OSHAcademy Safety Training Network - Documentation In a Safety and Health Management System

Documentation In a Safety and Health Management System

Any management system has documentation requirements. After all, if it isn’t documented, then there is no proof that it was done. System documentation provides, not only the proof that the system is in place, but the review and understanding of the documentation provides for the continual improvement of the system and the achievement of the management system goals.

Document the Policy

The first piece of documentation that is required is the policy statement. The policy statement must be written and kept current. As the policy statement is the driver for the whole system, assuring that it is documented and communicated is a key component of the overall management system. Remember that at least annually, and if the business goals change significantly, the policy statement must be reviewed to assure that it remains consistent with the goals of the business. These reviews should be documented as well, to show that the policy statement is current.

Document What Regulations Apply

A review of the legal applicability of regulations is documented. This entails a review of the OSHA regulations, state or local ordinances, and other guidelines that the company subscribes to, and a listing of the regulations applicable to the company operations. Programs or procedures are written and maintained that outline the regulations and how the company complies with them.

Document the Structure and Responsibilities of the System

Responsibilities and Authority for managing the overall program for the company and for any individual area programs, procedures or work instructions are documented. A listing, organizational chart or some other documentation should also be kept that reflects who is responsible for the overall safety and health management system and who has specific responsibilities under the system. Who does the legal reviews? Who sets the goals? Who determines the measures used to determine if the goals are achieved? Who is responsible for determining plans and implementing processes to achieve the goals? All these roles must be documented, so that every person associated with the management system understands what they must do, and who they need to contact for specific items.

Document the Objectives and Goals of the Management System

Meaningful and attainable goals should be set for the safety management system and should be documented. The established goals should be written down, and determinations made as to what processes and changes the company, management, staff and employees are going to make to attempt to achieve these set goals.

Document the Activities

The measurements taken, including baseline data, should be documented, to assist in determining (i.e. evidence) if there is progress toward achieving the goal, or not. Without the documented data, there is no evidence that the system is working. Measurements include health data (air samples, noise levels, etc.) as well as physical measurements (pH, electrical voltage, etc).

Once the goals are set and documented, the methods used to communicate information to employees should also be documented. A “communications” procedure is a good starting point. This procedure should outline how safety information is conveyed to employees and other interested people. Additionally, it should state the methods and processes employees use to bring safety issues and concerns to the attention of management. The procedure should state the methods used and types of information conveyed to employees. In some cases, employees must be informed not only of the general safety rules and regulations, but also about any specific measurements or hazards they have been (or will be) exposed to. In these cases, employees must be trained in measures and methods to prevent overexposures.

Employee training must also be documented. Are employees aware of the hazards in the workplace, are they trained to use procedures and equipment or other controls to reduce or eliminate those hazards, and are they provided the tools they need to protect themselves? In many cases documentation is more than just a list of attendees; some regulations require that the training content, measurement data and other items be included in the documentation.

How employees are involved in the process depends on the depth of the goals. Many problems have simple, easy, and inexpensive solutions. These types of solutions should be able to be implemented with a minimal amount of difficulty. They do not require an in-depth analysis of the problem or the data to come up with solutions. Not all process or equipment problems are this easy, however, and in such cases a team of operators, engineers and staff should be put together to come up with viable solutions. The type of problem would generally dictate who should be involved in the solutions team. If the problem is regulatory in nature and involves compliance, someone with awareness and knowledge of the regulatory requirements should be involved. If the problem is procedural in nature, operators and one supervisor need only be involved. If the problem is equipment or machinery in nature, the manufacturer or an engineer may need to be involved, again depending on the nature of the problem. The Job Hazard Analysis tool provided in module 2 of this training program is an excellent tool to diagnose problems and to assist in the process of coming up with viable solutions.

The hazards of non-routine activities should always be reviewed and documented prior to the activity. Again, the Job Hazard Analysis tool in module 2 of this training is a useful tool to help determine and document hazards, and to assist in developing viable solutions to a problem or concern.

Document Data and Measurements

Audits and inspection results and findings should be documented in any safety and health management system. These findings are excellent management tools to determine a baseline, establish goals for improvement and measure progress toward achievement of the goals. Corrective actions should be documented, including the reasons for the action, who is responsible for implementation, and dates for when implementation should be completed. Subsequent audits or inspections should verify that the set actions have been completed and are effective. In order to be comprehensive, the audit procedure should cover the auditing or inspection scope, frequency and methodologies, as well as the responsibilities and requirements for conducting audits and reporting results.

Accident Investigations should also be documented so that there is viable documentation that an individual concern or incident has been addressed. The formal methods used by the company should be established and documented so that the investigation process is thorough and consistent throughout the company.

Regular and routine maintenance and monitoring activities should be documented as well. These activities provide proof to an auditor, inspector or compliance officer that the company does take proactive measures to protect employee safety. Regular service and lubrication of a machine contributes not only to the useful life of the machine, but also to the safety of the operators in preventing machine failure. Routine monitoring of air, noise levels, chemical pH, or other types of monitoring, prove that the company is concerned about not only product safety and quality, but of the safety and health of their employees.

Whenever possible the hazards of machinery, equipment and processes should be “engineered out”. This initially occurs in the design stages, but frequently engineering controls must be implemented after the process or equipment is already designed and in place. Although after-the-fact controls are usually significantly more expensive than designing the hazards out from the beginning, many business owners and management personnel are not sufficiently trained in hazard recognition and control to see all the potential problems. This is not a slight on a business owner or manager, it is just a fact of business life. Controls should be documented to assist in future process or equipment designs and installations. Where controls are not adequate to address a safety concern, procedures and work instructions should be developed. The specific steps of the task or process should be outlined in the written procedure or work instruction so that employees can follow the steps and reduce their exposure to a serious hazard.

Document Changes and Corrective Actions

Changes to equipment and procedures should also be documented, including the reasons for change. Although this type of documentation does not have to be formal in nature, it should be retained, so that compliance officers and auditors can more easily monitor progress toward safety improvements. A change management process at the company should ensure that documentation related to the changes is maintained, and the reasoning for the changes recorded. This information should be retained for at least one year from the date that the change was fully implemented. Note that some regulations may require this documentation be kept for longer periods of time. Change management should also ensure that any procedures, programs or work instructions be reviewed and updated at the time of the change.

Corrective or preventive action taken to eliminate the cause of non-conformances is appropriate to the magnitude of problems and commensurate with the environmental impact. The organization implements and records any changes in the documented procedures resulting from corrective and preventing action. The organization evaluates and verifies the outcomes derived from corrective and preventing action.

Document Procedures and Records

Instructions or procedures outline the specific steps that must be taken by employees to assure that their tasks or activities remain compliant with the regulations. For example: individual LOTO procedures for each type of machinery that requires LOTO; steps to handle or dispose of biologically hazardous waste; or procedures for operating a forklift in the warehouse area. In a large company’s safety and health management system, these “lower level” procedures should reference the company’s main or overarching program. In smaller companies, these procedures and work instructions may be a single document.

Records are documented which include training records, established safety and health goals, results of measurements (ventilation readings, noise readings, air quality measurements, etc.), audit and inspection results, corrective actions taken, communication with authorities (OSHA, ANSI, EPA, etc.), injury logs and/or incident reporting data should be maintained.

Calibration records for equipment must be maintained. Employees who use calibrated equipment are trained in the calibration procedure and/or the use of the equipment. Equipment that requires calibration is set up on a regular schedule to assure that calibration is completed in accordance with established guidelines for that type of equipment.

All documentation should be legible, dated (with revision dates if applicable), readily identifiable, maintained, accessible to all employees, and regularly reviewed.

Document the Emergency Response Information

Emergency Evacuation and Response procedures are clearly written and clearly communicated to employees. Employees and responders must know what their responsibilities are in an emergency situation and be trained and capable of carrying them out.

Document Management Review and Involvement

The company management must periodically review the performance of the management system to assure that the established goals are adequate and meet the business needs of the company.

The management review addresses the possible need for changes to policy, objectives and other elements of the environmental management system, in the light of EMS audit results, changing circumstances and the commitment to continual improvement.

Source: RIT OSHA OUTREACH CENTER - Harwood Grant