Risks 587 - 22 December 2012

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Asbestos - the hidden killer
Hazards magazine
Hazards at Work

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Editor: Rory O'Neill of Hazards magazine. Comments to the TUC at [email protected]

TUC Risks is taking a seasonal break and will be back on 15 January 2013.

Union News

Quick fire move leaves workers dangerously insecure

A government move that will make it easier to for firms to fire their staff will do nothing for the economy but will leave workers much more insecure, the TUC has said. The warning came after ministers announced the 90-day consultation period before large-scale redundancies can take place is to be cut to 45 days from April 2013. Employment relations minister Jo Swinson said: 'Our reforms will strike an appropriate balance between making sure employees are engaged in decisions about their future and allowing employers greater certainty and flexibility to take necessary steps to restructure.' But TUC general secretary Brendan Barber responded: 'The last thing we need is for the government to make it easier to sack people. Unemployment has not gone as high as many feared because employers have worked with unions to save jobs, even if it has meant sharing round fewer hours and less work. The need to consult unions has made an important contribution to that, and also given staff, many of whom will have had years of loyal service, time to think through their options.' He added: 'These measures will not create a single extra job. The idea that an employer will change their mind about taking someone on because the statutory redundancy consultation period has been reduced from 90 to 45 days is close to absurd. Removing consultation rights from fixed-term contract staff will seriously increase job and financial insecurity for vulnerable groups of workers, and temporary staff will lose out on redeployment opportunities.' Recent reports have linked job insecurity to higher injury and sickness rates and poorer health overall, including a greater chance of suffering heart disease and strokes (Risks 573).

Injury highlights Crossrail safety concerns

Unite has demanded an investigation into an incident on the Crossrail project that left an electrician in hospital with 70 per cent burns. The man, who has not been named but who was working for subcontractor Barhale, was seriously injured on 12 December when he struck a below ground electrical cable on a Holborn site in central London. Unite had earlier raised concerns about safety standards, blacklisting (Risks 586) and victimisation of safety reps (Risks 575) on Europe's largest construction job. Unite national officer, Bernard McAulay said: 'There must now be an immediate open and transparent investigation into this serious accident. It is time Crossrail recognises the need to address our serious concerns over health and safety on the project. In the last two months there have been two major incidents.' He added: 'Unite is becoming increasingly concerned over the continued resistance of Crossrail Ltd to enter into meaningful discussions to establish an overarching collective agreement which will cover health and safety and industrial relations. The agreement reached with the unions for the Olympics delivered the project on time, to budget and without a major incident. Crossrail must now get serious about engaging meaningfully with Unite.' A spokesperson for the Blacklist Support Group, which protested outside the Department for Transport after the incident, commented: 'Having sacked safety reps for pointing out the danger of an exposed 12,000 volt live cable at their Westbourne Park site, Crossrail now need to explain how a worker was able to accidently cut through another live cable at their Holborn site. The resulting explosion set him on fire and has left him in hospital with 70 per cent burns.' He added that main contractors Bam, Ferrovial and Kier are in receipt of billions from the public purse for the project and called for 'a public enquiry now as to why they are putting their workers' lives at risk.'

Nautilus welcomes maritime safety report

Seafarers' union Nautilus has welcomed a parliamentary report that echoes the union's concerns over UK government cuts in maritime safety provision. Following a further inquiry into changes in the UK Coastguard service, the loss of emergency towing vessels (ETV) and the closure of the Maritime Incident Response Group's specialist at-sea fire-fighting service, the House of Commons transport committee last week warned search and rescue standards could be at risk (Risks 586). As well as raising concerns about the loss of experienced coastguard staff, MPs also highlighted warnings from Nautilus about the safety risks arising from the loss of ETVs around the UK coast. Their report added the 'decision to end funding of MIRG was short-sighted.' Nautilus general secretary Mark Dickinson commented: 'We welcome this report, which correctly identifies the potentially serious effects on safety at sea caused by spending cuts. We urge the government not to dismiss the warnings that are contained here, but to act urgently on the recommendations.'

Retired train driver gets work cancer

A train driver who was exposed to asbestos has received a 'substantial' payout after he was diagnosed with a devastating occupational disease. Robin Gould from Westbury, Wiltshire was diagnosed with mesothelioma in January 2012 after suffering from breathlessness. The 73-year-old retired member of the trade union ASLEF has been told by doctors that there is no cure for the asbestos related cancer. Mr Gould was exposed to asbestos while working on trains as a fireman, cleaner and then driver for the former British Railways Board. Asbestos was used to lag boilers and cylinders and between casings on the trains. Mr Gould, who worked on the railways until he retired after 55 years' service, was never provided with protection from the dust, nor warned about the dangers to his health. The out of court settlement negotiated by solicitors brought in by the union included a payment of £2,000 towards his care at Dorothy House Hospice Care, a charity based near Bradford-on-Avon. Mr Gould said: 'Dorothy House Hospice has provided me with a great deal of care during the last few months and I felt it was important that they were recompensed for their work.' Mick Whelan, ASLEF's general secretary, commented: 'Many of our members and retired members were exposed to asbestos working on the railways and we will continue to fight their corner to ensure they are fully compensated for asbestos disease.'

Other news

HSE gifts us a seasonal sanity clause

The Health and Safety Executive (HSE) has no intention of grounding Santa, the safety body's top official has confirmed. HSE chair Judith Hackitt was responding after a 14 December front page splash in the Daily Star headlined 'Elf and safety Santa ban' proclaimed: 'Health and safety nuts have banned Father Christmas from an annual parade that has been staged without a problem for almost 50 years. The bureaucrats ruled it would be too dangerous for the festive hero to sit on top of a float that travels at walking pace.' HSE's Judith Hackitt indicated the story, regarding an event planned by the Rotary Club in Sutton, south London, was Christmas crackers. She said: 'Clearly nobody wants Santa injured at this, his most important time of year. But regular parades take place all year around all over Britain and floats are a major part of that tradition. Others have been successful in finding ways of safely letting performers ride on vehicles so I am curious to know why you considered this was not possible.' Calling on the Rotary Club to reveal the real reason Sutton's Santa could be de-sleighed, the HSE chair added: 'There may be genuine reasons why the Rotary Club has taken this decision, but there is nothing in health and safety law which stands in your way.' In the run up to Christmas, HSE is urging firms not to be Christmas puddings. It is publishing its 'top twelve festive myths, gifted to HSE from media reports and correspondence received.' Top of the Xmas fairy tales are 'Santa needs a seatbelt in his sleigh' and 'workers are banned from putting up Christmas decorations in the office.'

Double standard should have workers fuming

A pollution double standard that means workers can be permanently exposed to levels of fumes several times the public safety limit has been highlighted by concerns raised at Edinburgh's Waverley train station. The Sunday Herald reported last week that exhaust fumes from trains and taxis, coupled with toxic dust kicked up by construction works, are endangering the health of commuters, tourists and workers - particularly those with asthma, lung or heart conditions. Network Rail commissioned consultants to monitor the station continually for three weeks in October and November. Their report found average levels of nitrogen dioxide varying from 205 to 304 micrograms per cubic metre, compared with the annual average 'air quality standard' of 40 required by European law. According to experts, the levels to which many passengers were exposed at peak times would be much higher than another legal limit of 200 micrograms per cubic metre, set for one hour's exposure. Scientists also found high levels of tiny particles known as PM10s, which inflame lung tissue and increase the risk of heart attacks and strokes. They were nearly twice as high as the air quality standard, and up to 10 times higher than in nearby streets. Dr Sean Semple, an air pollution expert from the University of Aberdeen, said the levels 'may breach internationally-agreed air quality standards. Pollution levels measured within the station could pose risks to people with asthma or heart and lung conditions. The risks need to be further investigated, and Network Rail should continue to do what it can to minimise pollution particularly from diesel engines within the station.' But he added: 'While the concentrations of pollutants are well within the workplace exposure limits that apply in the UK, Network Rail's data show that levels of nitrogen dioxide (NO2) are higher than the Air Quality Standards for public spaces.' This means the public are protected by a much tighter standard, despite spending only short periods in the heavily polluted station. Rail workers and concourse staff are exposed all day, every working day.

Legal challenge to unfit fit for work tests

A man who was incorrectly found fit for work under the government's disability benefit assessment is launching a legal action against the government and Atos, the private company performing the tests. Patrick Lynch, a former social care worker who was forced to stop work because of a condition affecting his brain, is seeking a judicial review of the controversial 'work capability assessment'. More than 11,000 disabled people a week are taking the tests, which involve interviews with Atos doctors and nurses to identify those who can work. Mr Lynch, the first individual to sue over the assessment, is claiming that the government and Atos failed to record an interview despite assurances from ministers that all could be taped. In his first interview in September 2010 Lynch was found fit for work - despite five months previously undergoing brain surgery and being told by his doctors 'I was on death's door. I mean I came in on crutches and could not pick things up because I was afraid of falling over.' An appeal against the Atos assessment was eventually successful. In his lawsuit, he argues that ministers and the company acted unlawfully in failing to provide enough devices to record sessions. Lynch's solicitor Tessa Gregory of Public Interest Lawyers says that the assessment process 'constitutes an unacceptable risk of unfairness. We hope these safeguards will be instituted to help mitigate that risk.' TUC general secretary Brendan Barber is backing the challenge. He said: 'Assessments of disability must be fair and proportionate, treat people with respect and be part of a consistent system. There is overwhelming evidence that they have fallen far short of these basic standards. It is right that they should be challenged in court.'

Birth defects linked to solvent exposures

Exposure to organic solvents during pregnancy increases the risk of certain types of birth defects, a new study indicates. Researchers found mothers with greater exposure were 4 to 12 times more likely to have babies with oral clefts than mothers with less exposure. Metabolites of two large classes of organic solvents - glycol ethers and chlorinated solvents - were linked to occupational use of cleaners and cosmetics in jobs such as hairdressers, chemists and nurses. Exposures at work are commonplace as solvents are present in many paints, adhesives, glues, coatings and are used as degreasing and cleaning agents. They also are used to produce dyes, polymers, plastics, textiles, printing inks, agricultural products and pharmaceuticals. This case-control study enrolled women in the second trimester of pregnancy in Brittany, France, from 2002-2006. The women were asked about their contact with 11 classes of products containing certain solvents from work, home or hobbies and about their occupation. They also provided a urine sample that was tested for 10 metabolites of glycol ethers and chlorinated solvents. The authors assessed exposures three ways: self-reported by the women, the tasks the women performed at work and levels of metabolites measured in the urine samples. Using either self-reporting or job classification, the more a pregnant women was exposed to solvents the more likely it was that her baby would have certain birth defects. Women who reported regular exposure to solvents were four times more likely to have a baby with an oral cleft compared to women who did not report regular exposure. Using job classifications, exposed women were 12 times more likely to have a baby with an oral cleft as compared to unexposed women.

  • Cordier, S, R Garlantézec, L Labat, F Rouget, C Monfort, N Bonvallot, B Roig, J Pulkkinen, C Chevrier and L Multigner. Exposure during pregnancy to glycol ethers and chlorinated solvents and the risk of congenital malformations. Epidemiology, volume 23, number 6 pages 806-12, 2012 [abstract]. Environmental Health News.

Crane driver drowns in icy river

A crawler crane driver drowned while dredging an icy river in Cambridgeshire when his machine tipped into the freezing water. The Environment Agency was fined £220,000 and ordered to pay £28,584 costs after admitting a catalogue of errors led to the employee losing his life. Simon Wenn, 43, died on 8 December 2010 while working with a colleague on the maintenance of the Counter Drain at Mepal. He was operating a crawler crane rigged as a dragline to dredge sediment from the bed of the watercourse. The water was frozen and the river bank on which the crane was positioned was frosty and wet. Timber tracking mats were laid to provide better grip and stability for the work, and to protect the grassy bank from damage. Cambridge Crown Court heard that at around 9.30am, Mr Wenn was repositioning one of the tracking mats. He used the crane to move the mat from behind and swing it to position in front of him. However, as it rotated the crane started to slowly slip towards the water and then tipped into the watercourse. Mr Wenn was trapped in the cab of the crane. Emergency services were called and tried to free him, but despite their best efforts both he and the machine continued to sink. He drowned as freezing water filled the cab and was pronounced dead at 8.19pm. An investigation by the Health and Safety Executive (HSE) found that the crane Mr Wenn was operating had been fitted with a 19 metre boom instead of the manufacture specified maximum of 16 metres when used as a dragline. HSE also established that the Environment Agency had made an inadequate assessment of the technical requirements at the Mepal site, and of the impact of the cold weather. The system of work for lifting and positioning the tracking mats was unsafe, and there was a lack of planning and competent site supervision. The death followed a similar incident in Norfolk in 2008 involving a smaller tracked machine operated by Environment Agency employees. HSE found the agency had failed to act on the findings of its own internal investigation into this incident.

Skip firm fined following death of worker

A skip company has been fined for a criminal safety offence at a West Bromwich site where an employee was killed when he was run over by a 13-tonne shovel loader. The Health and Safety Executive (HSE) prosecuted Need a Skip Ltd at Wolverhampton Crown Court for failing to ensure that workers and vehicles were safely segregated on the site. The 24-year-old worker, named in local papers as Wayne Meylan, died of his injuries at the firm's premises. The loader struck him as he was crouching over a manhole cleaning out a drain pump in the yard on 11 September 2006. HSE's investigation found that Need a Skip Ltd did not have a transport plan in place to segregate people from vehicles and the company's on-site health and safety training plan had not been adhered to. The court was told the company had previously been informed of the risks associated with workplace transport by HSE during a routine inspection. Need a Skip Limited pleaded guilty to a criminal safety breach and was fined £45,000 and ordered to pay costs of £125,000. After the hearing, HSE inspector Karl Raw said: 'The ad hoc approach by Need a Skip to its on-site activities, combined with heavy machinery moving around, meant there was a high potential for an incident to occur.'

Herdsman died after falling through dairy skylight

A herdsman died after carrying out unplanned and unsupervised repair work on a dairy roof and falling through a plastic skylight, a court has heard. William Luscombe, 65, was carrying out the work for his employer, TRD Griffin and Son Partnership at Willsworthy Farm, North Tamerton on 14 October 2010. Exeter Crown Court fined Roy Griffin, a partner in TRD Griffin and Son Partnership, £5,000 and ordered him to pay £8,800 in costs in the case brought by the Health and Safety Executive (HSE). The court was told Mr Luscombe had been lifted onto the roof in the bucket of a telehandler to carry out repairs. Plastic skylights are widely known to be fragile and liable to fail if someone stands on them. As he was working, Mr Luscombe fell three metres onto the concrete floor below, sustaining serious head injuries. He was airlifted to Derriford Hospital in Plymouth but later died of his injuries. The HSE investigation found that no plans had been made for the work, as required under law, despite a sign at the site which warned of a fragile roof on the dairy. Speaking after the hearing, HSE inspector Georgina Speake, said: 'Mr Luscombe, although an experienced herdsman, did not have any training for working on roofs and was working without supervision. No equipment was provided which could have prevented or mitigated the effects of a fall, such as safety nets or suitable boarding.' Farms are exempted from unannounced preventive HSE inspections. There will only normally be any chance of an HSE visit after a serious incident.

Dangerous scaffold leads to life-threatening fall

A plumber suffered life-threatening injuries in a fall at an outdoor activities centre after proper scaffolding was replaced with a defective tower scaffold. The 64-year-old man from Llandovery, who has asked not to be named, was working on the refurbishment of an accommodation block at the site near Gwynfe in Carmarthenshire when he fell three metres on 15 March 2012. He lost consciousness and suffered a bleed to his brain, a fracture to his cheek bone, bruised ribs and further damage to his existing back condition. He now requires morphine for his back pain and has been unable to return to work. Carmarthen Magistrates' Court was told the principal contractor overseeing the project, Evans Brothers Builders Ltd, had arranged for the scaffolding to be removed from the site before the injured worker had finished fitting new waste pipes to the outside of the building. He was given a scaffolding tower to use, but a Health and Safety Executive (HSE) investigation found this was in a dangerous condition. It did not have all of the protective guardrails around the platform to prevent workers falling off the edge and the worker who fell had to use an unsecured ladder leaning up against the tower to climb on and off it as there was no internal ladder access. Evans Brothers Builders Ltd pleaded guilty to a criminal breach of the Work at Height Regulations 2005 and was fined £5,000 and ordered to pay £3,685 in prosecution costs. Speaking after the hearing, HSE inspector Anne Marie Orrells said: 'If Evans Brothers Builders had planned the project properly then it would have known it needed to keep the scaffolding for a few more days, or provide alternative equipment so that the waste pipes could be fitted safely. The scaffolding tower and unsecured ladder it provided was clearly not fit for use and the moment the worker attempted to climb it, his life was put in danger.'

Pupils and school staff exposed to asbestos

Staffordshire County Council and a refurbishment firm have been fined for exposing a nursery class, school staff and two joiners to asbestos fibres. Rugeley firm G Evans (Services) Ltd was refurbishing Glenthorne Community Primary School in Cheslyn Hay for the council when the incident happened on Friday, 13 February 2009. Stafford Crown Court heard two joiners were cutting through a large built-in cupboard in the nursery class when they noticed unidentified material nailed to the back of it. They showed this to their site manager, who allowed them to carry on dismantling the cupboard and to detach the material. However, the material was asbestos insulating board, which by law should only be moved by a licensed asbestos removal contractor. The court heard the joiners used an ordinary vacuum cleaner to clear up dust and debris, which would have spread asbestos fibres in the air. Seventeen children aged between three and four, were in the classroom, together with a teacher and teaching assistant. A school cleaner, who was working in the classroom later in the day, was also exposed. The following Monday, an analyst, who was monitoring asbestos levels in the air during licensed asbestos removal work, spotted pieces of asbestos insulating board in an open skip. The school was closed immediately for investigation and subsequent decontamination. HSE inspector David Brassington said after the hearing: 'A series of assumptions and missed opportunities led to contractors, school staff and nursery age children being exposed to asbestos fibres during refurbishment work.' Staffordshire County Council was fined £10,000 and £5,000 costs. G Evans (Services) Ltd was fined £8,000 and ordered to pay £4,000 costs. Both had pleaded guilty to criminal safety offences.

International News

Australia: Xmas rush is fatal for truck drivers

A spate of fatal truck crashes on Australian roads in the run up to Christmas is a reminder of the pressures facing truck drivers every day when they step into the cab, their union has warned. Speaking on 17 December, Tony Sheldon, national secretary of the Transport Workers' Union (TWU) said: 'There have been a series of fatal truck crashes across the country in the past week, with reports indicating seven people losing their lives. The full details of each crash have yet to become clear and our thoughts are first and foremost with the families and loved ones of those involved. These incidents should be investigated not only by State road authorities and coroners, but also by workplace accident investigators, because the roads are a workplace for truck drivers.' He added: 'One death on our roads is too many, but when so many people are losing their lives in truck crashes each week, it highlights the scale of the safety crisis and the lethal pressures in the trucking industry. Every day across Australia, truck drivers and transport companies are forced to meet unrealistic demands and in the run up to Christmas, this pressure can become even greater.' The union leader said major transport clients, particularly in retail, need 'to take responsibility now for the safety of everyone in their supply chain and their role in pressuring truck drivers and transport companies through impossible demands, unreasonable demands and dangerously low rates of pay.'

Global: Union pressure on Walmart after fire

Three powerful global union organisations are demanding that Walmart acts to prevent deadly working conditions persisting in its supply chain. The call from the International Transport Workers' Federation (ITF), UNI and IndustriALL comes in the wake of a 22 November 2012 fire at Tazreen Fashions in Bangladesh, a firm producing Walmart's 'Faded Glory' brand clothing, in which over 100 workers died (Risks 586). The global unions are asking the world's largest retailer to provide fair redress for the victims, to support a full and transparent investigation, and to adopt 'meaningful measures' to prevent future incidents. They were speaking out as several shipments of clothing bound for Walmart from the Tazreen factory were scheduled to arrive on the US East Coast. Jyrki Raina, general secretary of IndustriALL, the global union for the garment sector, commented: 'Walmart and other brand owners and retailers profiting from the textile industry in Bangladesh must reveal their list of suppliers in full transparency and verify the safety standards and workers' rights at the factories they are sourcing from. Walmart must ensure their pricing and sourcing policy is based on their suppliers complying to safe working conditions so that a tragedy such the one at Tazreen Fashions does not occur again.' In the last two years, fires in Bangladesh and Pakistan have taken the lives of nearly 500 apparel workers, at plants producing for Gap, H&M, JC Penney, Target, Abercrombie & Fitch, the German retailer KiK and many others. Scott Nova of the Worker Rights Consortium said three factors explained how Bangladesh came to be the world's second largest apparel producer; 'the industry's lowest wages (a minimum apparel wage of 18 cents an hour), ruthless suppression of unions, and a breathtaking disregard for worker safety.'

Japan: Fukushima nuke plant operator admits blame

The operator of a Japanese nuclear power plant that blew up after the 2011 tsunami has admitted its lack of a safety culture and bad habits were behind the world's worst nuclear incident in 25 years. The operator, Tokyo Electric Power Co (Tepco), said it accepted the findings of a parliamentary inquiry into the Fukushima nuclear disaster that accused the company of collusion with industry regulators. The earthquake on 11 March 2011 generated a tsunami that smashed into the nuclear plant on Japan's north-east coast and triggered equipment failures that led to meltdowns and the release of large amounts of radiation into the air and sea. Takefumi Anegawa, the head of Tepco's company reform taskforce, said the report by a parliamentary committee contained 'so many descriptions about the lack of a safety culture and our bad habits.' He told a news conference in Tokyo at the Foreign Correspondents Club of Japan: 'We admit, we completely admit, that part of the parliamentary report' where the committee found the disaster was preventable and the result of 'collusion' between the company and regulators.

Korea: Samsung job did cause breast cancer

A South Korean government agency has accepted that working at a Samsung Electronics factory caused the breast cancer of a worker who died in March 2012. The Korea Workers' Compensation and Welfare Service, a part of the labour ministry, ruled there was a 'considerable causal relationship' between the woman's cancer and her five years of work at a semiconductor plant near Seoul. Samsung spokesperson James Chung said the multinational would not appeal the government's decision. The company is the world's largest maker of computer memory chips. The mother of two, DE Kim, died age 36, three years after being diagnosed with breast cancer. She worked for Samsung from 1995 to 2000. The agency did not say how much compensation was paid, but spokesperson Kang Byung-soo said it usually amounts to nearly four years of a worker's salary. 'There was an exposure to organic solvents and radiation. The earlier the exposure is, the more likely the cancer is caused,' the workers' compensation agency said in a statement about Mrs Kim's case. It added that it also reviewed records from overseas which showed that working night shifts is linked to a higher risk of breast cancer. Lee Jong-ran of the campaign group Supporters for the Health and Rights of People in the Semiconductor industry (SHARPS), said the latest decision will have a positive impact on Samsung employees who are hoping to prove a link between their diseases and working conditions at Samsung Electronics. 'Because the government recognised the link, people who have pending lawsuits will feel encouraged,' she said. In April, the compensation service compensated a former Samsung worker who suffered from aplastic anaemia. Last year, a Seoul court ruled that a Samsung semiconductor plant caused the cancer of two former employees (Risks 512). The compensation service, which had earlier rejected claims from the two workers, is appealing the court's decision.

USA: Low wage workers hurt most by work

Low waged workers injured or made ill at work face multiple disadvantages, with poor employment protection and health care costs compounding their suffering, a new study has found. 'Mom's off work 'cause she got hurt: The economic impact of workplace injuries and illnesses in the US's growing low-wage workforce', was published this week by researchers from George Washington University School of Public Health and Health Services (SPHHS). Co-author Celeste Monforton said: 'Workers earning the lowest wages are the least likely to have paid sick leave, so missing work to recuperate from a work-related injury or illness often means smaller pay cheques. For the millions of Americans living pay cheque to pay cheque, a few missed shifts can leave families struggling to pay rent and buy groceries.' Monforton and co-author Liz Borkowski point out low wage workers often get an unexpected surprise after an on-the-job injury or illness, even where they have insurance: Insurers generally do not have to provide wage replacement until the worker has lost between three and seven consecutive shifts. And workers at the low end of the wage scale are often discouraged from reporting on-the-job injuries as work-related - which leaves them with no insurance benefits at all. This means lost wages and health care costs - which can be considerable - are not covered. They call on policymakers to address this public health problem more forcefully by improving workplace safety and strengthening the safety net to reduce the negative impacts caused by the injuries and illnesses that still occur.


SUBSPORT case histories on substitution

SUBSPORT, the Substitution Support Portal, is an online resource that provides information to aid a reduction in the use of harmful substances used at work, including a database of alternatives to hazardous chemicals. The rapidly developing database now includes more than 200 substitution case stories. The information is not just provided by companies; a number on substitution case histories have been submitted by trade unions and other organisations, such as the Swedish National Substitution Group - a network of practitioners at universities and hospitals that promote substitution.

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