OHSAS 18001 Audit Checklist

OHSMS Gap Analysis Name of the Organization:

Audittee:

Facility Type:

Auditor:

Location:

Date:

Conducting the OHSMS Gap Analysis Objectives The OHSAS 18001 Standard is internationally recognized and used by industry and government organizations to enhance health and safety and operational effectiveness, efficiency, and performance. Conducting an OHSMS gap analysis is a key step in developing and implementing an OHSAS 18001 OHSMS. The objectives of this step include: • Assisting select Areas and facilities in determining how their health and safety management system compares to the 17 elements of the OHSAS 18001 OHSMS Standard, and • Improving OHSMS assessment tools and guidance to ensure practicality and compliance with health and safety requirements and other relevant requirements. Gap Analysis Background The OHSMS gap analysis is a self-evaluation. A series of questions will help you compare your organization’s current health and safety management practices against the OHSAS 18001 Standard. This comparison provides a baseline assessment of your organization and helps you to identify current systems in place for managing health and safety issues, including existing policies and procedures, roles and responsibilities, communication systems, training programs and others. As you conduct the analysis, you will recognize strengths and weaknesses of your organization’s present health and safety operations and determine the extent to which your operations conform to the OHSAS 18001 OHSMS Standard.

Upon completion of the analysis, you should be able to identify which of the 17 OHSMS elements are already in place and which you need to develop or further refine. Conducting the gap analysis will also help familiarize you with the OHSAS 18001 OHSMS Standard and the elements critical to developing, implementing, checking, and improving the OHSMS on a continual basis. Gap Analysis Questionnaire Description and Directions The OHSMS Gap Analysis Questionnaire is a tool to help you conduct an OHSMS gap analysis assessment on your organization. When undertaking this assessment, include people who have direct knowledge of as many health and safety and operational functions as possible. This is important so that several employees gain exposure to the OHSMS process and also because each employee brings specific knowledge about health and safety practices from his or her functional area. The questionnaire first asks for basic organizational information and background information about the respondent who will be completing the survey such as name, title, roles and responsibilities, and telephone number. The bulk of the questionnaire addresses the OHSAS 18001 requirements. There are 17 short sections of questions that correspond to the 17 OHSMS elements. The 17 sections fall under the five main OHSMS categories of health and safety policy; planning; implementation and operations; corrective action; and management review. Each of the sections are labeled with the OHSMS element number so you can easily reference additional information about the 17 elements of the Standard. There are three check boxes to the right of each of the questions on the Gap Analysis Questionnaire. After you respond to each question, place an "X" or a check in the block that best describes the status of the component as it relates to your OHSMS. The status blocks in the gap analysis tool are represented as follows:

Not in place

Status Partially in place

In Place

0

1

2

A numerical rating measuring your organization’s conformance to the OHSAS 18001 Standard is determined from the responses on this questionnaire. A numerical rating is given for each component response as follows: Not in place = 0 points

Partially in place = 1 point

In place = 2 points

The responses are totaled for the entire questionnaire resulting in your score. The highest score possible, 170, indicates all components of the 17 elements are ‘In place’ in your OHSMS (85 questions/components x 2 points for each component ‘In place’ = 170 points). This baseline assessment enables you to focus on continual improvement. In the electronic version of the OHSMS Gap Analysis Questionnaire provided with the OHSMS Toolkit, the second tab titled "Summary Chart", contains a bar chart to give you a visual depiction of the degree to which you conform to the OHSAS 18001 OHSMS Standard. This chart can be used in management presentations to show the progress of your OHSMS implementation. Hints 1) List of Required Documentation and Records: The OHSAS 18001 OHSMS Standard requires physical (or electronic) evidence of certain documents and records. This includes, for example, the organization's health and safety policy. There is a list at the end of this gap analysis questionnaire that highlights which items require physical (or electronic) evidence in the form of documentation or records. The list is organized by each of the 17 elements in the Standard. Elements of the OHSAS 18001 OHSMS Standard that require documentation are indicated in bold text in the gap analysis questionnaire for easy reference to the requirements of the Standard. 2) List of Reference Material: The second part of the list at the end of this gap analysis questionnaire is a list of reference materials you may already possess that could help you identify your current OHSMS status. This list is organized by each of the 17 elements of the Standard.

Question Category: health and safety policy OHSMS Element 1: health and safety policy (OHSAS 18001, Paragraph 4.2) Status Not in place

Partially in In place place

1. Has top management defined the organization's health and safety policy?

x

2. Does your procedure (process) for the health and safety policy ensure that the policy is appropriate to the nature, scale and health and safety risks of its activities, products, and services that are within the defined scope of your health and safety management system?

x

Finding / Corrective Action

Notes

3. Does your health and safety policy within the defined scope of your OHSMS commit to continual improvement and prevention of pollution?

x

4. Does your health and safety policy within the defined scope of your OHSMS commit to complying with applicable health and safety legal requirements and other health and safety requirements?

x

5. Does your procedure (process) for the health and safety policy provide a framework for setting and reviewing health and safety objectives and targets?

x

6. Does your procedure ensure that the health and safety policy is documented, implemented, and maintained?

x

7. Does your procedure (process) for the health and safety policy communicate the policy to all persons working for or on behalf of the 8. Does your procedure (process) for the health and safety policy make the policy available to the public?

Is the policy consistent with other corporate policies affecting the business? Status subtotals: Status Total: Percentage complete: Question Category: Planning

Policy awareness needs to be improved Policy Needs to be made available for public by making it available on KG website

x

x

x 0

2

12

14

16 points available

88

OHSMS Element 2: health and safety hazards (OHSAS 18001, Paragraph 4.3.1) Status Not in place

In Partially in place place

Finding / Corrective Action

Notes

9. Does your procedure (process) for health and safety hazards address: Identifying health and safety hazards of activities, products, and services within the defined scope of the OHSMS that it can control and those which it can influence taking into account planned or new developments, or new or modified activities, products and services?

x

10. Determining those hazards that have or can have intolerable risk on the health and safety? 11. Maintaining a documented up-to-date list of all hazards including those that are significant? 12. Ensuring that significant health and safety hazards are considered in developing, implementing and maintaining the OHSMS?

x

x

Is there a risk assessment process to determine significance or priority of identified health and safety hazards/risks? Status subtotals: Status Total: Percentage complete:

HIRA register to be kept up-todate

x

x

0

2

4

8 points available

6 75

OHSMS Element 3: Legal and Other Requirements (OHSAS 18001, Paragraph 4.3.2) Status Not in place

13. Does your procedure (process) for health and safety legal and other health and safety requirements address: – Identifying applicable legal requirements related to your organization's health and safety hazards? – Accessing applicable legal requirements related to your organization's health and safety hazards?

Partially in In place place

x

x

Finding / Corrective Action

Notes

– The organization shall review at a regular frequency any changes to legislation and keep this information up-to-date. – Communicating relevant information on legal and other requirements to persons working under the control of the organization, and other relevant interested parties.

x

x

14. Does your procedure ensure that health and safety legal and other health and safety requirements to which the organization subscribes are considered in developing, implementing and maintaining your organization's health and safety management system? Status subtotals: Status Total: Percentage complete:

x

0

0

6

10 points available

6 60

OHSMS Element 4: Objectives, Targets and Programme(s) (OHSAS 18001, Paragraph 4.3.3) Status

Does your procedure (process) for Objectives, Targets and Programmes address:

Not in place

Partially in In place place

15. Establishing and maintaining documented health and safety objectives and targets at relevant functions and levels within the organization? 16. Establishing measurable objectives and targets, where practicable, that are consistent with the health and safety policy, including the commitments to prevention of pollution, compliance with legal and other health and safety requirements and continual improvement? 17. The legal and other health and safety requirements, its significant health and safety hazards, its technology options and its financial, operational and business requirements and the views of interested parties when establishing and reviewing objectives and targets?

Finding / Corrective Action

x

x

x

Reference to HSE Policy statement needs to be given Objective review frequency needs to be defined

Notes

18. Does your procedure (process) address establishing and maintaining programs for achieving your organization's objectives and targets, including designating responsibility for achieving objectives and targets at relevant functions and levels of your organization? 19. Does your procedure (process) address establishing and maintaining programs for achieving your organization's objectives and targets, including the means and time-frame by which the objectives and targets are to be achieved? Have specific health and safety improvement objectives been communicated to all relevant business units and employees, contractors and suppliers? →Confirm that the facility has established compliance standards to be followed that are reasonably capable of reducing the prospect of criminal conduct. →Verify, where possible, that the facility has taken steps to achieve compliance with its health and safety standards.

x

Management programs needs to be prepared for achieving health and safety objectuves

x

x

x

x

Verify that the facility has a program in place to review the full range of capital projects, maintenance modifications, process changes, and R&D initiatives to identify potentially significant consequences.

x

→Determine if these review are performed in a timely manner, by appropriately trained professionals and if a formal methodology is employed.

x

Status subtotals:

Responsibilities needs to be defined

0

2

2

Status Total: Percentage complete:

10 points available

4 40

Question Category: Implementation and Operation OHSMS Element 5: Resources, roles, responsibility and authority (OHSAS 18001, Paragraph 4.4.1) Status

Does your procedure (process) for resources, roles, responsibility and authority address: 20. Management ensuring the availability of resources (human resources & specialized skills, internal infrastructure, technology and financial resources) essential for the implementation and control of the health and safety management system?

Not in place

x

21. Defining, documenting and communicating the roles, responsibilities and authorities to facilitate effective health and safety management? 22. Top management appointing a specific management representative who, irrespective of other responsibilities, has defined responsibilities and authority for: – Ensuring that an health and safety management system is established, implemented, and maintained in accordance with the requirements of OHSAS 18001? – Reporting on the performance of the health and safety management system to top management for review and as the basis for improvement?

Partially in In place place

x

x

x

Finding / Corrective Action

Notes

Verify if the roles and responsibilities cover: Legal/regulatory tracking; Updating/reviewing documentation control procedures; Training; Policy and procedure development; Contractor oversight; Follow-up to inspections/audits/periodic reviews; Updating the health and safety policy; Identifying health and safety hazards/risks of on-site operations; and, Responding to external requests for information.

x

Verify that the roles are clearly defined, documented, and understood and that there are no redundancies or gaps in the coverage. Interview staff from various operating departments to confirm that health and safety roles and responsibilities are clearly understood within the facility. Status subtotals: Status Total: Percentage complete:

x

x

0

1

4

5

8 points available

63

OHSMS Element 6: Competence, training and awareness (OHSAS 18001, Paragraph 4.4.2) Status

Does your procedure (process) for competence, training and awareness address:

Not in place

In Partially in place place

Finding / Corrective Action

Notes

23. Identifying training needs to ensure that any person(s) performing tasks on the organization's behalf that have the potential to cause (a) significant health and safety risk(s) identified by the organization is/are competent on the basis of appropriate education, training, or 24. experience? Identifying training needs associated with the organization's health and safety hazards and its OHSMS? Providing training or taking other actions to meet these needs?

x

x

25. Making persons working for the organization or on its behalf aware of: – The importance of conformity with the health and safety policy and procedures and with the requirements of the health and safety management system? – The significant health and safety risks, actual or potential, of their work and the health and safety benefits of improved personal performance? – Their roles and responsibilities in achieving conformity with the health and safety policy and procedures and with the requirements of the health and safety management system, including emergency preparedness and response requirements? – The potential consequences of departure from specified operating procedures?

x

x

x

x

The scope of training includes: Emergency response and preparedness; The importance of complying with established performance criteria and the potential consequences of departure from specified health and safety operating procedures; Adequate detail to motivate personnel to prevent, detect, and correct violations; and, The facility offers all staff an opportunity to attend internal health and safety training sessions.

x

Identify a sample of facility personnel who perform tasks that can cause high health and safety risk.

x

→Verify that these staff members have received appropriate health and safety training relative to the job functions/tasks performed.

x

Confirm that the facility promotes health and safety awareness through periodic memoranda, use of bulletin boards, health and safety newsletters, award programs, etc. Confirm whether staff with health and safety responsibilities have the relevant background, training, and capabilities to effectively carry out their responsibilities. Status subtotals: Status Total: Percentage complete: OHSMS Element 7: Communication (OHSAS 18001, Paragraph 4.4.3)

x

x

0

1 1 8

0

12 points available

Status

Does your procedure (process) for Communication address:

Not in place

26. Establishing and maintaining procedures for communication between the various levels and functions of your organization with regard to your organization's health and safety hazards and health and safety management system? HSE committee formation and meetings / HSE improvement suggestion schemes / HSE advices and other activities for consultation and participation of employees

Partially in In place place

Notes

x

x

27. Establishing and maintaining procedures for receiving, documenting, and responding to relevant consultation and participation from interested parties with regard to your organization's health and safety hazards and health and safety management system? 28. The organization's decision on whether to communicate externally on its significant health and safety hazards and the documentation of that decision? If the decision is to communicate externally on its significant health and safety hazards, does the organization have a method(s) for this external communication? Status subtotals: Status Total: Percentage complete:

Finding / Corrective Action

x

x

x 0

1

8

9

8 points available

113

OHSMS Element 8: Documentation (OHSAS 18001, Paragraph 4.4.4) Not in place

Status Partially in In place place

Finding / Corrective Action

Notes

29. Does your health and safety management system documentation include: – An health and safety policy, objectives and targets for your organization?

x

- a description of the scope of the health and safety management system?

x

– A description of the main elements of the health and safety management system and their interaction and reference to related documents?

x

– Documents and records required by the OHSAS 18001 Standard (at minimum those bolded in this gap analysis tool)?

x

– Documents and records the organization determined necessary to ensure the effective planning, operation and control of processes that relate to its significant health and safety hazards?

x

Status subtotals: Status Total: Percentage complete:

0

0

10

10 points available

10 100

OHSMS Element 9: Control of Documents (OHSAS 18001, Paragraph 4.4.5) Not in place

30. Does your document control procedure(s) address the need to control documents required by the health and safety management system and by the International Standard? 31. Does your document control procedure(s) address the need to: – Approve documents before they are issued? – Review and update them as necessary, and re-approve them before reissuing them?

Status Partially in In place place x

x x

Finding / Corrective Action

Notes

– Ensure changes and the current revision status of documents are identified? – Ensure current documents are available at points of use? – Ensure documents are legible and easily identifiable? – Ensure that external documentation you deem necessary for the planning and operation of the health and safety management system are identified and their distribution controlled? – Ensure obsolete documentation is not unintentionally used? – Identify obsolete documentation if it needs to be retained for any purpose? Evaluate whether: There are systems in place to ensure that all required reports are sent to regulators in a timely fashion; The documentation/records system clearly identifies the maintenance retention period, and disposition of records; and, Employees have access to health and safety documents they need to conduct job activities. Status subtotals: Status Total: Percentage complete:

x x x x x x

x

0

0

18

18

18 points available

100

OHSMS Element 10: Operational Control (OHSAS 18001, Paragraph 4.4.6) Status

Does your procedure (process) for Operational Controls: 32. Identify those operations that are associated with the identified significant health and safety hazards consistent with your organization's health and safety policy, objectives and targets?

Not in place

x

In Partially in place place

Finding / Corrective Action

Notes

33. Establish and maintain documented procedures to control situations for those operations where absence of documented procedure(s) could lead to deviation from your health and safety policy, objectives and targets? 34. Plan these operations in order that they are carried out under specific conditions, stipulate operating criteria, establish, implement and maintain health and safety procedures related to goods and services used by the organization and communicate applicable requirements to suppliers and contractors? Status subtotals: Status Total: Percentage complete:

x

x

0

0

0

6 points available

0 0

OHSMS Element 11: Emergency preparedness and response (OHSAS 18001, Paragraph 4.4.7) Status

Do you establish and maintain a procedure (process) for emergency preparedness and response that addresses how to:

Not in place

Partially in In place place

35. Identify potential emergency situations and potential accidents that can have (a) risk(s) on the health and safety and how the organization will respond? 36. Respond to actual emergency situations and accidents and prevent or mitigate associated health and safety risks? 37. Does your organization periodically review and, where necessary, revise the emergency preparedness and response procedures, in particular, after the occurrence of accidents or emergency situations? 38. Does your organization periodically test the emergency preparedness and response procedures where practicable? Confirm that the procedures have been updated, as appropriate, in response to new information or program reviews.

x

x

x

x

x

Finding / Corrective Action

Notes

Status subtotals: Status Total: Percentage complete:

0

1

6

8 points available

7 88

Question Category: Checking OHSMS Element 12: Monitoring and measurement (OHSAS 18001, Paragraph 4.5.1) Status

Do you establish and maintain a procedure (process) for monitoring and measurement that ensures: 39. Key characteristics of your operations (that can have a high health and safety risk) are monitored and measured on a regular basis? 40. Information is documented to monitor performance, applicable operational controls, and conformity with the objectives and targets of your organization? 41. Monitoring and measurement equipment is calibrated and maintained and all associated records are retained? Status subtotals: Status Total: Percentage complete:

Not in place

Partially in In place place

Finding / Corrective Action

Notes

x

x

x 0

0

2

6 points available

2 33

OHSMS Element 13: Evaluation of compliance (OHSAS 18001, Paragraph 4.5.2) Status Not in place

42. Does your procedure (process) to meet the organization's commitment to compliance ensure that you periodically evaluate compliance with applicable health and safety legal requirements and other health and safety requirements to which the organization subscribes? Status subtotals: Status Total: Percentage complete:

In Partially in place place

Legal compliance audit needs to be carried out

x

0

Finding / Corrective Action

0 0 0

0

2 points available

Notes

OHSMS Element 15: Nonconformity, corrective and preventive action (OHSAS 18001, Paragraph 4.5.3) Not in place

Status Partially in In place place

43. Do you establish and maintain a procedure (process) for Incident reporting and Investigation and taking corrective and preventive actions?

x

44. Do you establish and maintain a procedure (process) for controlling non-conformities and taking corrective and preventive actions?

x

45. Does the procedure for controlling non-conformities and taking corrective and preventive action ensure that: – Actual non-conformity(-ies) are identified and corrected and their health and safety risk(s) are mitigated?

x

– Actions are determined to eliminate the causes of actual and potential non-conformities and to prevent their recurrence?

x

– Are any measures taken to identify, correct, mitigate, prevent or eliminate the nonconformity(-ies) consistent with the magnitude of the problems and the health and safety risks encountered? 46. After corrective and preventive actions have been taken, are they reviewed and the program adjusted accordingly by implementing and documenting any new changes that result from the findings? Status subtotals: Status Total: Percentage complete:

Finding / Corrective Action

Notes

x

CAPA reports needs to be filled for all noncompliances

x 0

0

10

10

12 points available

83

OHSMS Element 16: Control of Records (OHSAS 18001, Paragraph 4.5.4) Status Not in place

Partially in In place place

Finding / Corrective Action

Notes

47. Has your organization created and maintained records as necessary that demonstrate compliance with the OHSMS and conformance to the requirements of the OHSAS 18001 Standard, including evaluation of compliance with health and safety legal requirements and other health and safety requirements to which the organization subscribes and the implementation of procedures and results achieved? 48. Does your procedure (process) for records management describe how the records will be identified, stored, protected, retrieved, retained, and disposed? 49. Are the records themselves legible, identifiable, and traceable? Status subtotals: Status Total: Percentage complete:

x

Responsibilities to be asigned for each record

x x 0

2

2

6 points available

4 67

OHSMS Element 17: Internal audit (OHSAS 18001, Paragraph 4.5.5) Status

Does your procedure (process) for an internal health and safety management system audit: 50. – Ensure that internal health and safety management system audits are conducted at planned intervals? – Determine whether the health and safety management system conforms to planned arrangements for health and safety management including the requirements of the OHSAS 18001 Standard?

Not in place

Partially in In place place

Finding / Corrective Action

x

x

– Determine whether the health and safety management system has been properly implemented and is maintained?

x

– Determine whether the health and safety management system provides information on the results of audits to management?

x

Internal audit needs to be carried out and recorded

Notes

51. Plan, establish and maintain the health and safety management audit program taking into consideration the health and safety importance of the operation(s) concerns and the results of previous audits?

Internal audit plan needs to be rpepared

x

52. – State the responsibilities and requirements for planning and conducting audits? – State the responsibilities and requirements for reporting results? – Define the audit criteria, scope, frequency and methods and explain how you have determined them? 53. Ensure that the selection of auditors and the conduct of the audits maintains the objectivity and impartiality of the audit process? Status subtotals: Status Total: Percentage complete:

x x x x 0

2

12

14

18 points available

78

Question Category: Management Review OHSMS Element 18: Management review (OHSAS 18001, Paragraph 4.6) Does your procedure (process) for Management Review: 54. Ensure continuing suitability, adequacy, and effectiveness of the health and safety management system through top management review of it at planned intervals? 55. Ensure that opportunities are assessed for improvement and the need for changes to the health and safety management system including the health and safety policy and health and safety objectives and targets are assessed? Ensure that the results of the management reviews are documented?

Not in place x

x

x

Status Partially in In place place

Finding / Corrective Action MRM plan needs to be prepared

Notes

56. Contain input which includes the following: results of health and safety management system audits, communication from external interested parties, the performance of the health and safety management system, the extent to which objectives and targets have been met, status of corrective and preventive actions, follow-up actions from previous management reviews, changing circumstances, and recommendations for improvement? 57. Ensure that the outputs from the management review include any decisions and actions related to possible changes to the health and safety policy, objectives and other elements of the health and safety management system, consistent with the commitment to continual improvement? Confirm that a review process exists to update the policy and to communicate changes to appropriate stakeholders. Status subtotals: Status Total: Percentage complete:

x

x

x 0

0

4

10 points available

4 40

Program Totals 0 14 Element subtotals: 114 Program Total: 67% Total Program percentage complete:

100

170 points available

100

% Complete

80 60 40 20 0

OHSAS 18001:2007 OHSMS Elements