How Do I Audit My System?

Unlike inspecting a work area, conducting an audit requires that you use several methods to obtain the necessary data. These methods typically include:

• Documentation review
• Interviews
• Site conditions assessment

Documentation

Every worksite will have, at an absolute minimum, written accident reports and the OSHA log of injuries and illnesses as required by law. Most companies should have written procedures and records of all their safety and health programs, as well as internal policies. The auditor should compare the written program to the written records of what occurred.

Interviews

In addition to the documentation, interviews can be very helpful in establishing what has occurred. There are two kinds of interviews, called formal and informal. The formal interviews are conducted privately with randomly selected employees who are asked preselected questions. Informal interviews occur at employee work stations and generally follow a list of topics.

To assess how well the worksite safety and health policy is communicated and understood, and how well the disciplinary system is working, ask the employees to explain them.

To gauge the effectiveness of safety and health training, interview hourly employees and first-line supervisors. Ask employees to describe what hazards they are exposed to, and how they are protected. Ask them to explain what they are supposed to do in several different types of emergencies. Ask supervisors how they teach, how they reinforce the teaching, how they enforce safety and health rules and safe work practices, and what their responsibilities are during emergency situations.

Interviews with management should focus on its involvement in and commitment to the safety and health program. Ask how the policy statement was created, and how that statement is communicated to all employees. Ask what information management receives about the safety and health activities, and what action management takes as a result of that information. Ask how management's commitment to safety and health is demonstrated to the workforce.

Site Conditions Review

The conditions at the worksite reveal much about the safety and health program's effectiveness. Worksite conditions can be observed indirectly by examining documents such as inspection reports, employee reports of hazards, and accident/incident investigations.

Site tours also may reveal hazards. Be careful, however, that the site tour does not become a routine inspection, with emphasis only on hazard correction. When a hazard is found, certainly take steps to ensure its correction. But in addition, ask what management system(s) should have prevented or controlled the hazard.

System Audits: Where to Turn

There is no concrete right or wrong way to audit your safety and health management system. OSHA doesn't require you to audit the system, or that you necessarily have a formal safety and health system — so how you audit is up to you.

But, there are some considerations. For starters, because there is no regulation, it can be difficult to figure out what to assess your system against. With inspections you have the regulations, for example, "Is the eyewash available when employees are exposed to corrosive?"

With a systems audit, you do not have that regulatory criteria. So, you have to develop your own audit protocol.

One place you might consider starting is the Safety and Health Program Assessment Worksheet (OSHA Form 33). This Form is used by OSHA's Consultation Services to review safety management programs. The form covers seven areas:

1. Hazard anticipation and detection
2. Hazard prevention and control
3. Planning and evaluation
4. Administration and supervision
5. Safety and health training
6. Management leadership
7. Employee participation

A blank Form 33 is provided on the following pages. Though some of the fields are intended for OSHA's in-house use, the form may prove to be a good management tool to perform your own self-assessment.

Oregon SHARP/Consultation provides tips for using the Safety and Health Program Assessment Worksheet. They walk you through what to look for under each element. For example, for the element that says you should have a comprehensive, baseline hazard survey conducted within the past five years, the Oregon OSHA tip sheet advises you that in order to get a score of "3" for that element, the baseline must be written. It provides similar practical tips throughout. If you combine the worksheet and these tips, you should have the tools to do a fairly thorough assessment of your safety management system.

To view the tips, visit www.cbs.state.or.us/external/osha/pdf/sharp/sharpassesstips. pdf.

Systems Audits: Going Beyond Inspections

Most employers conduct inspections or what some call walkthroughs, and many employers conduct audits, as well. But, there are some employers that don't conduct audits — and there are some that think they conduct audits, but what they really conduct are inspections or walkthroughs.

Inspections and walkthroughs are extremely important and in many cases dictated by government regulations. So, their importance cannot be discounted.

But, going beyond the simple inspection or walkthrough process — and implementing an effective audit process is also important.

What is an Inspection?

Simply stated, an inspection is the process of closely looking at the workplace for hazardous conditions or compliance violations. There are a variety of inspections that employers conduct — some at the department level, some at the equipment level, and some company-wide.

Typically, an inspection is based on either OSHA standards, industry standards, manufacturer's requirements, or a combination. Inspections are heavily associated with checklists (as you can find in this manual) — where you walk around and compare what you see to what's on the checklist.

What is a Systems Audit?

A simple definition of a systems audit is: the process of verifying whether the safety system conforms to the audit criteria and that the system is effective.

The audit criteria can be OSHA standards, company policies and procedures, or ANSI or industry standards. So, when you think of a systems audit, remember, it's more than just a regulatory check; it involves looking at your safety management system to identify strengths and weaknesses.

Differences Between Inspections and Audits

Now that we've defined what an inspection and an audit are, we can start to see the differences between the two processes. The following table provides an overview of these differences.

Inspections vs. audits
Inspections	Audits
Focus on physical items or conditions	Focus on processes and systems
"Look and see" approach	Interview, review documentation, and "look and see"
"Yes/no" answers	Progressive scale — "Nothing in place" to "Fully in place and satisfactory"
Done by employees on the floor, supervisor, safety committee	Done by objective party (safety manager, outside consultant, insurance representative)
Not very time consuming — usually 15 minutes to an hour	Can take several hours or days
Frequent — Daily/weekly/monthly/quarterly	Infrequent — Annual, bi-annual
Primarily focuses on weaknesses	Focuses on weaknesses and strengths
Identifies a hazard, fixes THAT hazard	Deals with system-wide problems (root cause of an isolated hazard)
Corrective actions are straightforward	Corrective actions are often broad, performance-oriented
Document/follow-up	Document/follow-up — more detailed findings
Required by OSHA in many cases	Not required in most cases. BUT: PPE hazard assessment Lockout/Tagout periodic inspection Confined spaces assessment Process Safety Management of Highly Hazardous Chemicals, 1910.119 Construction Jobsites, 1926.20(b)(2)