OHSAS 18001 REQUIREMENTS

4.1 General Requirements
(Pasal 1 PP NO.50/2012)

The organisation shall establish, document, implement, maintain and continually improve an OH&S management system in accordance with the requirements of the OHSAS standards and determine how it will fulfil these requirements.

The organisation shall define and document the scope of its OHS Management System.

4.2 Occupation, Health & Safety Policy
(Paragraph 1.1 Lampiran II, PP NO.50/2012)

There shall be a policy statement authorised by top management and ensure that within the defined scope of its OH&S management system it:

• appropriate to the nature & scale of the company’s OH&S Risks;
• that includes commitment to prevention of injury and ill health and continual improvement in OH&S management performance;
• that includes a commitment to continual improvement and commitment to comply with OH&S Legislation, and other requirements to which the company subscribes e.g. codes of practice;
• provides framework for setting and reviewing OH&S objectives;
• documented, implemented maintained and communicated to all persons working under control of organisation with an intent that they understand OH&S obligation;
• made available to interested parties;
• periodically reviewed.

Requirement for organization;

• The policy should be appropriate to the ‘significant’ risks identified through the OH&S Hazard identification and risk assessment processes. Evidences: Risk Assessment Records.

• The OH&S policy should include a commitment to continual improvement OH&S performance.                                                                                                                    Evidences: Documentary evidence is available to demonstrate that such an aspiration is being achieved.                                                                                                                                Evidences: OHS Objectives and Targets, Monitoring and Measurement Records, Corrective and Preventive action records. Records checked should demonstrate a trend towards improved performance. 

Requirement for organization;

• The OH&S policy should include a commitment to compliance with relevant legal and other requirements to which the organisation subscribes.  ‘Other requirements’ may include corporate or group health and safety policies, internal health and safety standards and specifications, industry codes of practice, or other policies e.g. Quality or Environmental, which state OH&S obligations.                                                                                      Evidences: Corporate or Group policies for compatibility with the organisations OH&S policy. 

That the policy makes reference to any internal safety standards and specifications, or industry codes of practice that are to be complied with.
EXAMPLE: Code of Practice for Workplace Amenities
If it the organisation’s intention to follow general Approved Codes of Practice (ACOP’s) a statement to that effect should also be included in the OHS policy
Evidences: The policy itself complies with the law.
EXAMPLE: Occupational Health and Safety Act 2000
Evidences: To see if the policy has been amended, in particular when there have been changes in circumstance such as:

• Group OHS policy amendments;
• New hazards being identified, through the risk assessment process;
• OHS objectives having been achieved. Evidences: To see that copies of the policy that have been issued are of the same issue status as the master copy. 
• Ensure the OH&S policy has been ‘communicated’ to ALL employees, making them aware of their individual OHS obligations. Consideration should also be given to how amendments to the policy are communicated and recorded. Evidences: Training and Awareness Records, for evidence that employees have been made aware of the OHS policy and their individual obligations. Evidences: Employees understanding of the OHS policy
• Ensure interested parties receive a copy of the OH&S policy. Evidences: Whether consideration has been given to Customers; Shareholders; Stakeholders; Visitors; Contractors; Temporary Workers; The General Public (particularly if they have access to the workplace) etc. Evidences: How the OHS policy is made available to the interested parties identified, and how subsequent amendments are communicated (as appropriate).
• Ensure that the OHS policy is periodically reviewed to ensure that it remains relevant and appropriate to the organisation. Evidences: Management Review Meeting minutes.

4.3.2 Legal and other requirements

4.3.2 OSHAS Requirements

The organisation shall establish, implement and maintain a procedure(s) for identifying and accessing legal and other OH&S requirements that are applicable to it.

The organization shall keep this information up-to-date;

The organization shall communicate relevant information on legal and other requirements to persons working under the control of the organisation and other relevant interested parties.

Requirement for organization;

• A procedure exists to identify and document the relevance of all OH&S legislation (and other requirements) 

• How access to the actual regulations are actually afforded.

• Evidence is available to show how ‘applicable’ regulations are identified and screened for relevance.

• How changes to OH&S legislation are monitored

• How are these changes communicated internally and requirements implemented

Requirement for organization;

• Evidences: That appropriate information, with regards legal and other OHS requirements, has been communicated to employees.

• Evidences: That ‘other relevant interested parties’ have been identified e.g. contractors, visitors (such as customers) the public etc. and that appropriate information, with regards legal and other OHS requirements have been communicated to them.

How can we ensure meet the actual compliance with legislation?

The objective evidence required in relation to compliance with legislative requirements for

e.g Notification/ registration with authorities and the associated emergency authority etc. Compliance with regulatory requirements. Availability of MSDS.

Ensure that persons are aware of the applicable Acts and Regulations for the organization being audited.

4.3.1 Hazard Identification, Risk Assessment and Determining Control

(Paragraph 2.1 Lampiran II, PP NO.50/2012)

The Legislative Framework for Health & Safety Risk Assessment

4.3.2 ‘Must identify and have access to applicable legal and other OHS requirements…that are applicable to it’ 

4.3.2 The organizations shall keep this information up to-date…communicated to employees and other interested parties’

Must be an element of evaluation of the legislation to identify particular sections or codes of the regulations to ensure they can be complied with.

4.5.5 Periodic evaluation of compliance with legislation/regulations must take place, i.e., via internal audit

Hazard Identification and Risk Control

Risks include those arising from the

• Way the work is performed. 

• Plant and substances used in the work. 

• Condition of the premises or any part of the premises where the work is carried out. 

Under an Act, employers must ensure that there is no risk to the health and safety of employees associated with the condition of any part of the premises controlled by the employer and any plant or substance that is used at work. 

The employer must also ensure that people at the work place, other than its employees, are not exposed to health and safety risks associated with the employer's activities.

Other Regulations Requiring Risk Assessments

• Manual Handling

• Personal Protective Equipment

• Working at Height

• Noise at Work 

• Confined Spaces

• Cranes and Hoists

• Driver Fatigue

• Electricity

• Chemicals

• Asbestos

• Fire precautions 

• Construction

• Warm Water Systems/Cooling Towers

• Powered vehicles/Plant

• Other ?

Hazard Identification, Assessment and Control

Identify, Evaluate, And Understand

In order to make INFORMED DECISIONS on what needs to be controlled and how

• Focuses resources (human, material and financial) 

• Critical element of the system

• Decisions affect many other system elements

• Careful planning pays dividends

 A Strategy for Hazard Assessment

1. What are our tasks, activities and services to be assessed?

2. What are the hazards linked to these?

3. Who are the persons exposed to the hazard

4. Identify the hazards

5. Aim to eliminate the hazards or reduce them to a minimum

6. Evaluate the residual risks

7. Develop precautionary strategies

8. Train operatives in new work methods

9. Implement precautionary measures

10. Monitor performance 

11. Review periodically and revise as necessary

 Step 1 : Look for the hazards 

• Observe - the activity or process being carried out;

• Consult - employees or their representatives;

• Check - the Accident Book/Incident Records;

• Review - manufacturers instructions, guidelines and data sheets. 

NOTE: Ignore the trivial and concentrate on significant hazards

 Step 2: Decide who might be harmed and how 

Don’t Forget:

• Young workers, trainees, new and expectant mothers etc who may be at particular risk;

• Cleaners, visitors, contractors, maintenance workers etc who may not be in the workplace at all times;

• Members of the public, or people you share your workplace with.

 Step 3 : Evaluate the risks and decide whether existing precautions are adequate

Consideration being given (as a minimum) to;

Legal Requirements

Industry Standards 

Approved Codes of Practice.

Step 4: Record your findings 

Assessments should be suitable and sufficient and should demonstrate that;

• a proper check was made;

• you asked who might be affected;

• you dealt with all the obvious significant hazards; 

• the precautions taken are reasonable and the remaining          

• risk is low.

 Step 5: Review and revise your assessments periodically

Assessments should be reviewed, particularly in light of changes to;

• plant and equipment;

• activities or processes;

• staff and their personal circumstances.

NOTE:  It is good practice to maintain and review assessments periodically to ensure effectiveness of the risk control measures so that precautions put in place are adequate and do not create ‘New’ hazards and improve where possible.

 Assessing Risk

 Requirement for organization;

Evidences: that a procedure has been developed for ongoing identification of hazards, the assessment of risks, and the implementation of necessary control measures.

Evidences: That all OH&S Risks have been identified

• The procedure facilitates the checking of both routine and non-routine activities.

• The procedure identify the hazards, and their subsequent controls for ALL persons 

• It covers facilities at the workplace, whether provided by the organisation or others.

• Assessments are revised  in light of significant change

Evidences: For assessment(s) being carried out prior to any significant process or activity change(s).

Evidences: that the documented procedure will ensure that the company will meet its legal obligations with regards risk assessment. 

• EXAMPLE: If the organisation carries out manual handling operations the procedure should make reference to the checks to be made as per Schedule 1 of the Manual Handling Operations Regulations 1992.

Evidences: Risk Assessment records, to see that in particular, the following areas have been considered;

• identification of  hazards;

• evaluation of risks with existing (or proposed) control measures in place (taking into account exposure to specific hazards, the likelihood of failure of the control measures, and the potential severity of consequences of injury or damage);

• evaluation of the tolerability of residual risk;

• identification of any additional risk control measures needed;

• evaluation of whether the risk control measures are sufficient to reduce the risk to a tolerable level.

The results of the Assessment of Risks shall be considered during the setting of objectives and targets. The results of the Assessment of Risks shall be kept up to date 

OHSAS 18001 Risk Assessment Requirements

 Establish and maintain procedures for:

1. the ongoing identification of hazards

2. Assessment of Risks

3. Implementation of necessary control measures

               Including:

– Routine and Non-routine activities;

– Activities of all personnel having access to the workplace (including subcontractors and visitors);

– Facilities at the Workplace.

Risk Assessment Techniques

• Job Safety Analysis (JSA)

• Failure Modes and Effects Analysis;

• Hazard and Operability Study (HAZOP);

• 5x5 Method; and

• numerous others………..

• The considerations shall be made on the following when developing Control measures

– Severity/consequence

– Likelihood/Occurrence

Risk Assessment - ‘5 x 5 method 

What:

• Standard Risk Assessment Method which enables a hazard rating to be determined based upon the likelihood and consequence of a particular hazard causing harm.

How:

• identify hazard;

• assess the risks - based upon likelihood and consequence of the hazard causing harm;

• develop plans to eliminate, combat or minimise the hazard at source. 

Risk (Likelihood)

5 = Daily Occurrence

4 = Weekly Occurrence

3 = Monthly Occurrence

2 = Quarterly Occurrence

1 = Annual Occurrence or  Greater 

OR

5 = Very Likely to  Occur/has occurred

4 = Probable

3 = Possible

2 = Remote

1 = Improbable

Severity (Consequence)

5 = Fatal outcome

4 = Major Injury (Reportable)

3 = Two Day Injury 

2 = Minor Injury (first aid only)

1 = Accident or incident where no injury occurs.

 Hierarchy of Risk Control Principles

Hierarchy of Control

• Under Clause 11 of Occupational Health and Safety Regulation 2001, employers must eliminate any reasonably foreseeable risk arising from the hazards referred to above and, where it is not reasonably practicable to eliminate the risk, it must be controlled. Risk control involves adopting one or more of the following measures, in decreasing order of preference, until the risk has been reduced to the lowest practicable level [Occupational Health and Safety Regulation 2001, Clause 5]:

– Substituting the hazard with a less severe one (e.g.. use a non-toxic chemical instead of a toxic one). 

– Isolating the hazard. 

– Adopting engineering controls (e.g.. machine guarding, fume extraction systems). 

– Adopting administrative controls (e.g.. operating procedures, training, instruction and information). 

– Using personal protective equipment. 

                        (Occupational Health and Safety Regulation 2001, Clause 15) 

Hazard/Risk Assessment Methodologies

The methodology shall…

• Be defined with regard scope, nature and timing;

• Provide for the classification of risks;

• Consistent with operating experience and the capabilities of  risk control measures employed;

• provide input into facility requirements, identification of  training needs and/or the development of formal controls;

• provide for the monitoring of action to ensure their effectiveness and timeliness of implementation.

Objectives and Management Programmes

4.3.3 Objectives and programmes

(Paragraph 2.3 Lampiran I, PP NO.50/2012)

Establish, implement & maintain documented OHS objectives at each relevant function and level of the organisation;

The objectives shall be measurable, consistent with the OH&S policy, including the commitment to prevention of injury, ill health, compliance to legal requirements and other requirements to which organisation subscribes and continual improvement.

When establishing such objectives consideration should be given to;

• Legal & other requirements;

• Hazards and risks;

• Technological options; 

• Financial, operational and business requirements and 

• the views of interested parties.

Should be SMART

Specific

Measurable

Achievable

Relevant

Time-bound

Examples of types of OHS objectives include: 

• reduction of risk levels;

• the introduction of additional features into the OH&S management system;

• the steps taken to improve existing features, or the consistency of their application;

• the elimination or the reduction in frequency of particular undesired incident(s);

• compliance with a legislative requirement.

Requirement for organization;

• Evidences:  That ALL OHS objectives have been encapsulated within the system. Check the business plan, group, and quality, environmental and departmental objectives, for OH&S elements that may have been excluded.

• Evidences: That objectives are consistent with the concept of continuous improvement, i.e. objectives should not be set to ‘maintain current levels of OHS performance’ (unless of course the objective was to ‘maintain the organisations zero accident performance’).

• Evidences: That personnel and/or functions which could have an effect on the outcome of a particular OH&S objective, have been made aware of how their contribution will ensure that the overall objective is achieved.

• Evidences: That when setting or reviewing its objectives the organisation has considered failure to meet legal obligations;

Where compliance is not met, check that objectives are set to comply by a agree timeframe with the regulator e.g. Objective; “To conduct specific Manual Handling Risk Assessments in order to comply fully with the Manual Handling Operations Regulations” 

Its ‘Significant’ Hazards and risks;

• Evidences: The organisation’s risk assessments, where a ‘significant’ or ‘intolerable’ hazard has been identified, check that an objective has been set to eliminate, control or minimise the hazard and the associated risks.

Technological options

• Evidences: The company has made an assessment as to the technological options available, to eliminate, control or minimise the ‘significant’ or ‘intolerable’ hazards and risks identified.

 EXAMPLE:

 Objective: “Eliminate the handling of hazardous substances in the production area through the introduction of mechanical feed controls”

• Evidences: That sufficient financial resources are provided. Checking the business plan, company accounts, or departmental budgets can assess this.

• Evidences: that objectives are balanced against other considerations e.g. productivity, quality and environmental to ensure they are attainable.

• Establish & maintain documented management programme(s) for achieving OH&S objectives;

• Responsibilities shall be assigned for the achievement of the company’s OH&S objectives, along with the means and time-scales by which the objectives are to be achieved.

• Management programme is to be regularly reviewed, and amended to address changes to the activities, products and services, or operating conditions of the organisation.

• Establish whether a formal OHS management programme has been developed to facilitate the achievement of the organisation’s OHS objectives.

Evidences: The management programme specifies;

• Who is responsible, and has overall authority, for achieving the OHS Objective(s);

• How the OHS objective(s) are to be achieved and the time-scale by which the objective(s) are to be achieved.

Evidences: To see that the programme(s) has been periodically reviewed and amended to address changes to the activities, products, services or operating conditions of the organisation.

4.4 Implementation and Operation

4.4.1 Resources, roles, responsibility, accountability and authority

Management to provide adequate resources required to implement, maintain and improve their OHSMS. 

The resources include 5 M’s 

• human resources and specialised skills (Man),

• technology (Machine, Method and materials)

• financial resources (Money).

These resources are also the potential organisational barriers to the effective implementation of an organisational OHS system. The organisations need to plan effectively to overcome these barriers.

How to over come potential barriers to effectively implementation of an organisational OHSMS. 

• Man – The organization may eliminate by conducting appropriate trainings to ensure all its personnel are aware of the OHS system in place and helps to the effective implementation of OHS.
• Machine – The organization should identify the machines, equipment that poses hazards to health and safety of its employees and thereafter initiate necessary action such as providing machine guarding, confinement, work permit system and other methods.
• Method – Some work instructions may need amendment where, records reveal health and safety matters were being jeopardized. This may need further studies to find out the best possible method of workmanship standard that may eliminate hazards on health and safety. Once the method is identified there should be proper implementation to be effective.   
• Materials – Material or items utilized by its employees, may on itself be a danger, it is necessary to determine the chemical composition or the component being used if it poses danger to the health and safety of the personnel being exposed to the materials.
• Money –Top management need to ensure sufficient financial resources to implement the system.
• Roles and responsibilities of personnel having an effect on OHS risks to be defined, documented and communicated;
• Ultimate responsibility for OHS rests with top management;
• Organisation to appoint OHS management representative who, irrespective of other responsibilities have responsibilities and authority for ;                                                               a) Ensuring the OHS system is established, implemented and maintained according to the standard;                                                                                                                                           b) Ensuring that reports on OHS performance are presented to top management 

• All those with management responsibility to demonstrate their commitment to continual improvement.
• Where contractors are involved, these areas of accountability and responsibility shall be clarified with respect to those contractors

Requirement for organization;

That OH&S responsibilities and authorities for all relevant personnel have been defined.

• Evidences: That OHS responsibilities have been clearly defined, in particular (where appropriate) for;

• Top management; 

• The Management Representative

• Line management 

• Process operators and the general workforce;

• Contract Managers ; Visitors; Temporary Workers; 

• Training managers 

• Equipment maintenance and use 

• Specialists 

• Employee OH&S representatives on consultative forums.

Requirement for organization;

That OHS responsibilities and authorities have been documented and matches with the corporate organisation structure.

Evidences: OHS System Documentation, in particular;

• Evidence of appointment of OHS representative

• job descriptions include responsibilities and authorities related to OHSMS;

• Organisation charts highlighting the OHS responsible personnel;

• That a process, for communicating roles and responsibilities to all employees and other relevant parties, exists and are effective.

Evidences: The appropriate people are aware of their responsibilities. (include a check to see that contractors, visitors etc responsibilities have been defined and effectively communicated)

• Evidence of active management participation and support for OHS, at all levels.

Evidences: That adequate resource is being provided (Human, financial, appropriate technology, specialised skills etc) to achieve the organisations OHS Policy and Objectives.

NOTE: Resources can be considered adequate if they are sufficient to carry out OH&S programmes and activities, including performance measurement and monitoring. 

• Personnel to be competent to perform task which impact upon health & safety;

• Procedure to be developed to make employees aware of;

• The importance of conformance with the OHS policy and procedures and the consequences of departure;

• the OHS consequences, actual and potential, or their work activities, and the benefits of improved performance;

• Their specific roles and responsibilities to enable OHS conformance.

• Training procedures shall take into account levels of:- responsibility, ability and literacy; and risk.

• That Competency requirements for individual roles are clearly defined and documented

Evidences: Job descriptions, training records, operational procedures etc.

– An analysis of competency and training needs has been undertaken. Training programmes/plans for individual employees have been developed.

– Range of training courses/products available for use within the organisation

– Training records, and records of evaluation of effectiveness of training.

– Verify training records for contractors and visitors, as applicable

4.4.2 Competence, Training & Awareness 

Procedures shall be in place to ensure that OHS competencies are developed and maintained. The personnel shall be assessed as competent for OHS responsibility, on the basis of skills achieved through 

• Education,

• Training

• Experience

The organisation shall ensure that all personnel, including contractors and visitors have undertaken training appropriate to the identified needs.

Training shall be carried out by persons with appropriate knowledge, skills and experience in OHS and training.

The organisation shall ensure that personnel to be competent to perform task which impact upon health & safety 

Procedure to be developed to make employees aware of;

• The importance of conformance with the OHS policy and procedures and the consequences of departure;

• the OHS consequences, actual and potential, or their work activities, and the benefits of improved performance;

• Their specific roles and responsibilities to enable OHS conformance.

Training procedures shall take into account levels of:-

• responsibility, ability and literacy; and risk.

Requirement for organization;

• That Competency requirements for individual roles are clearly defined and documented

Evidences: Job descriptions, training records, operational procedures etc.

– An analysis of competency and training needs has been undertaken. Training programmes/plans for individual employees have been developed.

– Range of training courses/products available for use within the organisation

– Training records, and records of evaluation of effectiveness of training.

– Verify training records for contractors and visitors, as applicable OHSAS 

4.4.3 Communication participation and Consultation

The organisation shall have a documented procedure for employee involvement and consultation for OHS issues and how information is communicated to and from employees and interested parties;

Employees shall be; 

• involved in the development and review of policies and procedures to manage risk;

• consulted where there are changes that affect workplace health and safety;

• informed of their OHS representative(s) and management representative

Typically consultation, communication and employee participation can be achieved by the use of;

• Team-briefing;

• Health & Safety Councils and Committees;

• Employee involvement/input into Hazard identification &    Risk Control;

• Suggestion Schemes;

• Notice Boards;

• Newsletters…. etc. 

Reporting

Procedures for timely reporting shall be established. Reporting to cover

• OHS performance reporting

• Reporting of incidents and system failure

• Reporting on hazard identification

• Reporting on hazard/risk assessment

• Reporting on preventive and corrective action

• Statutory reporting requirements

Requirement for organization;

• A formal procedure has been developed and documented to ensure that pertinent OHS information is communicated to and from employees and other interested parties.

• That all employees have been made aware of their employee OH&S representative(s), and specified management appointee.

• Evidence of formal management and employee consultations, in particular where there are changes that affect workplace health and safety. e.g. Minutes of OHS councils, trade union, health and safety meetings, Team Briefings etc (where appropriate);

• Employee involvement in hazard identification, risk assessment and risk control process; including the development and review of policies and procedures. 

• Risk assessment procedure and risk assessments.

• Initiatives to encourage employee OHS consultation, review and improvement activities in the workplace, and feedback to management on OH&S issues e.g. Suggestion schemes for OHS improvement, Team Briefing, OHS improvement teams etc (where appropriate).

• OHS briefings for employees and other interested parties, e.g. contractors or visitors; e.g. Employee, Contractor and visitor induction procedures for OHS briefings, and any other mechanisms the organisation may use to make the stated parties aware of any OH&S changes

4.4.4 Documentation

The organisation shall establish, implement and maintain information in paper or electronic form that;

• OH&S policy and objectives

• describe the scope of OH&S management system

• describes the core elements of the OH&S management system and their interaction;

• documents including records required by the standards and required by the organisation

• provides direction to related documents.

Requirement for organization;

• That an OH&S management system documentation overview or manual exists and is formally controlled.

• Document registers, master lists, indices will provide an indication of the documents forming part of the system and will act a guide when selecting documents to sample.

• that Procedures and work instructions make reference to associated documentation of particular use when establishing an audit trail.

• Records

4.4.5 Control of Documents

Procedures for controlling all documents and data forming part of the documented OH&S management system, to ensure that;

• Documents are approved prior to use.

• They are periodically reviewed, revised, and re-approves approved 

• the changes and the current revision status of documents are identified.

• only current/relevant versions are available at the point of use;

• they remain legible and  readily identifiable 

• Obsolete documents and data are promptly removed from all points of use and assured against unintended use.

• archived documents retained are suitably identified.

• External origin documents are identified and distribution is controlled

Requirement for organization;

• Document control procedures exist, which include assigned responsibilities and authorities.

• Evidence that the procedure is being followed, and that the organisation has full control over all of the documents forming part of the OHS management system. 

• Document registers, master lists or indexes.

• List of controlled documentation.

• Ensure that all OHS documentation issued is of the same issue status as the ‘master’ document, and there is no evidence of superseded documents in circulation.

• Legal requirements are kept up to date

• Obsolete copies of legal and other documents are maintained for reference and protected against unintended use e.g. securely stored, identified as ‘obsolete’, ‘archived’, ‘superseded’ or similar, 

• Examples of documentation - OHS Policy, Manuals, Procedures, Technical Data Sheets, Risk Assessments, Objectives and Targets, Management Programmes, Registers of Legislation, Induction Manuals etc.

• Verify that staff has access to the relevant legislative requirements.

4.4.6 Operational Control

• Identify the risks associated with operations and activities to plan, implement and maintain control measures :

• Establish documented procedures to cover situations where their absence could lead to deviations from the OHS policy and objectives;

• Stipulate operating criteria in the procedures;

• Procedures relating to the identified risks of goods, new equipment and services purchased, communicating relevant procedures to suppliers and contractors;

• Procedures to control workplace OHS risks at their source.

Requirement for organization;

• Documented procedures have been developed and are maintained to cover situations where there absence could lead to deviations from the policy and objectives, and which could result in a breach of legislation. Evidences: Risk assessments. 
• Where a risk cannot be eliminated, controlled or reduced to tolerable levels through engineering controls or changes in operational practice, ensure that formal operational procedures have been considered and developed (as appropriate). Evidences: That procedures have been developed and implemented (as appropriate) related to;
• OH&S risks of goods, new equipment and services purchased and or used by the organisation, change/new process or products.  Evidences: risk assessments and that (where appropriate) such procedures have been communicated to the appropriate suppliers and contractors. EXAMPLE
• It could be expected that a procedure for the evaluation, and periodic review, of the OHS competence of contractors be developed, where contractor incompetence has been identified as a ‘significant’ hazard.
• Evidences: That all procedures developed stipulate operating criteria i.e what to do and what not to do.

4.4.7 Emergency Preparedness & Response

Establish and maintain plans and procedures to:

• identify the potential for and responses to any incidents and emergency situations,

• preventing and mitigating the likely illness and injury that may be associated with them.

Emergency Plans should typically include;

• details of potential accidents and emergencies;

• details of responsible person(s) who will take charge in an emergency;

• general duties of all personnel during an emergency;

• evacuation procedures;

• interface with emergency services;

• communication with statutory bodies;

• availability of information during an emergency e.g. plant layout, drawings, contact telephone numbers etc

• Location of hazardous materials.

• Location of emergency equipment (inventories)

• Location of First Aid and medical supplies (inventories)

• Training of staff in emergency procedures

• Regular rehearsals for fire drill

• Regular inspections of Emergency equipment exit signs and alarms 

Emergency Equipment 

Should be provided and tested at specified intervals for operability, examples include;

• Alarm Systems and exit signs;

• Emergency Lighting and Power;

• Fire fighting equipment and detection devices;

• Means of escape;

• Critical isolation valves, switches and cut-outs;

• First aid equipment and provisions etc.

Requirement for organization;

• Documented emergency plans and procedures have been developed and implemented, commensurate with the OH&S hazards and risks identified, 

• Responsibilities for control of emergency situations and 

• training in emergency plans.

• Sufficient emergency equipment has been provided, based upon the findings of the risk assessment process.

• Check the availability of test records (inspection records) for emergency equipment and that the frequency and procedures followed are in line with the organisations legislative obligations, e.g.

1. An organisations fire certificate will specify the frequency of testing for fire alarms, fire fighting equipment etc
2. Records of: rehearsal fire drills

• Essential legislative requirements

4.5 Checking 

4.5.1 Performance measurement and monitoring 

The organisation shall establish and maintain procedures to monitor and measure the key characteristics of its operations and activities that can cause illness and injury on a regular basis. These procedures shall provide for:

• Both qualitative and quantitative measures, appropriate to the needs of the organization

• Monitoring to the extent to which the organization's OH&S objectives are met

• Monitoring the effectiveness of Controls   

• Proactive measures of performance that monitor conformance with the OH&S programmes, controls and operational criteria.   

• Reactive measures of performance that monitor ill health, incidents and other historical evidence of deficient OH&S performance.

• Recording of data and results of monitoring and measurement.

Monitoring Equipment

• For the appropriate monitoring equipment related to health and safety risks, the organization shall establish and maintain procedures for the calibration and maintenance of such equipment. 

• Calibration frequency shall be determined for the equipment.

• Records of calibration and maintenance activities and results shall be retained. 

Health surveillance

• The organisation shall identify those situations where employee health surveillance is required and shall implement appropriate systems. 

• Where specified by the legislation, the health of employees exposed to hazards shall be monitored and recorded.

• Employees shall have access to their own.

Why Health surveillance

Possible effect in case of omission: Health hazard to Employees. The organization will not be able to determine/identify any health changes that may be due to the occupational exposure to a hazard by an Individual who might be affected by it.

Requirement for organization;

• A procedure in place for monitoring health of employees who are exposed to specific hazards. 

• Verify Records of such results. 

• Verify the privacy of the records is maintained.

• Verify for any specified legislative requirements applicable to the organization.

• They shall be periodically verified to ensure accuracy of results. 

4.5.2 Evaluation of Compliance

The organisation shall establish, implement and maintain procedure(s) for periodically evaluating compliance with applicable legal requirements.

The organizations shall keep records of the results of the periodic evaluations.

4.5.3 Incident investigation, non conformity, corrective and preventive action

4.5.3.1 Incident Investigation

The organizations shall establish, implement and maintain a procedure(s) to record, investigate and analyse incidents

4.5.3.2 Nonconformity, corrective action and preventive action

The organisation shall establish and maintain procedures for defining responsibility and authority for the handling and investigation of 

• Incidents (accidents or near-misses)

• Non-conformances

and taking action to mitigate any consequences arising from accidents, incidents or non-conformances

Any corrective or preventive action taken to eliminate the causes of actual and potential non-conformances shall be appropriate to the magnitude of problems and commensurate with the OH&S risk encountered. 

Implement and record any changes in the documented procedures resulting from corrective and preventive action

Requirement for organization;

• Written Procedures 

• Defined responsibilities / authorities / requirements

• Requirement to report 

• Immediate investigation to determine the root cause (who, what, when).

• Record any changes in the OHSMS procedures and inform all interested party of any changes being made.

• Corrective actions and Follow-up

• Classification / Analysis / Communication

• Management involvement / review / input

• Link to change management / hazard identification / risk control

 4.5.4 Control of Records

The organisation shall establish and maintain procedures for the identification, maintenance and disposition of records, as well as the results of audits and management reviews.

• Records shall be legible, identifiable and traceable to the activities involved. 

• OH&S records shall be stored and maintained in such a way that they are readily retrievable and protected against damage, deterioration or loss.

• Their retention times shall be established and recorded. 

• Records shall be maintained, as appropriate to the system and to the organization, to demonstrate conformance to the specified criteria (e.g., OHSAS 18001). 

• Main criteria for determining which records are to be kept:

• Legislative requirements 

• Management system requirements

Requirement for organization;

• The procedure should identify:

• Which records are to be kept

• Who is responsible

• Manner of keeping records

• Retention times, etc.

4.5.5 Internal audits

The organisation shall establish and maintain an audit program and procedures for periodic OH&S management system audits to be carried out, in order to determine whether or not the OH&S management system:

• Conforms to planned arrangements for OH&S management including the requirements of the specification (e.g., OHSAS 18001)

• Has been effectively implemented and maintained; and

• Is effective in meeting the organization's policy and objectives 

• Provide information on the results of audits to management.

The audit program, including any schedule, shall be based on the results of risk assessments of the organization's activities, and the results of previous audits. 

The audit procedures shall cover the scope, frequency, methodologies and competencies, as well as the responsibilities and requirements for conducting audits and reporting results.

Selection of auditors and conduct of audits shall ensure objectivity and impartiality of the audit process.

Requirement for organization;

• Documented procedure for OHSMS Audit

• Audit reporting typical outputs include:

• Audit plan / program

• Audit reports (non-conformance reports, recommendations and corrective action requests)

• Non-conformance reports

• Evidence of reporting results of OH&S management system audit to management 

4.6 Management Review

• Top management shall, at intervals that it determines, review the OH&S management system, to ensure its continuing suitability, adequacy and effectiveness. 

• The management review process shall ensure that the necessary information is collected to allow management to carry out this evaluation. This review shall be documented.

• The management review shall address the possible need for changes to policy, objectives and other elements of the OH&S management system, in light of the OH&S management system audit results, changing circumstances and the commitment to continual improvement. 

Input to management review shall include

• Results of internal audits and evaluation of compliance with legal and other requirements

• The results of participation and consultation

• Relevant communication form external parties including complaints

• OH&S performance

• The extent to which objectives have been met

• Status of investigation, corrective and preventive actions.

• Follow up actions from the previous management reviews

• Changing circumstances

• Recommendations from improvement

Relevant output from review shall be made available for communication and consultation

Requirement for organization;

• Are management reviews conducted at intervals as determined by the organisation?

• Minutes of meeting

• Revisions to OH &S policy and objectives

• Specific corrective actions with target dates and responsibilities

• Specific improvements with target dates and responsibilities

• Time frame for completion of corrective actions

• Area of emphasis for future planning