Compliance audits have proven to be a highly effective risk management tool in Environmental, Health and Safety (EHS) programs. Health and safety auditing is an essential element of an organization's risk management program as supported by the inclusion of review or audit processes in industry and ISO standards.
Many occupational health and safety standards require periodic and/or annual assessments to ensure program effectiveness, proper implementation of internal safety controls, adequate employee competency, and appropriate use of established plans. In this article, we will focus on the most critical health and safety standards outlined by the U.S. Occupational Safety and Health Administration (OSHA).
Having a good understanding of regulatory target areas (such as OSHA's National Emphasis Programs) as well as commonly found audit gaps provides a solid baseline to configure audit focus areas. Common health and safety audit findings span all areas of OSHA's general industry standards, as well as process safety management.
It's important to identify the standards for which periodic and/or annual audits or inspections are required. For example, mandatory reviews are included in all of the following OSHA regulatory standards:
- 1910.119 - Process Safety Management (PSM)
- 1910.134 - Respiratory Protection
- 1910.146 - Permit-Required Confined Spaces
- 1910.147 - Control of Hazardous Energy (Lockout/Tagout)
- 1910.178 - Powered Industrial Trucks
- 1910.179 - Overhead and Gantry Cranes
- 1910.1030 - Bloodborne Pathogens Exposure Control Plans
- 1910.1450 - Occupational Exposure to Hazardous Chemicals in Laboratories
Not every facility is subject to every standard, which is why clear understanding of the applicability of the codes and standards is imperative to developing an effective health and safety program with a compliance audit element that can review applicability and reduce the risk of incident.
Auditing is also a key element in conformance to voluntary international health and safety management system standards such as ISO 45001 . In recent years, federal and authorized state occupational health and safety agencies have increased their emphasis on targeted enforcement. OSHA annually releases the top ten most violated regulatory standards based upon its annual inspection and enforcement program as well as the latest data from inspection and enforcement cases from violations.
Anatomy of a Health & Safety Audit
A health and safety audit should be a systematic, documented, and objective review of an audited entity (facility, program area, system) to evaluate its compliance status relative to audit criteria. A checklist may be applied using various criteria such as regulatory standard requirements, industry guidance, and agency enforcement directives and guidance, as well as the organization's corporate policies, procedures, and guidance. The audit may also be focused on a specific or set of regulatory programs, the elements of an overall management system program, and/or the health and safety requirements within a certain function, area, or process of a facility.
Upon review of the annual OSHA inspection data, there are notable trends within the compliance audit and inspection findings which may inform decision-making regarding a facility's upcoming inspections or scheduled audits.
Trending Compliance Audit Findings and Issues
The following findings occur most often as indicated by OSHA's data and author's experience. It's crucial to understand what types of citations OSHA is prioritizing and what part of your program corresponds. These program areas are based on the general OSHA Safety and Health Program Audit Tool and include examples of where the citation will be found.
OSHA's Safety And Health Program Audit Tool focuses on these specific program areas. The “Program Area” column of the chart refers to these numbered sections:
- Section 1: Management Leadership
- Section 2: Worker Participation
- Section 3: Hazard Identification and Assessment
- Section 4: Hazard Prevention and Control
- Section 5: Education and Training
- Section 6: Program Evaluation and Improvement
- Section 7: Communication and Coordination for Host Employers, Contractors, and Staffing Agencies
While not a complete listing of all possible findings, this list in Table 1 provides some common types of non-compliance issues encountered at many facilities. Audit results, of course, will vary based upon the applicable compliance obligations for each individual organization, the site's location, and the scope of the audit.
Table 1. Common Findings by OSHA Audit Type with Audit Tool Program Area
|OSHA Standard||Citation/Finding||Program Area|
Walking and Working Surfaces
|Lack of adequate inspection programs for portable or fixed industrial ladders||3, 6|
|Lack of fall protection hazard assessments||3|
|Lack of competent person inspection of systems / components||4|
Exits and Emergency Planning
|Absence of Emergency Action Plans or plans lack the required elements addressing all foreseeable emergencies||3|
|No assignment of employees to support emergencies and evacuations||1, 2|
|Failure to maintain required exits and emergency egress||2, 4, 5|
Fire Prevention Planning
|Failure to provide fire prevention plans or failure to update fire plans where new hazards/sources exist||1, 3|
|Failure to maintain or supervise emergency alarm systems||1, 4|
Process Safety Management
|Failure to identify and assess applicable site sources and processes such as chemical warehouses that exceed the plan thresholds of 10,000 lbs.||3|
|Failure to develop Mechanical Integrity (MI) Procedures||1, 3|
|Failure to conduct inspections||3, 6|
|Failure to correct deficiencies||4, 6|
|Failure to conduct inspections in accordance with recognized engineering practices (RAGAGEP)||3, 6|
Personal Protective Equipment and Respiratory Protection
|Lack of PPE hazard assessments or certifications that are current for site's processes||1, 3, 6|
|PPE is in poor condition, is improperly worn, or is not worn when required||1, 2|
|Lack of employee training on the use, limitations, proper wear, or inspection of respirators that are used||5|
|Employees have not been properly fit tested||4|
|Emergency use respirators are not maintained and inspected monthly as required||4, 6|
Confined Spaces / Permit-Required
|Site has not been inventoried for confined spaces including those that are permit-required||1, 3|
|Failure to post or inform employees about permit-required spaces||1, 5|
|Failure to develop or implement procedures for providing or summoning emergency services for rescue during a permit-required entry||1, 4, 7|
Control of hazardous energy
|Failure to develop equipment-specific procedures for lock out/tag out of hazardous energies||1, 4|
|Authorized and affected employees have not been determined and properly trained.||1, 5|
|Protective materials and hardware have not been specifically identified or are used for purposes other than lock out/tag out procedures||2, 5|
|Failure to conduct periodic inspection of energy control procedures||3, 6|
Powered Industrial Trucks (PIT)
|Failure to provide rated equipment for process hazard operation areas such as electrically classified areas||1, 3|
|Lack of pre-shift unit inspections||3, 6|
|PITs have been modified, affecting the manufacturer's certification or load rating||4, 6|
|PIT fuel storage and handling does not meet national or local code requirements such as fuel storage inside buildings||4|
Hand and Portable Powered Tools
|Tools are defective or are not listed for certain process areas such as use in wet locations||2, 3, 5|
|Guards for tools are missing or defective||2, 3|
|In-house fabricated jacks or jack stands are not properly rated or marked||4|
|Tool retainers are not in place for pneumatic tools||2, 3|
|Electrical / Hand and Portable Powered Tools||Lack of proper grounding for powered tools||3|
|Electrical equipment is not installed or used consistent with its listing and labeling (e.g. use of relocatable power taps (multi-plug power strips between appliances and permanent power, daisy chaining these units)||3, 5|
|Electrical installations lack proper grounding or conductors and insulation is frayed, cracked or in poor condition||3|
|Unused electrical raceways, gutters, junction box openings are not closed||2 3|
|Installed electrical installations such as panelboards, cabinets, etc. are not closed as required||2, 3|
|Disconnecting means for motors, appliances, etc. are not properly marked and labeled as required or are no longer legible||4|
|Sufficient access and working space are not provided or maintained for all electric equipment safe operation and maintenance, as required||2, 4, 5|
Toxic or Hazardous Substances
|Failure to inspect, identify, or mark and inform employees of the presence of asbestos-containing materials||3, 5|
|Lack of exposure assessments for toxic substances in employee work areas where metals or compounds containing beryllium, hexavalent chromium, or lead are used||3|
Toxic and hazardous substances: Bloodborne pathogens
|Failure to review and identify employees that are occupationally exposed to bloodborne pathogens or otherwise potentially infectious materials||1, 3|
|Lack of an Exposure Control Plan||1|
|Failure to provide or offer Hepatitis B vaccines to employees who are occupationally exposed after initial assignment||4|
|Failure to properly label containers of hazardous chemicals||2, 3, 5|
|Failure to maintain the required safety data sheets for each hazardous chemical in the workplace||4|
Occupational Exposure in Laboratories
|Failure to develop or update a Chemical Hygiene Plan, as required||1, 6|
|Lack of initial monitoring for new hazardous substances as required for regulated substances in laboratory processes||3|
As one would expect, many of these findings fall under the Hazard Identification and Hazard Prevention program areas; however, there are additional findings that should be considered. Often, audit findings do not include root cause analysis for an identified gap which may be needed to determine appropriate corrective actions including leadership responsibilities, employee requirements or training.
Keys to Successful Program Management
Ultimately, the success of a safety and health program depends on identifying hazards early when processes and equipment changes, ensuring employees are trained and aware of the requirements especially when employees or their roles and responsibilities change, and ensuring that controls (plans, programs, equipment, tools, etc.) are regularly reviewed, audited, and updated.
Identifying hazards early after changes
When changes occur to processes or equipment, it is imperative that these be evaluated for existing and new hazards. The appropriate method for identifying those hazards may vary (i.e. HAZOP, JHA or JSA exposure assessments, PPE hazard assessments) but the purpose is the same: identify the hazards so that they may be controlled and mitigate the risk to worker health and safety. Failure to conduct these assessments in a timely manner after process or equipment changes leaves creates opportunity for violations and incidents.
Involving employees in changes to ensure awareness and training
Employee awareness and training is critical to successful safety and health programs. Auditors evaluated training in several areas including emergency planning, personal protective equipment, respiratory protection, permit-required confined spaces, lockout/tagout, powered hand tools, electrical safety, toxic substances, and hazard communication. Companies with affects processes and equipment should review their employee education and training elements to identify gaps in the program. Regardless of the standard, ensure your program engages and involves employees.
Reviewing controls regularly
The final key element to successful health and safety programs is ensuring that controls (plans, programs, equipment, tools, etc.) are regularly reviewed/audited. Changes in personnel, equipment, technology, and procedures dictate that any hazard prevention controls be regularly reviewed to ensure they are still adequate for the risk mitigation required. Prioritize regular maintenance of the program by ensuring that time-based reviews/audits have the appropriate resources and are completed to the appropriate level and standard.
Managing Your Health and Safety Program
A well-crafted health & safety audit program addresses all applicable OSHA and state standards and considers areas of focus by OSHA and common findings during audits. Preparation for the H&S audit follow these general steps:
- Organize and have readily available records used to demonstrate compliance with the program areas being audited.
- Emphasize availability of records (e.g. training) maintained or managed by non-EHS departments, such as Human Resources or outside vendors.
- Assuring availability of personnel for interviews during the audit site visit. Interviews are a key element in auditing which allows the auditor to obtain first-hand knowledge regarding the implementation of H&S programs.
- Provide advanced information to auditors about site-specific safety requirements such as specific personal protective equipment requirements, and any COVID-19 site requirements and/or pre-visit restrictions.
The management of EHS compliance programs is a dynamic process within any organization. It consists of the ever changing interactions related to process controls, job task performance, and workplace conditions that occur across organizational functions such as senior leadership, middle management, line management, finance, production operators, engineering, and contractors. Periodic change in technology and personnel increases the complexity of these interactions.
Robust Auditing Programs are Key to Effective Risk Management
Within all these variables is the constant need for assessing system and enterprise business risks, including risks impacting employees. This risk assessment process should ensure that employees are exhibiting effective situational awareness of the risks, which can be a continual challenge given the variety of individual experiences and risk perceptions.
Time and time again, compliance audits have proven to be a highly effective risk management tool. Proper preparation and selection of highly skilled and experienced auditors will enhance the value of the overall process.
For assistance with Health and Safety Audits, please contact the author or call 800.229.6655.