639-IGC1 Element 8 Monitoring-V3

Element 8
Monitoring, Review and

Audit of Health and
Safety Performance
CHSS Ltd 2006

wpc/SJ/ae/IGC Element 8 Monitoring, Review and Audit of H&S Performance
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Sales Ref: sc/639/v3
CHSS Ltd 2006

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Contents
Page No
Introduction
Monitoring
Active and Reactive Monitoring
Active Monitoring
Reactive Monitoring
13
Performance Review
14
Auditing
15
Purpose and Scope
15
Pre-Audit Preparation
16
Internal and External Audits
19
References
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Introduction
Monitoring, review and audit are important steps in the management of occupational
health and safety. They constitute the feedback loop which enables the
organisation to collect data, analyse performance and implement corrective actions
to achieve continuous improvement.
Monitoring describes a range of methods used by organisations to measure what
they are doing to implement policy, to assess how effectively they are controlling
risks and how well they are developing a positive health and safety culture. This
includes both active and reactive monitoring.
Reviewing performance is a process of analysing data gathered through monitoring
techniques to make judgements about whether performance is adequate, i.e. that
risks are adequately controlled and managed.
Where performance is not adequate decisions will need to be made about how to
remedy the deficiencies.
Auditing is a critical examination of each stage of an organisations management
systems and procedures in order to establish whether or not systems exist, are
adequate and are used.
Without necessarily using these phrases, the techniques of monitoring, reviewing and
auditing are always incorporated into occupational health and safety management
systems (see Element 1), e.g.:
N
the ILO Occupational Safety and Health (OSH) Management System, ILOOSH 2001, includes stages of evaluation and action for improvement;
the OHSAS 18001 specification includes elements of checking and corrective

action and management review; and
the HSE guidance, Successful Health and Safety Management, HSG 65.
Monitoring
Measuring or monitoring performance is an essential step of managing any aspect of
business to identify strengths and weaknesses and measure progress against
objectives.
Peter Drucker is a quality management expert, who has given extensive advice about
business management. He suggested:
What gets measured, gets done. (Drucker, 1942).
This is a reminder of the importance of measuring performance if objectives are to be
achieved:
What gets done should be measured.
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Health and safety performance should be monitored at all levels of the organisation,
from day to day monitoring by line managers and supervisors, to periodic audits of
management systems.
Active and Reactive Monitoring

Performance measurement techniques fall into two broad categories:
Active (pro-active) monitoring: monitors organisational progress in health and
safety.
Reactive monitoring: monitors organisational failures.
Reactive Monitoring
Active Monitoring
Compliance with key performance
indicators (KPIs) and procedures
Near misses / incident investigation

Dangerous occurrences
Achieving annual plan targets, e.g.

completed risk assessments, training,
etc.
Accident and sickness absence

investigation
Benchmarking
Accident / ill-health statistics
Inspections of equipment and premises
Enforcing Authority intervention /

enforcement
Environmental monitoring, e.g. noise

Complaints by the workforce
Sampling the use of control measures,
PPE
Civil claims and insurance premiums
Tours of the workplace

Surveys, e.g. asbestos, machinery
Work observation
Audit
Monitoring organisational progress
Monitoring organisational failure
Table 1: Examples of Active and Reactive Monitoring
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Active Monitoring
Workplace Inspections
A general workplace inspection is a formal, structured examination of the physical
working environment.
The purpose of a safety inspection is to identify obvious hazards that are not
controlled to a specified standard and then to eliminate or control them.
General workplace inspections, whilst providing valuable information for the safety
practitioner and the organisation, have three major limitations:
N
some hazards are not visible, e.g. psychological stress, poor process
design;
some hazards are not always present, e.g. intermittent (irregular)

mechanical faults, overflowing or leaking vessels, hazards that may occur
only in certain circumstances; and
unsafe practices, e.g. people behaving in a manner which may expose them
to a hazard, such as taking short cuts across a moving conveyor. These are
just as important as hazards, but may not occur when employees know an
inspection is being carried out.
Type and Frequency of Inspection

Types of inspections include:
N
general workplace inspections by management, health and safety

representatives, etc.;
statutory inspections by competent person as required by national laws,

e.g. for lifting equipment, pressure vessels, etc;
compliance inspections to compare against performance standards

including legal compliance (which may form part of a regulatory inspection or
an audit); and
commissioning inspections of new processes, premises or equipment.
The frequency of inspection will depend upon factors such as the purpose of the
inspection, the person/s carrying out the inspection, the level of risk, and conditions
observed at the last inspection, e.g.:
N
general workplace inspections conducted by health and safety

representatives at least once every three months;
the frequency of statutory inspections of lifting equipment will depend upon

the type of equipment / accessory for lifting (tackle), and whether it is used for
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lifting people;
N
the frequency of compliance inspections by the Enforcing Authority will

depend upon the level of risk and the organisations ability to control the risk.
An organisation with poor conditions and management may be routinely
inspected several times per year; and
commissioning inspections may be carried out more frequently during the first
few months of operation to identify any unforeseen hazards or issues that
arise.
In addition the frequency of general workplace inspections may be tiered depending

upon who carries them out, e.g.:
N
a supervisor may carry out weekly housekeeping inspections;
a line manager may carry out 3 monthly inspections; and
a director / senior manager may carry out an inspection annually.
Competence of the Inspector

Inspections may be carried out by any number of suitably qualified (competent)
personnel, or a combination of people:
N
managers, supervisors and employees may be used to carry out general

workplace inspections. A checklist, form, or report may then be completed;
the safety officer / adviser may conduct an inspection to compare against

performance standards and legal compliance. A short report will usually be
written;
health and safety representatives generally have the right to conduct

inspections of the workplace. A health and safety representative may wish to
carry out an inspection in order to investigate complaints made by colleagues
or to establish compliance with specified standards;
the Enforcement Agencies will conduct inspections to determine

compliance with legal standards, carry out accident investigation, or
investigation of complaints; and
specific competent persons (often an insurance company inspector) may

be appointed where statutory engineering inspections are required, e.g.
cranes, hoists, accessories for lifting, pressure vessels, etc. A detailed report
will be written post inspection.
As a minimum the persons carrying out inspections will need:

N
a knowledge of the tool of workplace inspections, their advantages and

limitations;
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an understanding of the process, activity, or area;
a knowledge of the hazards associated with the process, activity, or area;
a knowledge of the acceptable performance standards required to control the

hazards;
an ability to complete a checklist, form and / or write a short report (as

applicable); and
experience of carrying out inspections.
Inspection Checklists
In many situations the use of a pre-prepared checklist of topics may be useful as a
memory aid and to prompt the inspector into examining the appropriate areas. A
checklist might include various points under headings such as:
N
condition of processes and other plant;
contractors;
electrical;
environmental conditions / transport routes;
fire protection;
first-aid provision;
hand held / portable tools;
hazardous substances;
housekeeping / cleanliness;
lifting equipment;
lighting;
manual handling;
mechanical / machinery guarding;
noise;
personal protective equipment;
pressure vessels;
safe access / egress;
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signs and abstracts;
suitability of stored materials;
temperature / ventilation; and
welfare conditions.
The above list is not exhaustive. It is also important to note that a disadvantage of a
checklist is that an individual may fail to see any issue which is not part of the list,
e.g. ergonomics is not mentioned on the above list.
Inspection Reports
Simply identifying hazards and listing them is unlikely to improve safety. Therefore,
inspections should lead to corrective action. Following an inspection it is essential to:
N
identify actions to eliminate or control the hazards now, and also to prevent
them from occurring again;
prioritise the actions to be taken;
set clear responsibilities and dates for action; and
identify a date for review of the actions.
Therefore the report needs to be short and persuasive to encourage management to

prioritise action according to the highest risk. To be effective the report should be
structured, summarising the key issues, and placing emphasis on the need for action.
The style will depend upon the purpose of the report and who is writing it (see
Element 4).
Safety Sampling
This is a regular random exercise in which unsafe acts and conditions are noted and
recorded. The workplace is divided into routes which assigned observers walk in an
allotted timescale, noting incidence of health and safety defects on pre-prepared
safety sampling sheets. The safety sampling sheets include tables of grouped and
coded retrospective and prospective unsafe conditions and practices, e.g.:
Group 1. Housekeeping
Code 1.1 slip hazard
1.2 trip hazard
1.3 fall hazard
1.4 accumulation of waste
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1.5 blocked or obstructed walkways / fire exits

1.6 poor storage of materials
1.7 spillages
1.8 poor cleanliness standards
Group 2 Protective clothing, not worn or defective
Code 2.1 no or defective eye protection
2.2 no or defective foot protection
2.3 no or defective overalls
2.4 no or defective gloves
2.5 no or defective head protection
etc.
Observers should report any serious defects or hazards immediately. The number of
omissions or non-compliances is then counted to provide a score of the overall
effectiveness of the safety performance. The technique has little scientific validity
(the observers attentiveness is sure to vary) but has the advantage of raising the
profile of the safety improvement effort. Corrective measures are then implemented
as necessary. Subsequent future safety sampling sheets should demonstrate an
improvement in performance.
Safety Tours
A safety tour is a planned unscheduled examination of the workplace to assess
whether or not acceptable standards of housekeeping, safe access, fire precautions,
etc. are being maintained. Some hazards may be identified but a tour gives a
general impression rather than a thorough analysis of hazards. Tours by senior
managers can demonstrate the profile of, and commitment to, health and safety.
Safety Surveys
A safety survey focuses on specific health and safety topics, e.g. a survey of fire
precautions, and is normally carried out by a specialist. Detailed reports on the main
strengths and weaknesses, with an action plan, are normally produced as a result of
surveys.
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Active
monitoring
method
Inspection
Outline
Purpose
A formal, structured
examination of the physical
working environment taking in
the whole area.
To identify obvious hazards and

eliminate or control the hazards.
e.g. a health and safety

representatives inspection or
a weekly supervisors
inspection.
Safety sampling A random sampling exercise
observing health and safety
conditions and practices.
e.g. to observe the use of
hearing protection.
To note any omissions or noncompliances. The number of

non-compliances are counted
to provide a score of the overall
effectiveness of safety
performance.
Safety tour
A planned tour of the

workplace via a predetermined
route, often by senior
management.
To assess generally whether

workplace standards are
acceptable and to raise the
profile of health and safety.
Safety survey
An examination of a specific
aspect of health and safety.
Normally carried out by a
specialist.
To determine the condition,

strengths and weaknesses of a
specific hazard.
e.g. machinery guarding,

building or fire precautions
survey.
Table 2: Summary of Active Monitoring Techniques
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Reactive Monitoring
Reactive Monitoring: monitors management failures that have occurred, e.g. data
on accidents, dangerous occurrences, near misses, ill-health, complaints by the
workforce and enforcement action, etc.
Another means of reactive monitoring includes the development of, and comparison
with, external accident statistics, e.g. comparison with accident statistics published,
by country, by the ILO. The ILO Occupational Safety and Health Convention,
C155, requires:
the establishment and application of procedures for the notification of
occupational accidents and diseases, by employers and, when appropriate,
insurance institutions and others directly concerned, and the production of
annual statistics on occupational accidents and diseases.
In the UK the HSE publish annual statistics accident and ill-health incidence rates per
100,000 employees by sector (see Element 2). Organisations in the same sector can
benchmark against these figures and therefore monitor their own performance. It is
an annual calculation and the figures need to be adjusted pro-rata if they cover a
shorter period or use a different multiplying factor. Such shorter-term rates should be
compared only with rates for exactly similar periods, not the national annual rates.
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Performance Review
The purpose of performance review is to analyse data gathered through monitoring
techniques and to make judgements about whether performance is adequate. The
review will then question whether the organisation:
N
achieves health and safety objectives;
implements effective risk controls;
ensures that awareness, training, communication and consultation

programmes for employees are effective;
learns lessons from management system failures;
implements information gained to improve the management system across

the whole organisation;
meets legal standards; and
reduces the risk of accidents and ill-health.
By identifying strengths and weaknesses, discovering where standards have dropped

and where changes have occurred, performance review helps to maintain
momentum in health and safety management, and to manage change.
The results of reactive monitoring will provide information about historical events
which are the result of management system failures, e.g. failure to train employees.
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Auditing
Purpose and Scope
An audit is a tool used to review the performance of the health and safety
management systems. It asks whether the system:
N
Exists;
is Adequate; and
is Used.
The purpose of an audit is to identify management or organisational failures which

are the root causes of accidents and ill-health, and strengths which can be promoted
throughout the whole organisation. A report will then be produced to assist the
implementation of corrective action.
Audits
Inspections
Tests the existence, adequacy and use

of safety management systems.
Identifies hazards that are not controlled

to a standard.
Includes physical inspection, interviews

and documentation checks.
Physical inspection only.
Identifies organisational failures which

are root causes of accidents and illhealth.
Very proactive.
Identifies unsafe conditions and some

unsafe actions which are immediate
causes of accidents.
Can be largely reactive if they lead to
quick fix of immediate causes rather than
corrective action of root causes.
Table 3: The Differences Between Audits and Inspections

There are several types of audit programmes, e.g.:
N
internal / external audits covering the organisation-wide health and safety

management system for the current year;
internal / external management system audits of contractors to verify

conformance with contractual requirements; and
certification / registration audits by an external body, e.g. CHSS, undertaking

an audit to assess conformity with a certified standard (OHSAS 18001).
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Objectives of the Audit

The audit objectives define what is to be accomplished by the audit, i.e. the audit
purpose. The objectives are defined by the client and may include the following:
N
the extent of conformity with the management systems;
an evaluation of the capability of management to ensure compliance with

legal requirements;
evaluation of the effectiveness of the management system to meet objectives;

and
identification of areas for potential improvement of the management system.
Scope of the Audit

The audit scope describes the extent and boundaries of the audit, such as physical
locations, business units, activities and processes to be audited, e.g. the auditors will
need to decide whether the audit includes non-routine operations such as the work of
maintenance or contractors. The audit may also address other disciplines such as
quality and environmental management systems. The scope will also include the
time period covered by the audit, e.g. current financial year.
Pre-Audit Preparation
Audits should be conducted according to planned arrangements. An annual plan will
identify a planned audit schedule for the entire organisation, the frequency of audits
being related to the risks associated with each area of operation, the results of
previous audits and the extent of change. Each audit will then take the following
steps:
1.
Setting audit objectives

The first step is to identify the objectives and scope of the audit programme.
2.
Selecting the audit team

The team may range from one person to a group of people, e.g. a health and
safety practitioner, a member of the management team, an occupational
health nurse / doctor, specialists such as radiation protection advisers or
chemists; or a multi disciplinary combined audit team such as health and
safety, environment and quality, etc. The size and composition of the team
will depend upon the audit objectives.
Competence will include technical ability, knowledge and experience of
auditing, and interpersonal, report writing and presentation skills.
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3.
Notifications and contact with the auditees

The audit leader will establish an audit plan and will then contact the auditee
to:
N
N
N
N
N
N
N
request the availability of documents, e.g. policy;

request data, e.g. accident rates;
provide a proposed audit schedule;
provide details of the proposed audit team;
arrange interviews with key personnel;
arrange the availability of a guide during the audit; and
explain how results will be fed back to the auditees.
This is usually achieved by notifying the organisation by letter with requests

for documents and data, etc., allowing plenty of time for the information to be
gathered. Following this, a meeting will be arranged with key personnel,
before the audit, to explain the objectives and process, and to answer
queries.
4.
Information gathering
Audits collect information using the following methods:
N
N
N
N
N
N
5.
interviews;
observations of activities and working conditions;
examination of documents, e.g. policy, procedures, risk assessments,
training records, etc;
records, e.g. inspection and maintenance records, minutes from safety
committee meetings, previous audit reports, etc;
analysis of data, e.g. accident and near miss trends; and
physical inspection of the workplace.
Interviews
Interviews are a key part of the audit and should be adapted to the situation
and the person being interviewed. The interview may aim to confirm
evidence, to assess the understanding of employees, or to assess the
capability of managers to implement the management system requirements,
etc. The auditor should:
N
N
N
N
N
N
hold interviews with persons from appropriate levels and functions

within the scope of the audit;
conduct interviews within normal working hours and at the workplace;
put the person being interviewed at ease;
explain the reason for the interview, and how the information will be
used;
start interviews by asking the person to describe their work;
avoid questions which bias the answer (i.e. leading questions);
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N
N
6.
summarise and review the results of the interview with the interviewee;
and
thank the interviewee for their co-operation.
Conclude
The auditors will then analyse the information and make conclusions. This
usually occurs away from the audited premises. However, auditors may
request clarification or further information about issues that arise.
7.
Report and presentation

A detailed written report will be produced and for each management failure
the following details will be included:
N
N
N
N
the failure that has occurred;

the priority / significance of the risk, e.g. likelihood and severity of
accident / ill-health, reputation, etc.;
the standards which applied; and
recommended action.
A presentation to senior management may also be made to summarise the

findings, highlight the most significant issues, and motivate action.
8.
Action by the organisation

The organisation should then take action to feed the information back into the
management system and to implement the action required. The use of
prioritised, timed and allocated action plans will aid the process.
Implementation of the action plan should then be monitored.
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Internal and External Audits

Independence is essential to achieve impartial audit conclusions based on the audit
evidence. Auditors need to be independent of the activity being audited and free
from bias and conflict of interest. However, that does not require auditors to be
external to the organisation, only external to the activity or process.
The advantages of using internal auditors tend to be the disadvantages of using
external auditors and visa versa:
Internal Audits
External Audits
Advantages
Disadvantages
Cheaper
More expensive
Easier to arrange
More time required to organise
Auditees may find the auditors less

threatening
May be more formal and therefore more

threatening to auditees
Disadvantages
Advantages
May be more influenced by internal

relationships
Less knowledge of internal relationships
Conclusions may not taken seriously by

organisation
Increased formality and experience may

give more weight to conclusions
May be biased, e.g. audit scores creating

competition between departments
Independent of internal competition
May be so familiar with organisation that

assumptions influence conclusions
Independence requires auditors to ask

obvious questions rather than make
assumptions
Table 4: The Advantages and Disadvantages of Internal and External Audits
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References
ILO
2001
ILO-OSH: Guidelines on Occupational Safety

and Health Management Systems.
ILO
1981
C155: Occupational Safety and Health

Convention.
BSI
1999
OHSAS 18000: Occupational Health and Safety

Assessment Series.
BSI
1999

Management Systems Specification.
BSI
2002

Management Systems Guidelines for the
Implementation of OHSAS 18001.
HSE
2003
HSG 65: Successful Health and Safety

Management.
Drucker, P. F.
1942
Future of Industrial Man.
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Notes
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Notes
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Element 8

Monitoring, Review and

CHSS Ltd 2006

CHSS Ltd 2006

Active and Reactive Monitoring

Purpose and Scope

Internal and External Audits

CHSS Ltd 2006

CHSS Ltd 2006

the OHSAS 18001 specification includes elements of checking and corrective

Active and Reactive Monitoring

Near misses / incident investigation

Achieving annual plan targets, e.g.

Accident and sickness absence

Accident / ill-health statistics

Inspections of equipment and premises

Enforcing Authority intervention /

Environmental monitoring, e.g. noise

Civil claims and insurance premiums

Tours of the workplace

Monitoring organisational failure

Table 1: Examples of Active and Reactive Monitoring

CHSS Ltd 2006

some hazards are not always present, e.g. intermittent (irregular)

Type and Frequency of Inspection

general workplace inspections by management, health and safety

statutory inspections by competent person as required by national laws,

compliance inspections to compare against performance standards

commissioning inspections of new processes, premises or equipment.

general workplace inspections conducted by health and safety

the frequency of statutory inspections of lifting equipment will depend upon

CHSS Ltd 2006

the frequency of compliance inspections by the Enforcing Authority will

In addition the frequency of general workplace inspections may be tiered depending

a supervisor may carry out weekly housekeeping inspections;

a line manager may carry out 3 monthly inspections; and

a director / senior manager may carry out an inspection annually.

Competence of the Inspector

managers, supervisors and employees may be used to carry out general

the safety officer / adviser may conduct an inspection to compare against

health and safety representatives generally have the right to conduct

the Enforcement Agencies will conduct inspections to determine

specific competent persons (often an insurance company inspector) may

As a minimum the persons carrying out inspections will need:

a knowledge of the tool of workplace inspections, their advantages and

CHSS Ltd 2006

an understanding of the process, activity, or area;

a knowledge of the hazards associated with the process, activity, or area;

a knowledge of the acceptable performance standards required to control the

an ability to complete a checklist, form and / or write a short report (as

experience of carrying out inspections.

condition of processes and other plant;

environmental conditions / transport routes;

hand held / portable tools;

mechanical / machinery guarding;

personal protective equipment;

safe access / egress;

CHSS Ltd 2006

signs and abstracts;

suitability of stored materials;

temperature / ventilation; and

prioritise the actions to be taken;

set clear responsibilities and dates for action; and

identify a date for review of the actions.