Help with Course Project. Must use APA Format throughout to include Reference Page.
Unit VIII Course Project
1. Conduct an audit of the following safety management system elements at your organization or an organization with which you are familiar and have access to the required information:
Below you will find some suggested sources for the objective evidence to support your evaluation:
Documents: Organizational safety manuals and instructions, safe operating procedures, and job hazard analyses Records: E-mails or letters from management to employees, safety meeting minutes, mishap logs, audit reports, Occupational Safety and· Health Administration (OSHA) citations, inspection reports, risk assessments, and training records
Interviews: Management personnel, supervisors, and employees
Observation: Walk through some workplaces to observe conditions for yourself.
2. For each management system element, discuss the objective evidence you found or were unable to find. Evaluate the effectiveness of the organization’s implementation of each element against available reference sources and best practice information. Use the following four-tier evaluation scheme to rate each element:
World Class: OHS performance
Strong: Conforming/complete, may have minor gaps with action plans
Moderate: Scattered non-conformances need to be addressed, positive trends/major elements in place Limited: Multiple or significant systemic non-conformances exist.
Appropriate references include the course textbook; textbooks from other college-level courses; ANSI/AIHA Z10-2012; other published consensus standards like ANSI, ASSE, AIHA, ISO, and NFPA; OSHA standards and voluntary guidelines; and articles published in professional journals. Blogs, Wikipedia, About.com, Ask.com, and other unmonitored Internet resources are not considered scholarly references and should not be used. Please contact your professor if you have any questions about the appropriateness of a source.
3. If an element is found to be less than World Class, provide recommendations for improvement. Be sure to use appropriate scholarly sources to support your recommendations.
4. Provide a summary of the overall status of the organization’s safety management system and comment on the degree of alignment between the safety management system and other management system efforts utilized at the facility.
The Unit VIII Course Project must be a minimum of seven pages and a maximum of 10 pages in length, not including the title and reference pages. A minimum of five professional sources must be used.
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Course Learning Outcomes for Unit VIII
Upon completion of this unit, students should be able to:
1. Develop effective safety management policy statements, goals, and objectives.
1.1 Develop recommendations to improve an existing safety management system based on
standards and best practices.
7. Examine management tools necessary to implement effective safety management systems.
7.1 Appraise the effectiveness of an organization’s incident investigation process.
7.2 Perform an audit of a safety management system and summarize findings in a report.
Reading Assignment
Chapter 21:
Evaluation and Corrective Action: Section 6.0 of Z10
Chapter 22:
Incident Investigation: Section 6.2 of Z10
Chapter 23:
Audit Requirements: Section 6.3 of Z10
Chapter 24:
Management Review: Section 7.0 of Z10
Unit Lesson
In this final unit, we will consider some important aspects of safety and health management systems and tie
some of this discussion in with the Plan-Do-Check-Act (PDCA) process. We will discuss, for instance, how
incident investigation fits into the big picture, and we will consider some scenarios in relation the PDCA so
that you can have a better grasp of how the PDCA process works to foster continuous improvement for
multiple projects taking place in a given organization. Our focus will be on safety and health, but keep in mind
that the PDCA process can be used throughout the organization for everything from hiring to upgrading office
decor.
A popular saying in management circles is, “What gets measured gets done,” or sometimes, “What gets
measured gets managed.” The second version has significant meaning for safety management systems. The
PDCA cycle compels us to Check, which is typically an activity that involves measuring the degree to which
we are successful in the first stages of a given endeavor. Often, when we begin to implement a plan, we
discover through observing the process, Checking, that there are bugs that need to be worked out, so we
work them out, thereby improving the process. In essence, our measurements help us reach conclusions
about effectiveness. Unfortunately, the effectiveness of many safety programs is simply measured by a
reduction in, or absence of, injuries and illnesses, and the PDCA cycle never really has a chance to go full
circle, particularly if incidents are low. Why worry about continuous improvement, after all, if everything seems
to be going along okay?
Complicating matters is the fact that the Occupational Safety and Health Administration (OSHA) uses incident
rates to compare industries, compare organizations within industries, and determine inspection priorities.
Incidence rates are certainly useful for OSHA, and the presence of high incidence rates can be an indicator of
serious problems, but lower incidence rates does not necessarily mean everything is okay for a given
UNIT VIII STUDY GUIDE
Auditing and Management Review
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UNIT x STUDY GUIDE
Title
employer. As we have noted throughout the course, risk of an incident is based on hazard severity and
probability of occurrence and cannot be brought to zero or accurately predicted. Indeed, some employers that
do not focus many resources on safety can sometimes go for years without a serious injury or illness just due
to chance alone. Although incidents and incidence rates can be useful, there are also drawbacks with using
them as a sole indicator of success.
Another concern that is common within industries with respect to incidence rates is goal setting that focuses
only on staying below industry incidence rates averages. Again, OSHA utilizes industry averages to identify
companies with higher industry rates to target for programed inspections. OSHA also requires facilities to be
below industry averages to participate in OSHA’s Voluntary Protection Program, so OSHA actually provides
incentives to focus on setting the bar at average rather than continuous improvement. Thus, not only are
incident rates not always the most dependable indicators, they also have an unintended effect of establishing
mediocre goals for safety performance as coming in just below average is considered a success in many
organizations.
If we do not want to rely solely on incidents to check our safety performance, then what do we use? Blair and
O’Toole (2010) suggest that organizations consider measuring activities such as safety walkthroughs, safety
meetings, and hazards corrected. Measuring such activities can help identify and mitigate factors that lead to
incidents. Indicators such as these can be useful for preventing injuries and illnesses from happening in the
first place. Because these types of activities tend to be done before an incident occurs, they are called leading
indicators. In other words, an indicator such as a safety meeting that emphasizes the need to pre-inspect
forklifts to make sure they are mechanically sound can help prevent a future accident such as toppling over
palletized product on the production floor due to faulty brakes.
The discussion of leading indicators does not mean that lagging indicators such as incident rates do not have
value, of course. Indeed, the actual instances themselves can yield valuable information and should not be
ignored simply because they are not perfect. For instance, incident trending can point to problem areas that
need immediate attention, and many large organizations with sophisticated safety and health management
systems spend a great deal of effort trending incidents in the workplace. If there are multiple laceration-
related injuries suddenly occurring in the shipping and receiving department, for instance, the multiple injuries
themselves can trigger a more thorough investigation of the trend in hope of preventing future occurrences.
This investigation may discover a common cause to the sudden spike in lacerations such as the inadvertent
purchase of the wrong type of box cutters by the purchasing department that do not have safety features
required by the company.
Manuele (2014) also notes that incident investigation can be a significant source of information. He indicates
that incident investigation should be given a much higher priority than is typically found in most organizational
safety programs. Unfortunately, many incident investigations are little more than paper exercises driven by
OSHA or Workers’ Compensation record-keeping specifications that fail to go beyond obvious employee
errors or workplace hazards in identifying causes. Current accident investigation theories recognize that there
are many layers of causal factors involved, even for adverse events where causes may seem obvious
(Oakley, 2012). The findings from a quality incident investigation that identifies system failures can be a
significant source of feedback, which can then be considered in the Plan phase of the PDCA process.
Throughout the course, we have focused on the management system outlined in ANSI/AIHA Z10, but that
does not mean other standards should not be used. The standards and best practices that are selected for
use in an organization are dependent on the maturity of the organization’s safety efforts and how the
organization manages other parts of its critical operations. If ISO management standards are used in other
parts of the organization, perhaps ISO 18000 is a better fit. Each organization is unique. ANSI/AIHA Z10 was
based on many of the best features from existing standards. Studying it in depth, as we have done in this
course, provides the safety practitioner insight into many of the other safety management system standards.
In looking at various occupational safety and health standards, however, it should be rather obvious that they
tend to be quite similar. One similarity that should stand out to the seasoned practitioner is the underlying
PDCA, continuous improvement cycle approach. Thus far in this unit lesson, we have focused on the Check
phase of the cycle in discussing the types of indicators we utilize to evaluate the success of our safety
endeavors. The next step is the Act phase in which we utilize the information and do something about the
information gathered, such as implementing corrective actions. Once we do so, we move forward in the cycle
once again to the Plan phase to take the next step toward improving the safety program further.
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UNIT x STUDY GUIDE
Title
It should be noted that the PDCA process and where a given process is in the cycle is not always simple,
clear cut, and easy to identify. Let’s consider a macro level application of the PDCA approach to illustrate.
Consider a large-scale management plan to retool a manufacturing operation with ergonomically designed
work stations based on an earlier ergonomics assessment. Once the plan has been laid, the Do phase may
involve a pilot study of a couple of work stations. The Check phase may involve a follow-up ergonomics
assessment of the workers using the new stations compared to old stations. The Act phase may include
tweaking and moving forward with the remainder of the installations. This moves us back to the Plan phase,
which may involve planning a similar project for another part of the plant where there are similar ergonomic
issues to further improve the facility’s safety performance or the new installations.
Within this overall project, however, there may be micro-level continuous improvement efforts taking place.
For instance, there is the ergonomics assessment which itself must be planned by the safety and health
management team. Once the Plan of the ergonomics assessment is complete, the actual assessment is
initiated which arguably places it in the Do phase. No assessment works perfectly, and evaluating how the
assessment is going Check, will result in adjustments and corrections to the investigation process to assure
the workstation analysis process yields the most useful information to assure success, Act. This is obviously a
learning process, and what is learned will be considered during the planning phase of the next ergonomics
investigation or in moving forward with the current one.
Likewise, the crew that is installing the new workstations will have their own PDCA cycles that results in
organizational learning and continuous improvement. The planning phase will require planning the actual
installation. What tools will be needed? What trades will be involved? The Do phase might involve installing
the first workstation. The Check phase might include evaluating the first work station, and the Act phase may
involve making the necessary corrections to increase efficiency and quality of the installations and moving on
to planning the installation of the remainder of the work stations.
What we see here is not just one overall, PDCA process, but multiple PDCA cycles taking place
simultaneously at different levels. The point of this all, of course, is that this process fosters organizational
learning which, in turn, results in continuous improvement at all levels of the organization. This continuous
improvement activity becomes incorporated into the actual culture of the organization and helps to drive
improvement and success throughout the organization.
References
Blair, E., & O’Toole, M. (2010). Leading measures. Professional Safety, 55(8), 29–34. Retrieved from
https://libraryresources.waldorf.edu/login?auth=CAS&url=http://search.ebscohost.com/login.aspx?dire
ct=true&db=bth&AN=53160422&site=ehost-live&scope=site
Manuele, F. A. (2014). Advanced safety management: Focusing on Z10 and serious injury prevention (2nd
ed.). Hoboken, NJ: Wiley.
Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and
applications (2nd ed.). Des Plaines, IL: American Society of Safety Engineers.
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UNIT x STUDY GUIDE
Title
Suggested Reading
In order to access the following resources, click the links below.
The additional chapter from the textbook and the additional resources below are suggested readings or
resources that can provide further reading and safety measures:
Chapter 25:
Comparison: Z10, Other Safety Guidelines and Standards, and VPP Certification
Blair, E., & O’Toole, M. (2010). Leading measures. Professional Safety, 55(8), 29-34. Retrieved from
https://libraryresources.waldorf.edu/login?auth=CAS&url=http://search.ebscohost.com/login.aspx?dire
ct=true&db=bth&AN=53160422&site=ehost-live&scope=site
Health & Safety Executive. (2001) A guide to measuring health & safety performance. Retrieved from
http://www.hse.gov.uk/opsunit/perfmeas
https://libraryresources.waldorf.edu/login?auth=CAS&url=http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=53160422&site=ehost-live&scope=site
https://libraryresources.waldorf.edu/login?auth=CAS&url=http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=53160422&site=ehost-live&scope=site
http://www.hse.gov.uk/opsunit/perfmeas
EVALUATION. AND CORRECTIVE
ACTION: SECTION 6.0 OF 210
In applying the Plan-Do-Check-Act concept for an occupational health and safety
management system, the last two steps are to evaluate performance (6.0A) and take
corrective action when nonconformance is found (6.0B). The following is a depiction
of the applied POCA concept and how it relates to the processes required in Section
6.0, “Evaluation and Corrective Action.”
Plan: Identify the problem(s) (hazards, risks, management system deficiencies,
and opportunities for improvement, as in the planning section, 4.0).
Plan: Analyze the problem(s).
Plan: Develop solutions.
Do: Implement solutions.
Check: Evaluate the results to determine that:
1. The problems were resolved, only partially resolved, or not resolved.
2. The actions taken did or did not create new hazards.
3. Acceptable risk levels were or were not achieved.
Accept the results, or tak~ additional corrective action, as needed.
<) . • • ' , I
Act:
ev
1
1t s~ys in Section 6.0C that processes are to be in place to “include results of a uation act· · · · (6 5) ” 1v1ties as part of the planqing process apd management review. . .
~ –.. · .
Seconct Editio ty :anagement: Focusing on ZJO and Serious lnJury Prevention,
© 2014 John ;.
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438 EVALUATION AND CORREC TIVE ACTION: SECTION 6.0 OF 210
dback processes in place to communicate . tions have iee h .
The intent is that orgamza learned about system s ortcollllngs, so that ding lesson~
back to manage~ent regar . l d d ·n the planning process. • · · an be me u e 1 appropriate acuv1ues c
NG MEASUREMENT, AND ASSESSMENT SECTION 6.1: MONITORI ‘
nt and assessment include workplace inspec. thod fi itoring measureme ‘ . .
~• s or mon ‘ incident tracking, employee mput, occupat1ona) health
uons, exposure assessme;ts, ro ance relative to applicable legal and other require-
assessment, assessment
O
pe orm . ti’ and other methods as required by the
ments as determined by the organiza on, · · . .
• al h alth and safety management system. Fmdings denvmg employer’s occupation e . ted arti s
from those processes are to be communicated to _mteres . p . e . .
Li · b dant on workp· lace inspections. That subJect 1s not addressed terature 1s a un . .
here further. Measurements of effectiveness ‘with respect to. exposure a_s~essments
and occupational health assessments are to determine ho~ well the requrrements in
the assessment and prioritization processes set forth Section 4.2 h~ve been ~l~lled.
They require that organizations have processes in place to assess nsks perta.irung to
health and safety exposures.
Although establishing p(?rformani;:e measures , is not one of the subjects listed
in the “shall” provi~ions in Section 6.0, the advisory comments say in E~.lC that
“organizations should devel(?p ~easures of performan~.e that enable them to see how
they are doing in preventing injuries and illnes.s,e~.”.
To have statistical validity, the performance mea,sures adopted should consider the
extent of the exposures (perhaps hours worked) as well as evaluations of the effec.
tiveness of safety and health management systems. Although the advisory information
in E6.1 C refers to occupational injury and illness rates as performance measures,
a precaution is given indicating that such rates shQuld not be the sole or primary
measurement tool. A dissertation that speaks of performance measures suitable for
organizations of various sizes may be found in the chapter “Measurement of Safety
Performance” in On the Practice of Safety, 4th edition.
The effectiveness of the processes outlined in Section 3.0, “Management Leadership
and Empl~yee Participation:• would be the basis of performance measurements on
empl~y~ mput. The p~isions !• Section 3 .2, “l;mployee Participation,” state: ‘The
~8amzation shall establish and implement Processes to ensure effective participation
:::: 07″upation~ h~°’. and ~afety management system by its employees at all
the orgamzat10n, mcludmg those working closest to the hazard(s).”
SECTION 6.2: INCIDENT lt.lVESTIGATION
Since I now give 8reater emphasis t h . . .
the spectrum of safety and h alth
O
t e importance of incident investigation within
subject appears here-.chapt e 22 ;a~age1?ent systems, a separate chapter on the
er · ncident tnvestigations, well made, can be a good
SECTION 6.5: FEEDBACK TO THE
PLANNING PROCESS 439
to identify cultural, operational, and technical .b .
sourc! r incidents that result in serious injury or dam contn uting factors, particu-
JarlY 10 . age.
s1:cr10N 6.3: AUDITS
11
vt”ng audits made of safety and health management ~ystem.s t d ‘ . . ria d ·ct ·t . . . o etermme their
~ectiveness an to 1 entI y opportumt1es for improvement 1· s the b. f S . eu• £ di . . su ~ect o ectmn
6.3, The goal of a sa ety au . t is to provide management with an assessment of the
–nlity of the safety culture m place and to provide recommendation h, th
IW1-‘ • ed Thi · s on ow e
culture can be improv . s important measurement process is also the subject of
a separate chapter, Chapter 23.
SECTION 6.4: CORRECTIVE AND PREVENTIVE ACTION
Although the requirements for corrective and preventive action are set forth briefly,
the importance of this section should not be minimized. To fulfill its requirements,
organizations are to have processes in place so that corrective actions are taken
expeditiously: on the deficiencies in occupational safety and health management
systems, inadequately controlled hazards, and newly identified hazards that are
discovered in the monitoring process.
This section also requires that processes be in place to “review and ensure the
effectiveness of corrective and preventive actions taken.” Item E6.4, an advisory,
says that an effective occupational health and safety management system would
“identify system deficiencies and control hazards in any part of the system to
an acceptable level of risk.” Item E6.4B offers a precaution-zero risk is not
attainable and should not be sought. It says that “risk cannot typically be elimi-
nated entirely, although it can be substantially reduced through application of the
hierarchy of controls. Residual risk is the remaining risk after controls have been
implemented.”
SECTION 6.5: FEEDBACK TO THE PLANNING PROCESS
The Purpose of this section is to assure that hazards, risks, and safety and he~~
rnanag th ru· toring measurement, au ,
• . ement system deficiencies observed in e mo ‘ . . . mmuni-1nc1dent . ti action act1v1t1es are co
cated IDvestigation, and corrective and pr~ven ve. h oing planning and
lllan to the appropriate parties and considered m t_ e ,;°:g objectives are to be
rev· agement review process. As a result of that commun~ca to achieve a more
ef£ 18~ and modifications are to be made in implementauon P
ective health and safety management syStem.
440 EVALUATION AND CORRECTIVE ACTION: SECTION 6.0 OF 210
CONCLUSION
When applying the Plan-Do-Check-Act continual improvement_process, an important
element is to determine whether the management systems put m place achieve what
is intended. That is the purpose of Section 6.0, to provide an ~valuation mechanism
so that system deficiencies can be identified and acted upon. This is an important
continual improvement function.
REFERENCE
Manuele, Fred A. On the Practice of Safety,’ 4th ed. Hoboken, NJ: Wiley, 2013.
111111
ctfAPTER 24
. \
MANAGEMENT R.EV.IEW;
SECTION 7.0 OF 210 .
section 7.0 opens with this statement: “This section defines the requirements fot the
periodic review of the occupational health and safety management system .. ” The
importance of the management review requirements in ZlO is inverse to the ·length of
this chapter. ,
In Chapter 1, “An Overview of ANSI/A/HA ZJ0-2005-the American National
Standard for Occupational Health and Safety Management Systems” we stated that
Section 3.0, Management Leadership and E!Ilployee,, Participation, is the most
important section in ZlO. Top management leadership is vital because it se~s, the
organization’s safety culture and because continual improvement processes cannot
be successful without effective top management direction. To achieve superior results,
top management must repeatedly “walk the talk”. · ‘
We also said that Section 7 .0, the management review section, was a close second
importance. Maintaining superior management ·leadership · requires that evalua-
tions be made of the effectiveness of safety processes so that improvements can be
made w_here necessary. J _ • •
Section 7 .1 requires that “the organizatioµ shall estabhs~ process for top
management to review the occupational health and safety management system at
least · · d · b’li ~nnually and to recommend improvements to ensure its continue suita 1 ty,
adequacy, and effectiveness ” This section lists inputs fo the management review
Process t b . . .. • , 0 e considered, among which are:
~ -····· .
Second ~fety’ Management: Focusing on ZJO anti Serious Injury Preventwn,
2014 Jo on .. Fred A. Manuele.
hn Wiley & Sons, Inc. Published 2014 by John Wiley & Sons, Inc.
483
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484 MANAGEMENT REVIEW: SECTION 7.0 OF 210
A. Progress in the reduction of risk
· G. Toe objectives to which objectives have been met
H. The performance of the occupat~on~l health_ and _safethy m~nag_ement
systems relative to expectations, takin~ mto cons_ideration c angmg c_ircum-
stances, resource needs, alignment with the busmess plan, and consistency
with the occupational health and safety policy.
At the conclusion of the review (Section 7 .2), top management shall determine the:
A. Future direction of the OHSMS based on business strategies and condi-
tions; and
‘ . ‘
B. Need for changes to the organization’s · policy, priorities, – bbje~tives:
resources, or other OHSMS elements. · ·
Action items for improvement are to be drafted as the performance assessment is
made and “Results and action items from the management reviews shall be docu-
mented, communicated to affected individuals, and tracked to completion.”
•As shown below, the management review process begins with the “check” step in
the Plan-Do-Check Act model and provides input to , senior management so ,that
processes put in place previously can be accepted as satisfactory or revised, as in the
“act” step.
Plan: Identify the problem(s) (hazards, risks, management system deficiencies,
and opportunities •for improvement, as in the planning section, 4.0).
Plan: Analyze the problem(s). ·
Plan: Develop ·solutions.
Do: Implement solutions. , ,
Check: Evall,late th,e results to determine that:
1. The problems were resolved~ only partially resolved, or not resolved.
2. The actions taken did or did not create new hazards.
3. Acceptable risk levels were or were not achieved.
Act: Accept the resu;Iis, o~ _take additional’ corrective action, as needed.
J •
. 1:he writers of the ZlO ~t{lnqard may apprecifl~~ the recognitiop given to the
significance of the s_tandard, particularly thi ~ 1}1.anagement revie’Y section. On
March
23
, ~005, a senous workplace disaster occurred at the BP Texas City refinery.
It resulted m 15 deaths and more than 170 injuries. A blue ribbon panel, populated
mostly by ~own experts, was created with financial support from the U.S. Chemical
Safety Re:-iew Board to “make a ~orough, independent, and credible assessment of
the effectivenes~ of BP’.s corporate oversight of safety management systems at its
five U.S . refinenes and its corporate •culture.”
MANAGEMENT REVIEW: SECTION 7.0 Of Z10 48~
e Report of the BP U.S. Refinerie,s Independe,nt Sq,fety Review Panel was
Th . January 2007 as a document available to the public It h b d 1n & • 1 • as ecome jssuen in occupational saiety cir~ es fl~ The Baker Report. The panel’s chair was
~ows A, Baker III, who served m sem~r go:vernment posjtions under tl)ree U.S.
JaIJl~dents. Several references are made m th~ r~port to sectioqs in 210.as recom-
pres ded practices. Those references, and by mf~rence the 210 standard, are
file~ that they represent the state of the art in safety and health management 1esnmonY . . ..
Ystems. . tak fr Th 5 h of the followmg, en om e Baker, Report, relates to the content of S::;: 3.o in ZlO, “Management Leadership and.Employee Participation.”
t • ! t
1n 2oos, theAmerican National ~tandards Institute (ANSI) approved “a voluntary
nsensus standard on occupational health and ·safety management systems.”
co dard. . ed d While the stan 1s onent towar occupational rather than process safety, the
Panel believes that the standard provides a ‘ useful tool in analyzing safety ,
management systems generally. The ANSI 210 standard emphasizes “continual .
unprovement and systematically eliminating the underlying or root causes of
deficiencies.” The standard indicates that an organization’s management should
provide leadership and assume overall responsibility for
I I:
• implementing, maintaining, and monitoring performance of the safety
system; , ·. ·
• providing appropriate financial, humah, and organizational resources to
plan, implement, operate,· check, correct, and review the system;
I defining roles, assigning rei~onsioilities, e’stablishing ‘·accountability,
and delegating authority to implement an effective system for continual
• I ; • o i f ,
IIDprovement
‘ • • . I ‘
• integrating the system into the organiiation’s other business syst~ms and
processes. (p. 131)
‘ . ‘
Elsewhere in The Bake~ Report, ob~rvati.on.~ are on management revi~ws ·that
are close to a verbatim copy of wh,at appears in thy, advisory column for Seqtion 7.
Whereas OHSMS is the term used in Section 7, .it has .been repl~ced by the safety
management system in the B~er Report.
‘
~e related comme~tary to the AN~I ‘210 s~ndard provides a usefol des~rip-
tion of tpe r,ole of liJld purpose for managem~nt reviews: , 1 •
‘ Manag~IJl~nt reyiews are a. c.’r,itical part qf the ~ontinuFU improvement of
the [safety management system]. . , • · ·
• The purpose of reviews is fo~ top management, with the participation ?f
[safety management system] leaders and process o~ners, to do a strategic
and critical evaluation of the performance of the [safety management
system], and•to recommend improvements.
486 MANAGEMENT REVIEW: SECTION 7.0 OF 210
. • · · t J·ust a presentation or a non-critical review of the • This review is no . . .
b h ld focus on results and opportumties for continual system, ut s ou . . . .
. t It is up to the organization to determine appropriate improvemen . • · Th h
f [ afiety management system] effectiveness. ey s ould also measures o s ] . . ,
evaluate how well the [safety management system IS integrated with
other business management systems, so it supports both health and safety
goals and business needs and strategies.
Reviews by top management are required because they have the a~thority to make
the necessary decisions about actions and resources, althou~h It may also be
appropriate to include other employee and management levels m th~ proces~. “To
be effective, the review process should ensur~ that the necessary mformatiQn is
available for top management to evaluate the continuing suitability, adequacy, •and
effectiveness of the [safety management system] …. Reviews should present results
(for example, a scorecard) to focus top management on the [safety management
system] elements mrn~t in need [of] their attention.”
At the conclusions of the reviews, . top management should make decisions,
give direction, and commit resources to implement the decisions. The
management review should include an assessment of the current [safety
management system] to address if the system is encompassing all of the risks
to which the organization is exposed. This portion of the review should include
a review of major risk exposures and, as~ the question, “Are there any holes” in
the current [safety management system] that. could a\low a risk that might not
be considered within the [safety management system]. (p. 225)
. . !
Section 3 .0, ”Management Leadership and Employee Participation,” and Section 7 .0,
”Management Review,” are vital and integrated parts of a whole. An organization
cannot achieve superior results if the’perfomiance in these two sections is not stellar.
A management review is to result in a documentation of the action items necessary A d’ M ‘ men~. It con~ists principally of a scorecard, whose purpose is to focus “top manage- s O t e occupat10nal health and safety managemen s ow e followmg perfonnance levels.
• Blue: world-class OHS pe..l’onn • Green: strong· confonni 1 ‘ ng complete, may have minor gaps with action plans
C REFERENCES 487
. 01oderate; sca~ered nonconformances need to be addressed, positive nds/01aJ . . , Red: maJ ‘1’he forego d Th . f A . gra~auo;; :Va1uation systems may be use_d-qualitative or quantitative. They also ake an ID1 , ” · ti’ · rn_ anization s size, opera ons, services, or culture.” A summary report will i,eacceP · • · ‘fhis management rev!eV.: sect10_n _gives ~a1e_ty and health professionals a mean- occup . . ‘th propasals to overcome shortcommgs. Such reports will have greater value if a In many companies, a major management review process is conducted annually REFERENCES
ANSI/AIHA Zl0-2012. American National Standard, Occupational Health and Safety The Repon of the BP U.S. Refineries Independent Safety Review Panel, at http://us.yhs4. p
cHAPTER 23
AUDIT REQUIREMENTS: Revisions made in the audit provisions in the 2012 version of ZlO have them relate d health management systems require- Section 6.3: Audits
The organization shall establish and implement a process to: has ap_propriately applied and effectively implemented OHSMS elements B. Audits shall be conducted by competent persons who are independent C. Document and communicate audit results to: representatives.
Second Ed ‘ ~Jety Management: Focusing 0 11 ZIO Qlld Serious Injury Prevention , Q 2014 Jo~~on._ Fred A. Manuel e.
Waley & Sons, Inc . Published 2014 by John WLley & Sons, Inc .
463 464 AUDIT REQUIREMENTS: SECTION 6.3 OF Z10
D. Immediately communicate situations identified in audits that could be Having audits made is a part of the Evaluation and Corrective Action processes in Safety audits perform a valuable function in that they determine the effectiveness Also, hazardous situations observed during an’ audit that could be contributing In the advisory column in ZlO opposite the audit requirements, two particularly 1. The safety audits required are not to be merely “compliance” oriented, meaning 2. To promote objectivity, audits are to be conducted by persons independent of To assist safety professionals fo ‘crafting or re-crafting safety and health audit • Establishe the purpose of an audit l •
• Explore management’s expectations with respect to audits . dit guides • Discuss the need to have safety and health management syste~ au . d • Provide information and resources for the development of suitable audit guides
d REASONABLE MANAGEMENT EXPECTATIONS: THE EXIT INTERVIEW 465
NCIPAL PURPOSE OF A SAFETY AUDIT: this book emphasis has been given to the premise that safety is culture Ss of a safety auditing program can only be measured in terms of the succe audits. (p. 36)
Toe Kase and Wiese observation can be supported easily. The paramount goal of as anization’s decision making. Thus, a safety audit report is to serve as a basis for SIGNIFICANCE OF OBSERVED HAZARDOUS SITUATIONS
Physical or hazardous situations in operations observed during a safety audit should l
be gained if no change is made in the overall deci~ion making to improve the • j.
. ‘ S.afety auditing is an exceptionally valuable process but is time consuming and expen- w O make audits should prepare well for the exit interview. That means:
• Having been objective in their evaluations of management systems eing able to support the prioritizing in management’system improvements they Propose 466 AUDIT REQUIREMENTS: SECTION 6.3 OF 210
In an exit interview with informed management personnel,. the auditor or aud’t 1. What are the most significant risks? spend attain sufficient risk reduction.?
Audit systems fail if they do not recognize management needs and if they are not Unfortunately, safety auditors ~annot absolutely ass_ure managements that every It should be ma9e clear to management. that applied safety auditing is based on a EVALUATIONS OF AUDITORS BVTHOSE AUDITED Safety professional~ should. also recognize that the time spent by auditors, the impres~ Four safety and health auditors spent a week making an audit of a 37 employee being disruptive because of the amount of th’eir time that the auditors con- 111111 AUDITOR COMPETENCY 467
f th criticisms made by location management pertained to the decision taken by f the fact that mamtammg tight cost controls was requrred by the organiza- AUDITOR COMPETENCY
hout ZlO there is an emphasis on identifying, prioritizing, and acting on r improvement.” To be able to identify and evaluate those “issues” as they exist in 0 aspects of their hazards and risks and that the audit report was superficial and of little Safety professionals who make audits need to consider how well they are prepared for An excerpt from a paper entitled ”Auditor Competency for Assessing Occupational Several studies have raised questions about the value of quality, environmental ~e foregoing excerpt pertains principally to audits made for management system by in-house personnel. upational h Ith d · d d appear her ea an safety management s!stem ~ud1to~s. Only c~n . ense ex~erpts gage who are external to their organizations. rom the Paper on Auditor Competency ge and skills m occupational health and safety management pnnc1ples
11111………_ • and methods and their application, and related science and technology to • Occupational health and safety management tools (including hazard • An understanding of the physical, chemical, and biological hazards and • The potential interactions of humans, machines, processes, and the work • Methodologies for exposure monitoring and assessment well-being hazards, risks, processes, products, and services to enable auditors to· This list, although abbreviated, provides a good foundation from which a safety ONE SIZE DOES NOT FIT ALL
Many of the statements made in Dan Petersen’s article “What Measures Should We Petersen questions the value of “packaged audits,” giving examples of studies d ONE SIZE DOES NOT FIT ALL 469
system elements ‘fhe re a . h . h . 2, • ns to determme w at is appenmg ty stuff. All elements in a sal;’ety management system while necessary . is mea h d h ‘ , fhlS uallY impact. on . those azar s t at pres~nt the_ ~eatest potential for harm, ra nvemco . . f al.fl . c In th · rta’ t ” t .fi ” kn 1 auditors, one of e items pde ms o sec or-s~eci ic ow edge of operational bthaz Je~ents to be emphasized, much should be made of “sector-specific hazards and . ks”-meaning those m erent m e operations at the location to be ~udited. In sorpe organizations th~ &ame aµdit ,guide i~ used f()r all locations aJ1d the audit This book emphasizes the prevention of seriou~ injuries. When the ,audit .system I~::for low-probabi~ity/serioµs ;-~onseque~c.e even.~ may be ~ess ~an_ !idequate. ic the de · · bb · d expanded a scnp~ve content of the el~m~n,ts to be audited _c~n ~e. a reviat~ or truly, be a1 elf;-t;milt audit system. · 470 AUDIT REQUIREMENTS: SECTION 6.3 OF 210
GUIDELINES FOR AN AUDIT SYSTEM
Appendix L gives guidance on how !o com~ly with the stand~d’s audit requir~ments. The degree of detail in this table may not be needed for every organization, but Therefore, modifications are to be made to fit the culture and the inherent hazards An example of such a practical adjustment in a safety and health evaluation system Appendix L also includes -“suggestions for the objective type of evidence that can The guidance given on objectivity is comparable to the instructions· given in the ~iilce it is proposed that safety professionals not develop a one.:size-fits-a!1 ey de~rmme· whether an organization meets· the requirements of its yotuntar~ fr ‘ th • for om e worksheet appear as Addendum A to this chapter. It is an excellent referenc~ < GUIDELINES FOR AN AUDIT SYSTEM 471
wn in Chapter 25, “Comparison: ZlO, Other Standards and Guidelines, and yPP Certt ZlO provisions, but there are also differences. Some of the VPP require- Reference Chapter 11, “A Primer on Hazard Analysis Chapter 15, “Safety Design Reviews” similarly, certai_n VPP requirements are not addressed in ZlO provisions. During , More specifically, the adequacy of the “Occupational Health Care Program and , Whether “Access to experts (for example, Certified Industrial Hygienists, Safety and health professionals would give appropriate consideration to “the Two other valuable resources that relate closely to the content of the “VPP Site- 1 tc the d’ comf au Itors and the personnel who review and act on ·audit reports are 472 AUDIT RE!JUIREMENTS: SECTION 6.3 OF 210
CONCLUSION
Auditing performance with re~pect to _established ~perational goals is good 1 Professionally done, safety audits provide valuab e m1ormatton to ec1s1on makers It is suggested that a safety professi_onal who propo~es that an organization After the gap analysis is made, a safety and ·health professional would assist Over time, ZlO will become the benchmark against which’. the adequacy of REFERENCES
ANSI/AillA Zl0-2012. American National Standard, Occupational Health and Safety “Auditor Competency for Assessing Occupational Health and Safety Management Systems.” Kase, Donald W. and K~y J. Wies~. Safety Auditing: A Manauement T~ol. New Y~rk: Wjley, 1990. ‘ · q ,t ,
Manuele,_ Fred A. On the Practic~ of Safety, 4th ed. l{obok~n. NJ: Wiley, 2013. dcsp/vpp/vpp_report/~i~-b~ ed.htrµJ. , ·
:etersen, Dan. “What Measures ~hould We Use, and Why?” Professional Safety, Oct. 199S. osh~.gov/dsg/topics/safetyhealth/pep.html. ‘ · · U,S. D~partment of Labor, OSl{A, at http://www.oshagov/SLTC/,etools/safetyheal form331.html · sHft:S VPP SITE-BASED SECTION I: MANAGEMENT LEADERSHIP AND EMPLOYEE A. Written Safety and Health Management System Involvement, Worksite Analysis, Hazard Prevention and Control, and Safety A2. Have all VPP elements and sub-elements been in place at least 1 year? If not, A3. ls the written safety and health management system at least minimally effective A4. Have any VPP documentation requirements been waived (as per FRN, Vol. B. Management Commitment & Leadership leadership with respect to ·the safety and health management system (as per Second Editety Management: Focusing 011 ZIO and Serious llljury Preve11tion, 1 ey & Sons, Inc . Published 2014 by John Wiley & Sons, Inc.
473 474
B2.
B3.
B4.
BS.
OSHl(S VPP SITE-BASED PARTICIPATION SITE WORKSHEET
How has the site communicated established policies ?and results-oriented C. Planning
C 1. How does the site integrate planning for safety and health with its overall C2. Is safety and health effectively integrated into the site’s overall management C3. For site-based construction sites, is safety included.in the planning phase of D. Authority and Line Accountability
Dl. Does top manage~ent accept ultimate responsibility for safety and health? I • ‘ ‘ I
and health functions are delegated to others.) If not; please explain. municated (for example, organization charts, job descriptions, etc.)? authority to ensure that hazards are corrected or . necessary changes to the ,, • , I , •
D4. How are managers, supervisors, and· employees held accouritable for meet- D5. Are adequate resources ( equipment, budget, or experts) dedicated to ensunng D6. Is access to experts (for example, Certified Industrial Hygienists, Certifi~ E. Contract Employees El. Does the site utilize contractors? Please· explain. . ? SECTION I: MANAGEMENT LEADERSHIP AND EMPLOYEE INVOLVEMENT When selecting onsite contractors/sub-contractors, how does the site eval- (including rates). . safety and health management system and to comply with all applicable ES. of hazards in the event that the contractor/sub-contractor fails to correct or E6.
E7. Have the contract provisions specifying penalties for safety and health E8. How does the site monitor the quality of the safety and health protection of E9.
EIO.
El 1.
Do contract provisions for contractors require the periodic review and F. Employee Involvement F3. F5.
F6.
F7. How were employees selected to be interviewed by the VPP team? 476 OSH-4:S Vp p SITE-BASED PARTICIPATION SITE WORKSHEET
1 s informed of the safety and health management F9 How were emp oyee “b’li. ? Pl 1 . sy_ em, ‘ant n”fy employee’s comprehension of the site’s safety and FlO. Did managemen ve · . · · . . .. Fl l. Do employees have access to results of self- mspectl~n, accident investiga- G. Safety and Health Management System Evaluation
G 1. Briefly describe the system in place for conducting_ an annual evaluation. management system, including the elements described in the Federal Register? 03. Does the annual evaluation include written recommendations in a narrative 04. Is the annual evaluation an effective tool for assessing the success of the GS. What evidence demonstrates that the site responded adequately to the rec- 06. Is the annual evaluation conducted by competent site, corporate, or other SECTION II: WORKSITE ANALYSIS
A. Baseline Hazard Analysis A2.
A3.
A4.
AS.
Has the site been at least minimally effective ·at identifying and document- Does the s~te have a doe:1;1mented s~pling strategy used to identify health nd equency ~ exposure), ~nd the number of exposed e.mployees? If not, please explain. · ‘ · · • , P mg, teS Q SECTION II: WORKSITE ANALYSIS 477
the site compare sampling results to the minimum· exposure limits or 6 poes . . 1· . (PE A , ore restrictive exposure lffilts Ls, TLVs, etc.) used? Please explain. A · If not, please exp run: or si_te- a_se · cons~ction sites, does the hazard t,.S. sampling data, ind.icate. that re~ords are being kept in logical order and e. Hazard Analysis of Significant Changes processes, what types of analys~s are performed to deterqtlne impact on safety B2. When implementing/introdu~ing non-routine tasks, materials or equipment, C. Hazard Analysis of Routine Activities routine operations and activities? . · ‘ 1 hazards, if appropriate? If not, please explain. ‘ and activities (e.g., job hazard analysis, HAZ-OPS, fault trees)? Please C4. Are the results of the hazard analysis of routine activities adequately For site-based construction sites, are hazard analyses conducted to address O,Rouu D1. alt~ lDspections (i.e., a minimally effective system identifies hazards · routine safety and health inspections conducted monthly, with tbe entire site cov d . . . . kl l 478
D3 .
D4.
D5.
D6 .
D7.
OSHl For site-based construction sites, are employees required to conduct insp ec- E. Hazard Reporting have them addressed? If not, please explain. management personnel in writing about safety and health concerns? Please E4. Do the employees agree that they have an effective system for reporting safety F. Hazard Tracking hazards being controlled? If not, please explain. provide feedback to employees for hazards they have reported? If not, F3. Does the hazard tracking system result in timely correction of hazards with F4. Does the hazard tracking system address hazards found by employees, G. Accident/Incident Investigations tigations, including near-misses? If not, please explain. . d and understood by all? If not, please explain. If 01 please explain . .
<
H,
SECTION Ill: HAZARD PREVENTION AND CONTROL 479
J,.re those conducting the investi~ations trained in accident/incident investi- T Root Cause, etc. ree, . . di GS. factors that led to an acc1dent/mc1?ent or a near-miss. 06· ously addressed 10 ~y pnor hazard analyses (e.g., baseline, self-inspection)? rrend Analysis
Does the site have a minimally effective means for identifying and assessing HJ. H3 . Did the team identify trends that should have been identified by the site? If H4. If there have been injury and/or illness trends, what adequate courses of HS. Does the site assess trends utilizing data from hazard reports and/or accident/ H6. Are the results of trend analyses shared with employees and management SECTION 111: HAZARD PREVENTION AND CONTROL
A. Hazard Prevention and Control
Al. Does the site select at least minimally.effective controls to prevent exposing A2. When the site selects hazard controls, does it follow the preferred hierarchy A exposure to hazards (for example, job rotation) . 4 tbose hazards not covered by engineering controls? If not, please explain . a confined space programs) recommended by hazard analyses and 1mple- · Are follow-up studies (where appropriate) conducted to ensure that hazard 480 OSH.A!S VPP SITE-BASED PARTICIPATION SITE WORKSHEET
Are h d trols documented and addressed in appropriate procedures, A7. azar con . , . . ?Pr ‘d 1 Disciplinary System . 1 din di · Ii · A8. Are there written employee safety procedures me u g a sc1p nary system? A9. Has the disciplinary system been clearly commurucated ~nd ~nf for both management and employees, when appropnate. not, please Emergency Procedures (including at least an evacuation drill annually)? e.g., evacuation routes or auditory systems? · at least one evacuation drill each year?
Preventive/Predictive Maintenance please explain. mendations) identify hazards that could result if equipment is not maintained A16. Does the preventive maintenance system detect hazardous failures before Persona/ Protective Equipment (PPE) required, its limitations, how to use it, and how to maintain it? If not, please A.20. Did the team observe employees using, storing, and maintaining PPB properly? Process Safety Management (PSM) 1910-119)? If yes, please answer questions A22-A25 below. Additionally, AZZ. Which chemicals that trigger the Process Safety Management (PSM) standard p.25.
SECTION IV: SAFETY AND HEALTH TRAINING 481
. h process(e’s) were followed from beginning to end and used to verify swers to the q~est1ons as e m t e _PSM application supplement, the ational Health Care Program Bl. physician services, first aid, and CPR/ABO) and special programs such as BZ. hazard identification and analysis, early recognition and treatment of ill- 3 Is the occupational health program adequate for the size and location of B. c. Recordkeeping terms of accuracy, form completion, etc.? If not, please explain. ing standard? keeping standard? tractors/sub-contractors at the site evaluated? Please explain. due to management pressure, production concerns, incentive programs, SECTION IV: SAFETY AND HEALTH TRAINING
A. Safety and Health Training A2. What are the safety and health training requirements for managers, super- 482
A4. A5.
A6.
OSHl>!S VPP SITE-BASED PARTICIPATION SITE WORKSHEET
A7.
A8. AlO.
All.
D th any/site operate an effective safety and health orientation oes e comp . Pl . INCIDENT INVESTIGATION: In Chapter 3, “Innovations in Serious Injury and Fatality Prevention,” comments Safety professionals are encouraged to make internal evaluations of the quality • Viewed incident inve~tigation as. a pote~tial source f~r selepting the improve- !ec0nd Editionty ;1<:nagement: Focusing on ZJO and Serious Injury Prevention,
2014 John W'l red A. Manuele.
1
ey & Sons, Inc. Published 2014 by John Wiley & .Sons, Inc.
441 442 INCIDENT INVESTIGATION: SECTION 6.2 OF 210
methods of operation and cultural causal factors for incidents and expos • Sought to have incident investigation given a much higher place within all of th To provide an information base for safety professionals who choose to promote • Discuss the incident investigation provisions in ZlO incident investigations improved if an organization has condoned a low quality • Promote having compassion for supervisors to record the reality of contributing and causal factors incident investigations INCIDENT INVESTIGATION PROVISIONS IN Z10
The requirements for incident investigation are set forth concisely in Section 6.2 Organizations shall establish processes to report, investigate and analyze inci- That is the whole of it-one brief paragraph on incident investigation sets forth • Incidents should be viewed as possible symptoms of problems in the occupational THE POSITION IN WH ICH SUPERVISORS ARE PLACED 443
. to identify and correct hazards and system deficiencies before jnc1den bows that incident mvestlgahons should be begun as soon as practical: tigations should be used for root-cause anaiysis to identify system or otber 1 arned from investigations are to be fed back into the planning and 1 .,55ons e Orrecuve C I
LE EXPLANATIONS FOR INCIDENT INVESTIGATIONS studies of incident investigation reports, oq a sc~le of 10, with 10 being best, anagement function is ofte_n done ~uperficially. 1 ran a Five Why exercise to examine the incident investigation process to try to THE POSITION IN WHICH SUPERVISORS ARE PLACED
When supervisors complete incident investigations, they are being asked to write 8 accident occurred in my area of supervision and I take full responsibility 1 or order ~0 · , . . , . _1 ‘ r repairs I sent him two months ago …. in the rpnsmg that supervisors would be reluctant ‘to write about shortcomings s1bJe, If s . n systems for which the people to whom they report are respon- ips could ‘result. 1 , • 444 INCIDENT INVESTIGATION: SECTION 6.2 OF 210
(fi t-line employees) and incident causation, Jame With respect to operators rs s . th · 1· nstigator of an accident, operators tend to be the Rather than bemg e mam • • • . d bad management dec1s10ns. Therr part 1s usually that of Supervisors are one step above line empl?yees. They_ als~ work in a “l~thal brew In some organizations, the procedure is to have a team of t~o or three investigate It is not difficult to understand that supervisors would· be averse to criticizing CULTURAL IMPLICATIONS THAT ENCOURAGE In some organizations, senior management insists on being informed of the factors In a company where management is fact -based and sincere when they say that . . • mves gation procedure 1s m place for serious mJunes and fatalities. , . · 1:actual · ti” • a was 1 icult for leaders at all levels to complet~ 1 ‘ mves gation reports that b · · It is known that the CEO reads th improvem~n.t.. on -cu1t4re requires fact determination and continual • ies, .Incident inv t” · . superior perform . . al ” cuLTURAL IMPLICATIONS THAT MAY IMPEDE GOOD INCIDENT INVESTIGATIONS 445
. ns some companies scored 8 out of a possible 1 o (M th 1 afetY ..-.panies, the positive sw.ety cu ture is driven by the senior ti’ s those co 111 ·nstances, by the oar o rectors. At those levels incident e . is rev1e le of the absence o an mterest m safety by executives and the b d f t,.n d how that absence was tume mto positive and active leadershi O change;~ authors were Patrick Frazee and Steven Simon. Excerpts follow. safety,
. ulture change at GM was driven from the top and realized through the ~e dramatic ~around at Alco~, where he not only improved safety, but also ~ng O’Neill attended, he asked, “Where’s the safety report?” There was none. What interpretation can be given to the foregoing? For this important aspect of To conclude on this subject: It is strongly recommended that if practicable, selected In my studies of the quality of investigations, reports prepared by · well-chosen CULTURAL IMPLICATIONS THAT MAY IMPEDE . I ,
Throughout this book the significance of an organization’s culture and how it affects 8 error in Process Safety where comments are made on the “Cultural Aspects of Data 01iecti s 446 INCIDENT INVESTIGATION: SECTION 6.2 OF Z10
A company ‘ s culture can make or break even a well-designed data collecti 0 reprisals, and feedback which indicates that the information being generated~ 18
factors are vital for the success of a data collection system and are all toee ‘ a In relation to the foregoing, the title of R. B. Whittingham’s book, The Bia What Whittingham wrote is indicative of an inadequate safety culture. As an An electrocution occurred. As required in that organization, the corporate When asked why the design shortcomings were not recorded as causal This culture of fear arose from the system of expected performance that Overcoming such a culture of fear in the process of improving incident investiga- Whittingham wrote: “Organizations, and sometimes whole industries, become Assume that the safety culture does not require effective incident inves~~au telY 11111 HAVIN.G COMPASSION FOR SUPERVISORS 447
h could be interpreted .as being accu~atory of management levels t t ey ‘d d . 0rtan , isor-and thus avo1 e . bove . 1. We . ·ured employee mentioned the hazard to me, but it was the kind of fhe 1nJ ed 2. . that we have tolerat . have bad work orders m mamtenance 1or three months to fix the wiring on tlUSeg • 1. dh · not expect. . . · sometimes the workers take ~hort~uts a~d don’t follo~ the SQPs. , 7_ The equipment i~ being run beyond its normal life cycle, and the risks in S. What we are asking our people to do is exhausting, ·and they make mistakes. to. The stuff that purchasing bought is cheaply made,. and it falls apart. Not doing thorough incident investigations is n9rmal in organizations where If safety professidnals’ promote improving the quality of incident investigation, HAVING COMPASSION FOR SUPERVISORS
In a huge number of published inve·stigation procedures, it is said that the first-line do supervisors get, does the training make them kno~ledgeably and technically ci ent inve t’ · · · · · · d d the s igations. How often do they complete mc1dent mvestlgatlons, an ° ll .
448 INCIDENT INVESTIGATION: SECTION 6.2 OF 210
forms and procedure manuals provide adequate support? It is unusual for a supervj members of teams that are given the responsibility to investigate accidents. or and others attend a training session and when they complete an incident investigation Supervisors, and others, should be provided with readily available reminder HOW SERIOUS CAN THE PROBLEM BE?
What follows is an extraction from material sent to me recently by a colleague who . This colleague made a presentation on incident investigation to a leadership group Participants were asked to choose as many of the subjects in Table 22.1 that they Subjects from 1 to 7 received positive scores at varying levels, indicating that TABLE22.1
1. Safety culture TABLE22.2
1. Very often 7% O IMPROVEMENT, START WITH A SELF-EVALUATION OF THE CULTURE 449 oN’ Phas1s. . . d h S Id for elll orty-four percent md1cate t at e om would the contributing factors pe ·n inves o~viouslYiow. That is embedded in the organi~ation’ s cult~re. And improvement t be 01 b’ l’ h’ th · will no dership and accounta 1 tty to ac 1eve e requrred culture change. A ~ew f reports. The culture problem was obvious at that time: Management NTHE WAY TO IMPROVEMENT, START WITH safety professionals who undertak~ to improve the quality of incident investigation 5 ~vestigation reports. In my studies the identification entries in incident investigation Thus, it is suggested that the evaluation concentrate on the incident descrip- In chapter 3, “Innovations in Seijous Injury and Fatality Prevention”, an outline rror Avoidance and Reduction!1 in this book because of its comments on human me 18 to be an analysis of: cttv1ties in whi h · .. · · ” hi h t d t’ effi . c senous mJunes .occur, 1or w c concentra e preven 10n The qu li a ty of causal factor determination and corrective action taking 450 INCIDENT INVESTIGATION: SECTIO.N 6.2 OF 210
• The culture that has been established over time with respect to good or not • Organizational levels that are to be influenced if improvements are to be made
From that analysis, a plan of action would be drafted to favorably influence th So, the plan of action must be well crafted to convince management of the value It is much, much easier to write all this than it will be for safety professionals to AN INTERESTING OBSERVATION
In the previous section it was said, among other things, that studies undertaken should In certain studies, safety directors in manufacturing operations were asked to have millwright, welder, carpenter maintenance, painter, electrician, machinist Percentages of serious injuries that occurred to nonproduction personnel-that is, · · s that There were some noted exceptions. In other manufacturing orgamzation . . . f analyses Data such as m the foregomg prompt the observation that the type 0 INCIDENT INVESTIGATION FORMS 451
SJECTS TO BE REVIEWED of the improve~en~ end:avor, _oth~r evaluations should be made, such as ~e foh;W such situations would affect the quality of investigations. urses taught on incident investigation, the instructor leads attendees to cone • in~estigation forms should focus on improving worker behavior . and little guidance is given on causal factors at levels above the worker. investigation form is identify the unsafe act committed by the worker . say: “Enter the unsafe act code.” The system allows the entry of only one causal When there is a lack of understanding of the fundam~ntals of incident causation INCIDENT INVESTIGATION FORMS
~P~ndix Kin ZlO provides a brief dissertation on th~ . value and outcome of an a resource from which to craft an incident investigation form particularly suited 1. No tr · · , · k . en Y 1s required that would lead an investigator to focus on what a wor er 2 . Provision is made to enter observations concerning the incident at three levels: 452 INCIDENT INVESTIGATION: SECTION 6.2 OF 210
. . . • determining possible causal factors by listing maior 3 Assistance 1s given m d R . d d Orrective actions are to be listed along with the originator’s 4 ecommen e c d/R · d ” A · and completion dates are to be recorded. . Process Owner.” to whom the report is sent.
THE FIVE-WHY TECHNIQUE
As incident investigation procedures are improved, the goal is to have contributing Highly skilled incident investigators may say that the five-why process is inad- For many organizations, achieving competence in applying the five-why technique The origin of the five-why pr9cess is attributed to Taiichi Ohno while he was at Since the premise on which the five-why concept is based is uncomplicated, it can Given an in~ide~t description, the investigator Would ask “why” five tim’.’5 to The ~tten incident description says that a tool-carrying wheeled cart tipped over was ~1mg to move 1t. She was seriously mJur · . r · e iameter of the casters is too small an carts are tippy. . WHAT THIS CHAPTER IS NOT 453
. th diameter of the casters too small? They were made that way in 3, WbY ‘ollowed the d1mens10ns given to them by engineering. did engineering give 1a_ nca~on _ imensions _1or casters that have been proven uld result from using small casters. did engineering not consider those hazards and nsks? It never occurred to conclusion: I [the dethpartment managerd] Jia~e maladde. engi~e~ring, aware of the :;!ct to the ne~d to f ~cus ,on hazards and risks ~n de~ign pro~ess. Also, eng Th d’ . b . 1 -. rs to fabrication: e caster 1ameter 1s to e tnp ed. On a high-priority basis, I have also alerted supervisors to the problem ‘in areas w)lere carts of that Sometimes, asking “why” as few as three times· gets to the root of a problem: on . ,\
• Management commitm_ent to identifying the reality of causal factors is an abso- • Take caie that the first “why” is really a “why” and not a “what” or a diversionary • Expect that repetition’ of five-why exerci~es will be necessary to get the idea 1 ~e sure that management is prepared to acf on ‘ilie systemic causal factors >’ I ,
WHAT THIS CHAPTER IS NOT iate actions to be taken, fact determination, objectivity, interviewing witnesses, 454 INCIDENT INVESTIGATION: SECTION 6.2 OF 210
developing incident investigation teams, or action plans. The chapter “Designer lncid 1~w For safety professionals who choose to be educated on more sophisticated in . INCIDENT INVESTIGATION .RESOURCES .
Since the names of the authors and publishers for each of the resources listed here are “Root Cal;lseAnalysis Guidance Document, DOE-NE-STD-1004-92.” Washington, This is a 69-page highly informative document. It is an instructive read. Various NRI MORT ‘!]s(!r’s Manual, NRI-1 (2002), a Generic Edition For Use with the In a discussion as to ”What is MORT,” these <;omments are made: "By ~e of
public domain documentation, MORT has spawned several variants, many of the~
translations of the' MORT_ Use(s Manual i~to other languages. ·The du~ability
of MORT 1s a testament to its construction and content; it is a highly _logical
expression of the functions required for an organization to manage risks effec-
tively." They say that this 2002 version of the MORT User's Manual aims to:
• Rephrase the questions in British English < INCIDENT INVESTIGATION RESOURCES 455
DOE-specific references • s tailor the questlon set to their own organizations • J-Ielp user
. they accomplished their purposes-to improve guidance on the investi- gatio~ ar!:~nating. The 69-page docµment is· available on the Internet at http ://www. I recom uire an understanding of the thinking on which MORT is based. A ~vte Now, to extend the resource list, three books .on incident investigation and , Guidelines for Preventing Human Error in Process Safety. New York: Center for This is a highly recommended text. Chapter 6 deals with data collection • Hendrick, Kingsley and Ludwig Benner, Jr. Investigating Accidents With STEP. Hendrick and Benner have developed an incident investigation system • Oakley, Jeffrey. Accident Investigation Techniques: Basic Theories, Analytical This is a relatively short and inexpensive book in which comments are made • Although an internet search will reveal a large number of companies offering Gano, Dean L. Apollo Root Cause Analysis: A New Way of Thinking. 456 INCIDENT INVESTIGATION: SECTION 6.2 OF 210
consultant in root-cause analysis for many yea,rs. His technique and his TapRoot Manual. Knoxville, TN: System Improvements, Inc. This book CONCLUSION
My studies on , incident investigation ·prompt the, conclusion that significant risk . If safety professionals want to · select leading indicators for safety management Assume that a safety professional decides to take action to improv~ the quality Many accident investigations do. not go far enough. They identify the technical When the determinations of.the causal chain are limited to the technical flaw Too often, ~ccident investigations blame a failure only on the last step in a For emphasis, I paraphrase: If the cultural, technical, organizational, and methods REFERENCES 457
REFERENCES J\NS~gement Syste~- Fai~ax, VA: American Industrial Hygiene Association, 2012. ASSE is . H E . p id I’ es for Preventing uman rror m rocess Safety. New York: Center for Chemical 0 Manuele, Fred A. Ont~ Practice ~f S~fety, 4th ed. Hoboken, NH: Wiley, 2013. 200 Reason, James. Human Error. New York: Cambridge University Press, 1990. Toe Five-Why System: http://www.mapwright.com.au/newsletter/fivewhys and http:// Whittingham, R. B. The Blame Machine, Why Human Error Causes Accidents. Burlington; ADDENDUM A
A.DEPICTION OF A SOCIO-TECHNICAL Advanced Safety Management: Focusing on ZJO and Serious Injury Prevention 458
11111 A DEPICTION OF A SOCIO-TECHNICAL CAUSATION MODEL 459
A socio-technical causation model for hazards-related lncidents ii.,established by the board of directors and senior mana&ement Management commitment or non-commitment to providing the controls + + and the inadequacies impact neeatively on
J • Risk assessment
• Competency and adequacy of staff • Maintenance for system integrity
• Management of change/ pre-job planning
• Procurement – safety specifications
• Risk-related systems
• Organization of work
• Training-motivation
• Employee participation
• Infonnation -communication
•Permits ·
• Inspections • Providing personal protective equipment
• Third party services
• Emergency planning and management
• Conformance/compliance assurance
• Performance measures Multiple causal factors derive from the inadequate controls – , Th The incident process begins with an initiating event. i r A REFERENCE FOR THE· SELECTION !
Designers of incident investigation· systems· should understand that the causal factors Workplace Design Considerations i 1. Hazards derive from basic design of facilities,, ~ardware, equipment, or tooling. ‘ I
3. Layout or position of hardware or equipment presents hazards. presented hazards. . 5. Work space for ,operation,. m.ain~na,nce, or storage is insufficient. Work Method Considerations Advanced Safety Management· R . Y oµs~ Inc. Published 2014 by John w·1 & FERENCE ,ARE .1: te work situation encouraged · riskier actions than prescribed work IJ111IleUJa k flow is hazardous. 7 wor . . 1 . ‘ __ ….. ~ure Partlculars No written or known job procedure. 10. Employee used substitute equipment, tools, or materials. Hazardous Conditions
1. Hazardous condition had not been recqgnized. 1~ , I
4. Hazardous condition was recognized but employees were not informed of the Personal Protective Equipment
1. Proper personal protective equipment (PPE) not specified for job. 2 6· p E ~ot used properly. Managem 2. In inspection program is ineffective. 8Pectio ai.ntenanc ·th · d t 462 SELECTION OF CAUSAL FACTORS AND CORRECTIVE ACTIONS A REFERENCE FOR THE
. d f hazards and right methods before commencing work c 5. Review not ma e o 1or 6. This job requires a job hazard/task/ergonomics analysis., function properly.
Corrective Actions To Be Considered
1. Job study to be recommended: job hazard/task/ergonomics analysis needed. capabilities and limitations. , their use.
7. Instruction to be given on the hazards of using improper or defective tools. 10. Necessary employee counseling will be provided. suited to the work. I,
13. For infrequently performed jobs, it is to be reinforced that a pre-job review of 14. Particular physical hazards discovered will be eliminated.
to achieve continual improvement in occupational health and safety management
systems, the as~ignment of responsibility for the actions to be taken, completion
dates,_ an~ r:
ppen IX Is to help managements fulfill the Zl0 management review require-
ment s attention on the part f h • t
~tyste~ thZaltOneed their attention and direction mostly.” The scorecard lists the major
I ems m on one page and ‘d & •
st tu f h f . . provi es 10r entering indicators of the implementation a s o eac o the prov1s1ons Wh · e
to be entered t h th · . en usmg the scorecard example given, colors ar 0
· 111 ance ,
, fel1°W• ·or elements m place
tre . nificant nonconformances exist, still needs focus
\fiolet: s1g . d . . • . or effort requrre ; maJor systematic nonconformances exist
ing color scheme is recorded here as an example of how performance
11•. ay be expresse . e wnters o ppend1x M properly recognized that a
vanelY . partant statement when they said that management review reports should
Ulttheorg ·1 ‘f. ti th . . , s ted more readi y 1 1t ts e organization s style and culture.
in ful oppartunity to assist m providing obJect1ve summary reports on the status of
g au·onal health and safety management systems and to present managements
WI tion addresses serious injury potential and risk reduction measures.
sec In accord with the POCA concept, the overriding theme of the management review
is to achieve continual improvement. Thus, having action items for improvement in
the review process and follow-through are vital.
and a summary progress report carrying the signature of the chief executive officer is
published. Such reports may be made available broadly, such as on the Internet.
Publication of the reports serves the purposes of good community relations as well as
good employee relations.
Management Systems. Fairfax, VA: American Industrial Hygiene Association, 2012. ASSE
is now the secretariat. Available at https://www.asse.org/cartpage.php?link=z10_2005.
search.yahoo.com/yhs/search?p=The+Report+of+the+BP+U.S.+Refineries+Independent+
S~ety+Review+Panel&hspart=att&hsimp=yhs-att_OOl&type=att_lego_portal_home,
Click on the Acrobat indicator.
SECTION 6.3 O F 210
more specifically to the occupational safety an
ments. They also require that audits be made by competent persons who are independent
of the activity being audited. In the following exhibit, words underlined were in the
preceding edition and have been remoyed. Words in bold type are the revisions and
additions. Words not underlined or not in bold remain the same.
A. Plan and conduct periodic audits to determine whether the or~anization
OHSMS has been established, implemented and maintained in confor-
mance with the requirements of this standard, including the processes
for identifying hazards and controlling risks.
of the activity being audited.
a. Those responsible for corrective and preventive action;
b. Area supervision; and
c. Other affected individuals, including employees and employee
expected to cause a fatality, serious injury, or illness in the immediate future
so that prompt corrective action under Section 6.4 is taken. ‘
Section 6.4. As is the case with every aspect of an organization’s endeavors, making
a periodic review of progress with respect to stated goals is good business practice.
Stated goals, in this instance, would be to have processes in place that meet the
requirements of ZlO.
or ineffectiveness of an organization’s safety and health management systems. In
accord with the audit requirements in ZlO, deficiencies noted during safety audits are
to be documented and communicated to those who can take action to eliminate them.
The deficiencies are to be prioritized for orderly consideration.
factors for fatalities, serious injuries, or illnesses are to be communicated immediately
to the proper decision makers so that actions can be taken on a high-priority basis. That
is in concert with one of the principal themes in this book-to improve serious injury
prevention.
important statements are made.
that they ·are not limited to determining compliance with laws, standards, cir
regulations. Although “compliance” may be considered in the audit process,
the intent is to have the audit be “system” oriented so as to evaluate the effec-
tiveness of the standard’s management processes.
,the activities being audited. But it is made clear that this advisory does not
mean that audits must be made by persons “external to the organization.”
systems to meet the requirements of ZlO, in this chapter we: . .
• Discuss the implications of hazardous situations observed
• Establish that safety auditors are also being ~udited during the audit process
• Comment on auditor qualifications
relate to the hazards and risks in the operations at the location bemg audite
rtlf pAI ovE THE SAFETY CULTURE
ro1MPA
‘fhl’OughoU~ts achieved with respect to safety are a direct reflection of an organization’s
dfiven . ~stheir book Safety Auditing: A ~anagement Tool, Kase and Wiese stated early
culture· dealing with successful aud1tmg that:
in a chapter
e l·t effects on the overall culture of the operation and enterprise that it chang •
afety and health management system audit is to have a beneficial effect on an
org . . • -~ 1 . improvement of an organization s sruety cu ture . A safety audit report provides an
assessment of the outcome~; ,of the safety-related decisions made by management
over the long term. Those outcomes are determined by evaluating the adequacy of
what really takes place with respect to the application of existing safety policies,
standards, procedures, and operating processes . . ,
be viewed principally as indicators of inadequacies in the safety management
processes that allowed them to exist. Assume that management takes corrective
action to eliminate every hazardous situation noted in an audit report. Still, little wil
management systems that allowed the hazardous situations to develop.
REASONABLE MANAGEMENT EXPECTATIONS:
THE EXIT INTERVIEW
sive. Safety profe~sionals should not be surprised if infomed, m!lllagements expect 0
.oteworthy results from .the audit process that benefit their operations. Safety profes-s1ona1s h · ,
• Havin . . . . .
, B . g good Justification for thetr findmgs
team should anticipate and prepare beforehand to respond to questions comparabl~
to the following:
2. What improvements in our management systems do we need to make?
3. In what priority order should I approach what you propose?
4. Are there alternative risk reduction solutions that we can consider?
5. Will you work with me to determine that the actions we take and the money we
looked upon as assisting management in attaini~g their operational goals. Safety
auditors will not be.perceived favorably if their work is not considered an ass~t to
managements who seek to improve their safety ,and health management systems and
their safety culttp”C, . ··
hazard and risk has been identified. Some hazard/risk situations remain obscur~,-~d
human beings have. not yet developed the perfection necessary to identify all of them.
As an example, the negative impact of less-than-adequate decisions affecting design
and engineering, purchasing, and maintenance may not be easily observable beca~se
their effect may not be felt for several years.
sampling technique and that it is patently impossible to identify 100% of the ha~ard/
risk situations and shortcomings in safety man~~ement systems.
‘ ‘
sions they create, and the time expenditures required of the personnel at the location
being audited are also being evaluated. Speculate on the possible comments made
upward by location management personnel to executive management for the following
situation. It happened.
‘ location. After the second day, employees complained · that the auditors were
sumed. To make matters worse, during the third day the lead auditor told the
location manager that the scorings being gi’ven to safety and health management
systems by the auditors were higher than usual and that the auditors would
have to delve further into operations. Why? Because, the lead auditor said, it
was expected that their report would outline management• system shortcomings
that need attention. Employees at the location became more irritated and co~-
plained because of the repetitive, valueless, and duplicatory interferences 10
their work.
one O hea~quarters per~on~e~ to s~nd four auditors to their 3: employee location,
in light o
uon’s culture,
nu-oug d afi t . . ed ational health an s e Y management system issues. Those issues are defin
~;: standard as “hazards, risks, management system deficiencies, and opportunities
;e operation being audited, safety professionals making the audit must have the
ecessary qualifications and competency.
Managements have often said that auditors had little knowledge of the technical
value. If safety audits are to be perceived as having value, the auditors must have the
professional qualifications to make them.
the situation at hand and how best to approach the management personnel in the organiza-
tion to be audited. Similarly, if persons external to an organization are engaged to make
safety audits, the safety professionals who engage them should examine their credentials.
Health & Safety Management Systems” will help in that regard. That paper (available
on the Internet) was issued jointly by the American Society of Safety Engineers,
the American Industrial Hygiene Association, and the American Board of Industrial
Hygiene in August 2005. They say that:
and occupational health and safety management system certification [audits].
Many of the concerns raised in these studies have focused on the competency
of the auditors performing conformity assessment audits.
~rtifications with respect’ to quality, environmental, and occupational safety and
eal~ management by persons external to an organization. Nevertheless, similar !:;10ns_ have been raised for many years about the value of comparable audits
occl’he ~aper contains an extensive listing related to specific knowledge and skills of
their e. They are to serve safety professionals m making a·prehmmary review of
rnay :;n capabilities as auditors and in assessing the qualifications of auditors they
Excerpts r ,
Occupati
knowJect onal saf~ty ~nd health management system auditors shou~d ~ave
468 AUDIT REQUIREMENTS: SECTION 6.3 OF 210
enable them to examine occupational health and safety management systems
and to generate appropriate audit findings and conclusions. Specific knowledge
and skills should include:
identification and risk assessment, selection and implementation of appro-
priate hazard controls, developing proactive and reactive performance
measures, understanding techniques to encourage employee participation,
and evaluation of work-related accidents and incidents)
other workplace factors affecting human well-being
environment
• Medical surveillance methodologies for monitoring human health and
• Methodologies for accident and incident investigations
• Methodologies used to monitor occupational safety and health performance
• Sector-specific education, experience, and knowledge of operational
comprehend and evaluate how the organization’s activities, raw mate-
rials, production methods and equipment, products, byproducts, and
business management systems may impact occupational health and safety
performance in the workplace
and health professional can make a self-evaluation with respect to competency in
relation to a particular audit undertaking.
Use, and Why?” concur with my experience. This is what I wrote about his article in
On The Practice of Safety.
that show that audit results did not always correlate to a firm’s accident experience.
There is a history of that sort of thing with respect to “packaged audits” in which
an audit guide is used that may not be sufficiently relative to the actual safety pra~-
tices and needs in the entity being audited. Petersen concluded that ‘.’the self-built
audit-one that accurately measures performance of a firm’s own safety system-
was viewed as the answer.” To construct such an audit, Petersen says, a firm must
define:
1. safetyl tive importance of each (weighting)
3_ Quesuo
do not eq ured by mcident frequency or seventy of mJury. Obviously, the safety
whether me~elements included, and those emphasized, in an audit system should
tJlanagem;n hazards that an entity really has to deal with. Keep in mind that hazards
relate to bO~ the characteristics of things and the actions or inactions of people.
include nnine what is really happening, an auditor must explore the safety management
the preceding listing o qu i cations 1or safety and health management system
ards risks, processes, an so on. When dra,fting an audit guide and in selecting
ee . h . th .
ns All hazards are not equal: Neither are the risk,s deriving from them equal. In a
chemical oper1:ttion where th~ inherent fire and e~plosion hazards ~e significant,
the processes in place and their. effec~iveness with respect to design and
engineering, control of fire and , explosion, potential, occupational health
exposures, training, inspection, ma,nagem~nt of ch~nge, _and procurement require
much great~r, attention than a warehouse where the only chemical.s used are for
cleaning purposes. Sinµlarly, provisions to avoid a!}to accidents are more significant
in the operation of a distribution center than if driving by employees is only incidental
to operations. .
system requu:es that ,i;n1m~rical or alphat?etical scorings be recorded for each element
being evaluatl?d, The weigh1;ings for the e)ements are the same regar~less of their
significance at the. location b~ip.g audited. Th~t practice is questi9nable.
requrr:s that ~dentical weightings be given to elements regar~less of the nature of the
operation~ being audited, the greater import of a particular; _!llanagement system in
:h: operation may be overlooked. Also, the a_!iditional pr~bing into ,that ma~agement
f~~m that \\’.OU~d be necessary t9 ide11tify those hazarqs ~at may .t,.e ~e cau_sal
80 that ems }hat ~reater effective~ess cap be. t1chieyed if tlie a~~ht_ guide is s_tr4ct~ed
aud. modificauo.ns can be made to suit the hazards and risks at the location bemg iledI ., · · ,, -‘
sionaJs ·w: our ~om~unication: age, it i~. appropriate to suggest that_ safpty ,prc;,fe~-
Wh’ h O craft audit systems consider using a flexible computer-based m~del m
lbat ~ouJd nq · the.4″, w~jghtings var(ed , to suit the exposures at mdividual locations.
The appendix lists all of the sections m Zl Om a table ~o”? and includes suggestions on
how implementation of them is to be evaluated obJectively. Co~ents concerning
adaptation of Appendix L support avoiding the development and tmplementation of a
”packaged” audit system-a one-size-fits-all model. They say that:
may be used as a template th~t can be modified to match the culture and needs
of each organization.
and risks in an organization. For example, is it ·necessary that there be a “documented
occupational health and safety policy” as required by ZlO for every location? Or is it
appropriate to recognize that for a small operation having as few as ten employees, a
verbal and demonstrated commitment by management to achieving superior control
of hazards and risks is sufficient?
can be found in OSHA’s “Safety and Health Management Systems eTool-Safety and
Health Assessment Worksheet.” In OSHA’s assessment process, an entry is to be made
for this point: There is a written (or oral, where ·appropriate) policy. The implication
is that, at times, an orally established safety policy is acceptable.
be used while conducting an OHSMS audit.” Suggestions include the types of docu-
ments and records to be examined, the titles of the persons to be interviewed, and the
activities to be observed. Trying to be objective during a safety and health audit is
vital to achieving good results.
VPP site Worksheet, which is completed to determine’ whether a location· meets
the requirements of OSHA’s· Voluiltary Protection Program’.. OSHA evaluators are to
support their c9nclusions as they evaluate system elements by indicating that they
derive from interviews; observations, or documentation. · ·
audit system, a specifically recommended audit guide to meet ZlO requirements ~s
not being presented in this chapter. Nevertheless t~ create or improve an audit
guide, it ‘is. suggested that the example audit plan’ in Appendix· L combined witb
the VPP sit~-based participation evaluation report used by OSHA auditors as
th
Protection Program serve as an excellent reference base. The VPP ‘Site-Base
par;ticipation evaluation report is available at http://www:osha.gov/dcsp/vpp/
vpp.:_report/site_based.html. , ·
. A .worksheet · is used by OSHA personnel in the ·evaluau·on process. Excerpts
those who want_to _develop audit guides ‘suited to operations at a particular tocaoon,
The Worksheet 1s, m a sense, an audit form.
f.S sh0.fjcation”, the VPP safety manageme~t system requirements are similar to
!JlaIIY of tbe t as specific as comparable provisions in Z 10. Those provisions are
lllents are ~01 w and references to them in this book are provided. •fied IN O ‘
jdeOU
subjec=t:..————————Risk assessment
l)eSign Reviews
Management of Change
Procurement
and Risk Assessment” and Chapter 12,
“Provisions for Risk Assessments in
Standards and Guidelines”
Chapter 19, “Management of Change”
Chapter 20, “The Procurement Process”
a ypp site review, evaluations are made to’ determine:
Recordkeeping”
Certified Safety Professionals, Occupational Nurses, or Engineers) is reasonably
available to the site, based upon the nature, conditions, complexity, and hazards
of the site?”
nature, conditions, complexity, and hazards of the site” as stated above to deter-
mine whether there was need to include comparable provisions in an audit guide
that they draft.
Bas_ed Participation Evaluation Report” and to many of the provisions in ZlO are
available on the Internet. Both are OSHA publications. One is the previously
mentioned “Safety and Health Management Systems eTool-Safety and Health
Assessment Worksheet.” Available at http://www.osha.gov/SLTC/etools/safetyhealth/
~mnt_worksheet.html.The other is “The Program Evaluation Profile (PEP),” avail-
a 1~ at http://www.osha.gov/dsg/topics/safetyhealth/pep.html.
a d ~th of these publications have another feature that will interest some safety
0
n
ealth professionals. They are a resource on scoring systems. If a numerical :h~ phha scoring system is to be -used, the right scoring system is th’e one with
ortable. i
b · ractice. The audit requirements m Z 10 are designed to meet that purpose. usmess p
• & • d · ·
who desire to achieve superior safety and health results.
meet ZlO’s audit requirements start with a gap analysis. The result would be
comparisons between the elements in the safety and health m~nagement systems
in place and the provisions in ZlO. Since the ZlO standard 1s a state-of-the-an
document, it is not surprising that many organizations do not have management
systems in place that meet all of its provisions . For a very large percentage
of organizations, a gap analysis will reveal $hortcomings with respect to design
reviews; management of change, risk assessments, a hierarchy of controls, and
procurement practices.
management in formulating an action plan to fulfill ZlO requirements. As progress is
made, the content of audit guides would be adjusted accordingly.
occupational safety and health management systems will be measured. Societal expec-
tations of employers with respect to their safety and health management systems will
be defined by the standard’s provisions. The audit system put.in place should assist
management in moving closer to compliance with the provisions in ZlO.
Management Systems. Fairfax, VA: American Industrial Hygiene Association, 2012. ASSE
is now the secretariat. Available at https://www.asse.org/cartpage.php?lipk=;z~0_2005.
Issued jointly by the American Society of S_afety Engineers, ~e American Industrial
Hygiene Association, and the American Board of Industrial Hygiene, 2005. Available on
the Internet: Enter th~ title i.Jl a search engine. .
OSHA’s VP~ Site-Based Participation.Evaluation Report. A,vail~ble at http://www.ospa.gov/
‘The Program Evaluation Profile (PEP) .” U.-S, Department of Labor OSHA. At. http!lfwww.
“S t” afety and Health Management Systems eTqol-Safety and Health Assessment Workshee th/
~ARTICIPATION SITE WORKSHEET
INVOLVEMENT
Al. Are all the elements (such as Management Leadership and Employee
and Health Training) kd sub-elements of a basic safety and health management
system part of a signed, written document? (For Federal Agencies, include 29
CFR 1960.) If not, please explain.
please identify those elements that have not been in place for at least 1 year.
to address the scope and complexity of worksite hazards? If not, please explain.
74, No. 6, 01/09/09 page 936, IV, and A.4)? If so, please explain.
Bl. Does management overall demonstrate at least minimally effective, visible
FRN, Vol. 74, No. 6, 01/09/09 page 936, IV. A.5.a-h)? Provide examples.
© 2014 John ~-ired A. Manuele.
goals and objectives for employee safety to employees .
Do employees understand the goals and objectives for the safety and health
management system?
Are the safety and health management system goals and objectives mean-
ingful and attainable? Provide examples supporting the meaningfulness
and attainability ( or lack thereof if answer is no) of the go~l(s ). (Attainability
can either be unrealistic/realistic goals or poor/good unplementation to
achieve them.)
How does the site measure its progress towards the safety and health management
system goals and objectives? Provide examples.
management planning process (for example, budget development, resource
allocation, or training)?
planning process? If not, please explain.
each project?
(Top management acknowledges ultimate responsibility even if some safety
D2. How is the assignme~t 9f authority and responsibility documented and com-
D3. Do the individuals assigned responsibility for safety and health have the
sa(ety and health management system are made? If not, please ~xplain.
ing their respcmsibilitie~ for ·workplace safety and health? (Are annual
performance. eva~tiatiqps for managers· ~ ·d supervisors required?) .
workplace safety and health? Provide examples.
Safety Professionals, Occupational Nurses, or Engineers), reasonably av_rul;
able, based upon the. nature, conditions, complexity, and hazards of the stte ·
If so, under what arrangements and how often·are they used?
‘
E2. Were there contractors/sub-contractors onsite at the time of the evaluauon ·
475
E3. uate the contract~r’s safety and health management system and performance
E4, Are contractors and subcontractors required to maintain an effective
OSHA and company safety and health rules and regulations? If not,
please ex~lai,n.
Does the site s contractor program cover the prompt correction and control
control such hazards? Provide examples.
How does the site document and communicate oversight, coordination, and
enforcement of safety and health expectations to contractors?
issues been enforced, when appropriate? If not, ple~e explain.
its contract employees?
analysis of injury and illness data? Provide examples.
If the contractors’ injury. and illness rates are above the average for their
industries, describe the site’s procedures that ensure that all employees
are provided effective protection on the worksite? If yes, please explain.
Based on your answers to the above items, is the contract oversight mini-
mally effective for the nature of the site? (Inadequate oversight is indicated
by significant hazards created by the contractor, employees exposed to
hazards, or a lack of host audits.) If not, please explain.
FI.
F2.
F4.
F8.
How many employees were interviewed formally? How many were inter-
viewed informally? · ‘
Do employees support the site’s participation in the VPP?
Do employees feel free to participate in the ‘safety and health management
system without fear of discrimination or reprisal? If so, please explain.
Are employees meaningfully involved in th~ _problem identification and res-
olution, or evaluation of the safety· and health management system (bey~nd
h_azardreporting)? (As per FRN page·936 IV, A.6.) For site-based construc~on
sites, does the company encourage strong labor-management commumca-
tion in the form of supervisor and employee partic~pation in toolbox safety
meetings and training, safety audits, incident investigations, etc.?
Are employees knowledgeable about the site’s safety and health
management system? If not, please explain. .
Are employees knowledgeable about the VPP? If no~, please explam. . .
~e the employees knowledgeable about OSHA rights and responsibil-
ities? If not, please explain
· VPP d OSHA rights and respons1 1 ties . ease exp a.in.
st
health management system, VPP, and OSH~ nghts _and res~ons1?1hties?
tion, appropriate medical record~, and personal samphng data upon request?
If not, please explain.
G2. Does the annual evaluation cover the aspects of the safety and health
If n9t, please explain. ·
format? If riot, please explain.
site’-s safety and health management system? Please explain.
ommendations made in the annual evaluation?
trained personnel experienced in performing evaluations?
Al.
ing the common safety and he~lth hazards asso~iated with the .site (such as
those found in OSHA regulations, building standards, etc., and for which
existing controls are well known)? If not, please explain.
What meth~s are used_ in _ the ~aseline hazar4 analysis to identify health
hazar~s? (Pleas~ includ~ examples of instances when initial screening and
full-shift s~pling were usel See FRN page 937, B.2.b.)
Does the company rely on histprical data to evaluate health hazards on the
~orksite? lf so, _did the company iden_tify any operations that differed sig-
mfica~tly from past experienc.e and qonduct additional analysis such as
samp~mg or monitoring t9 ensure employee protection? If so, please ,descnbe. .
~azards l:!.
_ assess _ empl9yees’ expQsu~e (including duration ,” route, and
0
Do sam l’ · ‘ ‘
t
mg, and analysis follow nationally recognized proce-dures? If not, please explain.
are m the site identify hazards (including health) that need further analysis? 7 Does 1· F , . b d .
analysis include studies to identify potential employee hazards, phase
analyses, tas~ analy.ses, etc.? . _ . . . . _
ooes industnal hygiene sampling data, such as mitial screenmg or full shift
include all sampling mfo~ation (fot example, sampling time, date,
employee, job title, concentrated measures, and calculations)? If not, please
explain the deficiencies ~d ~ow they are being addressed.
For site-based construction sites, are hazard analyses conducted to address A9,
safety and health for each phase of work?
Bl. When purchasing new ma~rials or equipment, or implementing new
and health, iand are. these analyses.adequ~~? .
or modifying processes, what types of analyses are performed ~o qetermine
impact on safety an9 health, and are these analyses adequate?
CI. ” Is there at least a minimally effective hazard analysis s·ystem in place for
C2. Does hazard identification and analysis address both ·safety and health
CJ. What hazard analysis technique(s) are employed for routine operations
explain.
cs. documented? If not, please explain.
safety and health hazards for specialty trade contractors during each phase
of Work?
ne Inspections
th~ site have a minimally effective system for perf?rmi~g safety and
D associated · h 1 1 · 2. Are Wit normal operations)? If not, p ease exp run. .
ere at least quarterly (construction sites: entire site wee Y·
tions as often as necessary, but not less than weekly, of their workplace/area
and of equipment?
Does the site incorporate hazards identified through baseline hazard analysi
accident investigations, annual evaluations, etc., into routine inspections t~
preventreoccurrence?
Are employees conducting inspections adequately trained in hazard
identification? If not, please explain.
Is the routine inspection system written, including documentation of results
indicating what needs to be corrected, by whom, and by when? If not, please
explain.
Did the VPP team find hazards that were not found/noted on the site’s
routine inspections? If so, please explaiQ.
El. Is there a minimally effective means for employees to report hazards and
E2. Does the hazard reporting system have an anonymous component?
E3. Does the site have a reliable system for employees to notify appropriate
describe.
and health concerns? If not, please explain.
Fl. Does a minimally effective hazard tracking system exist that result in
F2 . Does the hazard tracking system result in hazards being corrected and
please explain.
interim protection established when needed? Please describe.
hazard analysis of routine and non-routine activities, inspections, and
accident or incident investigations? If not, please explain.
G 1. ls there a minimally effective system for conducting accident/incident inves-
G2. ls the accident/incident investigation policy and procedures documente
G3. Is there a reporting system for near-misses that include tracking, etc.? n ‘
G4, gation techniques? Please expla.m what techniques are used, e.g., Fault-
vescribe bow mvesttga~ors . sc_over and document all the contributing
Were any unco~trolled ~azards discovered during the investigation previ-
If yes, please explam .
trends?
Have there been any injury and/or illness trends over the last three years? If H2.
so, please explain.
so, please describe.
action have been taken? Please explain.
incident.investigations to determine the potential for injuries and illnesses?
If not, please explain.
and utilized to direct resources, prioritize hazard controls and modify goals
to address trends? If not, please explain.
employees to hazards?
(engineering controls, administrative controls, work practice .~ontrols [e.g.,
lockout/tagout, bloodborne pathogens, and confined space programs], and
personal protective equipment) to eliminate or control hazards? Please pro-
vide examples, such as how exposures to health hazards were controlled.
3
. Describe any administrative controls used at the site to limit employee
A.
. Do the work practice controls and administrative controls adeqµately address
AS. Are the work practice controls (e.g., lockout/tagout, bloodborne path?genS,
nd
A mented at the site? If not, explain . 6
controls were adequate? If not, please explain.
safety and health rules, inspecuons, trammg, etc. . ov1 e examp es.
Describe the disciplinary system? ‘.
1
ofrced equally
explain
AlO. Does the site have minimally effective written procedures for emergencies?
Al 1. Did the site explain the frequency and types of emergency ~rills held
A12. Is the emergency response plan updated as changes occur in the work areas
A13. Did the site describe the system used ~o verify all employees’ participation in
A14. Does the site have a written preventivelpredictive maintenance system? If not,
A15. Did the hazard identification and analysis (including manufacturers’ recom-
properly? If not, please explain. ·
they occur? If not, please explain. Is the preventive maintenance system
adequate?
A17. How does the site select Personal Protective Equipment (PPB)?
A18. Did the site describe the PPB used at the site?
A19. Where PPB is required, do employees understand that it is required, why it is
explain.
If not, explain.
AZ l. Is the site covered by the Process Safety Management standard (29 CFR
ple~se compl~te eitlier the onsite evaluation supplement A or B, and t11e
ons~te evalu~tion supplement C. If not, skip to Section B.
are present?
W}tlC . k d . h
ai;M Questionnarre, and/or the Dynanuc Inspection Priority Lists?
p rify that contractor employees who perform maintenance, repair, turn-
Ve nd maior renovation, or specialty work on or adjacent to a covered pro-arou ‘ ad · · dd cess have receiv~ eq~atePtrSatMrung an emonstr~te appropriate knowledge
of hazards associated with . , such as non-routme tasks, process hazards,
hot work, emergency evacuation procedures, etc.? Please explain.
Is the PSM program ade~uat~ in that it addresses the elements of the PSM
standard and the PSM drrecttve? Please explain.
8, occUP Describe the occupational health care program (including availability of
audiograms or other medical tests used.
How are licensed occupational health professionals used in the site’s
ness and injury, and the system for limiting the severity of harm that might
result from workplace illness or injury? Is this use appropriate?
the site, as well as the nature of hazards found here? If not, please explain.
Cl. Are OSHA required recordkeeping forms being maintained properly in
CZ. Is the record keeper knowledgeable of 29 CFR 1904, OSHA’s recordkeep-
C3. What records were reviewed to determine compliance with the record-
C4. Do the injury and illness rates accurately reflect work performed by con-
CS. Was there any evidence of recordable injuries/illnesses not being reported
etc.? If yes, please explain.
Al.
A3.
visors, employees, and contractors? Please explain.
Is the training delivered by qualified instructors?
Does the training provided to managers, supervisors, and non-supervisory
employees (including contract employees) adequately address safety and
health hazards?
A9.
1
program for all employees including new hn:es? , ease exp am .
How are the safety and health training needs for employees d~termined?
Please explain. , . , . . .
Does the site provide minimally effective trammg to educate supervisors
and employees (including contract employees) regarding the known haz-
ards of the site and their controls? If not, please explain.
Are managers, supervisors, and non-supervisory employee& (including
contract employees) taught the safe work proced1,ires ,to follow in order to
protect themselves from h~s during initial, job training and subsequent
reinforcement training?
Who is trained in hazard identification and analysis? .. ·
Is training in hazard identification and analysis adequate for the conditions
and hazards of the site? If not, please explain.
Does management have a thorough understanding of .the. hazards of the
site? Provide examples that demonstrate their understanding.
Do managers, supervisors, and non-supervisory employees (including
contract employees) and visitors , on the site understand what to do in
emergency situations? Please explain. .
SECTION 6.2 OF 210
were made about analyses of over 1800 incident investigation reports to assess their
quality, with an emphasis on contributing and causal factors. It was also said that the
gap between established procedures on incident investigation and what actually takes
place can be enormous. Even in the best safety management systems, the quality of
incident investigation can be substantially less than adequate. For example, in a very
large organization, it was agreed-that if the safety staff promoted adoption of a system
as uncomplicated as the Five Why Technique to improve incident investigation and
the organization achieved a B + grade in two years, a huge step forward would have·
been taken.
of incident investigation to establish a database from which improvements can be
proposed. But they should be aware that such evaluations often indicate that culture
problems exist. They may find that it.had become accepted practice for supervisors,
~anagement personnel above the .supervisor level, and. safety ·professionals to
sign-off on shallow investigation reports, indicating that they, were acceptable. •
. In my studies I observed that safety professionals would better serve their clients’
lllterests if they:
1
~~Ilts .that should be made in ,safety management systems. Because-if incident
inve&tigation is done well, the reality of , the technical and organizational
that result in serious injuries and illnesses will be revealed. Ures
elements of a safety managemen_t system .. Because-~e ~u~ity of inciden~
investigation is a principal marker m evaluating an orgamzation s safety culture.
improvement in the incident investigation process, in this chapter we:
• Comment on the cultural difficulties facing safety professionals who try to have
of incident investigation
• Explain why supervisors who complete incident investigations may be reluctant
• Discuss why supervisors may not be adequately qualified to make thorough
• Suggest studies of needs and opportunities and courses of action for improvement . .
• Comment on incident investigation forms
• Promote use of the Five Why System . ,
• Make observations on selected resources
of ZlO. They are contained in one paragraph with no subsections. To fulfill the
standard’s requirements:
dents in order to address occupational health and safety management system
non-conformances and other .factors that. may •be causing. or contributing to ·
the occurrence of incidents. The investigations shall be performed in a timely
manner.
the requirements for this very important subject. It might seem that this safetY
management process is dealt with too briefly. On the other hand, within an AN!~
management system standard, all that needs to be said is said. Advisory comments
incident investigation are more extensive. They say that:
health and safety management system.
goal 1s , ‘fhe • . ts oecur. . . . .
• f;1’perience s
·dent inves 1 · d · 1 · · · • Jnc1 deficiencies for deve opmg an imp ementmg corrective action plans.
, i.,v • action processes.
pOSSGISooNE POORLY
SEIN ,
In IDY ·es were given scores ranging from 2 to 8, with an average of 5.7, and that
comparucould be a stretch. These relatively poor scores were troubling and prompted
~ve~ge into situations that exist in the investigation process that might be barriers to :~;’th determinl\tions of contributing factors and why this important safety
m Typically, first-line supervisors are given the responsibility to initiate an incident
investigation report. It is presumed. that they are clos~st to the work and they know
more of the details regarding what has occurred.
determine why there was such a huge gap betw.een. procedures adopted regarding
incident investigation and what actually takes place. As the Five Why exercise
proceeded, it became apparent that our model is flawed on several counts.
performance reviews on themselves and on the people to whom they report-all the
way up to the board of directors. · – · ·
h It is understandable that supervisors would tend to avoid expounding on their own
oncomings. The supervisor probably would not write:
;r
kt. 1 overlooked .. ~. I should have done …. My boss did not forward the
It is not su · · · , ·
, manageme t .
relationsh~Pervisors do write ·about such systems· shortcomings, adverse personnel
Reason wrote in Human Error that: ‘
. . f d 1:ects created by poor design, mcorrect mstallation mhentors o system ei, · . . . . • •
faul~y mthamfit_enalance h to a lethal brew whose ingredients have already been adding e n garms
long in the cooking.” (p. 173)
whose ingredient~ have .. alrea~y been long m the coo~ng. They have httle or no
influence on the original design of operations and work systems and are hampered in
being able to have major changes made in them. ·
certain accidents, such as all OSHA recordables. Then, if the team consists of fellow
supervisors, the team is expected to write a performance appraisal on the supervisor
for the area’ in which the accident occurred, and that supervisor’s boss, and her
boss-all the way up to the board of directors.
another supervisor and management personnel above the supervisor’s level. At every
level of management above the line supervisor, it would a:lso be normal to try to avoid
being factually critical of themselves. Self-preservation dominates at all levels.
GOOD INCIDENT INVESTIGATIONS
contributing to an accident and that reports be factual. An example follows.
tbey want t? ~ow_ about the contributing factors for accidents regardless of where
the respons1b11ity bes a special · ti” · · · ‘ · · ·
Management recognized th t ·t d”ffi ·
1
facilitator serv~s as the investi · ~ay e C~tical ~f themselves. Thus, an independent
edgeable people serve on th/:tlon and discussion team leader. At least five. knowl-
report is expected. earn. All members of the team know that a factual
complete, and sees that the eo le e reports, ask~ questions to a~&ure th~t they are
conclusion all of the recorn …. p dp : who repprt · to him. or her resolve to a proper h . uuuen ations mad Th , . .
et ~tions that the organizati , e. us, the CEO demonstrates by his or
8
In some compan · · . · · ·
will not tolerate other than . . ,y~ igatic;:>n, is
ance. In the studies made of the qu ity
tigauo • f be’ h d • ore an one f jnves accused me o mg a ar marker.) . o director . . ~s:
1
.u b d f di execu ves,
. 0111e 1 • xpenence .~d 111 s ed d personnel are held accountable for results . .., .. w an f . .
exantP d . . . oar o
&ectors ~the article “Building a Better Safety Vehicle: Leadership-Driven C~ltcan und 1n ,, bl’ h d . th ure
be
General Motors pu ts e 10 e January 2005 issue of ‘Professional
safety·~ent and engagement of the leadership at every level. What follows is
conuntry of how this was accomplished. Paul O’Neill chair at Alcoa J”oined the the sto . . . . ‘ ,
M board of directors m 1993. His commitment to worker safety was key to
generated quanufia?ledbotthom-hnthe results. So perhaps GM’s directors should
ot have been surpnse w en, as ey prepared to adjourn the first board meet-
0’Neill’s question-and its exposure of the status of safety at the ‘company-
would become a watershed in GM’s history. The President’s· Council …
decided to meet the challenge and take a close look at GM’s safety performance
and do whatever was necessary to improve it.
safety management-incident investigation-senior executive direction and involve-
ment are needed to drive improvement. In every company with which I am familiar,
that bas achieved stellar safety results, incident experience is reviewed regularly
at the chief executive officer level.
categories of incidents be investigated by teams consisting ‘mostly of personnel not
directly related to the area in which the accident occurred.
teams that were encouraged to be factual got the highest scores. That’s an idea that
safety professionals could promote.
Gooo INCIDENT INVESTIGATIONS
:ety:related decision making favorably or unfavorably has been ,emphasized.
E ere ‘.
a relative and all-too-truthful paragraph in Guidelines for Preventing Human
on Ystem Design.”
system. Essential requirements are minimal use of blame, freedom from fear
~
being used to make changes that will be beneficial to everybody. All thr
certain extent, under the control of management. (p. 259)
Machine: Why Human Error ,Causes Accidents, is particularly appropria%~
Whittingham say~ that his research shows that in some organizations, a “blame
culture” has evolved whereby the focus in their investigations is on individual human
error and that.the .corrective a_ction .stops at that level. That avoids seeking data on and
improving the management systems that may hav,e enabled the human error.
example of one -aspect of a negative safety culture, consider the following scenario.
It represents a culture of fear. , ,
safety director visited the location to expand on the investigation. During
discussion with the deceased employee’s immediate supervisor, it became
apparent that the supervisor knew of the design shortcomings in the lockout/
tagout system, of which there were many at the location.
factors in the investigation report, the supervisor’s response was: “Are you
crazy? I would get fired if I did. that. Correcting all these lockout/tagout prob-
lems will cost money and my boss doesn’t want to hear about things like that.”
management created. The supervisor completed the investigative report in accord
with what he believed management expected. He recorded the causal factor as
“employee failed to follow the locko_ut/tagout . procedure,” and the investigation
stopped there.
tion processes, wherever and to what extent it exists, will require careful analysis and
much persuasive diplomacy.
unwilling to look too closely at the system faults which caused the error. Instead_ tbe
attention is focused on the individual who made the error and blame is brought into
the equation.” (p. xii) . 1 by Actions necessary to remove error-provocative system faults can be taken on Y ust
management. For an incident investigation system. to be effective, management mare
demonstrate by what it does that it wants to know what the contributing causal fa~tot: ons:
Consider the following examples, limited to ten, of statements that coul~ le~ium~ore
be made in investigation reports but may be perceived as self-incriminaung.
.
a did not take the time to train this employee because we were too busy.
t111ng . . &
3 We · . . . · . uipment. ·
did not do pre-Job p annmg, an azardous situations came up that we did 4 We
It was the kind of a rush situation that often happens, and we understand that 5
The work is overly stressful and risky. Hazards were not properly considered 6. .
in the design process. , .
operating it are high. . . • . , .
9. We haven’t had time to write a Standard Operating Procedure for this job.
. 1,
management is not fact based and ~oes not promote and require that hazard and risk
problems be identified and acted upon. Situations of that sort defme safety culture
problems.
the reality of the safety culture in place must be evaluated and defined accurately as
an action plan for improvement is being formulated.
supervisor is best qualified to complete incident inve~tigations because he or she is
closest to the work and knows the most about the hazards and risks. That premise
needs rethinking .
. A safety professional should ask: How much training with respect to hazards and
q ;lilied, and how often is training provided? ·
and ?0ubt that supervisors become exceptionally knowledgeable about h~ards
0 nsks and thus well qualified to make good incident investigations after taking a ne. or two-day co . .d . . . A . urse on mc1 ent investigation.
in ‘d qu~sti0n that logically follows pertains to all personnel at all levels who do
. . . . Th al sor to complete two or three incident mvestigations m a year. at may so be the case £
Also, consideration needs to be given to the time lapse between when supervisors
report. It is generally accepted that knowledge obtained in a training session will not
be retained without frequent use. .
references, the content of which should be comparable to a combination of the two
addenda to this chapter.
has had extensive experience with incident investigation and who tries to influence
managements to examine and improve their systems .
for one of the largest manufacturers iµ the world. The group consisted of about 150 to
175 plant managers, pers<;>nnel directors, union presidents, and union bargaining chairs.
.l;>elieved could be contributing factors for the occurrence of accidents in the opera-
ti
they could be contributing factors in accidents. Then the group was asked to
record-How often these subjects appear in incident investigation reports? Results
are shown in Table 22.2.
2. Lack of employee participation
3. Inadequate hazard identification
4. Inadequate hazard controls
5. Inadequate management of change
6. Lack of preventive mainte~ance
7. Inadequate risk sensitivity
8. Don’t know
2. Often
3. Seldom
4. Never
5. Don’t know
22%
44%
20%
7%
..-Hi:WAYT
. . The audience consisted of managers and other upper-level
rsonnel. _F tigation reports . Twenty percent recorded Never. Is this broadly
appear~ of reality?
JescriP~ive the performance level expected by management for incident investiga-
uons 1s very ade until management upgrades · its expectat10ns and provides the
1
0ecessarY :rs ago, I had an involvement with that company and studied its incident
invesugaduon ry shallow incident investigations-and it was determined that the same
condone ve 13
applies in 20 .
~SELF-EVALUATION OFTHE CULTURE
bould begin with the first step m the Plan-Do-Check-Act process–define the
roblem. They should begin with an evaluation of a sampling of completed incident
forms-such as name, department, location of the accident, shift, time, occupation,
age, time in the job-got relatively high scor~s for thoroughness of completion.
tions, causal and contributing factor determination, and t)le corrective actions
taken. Considering efficient time usage, a safety professional may want to have
the evaluation include only incidents resulting in serious injury 9r illness, and
incidents and near misses that could have had serious results under slightly different
circum,stances.
for such a study was presented under the heading “Proposing a Study of Serious
Injuries.” Such a study will not be time ~onsuming since the data to be collected and
analyzed should already exist or can easily be obtained. To assist in the study, two
addenda to this chapter are provided. Both are taken from the fourth edition of On
the Practice of Safety. Addendum A describes, a sociotechnical causation model for
hazards-related incidents, and Addendum • B is a •reference for causal factors and
~orrective actions. Another good reference for this ·evaluation is Chapter 4 “Human
errors that b A may e made above the worker le.vel. 1 ,
outco safe_ty professional who undertakes such a study should keep in mind that its
• A . . I • ,, l I
, orts will be beneficial _
good causal factor determination and corrective action taking so
system of performance expected. The organization’s safety culture with respect t:
the quality of incident investigation will not be changed without support from senior
management.
of making the changes proposed: avoiding injuries to employees, good business
practice, cost reduction, waste reduction (lean), personnel relations, and fulfilling
community responsibility.
get it done. Culture changes are not accomplished easily. They require considerable
time and patience to achieve small steps forward.
identify activities in which serious injuries occur for which concentrated prevention
efforts will be beneficial. An example of such an initiative follows.
computer runs made of worker compensation cases valued at $25,000 or more. For
those studies, safety directors agreed that employees in their organizations who had
the following job titles were ancillary and support personnel. They did not work on
the production line producing product.
service technician, accounting
service engineer, storekeeper
administrator, salesperson, janitor, driver
warehouse, shipping
to ancillary and support personnel-in six companies were 78%, 72%, 72%, 67%,
63%, and 61 %. All of those companies are large, have good safety management
systems, and the statistical base is large enough to have some credibility.
had OSHA rates higher than industry averages, the percentage of serious injuries
that occurred to line employees was much higher. Also, if an organization a
division that was more inherently hazardous than manufacturing, such as nuning,
that operation skewed the statistics. .
suggested in the ZlO ·advisory column for incident investigation could produ~:
meaningful results from which proposals can be made on where activities cou
profitably be focused.
oftU;FI sU .
A-5 a part. taught about mc1dent mvestigation, what guidal).ce is given in procedure
wbat is betn~ whether the content ·and structure of the incident investigation form
manuals, der thorough investigations.
assist or~ wing define real-world situations as discovered in the sti.idies made.
consider
• In colude that 80 to 90% of accidents are caused principally by the unsafe acts
of workers.
In trUction is plainly given that the corrective actions proposed in incident
• In the incident investigation procedure manual ‘the same thought is conveyed
• After a description of an incident is recorded, the first instruction in an incident
• Instructions for a · computer-based data-entry system with respect to accidents
factor code.
and there is no need to identify contributing causal factors, supervisors, upper
levels of management, and safety professionals put their signatures on forms, indicating
approval, when the reality is that investigations are shallow and of llttle value.
Making the · additional reviews proposed in this chapter will help a safety profes-
sional define the extent of the problem and assist in crafti~g a course of action for
improvement.
‘.ncide_nt investigation-to prevent similar incidents from occurring-. and a sample
mvestigation form. This form presents a good basic outline, and its conte~t can serve
0 an organ· · • · · h · · h fi t r . izatton s operations. It has several positivy c aractenstics t at sa e Y
P 01ess1onals sh Id . . . . . fi . ou consider as they draft or revise mvest1gat10n orms.
dido d”d · ·
r 1 not do, to the exclusion of other causal factors .
supervisor, witnesses, and employees with insight.
· • E · t· Tools· Environment; Procedure; an Personnel, categones: qmpmen , • . . . .
· A • · · made to enter “Accepte eJecte . ctions or rationale name. prov1s1on 1s
5. A sign-off is required by the “Responsible/Approvmg Department Manager/
6. The report ends with the investigator’s signature and recordings of the persons
causal factors determined and acted upon properly. As a beginning step where the
incident investigation system needs much improvement, it is suggested that a
problem-solving process be considered for which the training and administrative
requirements are not extensive; that is the five-why technique.
equate because it does not promote the identification of causal factors resulting
from decisions made at a senior executive level. That is not necessarily so. Usually,
when inquiry gets to the fourth “why,” considerations are at the management levels
above the supervisor and may consider decisions made by the board of directors.
for incident ‘investigations will be a major step forward.
T?yota. He develop~d and promoted a practice of asking “why” five times to
determine what caused a problem so that root causal factors could be identified and
effective countermeasures could be implemented. The five-why process is applied in
a large number of settings for a huge variety of problems.
easily be adopted in the incident investigation process, as some safety professionals
h~ve done. For the complex incident situation occasionally encountered, starting
with the five-why system may lead to the use of event trees or fishbone diagrams or
more sophisticated investigation systems.
get to the contributing causal factors and outline the necessary corrective act1ons.
A not-overly-complex example follows.
on to an employee while she · tr.,· . · · ed
1. Why did the cart tip ove ? Th d’ d the
WbY is e. z. f bricauon shop. .
the a did the fabric~tion s?op ~alee carts with cast~rs that are too small?
‘fheY 1’ • b . . d ‘ .
4. WbY to be too small? Engmeenng did not consider the hazards and risks
that WO • • • .
5. :~esigner that use of the small casters would create hazardous situations.
. n problem. In at process, an e ucation 1scuss10n took place with
ineering was asked to study the matter an~ has given new design parame-
}:brication is to re~lace all casters on similar carts. A _3..0-day _ completion date
for that work was set. _ _
design are used. 1Jley have been advis~~d, to g~ther ,ail persoime~ who use the
carts and instruct them that larger casters are bemg placed o_n tool carts and that
until that is done, moving the carts is to be a two-person effort. I have asked our
safety director to alert her associates at other locations of this situation and how
we are handling it.
other occasions, may be necessary to ask “why” six times. Having analyzed incident
reports in which the five-why system was used, these precautions are offered:
lute necessity.
symptom. · •-
across: doing so in group meetings at several levels, but particularly at the
management level, is a good idea. · · ‘ ·· · ‘·
identified as skill is developed ih applying the five-why pro6ess, particularly
those that · f · .. ‘ · k ‘ 1 1 anse rom human errors made above the wor er eve .
Since the r , . . . .
abund iterature g1vmg guidance on incident investigation techmques 1s especially
· ant comm · · · ·t · 1rnrnea· ‘ ents are not being made here on such items as mvest1gat1on en ena,
Investigation” in the 4th edition of On the Practice of Safety gives a detailed rev·ent
of the methodology. Similar incident investigation procedure outlines appear in
resources described below. · e
dent investigation methods, the following reso~ces provide informatiqn on b~;;
analysis, change analysis, event tree analyses, failure moqe and effects analysis, and
fishbone (Ishikawa) diagrams.
shown, as well as the websites for some of them, they are not repeated in the reference
list at the end of this’ c\Iapter. The first two resources listed are highly recommended
for their content. Also, ·they are well worth the price. They are available on the
Internet and can be downloaded at no cost. ·
DC,: Us Department of Energy, 1992. Also at h~://us.yhs4.search.yahoo.com/yhs/
search ?p=DOE-NE-STD-1004-92&h,spart=att&hsimp=yhs-att_OO 1 &tyj>e=att_lego_
portal_home.
incident investigation techniques are discussed in an “Overview of Occurrence
Investigation.” Thus, . it is a resource on events and causal factor analysis,
change analysis, barrier analysis, tbe management oversight and risk tree
(MORT) analytical logic diagram, human performance evaluation, and
Kepner-Tregoe problem s_olving and decision making.
Management Oversight and Risk Tree Analytical Logic Diagram, is published by
The Noordwijk Risk ~tiative .Foun~ation in The Ne~erl,ands ..
• Improve guidance on the investigative application of MORT
• Restore “freshness” to the 1992 MORT question set
• Simplify the system of transfers in the chart
Rernove . .
1 believe “fr h ” d t · · f r ation, to restore es ness, an ° Slmph Y the system. What they have
done 1s rnJNR11 #search=’NRl%20Mort%20User%27s%20Manual’.
nri,eu,co mend that safety professionals who want to identify the reality of causal
, ctors acq · eel d ill · ia . w of the aforementlon ocuments w provide an inexpensive and valuable
educaU00· · · d al · li eel Th · causal factor identification an an ysis are st . ere are other resources besides these.
Chemical Process Safety of the American Institute of Chemical Engineers, 1994.
and incident analysis methods. Elsewhere~ comments are made on types
of human error causal factors, their nature, and how to identify and
analyze them .
New York: Marcel Dekker, 1987.
called “Sequentially Timed Events Plotting.” Several authors refer to
this thought-provoking system. This book is devoted entirely to the STEP
system.
Methods and Applications. Des Plaines, IL: American Society of Safety
Engineers, 2003.
on the incident investigation process generally, and on several investigation
and analytical techniques, such as events and causal factors analysis, change
analysis, tree analysis, and specialized computerized techniques.
consulting services on root causal factor analysis, I am listing two that have
published books on the subject and which have a known history with respect to
occupational safety and health.
Portland, OR: Apollonian Publications, 1999. Dean Gano has been a
literature are well regarded.
describes the root-cause identifying and analysis methods developed by the
staff at Systems Improvements. This company has also offered consulting
services on root-cause analysis for several years.
reduction, can be achieved if investigations are done well. If incident investigations
are thorough, the reality of the technical, organizational, methods of operation, and
cultural causa1 factors will be revealed .
system improvement, they would have a good data source for that purpose if incident
investigation reports identify causal factors realistically. I now believe that the quality
of incident investigation is · one of the principal markers in evaluating an organiza-
tion’s safety culture.
of incident investigation. It is proposed that the following comments about inci-
dent investigation as excerpted from the August 2003 “Report of the Columbia
Accident Investigation Board” be kept in mind as a base for reflection throughout
the endeavor. The report pertains to the Columbia spaceship disaster. It is accessed
at http://www.nasa.gov/columbia/home/CAIB_ Voll .html. ·
cause of the accident, and then connect it to a variant of “operator error.” But
this is seldom the entire issue.
and individual failure , typically the actions taken to prevent a similar eyent in
the future are also limited: fix the technical problem and replace or retrain
the individual responsible . Putting these corrections in place leads to another
mistake-the belief that the problem is solved.
complex process, “”.hen a more comprehensive understanding of that process
could reveal that earlier steps might be equally or even more, culpable.
In this Board’s opinion, unless the technical, organizational, and cultural
recommendations made in this report are implemented, little will have
been accomplished to lessen the phanc~ t~at another accident will follow.
(Vol. 1, Chap. 7 ,, p. 177)
of operation causal factors are not identified, analyzed, and resolved, u,tle will be
done to prevent recurrence of similar incidents.
AJHA zl0-2012. American National Standard, Occupational Health and Safety
now the secretanat. Available at https://www.asse.org/cartpage.php?link=z10_2005.
Gu ;
:ess Safety of the American Institute of Chemical Engineers, 1994.
NASA. Columbia Accident lnvestiga~on Report, Vol. 1, Chap. 7. Washington, DC: NASA,
3, http://www.nasa.gov/columb1a/home/CAIB_ Voll .html.
s·mon, Steven I., and Patrick R. Frazee. “Building a Better Safety Vehicle: Leadership-Driven
1 Culture Change at General Motors.” Professional Safety, Jan. 2005.
www.moresteam.com/toolbox/5-why-analysis.cfm. ., ,
MA: Elsevier-Butterworth-Heinemann, 2004. ‘ ·
CAUSATION MODEL FO R HAZARDS-
RELATED INCI DENTS IS PRESENTED
O N THE FOLLOWING PAGE
Second Edition. Fred A. Manuele. ‘
© 2014 John Wiley & Sons, Inc. Published 2014 by John Wiley & Sons, Inc .
An organization’s culture
+
ro achieve and maintain acceptable risk levels is an expression of the culture
Causal factors may derive from shortcomin_gs in controls when safety policies,
~dards, procedures. the accountability system. or their implementation, are
Inadequate with respect to • The design process and operational risk management
• Providing resources
‘ J •
• Incident investigation and analysis 1
‘ • Management reviews for continual improvement
I I f · I ·I
ere are _unw_anted energy flows or exposures to harmful substances.
~Ultiple interacting events occur sequentially or in parallel.
r s lted in sli htl diffe r ent circum st nces.
ADDENDUM B
OF CAUSAL FACTORS ,
AND CORRECTIVE ACTIONS
FOR INCIDENT INVESTIGATION
PROCEDURES AND REPORTS
and corrective actions included within inve•stigation forms or as separate informational
documents must be appropriate for the operations being conducted. The material
presented here should not be used without modification to suit needs.
” .
2. Hazardous materials need attention. ·
4. Environmental factors (heat, cold, noise, lighting, vibration, ventilation, etc.)
. /
6. Accessibility for maintenance work is .haza,rdous.
1. Work methods are overly stressful.
2. Wor~ methods are error-pro~~cative.
3. Job is overly difficult, unpleasant or· dang .
4 J b · • erous. . o requrres performance b
5. Job induces fatigue. eyond what an operator can deliver.
Second Edition. Fred A. Man~el:cusmg on ZJO and Serious Injury Prevention
© 2014 John Wile & s · ‘
460 · · 1 ey_ Sons, Inc.
FOR THE SELECTION OF CAUSAL FACTORS AND CORRECTIVE ACTIONS 461
6. d metbo s.
· . . ing of employees m re anon to equipment and materials is hazardous. s. pos1uon ..
Job PfV’iV”‘
1. Job procedures existed but did not address the hazards ..
~: Job procedures existed but employees did not know of them.
4_ Employee knew job procedures but deviate~ from them:
s. Deviation from job procedure not observed by superyision.
6. Employee not capable of doing this job (physically, work habits, or behaviorally).
7. Correct equipment, tools, or materials were not used.
8. Proper equipment, tools, or materials were not available.
9. Employee did not know ·where to obtain proper equipment, tools, or materials.
11. Defective or worn-out tools were used.
2. Hazardous condition was recbgnized but not report~d.
3. Hazardous condition was reported but no~ corrected.
appropriate ~nterimjob procedure.
· PPB specified for job but not available. · . · 1 3
· PPB specified for job, but employee did not know requirements. 4
· PPB specified for J. ob but employees did not know how to use or maintain. 5 PP ‘
· PE •nadequate.
ent and Supervisory Aspects 1· Genera}· .
3. l’r . . n procedure did not detect the hazards.
4. ~ning as respect identified hazards not provided, inadequate, or didn’t take.
e Wt respect to identified hazards was ma equa e.
a job done infrequently. . .
7. Supervisory responsibility and accountab~ity not defined or u~d~~stood.
8. Supervisors not adequately trained for assign~d safe~y responsibility.
9_ Emergency equipment not specified, not readily available, not used, or did not
2. Work methods to be revised to make them more compatible with worker
3. Job procedures to be changed to reduce risk.
4. Changes are to be proposed in work space, equipment location, or work:flow.
5. Improvement ~s to be recqmmended for environmental conditions.
6. Proper tools to be provided along with information on obtaining them and
8. Job procedure to be written or amended.
9. Additional training to be given concerning hazard avoidance on this job.
11. Disciplinary actions deemed ‘necessary. and will be taken.
12. Action is to be recommended with respect to employee who cannot become
hazards and procedures is to take place.
15. Improvement in inspection procedures to be initiated or proposed.
16. Maintenance inadequacies are to be addressed.
17 · Personal protective equipment shortcomings to be corrected.