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Course 716 - Safety Management System Evaluation

Safety guides and audits to make your job as a safety professional easier

_____20. Workplace injury/illness data are effectively analyzed.


  • Workplace injury/illness data should be analyzed to identify injury and illness types and to detect trends and patterns. Results of the analyses are useful in detecting hazards and setting priorities for hazard correction. If hazards are identified, the employer‘s adherence to established correction due dates suggests that an effective tracking system is in place.
  • Written analysis of data involving less than 10 injuries and illnesses is not always necessary. Interpretation of such small sets of data should be readily apparent without manipulation. However, responsible persons in your organization should have reviewed the data and be able to describe their conclusions in interviews. Also, note that combining data for multiple years can increase the size of the data set, thereby possibly justifying formal analysis.
  • A score of "3" on this element indicates that your organization undertakes collection and effective analysis of its injury and illness data or that less than 10 injuries and illnesses were recorded over the part three years, and responsible persons in your organization have informally interpreted those small data sets.

_____21. Hazard incidence data are effectively analyzed.


  • Hazard incidence data should be analyzed to identify hazard types and to detect trends and patterns. Results of the analyses are useful in setting hazard prevention priorities.
  • As in the analysis of injury and illness data, formal analysis of data involving fewer than 10 recorded hazards is not required, although informal analysis is appropriate. It is important that the facility look for the root cause to determine what factors allowed the hazard(s) to exist.
  • A score of "3" on this element indicates that your organization undertakes collection and formal analysis of its hazard incidence data or that less than 10 hazards were recorded over the past three years, and responsible persons in your organization have interpreted those data.

_____22. A safety and health goal and supporting objectives exist.


  • A "goal" is a broad statement of organizational intent. It sets the sights of your organization on a major achievement. Most goals are long-range in nature, involving multiple years of planning efforts. Some goals, however, are not time framed at all, representing instead your organization‘s commitment to maintain or continuously improve already existing levels of excellence. Goals may or may not be measurable or directly achievable.
  • A single safety and health goal brings coherence and unity-of-purpose to your organization‘s safety and health system. Nevertheless, an organization‘s setting more than one safety and health goal should not detract from this element.
  • Safety and health goals may be outcome-based or process-based. Examples of goal statements that are outcome-based are "We will have no workplace injuries or illnesses over the next three years" or "We will reduce our recordable injury rate by 80 percent over the next three years." The former goal represents zero tolerance, while the latter represents incremental improvement. As a rule, goals involving incremental advancement are preferable to zero-tolerance goals for those organizations that have considerable room for improvement in their outcome statistics.
  • Another issue associated with outcome-based goals is the potential for such goals to stimulate organizational and individual under-reporting of injuries and illnesses. Great care must be taken to ensure that organizations do not seek their outcome-based goals in a manner that discourages reporting of accidents, injuries, and illnesses.
  • Process-based goals are those that focus on operational and organizational safety and health characteristics, with little or no emphasis on injury or illness outcomes. Examples of process-based goals are "We will achieve an acceptable rating on the Safety and Health Program Assessment Worksheet within three years" or "We will achieve SHARP status within 18 months."
  • The first step in achieving a safety and health goal is the establishment of a set of objectives that support the goal. Objectives should be stated in terms of SMART criteria, i.e., Specific, Measurable, Achievable, Result-oriented (tied to the goal), and Time-framed (usually less than one year).

_____23. An action plan designed to accomplish your organization‘s safety and health objectives is in place.


  • Actions should be short-term and highly specific. Complex actions should be broken down into steps or other progress points. Incorporate SMART criteria (see tip for Attribute 22). Ideally, action statements will begin with an action verb. Action statements should identify those responsible for the action and the completion date.
  • The action plan is a list of all safety and health actions to be accomplished. Typically, the planning period is one year in order to coincide with annual objectives (Element 22) and comprehensive review (Element 25). However, multiple sequential action plans of shorter duration can achieve the same result.
  • Assigned responsibilities, and planned completion dates are the essential ingredients for all actions. Completion dates are desirable if progress is to be tracked directly on the plan. Actions should be correlated with relevant objectives by grouping or designation. A matrix format may be useful to depict actions that relate to more than one objective. Also, employers working to improve their score may wish to code their objectives and/or actions with the relevant element numbers.

_____24. A review of in place OSHA-mandated programs is conducted at least annually.


  • Periodic reviews to evaluate the operational effectiveness of applicable OSHA-mandated programs are a good safety and health practice. Some program standards, e.g. the 1910.146 standard governing permit-required confined space entry programs, actually specify a requirement for such reviews. Note that each mandated program represents a cross-section of your organization‘s larger safety and health system and a thorough review of the mandated program entails not only identification of operational defects (Elements 1-19), but also any managerial or cultural problems (Elements 20-58) that may limit effectiveness.
  • If your organization does not conduct periodic reviews of in-place mandated programs, a rating of "0" should be assigned to this element. If your organization has only one mandated program in place, and conducts a nearly complete review of that program, then the evaluator should assign a rating of "2" to this element. If review of the single program is thorough, a rating of "3" is appropriate.
  • If your organization has more than one mandated program in place and conducts periodic review of at least one, but not all of the programs, then the evaluator should assign a rating of "1" to this element. A rating of "2" is indicated when all of the in-place mandated programs are periodically reviewed, but minor improvement is needed in the quality of some or all of these reviews. Where there are multiple mandated programs in place, a rating of "3" always requires effective periodic review of each program.
  • Failure of your organization to implement an applicable OSHA-mandated program should be considered in the hazard identification portion of the consultation and in the rating of Element 13, rather than in the rating of this element.

_____25. A review of the overall safety and health management system is conducted at least annually.


  • An annual audit of your organizational safety and health system should be conducted on a formal basis. The appropriate level of written documentation for the audit will vary with the size of your organization and the complexity of the audit. The annual safety and health audit should highlight the accomplishments and identify the failures of the past year. The audit should also ascertain the underlying reasons for any failures so that these issues can be addressed. Ideally, the audit will correlate action successes and failures of the past year with outcome results such as injuries and illnesses. This correlation can be used to determine if these actions should be extended, changed or dropped, and to determine if new actions and/or objectives should be initiated.
  • There are numerous ways to perform an annual safety and health audit. It may be conducted internally or externally. Corporate staff commonly perform external audits for small units of the company. Internal audits may be performed by your organization‘s safety committee or by a special team assembled for that purpose. Regardless of the method, it is essential that the audit process be data driven with top management endorsement. Also, the most effective audits involve input from all levels of your organization - managers, supervisors, and workers. Top managers should be directly involved in the audit process or, at least, keenly aware of the audit results.
  • Some organizations have their safety and health system in a "continuous improvement" mode. The notion of an annual audit is not in conflict with this approach. The audit provides a "big picture" assessment of the overall impact that numerous small improvements are having on organizational performance.
  • Audits may be very brief in time and documentation if your organization successfully completed its planned safety and health actions, accomplished its objectives, and achieved the desired outcome results.