Safe Work Certified Audit Framework RETSD Compliance (WSHMS-11-023-02)

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Manitoba SAFE Work Certified Audit Framework

Credit / Copywrite (if applicable) Effective March 11, 2016

Administrative Guidelines

Under WCB Policy 52.30, SAFE Work Certified Program, SAFE Work Manitoba may publish standards and procedures that are consistent with the policy to support the administration and operation of the SAFE Work Certified Program, including:

the standards and procedures contained in the Administrative Guidelines that accompany the policy;
standards and procedures to support quality assurance and dispute resolution;
other standards and procedures as determined necessary by SAFE Work Manitoba to support and implement the SAFE Work Certified Program, such as the Audit Framework, the SAFE Work Certified Brand Standards and Guide, and the SAFE Work Certified Standards and Procedures.

Safe Work Certified Audit Framework

Workplace safety and health legislation, regulations and standards

Manitoba has well-developed legislative and regulatory requirements for workplace safety and health programs. The SAFE Work Certified Audit Framework is based on, and consistent with, these legal obligations, however obtaining safety and health certification does not verify that an employer is in compliance. The employer of a workplace must identify the legislation (including local bylaws), standards, safety and health guidelines, codes of practice, or any other information that is relevant to the safe management of their workplace activities. This information must be used by employers in the development of their safety and health management systems and considered by the auditors when they are auditing an employer to obtain safety and health certification.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

Safety and health management systems - continuous improvement

The dynamic and progressive nature of a safety and health management system is what differentiates it from a static safety and health program. The SAFE Work Certified audit is intended to support the development, evaluation and continuous improvement of a safety and health management system. The administration of a safety and health management system can be summarized as an ongoing process with four basic steps, Plan-Do-Check-Act.

Figure 1 - The Plan-Do-Check-Act Process for Continuous Improvement

The Plan-Do-Check-Act system is a four-stage process for continuous improvement. It also assists in facilitating safety and health integration with all other business functions. The application of this process requires the involvement of every person within an organization. This involvement includes collaborative efforts to identify problems and define objectives for improvement, implementing plans to accomplish stated objectives, reviewing outcomes, and developing solutions or making adjustments to address shortfalls. Specifically, this process will include such activities as:

1. Plan: Once a safety and health problem has been identified, a plan is developed to address the problem. Plans should be developed in accordance with legislation, regulations and industry best practices.

2. Do: Allocate the resources, personnel and equipment necessary to execute the plan. Provide any related training, instruction and supervision needed to ensure the plan’s success. Communicate with all stakeholders to promote involvement

3. Check: Measure and evaluate the effectiveness of the plan. This step involves studying actual results and comparing them against expected results.

4. Act: Respond to the evaluation of the plan’s effectiveness by making any necessary adjustments.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

Specific industry and workplace standards

Every industry and workplace is unique and the SAFE Work Certified audit accommodates this diversity. The principles-based approach of each of the SAFE Work Certified audit elements allows a safety and health system to be customized to the specific needs of a workplace. This can include considerations for size, industry, location or other unique characteristics. The SAFE Work Certified audit provides the flexibility to evaluate these diverse safety and health management systems. In addition, the SAFE Work Certified audit ensures worker input into both a safety and health management system and the audit.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

Performance based

Safety and health audits are intended to evaluate an employer’s safety and health management system against a set of defined criteria. Such an audit can be either prescriptive or performance based in approach. A prescriptive audit defines specific content which is required to be included in the management system. A performance-based audit defines outcomes that must be demonstrated as a result of the management system’s activities. The SAFE Work Certified audit is intended to be a performance-based audit.

Comprehensive safety and health audits involve document reviews, interviews and work observations. A SAFE Work Certified audit will also be verified and evaluated through document reviews, interviews and work observations. However, when conducting a SAFE Work Certified audit, an auditor will consider the defined outcomes of the SAFE Work Certified program as described in this framework. Using the evaluation points provided in the audit instrument, an auditor must determine whether the elements of an employer’s safety and health management system meet the intent, and fulfill the principles, of each element as described in this framework.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

Safe Work Certified Audit Content

Essential components

The SAFE Work Certified Program is based upon a safety and health management system with three essential components and their correlating measures. The essentials are:

1. Leadership Commitment

2. Hazard Identification and Risk Control

3. Worker Participation.

Figure 2 - Essential Components of the SAFE Work Certified Safety and Health Management System

The Leadership Commitment essential describes the employer’s commitment and the processes necessary for a successful safety and health management system. The Hazard Identification and Risk Control essential describes the safety and health activities related to identifying, assessing and controlling hazards in the workplace. Finally, the Worker Participation essential describes the requirement to engage, involve and protect workers. This document describes the elements and principles that support these essentials.

Essential #1 - Leadership commitment

Safety and health starts at the top and relies on leaders who have control and influence over their workplace and who commit to make safety and health a priority within the workplace. How an organization defines and communicates its safety and health goals and objectives, and demonstrates commitment to safety and health performance begins with, and is led by, a strong leadership team. An effective safety and health management system needs buy-in from leadership, a commitment to the program and a willingness to improve the workplace culture of safety.

A: Employer Committment

Intent

The employer makes a commitment to workplace safety and health, which is formalized, resourced and integrated into business operations, and which includes worker participation

Principles

The premise of this element is that the effectiveness of a successful safety and health management system is dependent upon the level of commitment of the ownership and senior management of the organization. In practical terms, the degree of an employer’s commitment is in direct relationship to their engagement in the system. An engaged employer, who will view safety and health beyond the duties they have under legislation and as a significant component of their organization’s operations. An engaged employer will demonstrate their commitment through such attributes as:

taking responsibility for the success of the system
integrating safety and health into operational decisions
actively managing safety activities rather than passively reacting to events
committing the resources needed for the success of the program.

Evaluation criteria

The employer has a safety and health policy signed by senior leadership, dated, current and posted in visible locations.
The safety and health policy and commitment to safety and health is communicated to all workers.
Safety and health is adequately resourced.
Critical equipment is maintained or updated as required to ensure a safe and healthy work environment.
There are appropriate investments in training, equipment, personal protective equipment (PPE) and safeguarding.
Staff are given time to conduct safety and health activities.
Safety and health is embedded into other management decisions and production processes as opposed to being an “add on”. (For example, safety responsibilities may be included in job descriptions; purchasing and maintenance decisions consider safety and health; budgeting decisions include safety;
corporate reporting and scorecards include the measurement of safety and health performance, etc.).

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

B: Evaluation and continuous Improvement

Intent

There is a safety and health management system in place, with goals and measures, that are regularly reviewed for continuous improvement.

Principles

The administration of a safety and health management system can be summarized as a management cycle with the four basic steps of Plan-Do-Check-Act. The dynamic and progressive nature of this cycle is what differentiates a safety and health management system from a static safety and health program. Each step in this cycle requires the active participation of the management and leadership of an organization.

This ongoing improvement cycle will include the following management steps:

ongoing evaluation of the system’s performance
meeting periodically to review the system
periodic review of the safety and health system’s elements
setting objectives for future performance
defining ongoing management and supervisory performance expectations
determining the need for changes or for the continued use of existing system elements.

Evaluation criteria

The effectiveness of a safety and health management system may be demonstrated in a number of ways:

There is an active safety and health management system cycle, such as the Plan-Do-Check-Act process for defining safety and health objectives, implementing safety and health activities, measuring safety and health performance, and reviewing safety and health results.
The safety and health management system is documented and includes all of the aspects of a comprehensive program, is user-friendly and organized, captures all of the safety and health essentials, includes legislative requirements, and is current.
The safety and health system is regularly evaluated for continuous improvement (scheduled and unscheduled).
Management tracks and maintains safety and health measures (including leading and lagging indicators such as injuries and illnesses, training records, audit scores, and safety and health program activities) and shares this information with the workforce.
Management has created and implemented an action plan to address recommendations and deficiencies identified in prior audits, inspections, or incidents.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

C: Safety is communicated & demonstrated

Intent

The employer effectively communicates and demonstrates its commitment to workplace safety and health.

Principles

Communication is a critical link that joins the safety and health program with the people it is designed to serve. In any safety and health management system there is a fundamental obligation to communicate hazard and hazard mitigation information to workers. This will include specific communication requirements regarding signage, signals, barriers, or safety data sheets (SDS). It will also include more general practices such as meetings, training, education, or written procedures. An employer may also use safety and health promotional materials such as booklets, pamphlets, posters and newsletters.

An evaluation of communication and engagement will involve not only the technical quality of these different communication channels, but also whether the communication is effective. Evaluating the effectiveness of safety and health communications includes consideration of many factors, including:

individual communication needs (e.g., literacy, language, etc.)
worker-to-worker communication (e.g., reporting incidents and hazards, looking out for each other) -
supervisor communication (e.g., orientation, training, responding to concerns)
quality of communication media (e.g., various formats and mediums, frequency, feedback loops, willingness
and openness to communication)
corporate communication (e.g., messaging, notification of changes, etc.).

The success of a safety and health management system is also dependent upon the degree to which employers communicate a commitment to a safe and healthy workplace by demonstrating the values described in the program. Employers need to lead by example.

Evaluation criteria

Effective safety and health management system engagement may be demonstrated in a number of ways:

Leaders demonstrate active involvement in safety and health by participating in internal and external safety activities:

Internal activities such as: safety and health events, huddles, inspections, investigations, or facility tours.
External safety and health activities may include being a member of a safety association, attending safety conferences or engaging in other safety and health related activities in the community.

Leaders embrace leading practices such as adopting the Canadian Standards Association (CSA) standard for psychological health and safety in the workplace and the CSA standard for training,
Senior leaders provide safety and health updates, progress reports to management, and communicate with staff on safety information and values,
There is communication feedback on investigation results, inspections, and any actions resulting from safety recommendations,
Two-way communication uses a variety of methods and channels that meet the needs of the workforce.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

D: Roles and responsibilities

Intent

Safety and health roles and responsibilities are clearly assigned, and all staff are held accountable.

Principles

Safety and health in the workplace is a shared responsibility. Everyone, including employers, supervisors, workers, contractors, committees and representatives and others, need to work together to prevent injury and illness. Everyone’s input is critical to ensuring well-functioning safety and health systems.

To this end, the employer must ensure that everyone in the workplace understands and carries out their safety and health roles and responsibilities consistent with the legal requirements, and all other requirements of the workplace’s specific safety and health program.

Evaluation criteria

Accountability for roles and responsibilities may be demonstrated in a number of ways:

Safety and health roles and responsibilities, training, qualifications and performance expectations are in writing (e.g., in job descriptions, policies, or a responsibility matrix).
Management and staff have received training on the internal responsibility system.
All levels of staff can demonstrate that they know and understand their roles and responsibilities.
All staff are held accountable for their safety and health performance and disciplinary action is taken where appropriate.
Safety and health rules, responsibilities, and consequences are documented and communicated.
There is staff assigned to support safety and health program activities that are supported by a senior manager.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

Essential #2 - Hazard identification and risk control

Every workplace has hazards that can result in injuries and illnesses. Hazard identification and risk control is the process of managing those hazards that have the potential to cause incidents, assessing the risks of these hazards and then developing corrective actions (controls) to eliminate or minimize those risks. All facets of work (e.g., jobs, equipment, machinery, worker activities or on-site conditions) and all types of hazards (e.g., physical, chemical, biological, environmental, psychological, psycho-social or musculoskeletal) need to be considered when identifying what can harm workers.

Hazards should be eliminated. Where hazards cannot be eliminated, the risks must be controlled to the greatest degree possible by following a hierarchy of controls: elimination, substitution, barriers, administrative practices and personal protective equipment. Once hazard controls are in place, they need to be communicated to all relevant persons through an appropriate method such as training, written safe work procedures, safety talks, or newsletters.

Employers need to verify controls are understood, have been implemented and are working effectively. Inspections and investigations are two safety management processes which help ensure controls are effective over time and that deficiencies have been addressed.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

E: Hazard identification, assessment & control

Intent

Workplace hazards have been identified, assessed and controlled.

Principles

Employers are responsible for identifying, assessing and controlling all foreseeable hazards associated with their operations and should involve all workplace parties, including the workers, in this process. A hazard is any factor that has the potential to cause an incident, injury or illness. Hazards take various forms and may be physical, chemical, biological, environmental, psychological, psycho-social or musculoskeletal. Some hazards will be readily apparent while other hazards need to be identified through targeted safety and health activities.

All identified hazards must be assessed to determine the level of risk they present to staff. Risk refers to the likelihood that a hazard will cause an injury, illness or occupational disease; the severity of the injury or disease; and the frequency of exposure. Certain types of hazards are predetermined by regulation or industry standards to be high risk. Work involving high-risk hazards may not be carried out until the hazard has been controlled.

A risk assessment must be conducted by a person knowledgeable and experienced in the work being done. If the work requires specialized training or certification, then the person conducting the risk assessment must have those qualifications. All hazards that present a risk to staff must be controlled in order to eliminate or reduce the risk to an acceptable level. In order of preference, the control measures that must be considered are:

1. elimination of the hazard

2. substitution of a less hazardous process or material

3. engineering controls

4. administrative controls, and/or

5. personal protective equipment (PPE).

Evaluation criteria

The effective identification, assessment and control of hazards are the critical functions of a safety and health management system. An effective hazard management system should use a comprehensive approach to identify hazards and should apply that approach to all aspects of the work being done.
Hazards should be identified with consideration to:

the type of hazard (e.g., physical, chemical, biological, environmental, psychological, psycho-social or musculoskeletal)
all regulatory requirements (e.g., confined spaces, lock out, working at heights, working alone, workplace harassment, violence, Workplace Hazardous Materials Information System [WHMIS] / Globally Harmonized Systems [GHS], etc.).

Hazards should be identified using multiple methods (e.g., inspections, first aid records, committee input, air quality assessments, staff input, etc.).
Risks should be assessed and prioritized. Corrective actions must be prioritized and implemented in a timely manner.
Hazards should be eliminated and risk controlled using the hierarchy of controls.
Where work requires specialized training or certification, the person conducting the hazard assessment and
developing the risk controls should have those qualifications.
The hazard identification and control process should include worker input and a system to verify that hazard controls remain effective over time.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

F: Emergency management

Intent

There is a system to manage potential emergencies in the workplace.

Principles

The safety and health management system must address the fact that the physical location and operations

of workplaces may present a possibility for emergency events which may put staff and visitors at risk. An

emergency risk assessment should be conducted for all work locations to identify such potential emergencies.

Emergency procedures should then be developed for any potential emergencies that may put staff at risk. In

practice, all sites must have fire emergency and first aid procedures.

An emergency risk assessment should be conducted at the beginning of all operations and reviewed at least

annually thereafter. When conducting the risk assessment, potential emergencies may be identified based

upon staff input, past history or recent events, input from safety personnel or authorities, or input from subject

matter specialists. Consideration should also be given to any neighbouring businesses with inherent hazards

that may impact nearby work locations. Based upon the risk assessment, procedures should be developed to

manage those emergencies for which there is an identified risk. Once developed, emergency plans should be

communicated to all affected persons, practiced on a regular basis, and reviewed at least annually.

Evaluation criteria

• The employer must have completed a risk assessment to determine potential emergencies and prioritize

those that need to be addressed.

• The employer must have an emergency plan that, at a minimum, addresses fire and medical emergencies.

• Where appropriate, the emergency response plan should include:

o communication procedures

o signage

o emergency contacts

o resources

o equipment and equipment maintenance

o roles and responsibilities

o evacuation plans

o rescue plans.

• The plans or procedures to address medical emergencies should, at a minimum, meet the regulatory

workplace first aid standard.

• All staff should be aware of their responsibilities in the emergency response plan and those with specific roles

must be trained appropriately.

• Emergency drills should be conducted at least annually or according to regulatory standards or best

practices.

• Deficiencies identified during drills should be identified and corrective measures taken.

• All buildings used as workplaces should have a fire safety plan.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

G: Contractors and others in the workplace

Intent

There is a system to ensure the safety and health of contracted workers, service providers and other people in

the workplace.

Principles

This element relates to two distinct workplace groups: contracted workers, who are integral to the employer’s

work processes, and other persons who are present in the workplace as customers, clients or visitors. If they

are present, the safety and health management system must address these two groups.

For the purpose of the safety and health management system, the management of contracted workers has three

distinct stages: selecting, monitoring and evaluating. The initial selection of a contracted worker should involve

consideration of their past safety and health performance. This may be evaluated based on work history, their

safety and health record and whether they are SAFE Work Certified. Once hired, employers have much the same

responsibilities to contracted workers that they have towards their own staff. Contracted workers must receive

a workplace safety and health orientation and complete workplace-specific training relative to their role. Once

a contracted worker is in the workplace, the employer must supervise their activities to ensure that they follow

safety and health rules and expectations. A contracted worker is required to participate in all workplace safety

and health activities, such as the workplace safety and health committee .

Other people

Other people in the workplace may refer to persons who are present in the workplace, but either do not have

a role related to the work or have a transitory role. An employer has a duty of care for the well-being of such

people, and that duty of care will vary depending on their relationship with the employer. Examples of such

relationships might be customers at a retail business who have come into the workplace to purchase items,

students at a school or college who are in the workplace to learn, or patients at a medical facility who are in

the workplace for treatment. In some situations, the person entering the workplace may also present a hazard.

A person entering a late night retail outlet may be there to commit a robbery, or a patient at an extended care

facility may present a lifting hazard to the staff.

For the purpose of the safety and health management system the duty of care for other people must be

appropriate to their dependence on the employer. To some extent, these responsibilities will be defined under

relevant safety and health standards such as public health or fire safety regulations. The relative hazard that

other people in the workplace may present must be evaluated under the Hazard Identification, Assessment and

Control element.

Evaluation criteria

This element relates to two distinct workplace groups: contracted workers, who are integral to the employer’s

work processes, and other people who are present in the workplace such as volunteers, consultants, clients

or visitors. The safety and health management system must address these two groups following different

principles:

• There should be safety and health criteria for the evaluation and selection of contracted workers.

• The employer should have a system to ensure contracted workers are made aware of the hazards of the

workplace through a formal orientation, monitoring and reporting process.

• There should be evidence that contracted worker safety and health activities are monitored and that they are

included in safety and health communication activities.

• If the employer is a prime contractor, they should fulfill the co-ordinating role of a prime contractor for the

worksite.

• Workers should be made aware of the potential hazards that contracted workers may bring to the workplace.

• There is a system to identify risks to, and ensure the safety and health of, volunteers, consultants, clients,

customers or visitors.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

H: Safety & health training & orientation

Intent

Employers ensure that workers are properly oriented to safety and health when they start or change their job,

and that workers have the training and competency to perform their jobs in a safe and healthy manner.

Principles

Providing workers with information about the hazards of their work and how to do their work safely is a

fundamental process within the safety and health management system. Training and orientation are the initial

processes by which information about workplace hazards and workplace safety and health are communicated

to workers.

Upon hiring, transferring from another location, or returning from an extended absence, staff should receive

a general safety and health orientation prior to beginning work. Each worker should also receive the training

necessary to ensure they understand the hazards of their specific job and how to perform their work safely.

This requires an individual training program that addresses a worker’s specific job duties, tasks and work

environment. A worker’s ongoing training should also ensure that when job duties change, their safety and

health skills and knowledge are kept current with the nature of their work.

To be effective, training should be provided in a manner that is appropriate to the subject matter and the learner.

Training should be delivered by a competent person in such a manner that it is understood by the learner.

Effective training should also include some method of verifying that the learner has actually understood the

training material and is able to apply it correctly.

Evaluation criteria

• New workers should receive an orientation before starting their jobs, that meets the content required by

workplace safety and health regulations.

• Workers should be provided with general and job-specific safety and health training by a competent person.

• Workers are provided with additional safety and health training when there are changes in work processes,

equipment, or changes to safety and health regulations.

• A system should be in place to ensure that all workers receive information and training on workplace

responsibilities, as well as on general and specific workplace hazards.

• Training should be documented through orientation forms, checklists, handbooks, manuals, tests, or

databases.

• Workers should be evaluated through tests or observations to ensure that safety and health information

provided in training has been retained and understood.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

I: Inspections

Intent

Workplaces, processes, vehicles, mobile equipment, tools and equipment are inspected to identify hazards,

address deficiencies and prevent the development of unsafe or unhealthy conditions.

Principles

The safety and health management system must include processes to ensure regular inspections of all facets

of workplaces, including but not limited to buildings, structures, grounds, tools, equipment, machinery, work

methods and practices, at intervals that will prevent the development of unsafe or unhealthy working conditions.

This will involve a formalized and documented program including, but not limited to:

• scheduled inspection of the overall workplace

• inspection of vehicles prior to use

• inspection of mobile equipment prior to use

• scheduled maintenance inspections of vehicles and mobile equipment.

This will also include a less formal program for the pre-use inspection of tools and equipment that may

malfunction or fail, resulting in incident or injury. Both the formal and informal programs must be supported by a

process for recording deficiencies identified through inspections and a means of ensuring that the deficiencies

are corrected.

Evaluation criteria

• A regular inspection program should ensure that risk control measures are in place and effectively protecting

workers from injuries and illness, and identify potential hazards that have not yet been assessed.

• Those conducting inspections should be properly trained in how to conduct the inspections and follow-up on

the inspection results.

• There should be a provision for both formal and informal inspections, which are routinely conducted with

safety and health committee or worker representative involvement.

• Deficiencies identified in inspections are brought to the attention of the people or departments responsible

for their correction.

• Corrective actions should be prioritized according to the level of risk.

• There should be a process to track deficiencies and corrective actions.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

J: Incident reporting and investigation

Intent

Work-related incidents are reported and investigated, and actions are taken to address deficiencies.

Principles

Incident reporting and incident investigating are among the most critical components of a safety and health

management system. Incidents are an immediate indication of a failure in the hazard management process and

provide an opportunity to correct that failure and prevent a recurrence of similar incidents. An effective incident

reporting and investigation element in a safety and health management system should include the following steps:

• ensure workers report all workplace incidents

• ensure serious incidents are followed up on and investigated

• ensure hazardous conditions identified in incident investigations are managed

• ensure critical incidents are reported to regulatory agencies and to other third parties.

Evaluation criteria

• There should be an effective incident reporting system that ensures workers report all workplace incidents

(including near miss incidents), and that incidents are reported to regulatory agencies and to other third

parties (e.g., the WCB, disability providers, or automotive insurers).

• Investigations into the circumstances of workplace incidents must be completed to:

o determine root causes, and ensure that uncontrolled risks are brought under control

o prevent the recurrence of similar incidents

o determine if training or changes in control methods, such as procedures and personal protective

equipment are required.

• All incidents should be investigated as soon as possible once the injured worker has been cared for and

potential hazards to investigators have been controlled.

• A standard investigation form should be used to gather all necessary information in an organized format.

• Deficiencies identified in investigations should be brought to the attention of the persons or departments that

are responsible for their correction.

• Corrective actions arising out of incident investigations should be prioritized according to their level of risk.

• The lessons learned from incident investigations should be communicated to staff.

• There should be clear processes, roles and responsibilities for reporting hazards and incidents.

• There should be clear processes, roles and responsibilities for assigning and ensuring corrective actions.

• There should be a process to track identified deficiencies and corrective actions.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

Essential #3 - Worker participation

Worker participation in workplace safety and health is essential to an effective safety and health program. Workers

need to have an active role and an empowered voice to work together with co-workers and managers in making

meaningful safety and health improvements. Real worker participation relies on open dialogue where worker input

into safety and health is not only valued, but is encouraged and welcomed. Workers should know that their personal

safety and health, and the safety and health of all workers, is a priority. Unions in the workplace have a role in

supporting worker participation.

K: Worker rights and responsibilities

Intent

Workers understand and are engaged in carrying out their rights and responsibilities.

Principles

The safety and health management system must include processes to ensure that workers are aware of their rights

and responsibilities, usually through training and communication programs. There must also be processes to allow

for their application, such as complaint and dispute resolution procedures.

The system must incorporate the principle that all workers have the following basic rights with regard to their

personal safety and health at work:

• The right to know of all hazards related to their work and the means to protect themselves from those

hazards.

• The right to refuse unsafe work if they feel that it will put them or their co-workers at risk.

• The right to participate in the company’s safety and health program activities, including the workplace

safety and health committee.

• The right to protection from discriminatory action.

As well, the system must incorporate the principle that all workers have the following basic responsibilities with

regard to their personal safety and health at work:

• The responsibility to report hazards to their supervisors.

• The responsibility to report incidents to their supervisor or to a first aid attendant.

• The responsibility to follow established safe work practices, procedures and rules.

• The responsibility to wear personal protective equipment and use the correct tools for the job.

• The responsibility to not engage in work that may harm themselves or others.

SAFE Work Certified Audit Framework

Evaluation criteria

Worker rights and responsibilities must be integrated into all aspects of the safety and health management

system and will be evident in such activities as:

• Workers should be trained to ensure they understand their rights and responsibilities.

• Workers should participate in safety and health activities including, but not limited to, inspections,

investigations, safety and health policy review, workplace safety and health committees and the development

of safe work procedures and other hazard identification and risk controls.

• Workers should have information and input into all aspects of safety and health programs, including program

evaluation, audits and audit action plans.

• Workers should know what can harm them, how to stay safe and be working safely.

• Workers should be encouraged to and be actively engaged in reporting safety and health concerns, hazards

and unsafe working conditions, and refusing work that they believe to be unsafe for themselves or someone

else in the workplace.

• Workers should NOT be subjected to, or fearful of, real or perceived discriminatory action.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

L: Workplace safety & health & representatives

Intent

There is an active and effective workplace safety and health committee or worker representative.

Principles

A workplace safety and health committee should contribute to creating a safe workplace that is free of hazards

through the following activities:

• hold regular committee meetings to review workplace safety

• participate in worksite inspections

• participate in incident investigations

• participate in risk assessments

• make suggestions as to how to improve workplace safety and health

• participate in the resolution of safety and health concerns

• participate in the resolution of work refusals, and

• participate in audits.

The establishment and activities of a workplace safety and health committee is governed by workplace safety

and health legislation. However, in general, the committee’s membership, activities and administration will have

the following characteristics:

• It is the responsibility of the employer to ensure the establishment of, and provide the availability of premises,

resources and personnel for the effective operation of the committee.

• The workplace safety and health committee will be properly constituted, having members representing both

management and workers.

• The committee will be led by two alternating co-chairpersons, one chosen by the employer members and the

other chosen by the worker members on the committee.

• The workplace safety and health committee will establish terms of reference pertaining to the administration

and operation of the committee.

• Each committee member is entitled to be informed of their responsibilities and receive training in relation to

their role on the committee.

• Committee members attending related training or performing committee duties are entitled to receive their

regular pay and benefits.

• The committee must keep accurate records of all matters that come before it, as well as minutes of all meetings.

Workplace safety and health representatives

A workplace safety and health representative is required to be designated for each workplace that does not

meet the general provisions to establish a workplace safety and health committee. Considerations include:

• Workplace safety and health representatives perform all of the same duties as set out for the workplace

safety and health committee.

• Workplace safety and health representatives are selected by the workers they represent, not by the employer.

• A workplace safety and health representative is entitled to the same training and support in their role as

workplace safety and health committee members.

• Workplace safety and health representatives are entitled to be compensated for attending training or performing

other activities required to fulfill their responsibilities.

Evaluation criteria

As per the points outlined above and all regulatory standards.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

M: Protecting vulnerable workers

Intent

There should be specific protections for vulnerable workers and provisions for their inclusion in safety and health

programs.

Principles

Some workers are at greater risk for workplace injury and illness due to a mix of individual and workplace

factors. Some workers may lack the power to alter those conditions. These factors and conditions include, but

are not limited to, newness (to job, work, country, etc.) precarious work (casual, temporary work, low wages,

etc.), language and socio-cultural barriers, high turnover/high-risk industry, disabilities (physical, mental,

cognitive, etc.).

To protect vulnerable workers, the safety and health management system should include the following:

1. awareness of the needs of vulnerable workers

2. a system to develop support processes appropriate to the characteristics of the vulnerable worker

3. a means of evaluating whether the support processes are effective.

Evaluation criteria

The employer should be aware of the factors and conditions that leave some workers at greater risk for injury

and how to minimize the impact of these.

The safety and health management system should recognize and address the specific needs of vulnerable

workers, and should ensure that vulnerable workers receive the support they require.

There should be broad methods to address vulnerabilities, such as considerations for literacy and language

in training, programs, culturally-appropriate communications, peer mentorship programs, accommodation

programming, open and healthy two-way communication.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)

N: Safety culture

Intent

Safety culture assessments are used to further support an understanding of the safety and health program

and to promote continuous improvement. Specific protections for vulnerable workers should be used.

Principles

Safety culture is a set of shared values and beliefs that influence actions and practices regarding workplace

safety and health, shaping how decisions are made, how the organization operates, and how peers and

leadership build safe and healthy workplaces.

Safety culture is part of the organization’s culture. It does not exist in isolation. Safety culture cannot be

managed, but it can be supported and influenced.

A workplace with a strong safety culture shares common values (e.g., what is considered important) and beliefs

(e.g., how values are achieved) which include:

Values:

• People expect safety and health in the workplace

• People in the workplace are our most valuable resource

• Safety and health is valued with productivity, quality and pay

Beliefs:

• Workplace injuries and illnesses can be prevented

• Leaders drive improvement

• We all play a part in building safe and healthy workplaces

A workplace enacting these values and beliefs characterizes a workplace with a strong safety culture.

Safety climate is related to safety culture − it is a snapshot of the attitudes and the shared perceptions workers

have regarding safety. Understanding attitudes of workers, and their perception of the employer’s commitment

to safety and health, can reveal information that may not be readily assessed through documentation or

observation.

Workers should have confidence in the safety and health of their work and workplace. Worker perceptions

should be considered in managing safety and health.

SAFE Work Certified Audit Framework

Evaluation criteria

Safety culture is not scored as part of an audit, rather it is used to support an understanding of the safety and

health program relative to the organization and for continuous improvement.

The Safety Culture element uses three distinct assessment tools requiring the auditor’s assessment and

comment:

1. Safety Culture Assessment (developed in collaboration with the Institute of Work and Health) provides the

workplace with an assessment which can further an understanding of their safety culture and contribute to

continuous improvement. Using the measurement scale provided for each of the 12 statements, the auditor

must determine the percentage of time each practice takes place within the organization as a whole. For

the purpose of this assessment, an audit means a formal process of evaluating and reporting on how the

organization manages safety and health in accordance with a recognized standard (e.g., CSA, OHSAS, ISO)

or a professional safety and health audit. “Regular” means that an audit is repeated at regular intervals (e.g.,

once every year or once every two years). The Safety Culture Assessment aligns to each of the safety culture

values, beliefs and dimensions. Assessment results will be used to support the broad evaluation of the SAFE

Work Certified program and safety culture in Manitoba. See: Appendix 4 for a sample of the Safety Culture

Assessment tool.

2. Safety Perceptions - Where workplaces have used safety culture assessments (e.g., surveys,

focus groups, etc.) the SAFE Work Certified auditor will also consider these results including:

• participation

• confidentiality

• corrective actions

• feedback loop to workers.

The SAFE Work Certified auditor must comment on workers’ perceptions of the organization’s commitment

to safety and health (see: questions 15 and 16 from worker interviews). Where there are negative responses,

or responses that are inconsistent with overall audit findings, the auditor should provide a recommendation to

improve safety perceptions.

3. Culture of Safety Maturity (Adapted from: www.energyinst.org/heartsandminds) - This tool is used to

indicate where an organization sits on the culture of safety and health spectrum. Upon completion of

audit activities, the auditor must indicate his or her assessment of the organization’s overall performance as

either: Generative - safety and health programming is fully integrated as a priority into all aspects of business

operations, Proactive - safety and health programming is driven by leaders and values that drive continuous

improvements, Calculative - safety and health programming is driven by managing hazards, or

Reactive - safety and health programming is driven by responses to incidents.

RETSD Prescriptive Objective Evidence (Best Practices and Standard Identification)

RETSD Performance Based Objective Evidence (Execution of Best Practices and Adherence to Standards)

RETSD Action Plan for Continual Improvement (Plan, Do, Study, Act)