Safe Systems of Work

A lack of safe systems of work resulted in a cargo handling company being fined after the employee was fatally crushed at a container park in Portsmouth.

On 25 August 2017, Mr Mieczyslaw Tadeusz Siwak, a 34-year-old father-of-one, was working for Portico Shipping Limited (formerly MMD (Shipping Services) Limited) on the night shift in the container park. His job was to connect refrigerated container units to electrical supplies, which his colleague had lifted into position for him using a container stacker vehicle. It was during one of these manoeuvres that Mr Siwak was fatally crushed between two containers.

An investigation by the Health and Safety Executive (HSE) found that the company routinely failed to provide adequate supervision of operatives and drivers working on the night shift to ensure safe systems of work were followed. This included failure to use safe walkways to segregate pedestrians from vehicles and the safe operation of container stackers by driving with shipping containers in the raised position to allow visibility.

Portico Shipping Limited of Guildhall Square, Portsmouth, Hampshire pleaded guilty to breaching Section 2(1) of the Health & Safety at Work etc. Act 1974. At Portsmouth Magistrates’ Court the company was fined £200,000 and ordered to pay costs of £15,631.61.

“Safe systems of work should be in place on sites with moving vehicles to prevent pedestrians coming into contact with traffic or moving machinery. When moving containers by container stacker, the load should be transported as low as possible whilst maintaining full line of sight.

“Supervisors must be given the necessary instruction and training to implement the safe systems of work and manage hazards during operation processes.

“This tragic incident was entirely preventable had the correct safety management procedures and supervision been in place at the site.”

HSE inspector Rebecca Lumb

Safe Systems of Work

A formal management system or framework can help you manage health and safety and ensure that you have safe systems of work in place – the decision whether to use a recognised management system is up to employers and it is not a requirement of the HSE. Examples include:

National and international standards such as:

  • ISO 45001:2018 Occupational health and safety management systems – Requirements with guidance for use
  • BS EN ISO 9001:2015 Quality management system

in-house standards, procedures or codes

sector-specific frameworks such as the:

  • Energy Institute’s High-level framework for process safety management
  • Chemical Industries Association’s Responsible Care framework

Although the language and methodology vary, the key actions can usually be traced back to Plan, Do, Check, Act methodology.

safe systems of work
Is a certified management system right for your business?

HSE Position on ISO 45001

ISO 45001 is an international standard for health and safety at work developed by national and international standards committees independent of government.  Introduced in March 2018, it replaced the current standard (BS OHSAS 18001) which will be withdrawn. Businesses had a three-year period to move from the old standard to the new one.

Businesses are not required by law to implement ISO 45001 or other similar management standards, but they can help provide a structured framework for ensuring a safe and healthy workplace.

If your organisation is small or low-risk, you will probably be able to demonstrate effective risk management without a formal management system. A simpler and less bureaucratic approach may be more appropriate such as that outlined in HSE’s guidance on health and safety made simple.

Implementing ISO 45001 may help your organisation demonstrate compliance with health and safety law. But, in some respects, it goes beyond what the law requires, so consider carefully whether to adopt it.

If your organisation already has a developed health and safety management structure, or you are familiar with other management standards, it may be straightforward for you to adopt ISO 45001. However, if your organisation is small, with less formal management processes, you may find it difficult to interpret what the standard asks for or gauge what proportionate implementation looks like.  This may particularly be the case if you are adopting management standards to meet supply chain requirements of customers or contracting bodies.

The HSE has expressed concern about the practical implementation of the standard, including audit and certification, and whether it can be easily tailored to work effectively for organisations of all sizes and levels of complexity in a way that’s in proportion to the risks they must control.

Contracting bodies and customers should therefore ask themselves whether the supplier really needs certification to 45001, or whether they can demonstrate competence in managing health and safety using other means.

Compliance with health and safety law

HSE inspectors continue to rely on a wide range of evidence and observations when assessing an organisation’s compliance with health and safety law, not just whether they claim to meet the ISO 45001 standard or not.  The HSE’s guide on managing for health and safety (HSG 65) may help your organisation as it provides a clear process-based approach to risk management. However, adopting a formalised management system approach, whether HSG65 or ISO 45001, may not be the most appropriate model for your businesses, particularly if it is small or low-risk.


Your organisation can apply the standard to your activities (in full, or in part) to help provide evidence of good health and safety management, and improvements made, without getting certification. However, you can only claim to conform to the standard if it is implemented fully.


To implement ISO 45001 in a proportionate way, auditors or certifiers should understand that it needs to be (i) tailored to an organisation’s size and level of complexity, and (ii) in proportion to the risks.  You should ensure that any auditor or certifier you use has evidence that they are competent to a recognised standard.  The certification body should be accredited by either the United Kingdom Accreditation Service (UKAS) for ISO 45001 or an equivalent accretion body that is member of the European Cooperation for Accreditation (EA) or the International Accreditation Forum (IAF).


Businesses should try to keep health and safety documents functional and concise, with the emphasis on their effectiveness rather than sheer volume of paperwork.  Focusing too much on the formal documentation of a health and safety management system will distract you from addressing the human elements of its implementation – the focus becomes the process of the system itself rather than actually controlling risks.

Attitudes and behaviours

Effectively managing for health and safety and having safe systems of work is not just about having a management or safety management system. The success of whatever process or system is in place still hinges on the attitudes and behaviours of people in the organisation (this is sometimes referred to as the ‘safety culture’).

The HSE has published Are you doing what you need to do? Which provides examples of what positive health and safety attitudes and behaviours will look like in the workplace. On the other hand, the examples provided of ‘What it looks like when done badly or not at all’ could indicate underlying cultural issues which employers should address.

Our health, safety and environmental consultants have experience in implementing management systems into client operations including ISO 9001, ISO 14001 and ISO 45001.  If your business needs advice and support with your management system, please contact one of the Ashbrooke team.