Man is a social animal and down the ages he has strived hard to discover himself through materialism and opulence. In this process he has landed himself and the rest to mind blowing ecological disasters that questioned his pursuits for comforts. Yet man is not ready to learn from his past. I would like to bring forth an incident that, by human error, has led to 7 deaths and many getting affected in the process. Many would not accept the fact that entertainment centres offer a large variety and scope for unhygienic conditions which generally tend to get ignored, in the name of commercialisation. Disease spread and its epidemeology is least understood by many, including experts, since the involvement of multitude of factors.
One chiller and one cooling tower gone out of service as shown in the figure above. Due to the failure of the fan scroll units the fan unit in tower 1 was isolated. The fan damper on tower 2 was reducing the volume of air that was passing up through the tower. Despite these failures, the system was still working as one chiller unit was servicing one cooling tower. The biocide drums were found empty which was the result of the failure of the chemical biocide dosing arrangement to deliver chemical into the system.
The erroneous administration of termination of the contract that was found in order between 1994 and March 2001 for the water treatment on the cooling towers at forum 28 building and entering into the new contract by the manager is one of the factors responsible for the havoc. The lack of knowledge and perhaps the commercial outlook of the manager led to faulty alternative contract in late 2000 that led to the cancellation of the contract and resignation of the manager.
The design Services Group (DSG) with its expertise and know-how in contract management that had procured the previous provider was involved in the procurement of the replacement contract. But Ms.Beckingham, the DSG manager had erred in the recording of the minutes of meeting in July 2001 where there was discussion on water treatment. "Checking /dosing to be omitted was recorded by her''. This error was acted upon while procuring the replacement contract. This was done in view of the expenditure involved, which resulted in not attending to chemical treatment, microbiological monitoring and system checks, thereby neglecting the Health and Safety law.
Recommendation:An appointment of responsible person with managerial skills would have bridged the communication gap between Forum28 and leaders which would have prevented the outbreak.The responsibilities and relationships within their Health and safety policy need to be defined by the organisations to avoid the ignorance of serious risks such as Legionella.
The laws to control and prevent outbreaks of Legionnaire's disease ensure that the operating systems such as cooling towers and other industrial hot water systems are managed properly so as to prevent the risk of exposure to Legionella bacteria. Approved Code of Practice and guidance, commonly referred to as L8, describes the legal duties and provides practical guidance on how to comply with the law. Assessment of risks of Legionnaire's disease, Preparation of plans or schemes to control the risks,managerial oversight and to put the plan into action are the criteria of L8.Programmes like inspection,maintenance involving regular cleaning and disinfection dosed with a biocide which acts as an effective chemical to prevent the growth of Legionella bacteria are included in the schemes of L8.Maintenance of records with safety operations of the cooling tower and the practical advices on the legal obligations are provided by L8.
The Health and Safety (Enforcing Authority) Regulations 1998 allocate to HSE and LAs the responsibility for enforcing the Health and Safety at Work etc Act 1974 and the relevant statutory provisions, subject to specific exceptions, in different premises, depending on the main activity. HSE regulates health and safety in factories, farms, mines, nuclear installations, offshore installations, hospitals, schools and many other sectors. Local authorities are responsible for enforcement in offices, shops and other services.
