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The audit trail

Initiating an audit trail for evaluating a safety and health program(s) is a way to test the effectiveness of written or informal programs. Depending on the amount of resources and time you want to devote, the process can be as simple as taking several of the incidents you may see listed on a company's annual OSHA 200 (annual summary of occupational injuries and illnesses), and tracking back through applicable company reports or programs. By taking this tactic, you can get a pretty good idea whether an effective safety and health program has been implemented.

Take the example of two eye injuries that were entered on one company's OSHA 200. The first step could be pulling the 101s or First Reports of Accidents or Illness for the two eye injuries. Full evaluation of the reported information first checks on proper recording, and then evaluates background information as to why the eye injury occurred. The company had listed the cause of the injury as employee failure to wear eye protection.

Root cause analysis

This is only the starting point for the audit trail. Now, the real search for root causes and the deeper evaluation of the company's programs can begin. Employee interviews revealed that one employee felt that the goggles provided did not fit. The other employee complained of the goggles fogging up, as the reason that the goggles were not being worn at the time of the injury. An interview with the manager revealed that the manager was reluctant to initiate the company disciplinary policy for the two employees who were excellent workers. Typical of most companies, the accident report blamed the victim. The company had well-written safety and health programs, performed recordkeeping accurately, and had trained their employees thoroughly. What was missing from their safety and health program?

Impact of Total Quality Management (TQM) principals on safety and health programs

If this company had applied basic TQM principals, they would have encouraged full evaluation of the sources of non-conformance (not wearing the goggles), rather than turning to discipline. If the manager had questioned all of the employees who perform the job that had resulted in two eye injuries, she would have found that 75% of the time employees indicated that they did not wear their goggles because they forgot them in their locker, 10% of the time employees felt that the goggles did not fit or slipped off, and 15% of the time employees felt that goggle fogging was a big problem. By addressing each of these issues separately, incidences of non-conformance could be significantly reduced. The manager could purchase retainer clips that attached the goggles directly to the hard hats. Changing style of goggles could eliminated the problem of lenses fogging. The manager also could purchase an extra supply so that any goggle damaged by chemicals could be immediately changed as needed.

If only the eye injury cases had been evaluated, a significant reason for not using the goggles (representing significant risk), would not have been addressed. In other words, the 75% of the employees who did not wear their goggles because they had left them in their lockers would not have been addressed.

If the employees had participated in the accident evaluation, additional input might have been garnered at the time of the first incident, preventing the second incident. Also, there was no discussion of the injury and illness entries or near misses each month during the safety and health committee meeting, indicating a failure to use the safety and health committee to address real, practical, and soluble problems in the workplace. Had the safety and health committee addressed the root causes during their meeting, they might also have been able to address all of the instances of non-conformance before the second injury.

Audit trail steps

After the first injury the following sequence of events should have taken place:

  • Perform accident analysis & appropriate recordkeeping.
  • Review accident report during the safety and health committee meeting for further input, determine corrective actions.
  • Determine whether any near misses had occurred for this job, and if so, why had they not been reported.
  • Review job safety hazard analysis (JSA) for the job in question, revise as necessary.
  • Re-evaluate disciplinary/incentive programs and how they impact true employee participation and reporting of near misses - modify if they are disincentives.
  • Retrain the employees and managers accordingly.
  • Perform an analysis of your conformance with identified critical safety behaviors to evaluate the effectiveness of corrective actions.

Additional positive outcomes

If the previous actions had been completed, a number of positive results could have occurred. First, by addressing the root causes the manager would have demonstrated her commitment to preventing eye injuries. Employee participation in the safety and health committee, accident analysis, job safety hazard analysis, and retraining employees, could have heightened employee knowledge and sensitivity to this critical safety behavior, and increased employee morale and feeling of being part of a team. As a result of goggle use becoming routine, eye injuries might have been reduced significantly or eliminated entirely.

Although reviewing OSHA 200 entries is a good tool for auditing a safety and health program, it is only one of many tools that can be used. Such an approach takes only a retroactive look at programs once a problem has occurred. Ideally, a company should try to be proactive in their approach.

What this audit approach does, however, is to look to see if the company's program is a "walking/working" program, with linkages that interconnect with other parts of the program. In effect, if there is an accident or a near miss, this process can be followed to see if there was the appropriate "ripple" effect. Would the near miss be reported? Once reported, would the JSA be reviewed, or would employees be retrained? Making an accident report, because it is expected, but not seeing evidence of the "ripple" effect, such as changing a JSA or retraining employees or purchasing new equipment, may be evidence that a safety and health program is a "paper program" and not a vital working document.