RCAT - GLOSSARY OF TERMS

STEP 3:
FOR EACH LOSS THAT WAS DUE TO EXPOSURE TO/CONTACT WITH A SOURCE OF ENERGY OR WITH A SUBSTANCE,
IDENTIFY THE WAY INN WHICH THE CONTACT OCCURRED AS WELL AS THE AGENCY.

3.1 CONTACTS

1. The “caught between” occurrence is one in which a person has been pinched, crushed or otherwise
caught between either a moving object, a stationary object or between two moving objects.

2. The “caught in” occurrence is one in which a person is trapped in some type of enclosure or a part
of a person’s body is caught fast in some type of opening.

3. The “caught on” occurrence is one in which a person (or some part of his clothing) has become
caught on some protruding object.

4. The “contacted with” occurrence is one in which a person has contacted some substance or object
capable of producing injury on the basis of mere non-forceful contact.

5. Drowning – Self explanatory

6. “Fall from elevation to lower level” occurrence is one in which a person falls below the level on
which he was standing or walking, e.g. he fall below foot level.

7. The “fall on same level” occurrence is one in which a person falls to the same level on which he was
standing or walking, e.g. he falls to foot level. This type of occurrence almost invariably involves
either slipping or tripping as the initial unexpected occurrence. For that reason, such occurrences
are sometimes referred to as slip and fall or trip and fall accidents.

8. The “handling” occurrence is one in which a person suffers injury or illness as a result of incorrect
stacking, storage, placement, etc.

9. The “overstress-strain” occurrence is one in which a person injures himself as a result of putting
excessive strain on some part of his body by either improper lifting, pushing, pulling or twisting.

10. The “struck against” occurrence is one in which a person contacts abruptly and with force some
object in his surroundings.

11. The “struck by” occurrence is one in which a person has been contacted abruptly and forcefully by
some object in motion.

12. Other (might include)

The “exposure” occurrence is one in which someone is exposed to harmful conditions such as toxic
gasses, fumes, vapours, heat, cold, ergonomic hazards, radioactive substances, noise, oxygen and
chemical emission over a period of time.

The “bodily reaction” occurrence is one in which a person imposed stress solely by free movement
of the body or assumption of a strained or unnatural body position.

The “Inundation” occurrence is one in which a person enters into water of unknown depth and
drowns.
Other glossary for Step 3:

Agency: The principal object or substance involved in the occurrence. The term is used either to designate the
object most directly causing the occurrence or the object associated with the energy source contact
which resulted in physical harm to people or damage to property.

Energy: Energy may include:

 Acoustic Energy: Excessive noise and vibration.

 Chemical Energy: Corrosive, toxic, flammable, or reactive substances. Involves a release of energy
ranging from “not violent” to “explosive” and “capable of detonation.”

 Kinetic (Impact) Energy: Energy from “things in motion” and “impact” and are associated with the
collision of objects in relative motion to each other. Includes impact between moving objects,
moving objects against a stationary object, falling objects, flying objects, and flying particles. Also
involves movement resulting from hazards of high pressure pneumatic, hydraulic systems.

 Mechanical Energy: Cut, crush, bend, shear, pinch, wrap, pull, and puncture. Such hazards are
associated with components that move in circular, transverse (single direction), or reciprocating
motion.

 Potential (Stored) Energy: Involves “stored energy”. Includes objects that are under pressure,
tension, or compression; or objects that attract or repulse one another. Susceptible to sudden
unexpected movement. Includes gravity – potential falling objects, potential falls of persons.
Includes forces transferred bio mechanically to the human body during lifting.

 Radiant Energy Hazards: Relatively short wavelength energy forms within the electromagnetic
spectrum. Includes infra-red, visible, microwave, ultra-violet, x-ray, and ionizing radiation.

 Thermal Energy: Excessive heat, extreme cold, sources of flame ignition, flame propagation, and
heat related explosions.
 STEP 5:
IDENTIFY POSSIBLE IMMEDIATE CAUSES.
Immediate causes are covered in the first two quadrants entitled Actions and Conditions.

ACTIONS

5.1 CONTACTS

1. Deviation (by individual): one individual fully aware that he was taking a risk but still decided to do
the job that way.

2. Deviation (by group): people fully aware that they were taking a risk but still decided to do the job
that way, e.g. solving a problem knowing that they have to infringe on the rules.

3. Deviation (by supervisor): a supervisor or other management person fully aware that he was taking
a risk but still decided to do the job that way.

4. Operation of equipment without authority: the person involved operated equipment for which he
was not authorized to do so, either because he did not have work permit, or for the person working
in his own department, he was told by his supervisor he was not allowed to work on it. This also
applies in situations where operating the equipment is not in the person’s job description and
therefore, understood that he is not authorized to operate the equipment, e.g. operating a forklift
without training or operating process equipment that is not included in the workers job function.

5. Improper position or posture for task: the person did not follow the human kinetic practices. The
person was working on an unsafe, unstable or non-standard work floor or was placing body parts in
unsafe position.

6. Overexertion of physical capability: did more than a person is physically able to do, e.g. carrying too
much weight, etc.

7. Work or motion at improper speed: the person involved was not working at the proper speed, not
taking time to do things safely, e.g. driving too fast, running or adding chemicals too fast or too slow,
etc.

8. Improper lifting: material being lifted, either by human or mechanical means, was lifted contrary to
proper practices or was over the capacity of the person or the lifting equipment.

9. Improper loading: the equipment was improperly loaded, e.g. a vehicle or centrifuge loaded to one
side or overloaded or wrong product in wrong place.

10. Shortcuts: the person involved in the work took a shortcut instead of performing the work in accord
with the procedure

11. Other: if none of the above categories apply, this category can be used.

5.2 USE OF TOOLS OR EQUIPMENT

1. Improper use of equipment: equipment was used for activities for which it was not designed or
equipment was misused, e.g. operating equipment beyond the maximum recommended
temperature.

2. Improper use of tools: tools were used for activities for which they were not designed or tools were
misused, e.g. possibly wrong tool for the job, using excessive force on a tool, etc.

3. Use of defective equipment (aware): knowing that the equipment was defective and still going on
with the work, e.g. running a forklift with leaking hydraulics.
 4. Use of defective tools (aware): knowing that tools were defective and still using them.

5. Improper placement of tools, equipment or materials: material or equipment placed in potentially

hazardous position.

6. Operation of equipment at improper speed: an operating limit was exceeded – the speed of a
grinding wheel, the assembly line was speeded up, operating throughput was surpassed, etc.

7. Servicing of equipment in operation: an attempt was made to service equipment without turning it
off – trying to clear a jammed machine, prodding out a plugged line, etc.

8. Other: if none of the above categories apply, this category can be used.

5.3 USE OF PROTECTIVE METHODS

1. Lack of knowledge of hazards present: knowing that the situation was not normal, the person
involved in the incident was not warned about the hazards.

2. Personal Protective Equipment not used: equipment prescribed in the procedures was not used.

3. Improper use of Personal Protective Equipment: the required PPE was used, but it was not used in
the proper way, e.g. non-fitting gas mask or wrong size of safety glasses or incorrect type of
respirator, not maintaining or inspecting the equipment correctly.

4. Servicing of energized equipment: the equipment was not electrically or mechanically safeguarded
according to lockout, red tag or line and equipment correctly.

5. Equipment or material not secured: equipment, materials or person was not secured against
movement or falling, e.g. ladder not secured, load not rigged properly, no toe boards on scaffolding,
etc.

6. Disabled guards, warning systems or safety devices: the proper guards, warning systems or other
safety devices were in place, but were disabled or overridden to allow the work to proceed without
these protections.

7. Removal of guards, warning systems or safety devices: the proper guards, warning systems or
other safety devices had been removed at some prior time and not reinstalled or reactivated.

8. Personal Protective Equipment not available: the necessary personal protective equipment was
not available to employees at their work site.

9. Other: if none of the above categories apply, this category can be used.

5.4 INATTENTION / LACK OF AWARENESS

1. Improper decision making or lack of judgement: the situation was wrongly judged and the wrong
decision was made.

2. Distracted by other concerns: the person involved was distracted and not attentive to the work in
progress, therefore, the person was not aware or aware too late that something had gone wrong.

3. Inattention to footing and surroundings: the person was just walking around and did not notice the
obstacle or the surface conditions of the ground.

4. Horseplay: person(s) involved in the event were engaged in inappropriate activities, including
practical jokes or clowning around.
 5. Acts of violence: any type of physical or mental confrontations that can cause bodily injury or
mental anguish.

6. Failure to warn / make safe: an individual had knowledge of a dangerous condition or activity, but
did not warn current or future persons of the exposure, e.g. not tagging a defective tool.

7. Use of drugs or alcohol: person(s) involved in the event were determined to be under the influence
of alcohol or drugs.

8. Routine activity without thought: the person involved was performing a routine activity, such as
walking, sitting down, stepping, etc. without conscious thought and was exposed to a hazard as a
result.

9. Other: if none of the above categories apply, this category can be used.

CONDITIONS

5.5 PROTECTIVE SYSTEMS

1. Inadequate guards or protective devices: adequate guards and protective devices that were needed
to protect the worker were not present.

2. Defective guards or protective devices: guards and protective devices were installed but failed at
the time of the incident.

3. Inadequate personal protective equipment: the personal protective equipment used was not
adequate for the situation at the time of the incident or the wrong type of personal protective
equipment was specified.

4. Defective personal protective equipment: the personal protective equipment was sufficient, but the
personal protective equipment used was defective at the time of the incident.

5. Inadequate warning systems: adequate warning systems were present but failed to provide notice
at the time of the incident.

6. Defective warning systems: adequate warning systems were present but failed at the time of the
incident.

7. Inadequate isolation of process or equipment: the equipment was not properly isolated and the
people involved were exposed to chemicals, hot surfaces, electricity, etc.

8. Inadequate safety devices: safety devices such as pressure relief valves or turbine over speed trips
were present, but did not act quickly enough to prevent the accident.

9. Defective safety devices: safety devices such as pressure relief valves or turbine over speed trips
failed to activate.

10. Other: if none of the above categories apply, this category can be used.

5.6 TRANSPORTATION, EQUIPMENT AND TOOLS

1. Defective vehicle, vessel, aircraft, or rolling stock, etc.: the right vehicle, vessel, aircraft or rolling
stock was being used, but was defective.

2. Inadequate vehicle, vessel, aircraft, or rolling stock etc for the purpose: the necessary vehicle,
vessel, aircraft or rolling stock to perform the function was not available, e.g. forklift being used as a
 crane.

3. Improperly prepared vessel, aircraft, or rolling stock etc: the vehicle, vessel, aircraft, or rolling stock
was not prepared adequately prior to the job or maintenance work, e.g. a vehicles pre check not
done prior to leaving the premises.

4. Defective equipment: the right type of equipment was being used, but the equipment was
defective.

5. Inadequate equipment for the purpose: the necessary type of vehicle to perform the function was
not available, e.g. forklift being used as a crane.

6. Improperly prepared equipment: the right equipment was being used, but the equipment had not
been properly repaired or serviced for use. E.g. a vessel not thoroughly cleaned off process
chemicals prior to entry.

7. Defective tools: the right kind of tool was selected, but the tool involved was defective.

8. Inadequate tools: the tools were not adequate for this purpose, or the proper tools were not
supplied.

9. Improperly prepared tools: the tools were not prepared properly before the job, e.g. not repaired
properly or not cleaned of contaminants.

10. Other: if none of the above categories apply, this category can be used.

5.7 WORK EXPOSURE

1. Fire and explosion: the incident was caused by a fire and / or explosion.

2. Noise: the incident was caused by a short term exposure to extremely high noise levels or by
continuous overexposure to noise, e.g. shock effect, process equipment, and high noise producing
tools.

3. Energised electrical systems: incident caused by system not fully de-energised.

4. Energised systems, other than electrical: incident was caused by a system not fully isolated from
gravitational, pneumatic, hydraulic or chemical energy sources.

5. Radiation: the incident was caused by dangerous radiation, e.g. x-ray, high frequency radiation,
laser, etc.

6. Temperature extremes: the incident was caused by an exposure to extreme high or low
temperatures.

7. Hazardous Chemical: the incident was cause by extremely hazardous chemicals used in the process,
e.g. reactive, toxic or ecologically dangerous chemicals.

8. Mechanical hazards: incident caused by sharp edges, moving equipment, etc.

9. Clutter or debris: housekeeping was inadequate or work location was not clean and orderly.

10. Storms or acts of nature: the incident was a direct or indirect result of a storm, tornado, hurricane,
hail storm, etc.

11. Slippery floor or walkways: the incident was caused by a slippery walking or working surface.
 12. Other: if none of the above categories apply, this category can be used.

5.8 WORKPLACE ENVIRONMENT / LAYOUT

1. Congestion or restricted motion: layout of the workplace was poor and not enough clearances were
available or accessibility to equipment or tools was poor.

2. Inadequate or excessive illumination: the workplace was poorly illuminated or the visibility was
poor.

3. Inadequate ventilation: poor ventilation, e.g. the temperature could rise too high, concentrations of
chemicals could rise or oxygen levels could decrease, etc.

4. Unprotected height: a contributing factor was work at an unprotected height, e.g. scaffold building,
in towers, or on roofs, etc.

5. Inadequate workplace layout: the controls, labels or displays used to monitor the work were not
adequate, e.g. the controls were out of normal reach, labels or displays were out of sight. Can also
include misinformation – such as mislabelled equipment or chemicals.

6. Other: if none of the above categories apply, this category can be used.

STEP 6:
IDENTIFY POSSIBLE ROOT CAUSES.
System causes are covered in the final two quadrants entitled Human Factors and Workplace Factors

HUMAN FACTORS: Human factors are those factors which are directly reflected in the person(s) and explain
why a person committed sub-standards act(s).

6.1 PHYSICAL CAPABILITIES

1. Vision deficiency: the incident happened because the person involved had a vision deficiency, e.g.
could not see over long distance, could not see alarms on the panel, etc.

2. Hearing deficiency: he incident happened because the person involved had a hearing deficiency, e.g.
could not hear the alarm.

3. Other sensory deficiency: a deficiency, like reduced feel or smell, contributed to the incident.

4. Reduced respiratory capacity: asthma, silicosis, asbestosis and other elated diseased contributed to
the incident or seriousness of the incident.

5. Other permanent physical disabilities: all other physical disabilities not mentioned above, e.g. weak
back, ankles, etc.

6. Temporary disabilities: Disabilities, which are temporary, like broken bones, muscle pains, migraine
headache, etc.

7. Inability to sustain body positions: the incident happened because the person involved did not have
the capability to sustain the required body position for a longer time.

8. Restricted range of body movement: a physical condition restricted the person’s movement and
was not planned for in the job activity, e.g. a temporary or permanent physical disability, wearing of
 Personal Protective Equipment, unusual weight, unusual heights, etc.

9. Substance sensitivities or allergies: the person involved in the incident was medically proven to be
allergic or sensitive to the substances involved.

10. Inadequate size or strength: the person assigned to the work did not have the size or strength to
complete the task safely, e.g. could not reach, could not lift, etc.

11. Diminished capacity due to medication: the side effects of medication limited the person’s physical
capability.

12. Diminished capacity due to inadequate intake of substance: the person’s diminished physical
capacity was due to insufficient substance intake, e.g. water, food, etc.

13. Other: if none of the above categories apply, this category can be used.

6.2 PHYSICAL CONDITIONS

1. Previous injury or illness: the incident happened because the person involved was ill (fever or any
other kind of illness) or had an existing injury before the incident happened.

2. Fatigue: the person involved in the incident was fatigued due to workload or to lack of rest, e.g. too
long working hours without time to relax, working more than 8 hours per shift, working double shifts
over a long period of time, or working for a too long period (e.g. no days off over a period of more
than seven days).

3. Diminished performance: the surrounding or conditions have lead to less than ordinary
performance, e.g. temperature extremes, lack of oxygen due to high elevations, atmospheric
pressure change, such as encountered during diving work.

4. Blood sugar deficiency: at the time of the incident, the person involved had a too low blood sugar.
This should be medically established.

5. Impairment due to drug or alcohol use: at the time of the incident, the person involved was under
the influence of alcohol or drugs.

6. Other: if none of the above categories apply, this category can be used.

6.3 MENTAL STATE

1. Poor judgement: although the person involved was well trained at the time of the incident, the
person did not choose an appropriate course of action.

2. Memory failure: although the person involved was well trained at the time of the incident, the
person could not remember how to act or react.

3. Poor coordination or reaction time: although the person involved knew exactly which actions to
take, the person was not capable of coordinating all the required actions or the reaction time was
too slow.

4. Emotional disturbances: the incident happened because the person involved was emotionally
disturbed.

5. Fears or phobias: the incident happened because the person involved had a fear or phobia, e.g.
someone who is afraid of working at heights, climbing ladders or claustrophobia, etc.
 6. Low mechanical aptitude: the person was confused on what actions to take because they did not
understand basic elements of how mechanical things work.

7. Low learning aptitude: the person involved had been well trained, but was confused due to limited
learning capability.

8. Influenced by medication: the persons mental state was diminished due to side effects of
medication (e.g. drowsy, light-headed)

9. Other: if none of the above categories apply, this category can be used.

6.4 MENTAL STRESS

1. Preoccupation with problems: the person involved in the incident was preoccupied with problems
and was not fully concentrated on the activities in progress, e.g. problems at work or at home.

2. Frustration: the incident happened because the person involved was frustrated, e.g. no promotion,
never received a positive reward from his supervisor, doing his very best and seeing no results, etc.

3. Confusing directions / demand: the person involved in the incident felt the work was not well
defined with proper direction or demands. Can be the result of too many people giving orders.

4. Conflicting directions / demands: conflicting directions or demands led to an incident, e.g. a rush
job but still having to follow all the time consuming safety procedures.

5. “Meaningless” or “degrading” activities: the person involved in the incident felt the work that the
person was doing was meaningless, e.g. cleaning up and the next day it is filthy again, degrading or
too much experience or education for this low classified job.

6. Emotional overload: the person was under high stress from either work or personal issues those
effects their emotional state.

7. Extreme judgement / decision demands: the work being done required judgement and decision
making that created stress, e.g. time sensitive decisions, high stakes in the outcome, incomplete
information in which to base the decision.

8. Extreme concentration or perception demands: the work environment contributed to the incident,
as the work required great concentration, e.g. a person is so absorbed in what they are doing, and
they fail to recognise a hazard.

9. Extreme boredom: the person is adversely affected by monotonous or repetitive work.

10. Other: if none of the above categories apply, this category can be used.

6.5 BEHAVIOUR

1. Improper performance is rewarded: although the supervisor knew that the person was not
following the safety procedures, guidelines of TA/JSA’s, the person was rewarded because the job
was completed quickly.

The worker may also have felt rewarded by performing improperly, e.g. if by taking shortcuts, an
unpleasant job is finished quicker, such as saving time / effort or opportunity to socialise with
others, in not following the prescribed work method, procedure, practice or rule.

2. Improper supervisory example: supervisors not giving the proper example to the people working in
their organisations.
 3. Inadequate identification of critical safe behaviours: in the organisation, it was not well identified
which safe behaviours were critical to preventing incidents.

4. Inadequate reinforcement of critical behaviours: a supervisor seeing someone not following the
safety procedures and guidelines and not correcting immediately is an example of inadequate
reinforcement of proper behaviour. Similarly, supervisors must note when employees are
performing correctly to adequately reinforce the proper performance. Peer pressure can also play a
role, if proper performance is criticised.

5. Inappropriate aggression: either the people were aggressive or actions were done and decisions
were taken in an aggressive way without really having an overview of the consequences.

6. Improper use of production incentives: the use of the incentives for production or timeliness has
created an incentive to ignore safety requirements.

7. Supervisor implied haste: the incident was caused by the supervisor’s implications that speed in
completing the work was more important than safety considerations.

8. Employee perceived haste: the incident was caused by the employee’s assumption that speed is
completing the work more important than safety considerations.

9. Habit / Personal performance: the incident was caused by the employee’s settled or regular
tendency or practice, which is hard to give up.

10. Vandalism: the incident was caused by the employees’ wilful or malicious damage to property,
process or the environment.

11. Other: if none of the above categories apply, this category can be used.

6.6 SKILL LEVEL

1. Inadequate assessment of required skills: the person involved believed they had the proper skills to
perform the work, but in fact, lacked required skills.

2. Inadequate practice of skill: the person involved was theoretically experienced but lacked practice
in performing the task.

3. Infrequent performance of skill: the person was trained in the job but the activity involved in the
incident was done on a very low frequency or the person involved rarely performed the activity.

4. Lack of coaching on skill: the incident happened because the person involved did not have the
coaching of a supervisor or experienced co-worker.

5. Insufficient review of instruction to establish skill: the person involved had training, but was not
given the opportunity to practice or perform the task as part of training to firmly establish the skill.

6. Other: if none of the above categories apply, this category can be used.

WORKPLACE FACTORS: Workplace / Process factors are those factors which are reflected in the
organisation’s working processes.

6.7 TRAINING / KNOWLEDGE TRANSFER

1. Inadequate knowledge transfer: a well-developed training effort was in place, but failed to transfer
the necessary knowledge. Reasons for this could include the inability of students to comprehend
(material beyond their level, language difficulties), inadequate instructor qualification, inadequate
 training equipment (lack of props or means to illustrate the topic) or misunderstood directions on
the part of the students.

2. Inadequate recall of training material: a well-developed training effort was successful in

transferring the necessary knowledge, but students were not able to recall the material when
needed. This could be the result of training not being reinforced on the job, or an inadequate
retraining frequency.

3. Inadequate training effort: some training was conducted, but it failed to accomplish the necessary
knowledge transfer. Potential causes include inadequate training programme design, poorly
developed training objectives, inadequate orientation programmes, inadequate initial training
efforts or poor means to determine if students have indeed mastered the material being taught.

4. No training provided: there was no effort made to train the particular person in this subject.
Reasons for this can include a failure to identify training was necessary, reliance on out of date or
inaccurate training records, a change in work methods or a conscious decision to forego training.

5. Other: if none of the above categories apply, this category can be used.

6.8 MANAGEMENT / SUPERVISION / EMPLOYEE LEADERSHIP

1. Conflicting roles / responsibilities: who was to be responsible for what was not clear and well
defined. This could include unclear reporting relationships, unclear assignments of responsibilities,
improper delegation or conflicting situations where more than one party appears to be responsible
for the same issue.

2. Inadequate leadership: the person assigned with the responsibility for aspects for safety had not
carried out their responsibility to the degree necessary for safe work. This could include lax
standards of performance being tolerated, inadequate accountability for safety performance, and
little performance feedback, inadequate knowledge of conditions at the work site or inadequate
safety promotion.

3. Inadequate correction of prior hazards / incidents: a hazard or incident had previously occurred to
draw attention to a deficiency, but there was an inadequate effort to correct that deficiency.

4. Inadequate identification of worksite / job hazards: the incident was caused by the failure to
perform or properly respond to a loss exposure study, such as a HAZOP review or Job Safety
Analysis.

5. Inadequate management of change system: the incident happened because a system or procedure
did not exist or was incomplete to ensure that changes which affect the process are adequately
assessed, documented and communicated.

6. Inadequate incident reporting / investigation systems: the incident reporting and investigation
procedures and guideline were not followed for incidents that happened in the department.
Therefore, the learning experiences and recommendations that could have prevented similar
incidents were not discovered or lack of tracking system to ensure follow-up was done or not
communicating the results of the investigation.

7. Inadequate or lack of safety meetings: safety meeting were not held or did not transfer essential
knowledge about safety issues related to the incident.

8. Inadequate performance measurement and assessment: the means to measure and track safety
performance were inadequate, leaving the organisation unsure of what needed to be done.

9. Other: if none of the above categories apply, this category can be used.
6.9 CONTRACTOR SELECTION AND OVERSIGHT

1. Lack of contractor pre-qualification: a contractor firm was hired to perform work without
successfully completing a pre-qualification review.

2. Inadequate contractor pre-qualifications: a pre-qualification review was conducted, but it failed to

identify deficiencies in the contractor’s capabilities.

3. Inadequate contractor selection: the selection of a contractor was made without all relevant data,
or without proper consideration of safety capabilities.

4. Use of a non approved contractor: a contractor firm who did not meet pre-qualification criteria was
hired to perform work.

5. Lack of job oversight: a contractors firm’s work was not inspected or audited to identify deficiencies
in outcomes or methods.

6. Inadequate oversight / supervision: a contractors firm’s work was inspected or audited, but
deficiencies present were not identified.

7. Other: if none of the above categories apply, this category can be used.

6.10 ENGINEERING DESIGN

1. Inadequate technical design: the incident was caused by a poor technical design, weak materials of
construction, valves in the wrong spot, lines in walkways, etc. The reasons for inadequate technical
design can be faulty input into the design process (bad information) or faulty design output (bad
design).

2. No / inadequate risk assessment: no risk assessment was undertaken at any stage (conceptual,
construction, commissioning, etc) on the facility process on equipment. The adequacy of safety
equipment has not been systematically measured.

3. Inadequate standards, specifications and / or design criteria: although the design criteria and
specifications had been followed, the specifications and criteria were not adequate and had to be
adopted.

4. Inadequate assessment of potential failure: the incident was caused by the fact that the potential
failure was not adequately assessed in the initial design stage.

5. Inadequate ergonomic design: the incident was caused by a poor ergonomic design, meaning that
there was not an optimal tuning between the equipment and human working with the equipment.

6. Inadequate monitoring of construction: although all design specifications and criteria had been
followed, inspections during the construction were not done adequately.

7. Inadequate assessment of operational readiness: the incident happened because the procedure for
handover from construction to production was not followed, software changes were not fully tested
or operating manuals and training were not completed.

8. Inadequate monitoring of initial operation: the incident happened because there was not enough
monitoring and analyses of the initial operation information.

9. Inadequate evaluation and / or documentation of change: the incident happened because

unevaluated changes were made and an unsafe situation was introduced. Documentation and
communication of the changes was required and could have been overlooked.

10. Other: if none of the above categories apply, this category can be used.
6.11 WORK PLANNING

1. Inadequate work planning: the work being done was not adequately planned in terms of people,
equipment, materials, procedures or permits.

2. Inadequate preventive maintenance: the incident happened because the failing piece of equipment
was not included in a preventive maintenance programme, was overdue or was wrongly overhauled.

3. Inadequate repair: the incident happened because the equipment failed due to wrong or
insufficient reparative maintenance.

4. Excessive wear and tear: the incident happened because the equipment that failed showed
excessive wear and tear due to corrosion, erosion, misuse, etc.

5. Inadequate reference materials or publications: the person doing the work did not have the proper
owner’s manual, vendor information, repair procedure, etc. to have proper knowledge to do the
work.

6. Inadequate audit / inspection / monitoring: the incident happened because the equipment failed
due to inadequate audit, inspection and monitoring because the required audit / inspection /
monitoring was not done adequately or was not done adequately or was not done at all.

7. Inadequate job placement (wrong person for the job): the selection process was not successful in
choosing a suitable worker for the particular job assignment.

8. Other: if none of the above categories apply, this category can be used.

6.12 PURCHASING, MATERIAL HANDLING AND MATERIAL CONTROL

1. Incorrect item received: the correct item was ordered, but an incorrect item was received. Reasons
for this can include incorrect specifications to vendors, inaccurate information on the requisition,
and inadequate control on who can modify order, an unauthorised substitution by the vendor,
inadequate product acceptance procedures or a failure to verify receipt of proper goods.

2. Inadequate research on materials / equipment: the lack of knowledge led to the wrong item being
ordered.

3. Inadequate mode or route of shipping: the hazard was created during shipment of the item – either
by lost custody or product degradation.

4. Improper handling of materials: the hazard was created due to improper handling of the material.

5. Improper storage of material or spare parts: materials and spare parts were stored in such a way
that there was risk of them falling down, resulting in damage or injury.

6. Inadequate material packing: packing of materials was not adequate for safeguarding the material
against harm.

7. Material shelf life exceeded: materials were not removed when their shelf life expired and became
unhealthy or unsafe for use due to their age.

8. Improper identification of hazardous material: the materials were not properly identified and
appropriate handling procedures were not used.
 9. Improper salvage or waste disposal: the hazard was created when an item was improperly de-
commissioned and disposed.

10. Inadequate use of health and safety data: the hazard was created when relevant health and safety
information was not exchanged or used.

11. Other: if none of the above categories apply, this category can be used.

6.13 TOOLS AND EQUIPMENT

1. Inadequate assessment of needs and risks: the wrong tools and equipment were provided, as a
result of the faulty assessment of what was needed to properly perform the work.

2. Inadequate human factors / ergonomics consideration: the tools and equipment provided did not
reflect the needs of the person performing the work.

3. Inadequate standards or specifications: improper tools and / or equipment were provided, as a

result of inadequate standards or specifications covering what should have been provided.

4. Inadequate availability: the need tools or equipment were not available at the job site.

5. Inadequate adjustment / repair / maintenance: the proper tools and equipment were available, but
were not in good repair when used.

6. Inadequate salvage and reclamation: tools and equipment that were removed from service for
overhaul were not properly repaired or destroyed, creating a hazard.

7. Inadequate removal or replacement of unsuitable items: items that were no longer serviceable
remained on the equipment.

8. No equipment record history: a hazard was created as a result of a failure to maintain proper
records on the equipment.

9. Inadequate equipment history: records were maintained, but failed to properly identify a hazard.

10. Other: if none of the above categories apply, this category can be used.

6.14 WORK RULES / POLICIES / STANDARD / PROCEDURES (PSP)

1. Lack of PSP for the task: there were no written PSP covering the work being performed at the time
of the incident. This could be the result of a failure to assign responsibility for the development of
PSP, or the failure to complete an adequate job safety analysis for the task.

2. Inadequate development of PSP: there was some PSP in place, but the PSP that were developed did
not fully meet the needs of the work. This could be the result of inadequate coordination with
design efforts, having un-knowledgeable people developing the PSP, not identifying the proper steps
to take in problem situations or a poor format that made the PSP difficult to use.
Were written procedures for the critical / job safety task available and were they based on a proper
task / job safety analysis?

3. Inadequate implementation of PSP, due to deficiencies: there were PSP in place, but the
implementation of the PSP was not complete due to deficiencies in these documents. This could
include things such as contradictory requirements, confusing formats, inaccurate sequence of steps,
technical errors, incomplete instructions, etc.

4. Inadequate enforcement of PSP: well crafted PSP were in place, but their use was not properly
enforced, for reasons such as inadequate monitoring of the work being done, inadequate
 supervisory knowledge of what was to be done or inadequate reinforcement with labels or signs.

5. Inadequate communication of PSP: there was an appropriate PSP in place, but it had not been
properly communicated. This could be the result of incomplete distribution, language difficulties,
incomplete integration with training efforts or out of date PSP still in use.

6. Inadequate task observation of PSP: there was some informal task observation done for some PSP
but not base on a risk based approach. This could be as a result of no or inadequate development of
a proper task observation system in place.

7. Other: if none of the above categories apply, this category can be used.
6.15 COMMUNICATION

1. Inadequate horizontal communication between peers: incident happened because there was no
communication or no adequate communication between peers and colleagues.

2. Inadequate vertical communication between supervisor and person: incident happened because
there was no communication or no adequate communication between supervision and workers, top
bottom and bottom up in the same organisation.

3. Inadequate communication between different organisations: organisations other than their own
were not properly informed.

4. Inadequate communication between work groups: the incident occurred because two or more
individuals or groups were working on the same task, but did not properly communicate.

5. Inadequate communication between shifts: the incident occurred due to poor shift handover
procedures, e.g. workers not expected to write detailed account of problems in a log.

6. Inadequate communication methods: the normal means of communicating information were not
adequate – phone lines busy, static on radios, writing was illegible, etc.

7. No communication method available: the proper tools (telephone, computer, mail, paging system
for emergencies, tapes, recorder, slides and projector boards) were not available.

8. Incorrect instructions: the person involved was given instructions, but the instructions were not
understood as meant and they were unclear or incomplete.

9. Inadequate communication due to job turnover: the person starting a task was not around to finish
it and those assigned to complete the work did not have the necessary information.

10. Inadequate communication of safety and health data, regulations or guidelines: the safety and
health data and new regulations were not discussed with the people performing the work.

11. Standard terminology not used: incident happened because either the terminologies were different
in departments or there was confusion, e.g. different pieces of equipment have the same numbers.
Standard codes and practices were not followed, e.g. colour coding for lines, electrical, etc.

12. Verification / repeat back techniques not used: a verbal message was misunderstood and went
unidentified because there was no verification / repeat back of the message by the recipient.

13. Message too long: confusion arose due to the length of the message.

14. Speech interference: a verbal message was not properly transmitted due to background noise, static
or other distractions.

15. Cultural / ethnic communication barriers: confusion arose due to interpretation of instructions
which were not understood as meant and was unclear.
 16. Other: if none of the above categories apply, this category can be used.

STEP 7:
INADEQUATE SYSTEM CONTROL FACTORS
The system failures, which directly permit basic / root causes to exist.

ELEMENTS OF AN EFFECTIVE SHEQ SYSTEM

1. Planning and Leadership
2. Competence, Training and Communications
3. Management of Operational Risk and Change
4. Operational Management and Design
5. Purchasing Systems
6. Work Rules and Operating Permits
7. Inspections
8. Occupational Health Systems
9. Personal Protective Equipment
10. Incident / Non-Conformity Reporting, Investigation and Analysis
11. Emergency Preparedness
12. Measurement, Monitoring and Audits
13. Corrective and Preventive Action Systems

7.1 PLANNING AND LEADERSHIP

Ensures that the SHEQ programme is established and maintained by having the right policies, roles, and
responsibilities established; that an accountability system exists and written programme requirements and
reference material are in place; that objectives and targets are established; that personal actions of leaders
demonstrate their commitment to the system; that regulatory requirements are defined; and that there is
adequate staffing and support.

1. Planning and Implementing: Top management should use the policy as a means of leading the
organisation toward improvement of its performance. An organisation’s policy should be an equal
and consistent part of the organisation’s overall policies and strategy and clearly communicating
management’s commitment to the SHEQ programme.

2. Resourcing: SHEQ is an important function and deserves to be managed well. Someone needs to be
assigned accountability for the activity. The appointee should be a member of TOP MANAGEMENT.
Likewise, lines of accountability and authority need to be well defined for the organisation as a
whole. Clear lines of reporting are needed to implement SHEQ programme activities.

3. Management Commitment: Management commitment is fundamental to the success of the SHEQ

programme. Commitment can be demonstrated in a number of ways such as:
 Include SHEQ as part of routine operating meetings, or having routine meeting with managers
to discuss the organisation’s SHEQ issues
 Participating in SHEQ talks and meetings with employees
 Conducting SHEQ visibility tours at least every 3 months
 Participating on SHEQ committees
 Reviewing segments of the SHEQ system, at least annually
 Involvement with SHEQ customers as a routine
 Participating in risk assessment studies
 Participating in internal audits of the management system
  Participation in the planned general inspection process
 Participation in SHEQ investigations
 Reviewing corrective actions at lease monthly

4. Document and data control: Management should define the documentation, including the relevant
records, needed to establish, implement and maintain the management system and to support an
effective and efficient operation of the organisation’s processes.

The nature and extent of the documentation should satisfy the contractual, statutory and regulatory
requirements, and the needs and expectations of customers and other interested parties and should
be appropriate to the organisation.

5. SHEQ committees and employee involvement: Both senior management as well as employees
representation should be included on the organisation’s SHEQ steering committees. It should also
review current programme status and determine necessary corrective actions.

6. SHEQ external regulations and standards: This refers to external regulations and standards created
and maintained by governmental authorities as well as industry associations. With the proliferation
of these types of document it is essential that the organisation have procedures for identifying and
responding to issues affecting them.

A list of relevant acts is not sufficient, as the organisation must know which requirements are
actually contained in such documents.

7. External relations: This deals with communications to outside organisations such as customers,
suppliers, community groups, the media, neighbours, environmental organisations such as Green
Peace, also industry associations, educational institutions and governmental organisations.

8. Management Reviews: Management must review the status of the SHEQ programme regularly to
identify deficiencies and areas needing improvement. Top Management, not their representatives,
must perform them; they must be based on valid information that truly reflect the state of the
organisation’s SHEQ programme; and they must allow for sufficient time to review the information
presented and determine corrective actions needed.

7.2 COMPETENCY, TRAINING AND COMMUNICATION

Appropriate competency and skill training as well as SHEQ training must take place; that employees receive
effective one-on-one communications, orientations and access to group meetings.

1. Employee orientations / awareness: General orientations are intended to provide employees with
initial information needed to perform their work properly.

Work-site orientations complement the general organisation-wide orientations. They both present
information, which is relevant to the work-site and work processes to which employees are exposed.

2. Competency and training needs identified: General competency and skill requirements should
define the knowledge and skills employees need to perform their work properly, efficiently and to
an acceptable level of competency quality. SHEQ should be an integral part of this training, e.g.
work related procedures and work instructions that have been analyzed for SHEQ requirements.

Management should ensure that the necessary competence is available for the effective and
efficient operation of the organisation. Management should consider analysis of both the present
and expected competence needs as compared to the competencies already existing in the
organisation.

3. Training programme content and delivery:

 Training objectives are established
 Instructor / facilitator / lead worker guidelines are established for carrying out the training.
These guidelines should establish time frames, teaching techniques, and material to reinforce
subjects, etc.
  A process exists to assess the student’s competency regarding the knowledge and skill being
taught.

Refresher training is needed to reinforce vital aspects of original training provided to the employee.
Knowledge fades over time, habits are formed, and new and innovative techniques for doing work
are continually developed. Refresher training should address each of these issues.

4. Training programme effectiveness: Too often training programmes miss the mark relative to
obtaining tangible results in the work organisation. With this in mind, the training programmes
should be assessed periodically to determine their effectiveness. Two aspects of the training
programme should be evaluated, the quantity of training given, and the results of the training given.

5. One-on-one communication: A defined personal communication technique is a formal method for

giving task instructions to another individual. There are various techniques used to give task
instructions, one of the most widely used methods is called Proper Task Instruction (PTI).

6. Group SHEQ meetings: Formal group meetings to discuss SHEQ issues should be planned in advance
and attended by organisation employees monthly. Providing presenters with written material is one
way to improve the quality of the meeting while taking some of the burden away from those who
have to make the presentations. To be most effective, the material should provide tips for
presenting the meeting in an effective manner.

7. Programme promotions: Recognizing groups of employees for good performance encourages

people to become involved in the SHEQ programme, and reinforces good behaviour as well as team
building.

7.3 MANAGEMENT OF OPERATIONAL RISK AND CHANGE

This ensures analysis of existing operations and jobs to identify SHEQ risks. It also ensures that appropriate
controls including procedures and practices for all work posing significant risk to the operation are in place
and observed.

1. Indentifying operational risk: The organisation should have a total appreciation of all significant
SHEQ risks in its domain, after using the processes of hazard identification, risk assessment and risk
control.

The hazard identification, risk assessment and risk control processes and their outputs should be the
basis of the whole SHEQ system.

The hazard identification, risk assessment and risk control processes should enable the organisation
to identify, evaluate and control its SHEQ risks on an ongoing basis.

In all cases, consideration should be given to normal and abnormal operations within the
organisation, and to potential emergency conditions.

2. Operation analysis: The organisation should identify its significant operations.

Since analysis can take a significant amount of resources, clear guidelines should be developed
which specify the analysis techniques to use. The guidelines should be based on loss potential and
should consider safety and health as well as environmental and quality losses.

3. Significant task identification and analysis: Ensures the organisation has identified tasks with the
potential to cause major loss to the organisation. At a minimum, harm to people, property, process,
quality and the environment must be considered when identifying significant tasks. Organisations
need to identify the relatively few significant tasks and make sure they are managed well.

4. Management of change: Management of change covers the identification and documentation of the
need for and the impact of change, and the review and approval of changes to processes and
products.
 Changes with SHEQ implications will inevitably occur at the organisation. New chemicals and
substances will be introduced and old tools, equipment and facilities will be modified.

Identification is essential before change can be evaluated and controls implemented. Special efforts
should be made to identify changes made by maintenance personnel, particularly when they do not
replace “in-kind” or when they modify piping, electrical and instrumentation systems.

Challenges presented by operating personnel are changes, which take operating processes outside
acceptable operating parameters.

Company personnel external to the organisation include divisional or corporate personnel who
modify processes and equipment and require these modifications to be implemented at the
organisation.

Regulations, codes and standards, as well as other statutory requirements can have a major impact
on the organisation’s change management process.

Organisational restructuring can result in risk to the SHEQ system. This type of change does not
always have immediate impact but manifests over a period of time. The loss of key people and
knowledge can result in processes not functioning. Personnel in support functions are usually the
first to be affected by organisational restructuring which results in medium to long term impact on
the SHEQ process.

5. Task and operation control: The purpose of doing operation and task / task analysis is to ensure
controls are put in place, which reduces the likelihood of accidents from occurring.

7.4 OPERATIONAL MANAGEMENT AND DESIGN

Ensure SHEQ reviews for all types of changes taking place at the site, whether they are to equipment, or
processes, and that appropriate controls are implemented prior to the change being implemented.

1. Planning for product realisation: Top management should ensure the effective and efficient
operation of realisation and support processes and the associated process network so that the
organisation has the capability of satisfying its interested parties. While realisation processes are
also necessary to the organisation and add value indirectly.

Any process is a sequence of related activities or an activity that has both input and output.
Management should define the required outputs of processes, and should indentify the necessary
inputs and activities required for their effective and efficient achievements.

2. Processes related to interested parties: The organisation should have a full understanding of the
process requirement of the customer, or other interested party, before initiating its actions to
comply. This understanding and its impact should be mutually acceptable to the participants.

3. Design and development: Top management should ensure that the organisation has defined,
implemented and maintained the necessary design and development processes to respond
effectively and efficiently to the needs and expectations of its customers and other interested
parties.

When designing and developing products or processes, management should ensure that the
organisation is not only capable of considering their basic performance and function, but all factors
that contribute to meeting the product and process performance expected by customers and other
interested parties.

4. Production and service functions: Top management should go beyond control of the realisation
processes in order to achieve both compliance with requirements and provide benefits to interested
parties. This may be achieved through improving the effectiveness and efficiency of the realization
processes and associated support processes, such as:
 Reducing waste
 Training of people
  Communicating and recording information
 Developing supplier capability
 Improving infrastructure
 Preventing problems
 Processing methods and process yield, and
 Methods of monitoring

Top management should go beyond control of the realisation processes in order to achieve both
compliance with requirements and provide benefits to interested parties. This may be achieved
through improving the effectiveness and efficiency of the realisation processes and associated
support processes, such as:
 Processing methods and process yield
 Methods of monitoring

7.5 PURCHASING SYSTEMS

Ensures SHEQ controls are formally considered and approved prior to the purchase of materials, equipment,
and contractor services.

1. Equipment, materials and suppliers: The ideal time to control SHEQ problems is before the material
or equipment arrives on site. This begins by having a process for reviewing new, rather than all,
purchases of material and equipment prior to its arrival on site. Typical purchases that must be
addressed include capital equipment, SHEQ related equipment, such as monitoring equipment,
personal protective equipment, chemicals, raw materials and environmental clean-up equipment.

2. Contractors: Organisations use contractors on a routine basis. The nature of work which contractors
perform varies significantly. All contractors should be managed well, but in practice there are simply
not enough resources to focus equally on them all.

Organisations need to focus on the critical few contractors, e.g. those that present a significant
chance of loss to their personnel or to the organisation. This typically includes contractors
performing long-term maintenance, construction, and those with specialized equipment and skills
that the organisation does not have, e.g. scuba equipment.

7.6 WORK RULES AND OPERATING PERMITS

The site should make sure that it applies for, or establishes and maintains the permits and rules it needs to
operate in an effective SHEQ manner.

1. Organisation permits and high risk work controls: The first function of a SHEQ programme is to
identify all loss exposures and take appropriate actions to control those exposures. In virtually all
organisations, there are existing permits to control confined space entry, trenching and shoring, hot
work, and others. An organized approach must be demonstrated. If permits have simply “grown-
up” over time, they probably need to be formally reviewed and updated.

2. Externally required permits: As is the case with site-specific permits, there is a need to identify loss
exposure related to externally required permits. These loss exposures however are created by
external authorities and must be identified so regulatory compliance needs are met.

3. Organisation SHEQ rule programme: Since an organisation is expected to have specific rules to help
control their SHEQ hazards, an assessment should be made to determine what the organisation’s
actual needs are. If the organisation has rules, which have evolved over time, these rules are
reviewed to determine their appropriateness.

7.7 INSPECTIONS
Ensures the site inspects and maintains all of its equipment, including SHEQ equipment, and work areas in a
manner that will detect and control SHEQ hazards before they result in accidents.

1. Planned general inspections: These inspections are planned, deliberate activities, which are
conducted on a regular frequency and encompass the entire operation. To help determine the
frequency at which the inspection should be conducted, the segments could be evaluated using a
 Hazard Analysis and Identification process to identify the risks. This analysis will help the operation
to determine a frequency of inspection consistent with the risk present in the segment.

High-risk areas, for example those where there is a significant man / machine interaction, higher risk
processes, etc. should be thoroughly inspected at least monthly. Lower risk areas such as tank
farms, lay-down areas, decommissioned operations, etc. could have a two monthly or quarterly
frequency. The important point is that the inspection frequency should be consistent with the
perceived risk. These inspections are a basic element in the risk control process.

2. Specialised SHEQ equipment inspections: Identifying the need for specialized equipment systems is
only the first step. Ensuring it is maintained well and available for use is a never-ending process.
The organisation should have formal inspection and maintenance systems for the equipment and
systems listed.

3. Mobile and material handling equipment: Inspecting mobile and material handling equipment is
not only good practice; it is often a regulatory requirement as well. Pre-use means that equipment
should be checked at start of work shift or prior to its use by an operator.

Other equipment includes such things as welding machines, power tools, self-containing breathing
apparatus, respirators, gas detectors, radiation monitors, etc. Pre-use inspections may include
calibration tests to ensure accuracy of monitoring.

4. Engineering maintenance systems: This process requires that a complete inventory is compiled
initially and updated as equipment changes are made. Such an inventory should start at a high level
and be broken down to at least equipment level, including structures, in a hierarchical format. This
inventory should include details of the equipment, such as technical specifications, manufacturers
with their relevant identification, as well as the official plant coding and make of equipment.

A high level risk assessment of the entire plant is needed to assure compliance.

5. Statutory compliance: Organisation management has a duty to review the applicable legislation o
the organisation and to identify all the relevant equipment at the organisation that is governed by
legislation.

6. Housekeeping inspections: A good housekeeping inspection programme complements a general

inspection programme. These are different, but complementary activities. Housekeeping
inspections focus on order while general inspections focus on identifying hazards.

7.8 OCCUPATIONAL HEALTH SYSTEMS

Ensures specific Health and Hygiene issues, not adequately addressed in other elements, are covered.

1. Occupational health administration: A key to a successful occupational medicine and occupational

hygiene programme is to have someone responsible for its management. From a practical point of
view, the two disciplines often have different characteristics. Occupational health is often perceived
to be a medical profession, and industrial hygiene is often perceived to be more of a technical
profession.

As described in the definition, Occupation health is a medical profession. As such the person
responsible for this area should have a formal medical background. In addition, the person should
be trained or well versed in specific topics discussed below.

2. Hazard recognition and evaluation: Qualitative and quantitative analyses are excellent means to
identify health hazards but there are other less sophisticated methods, which can and should be
used as well.

3. Hazard controls: The purpose of an occupational hygiene programme is to control health risks so
they do not result in harm to employees. With this in mind, there must be a system for developing
corrective actions to control those risks, which have been identified (control for the purpose
includes the full spectrum of activities ranging from elimination of the risks to treating it with an
 appropriate control method).

4. Occupational hygiene monitoring: Monitoring is an excellent way to assess whether or not hazard
controls are in place and working. Area monitoring is workplace monitoring, which includes
personal exposure monitoring. Common health hazards usually monitored include noise, air quality,
water, radiation, and lighting. Organisation should be able to provide a well-defined monitoring
plan which specifies when and where monitoring is required and that is being performed.

5. Occupational medicine: Placing employees on a job for which they have the physical ability to
perform well is essential. Physical capability analyses are a device to ensure that individuals are
placed on a job based on their ability to perform as opposed to some other non-job related factor.

Pre-placement medical examinations are excellent means to ensure employees can work without
harming themselves or their co-workers. They are, however, costly and often unnecessary. What is
required is that all new or transferred employees have a pre-placement medical examination. The
organisation is expected to identify those occupations, which require a pre-placement medical
exam. A medical professional is, ideally, a certified physician.

6. Records: The organisation must provide a system, which ensures that medical records under secure
control of medical personnel or responsible authority and that the human resources personnel
inform medical personnel of new or transferred employees so that the medical records can either be
obtained or kept current.

The system should include the following medical records:

 Pre-placement medical examinations
 Hearing test
 Pulmonary test
 Biological monitoring test
 All medical events reported to health care personnel

7.9 PERSONAL PROTECTIVE EQUIPMENT

Organisations should ensure that employees have appropriate personal protective equipment that will
reduce the likelihood of them being harmed as a result of work related exposures.

1. Personal protective equipment requirements: Identifying the type of personal protective

equipment (PPE) required, where it is required, and when it is required to be worn is an important
component of an effective PPE programme.

This assessment must include permanent employees, temporary staff, visitors, contractors and sub-
contractors.

2. Personal protective equipment availability: To be effective, PPE needs to be available to all

employees. Providing PPE to employees can be done in a variety of ways ranging from the
organisation providing every piece of equipment needed to the employee providing most of the
equipment needed. The organisation should define ways and means, which ensure that employees
receive the proper PPE in a fair and equitable manner.

3. Personal protective equipment compliance: Identifying needs and issuing appropriate PPE is all for
naught if the equipment is not used. With this in mind, the organisation should have a system for
monitoring PPE compliance on a routine basis. This is usually accomplished by conducting
compliance surveys.

7.10 INCIDENT NON-CONFORMITY REPORTING, INVESTIGATION AND ANALYSIS

Ensures the site has processes in place requiring all appropriate SHEQ accidents and incident to be reported
and investigated to identify their underlying causes.

1. Incident / non-conformity investigation process: A process must have requirements for reporting
and investigating incidents and be able to demonstrate that these requirements are being followed.
Requirements are defined through policies, procedures and standards.
 Participation in the investigation by first line managers and team leaders is essential since they are
often held personally accountable for the incident, they are ultimately the ones to take corrective
action, and they are knowledgeable regarding circumstances surrounding the incident.

2. Middle and senior management participation: Middle and senior managers should promptly
respond to and investigate, (at the scene) serious incidents and near misses. Their participation
demonstrates commitment and ensures appropriate attention will be given to determining the
causes and preventive actions needed.

Organisation must have defined what serious events are, and be able to demonstrate they are
reported and investigated. In other words, the type of events described must first be a part of the
organisation’s incident / non-conformity and near miss investigation programme before middle and
senior managers can consistently participate in their investigation.

3. Incident / non-conformity analysis: The organisation should determine the frequency which best
represents the site’s programme and multiplying the score for the frequency times the value factor
indicated. Incident / non-conformity frequency rates have many benefits and when used properly
will improve your organisation’s SHEQ programmes tremendously. Several of these benefits are
that: incident / non-conformity frequency rate have their problems and only through understanding
these problems will you be able to overcome them and take full advantage of their potential
benefits.

4. Record keeping: Keeping investigation reports centrally located allows for trend analysis, tracking of
corrective actions, and just plain good management. “Centrally” means a common location for the
entire organisation.

Organisation personnel should adhere to regulatory requirements for retaining incident

investigation reports.

7.11 EMERGENCY PREPAREDNESS

Ensures the site has appropriate plans developed and tested to be ready to promptly respond to any
probable SHEQ emergency that might occur.

1. Emergency preparedness administration: The emergency response plan should comply with
pertinent regulations. The plan should demonstrate that it is based on an assessment of risk and
that all types of probable emergencies have been addressed. Additional areas for consideration
include:
 Major property damage above an established cost
 Major loss due to undesired events
 Major environmental damage
 Floods, tornadoes, etc.
 Bomb threats, sabotage, strikes, etc.
 Potential off-site emergencies

Initial hazard / risk assessments should be undertaken by suitable qualified personnel.

2. Emergency response plan: A single emergency plan may not address all probable emergencies
and therefore more than one plan may be used.

The activities in 11.2.1 are fairly self-explanatory and necessary to ensure an effective
emergency plan exists. Even though each item is briefly stated, the amount of work and
systems needed to ensure the activity is addressed is significant.

Responding to emergencies and conducting emergency drills provide lessons, which can be
used to improve existing plans. There should be a formal process, which requires a debriefing
following a simulated or actual emergency. The debriefing should analyse the emergency and
determine what could have been done that will improve the organisation’s future response.
 The findings from these sessions should be integrated into the emergency plan.

3. Emergency response teams: Response team training is intended to provide team members
with the knowledge and skills needed to do their tasks well. As such, the training typically has
both classroom and field components.

The type of session can include table-top exercises, evacuation drills, spill clean-up exercises,
first aid competitions, extrication exercises, time to respond drills, mock-fires and fire
suppression exercises, “man-down” drills and many others.

4. Emergency equipment: Organisations must be properly prepared and able to respond to

probable emergencies and ensure that they are in compliance with the many regulatory
requirements and codes.

5. Mutual aid: help from outside agencies and neighbouring industries is vital to control
organisation emergencies. The organisation should identify local neighbouring companies, as
well as industry groups, which can provide meaningful mutual aid to the organisation in an
emergency.

7.12 MEASUREMENT, MONITORING AND AUDITS

Ensures site has appropriate systems in place to objectively evaluate and review how well its SHEQ systems
are doing.

1. Routine process measurements: Measurement data are important for making fact-based
decisions. Top management should ensure effective and efficient measurement, collection and
validation of data to ensure the organisation’s performance and the satisfaction of interested
parties. This should include review of the validity and purpose of measurements and the
intended use of data to ensure added value to the organisation.

The organisation should continually monitor its performance improvement actions and record
their implementation, as this can provide data for future improvements.

The results of the analysis of data from improvement activities should be one of the inputs to
management review in order to provide information for improving the performance of the
organisation.

2. System audits: Top management should ensure the establishment of an effective and efficient
internal audit process to assess the strengths and weaknesses of the SHEQ management
system.

The internal audit process acts as a management tool for independent assessment of any
designated process or activity. The internal audit process provides an independent tool for use
in obtaining objective evidence that the existing requirements have been met, since the internal
audit evaluates the effectiveness and efficiency of the organisation.

7.13 CORRECTIVE AND PREVENTIVE ACTION SYSTEM

Ensure there are proper systems in place so that appropriate corrective actions are defined and
implemented.

1. Corrective and preventive action process: An organisation should have corrective action
systems for each activity throughout the system; however, rather than evaluating those
systems on a case-by-case basis, they are evaluated once. This approach is compatible with ISO
9001. 14001 and OHSAS 18001 and hopefully will streamline the work being done to implement
corrective actions.

2. Corrective and preventive action communications: Management accountability and

responsibility for ensuring that corrective actions are implemented is vital to the success of a
 corrective action system.

Ensuring middle and senior manager’s review the corrective action status reports is an
important part of the corrective action system. A common way for reviewing status reports is
to conduct these reviews during regularly scheduled management meetings.

3. Control of non-conforming product: The management of the organisation should ensure the
establishment of an efficient process to provide for review and disposition of identified non-
conformities. Authorised people to determine if any trends or patterns of occurrence require
attention should conduct review of nonconformities. Negative trends should be considered for
improvement and as input to management review where reduction goals and resource needs
are considered.

People carrying out the review should have the competence to evaluate the total effects of the
nonconformity and should have the authority and resources to disposition the nonconformity
and to define appropriate corrective action. Acceptance of nonconformity disposition may be a
contractual requirement of the customer, or a requirement of other interested parties.

Three causes for inadequate control: The three main causes for inadequate control are the following:
 Inadequate system
 Inadequate standards
 Inadequate compliance with standards
Note: Addressing all three reasons for inadequate control is essential to ensure success.

Inadequate System: A SHEQ system may be inadequate because of too few or improper system activities. System –
an established way of carrying out an activity or series of activities. This includes the identification, training and
involvement of individuals responsible for the activity; a clear definition of the activity and how to do it; and a
mechanism to ensure that the activity is performed as expected.

Inadequate standards: A common cause of confusion and failure is standards that are not specific enough. SHEQ
standards not clear enough and / or priority assigned not high enough. Performance standards are not defined as
the criterion for effective performance of work or activities. SHEQ performance standards should define who is
responsible for performing what work and at what frequency or when and how often it is to be done.

Inadequate compliance with standards: Having the right system elements in place and the proper roles,
responsibilities and standards for performance established would all be meaningless if people do not comply with
them. This is the greatest reason for failure to control losses.

Corrective / remedial actions: The three basic steps in a systematic approach to selecting corrective actions are:
1) All major actions are considered
2) Analysis does not stop with familiar and favourite corrective actions, and
3) Each corrective action chosen for implementation is carefully thought out.