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Draft: Occupational Health and Safety Management System Accreditation Standard

1. Introduction

As defined in the Occupational Health and Safety Act (OHSA) a health and safety management system “means a coordinated system of procedures, processes and other measures that is designed to be implemented by employers in order to promote continuous improvement in occupational health and safety”.

It is a systematic approach that encourages and promotes the continual improvement of the management of occupational health and safety (OHS) in the workplace at a level beyond mere compliance with legislated requirements.

This draft voluntary Occupational Health and Safety Management System (OHSMS) Accreditation Standard is intended to recognize excellence in OHS management through the accreditation of OHSMS by the Chief Prevention Officer (CPO).

This draft standard has been prepared for consultation purposes related to the development of a CPO OHSMS Accreditation Standard. It is not intended to replace the OHSA or the regulations and reference should always be made to the official version of the legislation.

It is the responsibility of the workplace parties to ensure compliance with the legislation. This draft standard does not constitute legal advice. If you require assistance with respect to the interpretation of the legislation and its potential application in specific circumstances, please contact your legal counsel.

While this draft standard will be made public, Ministry of Labour inspectors will apply and enforce the OHSA and its regulations based upon the facts as they may find them in the workplace. This draft standard does not affect their enforcement discretion in any way.

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2. Purpose and objectives

The purpose of this draft standard is to outline the proposed elements that an OHSMS must contain in order to be accredited by the Chief Prevention Officer of Ontario.

The objectives of the occupational health and safety management system Accreditation Standard are to:

  1. Outline a best practice standard for effective occupational health and safety management systems;
  2. Reinforce the cooperation of all workplace parties in the promotion of the Internal Responsibility System;
  3. Encourage workplaces without health and safety management systems to work towards adopting them;
  4. Encourage employers who have already implemented health and safety management systems to engage in the continual improvement of their systems; and
  5. Encourage employers to champion health and safety in their business sector.

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3. Definitions

This section defines specific terms as they relate to this draft standard and in the context of occupational health and safety management system (OHSMS) requirements found under each element.

Audit
Systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled.
Audit program
A set of one or more audits planned for a specific time frame and directed towards a specific purpose.
Competence
As outlined in 5.2.6.1.
Competent person
As defined in the Occupational Health and Safety Act (OHSA): means a person who,
  1. is qualified because of knowledge, training and experience to organize the work and its performance;
  2. is familiar with the OHSA and the regulations that apply to the work; and
  3. has knowledge of any potential or actual danger to health or safety in the workplace.
Conformity
Fulfillment of a requirement. For the purpose of this standard, conformance is synonymous with conformity.
Continual improvement
Recurring process of enhancing the OHSMS in order to achieve improvements in overall occupational health and safety (OHS) performance consistent with the organization’s OHS policy.
Contractor
Person or organization providing services to another organization in accordance with agreed-upon specification, terms and conditions.
Corrective action
Action to eliminate the cause of a detected nonconformity or other undesirable situation. For the purposes of this standard, this refers to any action taken to fix an existing occupational health and safety problem or hazard.
Document
Medium containing information related to the OHSMS.
Harm
Physical injury, occupational illness, or other adverse effect to a person, whether acute or chronic.
Hazard
Source, situation or act with a potential for harm in terms of human injury or occupational illness.
Hazard identification
Process of recognizing that a hazard exists and defining its characteristics.
Incident
Work related event(s) in which an injury, fatality or occupational illness occurred; and includes event(s) where no injury or illness occurred, such as a near hit or property damage.
Interested party
Person or group, inside or outside the workplace, concerned with or affected by the occupational health and safety performance of an organization.
Legal requirements
The Occupational Health and Safety Act and its regulations.
Non-conformity
Non-fulfillment of a requirement.
Occupational health and safety (OHS)
Conditions and factors that affect, or could affect the health and safety of employees or other workers, inclusive of temporary workers and contractor personnel, visitors, suppliers, vendors, or any other person in the workplace.
Occupational health and safety management system (OHSMS)
A coordinated system of procedures, processes and other measures that is designed to be implemented by employers in order to promote continuous improvement in occupational health and safety.
Occupational illness
As defined in the Occupational Health and Safety Act as a condition that results from exposure in a workplace to a physical, chemical or biological agent to the extent that the normal physiological mechanisms are affected and the health of the worker is impaired thereby and includes an occupational disease for which a worker is entitled to benefits under the Workplace Safety and Insurance Act, 1997.
OHS objective
Occupational health and safety (OHS) goal, in terms of OHS performance, that an organization sets itself to achieve.
OHS performance
Measurable results of an organization’s management of its occupational health and safety (OHS) risks.
OHS policy
Overall intentions and direction of an organization related to its health and safety (OHS) performance as formally expressed by senior management.
Organization
Company, corporation, firm, enterprise, authority or institution, or part or combination thereof, whether incorporated or not, public or private, that has its own functions, management and administration.
Other requirements
Requirements or provisions the organization by which the organization subscribes, however are not legally binding.
Plan
Detailed method for doing or achieving something.
Preventative action
Action to eliminate the cause of a potential non-conformity or other undesirable potential situation. For the purposes of this standard, this refers to any action taken to fix a potential occupational health and safety problem.
Procedure
A documented, specified method to carry out an activity.
Process
A set of interrelated or interacting activities that transforms inputs into outputs.
Record
Document stating results achieved or providing evidence of activities performed.
Residual risk
Combination of the likelihood of the occurrence after the hierarchy of controls has been implemented for an identified hazard.
Risk
Combination of the likelihood of an occurrence of a hazardous event or exposure(s) and the severity of injury or occupational illness that can be caused by the event or exposure(s).
Risk assessment
Process of evaluating the risk(s) arising from a hazard(s), taking into account the adequacy of any existing controls, and deciding whether or not the risk(s) is acceptable.
Senior management
The person(s) at the highest level of an organization structure responsible for leading, managing and/or directing an organization’s day-to-day activities and/or operations.
Workplace
As defined in the Occupational Health and Safety Act means any land, premises, location or thing at, upon, in or near which a worker works.
Workplace parties
Includes, but is not limited to, the employer, supervisor(s), workers, constructor, owner, joint health and safety committee, and health and safety representative(s).

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4. Chief Prevention Officer occupational health and safety management systems accreditation

This section outlines the proposed process for Chief Prevention Officer (CPO) Accreditation.

4.1 Accreditation of occupational health and safety management systems

The Ministry of Labour understands there are multiple occupational health and safety management systems (OHSMS) standards available, and that there are also individually designed OHSMS that are established and implemented for the specific needs of an individual organization. In the interest of flexibility to allow employers to implement an existing standard or create a customized management system, the Ministry of Labour has developed this draft standard to acknowledge and accept different standards for review, provided that organizations are able to demonstrate that their OHSMS meets the intent of each of the elements of this draft standard.

The aim of a voluntary program is to provide a framework to recognize employers who successfully implement a CPO accredited OHSMS in their workplace, and who can meet additional criteria that demonstrates health and safety performance that is worthy of recognition.  

The development of a separate employer recognition criteria document, which would include the compliance criteria required to be met by an employer that applies to receiving CPO recognition, will be prepared separately and will be informed by the results of the ongoing consultation.

Recent amendments to the Occupational Health and Safety Act (OHSA) have provided the CPO with authority to establish an OHSMS accreditation and employer recognition program, specifically the CPO may:

  • establish standards that health and safety management systems would need to meet to become accredited;
  • accredit health and safety management systems that meet the CPO’s standards;
  • establish criteria that employers would need to meet to become recognized;
  • give recognition to an employer, upon the employer’s application, if the employer is a certified user of an accredited  health and safety management system and the employer  meets the criteria established by the CPO; and
  • publish the names of accredited programs and recognized employers.

As defined in the OHSA, a health and safety management system “means a coordinated system of procedures, processes and other measures that is designed to be implemented by employers in order to promote continuous improvement in occupational health and safety”.

Like other workplace management systems, an occupational health and safety management system utilises a “plan – do – check – act” cycle to implement, promote, monitor, and continuously improve all aspects of the health and safety performance of a workplace.

This draft standard sets out the elements and expectations that an occupational health and safety management system would need to have to be considered for accreditation by the CPO.

The elements in this draft standard are commonly found in, and are consistent with, internationally recognized occupational health and safety management systems standards.

The final standard will be voluntary, but once established any organization seeking accreditation of an OHSMS by the CPO would need to ensure the system meets the intent of each element and its constituent requirements.

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5. Elements

The purpose of this draft standard is to outline the proposed elements an occupational health and safety management system will need to include in order to be accredited by the Chief Prevention Officer (CPO).

5.1 Leadership, commitment and participation

5.1.1 Leadership and commitment

5.1.1.1 Commitment, leadership and effective participation are crucial to the success of an occupational health and safety management system.

5.1.1.2 Senior management shall take ultimate responsibility for the organization’s occupational health and safety (OHS) and the occupational health and safety management system (OHSMS).

5.1.1.3 Senior management shall designate one or more representatives, including one from senior management who, irrespective of other responsibilities, have defined roles, responsibilities, and authority for ensuring that an OHSMS is established, implemented and maintained in accordance with the requirements of this standard.

5.1.1.4 Senior management shall ensure the identity of the designated management representative(s) is made available to all persons working under the control of the organization.

5.1.1.5 Senior management shall promote and support:

  1. Effective processes to identify and eliminate identified hazards and control associated residual risk(s);
  2. Participation of working place parties at all levels and functions;
  3. Reporting on OHS performance to senior management; and
  4. Utilizing OHS performance as a basis for the continuous improvement of the OHSMS overall.

5.1.1.6 The organization shall define and document the scope of its OHSMS.

5.1.1.7 Senior management shall demonstrate leadership and commitment with respect to the OHSMS by:

  1. Taking overall responsibility and accountability for the protection of workers’ health and safety in the workplace;
  2. Promoting the effective implementation and continual improvement of the OHSMS;
  3. Defining roles, assigning responsibilities, establishing accountabilities, and delegating authority to establish, implement and maintain an effective OHSMS;
  4. Ensuring those identified in 5.1.1.7 (c) are documented and communicated to all interested parties;
  5. Ensuring workers, and where applicable, worker representatives are consulted and provided the opportunity to meaningfully and actively participate in the establishment and maintenance of each element of the OHSMS;
  6. Allocating necessary resources, inclusive of financial, human and organizational to properly plan, implement, monitor, review, correct and continually improve the OHSMS;
  7. Ensuring the OHS policy and related OHS objectives are established, compatible with the strategic direction of the organization, are measurable, and achieved;
  8. Reviewing the OHSMS at regularly planned intervals;
  9. Ensuring competent and effective supervision for the protection of worker’s health and safety; and
  10. Supporting relevant management roles to demonstrate their leadership as it applies to their areas of responsibility.

5.1.2 Worker participation

5.1.2.1 The organization shall establish, implement and maintain a procedure(s) or process to ensure active and meaningful participation in the planning, implementation and evaluation of the OHSMS.

5.1.2.2 As and where appropriate, the organization shall ensure that a worker representative(s) is appointed in accordance, inclusive of all rights, responsibilities, and duties, as prescribed in the Occupational Health and Safety Act.

5.1.2.3 As and where appropriate, the organization shall ensure a joint health and safety committee is established and maintained, inclusive of all rights, responsibilities, and duties, as prescribed in the Occupational Health and Safety Act.

5.1.2.4 The organization shall:

  1. Encourage and support worker participation by identifying and removing barriers to participation;
  2. Ensure workers, and where appropriate, worker representatives, are informed, consulted on, and given the opportunity to participate in all aspects of OHS associated with their risk, which include, but not limited to:
    1. Appropriate involvement in hazard identification, risk assessments and determination of controls;
    2. Appropriate involvement in incident investigations;
    3. Appropriate involvement in the development and review of OHS policies and objectives;
    4. Consultation where any changes may affect their OHS;
    5. Representation on any other OHS matters, as appropriate; and
    6. Access to relevant reports.

5.1.2.5 The organization shall ensure that, when appropriate, relevant external interested parties are consulted or informed about pertinent OHS matters.

5.1.3 Communication

5.1.3.1 The organization shall establish, implement and maintain a procedure(s) or process for:

  1. Communicating information about the OHSMS, OHS policy and implementation progress to all interested parties;
  2. Internal OHS communication among various levels and functions within the organization;
  3. External OHS communication among interested parties;
  4. Receiving, documenting and responding appropriately to internal and external communications related to OHS;
  5. Identifying and removing potential barriers, such as ability, language skills and literacy;
  6. Reporting of a workplace incident, hazard or risk in a timely manner; and
  7. Ensuring that input from workers or any interested party is received, considered and responded to in a timely manner.

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5.2 Planning and implementation

5.2.1 Occupational health and safety policy

5.2.1.1 Senior management shall establish, implement and maintain an occupational health and safety (OHS) policy appropriate to the scale and nature of the organization’s operations and activities, associated risks, and the scope for which the OHSMS is applicable.

5.2.1.2 The OHS policy must include a commitment to the:

  1. Prevention of injury and occupational illness;
  2. Compliance with all OHS legal and other requirements for which the organization subscribes;
  3. Consultation and participation of the workplace parties as appropriate; and
  4. Continual improvement in OHS management and performance.

5.2.1.3 The OHS policy must:

  1. Provide a framework for setting and reviewing OHS objectives;
  2. Be documented, implemented and maintained;
  3. Be communicated and made readily available to any interested party;
  4. Be reviewed as often as is necessary, but in any case, at least annually; and
  5. Be signed by the employer and the highest level of management at the workplace.

5.2.2 Identification of hazards, risk assessment and determination of controls

5.2.2.1 The organization shall establish, implement and maintain a documented hazard identification and risk assessment process or methodology to adequately identify hazards and prioritize risks based on the nature of the hazards and level of risk for each of its routine and non-routine operations and/or activities.

5.2.2.2 Risk assessments shall be conducted:

  1. By competent persons having knowledge, experience and training with regard to the particular operation and/or activity, inclusive of workers who may be exposed to the hazards and risks, and where appropriate, subject matter experts;
  2. Proactively prior to the commencement of performing any task(s) related to the operations and/or activity;
  3. Prior to the introduction of new equipment, material, substance or process;
  4. As part of the management of change process when there is a change to existing equipment, material, chemical or process; and
  5. When there is a change to the OHSMS that may impact upon the operations and/or activities.

5.2.2.3 The process for identifying hazards and assessing the associated risk must take into account:

  1. Hazards created in the workplace or in the vicinity of the workplace by work-related activities;
  2. Identified hazards originating outside of the workplace that may impact on the health and safety within the workplace for which the organization has control;
  3. Workers at a location not under direct control of the organization;
  4. Activities of any person having access to the workplace, inclusive of contractors, suppliers, vendors, or visitors;
  5. Legal requirements related to the work activities, inclusive of regulatory controls;
  6. The design and layout of the work area, installations, machinery, equipment, processes, related procedures or controls; and
  7. Human interaction with the workplace, inclusive of human behaviour, capabilities or any other human factor(s) that may impact on the health and safety of a worker or another person.

5.2.2.4 The process or methodology for identifying hazards and assessing the associated risks should also include or take into consideration contributing factors that may compound, leading a low priority risk to become a high priority.

5.2.2.5 When determining control measures with respect to the identified hazards and prioritized risks, the organization shall consider reducing the risk utilizing the hierarchy of controls principle. Control measures should reflect the following hierarchy:

  1. Elimination
  2. Substitution
  3. Engineering controls
  4. Administrative controls
  5. Personal Protective equipment

5.2.2.6 The organization shall ensure the OHS risks and associated control measures are taken into account when establishing, implementing and maintaining the OHSMS.

5.2.2.7 All hazard identifications, risk assessments and associate control measures shall be documented, kept current, reflect actual practice and be made readily available to any interested party.

5.2.3 Preventative and protective control measures

5.2.3.1 For the operations and/or activities where hazards have been identified and risks assessed, the organization shall establish, implement and maintain control measures to adequately protect against or otherwise control the hazards and risks identified.

5.2.3.2 Control measures must be suitable and sufficient to adequately control the hazard and eliminate or reduce the risk to a tolerable level, and shall take into account:

  1. The nature and extent of the hazards and risks identified;
  2. Controls related to any person, inclusive of workers, contractors, suppliers, vendors and visitors, who may be or become exposed to the hazard or risk;
  3. Controls related to purchased goods, equipment and services;
  4. Applicable legal and other requirements;
  5. Recognized standards, requirements, guidelines, codes of practice, instructions or other relevant considerations; and
  6. The organization’s ability and capacity to adequately control the hazard and eliminate or reduce the risk to a tolerable level.

5.2.3.3 Control measures shall be documented, communicated to all workplace parties, and made readily available at the point of use as required.

5.2.4 Legal and other requirements

5.2.4.1 The organization shall establish, implement and maintain a procedure to identify and document legal and other requirements as applicable to the workplace.

5.2.4.2 All legal and other requirements shall be taken into account, and incorporated as appropriate, into the establishment, implementation and maintenance of the OHSMS.

5.2.4.3 The organization shall ensure that the documentation of legal and other requirements are kept current, and that relevant information related to the legal and/or other requirements are communicated to the workplace parties as appropriate.

5.2.4.4 The organization shall establish, implement and maintain a procedure or process to periodically evaluate compliance with applicable OHS legal and other requirements applicable to the workplace.

5.2.4.5 The organization shall ensure records of evaluations are documented and records are retained.

5.2.5 OHS objectives

5.2.5.1 The organization shall establish, implement and maintain documented OHS objectives, with targets, for relevant functions and levels within the organization.

5.2.5.2 The objectives and targets shall:

  1. Be measureable;
  2. Be consistent with the OHS policy, inclusive of the commitments to:
    1. Prevention of injury and occupational illness
    2. Compliance with OHS legal and other requirements applicable to the workplace; and
    3. Continual improvement.
  3. Take into account:
    1. Previous objectives;
    2. Past performance;
    3. OHS hazards and risks;
    4. OHSMS system deficiencies; and
    5. Opportunities for improvement.
  4. Take into consideration:
    1. Technological options;
    2. Operational business and financial requirements of the organization;
    3. Other requirements or opportunities; and
    4. Views of interested parties.

5.2.5.3 The organization shall establish, implement and maintain a program or plan(s) to achieve its objectives, and include:

  1. The designation of responsibility and authority for achieving the objectives;
  2. Identification of the means and timeframe by which the objectives are to be achieved; and
  3. Provisions for the program or plan(s) to be reviewed at regular intervals and revised as appropriate, to ensure the objectives are achieved.

5.2.6 Competency and training

5.2.6.1 The organization shall ensure that any person performing a task for, or on behalf of, the organization is competent to do so by means of appropriate:

  1. Knowledge of the hazards and risks associated with the tasks for the operations and activities;
  2. Applied knowledge of the control measures associated with the hazards and risks;
  3. Training with regard to the hazards, risks and associated control measures;
  4. Experience working within the control measures; and
  5. Aptitudes, such as skillset, ability and willingness to deal with the hazards, risks and control measures.

5.2.6.2 The organization shall establish, implement and maintain a procedure or process for OHS training, which includes:

  1. A process to identify the competency expectations;
  2. Training needs analysis or assessment for each position;
  3. How the training will be administered and managed;
  4. The assessment evaluation, monitoring and reassessment evaluation criteria, as necessary; and
  5. A provision that ensures each of the above are conducted or administered by a competent person as defined by section 5.2.6.1.

5.2.6.3 OHS training shall include, as a minimum:

  1. Training as prescribed by applicable legislation;
  2. Roles, responsibilities and rights;
  3. The purpose of the OHSMS, and its respective elements;
  4. Importance of conformity to the OHS policy, procedures and the OHSMS overall;
  5. Legal and other requirements, inclusive of potential consequences for deviations or noncompliance;
  6. Importance of worker participation within the OHSMS; and
  7. Any such requirements to ensure the individual is able to meet the requirements of section 5.2.6.1.

5.2.6.4 The organization shall ensure required training or instruction is provided for each individual prior to the individual performing the required task.

5.2.6.5 The organization must take into account the differing levels of responsibility, literacy, language skills, overall ability and likelihood of exposure to the hazards and risk of the learner.

5.2.6.6 The organization shall retain a record of training for each individual for, as a minimum, the duration the training record is valid.

5.2.7 Emergency prevention, preparedness and response

5.2.7.1 The organization shall establish, implement and maintain procedure(s) to:

  1. Identify any potential emergency situation;
  2. Prevent, as far as reasonably practicable, an emergency situation from occurring;
  3. Establish response plans for how to respond to, and prevent or minimize injury or occupational illness, for each identified emergency situation; and
  4. How to test or drill for each identified emergency situation.

5.2.7.2 The organization shall identify the necessary resources to implement the prevention procedures and activate the response plans, inclusive of taking into account the needs of other interested parties, such as emergency services, authorities, or the general public.

5.2.7.3 The organization shall ensure that response equipment is maintained in good working condition and operationally ready at all times.

5.2.7.4 The organization shall also ensure that drills or testing of the response plans for each identified emergency situation are conducted periodically and in a manner that does not introduce new hazards. Records of drills and tests shall be retained.

5.2.7.5 Emergency prevention procedures and response plans shall be reviewed periodically, and revised as appropriate.

5.2.7.6 Emergency prevention procedures and response plans must be communicated with all interested parties, inclusive of specific training for any person with defined duties or responsibilities with the procedures or plans.

5.2.8 Documentation

5.2.8.1 The organization shall establish, implement and maintain a procedure or process for the control of documents and retention of records.

5.2.8.2 The OHSMS documentation shall include, as a minimum:

  1. Description of the scope for which the OHSMS is applicable;
  2. The OHS policy, objectives and performance measures;
  3. Description of the main elements, their interaction, and reference to related documents;
  4. Documents and records required by this standard;
  5. Documents and records determined by the organization to be necessary for planning, implementation, control, evaluation and overall management of the OHSMS.

5.2.8.3 The creation, collection and retention of documents and records shall comply with privacy laws, collective agreements and organizational policies, as appropriate.

5.2.8.4 Unless in contravention of the items identified in section 5.2.8.3, workers shall have the access relevant documents and records as they apply to their work or as an individual.

5.2.9 Control of documents

5.2.9.1 The organization shall establish, implement and maintain a procedure or process to:

  1. Ensure documents are approved prior to issue;
  2. Review, update, re-approve or withdraw documents as necessary;
  3. Ensure changes to, and current revision status of, documents are identified;
  4. Ensure relevant versions of applicable documents are readily available at the point of use;
  5. Ensure documents remain legible and readily identifiable;
  6. Ensure documents of external origin determined by the organization to be necessary for the planning and operation of the OHSMS are identified; and
  7. Prevent the unintended use of obsolete documents and identify such documents if they are retained for any purpose.

5.2.10 Control of records

5.2.10.1 The organization shall establish, implement and maintain a procedure or process:

  1. To maintain records as necessary to demonstrate conformity to the requirements of its OHSMS and this standard;
  2. Identify, store, protect, retrieve, retain and dispose of records;
  3. To ensure protection of privacy and confidentiality, as appropriate; and
  4. Ensure records are, and remain, legible, identifiable and traceable.

5.2.11 Management of change

5.2.11.1 The organization shall establish, implement and maintain a documented procedure or process to identify and eliminate hazards and assess and control risk(s) associated when:

  1. There is a significant change to its work processes, procedures, equipment, organizational structure, staffing, products, suppliers, vendors, contractors or services;
  2. New products, processes or services are introduced;
  3. New developments in OHS knowledge or technology is available and introduced; or
  4. There are changes to OHS legal, other requirements and, where applicable, agreements.

5.2.11.2 The organization shall ensure a hazard identification and risk assessment, methodology established, implemented and maintained for section 5.2.2 of this standard, is conducted prior to any management of change.

5.2.11.3 Every management of change shall be communicated with affected stakeholders, with information and training sessions where appropriate provided for any affected persons.

5.2.12 Procurement

5.2.12.1 The organization shall establish, implement and maintain a documented procedure or process to evaluate and manage the procurement of products, supplies, equipment, materials and other goods and services, and shall include:

  1. Identifying hazards and assessing risk associated with the use of the goods and services;
  2. Eliminating hazards, where possible, and controlling remaining risk(s); and
  3. Ensuring purchased goods and services conform to the organization’s OHSMS requirements.

5.2.12.2 The procedure or process for identifying hazards and assessing risks of procured goods and services shall follow the same methodology established, implemented and maintained for Section 5.2.2 of this standard.

5.2.13 Management of contractors

5.2.13.1 The organization shall establish, implement and maintain selection criteria to evaluate or pre-qualify contractors based partly on OHS performance prior to commencement of work.

5.2.13.2 The criteria shall address, as a minimum:

  1. The identification and elimination of hazards, and the competency and ability of the contractor to control of the risk(s) to the organization’s workers arising from the contractor’s activities and materials;
  2. The identification and elimination of hazards, and the competency and ability of the contractor to control of the risk(s) to the contractor and their workers arising from the organization’s activities and materials; and
  3. Communication with contractors when where there are changes affecting the organization’s OHSMS.

5.2.13.3 At multi-employer workplaces or multi-contractor worksites, the organization shall establish, implement, and maintain a documented procedure for, and lead the coordination of, relevant portions of its OHSMS with other affected organizations.

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5.3 Evaluation

5.3.1 Performance measuring and monitoring

5.3.1.1 The organization shall establish, implement and maintain documented procedure(s) or process to monitor and measure the organization’s OHS performance, and management of, the OHSMS on a regular basis.

5.3.1.2 The procedure(s) or process shall provide for:

  1. Qualitative and quantitative measurement methodologies appropriate to the needs, size and nature of the organization;
  2. Monitoring the extent to which the organization’s OHS policy and objectives are being met, as well as conformance to any OHS programs;
  3. Monitoring the effectiveness of the control measures; and
  4. Reactive performance measures such as incidents, occupational illness and other relevant historical evidence of deficient OHS performance.

5.3.1.3 The results of these measurements shall be recorded and communicated with interested workplace parties.

5.3.1.4 If equipment is required to monitor and measure, the procedure(s) or process shall also include provisions to ensure for the calibration and maintenance of such equipment, inclusive of records for each.

5.3.2 Incident investigation and analysis

5.3.2.1 The organization shall establish, implement and maintain a procedure(s) or process to report, investigate, record, analyze, document and maintain records for incidents, which shall include:

  1. Roles and responsibilities of the workplace parties involved in the investigation process, inclusive of workers and worker representatives;
  2. Determination of underlying OHS deficiencies, inclusive of causing or contributing factors to the occurrence of the incident;
  3. Actions to mitigate any consequences of an incident;
  4. Identifying the need for corrective actions and opportunities for preventative actions;
  5. Identifying opportunities for continual improvement; and
  6. Means of communicating investigation results and corrective actions to relevant interested parties, being mindful of privacy and confidentiality.

5.3.2.2 Investigations shall be conducted in a timely manner, and by competent persons only, inclusive of subject matter experts, as appropriate.

5.3.2.3 Investigations of an OHS incident shall identify any failures of the OHSMS. Investigations, inclusive of evidence, causal factors, actions taken and results of analysis shall be documented and retained.

5.3.3 Non-conformity, preventative and corrective action

5.3.3.1 The organization shall establish, implement and maintain a procedure(s) or process to address:

  1. Actual and potential non-conformities to the OHSMS requirements;
  2. Ineffective OHS risk controls;
  3. Corrective actions; and
  4. Preventative actions, as appropriate.

5.3.3.2 The procedure(s) or process shall define the requirements for:

  1. Identifying and correcting actual non-conformities and investigating the root cause;
  2. Identifying and preventing potential non-conformities;
  3. Conducting a hazard identification and risk assessment of the recommended actions to identify any potential hazards that may be created as a result of the corrective or preventative actions prior to implementation;
  4. Ensuring corrective actions are assigned and tracked to correct and mitigate the non-conformity;
  5. Ensuring preventative actions are assigned and tracked to prevent the occurrence of a non-conformity;
  6. Recording, tracking and communicating the corrective and preventative actions taken;
  7. Ensuring all affected elements as a result of the actions are updated in the OHSMS; and
  8. Monitoring and assessing the effectiveness of the corrective and preventative actions.

5.3.4 Internal audit

5.3.4.1 The organization shall establish, implement and maintain an audit program to ensure internal audits are conducted at regular and planned intervals.

5.3.4.2 The audit program shall be based on the results of risk assessments and results of previous audits.

5.3.4.3 The audit program shall identify the responsibilities, competencies and selection of the audit team(s) and Team Leaders.

5.3.4.4 The audit program shall include:

  1. Criteria for auditor competency and selection;
  2. Provisions for defining the audit scope;
  3. Identifying the frequency of audits;
  4. Audit methodology;
  5. Evidence gathering and analysis;
  6. Documentation and reporting of audit findings;
  7. Provisions to assign actions with specified timeframes for completion; and
  8. Communication with relevant interested parties.

5.3.4.5 The purpose of the audits are to objectively:

  1. Verify the extent to which the OHSMS has been implemented and maintained;
  2. Determine whether the OHSMS is effective in meeting the organizations policy and objectives;
  3. Identify:
    1. good practices
    2. areas of improvement
    3. non-conformities
  4. Determine and assign appropriate corrective actions to a competent person and track through to completion; and
  5. Provide information on results of audits to management.

5.3.5 Management review

5.3.5.1 Senior management shall review the organization’s OHSMS at regularly planned intervals to verify and ensure its continuing suitability, adequacy and effectiveness.

5.3.5.2 The reviews shall include:

  1. An assessment of the opportunities for improvement of the OHSMS, inclusive of the need for changes to the OHS policy and/or objectives;
  2. Review of current control strategies;
  3. Identification of emerging issues or trends, inclusive of best available methods, technologies, and procedures to address residual risk; and
  4. Implementation strategy for continual improvement.

5.3.5.3 Management reviews shall be documented, with records retained.

5.3.5.4 Input to management reviews shall include, as a minimum, the following OHS information:

  1. Results of:
    1. Audits;
    2. Evaluations of compliance with legal and other requirements as applicable to the workplace;
    3. Communication received from, and participation with, workers and worker representatives;
    4. Communication received from external interested parties, inclusive of complaints.
  2. The OHS performance of the organization;
  3. The extent to which objectives have been met;
  4. Effectiveness of procedures and processes to identify hazards, assess, prioritize, and control risks, inclusive of progress in the sustained or improved reduction of risk;
  5. Status of incident investigations, corrective actions and preventative actions;
  6. Follow-up actions from previous management reviews;
  7. Changing circumstances, including developments in legal and other requirements related to the organization’s OHS; and
  8. Recommendations for improvement.

5.3.5.5 Outputs from the management review must be consistent with the organization’s commitment to continual improvement, and include decisions and actions related to:

  1. OHS performance, OHS policy and objectives, and the need for change, if any;
  2. Allocation of resources to achieve the improvements; and
  3. Any other elements as appropriate for the OHSMS.

5.3.5.6 The organization shall establish, implement and maintain a process for recording and communication of the findings, conclusions and plans resulting from the management to all relevant parties, inclusive or workers and worker representative.