Occupational Health & Safety Practitioner. Reading HEALTH & SAFETY AUDITING

Transcription

1 Occupational Health & Safety Practitioner Reading HEALTH & SAFETY AUDITING January 2009

2 Contents OVERVIEW...1 SECTION 1: INTRODUCTION...2 SECTION 2: RELEVANCE OF AUDITING TO OHS MANAGEMENT...4 SECTION 3: AUDIT PLANNING AND ORGANISATION...7 SECTION 4: AUDIT DESIGN AND PREPARATION...10 SECTION 5: CARRYING OUT AN AUDIT...13 SECTION 6: CLOSING MEETING AND AUDIT REPORT...16 SUMMARY AND CONCLUSIONS...20 REFERENCES AND FURTHER READING...20

3 Government of Western Australia Department of Commerce Published by WorkSafe, PO Box 294, WEST PERTH WA Tel: Toll Free The SafetyLine Institute material has been prepared and published as part of Western Australia s contribution to national OHS skills development State of Western Australia. All rights reserved. Details of copyright conditions are published at the SafetyLine Institute website. Before using this publication note should be taken of the Disclaimer, which is published at the SafetyLine Institute website..

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5 OVERVIEW This reading provides a basic understanding of workplace inspections, checklists and procedural audits. The reading covers their advantages and disadvantages, and explains how to formulate one's own inspection procedure and procedural audit as part of the approach to accident prevention. Objectives After reading this information you should be able to: explain the relevance of the safety and health audit to occupational health and safety (OHS) management systems; identify the purposes of an OHS audit; outline the organisation and planning of an OHS audit; describe how to carry out an audit; identify the key features of an audit report; and detail the methods used to follow up and monitor the corrective actions resulting from an OHS audit. Author John Innes B. App. Sc. (Curtin), Grad Dip Occ Health & Safety Grad Dip Management, MBA, ALCM, ARM JANUARY 2009 SAFETYLINE INSTITUTE PAGE 1

6 Section 1: INTRODUCTION Glossary of terms When they are first used, glossary terms are indicated with an asterisk (*). Make sure that you are familiar with the Glossary of terms before going any further. Audit Horizontal auditing Vertical auditing Random auditing A health and safety audit must be clearly distinguished from other forms of monitoring, such as safety inspections. A safety audit may include inspections, but it is a more comprehensive concept, in that safety audits require a lot more work effort than inspections and usually take place over days or weeks. A safety inspection takes less time and is carried out more frequently, sometimes on a daily basis. A health and safety audit may have a number of purposes, including to identify the strengths and weaknesses of an OHS management system; and measure OHS performance. Horizontal auditing examines each functional area of an organisation to verify the adequacy and implementation of OHS system requirements. Each area is checked for conformance with OHS requirements applicable to that area. Vertical auditing means auditing across different areas of the organisation that are actively involved in a specific issue, for example, ordering, purchasing, using and training in personal protective equipment. The different areas are examined, normally in a logical sequence working forwards or backwards. Random auditing involves examining aspects of an organisation's operation as determined by the auditor, to the need to closely examine a particular activity or generally probe the system in a random manner, for example, after a serious accident. PAGE 2 SAFETYLINE INSTITUTE JANUARY 2009

7 1.1 Auditing is the final step Other readings have described the essential elements of an OHS management system, such as policy, planning, implementation and measuring performance. These elements are all necessary, but experience has shown that they are not sufficient to ensure that the system is performing adequately, or that the system itself is adequate. A low reported accident rate is no guarantee that risks are being effectively controlled, nor will it ensure the absence of injuries and disease in the future. KEY POINT Auditing provides a positive measurement of OHS activity that does not rely on accidents to happen before making improvements. Monitoring activities are an important signal of management's commitment to safety and health, and a valuable source of information for managers seeking to improve their safety and health management system. All control systems become less effective over time, and may become obsolete as a result of changes to the organisation's work processes. Auditing can be considered as the final step in the OHS management system. Auditing complements policy making, planning, implementation and measuring performance. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 3

8 Section 2: RELEVANCE OF AUDITING TO OSH MANAGEMENT 2.1 Audits are comprehensive activities A safety and health audit* must be clearly distinguished from other forms of monitoring, such as safety inspections. A safety audit may include inspections, but it is a more comprehensive concept, in that safety audits require a lot more work effort than inspections and usually take place over days or weeks. A safety inspection takes less time and is carried out more frequently, sometimes on a daily basis. 2.2 Purposes of OHS audits A safety and health audit may have a number of purposes, including to: identify the strengths and weaknesses of an occupational safety and health management system; measure OHS performance; establish the extent of legal compliance; define areas that require improvement; and compare the company's performance with an established standard. The purpose of the audit must be clearly established in advance by the organisation, because it will affect the type of audit used and how the audit is carried out. For example, an organisation wishing to compare itself to others would have to select a proprietary audit system that was widely used. PAGE 4 SAFETYLINE INSTITUTE JANUARY 2009

9 2.3 Commercial audit systems There are a number of proprietary audit systems available, including: ISRS 5 Star Safety Audit System CHASE (Complete Health and Safety Evaluation) Safetymap - Victoria WorkSafe Plan - Western Australia Safety Achiever Bonus Scheme - South Australia STOP System - Dupont NSCA 5 Star system Commercial audit systems have a number of advantages, as they are tried and tested in a large number of organisations. Many commercial audit systems have national or international recognition and credibility. The major disadvantage of a proprietary audit system is that it may not address all the problems in an organisation. It may be possible to alter or modify commercial audit systems to make them more suitable for your organisation, although you should check with the owner of the audit system before doing this. The following questions should be considered before selecting an option: Does the organisation have the expertise and resources to develop an effective audit system? Does the competent person have the necessary knowledge and skills in: - principles of loss control; - causes and effects of loss; - motivational skills; and - methods to improve performance? What are the consequences of failing to develop an adequate audit system in terms of resources? Off the shelf packages may appear to be expensive, but this cost must be offset against the costs involved in developing an alternative system in-house. The internally developed audit system JANUARY 2009 SAFETYLINE INSTITUTE PAGE 5

10 should be tailored to local needs, but a proprietary audit package may need further adaptation in any event. Using a previously developed audit system will save development time. On the other hand, commercial audit systems may require additional training of auditors before they can be accredited or licensed. 2.4 Audit sequence A systematic approach to accomplish an occupational safety and health audit consists of a series of well planned phases. Each phase is intended to achieve certain objectives and is dependent on the results of the preceding phase. Each phase is discussed in the remainder of the reading. PAGE 6 SAFETYLINE INSTITUTE JANUARY 2009

11 Section 3: AUDIT PLANNING AND ORGANISATION 3.1 Scope of the audit An OSH audit can be structured in different ways, depending on the objective. A compliance audit is concerned with past adherence to established requirements. Audits improve future performance by: identifying aspects of systems and procedures that need improvement; and making recommendations to management for change. The audit's objective will also influence the scope. An audit may look at: KEY POINT An audit can have several purposes. It is important to understand the audit's objective before starting to plan and organise. an entire facility; a single operation, eg, warehousing of products; a single issue, eg, personal protective equipment; OHS management systems; and technical aspects of work, eg, plant, equipment. 3.2 Horizontal, vertical and random auditing Another way of looking at the scope of an audit is in three categories: Horizontal auditing* Vertical auditing* Random auditing* Horizontal auditing examines each functional area of an organisation to verify the adequacy and implementation of OHS system requirements. Each area is checked for conformance with OHS requirements applicable to that area. Vertical auditing means auditing across different areas of the organisation that are actively involved in a specific issue, for example, ordering, purchasing, using and training in personal protective equipment. The different areas are examined, normally in a logical sequence working forwards or backwards. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 7

12 A = Horizontal audit B = Vertical audit C = Random audit Random auditing involves examining aspects of an organisation's operation as determined by the auditor, due to the need to closely examine a particular activity or generally probe the system in a random manner, for example, after a serious accident. 3.3 Internal or external auditors An important issue is the use of internal or external auditors. Audits carried out by internal employees provides advantages: Relatively low costs. Auditors already have knowledge of the enterprise. Confidentiality. Internal audits are usually carried out more frequently than external audits. However, there may be some disadvantages. The internal auditor may be too close to the problems and other workers, to carry out a truly objective assessment. Familiar problems can be overlooked or discounted as acceptable hazards. External auditors are expected to bring an objective viewpoint to the audit, because they have no vested interest in the enterprise. External auditors are frequently selected for their background and experience in a particular industry or activity, and can bring greater expertise in detecting problems and greater knowledge of their solutions. PAGE 8 SAFETYLINE INSTITUTE JANUARY 2009

13 Audits may be undertaken by one or more persons. A team approach, using managers, employees and health and safety representatives can improve cooperation and commitment to the audit's findings and recommendations. Audit teams may include line managers from other areas of the enterprise or the manager responsible for the audited area. Although the responsible manager may not be able to objectively grade their own performance, a manager can provide local knowledge and expertise, and has the opportunity to appraise the performance of their supervisors. 3.4 Audit planning process The audit planning process involves five key functions: 1. Description. The responsible parties, their duties, procedures and expected performance should be described. 2. Definition. The nature and scope of the audit must be established before the audit is carried out. 3. Designation. There must be a clear identification of the roles of senior management, line management, OHS staff and the workforce in the audit process. 4. Communication. The reporting procedures need to be clear. Audit reports generally go to the relevant manager and to the OHS section. 5. Record Keeping. The audit reports should be retained for future reference and review. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 9

14 Section 4: AUDIT DESIGN AND PREPARATION 4.1 Factors influencing audit design The design of an audit may reflect a number of factors: The nature of the hazards. The level of risk. Regulatory requirements. Previous experience, eg, audit findings or accident/incident record. One approach to audit design is to look for the most significant hazards. A list of potential problems with their consequences may reveal a range from trivial to serious. Those problems which may have severe consequences, for example, death, and may plausibly occur, are the areas that must be addressed by an audit. Previous experience, in the form of accidents or incidents, can be valuable in showing up these problem areas. The experience of other enterprises in the same industry is also relevant. Regulatory requirements are often based on past KEY POINT Work out the most significant hazards in terms of risk and likely consequences, and make sure that the audit covers these hazards. accident experiences that have been addressed by making laws to control their future occurrence, for example, machinery guarding, so they can also be a valuable guide to audit design. 4.2 Preparation considerations If an audit is designed for the organisation, there are a number of considerations: The key elements of the occupational safety and health management system and the criteria against which performance will be judged. The means for ensuring that the audit includes a representative sample of activities. How questions should be framed. The need for auditing aids, for example, check lists and inspection procedures. How the audit items are scored or rated. PAGE 10 SAFETYLINE INSTITUTE JANUARY 2009

15 Organisations are unique, and will wish to focus their efforts on different aspects of safety management. Although there are areas typically covered by most audits, audit questions can be tailored to match individual requirements. Organisations may also wish to set standards which are above the legal minimum and impose procedures on a local basis. In this case, the audit rating criteria should reflect the relevant company standards rather than regulatory standards. For economy, a sample of activities and individuals can be selected on the basis of auditor experience, accident rates, client concerns etc. Activities involving significant hazards should always be included in any sample. A sample for audit purposes does not have to be scientific to produce a randomised sample, but usually some type of systematic sampling is used. An example of systematic sampling is given below. Example of sampling Workforce Group Number 10% Sample Senior Management 10 (5%) 1 Middle Management 10 (5%) 1 Supervisors 20 (10%) 2 Workers 160 (80%) 16 Total 200 (100%) 20 (10%) Questionnaires can be used to assist auditors in structuring their activities and to act as a memory aid. Spaces should be provided on the questionnaire for brief explanations when yes-or-no answers are either inappropriate or are incomplete. While questionnaires are useful, they have their limitations and should be aligned to the audit's objectives. It is misleading to use standard questionnaires that do not reflect the scope or purpose of the audit. Questionnaires should not be routinely completed without auditors gaining an understanding of the organisation's operations. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 11

16 Checklists assure auditors that a survey is conducted properly. They provide guidance to auditors during a survey, and ensure that each important aspect of the audit is adequately addressed. But there is also the danger that the use of checklists may become mechanical and superficial and overlook the implications of items on the list. The auditor may need to be trained to carry out the role adequately. It is important to select auditors who possess the appropriate personal attributes to carry out a successful audit. 4.3 Auditor qualities Confident Diplomatic Inquisitive Good Listener Constructive Objective Analytical Honest Professional PAGE 12 SAFETYLINE INSTITUTE JANUARY 2009

17 Section 5: CARRYING OUT AN AUDIT 5.1 Key steps The main steps in carrying out an audit are: Preliminary phase - understanding the organisation to be audited. Interviewing key persons. Asking questions. Reviewing documentation. Observing work conditions. The three basic audit tools are inquiry, observation and verification testing. It is not possible to speak to 100% of the workforce in most organisations, so a sample of individuals must be selected. A common technique is to draw a number of persons from each level of the organisation, and seek the information from them. 5.2 Interview key persons The most important factors in interviewing are: interview the right people; be well prepared; let the interviewee relax; and adjust the interview style to suit the person. The design and preparation phases of the audit will ensure that the auditor is well prepared and knows what KEY POINT questions to ask. The interview should be Gather evidence by asking conducted in a relaxed atmosphere, and questions, looking at the auditor must expect to spend a short documents and observing work conditions. Use more period of time explaining the audit process than one method to and how it will be carried out. A more crosscheck the information. formal approach can be taken for interviews with senior managers, and the information should be extracted in the shortest time in order to let the person return to work. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 13

18 5.3 Ask questions The auditor must learn to ask questions that promote feedback of information, and gather additional information when the initial feedback is inadequate. Good examples of questions are as follows: Tell me about your involvement in risk assessments in your part of the organisation. How is safety performance measured? When do you carry out accident investigations? Open questions that use the words why, when, where, who, what and how require an informative answer rather than yes or no. When these words are combined with a request to show the auditor, they enable the auditor to verify what has been said. The results of interviews and questioning can be tape recorded, but many persons are not comfortable with this method, and it may lead to incorrect or misleading responses. The auditor should only write down the most significant responses if answers are recorded by hand, in order to keep the interview moving. 5.4 Review documentation A wide range of documentation may be reviewed during an audit, depending on the scope and the focus. Relevant documentation includes: Policy statement; Procedures manual; Inspection records; Safety committee agenda and minutes; Management job descriptions; Training plans and materials; Accident statistics; Safety rules and booklets; Emergency procedures; PAGE 14 SAFETYLINE INSTITUTE JANUARY 2009

19 Accident investigation reports; Maintenance records; Purchasing policy; Promotional materials; Previous audit results; and Records of statutory inspections. Looking at records and procedures for completeness, availability, accuracy and reliability is useful, before questioning persons who carry out the activities referred to in the documents for their understanding. There is often a gap between OHS documentation (what management thinks is happening) and OHS practice in the workplace. 5.5 Observe workplace conditions Information gathered by reviewing documents and interviews can also be verified by observation of workplace conditions and activities. Observations are usually focussed on those areas previously covered by documentation and interviews, and are not traditional workplace inspections, looking at all activities in the workplace. However, observation and questioning of operatives is also necessary to check on the effectiveness of workplace controls for significant risks. 5.6 Note problems for later investigation During the course of the audit, the auditor may discover something that is worthy of further investigation, but which leads away from the original plan of action. An auditor should always be prepared to follow these leads, but it may be better to note the potential problem and investigate it when the audit moves into the area where the trail leads. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 15

20 Section 6: CLOSING MEETING AND AUDIT REPORT 6.1 Closing meeting At the end of the data collection phase of the audit, the auditors should carry out a debriefing or closing session, with management representatives of the organisation or the part of it that is being audited. The closing meeting has several purposes including to: indicate significant safety and health problems that require urgent attention; foreshadow the findings of the written report; and highlight the strengths and weaknesses of the organisation. An early verbal report of serious failings is necessary because the written report is not usually completed for some time. The closing meeting also gives management representatives an opportunity to produce contrary evidence or additional information that can effect the audit findings. Verification of the audit findings is not a sign of weakness from the auditor, but it does prevent the authority of the report from being undermined later by wrong details. PAGE 16 SAFETYLINE INSTITUTE JANUARY 2009

21 6.2 Audit report The final product of an audit is the audit report. Without question the reporting phase of the audit process is most important. If the audit report does not motivate management to correct deficiencies, the audit's objectives will not be achieved. To a large degree, the usefulness of an audit report is related to its timeliness. This is especially true when a report contains unfavourable findings that require corrective action. The earlier that management is made aware of the audit results, the sooner corrective action can be taken. A recommended format for an audit report includes: Executive Summary Background Scope Overall evaluation Findings, recommendations and conclusions Action plan. Executive management may not have time to read extensive audit reports with full details and technical information, but will be interested in overall conditions and a summary of the problems. An executive summary transmits useful information to this audience in a condensed form. In KEY POINT Providing a timely final report will assist management to carry out these improvements. contrast, line management implementing corrective action is interested in details. The background may be limited to a description of the organisation and its business, along with the reason for the audit, for example, regularly scheduled or at management's request. A diagram of the organisation's operations is a useful inclusion. The report should also describe the scope of the audit: which aspects of the organisation's operation were reviewed and the time period covered by the review. The report must communicate to the reader exactly what the audit was designed to do. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 17

22 The scope should clearly identify the areas reviewed and indicate the depth of work in each area. If field conditions or findings required in-depth investigation of some factors and less attention to others, this should be clearly stated. It is appropriate for an auditor to express an overall opinion of the organisation's performance. A balanced approach is vital, and positive achievements as well as deficiencies must be described. This will also improve acceptance of recommendations for improvement. 6.3 Findings and recommendations The findings and recommendations must address four primary questions: What are the hazards associated with this organisation's operations? What factors can result in hazards becoming occupational safety and health risks? What actions can be taken to control these risks? How can the organisation manage these risks in the long-term? One method of organising the report is to present information as a series of topics. For each topic, describe the facts, for example, description of the element, the field verification and testing, and the criteria used. The findings usually take the form of brief comments about each element. The recommendations should normally be in the form of system improvements and specific corrections. An example of a system improvement might be the introduction of a selection and maintenance policy for personal protective equipment. A specific correction example could be the use of air-supplied respiratory protection when applying epoxy paint containing isocyanates in a spray booth. Recommendations must propose control measures that are practical, feasible and effective. The use of "overkill" or overspecification will reduce the credibility of the report and management acceptance. PAGE 18 SAFETYLINE INSTITUTE JANUARY 2009

23 The draft report should be discussed with the appropriate levels of management before the final version is produced. This serves three purposes: It allows the auditor to test the accuracy of the findings and the reasonableness of the recommendations. The auditor can begin to "sell" the recommendations and the benefits of rectifying deficiencies. Management's comments can be included in the report at the discretion of the auditor. The use of photographs may also improve understanding and acceptance of the report. 6.4 Action plan An action plan may be produced by the audit team or by the organisation's managers, depending on the previous arrangements made at the audit planning stage. An action plan usually contains a list of deficiencies to be rectified, the person responsible for the rectification, and the due date. The action plan should be followed up and reviewed to ensure that the actions have been carried out, or responsible management has taken the decision that the response to the report is complete. The action plan then forms part of the documentation to be examined at the next audit. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 19

24 SUMMARY AND CONCLUSIONS Requirements for a successful audit In summary, OHS audits are a necessary part of an OHS management system. Without monitoring, it will be difficult to establish the success or failure of an OHS program and the areas that can be improved. Typical requirements for a successful audit include: Commitment and support from senior management, such as adequate resources for the audit program. Well defined objectives, scope, methods and reporting channels for the audit. Selection and training of the audit team to ensure competence and credibility. Introducing improvements identified by the audit. Your feedback WorkSafe is committed to continuous improvement. If you take the time to complete the online Feedback Form at the SafetyLine Institute website you will assist us to maintain and improve our high standards. REFERENCES AND FURTHER READING Health and Safety Executive. Successful Health and Safety Management. London: HMSO. Standards Australia / Standards New Zealand AS/AZS 4801: Occupational Health and Safety Management Systems Specification with Guidance for use. PAGE 20 SAFETYLINE INSTITUTE JANUARY 2009