. The two workers decided to enter via the route the bread would take on the moving conveyor. They managed to get on the conveyor through a small unguarded gap.

Once the workers had entered the oven, they soon realised it was too hot. They were unable to get the attention of their colleagues outside of the oven, but eventually managed to alert them by shouting for help. Their colleagues tried to get them out of the oven, but they did not know how to do this, or locate how far they were inside the oven. Everyone was frantically trying to help but there seemed to be no-one in charge to take control of the situation. As a result of this, there was a delay in getting them out. There was no way to reverse the conveyor belt, so the workers had to forcibly pull off barriers and side panels to help them escape. Both workers who entered the oven suffered serious burns. Workers at the scene were not first-aid trained but did their best to help their colleagues. Unfortunately, both workers died from their injuries at the scene. The workers who helped get them out were traumatised by what they had witnessed and had to take extended periods off work to recover. There were also some workers who felt they could no longer work at the bakery
and resigned.

Following the accident, the bakery was closed for two weeks while an investigation took place. The associated downtime caused many missed production deadlines and loss of contracts. The organisation, the directors and duty shift manager were all prosecuted for breaches of health and safety legislation. They pleaded guilty to all the counts against them. The organisation was fined £350 000 and ordered to pay costs of £250 000. Since the accident, the bakery has lost bread orders due to clients not wanting to be associated with them.

3 thoughts on “Bakery Scenario”

  1. Interesting scenario, breakdown of puwer, no maintenance records of checks , no corrective actions, what risk assessment was made regarding going in to the oven after a cool off period and how is this measured. What temp was agreed, how were they allowed to get in via an acess hatch with no signage. No experience, poor leadership and a culture of production first and worker second.

  2. Incredible case study – there are some many breeches of health & safety protocol. There should have been clear procedures in place to follow in the case of a breakdown, all relevant staff should have read and signed that documentation to say they understand the procedures that need to be followed and the potential risks of not completing the job in the correct way. The ultimate impact on the business was significant.

    • Hi Colin,
      Can you identify what the breaches were and use information from the scenario to support your opinions?
      Reading and signing training documentation…any other ways of confirming that the training has been effective.
      Can you comment further on the significant impact on the business?


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