Columbia Southern University CH1 UNIT8 Evaluation & Corrective Action Paper Instructions Conduct an audit of the following safety management system element

Columbia Southern University CH1 UNIT8 Evaluation & Corrective Action Paper Instructions
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 SECTIONS

COURSE TEXTBOOK CHAPTERS

1. Occupational Health and Safety Management System

3.1.1

8

2. Occupational Health and Safety Policy

3.1.2

8

3. Responsibility and Authority

3.1.3

8

4. Employee Participation

3.2

8

5. Review Process, Assessment, and Prioritization

4.1, 4.2

9

6. Risk Assessment

5.1.1

11

7. Hierarchy of Controls

5.1.2

14

8. Design Review

5.1.3

15

9. Management of Change

5.1.3

19

10. Procurement

5.1.4

20

11. Monitoring and Measurement

6.1

21

12. Incident Investigation

6.2

22

13. Audits

6.3

23

14. Corrective and Preventive Actions

6.4

23

15. Feedback to the Planning Process

6.5

23

16. Management Review

7.1, 7.2

24 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
Z10-2012; other published consensus standards like ANSI, ASSE, AIHA,
ISO, and NFPA; OSHA standards and voluntary guidelines; and articles
published in professional journals. Blogs, Wikipedia, About.com,
Ask.com, and other unmonitored Internet resources are not considered
scholarly references and should not be used. Please contact your
professor if you have any questions about the appropriateness of a
source.
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 a minimum of seven pages and a maximum
of 10 pages in length, not including the title and reference pages. A minimum
of five professional sources must be used. UNIT VIII STUDY GUIDE
Auditing and Management Review
Course Learning Outcomes for Unit VIII
Upon completion of this unit, students should be able to:
1. Develop effective safety management policy statements, goals, and objectives.
1.1 Develop recommendations to improve an existing safety management system based on
standards and best practices.
7. Examine management tools necessary to implement effective safety management systems.
7.1 Appraise the effectiveness of an organization’s incident investigation process.
7.2 Perform an audit of a safety management system and summarize findings in a report.
Course/Unit
Learning Outcomes
Learning Activity
1
1.1
7
Unit lesson
Chapter 21;Chapter 24; Course Project
Unit lesson
7.1
7.2
Chapter 22; Course Project
Chapter 23; Chapter 24; Course Project
Reading Assignment
Chapter 21: Evaluation and Corrective Action: Section 6.0 of Z10
Chapter 22: Incident Investigation: Section 6.2 of Z10
Chapter 23: Audit Requirements: Section 6.3 of Z10
Chapter 24: Management Review: Section 7.0 of Z10
Unit Lesson
In this final unit, we will consider some important aspects of safety and health management systems and tie
some of this discussion in with the Plan-Do-Check-Act (PDCA) process. We will discuss, for instance, how
incident investigation fits into the big picture, and we will consider some scenarios in relation the PDCA so
that you can have a better grasp of how the PDCA process works to foster continuous improvement for
multiple projects taking place in a given organization. Our focus will be on safety and health, but keep in mind
that the PDCA process can be used throughout the organization for everything from hiring to upgrading office
decor.
A popular saying in management circles is, “What gets measured gets done,” or sometimes, “What gets
measured gets managed.” The second version has significant meaning for safety management systems. The
PDCA cycle compels us to Check, which is typically an activity that involves measuring the degree to which
we are successful in the first stages of a given endeavor. Often, when we begin to implement a plan, we
discover through observing the process, Checking, that there are bugs that need to be worked out, so we
work them out, thereby improving the process. In essence, our measurements help us reach conclusions
about effectiveness. Unfortunately, the effectiveness of many safety programs is simply measured by a
reduction in, or absence of, injuries and illnesses, and the PDCA cycle never really has a chance to go full
BOS 3651, Total Environmental Health and Safety Management
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circle, particularly if incidents are low. Why worry about continuous improvement,
after
all, if everything
UNIT
x STUDY
GUIDE seems
to be going along okay?
Title
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 need to pre-inspect
forklifts to make sure they are mechanically sound can help prevent a future accident such as toppling over
palletized product on the production floor due to faulty brakes.
The discussion of leading indicators does not mean that lagging indicators such as incident rates do not have
value, of course. Indeed, the actual instances themselves can yield valuable information and should not be
ignored simply because they are not perfect. For instance, incident trending can point to problem areas that
need immediate attention, and many large organizations with sophisticated safety and health management
systems spend a great deal of effort trending incidents in the workplace. If there are multiple lacerationrelated injuries suddenly occurring in the shipping and receiving department, for instance, the multiple injuries
themselves can trigger a more thorough investigation of the trend in hope of preventing future occurrences.
This investigation may discover a common cause to the sudden spike in lacerations such as the inadvertent
purchase of the wrong type of box cutters by the purchasing department that do not have safety features
required by the company.
Manuele (2014) also notes that incident investigation can be a significant source of information. He indicates
that incident investigation should be given a much higher priority than is typically found in most organizational
safety programs. Unfortunately, many incident investigations are little more than paper exercises driven by
OSHA or Workers’ Compensation record-keeping specifications that fail to go beyond obvious employee
errors or workplace hazards in identifying causes. Current accident investigation theories recognize that there
are many layers of causal factors involved, even for adverse events where causes may seem obvious
(Oakley, 2012). The findings from a quality incident investigation that identifies system failures can be a
significant source of feedback, which can then be considered in the Plan phase of the PDCA process.
Throughout the course, we have focused on the management system outlined in ANSI/AIHA Z10, but that
does not mean other standards should not be used. The standards and best practices that are selected for
use in an organization are dependent on the maturity of the organization’s safety efforts and how the
organization manages other parts of its critical operations. If ISO management standards are used in other
parts of the organization, perhaps ISO 18000 is a better fit. Each organization is unique. ANSI/AIHA Z10 was
based on many of the best features from existing standards. Studying it in depth, as we have done in this
course, provides the safety practitioner insight into many of the other safety management system standards.
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In looking at various occupational safety and health standards, however, it should
obvious
UNITbex rather
STUDY
GUIDEthat they
tend to be quite similar. One similarity that should stand out to the seasoned practitioner
is the underlying
Title
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 obviously a
learning process, and what is learned will be considered during the planning phase of the next ergonomics
investigation or in moving forward with the current one.
Likewise, the crew that is installing the new workstations will have their own PDCA cycles that results in
organizational learning and continuous improvement. The planning phase will require planning the actual
installation. What tools will be needed? What trades will be involved? The Do phase might involve installing
the first workstation. The Check phase might include evaluating the first work station, and the Act phase may
involve making the necessary corrections to increase efficiency and quality of the installations and moving on
to planning the installation of the remainder of the work stations.
What we see here is not just one overall, PDCA process, but multiple PDCA cycles taking place
simultaneously at different levels. The point of this all, of course, is that this process fosters organizational
learning which, in turn, results in continuous improvement at all levels of the organization. This continuous
improvement activity becomes incorporated into the actual culture of the organization and helps to drive
improvement and success throughout the organization.
References
Blair, E., & O’Toole, M. (2010). Leading measures. Professional Safety, 55(8), 29–34. Retrieved from
https://libraryresources.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. (2014). Advanced safety management: Focusing on Z10 and serious injury prevention (2nd
ed.). Hoboken, NJ: Wiley.
Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and
applications (2nd ed.). Des Plaines, IL: American Society of Safety Engineers.
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Suggested Reading
UNIT x STUDY GUIDE
Title
In order to access the following resources, click the links below.
The additional chapter from the textbook and the additional resources below are suggested readings or
resources that can provide further reading and safety measures:
Chapter 25: Comparison: Z10, Other Safety Guidelines and Standards, and VPP Certification
Blair, E., & O’Toole, M. (2010). Leading measures. Professional Safety, 55(8), 29–34. Retrieved from
https://libraryresources.columbiasouthern.edu/login?url=http://search.ebscohost.com/login.aspx?direc
t=true&db=bth&AN=53160422&site=ehost-live&scope=site
Health & Safety Executive. (2001) A guide to measuring health & safety performance. Retrieved from
http://www.hse.gov.uk/opsunit/perfmeas.pdf
BOS 3651, Total Environmental Health and Safety Management
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