Safety Management Systems

and Culture


Fenkins Chow
Industrial Centre


Jan 2014
1. What is
System
System concept based on
OHSAS 18001:2007

4.3 Planning
4.3.1 Hazard identification, risk
assessment & determining control
4.3.2 Legal & other requirements
4.3.3 Objectives & programme(s)

4.4 Implementation & Operation
4.4.1 Resources, roles, accountability&
authority
4.4.2 Competence, training & awareness
4.4.3 Communication, participation &
consultation
4.4.4 Documentation
4.4.5 Control of documents
4.4.6 Operation control
4.4.7 Emergency preparedness & response
4.5 Checking
4.5.1 Performance measurement & monitoring
4.5.2 Evaluation of compliance
4.5.3 Incident investigation, nonconformity,
corrective & preventive action
4.5.4 Control of records
4.5.5 Internal audit
Reference
4.6 Management Review
Please read: Section 4, BS OHSAS 18001:2007
PDCA Concept
Plan: establish the objectives and processes necessary to deliver
results in accordance with the organizations OH&S policy.

Do: implement the processes.

Check: monitor and measure processes against OH&S policy,
objectives, legal and other requirements, and report the results.

Act: take actions to continually improve OH&S performance.
Reference
BS OHSAS 18001: 2007, Occupational health and safety management
systems Requirements, page vi
M/C Operator
Machine
Safe M/C
Operation
Shop Supervisor
Machines
Safe M/Cs
Operation
M/C Operator
Machine
Safe M/C
Operation
M/C Operator
Machine
Safe M/C
Operation
- How to ensure safety?
Shop Supervisor
Machines
Safe M/Cs
Operation
Operation
observed by
inspector
Inspector compares
observation with safety
standards.
Manager to make any
corrective actions.
- Universal OHSMS Model
Occupational Health
and Safety
Management Systems,
Review and Analysis of
International, National,
and Regional Systems
and Proposals for a
New International
Document, 1998,
prepared for ILO by The
International
Occupational Hygiene
Association, available at
http://www.ilo.org/public
/english/protection/safe
work/cis/managmnt/ioh
a/index.htm
Reference
2. Is it
chaotic
What is the force
behind
SMS is a human system
Everyone has their operation/process
Everyone has their role/responsibility
Everyone will interact with each other
Input
Output
Output
Input
Roles, Responsibilities and Accountability
Every member of a company should own at least part of the
system, then s/he has a role.
Once you have a role, you should exercise your
responsibilities.
Whether you can run your responsibilities well or not, you are
accountable for the role assigned.
You can delegate responsibility to others, but you cant
delegate your accountability (ultimate responsibility) to other
position.

Illustration to explain Accountability &
Responsibility
Accountability Ultimate Responsibility
Responsibility A
Responsibility B
Responsibility C
Responsibility D
Responsibility E
Responsibility F
Accountability 1
Accountability 2
Responsibility A
Responsibility B
Responsibility C
Responsibility D
Responsibility E
Accountability 3
Responsibility A
Accountability 4
Responsibility C
Responsibility D
- Roles and Ownership
Example:
As a role of machine operator, he should own the machine,
including its safe use.
As a role of machine shop supervisor, he should own all the
machines, including provision of safe environment for the machine
operation.

Line ownership of the safety agenda is a direct extension of
management commitment. (p.185, Stewart)
Reference
Stewart, J.M., 2001, Managing for World Class Safety, John Wiley & Sons, USA
Every owner should be held accountable (to be responsible) for
his owned system and the associated sub-systems.
The owner is
required to exercise responsibilities
accountable for a task is responsible for ensuring that it is
completed in a manner which meets all expectations for it.

- Ownership and Responsibilities
Accountability: Accepting the consequences, good or bad, for the
outcome of a situation for which you are responsible.
when you are held accountable, your performance is measured
in relation to goals or objectives that may result in certain positive or
negative consequences (OSHA, quoted by Roughton et al, p 153)
Reference
Roughton, J.E., Mercurio, J.J., 2002, Developing an Effective Safety
Culture: A Leadership Approach, Butterworth-Heinemann.
- Responsibilities and Accountability
- Delegation
Report of the Somalia Commission of Inquiry, Accountability,
National Defence and the Canadian Forces:
A person who delegates authority is also responsible, and hence
accountable, not for the form of direct supervision that a supervisor is
expected to exercise but, rather, for control over the delegate and,
ultimately, for the actual acts performed by the delegate.

The act of delegation to another does not relieve the responsible official
of the duty to account. While one can delegate the authority to act, one
cannot thereby delegate one's assigned responsibility in relation to the
proper performance of such acts.

Issue No. 3 of Reporting Year 2010/11 (21 December 2010), Office of
The Ombudsman, Hong Kong:
Although it was the developer or contractor that installed/replaced the
water meters and recorded the meter numbers, WSD had the ultimate
responsibility to cross-check those data to ensure accuracy. It should not
have shifted its responsibility onto others.


Roles should be clearly defined
Before you can hold management/employees
accountable for their actions, make sure that they
know what is expected. (Roughton et al, p 152)
In larger org, managers must develop a MS for
clearly assigning safety responsibilities and
authority, and providing the necessary resources
to get this accomplished. (Roughton et al, p 139)

Reference
Roughton, J.E., Mercurio, J.J., 2002, Developing an Effective Safety Culture: A
Leadership Approach, Butterworth-Heinemann
Accountability - Examples
Taking a role
Ensuring that the target is achieved
Applying discretion and judgement to enable others to get to
the end of the path
The buck stops here
Monitoring that responsibilities are carried out and acting
where they are
Examples from BS OHSAS 18001, p. 8:
Top management shall take ultimate responsibility for OH&S and
the OH&S management system. (p. 8)
Top management shall .. b) defining roles, allocating
responsibilities and accountabilities and delegating authorities.
The top management appointee may delegate some of their duties
to a subordinate management representative(s) while still retaining
accountability.
A Railway-Industry Case in UK
Railtrack was the owner of a railway
It contracted out the maintenance of the track to
Amey Rail
A derailment occurred.
One of the major causes was the failure to maintain,
which was Amey Rails responsibility
Railtrack sought to put its failure into context by
pointing out that Amey Rail employed 2250 people
on maintenance in the region of the accident,
whereas Railtrack had only 25 supervising track
engineers.

Sec. 3 of HSWA, UK
General duties of employers and self-employed to
persons other than their employees:
3(1) It shall be the duty of every employer to
conduct his undertaking in such a way as to
ensure, so far as is reasonably practicable, that
persons not in his employment who may be
affected thereby are not thereby exposed to risks
to their health or safety.
3. Is the
system
running
- A Management Game
- You are working for this company
Technicians (10)
Engineering Manager
Engineers (5)
Director
General Office (4)
Form a group of 6:
1 acts as the Director
1 as the General Office
1 as the Manager
1 as Engineer
2 as Technicians

Expectations
In many companies, safety responsibilities are not
clearly defined.

While not defined, people in the org. will have
certain expectations in relation to safety.

Commitments are shown by actions /supports
Support must be present before expectation comes
In other words, support must be present before responsibility
can be exercised

For example:
Frontiers are expected to wear ear protectors in noisy env.
If so, they should be told by the supervisors when and how
to wear ear protectors.
The manager should ensure there is budget for ear
protectors and that budget is used.

How about if:
the manager does not set the budget or does not mind about
the use of the budget
the supervisors never make order of the ear protectors
the frontiers never ask for ear protectors
4 Levels of Staff
Frontier Employees at Operation Level
Expected to complying with rules and procedures
Need rules and procedures explained
Supervisors at Tactical Level
Select between fixed choices from a limited set of options, e.g. distribute tasks
Need resources provided
NB: Competent supervisor can mode frontiers into a team directed at common
goal
Managers at Strategic Level
Make decisions about resources required and allocate the resources
Need direction
Top Management at Strategic Level
Give direction and make decisions on levels of investment
Need supports from the key stakeholders
Conditions for running
Safety Climate vs Safety Culture
Safety climate - expressed attitudes towards safety within an
organization (Flin et al., 2000)
Climate as surface manifestation of culture and that culture manifests
itself in deeper levels of unconscious assumptions (Schein, 1990)
Culture less tractable and more complex than climate
Culture measured by qualitative methods whereas climate measured by
quantitative methods such as through questionnaire-based survey
(Denison, 1996)
Although an organization has the same policies and procedures,
individuals may interpret them differently. Why? See the following slides.

References
Flin, R., Mearns, K., O'Conner, P. & Bryden, R., 2000, Measuring safety
Climate: Identifying the common features Safety Science, Safety Science, v34, pp 177-192
Schein, E., 1990, Organizational culture, American Psychologist, v45, pp 109119
Denison, D., 1996, Academy of Management Review, What is the difference between organizational
culture and organizational climate? A natives point of view on a decade of paradigm wars, Academy of
Management Review v21, pp 619654
Albert Banduras
Model of Reciprocal Determinism
An individuals internal psychological factors, the environment they are
situated, and the behaviours they engage in, all operate as interacting
determinants that influence each other bi-directionally


Person
Behaviour Situation
Internal Psychological
Factors
External Observable
Factors
Application of Banduras Model to
Safety Climate and Safety Culture
Person
Safety Climate
Workforce attitudes to mgt
Mgt attitudes to workforce
Informedness about true state of affairs
Behaviour
Safety Behaviour
Mgt style
On-site behaviour
Priority setting
Situation
Safety Management Practices
Procedures
Environment
Design

Internal Psychological Factors
External Observable Factors
Safety Culture
What is Health and Safety Culture
product of individual and group values,
attitudes, competencies and patterns of
behaviour
that determine the commitment to, and the
style and proficiency of,
an organizations approach to health and
safety
Reference
BS 18004:2008, Guide to achieving effective occupational health and safety
performance, Sec. 3.22
Reference
Pulp and Paper Health and Safety Association, Fall 1998, Health and Safety Guardian, available at
http://www.pphsa.on.ca/pdfs/fall98.pdf, accessed on 5 Jan 2011
PATHOLOGICAL
who cares as long as were not caught
REACTIVE
Safety is important, we do a lot every time we have an
accident
CALCULATIVE
we have systems in place to manage all hazards
PROACTIVE
Safety leadership and values drive continuous
improvement
GENERATIVE
HSE is how we do business round here
Increasing Trust/Accountability
Culture Ladder by Patrick Hudson
Increasingly
informed
Please read: Hudson, P., Safety Culture, Theory and Practice, p. 8-7, Centre for
Safety Science, Leiden University
Videos
Progressive Ladder of Safety Culture
Generative Culture
Pathological
The organisation cares less about safety
than about not being caught.
This means:
people dont really care about safety, and are
only driven by regulatory compliance and
not getting caught
People would say, Of course we have accidents,
it is dangerous business.
Bad news is ignored.

Reactive
The organisation looks for fixes to accidents
and incidents after they happen.
This means:
safety only gets sufficient attention after things
have already gone wrong
Management say they take safety seriously about
safety but feels frustrated. They need to be forced
compliance.


Calculative
The organisation has systems in place to manage
hazards, however the system is applied
mechanically.
Staff and management follow the procedures but do
not necessarily believe those procedures are
critically important to their jobs or the operation.
Lots of audits in order to force people to comply with
procedures. Safety personnel shoulders a lot of
safety responsibilities.
Proactive
o Staff and management have begun to acquire beliefs that safety is
genuinely worthwhile.
o Looking forward. Consider what might go wrong in future and take
steps before being forced to.
o Line management takes over the safety function, while the safety
personnel provide advice rather than execution.
o Indicators become increasingly process-oriented rather than just
focused on incidents.
o The level of trust increases with people offering to accept
accountabilities (you can count on me) rather than just being told they
will be held accountable for some outcome. Workforce knows exactly
what managers expect.

Generative
o Safety behaviour is fully integrated into everything the
organisation does. The value system associated with safety
and safe working is fully internalised as beliefs, almost to
the point of invisibility.

o Phenomena:
Organizations set very high standards and attempt to exceed them
rather than be satisfied with minimum compliance
They dont just expect to get it right, they expect to get better.
Risks are not only controlled, but unforeseen risks are also
anticipated. Out-of-the-box innovations are needed rather than
doing things better (Zwetsloot et al, Spring 2013 cited in Green
Cross, 2013).
Like to learn and adapt.

Reference
Green Cross, 2013, The Zero Accidents Vision a commitment strategy for safety, vol.
23, no. 2, p. 6.
4. Run to
where
Culture + Systems
Safety management systems are still driven by paper
Minimum standards can be defined but this is not the best way to obtain
the extra benefits.
A good safety culture fills in the gaps.

Sound systems, practices and procedures are not adequate if merely
practised mechanically. They require an effective safety culture to
flourish.

So we need Safety Management Systems AND a Safety Culture.

Reference
Hudson, P., Achieving a Safety Culture in Aviation, Leiden University
Priorities
What top management considers important will get done.
People see what is really important by what they see their
bosses DO, not from what they hear them say.
Customers are in increasingly buying on safety as well as price.

Reference
Hudson, P., 2007, CAAS Aviation Safety Forum
Leadership
Staff commitment is influenced by their perceptions
of their supervisors commitment.
Top management are the ultimate supervisors.
If their commitment is genuine, sustained, and
manifested in their taking a keen professional
interest in OHS, their attitudes and behaviours
should cascade down the organization.
Reference
BS 18004:2008, Guide to achieving effective occupational health and safety
performance, p. 55
Some Characteristics of Positive Health and
Safety Culture shown by Leadership
Demonstrate visible OHS commitment, including their personal behaviour,
showing leadership by example. Make it clear that they are keen to hear the
bad news as well as good news and will take action on the information they
receive.
Senior staff and supervisors spend time discussing and promoting OHS in
the work environment; commend safe behaviour and express concern if OHS
procedures are not being followed. They do so even when the discussions
primarily concern operational matters.
OHS is managed with the same determination as other key business
objectives.
Health and safety representatives carry out their functions actively with the
support of management
OHS advisers have high status within the organization with direct access to
top management
OHS committees have high status, are proactive, are regularly attended by
senior staff, and publicize their work throughout the organization
Reference
BS 18004:2008, Guide to achieving effective occupational health and safety
performance, p. 53
System concept based on
BS8800:1996 (Suggested Ref. 1)
Source:
Elements of successful health
and safety management based
on the approach in HS(G)65
(extracted from BS 8800:1996)
ISR
Changes that affect EHS
Internal Factors:
1. Changes in staffing and org. structures
2. Changes in products, plant and processes
3. Process and software modifications

External Factors:
4. New or pending legislation, standards, or guidance
5. New knowledge and technology
6. Community / Clients new expectations
System concept based on BS 18004

Reference
Initial status review
BS 18004:2008, Guide to achieving effective occupational health and safety
performance, p. 53 (Suggested Ref. 2)
Definition by OHSAS 18002: 2007
Status Review: Formal evaluation of the OH&S
management system
Why doesnt it appear in the OHSAS18001 below?

System concept based on
OHSAS 18001:2007
Before PDCA starts,
OHSAS 18001 requires:
4.1 General Requirements: shall establish,
document, implement, maintain and continually improve
an OHS management system The organization shall
define and document the scope of its OHS management
system.

4.2 OH&S Policy: Top management shall define and
authorize the organizations OHS policy
Reference
BS OHSAS 18001: 2007, Occupational health and safety management
systems Requirements
HSE Management System
A framework for HSE Management in Shell
Alcohol
& Drugs
Policy
Audit
Plans
Road
Safety
Plan
Safety
Drills
Security
Policy
HSE
Policy
No Structure
Structure
Policy
Process
Task
Continuous
Improvement
Safety (HSE Cases)
Mgt.
policy
link
Reference
Hudson, P., 2007, CAAS Aviation Safety Forum
Another Example of Scope
Functions of Status Review
Review of the OHS arrangements and
procedures already in place (Smith et al., 2000)
Gives information of where the organization is
now in managing OH&S issues (Smith et al., 2000)
Indicates where the organization stands in
relation to managing risks (BS 18004:2008)
Most importantly, to answer what they are now
and what can be done.


BS8800:2004, Occupational Health & Safety Management Systems Guide
Smith, D., Hunt, G., Green, C., 2000, Managing Safety the Systems Way, BSI
References
Information Sought
Applicable legislative requirements dealing
with OHS issues
Stakeholders requirements
OHS risks faced by the organization
Existing OHS practices
Best practices within the organizations
employment sector
Efficiency and effectiveness of existing
resources devoted to OHS management

Approaches of Status Review
Questionnaire survey to gather the opinions from the
employees
Meetings with the employees to understand the existing
OHS issues and arrangements
Meetings with stakeholders, such as sub-contractors
and clients, to understand the needs for OHS
management
Safety inspection to measure and verify the existing OHS
issues and arrangements
Document review to find out the existing OHS
arrangements, traces of implementation of OHS
measures and other OHS requirements

Please read: David Smith, Geoff Hunt, Clive Green, 2000, Managing Safety
the Systems Way, Ch. 2, BSI, 2000

Relation between Initial SR and
Periodic SR
PSRs are a regular review of the OH&S
system
ISR is a one-off exercise at the start of a
new system design
PSR and ISR share similar approaches
Both should refer to external factors


5. Legal requirements on
SMS
What shall the
Specified Proprietors / Contractors do
Develop, implement and maintain a
Safety Management System (SMS) which
contains the specified elements
Reference
Factories and Industrial Undertakings (Safety Management) Regulation, Section 8
What shall the
Specified Proprietors / Contractors do
Develop, implement and maintain a
Safety Management System (SMS) which
contains the specified elements
Reference
Factories and Industrial Undertakings (Safety Management) Regulation, Section 8
Who are the Specified Proprietors / Contractors do
Reference
Factories and Industrial Undertakings (Safety Management) Regulation, Schedule 3, Sec. 2, 8, 9, 12
Part 2
Construction contractor / factory / shipyard
business / designated undertaking having 50
to 99 workers in a day working in a site /
factory / shipyard / workplace.
Part 4
Construction contractor / factory, shipyard
business / designated undertaking having 50 to
99 workers in a day working in 2 or more sites
/ factories / shipyards / workplaces.
Develop, implement and maintain
an SMS which contains the first 8
elements

Appoint competent safety review
officer to conduct Safety Review
annually (half-yearly for
construction work)

Read, countersign and date the
Safety Review Report

Draw up and submit a plan based on
any recommendations

IU involving (a) generation, transformation and transmission of electricity;
(b) the generation and transmission of town gas, or liquefied petroleum
gas; or
(c) container handling;
Part 1 (First 6 Elements):
Reference: Labour Department, 2002, CoP on Safety Management, p. 15
Promoted by Gov't as "Personal Protection Programme". See Sec.1(K)(vii), Reg. 15,
CAP 59Z: to assist in conducting safety promotion, health assurance and personal
protection programmes
Part 1 (Last 2 Elements):
Reference: Labour Department, 2002, CoP on Safety Management, p. 15
Who are the Specified Proprietors / Contractors do
Reference
Factories and Industrial Undertakings (Safety Management) Regulation, Schedule 3, Sec. 2, 8, 13, 16
Part 1
Construction contractor / factory, shipyard
business / designated undertaking having 100
or more workers in a day working in a site /
factory / shipyard / workplace.
Or construction contractor with a contract value
of $100 million or more.
Part 3
Construction contractor / factory, shipyard
business / designated undertaking having 100
or more workers in a day working in 2 or more
sites / factories / shipyards / workplaces.
Develop, implement and maintain
an SMS which contains the first 10
elements

Appoint a registered safety auditor to
conduct a
Safety Audit annually (half-
yearly for construction work)

Read, countersign and date the
Safety Audit Report

Draw up and submit a plan based on
any recommendations

IU involving (a) generation, transformation and transmission of electricity;
(b) the generation and transmission of town gas, or liquefied petroleum
gas; or
(c) container handling;
Part 2 (2 elements):
Reference: Labour Department, 2002, CoP on Safety Management, p. 15
How many audits?

A construction contractor has 4 constructions sites. Each of which has 100
workers. How many audits do they need to take per year?

Reference: Labour Department, 2002, CoP on Safety Management, Sec. 4.4
Development:
Status analysis (review) and
risk assessment to identify
what should be accomplished
Set safety policy and plan to
show how to accomplish the
objectives set
Implementation:
Prescribe relationships
between people and resources
by making arrangements and
identifying competencies
Execute control plans
Maintenance:
Routine proactive and reactive
monitoring to check
performance against agreed
standards
Assess performance to ensure
continued efficiency,
effectiveness and reliability of
the system
Reference: Labour Department, 2002, CoP on Safety Management, Sec. 4.1 to 4.4
Promoted by Gov't as "Safety Promotion Programme". See Sec.1(K)(vii), Reg. 15, CAP
59Z: to assist in conducting safety promotion, health assurance and personal
protection programmes

Part 3 (First 2 elements, yet implemented):
Reference: Labour Department, 2002, CoP on Safety Management, p. 15
Part 3 (Last 2 elements, yet implemented):
Promoted by Gov't as Process Control Programme". See Sec. 5.13, CoP on Safety
Management: This element refers to a process control programme



Promoted by Gov't as Health Assurance Programme". See Sec.1(K)(vii), Reg. 15, CAP
59Z: to assist in conducting safety promotion, health assurance and personal
protection programmes

Reference: Labour Department, 2002, CoP on Safety Management, p. 15
14 Elements = System


4.5 Application of the management model to individual elements of a safety
management system

The above management model should be adopted not only in the development,
implementation and maintenance of a safety management system, but also in the
development, implementation and maintenance of each and every element as
specified in Schedule 4 of the Safety Management Regulation constituting the system.


The law only requires to develop,
implement and maintain a safety
management system which contains the
elements specified
The law does not specify any system.
We should not just match the 14
elements with specific block of the
system in the CoP. Why?
RSO duties related to 14 elements
Safety Policy
assist in establishing, revising and reviewing a safety and health policy
assist in implementing safety and health plans, programmes, arrangements and measures
Safety Inspection Programme
inspect or direct safety supervisor to inspect the industrial undertaking
report the findings of the inspection to the proprietor and recommending what measures ought to be
taken
Accident/Incident Investigation
investigating and reporting, or causing to be investigated and reported to the proprietor, of any accident or
dangerous occurrence or bodily injury and making recommendations
Safety Training
assist in organizing a safety and health training programme
In-house Safety Rules
assist in devising in-house safety rules
Safety Committees
assist in establishing a safety committee and implementing its recommendations
Job Hazard Analysis
assist in job hazard analysis
Process Control Programme
advise the proprietor in the interest of the safety and health of any repairs or maintenance that ought to
be carried out
Safety Promotion Programme, Personal Protection Programme, Health Assurance Programme
assist in conducting safety promotion, health assurance and personal protection programmes
Reference: Reg. 15, CAP 59Z
Summary of Major OSH Development in HK
since 1986
28.02
24.12 24.32 23.64 21.5 23.48 24 22.2 23.4 20.7 18.8 15.7 17.5
310.9
333
369.3
374.4
353.5
364.3
302.3
294.8
275
232.7
219.9
227.4
247.9
198.4
149.8
114.6
85.2
68.1
60.3
79.84
66.29 67.1 68.19 65.96
70.13 73.9
66.9 66.2
61.5
54.7
49.6 51.5
0
50
100
150
200
250
300
350
400
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Manufact uring Indust ry Const ruct ion Indust ry Cat ering Indust ry
1986: launch of F&IU (Safety Officers and Safety Supervisors) R
Accident Rates per 1000 construction workers
1989: launch of the General
Duties of Proprietors
and Persons Employed
2000: pass of F&IU(SM)R
1995: release of Consultation
Paper on the Review of Industrial
Safety in Hong Kong
1997: launch of OSHO&R
6. Opportunities for
SMS
Occasions favoured for SMS
1. Arrival of new top manager
2. Major reorganization
3. Enactment of goal setting legislation
4. Aftermath of a serious hazardous event
5. Regulatory agency action
6. Failure to obtain a contract or be placed on
approved contractors list, as a result of clients
reservations



Reference
BS 18004:2008, Guide to achieving effective occupational health and safety
performance. P. 56 (supersedes BS8800: 2004, Occupational Health and Safety
Health Management Systems Guide, p. 26)
Conclusion: PDCA System led by positive
leadership to nurture a safety culture