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Instructions

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:

SAFETY MANAGEMENT SYSTEM ELEMENTS

ANSI/AIHA Z10.0-2019 SECTIONS

COURSE TEXTBOOK CHAPTERS

1. Occupational Health and Safety Management System

3.1.1

2

2. Occupational Health and Safety Policy

3.1.2

2

3. Responsibility and Authority

3.1.3

2

4. Employee Participation

3.2

2

5. Review Process, Assessment, and Prioritization

4.1, 4.2

12

6. Risk Assessment

5.1.1

4

7. Hierarchy of Controls

5.1.2

4 and 11

8. Design Review

5.1.3

12

9. Management of Change

5.1.3

14

10. Procurement

5.1.4

15

11. Monitoring and Measurement

6.1

16

12. Incident Investigation

6.2

16 and 19

13. Audits

6.3

18

14. Corrective and Preventive Actions

6.4

16

15. Feedback to the Planning Process

6.5

16

16. Management Review

7.1, 7.2

16

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.

· 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 Z10-2019; 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.

· 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.

· 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 at least seven pages and a maximum of 10 pages in length, not counting the title and references pages. In addition to your textbook, please provide at least five professional sources.

BOS 3651, Total Environmental Health and Safety Management 1

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.

4. Examine the components of an effective hazard prevention and control system.

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.

Course/Unit

Learning Outcomes

Learning Activity

1.1
Chapter 16

Chapter 17
Unit VIII Course Project

4 Unit VIII Course Project

7.1
Chapter 19

Unit VIII Course Project

7.2
Chapter 18

Chapter 17
Unit VIII Course Project

Required Unit Resources

Chapter 16: Evaluation and Corrective Action

Chapter 17: Management Review/Improvement

Chapter 18: Audit Requirements

Chapter 19: Incident Investigation

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

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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 do not necessarily mean everything is okay for a given 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 who 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 the
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 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 ne ed 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 lac erations 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 (2020) 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/ ASSP Z10.0-2019,
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/ ASSP
Z10.0-2019 was based on many of the best features from existing standards. Studying it in depth, as we have

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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.

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 obviousl y 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 cyc les 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, August). Leading measures: Enhancing safety climate and driving safety
performance. Professional Safety, 55(8), 29–34.

https://libraryresources.columbiasouthern.edu/login?url=http://search.ebscohost.com/login.aspx?direc

t=true&db=bth&AN=53160422&site=ehost-live&scope=site

Manuele, F. A. (2020). Advanced safety management: Focusing on Z10.0, 45001, and serious injury
prevention (3rd ed.). Wiley. https://bookshelf.vitalsource.com/#/books/9781119605409

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Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and

applications (2nd ed.). American Society of Safety Engineers.

Suggested Unit Resources

In order to access the following resource, click the link 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:

Addendum A: OSHA’s VPP Site-Based Participation Site Worksheet, pp. 408–417

Health & Safety Executive. (2001, December) A guide to measuring health & safety performance.

http://www.hse.gov.uk/opsunit/perfmeas.pdf

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