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Guides

How to Run a Successful Safety Assessment and Inspection Program

Dave Paoletta

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Last Updated: November 30, 2020

Research shows that companies who monitor workplace and job site conditions through a formal inspection or audit program have fewer injuries, fines from regulators, and, in many cases, better communication between workers and management personnel. 

Regular job site walks, also known as Gemba walks, formal process/procedure audits, and site program assessments, are aspects of a safety self-assessment program. 

In Part 2 of our Ultimate Guide to Safety Management System series, Dave Paoletta discussed the process of implementing your safety management system.

Now, in Part 3, Dave will explain the importance of self-inspections and get into the nitty-gritty of running incident investigations. By the end of this guide, you will understand what it means to design and run a fully-functional inspection and investigation program.

Are you new to this series? Go back and visit Part 1 here.

This article covers:

Types of Inspections 

Safety and health inspections serve several purposes, including:

  • To identify physical or process hazards
  • Assess compliance with company rules and safe work procedures
  • Assess compliance with OSHA or other regulatory standards
  • Evaluate the overall health and safety condition of the workplace
  • Evaluate supervisors’ safety and health oversight performance
  • Evaluate the workers’ safety and health oversight performance
  • Identify positive or negative trends in the overall health and safety condition of the workplace
  • Verify the implementation of corrective actions from deficiencies reported during prior inspections

The inspection’s purpose determines the detail and formality of various inspections. For example, most job-walks and Gemba walks don’t require a checklist as you need only a pad of paper to take notes. You can document any material deficiencies by generating a work order or sending an email to the individual responsible for fixing the issue. For these meetings, a designated note-taker captures informal minutes. These minutes allow measurement of week-to-week.

A self-inspection program can be beneficial to any organization. It should involve everyone from top management to the front-line worker. However, the main benefit is detecting unsafe conditions in time to provide a solution before someone is injured.

Self-inspections occur at various times and are conducted by various people, depending on the inspection’s scope and purpose. You should determine the schedule, list of participants, and any checklists at the start of a job or activity. You should also add these items to the organization’s JHA or Safety Program.

A broad view of self-inspections could see:

Daily – Each employee should inspect their work area, tools, and equipment at the beginning of each workday. Maintenance personnel, supervisors, and others whose duties take them into the work area should be continually checking for unsafe actions and conditions. You should report and correct any unsafe acts or conditions as soon as possible.

Weekly – Department heads, Superintendents, plant managers, and others who may not usually get into the production area or visit the work site should tour the area as part of a weekly inspection. These inspections should also involve having safety conversations with the employees.

Monthly – A planned monthly inspection usually involves the safety department and the safety committee: the participation of top management in such assessments shows that they have personal involvement and interest in safety. This type of inspection should cover all areas, including those areas where “no one ever goes.” It is advisable to strategically schedule the inspections to make maximum observations with the least amount of work interruption.

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Establishing the Self-Inspection Team

Self-inspections are a necessary part of any safety program. They involve employees in the loss control efforts, uncover unsafe conditions and practices, and increase morale through decisive action.

The inspection team should be limited in size to approximately eight members. Membership should represent hourly workers, supervision, and safety. A responsible member of management (supervisor or superintendent), who will provide the authority necessary to ensure its effectiveness, should provide the team’s supervision and direction. Specific responsibilities should be assigned (e.g., who will take notes, be the spokesperson, follow up on recommendations, etc.).

The team should ensure all areas covered cross the facility/site layout and workflow: 

  • materials storage and handling, 
  • forklift/equipment operations, safety standards, regulations, and costs
  • hazard recognition of unsafe acts and conditions

The team should also record any employee feedback gathered during the inspection.

1. Refresh your memory by reviewing previous inspections to ensure that previous recommendations or corrective actions have been completed.

2. Go back and review accident records for various areas, crafts, and departments. Information concerning how a particular accident occurred will often reveal hazards for correction.

3. Provide all necessary personal protective equipment, and request employees wear it in required areas.

4. Develop a preplanned route for inspections. It also will eliminate backtracking, unnecessary interruptions of production processes, and distractions. For large facilities or job sites, inspect one portion during each scheduled inspection to cover the whole operation within a reasonable period of time.

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Implementing Corrective Actions

The results of an inspection should prompt actions to correct the problems. Use the following guidelines to develop corrective actions:

1. Correct the cause of the problem whenever possible. If the authority needed is above the inspector’s, make certain you bring the issue to someone’s attention at the proper level of management.

2. When an individual has the authority to correct or minimize a problem or hazard, do it immediately.

3. Convey conditions that cannot be corrected immediately to management in a written report. List the conditions in the order of priority, including suggested solutions and compliance dates, if possible. Take immediate steps to temporarily address the problem, such as guarding it against employees, locking it out, etc.

4. Make employees aware of unsafe acts and conditions observed during inspections. Discuss the items with the employees and use their suggestions to prevent a recurrence. Management should advise the inspectors on what corrective actions will follow the suggestions or why actions will not be taken.

Remember to maintain records of inspections and corrective actions for review as appropriate for authorities having jurisdiction.

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Safety Program Review and Assessment

The main purpose of establishing a Safety Program Review and Assurance program is to identify and prioritize areas for continuous improvement. Although certain programs are required to be periodically reviewed to comply with OSHA standards, the various types of assessments, surveys, inspections, and interviews do not exist to check a box. They provide insight into the effectiveness of your safety programs and information on how we might improve upon what we have in place.

By proactively assessing our programs, we identify risks before events occur or before outside assessments identify these risks for us. This allows the Company to demonstrate proactive management of the program. In turn, taking these actions helps build confidence with stakeholders, management, and outside regulatory agencies. 

Depending on what specific written safety programs apply to your company, most require an annual review or an annual training refresher. A partial list is below:

  • Lockout/Tagout – Review of written energy control procedures AND observations of authorized employees performing LOTO
  • OSHA 300 Log posting (Feb 1 to April 30)
  • Hearing Conservation – Annual audiograms for employees, hearing conservation training
  • Bloodborne Pathogens – Exposure Control Plan review and update
  • Process Safety Management – Operating Procedures
  • HAZWOPER – Annual refresher training
  • Crane and Hoisting – Annual inspection by a Qualified Person
  • Respiratory Protection – Annual medical questionnaire, Employee Fit Testing
  • Portable Fire Extinguishers – Annual Inspection/certification & Employee Training
  • Asbestos Program – Annual Awareness Training/retraining
  • Lead Program – Annual Awareness Training/retraining

The goals of the program review and assurance system are to:

  • Ensure that ES&H systems are effective, improving over time, complying with their guiding regulations, and properly implemented the company
  • Identify and manage issues on a risk-based, graded-approach
  • Identify trends and resolve deficiencies
  • Monitor the effectiveness of controls and work performance
  • Promote continuous improvement
  • Communicate performance to key stakeholders and provide them with information to make informed management decisions

Program Assessments

Program self-assessments are subject matter expert (SME)-driven reviews and assessments of the programs under their management. The SME may be from the EHS Department or a team of knowledgeable and experienced individuals in the program area (i.e., a maintenance electrician assessing the Electrical Safety Program). 

Although SME-driven, program assessments should be a collaborative effort with feedback and input from affected stakeholders. The goal of the program assessment is to determine the following:

  • Do programs meet compliance requirements? 
  • Are effective controls in place and used?
  • Is there active and effective communication between EHS and stakeholders? 
  • Are employees following requirements even when EHS or management is not looking?

Inspection Records and Audit Reports

Accurate inspection records are important. They serve as evidence of the inspection program, provide documentation of necessary corrective actions, and provide a follow-up method to ensure completion. One of the easiest methods to record an inspection is to use a checklist.

You can find checklists in the Safesite template database. You can also build your own templates and tailor them to suit your individual requirements and upload them to your Safesite account. 

Checklists have several advantages. However, they don’t work as a replacement for inspections. They are no substitute for informed employees performing a careful observation of the workplace.

The use of checklists is especially helpful during periodic inspections of particular equipment. Qualified persons should inspect such items as conveyors, hoists, cranes, fire extinguishers, sprinkler systems, scaffolding, and ladders on a compliance-based schedule. 

You can use preventive maintenance software to schedule these types of programmed periodic inspections and operational readiness checks. However, any means of ensuring that equipment is checked on a schedule that is in accordance with manufacturers and OSHA requirements are adequate.

Audit Reports

You should create a summary report to discuss the program audited, the purpose and scope of the audit, audit team members, information and documents reviewed, and number of interviews or other data collected. 

A comparison of findings with the requirements of the written program (i.e., a Gap Analysis) can then describe both areas for improvement and areas that comply with the requirements. Finally, generate a list of corrective actions, with a responsible person or group assigned and estimated completion date.

Manage findings from self-assessments in accordance with the company’s Corrective Action Tracking or Issues Management process.

Observations and opportunities for improvement made by the audit team need to be evaluated and ranked for resolution. Some are simple and straightforward and will be initiated and completed by the SME directly with little guidance. Others may be complex, interfacing with other programs across multiple organizations and requiring significant resources to resolve. These issues will be shared with management and risk-ranked. Management will make decisions about actions to take and monitor high-priority issues to completion.

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Incident Investigation

An effective incident investigation process starts with prompt incident reporting. Every employee must understand that incidents are learning opportunities, not a means to blame and discipline them. 

Prompt reporting starts the process of incident analysis and corrective action development, leading to lowering the frequency and severity of incidents in company operations.

Accident and injury reporting is a critical aspect of an effective safety program. Accidents or work conditions that cause or might have caused injury, illness, environmental release, or property damage shall be promptly reported.

Reporting is mandatory to ensure the following:

  1. The cause of an accident or unsafe situation is properly investigated, identified, and corrected (if appropriate) to prevent an accident or the recurrence of an accident.
  2. OSHA reporting and recordkeeping requirements can be met. In some cases, specific reporting procedures apply, and you must report findings to OSHA within as few as eight hours.
  3. Reporting requirements for insurance purposes are met if an accident involves a work-related claim.
  4. The purpose of the investigation is to determine from discussions with those involved, all of the elements that combined to cause the accident. Failures in machinery and/or process safeguards will be determined, and effective corrective actions designed to prevent similar occurrences in the future. The investigation must be fact-finding, not fault-finding, and only incidences of negligence, disregard of direct instructions, or substance abuse will be referred to HR for possible disciplinary procedures.

Incident Investigation Process

The EHS Manager will determine whether to use a basic incident investigation process or a more thorough Learning Team approach based on the accident’s complexity and severity. 

  • Basic causal factor analysis is appropriate for minor events or incidents such as auto accidents not caused by company employees. The EHS Manager will determine which employees will participate in basic causal analysis teams. 
  • For serious accidents, convene a Learning Team, consisting of an EHS facilitator, the affected employees, the supervisor, and other engineers, maintenance technicians, or workers with relevant technical or process expertise. 

The Learning Team’s function is to thoroughly explore all aspects of the incident from surfacing all contributing factors, including system interactions and management policies and procedures.

Learning Teams require at least two meetings to gather information and create the fact pattern of the incident. You won’t discuss causal factors at this stage. The team then adjourns to reflect and decide if additional data will be necessary to understand the event fully.

Finally, the Team reconvenes, and if no additional data is needed, starts to discuss and agree on causal factors and corrective actions necessary for the final written report.

  • Using the knowledge gained from the investigation, a written report shall be prepared to describe incident circumstances and root causes and detail proposed corrective actions, who is responsible for completing them, and a due date for each.
  • Corrective actions should be based on the Hierarchy of Controls and stress elimination, substitution, and engineering controls whenever possible. (Note: Administrative controls, retraining, and PPE are ineffective at preventing the recurrence of accidents in the long term.)
  • A Safety Bulletin shall be prepared summarizing the accident, causal factors, and corrective actions and communicated to the organization’s relevant parts. It shouldn’t include any identifiable employee information.
    • The Safety Bulletin is a learning summary based on the accident. It is a tool for employees and supervisors to review the lessons learned and determine if any potentially unsafe conditions are still present in the workplace. 
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Corrective Action Management

The role of corrective actions in incident response is to address physical or engineering deficiencies that may cause system failures and behavioral nonconformities or deviations from safe work procedures.

Corrective measures may come from various sources, such as workplace audits and inspections, worker BBS observations, or causal analysis from post-incident investigations.

  1. Corrective actions should be based on the hierarchy of controls. The hierarchy of controls is a systematic approach to reducing, controlling, or eliminating risks, considering steps in a ranked and sequential order beginning with Elimination, Substitution, and Engineering controls. Address residual risks using Administrative controls such as procedures, warning signs, and personal protective equipment. The top three control measures, Elimination, Substitution, and Engineering controls, are most effective because they are less dependent on error-free human performance.
  2. Accepted Corrective Actions should be entered in a tracking log with the responsible person (or group), and the required implementation date noted. The Safety Manager or designee will frequently review the tracker and is responsible for working with the responsible person to implement the corrective action by the deadline.
  3. The EHS group should review completed corrective actions no later than six months after implementing the last corrective action. The purpose of the review is to determine if the corrective actions are effective and appropriate or if pre-conditions of the former accident are still in place. 
  4. If corrective actions are ineffective, you should contact management and propose a “pre-accident investigation” team to review the concern and determine further action.
  5. Effective corrective actions should be captured in a “Lessons Learned” database (or similar filing approach), so they are searchable and shareable with other sites and form a body of knowledge to guide future operations.

 

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Get Started with Your Inspection Program

Internal assessments and inspections play a vital role in your safety management system. Monitoring conditions regularly keeps you compliant, prevents incidents, and facilitates regular communication between all key players.

Don’t forget: once you have your inspection program up and running, you can use Safesite to run inspections and communicate corrective actions and results with the tap of a button.

Are you ready for the final part of Dave Paoletta’s Ultimate Guide to Safety Management Series?

Let’s head on over to Part 4: Guide to Communication and Recordkeeping for Safety Management Systems.

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Dave Paoletta

Author:

David Paoletta, MS, MBA, CSP, CUSP, is a research analyst and subject matter expert for Safesite, a safety management software company based in San Francisco, CA. He is also a principal consultant with New Dimensions in Safety in Alameda, CA. David has extensive utility field safety experience with PG&E and PNM New Mexico. He is a Past NM ASSE SPY Award winner and a Past President of the San Francisco Chapter ASSE.

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