Tag: incident investigation
One of the key requirements of the OHSAS 18001 standard is establishing a procedure for taking corrective and preventive action (section 22.214.171.124). Both corrective and preventive action need to include identifying the underlying causes – often called root causes – of whatever it is that is or went wrong.
This is not easy. Often, the root cause investigation ends with a determination along the lines of “Joe screwed up.” We play the blame game.
Although it is often used as a term of art in the safety field, “management of change” is not a defined term in OHSAS 18001:2007. It is, however; vital to an effective OH&S management system.
Explicit requirements for management of change were added into section 4.3.1 of OHSAS 18001 in the 2007 revision of the standard. This addition was an explicit request of the American Industrial Hygiene Association for purposes of aligning OHSAS 18001 with the U.S. Occupational Health and Safety Management System standard — ANSI/AIHA Z10-2005. In addition, management of change is also an explicit requirement for safety management systems implemented to comply with the Seveso II Directive (see Annex III of EU Council Directive 96/82/EC).
The following requirements related to management of change were added in section 4.3.1:
The procedures for hazard identification and risk assessment shall take into account:
g) changes or proposed changes in the organization, its activities or materials; h) modifications to the OH&S management system, including temporary changes, and their impacts on operations, processes and activities;…. For the management of change, the organization shall identify the OH&S hazards and risks associated with changes in the organization, the OH&S management system or its activities, prior to the introduction of such changes.
These new requirements cover four important concepts:
- Identification of the hazards associated with “change”
- Assessment of the risks associated with “change”
- Consideration of OH&S hazards and risks prior to the introduction of the “change”
- Implementation of the controls needed to address the hazards and risks associated with the “change”
For purposes of management of change within an OH&S management system, the changes that need to be addressed include:
- Organizational changes (e.g. personnel or staffing changes)
- Activity changes (e.g. changes to processes, equipment, infrastructure, software)
- Material changes (e.g. new chemicals, packaging)
- Changes to the OH&S management system (e.g. procedures)
Why is management of change so important?
Ineffective management of change is one of the leading causes of serious incidents. To quote the U.S. Chemical Safety and Hazard Investigation Board (CSB), “In industry, as elsewhere, change often brings progress. But it can also increase risks that, if not properly managed, create conditions that may lead to injuries, property damage or even death.” (from CSB press release announcing its 8/28/2001 Safety Bulletin concerning “Management of Change”) Ineffective management of change is one of the major contributing factors in many of the incident investigations conducted by the CSB. To check it out, go to the CSB web site at http://www.csb.gov and enter “management of change” as your search term at the link “Search this Site.”
© ENLAR® Compliance Services, Inc. (2007)