Title Page
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Conducted on
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Prepared by
4.1 General requirements
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The organization shall establish, document, implement, maintain, and continually improve an OH&S management system in accordance with the requirements of this OHSAS Standard and determine how it will fulfill these requirements.
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The organization shall define and document the scope of its OH&S management system.
4.2 Occupational Health & Safety policy
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Top management shall define and authorize the organization’s OH&S policy and ensure that within the defined scope of its OH&S management system it:
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a) is appropriate to the nature and scale of the organization’s OH&S risks;
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b) includes a commitment to prevention of injury and ill health and continual improvement in OH&S management and OH&S performance;
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c) includes a commitment to at least comply with applicable legal requirements and with other requirements to which the organization subscribes that relate to its OH&S hazards;
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d) provides the framework for setting and reviewing OH&S objectives;
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e) is documented, implemented and maintained;
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f) is communicated to all persons working under the control of the organization with the intent that they are made aware of their individual OH&S obligations;
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g) is available to interested parties;
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h) is reviewed periodically to ensure that it remains relevant and appropriate to the organization.
4.3 Planning
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4.3.1 Hazard Identification, risk assessment and determining controls
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The organization shall establish, implement and maintain a procedure(s) for the ongoing hazard identification, risk assessment, and determination of necessary controls.
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The procedure(s) for hazard identification and risk assessment shall take into account:
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a) routine and non-routine activities;
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b) activities of all persons having access to the workplace (including contractors and visitors);
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c) human behaviour, capabilities and other human factors;
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d) identified hazards originating outside the workplace capable of adversely affecting the health and safety of persons under the control of the organization within the workplace;
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e) hazards created in the vicinity of the workplace by work-related activities under the control of the organization;
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NOTE 1: It may be more appropriate for such hazards to be assessed as an environmental aspect.
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f) infrastructure, equipment and materials at the workplace, whether provided by the organization or others;
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g) changes or proposed changes in the organization, its activities, or materials;
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h) modifications to the OH&S management system, including temporary changes, and their impacts on operations, processes, and activities;
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i) any applicable legal obligations relating to risk assessment and implementation of necessary controls (see also the NOTE to 3.12);
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j) the design of work areas, processes, installations, machinery/equipment, operating procedures and work organization, including their adaptation to human capabilities.
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The organization’s methodology for hazard identification and risk assessment shall:
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a) be defined with respect to its scope, nature and timing to ensure it is proactive rather than reactive; and
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b) provide for the identification, prioritization and documentation of risks, and the application of controls, as appropriate.
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For the management of change, the organization shall identify the OH&S hazards and OH&S risks associated with changes in the organization, the OH&S management system, or its activities, prior to the introduction of such changes.
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The organization shall ensure that the results of these assessments are considered when determining controls.
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When determining controls, or considering changes to existing controls, consideration shall be given to reducing the risks according to the following hierarchy:
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a) elimination;
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b) substitution;
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c) engineering controls;
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d) signage/warnings and/or administrative controls;
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e) personal protective equipment.
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The organization shall document and keep the results of identification of hazards, risk assessments and determined controls up-to-date.
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The organization shall ensure that the OH&S risks and determined controls are taken into account when establishing, implementing and maintaining its OH&S management system.
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NOTE 2 For further guidance on hazard identification, risk assessment and determining controls, see OHSAS 18002.
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4.3.2 Legal and Other Requirements
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The organization shall establish, implement and maintain a procedure(s) for identifying and accessing the legal and other OH&S requirements that are applicable to it.
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The organization shall ensure that these applicable legal requirements and other requirements to which the organization subscribes are taken into account in establishing, implementing and maintaining its OH&S management system.
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The organization shall keep this information up-to-date.
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The organization shall communicate relevant information on legal and other requirements to persons working under the control of the organization, and other relevant interested parties.
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4.3.3 Objectives & Programme(s)
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The organization shall establish, implement and maintain documented OH&S objectives, at relevant functions and levels within the organization.
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The objectives shall be measurable, where practicable, and consistent with the OH&S policy, including the commitments to the prevention of injury and ill health, to compliance with applicable legal requirements and with other requirements to which the organization subscribes, and to continual improvement.
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When establishing and reviewing its objectives, an organization shall take into account the legal requirements and other requirements to which the organization subscribes, and its OH&S risks. It shall also consider its technological options, its financial, operational and business requirements, and the views of relevant interested parties.
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The organization shall establish, implement and maintain a programme(s) for achieving its objectives. Programme(s) shall include as a minimum:
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a) designation of responsibility and authority for achieving objectives at relevant functions and levels of the organization; and
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b) the means and time-frame by which the objectives are to be achieved.
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The programme(s) shall be reviewed at regular and planned intervals, and adjusted as necessary, to ensure that the objectives are achieved.
4.4 Implementation and Operation
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4.4.1 Resources, roles, responsibility, accountability and authority
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Top management shall take ultimate responsibility for OH&S and the OH&S management system.
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Top management shall demonstrate its commitment by:
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a) ensuring the availability of resources essential to establish,implement, maintain and improve the OH&S management system;
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NOTE 1: Resources include human resources and specialized skills, organizational infrastructure, technology and financial resources.
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b) defining roles, allocating responsibilities and accountabilities, and delegating authorities, to facilitate effective OH&S management; roles, responsibilities, accountabilities, and authorities shall be documented and communicated.
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The organization shall appoint a member(s) of top management with specific responsibility for OH&S, irrespective of other responsibilities, and with defined roles and authority for:
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a) ensuring that the OH&S management system is established, implemented and maintained in accordance with this OHSAS Standard;
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b) ensuring that reports on the performance of the OH&S management system are presented to top management for review and used as a basis for improvement of the OH&S management system.
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NOTE 2: The top management appointee (e.g. in a large organization, a Board or executive committee member) may delegate some of their duties to a subordinate management representative(s) while still retaining accountability
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The identity of the top management appointee shall be made available to all persons working under the control of the organization.
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All those with management responsibility shall demonstrate their commitment to the continual improvement of OH&S performance.
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The organization shall ensure that persons in the workplace take responsibility for aspects of OH&S over which they have control, including adherence to the organization’s applicable OH&S requirements.
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4.4.2 Competence, training and awareness
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The organization shall ensure that any person(s) under its control performing tasks that can impact on OH&S is (are) competent on the basis of appropriate education, training or experience, and shall retain associated records.
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The organization shall identify training needs associated with its OH&S risks and its OH&S management system. It shall provide training or take other action to meet these needs, evaluate the effectiveness of the training or action taken, and retain associated records.
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The organization shall establish, implement and maintain a procedure(s) to make persons working under its control aware of:
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a) the OH&S consequences, actual or potential, of their work activities, their behavior, and the OH&S benefits of improved personal performance;
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b) their roles and responsibilities and importance in achieving conformity to the OH&S policy and procedures and to the requirements of the OH&S management system, including emergency preparedness and response requirements (see 4.4.7);
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c) the potential consequences of departure from specified procedures.
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Training procedures shall take into account differing levels of:
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a) responsibility, ability, language skills and literacy; and
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b) risk.
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4.4.3 Communication, Participation and Consultation
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4.4.3.1 Communication
• With regard to its OH&S hazards and OH&S management system, the organization shall establish, implement and maintain a procedure(s) for: -
a) internal communication among the various levels and functions of the organization;
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b) communication with contractors and other visitors to the workplace;
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c) receiving, documenting and responding to relevant communications from external interested parties.
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4.4.3.2 Participation and Consultation
• The organization shall establish, implement, and maintain procedure(s) for:
a) the participation of workers by their: -
• appropriate involvement in hazard identification, risk assessments and determination of controls;
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• appropriate involvement in incident investigation;
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• involvement in the development and review of OH&S policies and objectives;
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• consultation where there are any changes that affect their OH&S;
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• representation on OH&S matters. Workers shall be informed about their participation arrangements, including who is their representative(s) on OH&S matters.
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The organization shall ensure that, when appropriate, relevant external interested parties are consulted about pertinent OH&S matters.
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Workers shall be informed about their participation arrangements, including who is their representative(s) on OH&S matters.
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b) consultation with contractors where there are changes that affect their OH&S.<br>
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The organization shall ensure that, when appropriate, relevant external interested parties are consulted about pertinent OH&S matters.
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4.4.4 Documentation
• The OH&S management system documentation shall include: -
a) the OH&S policy and objectives;
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b) description of the scope of the OH&S management system;
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c) description of the main elements of the OH&S management system and their interaction, and reference to related documents;
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d) documents, including records, required by this OHSAS Standard; and
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e) documents, including records, determined by the organization to be necessary to ensure the effective planning, operation and control of processes that relate to the management of its OH&S risks.
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NOTE: It is important that documentation is proportional to the level of complexity, hazards and risks concerned and is kept to the minimum required for effectiveness and efficiency.
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4.4.5 Control of Documents
Documents required by the OH&S management system and by this OHSAS Standard shall be controlled. Records are a special type of document and shall be controlled in accordance with the requirements given in 4.5.4. -
The organization shall establish, implement and maintain a procedure(s) to:
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a) approve documents for adequacy prior to issue;
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b) review and update as necessary and re-approve documents;
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c) ensure that changes and the current revision status of documents are identified;
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d) ensure that relevant versions of applicable documents are available at points of use;
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e) ensure that documents remain legible and readily identifiable;
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f) ensure that documents of external origin determined by the organization to be necessary for the planning and operation of the OH&S management system are identified and their distribution controlled; and
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g) prevent the unintended use of obsolete documents and apply suitable identification to them if they are retained for any purpose.
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4.4.6 Operational Control
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Workers shall be informed about their participation arrangements, including who is their representative(s) on OH&S matters.
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For those operations and activities, the organization shall implement and maintain:
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a) operational controls, as applicable to the organization and its activities; the organization shall integrate those operational controls into its overall OH&S management system;
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b) controls related to purchased goods, equipment and services;
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c) controls related to contractors and other visitors to the workplace;
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d) documented procedures, to cover situations where their absence could lead to deviations from the OH&S policy and the objectives;
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e) stipulated operating criteria where their absence could lead to deviations from the OH&S policy and objectives.
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4.4.7 Emergency Preparedness and Response
• The organization shall establish, implement and maintain a procedure(s): -
a) to identify the potential for emergency situations;
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b) to respond to such emergency situations.
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The organization shall respond to actual emergency situations and prevent or mitigate associated adverse OH&S consequences.
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In planning its emergency response the organization shall take account of the needs of relevant interested parties, e.g. emergency services and neighbours.
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The organization shall also periodically test its procedure(s) to respond to emergency situations, where practicable, involving relevant interested parties as appropriate.
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The organization shall periodically review and, where necessary, revise its emergency preparedness and response procedure(s), in particular, after periodical testing and after the occurrence of emergency situations (see 4.5.3).
4.5 Checking
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4.5.1 Performance Measurement and Monitoring
• The organization shall establish, implement and maintain a procedure(s) to monitor and measure OH&S performance on a regular basis. This procedure(s) shall provide for: -
a) both qualitative and quantitative measures, appropriate to the needs of the organization;
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b) monitoring of the extent to which the organization’s OH&S objectives are met;
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c) monitoring the effectiveness of controls (for health as well as for safety);
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d) proactive measures of performance that monitor conformance with the OH&S programme(s), controls and operational criteria;
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e) reactive measures of performance that monitor ill health, incidents (including accidents, near-misses, etc.), and other historical evidence of deficient OH&S performance;
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f) recording of data and results of monitoring and measurement sufficient to facilitate subsequent corrective action and preventive action analysis.
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If equipment is required to monitor or measure performance, the organization shall establish and maintain procedures for the calibration and maintenance of such equipment, as appropriate. Records of calibration and maintenance activities and results shall be retained.
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4.5.2 Evaluation of compliance
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4.5.2.1 Consistent with its commitment to compliance [see 4.2c)], the organization shall establish, implement and maintain a procedure(s) for periodically evaluating compliance with applicable legal requirements (see 4.3.2).
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- The organization shall keep records of the results of the periodic evaluations.
- NOTE The frequency of periodic evaluation may vary for differing legal requirements. -
4.5.2.2 The organization shall evaluate compliance with other requirements to which it subscribes (see 4.3.2). The organization may wish to combine this evaluation with the evaluation of legal compliance referred to in 4.5.2.1 or to establish a separate procedure(s).
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- The organization shall keep records of the results of the periodic evaluations.
- NOTE The frequency of periodic evaluation may vary for differing other requirements to which the organization subscribes. -
4.5.3 Incident Investigation, Non-conformity, Corrective & Preventive Action
4.5.3.1 Incident investigation
• The organization shall establish, implement and maintain a procedure(s) to record, investigate and analyse incidents in order to: -
a) determine underlying OH&S deficiencies and other factors that might be causing or contributing to the occurrence of incidents;
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b) identify the need for corrective action;
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c) identify opportunities for preventive action;
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d) identify opportunities for continual improvement;
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e) communicate the results of such investigations.
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The investigations shall be performed in a timely manner.
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Any identified need for corrective action or opportunities for preventive action shall be dealt with in accordance with the relevant parts of 4.5.3.2.
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The results of incident investigations shall be documented and maintained.
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4.5.3.2 Nonconformity, corrective action and preventive action
• The organization shall establish, implement and maintain a procedure(s) for dealing with actual and potential nonconformity(ies) and for taking corrective action and preventive action. The procedure(s) shall define requirements for: -
a) identifying and correcting nonconformity(ies) and taking action(s) to mitigate their OH&S consequences;
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b) investigating nonconformity(ies), determining their cause(s) and taking actions in order to avoid their recurrence;
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c) evaluating the need for action(s) to prevent nonconformity(ies) and implementing appropriate actions designed to avoid their occurrence;
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d) recording and communicating the results of corrective action(s) and preventive action(s) taken; and
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e) reviewing the effectiveness of corrective action(s) and preventive action(s) taken.
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Where the corrective action and preventive action identifies new or changed hazards or the need for new or changed controls, the procedure shall require that the proposed actions shall be taken through a risk assessment prior to implementation.
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Any corrective action or preventive action taken to eliminate the causes of actual and potential nonconformity(ies) shall be appropriate to the magnitude of problems and commensurate with the OH&S risk(s) encountered.
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The organization shall ensure that any necessary changes arising from corrective action and preventive action are made to the OH&S management system documentation.
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4.5.4 Control of Records
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The organization shall establish and maintain records as necessary to demonstrate conformity to the requirements of its OH&S management system and of this OHSAS Standard, and the results achieved.
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The organization shall establish, implement and maintain a procedure(s) for the identification, storage, protection, retrieval, retention and disposal of records.
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Records shall be and remain legible, identifiable and traceable.
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4.5.5 Internal Audit
• The organization shall ensure that internal audits of the OH&S management system are conducted at planned intervals to:
a) determine whether the OH&S management system: -
1) conforms to planned arrangements for OH&S management, including the requirements of this OHSAS Standard; and
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2) has been properly implemented and is maintained; and
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3) is effective in meeting the organization’s policy and objectives;
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b) provide information on the results of audits to management.
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Audit programme(s) shall be planned, established, implemented and maintained by the organization, based on the results of risk assessments of the organization’s activities, and the results of previous audits.
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Audit procedure(s) shall be established, implemented and maintained that address:
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a) the responsibilities, competencies, and requirements for planning and conducting audits, reporting results and retaining associated records; and
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b) the determination of audit criteria, scope, frequency and methods. Selection of auditors and conduct of audits shall ensure objectivity and the impartiality of the audit process.
4.6 Management Review
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Top management shall review the organization’s OH&S management system, at planned intervals, to ensure its continuing suitability, adequacy and effectiveness. Reviews shall include assessing opportunities for improvement and the need for changes to the OH&S management system, including the OH&S policy and OH&S objectives. Records of the management reviews shall be retained.
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Input to management reviews shall include:
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a) results of internal audits and evaluations of compliance with applicable legal requirements and with other requirements to which the organization subscribes;
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b) the results of participation and consultation (see 4.4.3);
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c) relevant communication(s) from external interested parties, including complaints;
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d) the OH&S performance of the organization;
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e) the extent to which objectives have been met;
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f) status of incident investigations, corrective actions and preventive actions;
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g) follow-up actions from previous management reviews;
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h) changing circumstances, including developments in legal and other requirements related to OH&S; and
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i) recommendations for improvement.
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The outputs from management reviews shall be consistent with the organization’s commitment to continual improvement and shall include any decisions and actions related to possible changes to:
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a) OH&S performance;
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b) OH&S policy and objectives;
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c) resources; and
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d) other elements of the OH&S management system.
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Relevant outputs from management review shall be made available for communication and consultation (see 4.4.3).
Completion
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Comments
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Name and Signature
