NCC Internal Audit - duplicate

Title Page

Document No.
Audit Title
Client / Site
Conducted on
Prepared by
Location
Personnel

Planning & Support

Is the employer commitment policy displayed in all buildings and reviewed annually, dated and signed by the CE?
Has the 3 forums viewed, agreed and then taken by reps to discuss at their H&S meetings and verified by the agenda sign off sheet?
Ask to see a copy of the agenda sign-off sheets for the H&S meeting. Employee attendance at these sessions must be verified by each employee's signature, otherwise the auditor must score the question NO.
Does the NCC and departments have a written current fiscal year budget which includes moneys for safety expenses (equipment, training, air monitoring services, etc.)?
The annual NCC or department budget must include safety expenses as specific line items (e.g., equipment, training, air monitoring services). Safety is not to be included as part of a general or other budget item.
Are health and safety responsibilities, clearly defined at all levels with a written job description and written performance appraisal (all levels means management, supervisory, employees)?
Ask to see samples of written job descriptions for each level.
Safety responsibilities are to be clearly defined at all levels in the NCC - management, supervisory, employees. This includes a written job description that specifically includes safety, and written performance appraisals. NCC expects safety is to receive a suitable weighting in any appraisal - typically 20 - 30%?
Does the reporting procedure encourage employees to report near miss incidents or effectively any safety issue or concern?
Verify this by reviewing the procedure and inspecting a sample of the forms with feedback.
The NCC must develop a written procedure for employee input on safety issues/concerns. This must include a requirement for a written response from the NCC or department management.
Does the reporting of a near-miss require the same consideration for investigation, corrective action and feedback as any safety incident?
All incidents should be investigated to determine root causes and have corrective actions considered. If incidents and corrective actions require prioritising then this should be based on potential consequence or a risk assessment. The seriousness of an injury should not determine the amount of effort put into investigation and prevention.
Does the incident investigation process focus on identifying root causes and system failures rather than individual actions and errors?
Decision trees and root cause analysis tools should be used to first determine factors that would lead to any employee taking the same action. It is the responsibility of management to first determine that factors under its control are adequate, like documentation, risk analysis, instruction, training and supervision.
Does NCC have a written criteria for choosing safety representatives for each department safety committee (S.C)?
Examples of written criteria can include, but are not limited to, the following:
- Annual rotation of S.C. chairperson
- At least 1 representative from each dept.
- Cannot serve (at the same time) on any other committees.
- Has not had a recordable injury/illness in the past year.
- Will serve as a liaison between department management and employees.
- Able to lead if needed.
- Able to communicate both verbally and written.
- Knowledge of their department.
- Able to work in a team setting.
- Should be respected by their peers.

Safety representatives for the hourly employees are not to be selected by management.
Does the NCC safety committees review accident investigation reports and also analyse the injury data for trends?
Ask to see copies of safety committee minutes and trend analyses.
The Safety committee should review all accident investigation reports and also analyse the injury data for trends, or review trend analyses prepared by others.
Do safety committee members have an allotted time per week/month to attend safety committee meetings and time to work on assigned projects related to safety?
Confirm safety committee attendance with the safety committee meeting minutes for the past consecutive 6 meetings.
Safety committee meetings must be held on a regular, scheduled basis. Members must be allowed time to attend the meetings and to work on any safety committee projects related to safety.

Expectations & Involvement

Does the Health and Safety committee keep detailed records of every meeting?
Ask for a copy of the minutes from the past 6 meetings.

The Safety committee must keep detailed records of every meeting. This should include:
- attendance (preferably signed by each attendee)
- items discussed
- records reviewed
- any action points
- who any actions were assigned to, and
- expected delivery date(s) for all action items.
Does the Health and Safety committee include management, team leaders, employees (at least one from each department) and union representatives?
Ask to see documentation which identifies all Safety Committee members by name and department.
The safety committee must include management, team leaders, at least one employee from each department and union representation. Attendee lists should identify the affiliation.
Does the Health and Safety committee discuss changes in OHS regulations, potential new hazards, and track progress of the NCC Safety Process?
The safety committee meeting minutes should reflect the following 3 issues every month:
1. changes/proposed changes in OHS regulations;
2. any activity concerning the NCC Safety Process; and
3. new or potential hazards in departments

Results from this meeting should form part of the feedback to employees at the next department safety meeting.
Is the Health and Safety committee formally evaluated for their effectiveness using documented critiques or questionnaire?
Ask to see completed evaluation forms for the past two years.

Evaluations must be completed by all NCC employees.

The safety committees should be formally evaluated for its effectiveness. This can include documented critiques or employee questionnaires. Where specific deficiencies are identified, the NCC management is to work with the committee to improve its effectiveness.
Does the NCC Health and Safety Lead approve and sign-off on all capital requisitions, purchase orders, and technical bids?
For a full score there needs to be a formal documented management of change process in use at NCC that covers all of the listed examples.

The health and safety lead must approve and sign-off wherever there is a potential safety concern. This includes all new materials (e.g., chemicals), all capital requisitions, all purchase orders involving new materials or equipment, and technical bids. Where the health and safety lead does not sign off on these items, the SLT manager is responsible and accountable for all safety related deficiencies.
On-going purchases of chemicals, PPE, etc. can be made by others from an approved list for specific purposes. The health and safety leads signature does not need to be on every purchase order.
Are all employees in all departments required to attend regular safety meetings?
Verify attendance by reviewing the sign-off sheets for the past 6 months. All means all:
- permanent
- temps
- seasonal
- salaried
- hourly

Every permanent, seasonal, temps, salaried and hourly employee in NCC must attend a monthly safety meeting. This includes office staff. The attendance must be verified by a signoff sheet. Each department manager is accountable for ensuring the meetings are held, and this is to be reflected in each manager's job description.

Departments are required to hold monthly safety meetings with set health and safety agenda items (see note 1). All employees in the department are expected to attend. To verify this requirement, the auditor will look for at least 80% attendance of all staff in the department for any one meeting. Also, all permanent employees must have attended at least 10 out of 12 meetings over a one year period. If employees can not attend for genuine reasons this should be noted on the attendance sheet and a system for individual follow-up and sign-off should be used to meet the above attendance requirements. An attendance sign-off sheet pre-printed with permanent employee names should be used to help track attendance.

Note 1. Fixed agenda items for safety meetings. These items should be permanently on the meeting agenda and minutes:
1. Injury Data
Feedback to employees from the review of injury data analysis from the last business unit safety committee meeting.
2. Incident Investigation Reports and Corrective Actions
Feedback to employees on all incidents and corresponding corrective actions that have occurred within the department over the past month
3. Any Potential New Hazards in the Workplace or Changes in Regulations
Informing employees of any changes to existing equipment and processes, upcoming installation of new equipment, or other changes that may affect them.
4. Issues/Concerns
Employees should be given the opportunity to raise any issues or concerns and have these responded to immediately by management and recorded in the minutes or an incident form initiated for further investigation.
Is the department manager a participant in monthly safety meetings and is this verified with his/her signature?
Review the sign-off sheets for the past 6 months.

NCC requires managers to lead by example. Accordingly, the department manager must participate in the monthly safety meetings and this must be verified with his/her signature. The requirement should be included in the manager's job description. In order to receive full credit the SLT's must attend one safety meeting per month. This does not refer to safety committee meetings.
Does an employee in the department, chosen at random, know when the last safety meeting was held, and does he/she know the topics discussed?
Are relevant Health and Safety regulations and standards easily accessible to all levels of plant employees in a location known to all employees?
Employees are to be advised on an annual basis with a sign off that they have been advised where they can access the relevant statutory health and safety requirements and NCC safety standards. These must be easily accessible to all levels of employees in the known location.

The H&S department will maintain a library that contains relevant regulations, standards, periodicals and other information. This will include processes and subscriptions to stay abreast of changes to regulations and regulatory and other requirements.
The department is required to inform all employees on an annual basis of the availability of this information and how to access it. This should be scheduled as a department safety meeting.
Has NCC designated a Safety and Health manager?
A full or part time safety manager who is lacking a written job description and written performance appraisal shall be scored a 3.

Every factory must designate a health and safety manager. For small factories, it is acceptable that the individual have other related duties (e.g., line manager with overall charge of the safety process).

At larger factories the individual should be responsible only for the safety process; although, a combined safety - environment role may be acceptable.

When auditing by department use the same score as for the whole plant.
Is the safety manager actively participating in a NCC educational forum and attends an annual local professional development event?
NCC requires Safety Managers to actively participate in and also undertake professional development by attending local seminars, conferences, workshops or other training events at least annually.

When auditing by department use the same score as for the whole NCC.
Has the overall safety performance of NCC been tied into the business plan for the current fiscal year?
Ask to see the business plan.

At NCC, safety is an integral part of our business, and health and safety performance is to be an integral part of the NCC business plan.
Has the department established written safety goals by prioritising it’s top five safety issues and risks and developing specific actions and metrics?
Review the written department safety goals.

These need to measure success at improving the safety risks identified in the department. They should not only be reactive measures like a reduction in incident rates, but rather measure proactive or preventative initiatives like improving conditions, changing behaviours, training, safety meeting attendance, increasing near-miss reporting, etc.
Did both the department manager and hourly employees participate in developing departmental safety goals and sign-off on the final copy of the goals?
Review the department goals.

A minimum requirement for hourly employee participation would be development of the departmental goals by a departmental safety committee that includes employee representatives.
Other methods of employee involvement include an employee focus group or a facilitated discussion at a department safety meeting.
Are department goals posted in the department?
See the department safety notice board.

Ergonomics

Does this NCC/business unit have a written ergonomic plan that includes the following: (Refer to Guidance)
Establishes an ergonomic team to develop and implement site-specific goals, objectives, priorities and strategies to reduce or eliminate ergonomic hazards.

Allocates appropriate resources and appointment of responsible persons to implement the recommendations of the ergonomic team.

Implements a hazard recognition, evaluation, and control process to identify and evaluate the ergonomic issues and to execute the necessary prevention/control measures.

Implements a proactive prevention process which encourages early reporting of ergonomic issues and requires ergonomically correct designs for new and modified tools, machinery, equipment, processes, or facilities.

Implements a medical management process which incorporates the principles of early recognition, complying with doctor recommended work restrictions, active surveillance/reporting, and timely treatment.

Develops and Implements an ergonomic training program to ensure all employees understand the hazards, preventative measures, how to report signs and symptoms, and the potential medical consequences associated with their job.

Provides for periodic review of the entire ergonomic process to ensure its success and to identify opportunities for improvement.
Does the NCC/business unit’s ergonomic team include the managers, team leaders and employees?
The structure and function of the ergonomic team needs to fit with the facilities management structure, process maturity and local requirements. Four examples of an acceptable structure are as follows. The main point being that all of the ergonomic requirements are covered but may be balanced between different groups:

1. A simple interpretation of the question with a specific team assembled for the purpose of fulfilling all of the requirements of the ergonomics section.

2. A steering committee or administration team run by the health and safety department that includes ergonomics on a monthly meeting agenda. The purpose of this team is to coordinate all ergonomics activities, measure and track progress, and provide expertise. The team may not include team leaders or employee representation but will initiate separate work teams with appropriate engineering, supervisory, employee and operator involvement as needed. The purpose of a work teams is to investigate a specific ergonomics issue, review new process/equipment design and installation, and recommend prevention/control measures.

3. Many facilities find it efficient to utilise the existing Safety Committee as the steering committee for ergonomics by adding it to their monthly meeting agenda. A fully functioning safety committee also included employee representation. Similarly to 2. above, this steering committee will initiate specific work teams as required.

4. For larger areas/departments, some of the functions of the ergonomics committee should be pushed further down to departmental safety meetings. The health and safety department still provides coordination across the sites but the departmental team is more central to the process and pulls in expertise from health and safety and engineering for specific projects. This works well were the area/department is structured around work centre management or self-directing work teams.

The written ergonomics plan will define the structure and how the requirements are fulfilled.
Has the ergonomic team defined goals, meet on a regular basis, and keep minutes of the meetings?
The oversite committee or administration team must have clear goals and objectives for the ergonomics program. Regular meetings keep the program active and can review strategy and assign priorities to actions and activities needed to achieve the objectives.
Does the ergonomic team perform the following? - Direct worksite data collection and site ergonomic analyses for existing issues and new process/equipment projects; - Review and interpreting analyses results; - Identify training requirements and training schedules; - Establish documentation procedures to track progress; - Develop/review ergonomic suggestions/recommendations; - Share solutions with other NCC locations; - Audit program effectiveness
* Direct worksite data collection and site ergonomic analyses for existing issues and new process/equipment projects;
* Review and interpreting analyses results;
* Identify training requirements and training schedules;
* Establish documentation procedures to track progress;
* Develop/review ergonomic suggestions/recommendations;
* Share solutions with other NCC locations;
* Audit program effectiveness
Has the responsibility and function of the ergonomics team been expanded to include Design for Safe Behaviour?
Design for Safe Behaviour may also be referred to as Human Error, Error Proofing or Mistake Proofing. It is the use of physical layout, design or automatic systems that either makes it impossible for a human error to occur or makes an error immediately obvious. The right design and layout of equipment should make the desired safe behaviour easier to perform than an unsafe behaviour, reducing motivation to take short-cuts and reducing the risk of error during upset conditions.
A simple example is always having a standardised design and operation of switches and controls, especially for use in emergencies. If lock-out is regularly required then the isolation point and lock-out equipment should be conveniently positioned to the task at hand.
Do employees actively participate in reviewing the design of their own work areas for safe behaviour?
Employees should be involved in work teams assigned to assess specific tasks or work areas and encouraged to report design issues or ideas that can reinforce safe behaviour and reduce errors.
Is a consistent procedure and standard form used to analyse and report ergonomic assessments and investigations?
Have employees received ergonomic training as follows: Ergonomic awareness for management and employees, and Job specific training for employees performing tasks with high risk factors
Has the employee ergonomic training been expanded to include Design for Safe Behaviour analysis?
Ergonomic BOS
Is a review of workplace design included in incident investigations?
A review of ergonomic factors should be automatic for all sprain, strain or musculoskeletal related injuries. However, workplace design should be considered in all incident investigations as a possible factor that can contribute to errors. For example, if lock-out was required but not used then where is the lock-out point located, how accessible is it and how difficult or time-consuming is the lock-out procedure relative to the task.
Have incident investigations identified and corrected system failures that lead to errors or unsafe behaviours?
Have employees involved in incident investigations been trained to identify design factors that lead to errors or unsafe behaviours?
In the design phase of new equipment/processes has ergonomics been thoroughly addressed?
Review "New Equipment Review Policy", and Ergonomics implementation policy.
In the design phase of new equipment/processes has Design for Safe Behaviour been thoroughly addressed?

Standards Implementation

Emergency Evacuation

At a minimum, does the employee emergency and fire prevention plan meet local regulated requirements and include the following: (Refer to Guidance)
1. Emergency Escape Procedures and Routes for each type of emergency.
3. Employee Accountability Procedures After Evacuations.
4. Rescue and Medical Duties.
5. Preferred Means of Reporting Fire and Emergencies.
6. Emergency and Fire Protection Coordinator.
7. Alarm Systems.
8. Fire Protection and Prevention Assignments.
9. Training.
10. Workplace Fire Hazards.
11. Post emergency evacuation routes (primary and secondary) throughout each department.
12. Public relations (dealing with outside agencies)

The emergency evacuation procedures need to include as a minimum:
- Identification on a site plan of the evacuation assembly points
- Clear allocation of people to assembly points
- A register of all people on site at any time, including visitors and contractors
- Identification of designated people who will check evacuees against the register
- Designated person who will contact the emergency services
Does all organisational areas/departments have an approved alarm system, which is fully operable at all times?
Verify that an alarm system is in place that indicates when site evacuation will proceed. The system must comply with relevant local and regional standards and be audible and / or visible to everyone on site immediately it is activated.
Are all fire alarm systems in this areas/department regularly tested and documented as follows: - To meet any local regulatory requirements - Regular audible or visual tests - An annual evacuation drill
The system testing, inspection and maintenance must comply with relevant local and regional standards.
Verify that the alarm is tested at set regular intervals as required by local regulation and the results documented.
Verify that training in the evacuation procedure is given and tested by holding a full evacuation at least every 6 months. This must be documented, improvement actions identified and resource allocated.
Are all exits in this areas/department free from obstructions at all times with no locks or fasteners to prevent escape in the event of an emergency?
Walk through the areas/departments and look at all exit doors.
Are all emergency exits doors in the area/department marked with exit signs and the pathways to those exits identified in a manner that is understandable to all employees?
Verify that all escape routes and emergency door exits are identified with signs.

Signs must be in the language dictated by the local building code (i.e. English, Spanish, French), the next most prominent language present in the workforce, and in pictograms.

The auditor should ensure that an exit, or path to an exit, is identifiable even in remote areas of the department.
Are doorways that can mistakenly be considered an exit or a way to reach an exit, marked or arranged so as not to confuse it with an exit?
All doors should be marked so that their purpose is recognisable (I.e. "storage", "conference room", etc.).
Is every department equipped with adequate reliable artificial illumination and are all exits reliably illuminated?
Inspection tags attached to the emergency lights will help the auditor identify how often inspections are completed. The auditor should also test some of the lights during the inspection to confirm their power supply.

Verify that emergency lighting is installed along all escape routes.
Do all exits in the area/department discharge directly to the street, or to a yard, court, or other open space that gives access to a public way?

HSNO

Is there a inventory of Hazardous Substances on the site, and does NCC have a copy?
Is there a site plan showing where HSNO items are stored on the site, and does NCC have a copy?
Is there a hazardous zones map on the site and does NCC have a copy?
Does NCC and the department have a list of approved handlers?
Does NCC and the department have a copy of electrical certificates?
Does NCC and the site have a copy of the location test certificates? (where required)
Does NCC and the site have a copy of the stationary tank certificate/s (where required)
Are SDS's (safety data sheets) available within 10 minutess of use of chemical?
Do all SDS's have a New Zealand suppler and emergency contact phone number?
Are all SDS's less than 5 years old.

Permit to Work

Has the department/area implemented a permit to work system for all non-routine tasks and work performed in locations not designed for standard work occupancy?
Permit to work systems are required under the following circumstances:

1. Work that introduces new hazards that are not normally present in the location that may require specific management and control. For example:
- Hot Work
- Contract or project work that introduces specific equipment, chemicals or other hazards into the work location.

2. Work performed in locations not designed for standard workplace occupancy. For example:
- Confined Space entry
- Large equipment access or entry
- Work at Height
- Ceiling spaces or crawl-ways
- Roof work
- Temperature extremes

3. Any non-routine task that involves workplace hazards that does not have documented JSA's/Risk Assessments and Safe Practices/Safe Systems of Work.
Have all hazards identified during permit to work activities been identified and control measures implemented prior to work commencing?
As a minimum sites should have specific procedures and forms for the following types of permit to work.
- Hot work
- Confined Space entry
- Work at Height
- Any other category of permit to work performed regularly or routinely

In addition to the specific procedures, a more generic risk assessment procedure is also required to be used for any other non-routine situation that may occur.
Does the manager or team leader sign-off all permit to work activities occurring within their department before work commences?
Managers and team leaders are responsible for any new hazards introduced into the department that may have an adverse effect on their employees. They cannot instruct their own employees to perform work that exposes them to hazards without adequate controls and procedures, or that an employee is not trained or competent to perform safely. They also need to coordinate work activities in the department to avoid conflicts, disruption or upset conditions.
Have all managers, team leaders and employees required to sign-off or approve permit to work activities been trained?
The training must be appropriate for the specific activity and the level of responsibility. The training also needs to include evidence of competency.

Contractors

Has the area/department implemented a contractor safety program that includes the following elements? - Induction into existing site rules and regulations - Communication regarding risks and hazards - Review of emergency response procedures - Other requirements as detailed in the Guidance
* Induction into existing site rules and regulations, with formal records of induction maintained.
for example - Contractors to comply with NCC safety rules
* Review of "Contractor Safety Expectation" program with contractor
* Communication regarding the exchange of risks associated with the contractors work and
those risks associated with the site activities prior to any work activity.
for example - Provide plant specific MSDS, Hot work/confined space permits
* Require contractor to provide NCC with MSDS, incident reports
and any information concerning hazards introduced by the contractor
* The provision of definitive method statements and risk assessments, which
identify how they intend to carry out their activities and the significant risks.
* Review plant specific EAP (emergency action plan) with contractors (documented)
including - A method of assuring contractor presence on site
* entry and exit location to the site
* a record of time on and off site
* named site person responsible for contractor on site
* Review permitted/prohibited access to NCC equipment or other restrictions.
* Maintain a separate injury/illness log for contractor's employees.
* Contractors selected partially based on past safety performance record
* Provide contractor with layouts and utility locations, upon request.
* Job site inspections of contractors
* Documentation that contractor has reviewed "Contractor Safety Expectation" program with their employees.
Is a register of approved contractors maintained? The approval criteria must be defined and documented.
Do contractors provide evidence of their competency to perform specified work? The criteria to ensure competency must be defined and documented to include as a minimum: - Competence of personnel (for example evidence of training or certifications)
Is the safety performance of contractors actively monitored or audited during the contract, including an inspection of specified physical controls?
Employers need to verify that the health and safety performance of contractors is actively monitored at agreed regular intervals for the duration of the contact. This can be demonstrated by minutes of meetings, site-inspection reports, check lists or similar.
There must also be a process to implement corrective actions identified during the inspections or monitoring.

Legal and Other Requirements

Do you have a process to identify and have knowledge of applicable legal/regulatory and other requirements?
Are legal/regulatory and other requirements documented?
Do you have a process in place to verify they you are in compliance with applicable legal/regulatory and other requirements?

House Keeping

Does the department have a documented monthly Safety Inspection program that includes the following elements: (Refer to Guidance)
- Machine guards (monthly)
- Lifting/pulling devices (i.e. hoists, chain falls, etc.) (quarterly)
- Slings and rigging equipment (annual)
- Electrical power equipment cords and extensions (quarterly)
- Ladders (quarterly and tagged)
- Emergency lighting (quarterly and tagged)
- PPE (monthly)
- Hand tools (quarterly)
- Welding/burning equipment (monthly)
- Fire extinguishers (monthly and tagged)
- Storage racks (every 6 months)
- Evacuation alarms/procedures (every 6 months)
- Drinking fountains (every 6 months)
- Gas cylinders storage (monthly)
- Bench grinders (monthly)
- Fume hoods (annually and tagged)
- Respirators (monthly)
- Fall protection (monthly)
- Safety shower eyewash fountain (monthly)
- Confine space entry equipment (monthly)
- Jack stands/nose stands (monthly and tagged)
- Air monitoring equipment (factory calibration annually with sticker)

Not all of these items should be on the same checklist. Many will be on monthly Housekeeping checklists (e.g.PPE) while others may be on an engineering maintenance check (e.g. lifting devices) or even daily pre-startup checks.
Are all Safety Inspections performed and documentation submitted to the department manager before the first day of the following month, or within 5 working days of the inspection?
On the completion of the inspection the documentation should be signed and dated by the Department Manager within 5 working days of the inspection.
Are the Safety Inspection results written and do they identify and rank the hazards and/or outages by frequency and severity potential?
Monthly Safety Inspection results should be:
- Written/documented
- Identify and rank outages

Definition of frequency: How many times a particular outage has been identified

Severity ranking could include the following:
- Immediately dangerous to life/health
- Severe/disabling injury
- LTI/minor injury
- Regulation or Standards violation
- Violation of good safe practice

To complete a safety inspection the frequency and severity of the findings must be completed in writing on the inspection form. The standard checklist should provide for this.
The frequency refers to how many times a particular outage has been identified on consecutive inspections.
The criteria for severity should be provided on the standard checklist. This could be consequence based or risk based.
Has each Safety Inspection item record been signed-off by the person(s) conducting the inspection, the department team leader and department manager?
Ask to see documentation.

Team Leader Responsibility

Are the team leaders conducting pre-shift inspections of their work area?
Are team leaders responsible to lead incident investigations for incidents that occur in their area of responsibility?
Are team leaders communicating incident details to all employees in their department when an incident occurs?
Are team leaders conducting safety observations for safe behaviour and conditions and correcting them immediately when observed through constructive feedback and positive reinforcement?
Are team leaders behaving safely everyday to set a good example for employees?
Are team leaders participating plant emergency action plan in their area to include emergency drills and readiness of all emergency equipment?
Are team leaders conducting safety (toolbox) meetings and routinely discussing safety with employees?
Are team leaders promoting an awareness among employees of group and individual safety performance and recognise safety performance?
Do team leaders ensure each employee has personal protective equipment and they understand their use and care of such equipment?
Do team leaders communicate to employees potential hazards associated with chemicals used in the area?
Do team leaders provide safety orientation and training to all newly hired and/or transferred employees?
Are team leaders knowledgeable of any job restrictions placed on any employees and ensure the job assignments are consistent with restrictions?
Do team leaders periodically observe individual job performance for compliance with procedures and proper use of personal protective equipment?
Do team leaders ensure that all new equipment or chemicals are reviewed for safety operation and handling prior to being introduced into the area, and ensure that appropriate information has been communicated to employees?

Training

Is there documented annual training for the managers, team leaders and personnel in the department designed to train them in each of the following? - NCC Safety Process - Safe Practices - Multi-cause incident investigation and root cause analysis - Behaviour observation and feedback
Annual training includes:
- NCC Safety Process
- Safe Practices
- Multi-cause incident investigation and root cause analysis
- Behaviour observation and feedback
Does NCC have a safety orientation program for new/transferred employees that includes the following topics?
- NCC occupational Safety and Health policy statement
- Reporting incidents and injuries
- hazard/risk communication
- personal protective equipment (respirators, hearing protection)
- ergonomics
- emergency action plan
- lockout / tagout
- Confined Space
- emergency response
- Fire extinguisher training
- Housekeeping
- Lifting
- Electrical safety
- Department specific Safe Practices
- First aid locations

Typically the orientation or induction program will be in two stages. The first stage containing all site specific information for all employees (e.g. hazard communication) and the second stage containing more department specific training (e.g. safe work practices).
Are there training programs for promoting "off the job" safety (i.e. Home, fire, vacation, fitness safety etc.)?
Does NCC or the department have an annual safety training schedule/plan that would include the following: - Month - Safety Topic - Trainer's name - Date for training?
Annual Training Schedule shall be posted in each dept. with the following information:
- Month
- Safety Topic
- Trainer's name
- Date for training

Basic requirements to be posted in the department are; Month, Safety topic, Trainer’s name and Date for training. As a minimum this needs to cover the monthly safety topics for the safety meetings for the year but should also include other training events, for example, forklift driving, first aid, confined space entry or other refresher training.

The training schedule should be based on a plan that uses a training matrix or needs assessment to match specific employees with specific training requirements.
Is there a method in place to determine the effectiveness of safety training or to assess competency?
See method or documentation.
- Training Guidelines or Standards
- Use of tests/exams
- Behaviour Observation documents
- Assessments
- Audits

The method needs to be appropriate to the type of training.
When allocating work to employees, employers should ensure that the demands of the job do not exceed the employees' ability to carry out the work without risk to themselves or others. To have some assurance there is a need to check the employees competence, or their ability to do the work required to the necessary standard. If the training relates to safety critical tasks that are more technical or higher risk then there is a greater duty of care to assess the employees competence.
For example, it is appropriate for forklift driver training to include both a written knowledge exam and an observational assessment of their driving skills by a suitably qualified trainer or assessor. Safety orientation for new employees typically involves a simple test, while for general awareness and information a signed attendance record may be sufficient.
Monitoring of the effectiveness of training can then carried out through behaviour observations or periodic re-evaluation of competencies.
Are Health and Safety training feedback evaluations (i.e. critiques) analysed by the trainer, and are modifications to the training program made?
All formal training sessions organised within the NCC or department should invite feedback from the participants through a feedback or critique form (this is not required for awareness sessions like safety meetings or toolbox meetings).
For external training courses it is good practice to invite feedback from employees regardless of any critiques that may be used by the external provider. The information should be passed on to the provider and also referred to when selecting providers for future training events.
Has a safety training plan been developed for management development in safety?
This plan refers to specific regulatory standards.

This should be part of the professional development of all managers with a minimum requirement to attend a suitable course or presentation every two years.
Are there individuals in each department of this NCC who are assigned and formally responsible for safety training?
The individuals shall have sufficient training and experience or knowledge to be considered competent to deliver the type or level of training they are responsible for.

Peer-to-peer training is the most effective when suitably skilled and competent workers can pass their knowledge and experience on to new employees.
Do all department managers and team leaders review Health and Safety training records (matrix) every 6 months to ensure accuracy?
An annual training plan should be developed identifying training requirements for all individuals within the department. This is often organised in the form of a matrix with cross-references between employees, jobs/tasks/equipment and dates. It may also be referred to as a needs assessment. This is then reviewed every six months against completed training and the plan updated for the next six months. The team leaders and department manager must be involved and sign-off on the review.
This is an important check to ensure that managers and team leaders do not request employees to perform tasks that they have not been trained in or not assessed as competent to perform.

Safe Practices

Have Risk Assessments and Safe Practices/Safe Systems of Work been developed for each task in the department, and do they include the following?
- Signed by the dept manager
- Department specific
- Defines required safe behavior
- Void of precautionary wording (i.e. "be careful, "use caution" etc.)
- Dated and revised annually
- Posted and/or available in the dept.
- Written safe practices or safe systems of work are based from a task based Risk Assessment process.
- Based on incident/accident history (used to prioritise development and review, often in conjunction with a risk assessment or potential consequence).

The written or safe systems of work are the resulting administrative controls from the risk assessment process and form the basis of task specific safety training by setting expectations and defining safe behavior. Suitable document control and cross-referencing with the risk assessment is required to demonstrate that any such instructions are appropriate for reducing employee exposure to hazards or risk to an acceptable level. This is especially important for operating machinery or other higher risk or serious consequence tasks.
The risk assessment process may also identify gaps or needs for additional engineering or physical controls that require a separate prioritised action planning process.

Verify that the risk assessment process is documented, implemented and maintained. This will include as a minimum the requirement to:
- authorise people to conduct risk assessment
- define the scope of the risk assessment
- identify and define hazards
- consider legal and other requirements
- assess the risks
- assess the risks introduced from change control
- identify control measures which eliminate or reduce the risk
- priorities the implementation of the control measures
- evaluate remaining risk after the control measure implementation
- use and maintain the control measures
- record and retain risk assessment outputs
- review and validate risk assessment
Is there a written procedure (i.e. progressive discipline policy) to insure that safe practices are followed in this department?
The following tools should be used in this order to handle unsafe behaviors and disregard for standards:
- Incident investigation decision tree
- Root cause analysis tool
- Confrontation of unsafe behaviors; and
- Implement progressive discipline policy for employees who disregard standards.

If an employee is injured or a near miss or an unsafe act is reported then the first purpose of an investigation is to determine the critical failure point. The following is an example of a simple decision tree. In moving down the following hierarchy, the first answer you give on the right is the critical failure point. The lower the number there is an increased management accountability. As the numbers increase there is increasing employee accountability:

1. Is the expectation documented? (No = system failure)
2. Is the specific hazard or risk identified? (No = system failure)
3. Are the controls and instructions adequate? (No = system failure)
4. Does the employee know the correct procedure or expectation? (No = Training inadequate)
5. Do employees routinely disregard the expectation? (Yes = Supervision inadequate)
6. Is the behavior a deliberate or intentional disregard? (Yes = Personal accountability)

The critical failure point may require further investigation and root cause analysis or there may be more than one failure point to investigate. Progressive discipline is only appropriate where personal accountability is identified as a failure point.
Has each employee in the department been trained in all applicable Safe Systems of Work and is this verified with a sign-off sheet?
This training applies to all new and transferred employees. The auditor must verify this by reviewing training documentation.
Are departmental Safe Systems of Work included in the department safety orientation program for new/transferred employees, and documented by a sign off sheet?
Sufficient verification must be provided to give assurance that all employees receive the appropriate training before being assigned work or tasks that require specific knowledge or safe systems of work.
Do employees in the department know what Safe Systems of Work are, and where they are located?
The safe systems of work that form the basis of task specific training must always be available for reference to employees in the workplace.

Ask employees "what is a safe system of work" is, and "Where are they located"? This also verifies the effectiveness of the training.

An effective audit method is to include all of the employee verification questions in a facilitated focus group discussion. This will determine how effectively the NCC Safety Process has been implemented to engage employee participation and involvement in safety management.

Leading Behaviour

Is the department manager involved in all high potential or serious incident investigations and are team leaders actively involved in incident investigations within their department?
This is the first requirement of felt leadership. Management must actively involve themselves in the safety process to demonstrate to employees that safety is a core organisational value that is integral to the success of the business.
Does the department take proactive measures to encourage increased near miss reporting?
Too much direct focus on eliminating LTI's or serious incidents can drive a culture of under-reporting and blame. To effectively lead a positive change in safety culture all incident reporting must be encouraged, placing particular focus on the opportunities for proactive and preventative action given by early reporting and near-miss reporting. In conjunction with other felt leadership initiatives this will lead to employees taking more direct accountability for their own safe behaviours.
When encouraging near-miss reporting it is essential to follow-up and complete the resulting corrective actions. The status of the corrective actions must also be communicated back to employees. This is necessary to have a positive and lasting influence on the safety culture. If you ask employees for their input and then do nothing it can result in a major setback for the safety process.
Some examples to encourage near-miss reporting are:
- Set increasing targets for number of near-miss reports. Typically near-miss incidents are 10 times first aid incidents and 100 times the LTI incidents. These numbers can be used as targets or use a minimum target for a year, equal to the number of employees.
- Place more management focus on increasing near-miss reporting rather than reducing LTI's. We need the incident reported and fixed before it becomes a LTI.
- Include increased near-miss reporting targets in departmental goals.
- Include increased near-miss reporting in the employee recognition program.
- Personal recognition or reward for employees whose reporting results in significant improvements.
Do managers and team leaders actively participate in behaviour observations on at least a monthly basis?
The NCC and department managers and team leaders are required to actively participate in the behaviour observation events and sign their observation records.
A team leader or manager signing the results of a behaviour observation conducted by another person does not count towards this question.
Do managers and team leaders follow a documented system to handle unsafe behaviours during a behaviour observation event?
The following tools should be used in this order to handle unsafe behaviours and disregard for standards:
- Incident investigation decision tree
- Root cause analysis tool
- Confrontation of unsafe behaviours; and
- Implement progressive discipline policy for employees who disregard standards.

This question refers to the handling of unsafe behaviour specifically in relation to BOS. If you have not began implementing BOS then it must be as no credit received.

If an employee is observed to not be following a behaviour expectation (such as a safe practice or safe system of work) then the first purpose of a confrontation procedure is to determine the critical failure point. For example, in moving down the following hierarchy the first answer you give to the right is the critical failure point with increased management accountability the lower the number. As the numbers increase there is increasing employee accountability:

1. Is the expectation documented? (No = system failure)
2. Is the specific hazard or risk identified? (No = system failure)
3. Are the controls and instructions adequate? (No = system failure)
4. Does the employee know the correct procedure or expectation? (No = Training inadequate)
5. Do employees routinely disregard the expectation? (Yes = Supervision inadequate)
6. Is the behaviour a deliberate or intentional disregard? (Yes = Personal accountability)

The critical failure point may require further investigation and root cause analysis or there may be more than one failure point to investigate. Progressive discipline is only appropriate where personal accountability is identified as a failure point.
Does the department manager conduct coached behaviour observations with team leaders to measure the effectiveness of safety management within the department?
A further implementation stage of felt leadership that is visible to employees, clearly sets company expectations and forms part of manager and team leader development.
Are team leaders held directly accountable for the coached behaviour observation results within their department/shift?
Statistical Analysis helps to develop an accurate picture of precisely which variables are predicators of accident frequency. This knowledge separates fact from myth and guesswork. A computer needs to be used to collect and organize the department's data. Information must be separate to reflect what is going on in each department and shift.
Do managers, team leaders or suitably qualified assessors conduct critical task observations?
The initial emphasis of BOS should be on safe behaviours related to tasks with high incident rates or potential for high severity injuries. The risk assessment process should clearly define and identify the critical tasks.
Has the incident and near-miss investigation process been expanded to include participation by employees?
Employees should not only be made aware of incidents and corrective actions in their department, but also actively participate in the investigation process. This is the most effective way to build awareness but can also lead to more in-depth root cause analysis from specialised knowledge and experience. The involvement also creates ownership of the corrective actions, making their implementation more effective.

Behaviour Observation

Has the behaviour observation program been expanded to include safe act observations by all levels of employees?
Once a BOS system is fully established, all levels of employees are expected to take part in gathering data.
If observations are always performed by the same one or two employees in the department then it is only a partial score. The aim is to engage all employees in the process by involving as many as possible over time.
Does behaviour observation documentation focus on safe versus unsafe behaviours in this department?
The initial emphasis of BOS should be on safe behaviours related to tasks with high incident rates or potential for high severity injuries.
Observation documentation and raw results need to clearly show the total number of observations split between safe behaviours and unsafe behaviours. Summaries of the results can be reported as a percentage of safe behaviours relative to the total observations.
Are Health and Safety performance monitoring results (BOS) presented on a monthly basis to upper management?
A summary of BOS Statistics should be reported to upper management. The auditor must review this documentation in order to score this question appropriately.
Does this department conduct, chart and post observed behaviours per shift?
Inspect the department's safety bulletin board for BOS charts.
Is there documentation of a report distributed to all department managers and team leaders, and the SLT on a monthly basis indicating the number of incidents under their supervision within their department?
Ask to see a copy of the report, graph and/or charts.
Full reporting would have breakdowns by department and include all incidents and near-miss, incident analysis, root cause and track corrective action closure.

Performance Tracking/Review

Are there diagrams (i.e., pareto charts, graphs, etc.) displayed in this department indicating current departmental safety status?
Reports and graphs should clearly state current status relative to NCC and department targets. It should also be possible to discern when the last lost time incident occurred for the department.
At the end of each fiscal year, is there a summary of all accident statistics distributed to all managers/team leaders for their department/business units?
If yes, ask to see annual summaries.

The annual summary is different from monthly reporting in that it includes a full year analysis of trends and root cause analysis. This information is an important input to the annual review and setting of the next years NCC's Safety Action Plan and department goals.

The end of year analysis of performance should also consider key learning's and best practices
Does the business unit manager and his/her direct reports review safety management practices annually?
Various inputs to the review should be considered, such as, the annual incident analysis summary, safety measures and performance results, behaviour observations, audit reports, regulatory activity and other requirements.
The purpose is to evaluate the effectiveness of safety management practices and make adjustments to policy, systems and resourcing as needed. The results of the review then influence the setting of the next years NCC's Safety Action Plan and department goals.