ISO45001 Safety Gap Analysis Report

Title Page

Audit details

Client
Conducted on
Prepared by
Location
Personnel

Summary of findings

Executive Summary
Assessment rating table and summary of findings

Audit Objective and Methodology

The objective of the ISO 45001 compliance review and this report is to assess compliance with the ISO 45001:2018 and to provide the organisation with guidance on how to achieve compliance within the scope of the international standard and Work Health and Safety (WHS) Legislation.

This report provides an overview of the organisation's WHS management system specifying whether the system conforms to the ISO 45001 criterion. Should there be an element that does not conform, the degree of non- compliance is stated as either ‘Minor Non-Conformance" or ‘Major Non-Conformance’ as per graphic below.

Section 2 of the audit report provides further background of the audit methodology, limitations

Improvement Opportunities

The key recommendations were identified within the audit as outlined within the report. The following are the top 5 identified opportunities as a result of this assessment.

ISO45001 assessment

4.0 Context of the organisation

4.1 Understanding the organisation and its context

Has the organisation determined external and internal issues that are relevant to its purpose and that affect its ability to achieve the intended outcome(s) of its WH&S management system.
Verification / Evidence
Comments
Compliance Score
Recommendation

4.2 Understanding the need and expectation of workers and other interested parties

Has the organisation determined:
a) the other interested parties, in addition to workers, that are relevant to the WH&S management system;
b) the relevant needs and expectations (i.e. requirements) of workers and other interested parties;
c) which of these needs and expectations are, or could become, legal requirements and other requirements.
Verification / Evidence
Comments
Compliance Score
Recommendation

4.3 Determine the scope of the WHS management system

The organisation shall determine the boundaries and applicability of the WH&S management system to establish its scope.
When determining this scope, has the organisation:
a) considered the external and internal issues referred to in 4.1;
b) taken into account the requirements referred to in 4.2;
c) taken into account the planned or performed work-related activities.
Does the WH&S management include the activities, products and services within the organisation's control or influence that can impact the organisation’s WH&S performance.
Is this scope available as documented information.
Verification / Evidence
Comments
Compliance Score
Recommendation

4.4 WHS management system

Has the organisation established, implemented, maintained and continually improved an WH&S management system, including the processes needed and their interactions, in accordance with the requirements of this document.
Verification / Evidence
Comments
Compliance Score
Recommendation

5.0 Leadership and worker participation

5.1 Leadership and commitment

Has top management demonstrated leadership and commitment with respect to the WH&S management system by:
a) taking overall responsibility and accountability for the prevention of work-related injury and ill health, as well as the provision of safe and healthy workplaces and activities;
b) ensuring that the WH&S policy and related WH&S objectives are established and are compatible with the strategic direction of the organisation;
c) ensuring the integration of the WH&S management system requirements into the organisation’s business processes;
d) ensuring that the resources needed to establish, implement, maintain and improve the WH&S management system are available;
e) communicating the importance of effective OH&S management and of conforming to the WH&S management system requirements;
f) ensuring that the WH&S management system achieves its intended outcome(s);
g) directing and supporting persons to contribute to the effectiveness of the WH&S management system;
h) ensuring and promoting continual improvement;
i) supporting other relevant management roles to demonstrate their leadership as it applies to their areas of responsibility;
j) developing, leading and promoting a culture in the organization that supports the intended outcomes of the WH&S management system;
k) protecting workers from reprisals when reporting incidents, hazards, risks and opportunities;
l) ensuring the organization establishes and implements a process(es) for consultation and participation of workers (see 5.4);
m) supporting the establishment and functioning of health and safety committees, [see 5.4 e) 1)].
NOTE Reference to “business” in this document can be interpreted broadly to mean those activities that are core to the purposes of the organisation’s existence.
Verification / Evidence
Comments
Compliance Score
Recommendation

5.2 OHS policy

Has top management established, implemented and maintained an WH&S policy that:
a) includes a commitment to provide safe and healthy working conditions for the prevention of work- related injury and ill health and is appropriate to the purpose, size and context of the organization and to the specific nature of its WH&S risks and WH&S opportunities;
b) provides a framework for setting the WH&S objectives;
c) includes a commitment to fulfill legal requirements and other requirements;
d) includes a commitment to eliminate hazards and reduce WH&S risks (see 8.1.2);
e) includes a commitment to continual improvement of the WH&S management system;
f) includes a commitment to consultation and participation of workers, and, where they exist, workers’ representatives.

Is the WH&S policy:
— available as documented information;
— communicated within the organisation;
— available to interested parties, as appropriate;
— relevant and appropriate.
Verification / Evidence
Comments
Compliance Score
Recommendation

5.3 Organisational roles, responsibilities and authorities

Has top management ensured that the responsibilities and authorities for relevant roles within the WH&S management system are assigned and communicated at all levels within the organization and maintained as documented information. Workers at each level of the organization shall assume responsibility for those aspects of the WH&S management system over which they have control.

NOTE: While responsibility and authority can be assigned, ultimately top management is still accountable for the functioning of the WH&S management system.

Has top management assigned the responsibility and authority for:
a) ensuring that the WH&S management system conforms to the requirements of this document;
b) reporting on the performance of the WH&S management system to top management.
Verification / Evidence
Comments
Compliance Score
Recommendation

5.4 Consultation and participation of workers

Has the organisation established, implemented and maintained a process(es) for consultation and participation of workers at all applicable levels and functions, and, where they exist, workers’ representatives, in the development, planning, implementation, performance evaluation and actions for improvement of the WH&S management system.

Does the organisation:
a) provide mechanisms, time, training and resources necessary for consultation and participation (NOTE 1 Worker representation can be a mechanism for consultation and participation);
b) provide timely access to clear, understandable and relevant information about the WH&S management system;
c) determine and remove obstacles or barriers to participation and minimize those that cannot be removed. (NOTE 2 Obstacles and barriers can include failure to respond to worker inputs or suggestions, language or literacy barriers, reprisals or threats of reprisals and policies or practices that discourage or penalize worker participation);
d) emphasize the consultation of non-managerial workers on the following:
1) determining the needs and expectations of interested parties (see 4.2);
2) establishing the WH&S policy (see 5.2);
3) assigning organisational roles, responsibilities and authorities, as applicable (see 5.3);
4) determining how to fulfill legal requirements and other requirements (see 6.1.3);
5) establishing WH&S objectives and planning to achieve them (see 6.2);
6) determining applicable controls for outsourcing, procurement and contractors (see 8.1.4);
7) determining what needs to be monitored, measured and evaluated (see 9.1);
8) planning, establishing, implementing and maintaining an audit programme(s) (see 9.2.2);
9) ensuring continual improvement (see 10.3);
e) emphasise the participation of non-managerial workers in the following:
1) determining the mechanisms for their consultation and participation;
2) identifying hazards and assessing risks and opportunities (see 6.1.1 and 6.1.2);
3) determining actions to eliminate hazards and reduce OH&S risks (see 6.1.4);
4) determining competence requirements, training needs, training and evaluating training (see 7.2);
5) determining what needs to be communicated and how this will be done (see 7.4);
6) determining control measures and their effective implementation and use (see 8.1, 8.1.3 and 8.2); investigating incidents and non-conformities and determining corrective actions (see 10.2).
NOTE 3 Emphasising the consultation and participation of non-managerial workers is intended to apply to persons carrying out the work activities, but is not intended to exclude, for example, managers who are impacted by work activities or other factors in the organization. NOTE 4 It is recognised that the provision of training at no cost to workers and the provision of training during working hours, where possible, can remove significant barriers to worker participation.
Verification / Evidence
Comments
Compliance Score
Recommendation

6.0 Planning

6.1 Actions to address risk and opportunities

6.1.1 General

When planning for the WH&S management system, has the organisation considered the issues referred to in 4.1 (context), the requirements referred to in 4.2 (interested parties) and 4.3 (the scope of its OH&S management system) and determine the risks and opportunities that need to be addressed to:
a) give assurance that the WH&S management system can achieve its intended outcome(s);
b) prevent, or reduce, undesired effects;
c) achieve continual improvement.

The following is taken into account by the organisation when determining risks and opportunities within the WH&S management system and its intended outcomes:
— hazards (see 6.1.2.1);
— WH&S risks and other risks (see 6.1.2.2);
— WH&S opportunities and other opportunities (see 6.1.2.3);
— legal requirements and other requirements (see 6.1.3).

The organisation, in its planning process(es), has assessed the risks and opportunities relevant to the intended outcomes of the WH&S management system associated with changes in the organisation, its processes or the WH&S management system. In the case of planned changes, permanent or temporary, this assessment shall be undertaken before the change is implemented (see 8.1.3).

The organisation maintained documented information in relation to:
— risks and opportunities;
— the process(es) and actions required to determine and address its risks and opportunities (see 6.1.2 to 6.1.4) to the extent necessary to have confidence that they are carried out as planned.
Verification / Evidence
Comments
Compliance Score
Recommendation

6.1.2 Hazard Identification and assessment of risks and opportunities

6.1.2.1 Hazard identification

Has the organisation established, implemented and maintain a process(es) for hazard identification that is ongoing and proactive and take into account the following.
a) how work is organized, social factors (including workload, work hours, victimisation, harassment and bullying), leadership and the culture in the organisation;s
b) routine and non-routine activities and situations, including hazards arising from:
1) infrastructure, equipment, materials, substances and the physical conditions of the workplace;
2) product and service design, research, development, testing, production, assembly, construction, service delivery, maintenance and disposal;
3) human factors;
4) how the work is performed;
c) past relevant incidents, internal or external to the organization, including emergencies, and their causes;
d) potential emergency situations;
e) people, including consideration of:
1) those with access to the workplace and their activities, including workers, contractors, visitors and other persons;
2) those in the vicinity of the workplace who can be affected by the activities of the organisation;
3) workers at a location not under the direct control of the organisation;
f) other issues, including consideration of:
1) the design of work areas, processes, installations, machinery/equipment, operating procedures and work organization, including their adaptation to the needs and capabilities of the workers involved;
2) situations occurring in the vicinity of the workplace caused by work-related activities under the control of the organization;
3) situations not controlled by the organisation and occurring in the vicinity of the workplace that can cause injury and ill health to persons in the workplace;
g) actual or proposed changes in organization, operations, processes, activities and the WH&S management system (see 8.1.3);
h) changes in knowledge of, and information about, hazards.
Verification / Evidence
Comments
Compliance Score
Recommendation

6.1.2.2 Assessment of WH&S risks and other risks to the WH&S management system

The organisation has established, implemented and maintain a process(es) to:
a) assess WH&S risks from the identified hazards, while taking into account the effectiveness of existing controls;
b) determine and assess the other risks related to the establishment, implementation, operation and maintenance of the WH&S management system.
The organisation’s methodology(ies) and criteria for the assessment of WH&S risks is defined with respect to their scope, nature and timing to ensure they are proactive rather than reactive and are used in a systematic way. Documented information is maintained and retained on the methodology(ies) and criteria.
Verification / Evidence
Comments
Compliance Score
Recommendation

6.1.2.3 Assessment of WH&S opportunities and other opportunities for the WH&S management system

The organisation has established, implemented and maintained a process(es) to assess:
a) WH&S opportunities to enhance WH&S performance, while taking into account planned changes to the organisation, its policies, its processes or its activities and:
1) opportunities to adapt work, work organization and work environment to workers;
2) opportunities to eliminate hazards and reduce WH&S risks;
b) other opportunities for improving the WH&S management system.
NOTE WH&S risks and WH&S opportunities can result in other risks and other opportunities for the organisation.
Verification / Evidence
Comments
Compliance Score
Recommendation

6.1.3 Determination of legal requirements and other requirements

The organisation has established, implemented and maintained a process(es) to:
a) determine and have access to up-to-date legal requirements and other requirements that are applicable to its hazards, WH&S risks and WH&S management system;
b) determine how these legal requirements and other requirements apply to the organization and what needs to be communicated;
c) take these legal requirements and other requirements into account when establishing, implementing, maintaining and continually improving the WH&S management system.
The organization shall maintain and retain documented information on its legal requirements and other requirements and shall ensure that it is updated to reflect any changes.
NOTE Legal requirements and other requirements can result in risks and opportunities for the organization.
Verification / Evidence
Comments
Compliance Score
Recommendation

6.1.4 Planning action

The organisation has planned:
a) actions to:
1) address these risks and opportunities (see 6.1.2.2 and 6.1.2.3);
2) address legal requirements and other requirements (see 6.1.3);
3) prepare for and respond to emergency situations (see 8.2);
b) how to:
1) integrate and implement the actions into its OH&S management system processes or other business processes;
2) evaluate the effectiveness of these actions.
The organisation shall take into account the hierarchy of controls (see 8.1.2) and outputs from the OH&S management system when planning to take action.
When planning its actions, the organization has considered best practices, technological options and financial, operational and business requirements.
Verification / Evidence
Comments
Compliance Score
Recommendation

6.2 WHS objectives and planning to achieve them

6.2.1 WHS objectives

The organisation has established WH&S objectives at relevant functions and levels in order to maintain and continually improve the WH&S management system and WH&S performance (see 10.3).
The WH&S objectives are:
a) consistent with the WH&S policy;
b) measurable (if practicable) or capable of performance evaluation;
c) take into account:
1) applicable requirements;
2) the results of the assessment of risks and opportunities (see 6.1.2.2 and 6.1.2.3);
3) the results of consultation with workers (see 5.4) and, where they exist, workers’ representatives are;
d) monitored;
e) communicated;
f) updated as appropriate.
Verification / Evidence
Comments
Compliance Score
Recommendation

6.2.2 Planning actions to achieve WHS objectives

When planning how to achieve its WH&S objectives, the organisation has determined:
a) what will be done;
b) what resources will be required;
c) who will be responsible;
d) when it will be completed;
e) how the results will be evaluated, including indicators for monitoring;
f) how the actions to achieve WH&S objectives will be integrated into the organization’s business processes.
The organisation maintains and retains documented information on the WH&S objectives and plans to achieve them.
Verification / Evidence
Comments
Compliance Score
Recommendation

7.0 Support

7.1 Resources

The organisation has determined and provided the resources needed for the establishment, implementation, maintenance and continual improvement of the WH&S management system.
Verification / Evidence
Comments
Compliance Score
Recommendation

7.2 Competence

The organisation has:
a) determined the necessary competence of workers that affects or can affect its WH&S performance;
b) ensure that workers are competent (including the ability to identify hazards) on the basis of appropriate education, training or experience;
c) where applicable, take actions to acquire and maintain the necessary competence, and evaluate the effectiveness of the actions taken;
d) retain appropriate documented information as evidence of competence.
NOTE Applicable actions can include, for example, the provision of training to, the mentoring of, or the re- assignment of currently employed persons, or the hiring or contracting of competent persons.
Verification / Evidence
Comments
Compliance Score
Recommendation

7.3 Awareness

Workers are made aware of:
a) the WH&S policy and WH&S objectives;
b) their contribution to the effectiveness of the WH&S management system, including the benefits of improved WH&S performance;
c) the implications and potential consequences of not conforming to the WH&S management system requirements;
d) incidents and the outcomes of investigations that are relevant to them;
e) hazards, WH&S risks and actions determined that are relevant to them;
f) the ability to remove themselves from work situations that they consider present an imminent and serious danger to their life or health, as well as the arrangements for protecting them from undue consequences for doing so.
Verification / Evidence
Comments
Compliance Score
Recommendation

7.4 Communication

7.4.1 General

The organisation has established, implemented and maintained the process(es) needed for the internal and external communications relevant to the WH&S management system, including determining:
a) on what it will communicate;
b) when to communicate;
c) with whom to communicate:
1) internally among the various levels and functions of the organisation;
2) among contractors and visitors to the workplace;
3) among other interested parties;
d) how to communicate.
The organisation takes into account diversity aspects (e.g. gender, language, culture, literacy, disability) when considering its communication needs.
The organisation ensures that the views of external interested parties are considered in establishing its communication process(es).

When establishing its communication process(es), the organisation has:
— taken into account its legal requirements and other requirements;
— ensured that WH&S information to be communicated is consistent with information generated within the WH&S management system, and is reliable.
The organisation responds to relevant communications on its WH&S management system.
The organisation retains documented information as evidence of its communications, as appropriate.
Verification / Evidence
Comments
Compliance Score
Recommendation

7.4.2 Internal communication

The organisation can demonstrate how it:
a) internally communicates information relevant to the WH&S management system among the various levels and functions of the organization, including changes to the WH&S management system, as appropriate;
b) ensures its communication process(es) enables workers to contribute to continual improvement.
Verification / Evidence
Comments
Compliance Score
Recommendation

7.4.3 External communication

The organisation externally communicates information relevant to the WH&S management system, as established by the organisation’s communication process(es) and taking into account its legal requirements and other requirements.
Verification / Evidence
Comments
Compliance Score
Recommendation

7.5 Documented information

7.5.1 General

The organisation’s WH&S management system includes:
a) documented information required by this document;
b) documented information determined by the organisation as being necessary for the effectiveness of the WH&S management system.

NOTE The extent of documented information for an WH&S management system can differ from one organisation to another due to:
— the size of organisation and its type of activities, processes, products and services;
— the need to demonstrate fulfillment of legal requirements and other requirements;
— the complexity of processes and their interactions;
— the competence of workers.
Verification / Evidence
Comments
Compliance Score
Recommendation

7.5.2 Creating and updating

When creating and updating documented information, the organisation ensures the following is considered:
a) identification and description (e.g. a title, date, author or reference number);
b) format (e.g. language, software version, graphics) and media (e.g. paper, electronic);
c) review and approval for suitability and adequacy.
Verification / Evidence
Comments
Compliance Score
Recommendation

7.5.3 Control of documented information

Documented information required by the WH&S management system and by this document is controlled to ensure:
a) it is available and suitable for use, where and when it is needed;
b) it is adequately protected (e.g. from loss of confidentiality, improper use or loss of integrity).

For the control of documented information, the organisation addresses the following activities, as applicable:
— distribution, access, retrieval and use;
— storage and preservation, including preservation of legibility;
— control of changes (e.g. version control);
— retention and disposition.

Documented information of external origin determined by the organization to be necessary for the planning and operation of the WH&S management system shall be identified, as appropriate, and controlled.
NOTE 1 Access can imply a decision regarding the permission to view the documented information only, or the permission and authority to view and change the documented information.
NOTE 2 Access to relevant documented information includes access by workers, and, where they exist, workers’ representatives.
Verification / Evidence
Comments
Compliance Score
Recommendation

8.0 Operation

8.1 Operational planning and control

8.1.1 General

The organisation plans, implements, controls and maintains the processes needed to meet requirements of the WH&S management system, and to implement the actions determined in Clause 6, by:
a) establishing criteria for the processes;
b) implementing control of the processes in accordance with the criteria;
c) maintaining and retaining documented information to the extent necessary to have confidence that the processes have been carried out as planned;
d) adapting work to workers.
At multi-employer workplaces, the organisation shall coordinate the relevant parts of the WH&S management system with the other organisations.
Verification / Evidence
Comments
Compliance Score
Recommendation

8.1.2 Eliminating hazards and reducing WHS risks

The organisation has established, implemented and maintained a process(es) for the elimination of hazards and reduction of WH&S risks using the following hierarchy of controls:
a) eliminate the hazard;
b) substitute with less hazardous processes, operations, materials or equipment;
c) use engineering controls and re-organisation of work;
d) use administrative controls, including training;
e) use adequate personal protective equipment.
NOTE In many countries, legal requirements and other requirements include the requirement that personal protective equipment (PPE) is provided at no cost to workers.
Verification / Evidence
Comments
Compliance Score
Recommendation

8.1.3 Management of change

The organisation has established a process(es) for the implementation and control of planned temporary and permanent changes that impact WH&S performance, including:
a) new products, services and processes, or changes to existing products, services and processes, including:
o workplace locations and surroundings;
o work organization;
o working conditions;
o equipment;
o work force;
b) changes to legal requirements and other requirements;
c) changes in knowledge or information about hazards and WH&S risks;
d) developments in knowledge and technology.
The organisation reviews the consequences of unintended changes, taking action to mitigate any adverse effects, as necessary.
Verification / Evidence
Comments
Compliance Score
Recommendation

8.1.4 Procurement

8.1.4.1 General

Changes can result in risks and opportunities. The organization has established, implemented and maintained a process(es) to control the procurement of products and services in order to ensure their conformity to its WH&S management system.
Verification / Evidence
Comments
Compliance Score
Recommendation

8.1.4.2 Contractors

The organisation coordinates its procurement process(es) with its contractors, in order to identify hazards and to assess and control the WH&S risks arising from:
a) the contractors’ activities and operations that impact the organisation;
b) the organisation’s activities and operations that impact the contractors’ workers;
c) the contractors’ activities and operations that impact other interested parties in the workplace.
The organisation ensures the requirements of its WH&S management system are met by contractors and their workers. The organisation’s procurement process(es) defines and apply work health and safety criteria for the selection of contractors.
NOTE It can be helpful to include the work health and safety criteria for the selection of contractors in the contractual documents.
Verification / Evidence
Comments
Compliance Score
Recommendation

8.1.4.3 Outsourcing

The organisation ensures outsourced functions and processes are controlled. The organisation ensures its outsourcing arrangements are consistent with legal requirements and other requirements and with achieving the intended outcomes of the WH&S management system. The type and degree of control to be applied to these functions and processes is defined within the WH&S management system.
NOTE Coordination with external providers can assist an organisation to address any impact that outsourcing has on its WH&S performance
Verification / Evidence
Comments
Compliance Score
Recommendation

8.2 Emergency preparedness and response

The organisation has established, implemented and maintained a process(es) needed to prepare for and respond to potential emergency situations, as identified in 6.1.2.1, including:
a) establishing a planned response to emergency situations, including the provision of first aid;
b) providing training for the planned response;
c) periodically testing and exercising the planned response capability;
d) evaluating performance and, as necessary, revising the planned response, including after testing and, in particular, after the occurrence of emergency situations;
e) communicating and providing relevant information to all workers on their duties and responsibilities;
f) communicating relevant information to contractors, visitors, emergency response services, government authorities and, as appropriate, the local community;
g) taking into account the needs and capabilities of all relevant interested parties and ensuring their involvement, as appropriate, in the development of the planned response.
The organisation shall maintain and retain documented information on the process(es) and on the plans for responding to potential emergency situations.
Verification / Evidence
Comments
Compliance Score
Recommendation

9.0 Performance evaluation

9.1 Monitoring, measure, analysis and performance evaluation

9.1.1 General

The organisation has established, implemented and maintained a process(es) for monitoring, measurement, analysis and performance evaluation.
The organisation has determine:
a) what needs to be monitored and measured, including:
1) the extent to which legal requirements and other requirements are fulfilled;
2) its activities and operations related to identified hazards, risks and opportunities;
3) progress towards achievement of the organisation’s WH&S objectives;
4) effectiveness of operational and other controls;
b) the methods for monitoring, measurement, analysis and performance evaluation, as applicable, to ensure valid results;
c) the criteria against which the organization will evaluate its WH&S performance;
d) when the monitoring and measuring shall be performed;
e) when the results from monitoring and measurement shall be analysed, evaluated and communicated.
The organisation shall evaluate the WH&S performance and determine the effectiveness of the WH&S management system.
The organisation shall ensure that monitoring and measuring equipment is calibrated or verified as applicable, and is used and maintained as appropriate.
NOTE There can be legal requirements or other requirements (e.g. national or international standards) concerning the calibration or verification of monitoring and measuring equipment.
The organisation retains appropriate documented information:
— as evidence of the results of monitoring, measurement, analysis and performance evaluation;
— on the maintenance, calibration or verification of measuring equipment.
Verification / Evidence
Comments
Compliance Score
Recommendation

9.1.2 Evaluation of compliance

The organisation has established, implemented and maintained a process(es) for evaluating compliance with legal requirements and other requirements (see 6.1.3).
The organisation has:
a) determined the frequency and method(s) for the evaluation of compliance;
b) evaluated compliance and take action if needed (see 10.2);
c) maintained knowledge and understanding of its compliance status with legal requirements and other requirements;
d) retained documented information of the compliance evaluation result(s).
Verification / Evidence
Comments
Compliance Score
Recommendation

9.2 Internal audit

9.2.1 General

The organisation conducts internal audits at planned intervals to provide information on whether the WH&S management system:
a) conforms to:
1) the organisation’s own requirements for its WH&S management system, including the WH&S policy and WH&S objectives;
2) the requirements of this document;
b) is effectively implemented and maintained.
Verification / Evidence
Comments
Compliance Score
Recommendation

9.2.2 Internal audit programme

The organisation has:
a) planned, established, implemented and maintained an audit programme(s) including the frequency, methods, responsibilities, consultation, planning requirements and reporting, which shall take into consideration the importance of the processes concerned and the results of previous audits;
b) defined the audit criteria and scope for each audit;
c) selected auditors and conduct audits to ensure objectivity and the impartiality of the audit process;
d) ensured that the results of the audits are reported to relevant managers; ensure that relevant audit results are reported to workers, and, where they exist, workers’ representatives, and other relevant interested parties;
e) taken action to address non-conformities and continually improve its OH&S performance (see Clause 10);
f) retained documented information as evidence of the implementation of the audit programme and the audit results.
NOTE For more information on auditing and the competence of auditors, see ISO 19011.
Verification / Evidence
Comments
Compliance Score
Recommendation

9.3 Management review

Top management reviews the organisation’s WH&S management system, at planned intervals, to ensure its continuing suitability, adequacy and effectiveness.
The management review includes consideration of:
a) the status of actions from previous management reviews;
b) changes in external and internal issues that are relevant to the WH&S management system, including:
1) the needs and expectations of interested parties;
2) legal requirements and other requirements;
3) risks and opportunities;
c) the extent to which the WH&S policy and the WH&S objectives have been met;
d) information on the WH&S performance, including trends in:
1) incidents, non-conformities, corrective actions and continual improvement;
2) monitoring and measurement results;
3) results of evaluation of compliance with legal requirements and other requirements;
4) audit results;
5) consultation and participation of workers;
6) risks and opportunities;
e) adequacy of resources for maintaining an effective WH&S management system;
f) relevant communication(s) with interested parties;
g) opportunities for continual improvement.

The outputs of the management review includes decisions related to:
— the continuing suitability, adequacy and effectiveness of the WH&S management system in achieving its intended outcomes;
— continual improvement opportunities;
— any need for changes to the WH&S management system;
— resources needed;
— actions, if needed;
— opportunities to improve integration of the WH&S management system with other business processes;
— any implications for the strategic direction of the organization.

Top management communicates the relevant outputs of management reviews to workers, and, where they exist, workers’ representatives (see 7.4).
The organization retains documented information as evidence of the results of management reviews.
Verification / Evidence
Comments
Compliance Score
Recommendation

10.0 Improvement

10.1 General

The organization determines opportunities for improvement (see Clause 9) and implements necessary actions to achieve the intended outcomes of its WH&S management system.
Verification / Evidence
Comments
Compliance Score
Recommendation

10.2 Incident, Nonconformity and corrective action

The organisation has established, implemented and maintained a process(es), including reporting, investigating and taking action, to determine and manage incidents and non-conformities.
When an incident or a nonconformity occurs, the organisation:
a) reacts in a timely manner to the incident or non-conformity and, as applicable:
1) takes action to control and correct it;
2) deals with the consequences;
b) evaluates, with the participation of workers (see 5.4) and the involvement of other relevant interested parties, the need for corrective action to eliminate the root cause(s) of the incident or nonconformity, in order that it does not recur or occur elsewhere, by:
1) investigating the incident or reviewing the non-conformity;
2) determining the cause(s) of the incident or non-conformity;
3) determining if similar incidents have occurred, if non-conformities exist, or if they could potentially occur;
c) reviews existing assessments of WH&S risks and other risks, as appropriate (see 6.1);
d) determines and implements any action needed, including corrective action, in accordance with the hierarchy of controls (see 8.1.2) and the management of change (see 8.1.3);
e) assesses WH&S risks that relate to new or changed hazards, prior to taking action;
f) reviews the effectiveness of any action taken, including corrective action;
g) makes changes to the WH&S management system, if necessary.

Corrective actions are appropriate to the effects or potential effects of the incidents or non-conformities encountered.

The organisation retains documented information as evidence of:
— the nature of the incidents or non-conformities and any subsequent actions taken;
— the results of any action and corrective action, including their effectiveness.

The organisation communicates this documented information to relevant workers, and, where they exist, workers’ representatives, and other relevant interested parties.
NOTE The reporting and investigation of incidents without undue delay can enable hazards to be eliminated and associated WH&S risks to be minimized as soon as possible.
Verification / Evidence
Comments
Compliance Score
Recommendation

10.3 Continual improvement

The organisation continually improves the suitability, adequacy and effectiveness of the WH&S management system, by:
a) enhancing WH&S performance;
b) promoting a culture that supports an WH&S management system;
c) promoting the participation of workers in implementing actions for the continual improvement of the WH&S management system;
d) communicating the relevant results of continual improvement to workers, and, where they exist, workers’ representatives;
e) maintaining and retaining documented information as evidence of continual improvement
Verification / Evidence
Comments
Compliance Score
Recommendation

Auditor sign off

Name
Signature

Annex A requirements

The following information relates to the detail provided within ISO45001:2018 Annex A which provides further guidance and clarification of audit requirements

Section 4 Context of the organization

A.4.1 Understanding the organization and its context
An understanding of the context of an organization is used to establish, implement, maintain and continually improve its OH&S management system. Internal and external issues can be positive or negative and include conditions, characteristics or changing circumstances that can affect the OH&S management system, for example:
a) external issues, such as:
1) the cultural, social, political, legal, financial, technological, economic and natural surroundings and market competition, whether international, national, regional or local;
2) introduction of new competitors, contractors, subcontractors, suppliers, partners and providers, new technologies, new laws and the emergence of new occupations;
3) new knowledge on products and their effect on health and safety;
4) key drivers and trends relevant to the industry or sector having impact on the organization;
5) relationships with, as well as perceptions and values of, its external interested parties;
6) changes in relation to any of the above;
b) internal issues, such as:
1) governance, organizational structure, roles and accountabilities;
2) policies, objectives and the strategies that are in place to achieve them;
3) the capabilities, understood in terms of resources, knowledge and competence (e.g. capital, time, human resources, processes, systems and technologies);
4) information systems, information flows and decision-making processes (both formal and informal);
5) introduction of new products, materials, services, tools, software, premises and equipment;
6) relationships with, as well as perceptions and values of, workers;
7) the culture in the organization;
8) standards, guidelines and models adopted by the organization;
9) the form and extent of contractual relationships, including, for example, outsourced activities;
10) working time arrangements;
11) working conditions;
12) changes in relation to any of the above.
A.4.2 Understanding the needs and expectations of workers and other interested parties
Interested parties, in addition to workers, can include:
a) legal and regulatory authorities (local, regional, state/provincial, national or international);
b) parent organizations;
c) suppliers, contractors and subcontractors;
d) workers’ representatives;
e) workers’ organizations (trade unions) and employers’ organizations;
f) owners, shareholders, clients, visitors, local community and neighbours of the organization and the general public;
g) customers, medical and other community services, media, academia, business associations and non-governmental organizations (NGOs);
h) occupational health and safety organizations, occupational safety and health-care professionals.
Some needs and expectations are mandatory; for example, because they have been incorporated into laws and regulations. The organization may also decide to voluntarily agree to, or adopt, other needs and expectations (e.g. subscribing to a voluntary initiative). Once the organization adopts them, they are addressed when planning and establishing the OH&S management system.
A.4.3 Determining the scope of the OH&S management system
An organization has the freedom and flexibility to define the boundaries and applicability of the OH&S management system. The boundaries and applicability may include the whole organization, or a specific part(s) of the organization, provided that the top management of that part of the organization has its own functions, responsibilities and authorities for establishing an OH&S management system.
The credibility of the organization’s OH&S management system will depend upon the choice of the boundaries. The scope should not be used to exclude activities, products and services that have or can impact the organization’s OH&S performance, or to evade its legal requirements and other requirements. The scope is a factual and representative statement of the organization’s operations included within its OH&S management system boundaries that should not mislead interested parties.
A.4.4 OH&S management system
The organization retains the authority, accountability and autonomy to decide how it will fulfil the requirements of this document, including the level of detail and extent to which it:
a) establishes one or more processes to have confidence that they are controlled, carried out as planned and achieve the intended outcomes of the OH&S management system;
b) integrates requirements of the OH&S management system into its various business processes (e.g. design and development, procurement, human resources, sales and marketing).
If this document is implemented for a specific part(s) of an organization, the policies and processes developed by other parts of the organization can be used to meet the requirements of this document, provided that they are applicable to the specific part(s) that will be subject to them and that they conform to the requirements of this document. Examples include corporate OH&S policies, education, training and competency programmes, and procurement controls.

Section 5 Leadership and worker participation

5.1 Leadership and commitment
Leadership and commitment from the organization’s top management, including awareness, responsiveness, active support and feedback, are critical for the success of the OH&S management system and achievement of its intended outcomes; therefore, top management has specific responsibilities for which they need to be personally involved or which they need to direct.
A culture that supports an organization’s OH&S management system is largely determined by top management and is the product of individual and group values, attitudes, managerial practices, perceptions, competencies and patterns of activities that determine the commitment to, and the style and proficiency of, its OH&S management system. It is characterized by, but not limited to, active participation of workers, cooperation and communications founded on mutual trust, shared perceptions of the importance of the OH&S management system by active involvement in detection of OH&S opportunities and confidence in the effectiveness of preventive and protective measures. An important way top management demonstrates leadership is by encouraging workers to report incidents, hazards, risks and opportunities and by protecting workers against reprisals, such as the threat of dismissal or disciplinary action, when they do so.
5.2 OH&S policy
The OH&S policy is a set of principles stated as commitments in which top management outlines the long-term direction of the organization to support and continually improve its OH&S performance. The OH&S policy provides an overall sense of direction, as well as a framework for the organization to set its objectives and take actions to achieve the intended outcomes of the OH&S management system.
These commitments are then reflected in the processes an organization establishes to ensure a robust, credible and reliable OH&S management system (including addressing the specific requirements in this document).
The term “minimize” is used in relation to OH&S risks to set out the organization’s aspirations for its OH&S management system. The term “reduce” is used to describe the process to achieve this.
In developing its OH&S policy, an organization should consider its consistency and coordination with other policies.
5.3 Organizational roles, responsibilities and authorities
Those involved in the organization’s OH&S management system should have a clear understanding of their role, responsibility(ies) and authority(ies) for achieving the intended outcomes of the OH&S management system.
While top management has overall responsibility and authority for the OH&S management system, every person in the workplace needs to take account not only of their own health and safety, but also the health and safety of others.
Top management being accountable means being answerable for decisions and activities to the organization’s governing bodies, legal authorities and, more broadly, its interested parties. It means having ultimate responsibility and relates to the person who is held to account if something is not done, is not done properly, does not work or fails to achieve its objective.
Workers should be enabled to report about hazardous situations so that action can be taken. They should be able to report concerns to responsible authorities as required, without the threat of dismissal, disciplinary action or other such reprisals.
The specific roles and responsibilities identified in 5.3 may be assigned to an individual, shared by several individuals, or assigned to a member of top management.
5.4 Consultation and participation of workers
The consultation and participation of workers, and, where they exist, workers’ representatives, can be key factors of success for an OH&S management system and should be encouraged through the processes established by the organization.
Consultation implies a two-way communication involving dialogue and exchanges. Consultation involves the timely provision of the information necessary for workers, and, where they exist, workers’ representatives, to give informed feedback to be considered by the organization before making a decision.
Participation enables workers to contribute to decision-making processes on OH&S performance measures and proposed changes.
Feedback on the OH&S management system is dependent upon worker participation. The organization should ensure workers at all levels are encouraged to report hazardous situations, so that preventive measures can be put in place and corrective action taken.
The reception of suggestions will be more effective if workers do not fear the threat of dismissal, disciplinary action or other such reprisals when making them.

Section 6 Planning

A.6.1 Actions to address risks and opportunities
A.6.1.1 General
Planning is not a single event, but an ongoing process, anticipating changing circumstances and continually determining risks and opportunities, both for the workers and for the OH&S management system.
Undesired effects can include work-related injury and ill health, noncompliance with legal requirements and other requirements, or damage to reputation.
Planning considers the relationships and interactions between the activities and requirements for the management system as a whole.
OH&S opportunities address the identification of hazards, how they are communicated, and the analysis and mitigation of known hazards. Other opportunities address system improvement strategies.
Examples of opportunities to improve OH&S performance:
a) inspection and auditing functions;
b) job hazard analysis (job safety analysis) and task-related assessments;
c) improving OH&S performance by alleviating monotonous work or work at a potentially hazardous pre-determined work rate;
d) permit to work and other recognition and control methods;
e) incident or nonconformity investigations and corrective actions;
f) ergonomic and other injury prevention-related assessments.
Examples of other opportunities to improve OH&S performance:
— integrating occupational health and safety requirements at the earliest stage in the life cycle of facilities, equipment or process planning for facilities relocation, process re-design or replacement of machinery and plant;
— integrating occupational health and safety requirements at the earliest stage of planning for facilities relocation, process re-design or replacement of machinery and plant;
— using new technologies to improve OH&S performance;
— improving the occupational health and safety culture, such as by extending competence related to occupational health and safety beyond requirements or encouraging workers to report incidents in a timely manner;
— improving the visibility of top management’s support for the OH&S management system;
— enhancing the incident investigation process(es);
— improving the process(es) for worker consultation and participation;
— benchmarking, including consideration of both the organization’s own past performance and that of other organizations;
— collaborating in forums that focus on topics dealing with occupational health and safety.
6.1.2 Hazard identification and assessment of risks and opportunities A.6.1.2.1 Hazard identification
The ongoing proactive identification of hazard begins at the conceptual design stage of any new workplace, facility, product or organization. It should continue as the design is detailed and then comes into operation, as well as being ongoing during its full life cycle to reflect current, changing and future activities.
While this document does not address product safety (i.e. safety to end-users of products), hazards to workers occurring during manufacture, construction, assembly or testing of products should be considered.
Hazard identification helps the organization recognize and understand the hazards in the workplace and to workers, in order to assess, prioritize and eliminate hazards or reduce OH&S risks.
Hazards can be physical, chemical, biological, psychosocial, mechanical, electrical or based on movement and energy.
The list given in 6.1.2.1 is not exhaustive.
NOTE The numbering of the following list items a) to f) does not correspond exactly to the numbering of the
list items given in 6.1.2.1.
The organization’s hazard identification process(es) should consider:
a) routine and non-routine activities and situations:
1) routine activities and situations create hazards through day-to-day operations and normal work activities;
2) non-routine activities and situations are occasional or unplanned;
3) short-term or long-term activities can create different hazards;
b) human factors:
1) relate to human capabilities, limitations and other characteristics;
2) information should be applied to tools, machines, systems, activities and environment for safe, comfortable human use;
3) should address three aspects: the activity, the worker and the organization, and how these interact with and impact on occupational health and safety;
c) new or changed hazards:
1) can arise when work processes are deteriorated, modified, adapted or evolved as a result of familiarity or changing circumstances;
2) understanding how work is actually performed (e.g. observing and discussing hazards with workers) can identify if OH&S risks are increased or reduced;
d) potential emergency situations:
1) unplanned or unscheduled situations that require an immediate response (e.g. a machine catching fire in the workplace, or a natural disaster in the vicinity of the workplace or at another location where workers are performing work-related activities);
2) include situations such as civil unrest at a location at which workers are performing work- related activities which requires their urgent evacuation;
e) people:
1) those in the vicinity of the workplace who could be affected by the activities of the organization (e.g. passers-by, contractors or immediate neighbours);
2) workers at a location not under the direct control of the organization, such as mobile workers or workers who travel to perform work-related activities at another location (e.g. postal workers, bus drivers, service personnel travelling to and working at a customer’s site);
3) home-based workers, or those who work alone;
f) changes in knowledge of, and information about, hazards:
1) sources of knowledge, information and new understanding about hazards can include published literature, research and development, feedback from workers, and review of the organization’s own operational experience;
2) these sources can provide new information about the hazards and OH&S risks.
6.1.2 Hazard identification and assessment of risks and opportunities
6.1.2.1 Hazard identification
The ongoing proactive identification of hazard begins at the conceptual design stage of any new workplace, facility, product or organization. It should continue as the design is detailed and then comes into operation, as well as being ongoing during its full life cycle to reflect current, changing and future activities.
While this document does not address product safety (i.e. safety to end-users of products), hazards to workers occurring during manufacture, construction, assembly or testing of products should be considered.
Hazard identification helps the organization recognize and understand the hazards in the workplace and to workers, in order to assess, prioritize and eliminate hazards or reduce OH&S risks.
Hazards can be physical, chemical, biological, psychosocial, mechanical, electrical or based on movement and energy.
The list given in 6.1.2.1 is not exhaustive.
NOTE The numbering of the following list items a) to f) does not correspond exactly to the numbering of the
list items given in 6.1.2.1.
The organization’s hazard identification process(es) should consider:
a) routine and non-routine activities and situations:
1) routine activities and situations create hazards through day-to-day operations and normal work activities;
2) non-routine activities and situations are occasional or unplanned;
3) short-term or long-term activities can create different hazards;
b) human factors:
1) relate to human capabilities, limitations and other characteristics;
2) information should be applied to tools, machines, systems, activities and environment for safe, comfortable human use;
3) should address three aspects: the activity, the worker and the organization, and how these interact with and impact on occupational health and safety;
c) new or changed hazards:
1) can arise when work processes are deteriorated, modified, adapted or evolved as a result of familiarity or changing circumstances;
2) understanding how work is actually performed (e.g. observing and discussing hazards with workers) can identify if OH&S risks are increased or reduced;
d) potential emergency situations:
1) unplanned or unscheduled situations that require an immediate response (e.g. a machine catching fire in the workplace, or a natural disaster in the vicinity of the workplace or at another location where workers are performing work-related activities);
2) include situations such as civil unrest at a location at which workers are performing work- related activities which requires their urgent evacuation;
e) people:
1) those in the vicinity of the workplace who could be affected by the activities of the organization (e.g. passers-by, contractors or immediate neighbours);
2) workers at a location not under the direct control of the organization, such as mobile workers or workers who travel to perform work-related activities at another location (e.g. postal workers, bus drivers, service personnel travelling to and working at a customer’s site);
3) home-based workers, or those who work alone;
f) changes in knowledge of, and information about, hazards:
1) sources of knowledge, information and new understanding about hazards can include published literature, research and development, feedback from workers, and review of the organization’s own operational experience;
2) these sources can provide new information about the hazards and OH&S risks.
6.1.2.2 Assessment of OH&S risks and other risks to the OH&S management system
An organization can use different methods to assess OH&S risks as part of its overall strategy for addressing different hazards or activities. The method and complexity of assessment does not depend on the size of the organization, but on the hazards associated with the activities of the organization.
Other risks to the OH&S management system should also be assessed using appropriate methods.
Processes for the assessment of risk to the OH&S management system should consider day-to- day operations and decisions (e.g. peaks in work flow, restructuring) as well as external issues (e.g. economic change). Methodologies can include ongoing consultation of workers affected by day-to-day activities (e.g. changes in work load), monitoring and communication of new legal requirements and other requirements (e.g. regulatory reform, revisions to collective agreements regarding occupational health and safety), and ensuring resources meet existing and changing needs (e.g. training on, or procurement of, new improved equipment or supplies).
6.1.2.3 Assessment of OH&S opportunities and other opportunities for the OH&S management system
The process for assessment should consider the OH&S opportunities and other opportunities determined, their benefits and potential to improve OH&S performance.
6.1.3 Determination of legal requirements and other requirements
a) Legal requirements can include:
1) legislation (national, regional or international), including statutes and regulations
2) decrees and directives;
3) orders issued by regulators;
4) permits, licences or other forms of authorization;
5) judgments of courts or administrative tribunals;
6) treaties, conventions, protocols;
7) collective bargaining agreements.
b) Other requirements can include:
1) the organization’s requirements;
2) contractual conditions;
3) employment agreements;
4) agreements with interested parties;
5) agreements with health authorities;
6) non-regulatory standards, consensus standards and guidelines;
7) voluntary principles, codes of practice, technical specifications, charters;
8) public commitments of the organization or its parent organization.
6.1.4 Planning action
The actions planned should primarily be managed through the OH&S management system and should involve integration with other business processes, such as those established for the management of the environment, quality, business continuity, risk, financial or human resources. The implementation of the actions taken is expected to achieve the intended outcomes of the OH&S management system.
When the assessment of OH&S risks and other risks has identified the need for controls, the planning activity determines how these are implemented in operation (see Clause 8); for example, determining whether to incorporate these controls into work instructions or into actions to improve competence. Other controls can take the form of measuring or monitoring (see Clause 9).
Actions to address risks and opportunities should also be considered under the management of change (see 8.1.3) to ensure there are no resulting unintended consequences.
6.2 OH&S objectives and planning to achieve them
6.2.1 OH&S objectives
Objectives are established to maintain and improve OH&S performance. The objectives should be linked to risks and opportunities and performance criteria which the organization has identified as being necessary for the achievement of the intended outcomes of the OH&S management system.
OH&S objectives can be integrated with other business objectives and should be set at relevant functions and levels. Objectives can be strategic, tactical or operational:
a) strategic objectives can be set to improve the overall performance of the OH&S management system (e.g. to eliminate noise exposure);
b) tactical objectives can be set at facility, project or process level (e.g. to reduce noise at source);
c) operational objectives can be set at the activity level (e.g. the enclosure of individual machines to reduce noise).
The measurement of OH&S objectives can be qualitative or quantitative. Qualitative measures can be approximations, such as those obtained from surveys, interviews and observations. The organization is not required to establish OH&S objectives for every risk and opportunity it determines.
6.2.2 Planning to achieve OH&S objectives
The organization can plan to achieve objectives individually or collectively. Plans can be developed for multiple objectives where necessary.
The organization should examine the resources required (e.g. financial, human, equipment, infrastructure) to achieve its objectives.
When practicable, each objective should be associated with an indicator which can be strategic, tactical or operational.

Section 7 Support

7.1 Resources
Examples of resources include human, natural, infrastructure, technology and financial.
Examples of infrastructure include the organization’s buildings, plant, equipment, utilities, information technology and communications systems, and emergency containment systems.
7.2 Competence
The competence of workers should include the knowledge and skills needed to appropriately identify the hazards and deal with the OH&S risks associated with their work and workplace.
In determining the competence for each role, the organization should take into account things such as:
a) the education, training, qualification and experience necessary to undertake the role and the re- training necessary to maintain competence;
b) the work environment;
c) the preventive and control measures resulting from the risk assessment process(es);
d) the requirements applicable to the OH&S management system;
e) legal requirements and other requirements;
f) the OH&S policy;
g) the potential consequences of compliance and noncompliance, including the impact on the worker’s health and safety;
h) the value of participation of workers in the OH&S management system based on their knowledge and skill;
i) the duties and responsibilities associated with the roles;
j) individual capabilities, including experience, language skills, literacy and diversity;
k) the relevant updating of the competence made necessary by context or work changes.
Workers can assist the organization in determining the competence needed for roles.
Workers should have the necessary competence to remove themselves from situations of imminent and serious danger. For this purpose, it is important that workers are provided with sufficient training on hazards and risks associated with their work.
As appropriate, workers should receive the training required to enable them to carry out their representative functions for occupational health and safety effectively.
In many countries, it is a legal requirement to provide training at no cost to workers.
7.3 Awareness
In addition to workers (especially temporary workers), contractors, visitors and any other parties should be aware of the OH&S risks to which they are exposed.
7.4 Communication
The communication process(es) established by the organization should provide for the gathering, updating and dissemination of information. It should ensure that relevant information is provided, is received and is understandable to all relevant workers and interested parties.
7.5 Documented information
It is important to keep the complexity of the documented information at the minimum level possible to ensure effectiveness, efficiency and simplicity at the same time.
This should include documented information regarding planning to address legal requirements and other requirements and on evaluations of the effectiveness of these actions.
The actions described in 7.5.3 are particularly aimed at preventing unintended use of obsolete documented information.
Examples of confidential information include personal and medical information.

Section 8 Operation

8.1 Operational planning and control
8.1.1 General
Operational planning and control of the processes need to be established and implemented as necessary to enhance occupational health and safety, by eliminating hazards or, if not practicable, by reducing the OH&S risks to levels as low as reasonably practicable for operational areas and activities.
Examples of operational control of the processes include:
a) the use of procedures and systems of work;
b) ensuring the competence of workers;
c) establishing preventive or predictive maintenance and inspection programmes;
d) specifications for the procurement of goods and services;
e) application of legal requirements and other requirements, or manufacturers’ instructions for equipment;
f) engineering and administrative controls;
g) adapting work to workers; for example, by:
1) defining, or redefining, how the work is organized;
2) the induction of new workers;
3) defining, or redefining, processes and working environments;
4) using ergonomic approaches when designing new, or modifying, workplaces, equipment, etc.
8.1.2 Eliminating hazards and reducing OH&S risks
The hierarchy of controls is intended to provide a systematic approach to enhance occupational health and safety, eliminate hazards, and reduce or control OH&S risks. Each control is considered less effective than the one before it. It is usual to combine several controls in order to succeed in reducing the OH&S risks to a level that is as low as reasonably practicable.
The following examples are given to illustrate measures that can be implemented at each level.
a) Elimination: removing the hazard; stopping using hazardous chemicals; applying ergonomics approaches when planning new workplaces; eliminating monotonous work or work that causes negative stress; removing fork-lift trucks from an area.
b) Substitution: replacing the hazardous with less hazardous; changing to answering customer complaints with online guidance; combating OH&S risks at source; adapting to technical progress (e.g. replacing solvent-based paint by water-based paint; changing slippery floor material; lowering voltage requirements for equipment).
c) Engineering controls, reorganization of work, or both: isolating people from hazard; implementing collective protective measures (e.g. isolation, machine guarding, ventilation systems); addressing mechanical handling; reducing noise; protecting against falls from height by using guard rails; reorganizing work to avoid people working alone, unhealthy work hours and workload, or to prevent victimization.
d) Administrative controls including training: conducting periodic safety equipment inspections; conducting training to prevent bullying and harassment; managing health and safety coordination with subcontractors’ activities; conducting induction training; administrating forklift driving licences; providing instructions on how to report incidents, nonconformities and victimization without fear of retribution; changing the work patterns (e.g. shifts) of workers; managing a health or medical surveillance programme for workers who have been identified as at risk (e.g. related to hearing, hand-arm vibration, respiratory disorders, skin disorders or exposure); giving appropriate instructions to workers (e.g. entry control processes).
e) Personal protective equipment (PPE): providing adequate PPE, including clothing and instructions for PPE utilization and maintenance (e.g. safety shoes, safety glasses, hearing protection, gloves).
8.1.3 Management of change
The objective of a management of change process is to enhance occupational health and safety at work, by minimizing the introduction of new hazards and OH&S risks into the work environment as changes occur (e.g. with technology, equipment, facilities, work practices and procedures, design specifications, raw materials, staffing, standards or regulations). Depending on the nature of an expected change, the organization can use an appropriate methodology(ies) (e.g. design review) for assessing the OH&S risks and the OH&S opportunities of the change. The need to manage change can be an outcome of planning (see 6.1.4).
8.1.4 Procurement
8.1.4.1 General
The procurement process(es) should be used to determine, assess and eliminate hazards, and to reduce OH&S risks associated with, for example, products, hazardous materials or substances, raw materials, equipment, or services before their introduction into the workplace.
The organization’s procurement process(es) should address requirements including, for example, supplies, equipment, raw materials, and other goods and related services purchased by the organization
to conform to the organization’s OH&S management system. The process should also address any needs for consultation (see 5.4) and communication (see 7.4).
The organization should verify that equipment, installations and materials are safe for use by workers by ensuring:
a) equipment is delivered according to specification and is tested to ensure it works as intended;
b) installations are commissioned to ensure they function as designed;
c) materials are delivered according to their specifications;
d) any usage requirements, precautions or other protective measures are communicated and made available.
8.1.4.2 Contractors
The need for coordination recognizes that some contractors (i.e. external providers) possess specialized knowledge, skills, methods and means.
Examples of contractor activities and operations include maintenance, construction, operations, security, cleaning and a number of other functions. Contractors can also include consultants or specialists in administrative, accounting and other functions. Assignment of activities to contractors does not eliminate the organization’s responsibility for the occupational health and safety of workers.
An organization can achieve coordination of its contractors’ activities through the use of contracts that clearly define the responsibilities of the parties involved. An organization can use a variety of tools for ensuring contractors’ OH&S performance in the workplace (e.g. contract award mechanisms or pre- qualification criteria which consider past health and safety performance, safety training, or health and safety capabilities, as well as direct contract requirements).
When coordinating with contractors, the organization should give consideration to the reporting of hazards between itself and its contractors, controlling worker access to hazardous areas, and procedures to follow in emergencies. The organization should specify how the contractor will coordinate its activities with the organization’s own OH&S management system processes (e.g. those used for controlling entry, for confined space entry, exposure assessment and process safety management) and for the reporting of incidents.
The organization should verify that contractors are capable of performing their tasks before being allowed to proceed with their work; for example, by verifying that:
a) OH&S performance records are satisfactory;
b) qualification, experience and competence criteria for workers are specified and have been met (e.g. through training);
c) resources, equipment and work preparations are adequate and ready for the work to proceed.
8.1.4.3 Outsourcing
When outsourcing, the organization needs to have control of the outsourced functions and process(es) to achieve the intended outcome(s) of the OH&S management system. In the outsourced functions and process(es), the responsibility for conforming to the requirements of this document is retained by the organization.
The organization should establish the extent of control over outsourced function(s) or process(es) based upon factors such as:
— the ability of the external organization to meet the organization’s OH&S management system requirements;
— the technical competence of the organization to define appropriate controls or assess the adequacy of controls;
— the potential effect the outsourced process or function will have on the organization’s ability to achieve the intended outcome of its OH&S management system;
— the extent to which the outsourced process or function is shared;
— the capability of the organization to achieve the necessary control through the application of its procurement process;
— opportunities for improvement.
In some countries, legal requirements address outsourced functions or processes.
8.2 Emergency preparedness and response
Emergency preparedness plans can include natural, technical and man-made events that occur inside and outside normal working hours.

Section 9 Performance evaluation

9.1 Monitoring, measurement, analysis and performance evaluation
9.1.1 General
In order to achieve the intended outcomes of the OH&S management system, the processes should be monitored, measured and analysed.
a) Examples of what could be monitored and measured can include, but are not limited to:
1) occupational health complaints, health of workers (through surveillance) and work environment;
2) work-related incidents, injuries and ill health, and complaints, including trends;
3) the effectiveness of operational controls and emergency exercises, or the need to modify or introduce new controls;
4) competence.
b) Examples of what could be monitored and measured to evaluate the fulfilment of legal requirements can include, but are not limited to:
1) identified legal requirements (e.g. whether all legal requirements have been determined, and whether the organization’s documented information of them is kept up-to-date);
2) collective agreements (when legally binding);
3) the status of identified gaps in compliance.
c) Examples of what could be monitored and measured to evaluate the fulfilment of other requirements can include, but are not limited to:
1) collective agreements (when not legally binding);
2) standards and codes;
3) corporate and other policies, rules and regulations;
4) insurance requirements.
d) Criteria are what the organization can use to compare its performance against.
1) Examples are benchmarks against:
i. other organizations;
ii. standards and codes;
iii. the organization’s own codes and objectives;
iv. OH&S statistics.
2) To measure criteria, indicators are typically used; for example:
i. if the criterion is a comparison of incidents, the organization may choose to look at frequency, type, severity or number of incidents; then the indicator could be the determined rate within each one of these criteria;
ii. ii) if the criterion is a comparison of completions of corrective actions, then the indicator could be the percentage completed on time.
Monitoring can involve continual checking, supervising, critically observing or determining the status in order to identify change from the performance level required or expected. Monitoring can be applied to the OH&S management system, to processes or to controls. Examples include the use of interviews, reviews of documented information and observations of work being performed.
Measurement generally involves the assignment of numbers to objects or events. It is the basis for quantitative data and is generally associated with the performance evaluation of safety programmes and health surveillance. Examples include the use of calibrated or verified equipment to measure exposure to a hazardous substance or the calculation of the safe distance from a hazard.
Analysis is the process of examining data to reveal relationships, patterns and trends. This can mean the use of statistical operations, including information from other similar organizations, to help draw conclusions from the data. This process is most often associated with measurement activities.
Performance evaluation is an activity undertaken to determine the suitability, adequacy and effectiveness of the subject matter to achieve the established objectives of the OH&S management system.
9.1.2 Evaluation of compliance
The frequency and timing of compliance evaluations can vary depending on the importance of the requirement, variations in operating conditions, changes in legal requirements and other requirements and the organization’s past performance. An organization can use a variety of methods to maintain its knowledge and understanding of its compliance status.
9.2 Internal audit
The extent of the audit programme should be based on the complexity and level of maturity of the OH&S management system.
An organization can establish objectivity and impartiality of the internal audit by creating a process(es) that separates auditors’ roles as internal auditors from their normal assigned duties, or the organization can also use external people for this function.
9.3 Management review
The terms used in relation to management review should be understood as follows:
a) “suitability” refers to how the OH&S management system fits the organization, its operation, its culture and business systems;
b) “adequacy” refers to whether the OH&S management system is implemented appropriately;
c) “effectiveness” refers to whether the OH&S management system is achieving the intended outcome.
The management review topics listed in 9.3 a) to g) need not be addressed all at once; the organization should determine when and how the management review topics are addressed.

Section 10 Improvement

10.1 General
The organization should consider the results from analysis and evaluation of OH&S performance, evaluation of compliance, internal audits and management review when taking action to improve.
Examples of improvement include corrective action, continual improvement, breakthrough change, innovation and re-organization.
10.2 Incident, nonconformity and corrective action
Separate processes may exist for incident investigations and nonconformities reviews, or these may be combined as a single process, depending on the organization’s requirements.
Examples of incidents, nonconformities and corrective actions can include, but are not limited to:
a) incidents: same level fall with or without injury; broken leg; asbestosis; hearing loss; damage to buildings or vehicles where they can lead to OH&S risks;
b) nonconformities: protective equipment not functioning properly; failure to fulfil legal requirements and other requirements; prescribed procedures not being followed;
c) corrective actions (as indicated by the hierarchy of controls; see 8.1.2): eliminating hazards; substituting with less hazardous materials; redesigning or modifying equipment or tools; developing procedures; improving the competence of affected workers; changing the frequency of use; using personal protective equipment.
Root cause analysis refers to the practice of exploring all the possible factors associated with an incident or nonconformity by asking what happened, how it happened and why it happened, to provide the input for what can be done to prevent it from happening again.
When determining the root cause of an incident or nonconformity, the organization should use methods appropriate to the nature of the incident or nonconformity being analysed. The focus of root cause analysis is prevention. This analysis can identify multiple contributory failures, including factors related to communication, competence, fatigue, equipment or procedures.
Reviewing the effectiveness of corrective actions [see 10.2 f)] refers to the extent to which the implemented corrective actions adequately control the root cause(s).
10.3 Continual improvement
Examples of continual improvement issues include, but are not limited to:
a) new technology;
b) good practices, both internal and external to the organization;
c) suggestions and recommendations from interested parties;
d) new knowledge and understanding of occupational health and safety-related issues;
e) new or improved materials;
f) changes in worker capabilities or competence;
g) achieving improved performance with fewer resources (i.e. simplification, streamlining, etc.).

Audit Limitations and Documents Reviewed

Audit Limitations

Under the terms of the Auditor’s engagement the Auditor has examined the status of the Client’s Work Health and Safety Management System. The Auditor has relied on information and documents provided by the Client. The Auditor expresses no opinion as to the accuracy, truth, sufficiency, or legality of the information provided by the Client in respect of the Client’s quality, environmental and health and safety standards.
This Report has been prepared in accordance with generally accepted practices (including the standards set out in ISO 45001:2018 International Standard Occupational Health and Safety Management Systems using standards of care and diligence normally practiced by recognised consulting firms performing services of a similar nature.
It is a condition of the provision of this Report that any liability of the Auditor to the Client for anything contained or stated herein shall be limited to the amount of the fee actually paid or payable by the Client to the Auditor for this Report. It is a further condition of the provision of this Report that any liability of the Auditor to the Client for anything contained or stated in the Report to the fullest extent permitted by law is hereby excluded unless the claim giving rise to such liability is made in writing to the Auditor within twelve (12) months of the date of this Report.
This Report is issued with the understanding that it is the responsibility of the Client, to ensure that the information contained herein is brought to the attention of the appropriate regulatory agencies, where required by law.
Neither the Auditor nor any member associate or employee of the Auditor undertakes any responsibility for any injury, loss or damage claimed by the Client arising out of a claim by any third party against the Client regarding this Report.

Documents Reviewed

Reference is made throughout the report to WHS documents that were provided to XYZ by XYZ for the purpose of conducting the ISO 45001 compliance review.

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Audit details

Summary of findings

Audit Objective and Methodology

Improvement Opportunities

4.0 Context of the organisation

4.1 Understanding the organisation and its context

4.2 Understanding the need and expectation of workers and other interested parties

4.3 Determine the scope of the WHS management system

4.4 WHS management system

5.0 Leadership and worker participation

5.1 Leadership and commitment

5.2 OHS policy

5.3 Organisational roles, responsibilities and authorities

5.4 Consultation and participation of workers

6.0 Planning

6.1 Actions to address risk and opportunities

6.1.1 General

6.1.2 Hazard Identification and assessment of risks and opportunities

6.1.2.1 Hazard identification

6.1.2.2 Assessment of WH&S risks and other risks to the WH&S management system

6.1.2.3 Assessment of WH&S opportunities and other opportunities for the WH&S management system

6.1.3 Determination of legal requirements and other requirements

6.1.4 Planning action

6.2 WHS objectives and planning to achieve them

6.2.1 WHS objectives

6.2.2 Planning actions to achieve WHS objectives

7.0 Support

7.1 Resources

7.2 Competence

7.3 Awareness

7.4 Communication

7.4.1 General

7.4.2 Internal communication

7.4.3 External communication

7.5 Documented information

7.5.1 General

7.5.2 Creating and updating

7.5.3 Control of documented information

8.0 Operation

8.1 Operational planning and control

8.1.1 General

8.1.2 Eliminating hazards and reducing WHS risks

8.1.3 Management of change

8.1.4 Procurement

8.1.4.1 General

8.1.4.2 Contractors

8.1.4.3 Outsourcing

8.2 Emergency preparedness and response

9.0 Performance evaluation

9.1 Monitoring, measure, analysis and performance evaluation

9.1.1 General

9.1.2 Evaluation of compliance

9.2 Internal audit

9.2.1 General

9.2.2 Internal audit programme

9.3 Management review

10.0 Improvement

10.1 General

10.2 Incident, Nonconformity and corrective action

10.3 Continual improvement

Auditor sign off

Section 4 Context of the organization

Section 5 Leadership and worker participation

Section 6 Planning

Section 7 Support

Section 8 Operation

Section 9 Performance evaluation

Section 10 Improvement

Audit Limitations

Documents Reviewed

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