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BROOKHAVEN NATIONAL LABORATORY
SBMS Interim Procedure
________________________________________________________________________
Interim Procedure Number: 2004-18001-005 Revision: 12 on 1-26-07
Title: 18001 Audit Checklist
Point of Contact: Pat Williams
Management System: Occupational Safety and Health
Effective Date: April 30, 2004 Expiration Date: December 15, 2007
Approved by (line management, Management System Steward): Jim Tarpinian
Approved by (Deputy Director, Operations): Michael J. Bebon
Applicability: All BNL Organizations Participating in OHSAS 18001 Registration
________________________________________________________________________
Table of Contents
1. Purpose ............................................................................................................................................. 2
2. Definitions (for general definitions reference SBMS)...................................................................... 2
3. Responsibilities................................................................................................................................. 2
4. Scope................................................................................................................................................. 3
5. Procedure.......................................................................................................................................... 3
Audit Checklist
General Requirements .............................................................................................................................. 5
OSH Policy............................................................................................................................................... 6
Planning For Hazard Identification, Risk Assessment And Risk Control................................................ 7
Legal and Other Requirements ................................................................................................................. 9
Objectives ............................................................................................................................................... 10
OSH Management Program(s) ............................................................................................................... 11
Structure and Responsibility................................................................................................................... 12
Training, Awareness and Competence ................................................................................................... 13
Consultation and Communication .......................................................................................................... 14
Documentation........................................................................................................................................ 15
Document and Data Control.................................................................................................................. 16
Operational Control ................................................................................................................................ 17
Emergency Preparedness and Response................................................................................................. 18
Performance Measurement and Monitoring........................................................................................... 19
Accidents, Incidents, Nonconformances And Corrective And Preventive Action................................. 20
Records and Records Management ........................................................................................................ 21
Audit ....................................................................................................................................................... 22
Management Review .............................................................................................................................. 23
Activity Checklist................................................................................................................................... 24
18001 Audit Checklist 1
1. Purpose
1.1. To define an assessment (audit) program.
2. Definitions (for general definitions reference SBMS)
2.1. Finding - Results of the evaluation of the collected audit evidence compared with the agreed
audit criteria. Audit findings provide the basis for the audit report. While all findings of
nonconformity must be documented, findings of conformity may be documented if within the
agreed upon audit scope.
2.2. Nonconformance - An activity, attribute, or document, which fails to comply with established
requirements, and may lead to a condition having an adverse effect on quality, environment,
ES&H, operations, or reliability.
2.3. Major nonconformance - A lack of an element, procedure, or a non-fulfilled requirement that
puts the process/system at jeopardy, and could lead to significant impact on quality,
environment, ES&H, operations, or reliability.
2.4. Minor nonconformance - An observed lapse in a program, process, procedure, or requirement,
usually single incidents that do not have a significant impact on the quality, environment,
ES&H, operations, or reliability.
2.5. Noncompliance - Non-adherence to an applicable regulatory requirement.
2.6. Recommendations (opportunity for improvement) - A suggested means of improving an
activity or fulfilling the intent of a requirement.
3. Responsibilities
3.1. The OSH Management System Representatives shall implement this assessment program
within their organizations.
3.2. Assessments (audits) shall be conducted by competent persons, internal or external to the
organization being audited, who are independent of the activity being audited and are familiar
with the requirements of the OSHAS 18001 management system.
3.3. The OSH Management System Representatives shall ensure that the assessment team has
either formal or on-the-job training in the following areas:
3.3.1. Applicable occupational safety and health issues likely to be associated with the facility
operations and related management issues. For example, BNL personnel who meet this
requirement are workers, technicians, professionals, managers and scientists who have
completed their BNL training requirements and who are familiar with the operation or
organization being assessed.
3.3.2. Applicable occupational safety and health laws, regulations, and related documents or
occupational safety and health management systems and Subject Areas.
3.4. The OSH Management System Representatives shall ensure that the lead assessor has
experience and training conducting assessments. Training such as OHSAS 18001 Internal
18001 Audit Checklist 2
18001 Audit Checklist.doc 3
Auditor and Foundation Training Course or equivalent is appropriate. If technical experts are
used on the assessment team, they are not required to have experience conducting assessments.
3.5. The OSH Management System Representatives shall ensure that the assessment team members
have the following personal attributes and skills:
• The ability to clearly express concepts and ideas, orally and in writing.
• Strong observational, organizational, listening, and communication skills.
• The ability to maintain independence and objectivity.
• The ability to reach sound judgment based on objective evidence.
4. Scope
4.1. The checklist consists of key questions that might trigger safety or environmental
requirements.
5. Procedure
5.1. Schedule – The OSH Management System Representative shall maintain an assessment
schedule. The scheduling of assessments should be flexible with the allocation of resources
based on the following factors:
• Importance, status, risk, and complexity of the activity, item, or process.
• Problems encountered with the activity, or item.
• Scheduling of specific activities.
• Availability of qualified personnel.
• A review of findings reported in previous assessments.
5.2. OSH Management System Representative shall perform an annual OSH Management System
assessment, per the requirements in the attached Audit Checklist, in order to determine
whether the OSH management system and its elements are in place, adequate, and effective in
protecting the safety and health of workers and preventing incidents.
5.3. OSH Management System Representative shall perform more frequent OSH assessments of
specific areas or processes if appropriate, depending on the importance of the activity, process
change, previous assessment results, or as determined by the organization’s management.
5.4. Emphasis will be placed on process improvement and verification of sustained effectiveness of
action taken to correct previous deficiencies.
5.5. Assessments shall evaluate conformance to established requirements. That is, the examination
of objective evidence demonstrating that activities, procedures, instructions, and records are
being properly executed and documented.
5.6. Before conducting an assessment, the auditor shall:
5.6.1. Consult with the organizations management in order to determine the membership of
the assessment team.
5.6.2. Review existing assessment documentation to verify applicability of criteria.
5.6.3. Review nonconformances and recommendations documented on previous assessment
reports, nonconformance reports, etc., to determine if there are known problems with an
activity, or additional items that should be added to the assessment criteria.
5.6.4. Confer with the person responsible for the activity and determine assessment date(s),
and the names and locations of the personnel who should be contacted.
5.6.5. Request information, procedures, data, etc. that will facilitate the conduct of the
assessment.
5.6.6. During the assessment, the auditor shall verify that documentation called out by
procedures and program requirements are accurate and complete. All concerns shall be
brought to the attention of the person responsible for the area for possible resolution or
correction prior to the completion of the audit. No corrective action will be required for
any deficiency satisfactorily resolved prior to the completion of the assessment. However,
a record of the concern shall be included in the assessment report, and acknowledged as
having been resolved.
5.6.7. Responsible personnel are to be notified and immediate corrective action taken, as
appropriate, for deficiencies that will adversely affect OSH or property. Interim actions
may be initiated to provide needed controls while investigations and implementation of
permanent corrective actions are accomplished. Follow-up assessments shall be
performed to verify the effectiveness of the corrective actions.
5.7. All assessment documentation shall comply with the requirements of the applicable SBMS
Subject Areas.
5.8. A draft copy of the assessment report shall be distributed for preliminary review to those
individuals directly involved in the assessment.
5.9. Assessment reports shall contain the concurrence of the management of the area assessed.
5.10. Assessments without major or minor nonconformances shall be considered closed when
the assessment report is issued.
5.11. Assessments with documented major, and/or minor nonconformances, are considered
closed when proposed corrective/preventive actions are accepted by the assessment personnel
and management.
5.12. Nonconformances, which are the result of an OSH assessment, shall be documented per
the requirements of the Nonconformance and Corrective and Preventive Action SBMS subject
area.
5.13. Major and minor nonconformances shall be tracked to closure via the BNL Assessment
Tracking System (ATS) or Family ATS.
5.14. Assessments reports shall be maintained by the organization being assessed. Retention
time for assessment documentation shall per the requirements of SBMS.
18001 Audit Checklist.doc 4
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 5
OHS Management System Model GENERAL REQUIREMENTS Auditor:
ELEMENT: 4.1 TITLE: General Requirements
OHSAS 18001 STANDARD: NO PARTIAL YES
The organization shall establish and maintain an OSH management system, the
requirements of which are set out in Clause 4 of OHSAS 18001-1999.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Has a program been established?
Is the scope of the program clearly defined?
How long has the program been established?
Is it being maintained the requirements of OHSAS 18001-1999?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 6
OSH Management System Model OS&H POLICY Auditor:
ELEMENT: 4.2 TITLE: OSH Policy
OHSAS 18001 STANDARD: NO PARTIAL YES
There shall be an occupational health and safety policy authorized by the
organization’s top management that clearly states overall health and safety objectives
and a commitment to improving health and safety performance.
The policy shall :
a) be appropriate to the nature and scale of the organization’s OSH risks;
b) include a commitment to continual improvement;
c) include a commitment to at least comply with current applicable OSH legislation
and with other requirements to which the organization subscribes;
d) be documented, implemented and maintained;
e) be communicated to all employees with the intent that employees are made aware
of their individual OSH obligations;
f) be available to interested parties; and
g) be reviewed periodically to ensure that it remains relevant and appropriate to the
organization.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
What is the organization’s policy?
Is the policy defined and is it appropriate to the type, size, and OSH impacts of the organization’s activities?
Does the policy include a commitment to continual improvement in the organization’s operations?
Does the policy reflect the organizations hazard identification, risk assessment and risk control in the organization’s activities and
facilities?
Does the policy include a commitment to compliance to legal requirements?
Is the policy documented, implemented, maintained (periodically reviewed) and communicated to all employees and are they
aware of their responsibilities to the OSH?
Is the policy available to interested parties?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 7
OSH Management System Model PLANNING Auditor:
ELEMENT: 4.3.1 TITLE: Planning For Hazard Identification, Risk Assessment And Risk Control
OHSAS 18001 STANDARD: NO PARTIAL YES
The organization shall establish and maintain procedures for the ongoing
identification of hazards, the assessment of risks, and the implementation of necessary
control measures. These shall include:
a) routine and non-routine activities;
b) activities of all personnel having access to the workplace (including
subcontractors and visitors);
c) facilities at the workplace, whether provided by the organization or others.
The organization shall ensure that the results of these assessments and the effects of
these controls are considered when setting its OSH objectives. The organization shall
document and keep this information up to date.
The organization’s methodology for hazard identification and risk assessment shall:
a) be defined with respect to its scope, nature and timing to ensure it is proactive
rather than reactive;
b) provide for the classification of risks and identification of those that are to be
eliminated or controlled by measures as defined in 4.3.3 and 4.3.4;
c) be consistent with operating experience and the capabilities of risk control
measures employed;
d) provide input into the determination of facility requirements, identification of
training needs and/or development of operational controls;
e) provide for the monitoring of required actions to ensure both the effectiveness
and timeliness of their implementation.
NOTE For further guidance on hazard identification, risk assessment and risk control,
see OHSAS 18002.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 8
OPTIONAL AUDITOR QUESTIONS:
Are there documented and maintained procedures to establish and update hazards, risks and implementation of controls?
Does the procedure cover routine and non routine activities?
Does the procedure cover all personnel and facilities?
What mechanism is used to initiate hazard review/revision when operations change?
Do the criteria for the assessment of risk address both likelihood and consequence?
Are there records to provide evidence of analysis of hazards, risks and controls?
Are there any obvious hazards that should have been considered and were not? If not, why not?
Are results of assessments and effects of controls considered when setting OSH objectives and are they documented and up to
date?
Does the methodology:
a) define scope, nature and timing?
b) ensure proactive rather than reactive assessments?
c) provide for classification of risk tolerability?
d) identify those to be eliminated or controlled?
e) assure consistency with operating experience? (Ref. 4.3.1C of OHSAS 18002-2000)
f) assure consistency with effectiveness of risk control measures?
Does the methodology provide input into determination of facility requirements, training needs and operational controls?
Does the methodology provide for monitoring of required actions to ensure timeliness and effectiveness of implementation?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 9
OSH Management System Model PLANNING Auditor:
ELEMENT: 4.3.2 TITLE: Legal and Other Requirements
OHSAS 18001 STANDARD: NO PARTIAL YES
The organization shall establish and maintain a procedure for identifying and
accessing the legal and other OSH requirements that are applicable to it.
The organization shall keep this information up-to-date. It shall communicate relevant
information on legal and other requirements to its employees and other relevant
interested parties.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Is there a documented procedure for the organization to identify and have access to all applicable legal requirements?
Is someone (or more than one) designated to keep current on requirements?
What are the resources, references and methods to keep current?
How is applicability of new requirements determined?
How are requirements communicated to all interested party?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 10
OSH Management System Model PLANNING Auditor:
ELEMENT: 4.3.3 TITLE: Objectives
OHSAS 18001 STANDARD: NO PARTIAL YES
The organization shall establish and maintain documented occupational health and
safety objectives, at each relevant function and level within the organization.
NOTE Objectives should be quantified wherever practicable.
When establishing and reviewing its objectives, an organization shall consider its
legal and other requirements, its OSH hazards and risks, its technological options, its
financial, operational and business requirements, and the views of interested parties.
The objectives shall be consistent with the OSH policy, including the commitment to
continual improvement.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Has the organization established and maintained OSH objectives?
Have the documented objectives considered legal and other requirements?
Are objectives reasonable and measurable?
Is there a documented and maintained procedure for periodically reviewing objectives?
Are objectives communicated to the employees that are supposed to achieve them?
Are organizational objectives consistent with Lab/higher level objectives?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 11
OSH Management System Model PLANNING Auditor:
ELEMENT: 4.3.4 TITLE: OSH Management Program(s)
OHSAS 18001 STANDARD: NO PARTIAL YES
The organization shall establish and maintain (an) OSH management program(s) for
achieving its objectives. This shall include documentation of :
a) the designated responsibility and authority for achievement of the objectives at
relevant functions and levels of the organization; and
b) the means and time-scale by which objectives are to be achieved.
The OSH management program(s) shall be reviewed at regular and planned intervals.
Where necessary the OSH management program(s) shall be amended to address
changes to the activities, products, services, or operating conditions of the
organization.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Are there programs to achieve all the identified objectives?
Do the programs include schedules for completion and resources necessary to achieve the objectives?
Do the programs assign responsibilities for completion of tasks in achieving objectives?
Are all procedures that supplement the OHS management program available to the appropriate personnel and current?
Are the management programs reviewed at planned intervals and amended as required?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 12
OSH Management System Model IMPLEMENTATION AND
OPERATION
Auditor:
ELEMENT: 4.4.1 TITLE: Structure and Responsibility
OHSAS 18001 STANDARD: NO PARTIAL YES
The roles, responsibilities and authorities of personnel who manage, perform and
verify activities having an effect on the OSH risks of the organization’s activities,
facilities and processes, shall be defined, documented and communicated in order to
facilitate OSH management.
Ultimate responsibility for occupational health and safety rests with top management.
The organization shall appoint a member of top management (e.g. in a large
organization, a Board or executive committee member) with particular responsibility
for ensuring that the OSH management system is properly implemented and
performing to requirements in all locations and spheres of operation within the
organization.
Management shall provide resources essential to the implementation, control and
improvement of the OSH management system.
NOTE Resources include human resources and specialized skills, technology and
financial resources.
The organization’s management appointee shall have a defined role, responsibility and
authority for:
a) ensuring that OSH management system requirements are established, implemented
and maintained in accordance with this OHSAS specification;
b) ensuring that reports on the performance of the OSH management system are
presented to top management for review and as a basis for improvement of the OSH
management system.
All those with management responsibility shall demonstrate their commitment to the
continual improvement of OSH performance.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Are roles and responsibility, and authorities defined, documented and communicated?
Has management provided the necessary resources (people, technology, money) to implement this OSH program?
Has the organization appointed an OSH management appointee from top management?
Does the R2A2 of the OSH management appointee document sufficient authority to accomplish a & b above?
How does management demonstrate their commitment for continual improvement of OSH performance?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 13
OSH Management System Model IMPLEMENTATION AND
OPERATION
Auditor:
ELEMENT: 4.4.2 TITLE: Training, Awareness and Competence
OHSAS 18001 STANDARD: NO PARTIAL YES
Personnel shall be competent to perform tasks that may impact on OSH in the
workplace. Competence shall be defined in terms of appropriate education, training
and/or experience. The organization shall establish and maintain procedures to ensure
that its employees working at each relevant function and level are aware of:
a) the importance of conformance to the OSH policy and procedures, and to the
requirements of the OSH management system;
b) the OSH consequences, actual or potential, of their work activities and the OSH
benefits of improved personal performance;
c) their roles and responsibilities in achieving conformance to the OSH policy and
procedures and to the requirements of the OSH management system, including
emergency preparedness and response requirements (see 4.4.7);
d) the potential consequences of departure from specified operating procedures.
Training procedures shall take into account differing levels of:
a) responsibility, ability and literacy; and
b) risk.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Are procedures established and maintained to make employees aware of a – d above?
How do you ensure personnel are competent to perform tasks that impact OHS?
Has the appropriate training been done and, where required, by qualified trainers?
Do the training procedures take into account the differing levels of responsibility, ability, literacy and risk?
Are there specific, documented minimum requirements for each person performing a task that can cause significant OHS impact?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 14
OSH Management System Model IMPLEMENTATION AND
OPERATION
Auditor:
ELEMENT: 4.4.3 TITLE: Consultation and Communication
OHSAS 18001 STANDARD: NO PARTIAL YES
The organization shall have procedures for ensuring that pertinent OSH information is
communicated to and from employees and other interested parties.
Employee involvement and consultation arrangements shall be documented and
interested parties informed.
Employees shall be
a) involved in development and review of policies and procedures to manage risks
b) consulted where there are any changes that affect workplace health and safety;
c) represented on health and safety matters; and
d) informed as to who is their employee OSH representative(s) and specified
management appointee (see 4.4.1).
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Are there procedures that are maintained for communications to and from interested parties regarding the organization’s pertinent
OSH information?
How are communications to and from interested parties documented?
How are internal communications between different levels and different functions documented? How do you have feedback to
management?
How are employees involved in the development of policies and procedures to manage risks?
How are employees consulted for changes that affect workplace health and safety?
How are employees represented on OHS matters?
Do people know who their employee OHS representative and/or management appointees are?
How are OHS representatives involved in communication mechanisms with management?
What initiatives do you have to encourage OHS consultations and improvement activities?
What mechanisms are used to communicate OHS concerns or information to all interested parties and employees; e.g.,
inspections, briefings, notice boards, OHS newsletter, OHS poster programs?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 15
OSH Management System Model IMPLEMENTATION AND
OPERATION
Auditor:
ELEMENT: 4.4.4 TITLE: Documentation
OHSAS 18001 STANDARD: NO PARTIAL YES
The organization shall establish and maintain information, in a suitable medium such
as paper or electronic form, that :
a) describes the core elements of the management system and their interaction; and
b) provides direction to related documentation.
NOTE It is important that documentation is kept to the minimum required for
effectiveness and efficiency.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
How has the organization documented the core elements of its OHSAS 18001 system?
How does the organization show linkage between all upper and lower level documentation?
Does the system document how the related documentation, both internal and external, [regulations, permits, forms, etc.] are to be
used?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 16
OSH Management System Model IMPLEMENTATION AND
OPERATION
Auditor:
ELEMENT: 4.4.5 TITLE: Document and Data Control
OHSAS 18001 STANDARD: NO PARTIAL YES
The organization shall establish and maintain procedures for controlling all documents
and data required by this OHSAS specification to ensure that:
a) they can be located;
b) they are periodically reviewed, revised as necessary and approved for adequacy by
authorized personnel;
c) current versions of relevant documents and data are available at all locations where
operations essential to the effective functioning of the OSH system are performed;
d) obsolete documents and data are promptly removed from all points of issue and
points of use or otherwise assured against unintended use; and
e) archival documents and data retained for legal or knowledge preservation purposes
or both, are suitably identified.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Are there procedures for controlling and maintaining all documents (e.g., procedures and instructions) and/or data (e.g.,
engineering drawings and MSDS) required by this standard? Are the documents/data accessible (e.g., can the employee access
the documents/data they need), including during an emergency?
Are the documents/data periodically reviewed, revised and approved for adequacy by authorized personnel?
Are latest versions of documents/data available in all areas and by all personnel that perform tasks essential to the effective
functioning of the OSH?
Are obsolete documents/data removed from use and assured from unintended use? Are historical copies maintained & labeled?
Are those obsolete documents/data that are retained for legal or knowledge reasons clearly identified?
Are documents/data dated with the latest revision, orderly, legible and retained for a specified period?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 17
OSH Management System Model IMPLEMENTATION AND
OPERATION
Auditor:
ELEMENT: 4.4.6 TITLE: Operational Control
OHSAS 18001 STANDARD: NO PARTIAL YES
The organization shall identify those operations and activities that are associated with
identified risks where control measures need to be applied. The organization shall plan
these activities, including maintenance, in order to ensure that they are carried out
under specified conditions by:
a) establishing and maintaining documented procedures to cover situations where their
absence could lead to deviations from the OSH policy and the objectives;
b) stipulating operating criteria in the procedures;
c) establishing and maintaining procedures related to the identified OSH risks of
goods, equipment and services purchased and/or used by the organization and
communicating relevant procedures and requirements to suppliers and contractors;
d) establishing and maintaining procedures for the design of workplace, process,
installations, machinery, operating procedures and work organization, including their
adaptation to human capabilities, in order to eliminate or reduce OSH risks at their
source.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Have the operations and activities, including maintenance, been identified that are associated with the identified OSH risks where
control measures need to be applied?
Have procedures been established and maintained for the above operations that, if they are not followed for these situations,
could lead to deviations from the OSH policy and the objectives?
Are operating criteria clearly established and document/data in the procedures for the operations and activities identified above?
Have the identified OSH risks of goods, materials, equipment and services used in the above operations and activities been
identified?
Are there procedures for handling goods, materials, equipment and services used in the activities associated with identified risks
where controls need to be applied?
Are relevant procedures and requirements communicated to the appropriate suppliers and contractors (are operational controls in
place and working as expected)?
Are records of operational controls and performance indicators managed and retained per plans?
Are there procedures to reduce OS&H risks in design and workplace processes (Ref. d above)?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 18
OSH Management System Model IMPLEMENTATION AND
OPERATION
Auditor:
ELEMENT: 4.4.7 TITLE: Emergency Preparedness and Response
OHSAS 18001 STANDARD: NO PARTIAL YES
The organization shall establish and maintain plans and procedures to identify the
potential for, and responses to, incidents and emergency situations, and for preventing
and mitigating the likely illness and injury that may be associated with them.
The organization shall review its emergency preparedness and response plans and
procedures, in particular after the occurrence of incidents or emergency situations.
The organization shall also periodically test such procedures where practicable.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Are there maintained procedures to identify potential for accidents and emergency situations?
Are there maintained procedures to respond to accidents and emergency situations?
Are there maintained procedures to prevent and minimize the OSH risks that may be associated with the identified accidents and
emergency situations?
Are there reviews and revisions of the emergency preparedness and response procedures, particularly after an incident?
Are there periodical tests of the above procedures?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 19
OSH Management System Model CHECKING AND CORRECTIVE
ACTION
Auditor:
ELEMENT: 4.5.1 TITLE: Performance Measurement and Monitoring
OHSAS 18001 STANDARD: NO PARTIAL YES
The organization shall establish and maintain procedures to monitor and measure
OSH performance on a regular basis. These procedures shall provide for:
a) both qualitative and quantitative measures, appropriate to the needs of the
organization;
b) monitoring of the extent to which the organization’s OSH objectives are met;
c) proactive measures of performance that monitor compliance with the OSH
d) management program, operational criteria and applicable legislation and
regulatory requirements;
e) reactive measures of performance to monitor accidents, ill health, incidents
(including near-misses) and other historical evidence of deficient OSH
performance;
f) recording of data and results of monitoring and measurement sufficient to
facilitate subsequent corrective and preventive action analysis.
If monitoring equipment is required for performance measurement and monitoring,
the organization shall establish and maintain procedures for the calibration and
maintenance of such equipment. Records of calibration and maintenance activities and
results shall be retained.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Do the procedures address qualitative and quantitative measures?
Are procedures document/data and maintained to monitor and measure OSH performance on a regular basis?
Are monitoring of OSH objectives performed?
Does the OSH management program include proactive measures to address operational criteria, legal requirements and regulatory
standards?
Are there reactive measures of performance to monitor accidents, ill health, incidents (including near-misses) and other historical
evidence of deficient OSH performance?
Are OSH performance indicators evaluated for corrective and preventative action?
Are the indicators of OSH performance communicated to management?
Is OSH monitoring equipment required for performance measurement and monitoring calibrated? If so, is there a documented
calibration and maintenance procedure(s)?
Are the records for the calibrations and maintenance results retained?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 20
OSH Management System Model CHECKING AND CORRECTIVE
ACTION
Auditor:
ELEMENT: 4.5.2 TITLE: Accidents, Incidents, Nonconformances And Corrective And Preventive Action
OHSAS 18001 STANDARD: NO PARTIAL YES
The organization shall establish and maintain procedures for defining responsibility
and authorityfor:
a) the handling and investigation of:
1. accidents;
2. incidents;
3. non-conformances;
b) taking action to mitigate any consequences arising from accidents, incidents or
nonconformances;
c) the initiation and completion of corrective and preventive actions;
d) confirmation of the effectiveness of corrective and preventive actions taken.
These procedures shall require that all proposed corrective and preventive actions
shall be reviewed through the risk assessment process prior to implementation.
Any corrective or preventive action taken to eliminate the causes of actual and
potential nonconformances shall be appropriate to the magnitude of problems and
commensurate with the OSH risk encountered.
The organization shall implement and record any changes in the documented
procedures resulting from corrective and preventive action.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Are procedures documented and maintained for defining responsibility and authority for handling and investigating of accidents,
incidents and nonconformances?
Are procedures documented and maintained for initiating and completing corrective and preventive action? Is a risk assessment
conducted for these actions?
Are appropriate corrective and preventive actions taken?
Are the results of the corrective and preventive actions implemented and recorded?
How does the organization implement and record any changes in their documented procedures resulting from corrective and
preventative actions?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 21
OSH Management System Model CHECKING AND CORRECTIVE
ACTION
Auditor:
ELEMENT: 4.5.3 TITLE: Records and Records Management
OHSAS 18001 STANDARD: NO PARTIAL YES
The organization shall establish and maintain procedures for the identification,
maintenance and disposition of OSH records, as well as the results of audits and
reviews.
OSH records shall be legible, identifiable and traceable to the activities involved.
OSH records shall be stored and maintained in such a way that they are readily
retrievable and protected against damage, deterioration or loss. Their retention times
shall be established and recorded.
Records shall be maintained, as appropriate to the system and to the organization, to
demonstrate conformance to this OHSAS specification.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Are procedures documented and maintained for the identification, maintenance and disposition of OSH records?
Are the records legible, identifiable and traceable to the activities involved?
Are the records stored and maintained such that they are readily retrievable and protected against damage, deterioration or loss?
Are there specified retention times for all of the records identified?
Are the records maintained in a manner to demonstrate conformance with the standard and appropriate to the system and the
organization?
Is consideration given to confidentially?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 22
OSH Management System Model CHECKING AND CORRECTIVE
ACTION
Auditor:
ELEMENT: 4.5.4 TITLE: Audit
OHSAS 18001 STANDARD: NO PARTIAL YES
OSH management system audits to be carried out, in order to:
a) determine whether or not the OSH management system:
1) conforms to planned arrangements for OSH management including the
requirements of this OHSAS specification;
2) has been properly implemented and maintained; and
3) is effective in meeting the organization’s policy and objectives;
b) review the results of previous audits;
c) provide information on the results of audits to management.
The audit program, including any schedule, shall be based on the results of risk
assessments of the organization’s activities, and the results of previous audits. The
audit procedures shall cover the scope, frequency, methodologies and competencies,
as well as the responsibilities and requirements for conducting audits and reporting
results.
Wherever possible, audits shall be conducted by personnel independent of those
having direct responsibility for the activity being examined.
NOTE The word “independent” here does not necessarily mean external to the
organization.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Are procedures documented and maintained for periodic OSH audits?
Does the procedure for OSH audits include the scope of the audit, frequency, methodologies used, responsibilities, requirements,
and method of reporting results?
Does the OSH audit determine whether their OSH has been implemented and maintained and conforms to this standard and
organization’s OSH policy and objectives?
Does the OSH audit provide results of the audits to management?
Is the audit program and schedule based on risk assessments and the results of previous audits?
Does the procedure address the independence of auditors?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 23
OSH Management System Model MANAGEMENT REVIEW Auditor:
ELEMENT: 4.6 TITLE: Management Review
OHSAS 18001 STANDARD: NO PARTIAL YES
The organization’s top management shall, at intervals that it determines, review the
OSH management system, to ensure its continuing suitability, adequacy and
effectiveness. The management review process shall ensure that the necessary
information is collected to allow management to carry out this evaluation. This review
shall be documented.
The management review shall address the possible need for changes to policy,
objectives and other elements of the OSH management system, in the light of OSH
management system audit results, changing circumstances and the commitment to
continual improvement.
FACILITY IMPLEMENTATION OF STANDARD:
EXISTING PROCEDURES AND DOCUMENTATION (LIST):
COMMENTS:
EVALUATION:
MEETS REQUIREMENT MINOR
NONCONFORMANCE
MAJOR NONCONFORMANCE
OPTIONAL AUDITOR QUESTIONS:
Has top management performed a review of the OSH management system on a periodic basis? Is it documented?
Does the review address the system's:
a) continued suitability
b) adequacy
c) effectiveness
Does the review address possible need to change its policy, objectives and other elements of the OSH management system? Has
this been conducted in light of OSH management system audit results, continual improvement and changing circumstances?
Does the record of the review include a list of information used for the management evaluation?
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 24
Activity Checklist
Criteria
Activity
1:
Activity
2:
Activity
3:
Activity
4:
Activity
5:
Knowledge of OSH policy CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
Knowledge of existence of OSH management system CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
OSH job risks CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
____________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
Awareness of how to avoid OSH hazards CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
Awareness of how to contribute to organization’s
programs (e.g., feedback, involvement on committees, risk
assessments, work planning)
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:______
Awareness of emergency response/actions CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
How have affected employee/guests been made aware of
new requirements
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
Brookhaven National Laboratory
OHSAS 18001 OSH Assessment
Organization: Date: Lead Auditor:
18001 Audit Checklist.doc 25
Criteria
Activity
1:
Activity
2:
Activity
3:
Activity
4:
Activity
5:
How are objectives made known to the employee/guests
that are supposed to achieve them
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
Do employee/guests know their OS&H roles, authorities
and responsibilities
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
Are operational controls in place and working as
specified
CON
MIN
MAJ
COM
OBS
Footnote:
_________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
Do employee/guests know the consequence of deviating
from established procedures
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
Are employee/guests aware and ready to execute
emergency procedures for such
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
Have contractors/interested parties been informed on any
relevant operational controls
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
CON
MIN
MAJ
COM
OBS
Footnote:
__________
Footnotes/Comments:

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18001 audit-checklist

  • 1. BROOKHAVEN NATIONAL LABORATORY SBMS Interim Procedure ________________________________________________________________________ Interim Procedure Number: 2004-18001-005 Revision: 12 on 1-26-07 Title: 18001 Audit Checklist Point of Contact: Pat Williams Management System: Occupational Safety and Health Effective Date: April 30, 2004 Expiration Date: December 15, 2007 Approved by (line management, Management System Steward): Jim Tarpinian Approved by (Deputy Director, Operations): Michael J. Bebon Applicability: All BNL Organizations Participating in OHSAS 18001 Registration ________________________________________________________________________ Table of Contents 1. Purpose ............................................................................................................................................. 2 2. Definitions (for general definitions reference SBMS)...................................................................... 2 3. Responsibilities................................................................................................................................. 2 4. Scope................................................................................................................................................. 3 5. Procedure.......................................................................................................................................... 3 Audit Checklist General Requirements .............................................................................................................................. 5 OSH Policy............................................................................................................................................... 6 Planning For Hazard Identification, Risk Assessment And Risk Control................................................ 7 Legal and Other Requirements ................................................................................................................. 9 Objectives ............................................................................................................................................... 10 OSH Management Program(s) ............................................................................................................... 11 Structure and Responsibility................................................................................................................... 12 Training, Awareness and Competence ................................................................................................... 13 Consultation and Communication .......................................................................................................... 14 Documentation........................................................................................................................................ 15 Document and Data Control.................................................................................................................. 16 Operational Control ................................................................................................................................ 17 Emergency Preparedness and Response................................................................................................. 18 Performance Measurement and Monitoring........................................................................................... 19 Accidents, Incidents, Nonconformances And Corrective And Preventive Action................................. 20 Records and Records Management ........................................................................................................ 21 Audit ....................................................................................................................................................... 22 Management Review .............................................................................................................................. 23 Activity Checklist................................................................................................................................... 24 18001 Audit Checklist 1
  • 2. 1. Purpose 1.1. To define an assessment (audit) program. 2. Definitions (for general definitions reference SBMS) 2.1. Finding - Results of the evaluation of the collected audit evidence compared with the agreed audit criteria. Audit findings provide the basis for the audit report. While all findings of nonconformity must be documented, findings of conformity may be documented if within the agreed upon audit scope. 2.2. Nonconformance - An activity, attribute, or document, which fails to comply with established requirements, and may lead to a condition having an adverse effect on quality, environment, ES&H, operations, or reliability. 2.3. Major nonconformance - A lack of an element, procedure, or a non-fulfilled requirement that puts the process/system at jeopardy, and could lead to significant impact on quality, environment, ES&H, operations, or reliability. 2.4. Minor nonconformance - An observed lapse in a program, process, procedure, or requirement, usually single incidents that do not have a significant impact on the quality, environment, ES&H, operations, or reliability. 2.5. Noncompliance - Non-adherence to an applicable regulatory requirement. 2.6. Recommendations (opportunity for improvement) - A suggested means of improving an activity or fulfilling the intent of a requirement. 3. Responsibilities 3.1. The OSH Management System Representatives shall implement this assessment program within their organizations. 3.2. Assessments (audits) shall be conducted by competent persons, internal or external to the organization being audited, who are independent of the activity being audited and are familiar with the requirements of the OSHAS 18001 management system. 3.3. The OSH Management System Representatives shall ensure that the assessment team has either formal or on-the-job training in the following areas: 3.3.1. Applicable occupational safety and health issues likely to be associated with the facility operations and related management issues. For example, BNL personnel who meet this requirement are workers, technicians, professionals, managers and scientists who have completed their BNL training requirements and who are familiar with the operation or organization being assessed. 3.3.2. Applicable occupational safety and health laws, regulations, and related documents or occupational safety and health management systems and Subject Areas. 3.4. The OSH Management System Representatives shall ensure that the lead assessor has experience and training conducting assessments. Training such as OHSAS 18001 Internal 18001 Audit Checklist 2
  • 3. 18001 Audit Checklist.doc 3 Auditor and Foundation Training Course or equivalent is appropriate. If technical experts are used on the assessment team, they are not required to have experience conducting assessments. 3.5. The OSH Management System Representatives shall ensure that the assessment team members have the following personal attributes and skills: • The ability to clearly express concepts and ideas, orally and in writing. • Strong observational, organizational, listening, and communication skills. • The ability to maintain independence and objectivity. • The ability to reach sound judgment based on objective evidence. 4. Scope 4.1. The checklist consists of key questions that might trigger safety or environmental requirements. 5. Procedure 5.1. Schedule – The OSH Management System Representative shall maintain an assessment schedule. The scheduling of assessments should be flexible with the allocation of resources based on the following factors: • Importance, status, risk, and complexity of the activity, item, or process. • Problems encountered with the activity, or item. • Scheduling of specific activities. • Availability of qualified personnel. • A review of findings reported in previous assessments. 5.2. OSH Management System Representative shall perform an annual OSH Management System assessment, per the requirements in the attached Audit Checklist, in order to determine whether the OSH management system and its elements are in place, adequate, and effective in protecting the safety and health of workers and preventing incidents. 5.3. OSH Management System Representative shall perform more frequent OSH assessments of specific areas or processes if appropriate, depending on the importance of the activity, process change, previous assessment results, or as determined by the organization’s management. 5.4. Emphasis will be placed on process improvement and verification of sustained effectiveness of action taken to correct previous deficiencies. 5.5. Assessments shall evaluate conformance to established requirements. That is, the examination of objective evidence demonstrating that activities, procedures, instructions, and records are being properly executed and documented. 5.6. Before conducting an assessment, the auditor shall: 5.6.1. Consult with the organizations management in order to determine the membership of the assessment team.
  • 4. 5.6.2. Review existing assessment documentation to verify applicability of criteria. 5.6.3. Review nonconformances and recommendations documented on previous assessment reports, nonconformance reports, etc., to determine if there are known problems with an activity, or additional items that should be added to the assessment criteria. 5.6.4. Confer with the person responsible for the activity and determine assessment date(s), and the names and locations of the personnel who should be contacted. 5.6.5. Request information, procedures, data, etc. that will facilitate the conduct of the assessment. 5.6.6. During the assessment, the auditor shall verify that documentation called out by procedures and program requirements are accurate and complete. All concerns shall be brought to the attention of the person responsible for the area for possible resolution or correction prior to the completion of the audit. No corrective action will be required for any deficiency satisfactorily resolved prior to the completion of the assessment. However, a record of the concern shall be included in the assessment report, and acknowledged as having been resolved. 5.6.7. Responsible personnel are to be notified and immediate corrective action taken, as appropriate, for deficiencies that will adversely affect OSH or property. Interim actions may be initiated to provide needed controls while investigations and implementation of permanent corrective actions are accomplished. Follow-up assessments shall be performed to verify the effectiveness of the corrective actions. 5.7. All assessment documentation shall comply with the requirements of the applicable SBMS Subject Areas. 5.8. A draft copy of the assessment report shall be distributed for preliminary review to those individuals directly involved in the assessment. 5.9. Assessment reports shall contain the concurrence of the management of the area assessed. 5.10. Assessments without major or minor nonconformances shall be considered closed when the assessment report is issued. 5.11. Assessments with documented major, and/or minor nonconformances, are considered closed when proposed corrective/preventive actions are accepted by the assessment personnel and management. 5.12. Nonconformances, which are the result of an OSH assessment, shall be documented per the requirements of the Nonconformance and Corrective and Preventive Action SBMS subject area. 5.13. Major and minor nonconformances shall be tracked to closure via the BNL Assessment Tracking System (ATS) or Family ATS. 5.14. Assessments reports shall be maintained by the organization being assessed. Retention time for assessment documentation shall per the requirements of SBMS. 18001 Audit Checklist.doc 4
  • 5. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 5 OHS Management System Model GENERAL REQUIREMENTS Auditor: ELEMENT: 4.1 TITLE: General Requirements OHSAS 18001 STANDARD: NO PARTIAL YES The organization shall establish and maintain an OSH management system, the requirements of which are set out in Clause 4 of OHSAS 18001-1999. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Has a program been established? Is the scope of the program clearly defined? How long has the program been established? Is it being maintained the requirements of OHSAS 18001-1999?
  • 6. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 6 OSH Management System Model OS&H POLICY Auditor: ELEMENT: 4.2 TITLE: OSH Policy OHSAS 18001 STANDARD: NO PARTIAL YES There shall be an occupational health and safety policy authorized by the organization’s top management that clearly states overall health and safety objectives and a commitment to improving health and safety performance. The policy shall : a) be appropriate to the nature and scale of the organization’s OSH risks; b) include a commitment to continual improvement; c) include a commitment to at least comply with current applicable OSH legislation and with other requirements to which the organization subscribes; d) be documented, implemented and maintained; e) be communicated to all employees with the intent that employees are made aware of their individual OSH obligations; f) be available to interested parties; and g) be reviewed periodically to ensure that it remains relevant and appropriate to the organization. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: What is the organization’s policy? Is the policy defined and is it appropriate to the type, size, and OSH impacts of the organization’s activities? Does the policy include a commitment to continual improvement in the organization’s operations? Does the policy reflect the organizations hazard identification, risk assessment and risk control in the organization’s activities and facilities? Does the policy include a commitment to compliance to legal requirements? Is the policy documented, implemented, maintained (periodically reviewed) and communicated to all employees and are they aware of their responsibilities to the OSH? Is the policy available to interested parties?
  • 7. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 7 OSH Management System Model PLANNING Auditor: ELEMENT: 4.3.1 TITLE: Planning For Hazard Identification, Risk Assessment And Risk Control OHSAS 18001 STANDARD: NO PARTIAL YES The organization shall establish and maintain procedures for the ongoing identification of hazards, the assessment of risks, and the implementation of necessary control measures. These shall include: a) routine and non-routine activities; b) activities of all personnel having access to the workplace (including subcontractors and visitors); c) facilities at the workplace, whether provided by the organization or others. The organization shall ensure that the results of these assessments and the effects of these controls are considered when setting its OSH objectives. The organization shall document and keep this information up to date. The organization’s methodology for hazard identification and risk assessment shall: a) be defined with respect to its scope, nature and timing to ensure it is proactive rather than reactive; b) provide for the classification of risks and identification of those that are to be eliminated or controlled by measures as defined in 4.3.3 and 4.3.4; c) be consistent with operating experience and the capabilities of risk control measures employed; d) provide input into the determination of facility requirements, identification of training needs and/or development of operational controls; e) provide for the monitoring of required actions to ensure both the effectiveness and timeliness of their implementation. NOTE For further guidance on hazard identification, risk assessment and risk control, see OHSAS 18002. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE
  • 8. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 8 OPTIONAL AUDITOR QUESTIONS: Are there documented and maintained procedures to establish and update hazards, risks and implementation of controls? Does the procedure cover routine and non routine activities? Does the procedure cover all personnel and facilities? What mechanism is used to initiate hazard review/revision when operations change? Do the criteria for the assessment of risk address both likelihood and consequence? Are there records to provide evidence of analysis of hazards, risks and controls? Are there any obvious hazards that should have been considered and were not? If not, why not? Are results of assessments and effects of controls considered when setting OSH objectives and are they documented and up to date? Does the methodology: a) define scope, nature and timing? b) ensure proactive rather than reactive assessments? c) provide for classification of risk tolerability? d) identify those to be eliminated or controlled? e) assure consistency with operating experience? (Ref. 4.3.1C of OHSAS 18002-2000) f) assure consistency with effectiveness of risk control measures? Does the methodology provide input into determination of facility requirements, training needs and operational controls? Does the methodology provide for monitoring of required actions to ensure timeliness and effectiveness of implementation?
  • 9. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 9 OSH Management System Model PLANNING Auditor: ELEMENT: 4.3.2 TITLE: Legal and Other Requirements OHSAS 18001 STANDARD: NO PARTIAL YES The organization shall establish and maintain a procedure for identifying and accessing the legal and other OSH requirements that are applicable to it. The organization shall keep this information up-to-date. It shall communicate relevant information on legal and other requirements to its employees and other relevant interested parties. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Is there a documented procedure for the organization to identify and have access to all applicable legal requirements? Is someone (or more than one) designated to keep current on requirements? What are the resources, references and methods to keep current? How is applicability of new requirements determined? How are requirements communicated to all interested party?
  • 10. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 10 OSH Management System Model PLANNING Auditor: ELEMENT: 4.3.3 TITLE: Objectives OHSAS 18001 STANDARD: NO PARTIAL YES The organization shall establish and maintain documented occupational health and safety objectives, at each relevant function and level within the organization. NOTE Objectives should be quantified wherever practicable. When establishing and reviewing its objectives, an organization shall consider its legal and other requirements, its OSH hazards and risks, its technological options, its financial, operational and business requirements, and the views of interested parties. The objectives shall be consistent with the OSH policy, including the commitment to continual improvement. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Has the organization established and maintained OSH objectives? Have the documented objectives considered legal and other requirements? Are objectives reasonable and measurable? Is there a documented and maintained procedure for periodically reviewing objectives? Are objectives communicated to the employees that are supposed to achieve them? Are organizational objectives consistent with Lab/higher level objectives?
  • 11. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 11 OSH Management System Model PLANNING Auditor: ELEMENT: 4.3.4 TITLE: OSH Management Program(s) OHSAS 18001 STANDARD: NO PARTIAL YES The organization shall establish and maintain (an) OSH management program(s) for achieving its objectives. This shall include documentation of : a) the designated responsibility and authority for achievement of the objectives at relevant functions and levels of the organization; and b) the means and time-scale by which objectives are to be achieved. The OSH management program(s) shall be reviewed at regular and planned intervals. Where necessary the OSH management program(s) shall be amended to address changes to the activities, products, services, or operating conditions of the organization. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Are there programs to achieve all the identified objectives? Do the programs include schedules for completion and resources necessary to achieve the objectives? Do the programs assign responsibilities for completion of tasks in achieving objectives? Are all procedures that supplement the OHS management program available to the appropriate personnel and current? Are the management programs reviewed at planned intervals and amended as required?
  • 12. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 12 OSH Management System Model IMPLEMENTATION AND OPERATION Auditor: ELEMENT: 4.4.1 TITLE: Structure and Responsibility OHSAS 18001 STANDARD: NO PARTIAL YES The roles, responsibilities and authorities of personnel who manage, perform and verify activities having an effect on the OSH risks of the organization’s activities, facilities and processes, shall be defined, documented and communicated in order to facilitate OSH management. Ultimate responsibility for occupational health and safety rests with top management. The organization shall appoint a member of top management (e.g. in a large organization, a Board or executive committee member) with particular responsibility for ensuring that the OSH management system is properly implemented and performing to requirements in all locations and spheres of operation within the organization. Management shall provide resources essential to the implementation, control and improvement of the OSH management system. NOTE Resources include human resources and specialized skills, technology and financial resources. The organization’s management appointee shall have a defined role, responsibility and authority for: a) ensuring that OSH management system requirements are established, implemented and maintained in accordance with this OHSAS specification; b) ensuring that reports on the performance of the OSH management system are presented to top management for review and as a basis for improvement of the OSH management system. All those with management responsibility shall demonstrate their commitment to the continual improvement of OSH performance. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Are roles and responsibility, and authorities defined, documented and communicated? Has management provided the necessary resources (people, technology, money) to implement this OSH program? Has the organization appointed an OSH management appointee from top management? Does the R2A2 of the OSH management appointee document sufficient authority to accomplish a & b above? How does management demonstrate their commitment for continual improvement of OSH performance?
  • 13. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 13 OSH Management System Model IMPLEMENTATION AND OPERATION Auditor: ELEMENT: 4.4.2 TITLE: Training, Awareness and Competence OHSAS 18001 STANDARD: NO PARTIAL YES Personnel shall be competent to perform tasks that may impact on OSH in the workplace. Competence shall be defined in terms of appropriate education, training and/or experience. The organization shall establish and maintain procedures to ensure that its employees working at each relevant function and level are aware of: a) the importance of conformance to the OSH policy and procedures, and to the requirements of the OSH management system; b) the OSH consequences, actual or potential, of their work activities and the OSH benefits of improved personal performance; c) their roles and responsibilities in achieving conformance to the OSH policy and procedures and to the requirements of the OSH management system, including emergency preparedness and response requirements (see 4.4.7); d) the potential consequences of departure from specified operating procedures. Training procedures shall take into account differing levels of: a) responsibility, ability and literacy; and b) risk. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Are procedures established and maintained to make employees aware of a – d above? How do you ensure personnel are competent to perform tasks that impact OHS? Has the appropriate training been done and, where required, by qualified trainers? Do the training procedures take into account the differing levels of responsibility, ability, literacy and risk? Are there specific, documented minimum requirements for each person performing a task that can cause significant OHS impact?
  • 14. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 14 OSH Management System Model IMPLEMENTATION AND OPERATION Auditor: ELEMENT: 4.4.3 TITLE: Consultation and Communication OHSAS 18001 STANDARD: NO PARTIAL YES The organization shall have procedures for ensuring that pertinent OSH information is communicated to and from employees and other interested parties. Employee involvement and consultation arrangements shall be documented and interested parties informed. Employees shall be a) involved in development and review of policies and procedures to manage risks b) consulted where there are any changes that affect workplace health and safety; c) represented on health and safety matters; and d) informed as to who is their employee OSH representative(s) and specified management appointee (see 4.4.1). FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Are there procedures that are maintained for communications to and from interested parties regarding the organization’s pertinent OSH information? How are communications to and from interested parties documented? How are internal communications between different levels and different functions documented? How do you have feedback to management? How are employees involved in the development of policies and procedures to manage risks? How are employees consulted for changes that affect workplace health and safety? How are employees represented on OHS matters? Do people know who their employee OHS representative and/or management appointees are? How are OHS representatives involved in communication mechanisms with management? What initiatives do you have to encourage OHS consultations and improvement activities? What mechanisms are used to communicate OHS concerns or information to all interested parties and employees; e.g., inspections, briefings, notice boards, OHS newsletter, OHS poster programs?
  • 15. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 15 OSH Management System Model IMPLEMENTATION AND OPERATION Auditor: ELEMENT: 4.4.4 TITLE: Documentation OHSAS 18001 STANDARD: NO PARTIAL YES The organization shall establish and maintain information, in a suitable medium such as paper or electronic form, that : a) describes the core elements of the management system and their interaction; and b) provides direction to related documentation. NOTE It is important that documentation is kept to the minimum required for effectiveness and efficiency. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: How has the organization documented the core elements of its OHSAS 18001 system? How does the organization show linkage between all upper and lower level documentation? Does the system document how the related documentation, both internal and external, [regulations, permits, forms, etc.] are to be used?
  • 16. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 16 OSH Management System Model IMPLEMENTATION AND OPERATION Auditor: ELEMENT: 4.4.5 TITLE: Document and Data Control OHSAS 18001 STANDARD: NO PARTIAL YES The organization shall establish and maintain procedures for controlling all documents and data required by this OHSAS specification to ensure that: a) they can be located; b) they are periodically reviewed, revised as necessary and approved for adequacy by authorized personnel; c) current versions of relevant documents and data are available at all locations where operations essential to the effective functioning of the OSH system are performed; d) obsolete documents and data are promptly removed from all points of issue and points of use or otherwise assured against unintended use; and e) archival documents and data retained for legal or knowledge preservation purposes or both, are suitably identified. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Are there procedures for controlling and maintaining all documents (e.g., procedures and instructions) and/or data (e.g., engineering drawings and MSDS) required by this standard? Are the documents/data accessible (e.g., can the employee access the documents/data they need), including during an emergency? Are the documents/data periodically reviewed, revised and approved for adequacy by authorized personnel? Are latest versions of documents/data available in all areas and by all personnel that perform tasks essential to the effective functioning of the OSH? Are obsolete documents/data removed from use and assured from unintended use? Are historical copies maintained & labeled? Are those obsolete documents/data that are retained for legal or knowledge reasons clearly identified? Are documents/data dated with the latest revision, orderly, legible and retained for a specified period?
  • 17. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 17 OSH Management System Model IMPLEMENTATION AND OPERATION Auditor: ELEMENT: 4.4.6 TITLE: Operational Control OHSAS 18001 STANDARD: NO PARTIAL YES The organization shall identify those operations and activities that are associated with identified risks where control measures need to be applied. The organization shall plan these activities, including maintenance, in order to ensure that they are carried out under specified conditions by: a) establishing and maintaining documented procedures to cover situations where their absence could lead to deviations from the OSH policy and the objectives; b) stipulating operating criteria in the procedures; c) establishing and maintaining procedures related to the identified OSH risks of goods, equipment and services purchased and/or used by the organization and communicating relevant procedures and requirements to suppliers and contractors; d) establishing and maintaining procedures for the design of workplace, process, installations, machinery, operating procedures and work organization, including their adaptation to human capabilities, in order to eliminate or reduce OSH risks at their source. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Have the operations and activities, including maintenance, been identified that are associated with the identified OSH risks where control measures need to be applied? Have procedures been established and maintained for the above operations that, if they are not followed for these situations, could lead to deviations from the OSH policy and the objectives? Are operating criteria clearly established and document/data in the procedures for the operations and activities identified above? Have the identified OSH risks of goods, materials, equipment and services used in the above operations and activities been identified? Are there procedures for handling goods, materials, equipment and services used in the activities associated with identified risks where controls need to be applied? Are relevant procedures and requirements communicated to the appropriate suppliers and contractors (are operational controls in place and working as expected)? Are records of operational controls and performance indicators managed and retained per plans? Are there procedures to reduce OS&H risks in design and workplace processes (Ref. d above)?
  • 18. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 18 OSH Management System Model IMPLEMENTATION AND OPERATION Auditor: ELEMENT: 4.4.7 TITLE: Emergency Preparedness and Response OHSAS 18001 STANDARD: NO PARTIAL YES The organization shall establish and maintain plans and procedures to identify the potential for, and responses to, incidents and emergency situations, and for preventing and mitigating the likely illness and injury that may be associated with them. The organization shall review its emergency preparedness and response plans and procedures, in particular after the occurrence of incidents or emergency situations. The organization shall also periodically test such procedures where practicable. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Are there maintained procedures to identify potential for accidents and emergency situations? Are there maintained procedures to respond to accidents and emergency situations? Are there maintained procedures to prevent and minimize the OSH risks that may be associated with the identified accidents and emergency situations? Are there reviews and revisions of the emergency preparedness and response procedures, particularly after an incident? Are there periodical tests of the above procedures?
  • 19. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 19 OSH Management System Model CHECKING AND CORRECTIVE ACTION Auditor: ELEMENT: 4.5.1 TITLE: Performance Measurement and Monitoring OHSAS 18001 STANDARD: NO PARTIAL YES The organization shall establish and maintain procedures to monitor and measure OSH performance on a regular basis. These procedures shall provide for: a) both qualitative and quantitative measures, appropriate to the needs of the organization; b) monitoring of the extent to which the organization’s OSH objectives are met; c) proactive measures of performance that monitor compliance with the OSH d) management program, operational criteria and applicable legislation and regulatory requirements; e) reactive measures of performance to monitor accidents, ill health, incidents (including near-misses) and other historical evidence of deficient OSH performance; f) recording of data and results of monitoring and measurement sufficient to facilitate subsequent corrective and preventive action analysis. If monitoring equipment is required for performance measurement and monitoring, the organization shall establish and maintain procedures for the calibration and maintenance of such equipment. Records of calibration and maintenance activities and results shall be retained. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Do the procedures address qualitative and quantitative measures? Are procedures document/data and maintained to monitor and measure OSH performance on a regular basis? Are monitoring of OSH objectives performed? Does the OSH management program include proactive measures to address operational criteria, legal requirements and regulatory standards? Are there reactive measures of performance to monitor accidents, ill health, incidents (including near-misses) and other historical evidence of deficient OSH performance? Are OSH performance indicators evaluated for corrective and preventative action? Are the indicators of OSH performance communicated to management? Is OSH monitoring equipment required for performance measurement and monitoring calibrated? If so, is there a documented calibration and maintenance procedure(s)? Are the records for the calibrations and maintenance results retained?
  • 20. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 20 OSH Management System Model CHECKING AND CORRECTIVE ACTION Auditor: ELEMENT: 4.5.2 TITLE: Accidents, Incidents, Nonconformances And Corrective And Preventive Action OHSAS 18001 STANDARD: NO PARTIAL YES The organization shall establish and maintain procedures for defining responsibility and authorityfor: a) the handling and investigation of: 1. accidents; 2. incidents; 3. non-conformances; b) taking action to mitigate any consequences arising from accidents, incidents or nonconformances; c) the initiation and completion of corrective and preventive actions; d) confirmation of the effectiveness of corrective and preventive actions taken. These procedures shall require that all proposed corrective and preventive actions shall be reviewed through the risk assessment process prior to implementation. Any corrective or preventive action taken to eliminate the causes of actual and potential nonconformances shall be appropriate to the magnitude of problems and commensurate with the OSH risk encountered. The organization shall implement and record any changes in the documented procedures resulting from corrective and preventive action. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Are procedures documented and maintained for defining responsibility and authority for handling and investigating of accidents, incidents and nonconformances? Are procedures documented and maintained for initiating and completing corrective and preventive action? Is a risk assessment conducted for these actions? Are appropriate corrective and preventive actions taken? Are the results of the corrective and preventive actions implemented and recorded? How does the organization implement and record any changes in their documented procedures resulting from corrective and preventative actions?
  • 21. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 21 OSH Management System Model CHECKING AND CORRECTIVE ACTION Auditor: ELEMENT: 4.5.3 TITLE: Records and Records Management OHSAS 18001 STANDARD: NO PARTIAL YES The organization shall establish and maintain procedures for the identification, maintenance and disposition of OSH records, as well as the results of audits and reviews. OSH records shall be legible, identifiable and traceable to the activities involved. OSH records shall be stored and maintained in such a way that they are readily retrievable and protected against damage, deterioration or loss. Their retention times shall be established and recorded. Records shall be maintained, as appropriate to the system and to the organization, to demonstrate conformance to this OHSAS specification. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Are procedures documented and maintained for the identification, maintenance and disposition of OSH records? Are the records legible, identifiable and traceable to the activities involved? Are the records stored and maintained such that they are readily retrievable and protected against damage, deterioration or loss? Are there specified retention times for all of the records identified? Are the records maintained in a manner to demonstrate conformance with the standard and appropriate to the system and the organization? Is consideration given to confidentially?
  • 22. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 22 OSH Management System Model CHECKING AND CORRECTIVE ACTION Auditor: ELEMENT: 4.5.4 TITLE: Audit OHSAS 18001 STANDARD: NO PARTIAL YES OSH management system audits to be carried out, in order to: a) determine whether or not the OSH management system: 1) conforms to planned arrangements for OSH management including the requirements of this OHSAS specification; 2) has been properly implemented and maintained; and 3) is effective in meeting the organization’s policy and objectives; b) review the results of previous audits; c) provide information on the results of audits to management. The audit program, including any schedule, shall be based on the results of risk assessments of the organization’s activities, and the results of previous audits. The audit procedures shall cover the scope, frequency, methodologies and competencies, as well as the responsibilities and requirements for conducting audits and reporting results. Wherever possible, audits shall be conducted by personnel independent of those having direct responsibility for the activity being examined. NOTE The word “independent” here does not necessarily mean external to the organization. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Are procedures documented and maintained for periodic OSH audits? Does the procedure for OSH audits include the scope of the audit, frequency, methodologies used, responsibilities, requirements, and method of reporting results? Does the OSH audit determine whether their OSH has been implemented and maintained and conforms to this standard and organization’s OSH policy and objectives? Does the OSH audit provide results of the audits to management? Is the audit program and schedule based on risk assessments and the results of previous audits? Does the procedure address the independence of auditors?
  • 23. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 23 OSH Management System Model MANAGEMENT REVIEW Auditor: ELEMENT: 4.6 TITLE: Management Review OHSAS 18001 STANDARD: NO PARTIAL YES The organization’s top management shall, at intervals that it determines, review the OSH management system, to ensure its continuing suitability, adequacy and effectiveness. The management review process shall ensure that the necessary information is collected to allow management to carry out this evaluation. This review shall be documented. The management review shall address the possible need for changes to policy, objectives and other elements of the OSH management system, in the light of OSH management system audit results, changing circumstances and the commitment to continual improvement. FACILITY IMPLEMENTATION OF STANDARD: EXISTING PROCEDURES AND DOCUMENTATION (LIST): COMMENTS: EVALUATION: MEETS REQUIREMENT MINOR NONCONFORMANCE MAJOR NONCONFORMANCE OPTIONAL AUDITOR QUESTIONS: Has top management performed a review of the OSH management system on a periodic basis? Is it documented? Does the review address the system's: a) continued suitability b) adequacy c) effectiveness Does the review address possible need to change its policy, objectives and other elements of the OSH management system? Has this been conducted in light of OSH management system audit results, continual improvement and changing circumstances? Does the record of the review include a list of information used for the management evaluation?
  • 24. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 24 Activity Checklist Criteria Activity 1: Activity 2: Activity 3: Activity 4: Activity 5: Knowledge of OSH policy CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ Knowledge of existence of OSH management system CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ OSH job risks CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: ____________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ Awareness of how to avoid OSH hazards CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ Awareness of how to contribute to organization’s programs (e.g., feedback, involvement on committees, risk assessments, work planning) CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote:______ Awareness of emergency response/actions CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ How have affected employee/guests been made aware of new requirements CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________
  • 25. Brookhaven National Laboratory OHSAS 18001 OSH Assessment Organization: Date: Lead Auditor: 18001 Audit Checklist.doc 25 Criteria Activity 1: Activity 2: Activity 3: Activity 4: Activity 5: How are objectives made known to the employee/guests that are supposed to achieve them CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ Do employee/guests know their OS&H roles, authorities and responsibilities CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ Are operational controls in place and working as specified CON MIN MAJ COM OBS Footnote: _________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ Do employee/guests know the consequence of deviating from established procedures CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ Are employee/guests aware and ready to execute emergency procedures for such CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ Have contractors/interested parties been informed on any relevant operational controls CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ CON MIN MAJ COM OBS Footnote: __________ Footnotes/Comments: