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cHAPTER 23

AUDIT REQUIREMENTS: SECTION 6.3 O F 210

Revisions made in the audit provisions in the 2012 version of ZlO have them relate more specifically to the occupational safety and health management systems require- 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.

Section 6.3: Audits

The organization shall establish and implement a process to: A. Plan and conduct periodic audits to determine whether the or~anization

has ap_propriately applied and effectively implemented OHSMS elements 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.

B. Audits shall be conducted by competent persons who are independent of the activity being audited.

C. Document and communicate audit results to: a. Those responsible for corrective and preventive action; b. Area supervision; and c. Other affected individuals, including employees and employee

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 .

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464 AUDIT REQUIREMENTS: SECTION 6.3 OF Z10

D. Immediately communicate situations identified in audits that could be expected to cause a fatality, serious injury, or illness in the immediate future so that prompt corrective action under Section 6.4 is taken. '

Having audits made is a part of the Evaluation and Corrective Action processes in 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.

Safety audits perform a valuable function in that they determine the effectiveness 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.

Also, hazardous situations observed during an' audit that could be contributing 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.

In the advisory column in ZlO opposite the audit requirements, two particularly important statements are made.

1. The safety audits required are not to be merely "compliance" oriented, meaning 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.

2. To promote objectivity, audits are to be conducted by persons independent of ,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."

To assist safety professionals fo 'crafting or re-crafting safety and health audit systems to meet the requirements of ZlO, in this chapter we: . .

• Establishe the purpose of an audit • Discuss the implications of hazardous situations observed

l •

• Explore management's expectations with respect to audits • Establish that safety auditors are also being ~udited during the audit process • Comment on auditor qualifications

. dit guides • Discuss the need to have safety and health management syste~ au . d relate to the hazards and risks in the operations at the location bemg audite

• Provide information and resources for the development of suitable audit guides

REASONABLE MANAGEMENT EXPECTATIONS: THE EXIT INTERVIEW 465

NCIPAL PURPOSE OF A SAFETY AUDIT: rtlf pAI ovE THE SAFETY CULTURE ro1MPA

this book emphasis has been given to the premise that safety is culture '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

Ss of a safety auditing program can only be measured in terms of the succe e l·t effects on the overall culture of the operation and enterprise that it chang •

audits. (p. 36)

Toe Kase and Wiese observation can be supported easily. The paramount goal of afety and health management system audit is to have a beneficial effect on an

as anization's decision making. Thus, a safety audit report is to serve as a basis for 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 . . ,

SIGNIFICANCE OF OBSERVED HAZARDOUS SITUATIONS

Physical or hazardous situations in operations observed during a safety audit should 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 will be gained if no change is made in the overall deci~ion making to improve the management systems that allowed the hazardous situations to develop.

• j.

. ' REASONABLE MANAGEMENT EXPECTATIONS: THE EXIT INTERVIEW

S.afety auditing is an exceptionally valuable process but is time consuming and expen- 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 · ,

w O make audits should prepare well for the exit interview. That means:

• Having been objective in their evaluations of management systems • Havin . . . . . , B . g good Justification for thetr findmgs

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 team should anticipate and prepare beforehand to respond to questions comparabl~ to the following:

1. What are the most significant risks? 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

spend attain sufficient risk reduction.?

Audit systems fail if they do not recognize management needs and if they are not 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, . ··

Unfortunately, safety auditors ~annot absolutely ass_ure managements that every 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.

It should be ma9e clear to management. that applied safety auditing is based on a sampling technique and that it is patently impossible to identify 100% of the ha~ard/ risk situations and shortcomings in safety man~~ement systems.

EVALUATIONS OF AUDITORS BVTHOSE AUDITED ' '

Safety professional~ should. also recognize that the time spent by auditors, the impres~ 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.

Four safety and health auditors spent a week making an audit of a 37 employee ' location. After the second day, employees complained · that the auditors were

being disruptive because of the amount of th'eir time that the auditors con- 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.

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AUDITOR COMPETENCY 467

f th criticisms made by location management pertained to the decision one O hea~quarters per~on~e~ to s~nd four auditors to their 3: employee location,

taken by f the fact that mamtammg tight cost controls was requrred by the organiza- in light o uon's culture,

AUDITOR COMPETENCY

hout ZlO there is an emphasis on identifying, prioritizing, and acting on 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

r improvement." To be able to identify and evaluate those "issues" as they exist in ;e operation being audited, safety professionals making the audit must have the ecessary qualifications and competency.

0 Managements have often said that auditors had little knowledge of the technical

aspects of their hazards and risks and that the audit report was superficial and of little value. If safety audits are to be perceived as having value, the auditors must have the professional qualifications to make them.

Safety professionals who make audits need to consider how well they are prepared for 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.

An excerpt from a paper entitled ''Auditor Competency for Assessing Occupational 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:

Several studies have raised questions about the value of quality, environmental 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.

~e foregoing excerpt pertains principally to audits made for management system ~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

by in-house personnel. occl'he ~aper contains an extensive listing related to specific knowledge and skills of

upational h Ith d · d d appear her ea an safety management s!stem ~ud1to~s. Only c~n . ense ex~erpts 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

gage who are external to their organizations. Excerpts r ,

rom the Paper on Auditor Competency Occupati knowJect onal saf~ty ~nd health management system auditors shou~d ~ave

ge and skills m occupational health and safety management pnnc1ples

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• 468 AUDIT REQUIREMENTS: SECTION 6.3 OF 210

and methods and their application, and related science and technology to enable them to examine occupational health and safety management systems and to generate appropriate audit findings and conclusions. Specific knowledge and skills should include:

• Occupational health and safety management tools (including hazard 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)

• An understanding of the physical, chemical, and biological hazards and other workplace factors affecting human well-being

• The potential interactions of humans, machines, processes, and the work environment

• Methodologies for exposure monitoring and assessment • Medical surveillance methodologies for monitoring human health and

well-being • Methodologies for accident and incident investigations • Methodologies used to monitor occupational safety and health performance • Sector-specific education, experience, and knowledge of operational

hazards, risks, processes, products, and services to enable auditors to· 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

This list, although abbreviated, provides a good foundation from which a safety and health professional can make a self-evaluation with respect to competency in relation to a particular audit undertaking.

ONE SIZE DOES NOT FIT ALL

Many of the statements made in Dan Petersen's article "What Measures Should We Use, and Why?" concur with my experience. This is what I wrote about his article in On The Practice of Safety.

Petersen questions the value of "packaged audits," giving examples of studies 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:

ONE SIZE DOES NOT FIT ALL 469

system elements 1. safetyl tive importance of each (weighting)

'fhe re a . h . h . 2, • ns to determme w at is appenmg 3_ Quesuo

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, 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

ra<le~ place, what is expected of them, and which systems are effective or ineffec- ystems in . ' . k Th . .cc • s_ . ntrolling an entity s ns s. at, m euect, results m a culture appraisal.

nvemco . . f al.fl . c the preceding listing o qu i cations 1or safety and health management system

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 ards risks, processes, an so on. When dra,fting an audit guide and in selecting

bthaz Je~ents to be emphasized, much should be made of "sector-specific hazards and ee . h . th .

. ks"-meaning those m erent m e operations at the location to be ~udited. 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. .

In sorpe organizations th~ &ame aµdit ,guide i~ used f()r all locations aJ1d the audit 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.

This book emphasizes the prevention of seriou~ injuries. When the ,audit .system 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

I~::for low-probabi~ity/serioµs ;-~onseque~c.e even.~ may be ~ess ~an_ !idequate. 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

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 lbat ~ouJd nq · the.4", w~jghtings var(ed , to suit the exposures at mdividual locations.

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 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:

The degree of detail in this table may not be needed for every organization, but may be used as a template th~t can be modified to match the culture and needs of each organization.

Therefore, modifications are to be made to fit the culture and the inherent hazards 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?

An example of such a practical adjustment in a safety and health evaluation system 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.

Appendix L also includes -"suggestions for the objective type of evidence that can 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.

The guidance given on objectivity is comparable to the instructions· given in the 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. · ·

~iilce it is proposed that safety professionals not develop a one.:size-fits-a!1 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

ey de~rmme· whether an organization meets· the requirements of its yotuntar~ 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

fr ' th • for om e worksheet appear as Addendum A to this chapter. It is an excellent referenc~ those who want_to _develop audit guides 'suited to operations at a particular tocaoon, The Worksheet 1s, m a sense, an audit form.

GUIDELINES FOR AN AUDIT SYSTEM 471

wn in Chapter 25, "Comparison: ZlO, Other Standards and Guidelines, and f.S sh0.fjcation", the VPP safety manageme~t system requirements are similar to

yPP Certt ZlO provisions, but there are also differences. Some of the VPP require- !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

Reference subjec=t:..------------------------Risk assessment l)eSign Reviews Management of Change Procurement

Chapter 11, "A Primer on Hazard Analysis and Risk Assessment" and Chapter 12, "Provisions for Risk Assessments in Standards and Guidelines"

Chapter 15, "Safety Design Reviews" Chapter 19, "Management of Change" Chapter 20, "The Procurement Process"

similarly, certai_n VPP requirements are not addressed in ZlO provisions. During a ypp site review, evaluations are made to' determine:

, More specifically, the adequacy of the "Occupational Health Care Program and Recordkeeping"

, Whether "Access to experts (for example, Certified Industrial Hygienists, Certified Safety Professionals, Occupational Nurses, or Engineers) is reasonably available to the site, based upon the nature, conditions, complexity, and hazards of the site?"

Safety and health professionals would give appropriate consideration to "the 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.

Two other valuable resources that relate closely to the content of the "VPP Site- 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

1 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

tc the d' comf au Itors and the personnel who review and act on ·audit reports are ortable. i

472 AUDIT RE!JUIREMENTS: SECTION 6.3 OF 210

CONCLUSION

Auditing performance with re~pect to _established ~perational goals is good b · ractice. The audit requirements m Z 10 are designed to meet that purpose. usmess p

1 • & • d · ·

Professionally done, safety audits provide valuab e m1ormatton to ec1s1on makers who desire to achieve superior safety and health results.

It is suggested that a safety professi_onal who propo~es that an organization 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.

After the gap analysis is made, a safety and ·health professional would assist management in formulating an action plan to fulfill ZlO requirements. As progress is made, the content of audit guides would be adjusted accordingly.

Over time, ZlO will become the benchmark against which'. the adequacy of 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.

REFERENCES

ANSI/AillA Zl0-2012. American National Standard, Occupational Health and Safety 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.

"Auditor Competency for Assessing Occupational Health and Safety Management Systems." 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. .

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. OSHA's VP~ Site-Based Participation.Evaluation Report. A,vail~ble at http://www.ospa.gov/

dcsp/vpp/vpp_report/~i~-b~ ed.htrµJ. , ·

:etersen, Dan. "What Measures ~hould We Use, and Why?" Professional Safety, Oct. 199S. 'The Program Evaluation Profile (PEP) ." U.-S, Department of Labor OSHA. At. http!lfwww.

osh~.gov/dsg/topics/safetyhealth/pep.html. ' · · "S t" afety and Health Management Systems eTqol-Safety and Health Assessment Workshee th/

U,S. D~partment of Labor, OSl{A, at http://www.oshagov/SLTC/,etools/safetyheal form331.html ·

sHft:S VPP SITE-BASED ~ARTICIPATION SITE WORKSHEET

SECTION I: MANAGEMENT LEADERSHIP AND EMPLOYEE INVOLVEMENT

A. Written Safety and Health Management System Al. Are all the elements (such as Management Leadership and Employee

Involvement, Worksite Analysis, Hazard Prevention and Control, and Safety 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.

A2. Have all VPP elements and sub-elements been in place at least 1 year? If not, please identify those elements that have not been in place for at least 1 year.

A3. ls the written safety and health management system at least minimally effective to address the scope and complexity of worksite hazards? If not, please explain.

A4. Have any VPP documentation requirements been waived (as per FRN, Vol. 74, No. 6, 01/09/09 page 936, IV, and A.4)? If so, please explain.

B. Management Commitment & Leadership Bl. Does management overall demonstrate at least minimally effective, visible

leadership with respect to ·the safety and health management system (as per FRN, Vol. 74, No. 6, 01/09/09 page 936, IV. A.5.a-h)? Provide examples.

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B2.

B3.

B4.

BS.

OSHl(S VPP SITE-BASED PARTICIPATION SITE WORKSHEET

How has the site communicated established policies ?and results-oriented 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.

C. Planning

C 1. How does the site integrate planning for safety and health with its overall management planning process (for example, budget development, resource allocation, or training)?

C2. Is safety and health effectively integrated into the site's overall management planning process? If not, please explain.

C3. For site-based construction sites, is safety included.in the planning phase of each project?

D. Authority and Line Accountability

Dl. Does top manage~ent accept ultimate responsibility for safety and health? (Top management acknowledges ultimate responsibility even if some safety

I • ' ' I

and health functions are delegated to others.) If not; please explain. D2. How is the assignme~t 9f authority and responsibility documented and com-

municated (for example, organization charts, job descriptions, etc.)? D3. Do the individuals assigned responsibility for safety and health have the

authority to ensure that hazards are corrected or . necessary changes to the sa(ety and health management system are made? If not, please ~xplain.

,, • , I , •

D4. How are managers, supervisors, and· employees held accouritable for meet- ing their respcmsibilitie~ for ·workplace safety and health? (Are annual performance. eva~tiatiqps for managers· ~ ·d supervisors required?) .

D5. Are adequate resources ( equipment, budget, or experts) dedicated to ensunng workplace safety and health? Provide examples.

D6. Is access to experts (for example, Certified Industrial Hygienists, Certifi~ 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?

E. Contract Employees '

El. Does the site utilize contractors? Please· explain. . ? E2. Were there contractors/sub-contractors onsite at the time of the evaluauon ·

SECTION I: MANAGEMENT LEADERSHIP AND EMPLOYEE INVOLVEMENT 475

When selecting onsite contractors/sub-contractors, how does the site eval- E3. uate the contract~r's safety and health management system and performance

(including rates). . E4, Are contractors and subcontractors required to maintain an effective

safety and health management system and to comply with all applicable 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

ES. of hazards in the event that the contractor/sub-contractor fails to correct or control such hazards? Provide examples. How does the site document and communicate oversight, coordination, and enforcement of safety and health expectations to contractors?

E6.

E7. Have the contract provisions specifying penalties for safety and health issues been enforced, when appropriate? If not, ple~e explain.

E8. How does the site monitor the quality of the safety and health protection of its contract employees?

E9.

EIO.

El 1.

Do contract provisions for contractors require the periodic review and 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.

F. Employee Involvement FI. F2.

F3. F4.

F5.

F6.

F7. F8.

How were employees selected to be interviewed by the VPP team? 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

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 . · VPP d OSHA rights and respons1 1 ties . ease exp a.in.

sy_ st

em, 'ant n"fy employee's comprehension of the site's safety and FlO. Did managemen ve · . · · . . .. health management system, VPP, and OSH~ nghts _and res~ons1?1hties?

Fl l. Do employees have access to results of self- mspectl~n, accident investiga- tion, appropriate medical record~, and personal samphng data upon request? If not, please explain.

G. Safety and Health Management System Evaluation

G 1. Briefly describe the system in place for conducting_ an annual evaluation. G2. Does the annual evaluation cover the aspects of the safety and health

management system, including the elements described in the Federal Register? If n9t, please explain. ·

03. Does the annual evaluation include written recommendations in a narrative format? If riot, please explain.

04. Is the annual evaluation an effective tool for assessing the success of the site'-s safety and health management system? Please explain.

GS. What evidence demonstrates that the site responded adequately to the rec- ommendations made in the annual evaluation?

06. Is the annual evaluation conducted by competent site, corporate, or other trained personnel experienced in performing evaluations?

SECTION II: WORKSITE ANALYSIS

A. Baseline Hazard Analysis Al.

A2.

A3.

A4.

AS.

Has the site been at least minimally effective ·at identifying and document- 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. .

Does the s~te have a doe:1;1mented s~pling strategy used to identify health ~azards l:!.

nd _ assess _ empl9yees' expQsu~e (including duration ," route, and

equency 0

~ exposure), ~nd the number of exposed e.mployees? If not, please explain. · ' · · • Do sam l' · ' '

, P mg, teS t mg, and analysis follow nationally recognized proce-dures? If not, please explain.

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. are m the site identify hazards (including health) that need further analysis? 7 Does 1· F , . b d .

A · If not, please exp run: or si_te- a_se · cons~ction sites, does the hazard 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

t,.S. sampling data, ind.icate. that re~ords are being kept in logical order and 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?

e. Hazard Analysis of Significant Changes Bl. When purchasing new ma~rials or equipment, or implementing new

processes, what types of analys~s are performed to deterqtlne impact on safety and health, iand are. these analyses.adequ~~? .

B2. When implementing/introdu~ing non-routine tasks, materials or equipment, or modifying processes, what types of analyses are performed ~o qetermine impact on safety an9 health, and are these analyses adequate?

C. Hazard Analysis of Routine Activities CI. " Is there at least a minimally effective hazard analysis s·ystem in place for

routine operations and activities? . · ' 1 C2. Does hazard identification and analysis address both ·safety and health

hazards, if appropriate? If not, please explain. ' CJ. What hazard analysis technique(s) are employed for routine operations

and activities (e.g., job hazard analysis, HAZ-OPS, fault trees)? Please explain.

C4. Are the results of the hazard analysis of routine activities adequately cs. documented? If not, please explain.

For site-based construction sites, are hazard analyses conducted to address safety and health hazards for specialty trade contractors during each phase of Work?

O,Rouu ne Inspections

D1. th~ site have a minimally effective system for perf?rmi~g safety and

alt~ lDspections (i.e., a minimally effective system identifies hazards D associated · h 1 1 · 2. Are Wit normal operations)? If not, p ease exp run. .

· routine safety and health inspections conducted monthly, with tbe entire site cov d . . . . kl ere at least quarterly (construction sites: entire site wee Y·

478

D3 .

D4.

D5.

D6 .

D7.

OSHl<S VPP SITE-BASED PARTICIPATION SITE WORKSHEET

For site-based construction sites, are employees required to conduct insp ec- 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.

E. Hazard Reporting El. Is there a minimally effective means for employees to report hazards and

have them addressed? If not, please explain. E2. Does the hazard reporting system have an anonymous component? E3. Does the site have a reliable system for employees to notify appropriate

management personnel in writing about safety and health concerns? Please describe.

E4. Do the employees agree that they have an effective system for reporting safety and health concerns? If not, please explain.

F. Hazard Tracking Fl. Does a minimally effective hazard tracking system exist that result in

hazards being controlled? If not, please explain. F2 . Does the hazard tracking system result in hazards being corrected and

provide feedback to employees for hazards they have reported? If not, please explain.

F3. Does the hazard tracking system result in timely correction of hazards with interim protection established when needed? Please describe.

F4. Does the hazard tracking system address hazards found by employees, hazard analysis of routine and non-routine activities, inspections, and accident or incident investigations? If not, please explain.

G. Accident/Incident Investigations G 1. ls there a minimally effective system for conducting accident/incident inves-

tigations, including near-misses? If not, please explain. . d G2. ls the accident/incident investigation policy and procedures documente

and understood by all? If not, please explain. If 01 G3. Is there a reporting system for near-misses that include tracking, etc.? n '

please explain . .

SECTION Ill: HAZARD PREVENTION AND CONTROL 479

J,.re those conducting the investi~ations trained in accident/incident investi- G4, gation techniques? Please expla.m what techniques are used, e.g., Fault-

T Root Cause, etc. ree, . . di vescribe bow mvesttga~ors . sc_over and document all the contributing

GS. factors that led to an acc1dent/mc1?ent or a near-miss. Were any unco~trolled ~azards discovered during the investigation previ-

06· ously addressed 10 ~y pnor hazard analyses (e.g., baseline, self-inspection)? If yes, please explam .

rrend Analysis

Does the site have a minimally effective means for identifying and assessing HJ. trends? Have there been any injury and/or illness trends over the last three years? If H2. so, please explain.

H3 . Did the team identify trends that should have been identified by the site? If so, please describe.

H4. If there have been injury and/or illness trends, what adequate courses of action have been taken? Please explain.

HS. Does the site assess trends utilizing data from hazard reports and/or accident/ incident.investigations to determine the potential for injuries and illnesses? If not, please explain.

H6. Are the results of trend analyses shared with employees and management and utilized to direct resources, prioritize hazard controls and modify goals to address trends? If not, please explain.

SECTION 111: HAZARD PREVENTION AND CONTROL

A. Hazard Prevention and Control

Al. Does the site select at least minimally.effective controls to prevent exposing employees to hazards?

A2. When the site selects hazard controls, does it follow the preferred hierarchy (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.

A 3 . Describe any administrative controls used at the site to limit employee

exposure to hazards (for example, job rotation) . A.

4 . Do the work practice controls and administrative controls adeqµately address

tbose hazards not covered by engineering controls? If not, please explain . AS. Are the work practice controls (e.g., lockout/tagout, bloodborne path?genS,

a nd

confined space programs) recommended by hazard analyses and 1mple- A mented at the site? If not, explain . 6

· Are follow-up studies (where appropriate) conducted to ensure that hazard controls were adequate? If not, please explain.

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 safety and health rules, inspecuons, trammg, etc. . ov1 e examp es.

Disciplinary System . 1 din di · Ii · A8. Are there written employee safety procedures me u g a sc1p nary system? Describe the disciplinary system? '.

A9. Has the disciplinary system been clearly commurucated ~nd ~nf 1 ofrced equally

for both management and employees, when appropnate. not, please explain

Emergency Procedures 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

(including at least an evacuation drill annually)? A12. Is the emergency response plan updated as changes occur in the work areas

e.g., evacuation routes or auditory systems? · A13. Did the site describe the system used ~o verify all employees' participation in

at least one evacuation drill each year?

Preventive/Predictive Maintenance A14. Does the site have a written preventivelpredictive maintenance system? If not,

please explain. A15. Did the hazard identification and analysis (including manufacturers' recom-

mendations) identify hazards that could result if equipment is not maintained properly? If not, please explain. ·

A16. Does the preventive maintenance system detect hazardous failures before they occur? If not, please explain. Is the preventive maintenance system adequate?

Persona/ Protective Equipment (PPE) 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

required, its limitations, how to use it, and how to maintain it? If not, please explain.

A.20. Did the team observe employees using, storing, and maintaining PPB properly? If not, explain.

Process Safety Management (PSM) AZ l. Is the site covered by the Process Safety Management standard (29 CFR

1910-119)? If yes, please answer questions A22-A25 below. Additionally, 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.

AZZ. Which chemicals that trigger the Process Safety Management (PSM) standard are present?

p.25.

SECTION IV: SAFETY AND HEALTH TRAINING 481

. h process(e's) were followed from beginning to end and used to verify W}tlC . k d . h

swers to the q~est1ons as e m t e _PSM application supplement, the 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.

ational Health Care Program 8, occUP Describe the occupational health care program (including availability of

Bl. physician services, first aid, and CPR/ABO) and special programs such as audiograms or other medical tests used. How are licensed occupational health professionals used in the site's

BZ. hazard identification and analysis, early recognition and treatment of ill- ness and injury, and the system for limiting the severity of harm that might result from workplace illness or injury? Is this use appropriate?

3 Is the occupational health program adequate for the size and location of B. the site, as well as the nature of hazards found here? If not, please explain.

c. Recordkeeping Cl. Are OSHA required recordkeeping forms being maintained properly in

terms of accuracy, form completion, etc.? If not, please explain. CZ. Is the record keeper knowledgeable of 29 CFR 1904, OSHA's recordkeep-

ing standard? C3. What records were reviewed to determine compliance with the record-

keeping standard? C4. Do the injury and illness rates accurately reflect work performed by con-

tractors/sub-contractors at the site evaluated? Please explain. CS. Was there any evidence of recordable injuries/illnesses not being reported

due to management pressure, production concerns, incentive programs, etc.? If yes, please explain.

SECTION IV: SAFETY AND HEALTH TRAINING

A. Safety and Health Training Al.

A2. A3.

What are the safety and health training requirements for managers, super- 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?

482

A4.

A5.

A6.

OSHl>!S VPP SITE-BASED PARTICIPATION SITE WORKSHEET

A7.

A8. A9.

AlO.

All.

D th any/site operate an effective safety and health orientation oes e comp . Pl 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. .