Safety Management System

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Ikhwan Muhammad – Safety Management System Assignment 3

Project Assignment: Safety Management System Re-Design & Strategic Plan General Discussion & Potential Solutions of the Problems The accident occurred in Helpful Corporation is a manifestation of human error problems. Rather than taking a person approach and blaming individuals, it is better to take a system approach to explore the accident causation. From the self-audit, the company found three main areas of deficiency that need to be improved: objective and target, responsibility and accountability, and hazard identification. Based on this, it is apparent that the accident was the result of the breach the defense which made accident trajectories. Objective and target Firstly, in this case, the problem occurred when the company decided to reduce the number of worker and rely more on automated tasks and batch-processing machinery, without updating the OHS (Occupational Health & Safety) targets and objectives in order to address the latest decision. The company did not comply with the Australian Standard it adheres. As outlined in AS/NZS 4801:2001, company should provide appropriate establishment, implementation, and documentation of OHS targets & objectives (Standards Australia, 2001). AS/NZS 4801:2001 demands the company to put into consideration legal aspects, risks and hazards, technological options, operational and business requirements, and views of interested parties of the OHS targets & objectives (Standards Australia, 2001). The potential solution of this is to update the OHS target and objectives – specifically in relation to automated tasks and batch-processing machinery. The updated OHS target should be made consistent with OHS policy (Standards Australia, 2001). Specific for assessing Risk analysis of technological system, AS/NZS 3931:1998 has specified the list of the possible methods of analysis include HAZOP (Hazard and Operability) study, FMEA (Fault Modes and Effect Analysis), FTA (Fault Tree Analysis), ETA (Event Tree Analysis), PHA (Preliminary Hazard Analysis), and HRA (human Reliability Assessment) (Standards Australia, 1998) Responsibility and accountability Secondly, the contractors involved in plant maintenance don’t have the awareness of potential hazards posed by the chemical substances and active ingredients used in the process, which lead to the problem of this company. It is believed that the root of this problem is from the lack of clear responsibility and accountability of the contractors’ management.

Ikhwan Muhammad – Safety Management System Assignment 3

In relation to responsibility and accountability, AS/NZS 4801:2001 demands that the areas of accountability and responsibility of every person in OHSMS’s operation should be defined, documented and communicated ; In the involvement of contractors, the company should provide further clarification (Standards Australia, 2001). Moreover, the standard also demands the company to appoint a management representative who has specific roles, responsibilities, and authorities to: 1.) ensure the establishment, implementation and maintenance of OHSMS (Occupational Health & Safety Management System) requirements in accordance to AS 4801:2001, and 2.) provide reports to the top management on the performance of OHSMS; these reports will be used for review and as a basis to improve OHSMS (Standards Australia, 2001). The potential solution of this is to increase the awareness of hazard, define specific role of each person in charge, and maintain intense communication between company and contractor – especially in terms of potential hazards. The company needs to designate certain level of responsibility and accountability to the contractors, and communicate it during the induction program. The importance of communication in safety performance is outlined in numerous literatures (e.g. Bentley & Haslam, 2001; Cigularov, Chen, & Rosecrance, 2010; Leonard, Graham, & Bonacum, 2004; Smith, Cohen, Cohen, & Cleveland, 1978). Good safety communication is proposed as a recommended safety practice that should be adopted to improve occupational safety (Bentley & Haslam, 2001). This is further supported by the role of safety communication in reducing the number of occupational accidents and injuries (e.g.Mearns, Flin, Gordon, & Fleming, 1998; Mearns, Whitaker, & Flin, 2003; Morgeson & Hofmann, 1999; Probst, 2004; Sawacha, Naoum, & Fong, 1999; Siu, Phillips, & Leung, 2004). However, Clarke (2006) suggests that job communication is not a significant factor in predicting safety outcome. She suggests that accidents and unsafe acts are more affected by the worker’s perception on the work environment. Hazard identification Thirdly, the problem arise when the worker is not using the incident reporting system effectively, the workers claimed that there are certain issues in the reporting system, including the lack of follow-up by management, the punishment of individuals, intranet access difficulty, and the lack of use of the data in trend analysis. As emphasized by AS/NZS 4801:2001, it is obligated for the company to take the following points into account when identifying workplace’s hazards; 1.) single or combination of events that increase the risk of injury or illness, 2.) the nature of injury and illness’ potentiality posed in work activities, product, or services, and 3.) previous illnesses, incidents, and injuries. Furthermore, AS 4801:2001 further specify certain points to consider the in the identification process: 1.) the organization, management, and implementation of work and the changes occurred in the process, 2.) designs of equipment, plant, materials, work processes, and

Ikhwan Muhammad – Safety Management System Assignment 3

workplaces, 3.) purchases of services and goods, 4.) contracts and subcontracts of labor, services, equipment, and plant, and 5.) maintenance and inspection (Standards Australia, 2001). The potential solutions of this is to increase the follow up of incident report, eliminate the punishment, focus on fixing the potential problem, eliminate the difficulty in intranet access and use the data in trend analysis. The blaming culture, a problem found in this case, is associated with person approach. As emphasized by Reason (2000), individuals suffer from a greater tendency to get blamed when incidents happen because they possess the capability of choosing between safe and unsafe act. In fact, it is more satisfying to target the individuals than institutions (Reason, 2000). To prevent the worker from being put on the spot, anonymous incident report system can be introduced. This is proven by Nakajima, Kurata, and Takeda (2005), who proposed that a voluntary and anonymous web-based incident reporting system will improve incident reporting. The reporting system combine with responsible staff, staff education, and feedback procedure will in turn promote safety culture. The philosophies to be adopted by the company Before specifying the re-designed components, there are essential philosophies that should be adopted by the company in each area of improvement: Objective and target OHS objective is defined as ‘overall OHS goals in terms of OHS performance, arising from the occupational health and safety policy that an organization sets itself to achieve, and which are quantified where practicable’, while OHS target is defined as ‘a detailed performance requirement, quantified wherever practicable, and pertaining to organization, that arises from the health and safety objectives and that need to be met in order to achieve those objectives’ (Standards Australia, 2001) It is important for the company to understand the importance of defining appropriate objective and target to achieve a definite goal in safety; therefore, the objectives should be made specific and the targets should be made measurable (Standards Australia, 2001). The company also needs to take existing preventive measures appropriately, and n order to monitor the process of achieving the objective and target, the company should use appropriate performance indicator (Standards Australia, 2001). In terms of technological options, the considerations that should be taken into account include the use of best available technology where economically viable, cost effective, and judged appropriate (Standards Australia, 2001). In relation to the use of automated tasks and batch-processing machinery, the company needs to understand the socio-technical system and the role of human factor.

Ikhwan Muhammad – Safety Management System Assignment 3

Responsibility and accountability Safety responsibility is defined as an obligation to achieve a successful conclusion of safety related task by using necessary action, while safety accountability is defined as an obligation to answer for action by demonstrating task achievement and taking responsibility of safety performance according to the specified expectation (SKYbrary, 2012). It is essential for the company to understand that the OHS targets and objectives require appropriate designation of responsibility and accountability. The designated person should possess appropriate level of skill and resource that suffice the requirement of the responsibility and accountability. The induction program should provide every new worker with adequate training and resources to meet the accountability level. Delegation of safety responsibility is possible as long as it is properly documented, while delegation of safety accountability is not possible because it defines the obligation of the responsible person to demonstrate the satisfactory discharge of his/her safety responsibilities (SKYbrary, 2012). AS/NZS 4801:2001 highlights that the highest level of management should be the first to start committing OHSMS and be the first place to begin the accountability of OHS (Standards Australia, 2001). The standard further specifies the responsibility of the top management, including establishing OHS policy, ensuring OHSMS implementation, designating a management representative specific to implement OHSMS, and providing appropriate level of resources to OHSMS. Furthermore, the management needs to understand the principle of ‘active and latent failures’. Active failures are defined by Reason (2000) as the unsafe acts done by the people in the closest contact with the system, while latent failures are the failures arise from latent pathologic system which can be caused by the decision of top management level. This is the reason why the top management should be committed to the safety at the first place. Hazard identification AS 4801 defines hazard identification as ‘the process of recognizing that a hazard exists and defining its characteristics’ (Standards Australia, 2001). The standard further highlighted that the requirement of hazard identification should be included in the documented procedure during the design stage. The company should examine technical data and other information relevant to OHS before any decision to purchase goods and service is made (Standards Australia, 2001). However, in the process, the company doesn’t necessarily need to conduct evaluation for each product and only have to identify the products with significant hazards or unacceptable risk (Standards Australia, 2001). It is important for the company to recognize hazard identification as an essential part of risk management process. One of most important hazard identification tools, that the company needs to adopt, is the hazard reporting. Furthermore, the most appropriate person to report the

Ikhwan Muhammad – Safety Management System Assignment 3

existence of hazard and the possible control option is the one who face the hazard in a daily basis – the worker (ICAO, 2009). Therefore, it is important for the company to develop a reporting culture and encourage the worker to report the hazard they face frequently. However, as outlined by Reason (2000), to be able to establish a reporting culture, the company must first adopt a ‘just culture’ by dividing clearly between a point of ‘blameless’ and a point of ‘blameworthy’. Revision of the safety management system documentation Documentation of safety management system is a set of documents comprising the company’s safety policy statements which aimed to ensure the company achieves its safety objectives (SKYbrary, 2012). The relevant aspect that should be revised in the safety management system documentation in this company includes personnel and responsibilities, procedures and workflow, tools, and metrics – performance monitoring and measurement. The draft of the revised section is provided in appendix 1. Brief Strategic Plan The roll out of the management system change comprises list of tactical plans with detailed explanation and specific date. Firstly, the company should gain the management commitment to the changes. The main points of change in this case includes re-defining of OHS targets and objectives, re-designation of responsibility and accountability, and re-designing of hazard reporting system. After documented properly, the management system changes should be specified and communicated to relevant workers. However, there are several barriers of implementation in this list of change of management system, including the barriers in communication and reporting system. Another possible barrier is the inadequate skill and resources to meet the requirement of responsibility and accountability, therefore the company should provide appropriate level of induction program. The barrier in commitment should be tackled by maintaining frequent and intense communication to each stakeholder, internally and externally. Monitoring of performance can be made by the use of safety performance monitoring, which include: 1.) hazard reporting system, 2.) safety audit, 3.) safety survey, 4.) safety reviews, 5.) safety studies, and 6.) internal safety investigations (ICAO, 2009). Furthermore, lag indicator and lead indicator are the useful tools to indicate safety performance. The combination of the two indicators provides a comprehensive understanding on how the change might have given effect to the safety management system as a whole. Lag indicator, or output measurement, focus on the product of the system’s change. There are numerous lag indicators that can be used to indicate the level of safety in this company; some of them include number of incidents and accidents, cost of work compensations, number of injuries,

Ikhwan Muhammad – Safety Management System Assignment 3

and number of property damages. In relation to this, the company can follow the method of recording information on injury and disease experience at the workplace specified in AS 1885.1:1990 (Standards Australia, 1990). Lead indicator, or process measurement, focus in the process of the system’s change. It represents the process of change within the system. The lead indicators that can be used in this case include roll-out of safety-related KPI (Key Performance Indicator)’s to middle management (accountability), number of new hazard identified (hazard identification), number of safety reports (reporting),and development of new objectives and targets (objectives and targets). To ensure success, the company needs to conduct periodical review of the implementation of the change. The adherence to standard demands periodical review to maintain its effectiveness. Depends on the risks and hazards, OHSMS need to be evaluated at least every two years or less and its policy, objective and procedure should be reviewed by the level of management that establish them (Standards Australia, 2001). AS/NZS 4801:2001 outline the following points to be included in the review: 1.) results from audits, 2.) the extent to which objectives and targets have been met, 3.) the continuing suitability of the OHSMS in relation to changing conditions and information, and 4.) concerns of relevant interest parties (Standards Australia, 2001). References Bentley, T., & Haslam, R. (2001). A comparison of safety practices used by managers of high and low accident rate postal delivery offices. Safety science, 37(1), 19-37. Cigularov, K. P., Chen, P. Y., & Rosecrance, J. (2010). The effects of error management climate and safety communication on safety: A multi-level study. Accident Analysis & Prevention, 42(5), 1498-1506. Clarke, S. (2006). Safety climate in an automobile manufacturing plant: The effects of work environment, job communication and safety attitudes on accidents and unsafe behaviour. Personnel Review, 35(4), 413-430. ICAO. (2009). ICAO Doc 8959 - Safety Management Manual. Retrieved from www.icao.int website: http://www.icao.int/safety/ism/Guidance%20Materials/DOC_9859_FULL_EN.pdf Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 13(suppl 1), i85-i90. Mearns, K., Flin, R., Gordon, R., & Fleming, M. (1998). Measuring safety climate on offshore installations. Work & Stress, 12(3), 238-254. Mearns, K., Whitaker, S. M., & Flin, R. (2003). Safety climate, safety management practice and safety performance in offshore environments. Safety science, 41(8), 641-680. Morgeson, F. P., & Hofmann, D. A. (1999). The structure and function of collective constructs: Implications for multilevel research and theory development. Academy of Management Review, 249-265.

Ikhwan Muhammad – Safety Management System Assignment 3

Nakajima, K., Kurata, Y., & Takeda, H. (2005). A web-based incident reporting system and multidisciplinary collaborative projects for patient safety in a Japanese hospital. Quality and Safety in Health Care, 14(2), 123-129. Probst, T. M. (2004). Safety and insecurity: exploring the moderating effect of organizational safety climate. Journal of Occupational Health Psychology, 9(1), 3. Reason, J. (2000). Human error: models and management. Bmj, 320(7237), 768-770. Sawacha, E., Naoum, S., & Fong, D. (1999). Factors affecting safety performance on construction sites. International Journal of Project Management, 17(5), 309-315. Siu, O.-l., Phillips, D. R., & Leung, T.-w. (2004). Safety climate and safety performance among construction workers in Hong Kong: The role of psychological strains as mediators. Accident Analysis & Prevention, 36(3), 359-366. doi: 10.1016/s00014575(03)00016-2 SKYbrary. (2012). Safety Accountabilities and Responsibilities. Safety Management Retrieved 9 November, 2012, from www.skybrary.aero/index.php/safety_accountabilities_and_responsibilities Smith, M. J., Cohen, H. H., Cohen, A., & Cleveland, R. J. (1978). Characteristics of successful safety programs. Journal of Safety Research; Journal of Safety Research. Standards Australia. (1990). AS 1885.1:1990 Workplace injury and disease recording standard. Retrieved from http://www.saiglobal.com/online/ Standards Australia. (1998). AS/NZS 3931:1998 Risk analysis of technological systems Application guide. Retrieved from http://www.saiglobal.com/online/ Standards Australia. (2001). AS/NZS 4801:2001 Occupational health and safety management systems Specification with guidance for use. Retrieved from http://www.saiglobal.com/online/

Ikhwan Muhammad – Safety Management System Assignment 3

APPENDIX 1. Safety Management System Draft 1. Personnel and responsibilities Designate an OHS committee to be responsible and accountable on the implementation of OHSMS All personnel (including contractors) are responsible for their OHS performance The induction program should specify clearly the list of accountability and responsibility of each job

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Procedures and work-flow - Technological assessment should be made in the adoption of new technological system or machine prior to the use. - The risk analysis of technological system should be based on AS/NZS 3931 - The contractors should be informed of their level of OHS responsibility and accountability during the induction program - Establish appropriate reporting mechanism - Establish frequent mechanism of communication and consultation with external and internal stakeholder - Provide training and induction program for worker handling the automated tasks and batch-processing machinery Tools - Introduce web based hazard reporting tool - Use the workplace injury and recording standard based on AS/NZS 1885.1 - Introduce tools to improve safety communication, including: safety policies, procedures, newsletters, bulletins, and websites. Metrics – performance monitoring and measurement. Lag indicators: number of incidents and accidents, cost of work compensations, number of injuries, and number of property damages. Lead indicators: roll-out of safety-related KPI’s to middle management (accountability), number of new hazard identified (hazard identification), number of safety reports (reporting),and development of new objectives and targets (objectives and targets).

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