When the obscured sign really shouldn’t have been a factor – you don’t mix chemicals
What happened?
Technicians were fixing swimming pool filtration equipment at Springs Leisure Centre in Sheffield, operated by Sheffield City Trust, in May 2016. Two chemicals were present where they were working. There was a safety notice warning against mixing the two chemicals, but this was partially obscured and the instruction manual and risk assessment documents were not stored with the equipment.
The two chemicals did mix, and chlorine gas escaped into the swimming pool area.
The gas was able to escape as initially the doors between the plant room and the pool were propped open, but when the maintenance workers realised what had happened they shut the doors and opened the fire escape.
However, a combination of the draught and a fault with the ventilation system meant the gas continued to escape into the pool area. The leisure centre had to be evacuated.
The incident led to eight children and six adults being treated for minor burns. None of those involved in the incident had any ongoing health problems as a result.
Legal Outcome
The prosecutor at the court case argued that had a safety notice warning against mixing the two chemicals not been partially obscured, and the instruction manual and risk assessment documents been stored with the equipment, then the incident could have been avoided.
A spokesman for the city trust responsible for the leisure centre said the incident was the result of a ‘convergence of unlikely factors.’
Sheffield City Trust admitted breaching health and safety rules, and were fined £7,000 and ordered it to pay £5,500 costs in December 2017. The judge said: “We feel insufficient attention has taken place regarding safety notices and the incorrect siting of instruction manuals”.
What can we learn from what happened?
There is no doubt that safety notices and other forms of information detailing the potential for risk were necessary, and them being partially obscured, or not present is clearly a mistake. Such availability of information, however, should only be regarded as a back-up control to support other controls. A technician working in a swimming pool plant room really should not need a sign to tell him or her that chemicals must not be mixed. It’s pretty fundamental, and one of the first things you are taught.
Also, one of the first controls should be the effective segregation of the incompatible chemicals, so they can’t mix. We don’t have details of the plant room layout or the competency of the technicians, but these measures come way before putting a sign up or having a manual on the shelf.
The trust since provided further training to maintenance staff at its twenty-seven venues and manuals and risk assessment documents were kept with the machinery.
Source of Information
SHP Online