Management failures that contributed to the accident:

1. Inadequate communication:
* Supervisor failed to read out crucial announcements about the contractor’s
presence (Ref: “Deciding it can be done later, they put the announcement sheet
in their pocket”).
* Contractor was unfamiliar with the layout and crossed a roadway to find
assistance (Ref: “The contractor runs across one of the roadways”).
* Supervisor left worker B alone with limited information after raising concerns
about workload (Ref: “They go on to say that flights of that size normally require
multiple ALAs”).
2. Poor supervision:
* Supervisor left the zone during the contractor’s work and the accident (Ref:
“The supervisor is then called away to resolve an issue in the neighbouring
zone”).
* Supervisor neglected to address worker B’s concerns about working alone and
dealing with excessive baggage (Ref: “This irritates worker C who tells worker B
to do as they are told”).
* Lack of adequate follow-up after assigning responsibilities to worker C (Ref:
“The supervisor tells worker C to allocate the distribution points”).
3. Unhealthy team dynamics:
* Informal hierarchy where older workers pressure younger ones (Ref: “most of
the ALAs have a good working relationship within their teams. There is an
informal hierarchy where the longest serving workers feel that they are justified
in giving orders to the newer or younger workers”).
* Worker C bullied worker B into accepting a challenging task alone (Ref: “This
irritates worker C who tells worker B to do as they are told, or they will report
worker B to the supervisor”).
* Worker C disregarded worker B’s concerns and laughed at their situation (Ref:
“As worker B is walking to their distribution point, they see other workers
laughing and pointing at them”).
4. Pressure to prioritize speed over safety:
* Emphasis on on-time baggage delivery leading to rushing and cutting corners
(Ref: “the highest priority is to deliver the baggage to the correct aircraft on
time. This has resulted in an increase in near misses in the past year”).
* Worker B felt compelled to exceed the speed limit due to perceived time
pressure (Ref: “concerned that they are late, they drive the tow truck faster than
the speed limit”).
5. Insufficient training and support for new workers:
* Limited experience of worker B may have hampered their ability to handle the
situation adequately (Ref: “Worker B began working as an ALA in zone 3; this was
one week before their 18th birthday”).
* Lack of targeted training for new ALAs on handling high-pressure situations and
challenging workloads.

6. Inadequate staffing and resource allocation:

* Assigning single worker to manage high volume baggage from a large flight
(Ref: “worker B is managing this on their own”).
* Potential understaffing leading to pressure on individual workers to perform
tasks quickly.

7. Lack of safety culture:

* Near misses not addressed effectively (Ref: “near misses in the past year”).
* Potential tolerance for unsafe practices due to focus on productivity.
* Limited focus on building a culture of safety and open communication.

8. Inadequate risk assessment and management:

* Potential risks associated with contractor presence and unfamiliar layout not
fully assessed (Ref: “The supervisor remarks that “that is good and should save
me time showing you around. We use the same plant, equipment and processes
here, but we have a different layout”).
* Lack of regular safety audits and hazard assessments.

9. Insufficient training for supervisors:

* Supervisor may not have received training on managing complex situations,
near misses, and contractor interactions.

10. Inadequate communication with contractors:

* Contractor arrival and work area not clearly communicated to all personnel
(Ref: “The supervisor tells worker C to allocate the distribution points”).
* Contractor not given proper safety briefing and layout familiarization (Ref: “The
contractor had only worked in zone 1 of this airport”).

11. Ignoring worker concerns:

* Supervisor failed to follow up on worker C potentially delegating unsafe tasks
(Ref: “This irritates worker C who tells worker B to do as they are told, or they will
report worker B to the supervisor”).
* Lack of system for reporting and addressing concerns without fear of
retribution.

12. Overreliance on informal power structures:

* Allowing worker C to act as an “unofficial deputy” potentially creating confusion
and bypassing formal supervision channels (Ref: “Worker C has worked in zone 3
for the longest time, and often acts as an unofficial deputy for the zone 3
supervisor”).

13. Inadequate enforcement of safety rules and procedures:

* Speed limit violations tolerated or not addressed effectively (Ref: “concerned
that they are late, they drive the tow truck faster
14. Insufficient investment in safety technology:
* The scenario doesn’t mention technology like proximity sensors or improved
warning systems (Ref: “Scenario does not mention specific safety technology”).
* Lack of investment in technology that could potentially help prevent accidents
like this one.
15. Inadequate incident investigation and **
* No information is provided in the scenario regarding previous incident
investigations or corrective actions taken (Ref: “Scenario lacks information on
past incident investigation”).
* Lack of a robust system for learning from past incidents and implementing
measures to prevent future occurrences.

Rephrased Answers:
1. As in scenario, supervisor show negligence in reading out important
announcements regarding the contractor’s presence that leads to inadequate
communication. Henceforth, he failed in said regard leading to severe
accident.
2. From the scenario, it can be observed that supervisor went out of the zone
during the contractor’s work and the accident remaining the cause of failures
contributed to the accident.
3. Through scenario, informal hierarchy also contributed to the accident where
experienced workers pressurized inexperienced workers. This informal
hierarchy disturbs the environment of health and safety of the workers as
seen in scenario.
4. As per scenario, speed remain the priority over safety by putting pressure on
the employee. As worker B was being compelled to increase the speed limit
due to time constraint.
5. As seen in scenario, there was limited training and support for the new
workers, due to which worker B was unable to handle the situation efficiently
and effectively.
6. From scenario, worker B was managing the high volume baggage from a big
flight by his own due to which he was over-utilized. This shows the inadequate
resource allocation and understaffing which remain the potential cause of
accident.
7. As from scenario, near misses were always used to be ignored. It reflects the
lack of safety culture. Management has limited focus to introduce safety
culture and open communication.
8. By scenario, potential risks along with contractor presence and improper
layout were not completely evaluated. As it lead to inadequate management
as well as risk assessment, and no regular safety and hazards audits were
assessed.
9. From scenario, Supervisors haven’t had training on managing critical
situations, contractor interactions and near misses. Management has
provided insufficient training to the supervisors.
10. In scenario, contractor arrival and workplace were not being communicated
and shared with all work force, showing inadequate communication with
contractors.
11. As per scenario, supervisor failed to have a follow up on worker C potentially
given unsafe tasks. This displays the lack of mechanized system for reporting
and resolving concern without any fear.
12. In scenario, worker C act as an unofficial spokesperson by enhancing
confusions and bypassing the formal channels leading to the informal power
hierarchial structures.
13. As in scenario, speed limit violations are not completely being addressed or
resolved by having inadequate execution of safety rules and procedures.
14.