Applying The Safe Place Safe Person Safe System Framework To Improve OHS Management Makin 2009

Applying the “safe place, safe person,
safe systems” framework to improve

OHS management: a new integrated
approach
by
Anne-Marie Makin
Student number: 8338957
A thesis submitted for completion

of the degree of Doctor of Philosophy
School of Risk and Safety Sciences
The University of New South Wales
Submitted November 2008

Accepted July 2009
0.1 Declaration
“I hereby declare that this submission is my own work and that, to the best
of my knowledge and belief, it contains no material previously published or
written by another person nor material which to a substantial extent has
been accepted for the award of any other degree or diploma of the
university or other institute of higher learning, except where due
acknowledgment is made in the thesis. I also declare that the intellectual
content of this thesis is my own work, except to the extent that assistance
from others in the project’s design and conception or in style, presentation
and linguistic expression is acknowledged.”
Signed……………………………………………………………….
Date:…………………………………………………………………
0.2 Copyright Statement
“I hereby grant the University of New South Wales or its agents the right to
archive and to make available my thesis or dissertation in whole or part in
the University libraries in all forms of media, now or here after known,
subject to the provisions of the Copyright Act 1968. I retain all proprietary
rights such as patent rights. I also retain the right to use in future works
(such as articles or books) all or part of this thesis or dissertation.
I also authorise University Microfilms to use the 350 word abstract of my

thesis in Dissertation Abstract International.
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of the digital copy of my thesis or dissertation.”
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ii
0.3 Authenticity Statement
“I certify that the Library deposit digital copy is a direct equivalent of the
final officially approved version of my thesis. No emendation of content
has occurred and if there are any minor variations in formatting, they are
the result of the conversion to digital format.”
Signed……………………………………………………………….
Date:…………………………………………………………………
Anne-Marie Makin
July, 2009
iii
0.4 Acknowledgements
I wish to acknowledge a number of key people for their assistance and
support throughout the course of this study:
Professor Chris Winder for his insight, guidance, patience, dedication and
practical assistance. His motivation and enthusiasm have been a source
of inspiration to me, and his belief in me from the start a precious blessing.
Murray, and our beautiful children Danielle & Andrew, for the balance,
support, comfort and joy they bring. My parents, Olga and Emmanuel
Gialanze – their deep faith and wisdom have been a constant source of
strength. Also, my sisters, Vivien and Evelyn, for their encouragement,
support and proof reading.
To my dear friends Vicki Forrest, Vicky Devine and Ruth Truswell, for their
time to just listen and be there. I thank God for the gift of their enduring
friendship, wit and wisdom. Also I wish to thank Marie Horvath, Antoinette
Grech and honour the memory of Lucy Criniti. All amazing women who
were able to overcome adversity with their kindness, warmth and strength
of spirit.
Dr Carlo Caponecchecia, Dr Anne Wyatt; Dr Christian Khalil; Dr Shahnaz

Bakand; and Dr Silvia Silva for their practical suggestions and guidance.
To all the members of the expert panel that participated in the peer review
for their time and constructive comments. To Tony Natoli from the UNSW
library, for his patience, persistence, advice and perennial good cheer.
The administrative and professional staff of the School of Risk and Safety
Sciences for their excellent ongoing assistance and general helpfulness.
Col Simpson, dear friend and colleague, for his constant support, counsel,
reliability, wondrous friendship and many, many years of nurturing.
Many thanks to you all. This journey was a team effort.
Anne-Marie Makin,
July, 2009
iv
“ Not everything that can be counted counts, and
not everything that counts can be counted.”
Albert Einstein
v
0.5 Abstract
A new model was developed to enhance the understanding of the full
context of work associated hazards, to explore the connection between OHS
performance and a systematic approach to safety, and to simplify
approaches to OHS management. This Safe Place, Safe Person, Safe
Systems model was derived from the literature and used as the basis for the
development of a framework, consisting of 60 elements which was
transformed into an assessment tool. This assessment tool was trialled with
a pilot study on a medium sized manufacturing plant in the plastics industry,
and the tool and Preliminary Report peer reviewed by an expert panel using
the Nominal Group Technique. After refinements were made to the
assessment tool it was applied to eight case studies that were drawn from
advertisements. This qualitative study consisted of two parts: firstly the
assessment using the Safe Place, Safe Person, Safe Systems framework;
and secondly a controlled self assessment exercise to target improvements
to three of the elements over a period of four months. The study illustrated
that the Safe Place, Safe Person, Safe Systems framework could be
successfully applied in a range of industries to promote OHS improvements
and to provide a systematic, planned approach to fulfilling OHS
responsibilities. The application of this framework highlighted that: there is a
need for further education on the correct application of the risk assessment
process and the responsibilities owed to contractors; techniques such as
dynamic risk assessments are more suitable where the place of work is
variable and hazards are unpredictable; more focus is needed on the
appropriate management of hazardous substances with long term health
consequences; and that the level of formality invoked for treating hazards
does not necessarily equate to improved risk reduction outcomes. The Safe
Place, Safe Person, Safe Systems framework was found to be applicable to
small, medium and large organisations provided the assessment was
scoped to a small division of relatively homogeneous activity to ensure a
more representative hazard profile. This approach has provided a way
forward to simplify OHS management and also offers practical direction for
implementing a targeted OHS improvement program.
0.6 Table of Contents
0.1 Declaration__________________________________________ ii
0.2 Copyright Statement __________________________________ ii
0.3 Authenticity Statement________________________________ iii
0.4 Acknowledgements __________________________________ iv
0.5 Abstract ___________________________________________ vi
0.6 Table of Contents ___________________________________ vii
List of Figures ______________________________________x
List of Tables_____________________________________ xiii
0.7 List of Publications__________________________________xviii
1. INTRODUCTION _____________________________________________2
1.1 Background _________________________________________2
1.2 Development of OHS Legislation_________________________8
1.2.1 Historical Legal Developments in Britain Leading to the
Creation of a Statutory Duty of Care _______________9
1.2.2 The Robens Report – Lost in Translation?___________12
1.2.3 Australian Developments in OH&S_________________15
1.2.4 Other International Influences ____________________19
1.2.5 The Effectiveness of Robens’ Style Legislation _______23
1.2.6 Incentives for Change __________________________34
2. STRATEGIES TO IMPROVE OCCUPATIONAL HEALTH AND SAFETY _________40

2.1 Understanding the Context of Workplace Hazards __________44
2.2 Focusing on the Hardware and Operating Environment ______52
2.2.1 Safe Place Strategies___________________________55
2.2.2 The Strengths and Limitations of Safe Place Strategies
in Practice ___________________________________63
2.3 Focusing on People __________________________________70
2.3.1 Safe Person Strategies _________________________74
2.3.2 The Strengths and Limitations of Safe Person
Strategies in Practice __________________________96
2.4 Focusing on Management Strategies and Methodology ______99
2.4.1 Safe Systems Strategies _______________________102
2.4.2 The Strengths and Limitations of Safe Systems
Strategies in Practice _________________________103
3. DEVELOPMENT OF THE OHS MS MODEL FRAMEWORK ______________107

3.2 OHS Model Framework Development ___________________110
3.3 Analysis of National and International OHS MS Structures ___116
3.4 Emergent trends in OHS MS structures__________________131
4. MEASURING & EVALUATING SAFETY PERFORMANCE ________________138

4.1 From the Perspective of Management___________________140
4.2 From an Operations Perspective _______________________146
4.3 From the Perspective of the Individual Worker ____________152
vii
4.4 Summary _________________________________________155
5. PREVIOUS STUDIES AND GAP ANALYSIS _________________________159

5.1 Summary of Studies and the Way Forward _______________172
5.2 Towards the Safe Organisation ________________________179
6. RESEARCH PROJECT AIMS, RESEARCH QUESTIONS AND OBJECTIVES____184

6.1 Area of Research___________________________________184
6.2 Project Aims_______________________________________185
6.3 Research Questions ________________________________187
7. METHODOLOGY __________________________________________190
7.1 Research Methods__________________________________190
7.1.1 Rationale for the Study_________________________190
7.1.2 Sampling Strategy ____________________________191
7.2 Establishing Validity_________________________________192
7.2.1 Construct Validity _____________________________192
7.2.2 Internal Validity_______________________________193
7.2.3 External Validity ______________________________195
7.2.4 Reliability ___________________________________196
7.3 Development of Pilot Study Research Instruments _________196
7.4 Ethics Approval ____________________________________197
7.5 Significance of the Pilot Study _________________________197
7.6 Methodology for the Pilot Study ________________________199
7.7 Potential Outcomes _________________________________201
8. PILOT STUDY RESULTS _____________________________________204

8.1 Preliminary Results _________________________________204
8.2 Discussion of Key Findings from the Pilot Study ___________209
8.3 Lessons from Stage One of the Preliminary Pilot Study _____213
8.4 Lessons from Stage Two of the Pilot Study: Monthly Self
Assessments and the Evaluation Survey _______________216
8.5 Improvements Resulting from the Application of the Nominal
Group Technique _________________________________218
8.6 Pilot Study Summary - Strengths and Limitations __________221
9. INDIVIDUAL CASE STUDY RESULTS -SUMMARY AND DISCUSSION _______223

9.1 Case Study 1 ______________________________________223
9.1.1 Case Study 1 Results Summary__________________223
9.1.2 Discussion of the Main Findings for Case Study 1 ____226
9.2 Case Study 2 ______________________________________232
9.2.2 Results Summary for Case Study 2 _______________232
9.2.2 Discussion of Main Findings for Case Study 2 _______235
9.3 Case Study 3 ______________________________________240
9.4 Case Study 4 ______________________________________249
viii
9.5 Case Study 5 ______________________________________259
9.6 Case Study 6 ______________________________________267
9.7 Case Study 7 ______________________________________276
9.8 Case Study 8 ______________________________________283
10. COMPARISON OF CROSS CASE RESULTS _______________________292

10.1 Comparison of the Existing Level of OHS MS Infrastructure
across the Eight Case Studies _______________________295
10.2 Comparison of the Distribution of Final Scores after
Interventions Applied across the Eight Case Studies ______301
10.3 Comparison of Total Risk Scores _____________________316
10.4 Perceptions of Important Elements for an OHS MS________320
11. DISCUSSION ____________________________________________322

11.1 Discussion of Results across the Eight Case Studies ______322
11.2 Cross Case Synthesis - Emergent Themes ______________333
11.3 Answering the Research Questions____________________341
11.4 Potential Applications of the “Safe Place, Safe Person, Safe
Systems” Framework ______________________________350
11.5 Limitations of the Study _____________________________354
12. RECOMMENDATIONS AND CONCLUSION _______________________359

12.1 Recommendations_________________________________359
12.2 Future Directions __________________________________362
12.3. Conclusion ______________________________________364
13. REFERENCES __________________________________________368
14. APPENDICES ___________________________________________394

Appendix 1 __________________________________________394
Definition of OHS MS Framework Elements _________________394
Safe Place Strategies: Elements and Definition Criteria ____394
Safe Person Strategies: Elements and Definition Criteria ___397
Safe Systems Strategies: Elements and Definition Criteria__400
Appendix 2: Study Advertisement _________________________403
Appendix 3: Study Brochure (Tri-fold Pamphlet Side 1) ________404
(Tri-fold Pamphlet Side 2) ___________________________405
Appendix 4: The Nominal Group Technique _________________406
Guidelines as per Delbeqc __________________________406
ix
Appendix 5: Case Study Protocol _________________________408
Appendix 6: Hazard Profiling Questionnaire - Without Interventions in
Place __________________________________________411
Appendix 7: Assessment of Current Controls against Proposed Safe
Place, Safe Person, Safe Systems Framework___________429
Appendix 8: Performance Measurement Indicator Guidelines____449
Appendix 9: Guidelines for the Targeted Selection of Three Building
Blocks for Improvement_____________________________457
Appendix 10: Example of the Pro-Forma for the Customised Self -
Assessment Tool__________________________________459
Appendix 11:Follow-Up Evaluation ________________________460
Appendix 12: Pilot Case Study Report______________________461
Appendix 13: Project Field Kit ____________________________494
Executive Summary____________________________________495
Safe Place Elements _______________________________501
Definition Criteria , Scope and Key Risks _______________501
Safe Person Elements______________________________506
Safe System Elements _____________________________511
Appendix 14: The “Safe Place, Safe Person, Safe Systems” OHS
Management Assessment Tool_______________________520
Appendix 15: Case Study 1 Preliminary Results Report ________581
Appendix 23: Monthly Self Assessments____________________861
Appendix 24: Follow-Up Evaluation Surveys _________________951
Appendix 25: Sharing Good Practice_______________________965
List of Figures
Figure 1: The Organisation ______________________________43
Figure 2: Examples of Possible Hazard Profiles for Different
Organisations__________________________________51
Figure 3: Context of Workplace Hazards – Focusing on the
Hardware & Operating Environment ________________52
Figure 4: The Context of Workplace Hazards: Focusing on
People _______________________________________70
Management Strategies and Methodology ___________99
Figure 6: Breakdown of Workplace Activities _______________107
x
Figure 7: Breakdown of Specialised Activities _______________108
Figure 8: Cycle of Improvement _________________________109
Figure 9: The Safe Organisation - Blending Strategies & Co-
ordinating Defences through the use of a Model OHS
MS Framework________________________________180
Figure 10: Model for Integrated Systematic OHS Management _182
Figure 11: Pilot Study Initial and Final Scores - Safe Place
Elements ____________________________________207
Figure 12: Pilot Study Initial and Final Scores - Safe Person
Elements ____________________________________207
Figure 13: Pilot Study Initial and Final Scores – Safe Systems
Elements ____________________________________208
Figure 14: Pilot Study - Distribution of Risks Without
Interventions and With Interventions in Place ________208
Figure 15: Injury and Incident Results after Completion of Stage
two of the Pilot Study ___________________________217
Figure 16: Case Study 1 Initial and Final Scores - Safe Place
Elements ____________________________________224
Figure 17: Case Study 1 Initial and Final Scores - Safe Person
Elements ____________________________________224
Figure 18: Case Study1 Initial and Final Scores - Safe Systems
Elements ____________________________________225
Figure 19: Case Study 1 - Distribution of Risks Without
Figure 20: Case Study 1 - Risk Reduction after Interventions
Applied______________________________________226
Figure 21: Case Study 2 Initial and Final Scores - Safe Place
Elements ____________________________________233
Figure 22: Case Study 2 Initial and Final Scores - Safe Person
Elements ____________________________________233
Figure 23: Case Study 2 Initial and Final Scores- Safe Systems
Elements ____________________________________234
xi
Applied______________________________________235
Figure 26: Case Study 3 Initial and Final Scores- Safe Place
Elements.____________________________________241
Figure 27: Case Study 3 Initial and Final Scores- Safe Person
Elements ____________________________________241
Figure 28: Case Study 3 Initial and Final Scores – Safe Systems
Elements ____________________________________242
Applied______________________________________243
Elements.____________________________________250
Elements ____________________________________250
Elements ____________________________________251
Applied______________________________________252
Elements ____________________________________260
Elements ____________________________________260
Elements ____________________________________261
Applied______________________________________262
Elements ____________________________________268
xii
Elements ____________________________________268
Figure 43: Case Study 6 Initial and Final Scores – Safe Systems269
Applied______________________________________270
Elements ____________________________________277
Elements ____________________________________277
Elements ____________________________________278
Figure 50: Case Study 7 Risk Reduction after Interventions
Applied______________________________________279
Elements ____________________________________284
Elements ____________________________________284
Elements ____________________________________285
Applied______________________________________286
List of Tables
Table 1: Examples of Potential Hazards Relating to the
Hardware and Operating Environment_______________54
xiii
Table 2: Examples of Potential Hazards Generated as a Result
of Changes to the Hardware and Operating
Environment___________________________________55
Table 3: Examples of Safe Place Strategies _________________69
Table 4: Examples of Hazards Affecting People ______________73
Table 5: Examples of Hazards Generated from Changes to the
People Sector _________________________________73
Table 6: Examples of Safe Person Strategies ________________98
Table 7: Examples of Potential Hazards Generated from
Management Strategies and Methodology: __________101
Table 8: Examples of Potential Hazards Generated from
Changes to Management Strategies and Methodology
Used: _______________________________________101
Table 9: Examples of Safe Systems Strategies______________106
Table 10: Proposed OHS MS Model Framework. ____________115
Table 11: Comparison of Selected OHS MS with Safe Place
Criteria ______________________________________118
Table 12: Comparison of Selected OHS MS with Safe Person
Criteria ______________________________________119
Table 13: Comparison of Selected OHS MS with Safe Systems
Criteria ______________________________________120
Table 14: OHS MS at a Glance: Proportion of Safe Place, Safe
Person and Safe Systems Building Blocks __________124
Table 15: Distinguishing Features of Selected OHS MS
Structures ___________________________________129
Table 16: The Perspective of Various Measurement Indicators _140
Table 17: Strengths and Limitations of Various Measurement
Indicators ____________________________________156
Table 18: Analysis of Previous Studies Pertaining to OHS
Management _________________________________161
Table 19: Operational Characteristics _____________________191
Table 20: Number of Elements Handled Formally, Informally and
Not Addressed ________________________________206
xiv
Table 21:The New, Improved “Safe Place, Safe Person, Safe
Systems” OHS Management Framework ___________220
Table 22: Case Study 1 - Number of Elements Handled
Formally, Informally and Not Addressed. ____________223
Table 30: Summary of Case Study Characteristics ___________292
Table 31: Total Risk Reduction Factors for each Case Study
Showing Individual Risk Reduction Factors for Safe
Place, Safe Person and Safe Systems Components ___318
Table of Charts
Chart 1: Comparison of the Number of Safe Place Elements
Addressed Across the 11 OHS MS Structures Analysed 121
Chart 2: Comparison of Safe Person Elements Addressed
Across the 11 OHS MS Structures Analysed _________122
Chart 3: Comparison of Safe Systems Elements Addressed
Across the 11 OHS MS Structures Analysed _________123
Chart 4: Comparing OHS MS Structures with the number of
Suggested Safe Place Building Blocks _____________125
Suggested Safe Person Building Blocks ____________126
xv
Suggested Safe System Building Blocks ____________127
Chart 7: Comprehensiveness of OHS MS Structures –
Comparing the Total Number of Suggested Elements__128
Chart 8: Total Number of Safe Place Elements Addressed
Formally Across the Eight Case Studies ____________295
Chart 9: Total Number of Safe Person Elements Addressed
Chart 10: Total Number of Safe Systems Elements Addressed
Chart 11: Total Number of Safe Place Elements Not Addressed
Across the Eight Case Studies____________________298
Chart 12: Total Number of Safe Person Elements Not Addressed
Across the Eight Case Studies____________________299
Chart 13: Total Number of Safe Systems Elements Not
Addressed Across the Eight Case Studies __________300
Chart 14: The Number of “High” Risk Rankings Allocated, After
Interventions Applied, for Each Safe Place Element ___301
Interventions Applied, for Each Safe Person Element __302
Interventions Applied, for Each Safe Systems Element _303
Chart 17: The Number of “Medium - High” Risk Rankings
Allocated, After Interventions Applied, for Each Safe
Place Element ________________________________304
Person Element _______________________________305
Systems Element ______________________________306
Chart 20: The Number of “Medium” Risk Rankings Allocated,
After Interventions Applied, for Each Safe Place
Element _____________________________________307
xvi
After Interventions Applied, for Each Safe Person
Element _____________________________________308
After Interventions Applied, for Each Safe Systems
Element _____________________________________309
Chart 23: The Number of “Low” Risk Rankings Allocated, After
Chart 26: The Number of “Well Done” Rankings Allocated, After
Chart 29: Comparison of Accumulated Risk Scores for Each
Case Study for Safe Place, Safe Person and Safe
Systems Elements, Without Interventions Applied_____316
Chart 30: Comparison of Accumulated Risk Scores for Each
Case Study for Safe Place, Safe Person and Safe
Systems Elements, With Interventions Applied _______317
Chart 31: Comparison of Total Accumulated Risk Scores for
Each Case Study With and Without Interventions
Applied______________________________________318
Chart 32: Total Accumulated Risk Scores, With and Without
Interventions, Across the Eight Case Studies ________319
Chart 33: Perceptions of the Most Important Elements of an
OHS MS from the Follow-Up Evaluation ____________320
xvii
0.7 List of Publications
Book Chapter
x Makin A.-M., Winder, C. (2007) OHSE Risk assessment and control.
Chapter 8 in: Master OH&E Guide, 2nd edition. CCH, Sydney pp 121-
132.
Peer Reviewed Papers
x Makin, A.-M., Winder, C. (2009) Managing hazards in the workplace

using organisational management systems – a safe place, safe
person, safe systems approach. Journal of Risk Research, In Press.
x Makin, A.-M., Winder, C. (2009) Development of an assessment tool

to assist OHS management based upon the Safe Place, Safe Person,
Safe Systems framework. In Safety, Reliability and Risk Analysis:
theory Methods and Applications (Martorell, S., Soares, C.G., Barnett,
J., eds) Taylor and Francis; London, pp 739-747.
x Makin, A.-M., Winder, C. (2008) A new conceptual framework to

improve the application of occupational health and safety
management systems. Safety Science, 46(6): 935-948.
x Makin, A.-M., Winder, C. (2007) Emergent trends in safety

management systems; An analysis of established international
systems. In Risk, Reliability and Societal Safety (Aven, T., Vinnem,
J.E., eds) Taylor and Francis; London, pp 1237-1244.
x Makin, A.-M., Winder, C. (2007) Measuring and evaluating safety

performance. In Risk, Reliability and Societal Safety (Aven, T.,
Vinnem, J.E., eds) Taylor and Francis; London, pp 1245-1252.
x Makin, A.-M., Winder, C. (2006) Do self-assessment tools assist the

effectiveness of performance-based OHS legislation? Journal of
Occupational Health and Safety - Australia and New Zealand, 22(3):
261-267.
Editorials
x Makin, A-M., Winder, C. (2008) Dynamic risk assessments: When

time is a real constraint. The Journal of Occupational Health and
Safety Australia and New Zealand; 24(5) pp: 379-382.
x Makin, A-M., Winder, C. (2007) Systematic OHS management: What

makes it work? The Journal of Occupational Health and Safety
Australia and New Zealand; 23 (4) pp: 291-294.
x Winder, C., Makin, A.-M. (2006) Hierarchy of controls: inflexible

dogma or flexible decision-making? Journal of Occupational Health
and Safety - Australia and New Zealand, 22(1): 3-6.
xix
Part 1: Introduction,
Literature Review and Model
Development
1
1. INTRODUCTION
1.1 Background
The definitions of Occupational Health and Safety Management Systems

(OHS MS) available in the literature are wide and varied, each offering
different perspectives or merits associated with their use. Some have been
defined by the elements they are composed of, others by the objectives
they seek to achieve, and some incorporate both.1-3 There are those
definitions of OHS MS that focus on the linking of various parts, call on
systems theory or emphasise certain aspects of the approach – typically
that it is planned, documented and verifiable.4-7 In order to add to the
fabric of available definitions, the following statement is presented which
intends to address a gap in the literature and attempts to analyse and
coalesce the varying definitions available:
An OHS MS is a framework that facilitates the management of health and safety

within an organisation by providing:
allocation of responsibility and accountability,
a repertoire of strategies for dealing with work related hazards/risks,
cues for the timing and co-ordination of key system elements,
links to ensure interested and affected parties are kept informed and
updated and communication channels are open,
contingency plans for handling situations where preventive measures

have failed,
tools for enhancing the understanding of the system and to provide

opportunities for continuous learning, and
a means of identifying system strengths and vulnerabilities.
The presence of an OHS MS serves as a catalyst for improvement and

learning. When a mature OHS MS is in place, like a catalyst, the system
2
remains largely unchanged at the end of the process. The emphasis then
shifts from the mechanisms of the system to the tools, triggers and
communication links that the system provides to achieve the desired
outcome of a safe workplace. The rate at which this outcome is achieved
will depend largely on the organisation’s ability to: 8
implement changes that are planned, proactive and preventive,
learn from past experiences both internal and external to the

organisation, and
maintain and improve upon practices found to be conducive to

enhanced OHS performance.
None of this, of course, can be achieved without genuine commitment and

support from the directing minds of the organisation.
Working with the statement of an OHS MS presented for the purposes of

this thesis, one would not expect to find a direct correlation between the
presence of an OHS MS and injury rates per se, but only a correlation
between the change in injury experience and the presence of a fully
implemented OHS MS. If the particular OHS MS structure being used was
unsuited to the hazard profile or other unique needs of the organisation,
then there is no reason why a correlation between injury rates and the
OHS MS would exist. This highlights two important determinants of an
effective OHS MS - suitability and appropriateness to the task and the
degree of implementation as evidenced by compliance with the system.3, 9
Difficulties in separating these two issues may also explain why there is a
notable lack of empirical evidence available from studies on what
constitutes an effective OHS MS.10-12 The current paucity of information
available may also be considered an indicator of the complexity of the
issues involved, their highly interactive nature, and the need for a broad
based approach towards the elimination of workplace injuries and
illnesses.
3
Many times the need to address safety has been justified by the
unacceptable cost of workplace accidents and compensation claims, or
driven by the fear aroused by disasters such as Flixborough (1974),
Seveso (1976), Bhophal (1984), and Piper Alpha (1988).13, 14
These
tragedies have at times provided the necessary impetus for change in
legislation and have attracted much public attention, albeit in an
unfortunate way.12, 15, 16 However, the most important reason for the focus
on worker safety is much more fundamental – it is a moral and ethical
imperative.11, 17, 18 No one should be harmed physically or psychologically
in the process of earning an income.19 Crucial to this concept is the notion
that employers and employees acknowledge they have a duty and must
take responsibility for their actions because safety is everyone’s
responsibility, and as such it should be a natural part of all workplace
activities. As cited in Redinger by Follet: 20
“taking of responsibility is usually the most vital matter in the life of every human
being, just as the allotting of responsibility is the most important part of business
administration.”
In the past, employees sometimes traded personal safety for danger

money or allowances to use personal protective equipment.21 This is no
longer acceptable. It is acknowledged that employers must take the
greater share of the legal responsibility, as they have the ultimate control
of the workplace and are usually the greatest financial benefactors of the
business undertakings.22 On a societal level, governments and regulatory
authorities reinforce this responsibility through the “duty of care” owed,
and the need for this responsibility to be fulfilled in the spirit of worker
23
participation, through the “duty to inform” and the “duty to consult.”
Within organisations, Peterson argues that it is only through the fixing of
accountability that responsibility will be accepted, because people will only
devote attention to those things that are being measured.24
Whether or not an organisation will take on the responsibility for actions

and have the ability to learn from their past mistakes will impact upon their
4
development and level of organisational maturity. By taking risks that have
been thought through and the negative consequences minimised to an
acceptable level, responsible expansion and progress can be made. 25
When the responsibility for actions is accepted, and efforts are made to
understand the nature of the process at hand, potential problems can be
anticipated and defence strategies can be put in place. Where these
strategies have been insufficient, lessons are learnt by examining the root
cause of incidents and taking action to prevent these problems from
recurring.26 The effectiveness of responses is examined, and there is good
communication between the parties. Safety will be incorporated as part of
the culture of the business, and integrated into everyday activities
becoming simply “the way we do things around here.” 11
Alternatively, this responsibility can be denied or ignored. In these cases

the learning process will be slow or absent as there is no motivation to
understand the nature of processes that contribute to safety, and
corrective action may be forced upon the organisation externally by
regulatory authorities or external intervention by unions or the media.
Resistance to these changes may be exacerbated simply because they
are driven by external forces. Remedial action may be taken in a purely
reactive manner, and superficial “band aid” solutions applied. There will be
no improvement in the rate of injury or illness experience, and possibly a
deterioration will be seen as the organisation tries to recover as it attempts
to deal with each undesired event in an ad hoc manner, potentially fixing
one problem inadequately only to create another.27
The purpose of this thesis is to provide a means of avoiding the above

scenario by trialling an assessment tool that allows organisations to gauge
the effectiveness of the OHS MS it already has in place and identify areas
of weakness within their system.
There have been numerous paradigms that have driven the trends in
preventive strategies over the years. They fall into three main categories:28
5
those that focus on the technical aspects of the workplace – the
equipment, environment and operating conditions; 29-31
those that focus on people and human factors, including behavioural-

based safety; 32-35 and
those that focus on the system including leadership, culture and

management philosophies, such as Total Quality Management. 2, 36-38
There are also those strategies that concentrate on the interface between
the people dimension and the operating environment, for example
ergonomics, or between the people/system interface such as competency
training.39, 40 Synthesising these defence strategies in the development of
a model for safety management will provide the capacity and flexibility
necessary to deal with the assortment of hazards present in workplaces
today. Furthermore, developing a clear understanding of the limitations of
the various techniques will help determine whether such strategies are
being applied under the conditions necessary to realise their full potential.
Many OHS MS structures such as AS/NZS 4801 have been based on the
Deming “plan–do-check-improve” cycle. AS/NZS 4801 is set out in five
broad sections: - OHS Policy; Planning; Implementation; Measurement
and Evaluation; and Management Review.41 Notably policy has been
separated from the planning section to emphasise the importance of
management commitment. This basis is well suited to development of an
assessment tool, because the concepts of the continuous improvement
cycle can be translated into a learning exercise for the organisation.
Hence, the planned assessment tool, based on a three-part model

incorporating operating, people and system factors embedded in an
Deming “plan-do-check-improve” layout will appraise whether the OHS MS
in place matches the hazard profile of the organisation and how
effectively the existing OHS MS identifies and controls various specific
workplace hazards.
6
The study will be open to a variety of organisations, covering those
businesses whose operations are routine; specialised; organisations that
monitor their process and use feedback for improvement as well as those
that are in position to use best practice to help determine where the
planned assessment tool will be most suitable. It is envisaged that from
this research a means of systematically examining workplace hazards and
identifying corresponding building blocks of OHS MS that are designed to
control the particular risks will pave the way for responsible growth and
sustainable safety.
7
1.2 Development of OHS Legislation
With the perspective that safety is an individual as well as a collective

responsibility, the question arises as to how much responsibility
governments should take for the prevention of death, injury and illness in
the workplace. The following discussion examines the development of
Robens’ model for self-regulation and the evolution of performance-based
legislation. The concept of a statutory duty of care which already exists in
common law and the notion of worker participation underpin the Robens’
model and represent a quantum change from the older style regulations
that originally focused on inspection and prescribed forms of safety control
such as machine guarding. Whilst the concept of self-regulation caters for
the increasing complexity of hazards in the workplace and advances in
technology, finding the right support mechanisms to enable this style of
legislation to achieve its aims has been a case of trial and error, with new
lessons being learnt from every major disaster or common law judgments.
The influences that have shaped the current style legislation in Australia
will be discussed, together with the problems that have emerged and the
conditions most favourable for successful implementation. Consideration
is also given to whether better alternatives exist elsewhere, particularly
interstate or overseas, and if opportunities for further improvements are
available.
It will be shown that the capacity for law to prevent workplace injury and
illness is at best, limited. Hopkins reinforces this point with a call for “pure
risk prosecutions”, where prosecutions are made without actual harm
having been caused, but where the circumstances would be likely to lead
to such events.42 However OHS regulators have been reluctant to follow
this approach, preferring to punish only when harm is proven. Despite the
dismal yearly statistics that demonstrate the weakness of current OHS
strategies there appears to be little incentive for corporations to voluntarily
improve OHS practice, apart from the threat of personally prosecuting
managers and directors. Even with this threat, the results are not always
8
constructive.42 OHS MS are then presented as an ideal means of support
for the Robens’ model, with the additional benefit of providing an effective
tool for organisations to demonstrate legislative compliance and due
diligence.
1.2.1 Historical Legal Developments in Britain Leading to the

Creation of a Statutory Duty of Care
The framework of Australian legislation has largely followed developments

in Britain, originally borne out the squalor and appalling conditions
generated in the manufacturing textile industries. Gunningham describes
how in 1784 in Manchester, a fever epidemic that started with pauper
apprentices and later spread through the community was attributed to long
working hours, overcrowding and unsanitary conditions in the large cotton
factories.43 Setting a precedent for legal intervention as a means of social
justice in the workplace, the Health and Morals of Apprentices Act was
enacted in 1802 to protect pauper children who were essentially being
used as slaves. This was replaced by the 1819 Act for the Regulation of
Cotton Mills and Factories to include free children but was narrow in
application and led to only two convictions. Many cases were awarded a
penalty of a guinea, leading to the term a sovereign remedy. The 1833
Factories Regulation Act ensued, and was the first Act to invest power in a
local inspectorate, although enforcement was dubious and penalties
weak.44 In the Amendment Act of 1844, provisions for machine guarding
were introduced, much to the opposition of the mill owners. The scope
was still restricted to the major textile industries until the Act of 1864, when
it was extended to cover six high-risk trades. These included pottery that
carried the threat of lead poisoning, and matchmaking associated with
painful necrosis of the jawbone from the handling of phosphorus. Separate
legislation emerged to address coal mines (1842); railways (1900); all
factories as legally defined (1937); agriculture (1956); and shops and
offices (1963). With technology developing at a great rate, the legislative
coverage of industries was fragmented and not all persons in the
workforce were protected.43
9
Few avenues were available to recompense injured workers, although
Bohle, James and Quinlan note the development of a number of largely
powerless “self-help” remedies emanating from benevolent societies and
trade unions founded by craftsmen. These authors portray
disenchantment amongst the working class as playing a key role in the
introduction of the 1880 Employers’ Liability Act, which provided manual
workers with access to restricted claims.45 As this was still perceived to be
a poor remedy to the situation, a no-fault system of workers’ compensation
was instigated in 1897, based on the German model introduced by
Bismark.46 Prior to this development, attempts to make common law
claims against employers under their contract of employment were fraught
with difficulty. In Priestly v. Fowler in 1837, the doctrine of common
employment had been established underpinned, as suggested by Brooks,
by the doctrine of voluntary assumption of risk.47 This effectively placed a
limitation on the employers’ vicarious liability so that in the case of a
breach committed by a fellow employee (said to be in common
employment), there was no common law recourse for justice from the
employer.48 In what Brooks describes as a “hundred years war”, it was not
until the Wilson and Clyde Coal v. English case in 1938 that the
employers’ obligation was recognized as a personal duty that could not be
delegated.44, 47
This was the culmination of a number of precedents that
had developed, slowly eroding the harsh doctrine of common employment:
46, 48
1850 Hutchinson v. York, Newcastle and Berwick Railway Co.:

Duty on employers to select competent staff.
1858 William v. Clough: Duty on employers to provide safe

premises and plant.
1862 Clarke v. Holmes: Duty on employers to provide a safe system

of work.
1915 Toronto Power Co. v. Paskwan: Duty on employers to provide

safe plant could not be delegated to a competent person.
10
1938 Wilson and Clyde Coal v. English: Duty on employers to
provide a safe place of work; safe premises, plant and materials;
competent staff; effective supervision; and a safe system of work.
These and other common law precedents made contributions to what is

now regarded as the “employer duty of care.” The Wilson and Clyde Coal
v. English case also served to reinforce the principle of negligent conduct
that had emerged with the landmark case of Donoghue v. Stevenson
(1932) in the House of Lords. It was from this product liability case where
Ms Donoghue successfully sued the manufacturer after finding a
decomposed snail in her ginger beer that the duty of care evolved. In the
words of Lord Atkins, drawing from the parable of the Good Samaritan: 49
“The rule that you are to love your neighbour becomes in law, you must not injure
your neighbour; and the lawyers question, Who is my neighbour? receives a
restricted reply. You must take reasonable care to avoid acts or omissions which
you can reasonably foresee would be likely to injure your neighbour. Who, then in
law is my neighbour? The answer seems to be – persons so closely and directly
affected by my actions that I ought reasonably have them in my contemplation as
being so affected when I am directing my mind to the acts and omissions which
are called in question.”
Whilst this established a fundamental duty of care in common law, and

had enormous legal significance for example in tort law, as a vehicle of
restitution for injured workers it was not always satisfactory - being time-
consuming, expensive, and adversarial because remedies had to be
sought in the courts. Furthermore, it required the demonstration of “fault”
of the employer by the employee. In cases where contributory negligence
was a factor, pursuit of damages under the old system of breach of
employer contract may have been preferable, as this was held to only be
applicable in tort law. Essentially the duties under both tort and contract
law were the same, as were the problems encountered.44, 46
The passing of the various Factories Acts had opened up another

possibility for common law compensation – breach of statutory duty, as the
doctrines of voluntary assumption of risk and common employment were
11
not considered to apply.44 Until the 1940’s, the main obstacle for workers
and main defence for employers invoking this route was contributory
negligence, which was able to form a complete defence for breach of
statutory duty. Although it has re-emerged as a partial defence today, the
removal of this defence for many years made it an attractive option for
workers seeking redress.44, 46
The advantages of this pathway were that
there was no need to demonstrate foreseeability, preventability or lack of
reasonable care, unless it specifically formed part of the statutory duty
itself.48 Furthermore, the payouts from common law claims for serious
injuries were generally higher than for workers compensation schemes.19
As work related fatalities continued in Britain in the order of 1000 per year,
there was growing dissatisfaction with traditional prescriptive style
legislation that was “piecemeal,” did not apply to all industries and did not
protect all workers.50, 51
In 1972, the UK Robens Royal Commission into
workplace safety recommended the development of generic performance-
based occupational health and safety legislation to establish in law the
employer’s duty of care, through a system of communication, training and
self-regulation.52 As it was recognised that litigation was a reactionary,
frustrating and costly exercise, usually unable to ever restore a worker to
their pre-injury condition, the Health and Safety at Work (HSW) Act 1974
attempted to endorse the findings of the Robens Report, with the intention
to use the threat of more comprehensive and broader punitive action as an
incentive for prevention of workplace injuries and illnesses.53
1.2.2 The Robens Report – Lost in Translation?
The spirit of the Robens Report was revolutionary for its time,
recommending that responsibility be moved from the regulators back to
industry where the hazards and risks originated. This concept of self-
regulation was to be achieved through management-worker consultation
and more involved employee participation through the establishment of
joint safety committees and the election of employees’ safety
representatives.54 It was envisaged that the safety representatives would
be empowered to conduct workplace inspections and have access to
12
regulatory inspectors as necessary. Robens considered that mandating
such provisions might be too restrictive, suggesting as an alternative the
enactment of a general duty to consult with the details of how this might be
attained encapsulated within a code of practice.55
Whilst self-regulation seems an intuitively logical means of promoting

ownership of the problem with those who are in an ideal position to
generate workable solutions, the concept of self-regulation was not without
its critics.54 A valid argument for the old prescriptive style legislation was
that the duty holder knew precisely what was expected, making the
enforcement task more straightforward. As a counter to this, there has
been growing recognition of the changing nature of workplace hazards,
with acknowledgement that many dangers arise not only from the physical
environment, but also from the way in which work is organised.22, 50, 56
Critics such as Brooks felt that the law had not been given a chance to
work, and twisted the significance of statements in the Robens report such
as “the single most important reason for accidents at work is apathy” to
imply “worker apathy”, even though it was admitted that these words were
not specifically used in the report.48, 50
Furthermore, employer apathy
should not be discounted. Reluctance aside, self-regulation offered a more
flexible alternative to the traditional “command and control” style
legislation, more suited to a rapidly changing and dynamic society.57
Robens saw the role of worker participation and consultation as crucial to

the success of the self-regulation concept. Workplace consultation could
certainly, in theory, be an effective means of improving safety in the
workplace, provided that the agenda of safety committee meetings had not
been hijacked, employees were sufficiently skilled in the workings of the
process and meaningful consultation was in fact taking place.58 Yet there
lies an inherent conflict between the duty of consultation and the authority-
control gradient underpinning the employer-employee relationship. A
consultative approach requires that the employer and employee have a
more level relationship. This explains why a number of authors such as
Saksvik, Quinlan and Frick emphasise trade union support as a key factor
13
for the success of participatory workplace arrangements.59 60 Furthermore,
authentic consultation requires trust between the two parties – a situation
that is more ideal than commonplace.61 This suggests that in places where
union involvement is weak or absent, the existence of a favourable safety
culture may be a vital ingredient for fruitful worker participation and
meaningful workplace consultation.
Creighton attributed many of the recommendations of the International

Labour Organisation (ILO) Standards – The Occupational Health and
Safety Convention 1981 (No 155) directly to the Robens’ model. This gave
further credence to the philosophies espoused by Robens, and took the
influence of his work to a new level.62
It is interesting that some aspects of the Robens Report such as the

general duty clause and worker participation were widely embraced, while
some other insightful perspectives on inspectorate and workplace reform
were downplayed. For example, the recommendation that a general duty
of care replace the proliferation of ad hoc regulations that were
cumbersome, difficult to interpret, and lagging behind technology was well
received, as was the notion that supporting guidance material should be
embodied in standards or codes of practice.44 Yet, the emphasis that
Robens placed on the use of improvement and prohibition notices to
reinforce the preventive nature of the legislation, an aspect that would
always have been limited by the available resources of an inspectorate
body, did not receive similar attention.52 Also downplayed were the points
Robens made about responsibility for actions, the accountability of
management at the highest level, the pivotal role line supervisors play in
assessing the practicability of safety arrangements and the need to hold
line management accountable within their sphere of influence. Robens
advocated that safety should be handled like any other business function,
echoing the words of Heinrich many years before.55, 63
14
“The essential import of these approaches is that the employer who wants to
prevent injuries in the future, to reduce loss and damage, and to increase
efficiency, must look systematically at the total pattern of accidental happenings –
whether or not they are caused by injury or damage – and must plan a
comprehensive system of prevention rather than rely on ad hoc patching up of
deficiencies which injury-accidents have brought to light.”…
“We are encouraged by the increasing interest shown by employers in the

development of more systematic approaches to prevention. … More needs to be
done to increase industry’s capacity for this kind of systematic self-regulation.”
The promotion of a systematic approach to safety was a particularly

enlightened observation in the Robens Report that seems to have been
overshadowed by the simultaneous launch of a number of innovative
concepts: 55
It is here that the Robens Report clearly indicates that the intention behind
the concept of self-regulation was not only one of worker participation, but
also included the development of a deeper, more process-driven
systematic response that was preventive and predictive in nature. Also
hinted at here is the need to develop guidance material that would help
stimulate industry to move in this direction. Potentially overwhelming and
challenging to traditional mindsets, the encouragement of a systems
approach to safety was, nevertheless, ahead of its time.
1.2.3 Australian Developments in OH&S
Mirroring developments in Britain, the Williams Inquiry in 1980 in New

South Wales (NSW) also recommended enactment of performance based
occupational health and safety (OHS) legislation that covered all workers
and all workplaces.21 This led to enactment of the Occupational Health
and Safety (OHS) Act (NSW) in 1983, and although it contained a general
duty clause limited by “reasonable practicability”, it had not reflected the
true spirit of the Robens Report, presenting as a hybrid between
prescriptive and performance based standard models.
15
By 1995, aspects of the Robens’ style legislation had been adopted by all
the various Australian jurisdictions. Notably South Australia, Victoria and
the Australian Capital Territory (ACT) had gone much further than the
other states with worker participation, having empowered health and
safety representatives with the option to cease work in certain
circumstances. Some critics viewed this as a rejection of the Robens’
model which presumes equal bargaining power between workers and
management.22, 64
Queensland took a unique positive tack, requiring the
appointment of an appropriately qualified health and safety officer in firms
of 30 or more people to assist employers in OHS matters.65, 66
By the end of the nineties there was still a plethora of OHS related
regulations under a number of different Acts. This situation was rectified in
NSW with the OHS Regulation 2001(NSW) made under the current OHS
Act 2000 (NSW) repealing and consolidating 37 old style regulations under
the Factories, Shops and Industries Act 1962 (NSW), the Construction
Safety Act 1912 (NSW) and the OHS Act 1983 (NSW).67, 68 Although the
1983 Act referenced the establishment and functions of a safety
committee, there was no specific “duty to consult”. Whilst there was not a
great deal of difference between the OHS Act 2000 (NSW) and its
predecessor, the duties where placed in a much more logical order, and
there has been greater emphasis on workplace consultation with the new
“duty to consult” being placed second only to the employer’s duty of care.
The 2000 Act also required the employer to value the outcomes of the
consultation process.67, 69
Currently all states and territories in Australia are covered by workers’

compensation schemes, although there are significant differences across
the various jurisdictions. In Tasmania and the ACT there are no limits on
common law claims whilst Victoria, South Australia (SA) and the Northern
Territory (NT) have moved to almost completely cut off access to common
law damages, following trends in the United States (US) and New Zealand
(NZ). Other states such as NSW, Western Australia (WA) and
16
Queensland, as well as the Commonwealth have taken a more moderate
approach by having limited provisions for access to common law.19, 46
Perhaps in response to the difficulties of having different OHS regulations

across Australia, most jurisdictions with the exception of the NT, the ACT
and Tasmania have developed audit tools to assist legislative compliance.
The NT provides general OHS guidance material, whilst the ACT and
Tasmania have chosen to focus more on small business, producing a
number of self-help tools that are freely available from the respective
regulatory authorities.70-73 Common themes appearing in the audit tools
available from Victoria, Queensland, SA, WA, and NSW include:
the provision of systematic, structured guidelines for improving OHS

management and practice,
emphasis on management leadership and commitment; employee

participation and involvement; and the need to understand and
control workplace hazards,
references to the relevant OHS legislation to assist employers

through their respective OHS compliance duties,
tiering systems to package the potentially overwhelming amount of

information into digestible portions and to reflect different levels of
achievement, and
incentive schemes for workers’ compensation premium discounts

(WA, SA and previously NSW) or self-insurance options (Victoria or
Queensland).
Despite all the auditing tools containing threads of similarity, they remain
sufficiently different to be considered uniquely branded. Of particular note
are Victoria, SA and Queensland. Victoria took the lead by being the first
state in the 1990’s to develop an auditing tool, and modelled their
proprietary SafetyMAP package on the ISO 9000 quality management
standards series. SA preferred instead to use AS/NZS 4801 as a template
for their Safety Achiever Business Scheme (SABS) with modifications
17
made to incorporate workers’ compensation and rehabilitation.
Queensland, in a display of positive initiative, use layered vertical audits in
their Tri-Safe system to crosscheck that evidence from management was
supported by the practices of line supervisors and workers.36, 74-80
As illustrated above, there is considerable variation amongst provisions for

OHS across Australia, which is frustratingly difficult for organisations
operating over a number of jurisdictions that have to deal with up to nine
different legal systems. This was a relic from Australia’s colonial past, with
each jurisdiction following developments in the United Kingdom (UK) in an
independent, ad hoc manner. In an attempt to overcome this problem,
attention turned to the constitution as a possible remedy. Whilst there are
limited provisions in the Australian Constitution under s 51(37), OHS
remains a matter for the states unless they voluntarily decide to refer their
powers back to the Commonwealth, which no jurisdiction has done. Even
though this scenario is considered unlikely, there is an alternative route via
the external affairs powers conferred in s51 of the Constitution, which
Creighton suggests could be invoked through the ILO Convention No. 155.
Theoretically a legal option is available, although Bohle and Quinlan
suggest a political reluctance to seize this path.46, 64
Previously, the only
move towards national uniformity was the formation of the National
Occupational Health and Safety Commission (NOHSC) in 1985, which
was a tripartite body comprising of government or expert members,
employer councils and union representatives. NOHSC had no inspectorate
authority or legal administration tasks (this function is covered at the
Commonwealth level by Comcare), but provided a resource for research,
statistics and the development of a number of national advisory codes and
informative publications.65, 66
Codes of practice and standards are not
legally binding, but can be used to demonstrate whether or not an
employer has followed best practice. Failure to follow a code of practice,
especially state endorsed codes, could form evidence that not all was
done that was reasonably practicable, unless the defendant could show
the existence of a better arrangement in place.65, 81 NOHSC was replaced
by the Australian Safety and Compensation Council (ASCC) in 2005. The
18
impact of ASCC on future developments in OHS is yet to be seen.82 With
a change in Federal Government in late 2007, it appears that calls for
nationally uniform OHS regulations will be further investigated.
1.2.4 Other International Influences
After the 1970’s, broader influences from the international arena have
impacted the course of legislation in Australia. The formation of NOHSC
was influenced from the United States (US). The US has the National
Institute of Occupational Safety and Health (NIOSH). However,
arrangements in the US are quite different from Australia, with the
retention of a more prescriptive style legislation in the Occupational Safety
and Health Act 1970 and the Occupational Safety and Health
Administration (OSHA) being the main federal agency having enforcement
powers in approximately 25 states. In other states this power has been
delegated out and is handled by approved state plans. OHSA also
administer a Voluntary Protection Program (VPP) that has been operating
since 1982. The program has a tiering system to identify two levels of
achievement, as well as alternative workable systems – star, merit and
demonstration. The incentive to comply with the VPP is a reduced number
of scheduled inspections. There are four key elements to the program: -
management leadership and employee involvement; worksite analysis to
assess hazards; hazard prevention and control; and safety training.83-85
In Europe, the formation of the European Community (EC), the Single

European Act 1986, and the development of a number of ‘daughter’
Framework Directives have had considerable impact on the direction of
OHS legislation within the European Union (EU). One of the main
elements originating from the 1989 EU Framework Directive 89/391 has
been the use of a documented risk assessment strategy. This entails
evaluation of workplace hazards and controlling the risks at the source.
Where this is not possible, management strategies to treat the risks must
be applied, based on preventive principles. Workers were to be involved in
the collection of information for this purpose. These principles have been
taken up by a number of countries in Europe, including the UK (1992),
19
Denmark (1997), the Netherlands (1994) and Greece (1996).59, 86, 87 This
influence extended to the revamped OHS Regulations 2001 (NSW) that
focused heavily on risk assessment methodology.59
Prior to the 1989 EU Framework Directive 89/391, there had been a

number of significant disasters – Flixborough in 1974, Bhopal in 1984 and
Piper Alpha in 1988, all tending to reinforce the inherent sensibility of
workplace risk assessment, the importance of robust control measures
and better OHS management.
In Flixborough, England, a temporary modification to existing plant went

terribly wrong when the makeshift pipe work failed, and the resulting
vapour cloud explosion killed 28 men. Unqualified personnel had failed to
take into account the torsional forces involved when connecting two tanks
of cyclohexane that were not horizontally aligned. The only documentation
of the change was a chalk drawing on the workshop floor. Ten years later
in the UK, the introduction of the Control of Industrial Major Accident
Hazards (CIMAH) Regulations 1984 were commonly attributed to
Flixborough. This legislation required organisations storing specified
88
quantities of hazardous materials to prepare a “safety case.” A “safety
case” is a stand-alone document covering: the identification of potential
hazards; an assessment of the likelihood of the identified hazards
occurring; a description of risk reduction strategies in place to control the
perceived risk to acceptable levels; and emergency preparedness
arrangements.16 Later in 1993 after the Piper Alpha disaster, new
regulations for off-shore facilities also called for operators to submit a
safety case, with the obligations extended to include an explanation of
how the operator’s safety management system will actually achieve safety
objectives and be able to adapt to incorporate changes where
necessary.89
The 1982 Seveso Directive (82/501/EEC) required the notification of major

industrial accidents involving hazardous substances to the European
Commission. This directive was named after the 1976 accident in Seveso,
near Milan, Italy, involving a release of dioxins. Without claiming any lives,
20
the impact of this toxic fallout was far reaching – it contaminated the land
of a surrounding village and was responsible for around 250 people
developing the disfiguring skin disease chloracne.15 The Seveso II
Directive (96/82/EC) in 1997 helped to clear up the definition of what
constituted a major accident and widened the recommendations to include
voluntary reporting of near misses.90 The recommendation to report near
misses has appeared in the OHS Regulation 2001(NSW) as an internal
reporting requirement.69 However enforcement of such a requirement
remains paradoxical by nature because there is no damage or injury to
prove that the incident happened.
During the early 1990’s two Scandinavian countries - Norway and

Sweden, mandated an internal control strategy. In Norway this
commenced in 1992, and involved legislating requirements for OHS MS.
Saksvik and Quinlan attributed the impetus for such a change to two main
factors: 59
the collapse of the Alexander Kielland oil rig platform in 1980 during a
storm which killed 123 workers; and
the total quality management (TQM) movement and implementation

of the ISO 9000 quality management standards series which were
typically in use by the offshore oil industry.
The move to formally regulate OHS MS in Norway was set in the following
context: 59, 91
a high proportion of a relatively stable work force involved in the off-

shore oil, gas and related industries,
an atmosphere of strong but co-operative union involvement,
the governing inspectorate having a strong presence, and
regulatory authorities that supported the trade unions.
21
This style of legislation has been in place for a considerable period of time.
The lessons learnt from this approach were:59, 92
the pitfalls of becoming lost in the mechanism of the system, such as

paper compliance and stifling bureaucracy, and
difficulties for small firms trying to comply and if unable to do so,

being in breach of the law.
Overall, the approach has been generally regarded as a success, with

sympathy for the concerns of small businesses widely acknowledged.
Some critics have cynically portrayed this style as being very “top-down”
and an excuse to incorporate management jargon into the sphere of
contemporary consciousness.59 In contrast to this, Saksvik, Torvatn and
Nytro describe the benefits of the systems approach, suggesting links to
lower rates of absenteeism, improved overall worker well-being and
insightfully, the process of organisational learning.92
The Alexander Kielland tragedy in 1980 would certainly have reinforced

the need for safe work practices on a local level; however, it was not until
1992 that Norway took this direction, two years after Sweden. During this
time there had been the horror story of Bhopal, India, in 1984, where a
runaway reaction released 25 tonnes of methyl isocyanate (MIC), resulting
in the official deaths of nearly 2000 people, and injuring up to 200,000.
The cause of the runaway reaction was contamination of a storage tank
containing MIC with water. In the investigations unfolding from this tragedy
emerged the sad revelation that there was no need to have stored such a
dangerous material in the first instance – it was a chemical intermediate
that could have been used without delay.93 This reinforced the importance
of eliminating hazards at the source where ever possible as per the
hierarchy of controls.
If the Bhopal catastrophe had a surreal, distant element to it, the fire on
the Piper Alpha oil rig in the UK North Sea would not have. The Piper
Alpha disaster in 1988 resulted in the deaths of 167 people. The
recommendations released in 1990 from the public inquiry led by Lord
22
Cullen pointed to the failure of the permit to work system, as well as other
problems within the organisation, risk assessment, training and existing
legislation.94
With the need to focus on management systems becoming ever more

apparent, and with examples from Norway and Sweden already in
existence, another important outcome from the Seveso II Directive
(96/82/EC) was the requirement for organisations holding certain
quantities of hazardous materials to implement a Safety Management
System (SMS).95, 96
Hence, the picture that emerges from overseas was
the growing realisation that not only were risk assessment, control and
reporting vital, but that there was an important co-ordinating role for OHS
MS, especially for large organisations with high levels of risks.
1.2.5 The Effectiveness of Robens’ Style Legislation
When considering the effectiveness of Robens’ style legislation, it is

important to bear in mind the philosophical nature of the persuasion
versus punishment debate underpinning the preferential use of an
outcome oriented legal framework for OHS.97 With Australia having
embarked on the persuasion option, there appears to be significant limits
to what this style of legislation can realistically achieve. Performance
based legislation represents a more mature positioning of the law. The
embodiment of a statutory “duty of care” and a statutory “duty to consult”
has an educative role, promoting the expectations that society has on the
type of relationship that should exist between the employer and the
employee.97, 98
It is appropriate that the law should reflect these
sentiments, and whilst the law provides direction, questions remain as to
how effective the legislation can be in preventing workplace injury and
illness without spelling out the means to achieve the desired outcomes or
taking a highly punitive approach. Furthermore, if the current application of
Robens’ style legislation is not delivering then the following questions are
posed:
Are alternative models available, other than strictly prescriptive or

persuasive?
23
Are these models applicable to the Australian context?
Do these alternatives generate worse problems?
Experience from the UK has demonstrated the difficulty in finding the

correct blend of supporting regulations to effectively implement generic
performance based legislation. The moves to focus on risk assessment,
and later OHS MS in Scandinavia, illustrate the need to develop the
requirements more fully, and the importance of striking a balance between
broadly stated goals and the specification of the processes to fulfil these
aims.
Further lessons from the UK emerged when the injury rates began to
increase again in the 1980’s, after an initial drop attributed to the
introduction of performance based legislation.99 In the period of self-
reflection that followed, Dawson et al recommended that senior executives
include safety objectives in management appraisals and that annual
reports include the presentation of serious and fatal incident rates as well
as the disclosure of any formal dealings with the courts or safety
inspectors. Other recommendations for the safety inspectorate included
increased fines and penalties, greater use of informal notices and advice
to be followed through, and the need to conduct more frequent and
probing workplace inspections.100 These later recommendations rely on
the availability of resources and indicate that the success of a more
persuasive style of enforcement would need the support of a heavily
funded regulatory body. Given that such authorities will always be under
financial scrutiny and pressure, this presents an on-going constraint to the
application of Robens’ model.97
Robens had highlighted an important role for trade unions in participative

workplace safety arrangements and a strong co-operative trade union
environment also supported the success of the Scandinavian internal
control model. This is in contrast to the situation in the US, where a more
prescriptive legislation has been retained and the position of trade unions
is weaker.101 Interestingly, the emphasis on the workplace by the
24
legislation and US OSHA has been counter balanced by a focus on safe
behaviour and safety culture by some prominent employers such as
DuPont, who despite criticisms for under-reporting of lost time injuries
(LTI’s), are still considered to have iconic status in OHS performance.102-
104
This suggests that problems foreseen with translating the Robens’ or
internal control model to Australia due to diminished trade union support
could be addressed by an alternative support mechanism - a highly
developed safety culture.59, 91, 105
Just exactly what safety culture means has been the subject of much
deliberation within the literature.106 Reason makes a poignant remark
when he questions whether safety culture is something that an
organisation possesses or whether it is something that it actually is.
Reason then goes on to suggest the need for an informed culture which
he believes is comprised of a “reporting culture, a just culture, a flexible
culture and a learning culture”.107 Weick proposes that organisational
culture provides:108
“A homogenous set of assumptions and decision premises which when they are
invoked on a local and decentralized basis, preserve coordination and
centralization. Most important, when centralization occurs via decision premises
and assumptions, compliance occurs without surveillance.”
However, as promising a concept as this is, attempts to measure and

assess the existence of such an entity remain difficult, although
researchers such as Grote and Flin are exploring the predictive validity of
some recently developed survey instruments.106, 109
Another potential drawback of the application of performance-based

legislation lies in its inability to provide a sufficient resource for
businesses. Whilst the Robens’ model promoted the use of codes of
practices and standards to capture the necessary level of detail, these do
not carry the same perceived legal standing as acts or regulations, despite
having evidentiary status.19 This increases the degree of difficulty in
persuading corporations to follow such recommendations. Hopkins
25
promoted regulations as a potentially powerful but under-utilised resource
for organisations. To support this notion, Hopkins cited Gun’s South
Australian study in 1992 that suggested with proper enforcement and
application of regulations up to 50% of injuries could be prevented.98 So
the question remains, has Australia seen the right blend of legislation yet?
Kim explored this very question in 2004 when she compared the handling
of hazardous substances in the oral health industry in Queensland under
performance-based legislation with fluorescent lamp manufacturers in
Korea under more prescriptive regulations. Kim came to the conclusion
that for the management of high-risk substances such as lead and
mercury in the workplace, a combination of the two styles would deliver a
better outcome.14
By the mid 1990’s it was clear that the existing application of the Roben’s
style legislation in NSW was not achieving its aims to reduce workplace
injuries and illness, and from 1996-98 the Legislative Council Standing
Committee on Law and Justice recommended overhaul of NSW OHS
legislation that took effect in 2000/2001.66, 68
It was not that the Robens’
style legislation was considered a failure, but that there was a need to
capture the intent of the Robens Report more authentically.54
Johnstone and Gunningham highlighted the following problems that

existed with the legislation at that time: 22, 110, 111
prosecutions focused on the events immediately leading up to the

injury rather than uncovering broader system or organisational
factors,
there was little incentive to do more than meet minimum standards

(which by default become maximum standards),
trivial or inadequate penalties being imposed did not provide a

sufficient deterrent factor for large organisations,
26
inability to capture the changing nature of illness and injury, for
example hazards arising from the changing organisation and
structure of work activities, and
failure to accommodate the trend towards a more fluid labour force

with greater use of part-time and casual employment, outsourcing via
contractors and subcontractors, labour hire agencies as well as
franchising arrangements.56
In 2001, Johnstone and Gunningham campaigned for the introduction of a

third style of legislation - a systems approach, having witnessed the
relative success of such moves in the Scandinavian countries.84 To
accommodate the concerns drawn from the internal control model, a “two
track” scenario was presented. Traditional compliance with the legislation
was proposed as track one, a likely option for small businesses. As an
alternative, track two would offer organisations an opportunity to
demonstrate compliance with a certified OHS MS. As an incentive for
taking the track two pathway, the waiving of traditional track one
compliance requirements was suggested.110
The two-track strategy was rejected by the Industry Commission and the
Australian Council of Trade Unions (ACTU), with some observers
considering it to be a watering down of the law.110, 112
OHS regulators
insisted that compliance with OHS legislation remain even with an OHS
MS.2 In his OHS MS Strategic Issues Report issued by NOHSC,
Bottomley had noted that OHS MS were more suited to “a large, static
6
workplace with a stable workforce.” Quinlan and Mayhew examined in
considerable detail the growth of precarious employment in Australia and
the ensuing difficulties for maintaining worker safety in small workplaces.
Implementing OHS MS in a highly fractured labour market was considered
to be problematic on all levels.56 There were also concerns surrounding
the auditor requirements, such as the high level of expertise that would be
necessary, and the lack of incentive to attract a pool of qualified auditors
to the role, as the potential conflict of interest would cut off more lucrative
on-going consulting revenue.3 Other issues highlighted from studies in
27
Michigan were the potential for corruption within the auditing arena, and
the potential exposure of auditors to litigation claims.113-116 The call for a
two-track strategy was abandoned.
Also around the same time Gallagher was promoting the “adaptive
hazards manager” as a best practice model which was based on a risk
assessment approach combined with strong workplace consultation,
management involvement and a more integrated approach to health and
safety.10 Bottomley went so far as to make the point that “Gallagher, in her
study, found that an unambiguous link between health and safety systems
and reductions in injury and ill health could not be demonstrated.” This
was erroneous since Gallagher had used a case study methodology, and
an audit tool based on a modified version of SafetyMAP to categorise
twenty enterprises. Having done so, statistical analysis was not applicable,
nor was extrapolation of results to a wider population.10 Bottomley went on
to recommend that the “majority of low-risk small businesses use
traditional hazard management methods” and only the small proportion of
high-risk small businesses be targeted for a limited OHS MS.6
The revamped OHS Regulation 2001 (NSW) captured Bottomley’s

recommendations in combination with the model put forward in
Gallagher’s study. Principal contractors in the high-risk construction
industry for work over $250K were required to implement safety
management plans, and sub-contractors were to submit safe work method
statements. The rest of the regulation maintained a risk assessment focus,
consistent with the promotion of a “safe place” rather than a ”safe person“
ethos, following trends in Europe as opposed to the US. The new style
NSW regulations made no other mention of OHS MS, nor were they
formally mentioned in the OHS Act 2000.10, 67, 117
According to figures released by WorkCover NSW, changes to the

legislation appear to have had a positive impact on OHS performance in
the workplace.68 However, there still remain a number of issues with the
current application of Robens’ style legislation in general:
28
The Australian Chamber of Commerce and Industry (ACCI) made the
point that a survey of business attitudes revealed a great reluctance
to approach regulatory bodies for OHS advice when the same entity
has the capacity to prosecute them.118
Frick and Hopkins highlight the inherent conflict of interest that exists
if regulatory bodies also administer workers compensation schemes.
For example, hazardous substances associated with long latency
illnesses may not receive the same attention as other accident
hazards that result in prompt claims. Similarly, hazards that lead to
catastrophic failures may go unnoticed if they are rare and are not
preceded by claims or other injury experience.60, 119
Jensen describes the phenomenon of “sidecar” learning based on

experiences from Denmark that can occur with the use of
participatory schemes, a critical feature in the Robens’ model. In the
“sidecar” concept, the safety function is marginalised, with
workgroups focusing on relatively minor problems. The resolution of
these issues remains encapsulated within the participatory
mechanism and detached from the corporate decision making
processes.23 Wyatt and Sinclair also observed cases of OHS
committees in Australia remaining “bogged down with trivial
maintenance-type issues rather than operating at the policy
120
development level as the Regulation empowers them to do.”
Hence “sidecar” functioning could pose a substantial threat to the
effective application of existing legislation, serving as a smoke screen
to create the illusion of workplace consultation when nothing of
substance is being discussed.
There is a tendency to push the liability for high-risk work onto small
contractors, who are poorly placed to bear the risk.3, 56, 121
An
example of this is the widespread use of non-English speaking
background (NESB) contract labour to undertake cleaning work,
involving the use of numerous hazardous substances.
29
Small businesses in particular still need to know specifically what they
have to do, and are unlikely to have sufficient funding to access
consultants or other specialist support.68, 122
The mistaken belief that a plea of ignorance might mitigate a penalty

in the event of an incident.123, 124
Fear of documenting hazards has emerged as a formidable setback to the

role of regulations in safeguarding the worker. Without well-documented
hazards, the learning cycle is disconnected and the basis for important
dialogue between management and employees disintegrates. In what
could be construed as a futile attempt to wash managements’ hands of
responsibility, undocumented hazards stifle the potential for continual
improvement and breach the employer’s duty to inform and train.
The proliferation of this myth was highlighted in the case of WorkCover

NSW v Warman International Ltd (2001) in the court of the New South
Wales Industrial Commission. In this case Warman was being prosecuted
over a foundry accident where a worker experienced difficulty
manoeuvring a large ladle of molten metal, which eventually spilt resulting
in third degree burns to the worker’s foot. The defendant pleaded that the
particular operation leading to the accident was not a normal work
practice; therefore a risk assessment had not been performed, so the risk
could not have actually been foreseen. Judge Walton’s counter to this was
that the failure to identify the risk indicated an inherent flaw in their safety
systems.123
When considering whether alternative models fare any better, it is worth

noting the situation in the US where the possibility exists of being
prosecuted for a “wilful violation”. Fear of documenting hazards and
preparing audit reports has led legal US commentators such as Yohay to
advise companies to exercise extreme caution in the wording of their
assessment reports, including not to “undertake audits without the firm
125
intent to remedy hazards that are uncovered in the process.” Along
similar lines, the use of the control test to establish the liability of
30
contractors has also led to the suggestion that principal contractors on
multi-employer worksites supervise sub-contractors at an arm’s length.
Yohay advised principal contractors to distance themselves from any
issues where the impact is restricted to the welfare of the sub-contractors’
employees.126 Gallagher, Underhill and Rimmer point to similar
developments with labour hire companies in Australia, citing Bluff’s
comments that “there is a tendency for client companies to distance
3
themselves to ensure that they’re not seen as direct employers.” Such a
highly legalistic approach to worker safety defies the notion of a “duty of
care” and the moral obligations of employers. This sends a dire warning of
how things could turn should the persuasion argument give way to a more
negative, adversarial approach. It also highlights the problems with the US
approach where ignorance can be used as a defence under their system
in a way that it is not possible under Australian law.
Stringent requirements for contractors in the construction industry in NSW

to produce safety management plans may encourage the adoption of
token systems simply as a means of “ticking the box”. Gallagher, Underhill
and Rimmer reinforce this observation, highlighting the problem of “paper
systems” developing in response to tender requirements imposed by
principal contractors on subcontractors to have their own OHS MS.3
Although Mayhew encourages the incorporation of OHS clauses in
contracts and bank loan conditions to guarantee attention to OHS issues,
this strategy could be subject to abuse.121 It then becomes possible for
larger companies to manipulate small businesses if excessively difficult
OHS contract conditions are used as a reason for withholding payments or
as a means of eliminating them from a tender.
Small businesses will inevitably experience problems regardless of the

style of legislation imposed, as they have fewer resources available and
less infrastructure to carry them.127 Small businesses are reliant on larger
organisations for their livelihood, so an element of survival by whatever
3, 128
means is necessary will always exist. Tapping into the financial
pressure that a principal contractor is able to exert on sub-contractors is
31
likely to be one of the main means of ensuring compliance with the new
NSW OHS regulations, as principal contractors seek to cover themselves
within the law. Whilst this may be effective in increasing OHS awareness
amongst sub-contractors, it will do so in a negative light if the action has
been forced upon them.
One of the biggest tests for the effective application of the Robens’ style
legislation was the explosion at Esso’s Longford gas plant in 1998 that
killed two people, injured eight others and left Melbourne without gas for
two and a half weeks. Esso was a self-insurer, and in order to qualify they
had to pass the initial assessment stage of SafetyMAP, which notably did
not include self-auditing requirements. Even though there was a
requirement in element 6.1.1 of SafetyMAP to identify hazards and assess
the risks of work processes, the auditors had overlooked the fact that a
systematic hazard and operability study of the plant had not been
performed, nor did they pick up the hazard of cold metal embrittlement,
which lead to the critical failure of one of the heat exchangers. In the Royal
Commission that followed, many problems within Esso were uncovered,
including communication failures, downsizing and the subsequent
relocation of available expertise away from Longford, lack of a reporting
culture and inadequate risk assessment. Furthermore, the Victorian
WorkCover Authority had failed to detect problems on the site prior to the
event.9, 129, 130
Clearly the existing legislative framework is unable to prevent disasters of

such an intricate nature in high-risk industries. With the ever-increasing
complexity of industries and technology, the onus to do the right thing
must come from within the organisation itself, and must primarily come
from senior management.
In summary, whilst in theory the Robens’ style legislation is progressive

and should present the way forward, to be effective in practice the
following conditions would appear to provide the most favourable climate
for its success:
32
supportive regulations or codes of practice/standards, where primary
legislation does not provide the necessary details of the processes
involved to achieve OHS aims;
sufficient funding of regulatory bodies to enable greater application of

informal advice for workplace improvements and the time to follow up
such requests;
the formation of strong links between regulatory authorities and

industry that enable organisations to approach them for help and
guidance without fear of prosecution;
dissemination of legal precedents that encourage organisations to

document hazards in the workplace without fear of self-incrimination;
high level support for small businesses from regulatory bodies that is
either freely available or for a minimal fee;
the existence of an appropriate safety culture in organisations that

promotes a consultative environment characterised by open,
forthright communication and meaningful dialogue;
access to trade union support where necessary; and
management and line supervisors that are seen to be accountable for

OHS and are committed to a genuine employer-employee
partnership.
The factors conducive to the effective application of the Robens’ model will
be subject to funding constraints, political trends and market forces; just as
organisations will be driven by the desire for self-protection and economic
survival. Realistically, performance-based legislation can only ever be
expected to have limited success in the prevention of workplace incidents,
especially given the dynamic and complex nature of hazards present in
the workplace today. Despite these limitations, the law will always have an
important role to play in maintaining social justice in the workplace,
educating employers as to the standards that are expected and visibly
33
demonstrating serious consequences for failure to use every reasonably
practicable means to protect worker’s safety and health. To this end, a
persuasive approach is more desirable, although it is likely to take some
time and fine-tuning before this model will flourish.
1.2.6 Incentives for Change
It appears that the incidents that have the most impact are not necessarily
the ones that cause the most death or disability, but the ones that cause
the most inconvenience or have high emotional impact. For example, the
public’s attention was certainly captured when the disruption to
Melbourne’s gas supply after the Longford explosion resulted in cold
showers for two and a half weeks.131 Other examples are those that create
an indelible memory, such as the images of the Piper Alpha platform
burning, which was well publicised and widely distributed for training
purposes. Society seems to have become desensitised to the statistics on
OHS that are generated each year such as those provided below.
The following statistics on the cost of OHS failures are made available
from State Workers Compensation agencies and NOHSC.132 In 2001,
there were 319 compensated fatalities (287 males, 30 females) in
Australia. A further 71 compensated fatalities occurred on work related
journeys. There were 142,700 new workers compensation cases reported
(99,671 males, 42,799 females). Almost three quarters of new
compensated cases occur in the Manufacturing, the Wholesale and Retail
Trades, Construction, Transport, Agriculture and Health Care industries.
In 2001, there were 1.5 million working weeks lost by new cases requiring
workers compensation. The average duration of case was ten weeks; the
average cost of a claim was ten thousand dollars. Other costs (new staff,
training, lost orders, reduced production, increased sickness and welfare
payments) can increase these costs, to ten to fifteen billion dollars a year.
This list is not meant to be exhaustive - other costs also exist, including
the impact of illness on morale, job satisfaction and worker loyalty. While
difficult to measure, such intangibles can have a profound effect on
productivity.133 In all, the cost of work-related injury and disease to the
34
Australian employer, worker and community is conservatively estimated at
around 40 billion dollars a year, and this figure could be doubled if the cost
of pain, suffering and early death were to be included.134
Despite quantifying the problem to some extent, whilst ever these statistics
appear to be tolerated within society, they are unlikely to provide impetus
for change. These figures do, however, capture quite clearly the limits of
the legislation as a means of protecting the workers. As Hopkins explains,
whilst breaches of duty of care typically rely on harm being caused to
demonstrate an offence, the law can only provide a reactive tool, even
though the intention is one of prevention.97, 98
Bottomley cites the following factors that encourage corporations to take

up a proactive approach to OHS: 6
fear of loss of credibility and reputation;
fear of business interruption and the resulting loss of consumer/

customer confidence;
fear of penalties;
desire to reduce compensation costs; and
a perceived moral/ethical duty to comply with OHS regulations.
Hopkins contests that the drive for employers to reduce workers’

compensation costs can only provide a limited incentive to embrace safe
work practices, for example where a change to safer technology would
involve greater expense than the potential compensation payouts. Along
the same lines runs the argument that fines and penalties provide only a
limited deterrence factor especially if they are not publicised.22, 97
Relatively small penalties can increase the attractiveness of taking risks

with workers’ safety and health if the perceived risk of being caught is
minimal. This has led some authors to suggest that the larger penalties
associated with common law damages claims would provide much greater
45, 97
enticement for organisations to take preventive OHS measures.
35
However, this could be counterproductive as the employer can insure
against common law liability. As premiums increase with additional claims,
the resulting coping strategies are likely to be associated with more
aggressive claims management and information suppression.135, 136 In fact
rather than being a preventive measure, the fear of common law damages
has lead to proliferation of contracts that require ever increasing amounts
of insurance coverage, which to some extent could encourage dubious
litigation activity.
The fear of personal prosecution does strike a chord of vulnerability and

may provide a powerful incentive for the prevention of workplace injuries
and illnesses. In NSW, the opportunity to harness the high level of
motivation arising from the fear of personal exposure to liability has been
limited to cases where it can be shown that: 67
the person was concerned in the management of the corporation,

and that
they were in a position to influence the conduct of the corporation in

relation to the offence.
Typically these provisions have been used to effect in smaller firms where
the directors and managers are more involved with the daily running of the
business. Large corporations have so far remained relatively immune to
prosecution, protected by the layers within the management hierarchy.67,
137
Despite the relative failure of these provisions to target larger

organisations, Tooma cites the case of Batty v. C I & D Industries and
Grigor [1995] NSWIRC 226, where the director of a concrete fabrication
firm was personally fined 20 thousand dollars after a worker lost his arm in
an unguarded agitator. This is not an unsubstantial sum, and highlights the
importance of being able to demonstrate due diligence as a legitimate
defence.67
36
In 2005 in Newcastle Wallsend Coal Company and others v. McMartin
[2005] NSWIRComm31, two corporations were fined in the order of one
million dollars and two managers and a surveyor were convicted and
personally fined between 30 and 42 thousand dollars.138 In this case,
which occurred in November 1996, miners accidentally broke into an
abandoned underground mine that had been flooded. The resulting inrush
of water killed four miners. The plans that had been relied upon were
inaccurate and it turned out that the location of the abandoned mine was
100 metres closer than was anticipated. Even though there was no intent
to harm these workers, the courts found the mine managers and surveyors
to be culpable and that, in effect, they should have known better.139 In
Newcastle Wallsend Coal Company and other v. McMartin (no 2) [2007]
NSWIRComm 125, it was noted that the corporations offered a plea
bargain of guilty in exchange for dropping the personal charges against
the mine managers and the surveyor.140 This was unsuccessful, and sent
a very strong message to the community and the mining industry. How
effective this was a means of deterrence was an issue of some
considerable debate, yet the need for more preventive and proactive
measures to protect the community from such disasters was again
highlighted.42 Had all due diligence been applied in the above case, it is
unlikely that inaccurate plans would have been used in the first instance.
WorkCover NSW and Tooma offer the following advice on what actually
constitutes due diligence: 67, 141
awareness of relevant OHS legislation, standards and codes of

practice;
a safe system of work that manages hazards and controls the OHS
risks identified in the workplace;
a system that is consistent with industry standards and practice;
the provision of on-going OHS training and instruction to all

employees;
37
competent supervision;
open communication with employees about potential hazards to

health and safety;
provision of adequate time and resources to support an OHS

program;
the timely reporting of safety or health concerns to the board or top

level management;
prompt responses by the board or top level management to any

indications of system failure; and
the regular review and monitoring of the safety program in place.
In the case of Inspector Christensen v Harnischfeger of Australia Pty Ltd

trading as Minepro Services AND the labour hire company Zelbarry
International Pty Ltd, Judge Haylen stressed the importance of not only
having a safe system of work, but also ensuring effective auditing of the
system. In this instance, the jig being used by a worker to weld a band on
a bucket for open cut mining failed, striking him on the head and fracturing
his skull. Zelbarry, a labour hire agency, had supplied the worker. In
response to Harnischfeger, Judge Haylen made the following comments:
“the provision of a safe system of work is of little or no value if the defendant did not
take effective steps to obtain compliance.”
As for Zelbarry, Judge Haylen rebuked them for having relied on

Harnischfeger’s system of work without undertaking their own risk
analysis, or checking Harnischfeger’s OHS management system for
adequacy.123
In conclusion to the discussion on the development of OHS legislation, it is

evident that fear of personal prosecution for directors and managers
provides one of the greatest sources of motivation for corporations to
38
undertake preventive and proactive OHS activities, but management by
fear is not ideal, nor desirable. Replacing this fear with knowledge,
competence and commitment is far more preferable.
The means of demonstrating due diligence embodies strategies that have

true potential for making a difference to OHS in the workplace. Whilst
performance based legislation will be inherently limited by constraints of
economics, politics, market forces and the rapid pace of technological
change, it provides employers with the direction that is desired and
advocates fundamental concepts such as a neighbourly “duty of care” and
a “duty to consult”. These concepts promote the dignity and respect of
workers, as well as training industry to accept responsibility for the risks
and hazards that they generate.
In the course of the discussion of the development of OHS legislation and

the effectiveness of the Robens’ model, gaps in the current level of
support for the existing style of legislation are clear. Despite the great
opposition to the adoption of a formal systems approach in Australia,
similar to the internal control model in Scandinavia, systematic OHS
management can offer an ideal level of backing for moves towards self-
regulation.
An assessment tool that covered the core requirements of the relevant

OHS standards could serve as a valuable means of demonstrating due
diligence whilst actively promoting awareness of management’s obligation
to take every reasonable precaution to ensure the protection of employees
and others in the workplace.141 Hence the need for an assessment tool
clearly exists, especially one that could provide benchmarking within
organisations as well as across the various industry sectors.
39
2. STRATEGIES TO IMPROVE OCCUPATIONAL
HEALTH AND SAFETY
Whilst the law and punitive measures clearly have their place, many
theorists have exposed the limitations of punishment as a means of
behaviour modification.142-144 A number of difficulties associated with
resorting to legislation to protect the health and safety of workers are
highlighted below:
For punishment to be effective, it must consistently and openly

enforced.142-145 The ability to administer punishment consistently is
related to the frequency of violations. If non-compliance is
widespread, it is often only the worst cases that are addressed. In
such instances, it is almost impossible to achieve consistent
enforcement on a large scale. This leads to a further problem
referred to by Geller as “perceived inconsistency”, which he aptly
describes as the “root of mistrust and lowered credibility”.146
Penalties set by regulatory authorities need to be consistent with

community expectations and high enough to deter inappropriate
behaviour.147 However, organisations may view harsher penalties as
an expedient means of generating revenue. This presents a
significant dilemma if the relationship between industry and the
enforcing authority is to be protected. In addition to damaging
relationships, punishment creates a defensive environment,
142
discouraging cooperation and problem-solving.
Should an adversarial climate develop, there is the risk of reinforcing

the wrong type of behaviour. Under these circumstances, more may
be learnt about avoiding litigation through the use of cautiously
worded reports and the restrained documentation of hazards than
actually promoting a safe and healthy workplace.125, 126, 142
Geller,
citing Skinner’s work in behavioural science, refers to this response
as “counter control”. Counter control is explained as a reaction to “a
40
perceived loss of control or freedom … most likely when negative
consequence contingency is implemented.” 146
Overly stringent OHS requirements can encourage the proliferation

of “paper systems” and token compliance.3 This passive-aggressive
response may again develop due to the apparent loss of situational
control.148 Like Robens before him, Geller referred to this minimal
response as “apathy”, and suggested that it also leads to a decline in
employee involvement.149
It is more productive to direct funds to OHS improvements than to

pay fines, although it is acknowledged that some businesses would
not voluntarily allocate resources to OHS issues without sufficient
external pressure.50 This pressure is strongest for small businesses
where fines can have a significant impact on cash flow.121
As many occupational illnesses having long latency periods, the

need for remedial action may become apparent only after damaging
exposures or practices have occurred. The long latency periods of
such diseases also makes it difficult to associate the causal
exposures with the negative outcomes, which may entrench unsafe
work practices.150 In such situations the importance of early
intervention is self-evident.
Clearly, the successful application of Robens’ style legislation also relies

heavily on industry initiatives to assess workplace risks and implement
control measures if a positive, co-operative climate is to be fostered rather
than an antagonistic one. The safety of workers cannot be guaranteed by
relying on legislation alone, and preventive techniques need to be tailored
to individual workplaces and circumstances. In order to achieve these
aims industry must have access to specialist knowledge or OHS guidance
material.122 Without supporting knowledge and the availability of self-help
tools to facilitate the implementation of proactive measures, moves to self-
regulation will be fraught with difficulty. As Deming pointed out: 41
41
“Support of top management is not enough … They must know what it is that they
are committed to – that is, what they must do.”
The following discussion will provide a broad overview of the diverse

strategies that organisations have available to build prevention into their
businesses and the dominant paradigms that have influenced the
development of these techniques. For the benefit of systematic analysis,
the workplace will be broken down into three main elements that when
brought together uniquely define the profile of the organisation.151 Without
any one of these three elements the organisation would not exist:
the people to whom a duty of care is owed;
the hardware and operating environment that people use or convert

in order to produce goods and/or services; and
the management strategies and methodology employed to organise

and direct the transformation of resources into organisational
outputs.
The organisation also exists within an external environment that impacts

on the nature of the organisation, but is sometimes beyond its control.94,
151
Hazards in the workplace may emerge from within, or from changes to,
any of these three elements; at the interfaces between these elements; or
at the boundaries with the external environment. The defences invoked to
address these hazards will be examined in this thesis, together with their
relative strengths and weaknesses.152
42
Figure 1: The Organisation
External
Environment
Legislations
People
Social Culture
Norms & Values
Management
Strategies & Methodology Economic
Physical Climate
climate
Hardware & Operating Environment
43
2.1 Understanding the Context of Workplace
Hazards
A recurring theme in the literature examining prevention and control

strategies has been the philosophical argument surrounding the safe place
versus safe person approach. Interestingly, this argument also represents
a great geographical divide – with the proponents for the safe place
strategies often being located in the UK, Europe and Australia, whilst the
US has embraced the safe person approach. 10, 28, 63, 86, 117, 142, 153
Although there are staunch differences in viewpoints, there have been

some recent moves to appreciate the merits of the alternative perspective,
especially from the US.60, 154-156 For example, Krause notes that: 155
“Many managers look to address behavior only when facility issues have been
addressed …. The behavioral component and facilities component interact in
such a way that one must accomplish both in order to reach the desired
outcome.”
Studies of the DuPont facilities - well known for their behavioural safety
focus and very low injury rates, show that they do not rely entirely on
behavioural based safety (BBS) techniques, but also dedicate
considerable effort to eliminating hazards at their source.102 However, the
proponents of the safe place paradigm are less likely to be enthusiastic
about promoting BBS unless hazards within the operating environment
have already been addressed.60, 156 This seems intuitively logical since it
would be unreasonable to expect to keep workers safe if they were
constantly exposed to dangerous equipment, poor environmental
conditions or harmful substances. Heinrich, Petersen and Roos make the
following important observation: 157
“The most ardent supporters of the belief that worker-failure accident causes are
predominant are, nevertheless, firmly convinced that mechanical guarding and
correction of mechanical and physical hazards are fundamental and first
requirements of a complete safety program.”
44
These comments represent a significant refinement to Heinrich’s earlier
work, which justified focusing primarily on unsafe acts with: “Common
sense dictates that the preventive effort be first toward the thing most
63
easily and quickly corrected.” It is clear to see how appealing this
statement would be to employers, offering the potential for quick returns
on improved safety performance for little capital investment.
Upon examination, it becomes evident that underpinning these juxtaposed

paradigms are fundamental differences in the models for injury and illness
causation, and the weighting given to the influence of the various types of
hazards encountered in the workplace. These models, mental or
otherwise, will influence the selection of preventive strategies, and failure
to accurately account for all significant hazards in the workplace can only
ever result in limited success.158
To illustrate this point, Heinrich’s domino theory released in 1931 was

presented as a straight chain of causation and assumed that control of the
final “unsafe act” would have the most impact on the prevention of
workplace accidents. The model suggested that the following sequence of
factors culminated in an injury: 63
social environment;
fault of person;
unsafe act and/or mechanical or physical hazard;
the accident; and
the injury.
As the unsafe act and/or unsafe condition were viewed as immediate

precursors to the accident, removing this important factor was considered
to guarantee accident prevention. Invoking a vivid analogy with falling
dominoes to reinforce his theory, it was argued that the tipping of factors
45
further upstream would have no impact on the final outcome if the unsafe
act/unsafe condition factor had been eliminated (removal of the domino).
However, this model was only linear because the unsafe act/unsafe
condition factors were combined together. Even though the importance of
both safe person and safe place factors were recognised, the emphasis
was placed primarily on the unsafe act. As noted earlier, this derived from
the belief that changing workers’ behaviour was the easiest and most
expedient means of effecting change.63 Heinrich’s domino theory model
was attractive in its simplicity. The convincing parallel with the dominoes,
an experience that most people could relate to, also served as a
persuasive, visual marketing tool.
Heinrich’s model used some disparaging terminology - such as “fault of

person”. The word fault is easily associated with blame and so the model
rendered itself susceptible to criticism on the basis that it could encourage
employers to relinquish their duty to provide a safe workplace, and transfer
the responsibility for safety solely to the worker.102, 159
Although “unsafe
act” prevention strategies stemming from Heinrich’s work have been
heavily criticised on account of this, apportioning blame to workers was
not Heinrich’s original intention. Heinrich vehemently rebuked the shifting
of responsibility to the worker with the following: “the responsibility lies first
of all with the employer.” Heinrich added that: “Management’s
responsibility for controlling unsafe acts exists chiefly because these
unsafe acts occur in the course of employment that management creates
63
and then directs.” It appears that the importance of these sentiments
were lost to the attention centred on the domino theory.
Heinrich’s model was modified by Bird to emphasise management’s input

into the sequence of events as shown below: 157
lack of control - management;
basic causes - origins;
immediate causes – symptoms;
46
accident – contact; and
injury/damage loss.
Bird opened up Heinrich’s model by using far less restrictive labels and
distinguished between underlying causes and the more superficial
symptoms that ultimately manifest in accidents. This distinction between
proximate and underlying causes was a significant departure from
Heinrich’s model because it promoted the concept of multiple causes
rather than a single chain of events.
Peterson sums up multiple causation theory with the following: 24
“The theory of multiple causation states that these factors combine together in a
random fashion, causing accidents … When we look only deep enough to find the
act or condition, we deal only at a symptomatic level. This act or condition may be
the “proximate cause”, but invariably it is not the “root cause”. To effect
permanent change, we must deal with the root causes of accidents.”
In Reason’s model, organisational factors are depicted as the underlying

causes of “error provoking workplace conditions”, which in turn are
portrayed as the underlying causes of unsafe acts.152 Petersen supports
Reason’s model noting, “Root causes often relate to the management
system. They may be due to management’s policies and procedures,
34
supervision and its effectiveness, training etc.” Both of these extend
Bird’s earlier work by acknowledging the importance of management and
organisational factors.
Whilst it is beyond the scope of this literature review to examine all models
of accident causation, it is useful to highlight some fundamental
differences between the simple and more complex models.
In stark contrast to linear models originating from Heinrich’s domino theory

are the branched models, such as those that invoke decision Fault Trees,
Management Oversight and Risk Tree (MORT) or Human Factors
analysis.160-162 Some of these models can become quite intricate and Kletz
47
makes the sensible observation that it is important not to become too
involved or distracted with the actual modelling, and that models should
only be used where they are considered to assist the understanding of the
events giving rise to potential or actual accidents.163
There are also the “ball and stick” human factor models. Elwyn Edwards’
Software (S), Hardware (H), Environment (E) and Liveware (L) - (SHEL)
model provides another systematic, analytical tool for incident
investigations and emerged from the aviation industry in 1972. The model
is three-dimensional and examines the potential for accidents at the
interface of the liveware (human) element with each of the other
components: L-S, L-H, L-E and L-L. The liveware are the operators or
players within the system, and the model considers their skills, limitations,
physical and psychological status. This model is extremely comprehensive
and has the benefit of not only considering the system when it is static, but
also when there are states of flux.151
It can be seen that there are numerous models of accident causation

available, differentiated by the focus of their analysis and the “stop rule”
applied to decide when to cease examining causes.164 An overview of the
various models suggests that selection may be influenced by:
a perception of what hazards are within the sphere of influence; or
what factors are most easily controlled; or
the conditions likely to have the greatest final impact on safety

performance.
Safe place theorists prefer to analyse those things that are more
predictable and hence easier to control, avoiding the complexities of
human behaviour.163 Instead of concentrating on the unsafe act, safe
place strategists consider the potential for accidents to occur by
conducting a comprehensive risk assessment of the workplace, then
applying the hierarchy of controls to eliminate hazards or risks from the
source wherever possible.159 As a counter to this, Sulzer-Azaroff contests
48
that examination of accident data reveals that injuries continue to occur
even when the hazards associated with the working environment have
been carefully analysed and addressed.145 Safe person proponents
dissect incidents into the unsafe action and the resulting injury and focus
on eliminating the unsafe action as a means of prevention, seeing humans
as the weak link in the chain of causation.63 Alternatively, some human
factors models such as Ramsey’s, examine options when an individual is
confronted with a hazardous situation including the choice whether or not
to avoid the hazard and the ability to be able to do so.162
Rasmussen questions the adequacy of existing accident causation

models, arguing that despite the numerous models available, accidents
continue to happen.57 Benner, after examination of fourteen different
models and seventeen accident investigation techniques, suggests that
many are contradictory and so they cannot all be correct.165 Rasmussen
explains this with the insightful observation that analysts have the
tendency to find what they are looking for.164 Whilst this may be the case,
there is still considerable merit to be extracted from various aspects of
many of these models, even if they do not address the entire hazard
landscape when applied independently.
Due to moves towards a more dynamic, rapidly changing society, in stark

contrast to the era of Fordism characterised by stable employment and
industry that ended in the 1980’s, Rasmussen asserts that it is
increasingly difficult to find a single, comprehensive model that takes all
the socio-technical factors into account.14, 57
In light of such obstacles,
Rasmussen advocates a very practical approach to “navigating the safety
space” with the following: 57, 166
“ … making the boundaries explicit and known and by giving opportunities to

develop coping skills at boundaries”
Translating this method to the application of prevention and control

strategies, the concept of the safe organisation is presented to bring
together the merits of both the “safe person” and “safe place” paradigms,
49
as well as acknowledging the importance of management strategies,
systems and methodology in the protection of worker safety and health. As
part of this paradigm shift, OHS MS frameworks have the benefit of being
able to provide the overall co-ordination of prevention and control
strategies at the boundaries of safe operation. The identification of
hazards, and corresponding prevention and control measures therefore
provides the foundation and “sizing criteria” for a successful OHS MS
framework.167 In order to develop such a framework, an adaptation of
Elwyn Edwards’ SHEL model provides a useful tool for guided, systematic
hazard identification, that also clarifies the context of workplace hazards.29,
151
This technique will be used to form the basis of an OHS MS framework
that will allow the hazard profile of an organisation to be assessed to
ensure that appropriate prevention and control strategies have been
invoked. Finally, a number of the strategies will be classified into four
areas: planning; implementation; measurement or review; to illustrate
where they are located on the continual improvement cycle.2, 41
50
Figure 2: Examples of Possible Hazard Profiles for Different
Organisations
Manufacturing
Industry f Highly hazardous
infrastructure
P f Few operators
f Numerous
H procedures
Health Care
f Large staff
numbers
f High stress
P
f Stringent
procedures
H M f Biological hazards
f Ergonomic hazards
Public Service
f Large staff
numbers
P f Large
bureaucracy
f Low hazard
infrastructure
H M f Ergonomic
hazards
Key: P = People
H = Hardware and Operating Environment
M = Management Strategies and Methodology
51
2.2 Focusing on the Hardware and Operating
Environment
The hardware and operating environment component of the organisation

will be defined to include all the hardware, infrastructure, equipment, tools,
material resources, live (excluding human) resources, and the physical
environment that people either use or convert to produce goods or
services.151 Examples include process machinery; vehicles; buildings;
furniture; electrical goods; stationery; computers; telecommunications;
audio-visual equipment; livestock; land; plants; personal protective
equipment; hazardous substances and other raw materials.168
Hazards may be generated from within the hardware and operating

environment or as a result of its interaction with people; management
strategies and methodology; and/or the external environment.28, 40, 151
Figure 3: Context of Workplace Hazards – Focusing on the Hardware

& Operating Environment
People
Interfaces
Hardware & Management
Operating Strategies &
Environment Methodology
52
The potential for harm from within the hardware and operating
environment may involve: mechanical failures; faulty equipment; process
design failures; dangerous atmospheres or entrapment hazards from
confined spaces; dangerous goods such as flammable or combustible
materials and corrosive liquids; sources of ignition; unsafe storage such as
dangerously stacked pallets or blocked exits and walkways; electrical
hazards including static electricity, electrical fires and electrocution;
radiation; working at heights; hazardous substances such as toxic metals,
gases and vapours, some of which may pose a threat to reproduction;
biohazards such as illnesses contracted from livestock; and moving
vehicles, including forklifts.36, 69, 158, 169-178
On the interface between the hardware and operating environment and

people lie ergonomic hazards such as noise; vibration; lighting/glare;
unguarded machinery such as exposed pinch points; workstation design;
slippery surfaces; manual handling issues and poor ammenities.69, 179-183
On the interface between the hardware and operating environment and

management strategies and methodology are those hazards related to
poor decisions concerning the operation of equipment or facilities, for
example – failure to test protective equipment and alarms; failure to
maintain equipment in good working order when business closure is a real
possibility; or where shortcuts have been taken with the application of
equipment or processes to ensure continuity of output or to increase
production.93, 184, 185
Hazards originating from interactions between the external physical

environment and the hardware and operating environment may be related
to climate, for example: heat and humidity causing heat stress; exposure
to the cold; or ultra violet (UV) radiation in the case of outdoor workers.186,
187
Mechanical failure may also result from exposure of equipment to the
elements, for example in the case of the brittle failure, as was the case in
the Longford explosion.188
53
Other influences from the external environment may include a depressed
economic climate, and the resulting pressure this may have on equipment
selection, the frequency of maintenance or the ability to purchase
adequate protective equipment.3, 128 The stringency of regulations in force
may also affect the standard to which a plant or facility has been built, and
the type of plant or equipment selected. This effect may be more obvious
in businesses operating over several jurisdictions.
Finally, hazards may result from changes to the hardware and operating
environment such as when new equipment is installed. Failure to carefully
consider the full impact of modifications can have a disastrous impact on
an organisation, as was the case with Flixborough.88, 151 Storms and other
natural disasters or even terrorism may create changes to the hardware
and operating environment, resulting in emergency situations.189, 190
Table 1: Examples of Potential Hazards Relating to the Hardware and

Operating Environment
Mechanical Failures Hazardous Substances
Process Design Failures Unstable Storage - Fall Hazards
Faulty Equipment/Tools Unsafe Storage - Trip Hazards
Electrocution Blocked Exits/ Access ways
Static Electricity Manual Handling
Sources of Ignition Unguarded Machinery
Confined Spaces Slippery Surfaces
Working at Heights Noise/Vibration
Dangerous Goods Lighting/ Glare
Poor Ergonomic Design UV Exposure
Poor Amenities Heat/ Cold/ Humidity
Failure to Test Alarms/ Protective Biohazards

Equipment
Failure to Maintain Equipment Reproductive Hazards
High Levels of Competition Financial Restrictions on

Equipment Selection/ Maintenance
54
Table 2: Examples of Potential Hazards Generated as a Result of
Changes to the Hardware and Operating Environment
Fire Mechanical Failure
Explosion Structural Collapse
Loss of Containment Vapour Cloud
Flooding Water Damage
2.2.1 Safe Place Strategies
Safe place strategies focus on creating an environment that is free from

harm -ideally this would translate into an “inherently safe” workplace.159
Safe place strategists achieve this aim through the application of risk
management philosophy, primarily by conducting risk assessments to
determine those factors that have the greatest potential to cause illness
and injury.23, 191 Safe place strategies may be implemented at any of the
planning, implementation, measurement and review phases of the Deming
“plan-do-check-act” cycle, and are most effective when all four stages
have been considered.41 Safe place strategies deal with the existing
physical environment and are based on best practice, reasonable
forseeability and reasonable practicability.
Risk Assessment:
Risk assessment is defined here to include three stages:192-194
(i) hazard identification;
(ii) an assessment of the level of risk - taking into account the likelihood
that the hazard will cause harm, the degree of exposure and the
severity of potential harm caused; and
(iii) the application of control measures to minimise the risk if the

assessment suggests that the risk is a problem.
55
The “hierarchy of controls” is typically used to describe the order of
preference for the selection of control measures as follows:159, 195, 196
Elimination - the permanent removal of a hazard is the most

desirable control method. Examples include the phasing out of lead
in petrol and paints; and the staged restrictions on the use of
asbestos, now prohibited in Australia since 2003.
Substitution - replacing a known hazard with a less harmful

substance or using an alternative method that involves a lower level
of risk. Examples include the handling of toxic substances as solid
briquettes rather than as powders or liquids to reduce the potential
for spillage and dust; and the use of alcohol to replace mercury in
thermometers.
Engineering Controls (including Isolation) – may involve isolating the

person from the hazard by some form of barrier or by “engineering
out” the degree of exposure. Examples include the use of machine
guarding to prevent fingers being caught in roller pinch-points; and
the use of local exhaust ventilation to extract fumes during welding.
Administrative controls - limit exposure to the hazardous condition

through specific controls such as safe work methods, warning signs,
and restricted entry; and/or generic controls such as housekeeping
rules, permit to work systems, scheduling of activities to reduce the
potential for exposure, and job rotation.
Personal Protective Equipment (PPE) – is worn to provide a

protective barrier between the person and the hazard and is a means
of last resort. The weakness of this control method is that it relies on
the equipment being correctly specified and worn as required. It is
doubtful that the enforcement of PPE will be readily accepted if the
PPE is uncomfortable or cumbersome to wear, and in some cases
has created additional hazards such as heat stress.186
56
PPE may be useful as a “stop gap” measure whilst engineering
control or substitution methods are being evaluated; in emergency
situations; for specialist jobs such as asbestos removal; and for work
involving variable locations where existing control measures may be
unknown or unreliable.196 Examples include head and hearing
protection, safety glasses, gloves, safety boots, breathing apparatus
and fall protection equipment.
Although this simplified, three-step risk assessment methodology is

commonly referred to in general practice and OHS regulations, it only
represents part of the more rigorous risk management process described
below: 29, 69 158, 192
(i) Establishing the Risk Context: The organisation should be

considered as a whole, legal requirements identified, criteria
developed against which the risk may be evaluated, and the method
of analysis established. This anticipatory step is frequently
overlooked, with risk assessments often only focusing on a narrow
section of the overall system.197
(ii) Identifying the Risk: Risk identification should consider both normal
and abnormal situations, start-ups/shut-downs, shift change-overs,
routine and non-routine maintenance and modifications to the normal
operating environment.198 For this reason, a single workplace
inspection is unlikely to account for all the sources of potential
hazards as it only represents the situation at a given point in time.
However, this may serve as a useful starting point.158, 168
Reason stresses the importance of considering the maintenance

function during the risk assessment process by highlighting the
number of maintenance failures that have been implicated in major
disasters - including Flixborough, Piper Alpha and Bhopal.199
Included amongst the multiple factors contributing to the Bhopal
tragedy was a flare tower that was disconnected, a refrigeration plant
that was off-line, and fouled pipe work and valves.93, 199 Reason also
57
points out the opportunity for error in the assembly of installations
which may be overlooked. To illustrate this point, Reason takes the
example of assembling a bolt with eight nuts. If the objective is to
assemble the bolt in a specific order, there are over 40,000 ways
(eight factorial) that the nuts could be reconfigured, yet there is only
one way to undo the arrangement - by simply sliding each nut off the
bolt. 199
The hazard identification process may draw information from the

following sources:168, 191, 195, 200
incident/injury records;
workplace inspections;
job task analysis;
specialist advice or audits including the use of ergonomists and

occupational hygienists;
formal hazard analysis including fault trees analysis, failure

mode and effect analysis (FMEA), probability analysis,
simulation and computer modelling;192, 200, 201
deviation analysis such as hazard and operability studies

(HAZOP) where key words such as “too high“ or “too low” are
used to systematically guide a consideration of each section of
the process for potentially dangerous occurrences;201, 202
objective peer review – often used where only a limited number

of people have the required specialist knowledge to be able to
foresee process or design problems; 203 and
informal methods such as brainstorming, tool box talks,

observation, checklist surveys and walk-arounds.168, 204
(iii) Analysing the Risks: At this stage evidence or information is collected

on the nature and consequences of the risk, the means by which it
58
may cause harm and the magnitude of the risk. Codes of practice,
standards, material safety data sheets (MSDS), exposure limits and
regulations may need to be considered at this point.191 An evaluation
of the effectiveness of existing control measures is also desirable at
this time, although Main suggests that in the first instance it may be
more useful to consider the hazards as if no control measures were
in place to get a better appreciation of the full spectrum of risk
possibilities. Monitoring may be required to determine the level of
exposure where exposure standards exist, for example with noise,
radiation or hazardous substances. 158, 191
Risks may be evaluated subjectively with qualitative risk assessment

using descriptors to capture both the severity and likelihood of an
event in order to determine a ranking position on a risk matrix;
numerically with quantitative risk assessment to denote the
probability of an adverse event occurring; or by using a combination
of qualitative and quantitative methods.192-194
The strength of qualitative risk assessment lies in its simplicity and

expediency for screening exercises, although inconsistencies may be
encountered whenever the severity of the outcome includes the
possibility of a fatality.192, 205
Cross argues that workplace fatalities
are not within the realm of common experience and so the likelihood
of these events may be underestimated. Cross recommends that
such activities should be subject to more detailed assessments.158 As
a counter to this, Underwood, Winder and Wyatt suggest that when a
fatality is possible, for example in the case of electrical hazards, the
risk may be overestimated by a ranking order of high or extreme,
leading to unnecessary restrictions on work practices.127 However, it
is less likely that there will be a problem when a suitably qualified
electrician is performing the role. In this example the use of qualified
personnel is a reasonable control, and the residual risk with this
control in place is much lower than if no electricians where available
to perform the task. This highlights the potential for inconsistency
59
depending on the sophistication of the matrix model used and the
individual assessors involved.206 Cross contends that it is not so
much the ranking order that is important, but the increased level of
understanding of the risk that has been gained through the
discussions.158 Whilst this may be a valid point, it may be of little
practical assistance to those trying to prioritise the allocation of
scarce resources.
Techniques employed in quantitative risk assessment are frequently

derived from variations of fault tree analysis. Fault tree analysis
clarifies the relationship between adverse events through the use of
“and/or” gate logic, which also assists in calculating the probability of
events.192 The value of quantitative risk assessment is highly
dependent on the reliability of the estimations, the degree of
uncertainty in the predictions and the validity of the modelling
invoked.158, 192, 207
Semi-quantitative analysis involves assigning a weighting or value to

the qualitative descriptors. Caution is necessary when using semi-
quantitative techniques when there are extremes in either the
severity or likelihood, as the weightings may misrepresent the relative
significance of events, or suggest a level of precision in the analysis
that does not actually exist.192
(iv) Evaluating the Risks. This stage involves comparing the level of risk
determined to the acceptance criteria previously established.
Regulations require that risks be reduced to a level that is as low as
reasonably practicable (ALARP).192 ‘Reasonably practicable” requires
a sensible balancing of the magnitude of the risk with the sacrifice
involved to successfully address it, and may necessitate some level
of value judgements. Decisions to accept the risk should consider not
only the organisation itself, but also the tolerability of the risk to other
affected parties.208, 209 Hopkins observes that this decision is fraught
with difficulty, as the question of “acceptability to whom” raises moral
dilemmas and the controversial issue of the value of human life.197, 210
60
The concept of individual versus societal risk should not be
discounted and may provide useful ancillary information in situations
where not only the individual worker is exposed, but also large
numbers of the public.197 Gadd, Keeley and Balmforth highlight the
danger of downplaying the risk of a highly hazardous activity on the
basis that only one individual has been exposed for a short period of
time. Gadd, Keeley and Balmforth go on to explain: 211
“It is not appropriate to divide the time spent on the hazardous activity
between several individuals and estimate the risk on this basis (the ‘salami
slicing’ technique). For example, if any one person is only exposed to the
hazard for a short time, but someone is always exposed, it would give a
misleading picture of the risk to estimate the risk from this hazard by taking
into account the exposure time of each individual.”
Also cautioned against is the failure of organisations to consider

relevant best practice and the inappropriate use of cost benefit
analysis to exaggerate the costs to reduce the attractiveness of a
particular option.211
(v) Risk Treatment. The range of outcomes from this stage of the risk
management process may include the decision to: 212
avoid the risk entirely;
to retain and manage the risk;
outsource the risk; or
to insure to minimise the financial impact when prevention and

control methods have failed.
Examples of outsourcing the risk include the use of contractors and

subcontractors or relocating offshore where the legislation may be
less stringent. Cross points out that subcontractors are often used in
the mistaken belief that organisations can transfer the duty of care
61
owed to their own employees onto the subcontractor. However, the
liability for injury and illness towards an organisation’s own
employees can only be reduced in the rare instances where the
subcontractors have been allocated full site control.158, 195
Where a decision has been made to retain the risk, plans on how this
residual risk will be managed involve the application of the hierarchy
of controls.195 Emergency planning always remains a core
requirement as the residual risks in these instances can never be
addressed entirely.189, 213
With the growing emergence of terrorism,
and the need to deal with the consequences of natural disasters and
other critical unplanned events, the importance of emergency
planning is self evident.195 The need for business continuity planning
to ensure key operational functions are protected and the importance
of having critical incident recovery strategies in place is becoming
more obvious and the subject of increased levels of attention.191
(vi) Monitor and Review: An essential stage of the risk management

process where the effectiveness of the risk reduction strategies
utilised is evaluated. Methods available to complete this stage
include: 158, 191, 214
follow-up workplace inspections;
review of injury and incident data, including trend analysis;
review of near miss reports and investigations;
comparison of occupational hygiene monitoring data to baseline

assessments to check the effectiveness of engineering control
measures;
surveillance audits;
commissioning exercises to ensure that projects have been

delivered as specified before being accepted;
62
audiometry surveillance;
medical surveillance;
exit interviews and review of turn-over rates, and
reporting of results to the directing minds of the organisation or

other overseeing body.
This process is often iterative and may require fine-tuning to obtain

the desired results. Comprehensive reviews enhance the
understanding of the overall processes and encourage continual
improvement.215 Documentation of this step has the added benefit of
providing evidence that due diligence has been exercised.191
Communicating these results also serves to add to the body of
knowledge pertaining to the various hazards identified both inside
and outside the organisation, as well as fostering trust and goodwill
by demonstrating the duty of care and consultation in action.216
2.2.2 The Strengths and Limitations of Safe Place Strategies in

Practice
Safe place strategies underpinned by the risk assessment process forms

the cornerstone of a safety program, ensuring that the workers’ actual
surroundings and facilities are as safe as reasonably practicable.158, 159
Risk assessment can be a detailed, sophisticated process when the full

risk management methodology has been invoked, or it can be applied on a
more informal basis with qualitative risk analysis.205 The need for a
qualitative or quantitative approach (or blend of the two) will be indicated
by the types of hazards that dominate the total hazard profile. For
example, a nuclear plant will clearly need a sophisticated quantitative
approach, whilst this may be unnecessary for a small retailer. One of the
greatest benefits of the risk management approach lies in its flexibility and
adaptability. It is through this fundamental hazard identification stage that
action plans and control strategies can be customised to address the
needs of a particular organisation.
63
Risk assessment strategies can be applied to routine and non-routine
activities or to project specific work, for example in the construction
industry where each new project involves a different scenario with a
unique risk profile.204 However, safe place strategies are likely to be more
successful where there is more information and experience available
regarding the nature of the risks and hazards likely to be encountered.
Other advantages of the safe place approach concern manufacturers and

large-scale organizations. These have the benefit of being able to extract
“economies of scale” from the risk assessment process for example with
the use of generic risk assessments that can be customised for the
individual sites or functions. The tailoring of solutions is much more
arduous for small businesses as they have to prepare “one-off” safety
plans and have fewer resources at their disposal. 23
As far as shortcomings of the risk management process are concerned,

the length and intensity of the technique can sometimes discourage its
use, with some businesses refusing to undertake risk assessments unless
they are deemed to “add value”.205 This is highly subjective, and may not
reflect the requirement for specific risk assessments to be carried out for
all significant risks.2 The term “significant” may be manipulated by the
particular risk matrix method used and the assessors involved.
Furthermore, a risk assessment carried out by one person in isolation
without review or consultation of affected parties should not be considered
a valid application of the risk assessment process.
It is crucial that sufficient time has been allowed to conduct the evaluation
stage to enable the most appropriate solutions to be implemented.197
Where this is not the case, issues may be dealt with superficially on the
basis of expedience, rather than eliminating problems from the source.217
Jensen warns of the problem of focusing on minor, day-to-day issues

when the need to perform risk assessments is mandated, resulting in the
neglect of more important strategic issues.23, 120 This may stem from a lack
of basic problem-solving skills.117 When training needs are identified, it is
64
important not only to ensure personnel are instructed on risk management
methodology, but also in the analytical skills that should accompany it.
This includes the ability to distinguish between actions that provide
temporary relief of the hazardous situation, and the use of more
permanent solutions that address the problem at its source.217
Failure to consider organisational, societal and human factors is another

common pitfall of the risk assessment process, as the process is often
only applied in a narrow context. When estimating societal risk, there is a
tendency to underestimate risks to the general public if an individual
exposure is used as the basis of the risk calculation. This may erroneously
result in the risk been considered negligible when a given individual’s
exposure is only for a short period of time.197, 218
Risk perception is in itself a highly contentious issue as perception by

definition, will vary from individual to individual.219 This can lead to
inconsistency in the risk analysis stage.206 Flemming, Geller and Adams
suggest the following factors influence the perception of risk: 216, 220, 221
what is known about the risk including future implications;
the apparent level of control over the situation;
situational awareness and understanding of outside influences;
the depth of task knowledge;
whether the potential consequences relate to everyday experiences,

require specialist knowledge or are the subject of speculation;
experience and the frequency of previous task performance;
the potential to imagine vivid, gruesome or frightening outcomes; and
personality-dependent risk taking attributes.
Complacency can be very dangerous where the task is routinely

performed - leading to risk habituation. Activities with low level
65
consequences but high levels of frequency are prone to being
underestimated. This phenomenon may be overcome by ensuring the
involvement of objective team members during the risk assessment
stage.216
Kouabenan discusses the effect of the different roles and beliefs that are
brought to the risk assessment process, and how the perception of the risk
target may influence the final evaluation of the control measures applied.
This aspect may be important for organisations involved in transfers of
technology across different cultures, particularly from developed to
developing nations.222
Lack of situational awareness has been implicated in many disasters and

is a critical factor when outside specialists are called in to identify hazards
on a site where they have no prior experience. Expertise on a chemical
plant can take many years to acquire, and every chemical plant is different
in some way. The following example cited by Adams highlights problems
where repair work has been scheduled without considering the impact on
adjoining plant and equipment. In this case, welding was scheduled on a
very long vent line that led into the top of a tank. The place where the
welding was planned was quite a distance from the actual tank and the
welders were unaware that the tank held wastewater contaminated with
hydrocarbons. The hydrocarbon fumes in the pipe work where ignited by
the welding, causing the tank to explode.216 This illustrates the danger of
analysing risks in isolation, a problem that is accentuated when those
assigned to the task lack in-depth understanding of the process.
Risk assessment is therefore most reliable when handling problems of a

predictable nature, or where there is substantial evidence collected to
support assertions. Where uncertainty in quantitative risk assessment
values has been underestimated, the results may proliferate a false sense
of confidence.192
Hopkins also questions the philosophical basis of quantitative risk

assessment, arguing that quantitative risk assessment implies that
66
accidents are inevitable, random events. Another perspective is that all
accidents are preventable and have causes that once understood may be
addressed. Hopkins also suggests that the lure of an elegant solution and
the sense of control they afford may override the desire to investigate and
factor in the unpredictable nature of individuals and the dynamics and
pressures of modern organisations.208 Geller vehemently opposes the
concept that “all accidents are preventable”, considering this to be
fundamentally flawed on the basis of the complexity of human
behaviour.221 It is certainly easier to launch a safety campaign with the
belief that accidents are preventable, although some critics cynically
suggest that this merely allows organisations to transfer blame onto
individual workers.144, 156, 221 It is asserted here that whilst most accidents
are preventable, the degree of difficulty involved ranges from being
relatively straightforward to overwhelming. The suggestion that all
accidents are preventable may be used as a statement of commitment
from organisations, and that in itself does have some merit provided that
the organisation recognises the need to provide the resources that will
allow this to be possible, and the difficulty therein.
One of the greatest drawbacks with risk management methodology is that

its application may unveil long lists of prevention and controls requiring
capital expenditure. Small businesses and other managers with pressing
budgetary constraints may not always welcome this information.3, 122 There
is also the possibility that funds set aside to address safety program
issues may be transferred across to other, seemingly more important
projects. These issues demonstrate the advantage of using a due
diligence plan that is realistic, regularly reviewed, monitored and adhered
to. Such a plan recognises the economic realities of the business world,
acknowledging that with limited funds projects must be carefully prioritised
and planned ahead. In the event of a successful prosecution, a well
maintained due diligence program may serve to reduce the size of the
penalty imposed by the courts, as well as providing a legitimate defence
for directors and other concerned in the management of the corporation.67,
141
67
In summary, safe place strategies offer techniques that strive to ensure
that the existing physical environment is harm-free. They are best applied
when funding is plentiful, resources including time have been allowed for,
and the risks have been assessed by those with the necessary balance of
skills to do so in a spirit of genuine consultation.
68
Table 3: Examples of Safe Place Strategies
Safe Place Strategies
Planning Phase
Risk Assessments: Qualitative eg, Working at Heights; Confined Spaces; Electrical;
Machine Guarding; and Hazardous Substances.
Risk Assessments: Quantitative eg, Mechanical Failure or Process Failure.
Ergonomic Assessment: eg, Noise; Lighting; Manual Handling; and Climate.
Peer Design Reviews/ Deviation Analysis - eg HAZOP
Environmental or Personal Hygiene Monitoring for Initial Assessment Purposes
Emergency Preparedness
Implementation Phase
Application of Risk Control Measures - Elimination/ Substitution/
“Engineering Out”; Barrier Methods and Signage
Preventive Maintenance
Permit to Work Systems - Electrical; Hot Work; Confined Space; Working at Heights
Modification Procedures
Testing of Protective Systems/Equipment
Emergency Evacuation Drills
The Conducting of Larger Scale Environmental or Personal Hygiene Monitoring
Measurement Phase
Housekeeping Inspections/ Plant Inspections
Specialist Audits
Analysis of Results of Environmental & Personal Hygiene Monitoring
Health Surveillance
Review Phase
Evaluation of Existing Risk Control Methods/ Evaluation of Drills
Formal Commissioning Prior to Acceptance of Projects/Modifications
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2.3 Focusing on People
The people component of the organisation will be defined to include all

those to whom a duty of care is owed – the employees; members of the
public or visitors utilising or accessing premises within the organisation’s
control; or contractors that may be under the direction or control of the
organisation, operating within the organisation’s facilities or whose welfare
may be affected by the actions of other employees.69, 223, 224

People
External
Environment
People
Interfaces
Hazards may be generated from within the people section of the

organisation, not only from the people themselves, but also from the way
in which people relate to others; or as a result of interactions between
people and the hardware and operating environment; management
strategies and methodology; and/or the external environment.
70
Harm arising from within the people component of the organisation may
stem from singular or combined psychological, biological or socio-cultural
factors. Examples may include:
discrimination on the basis of gender, sexuality, religious beliefs,

pregnancy, disability or family care requirements;225, 226
bullying, sexual or racial harassment, horseplay, practical jokes or

“initiation rites”;225, 227, 228
violence initiated from within the workplace, for example in the case
of patients abusing health care workers in the mental health industry
or violence initiated against workers in the case of armed theft;190
conflict, mistrust and antagonism where workplace relationships have

broken down;229, 230
impaired judgement resulting from cases of substance abuse or

workers experiencing grief or loss;231, 232
contagious illness and disease, 233, 234 and
communication problems, including instances where people are

working in isolation or where language barriers exist.235, 236
Examination of the interface between the people component and the

hardware and operating environment may reveal hazards associated with
poor design, human error and the limitations of humans as information
processors. This may include:
working memory overload – for example Miller found that five to nine
unrelated items can be successfully retained in the working memory
“desktop” at one time and workplace tasks that require more may be
problematic;237
code incompatibility – codes are used to store information received

by the senses: tasks involving verbal/phonetic codes and
visual/spatial codes are better suited to operate together than
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activities employing two common codes such as speaking and
writing which are both verbal;238
perception errors – the interpretation of stimulus may be affected by

mental predisposition or expectation;239, 240
recall errors and the transferral of information from short-term

memory to long-term may be influenced by mood, state, motivation,
association and context at the time of learning;240
“tunnelling of attention” and misplaced priorities brought on by

stressful circumstances;239, 241 and
breakdown of selective attention – the ability to decipher important

information amidst multiple stimuli, or the breakdown of focused
attention where concentration is required under conditions of
fatigue.239
On the interface between the people component and management

strategies and methodology are hazards concerning the way in which work
is organised.242 Examples include stress and/or fatigue resulting from shift
work arrangements, overtime, monotonous tasks or the pace of production
activities.243 Stress may also result from the following:244-246
role ambiguity/role conflict;
responsibility for actions without the necessary authority;
career uncertainty; and
lack of perceived control over a situation.
Analysis of the interface between the people and the external environment
may reveal hazards resulting from the influence of customs, norms and
social culture. Examples include the social acceptability of wearing
personal protective equipment; expectations about the length of time spent
at work away from the family (work/life balance); or the willingness to be
assertive when rights have been violated.102
72
Low morale underpinned by resistance to change would be an example of
a hazard arising from changes to the people sector of an organisation.
This low morale and associated workplace stress may be indicated by
unusually high turnover rates and absenteeism levels.227, 246 Furthermore,
dangerous situations may develop from loss of expertise from a business
unit, as was the case with the Esso gas plant explosion at Longford, where
downsizing had lead to the relocation of engineers offsite.91
Table 4: Examples of Hazards Affecting People
Discrimination Rule-based errors
Harassment Skill-based Errors
Stress Knowledge-based Errors
Fatigue Communication Breakdown
Bullying Conflict/ Mistrust/ Antagonism
Workplace Violence Peer Pressure
Violence/Abuse (Public) Working Memory Overload
Substance Abuse Breakdown of Selective Attention
Contagious Illnesses & Disease Breakdown of Focused Attention
Mental/ Physical Illnesses Isolation/ Lone workers
Personal/ Emotional Issues Language Barriers
Table 5: Examples of Hazards Generated from Changes to the People

Sector
Loss of expertise/ skill Low morale
Loss of corporate memory Stress
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2.3.1 Safe Person Strategies
Safe person strategies focus on people, and included here are prevention
and control measures such as training; human resources functions such
as selecting appropriately qualified personnel; and behavioural based
safety where critical safe behaviours are identified and encouraged. Safe
person techniques offer a means of dealing with the residual risk once the
physical hazards of the workplace have been addressed, as the residual
risk can never be entirely eradicated. The following offers a review of
some of the main strategies available that fall under the safe person
category.
Pre-employment Screening
Pre-employment screening is widely used in large manufacturing

industries and Quinlan and Bohle suggest that it should be used to assist
in the selection of the most suitable roles for workers, rather than to
screen out candidates considered to be a high risk for future workers’
compensation claims.247 Pre-employment screening is useful in the
247, 248
following circumstances:
to assess whether a person is fit to carry out a specific task;
to identify workers that may have a greater susceptibility to

workplace hazards as a result of a particular medical condition, for
example working at heights would be unsuitable for epileptics, and
those with congenital enzyme deficiencies would be hypersensitive
to some toxicants and at greater risk of asthma from exposure to
irritants;
where a worker’s ill-health may expose other workers or members of

the public; or
to prevent aggravation of a pre-existing condition.
Pre-employment screening may take the form of a medical examination

with a consultant physician; an assessment by a trained OHS nurse; or
74
more economically through the use of a simple questionnaire to indicate if
further medical screening is necessary.248, 249 The construction of medical
assessments needs to be carefully considered to avoid the potential for
discrimination or equal opportunity claims. The Anti-Discrimination Board
(ADB) of NSW recommends that testing should only be carried out on
candidates that meet all other job requirements, and only relate to
essential job duties. The ADB present the following examples of misuse of
medical information:250
using pre-employment medicals as a means of culling before the

interview process;
lines of enquiry during the interview regarding previous injuries or

workers’ compensation claims; and
disclosure of pre-employment medical results to others.
Evidence from pre-employment screening may only be used to exclude a

candidate if the employer is able to demonstrate that it would cause undue
hardship to modify the task or work station to accommodate the worker’s
special needs.247, 248
In the case where limitations are found, Ellis
challenges the traditional practice where the physician provides a
statement of being either fit or unfit for the position, and instead calls for
more open communication so the extent to which duties may be
reasonably adjusted is well understood. In such circumstances the need
for “transparency” regarding the information that passes between the
health practitioner and the employer would be vital to ensure
confidentiality.251
Health Surveillance
Pre-employment medicals provide an opportunity to collect baseline

information for comparison with subsequent health surveillance results.
Examinations may include lung function tests, audiometry, or the collection
of blood or urine samples for biological monitoring where the levels of
particular toxicants or their by-products are analysed. While not
75
preventive, these measurements offer a means of evaluating the success
or otherwise of current hazard control strategies. As these results are
downstream indicators, any indications of harm due to occupational
exposure would require an immediate management response, as well as
observance of local OHS legislation requirements for reporting where
necessary.247, 249
Health surveillance is required by certain jurisdictions
where highly hazardous materials are being handled, for example in the
case of lead or asbestos.69
Quinlan and Bohle note that the use of biological monitoring and X-rays
presents “practical and ethical limitations” as X-rays may expose workers
to unnecessary risks and biological monitoring may be considered
invasive. Quinlan and Bohle highlight the importance of obtaining samples
“without imposing unreasonable danger, inconvenience or discomfort to
the workers involved”.247
Employee Selection Criteria
Failure to select appropriate personnel has been implied as a contributory

factor in a number of accident causation models, and Heinrich’s domino
theory placed considerable emphasis on personal characteristics such as
temperament.157, 252, 253 The need to define the requirements to ensure that
a person has the skill and competency to perform a particular role safely is
widely acknowledged as evidenced by its incorporation into a number of
OHS MS self-audit tools.2, 77-79 Caution must be exercised to ensure that
the recruitment process complies with local equal opportunity
254
legislation. Petersen warns that many tests may be illegal under such
laws, unless successful application of results can be demonstrated.255
Clarke and Robertson conducted a meta-analysis of 45 studies to

challenge common perceptions associating personality traits such as
extraversion with accident involvement. This meta-analysis concentrated
on the main five personality factors that had been explored in previous
work: - extraversion; neuroticism (characterised by high anxiety, self-
consciousness, impulsivity, distractibility and a negative outlook);
76
conscientiousness; agreeableness (helpful and tolerant); and openness
(imaginative and broadminded). Overall, the results suggested that low
agreeableness and low conscientiousness were predictors of accident
involvement, but in an occupational context, neuroticism and low levels of
agreeableness were significant. Attempts to explain the results sought to
link a preoccupation with personal worries and the inability to conduct
successful interpersonal relationships with a susceptibility to workplace
accidents.256
It is observed that the OHS literature focuses more on the need for training
and skills analysis to ensure competency to perform tasks safely, than on
defining the requirements for personnel at the selection stage. This is in
contrast to total quality management approaches that view personnel
selection as a controlling input into the process.257 Whilst the emphasis on
training on the job may be perceived as a practical approach, and is
always necessary to some extent, it is contended that ignoring employee
selection criteria represents false economy as the additional expense in
hiring more qualified personnel may well be offset by the risk of having
inexperienced staff spending considerable time on the learning curve,
potentially exposing others to harm.
Policies
Policies are used to motivate supervisors to perform in a specific,

desirable way by understanding the will of management.258 Richardson
stresses that written policies are only one expression of management’s
intentions, and must be supported by actions consistent with the
information in the policy to be credible, quoting Albert Schweitzer: 259
“Example is not the main thing in influencing others, it’s the only thing.”
Petersen supports these sentiments with his warning that failure to provide
a suitable work environment whilst claiming “safety first” serves to
generate cynicism.260 Richardson suggests that employers confuse the
77
policy with the written document, when the policy is actually the attitude
conveyed by management as witnessed by their response to everyday
situations.259 Geller extends this concept by promoting safety as value
rather than a priority.261
“Safety should be a value that employees bring to every job, regardless of

priorities or task requirements. It should be an unwritten rule (social norm), one
followed regardless of the situation.”
The advantage of this strategy is that it carefully avoids the conflict

between safety and production by placing safety on an entirely different
emotional level, appealing more to a sense of moral obligations and code
of behaviour.
A range of policies may be invoked to protect OHS interests and related

topics include: health and safety; equal opportunity; anti-discrimination;
anti-bullying; anti-violence; harassment-free workplaces; smoke-free
environment; drugs and alcohol; and the promotion of family-friendly work
arrangements.262, 263
The positive benefits of having these policies
articulated are that this sends a strong message of what is expected and
also clarifies management’s position on these issues.
Training
Employee education and training equip staff with the necessary skills to
fulfill their OHS responsibilities. Training in awareness of workplace
hazards and safe work methods can only be effective if the design of the
physical work environment encourages safe practices, as it is human
nature to find the most expedient method for performing the task.260 247
The type of training delivered may vary in its level of sophistication to

encompass the following range: 264
receipt of written site safety rules;
induction training for staff, contractors and visitors;
78
training on critical safe working procedures and complying with
legislative requirements that are linked to actual workplace hazards
(context specific training);
broader awareness training of non-critical procedures; to
in-depth safety education.
The effectiveness of training may be substantially improved by ensuring

that a skills audit and thorough training needs analysis has been
performed for each employee at the onset and by conducting post training
evaluations. Petersen encapsulates the importance of these processes by
encouraging employers to ask the following questions, paraphrased from a
quote by Robert Mager: 265
“Where am I going?
How shall I get there? and
How will I know when I’ve arrived?”
Petersen suggests that the answer to the first question should consider
three key areas: the business as a whole; the operational unit; and the
individual employees.265
It appears that the acquisition of problem solving skills is often overlooked

in the development of training programs, with greater emphasis being
placed on addressing immediate task requirements. This is unfortunate as
these skills provide the foundation for dealing with safety issues that are
uncovered by safety inspections and incident investigations. 117, 144, 217, 266
Tasks or situations that are performed infrequently - such as first aid or

emergency evacuations, require periodic refresher training to maintain skill
267
levels. Petersen reinforces this message by stressing the need to
practice what is learnt and adds that training conducted over a number of
79
short intervals is more likely to be retained than information received in
one large block. 265
Ellis elaborates further on techniques that will assist adult learning with the
following:268
aim to engage more than one sense in the learning process, for
example by incorporating learning exercises, discussions,
audiovisual aids and/or summary material;
provide opportunities for feedback on performance;
offer early opportunities to reward successful learning; and
ensure that the beginning and endpoints of learning sessions are

used wisely as they are most easily recalled, for example provide an
overview of the topic at the onset and a quick summation to
conclude.
Martin discusses the advantages of on-line learning including flexibility,

accessibility and cost-effectiveness. However, whilst this technique may
suit the dissemination of factual material, it may not be as effective for
conveying attitudes towards safety. Martin cautions that on-line learning
does not cater for individual learning style preferences.264
Geller clarifies the distinction between safety training and education,

explaining that training targets actions whilst safety education relates more
to the underlying principles behind the actions:269
“Attitudes, beliefs, values, intentions and perceptions can be influenced directly

through education; whereas behaviours are directly influenced through training.”
Training and education are complementary - one reinforces the other. By

adding meaningfulness to the information it is also more likely to be
265, 267
retained. Hopkins implies that without deeper process knowledge
and understanding, the value of training is minimal. Hopkins considers the
80
lack of operator safety education to have played a significant role amongst
the factors contributing to the Esso gas plant explosion at Longford.270
Training sessions should be recorded to provide evidence to demonstrate

the contribution towards due diligence shown, to enable effective tracking
and provide for future planning. Training should be conducted by those
competent and qualified to do so. Where possible, trainees should be
assessed.271
Mentoring and Buddy Systems
Martin discusses the use of mentoring programs as a means of improving

OHS management in organisations, citing the work of Wilson and Shaw in
2002 which examined the pairing of senior managers from one
organisation with another. Martin highlights the importance of the
relationships built, the trust and understanding engendered, the broader
perspective of experience, and the sign of deep management commitment
that may stem from such programs.264
Conflict Resolution
Petersen suggests that unresolved workplace conflict may manifest in the
following ways:272
apathy and a deliberate decision to ignore workplace rules;
mediocrity;
tuning out;
substance abuse;
leaving the organisation;
“pseudo injuries”;
venting; and in extreme cases
labour disputes, strikes and sabotage.
81
Strategies to recognise and deal with conflict may reduce work related
stress and help diffuse potentially volatile situations.
Work Reorganisation/ Task Restructuring
Job enrichment may be used to overcome boredom and associated

feelings of fatigue. Providing more meaningful work enables the worker to
realise their full potential, and may improve job satisfaction. Kroemer and
Grandjean recommend the careful matching of employee capabilities to
the work demands to avoid both boredom and frustration. This may be
achieved by increasing the range of tasks, allocating higher levels of
responsibility and encouraging greater worker participation in decision-
making processes. Task restructuring or job rotation may be necessary
where prolonged exposure increases the risk of manual handling injuries,
fatigue or boredom. The strategic use of rest pauses is also advocated to
maintain performance and efficiency. Regardless of their format - whether
they be prescribed or as waiting periods, it is suggested that they should
combine to represent approximately 15% of total working time.273
Security
Concerns for personal safety may induce higher stress levels and affect
general well being. However, although these effects are on the individual,
the remedy often requires changes to the individual’s physical workplace,
and so this may be dealt with in examinations of either the hardware and
operating environment or when focusing on people.
Security arrangements should be considered as a preventive measure

wherever there is a threat to personal or organisational safety.274 Yohay
and Peppe highlight the following scenarios considered to be at risk of
workplace violence:275
carrying large amounts of cash for financial transactions;
exchanging money in public view;
working in isolation or in small numbers;
82
working night shifts or early mornings;
guarding valuables or people;
working in a high crime rate area;
employees delivering goods and services (especially if these can be

easily traded for money); and
where there is a high degree of interface with the public.
Prevention strategies include:276
use of security personnel;
duress alarms;
global positioning systems linked to cars and mobile phones, for

example as used by taxi drivers;
use of a coded distress signal;
metal detectors on entrance ways;
improved lighting and increased visibility;
pleasant surroundings in waiting rooms including pastel colours,

comfortable seating, availability of drinking water, and climate control;
“target hardening” such as deadlocks on cabinets with valuables,

wide & high counters at enquiry desks, and
minimal furniture in interview rooms and the absence of items that

could be potentially used as weapons.
Lone or Remote Workers
Despite the emergence of an “alternative workforce” with increasing

numbers of employees working remotely, there is a paucity of information
83
available in the literature to address the safety issues involved when
workers perform their duties in isolation.277
In the event of experiencing a medical condition such as stroke or heart

attack or in the case of an injury, failure to obtain prompt medical
assistance could serve to aggravate the injury, cause considerable
distress or result in an unnecessary fatality.236 Examples where this may
be necessary include: farmers; working at heights; utility workers; mobile
sales and service personnel; workers during weekends or public holidays;
and lone operators or shop assistants.277
Control measures may include: lone workers informing other personnel

where they will be or agreeing to communicate at regular time intervals;
use of pagers and mobile telephones; having well displayed or
personalised emergency contact numbers listings; and protocols for
suitable authorisation of work arrangements.236
Awareness of Fatigue and Circadian Rhythms
La Dou and Coleman note that major catastrophes such as Three Mile
Island, Bhopal and Chernobyl have all occurred between the hours of
midnight and four o’clock in the morning.243
The body’s circadian rhythm is normally geared towards work readiness in

the early morning and the second half of the afternoon. Disturbance of this
natural rhythm through shift work may lead to irritability, depression, work
disinterest, unhealthy eating habits, and digestive problems such as
ulcers. This biological clock is affected by zeitbergers or “time markers”
such as light and darkness, social cues, meals, knowledge of local time
and routines, and if disrupted may take several weeks to readjust.278
Strategies to help maintain alertness and minimise circadian dysrythmia

where night shifts are necessary include:243
the use of quickly rotating shifts that involve only one or two night
shifts at a time so that the body’s internal clock has no chance to
reset;279
84
where rotating shifts are used, the use of forward rotating cycles is
preferable;278
avoidance of monotonous tasks;
climate control with temperatures set on the lower levels of the

comfort range;
good air circulation; and
bright lighting;279
Schur promotes the concept of providing designated napping facilities

such as a recliner, in the belief that it is better that it happens in a
controlled and manageable way. Schur also advocates the importance of
employee participation in the rostering schedule.279
Sensitivity to Cultural Diversity
Where there is cultural diversity, safety information needs to be

transmitted in a format that may be understood by all workers. This may
involve the use of interpreting services to provide information pamphlets in
different languages, the use of diagrams in warning signage,
demonstrations of safe working methods, and the use of other visual aids.
Means of assessing that information has been understood is particularly
vital where language barriers exist, and may take the form of on-the-job
assessments.235, 280
Sensitivity to Pregnancy and Nursing Mothers
Apart from ionizing radiation such as X-rays, hazardous chemicals such as

lead, mercury, anaesthetic agents and organophosphate pesticides;
biological hazards such as rubella, listeria and parasites such as
toxoplasma that can affect the developing embryo or foetus; there are a
number of other physical hazards that are of special concern during
pregnancy. These include:281
standing for long periods;
85
travel;
ergonomic problems due to a changed weight distribution that may

prevent pregnant workers from getting close to loads and counters,
and an altered center of gravity that may affect posture and balance;
increased sensitivity to heat stress; and
regular exposure to low frequency vibration, shocks, or excessive

movement.
Other human factors for consideration include:282
proneness to nausea and vomiting;
backache,
earlier onset of fatigue; and
the potential for difficulty in concentrating due to metabolic changes.
Breastfeeding women require access to seating and private, hygienic

facilities. Refrigeration for expressed breast milk and secure storage for
lactation equipment should also be provided.281
Temporary adjustment of working conditions, shift patterns, and/or hours;

increased rest periods or even a transfer may be necessary.282 In keeping
with anti-discrimination rules, if pregnant or lactating women are being
treated differently, they should not be disadvantaged as a result.281
Young Worker Considerations
Workers under the age of 25 have been found by WorkCover NSW to be

prone to the following five types of injuries: sprains and strains; open
wounds; fractures; bruising and crushing, and burns. The main causes of
injuries cited were manual handling; slips, trips and falls; being hit by
moving objects; falling from a height; and hitting moving objects.
WorkCover attributes this to a lack of experience and familiarity with local
procedures.283 Mentoring programs, providing appealing designs and
86
colours for PPE, and implementing multi-media training are suggested
techniques to cater for the special needs of younger workers.264, 283, 284
Comcare also points out that younger workers are at increased risk of
bullying.285
Older Worker Considerations
Reductions in birth rates and the introduction on anti-discriminatory

legislation prohibiting forced retirement have introduced new challenges in
OHS to accommodate an aging workforce.226, 286 Areas for consideration
in connection with the aging process include:286
reluctance or difficulty with learning new tasks;264
loss of visual acuity;
hearing loss and increased sensitivity to loudness;
reduced aerobic capacity; and
reduction in joint mobility, strength, reaction times and manual

dexterity.
Statistics provided by Kisner and Pratt from the US indicate that older
workers are “more likely to experience injuries that result in death or
permanent disability”, and machines, motor vehicles and falls featured
amongst the major causes of worker fatalities for those aged over 65.287
Kowalski-Trakofler et al highlight research indicating that any physical

decline is counterbalanced by the growth in wisdom, emotional maturity
and experience that accompanies age.286 Strategies to accommodate
senior workers include the use of technology to overcome limitations
presented by physically demanding tasks; training in general ergonomics
and postural awareness; and the implementation of wellness programs.286,
288
87
Wellness Programs
Wellness programs may include: management of diseases such as

diabetes and hypertension; the promotion of exercise, healthy nutrition
and relaxation methods; cancer screening; health appraisal; flu vaccines;
and support for those quitting smoking. Not only do these measures
protect the employers’ most valuable asset - the workers, but wellness
programs also demonstrate that employers genuinely care for the health of
their employees. The long term benefits associated with investing in
worker health include improvements to both employee morale and the
corporate image, as well as the potential to reduce turnover and
absenteeism.286, 289
Strategies to Overcome Substance Abuse
There are conflicting theories on the most effective approach to substance

abuse in the workplace. After conducting a meta-analysis of available
research on various control strategies such as policies, and interventions
such as drug testing programs and counselling, Allsop and Phillips report
that the results remain ambiguous.290 Conversely, Petersen advocates
drug testing at the pre-employment medical phase. He argues that this
strategy will discourage those with substance abuse problems from
applying for the positions in the first instance, and that employers have a
duty to ensure the safety of fellow employees in the workplace and others,
for example where substance abuse may interfere with the safe use of
machinery or the ability to drive.289
Drug testing programs may however simply transfer the risk elsewhere
and Allsop and Phillips’ suggest blending substance abuse strategies into
employee assistance programs (EAP’s) or wellness programs. Ellis also
endorses this approach, and insightfully suggests that successful
intervention is underpinned by non-judgmental support from supervisors,
trained to detect a decline in work performance.291 These sentiments are
well captured by the following citation taken from Edwards: 290
88
“Experience seems … to teach that preventive action on drug problems can never
be imposed by society or culture. All such action if it is to have a chance of
success has to be based on a willingness to listen, to understand, and to be told.
Prevention is then an invitation to change, rather than an edict and the invitation
to change will only be accepted if it is sensible.”
Bell and Bell reinforce the use of EAP services, and challenge the legality
of pre-employment drug and alcohol screening under local anti-
discrimination laws, viewing alcoholism as a disease. They connect the
success of EAP’s in these instances with the strong incentive for affected
workers to maintain their financial security.292
Employee Assistance Programs (EAP)
EAP’s developed originally as a response to dealing with drug and alcohol

problems in the workplace, by offering a referral to specialist help and
counselling. EAP’s have now been extended to incorporate a broad range
of services including workplace conflict mediation, emotional problems,
work related stress and any issues impacting on workplace
291
performance. Confidentiality, voluntary participation, ease of
accessibility and free service are common features of these services.289
Where OHS services are located on site, counselling services may be
offered by trained OHS staff or the occupational physician.249 The
advantage of in-house systems is that they have greater appreciation of
organisational issues.291
Irrespective of whether the source of the problem originates from home or

work, workers suffering from stress or emotional problems will have
strained interpersonal work relationships which could negatively impact on
others in the workplace.256 This could potentially place fellow workers at
risk if their decision making capability has been compromised. The
availability of EAP services may provide a welcome outlet for problems
that if left untreated could escalate to the point where management of the
workers’ performance becomes increasingly difficult.
89
Peer support programs may be particularly useful in cases where there is
reluctance to use EAP services, or as a means of enhancing their
effectiveness.291 This has been particularly beneficial in emergency
service and voluntary organisations dealing with critical incidents, where
there is a preference to speak with someone who is intimately familiar with
the circumstances surrounding the incident or who has been in a similar
situation. Critical incident support programs and peer debriefing may be
helpful in reducing the effects of post incident trauma.293
Personal Protective Equipment (PPE)
Stephenson notes that PPE is sometimes classified within the safe person
control strategies category on the basis that PPE is worn on the person
and that its reliability depends on human intervention, such as fit and
correct use, to be effective. Stephenson also makes a salient point when
he observes that in practice most control techniques are rarely used in
isolation and that PPE is often used in combination with other types of
controls.294
Rehabilitation and Injury Management
First aid and medical treatment of workplace injuries should be rapid to

reduce injury impact and to optimise repair and recovery. Rehabilitation
programs are not preventive, but their merit is in the limitation of damage
already sustained where control measures have failed.
Rehabilitation attempts to restore the worker to their pre-injury condition,

hopefully returning them to a workplace that has identified and dealt with
the cause of the injury. There are significant psychological advantages in
returning the injured employee back into the workforce once they are
capable of light or suitable duties, as prolonged periods away from
meaningful employment and loss of contact with workplace peers can
lower self-esteem and confidence.247, 295
Strategies for returning the
worker back to gainful employment should be in accordance with the
following order of preference:296
90
Same position/same workplace
Modified job/same workplace
Different position/same workplace
Similar or modified position/ different workplace
Different position/different workplace.
Behavioural Based Safety (BBS)
BBS involves the identification and reinforcement of critical safe practices.

BBS campaigns can promote cultural change by altering attitudes towards
reporting of incidents and the encouragement of thinking through actions
so employees are effectively performing dynamic risk assessments as a
matter of routine. Geller suggests that BBS programs encourage workers
to take responsibility for their actions so less surveillance is necessary,
effectively promoting “safety self-management”. 33
Originally BBS proponents dissected incidents into the unsafe action and
the resulting injury, and then focused on eliminating the unsafe act as a
means of prevention.63 This cast human factors as the weak link in the
chain of causation.294 Interestingly, Kouabenean’s work on causal
attribution suggested that those being exposed to accidents on the shop
floor were more likely to attribute the cause to poor working conditions,
whilst those higher up in management and not exposed where most likely
to suggest lack of care or inattention.297
As BBS was heavily criticised for its potential to be abused to “blame the
worker” these techniques have been revamped with a much more
optimistic, constructive approach.155 BBS has since been transformed into
an attempt to eliminate the motives behind unsafe actions, identifying and
encouraging critical safe behaviours through systems of reward and
praise, and promoting the reporting of incidents.261, 298 A number of studies
have emphasised the importance of providing feedback to encourage
critical safe behaviours.145, 299 However, Ray et al suggest that the benefit
91
of these programs may lie simply in the additional attention focused on
safety at the time, and highlights the need for employees to learn how to
“read their environment” and respond accordingly in order to maintain and
sustain performance improvements after the observation programs have
ceased.300 Not all persons are naturally able to do this, and the effects of
stress to induce tunnelling of attention should be not be discounted.239
BBS programs have been used successfully to encourage workers and

their managers to acquire the habit of conducting dynamic, informal risk
assessments by asking the following series of questions as for example, in
the Du Pont “STOP” and “Take Two” programs:
What am I about to do?
What could go wrong?
How could I perform the task safely?
This not only furnishes the employees with valuable skills, but also creates
a forgiving “safety buffer” to accommodate a less than perfect physical
working environment and the economic realities of the business world
where hazards identified are not dealt with immediately but prioritised and
addressed when sufficient funding becomes available.142
Understanding the concepts behind behavioural change programs should

also prompt management to reflect on their own actions to assess whether
or not they are positively reinforcing unsafe behaviours, for example
through production bonus schemes.
Reward Campaigns
It is generally accepted amongst the behavioural scientists that reward

systems are a powerful tool for encouraging desirable safe work practices,
although there is some debate regarding the format these rewards should
take.301, 302 Geller favours the use of praise and recognition, discouraging
the use of monetary rewards by contending that “We cannot expect
external rewards for all the important management related behaviours we
92
need to do … We need to start with the right vision, theory and principles,
and hold ourselves accountable with internal consequences”.302 Improved
status, public recognition, private praise, “second hand” praise - where
good work is relayed to a third party in the hope that it will eventually filter
back to the originator, special privileges, preferred job assignments, and
celebratory meals all provide alternative reward systems. 303
When using positive reinforcement techniques to modify behaviour,

strategic use of the reward schedule, that is the timing of the reward, will
improve the likelihood of maintaining the desired outcome in the long term.
If the reward schedule is fixed, the desired behaviour is likely to disappear
when the reward is removed. However, if the reward schedule is variable,
interest is likely to be maintained in anticipation, provided the reward is
sufficiently desirable. For enduring changes to work practices, it is
recommended that the reward schedule is fixed and immediate during the
introduction phase, and then gradually transferred to a variable schedule.
144, 145
Hale cites the profitability of poker machines and the difficulty in
extinguishing such habits to demonstrate how successful a variable
reward schedule can be.304
Perception Surveys
Perception surveys often take the form of a questionnaire and are used to
gauge employee morale, safety attitudes, and the effectiveness of
particular safety program components.305, 306
Bailey suggests that the
advantage of using perception surveys is their ability to easily capture the
weaknesses in program elements as observed by employees and
management.307 Bailey reports that these surveys are particularly useful
when safety performance has reached a plateau, and there is scope for
focusing on behavioural factors.307
Mearns et al suggests that questionnaire surveys relating to safety culture

should be more appropriately termed climate surveys because they
capture a snapshot of the prevailing safety culture.308 A number of safety
climate survey instruments have been developed to assess the impact of
93
interventions, for example in the Health Care industry.106 Common themes
in these climate measures have included perceptions of management’s
behaviours and attitudes; existence of safety systems; attitudes towards
risk; the balance between production pressure and safety issues;
perceived competence of the workforce; and compliance with safety rules
and procedures. 309
Perception surveys also have been used successfully in conjunction with

risk assessments to determine the perceived effectiveness of interventions
and to evaluate the perceived merit of further improvement options.310
Where psychological stress is a suspected contributor to workplace

accidents, perception surveys may assist in uncovering the causes of such
stress and to test options for the way forward. For example, Tint and
Reinhold used a perception survey to help acknowledge the link between
stress factors and a variety of health complaints in the workplace. Their
study was used to promote the use of suitable work organisation
arrangements, ergonomically designed workstations and more open
dialogue between management and employees.311
Off-the Job Safety Programs
Off-the-job safety programs encourage workers to “live and breathe”

safety, providing reinforcement and consistency. Elements of off-the job
safety programs may include safe driving skills, defensive driving
programs, as well as education and awareness of commonly encountered
home hazards through posters, pamphlets and newsletters. The following
topics are typically covered: 312-315
hazardous materials such as paints, oils, cleaners and pesticides;
ergonomics for home offices and hobbies;
slips, trips and falls;
correct use of PPE, for example when gardening or lawn mowing;
94
ladder safety and working at heights,
electrical safety with household appliances,
scalds from hot water systems;
kitchen safety – avoiding cuts and burns;
smoke detectors and fire extinguishers,
personal security, and
home safety checklists.
Off-the-job safety programs demonstrate genuine caring and commitment

from the employer, and foster important attitudes that strengthen and
support safe work practices.312, 315
Accountability/Performance Appraisal
Several authors promote the incorporation of safety criteria into the

performance appraisal process, and Heinrich points to the supervisor as
the vital person to target as he argues they have the most influence over
the workers’ behaviour.63, 301, 302 Petersen emphatically reinforces the need
for accountability and believes that personnel will only accept
301
responsibility for requirements that are measurable. Quinlan and Bohle
qualify this by stating that OHS responsibilities and accountability should
reflect the level of “discretionary power that they exercise”.247
Richardson perceptively illuminates the danger of using injury statistics or

other negative measures for performance appraisal purposes, linking this
practice to under-reporting and suggests the use of positive action items
as an alternative.316 Geller downplays the significance of performance
appraisals on the basis that they are open to manipulation, reinforcing
Richardson’s views. Geller suggests that staff rise to the occasion shortly
before an appraisal is conducted, only to return to their old habits once the
process is over. To circumvent these problems, Geller expands upon
95
Richardson’s approach by recommending continuous assessment on
three levels:317
environmental factors such as housekeeping;
critical safe behaviours and work practices, as noted through the use
of observation checklists; and
attitudes towards safety.
2.3.2 The Strengths and Limitations of Safe Person Strategies in

Practice
Safe person strategies have the advantage of being able to deal with
potential hazards of a more complex nature and irregular nature, and this
is reflected in the broad range of treatment options available. Where the
elimination of hazards is not a viable option, methods for coping with the
possibility of danger provides a sensible alternative, and in some cases
this may simply involve creating awareness of the potential for problems to
arise.318 Furthermore, not all workplaces are “fixed”, many workers are
required to travel to various locations where the nature of the physical
work environment may be unknown or their purpose may be to make the
area safe. Examples include repair and maintenance work, asbestos
removalists, and emergency service workers. In these instances it may be
necessary to draw upon competency skills, training, the ability to routinely
perform informal risk assessments and the strength of their situational
judgement. Safe person strategies are therefore particularly useful for non-
routine and specialist work environments.
Petersen makes the observation that many safety program initiatives

restrict employees from using their own judgement, and essentially do the
thinking for them. Citing Chris Argyris’s incongruency theory, which
suggests such constraints frustrate the natural process of growth and
maturation, Petersen argues that safety programs should be more
participative and “reduce employee dependence, subordination and
submissiveness”.319 Whilst it is acknowledged that some constraints will
always be necessary, the recognition that some processes do not require
96
tight control and may benefit from providing some level of flexibility is a
salient factor in itself.
Due to the high level of personal input, safe person strategies can be time
consuming. Training, mentoring and educating employees demands not
only time but patience. These resources may be difficult to secure when
production demands are high.
It is important to stress that safe person strategies are not just simply
about BBS, but include many other important factors such as training and
competency. Safe person strategies deal with the perspective of the
individual and recognise psycho-social hazards such as workplace stress
and bullying. By taking into account individual factors, safe person
strategies are able to work in conjunction with changes to the physical
workplace and encourage workers to apply their judgement and expertise.
They also help define the situations under which work should cease or
where further assistance is required.
As safe person strategies rely predominantly on the individual, these

strategies may be limited by the complexities of human behaviour, fatigue
and times of job or life stress. These must be appreciated at the time of
application and allowances or additional controls used to counteract these
parameters.
97
Table 6: Examples of Safe Person Strategies
Safe Person Strategies
Planning Phase
Employee Selection Criteria
Pre-Employment Health Screening
Anti-Bullying/ Equal Opportunity Policies
Family-friendly, Flexible Work Arrangements
Training Needs Analysis
Competencies for Future Directions Identified
Inductions
Training Programs/ Refresher Training
On-going Education/ Alert Bulletins/ Professional Networking
Behaviour Modification
Rehabilitation Programs
Sensitivity to Diversity Including Cultural Differences; Younger/Older Workers;
Employee Assistance Programs
Reward Programs/ Safety Campaigns
Communication/ Contact Systems
Measurement Phase
Unsafe/ Safe Acts Observations
Perception Surveys
Feedback Programs
Health Surveillance
Review Phase
Performance Appraisal – Safe Working Criteria
Review of Reasons for Turn-Over Rates
98
2.4 Focusing on Management Strategies and
Methodology
Management strategies and methodology will be defined to include the

ways in which both the people and the hardware and operating
environment are organised and directed in order to transform resources
into organisational outputs, whether they be goods or services. This will
include leadership, culture, planning, specialist and technical expertise,
competency, work methods, and the systems utilised in the process.

Management Strategies and Methodology
External
People Environment
Interfaces
Hazards generated from within the management strategies and

methodology component of the organisation may derive from lack of
leadership, commitment or competence.41 Failure by management to
acquaint themselves with their legal OH&S obligations, remain current with
changes or to identify areas of non-compliance with local regulations may
also place workers at greater risk of illness and injury.2, 141 Hazards may
99
also develop as a response to the culture of the organisation, for example
if reporting of incidents were discouraged, or if safety was not valued by
the organisation.261, 320, 321
On the interface between management strategies and methodology and

the people section are hazards arising from a lack of consultation, poor
supervision and wilful violations from people in response to over
specification of procedures, under specification of procedures or generally
poor procedures.141, 322, 323 Hazards may also occur as a result of failure to
generate a procedure where consistency is required.324 Decisions to use
high levels of contracting personnel as opposed to permanent employees
may also generate hazards due to workforce instability and lack of local
knowledge.56
The interface between management strategies and the physical workplace

may highlight hazards where there has been a failure to understand the
workplace or where many “defences in depth” have been applied. This
may create problems in emergency situations if the purpose of defence
mechanisms has been obscured or if their impact on other sections of the
process is not understood.325, 326
Other hazards may emerge due to the
selection of particular work practices or the structuring of organisational
activities.242
Negative influences from the external environment on management

strategies and methodology include cases where adversarial relationships
have developed between the local regulatory authority and industry, which
may restrain the willingness to document workplace hazards and
potentially inhibit the consultation process. The level of unionism and the
ability to call on external support may also influence the power balance
between management and the workers, which may also impact upon
management attitudes and readiness to deal with safety and health related
issues in the workplace. Other hazards related to the external environment
include the impact of high levels of competition which may result in the
sacrifice of safe working methods in order to remain competitive within the
marketplace.3
100
Hazards related to changes to management strategies and methodology
may originate from failure to communicate revisions to work methods and
procedures, or failure to consider those affected or impacted by
changes.324 Also included here are hazards linked to too much flux and
instability within the workforce, for example when downsizing of a
business is occurring.91, 185
Table 7: Examples of Potential Hazards Generated from Management

Strategies and Methodology:
Lack of Leadership/ Direction Too Many Rules
Lack of Commitment No Rules
Lack of Competence Bad Rules
Lack of Consultation Wilful Violations
Poor Supervision Software Inadequacies
Failing to Understand the Process Failing to Test the System
Poor Work Organisation Information Suppression
Table 8: Examples of Potential Hazards Generated from Changes to

Management Strategies and Methodology Used:
Lack of Experience Lack of Clarity
Misinformation Too Much Flux, Instability
101
2.4.1 Safe Systems Strategies
A safe systems approach focuses on understanding the process, and

views the level of injuries experienced or lack there of, as a product of the
system capability. Features of this strategy include: 327
x defining the requirements for the safe operation up front;
x ensuring that inputs into the process come together in a manner that
is controlled and without danger to those involved – safe procedures
are in place; ensuring that critical information is communicated in the
appropriate time frame;
x searching for the root causes of incidents when these arise to

eliminate problems from recurring;
x regular monitoring and evaluation of performance against set criteria;

and
x review of the process to ensure it is working properly.
Establishing safety criteria for the selection of personnel, suppliers, raw

materials, design and equipment are of a more preventive nature, whilst
incident investigations are after the fact. Again, it is unlikely that all the
requirements for safe working conditions will have been identified from the
onset and allowances have to be made for unexpected equipment failures,
the complexity of human behaviour and the natural limitations of humans
as information processors. Both preventive and reactive strategies need to
be in place to manage safety and health effectively, and one of the merits
of a systems approach are the cues and prompts that it provides to
facilitate both of these responses.
A safe system approach usually requires the provision of regular feedback

and open communication to further a deeper understanding of the work
process and the impact of key variables.5 However, there are continuing
problems with the use of measures for safety failures such as illness and
injury statistics for assessing safety performance as they may be linked
with organisational politics and the need for managers to save face.
102
Under-reporting presents a major threat to safety program improvements
because it is difficult to understand a situation when the facts have been
distorted or worse, are absent.298 A culture of trust, respect and
transparency must be in place before a systems approach will work
effectively.105, 328 One of the redeeming features of a systems approach is
that when a problem has been identified, examination of the system can
redirect unwelcomed attention away from managers or workers, reducing
the opportunity for blame and encouraging solutions that benefit the
organisation as a whole.
2.4.2 The Strengths and Limitations of Safe Systems Strategies in

Practice
Safe system strategies build safety in at the concept stage and are most
effective when delivered within a suitable culture. However, a systematic
approach does sometimes involve a high level of bureaucracy, and as a
result OHS MS have been particularly criticised for becoming ‘‘paper
tigers”, which has often resulted in their benefits being restricted to large
scale manufacturers with routine, continuous operations.149 Problems with
OHS MS may also occur when the proposed corrective action continually
results in piecemeal changes to the procedures rather than searching for
higher order solutions that address either the physical or conceptual core
issues. Constant changes to procedures results in end users losing
confidence in the system. Furthermore, it is important not to over specify
the system. It is important to appreciate the difference between
applications where human judgement and experience add value and
where consistency and replication are necessary. These criticisms
represent an opportunity to restore OHS MS to their intended purpose – to
provide one of the most preventive means of delivering OHS benefits to
the workplace, wherever it might be. Implicit in this intention are the
fundamental concepts of planning, understanding the process, making
adjustments where necessary, and continual evaluation of outcomes.195
The literature has argued for the pursuit of a systematic approach rather
59, 91, 329
than the application of OHS MS. Yet, they are one and the same
103
and this argument may highlight some ambiguity surrounding suggested
OHS MS structures as offered by AS/NZS 4804 and Safety MAP that may
not have been customised for a particular organisation, as opposed to the
policies, plans, procedures and work instructions that comprise the actual
OHS MS themselves.2, 77 OHS MS structures simply provide guidelines on
essential criteria for the safety program content, whilst the systematic
approach found within the OHS MS allows information to be collected and
communicated so that critical processes are controlled to ensure safe
operations.
The management of a highly contingent workforce is becoming typical for

the modern employer. This brings with it many additional risks that are well
suited to the application of a safe systems approach, such as the use of
permits to work and verification activities.330
The use of OHS MS and the systems strategies applied therein have been
rebuked for being too heavily orchestrated by management.91 Petersen
interprets this heavy handed approach as management’s response to the
rejection of workplace rules, and cynically views the proliferation of
“pseudo participation/communication programs” as a futile attempt to
pacify workers.319 This highlights the difficulties that naturally arise from
the employer-employee control gradient, the counter productivity of token
gestures and the need for workers to see the reasoning behind restrictions
where they have been enforced. Without meaningful consultation in place
and genuine worker participation the use of OHS MS and a systems
approach cannot be effective. This point has been well documented within
the literature and remains a fair criticism. Without feedback from end
users, the improvement process is stifled. The ability to manage the
process without hidden agendas coming into play remains a formidable
challenge in many organisations. The need for trust and transparency is
again highlighted .328
Finally, the conventional application of risk management plays a very

important role in a systematic approach to occupational health and safety,
but it is not the complete picture. Not only should hazards and risks be
104
identified on a broader, organisational context, but they must be handled
in an appropriate manner. Solutions must be planned for and outcomes
measured. Evaluation of solutions must take place and the information
captured to improve operations. Changes need to be communicated to
those impacted by the change. Triggers need to be in place so people
know when to conduct a risk assessment, how to conduct one effectively,
who to involve and who to inform of the outcome. Risk assessments need
to be performed by people with the necessary technical competencies who
have contextual knowledge of the workplace as well as having skills in
performing the risk assessment itself. It is important to know when the
scope of the risk assessment is within the capabilities of those internal to
an organisation, and when specialist assistance is required. OHS MS can
help orchestrate all these activities so they are logically co-ordinated and
sequenced to provide information within the timelines necessary.
105
Table 9: Examples of Safe Systems Strategies
Safe Systems Strategies
Planning Phase
Goals for Safe Operation Agreed and Accepted
Safety Criteria for Inputs Defined- Suppliers; Design: Skill Acquisition
Due Diligence Plan
Critical Information Identified
Time and Resources Allocated for Solutions
System Interfaces Defined -Service Agreements include OHS Criteria
Safe Working Procedures
Meaningful OHS Consultation
Competent Supervision
OHS MS Framework and Procedure Revisions and Legislative Updates
Incident Management/ Investigation
Preventive Action
Measurement Phase
Injury/Illness Reporting
Scales of Measurement Adjusted to Collect Sufficient Quantity of Data
Near Miss Reporting
Controlled Self Assessments
Validation Audits ( Checking System Construction)
Verification Audits ( Checking Compliance)
Review Phase
Time Allocated and Used to Review the System Against Long and Short Term Goals
Management Review
Due Diligence Review
106
3. DEVELOPMENT OF THE OHS MS MODEL
FRAMEWORK
One of the major criticisms regarding the use of OHS MS has been the
problem of “over specification” and the recognition that “one size does not
fit all”.331 In order to develop a more customised approach to overcome
these problems, it is useful to examine the fundamental construction of
workplace activities.
Most activities can be broken down into segments comprising of:
Specialised/complex elements;
Routine elements; and
Unplanned, unwelcome or unexpected events – see Figure 6.
Figure 6: Breakdown of Workplace Activities
Workplace Activities
Specialised Activities Unplanned Events
Routine Activities
These specialised activities can be further broken down into high skill
components, simple routine components and unplanned components as
shown in Figure 7.
107
Figure 7: Breakdown of Specialised Activities
Specialised Activities
High Skill, Complex Unplanned

Components Components
Simple, Routine
Components
High skill/complex and unplanned components often involve some level of

competency training and may draw upon situational judgement based on
years of experience. The application of these high level skills will be
dependent upon the unique blend of circumstances presenting at the time,
and there may be a multitude of techniques available for dealing with the
given situation. In these instances, guidance on the selection of the most
appropriate way forward may be difficult to capture in a procedure, and
this type of restriction is unlikely to benefit the process.
Once routine sub-elements of the more complicated overall process have

been identified, these can be further improved through the use of
monitoring and feedback mechanisms. This period of fine tuning will be
referred to in this thesis as the “progressive” stage as this promotes a
better understanding of the process and allows that portion of the activity
to be mastered.
It is only after the process has been mastered that it is possible to enter
into what will be termed the “strategic planning” phase. When operating in
the strategic planning phase there is the opportunity to consider the use of
best practice, alternative options, and new directions.
108
Figure 8: Cycle of Improvement
Specialised Activities Identify and acknowledge where

complex components exist. These
may require a high level of skills such
as competency training, judgement and
experience to manage effectively.
Identify simple routine

subcomponents
Fine tune the process
Apply strategic thinking once the

process has been mastered
Goleman suggests that the ability to see the wider picture as in the
strategic planning phase, represents one of the highest orders of
thinking.332
Hence, the building blocks of an OHS MS will fall into the following
categories:
Complex components where flexibility and high skill levels are

retained, for example training;
Routine components that benefit from consistency, for example

record keeping activities;
Contingency plans for unplanned, unwelcome or unexpected events,

such as emergency preparedness;
Progressive elements where monitoring for the purpose of

improvement is desirable, such as self checking and internal
auditing; and
Strategic elements that consider the wider scenario, and are geared
towards efficiency, control and growth, including evaluation exercises
such as management and operational reviews.
109
This analysis strongly supports and extends the use of the Deming “Plan-
Do-Check-Act” cycle for the OHS MS model framework, and also provides
a means of sorting the constituent elements into a logical time sequence.41
The strategic elements correspond to the “planning” phase and these
would include all the review functions. The combination of both routine
and complex activities represents the “doing” stage; with the exception
that this implementation stage has been amended to recognise the
differences needed in managing routine and complex activities. Many of
these implementation stage activities have been discussed previously
under the various strategies available to prevent and control workplace
hazards. The “checking” section is covered by the progressive elements
and it is here that data is collected to gain a better understanding of the
processes involved. The “action” phase equates to the contingency
responses such as emergency planning, incident management and
rehabilitation that deal with situations where prevention and control
measures have failed. Although these contingency elements are reactive
by nature, they are still very necessary and offer learning opportunities for
the organisation.
Hence, a comprehensive OHS MS framework would need to incorporate

all of these phases, as well as suggesting cues for the optimal sequencing
of events.
3.2 OHS Model Framework Development
Gallagher suggested that there was a high level of agreement about the
following individual components of an OHS MS:333
Organisation, responsibility, accountability -
Senior management commitment and active participation;
Line management/Supervisor involvement;
Specialist personnel;
110
Management accountability;
Performance measurement;
Management systems (starting with the OHS Policy).
Consultative arrangements;
OHS Committee;
Worker/management participation in workplace risk issues;
Issue resolution procedures, and also
Specific programs including:
Systems for risk management, including workplace critical risks;
OHS information and promotion;
Health and safety rules and procedures;
Assessment of training needs and a training program;
Workplace assessments and inspections;
Systems for first aid and medical surveillance;
Emergency response;
Procedures for purchasing, contract review, contractors and so on;
Incident reporting and investigation;
Systems for monitoring and review; and
Record keeping systems for risk management and incident

investigation.
However, an examination of the popular OHS MS structures currently

available suggest that there is considerable variation on the emphasis and
arrangement of the elements within these models depending on the
location of the operation, regulatory requirements and influencing
paradigms. Whilst this may seem to be a subtle difference only, it appears
to be a stronger influence in the acceptance of the system and ease of
implementation.
111
When reviewing OHS MS structures currently available, Victoria’s
SafetyMAP program introduced in the early 1990’s emerges as one of the
most dominant models. It includes a means of rewarding employers who
had a good safety record through the workers’ compensation system and
who had applied a proactive approach to managing workplace health and
safety.130
Other systems followed, such as:
TriSafe management systems audit (Queensland);79
Safety Achiever Business Scheme (South Australia);74
WorkSafe Plan (Western Australia);76
Safety-Wise ComCare (Commonwealth).230
Each system has strengths and weakness and targets a particular industry
profile. SafetyMAP is well suited to a large, stable manufacturing
organisation, whilst ComCare covers psychological hazards in more
depth, which is appropriate in a public service organisation.77, 230
Queensland’s Tri-Safe has tiered audits and seeks to verify compliance by

cross-checking evidence from the employees on the shop-floor with
information from upper management.79 South Australia’s Safety Achiever
Bonus Scheme is modelled on AS/NZS 4801 with modifications to include
workers’ compensation.74 It also provides a free, simple audit tool based
on Excel with colour coding that may be printed onto a few pages and
placed on a notice board.75 The Australian Capital Territory (ACT) and
Tasmanian regulatory bodies cater well to small firms with the provision of
an assortment of downloadable tools.72, 73 Whilst all emphasise the need
for consultation, there is little in the promotion of training in problem-
solving skills.
All the OHS MS structures offered by the major jurisdictions within

Australia provide a legislative interface, which is useful for a baseline
assessment and helpful in understanding what regulatory obligations must
112
be met. However, the difficulty arises when businesses operate over
numerous jurisdictions and have multiple regulations to follow.
There are also a plethora of commercial systems available for purchase

off the shelf, or for customising through the use of consultants. Do-it-
yourself kits are available from some jurisdictions for small businesses and
there is also an assortment of downloadable OHS MS from the internet for
a relatively small fee. However, the concept that a system can be obtained
and deemed to be adequate without sufficient consideration of the
individual organisations’ needs and hazard profile is fraught with danger.
Despite the multitude of OHS MS available there is still a reticence to

formally mandate the use of such structures as in the internal control
models in Norway and Sweden.334 Criticisms of this approach have been
based on the difficulty and expense for small businesses; the potential for
token compliance and excessive bureaucracy; the complications of a
fragmented labour market; and the need to take into account remote or
mobile workplaces. All these increase the challenge to identify the building
blocks of an OHS MS framework that will be widely acceptable and offer
efficiency and streamlining of the occupational health and safety
management process.
It is asserted here that rather than focusing on a particular OHS MS

structure that is currently available and using that as a basis for an
assessment tool, it would be far more comprehensive to develop a
framework derived from a combination of the safe place, safe person and
safe systems strategies found within the literature.
The benefits offered by this approach are:
there is no assumption made about the validity of one particular

management system structure;
it ensures that the entire hazard landscape has been considered;
it allows tailoring to suit individual organisation needs;
113
it provides a framework for future analysis and thereby prompts
reflection and problem solving;
it provides acknowledgement of complex tasks that are not suited to

the restrictiveness of documentation and guidance on how to identify
critical sub routines that may benefit from consistency and
streamlining; and
it checks whether the full spectrum of components have been

invoked – those that deal with complex and routine activities,
unplanned events as well as provision for progressive and strategic
exercises.
On this basis, the following building block components are presented in

10, having been derived from the earlier sections of the literature review
pertaining to safe place, safe person and safe systems strategies. This
framework has been divided into three core sections to allow separate
consideration of each of the safe place, safe person and safe systems
aspects to ensure that the entire context of workplace hazards have been
examined. This also allows reflection on the different perspectives offered
by operations, the individual worker and management. The elements have
been colour coded to illustrate where the elements are located on the
Deming “Plan-Do-Check-Act” cycle, and this also offers an indication of
the most appropriate timing for the application of the activities suggested
therein. As can be seen, the proposed framework covers all stages of the
continual improvement cycle. The proposed framework illustrates how the
improvement cycle is iterative in nature as the information collected from
the review stages may be fed back into the conceptual policy and planning
activities at the top of the framework. Equal weighting has been given to
the safe place, safe person and safe systems components respectively to
ensure there remains a balanced approach to the different perspectives.
Finally, a definition of each building block element has been listed in
Appendix 1.
114
Table 10: Proposed OHS MS Model Framework.
Safe Place Safe Person Safe Systems

Equal Opportunity/
Baseline Risk Assessment OHS Policy
Anti-Harassment
Ergonomic Assessments Training Needs Analysis Goal setting
Inductions-Contractors/
Access/Egress Accountability
Visitors
Skill Acquisition - (criteria Due Diligence Review/
Plant/Equipment
screening) Gap Analysis
Work Organisation-Fatigue/ Resource Allocation/
Storage/Handling/Disposal
Stress Awareness Administration
Procurement with OHS
Amenities/Environment Accommodating Diversity
Criteria
Job Descriptions –Task Supply with OHS
Electrical
Structure Consideration
Noise Training Competent Supervision
Behaviour Modification (PPI’s

Hazardous Substances Safe Working Procedures
Observation Programs)
Biohazards Health Promotion Communication
Networking, Mentoring,
Radiation Consultation
Further Education
Installation/Demolition Conflict Resolution Legislative Updates
Preventive Employee Assistance

Procedural Updates
Maintenance/Repairs Programs
Modifications – Peer Review/
First Aid/Reporting Record Keeping/Archives
Commissioning
Customer Service –Recall/
Security – Site/Personal Rehabilitation
Hotlines
Emergency Preparedness Health Surveillance Incident Management
Housekeeping Performance Appraisals Self Assessment Tool
Plant Inspections/Monitoring Feedback Programs Audits
Review of Personnel
Risk Review System Review
Turnover
Key
Strategic Complex Contingency
Progressive Routine
115
3.3 Analysis of National and International OHS MS
Structures
To trial the suitability of the proposed framework given in Table 10 as the

basis of an OHS MS assessment tool, eleven national and international
OHS MS structures were selected for a desktop analysis. The criteria
invoked for selection of OHS MS structures was that they were easily
accessible, comprehensive and widely accepted. The following OHS MS
models were reviewed:
AS/NZS 4801/4804 (Australia/New Zealand);2, 195
SafetyMAP (Victoria);77
Safety-Wise (Commonwealth of Australia);230
WorkSafe (Western Australia);76
Safety Achiever Business Scheme (SABS) (South Australia);74
International Labour Organisation (ILO);335
Seveso II (European Union);96
American National Standards Institute, American Industrial Hygiene

Association(ANSI/ AIHA) Z10-2005;336 and
Voluntary Protection Program (United States);85 and
Occupational Health and Safety Assessment Series (OHSAS)

18000.37, 337
In the analysis that follows:
Tables 11-13 were used to identify whether the elements suggested

in the proposed OHS MS framework given in Table 9 were present in
the OHS MS structures analysed;
116
Charts1-3 rank the number of each of the safe place, safe person
and safe systems elements respectively that may be found within the
OHS MS structures analysed. This was to give an indication of the
popularity of the individual components.
Table 14 demonstrates the balance of safe place, safe person and

safe systems elements within each of the OHS MS structures
analysed through the use of pie charts. This is to provide a visual
representation of the focus of the particular OHS MS structure.
Charts 4-6 build on this analysis, providing the total number of safe
place, safe person and safe system elements found in each of the
systems.
Chart 7 gives the total number of suggested OHS MS elements

mentioned within the individual OHS MS structures analysed to
evaluate their level of comprehensiveness; and finally
Table 15 provides a brief listing of distinguishing features for each of

the eleven OHS MS structures, highlighting their key strengths and
limitations.
117
Table 11: Comparison of Selected OHS MS with Safe Place Criteria
Safe Place Criteria
Baseline Risk Assessment

Gap analysis
Ergonomic Assessment
Access/Egress
Plant/Equipment
Storage/Handling/Disposal
Amenities/Environment
Electrical
Noise
Hazardous substances
Biohazards
Radiation
Preventive Maintenance/
Repairs
Modifications - Peer Review/
Commissioning
Installation/Demolition
Security – Site/Personal
Emergency Preparedness/
Response
Housekeeping
Plant Inspections/
Monitoring
Risk Review/Evaluation
4801/4804 (AUS/NZ) 3 3 2 3 3 2 2 2 3 3 2 3 2 3 2 3 3 3 3
Safety Map (VIC) 3 3 3 3 3 3 3 3 3 2 3 3 2 2 2 3 3 3 3
Tri-Safe (QLD) 3 3 2 3 3 3 3 3 3 3 3 3 2 2 3 3 3 3 3
Safety-Wise (Com) 3 3 3 3 3 3 3 3 3 2 2 3 3 3 2 3 3 3 3
WorkSafe (WA) 3 2 2 3 3 2 3 2 3 2 2 2 3 2 3 3 3 3 3
SABS (SA) 3 3 2 3 2 2 2 2 2 2 2 2 3 3 2 3 3 3 3
ILO 3 3 2 2 2 2 2 2 2 2 2 2 3 2 2 3 3 3 3
Seveso II (EU) 3 2 2 3 3 2 2 2 2 2 2 3 3 3 3 3 3 3 3
ANSI/ AIHA (US) 3 3 2 3 3 2 3 3 3 3 3 3 3 3 3 3 3 3 3
VPP (US) 3 3 2 3 2 2 3 3 3 2 2 3 2 3 2 3 3 3 3
OHSAS 18000 (UK) 3 3 3 3 3 3 2 3 3 2 3 3 3 3 2 3 3 3 3
118
ILO
VPP (US)
SABS (SA)
Seveso II (EU)
Tri-Safe (QLD)
WorkSafe (WA)
ANSI/ AIHA (US)

Safety Map (VIC)
Safety-Wise (Com)
OHSAS 18000 (UK)

4801/4804 (AUS/NZ)
Safe Person Criteria
Equal Opportunity/
2
2
2
2
2
3
3
3
3
3
3
Anti-harassment Policies
3
3
3
3
3
3
3
3
3
3
3

2
3
3
3
3
3
3
3
3
3
3
Visitors
Skills Acquisition –Criteria/
2
2
3
3
3
3
3
3
3
3
3
Screening
Work Organisation –
2
2
2
2
2
3
3
3
3
3
3
Fatigue/Stress Awareness
Accommodating Diversity
2
3
3
3
3
3
3
3
3
3
3
Job Descriptions –Task

2
2
2
2
3
3
3
3
3
3
3
3 Structure
3
3
3
3
3
3
3
3
3
3
119
Training
2
2
2
2
2
3
3
3
3
3
3
(PPI’s Observation)
Table 12: Comparison of Selected OHS MS with Safe Person Criteria
2
2
2
2
2
2
2
2
3
3
3
Health Promotion
2
2
2
2
2
2
2
2
2
2
3
Further Education
Conflict Resolution
2
2
2
2
2
2
2
2
3
3
3 Employee Assistance
2
2
2
2
2
2
2
2
2
3
3
Programs
First Aid/ Reporting
2
2
3
3
3
3
3
3
3
3
3
Rehabilitation
2
2
2
2
2
2
2
3
3
3
3
Health Surveillance
2
2
2
2
3
3
3
3
3
3
3
Performance Appraisals
2
2
2
2
2
2
2
3
3
3
3
Feedback Programs
2
2
2
2
2
2
3
3
3
3
3
Review of Personnel Turn
2
2
2
2
2
2
2
2
2
2
3
Over
Table 13: Comparison of Selected OHS MS with Safe Systems Criteria
Safe System
Criteria
OHS Policy
Goal Setting
Accountability
Due Diligence Review/
Gap Analysis
Resource Allocation/
Administration
Criteria
Supply with OHS
Consideration
Communication
Consultation
Legislative Updates
Procedural Updates
Record Keeping/Archives
Customer Service –Recall/
Hotlines
Incident Management
Self Assessment Tool
Audits
System Review
4801/4804(AUS/NZ) 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 3 3
Safety Map (VIC) 3 3 3 3 2 3 3 3 3 3 3 3 3 3 2 3 3 3 3
Tri-Safe (QLD) 3 3 3 3 3 3 2 3 3 3 3 3 3 3 2 3 3 3 2
Safety-Wise (Com) 3 3 3 2 2 3 2 3 3 3 3 2 2 3 2 3 3 2 2
WorkSafe (WA) 3 3 3 3 3 2 2 3 2 3 3 3 2 2 3 3 3 2 3
SABS (SA) 3 3 3 3 3 3 3 3 2 3 3 3 3 3 3 3 3 3 3
ILO 3 3 3 3 3 3 2 3 3 3 3 3 3 3 2 3 2 3 3
Seveso II (EU) 3 3 3 2 3 2 2 3 2 3 3 2 3 2 2 3 2 3 3
ANSI/ AIHA (US) 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 3 3 3 3
VPP (US) 3 3 3 3 3 2 2 3 2 3 3 2 2 2 2 3 3 3 3
OHSAS 18000 (UK) 3 3 3 3 3 3 2 3 3 3 3 3 3 3 2 3 2 3 3
120
Chart 1: Comparison of the Number of Safe Place Elements Addressed Across the 11 OHS MS Structures Analysed
Emergency Preparedness/ Response

Baseline Risk Assessment gap analysis
Risk Review /Evaluation
Plant Inspections/ Monitoring
Housekeeping
Plant/Equipment
Hazardous substances
Storage/ Handling/ Disposal
Preventive maintenance/ Repairs
Installations/ Demolitions
Modifications
Noise
Electrical
Security – Site/ Personal
Radiation
Biohazards
Access/ Egress
0 2 4 6 8 10
121
Chart 2: Comparison of Safe Person Elements Addressed Across the 11 OHS MS Structures Analysed
Training
Inductions-Contractors/ Visitors
Skills Acquisition –Criteria/ Screening
Job Descriptions –Task Structure
Health Surveillance
Equal Opportunity/ Anti-harassment Policies
Behaviour Modification (PPI’s Observation)
Work Organisation –Fatigue/Stress Awareness
Feedback Programs
Rehabilitation
Health Promotion
Conflict Resolution
Review of Personnel Turn Over Rates
Networking, Mentoring, Further Education
0 1 2 3 4 5 6 7 8 9 10 11 12
122
Chart 3: Comparison of Safe Systems Elements Addressed Across the 11 OHS MS Structures Analysed
OHS Policy
Goal Setting
Accountability
Consultation
Communication
Incident Management
System Review
Audits
Due Diligence Review/Gap Analysis
Resource Allocation/ Administration
Procurement with OHS Criteria
Record Keeping/ Archives
Procedural Updates
Legislative Updates
Supply with OHS Consideration
Customer Service
0 2 4 6 8 10
123
Table 14: OHS MS at a Glance: Proportion of Safe Place, Safe Person and Safe Systems Building Blocks
ANSI/AIHA Z10 AS/NZS 4801/4804 OHSAS 18000 SafetyMAP
Safety-Wise Tri-Safe SABS ILO
Worksafe VPP Seveso II

Key
Safe Place
Safe Person
Safe Systems
124
Chart 4: Comparing OHS MS Structures with the number of Suggested Safe Place Building Blocks
OHSAS 18000 series
ANSI/ AIHA
Tri-Safe
Safety-Wise
SafetyMAP
VPP
AS/NZI 4801/4804
Seveso II
WorkSafe
SABS
ILO
0 2 4 6 8 10 12 14 16 18
Number of Suggested Safe Place Building Blocks
125
Chart 5: Comparing OHS MS Structures with the number of Suggested Safe Person Building Blocks
ANSI/ AIHA
Safety-Wise
ILO
SafetyMAP
SABS
OHSAS 18000 series
AS/NZI 4801/4804
WorkSafe
Tri-Safe
VPP
Seveso II
0 2 4 6 8 10 12 14 16 18
126
Chart 6: Comparing OHS MS Structures with the number of Suggested Safe Systems Building Blocks
ANSI/ AIHA
AS/NZI 4801/4804
SABS
SafetyMAP
ILO
Tri-Safe
OHSAS 18000 series
WorkSafe
VPP
Seveso II
Safety-Wise
0 2 4 6 8 10 12 14 16 18
Number of Suggested Safe System Building Blocks
127
Chart 7: Comprehensiveness of OHS MS Structures – Comparing the Total Number of Suggested Elements
ANSI/ AIHA
OHSAS 18000 series
SafetyMAP
Tri-Safe
Safety-Wise
AS/NZI 4801/4804
SABS
ILO
WorkSafe
VPP
Seveso II
0 5 10 15 20 25 30 35 40 45 50 55
128
Table 15: Distinguishing Features of Selected OHS MS Structures
OHS MS Structure Strengths Limitations
4801 (AUS/NZ) Comprehensive planning guide Rehabilitation not mentioned in the standard but does appear in the
Identification of resource needs prominent guidelines
Safe procurement and supply emphasised Very limited guidance on potential hazards
Includes Health Surveillance Human factors are considered but no psychological factors
Records/ Documentation section render it suitable for integration into a No self assessment tool available
Quality System
Safety Map (VIC) Safe procurement & supply included Less emphasis on psychological factors
Safe maintenance/ repairs emphasised Temptation to remain at the initial assessment phase
Three stages of implementation – use of a realistic, staged approach
Tri-Safe (QLD) Three levels of data collection - employer, line manager and employee. Few psychological hazards identified
Scores must be confirmed by qualitative assessment. Elements are Rehabilitation not included
weighted. Would be time consuming to apply – many questions involved
Comprehensive identification of workplace hazards – includes workplace Asks whether there is supervision of contractors/ visitors/ others, but does
violence, biological and radiation hazards not specifically require inductions
Handles procurement well
Considers the use of the performance appraisal
Very practical – geared for a systematic management of OHS hazards
rather than the use of controlled documents
Safety-Wise (Com) Leadership emphasised No internal audit or management review included
Psychological hazards identified Resource levels not identified
Ergonomic hazards identified No safe design/ supply elements
Plentiful guidance on particular hazards
Consultation & participation emphasised
WorkSafe (WA) Three recognised stages of implementation No rehabilitation element
Emphasises provision of resources and time, training and commitment Little guidance on individual hazards
Comprehensive contractor management No safe procurement (other than contractors)/ supply requirements
129
OHS MS Structure Strengths Limitations
SABS (SA) Clear, concise presentation of information Little guidance on workplace hazards
Three levels of implementation Potential to lose information in the presentation of the guidance material
Achievement may be easily presented for wider communication
ILO Worker participation emphasised Safe design, safe supply excluded
Management of change seen as critical Little on psychological factors
Comprehensive contractor management
Seveso II Management of change seen as critical Not suitable for small businesses
Emergency preparedness emphasised
Suits major hazardous, manufacturing operations
ANSI/ AIHA Z10-2005 Brief, straightforward document Little detailed information on the types of hazards that may be
Emphasises safe design and review of changes encountered
Separates objectives out of the policy statement - policy more of a
pledge of commitment and expression of corporate values
Excellent guidance on the types of objective evidence that would
demonstrate compliance and the use of performance indicators.
Emergency preparedness considers the needs of those who are disabled
Confronts the problem of “numbers management”
Confronts the problem of using reward schemes and how this may
encourage under-reporting
Highlights the importance of education and mentions mentoring.
Deals with attitudes and potential barriers to OHS program
implementation
VPP (US) Very simple and straightforward No emphasis on reporting or documentation
Three levels of achievement Very little on health or psychological hazards
Targets 4 critical areas – management, leadership and employee
involvement; worksite analysis; hazard prevention and control; and
safety and health training;
OHSAS 18000 (UK) Brief and straightforward Format of guidelines repetitive
Logical, simple formatting yet comprehensive Psychological hazards not identified
No mention of first aid
130
3.4 Emergent trends in OHS MS structures
The analysis from Tables 11-13 reveals a growing willingness to address

the more subtle issues that if left ignored have the potential for widespread
negative repercussions – such as safe procurement and more recently,
safe supply. This quantum shift from the obvious to the underlying causes
indicates a growth in strategic manoeuvering, and an increased
awareness of linkages and interfaces. It is in these interfaces where the
boundaries of control are less defined and may require negotiation
between two or more parties, that inherent vulnerability surfaces.
Acknowledgement of these interfaces extends the number of possible
control options available and indicates an appreciation of the wider
contextual fabric that confronts the modern employer.
It is interesting to note that whilst it has become more widely accepted that
purchasing activities will require OHS consideration, there has been a
greater reluctance to take on design issues, except where the
ramifications are internal as with modifications to existing equipment or in
the case of introducing new equipment. It appears that the strategy has
been to ensure that the customers demand OHS compatibility, driving the
process from the end user, rather than to initiate safe supply from the
onset.
Conspicuous by its virtual absence was the mention of personal protective

equipment in many of the OHS MS structure documents. This articulates
moves to respond with increasingly higher order controls and a more
strategic outlook.
The latest ANSI/AIHA Z10-2005 standard from the US was distinctive in its
emphasis on the consideration of human factors, not just from an
ergonomic perspective, but also with an appreciation of the biophysical
limitations humans have in the processing of information. The illustrative
example given was to ensure that the frequency used by warning lights
was one that the human eye was most receptive to. Recommendations
131
are also made to document the review process – a useful exercise should
the need to demonstrate due diligence arise.
An awareness of the importance of work organisation and the breakdown

of tasks for analysis was a feature of the AS/NZS 4801/4804, Safety-Wise
(Commonwealth) and Queensland’s Tri-Safe. Safety-Wise was particularly
appreciative of psychological hazards and the need to accommodate
diversity in the workplace. Safety-Wise acknowledged assertively the
problem of an individual having lack of control over their own workloads,
and the stress this may cause. This was a refreshing admission that is
worthy of notice and replication. Tri-Safe was one of the only structures to
mention the possibility of workplace violence, an unfortunate but realistic
reflection of the increasing spectrum of workplace hazards.
A number of OHS MS structures promoted a staged approach to

implementation such as the South Australian Safety Achiever Business
Scheme (SABS) and Victoria’s Safety MAP. This tiered approach is useful,
but not without drawbacks – the most obvious being the temptation to stop
at the first phase, as “minimal compliance”. Evidence of this was seen with
the Esso Longford disaster where only the first stage of implementation of
Safety MAP was required for self-insurance purposes, which did not
include the requirement for internal audits. When these minimum
requirements paradoxically become the acceptable standard, the potential
for exposure increases. The challenge for OHS MS implementation is to
alleviate the overwhelming nature of the task ahead by breaking it down
into palatable portions, without encouraging a minimalist approach.
Tri-Safe was also unique in its attempt to triangulate data – using

information from management, line managers and employees. This
emphasised the need for genuine as opposed to token compliance.
Western Australia’s WorkSafe highlighted an appreciation of production
issues and the conflict between good intentions and the demands of
providing returns on investments. By targeting not only the need for
management commitment to be demonstrated by the provision of financial
132
resources but also those of time, the point was made that genuine
commitment reaches beyond finances.
Within the safe place criteria, it would appear that essential elements
include:
a baseline risk assessment and plans for ongoing reviews;
integrity of plant and equipment;
the need to assess for manual handling and other ergonomic factors;
the control and management of hazardous substances
workplace inspections; and
emergency preparedness and response.
Of note was the inclusion of the requirement to consider the disabled in an

emergency situation by the ANSI/AIHA Z10-2005 standard. This reflects
an acceptance of diversity within the workplace, and the need to take this
into account in both normal and abnormal situations.
The decision on whether to provide specific guidance regarding potential

hazards or to generalise was a major distinguishing feature amongst the
various OHS MS structures. The advantage of making certain structures
applicable to a wider audience would need to be offset against the
pragmatic stance adopted by a number of jurisdiction based structures.
This lack of detail may be perceived as frustrating for a number of smaller
businesses that would prefer to solve their issues internally. For some, the
cost of outside expertise would be more judiciously spent on rectifying
existing problems.
Amongst the safe person criteria, training – the various sorts and the need
to ensure that the information was presented in a manner that could be
understood by all those requiring the information, was the most popular
theme. The new ANSI/AIHA standard emphasised the need to also
educate- reinforcing the adoption of a more strategic approach. This
133
included engineers being educated in safe design; the necessary parties
being educated in investigation and hazards identification skills; as well as
the need to consider OHS impacts in purchasing arrangements.
Networking and further education were only mentioned in one of the OHS
MS structures reviewed, and there may be some time lag before this
suggested item gains widespread acceptance as the benefits are more
long term.
The inclusion of psychological hazards is perhaps a more difficult task,

again possibly due to the nebulous nature of the boundaries of employer
influence and the difficulty identifying them. No doubt an interface that has
very real effects in the workplace, the attempt to overcome this undeniable
barrier takes the role of the employer to a more personal level. It is argued
that the benefits of having a safe workplace may be lost if people do not
actually want to work there.
As far as safe system elements were concerned, the need for direction
and leadership were prominent, as well as the need for consultation,
communication and incident investigations. Also heavily featured were the
common themes of the importance of having a policy, setting goals,
performing audits and conducting regular system reviews. Some OHS MS
structures were concerned with the need for document control, whilst in
others this was not considered as vital. The decision by some
organisations to downplay the document control side was viewed as an
attempt to break away from the “paper tiger” image, promoting instead the
systematic approach without dictating the delivery method. Whilst this may
be advantageous in the short term, it is likely that the need for inclusion of
elements that ensure the use of the most current information will emerge
by necessity.
One of the most pleasing features of the ANSI/AIHA standard was the
more balanced approach to risk assessment with the emphasis of the
need to prioritise workplace issues sensibly. The new standard offers
considerable guidance on setting of objectives. This is very pragmatic and
demonstrates that it is necessary not only to have an overriding goal, but
134
to break it up into achievable subsections. This also serves a second
purpose – to allow for a number of small, early victories that may supply
the encouragement necessary to propel the process forward, so that
eventually it becomes self sustaining. This need for continual, useful
feedback is vital to the success of any new program introduced.
A novel feature of the ANSI/AIHA Z10-2005 standard is the direct

approach it has taken to many commonly experienced barriers to OHS
implementation. It openly confronts the problems of manipulating reports
of injuries by either reclassification, or under-reporting per se, and sternly
cautions against the use of incentive schemes to improve safety
performance. This endeavours to remove attempts to demonstrate “token
compliance” and is warmly welcomed. It also warns against conducting
safety training outside of paid working hours and even cautions against
the potential for creating resentment should staff be left under-resourced
whilst others have been taken out of their normal duties to receive training.
In reference to Table 14, OHS MS at a Glance: Proportion of Safe Place,

Safe Person, and Safe Systems Building Blocks, it can be seen that some
OHS MS such as Seveso II, are geared towards manufacturing
organisations that are more capital than labour intensive; whilst others are
more balanced in their construction by incorporating a mix of safe place,
safe person and safe system criteria such as Safety-Wise. Models that
were heavily systems oriented included AS/NZS 4801/4804, ILO, SABS
and Seveso II. SafetyMAP, OHSAS 18000, ANSI/ AIHA Z10 -2005,
TriSafe, WorkSafe, and VPP displayed fairly similar proportions of safe
place and safe system elements, with safe person elements taking a
lesser role. This is not surprising due to the ongoing safe place/safe
person schism that had characterised the debates in this area for some
time. The fact that more elements are beginning to emerge in the safe
person area does suggest that future trends may include a more even
distribution of the three pivotal areas. OHS MS structures such as Safety-
Wise may therefore be more suited to organisations that have a high
labour component, or large office environment.
135
Charts 4, 5 and 6 considered in turn the number of suggested safe place,
safe person and safe systems building block components contained within
the various OHS MS models reviewed. From this analysis there appeared
to be the most agreement in the area of safe systems and the least in the
safe person arena. There was also substantial agreement over safe place
elements, however the decision by some models to refer to hazards
generically rather than specifically accounted for the greater than expected
spread of results. Whilst it would be unreasonable to suggest that every
hazard needs to be spelt out for employers, it appears to be more useful if
some critical hazards and particularly dangerous interfaces are brought
into focus.
In terms of comprehensiveness and in reference to Chart 7, the

ANSI/AIHA Z10-2005 standard contained 48 of the 57 suggested building
blocks for an OHS MS, and was by far the most extensive in terms of
coverage. This was followed by the OHSAS 18000 series and SafetyMAP
which were ranked equally at second place, then followed by Tri-Safe,
then AS/NZS 4801/4804 and Safety-Wise. All of the above mentioned
OHS MS structures contained at least 40 of the 57 suggested building
block elements. Again, the decision to refer to generic hazards rather than
specifying particular ones had a significant impact on the outcome.
In summary, it is evident that recommendations and guidelines for OHS

MS structures are heading towards a much more strategic focus. This
progress from the “here and now” to lessons being learnt from the past to
provide a safer future impart a temporal factor that makes the OHS MS
structure a useful tool for the planning of any business activities. Also
evident is the growing courage to tackle the more complicated
psychological issues within the workplace, and an acknowledgement that
workplaces are less defined than they may have been previously. This
departure from concentrating purely on the existing physical environment
represents a maturing of the OHS MS process.
It can be seen from the preceding discussion that the application of this
safe place, safe person and safe system framework may provide a useful
136
analytical tool that may be extended to a variety of workplaces as it
encompasses a very broad range of prevention and control strategies.
Assessing the relevance of these strategies to individual organisations will
also assist them to identify their unique hazard profile, a process that
would benefit from periodic review.
137
4. MEASURING & EVALUATING SAFETY
PERFORMANCE
Once a decision has been made to embark upon an OHS improvement

program, it is important to take measures to assess how successfully this
process has been applied. It is also crucial to identify areas of strengths
and weaknesses to enhance the organisational learning process.
Most measures will present a particular aspect of the OHS program and
the interpretation of the results will vary according to the perspective from
which they have been assessed. The perspectives of management,
operations and the individual worker are likely to reflect different issues
and areas of concern, mirroring the different motivational factors that direct
their actions and decision making processes. The validity of one
perspective over another is highly subjective and depends on whether the
objective of the measurement was to:
establish baseline conditions;
generate improvements in a certain area of operations;
to assist management in the decision making process;
to gather alternative opinions; or
to assess the perceived effectiveness of changes.
It is unlikely that measures taken from one perspective would be entirely

accurate, just as the benefits of any corrective actions implemented would
be limited if they did not consider the full context of the situation and those
affected by the changes. As an example, an injury reported from the
perspective of the injured worker will almost certainly be different from the
information reported by the injured worker’s supervisor. Explanations for
root causes may be entirely different, and different once again if the
incident was reported by a member of the organisation’s executive.297 In
this instance, which data is more reliable? If the data is biased from the
138
onset, this will impact the nature and effectiveness of the solutions
generated. Hence there is a clear need to take multiple measures and
attempt to capture different perspectives.
To assist this process, the following literature review was conducted to

provide a concise summary of a number of commonly encountered
methods to measure or capture safety performance. Injuries, illnesses and
unusual occurrences such as near misses or near hits are all undesirable
events and so there have been recent attempts to find more positive
indicators. It would appear that like most metrics, the key is to find
something that is meaningful, robust, representative and not susceptible to
manipulation. Many measures achieve this in some but not in all cases.
Measurement, especially against planned targets or objectives, has the
advantage of focusing management’s attention.
Organisations may become unreceptive and apathetic if there is an

overload of data presented or if the measures are unlikely to lead to visible
changes in the workplace. Therefore, it is important to maintain interest by
having a range of metrics available that may target specific areas on a
strategic or rotating basis. Understanding the strengths and limitations of
the various indicators is therefore crucial if they are to be applied in the
most appropriate manner. One fundamental concept remains - without
some baseline measurement it would be difficult to assess improvement or
otherwise.
139
Table 16: The Perspective of Various Measurement Indicators
Perspective Short Term Long Term
Management Lost time injuries/Workers Due diligence reviews/

compensation data gap analysis
Medical treatment injuries/First aid Auditing

reports
Maturity grid measurements
Operations Control charts/Trend charts Risk assessments
Positive performance indicators
Safe/Unsafe acts observations
Controlled self assessment
Individual Near hit reporting Staff turnover rates
Perception Surveys
Table 16 illustrates a range of OHS performance indicators, the

perspective from which they are usually drawn and the time span they are
usually invoked over. A critique of some of the most popular indicators
follows.
4.1 From the Perspective of Management
4.1.1 Lost Time Injuries and Workers Compensation Data
Lost time injuries are a major measure used by industry and insurance
organisations to assess safety performance. As such, they are measures
of safety failure and are not a true indicator of all safety-related activities.
Some of the problems associated with lost-time injury frequency rates

(LTFR’s) and workers’ compensation data include:147
incentives to under-report to reduce premiums;
under-representation of occupational illnesses and diseases;
under-representation of self-employed workers, contractors, labour-

hire workers and others; and
the responses tend to be reactive by nature.
140
Such measures are called trailing indicators, and should be used with
caution. A business may become so engrossed in the management of
injury classifications, that it focuses on the definition rather than the root
cause.136 The typical example here is where injured workers are brought in
to be “at work” before they are well simply to avoid the injury being
categorised as “lost time”.338 Placing too much emphasis on injury
statistics may also have a negative effect by sending reporting
underground or masking serious injuries, especially if a reduction in the
number of injuries is linked to a bonus or other financial rewards.136
Clearly, an organisation cannot expect injury rates to reflect progress

made on managing chemical safety or dealing with psycho-social issues.
Injury rates will most often reflect changes made to the physical workplace
and possibly changes made in behaviours and attitude. Hence the scope
of this indicator and its meaning must be conveyed to management so that
changes in injury rates are not taken out of context and plateau effects are
not misinterpreted to suggest that current actions are not being helpful.
Whilst the incentive exists for the manipulation of indicators associated

with direct financial benefits, the success of such ploys is less likely when
alternate cross-checks are in place. In some cases it may be necessary to
quantify in monetary terms both the direct and indirect costs of injuries so
as to “work with the same currency” as other business units.
LTFR’s may be useful to larger organisations and provide a means of

benchmarking across various sites, industries or even internationally, yet
these figures may not be meaningful to smaller businesses with very low
incidents of injury or illness. The difficulty with reporting lost time
frequency rates expressed in injuries per million person-hours is that
unless the person using the figure is familiar with benchmarking exercises,
it does not communicate the significance of the number of actual injuries
experienced within the local work environment.
141
4.1.2 Medical Treatment and First Aid Injuries
While medical treatment injuries (MTI’s) and first aid injuries are still
negative measures, the advantages of reporting these on a regular basis
are that they are straightforward, easy to conceptualise and usually
provide sufficient data to analyse. First aid injuries and the administration
of non-prescription analgesic or anti-inflammatory medication can also be
semi cross-checked against stock in first aid cabinets, provided that there
is a suitable policy of recording all usage so non-occupational use can be
distinguished from occupational uses.
4.1.3 Due Diligence Plan Reviews and Gap Analysis
Some organisations use a due diligence plan or undertake a gap analysis

to drive the OHS improvement program forward. These usually result in a
list of projects that once implemented will improve OHS regulatory
compliance. Persons responsible for the individual tasks should be clearly
allocated and time frames identified for the completion of projects.336
Projects are usually prioritised according the level of associated risk, and
the existence of such a plan demonstrates a willingness to abide by local
regulations, whilst acknowledging that often only limited funds are
available. Review of these plans is crucial to demonstrate due diligence,
and provided that realistic deadlines have been agreed upon, monitoring
the clearance rate of projects provides a useful means of gauging the
reality and sincerity of management commitment.67, 339
4.1.4 Auditing
An audit should not be confused with a workplace inspection, hazard

spotting exercise or gap analysis. The ANSI/AIHA Z10-2005 standard
defines an audit as “a systematic process for obtaining information and
data and evaluating it objectively to determine the extent to which defined
criteria are fulfilled”.336 When applied specifically to OHS MS, there are
two distinct types of audits:
142
Validation audit: This determines whether the system being audited is
actually capable of delivering the desired OHS benefits. Often this may be
assessed against defined criteria such as an accepted OHS MS structure,
for example a standard.
Compliance or verification audit: The intention of these audits is to assess

compliance with defined criteria such as the organisation’s own
procedures and policies.340 Such audits may be conducted internally or
once the OHS MS been implemented for some time, by an external third
party.
It is essential to understand the purpose of the audit from the onset – is

the system itself being checked or is it its application? Logically, a
validation audit must precede a verification audit, although in practice they
are sometimes combined.
The frequency of an audit may vary from anywhere between six months
and two to three years, depending upon the stage of implementation of the
OHS MS.340 Once the OHS MS has been constructed and implemented
effectively, validation audits should be used to determine its ongoing
suitability. During the initial implementation phase, these validation audits
may occur more regularly to ascertain whether the system is adding value.
The results of compliance audits may suggest areas that are simply not
working, for example in cases where the system requirements have been
imposed without consultation, feedback or sound justification. Internal
auditing and management reviews form essential components of the self-
regulation process.153
Professional judgement, objectivity, competence and experience are all

necessary precursors for a reliable audit.
In theory, an audit appears to be a sensible test for the effectiveness of an

OHS MS, based on the premise that by focusing on improving the
process, a desirable outcome will naturally follow. Surprisingly, this has
not been substantiated by studies - implying that there are major issues
with the effective application of OHS MS in practice.1, 341
Difficulties
143
associated with attempts to correlate improved OHS performance as
measured by a reduction in injury rates, with audit results include the
following:
the audit tool may not reflect the hazard profile of the particular
organisation; 59, 329, 342
the auditor may not have sufficient experience with the process or
appreciation of the nature of the organisation to be able to determine
whether all the hazards have been effectively captured by the OHS
MS in place;59, 147, 342
there is the potential for corporate politics to interfere with the

outcome;114
the number of requirements may be overwhelming, causing some

organisations to stop at the internal audit process, or abandon the
process entirely;17
parties being audited may reject the findings and refuse to follow-up
on recommended actions if the value of the audit is not appreciated
or accepted from the onset;340 and
some schemes engender a false sense of confidence leading to

complacency.343
Compliance or verification audits are most effective when a triangulated

approach has been invoked – combining evidence assembled from
interviews, together with general observations and supporting
documentation. Despite the numerous difficulties with the audit
application, the benefits of introducing objective and independent
observers who are aware of best practice should not be overlooked.147 As
captured insightfully by Nash, the success of an auditor hinges on the
“ability to see beyond fresh paint and listen to what people aren’t telling
you”.114
144
4.1.5 Maturity Grid Concept
Applied mainly in the context of assessing organisational safety culture,

this concept is traditionally attributed to the work of Westrum, was heavily
endorsed by Reason and Hudson and then later extended by Parker et al
in 2006. Westrum originally proposed three typologies that promoted the
positive qualities associated with high reliability organisations as identified
by Weick in 1987: pathological, bureaucratic and generative. The term
generative was used to describe an organisational environment that was
open to new information and ideas and accepted responsibility. On the
other end of the spectrum, pathological organisations abdicated
responsibility, disguised failures, and rejected new information and ideas.
Reason later retained the two extremes – pathological and bureaucratic
and subdivided the middle level of bureaucratic into three – reactive,
calculative and proactive. The term “reactive” described those
organisations that, as the label implies, respond to accidents but do little in
the way of prevention. Calculative organisations were described as
having a systematic approach, but with considerable bureaucracy –
essentially good intentions however the aims were not necessarily
achieved beyond superficial problem solving. Proactive organisations
displayed strong planning activities and attempted to address root causes.
The generative classification was extended to highlight positive qualities
such as trust, perseverance, and an understanding of potential hazards
beyond the physical environment. 344
These models offer some fresh perspectives on desirable attributes within

organisations to enhance OHS performance, including the need to care for
345
colleagues and the importance of follow-up on audit recommendations.
A major criticism of the maturity model is that the pathological – reactive –
calculative – proactive – generative spectrum offers only one approach to
management of OHS and provides a categorisation to the whole
management system that may not apply to all the individual aspects or
elements. The maturity terminology does not really address outcomes
and so is more of a management tool to address management issues.
145
Further, individual components of OHS systems in organisations do not
always need complex systems at the upper end of the spectrum.
A multitude of variations on this conceptual framework have been

presented, with every deviation highlighting features considered
substantially connected to the sought after yet elusive definition of “safety
culture”. Work by Eckenfelder, Fleming and Hansen reinforces a growing
acceptance that there are definite stages to the path of organisational
maturity, although agreement on the particular pathway is mixed.346-349 It is
noteworthy that many of the descriptors used to describe early phases are
often negative, some to the point of disparaging, presumably to incite
progression towards more desirable objectives. These typologies are also
often very subjective, sometimes lacking in concrete descriptors of what is
actually required to promote progression to the next stage.
Hudson has reported the recent success of his “Hearts and Minds”
program aimed at improving safety culture in the petrochemical industry.
This comprised of a number of toolkits and starter packs. Tools available
included: “HSE understanding your culture”; “Seeing yourself as others
see you”; “Making change last”; ‘Risk assessment matrix: Bringing it to
life”; “Achieving situation awareness; The rule of 3”; “Managing rule
breaking”; “Improving supervision”; “Working safely”; and “Driving for
excellence”. The importance of management commitment was considered
to be critical to the successful launch of the project.350
4.2 From an Operations Perspective
4.2.1 Risk Assessments
A previous discussion in Section 2.2.1 Safe Place Strategies provides an

overview on risk assessment methodology.
The combined use of both generic and dynamic risk assessments is

becoming increasingly popular and has been used with some success in
both the fire fighting and the emergency services sectors. These methods
146
are particularly useful for high risk situations where there is little time
available and the potential for high stress levels.
Dynamic risk assessments apply to situations where it is possible to

perform a generic risk assessment for most reasonably foreseeable
scenarios, but where it is impossible to identify all the unique hazards that
present at the actual time due to the particular set of circumstances
encountered. In these cases, the risks must be managed by drawing on
experience and common sense as the situation unfolds.351
Where dynamic risk assessments are used, it may be appropriate to

record on the underlying general risk assessment:
any specific legal requirements that must be met or codes of practice

that are applicable;
the level of training or competence required;
circumstances where additional evaluation is needed should

unforeseen problems arise;
circumstances where specialist assistance may be required;
clear guidelines for circumstances where work should cease and the
individuals remove themselves from the situation where this is
possible.
Dynamic risk assessments should be conducted within the scope of

existing generic risk assessments. Training in dynamic risk assessments
essentially promotes the practice of stopping and thinking through the
optimal way to deal with the hazardous situation before rushing in. Such
training can be workshopped with typical scenarios as practice prior to
exposure on the field. Debriefings from actual experiences in the field and
any lessons learnt should then be used for updating and improving the
training packages.352
Experiences from the UK have already shown that situations where the
use of dynamic risk assessments are commonplace can still be dangerous
if the organisation reinforces unacceptable risk taking behaviour through
147
awards, recognition, prestige or promotion. It is clear that dynamic risk
assessments have a better chance of maintaining safe working conditions
when: 353
they are underpinned by thorough and vigorous generic risk

assessments;
there is ample provision for continuous learning;
the values of the organisation reinforce the safety of the individual,

and
work ethics are clear so that limits are defined.
Where dynamic risk assessments are being used it may be difficult to

measure safety performance directly, so other indirect measures may be
necessary. Examples of these indirect measures may include the number
of calls to back up services or information hotlines as a means of gauging
how frequently the system is being used.
4.2.2 Control Charts and Trend Charts
Control and trend charts are measures that were introduced in the total
quality management (TQM) era of the late eighties and early nineties. By
plotting safety records in the same manner as quality non-conformances,
the aim was to identify trends and distinguish between common cause
variation and special cause variation in order to facilitate process
improvements. Common cause variation referred to those points that
were within the control bands, and special cause variation was denoted by
points that occurred outside the control limits, which are set at three
standard deviations on either side of the mean. Carder and Ragan argued
that the injuries and illnesses experienced were simply a manifestation of
the capability of the current system, and that in the past such events were
incorrectly treated as “special cause” variations.341 Interestingly, removal
of special causes of variation does not actually improve the process, but
148
simply brings the results back to the natural level of variation as a function
of the processes currently in place.326
Some incidents or injuries may manifest as the result of external

influences that are beyond the control of the organisation. This highlights
a perennial problem – the extent to which the causes of incidents should
be investigated. It would seem sensible to suggest that all must be done
that is within the sphere of influence of the organisation.
Simply following the trends and observing whether there are patterns from
control charts or any other plot of incidents provides significant benefits,
particularly in the situation where a plateau is occurring.85 This signals an
alert to provide a systematic change to current processes if further
benefits are to be realised, although it is often interpreted as the point to
introduce behavioural based safety techniques. However, any change
implemented is unlikely to have enduring effects unless the root causes of
the problems have been addressed, whether this involves behavioural
change or otherwise.
A key point to note here is the need to change the measure of

performance from a coarser to a finer indicator as further improvements
are sought. For example, as injury rates fall, focus may shift from LTI’s
and MTI’s to concentrate on first aid injuries, which may provide more data
to work with to extract opportunities for improvements. Ongoing
awareness of the coarseness of the measure will promote the continual
improvement pathway.
Although the popularity of the control chart method has waned

considerably, possibly due to the need for establishing the control limits
and continual assessment of the standard deviations, the importance of
making enduring changes to the processes that govern final outcomes has
clear merit. The TQM era must be recognised for emphasising the
importance of proactive versus reactive measures and for promoting the
concept that the responsibility for negative outcomes rests largely with the
process owners and managers.
149
4.2.3 Positive Performance Indicators (PPI’s)
PPI’s may be viewed as a derivative of the TQM era - promoting the

examination of processes that impinge on safety outcomes, whilst
removing the difficulties and resistance to the use of statistical control
methods.
PPI’s may be applied to any point that is upstream of the final outcome.
The aim is to improve the elements that combine to produce the end
result. The Australian Federal OHS Authority Comcare provides a clear
definition with the following: “Outcome indicators show if an organisation is
achieving its targets while PPI’s measure the actions taken to achieve
targets”.354
The Audit Commission, UK offers the following advice for the general
selection of performance indicators:355
clarity of purpose - an appreciation of how the information will be

used and by whom;
focus - on areas that are priorities for the improvement process;
alignment - there should be convergence with higher objectives;
balanced objectives - between short-term and long term targets;
regular refinement - indicators should become more challenging as

time progresses and more information about the processes is learnt;
and
robustness - the need to be able to withstand scrutiny and validation.
The UK Audit Commission even promotes the use of PPI’s to exert

pressure where necessary, for example if the length of time to complete
investigations was considered to be excessive. Including PPI’s that
spotlight management activity as well as employee behaviours may
reinforce the message that everyone is responsible for safety, not just a
150
select few.356 PPI’s should ideally be formulated under a framework of
consultation to encourage ownership. 354, 355, 357
There are numerous warnings within the literature to ensure a sensible

approach with PPI’s, such as not using so many that it becomes
overwhelming or too time consuming; not using unnecessary PPI’s that
sidetrack attention from important issues; and not selecting PPI’s where
the information received would not be acted upon. 354, 358
4.2.4 Safe/Unsafe Acts Observations
Safe act observations may be viewed as PPI’s that focus on critical safe
behaviours. The emphasis on safe rather than unsafe acts reflects a
growing awareness of the need to provide positive feedback to reinforce
desirable behaviour, and a detachment from earlier campaigns that may
have been construed as blaming the worker. Much of this work was
pioneered by Komaki et al, and later supported by Krause et al and
Sulzer-Azaroff.145, 359
There is clear merit in encouraging individuals to be more in-tune with their

workplace environment and in remaining alert to potentially dangerous
situations. It may be more useful to seek out those persons who are adept
at reading their environment to champion such behavioural programs and
also to promote awareness of the dangers of becoming detached and
insulated from one’s physical work environment.
The main limitations with the use of these programs are that the
information may be time consuming to collect and only offer benefits whilst
the attention is being focused on the particular behaviours under scrutiny.
For enduring benefits, careful consideration needs to be given to the types
of positive reinforcements used, and whether the rewards are delivered on
a fixed or variable basis (see the discussion on BBS in Section 2.3.1 Safe
Person Strategies). Some of the main advantages with these unsafe/safe
acts observation programs are quick results for comparatively little capital
expenditure; however the effects are likely to be short-lived unless the
151
changes in behaviour have been accepted and are aligned with internal
values.360
4.2.5 Controlled Self–Assessment
As suggested by HB 4360:2004 Risk Management Guidelines Companion

to AS/NZS 4360:2004, auditing alone is insufficient to effectively monitor
and review risks to health and safety. The intent of controlled self-
assessments are to ensure that current treatment strategies are effective
and that new threats have not emerged.192
The advantage of using controlled self assessments on a regular basis is

to encourage the habit of periodic checking. This is preferable to waiting
for an audit, as there is less opportunity for improvement strategies to go
off track. Furthermore, these reviews often provide a framework for
comments, which may offer richer and perhaps more subtle information
than any quantitative or semi quantitative results.
One of the greatest benefits of using controlled self-assessments is that

line management are given an opportunity to address their own problems
before an outside observer is called in. Analogous to “client centred
therapy”, this works on the basis that those who own the problem are in
the best position to solve it, and so the possibility of a full and frank
disclosure is more likely when conducting investigations.361 Spot checking
of a small random sample of results by a co-worker can improve the
nature of the results by overcoming the greatest potential disadvantage –
the lack of objectivity.
4.3 From the Perspective of the Individual Worker
4.3.1 Staff Turnover Rates
According to Argyris as developed in his incongruency theory, individuals

experiencing frustration and conflict due to organisational demands may
respond by leaving or becoming unresponsive, disinterested and
apathetic.362
152
A questionnaire study by Shannon et al that surveyed 770 companies and
received responses from 417, found that “companies with older workers,
workers with longer seniority, and with low turn over rates tend to have
lower LTFR”.363
A Finnish study reported a correlation between the downsizing of an

organisation and the health of remaining employees subsequent to the
downsizing. Negative health effects after downsizing were found to be
more pronounced for workers over the age of 50; in larger work places; for
those with poorer health before downsizing; and for those on higher
incomes.364
4.3.2 Near Miss/Hit Reporting
Jones et al define a near miss or hit as a “hazardous situation, event or

unsafe act where the sequence of events could have caused an accident if
it had not been interrupted: A learning experience for internal use by the
company”.90
Whether the terms “near misses”, “near hits”, “unusual occurrences” or

“unusual incidents” are used is likely to reflect the track record of past
events of concern within local work environment. For example, near hit
implies a potential contact injury, whereas an unusual occurrence may be
an unexpected pressure release from a chemical plant. The difficulty with
using the term “unusual” is that it suggests a low frequency event, and in
some cases the undesirable event is not unusual, so some events may
escape reporting on this basis. Whatever terminology is used, the concept
is to provide additional opportunities to rectify the potential for negative
impacts on safety and health. These indicators are particularly useful
where there is the potential for high consequence, low probability events,
and may overcome psychological barriers towards documenting incidents
within the workplace.136 A limitation of this indicator is that there is little
scope for cross-referencing if the event didn’t actually cause harm and it
may sometimes even be associated with over-reporting of events.
153
Where a very high number of events are reported it may be necessary to
screen and prioritise reports to ensure the most effective use of
investigative resources.90 For organisations that have only recently
embarked on a process of improving organisational safety, the large
numbers of reports may become overwhelming and jeopardise the quality
of investigations for more significant events. Where there is the potential
for negative ramifications in drawing attention to events, the possibility of
anonymous reporting should be considered.107
4.3.3 Perception Surveys
Perception surveys have developed in a response to the numerous

difficulties associated with correlating performance with injury rates. As
articulated by Petersen, “perception surveys assess what hourly
employees think about what works and what does not work in a safety
system”.365 Areas typically investigated by these surveys includes
management credibility, visible leadership; employee involvement;
flexibility of work conditions; recognition; enforcement of safety rules; the
competence of line management; housekeeping; investigations and even
the success of substance abuse programs. 307
Grote and Kunzler conducted an elaborate perception survey to assess

safety culture in the petrochemical industry across six sites. Questions
covered three main topics - operational safety; safety and design
strategies; and personal job needs which included quality of training and
job design. Operational safety was subdivided in three sections - enacted
safety, formal safety and technical safety. The survey was designed to
compliment formal audit techniques with the objective of providing a
greater insight into the effectiveness of management methods and safety
culture. No correlation was attempted between results and injury rates. 366
Perception surveys also have merit in their symbolic nature - by

demonstrating that employee feedback is valued. The findings are less
definitive and may not be extrapolated to a wider population, yet there is
significant merit in the understanding and insight obtained from the
154
examination of a particular area in such detail. Lastly, if perception
surveys are used, it is important to provide feedback to employees about
their responses and what action management proposes to address their
concerns.
4.4 Summary
As indicated in Table 17, there are a variety of measurement techniques

available to improve safety performance, each with their various strengths
and limitations. Emergent themes from the analysis includes the need to
break down larger goals into short term objectives; the need for multiple
measures; and the need to change the yardstick as performance improves
to avoid stagnation.
Outcome indicators such as the number of injuries still firmly have their
place as they send critical information and there is little value in denying
their importance. However, a reduction in injuries is unlikely to eventuate
without the regular tracking of carefully aligned supporting activities that
contribute to safe work practices.
The need to preserve employer/employee relationships and maintain

morale is another important theme. Parameters that indicate desirable
activities and show pathways for success are particularly useful. Bearing
in mind the potential for data to be manipulated, an understanding of how
this may occur may assist in the selection of indicators and ensure that
suitable cross-checks are in place. Finally, a clear understanding of who
will be using the information and for what purpose is crucial to the
selection process. Ultimately, it is the target audience that dictates the
type of indicator necessary so it is essential that the aims and objectives of
using the particular indicator are clearly understood by all parties from the
onset.
155
Table 17: Strengths and Limitations of Various Measurement Indicators
Measurement Strengths Limitations
LTI’s Links to Workers’ Compensation premiums may provide a Subject to manipulation

financial incentive to embark on OHS programs
May encourage under-reporting
High rates indicate serious problems – necessary information
Site comparisons may cause “sibling rivalry”
on outcomes
Easy to become emotionally detached from figures
May be used for benchmarking purposes over business units
and multiple sites
MTI’s/ First Aid Injuries Numbers are meaningful May be subject to manipulation/ under-reporting if linked to
reward schemes
Trends and patterns may be analysed
Negative, high numbers may lower morale
Provides information for investigation and problem solving
Realistic – necessary information
Outcome indicators allow progress to be evaluated
Due Diligence Plan Reviews/ Provides critical information Time lines for actions may be continually extended
Gap Analysis Demonstrates due diligence and good corporate citizenship Responsibility for action items must be clear
Audits Highlights strengths and weaknesses of the system Audit tool must accurately reflect the hazard profile to avoid
giving a false sense of security
Attracts management’s attention
Auditors may lack local process knowledge necessary to
Encourages system users to learn requirements and become
detect flaws
aware of responsibilities
Recommendations may not be accepted and actioned
Preparation for audits provides an opportunity to tidy up loose
ends and bring documentation up to date May be used for political purposes
Objectivity when independent auditors used Expensive and time consuming
Excellent for determining system faults, whether any changes Fear of self-incrimination if recommendations are not actioned
to the system have been taken into account and whether audit
Infrequent use – potential for systems to go off track if there
criteria being used is still appropriate
are large time lags between audits
Vigorous, documented
Follow through demonstrates due diligence
156
Maturity Grid/ Models Helpful to draw attention to organisational safety culture and Descriptors may be negative and cynical – potentially
safety values discouraging and may “stick”
May promote changes in attitudes towards problem solving Vagueness - descriptors need to be customised for individual
applications so the actual pathway to improvement is evident
May encourage strategic thinking
Subjectivity of measurement – difficult for cross comparisons
On an organisational level, descriptors may be used to reflect
visions and stepwise improvements The scope of application of the descriptor should be defined to
prevent unfair generalisations being made.
May be useful in aligning goals and working towards a
common purpose
Risk Assessments Provides Operations with critical information The full process can be lengthy, time consuming and requires
plentiful resources
Assists in knowledge collection and helps create an
understanding of what needs to be addressed Needs to be regularly updated
Can be applied universally Must be performed by those with the necessary balance of
skills and in an atmosphere of consultation - a risk assessment
Works well when there is plenty of information regarding the
conducted by one person that impacts on the health and
nature of the specific hazard being assessed
welfare of others is not a valid assessment unless those
Works well for predictable hazards affected have been consulted
Bench marked against reasonable practicability Need to know when to get specialist advice
Can be affected by differences in risk perception and the level
of situational awareness
Control Charts Focuses attention Plotting is more complicated

Provides information about system capability Users may become lost in the numbers if the strategic purpose
is downplayed
Trends may be used predictively to initiate changes
Positive Performance Indicators Provides information about the processes that are used to May be subject to manipulation
(PPI’s) achieve targets
Too many PPIs may become too onerous
May be used strategically to target areas that are in need of
Impact may wear off over time, PPIs need to be rotated
improvement
Only useful if the results lead to action
Offers the opportunity to have small victories – may boost
morale
157
Unsafe/ Safe Act Observations Focuses attention on critical safe behaviours May be seen as “blaming the worker” or an abdication of
employer responsibility if used inappropriately
Encourages awareness of consequences and the taking of
responsibility for one’s own actions May break down trust if co-workers report on each other and
anonymity is not respected
Fosters an attitude of care for colleagues
Could be exploited to divert funding from projects to improve
May teach workers how to “read” their environment
the physical environment and infrastructure
Controlled Self Assessments When performed on a regular basis ensures that Lack of objectivity if independent spot checks not conducted
documentation is updated consistently
Requires follow through
Higher frequency of checks – less likelihood of system going
Value depends on quality and reliability of parameters used
off track
Good for monitoring compliance – poor compliance may
indicate weaknesses in system construction
Performed in-house, more incentive for full and frank
disclosure
Opens communication channels with upper management
Turn Over Rates May indicate psycho-social or work-organisation hazards Confounding factors may overstate or misrepresent information
May provide a source of financial incentive for program
improvements
Perception Surveys Spotlights areas of concern Individual results generally do lend not themselves to wider
extrapolation
Informal surveys are easy to construct
Generally “self reports” may be biased towards providing
Provides a rich source of information not captured by other
desirable answers unless anonymity is protected
methods about the particular site/organisation surveyed
May generate cynicism if surveys do not result in action
Demonstrates employees feedback is valued
Near Misses/ Hits Provides data for preventive action and opportunities for Decisions to report may be subject to politics and safety culture
learning
Reluctance to report may lead to inconsistencies if
Indicates good intentions and the desire for improved comparisons are used
performance
May “overload” the system
158
5. PREVIOUS STUDIES AND GAP ANALYSIS
One of the most notable features in this area of research is the lack of
empirical studies available to confirm the benefits of implementing a
systematic approach to safety. Attempts to provide this empirical evidence
have been fraught with difficulties, suggesting that perhaps the mechanics
involved in the application of systematic OHS management and barriers to
the implementation of OHS MS are not well enough understood, or that
the available tools are not yet sufficiently refined. Despite the frustration
that previous attempts to correlate systematic improvements with a
corresponding reduction in injuries and illnesses may have experienced,
there are many valuable lessons to be learnt to steer the direction of
forthcoming research.
Table 18: Analysis of Previous Studies Pertaining to OHS Management

describes in some detail the key studies that have been conducted in the
past that are particularly relevant to the successful application of OHS MS.
There have been a number of studies related to safety culture, but whilst
connected, they are beyond the scope of this particular area of research
which is focusing on a systematic approach to safety and health. The
studies are presented in chronological order to illustrate the emerging
picture of OHS management and to highlight how governing paradigms
have influenced the nature and design of research conducted. The
following studies were examined:
Cohen, Smith and Cohen (1975) 367
Shannon et al (1996) 363
Culvenor (1997) 117
Vredenburgh (1998) 368
Redinger (1998) 13
Gallagher (2000) 10
Saksvik, Torvatn and Nytro (2003)92
Trethewy (2003) 369
159
Barbeau et al (2004) 370
LaMontagne et al (2004),329
Kim (2004),14
Simpson (2006),371 and
Loebakka (2008).372
160
Table 18: Analysis of Previous Studies Pertaining to OHS Management
Date Author Title Design and Objectives and Findings Strengths, Limitations and
Sample Size Lessons Learnt
1975 Cohen, Smith Safety Program Cross-Sectional Aim to determine whether there are discernable Attempted to reduce the number of confounders
and Cohen Practices in differences in safety practices between high and by matching organisations within the same type
High Versus Paired Chi- low accident rate companies. of operational activities.
U.S Low Accident squared analysis
Department of Rate Companies Areas explored included: Rigorous experimental design to determine if
Health 42 pairs of high
– an Interim and low accident management commitment to safety; practices are different in high/low accident
Education and Report organisations using appropriate non-parametric
Welfare, companies motivational approaches;
across six statistical analysis for differences in means.
job safety training;
Centre for different types of
Disease industries nature of hazard control practices; Injury rates included recordable cases of
Control, nature of investigation and reporting; and accidental injuries requiring more than first aid.
NIOSH Pairs matched for
demographics of workforce Other factors associated with low injury
industrial
operations Findings associated with companies with low companies included clean, roomy facilities, with
accident rates included: adequate ventilation, noise control and lighting.
High accident The existence of safety committees per se was
rate safety given prominence and greater not found to be a discerning feature.
organisations commitment to safety efforts
having at least Limitations to the study to the study were the
awareness of practices outside the
double the rate of inability to extrapolate results to a wider
organisation to improve safety
the matched low population due to cross-sectional design and lack
consciousness;
rate organisation of temporal factor. No causation may be inferred.
variety of incentive techniques utilized;
Mail out Results are from one source – self reports. No
questionnaire- more opportunities for general and
cross checks with documentation or on site
predominantly specialised safety training;
observations to triangulate data.
Yes/no answers human approach to rule violations;
Attempts at correlating compensation data were
(96 pairs regular informal workplace inspections; inconclusive.
originally formed
balance between engineering and non-
from 192
engineering hazard management; and
organisations)
presence of a stable workforce - older,
married with longer time in the position.
161
1996 Shannon et al Workplace Cross-sectional Objective was to create a profile of characteristics Qualitative study - important emergent themes
Organisational Survey associated with excellent, good and poor OHS were that token compliance is insufficient, and
McMaster Correlates of performers. that efforts must demonstrate good faith.
University, Lost-Time Pilot study - 60
Ontario Accidents in workplaces Findings: Lower LTFR’s associated with Random sampling used within stratified groups.
Canada Manufacturing Groups stratified by high low and medium LTFR’s
Response from
435 out of 718 concrete demonstration of management and the number of employees – over 50; 50-99;
eligible commitment; and over 100.
workplaces
worker involvement in decision making; Samples drawn from six groups – metal articles;
(56%)
plastic articles; grain products; textile
willingness of safety committees to conduct manufacturers; printers and automobile
internal problem solving; manufacturers.
a more experienced workforce. Fair response rate – still potential for responder
bias. Extensive survey – length resulted in some
inclusion of health and safety criteria in job missing data, limited ability for multivariable
descriptions; analysis.
inclusion of health and safety in annual There is no temporal component – results may
appraisals; and not be extrapolated to a wider population,
causality cannot be inferred. Snapshot only.
attendance of senior managers at health
and safety committee meetings. Limitations of using LTFR’s – potential for under-
reporting, may dilute findings.
1997 Culvenor Breaking the Case Study The aim was to demonstrate the benefits of Methods used to demonstrate construct validity
Safety Barrier creative thinking – applying de Bono’s six thinking and method to validate tools used unclear
University of hats method, on safety design/ safe place
Ballarat strategies. Attempts to generalise and extrapolate findings
unfounded
Fictitious cases developed and subjects asked to
generate solutions. Subjectivity of author apparent - clearly an
opponent of “safe person” strategies (taken to
Suggested that creative thinking enhances imply behavioural based safety); for example
generation of safe place solutions. literature review includes section on “Safe
Behaviour Promotions: The Myth of the Careless
Promoted “Safe Place” strategies over “Safe Worker”.
Person”.
162
1998 Vredenburgh Safety Cross-sectional Aim was to correlate six variables typically Response rate and power of study low.
Management: associated with improved safety culture (as defined
California Which Linear multiple Cross-sectional design cannot be used to infer
as the way the norms, beliefs and attitudes
School of Organisational regression of causal relationship as there is no temporal factor,
minimize exposure of employees to conditions
Professional Factors Predict factor analysis 368
results are a snapshot only.
considered dangerous) with injury rates.
Psychology Hospital Originally 75
Employee Injury surveys mailed – Variables included: Results cannot be generalised to wider
Rates 3 returned population as a result of study design.
Participation
194 phone calls – Obvious difficulty in obtaining respondents.
125 surveys Management Commitment
mailed, 74
returned, 62 met Training
selection criteria.
Hiring/Selection
Communication and Feedback
Rewards
Correlation found between injury rates and only one

variable – hiring of personnel.
Output included the establishment of a bone fide

requirement for past safety record/ practice
information to be used for hiring of employees (so
as to avoid discrimination claims).
163
1998 Redinger OHS MS Case Study After reviewing 13 possible models for use as input Internal validity for OHS MS Assessment
Conformity to the development of a universal assessment Instrument via Delphi Method – panel of sixteen
University of Assessment: 3 Pilot Studies –
instrument; 4 were selected – OSHA Voluntary experts used to evaluate the questions proposed.
Michigan Development field tests
Protection Program (VPP); British Standards
and Evaluation Institute (BSI) OHSMS, BS 8800:1996; American Each expert given the questionnaire and asked
of a Universal Industrial Hygiene Association; and ISO for feedback and rating to do with clarity of
Assessment 14001:1996. expression; relevance to input clauses; and rank
Instrument order of importance of the principles. Options for
Universal Assessment Tool developed and trialled not ranking order or suggestion of additional
on 3 sites using case study methodology developed principles permitted.
by Yin and the United States Environmental
Protection Agency’s Quality Manual for Experts nominated sections of the questionnaire
Environmental Programs (USEPA). that were most relevant to area of expertise.
Unit of analysis was the organisations OHS MS Rigorous development of tool. Panel of experts
derived from academia, industry, government
Organisations were de-identified, and were and standard setting bodies.
selected from advertisements in a journal
Construct validity supported by pilot studies and
One week spent at each site the triangulation of field data- interviews;
observations and documentation/records.
6 research questions (working hypotheses)
pertaining to OHS MS were defined to guide External validity established by analytical
research –covering definition of variables at a generalization based on field experiences.
conceptual level; operational level; how they are
measured and how scores are interpreted. Three articles have been published.
No statistical inference possible from case study

methodology.
Limitation – potential bias from selected models

used as input for assessment instrument.
Model has been used to influence new ANSI/

AHIA Z10:2005 standard.
164
2000 Gallagher Occupational Case Study The study examined organisations by assessing Strengths – conceptual, in-depth analysis,
Health and against audit criteria that had been adapted from potential to find explanations for complex
Deakin Safety Systems: 20 participants SafetyMAP with a view to determine how processes and extend/modify current paradigms.
University, System Types organisations manage OHS.
Melbourne Mail out
and Case study results cannot be extrapolated to a
Effectiveness Questionnaire 4 typologies where developed. wider population, statistical inference not
used for survey Innovative/Safe Person- Sophisticated possible
Behavioural
Potential bias of the researcher due to
Innovative/Safe Place- Adaptive Hazards relationship with case study participants
Manager
Construct validity relied on feedback from
Traditional/Safe Place - Unsafe Act participants of case reports and some
Minimisers; and triangulation of data.
Traditional/Safe Place – Traditional External “validity of study” not measured by
Engineering and Design representativeness but by the quality of emergent
10
The adaptive hazards manager (eliminating theory” and “cogency of theoretical reasoning “
hazards at the source, applying risk management
Unreliability of injury data and inconclusiveness
strategies and exhibiting a high level of employee
of audit data rationale for the case study
involvement) was promoted as the way forward.
selection.
Safe person strategies perceived as a legacy that
refuses to die. Major difficulty with study –no before/after
analysis. Progressive impact of OHS MS not
Main finding was that one type OHS MS does not fit discernable.
all
Basis of several National Occupational Health
Only two cases found to have highly developed and Safety Commission (NOHSC) Reports
OHS MS, 6 developed OHS MS and 12 (sponsors).
underdeveloped OHS MS
Audit tool used for assessment would not have
rated “safe person” strategies as highly (see
Table 16); Tool potentially biased towards the
findings from the onset.
165
2003 Saksvik , Systematic Cross-sectional Aims: Even with large sample size, response rate 45%.
Torvatn and Occupational interview Private sector comprised 66% of the sample.
Nytro Health and (i) to analyse the extent of implementation of 46% had less than 11; 39% had between 11 and
Safety Work in Computer aided internal control (IC) requirements in Norway since 100; 15% had more than 100 members.
Department of Norway: a telephone survey regulations mandating OHS MS came into effect in
Quota sampling used: aiming to provide a
Psychology Decade of 1992;
Randomized representative sample based on specific criteria.
Norwegian Implementation sample (ii) investigate whether enterprises claiming to have Problems encountered included:
University of implemented IC requirements actually
Science and 2092 participants (i) inability to contact employer
Technology had registered IC status; (ii) refusal to participate.
created or modified OHS improvement Long survey – 61 questions
plans;
Self-reporting - possible subjectivity of
developed measures by which OHS respondents and desire to provide a favourable
improvement can be measured, response. Also there may have been a desire to
provided employees with the necessary justify expenditure of time and funds.
skills to become involved in decision Suggested longitudinal studies to discern
making, and whether high level of implementation actually
that both management and workers translated into meaningful activities on the
displayed interest in participation process. organisational level.
Findings:
Implementation rate had increased from 8%
in 1993; to 47% in 1999; In 1999 39% said
they were in the process of implementation.
61% claimed to have improved their OHS
outcomes as measured by injuries and
sickness absenteeism.
Improved reporting resulted in an apparent
increase in injury rates
Promoted the concept of organisational learning
and how this is assisted by a systematic approach.
Portrayed IC as very top-down management.
166
2003 Trethewy Influences on Intervention Aim was to study the relationship between a series Previously validated perception (Culture) survey
Subcontractor Style of management interventions and; used to confirm effectiveness of interventions.
University of OHS Correlation between Safety Meter results and
New South Management 10 Construction Changes in attitude and perception of risk
Lost Time Injuries attempted, but findings
Wales Outcomes in sites and behaviour of contractors
conflicted
Construction before and after Traditional outcome LTI indicators Methodology for internal, construct and external
analysis over six validation of results unclear.
months Interventions included :
Attempt at triangulation through use of survey
(periodic Formulation of trade specific hazard profiles assumed although case study approach not
monitoring Development of pro-formas - Subcontractor identified from onset.
fortnightly) S (Subby) Pack Outputs included the development of useful
and subcontractor material and hazard profiles used
Adaptation of TR (Construction Safety) adopted by WorkCover NSW
Cross-sectional Index previously developed in Finland, now
called “Safety Meter” used for behavioural Demonstrated the difficulty of applying statistical
(survey) techniques to this type of research
based safety “positive performance
indicators”
Improvement of Safety Meter Scores for 70% of
sites considered evidence of Safety Meter
Effectiveness.
2004 Barbeau et al Assessment of Case study Aim to assess management commitment and Data bases used to identify small manufacturers.
Occupational employee involvement; workplace analysis; hazard Of 224 worksites found, 133 met eligibility criteria
Centre for Health and Randomised prevention and control; and education and training and 26 consented.
Community – Safety Programs sample used in low wage, culturally diverse, small workplaces.
Based Strength - combination of open ended questions
in Small 25 small used to capture informal methods of OHS
Research, Businesses Survey aligned with criteria for Voluntary Protection
Dana Farber worksites – mean Program management, and closed questions for
Cancer number of 96 assessment of formal, systematic approaches.
workers per site Emergent themes: size is not a barrier to
Institute, Limitations of self-reporting and the use the
comprehensive safety programs, but may need
Boston Survey weighted survey results - subjectivity.
more outside assistance; reality of production
pressure and language barriers. Recommended the use of triangulated data for
future research in this area.
167
2004 La Montagne Assessing and Randomised Hypothesis (1) Workers more likely to make healthy Randomised sample used to avoid bias – needed
et al Intervening on Intervention lifestyle behaviour changes if OH risks were the assistance of biostatistician.
OHS Style addressed at the same time. 89 companies contacted, 41 eligible; 17 agreed
Programmes: to participate, 2 dropped out. Highlights difficulty
Effectiveness 15 sites Hypothesis(2) Integrated intervention sites would
show greater improvement at an organisational in obtaining participants.
Evaluation of the Controls=8
Wellworks-2 level as measured by change in score over 16 Very time consuming – personal contacts;
Intervention in Interventions =7 months assessed by the Wellworks-2 measurement education sessions; technical assistance to
15 instrument. managers; written material for distribution and
Manufacturing presentation to OHS committees.
Primary outcome was changes in smoking and
Worksites eating behaviours Results not as favourable as expected given the
effort applied.
Integrated intervention technique involved a tri-level
social ecological framework: Small sample size
worker (health promotion); Weighting of assessment instrument – subjective

Suggested that individual hazard profiles of
organisation (Wellworks-2 Assessment of organisations may be a confounding factor.
systematic management); and
Tried to measure systematic approach to OHS
physical environment – targeting of rather than any particular OHS MS structure.
hazardous substances.
Raised awareness of tri-level approach – worker,
Assessment tool grouped into 4 categories as per organisation and physical environment.
Voluntary Protection Program. Scores for 4 areas
No attempt was made to correlate assessment
weighted (management commitment and employee
score with injuries/illness although suggested for
participation 36/100; workplace analysis 28/100;
future research.
hazard prevention and control 24/100; and training
and education 12/100). Suggests that there is a considerable time lag
between the application of integrated
After 16 months with applied intervention, only one interventions and the manifestation of favourable
of the four categories – management commitment results. More than 16 months may be necessary
and employee participation improved at a to see more visible change. This time factor
statistically significant level. presents a considerable constraint for the typical
time frame available for a doctoral project.
168
2004 Kim The Role of Case Study Aims were to study the effectiveness of : OHS MS self assessment questionnaire
Legislation in developed by five OHS experts and evaluated by
Centre of Driving Good Mercury study – the management of mercury exposure in the a panel of 9 members from the Safety Institute of
Public Health OHS MS: A fluorescent lamp manufacturing industry in Australia.
Research Epidemiological Korea and an oral health service, and lead
Comparison of data examined OHS MS questionnaire based on ILO model.
Queensland Prescriptive and exposure in Australia by surveying doctors
University of Performance Biological designated for lead surveillance; Basis of internal validity for OHS MS
Technology Based monitoring from 8 questionnaire was the Nominal Group
legislative arrangements for health
Legislation workplaces in Technique (a variation on the Delphi Method
surveillance in both places;
Korea where a panel is used instead of individual mail-
characteristics of OHS MS in use in Korea outs).
In Queensland and Australia; and
45 exposed Statistical analysis of data performed on OHS
workers –Survey, prescriptive versus performance-based MS questionnaire using SPSS (version 10.1.0)
Interview and legislation in protecting OHS of heavy metal for Windows. Chi-Squared Analysis for
Biological exposed workers. association between groups, Fischer’s Exact
Monitoring Test used for sample sizes less than 5.
Findings:
Small sample size for Korea made comparison’s
N=45 exposed
33% of Australian organisations surveyed difficult.
lead study – had a fully implemented OHS MS Survey results cannot be extrapolated to wider
(i) mail out Rate of implementation of OHS MS in populations, no temporal component.
survey; 36 smaller businesses (less than 30
doctors Low response rate and self-reported data -
employees) 40% of that of larger subjectivity of results
responded (54%) organisations. Small businesses may lack
(ii) Work practice necessary resources for OHS MS Triangulation of data applied for mercury study
interviews in Queensland– biological monitoring
Prescriptive style seen as reactive – reliant (quantitative), interview and questionnaire.
OHS MS on biological monitoring to signal need for
comparison via changes; performance based viewed as
self-assessment more proactive. Weakness of performance-
questionnaire based legislation considered to be emphasis
(198 mailed out placed on the use of risk assessments by
in Australia, 40 those unqualified to establish the extent of
returned (22%). risk to exposed persons.
Five surveyed in
Korea) Concluded that elements of both styles
necessary.
169
2006 Simpson An investigation Multiple methods Aims were to: There is considerable difficulty in linking OHS
into the use of including: PPI’s with outcome measures to evaluate the
University of positive To develop a set of paper based self effectiveness of OHS management strategies.
New South performance (i) the use of a assessment tools incorporating quantitative
Wales behaviour based OHS PPI’s to measure the local It was considered to be of limited value to
indicators to attempt to use a quantitative approach.
measure OHS measurement implementation of the OHS strategic plan,
performance tool for and pilot this in Postal Managers. Recommendations for future work included
quantitative investigations into the possible association
assessment; To validate and extend findings of the pilot
between PPI’s and OHS measures of exposures
study.
such as behaviour based measures and for more
(ii) focus group
The development of a web-based software qualitative indicators to be adopted.
interviews;
application to facilitate OHS PPI data
(iii) self collection and reporting.
assessment
worksheets. Findings:
One large multi- The study found that the OHS PPI self
site organisation assessment tool could be used successfully
by local Postal Managers and that this was
perceived to improve implementation of the
OHS strategic plan: “What gets measured
gets done.”
No statistically valid correlation could be
made between the use of PPI’s and
improved OHS performance under the given
pilot arrangement.
170
2008 Loebakka Factors defining Cross-sectional Aims: Limitations:
the relationships survey To investigate the factors that relate to the Convenience sample taken at the National Safety
Marshall between safety
Goldsmith N=156 development of high performance safety Council 95th Annual Safety Congress and
management management systems (SMS) by extending the work Exposition in Chicago attended by 7000
School of strategies and
Management Convenience of Ansoff’s and McDonnell’s Strategic Success individuals over one week in October 2007.
safety sample Hypothesis and Lorton’s application of this to
performance environmental management systems. Respondents were within proximity to Chicago
Alliant
Quantitative and from the manufacturing sector, a potential
International
analysis using The following relationships were explored between confounding variable.
University, San
Diego. linear regression safety performance and Potential for multiple responses from one
(i) the SMS aggressiveness gap; organisation.
Potential for state level regulations re
(ii) SMS responsiveness gap;
compensation and insurance requirements in the
(iii) Safety posture; particular region may have introduced another
confounding variable.
(iv) Safety school orientation (Management/
Behavioural/ Engineering or Health); Self reported data, no capacity to verify results.
No causal connection can be made through the
and between SMS posture and
existing design as there is no temporal
component to the study – snap shot only.
(v) SMS aggressiveness; and
Strengths
(vi) SMS responsiveness.
Internal validation of research instrument through
Findings: peer review and also literature search.
Safety performance improved as organisations Large sample size

aligned SMS aggressiveness and responsiveness
to the level of SMS turbulence.
Future recommendations:
Supported the importance of management
More detailed study of the performance and
commitment, competence and capacity in the
characteristics of management and behavioural
formation of an organisation’s SMS.
school orientations.
Supported the relationship between higher levels of Application of strategic success hypothesis to
safety performance and (i) a more proactive SMS other management systems including quality,
posture and (ii) management and behavioural financial and human resources.
school orientations as hypothesised.
171
5.1 Summary of Studies and the Way Forward
The work of Cohen, Smith and Cohen in 1975 was a landmark study in
this area of research because it was the first time rigorous statistical
analysis had been applied to explore the relationship between safety
practices and high and low accident rates. The design of the study was a
cross-sectional survey so it was impossible to make a casual connection
between the actual practices and the accident rates, but investigation into
the prevalence of certain practices in high and low accident rate
organisations, through a paired chi-squared parametric analysis of the
means, was certainly able to suggest the possibility of finding a causal
connection with a longitudinal study in the future. Areas of promise and
importance to OHS practitioners as markers of better OHS performance
included: 367
good housekeeping;
high quality of facilities and amenities;
the provision of opportunities for training;
an appreciation of both engineering and non-engineering approaches

to hazard control;
a more compassionate response to rule violations; and
a stable workforce.
Interestingly, the rigour of this study design has not been replicated
elsewhere. This forewarns of the enormous effort involved in carefully
matching the pairs of high and low accident rate organisations so that
confounders related to varying hazard profiles across industries may be
eliminated.
Shannon et al continued along the same lines as Cohen et al by once

again attempting to assemble a list of desirable characteristics associated
with good OHS performance as measured by low LTFR’s. The difference
172
in this study’s construction was that randomised sampling was used within
groups stratified according to their size and LTFR rate. Whilst this design
was selected to enable the findings to be generalised to a wide range of
employers – small, medium and large, as well as good, medium and poor
LTFR raters, the potential bias from self reporting and medium response
rates was a limiting factor in the interpretation of the results. Furthermore
there was no allowance for differing hazard profiles for the various
industries involved. Of note, the authors report that “given its limitations we
do not emphasise our regression analysis”.363 Emergent themes included
reinforcing the importance of low turn-over rates and an experienced
workforce; the need to empower employees; inclusion of OHS factors in
job descriptions and annual reviews; and the need for visible
demonstrations of management commitment such as attending safety
committee meetings.
Culvenor’s research was of particular interest because it articulated the

diametrically opposed views on how OHS should be managed –
juxtaposing the emphasis on treating hazards at the source (coining the
term “safe place” approach) against the emphasis on changing worker
behaviour (coined as the “safe person” approach).117 Culvenor’s attitude
was one of overwhelming opposition to behavioural techniques, yet his
actual research focused on the use of creative thinking to enhance safe
place solutions. This strong opposition to the continued use of safe person
strategies suggested that there was an opportunity to search within the
behavioural based philosophy, and provide an explanation for its
continued endorsement, particularly in the US.
Vredenburgh’s work was heavily influenced by Cohen et al again

searching for an association between management practices and low
injury rates. It is evident that application of this cross-sectional study
design with its inherent weaknesses of self-reporting and absence of a
temporal factor was also seriously constrained by the ability to obtain
willing participants as the low response factors affected the perceived
value of the findings. No statistically significant correlation was found
between management practices typically considered to be linked with
173
lower injury rates such as training and management commitment, although
a correlation was made with hiring practices.368
Redinger’s research was another landmark study in the area of OHS MS.
Set against the contextual backdrop of the TQM era, this was the first
doctoral project that lead to the development of an OHS MS model
structure. The difficulty with this new area of research was that there were
no other studies for comparison purposes. Determination of internal
validity – to ensure that the measurement tool did in fact measure what it
intended to measure, could only be obtained through extensive peer
review.373, 374 This was achieved using the Delphi Method – by sending the
proposed measurement tool to a panel of independent experts for
comment. The panel members were selected from a variety of sources:
academia, industry, government and standard setting bodies to provide
balanced perspectives. Designed as a case study, the instrument was
then piloted on three sites. The construct validity of the pilot tests was
demonstrated by triangulation of the field study results – comparing the
results of observations, interviews and documentary evidence.375 The
rigour of Redinger’s work renders itself as an exemplary model for further
research in this area, and the value of the study’s contribution to the
existing body of knowledge is marked by the influence it has had on the
development of the ANSI-AIHA-Z10: 2005 standard of the US.
In Australia, the work of Gallagher was instrumental to promoting changes

in the direction of state legislation towards the adoption of a risk
management approach. Gallagher’s work set out to determine the
effectiveness of OHS MS. Her finding that “one size does not fit all” was
pivotal in the decision not to mandate the implementation of OHS MS
unlike the internal control path of Norway and Sweden. Gallagher defined
four different management style typologies and promoted the “adaptive
hazards manager” as the way forward. This supported studies in Norway
that found that internal control had not been widely embraced by small
businesses.149 The “adaptive hazard manager” was certainly a sensible
approach for dealing with small to medium sized organisations, relying on
industry to determine their own hazards and to ensure that they had
174
sufficient controls in place. Guideline standards were available for larger
organisations to model their own OHS MS, if they so desired.271 The
weakness in this concept was that it relied on industries knowing what
hazards they were looking for in the first instance. However, if there was
insufficient guidance in this area, this would still present problems for
organisations, especially the smaller organisations the legislation was
intending to help. This presented an opportunity for continuing research.
Following Gallagher’s study, research from Norway by Sakvik, Torvatn

and Nytro became available showing that there was approximately a 50%
implementation rate of internal control one decade after the regulations
came into effect. Despite portraying OHS MS as a very “top down” style of
management, it was still conceded that improvements measured by a
reduction of injuries and sickness absenteeism had been achieved, and
notably, there was unlikely to be any changes made to amend the style of
the regulations.92 However, this information was the result of a cross-
sectional survey, and there was still no empirical evidence to prove that
systematic approaches to safety were associated with improved OHS
performance.
Trethewy was unable to demonstrate a statistically significant correlation

between the use of upstream measures such as positive performance
indicators and a reduction in lost time injuries.369 However, the fact that
this was unachievable strongly suggests the need to develop alternative
measures for performance improvements to provide encouragement to
organisations along the way. It was likely that the chosen time frame – six
months, was insufficient to see such results. Organisations still need to be
motivated to continue with intervention techniques, whatever form they
take. This presented another research opportunity to explore the
connection between specific control measures and appropriate
measurement tools.
The work of Barbeau et al was useful in challenging the notion that a

systems approach was not suitable for small businesses. Through the use
of a well designed case study, a number of themes emerged including the
175
need to consider the reality of production pressures; and the problems of
implementing safety programs when language barriers are present.370
In an attempt to provide empirical evidence to demonstrate the benefits of

a systems approach, LaMontangne used a randomised controlled trial with
the aim of detecting improvements on an audit-style measurement
instrument after the application a number of systematic management
interventions. After a period of sixteen months, the only improvement
measured by the assessment tool was for the element of “management
commitment and employee participation”. Despite the frustrations of this
research effort, a number of very valuable lessons were learnt. The hazard
profile of the various organisations was thought to be a major confounder,
so a randomised controlled trial was not the best design in this instance.329
Although sixteen months was a significant period of time to have waited to
reassess the worksites, it was possible that the time lag for benefits to
appear may have been even longer. Whist an improvement was only
apparent in one element, this may have been a precursor to the start in
other areas, as without improvements in the level of management
commitment and employee participation, benefits are unlikely to manifest
anywhere else. Finally, validation through the use of triangulation was
strongly recommended for future research.
Research by Kim considered OHS MS as pivotal to the application of

performance based legislation, and so provided some analysis on the
uptake of OHS MS through a survey using an audit style assessment tool
based on the ILO guidelines.14 Although the research was not specifically
about OHS MS, the findings suggest that there are still a number of issues
with their application which are not well understood.
Simpson investigated the use of positive performance indicators to assist

the implementation of the OHS strategic plan in a large national postal
corporation. Again the statistical analysis was found to be of little value,
but recommendations did suggest the use of more qualitative indicators,
and to link them with actual workplace exposures. 371
176
Finally, Loebbaka took a management school approach and performed a
linear regression on survey results from 156 respondents of the 7000
individuals who attended a Safety Conference over a week in Chicago in
2007. The survey was based on a self assessment tool that concentrated
the strategic success hypothesis developed originally by Ansoff and
extended by Lorton (2006). This research continued along the lines of the
maturity grid concept and the results unsurprisingly supported the
importance of management commitment, competence and capacity in the
formation of an organisation’s safety management system (SMS). The
research also suggested that higher levels of safety performance were
associated with a more proactive SMS posture and management and
behavioural school orientations. Whilst this work did reinforce much of the
work already undertaken in the US, it did not set out to specifically
examine the structure of the SMS used, but more the strategic
preferences and the connection with safety performance as defined in
terms of illness and injury data, as well as worker’s compensation
statistics and insurance premiums. Whether these measures are true
indicators of the full context of an organisation’s OHS performance are
subject to debate, and so the premise on which the research was founded
is arguable. Furthermore, the desirable components of a SMS were
heavily influenced by the work of Hansen (2006) who had suggested only
seven basic elements for an effective SMS including: policy, leadership
and accountability; organisational infrastructure; strategic planning; SHEQ
management; customers, contractors and suppliers; performance
monitoring; and continuous improvement.372 This study could be surmised
as a very broad based, management school approach, without exploring
the actual risks presenting to the various organisations or how this might
influence safety performance outcomes. Whilst this is one of the few
studies quantitative studies available, the limitations of the cross-sectional
design, the particular convenience sample used and self reported data
make it difficult to extrapolate the findings to a wider context or range of
industries outside of the manufacturing sector. Furthermore, linking a
decrease in injury rates with a behavioural school philosophy rather than
an engineering school ethos is somewhat contradictory as this may simply
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have implied that hazards in the physical workplace had already been
addressed. There would be no way of deducing this information from the
survey conducted.
Therefore a gap in the research clearly exists to explore the potential

barriers to systematic OHS Management. Previous research suggests the
following:
there is a need to understand more fully the hazard profile of an

organisation and how this may be determined;
there is a need to understand how the nature of the organisation may

influence the selection of control strategies;
there is an opportunity to extract benefits from a wide variety of

management practices identified through various studies as having a
possible association with improved OHS performance;
there is a need to understand better ways of measuring improved

OHS performance instead of relying on LTFR’s or injury rates, and
how these may be linked with particular defence strategies; and
that time lags may play a significant role in detecting the benefits of
an OHS MS.
These types of opportunities lend themselves to a qualitative case study

design method where there is the opportunity to explore factors in much
greater depth. It is postulated that until these factors are more fully
understood, the benefits of a systems approach may not be easily
discernable nor may they be disseminated to a wider audience.
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5.2 Towards the Safe Organisation
The vision held for the safe organisation of the future would be for an
organisation that: operates with an understanding of the full spectrum of
potential hazards and checks to see whether they are present locally;
recognises that there are multiple strategies available for prevention and
control of risks and makes use of them as necessary; does not become
sidetracked with bureaucracy; and is open to the possibility of change.
A systematic approach to OHS enables the co-ordination of the various

safe place, safe person and safe system strategies available so that they
are delivered strategically to provide the greatest opportunity for
improvement. OHS MS can provide prompts and triggers to remind
systems users to take care – a most important feature when the
distractions of everyday business activities may interfere with the
application of safe work practices.
A systematic approach to OHS is most useful when there are a multitude

of hazards presenting. Therefore, it is futile to try and correlate the
presence of an OHS MS with reduced injury rates, because one of the
main reasons to use an OHS MS is to make the management of large
scale OHS problems easier. The merit of applying an OHS MS can
therefore only be measured by a change in OHS performance over a
period of time that is sufficient to allow the strategies invoked to develop
and flourish.
Each organisation is likely to have different needs, and it is expected that
there will be variations between different industry sectors, between private
and government organisations as well as to do with local context factors. It
is therefore suggested that any tool developed will need to be customised
for the individual organisation and that this same tool may not necessarily
be successfully applied elsewhere. However, the development of a
generic template that could be locally customised would be of
considerable benefit. There would also be potential for such a tool to be
179
used for benchmarking exercises within large organisations or across
industry.
Figure 9: The Safe Organisation - Blending Strategies & Co-

ordinating Defences through the use of a Model OHS MS Framework
External
People Environment
Hazards
OHS MS
Hazards Hazards
External
Safe
Person Environment
Strategies
Safe
Organisation
Safe Safe
Place Systems
Strategies Strategies
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When hazards are examined systematically to include:
the people to whom duty of care is owed;

the management strategies and methodologies invoked; and
the hardware and operating environment;
and the interfaces that exist between these areas and the external
environment, a picture for hazard prevention and control strategies
emerges that permeates through all the business units of a typical
organisation.
Hence the vision of the safe organisation of the future is an organisation

that uses its knowledge and translates this into meaningful action. These
actions would reflect safety being held as a core value, taking the duty of
care to more than the fulfilment of a legal obligation. When this occurs, this
demonstrates active caring for the safety, health and well-being of oneself
and fellow workers. It is envisaged that through the application of a
systematic approach to OHS and the development of an assessment tool
based on the safe place, safe person, safe system framework, not only will
individual organisations be able to benefit, but also the community as a
whole.
181
Figure 10: Model for Integrated Systematic OHS Management
Line
Leadership
Operations Management
Team
Purchasing
Engineering &
Maintenance
OHS MS
Sales and
Occupational Marketing
Health Services
OHS
Human
Functions
Resources
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Part 2: Research Project
Aims and Research
Questions
183
6. RESEARCH PROJECT AIMS, RESEARCH
QUESTIONS AND OBJECTIVES
6.1 Area of Research
Performance based legislation, which outlines general duties and

encourages consultation between employers and employees, does not
prescribe the actual systems necessary for employers to achieve
compliance, although competency training, hazard identification, risk
assessment and control, incident investigation, and workers’
compensation and rehabilitation are all recognised as common OHS
activities in most organisations. Compliance activities concerning OHS
legislation have therefore developed unsystematically.
Whilst the use of a systematic approach to OHS has much to offer, there
are still many barriers to its implementation that need to be examined. The
challenge, therefore, is to remove the perception of difficulty and simplify
OHS MS structures so that more organisations will use them. By reframing
the key elements of OHS MS structures as a series of prevention and
control mechanisms, the value added by their application may become
more obvious. A more simplified framework that recognises socio-
psychological hazards as well as hazards directly related to poor
management, over specification of procedures, failure to communicate
and inform, and decisions to remain ignorant by not investigating incidents
or potential hazards, is likely to make a substantial contribution to the
existing body of knowledge.
Although the literature has acknowledged the potential existence of a

three way, integrated approach to OHS management by considering in
turn:
the physical environment and infrastructure;
the people towards whom a duty of care is owed; and
the management strategies and methodology invoked;
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there have not been any previous attempts to bring this conceptual
framework together, specifically using OHS MS to mobilise these three
lines of defence. It is in this application of safe place, safe person and safe
systems strategies to address hazards within organisations on all three
fronts, and the reframing of the typical elements of OHS MS models as
prevention and control strategies, that the contribution of this research to
the existing body of knowledge is new.151, 201, 376
The research conducted by Kim suggests that the uptake of systematic

approaches to safety is still fairly limited, corroborating the work of
Gallagher.10, 14 This major issue must be addressed as a matter of priority
before any larger scale, quantitative research may be undertaken in the
future.
For successful implementation, the foundations of a model for systematic

OHS management must be examined in detail, together with an
awareness of the difficulties that may be encountered along the way.
Previous studies recommend that the direction of future research should
take a more in depth, exploratory approach to understanding the
contextual backdrop that confronts contemporary employers endeavouring
to fulfil their OHS duty of care. It is envisaged that this strategy may be
particularly useful for illuminating the specific issues related to smaller and
medium sized enterprises that traditionally have had fewer resources at
their disposal to assist them in honouring their due diligence obligations.
6.2 Project Aims
The main objective of this research is to develop and apply a new OHS
management tool to assist organisations in identifying and fulfilling their
OHS responsibilities, by providing a means of evaluating an organisation’s
unique hazard profile and offering feedback on the success of their current
OHS improvement programs.
It is intended that this new conceptual framework based on “safe place,

safe person, safe systems” model developed within this thesis will form the
basis of the new OHS management assessment tool. This assessment
185
instrument will be used to perform a risk ranking exercise, evaluating the
potential OHS hazards presenting to the organisation without any
interventions in place, and then also with prevention and control strategies
in place, to reduce the level of residual risk.
This evaluation, with and without interventions in place, will therefore give
the organisation an indication of how effective their OHS program has
been, and help highlight areas of strengths as well as areas of weakness
that could benefit from a greater focus of attention and resources.
A report will be compiled providing a brief synopsis of the organisation’s

current position against each of the OHS MS elements identified by the
“safe place, safe person, safe systems” framework. This threefold
approach aims to capture the different perspectives on the success of
current OHS activities as seen by operations, the individual worker; and
management.
It is a secondary objective of this study to determine how the application of

these OHS prevention and control strategies and the systematic approach
to OHS management is influenced by the nature, size and operating
context of the particular organisation.
Finally, this research aims to identify an effective means of utilising the

information obtained from the OHS management assessment tool in order
to propel the OHS improvement program forward in a manner that is
targeted, sustainable and delivers visible OHS benefits.
186
6.3 Research Questions
The overarching research question for this study is to explore whether

systematic OHS management is linked to improved OHS performance.
However, this is qualified by the underlying hypothesis that a systematic
approach to safety, denoted by the existence of various elements of an
OHS MS structure, will not be reflected by improved safety and health
performance unless:
(i) the hazard profile of the organisation has been accurately determined
and adequately addressed by the current prevention and control
strategies in place;
(ii) the application of sufficient systematic prevention and controls has

been in place for a significant period of time, and
(iii) suitable indicators have been developed to provide feedback as to

the effectiveness of individual prevention and control strategies
selected.
Before such a hypothesis may be tested using a quantitative, intervention

style study, it is clear from the previous research in this area that more
understanding is needed to explore: what constitutes a systematic
approach to safety; how this is relevant to a wider variety of organisations
not just large manufacturers; what are the confounding variables; and how
a comprehensive system may be developed that addresses the entire
hazard landscape, not just issues surrounding the physical work
environment.
Therefore, to guide and focus the research so that a more complete

picture of the problem emerges to allow the extension or modification of
existing theory and governing paradigms, the following questions will be
specifically used to direct the research efforts:
1) How do contemporary employers go about fulfilling their OHS

obligations?
187
2) How can a systematic approach to OHS be identified?
3) What are the barriers to the uptake of a systematic approach to

safety?
4) What questions may be used to promote a systematic examination of

the entire context of workplace hazards?
5) What indicators are available on an operational level that may

suggest the existence of particular workplace hazards?
6) What strategies are typically invoked to prevent and control particular

workplace hazards on the following three levels: the physical
environment and infrastructure; the individual; and at a managerial
level?
7) What are the most suitable measurement indicators to gauge the

effectiveness of the particular prevention and control strategies
invoked?
8) Which prevention and control strategies are considered essential on

a broad level, and which strategies are industry specific?
9) How does the nature of the organisation influence the type of

prevention and control strategies selected; and
10) What is the order of implementation of these prevention and control

strategies that leads to the development of a clear pathway to OHS
improvements?
These questions are particularly suited to the use of a qualitative case

study design strategy as the basis for this research. This will facilitate the
examination of these questions in more depth, whilst also providing the
opportunity for rich analysis and vivid illustrations of how a “safe place,
safe person, safe systems” framework may be applied to assist OHS
activities in the workplace.377, 378
188
Part 3: Methodology
189
7. METHODOLOGY
7.1 Research Methods

7.1.1 Rationale for the Study
A multiple case study design has been selected for this research,
according to the practices of Yin.379 Yin notes that a case study design is
the appropriate technique to explore “how” research questions in
contemporary settings. This ability to observe without the need to control
variables distinguishes the case study strategy from experimental designs,
where control over behavioural events is assumed. The case study
strategy does not preclude the use of quantitative elements, although in
these circumstances, qualitative techniques are more appropriate because
the issues facing individual organisations were being examined, rather
than an attempt to make statistically valid generalisations. Yin offers the
following guidelines that indicate the preferential use of a case study
design:378
“The case study inquiry:
copes with technically distinctive situations in which there will be many

more variables of interest than data points, and as a result
relies on multiple sources of evidence, with data needing to converge in

a triangulation fashion, and as another result
benefits from the prior development of theoretical prepositions to guide

data collection and analysis.”
The use of a multiple case study design is considered to be the method of

choice for this particular application as the use of multiple cases
strengthens the credibility and robustness of the findings, and allows the
use of replication logic to assist with explanations and illustrations of the
phenomenon described.380 Hence, the multiple case study strategy
provides a fitting setting against which the practical application of the “safe
place, safe person, safe systems” OHS management framework can be
tested for suitability and appropriateness.
190
7.1.2 Sampling Strategy
Case study participants were invited into the study through the use of
advertisements. These were placed on the UNSW School of Safety
Science website as well as in an Australasian OHS Journal. A minimum of
three and a maximum of ten organisations were considered for inclusion in
the study. Details of the advertisement may be found in Appendix 2.
A purposeful random sampling strategy as described by Patton was aimed

for.381 The sample was random in that the responses to the advertisement
were open to all organisations interested in OHS, and actual responses
could not have been predicted or influenced by the researcher. Given the
purposeful nature of the sampling strategy, and the likelihood that only
highly motivated organisations would apply, it is necessary to exercise
caution with any generalisations made, as any extrapolations are likely to
be context specific. The case study participants were classified according
to the following operational characteristics, purpose built for the study:
Table 19: Operational Characteristics
Profile Operational Characteristics
Work processes are either simplistic or they may be complex

Routine
but “mastered” and performed automatically with skill and
precision. There is little scope for unplanned events. The
process outputs are known and unlikely to change. Outcomes
are predictable.
Complex activities are undertaken, there is a high level of

Specialised
individual skill involved for which substantial training (either
academic or on the job) has been received and the focus of
business activities is narrow. There is the distinct possibility of
unforeseen events occurring, for which on the job experience is
necessary. A variety of related but different process outputs are
possible. Individual outcomes are unique.
Attempts are being made to gain an understanding of the

Progressive
processes with a view to improve. There is widespread
application of monitoring and the use of feedback. Both
upstream and downstream indicators are in use. Outcomes are
predictable but improvement is expected.
Substantial understanding of internal processes has already

Strategic Planners
taken place, sub-processes are considered to be “mastered”
and the organisation is therefore in a position to look at newer
methods and in a financial position to consider the use of best
practice. Outcomes may change.
191
The classifications shown in Table 19 were used to explore any possible
links between the profiles and preferences for the types of prevention and
control strategies applied.
During the recruitment stage, a study brochure was developed to provide

those organisations that expressed interest in the study with more details
about:
the aims of the study;
the amount of researcher involvement;
how the research may impact upon their operation;
typical times frames involved;
their required involvement in the study; and
expected outcomes.
The organisations were de-identified to preserve their anonymity. As it was

anticipated that most participants were motivated towards involvement
based on a genuine desire to improve their OHS performance, this aspect
was intended to encourage participation and address any concerns related
to the possible exposure of their OHS issues to regulatory authorities.
7.2 Establishing Validity

7.2.1 Construct Validity
The construct validity, which refers to correctness of the operational

measures used to assess the concepts under examination, was
established on three levels:
(i) The derivation of the “safe place, safe person, safe systems” OHS
MS model framework from an extensive review of the literature.
(ii) Peer review through the course of the development stage during
conferences, both nationally and internationally (see the list of
192
publications, following the table of contents). Lincoln and Guba
describe in some length the value of peer debriefing as a means of
establishing credibility. The benefits of this process are the
opportunities to challenge current working hypotheses, and where
these cannot be defended, the possibility of reconsidering the current
position.382
(iii) Triangulation of data during the field work. Triangulation methods

seek to find convergence of multiple sources of information including
observations; questionnaire and interview responses; and objective
documentary evidence.380 The aim of triangulation is to provide
multiple perspectives, and in doing so overcome the potential for bias
in each individual method. A collage is then formed to give depth and
breadth to the understanding of complex issues.375 Patton insightfully
notes that another important role for the triangulation process is not
only to find convergence, but to direct the research process further
where anomalies are found to exist.383 To check the veracity of the
conclusions drawn via the triangulation process, the review of draft
case reports by several key informants also forms an essential part of
the validation process.380
7.2.2 Internal Validity
As it was proposed to use an OHS management assessment tool to

perform a risk ranking exercise for each of the case study participants, the
internal validity of this tool was established through the application of the
nominal group technique, as described by Delbecq et al.14, 384
The peer
review process was timed to take place after the first stage of the pilot
study involving the use of the assessment tool. This was to provide the
expert panel with additional information during the peer review process.
An alternative option to provide internal validity would be through the use

of the Delphi Method. The Delphi Method involves the use of an expert
panel, with each member receiving the document for review. The review is
performed independently and returned. This is to avoid the potential for
domination or influence from other members. Multiple rounds of the
193
review then take place until convergence is reached. The issue of
convergence forms the critical point where the application of the Delphi
Method is challenged. Without skillful determination of the end point, there
is the possibility of creating a very long, drawn out process.385-387 The
nominal group technique was selected over the Delphi Method for a
number of reasons:
the extensive nature of the literature review which formed the primary
source of input into the process. It is postulated that this wider source
of input information may counteract any potential for bias in the
construction of the questionnaire or the potential for replication of
errors that may occur if a narrow range of input material were used
instead.13
the potential for the Delphi Method to become overly extended if

difficulty is encountered reaching a consensus, or if the return of the
reviewed material is delayed; and
the synergistic effect when working together in a “workshop” setting

as suggested by the nominal group technique was thought not only
to streamline the process, but had the potential to enrich the final
product.
The nominal group technique is not without limitations, namely the

potential for domination of certain members, and the possibility of
groupthink.388 In order to counteract this potential bias, the guidelines
offered by Delbeqc, Van de Ven and Gustafson for conflict resolution and
the constructive use of diverging opinions was observed; and the final
voting stage was conducted in a manner that preserved the privacy and
anonymity of the participants.389 Particular details concerning the
application of the nominal group technique are given in Appendix 4.
Other means of peer review such as the use of focus groups were
considered. However, this was not deemed to be suitable for this research
as the potential bias resulting from the use of a convenience sample and
the less structured format would not support the level of objectivity
194
required.390 The use of focus groups may, however, be useful in future
research in preliminary screening exercises to trial survey questionnaires
or to further explore the perceived barriers to the uptake of a systematic
approach to OHS within particular industry sectors.391
It is also noted for qualitative observations, interviews and descriptions

provided, that the actual researcher operates as the research instrument,
in which case the trustworthiness of the study hinges on the credibility of
the researcher. The following factors were considered essential for the
successful application of the research process: maintaining objectivity and
neutrality; ensuring transparency of the findings and the data collection
process; and displaying competence and professionalism during execution
of the field work.382, 383, 392
It is emphasised that the objective of internal validation in qualitative

research is to provide credibility and trustworthiness, in a manner
analogous to ensuring that the equipment selected for quantitative
research is appropriate and has been calibrated before use.393
7.2.3 External Validity
In a multiple case study design, external validity is provided to some

extent by the replication logic applied to the cross-synthesis of case
studies.380 There is also the technique of finding negative cases to
demonstrate exceptions to the rule where patterns and trends have been
identified. However, Patton cites Lincoln and Guba’s assertion that:383
“It is virtually impossible to imagine any human behaviour that is not heavily
mediated by the context in which it occurs.”
The concepts of transferability and fittingness are suggested in preference

to the term “external validity”, these being related to the degree of
similarity occurring between the two contexts.382 Yin explains that the
purpose of this external validity is not for statistical inference or to
establish causation, but to ensure the coherence of theoretical reasoning
for the development of emergent themes and paradigm shifts. In this
195
sense, the validation process for qualitative research does not try to
achieve the same goals as quantitative research.378 Provided this is clearly
understood from the onset, the rigor of the study is maintained.
7.2.4 Reliability
The reliability of the study, referring to the consistency of findings and the
ability to reproduce the results if the study were to be repeated, was
greatly assisted through the use of the OHS management assessment
tool. This provided a highly structured format for the questionnaires and
the collection of data. A simple case study protocol was also developed
after an initial pilot study, to ensure consistency of approach between
different participants. The details of the case study protocol are outlined in
Appendix 5.
All documents and ancillary information used during the assessment

process were filed in separate folders for each of the case study
participants. This information shall be kept secure and confidential, and
destroyed after a predetermined time once the study has been completed
in accordance with the ethics approval for the project. Any information
used may only be used with the explicit approval of those providing such
information, and only from those who have the authority to make such
decisions.
7.3 Development of Pilot Study Research

Instruments
Specifically this involved the preparation of:
definition criteria for each element within the safe place, safe person,
safe systems framework (Appendix 1) based on the findings from the
literature review;
the hazard profile questionnaire used to assess the unique OHS

problems facing the organisation considered without any
interventions in place to reduce the risk (Appendix 6);
196
the questionnaire used to assess the effectiveness of current
prevention and control strategies in place against the proposed safe
place, safe person, safe systems framework, that is with interventions
in place (Appendix 7); It should be noted that Appendices 6 and 7
were developed from the material reviewed in the literature survey
interpreted in the light of the researcher’s own prior industry
experience.
guidance material for use during stage two of the study on the
selection of performance indicators to gauge whether their planned
improvement activities have in fact been effective (Appendix 8);
guidelines for stage two of the study on how to approach the exercise
involving the targeted selection of three building block elements for
improvement (Appendix 9);
a pro-forma to be used for the monthly self-assessment; and
an evaluation survey.
7.4 Ethics Approval
Ethics approval was granted for this study by the Human Ethics Advisory
Panel “H” from the University of New South Wales on June 14, 2007;
Reference 08/2007/22.
7.5 Significance of the Pilot Study
The pilot study was considered to have been a crucial stage of the
research project and a prime indicator of the likely success or otherwise of
the study. It also provided essential information regarding:
time frames necessary to conduct individual stages;
co-operation levels;
differences in perspectives between management, operations and

the individual workers;
197
whether the questions used where easily understood or open to
misinterpretation;
the level of intrusiveness caused by observation activities and

whether or not this would impact on the findings;
possible areas of difficulty in the collection of data; and
the likely reception and repercussions of the study findings.
A secondary objective of the pilot study was to trial the use of a more
positive, discreet reporting style. The use of emotive language was
avoided wherever possible and the preliminary report written in a style that
preserved the confidentiality of the informants and the actual organisation
being examined. Whilst this did imply that the findings had to be
generalised, rather than have specific problem areas documented in great
detail, the benefits of this style were considered to outweigh any losses. It
was anticipated that the participants already had a good understanding of
areas that were likely to be of OHS concern and therefore did not need
this expanded. Organisations did, however, need to know what their
priorities should be in terms of providing resources and where to obtain
guidance on improvement activities.
A highly visual representation of data in the report findings was used to

cater for the need to receive information quickly and in a high impact
format. Colour coding was used to indicate areas of strengths and
weaknesses. This was to counteract problems commonly encountered
with audit reports, such the difficulty in quickly extracting pertinent
information.
It was also important that the pilot study participants felt that they were in
control of all the events taking place, and that the research was not the
cause of inconvenience or disruption to normal operational activities.
Elements selected for improvement in stage two of the study were to
involve areas of their choosing without influence from the researcher.
Their selection was to be based upon the information presented in the
198
Preliminary Report in combination with their own personal knowledge and
experience within the organisation.
Finally, one of the most important outcomes of the pilot study was to
provide opportunities to refine the safe place, safe person, safe system
framework by improving the quality of the questionnaires used and finding
means to streamline the actual assessment process.
7.6 Methodology for the Pilot Study
The site selected for the pilot study occupied less than ten hectares and
was surrounded by both residential and industrial areas. There were 130
employees present, with seven senior managers and approximately
eleven sales and customer service representatives. The manufacturing
plant operated over 12 hour shifts, 24 hours a day, seven days per week.
Many of the informants were very experienced, all with over five years
experience with the organisation. The operations manager and shift
manager each had over 30 years of experience.
The field work for the pilot study comprised of the following activities:
The pilot study organisation was interviewed about the existence of

particular hazards and indicators that may alert them to their
presence. This information was documented on the questionnaire
sheet. A walk through inspection of the organisation was conducted
and observations recorded to confirm this information and to check
whether other hazards were also present. Information was cross
checked at various levels of the organisation to ensure that the
different perspectives of management, operations and the individual
workers had been taken into consideration.
After the hazards profiling exercise, the organisation was interviewed

about the control strategies that they currently had in place to
minimise the potential hazards identified. This information was
collected for inclusion in the Preliminary Report.
199
An assessment of the current control strategies was made against
the proposed model for the building blocks of OHS MS. Documentary
evidence was collected to substantiate interview responses, and
observations were cross checked against verbal information
supplied. The proportion of safe place, safe person and safe system
elements were analysed and assessed to determine whether this
reflected the full hazard profile identified.
The number of elements that were addressed formally, informally

and not at all by the organisation were noted.
A report was prepared with the preliminary results and presented to

key personnel in management.
The pilot study participants were then asked to identify three areas
considered to be in the most urgent need of attention. They were
asked to select corresponding control strategies, with guidance
offered from the proposed safe place, safe person, safe systems
framework.
Information was provided on the strengths and limitations of various

performance measurement indicators. They were asked to select
indicators that were most appropriate for the areas they had targeted
for improvement so they could determine whether or not their actions
had been beneficial.
The pilot study organisation was then asked to regularly monitor the
progress of these three areas over a period of four months. This
formed the basis of their customised monthly self-assessment. For
each of the three areas selected, they had to ask three questions that
would result in actions leading to a reduced level of residual risk for
the problem areas identified. The questions were to be phrased in
such a way that would generate a clear “yes” or “no” answer. Where
a “no” response was entered, an explanation of the current status of
the proposed activity was to be recorded. Where possible, these
monthly self-assessments were to be cross-checked by someone
200
within the organisation who was independent of the activity, or by
members of the safety committee. Results were emailed to the
researcher on a monthly basis so that progress could be tracked.
An evaluation survey was conducted at the end of the exercise to

explore how the research activities were received, whether the
hazard questionnaire and building block model was considered
useful, what areas of the study they liked the least and what
elements the organisation considered were critical to systematic
OHS improvement.
7.7 Potential Outcomes

The most important outcome of the pilot study was that it provided the
information necessary to generate improvements to the proposed safe
place, safe person, safe systems framework. This information was able to
be conveyed to the expert panel during the nominal group technique peer
review process; and was used ultimately to determine whether or not this
framework was suitable for wider case study application.
The pilot study suggested that this technique was most suitable for small
to medium sized organisations. However, this hypothesis still required
further testing.
Once the new safe place, safe person, safe systems framework had been
refined and its application trialled on a number of case studies, it is
suggested that later outcomes of the study may include:
the development of a generic questionnaire that may be used to

assist organisations in understanding and documenting their
individual hazard profile;
development of guidelines on how the nature and size of the

organisation may influence the application of particular building
blocks elements;
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development of guidelines on the order of implementation of the
various OHS MS building blocks so a “pathway” to the improvement
process is apparent;
the development of a wide range of industry specific OHS MS

templates;
direction for future studies to perform validation exercises on industry

specific OHS MS models; and ultimately
extension of the existing hierarchy of control model so that guidelines

exist, not only for hazards of the physical environment and
infrastructure, but also for the treatment of risks associated with
psycho-social hazards and those associated with management
practices.
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Part 4: Results
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8. PILOT STUDY RESULTS
8.1 Preliminary Results
The pilot study was conducted on a medium sized plastics manufacturing

facility in the Sydney metropolitan area during March to June, 2007. The
pilot organisation was keen to have a risk assessment exercise performed
on their plant as the site was under increasing financial pressure and
needed to prioritise the allocation of their limited OHS funding carefully.
The sampling strategy for the pilot study was opportunistic, as the
organisation was known to the researcher prior to the study. However, this
was not the situation with the later case studies where a purposeful,
random strategy was aimed for.
A project field kit was distributed to the pilot study participants prior to the
start, so they could acquaint themselves with the information contained in
the following appendices:
Appendix 1: Definition of OHS MS Framework Elements;
Appendix 6: Hazard Profiling Questionnaire - Without Interventions in

Place;
Appendix 7: Assessment of Current Controls Against the Proposed

Safe Place, Safe Person, Safe Systems Framework;
Appendix 8: Performance Measurement Indicator Guidelines;
Appendix 9: Guidelines for the Targeted Selection of Three Building

Blocks for Improvement;
Appendix 10: Example of the Pro-Forma for the Customised Self

Assessment Tool, and
Appendix 11: Follow-Up Evaluation.
The information contained in Appendix 1 was found to be somewhat

difficult to interpret for those who were not familiar with the requirements
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typically found in OHS MS structures such as AS/NZS 4801:2001
Occupational Health and Safety Management Systems - Specification with
Guidance for Use.2 A decision was then made to change the format of the
information to cater for personnel who were more production or outcome
oriented. The safe place, safe person, safe systems elements were then
presented in two formats: one to explain what the requirements entail and
the other to concisely communicate the risk presenting to the organisation
should these elements be overlooked. The material was also colour coded
so that they could quickly choose which section of information they
preferred to read and could scan the documents more easily.
Prior to the actual assessments, the organisation was contacted to co-

ordinate the availability of staff and other personnel during the risk ranking
exercises; to arrange a site induction; and also to ensure that the
requirements for personal protective clothing were clear. All meetings
times were confirmed prior to the date. On some occasions, meeting times
were deferred due to production problems or other urgent engagements.
The risk ranking exercise was then performed using the unrevised
questionnaires in Appendices 6 and 7. These contained a series of
prompts to examine the potential risk factors and possible prevention and
control strategies for each of the 57 elements of the proposed framework.
The three aspects – safe place, safe person and safe systems, were
assessed separately.
During the risk ranking exercise, consideration was given to whether each
element applied to the pilot site and if they were handled on a formal or an
informal basis. Formal procedures were those that were governed by
documented procedures, whilst informal methods tended to rely more on
common practices. Elements not currently addressed by the organisation
were also noted. It was found that all but one of the elements applied –
Customer Service- Recall/Hotlines, on the grounds that it was an
intermediate product and there were no direct dealings with the end users.
The results of this exercise are found in Table 20.
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Table 20: Number of Elements Handled Formally, Informally and Not
Addressed
No. of Formal Elements 5
No. of Informal Elements 36
No. of Elements Not Addressed 15
No. Of Elements Not Applicable 1
Total 57
The applicable elements were then ranked according to the risk on a scale
of one to four with 4 = High: 3 = Medium-High; 2 = Medium; 1 = Low.
Elements which were handled with expertise were allocated a risk ranking
of zero, with 0 = Well Done. This was to ensure that the evaluation also
provided positive feedback as a source of encouragement.
These rankings were then used to assess the hazard profile of the
organisation without any prevention and control strategies applied – before
interventions; and then finally with interventions in place to evaluate the
residual risk after the prevention and control strategies had been
implemented.
The total value of the scores from the risk ranking exercises were then
summed and distributed across the three main areas where hazards may
arise - safe place, safe person, safe systems, to provide a visual
representation of where the organisation was most exposed to breaches
of duty of care before and after risk treatment options were applied.
The complete Preliminary Report as presented to the pilot study

participants is given in Appendix 12. This also contains details regarding
the status of each element at the time of the assessments, together with
the “after” rating, in the section of the report titled: “Main Findings, Element
by Element.
A summary of the results are shown in the following Figures: 11-14.
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Figure 11: Pilot Study Initial and Final Scores - Safe Place Elements
Emergency Preparedeness
Hazardous Substances
Noise
Ergonomic Assessments
Risk Review
Modifications
Housekeeping
Security - Site / Personal
Preventive Maintenance/ Repairs
Amenities/ Environment
Storage/ Handling /Disposal
Plant/ Equipment
Access/Egress
Radiation
Biohazards
Electrical
0 1 2 3 4
After Before
Risk Ranking Scores

0 1 2 3 4
Well Done Low Medium Medium-High High
Figure 12: Pilot Study Initial and Final Scores - Safe Person Elements
Work Organisation
Training
Selection Criteria
Review of Personnel Turnover
Rehabilitation
Networking, etc
Job Descriptions-Task Structure
Inductions
Health Surveillance
Health Promotion
Feedback Programs
Equal Opportunity
Conflict Resolution
0 1 2 3 4
After Before
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Figure 13: Pilot Study Initial and Final Scores – Safe Systems
Elements
Self-Assessment Tool
Incident Management
Consultation
Due Diligence Review/ Gap Analysis
System Rewiew
Audits
Legislative Updates
Communication
Accountability
Goal Setting
OHS Policy
Procedural Updates
0 1 2 3 4
After Before
Risk Ranking Scores

0 1 2 3 4
Figure 14: Pilot Study - Distribution of Risks Without Interventions

and With Interventions in Place
Without Interventions (Before) With Interventions (After)
Legend
Safe Safe Safe
Safe Place 37% Safe Place 39%

Safe Person 29% Safe Person 25%
Safe Systems 34% Safe Systems 36%
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Approximately three weeks after these risk ranking exercises had been
completed, the Preliminary Report was presented to senior managers.
During the presentation, they were asked to select three elements that the
organisation wanted to target for improvement. The elements selected for
stage two of the pilot study were: work organisation, incident management
and access and egress. These elements were agreed upon by the senior
managers present. The organisation was then requested to develop three
questions related to the outputs associated with each of the three
elements targeted for improvement over a time frame of four months. The
actual questions developed for the monthly self assessment and monthly
progress over the four month period can be found in Appendix 23.
The organisation chose to continue monitoring lost time injuries, medical

treatment injuries, first aid injuries and near misses to determine whether
or not the three elements selected had been improved. These results are
also provided in Appendix 23, following the 4th month’s results.
8.2 Discussion of Key Findings from the Pilot Study
The application of the Safe Place, Safe Person, Safe Systems framework
was found to be very useful for highlighting areas of inherent risk for the
organisation and attracting attention to elements where vulnerability
existed should current prevention and control strategies fail. This was
illustrated in particular by a number of key elements. For example,
electrical testing needed to be conducted on plant and machinery in some
instances whilst the machines where running. This was a high risk activity,
so in the hazard profile it was rated as high. However, the contractors that
had been used to carry out this task had a long period of experience and
history with the facility, and had a high degree of local knowledge.
Therefore, once interventions were used to manage the situation, the
residual risk was reduced to low. By having a “before” rating of high and
an “after” rating of low, the point was conveyed that should the personnel
currently being used for this task change, so would the risk presenting to
the business. Hence, this was an area of potential vulnerability. In another
example, the facility had an emergency plan documented in accordance
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with the local OHS regulations. Emergency assembly points had been
identified and key management personnel trained. However, the contact
list had not been updated and employees working in the plant had not had
a emergency drill for more than 18 months, so the effectiveness of the
interventions applied was minimal, resulting both the “before” and “after”
ratings being high.
The distribution of risks across the three areas did not change dramatically
before and after the interventions were applied – with the residual risk
shrinking only slightly in the safe person area. As this was a qualitative
assessment, the percentages have only been included to help read the
diagrammatic representation and care should be taken not to attach undue
significance to the actual numbers. This exercise was an important
illustration to the business as it was under a period of restricted cash flow,
so there was little opportunity to address the problems related to the
physical equipment, machinery and work environment. In an attempt to
manage the situation, the operations personnel had relied typically on
“safe person strategies” by utilising a high level of personnel competence,
experience and skill. While this was admirable, the fact remained that the
physical work environment and plant posed a significant threat to the
overarching safety and welfare of the workers, and this risk would be even
higher if key management personnel were to leave. Furthermore, the
organisation had elected to handle most of its risks informally on an “as
needs” basis. There was little documentation and few formal triggers and
cues to remind personnel when actions were necessary. Therefore, the
residual risk in the safe systems area remained significant, and the lack of
documentation could be detrimental to the organisation in the case of
litigation as there would be little objective evidence to demonstrate the
precautionary measures they were taking.
The customisation aspect of the framework was not illustrated by the pilot
study organisation as well as expected, as all but one of the elements
were found to apply. However, had another smaller site been selected for
the pilot study, it was possible that many more elements would not have
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applied and this would have illustrated this customisation aspect more
vividly.
One of the most useful findings of the pilot study was the ability of the
analysis to draw attention to the impact of work organisation and problems
with resource allocation and administration. By separating the three areas
– safe place, safe person and safe systems, the study was able to
highlight the effect of the 12 hour shift arrangements which exacerbated
the problems with manual handling, solvent exposure and noise. Although
the shift pattern was very much desired by the factory operators due to the
extended break periods, there was greater potential for fatigue and
prolonged exposure to solvents as well as noise. Hence, whilst not directly
obvious to management due to their focus on the physical work
environment, this issue was reconsidered and a decision made to
investigate patterns in the timing of injuries to see if there was a
correlation between injury frequency and the length of time on a shift.
Attention was also drawn to the restrictive cash flow for the organisation
which resulted in significant delays in dealing with problems related to the
physical workplace. The analysis also highlighted that sufficient time to
address safety and health issues had not been factored into daily
workloads and responsibilities.
On a more optimistic note, areas that were handled well by the pilot site
were acknowledged such as inductions, consultation, and first aid/
reporting. This positive reinforcement provided some incentive to take the
other elements to the same level of achievement.
The format of the report was well received by the pilot organisation. The
actual structure of the report had developed as a result of feedback during
the pilot study exercise and perceptions of what the organisation would
find most suitable. It was evident that information needed to be delivered
quickly as time was a scarce and valuable commodity and that there was
only a small window of opportunity over which the impact and the
significance of the findings could be communicated to senior
management. The decision to reconfigure the definition criteria to provide
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succinct information regarding the possible consequences should these
elements be ignored was also appreciated and it was found that those
reading the report tended to focus on the new format. The highly visual
representation of data was also well suited to a presentation style delivery
and the report was actually shown via an overhead projector in a
conference room. This encouraged a much more interactive style of
communication, with the questions for stage two being developed during
the meeting by amending an electronic version of the pro-forma shown in
Appendix 10.
The more generalised style of writing used in the report was a result of a
deliberate decision to preserve the identity of the pilot study organisation
and the individual identity of informants as much as possible. This was
found to encourage the distribution of the report and the findings of the
study were made readily available to the OHS committee members.
Although a draft version of the report was given to the operations manager
for review prior to issue in final copy, no changes were requested and the
report was accepted as a true representation of the situation presenting
during the period over which the assessments were made.
The pilot exercise was considered to be very successful in achieving its

aims and stage two of the pilot study with the monthly self assessments
was undertaken with a high level of enthusiasm.
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8.3 Lessons from Stage One of the Preliminary Pilot
Study
A number of valuable lessons were learnt during stage one of the pilot
study that were used to refine the procedures later applied in the case
studies. With this information, the case study protocol was developed to
ensure the use of an efficient and consistent approach across the case
study participants and to provide a means of avoiding problems
highlighted during the pilot study process.
One of the most difficult findings was the tendency of the pilot study
organisation to reschedule appointments. The frequency of deferred
arrangements was at times frustrating as these results formed part of the
critical path for the project timelines. However, this was outside the control
of the researcher and it was decided to ensure that the dates for follow up
appointments would be organised as early as possible, and confirmed at
the previous assessment as well as a few days before the scheduled one.
The importance of obtaining multiple perspectives and exploring the

differences in opinion between individuals, operations and also
management personnel was found to be crucial to not only the construct
validity, but also to the face validity of the findings. On occasions
significant variations were encountered, and these prompted the
researcher to delve deeper into the particular issues. Generally it was
noted that the opinions of management were more optimistic, the
individual workers on the plant were somewhat pessimistic, and
operations staff tended to fall somewhere in-between. In these instances it
was vital to cross-check documentary evidence and note observed
practices. It was clear from these experiences that returning to the
organisation on different days was necessary to capture a more
representative sample of the usual practices. It appeared that it took at
least two visits before the participants felt at ease and during the first visit,
operators were being very careful to follow formal procedures. As a
consequence of this, the first visit to future case study participants was
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allocated purely for a site orientation and to familiarise staff with the
proceedings of the study. Where possible, it was suggested to inform
personnel of the impending study via prior OHS committee meetings and
preferably, that this information be documented in the minutes.
Ensuring an efficient assessment process was considered to be

fundamental to the success of the future case studies. However, the time
taken to complete the questionnaires given in Appendices 6 and 7 was
found to be excessive and the structure of the assessment had to be
radically simplified. Consequently, it was decided that the before and after
evaluations should be conducted simultaneously, and that this would avoid
the experience in the pilot study of going backwards and forwards
between the questionnaires provided in Appendices 6 and 7. Hence a new
improved format was put forward for examination by the expert panel
during the peer review process.
A further observation during the pilot study was that by supplying the
questionnaires with the prompts prior to the study to acquaint the
participants with the procedures, there was the possibility that the
informants would provide responses that they may have thought were
desirable or pleasing to the researcher, and cross-checks of information
indicated that this had occurred on a few occasions. This phenomenon
resulted in the prompt information being removed from the project field kit
and supplied separately in the Safe Place, Safe Person, Safe Systems
OHS Management assessment tool. This was to be provided to the
participants at the completion of the risk ranking exercises.
A brief period of unease for the participants was often noted immediately
after areas of weakness were identified. In many cases the problems
identified were simply the result of attempts to remedy one area of
concern with unforeseen consequences. Hence, often one problem was
solved only to create another. Acknowledging their good intentions and
taking the time to explain other perspectives was found to be a useful step
in moving the process forward constructively. Where necessary, external
214
reference material was used to support findings presented. This
transformed a potential cause of conflict into a fruitful learning exercise.
The particular colour coding used in the pilot study report was retained as
it was believed that this had enhanced the acceptance of the information
and greatly assisted the communication process. However, the data
provided in Figure 14: Pilot Study – Distribution of Risks Without
Interventions and With Interventions in Place, was perceived to cause
some confusion as to the significance of the distribution effects, especially
as the changes before and after were not as great as anticipated. Whilst
these results could be well explained by the particular circumstances, it
was evident that the means of conveying the effectiveness of the
prevention and control strategies applied had to be reconsidered (see
Figure 20 for the modified graph).
Finally, the size of the organisation that the assessment exercise was
most suitable for needed to be carefully considered to ensure that the
hazard profiles were representative of the activities investigated. For
example, the hazards experienced by factory operators were found to be
quite different from the sales and customer service representatives.
Hence, the best results were most likely to result from precisely scoped
exercises that reflected a homogenous activity. So, whilst it was originally
thought that the proposed Safe Place, Safe Person, Safe Systems
framework was ideally suited to small to medium enterprises, it would be
possible to apply the framework to larger organisations provided that the
area assessed was limited to a particular division or function of the
organisation.
Therefore stage one of the pilot study proved to be a valuable learning

exercise, greatly enriching the development process and the quality of the
final outcomes.
215
8.4 Lessons from Stage Two of the Pilot Study:
Monthly Self Assessments and the Evaluation
Survey
The second stage of the pilot study involving a monthly questionnaire was
found to be more difficult to implement and depended on having someone
within the organisation who was highly motivated to see the process
through. Fortunately, the preliminary results of the OHS assessment on
the pilot study were considered to be very worthwhile by the organisation
and this generated enough enthusiasm to proceed to the second stage.
However, the organisation was undergoing a period of flux and
management turnover, so this second stage was delayed until the
situation settled.
Although the OHS assessment was conducted with the preliminary tool in
March and April 2007, the second stage didn’t proceed until the following
October even though the agreed follow up actions were decided in June.
Despite these delays, a clear improvement in OHS performance was
observed (see Figure 15).
A considerable time lag was observed until the benefits of the self
assessment program came into fruition, such as discussing the outcomes
of two incident investigations per month at informal operational meetings.
Whilst no statistical correlation was attempted due to the qualitative nature
of the study, a further explanation of the improved trend was the increased
focus and attention on safety and health promoted by the study and the
use of a targeted approach that was realistic.
216
Figure 15: Injury and Incident Results after Completion of Stage two
of the Pilot Study
14
12
10
0
Jun Jul Aug Sep Oct Nov Dec Jan
LTI's Medical treatments First Aid treatments Reports
Feedback from the evaluation survey was positive, and the respondent
from the pilot study would recommend the use of the Safe Place, Safe
Person, Safe Systems framework to other organisations because:
“ … it supplied a simple self evaluation process and simple definition criteria for
each element.”
Although their particular situation with a restricted cash flow and under-
resourcing did make it difficult to devote the time to stage two, the
organisation was able to remain focused and reasonably on track with
targets. Injury rates were found to improve, most likely due to the
increased attention being place on OHS as a result of the study. These
results also highlighted the benefits of having a highly motivated person
internal to the organisation to champion the process and follow up the
improvement program.
217
8.5 Improvements Resulting from the Application of
the Nominal Group Technique
The use of the Nominal Group Technique was found to be of great benefit
to the development of the OHS assessment tool by offering an opportunity
for vigorous peer review by a group of experts of varying backgrounds.
The final panel members included representation by a manual handling
expert, a psychologist, an occupational hygienist, a dangerous goods
expert, a human factors analyst, three members with chemical engineering
experience, an occupational toxicologist and industry representatives with
experience in manufacturing and design. Three academics were involved
including the chairman of the Standards Australia committee for the
development of AS/NZS 4804/4801:2001 Occupational Health and Safety
Management Systems (Standards Australia. 2001a, 2001b). All but two of
the invited members were able to attend on the day, but all provided input
to the process.
The program was steered and facilitated by an academic who was not
involved in the actual development of the tool itself to maintain objectivity.
Although there were clearly differing views from some of the panel
members this was not unexpected as each brought their own perspective
and experience and sharing this was in itself a worthwhile exercise. Where
differing opinions remained unresolved, the members were directed to
express their views at the confidential voting stage, and to cast their votes
on the balance of information available. Once the votes were tallied and
the feedback worked into the final version of the assessment tool, the
panel members were given another opportunity to express any concern
with the final outcome by feeding information back to the researcher within
a reasonable time period. No changes were requested and most panel
members expressed satisfaction with the final outcome.
As a result of the Nominal Group Technique review process, three new

elements were added: Receipt/Despatch to cover OHS issues associated
with transportation of materials to and from the workplace; Personal
Protection Equipment to address issues related to the safe use of PPE;
218
and Contractor Management to ensure clear lines of control and
responsibility. Details of changes within elements in the framework model
were:
Training Needs Analysis was incorporated into Training.
Work Organisation - Fatigue and Stress Awareness was modified to

remove stress awareness, which became its own element.
Noise included more information on vibration.
Access/Egress included a reference to disabled access/egress.
Risk Review was renamed Operational Risk Review.
Self Assessment Tool was renamed Self Assessment
Plant Inspections/Monitoring was renamed Inspections/Monitoring and

the explanatory information modified to reflect the intention that this
was not the walk around inspections associated with housekeeping
but more to do with understanding the process.
Storage/Handling/Disposal had Storage/Handling removed so the

element referred entirely to Disposal, and a new element of
Receipt/Despatch was created.
Ergonomic Assessment was renamed Ergonomic Evaluation and had

any references to Occupational Hygiene removed from the
explanatory material.
The new, improved version of the 60 element Safe Place, Safe Person,
Safe Systems OHS MS model framework is given in Table 21. This was
used for the multiple case studies, together with the revised Safe Place,
Safe Person, Safe Systems assessment tool, provided in full in Appendix
14.
219
Table 21: The New, Improved “Safe Place, Safe Person, Safe
Systems” OHS Management Framework

Equal Opportunity/
Anti-Harassment
Ergonomic Evaluations Accommodating Diversity Goal setting
Access/Egress Selection Criteria Accountability
Inductions-Including Due Diligence Review/

Plant/Equipment
Visitors/Contractors Gap Analysis
Amenities/Environment Training
Administration
Receipt/Despatch Work Organisation - Fatigue Contractor Management

Electrical Stress Awareness
Criteria
Noise
Structure consideration
Hazardous
Substances/Dangerous Behaviour Modification Competent Supervision
G d
Biohazards Health Promotion Safe Working Procedures
Networking/Mentoring/
Radiation Communication
Further Education
Disposal Conflict Resolution Consultation
Employee Assistance
Installation/Demolition Legislative Updates
Programs
Preventive Maintenance/ Personal Protection
Procedural Updates
Repairs Equipment
First Aid/Reporting Record Keeping/Archives
Commissioning
Workers’ Compensation/ Customer Service –
Rehabilitation Recall/Hotlines
Security – Site /Personal Health Surveillance Incident Management
Housekeeping Performance Appraisals Self Assessment
Inspections/Monitoring Feedback Programs Audits
Review of Personnel
Operational Review System Review
Turnover
Key
Progressive Routine
220
8.6 Pilot Study Summary - Strengths and
Limitations
The development of the Safe Place, Safe Person, Safe Systems OHS MS
model framework was found to be a very dynamic process, and a high
degree of flexibility was needed by the researcher to respond promptly
and appropriately to feedback received from the pilot study participants.
This was made possible by being aware of the need for objectivity and
neutrality and a willingness to explore the natural unfolding of events,
many of which were outside the control of the researcher.
One of the limiting factors of the study was the time taken to complete the
two stages and the effect of changes in key liaison personnel. Due to a
serious health issue, the person who was the initial contact was
unavailable for stage two, and this resulted in significant delays before the
situation had settled sufficiently to continue with stage two. This did
forewarn of the likely disruptions that could be expected if these
circumstances were replicated during the case studies. This also
suggested the need to schedule concurrent case study appointment times
to avoid delays in the completion of the overall project.
Clearly the success of the Nominal Group Technique was heavily

influenced by the range, breadth and depth of the experience of the panel
members selected. The careful selection of members to ensure coverage
of all three aspects - Safe Place, Safe Person and Safe Systems, as well
as providing a blend of academic and industrial input, was considered to
be a major strength of the development process. Furthermore, the
application of the Nominal Group Technique would not have been as
effective without the ability to feedback rich experiences from the pilot
study.
The use of a pilot study combined with the Nominal Group Technique to
trial the application of the Safe Place, Safe Person, Safe System
framework was found to be very rewarding and enabled the research to
proceed to the next level with a high degree of confidence in the proposed
221
methods and likely timeframes of individual stages. Furthermore, it was
found that the application of this tool was not limited to small to medium
enterprises as originally thought, but could be extended to small divisions
of larger organisations.
222
9. INDIVIDUAL CASE STUDY RESULTS -
SUMMARY AND DISCUSSION
9.1 Case Study 1

9.1.1 Case Study 1 Results Summary
Case study 1 was conducted on a small/medium sized paints

manufacturing facility in the Sydney metropolitan region between October
and November, 2007.
The site occupied less than 1.5 hectares and was surrounded by light,
medium and heavy industry. There were a total of 40 employees present,
with four senior managers, eight technical staff and approximately 3 sales
representatives. The manufacturing plant operated over one, eight hour
day shift, five days per week. This was a family business and the
managing director and one senior manager were related. The managing
director was very proud of the organisation and the amenities were very
comfortable and pleasant. The business was in a state of growth.
The case study was conducted according to the protocol given in

Appendix 5. The complete Preliminary Report as presented to the case
study participants is given in Appendix 15, together with the element by
element details. A summary of the results follows in Table 22, and Figures:
16-20.
Table 22: Case Study 1 - Number of Elements Handled Formally,

Informally and Not Addressed.
No. of Elements Not Applicable 0
Total 60
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Figure 16: Case Study 1 Initial and Final Scores - Safe Place Elements
Hazardous Substances/Dangerous Goods
Receipt/Despatch
Operational Risk Review
Modifications
Plant/ Equipment
Ergonomic Evaluations
Inspections/ Monitoring
Disposal
Electrical
Housekeeping
Noise
Biohazards
Radiation
Ammenities/Environment
Access/Egress
0 1 2 3 4
With Interventions Without Interventions
Risk Ranking Scores

0 1 2 3 4
Figure 17: Case Study 1 Initial and Final Scores - Safe Person Elements
Health Surveillance
Selection Criteria
Workers' Comp/Rehab
Training
Inductions Visitors/Contractors
Job Descriptions
Feedback Programs
Networking, etc
Health Promotion
Personal Protective Equipment
Stress Awareness
Conflict Resolution
Equal Opportunity
Work Organisation- Fatigue
0 1 2 3 4
224
Figure 18: Case Study1 Initial and Final Scores - Safe Systems Elements
Contractor Management
Legislative Updates
Due Diligence/ Gap Analysis
Incident Management
Consultation
System Rewiew
Audits
Self-Assessment
Goal Setting
OHS Policy
Procedural Updates
Supply with OHS
Customer Service
Communication
Resource Alloc/ Admin
Accountability
0 1 2 3 4
With Intervention Without Intervention
Risk Ranking Scores

0 1 2 3 4
Figure 19: Case Study 1 - Distribution of Risks Without Interventions

Legend

225
Figure 20: Case Study 1 - Risk Reduction after Interventions Applied
80
70
60
Risk Ranking
50
40
30
20
10
0
Legend Without
With Intervention
Intervention
The elements selected for stage two were: contractor management, health
surveillance and emergency preparedness. In addition to this, they also
wanted to work on workers’ compensation/rehabilitation, and hazardous
substances. These elements were agreed upon by the managing director
and the OHS administrator. The actual questions developed for the
monthly self assessment and monthly progress over the four month period
can be found in Appendix 23.
9.1.2 Discussion of the Main Findings for Case Study 1
was able to quickly illuminate the hazards that had not received due
consideration because the consequences were not immediately obvious,
such as the hazards related to long term chemical exposures. Many of the
chemicals handled had long latency periods before the onset of potentially
irreversible side-effects. In addition to this problem was the perception that
chronic exposure to lower levels of toxicants over long periods of time
226
would not adversely effect health, despite evidence in the literature to the
contrary.394
The main OHS concern for operations personnel was the threat of static
electricity and the potential for a fire or explosion of organic vapours. The
interventions applied were able to reduce the risk presenting from these
hazards from a rating of high to low. However there were many other
important issues on the site, such as emergency preparedness and
contractor control. There were no formal documents for emergency
planning although alarms had been installed and evacuation drills
organised. Furthermore, contractor control was minimal, and this was of
particular concern due to the static electricity hazards present and the
potential for vapours. Asbestos was also present on the site and this had
not been detailed in an asbestos register or made known to contractors
during inductions. It was noted that there were some misconceptions
regarding the responsibility that was owed to contractors and the systems
needed to demonstrate that all due diligence had been applied.
Personal protective equipment (PPE) was handled reasonably well given

the language barriers that existed on the site. To overcome this problem,
despite having over a thousand different chemicals to handle, the chief
chemist had organised the chemicals into six groups. Each group was
allocated a different letter which corresponded to a particular combination
of PPE. The requirements for each category were then illustrated visually
on large poster placed near the workstations where the PPE was being
used (see Appendix 26 on sharing good practice).
The arrangements for work organisation were excellent for this particular
operation as fatigue would have increased the risk factors substantially.
The normal shifts, early starts and early finishes were welcomed by the
personnel. Interestingly, there was no artificial lighting in the factory due to
the expense of intrinsically safe lighting arrangements, so work was only
conducted during daylight hours.
227
Of particular interest was the observation that the smaller nature of the
organisation allowed the managing director to maintain very close
relationships with personnel. This allowed the managing director to remain
acutely aware of the staff’s demeanor or whether they were under any
personal stress which could render them unfit for duties. In such situations
where a high degree of distraction or preoccupation with personal issues
was evident, employees were simply asked to take leave. Although the
element of stress awareness was given a high rating prior to interventions
due to the need for constant, high levels of alertness, the ranking was
reduced to low after this informal, yet effective, risk treatment option had
been applied.
A number of dangerous chemicals were handled that had potential for long
term health effects; however there were no health surveillance programs
in place. The use of this method to ensure the effectiveness of current
controls applied was not appreciated, and it appeared that too much trust
was placed in lower order controls such as PPE. A fume exhaust
arrangement was also in operation but its effectiveness was significantly
reduced during warmer weather. This was brought to the attention of
management as a matter of priority. It could be said that management
were very prompt in responding to items in need of quick rectification.
During the time of the assessment, the organisation had a very

rudimentary OHS MS in place, with little focus or prioritising of OHS
issues. An “off the shelf” OHS MS structure had been purchased, and this
was found to be inadequate as the requirements were not easily
customised to the individual site. OHS was handled typically on an
informal basis by line managers. Furthermore, as OHS duties were only a
part-time function of the administrator, and as this was not an area of
familiarity or expertise, other clerical work tended to dominate the daily
workload. Despite this, the incumbent was highly dedicated, enthusiastic
and motivated to take OHS issues forward once OHS requirements were
fully understood.
228
The most useful finding of the study was the ability of the Safe Place, Safe
Person, Safe Systems framework to demonstrate quite vividly how the size
of the organisation and the nature of the relationships between
management and staff were able to deal quite effectively with serious
static electricity hazards, enabling a significant level of risk reduction in
both the safe place and safe person areas. This was well illustrated by
examining Figures19-20. Although the hazards of the physical
environment did dominate the hazard profile of the organisation and these
were addressed reasonably well, Figures 19 and 20 highlighted that
hazards relating to the people area were also significant, and that there
was scope to make further improvements in this area. In this instance the
methods for dealing with the static electricity hazards were well
established and known. The use of outside expertise was a sensible
approach to the existing scenario. Methods for dealing with the chemical
hazards were less well known, especially given the extraordinary number
of chemicals handled by the site. As this was a highly specialised area,
identifying the appropriate help was a difficult task and guidance was
necessary. Although PPE was available, this was relied on too heavily,
with its effectiveness being limited by the degree to which it was being
used as intended and whether or not it had been selected correctly in the
first place.
Strong peer support emerged as an effective means of risk reduction not

only for the elements of stress awareness and work organisation, but also
for dealing with static electricity hazards. An example of this support
occurred when the supervisor was able to alert one of the operators very
discreetly that they had forgotten to connect the earth line on the mixing
tank – a simple lapse on a busy day that could have had dire
consequences had it been ignored.
Again, the customisation aspect of the framework was not illustrated by

this case study as all of the elements were found to apply. It was
considered that the customisation aspect was now more related to the
degree to which individual elements were applied, rather than their actual
absence or presence.
229
The format of the report was well received by the organisation, and the
use of a graph, Figure 20, was incorporated into the report. This was
found to be of great assistance in conveying the effectiveness of current
prevention and control strategies clearly and concisely with a high level of
impact. The style of this new graph was assisted by feedback from case
study 1 participants as the problem recognised during the pilot stage with
the format of Figure 14 had not been sufficiently resolved. As a result of its
success, the style and use of Figure 20 was retained for the remainder of
the case studies.
In contrast to the pilot study, this organisation was well resourced and the
smaller nature of the organisation appeared to enhance the ability to deal
effectively with some very high level risks. This was attributed to the flat
organisational structure and lack of bureaucracy, which assisted the flow
of communications and the speed at which the outcomes of decisions
could be implemented. The organisation was placed in the “progressive”
category according to the classifications provided in Table 19. Whilst the
organisation was smaller, the need for a large OHS MS was not pressing,
although a more systematic approach towards dealing with OHS issues
would have been beneficial.
It was very refreshing to observe managements’ clear and full acceptance

of OHS accountability. The smaller size of the organisation and family
business ethos were believed to have been major contributors to the
element of accountability receiving an after rating of “well done”.
Stage two of the study was welcomed as the organisation was in urgent
need of direction and appreciated the risk ranking exercises as this was
able to help establish priorities for an improvement program. The
organisation continued very diligently with the monthly self assessment
exercises over the period of months that followed. The festive season was
the cause of some disruption, however this had been anticipated (see
Appendix 23). The organisation found the targeted approach to be
worthwhile and opted to continue with the self assessment program after
the study had been completed. The organisation were given a copy of the
230
Safe Place, Safe Person, Safe Systems OHS management assessment
tool after completion of stage one of the study to assist them with ideas for
handling stage two.
As their organisation’s OHS MS infrastructure was still in its infancy and

very few injuries were experienced, the need to measure the effectiveness
of the monthly self assessment intervention was not deemed to be of
importance by the participant who was championing the program. What
was considered to be more important was the greater awareness of OHS
that had developed and the increase in OHS dialogue that had been
generated during the study timeframe. The most useful feedback received
from the evaluation survey (see Appendix 24) was:
“The Management Assessment Tool is easy to follow covering three areas Safe
Place, Safe Person and Safe System … Using the Self Assessment Tool, you can
methodically improve or implement OHS systems and procedures allocating
responsibility and time frames for completion … we will continue to use the “Self
Assessment Tool” and methodically increase safety awareness and culture.”
This strongly suggested that this new Safe Place, Safe Person, Safe
Systems OHS management framework and assessment tool could be
particularly useful in situations where existing OHS systems were still in
their infancy and direction and focus was needed. In this unique instance
the lack of existing OHS systems assisted the uptake of the intervention
and helped to propel the OHS program forward whilst also providing
visible workplace improvements.
231
9.2 Case Study 2
9.2.2 Results Summary for Case Study 2
Case study 2 was conducted on a medium sized foam recycling facility in

the Sydney metropolitan region, also between October and November,
2007.
The site occupied approximately 4.5 hectares and was surrounded by light
to medium industries, as well as a commercial zone on the eastern
boundary. There were a total of 49 employees present, with one senior
manager on site, seven technical staff and three in the despatch team.
There were also five maintenance crew members and two long term
contractors. The manufacturing plant operated over three shifts, 24 hours
per day, six days per week. Maintenance work was usually organised on
the seventh day. Funding for projects was readily available.

21-25.

Total 60
232
Figure 21: Case Study 2 Initial and Final Scores - Safe Place Elements
Electrical
Plant/ Equipment
Noise
Receipt/Despatch
Housekeeping
Modifications
Disposal
Radiation
Biohazards
Access/Egress
0 1 2 3 4
Risk Ranking Scores

0 1 2 3 4
Figure 22: Case Study 2 Initial and Final Scores - Safe Person Elements
Inductions
Selection Criteria
Feedback Programs
Stress Awareness
Work Organisation
Training
Networking etc
Job Descriptions
Conflict Resolution
Equal Opportunity
Health Surveillance
Workers' Comp/Rehab
Health Promotion
0 1 2 3 4
233
Figure 23: Case Study 2 Initial and Final Scores- Safe Systems Elements
Due Diligence / Gap Analysis
Audits
Procedural Updates
Legislative Updates
Accountability
Goal Setting
OHS Policy
Incident Management
System Rewiew
Self-Assessment
Consultation
Resources
Communication
0 1 2 3 4
Risk Ranking Scores

0 1 2 3 4

Legend

234
80
70
60
Risk Ranking
50
40
30
20
10
0
Legend Without
With Intervention
Intervention
The elements selected for stage two of the study were: hazardous
substances, noise and contractor management. These elements were
agreed upon by the senior manager on site. The actual questions
developed for the monthly self assessments can be found in Appendix 23.
Due to the loss of the site OHS coordinator, the monthly self assessments
were returned for only two months, one of which was spent deliberating
the questions to be asked.
9.2.2 Discussion of Main Findings for Case Study 2
One of the most notable hazards on site was the presence of isocyanates
- a known respiratory sensitiser at very low concentrations. Much attention
was devoted to ensuring that this compound was well controlled. However,
there were other obvious odours present in the factory that were not
specifically identified, nor was any attempt made to reduce the emissions.
These fumes appeared to be associated with the bundles of assorted left
over foam remnants that were being used for recycling. The presence of
these volatile organic compounds combined with the high levels of dust
235
and dry air were risk factors for fires, a number of which had already been
experienced over the last few years. Despite these incidents there were no
hazardous area classification diagrams available or other rules regarding
the specification of electrical equipment in potentially flammable
atmospheres.
Noise levels were high and constant, and the ability to engineer the noise
out from the source was limited by the technology selected for the
operation which involved a milling machine to break up the foam scraps.
Noise reduction relied predominantly on the use of hearing protectors. The
potential for isolation with the high level of hearing protection was
problematic due to the need to be on constant alert for forklifts involved in
the despatch process. Furthermore, the incessant noise and vibration,
combined with the odours, contributed to the early onset of fatigue in the
plant area.
Exposure to manual handling was high although it was observed that

movements were smooth and training in manual handling techniques had
been very successful. There was, however, a high risk of serious
lacerations from cutting bundles of scrap that were tied with metal
fasteners.
During the time of the assessment the OHS manager was highly
motivated and had devoted considerable time to health promotion, OHS
committee meetings, training and emergency preparedness. Inductions
were thorough for new visitors although disclosure of site hazards was
incomplete. This minimalist approach to the disclosure of hazards,
especially with respect to the presence of respiratory sensitisers, would
clearly fail to protect vulnerable persons entering the site. Again there was
an apparent misunderstanding about the responsibilities owed towards
contractors.
The organisation was very risk assessment focused and had a number of
highly sophisticated electronic systems in place to keep track of actions.
However, this emphasis on risk assessment appeared to divert resources
236
away from thorough problem solving during the incident investigation
process. Incident investigations were often circular with the outcomes
often simply calling for better risk assessments. This having been
recognised, there was no attempt to improve problem solving skills or
consider the use of multiple perspectives during the root cause analysis
stage. Also, the highly structured pro-formas in use tended to steer
investigations down certain predetermined paths, often without
considering the full context of the situation. This reinforced the need for a
careful balance between proactive and reactive measures. In this
instance, all the energy was being dissipated on upstream activities, and
the lack of good system review allowed this imbalance to continue
undetected.
The use of the Safe Place, Safe Person, Safe Systems Framework clearly
illustrated how the high level of risks in the physical work place were
managed predominantly with safe person strategies rather than removing
the physical hazards from the source. This technique was relatively
successful due to the high level of experience and competence of
supervisory staff. However, this did result in employees being constantly
exposed to unpleasant working conditions, cumbersome PPE
requirements and potential long term health risks related to noise and
volatile organics. Persons with atopic predispositions would clearly have
been at risk. Alternative production methods that were inherently safer
were under consideration but still in the trial stage which appeared to be
long and protracted. Furthermore, the capital expense associated with
such changes was potentially prohibitive. This was well illustrated by
Figure 24. Figure 25 demonstrated how the safe systems area actually
had the lowest level of overall risk reduction, despite the OHS MS being
quite sophisticated and mature in relative terms.
All but one of the 60 elements was found to apply - with customer service/
recall/hotlines being the exception. Again the product was an intermediate
that was used within the larger organisation. The most obvious issues
associated with the use of the largely formal methods were the potential to
overload the system with unfinished actions, and the delays caused as a
237
result of the shear number of people involved in the decision making
processes.
The site was considered to be in the “progressive” category according to

the classifications given in Table 19 as the process was still being fine
tuned and they were not in a position to be using best practice.
The use of remote management and the large size of the organisation
appeared to result in the development of splinter groups that had a
propensity to focus on their own goals and agendas. Evidence of
disgruntled workers was apparent during the assessment period and it
was evident that attempts were being made to use the OHS system to
gain attention for other unrelated issues. This was a cause of frustration
for some of the senior and technical staff.
This case study illustrated that whilst the attachment of the site to a larger
organisation provided many positive benefits such as strong cash flow and
electronic systems, the placement of too much trust in electronic systems
and documented action plans was detracting from the basic understanding
of key issues that would have been readily identified in specialist audits.
This would have provided an opportunity to undertake visual inspections
and the use of objective outside observers may have challenged some of
the narrowly focused risk assessments.
Feedback from the evaluation survey suggested that there were some
problems in trying to superimpose the monthly self assessment process
into existing systems that were already highly developed. Only two self
assessments were returned. The first month used questions from the
organisation’s existing systems, and only in the second month were
questions refined to reflect site issues more accurately. Difficulty was
encountered trying to find questions that would compliment the current
systems without causing excessive duplication of work. As a result, no
attempts were made to measure the effectiveness of the intervention as
very little progress was made. The participants did not consider the use of
238
the intervention suitable for their organisation, but did make the following
comment, given in full in Appendix 24:
“I would however recommend this study to other companies because I found it

to be comprehensive and detailed.”
This case study was an archetypal example of how high levels of

bureaucracy and complex hierarchies within an organisation can pose a
significant hazard by delaying the organisation’s responsiveness to urgent
OHS issues, which in this example involved recurrent factory fires and
health effects associated with chronic exposure to volatile and toxic
organic compounds.
239
9.3 Case Study 3
Case study 3 was conducted on a small/medium sized organisation that
manufactured and assembled dangerous goods between November and
December, 2007. The business was located outside the Sydney
metropolitan region in a semi-rural setting.
The site occupied less than 15 hectares and was surrounded by semi-rural
properties on all boundaries. There were a total of 20 full-time employees
with a float of 30-40 casuals that were employed on an “as needs” basis.
There were two directors and five senior managers. The organisation
comprised of two main functions: the manufacturing and assembly
operation; and the management of festive events. To ensure that the
hazard profiles developed with the risk ranking exercises were consistent
and representative of a homogeneous activity, the manufacturing and
assembly operation was selected for the study. The organisation was a
family business and the manufacturing and assembly operation was
conducted five days per week from 7.00 am to 3.00 pm. The organisation
was classified as a “strategic planner” according to the categories given in
Table 19. The process had clearly been mastered and they were in a
position to consider best practice.
The case study was performed according to the protocol given in

26-30.
Total 60
240
Elements.
Receipt/Despatch
Housekeeping
Disposal
Biohazards
Plant/ Equipment
Modifications
Electrical
Access/Egress
Radiation
Noise
0 1 2 3
Risk Ranking Scores

0 1 2 3 4
Elements
Health Surveillance
Workers' Comp/Rehab
Stress Awareness
Training
Inductions
Selection Criteria
Feedback Programs
Equal Opportunity
Work Organisation
Conflict Resolution
Job Descriptions
Networking etc
Health Promotion
0 1 2 3
241
Elements
Incident Management
Consultation
Self-Assessment
OHS Policy
Customer Service- Recall/ Hotlines
Communication
Audits
Procedural Updates
Legislative Updates
Goal Setting
System Rewiew
Accountability
0 1 2 3
Risk Ranking Scores

0 1 2 3 4

Legend

Safe Person 31% Safe Person 34
242
80
70
60
Risk Ranking
50
40
30
20
10
0
Legend With
Without Intervention
Intervention
substances, emergency preparedness and inductions - including
contractors and visitors. These elements were agreed upon by the OHS
manager and one of the directors. The actual questions developed for the
monthly self assessments can be found in Appendix 23.
One of the most obvious hazards on the site was the risk of an
uncontrolled explosion or fire. Despite the enormous risks, the
organisation had developed a very sophisticated level of expertise and the
practice had been handed down from one generation to another. Whilst
resources were not plentiful, the high level risks were managed very
effectively by only dealing with small groups of trusted individuals, many of
whom were well known to the family or were related. All electrical work
243
was carried out meticulously and static electricity hazards were handled
exceptionally well – see Appendix 25 on sharing good practice. Electrical
storms were of particular concern. In these instances, all
assembly/manufacturing work ceased and employees returned to the main
office area, a safe distance from stockpiles of potentially explosive
materials.
Interestingly, a decision had been made not to invest in large scale fire
fighting equipment or deluge systems as these were considered to be
ineffective and to provide little guarantee of safety should an unfavourable
turn of events arise. Instead, the individual work stations were spread out
across the property and many of the assembly areas involved lone
workers. Hence, they had accepted the possibility of a fatality, but had
taken measures to ensure that should the worst case scenario eventuate,
the number of lives lost would be minimal. This extraordinary acceptance
of such a high level of risk was mediated by the fact that many of the
employees were family members, or very good friends. Therefore, the duty
of care was not just a legal obligation but more of a family commitment.
The obvious risk due to static electricity was taken very seriously and the
resources available were spent in preventive rather than reactive
measures.
Another area to note was the lack of specialist chemical expertise on the
site despite the highly toxic nature of some of the components being
handled. This became evident in an inspection of the material safety data
sheets (MSDS) prepared by the organisation which did not include useful
information for those handling the products should there be a loss of
containment. However, once the purpose of the material safety data
sheets was explained this situation was promptly rectified, and later
prepared MSDS were found to be of a much higher standard.
The lack of chemical expertise also meant that the possibility of toxic
fumes resulting from an emergency situation had been overlooked, a
factor which could easily increase the number of serious injuries or
244
fatalities anticipated. The remote nature of the site could also create
difficulties for access by ambulance and other emergency vehicles.
The type of chemical compounds being handled indicated the need for
chemical surveillance, however this had not been considered. An
alternative option was to reduce the chemical inventory and eliminate the
chemicals that were known to be particularly dangerous.
The small size of the organisation made it difficult to negotiate or enforce

OHS requirements on the large contractors used to transport their finished
goods. Due to the explosive nature of the product, there were only a
limited number of carriers available. Ensuring that the carriers followed
their safe systems of work was an arduous task, and due to the
organisation’s small size, they did not believe they had the negotiating
power to enforce such requirements.
Site inductions were very simplistic and did not convey all the hazards
present on the site. Given the complexities of the manufacturing and
assembly processes, the induction would be quite long if it were to cover
all the areas adequately. The site was very large, with different areas
having specific hazards. A more customised approach was later adopted
with three different inductions catering for contractors, escorted visitors
and unescorted visitors.
The semi-rural setting provided the first opportunity to observe a more

unusual biohazard – a caterpillar that had infested the property. This was
the cause of some workers experiencing a very severe allergic reaction.
The caterpillar had been introduced onto the site through contaminated
supply boxes. A regular regime of spraying the trees with insecticide had
been introduced which had the situation under reasonable control.
The current OHS MS in the organisation was very rudimentary. Of the 60

elements suggested only 11 had been addressed with formal systems and
36 had been addressed informally. All 60 elements were found to be
relevant to this organisation. Significant attempts had been made to
perform and document risk assessments, as required by the State OHS
245
regulations. This tended to create excessive paperwork and consume the
minimal OHS resources without providing a clear pathway to improvement.
It was evident that all the best intentions were there, but the lack of focus
and direction resulted in ad hoc improvements.
Elements that were handled well include accountability, competent

supervision, and performance appraisal. The small size of the organisation
assisted the speed of communications and the owner’s clear acceptance
of responsibility was demonstrated by visible actions.
The use of the Safe Place, Safe Person, Safe Systems framework was
able to illustrate how the attention and energy of available OHS resources
had been focused on those safe place hazards that had immediate
consequences, but little consideration had been given to chemical hazards
with long term health effects, as was seen in case study 1. Whilst the
ultimate outcome of these potential hazards was the same – death or
serious debilitation from either a fire/explosion or serious illness; the long
term health effects had essentially been dismissed.
Furthermore, the Safe Place, Safe Person, Safe Systems framework was
able to illuminate the imbalance in the strategies applied, highlighting how
the energy devoted to front end risk assessments was overloading the
system with unfinished actions, leaving other areas such as incident
investigations very exposed. There was a clear need to question the use
of paperwork that did not lead to meaningful output.
In this case study, it was clear that time was a precious commodity, and
resources were stretched. Hence the mode of OHS information delivery
had to be quick and of high impact. It was observed that a number of safe
working procedures were presented in flowchart format on laminated
pages placed on the wall near the point of use.
The Preliminary Report was presented to the OHS manager and the two
directors. The visual representation of data was greatly appreciated and
the directors focused mainly on Figure 30: Risk Reduction after
Interventions Applied to digest information from the study. A draft report
246
had been accepted without change as a true and fair representation of the
situation during the time of the assessments; although they did not
necessarily agree with all the “high” after ratings, considering some to be
of less relevance to them. This was the case with the element of health
surveillance where they were not strictly in compliance with the State OHS
regulations. It was observed that compliance with State OHS regulations
was not a strong motivational factor for action for a number of the case
studies. This was noticed typically where there was the absence of
obvious, negative, short term consequences. This also reinforces the
points made by Hale and Glendon regarding the strategic use of the
reward schedule to change behaviours.304
Stage two of the study was entered into very diligently and there was a
clear level of enthusiasm and dedication by the OHS manager who was
championing the study. The monthly self assessments were conducted
rigorously with considerable effort being directed at framing the questions
appropriately. There was a relatively high clearance rate of actions that
had been agreed upon at the start. No attempts were made to measure
the effectiveness of the intervention as this did not appear to be that
important to the participants. The following comments were disclosed in a
personal communication with the main informant from case study 3 and
have been reproduced with permission. These reinforce the concept of
mindfulness as discussed by Weick and Sutcliffe:395
“A good sign is that incident/near miss reports are being reported when they
arise and this is without reminding people about how to go about this process.
This says to me that OH&S issues are in “most” peoples’ minds and that they
are being proactive about reporting and fixing issues. However there is no
visible reduction in the past four months on incident/near misses (no incidents)
but I now have a good paper trail that outlines some trends and areas that may
need attention in the near future … “
This paradoxical effect of no reduction of incidents after the intervention

may be explained by an increase in reporting activity, simply reflecting the
247
capturing of greater volumes of information, and a common phenomenon
at this early stage of the improvement process.
The evaluation survey offered some interesting insights into the dilemmas
faced by smaller businesses, such as not knowing where to start and
perceptions of OHS compliance being overwhelming with the resources at
hand. Excerpts of some of the positive feedback, which is found in full in
Appendix 24, included:
“Most valuable parts (of the study) were:
Identifying all the areas of weakness within the company
Learning about the 60 elements of the system and identifying the

appropriate risks
Analysing each individual element and breaking down each risk to

determine the ratings.”
This feedback suggested that the Safe Place, Safe Person, Safe Systems
framework may be applied with success in organisations that have very
little in the way of an existing OHS MS. Furthermore, by concentrating on
just a few elements as a starting point, the overwhelming nature of the
task ahead is broken down into manageable portions. This provides the
opportunity for some visible short term improvements and early victories to
help promote the OHS program and secure upper management support.
248
9.4 Case Study 4
Case study 4 was conducted on a large national media organisation

between December 2007 and early January 2008.
The site was located in the Sydney metropolitan region. To ensure that the
hazard profiles developed with the risk ranking exercises were consistent
and representative of a homogeneous activity, a small division of the
organisation was selected that dealt with the film crew for news and
current affairs. Of particular note in this case study was that the “place”
was variable, unlike the previous case studies where the risk ranking
exercises consisted of evaluating a fixed, known area. It was necessary at
times to accompany the crew “on location” to obtain a better
understanding of the unique hazards experienced in these circumstances.
The division was classified as “progressive” according to the categories
given in Table 19, as there were aspects of the operation that were still
being mastered.

31-35.

Total 60
249
Figure 31: Case Study 4 Initial and Final Scores- Safe Place Elements.
Radiation
Noise
Access/Egress
Modifications
Biohazards
Electrical
Plant/ Equipment
Disposal
Housekeeping
Receipt/Despatch
0 1 2 3 4
Risk Ranking Scores

0 1 2 3 4
Figure 32: Case Study 4 Initial and Final Scores- Safe Person Elements
Stress Awareness
Work Organisation
Inductions
Health Surveillance
Conflict Resolution
Training and Skills

Job Descriptions
Selection Criteria
Feedback Programs
Networking etc
Health Promotion
Workers' Comp/Rehab
Equal Opportunity
0 1 2 3 4
250
Elements
Accountability
Communication
OHS Policy
System Rewiew
Goal Setting
Incident Management
Self-Assessment
Legislative Updates
Audits
Procedural Updates
0 1 2 3 4
Risk Ranking Scores

0 1 2 3 4

Legend

251
80
70
60
Risk Ranking
50
40
30
20
10
0
Legend Without Intervention With Intervention
The elements selected for stage two of the study were: baseline risk
assessments, inductions - including contractors and visitors, and feedback
and consultation. Some of the names of the elements were changed for
the organisation to fit into the existing culture. Inductions - including
contractors and visitors was renamed “inductions, training and
awareness”, and consultation was called “feedback and consultation” as
the word consultation had previous connotations with enterprise
bargaining. These elements were agreed upon by the national OHS
advisor and the film crew supervisor. The actual questions developed for
the monthly self assessments can be found in Appendix 23.
The most obvious potential hazard in this case study was associated with
the variable workplace setting and the use of film crew who were
essentially lone workers. The film crew comprised mainly of contractors
and again there were misconceptions regarding the level of duty owed,
especially with respect to inductions and informing them of the types of
252
hazards that may be encountered on location. The situation of a single
person crew had developed as a result of a previous enterprise bargaining
agreement for which a pay rise was exchanged. The crew member is
usually accompanied by a journalist; however they are not normally
available to assist with technical issues or to carry equipment. Filming
sometimes involved walking backwards down court foyer stairs, or
attending potential riot areas with the threat of physical violence from
locals. Without a “buddy” to accompany them and warn them of impending
danger, perceived stress levels were high. Further to this, the market was
very competitive and the film crew often had great pride of workmanship.
Extreme levels of personal risks were often accepted in order to get prize
winning footage, or to move strategically into more prestigious production
zones within the organisation. The intensity of work was high when it was
available; however, this was balanced by long periods of downtime.
Planning arrangements to avoid the use of single person crew were
agreed to in theory; however, in practice, it was a matter of whoever was
nearby to film the story. The “race” to be the first on the scene was part of
the high adrenaline culture and there was a great reluctance to turn down
work over personal safety issues.
The scheduling situation was not helped by the departmental

arrangements that were structured so that the film crews were providing a
service function to the news room journalists. This implied that they were
not working on the same team, despite the fact that one could not exist
without the other. The arrangement resulted in an inability of the news
room personnel to empathise with the work conditions experienced by the
film crew, and vice versa. Work place consultation was conducted on a
very high level, and there was no dialogue between the contractors (some
of whom were long term) and the people assigning jobs. The culture of the
organisation and importance attached to hierarchal status encouraged the
current situation to remain unchallenged.
The ergonomic situation was difficult to manage as some crews had

preferences for different types of equipment, and there was a belief that
the benefits of lighter equipment were offset by a reduction in the picture
253
quality. Whether this was in fact true or just personal preference, was a
matter of debate. Using trolleys with wheels to carry equipment was not
always convenient. What was desirable was something that could be
thrown over one’s back to allow the easy negotiation of stairways and
promote independent travel.
The organisation was highly bureaucratic and there was a great emphasis
on documentation, much of which existed on the organisation’s internal
website. Interestingly, this mode of information delivery was not suited to
the intended users, who appeared to prefer receiving most of their
information visually. Time was a precious commodity and information had
to be conveyed in a high impact format to engage them in the process. A
tiered formal risk assessment process was required by the organisation to
address the hazards associated with single person crews. These formal
risk assessments were meant to be performed prior to the assignment of
crew to each project. In practice, this was not working and the procedure
was simply ignored.
This particular division of the organisation handled very well the elements
of equal opportunity/anti-harassment; accommodating diversity; workers’
compensation and rehabilitation and competent supervision. A significant
amount of effort had been focused on providing a computer based list of
safe working procedures for commonly experienced hazards, for example
potential hearing damage from headsets, and working around radio
transmitters. This was of high quality and very comprehensive, however,
personnel had to have a high degree of familiarity with the operations to
navigate successfully around the websites.
was able to quickly highlight the problems associated with a variable
“place” and the need to consider alternative means of risk assessment.
The framework was also able to draw attention to the stress levels being
experienced by many of the individuals within the organisation. This
illustrated how the internal structuring of the divisions and work groups
made it easier to expose “unknown workers” to undesirable situations.
254
This need to develop a better appreciation of the factors that impacted on
the crew member’s daily experiences was brought to the attention of the
supervisor. Later on, an increased level of dialogue was noted, and this
was a small, yet significant, positive outcome of the study (see the
Appendix 23).
Another issue highlighted by the use of the Safe Place, Safe Person, Safe
Systems framework was the stress resulting from the allocation of
responsibility that was not commensurate with authority. The lack of
resources and empowerment of those assigned to promote safety and
health suggested unresolved problems at a higher level. This was a clear
source of frustration for those that had to manage these OHS issues on a
daily basis. The use of heavy documentation appeared to create a false
sense of confidence in the ability of the current OHS MS to successfully
deal with workplace hazards. It was stressed that these systems were only
helpful if they actually translated into real actions that demonstrated visible
improvements.
It was observed that this large organisation had developed a number of

subcultures and mechanisms to cope with the noticeably high levels of
stress. A very dry sense of office humour was a welcomed relief from more
monotonous activities. The presence of strong informal cliques was also
observed, signifying a high level of internal fragmentation.
A recurring observation was the good intentions of the parties involved,

but a simple lack of knowledge of options available to move forward
constructively. The OHS advisor was highly motivated to improve the
system and was keen to explore newer options for managing the risk
under often stressful, unpredictable and complex scenarios.
All of the 60 elements were found to apply to this organisation. Most of the
elements were handled formally, 14 were handled informally and five were
not addressed at all. The elements not addressed included: operational
review; behaviour modification; health surveillance; self assessment and
system review. A relatively high level of residual risk was noted across all
255
three areas - safe place, safe person and safe systems. There was a
strong need to streamline and customise critical information to cater for
the personality and preferences of the people it was designed to protect.
The overly bureaucratic systems encouraged staff to find means around
the obstacles or simply ignore procedures that were too cumbersome. This
had the effect of often dismantling the protection the system was intending
to provide. Without objective periodic auditing of the systems, the
organisation was unable to respond to aspects that were clearly
unworkable.
The Preliminary Report was reviewed by the OHS advisor prior to wider
distribution and accepted as a true representation of the situation
presenting at the time of the assessment process. Only a few minor
changes were requested to some of the descriptors used to blend in with
the existing culture and accepted vernacular.
Stage two of the study took some time to commence, and this was
attributed to internal restructuring arrangements that were occurring
concurrently. Planning for the use of more informative induction and
training material was taken up in the monthly self assessments. One
month was used simply to frame the questions and the subsequent two
month’s results were used to organise the collection of footage for training
and to plan for the discussion of recent incidents in informal forums. The
supervisor decided that the questions needed to be short and the aim was
to start slowly with this new intervention. By the end of the four months,
footage had been identified but not yet converted into a training package.
The need to establish a “forum” as such was reconsidered. It was later
considered to be sufficient that there was a greater willingness to discuss
problems openly as they arose.
Feedback from the evaluation survey, which appears in full in Appendix

24, was very positive, although it was obvious that conducting this study
was difficult given their level of available resources. An excerpt from the
survey follows on what they considered to be the most valuable part of the
exercise:
256
“Having to think about the results, particularly the (poor) ones you don’t
like and which pertain to regular parts of the work.
Getting the attention of managers and supervisors to address the

issues.”
In terms of the study’s influence on changing any future customs and

practices, the following response was given:
“Yes but not necessarily on its own … changes in personnel, particularly a

new manager and a willing supervisor … made it a bit easier than before to
attempt to measure and address some long-standing issues in this area.
Management commitment to the process has been felt and more incident
reporting encouraged.
Using the video footage of the crews themselves will help personalize and
internalize their responses to safer operation. Consequences and near
misses are highly visible and available to remind crews of the field safety
issues. It gets buy-in. They become part of the solution – creating safe work
practices. They are creating/developing more responsibility for their own
actions.”
This provided considerable insight into the factors at play and some of the
obstacles to the implementation of OHS improvement programs. The
importance of management commitment cannot be over stated and the
increased level of commitment that occurred during the course of the
study as a result of their internal changes was very encouraging. The
benefits of group participation and active involvement in the solutions were
also highlighted.
The visibility and transparency of the risk ranking exercise were also
positive factors that enhanced the acceptability of the study to the
participants. The process of interviewing crew members by an objective
and independent party was also helpful to the organisation as this
reaffirmed the participant’s good will and commitment towards addressing
ongoing OHS concerns, as illustrated by the following survey response:
257
“Staff realized that we (including their local supervisor and his managers) were
more actively pursuing solutions to issues that have been around for a long time.”
Along the same lines, the comments below were made in a personal
communication with the local supervisor, and reproduced with permission:
“This has been a useful exercise but the timing has been unfortunate, with so
many … projects underway at the moment. Field crew provide subjective
feedback on the nature of single person crew (SPC) work … there has been less
criticism in the last few months with regard to inappropriate SPC work. This is
obviously heading in the right direction.”
In this case, performing the study may have even provided a pre-emptive
strike to reduce mounting tension and unease within the existing
workgroup. Once again the frustration of not having adequate time to
address OHS issues was apparent.
Finding an objective measure of the effectiveness of the study was

difficult, and the four months following the risk ranking exercise was
probably insufficient to be able to determine this. However, what was
unfolding was that the rate of organisational responsiveness to important
OHS issues was a key OHS performance indicator not previously
considered.
258
9.5 Case Study 5
Case study 5 was conducted in January 2008 on a suburban pharmacy

located in a small cluster of local businesses, unattached to a shopping
complex, in the Sydney metropolitan area. The organisation was a micro
business with less than ten employees and typically only two employees
on the premises at one time. The actual shop was very small. The
business was open from 9.00 am to 6.00 pm five days per week and from
9.00 am to 2.00 pm on Saturdays. The organisation was classified as a
“specialist” according to the categories given in Table 19. Although the
business extended its retail selection to include more than just
pharmaceuticals, the provision of specialist advice was a key marketing
point. The owner was the chief chemist, and a close family relative worked
as the relief pharmacist on two of the five weekdays.

Appendix 5, with the only amendment being that the risk ranking exercises
were completed over two instead of four days, due to the smaller size of
the business. The complete Preliminary Report as presented to the case
36-40.

Total 60
259
Figure 36: Case Study 5 Initial and Final Scores- Safe Place Elements
Access/Egress
Housekeeping
Receipt/Despatch
Disposal
Biohazards
Electrical
Plant/ Equipment
Modifications
Radiation
Noise
0 1 2 3 4
Risk Ranking Scores

0 1 2 3 4
Stress Awareness
Work Organisation
Workers' Comp/Rehab
Inductions
Health Promotion
Selection Criteria
Conflict Resolution
Networking etc

Job Descriptions
Feedback Programs
Health Surveillance
Training
Equal Opportunity
0 1 2 3 4
260
Elements
Accountability
Legislative Updates
System Rewiew
Audits
Self-Assessment
Procedural Updates
Goal Setting
Consultation
Communication
OHS Policy
0 1 2 3
Risk Ranking Scores

0 1 2 3 4

Legend

261
70
60
50
Risk Ranking
40
30
20
10
0
With
Without Inter
Legend
Intervention venti
on
The elements selected for stage two of the study were: access and
egress, ergonomics, and security. These elements were agreed upon by
the business owner. The actual questions developed for the monthly self
assessments can be found in Appendix 23
This case study was different to the others previously examined due to the
very small size and vey limited funding for OHS issues available. The most
obvious hazards to the researcher were to do with the size restrictions and
limited floor space, however, to the participants, the most pertinent hazard
was the threat of an armed hold-up to obtain access to cash or other
restricted drugs kept on the premises. Interestingly, there has never been
such an incident on these premises, however, past experiences that were
clearly very traumatic to the chief chemist, and this perceived threat,
tended to dominate the overall approach to safety in the pharmacy. The
262
back door had been kept permanently padlocked to eliminate the
possibility of someone entering through the back door unnoticed.
However, this also restricted access and egress and left only one entrance
to the premises through the front door. Should this access way become
blocked, there would be no other exit as the key to the padlock was kept
on the chief chemist’s person, even when off site. This was of particular
concern because the main access was on the street front; therefore
access to the front entrance way was not always within their control. A
small bathroom attached to the side of the back room could have been
used to detain the employee(s) in the event of a robbery. Hence, attempts
to reduce the threat of an armed hold-up had created other hazards, and
may have made the consequences of the original threat even more
serious.
Ergonomics were another issue that had resulted in the employees living
with ongoing complaints, and apparently accepting the situation as
unresolvable. Due to the small size of the shop and the need to be on
constant watch for customers as well as shoplifters, the chief chemist
spent long periods standing behind a raised counter front. This manifested
in the chief chemist experiencing painful and sometimes swollen legs by
the end of the working day.
Many of the customers were observed to enter the chemist to obtain

specialist advice and counselling on various matters. The chief chemist
was well suited to this role, and was very easy to engage in conversation.
The customers were noted to have an obvious preference for dealing with
the chief chemist, as opposed to the relief staff. This had the effect of
compressing the available time for the chief chemist to complete
workloads, as many of the customers would save their concerns for the
three days when the owner was present. Unsurprisingly, the chief chemist
was observed to be experiencing high levels of stress which were not
helped by the physical ailments related to standing for long periods.
The use of the Safe Place, Safe Person, Safe System framework was able
to highlight how problems with the physical workplace were to some extent
263
compensated by vigorous application of safe person and safe systems
strategies. High levels of personal expertise enabled the owners to provide
outstanding customer service, and the application of safe systems
ensured that there were some excellent policies in place, which were
clearly enforced with staff members. The owner was extremely dedicated
in the role and devoted much of the day to providing high quality care to
the customers. Concern for personal welfare seemed to be of less
importance.
Another point of interest was the potential seriousness of performing

narrowly focused risk assessments without due consideration of the all the
persons affected by the outcome. Decisions that may be valid and
acceptable for one person may not necessarily be acceptable for others,
and this was particularly noticeable where there were great differences in
experience levels and status within the organisation. An example of this
was the decision to bolt the back door which was made by the owner but
the consequences of the decision could have impacted on some very
junior, casual staff. Whilst the possibility of a hold-up was real, so was the
threat of being trapped by a fire. This would also be very traumatic and
possibly life threatening. Hence, the need to consider multiple
perspectives during the risk assessment process emerged as a crucial
point that had clearly been overlooked in this instance.
All the 60 elements were found to be applicable to the organisation,

however only eight had been addressed formally and 37 informally. Quite
a large number of the suggested elements were not addressed at all, and
it was noted that the OHS MS in place was established on an “as needs”
basis with emphasis on those elements that were perceived to add the
most value given the restricted cash flow and time available.
Stage two of the study was quite difficult to implement and the review of
the Preliminary Report took a long time as the owner was concerned
about some of the findings. The report was accepted in due course after
the rationales behind some of the findings were explained. The “high” after
rating for access and egress was a point of contention, as the owner had
264
not previously considered the problem of only having one small exit from
the front of the store. Furthermore, the issues related to ergonomics would
take a considerable amount of capital to address at the root cause level,
and a redesign of the store was not economically feasible. After some
considerable time to explain the process of monthly self assessments,
three self assessments were returned of which one month was spent in
deciding on the actual questions. Due to the stretched resources the aim
was to keep the questions simple and concise. By the end of the
assessment period, all the targeted issues had been addressed. A fatigue
mat that had been purchased prior to the study was thought not to have
been effective, and so was moved. By the end of the study period, the
mat’s effectiveness was reconsidered, and replaced in the original spot. A
foot stool was also placed in the dispensary area to help relieve some of
the pressure from standing in the one area and promote better circulation.
The key to the padlock for the backdoor was made more accessible and
emergency drills were now being performed.
Feedback from the evaluation survey indicated that it was a great struggle
for a micro business to devote time to OHS issues, and there was an
obvious need to have access to OHS resources and advice without
placing further drains on the existing cash flow. As to whether this study
was of benefit to the organisation, the response was:
“Yes, it was a thorough OHS assessment that small organisations do not have
easy access to or are able to afford. However, it appears more useful to larger
organizations than mine.”
The main difficulty and frustration perceived by the researcher was having
a report that highlighted areas of vulnerability and the participant simply
not being in a financial position to implement long term solutions, and
being overstretched with daily workloads to be able to devote sufficient
time to OHS concerns. Even drawing attention to those elements that
were handled very well, such as training and skills and competent
265
supervision, did not detract from the apparently overwhelming task to
reach a higher level of overall OHS compliance. This strongly suggested
that a pool of resources should be made available to these very small
businesses at minimal or no cost, perhaps from a union or other
association.
266
9.6 Case Study 6
Case study 6 was conducted on a medium sized chemical processing

plant and dangerous goods storage facility in rural New South Wales, in
January 2008.
The site occupied ten hectares and was located in a rural/mining region.
There were 40 employees in total including two senior managers; four
personnel in the technical, sales and administration area; and six
operators in manufacturing. Distribution comprised of 28 employees with a
float of 15. The manufacturing plant operated over three shifts, 24 hours a
day, five days per week. Maintenance was carried out during the
weekends. In contrast to case study 3, this was a smaller division of a
multi-national organisation that already had in place a mature OHS MS.
The organisation was in the midst of a transition period where the old plant
was due to be replaced with newer technology and best practice.
However, during the time of the assessment, the old plant and equipment
was still in use. The organisation was classified as a strategic planner
according to the categories offered in Table 19.

41-45.

Total 60
267

Plant/ Equipment
Modifications
Radiation
Electrical
Receipt/Despatch
Noise
Disposal
Access/Egress
Housekeeping
Biohazards
0 1 2 3 4
Risk Ranking Scores

0 1 2 3 4

Health Surveillance
Conflict Resolution
Stress Awareness
Work Organisation
Training
Inductions
Networking etc
Job Descriptions
Feedback Programs
Selection Criteria
Equal Opportunity
Workers' Comp/Rehab
Health Promotion
0 1 2 3 4
268
System Rewiew
Procedural Updates
Audits
Incident Management
Legislative Updates
Accountability
OHS Policy
Self-Assessment
Goal Setting
Communication
0 1 2 3 4
Risk Ranking Scores

0 1 2 3 4

Legend

269
80
70
60
Risk Ranking
50
40
30
20
10
0
substances, ergonomics, and behaviour modification. These elements
were agreed upon during a team meeting with the operations manager
present, after an interactive presentation of the Preliminary Report. The
actual questions developed for the monthly self assessments can be found
in Appendix 23
demonstrated how the dominant risk in the physical hardware and
operating environment had been offset through the use of safe person
strategies and to a lesser extent, the implementation of a sophisticated
OHS MS (see Figure 45).
The most obvious hazards on the site were associated with the storage of
dangerous goods and the nature of the chemicals being manufactured.
Despite the extremely high risks, the level of expertise and competence
270
displayed by the team members instilled a high level of confidence in the
physical safety of the operation. Pressure to increase production levels
was evident, and the ad hoc growth of the original plant had resulted in
equipment that was difficult to isolate safely prior to maintenance. Wear
and tear on the plant was high due to the corrosive nature of the
chemicals in use. Access for maintenance was often restricted due to the
physical layout of the plant and the widespread use of insulated pipe work.
A significant injection of capital would have been necessary to reduce the
residual risk in the physical work environment to a more acceptable level.
The organisation used a large number of heavy vehicles and was well
aware of the risks associated with this mobile plant equipment. A
sophisticated internal audit system had been developed to manage these
risks and appeared to be working very well. Other areas of note were the
employee assistance program and the excellent service provided by the
rehabilitation co-ordinator. Also exemplary was the management style of
the operations manager who fostered team building and the taking of
responsibility for one’s own actions (see Appendix 25 on sharing good
practice). The following comments also capture what embodies the ethos
by which he managed the group (see Appendix 24 for the extended
version).
“Most systems fail because as businesses we fail to walk the talk and allow too
many exceptions to occur. The standard should apply to all, always and
everywhere.”
“We have often built in conflicting priorities within the business (ie profitability vs
speed) all personnel need one set of priorities that can’t be misinterpreted.”
“If you have to explain it – it is too complex. Systems need to be easy to read -
focused to the reader and provide a consistent message (ie the same question
gets the same answer - whoever you ask).”
“Most documented processes fail due to their inability to keep pace with change
in the operational world - usually linked to being overly complex.”
“All processes must be aligned with the business vision and values. Safety
cannot be seen as a functional add on – it is part of risk management which is
what doing business is about.”
271
The selection process for employing new staff was documented and
formalised, however, a process of natural selection and the types of
personalities drawn to high risk job functions did appear to predominate.
The organisation tended to attract those that were practically minded, for
example with rural/agricultural experience who were able to work within
boundaries and manage complex situations.
There was a somewhat fatalistic attitude towards emergency planning on

the site. The potential for toxic fumes from the chemicals was not widely
acknowledged or planned for. Expressions such as “run upwind” were
offered during the interview process in response to questions regarding
what to do in the case of an emergency. A very dry sense of humour was
an apparent coping mechanism for the grim possibilities that confronted
them on a regular basis.
The potential for explosion was well understood. Those interviewed had a
deep respect for the inherent dangers of the chemicals in use, and this
was expected and demanded of everyone. In this small, rural community,
all members of the team were well known to each, and so were their
families. Mutual trust was a significant factor in the smooth running of the
operation, and there was a zero tolerance attitude towards anyone whose
behaviour was perceived to jeopardise the safety of the operation.
Hot weather was a major concern for contractors being used to maintain
lawns. Very stringent PPE requirements aimed at reducing UV exposure
had the potential to transfer the risk elsewhere. The possibility of
developing heat stress was significant due to the corporate requirements
for appropriate clothing whilst on site.
The site was very security conscious due to the nature of the chemicals
being stored. A vigorous program aimed at ensuring contractor control
was well established and was observed to be working well during the
week. Rousseau and Libuser recommend enlisting only a small pool of
known contractors to reduce the risk factors by establishing closer
relationships and increasing the potential for intimate site knowledge to
272
develop.330 The sense of this strategy is self evident with the potential to
simplify the induction programs. The ability of the organisation to fulfil their
duty of care is far more difficult with higher volumes of contractors on site.
All of the 60 elements were applicable to the site and 57 had been
addressed formally and only three informally. These were: behaviour
modification; feedback programs and review of personnel turnover. Areas
identified as still being at high risk were plant/equipment, hazardous
substances/dangerous goods and personal protective equipment. The
Safe Place, Safe Person, Safe Systems framework was able to highlight
the need for balance between the energy directed into supplying
information into the sophisticated electronic systems and the energy
directed towards actually following through and implementing actions as
described. In a number of instances cross-checks on the plant did not
support actions reported, and many of the corrective actions that required
amendments to the procedure were not documented to reflect the change.
Hence what was in place was a system that on the surface appeared to be
very thorough until visual inspections were performed. The plans for the
new plant provided a plausible excuse for the lack of follow through with
documentation from an operational perspective. Justifications for lack of
action and tolerance of high levels of residual risk could potentially result
in a high, short term option becoming long and protracted, with potentially
dire consequences.
Behavioural modification programs were in place to recognise the high

level of residual risk and the unpredictability of situations. This dynamic
risk assessment program, which essentially encouraged staff to stop and
think actions through before rushing in, required documentation in a
pocket sized note book. The booklet had been designed so that hazards
were identified, the associated risks described, the adequacy of control
measures considered and the methods for conducting job tasks reviewed.
This system had been implemented so that it was a monthly requirement
for each employee to perform one assessment per day. Unfortunately, this
exercise was perceived as monotonous, and what was established to
reduce the potential for risk habituation was being completed in a
273
minimalist fashion, purely to appease management. This supported the
literature on the importance of the reward schedule in modifying
behaviours and the types of schedules necessary to avoid desirable
behaviours being extinguished. In this scenario, the use of documentation
would have been useful to train staff in the dynamic risk assessment
technique, and a fixed reward should have been considered during the
early phase of the program. Once the technique had been mastered, the
need for documentation could have been relaxed, and a variable reward
schedule offered at unpredictable intervals.304, 352 The use of dynamic risk
assessments could have been established through competency
assessments using typical scenarios or through spot checks. The
requirement for documentation actually defeated the original purpose of
the program, which was intended to promote safe work practices and stop
impulsive behaviour. Now, instead of being more in-tune with their work
environment, the need to document these assessments was actually
causing them to “tune out” and go into automatic mode once again.
The Preliminary Report was accepted as a true representation of the

situation during the time of the assessments. Stage two took some time to
commence, and again problems were experienced trying to avoid
duplication of work and blend the monthly self assessments with existing
practices. The instructions for the first month’s assessment questions were
misinterpreted and three questions were asked in total that were already
being used for reporting purposes. The reluctance to create additional
work was understandable as the operation was being overloaded with
prompts from the electronic system to complete unfinished actions from
numerous internal audits and incident investigations. In the second month
fresh attempts were made and the elements targeted were hazardous
substances, ergonomics and behaviour modification.
Feedback from the evaluation survey was useful for providing insights into
the potential application of the Safe Place, Safe Person, Safe Systems
framework. The following excerpts from the survey illustrate this (the full
responses may be found in Appendix 24).
274
“Yes it was of benefit, if only to get an external perspective. My business is very
inward looking and this often blinds us to issues. I would recommend this process
to a company as a useful benchmarking exercise or as a demonstration of duty of
care.”
Another comment which provided insight into the perception of the

purpose of OHS MS in the workplace:
“As a general statement most of the OHS system is focused on being a defensive
document … rather than trying to continually improve safety. For me there are two
main components to safe operation: the safety you can build into the process …
and the safe behaviours we bring to the operation … the ideal system would be a
balance of both of these philosophies.”
This demonstrates that over emphasis on the systems side can result in a
loss of confidence in large corporate OHS systems and caste doubts on
the value of the paperwork. When these comments are viewed against the
scores from the risk ranking exercises that highlighted a lack of follow
through, such observations are not surprising. Without the provision of
adequate levels of resourcing, including the allowance of sufficient time to
discharge OHS duties, an OHS MS can provide the illusion of action.
Without follow through, even the most sophisticated systems can be
empty and absorb resources that would be better utilised in practical
applications.
In summary, this case study illustrated the need for balanced strategies,
constant vigilance and an appreciation of multiple perspectives. Also
captured was strength of safe person strategies to cope with enormously
difficult circumstances. This case study demonstrated that with mutual
trust and strong leadership, extremely high risks can be managed without
serious injuries for relatively long periods of time.
275
9.7 Case Study 7
Case study 7 was conducted between February and March, 2008 on a

service organisation. The organisation’s main function was to provide
support, training, supplies and co-ordination of volunteers to assist in crisis
situations. The head office of the organisation was located in a
metropolitan area of New South Wales and there were a number of
associated regional offices. Each office had a supply store attached. The
scope of the study was limited to the direct staff within the organisation
and the assessment did not apply to the volunteer members. This was for
two reasons: volunteers performed very different activities from the office
staff and there was a need to assess a homogeneous area of activity; and
secondly, the large numbers of volunteers involved and their various
locations would have made the assessments very difficult. Volunteer work
was very high risk, in variable locations and of an unpredictable nature.
The organisation was classified as a “specialist” according to the
categories given in Table 19.

46-50.

Total 60
276

Plant/ Equipment
Receipt/Despatch
Electrical
Access/Egress
Housekeeping
Modifications
Radiation
Noise
Disposal
Biohazards
0 1 2 3 4
Risk Ranking Scores

0 1 2 3 4
Stress Awareness
Inductions
Health Surveillance
Health Promotion
Work Organisation
Networking etc
Job Descriptions
Feedback Programs
Equal Opportunity
Training
Conflict Resolution
Selection Criteria
Workers' Comp/Rehab
0 1 2 3 4
277
Elements
Incident Management
Communication
System Rewiew
Audits
Self-Assessment
Procedural Updates
Consultation
Legislative Updates
Accountability
Goal Setting
OHS Policy
0 1 2 3 4
Risk Ranking Scores

0 1 2 3 4

Legend

278
Figure 50: Case Study 7 Risk Reduction after Interventions Applied
70
60
50
Risk Ranking
40
30
20
10
0
Case study 7 did not participate in stage two of the study, but did complete
an evaluation survey, which may be found in Appendix 24.
The organisation was very proficient in training volunteers on the use of

dynamic risk assessments. A high impact training video had been
produced and was very informative in demonstrating the application of
skills in a typical scenario. However, these skills did not appear to have
been translated for application within the support staff environment and
there was a high level of residual risk still associated with the physical
work areas including the stores.
Many of the staff members appeared to view themselves as part of the

larger pool of volunteers, rather than as providing a service for the
management of volunteers. The organisation was very mindful of the need
to provide peer support to reduce the likelihood of post traumatic stress for
the volunteer workers. This was handled exceptionally well. However,
what was evident during the assessment process was that this same level
279
of expertise was not being applied within the support organisation. High
levels of stress were observed within the organisation and it was possible
that the obvious nature of the risks associated with the volunteer work may
have made the risks related to the OHS of the support staff appear less
significant by comparison. The chronic exposure to less obvious hazards,
such as stress related to workloads and having to cope without sufficient
formal systems in place appeared to be having an insidious long term
effect on the employees. A point was made in the Preliminary Report to
remind the staff that without looking after their own welfare, they would be
unable to continue to attend to the needs of others.
Consultation was taking place on a quarterly basis. It appeared that this

was too infrequent to build up enough momentum to move forward and
obtain visible progress on a number of issues. The OHS committee was
run in a very formal manner, and the OHS coordinator requested that the
results of the Preliminary Report be presented at this meeting. This was
received very positively and allowed the information to be communicated
to a larger audience. The presentation also served to demonstrate the
intention to improve in OHS areas.
was able to show how safe person strategies were the preferred method
for managing the risks, followed to a lesser extent by safe system
strategies. The organisation was clearly very comfortable with the
application of safe person strategies as this was their area of proficiency.
Of the 60 elements, all applied to the organisation. The organisation was

only at the planning stage for a formal, documented OHS MS, and
handled 26 elements formally and 28 informally. As the organisation was
part of the public sector, a number of policies and formal methods were
related to the need to comply with government requirements and
overarching bureaucracy. Areas related to contractor control and
hazardous substances were still in need of attention.
280
The Preliminary Report was accepted as a true representation of the
situation presenting at the time of the assessment. Stage two of the study
did not manage to progress at all, although it appeared that resourcing
was an area of concern. It was observed that in the minutes of the OHS
meetings, many of the actions were allocated to the one person, who was
essentially driving the process within the organisation. Hence, support
staff for OHS related projects were already stretched.
The responses to the evaluation survey can be found in full in Appendix

24. Feedback suggested that the study was helpful in highlighting issues
related to stress awareness and stress management, and was able to
instigate changes in these areas. Other feedback included the following
excerpts:
“The study has been very beneficial not just the system itself, the risk assessments,
but also the presentation that was given to our OHS committee … I would
recommend this study to other organisations as it requires minimal involvement
from the organisation but provides high impact results which can be used to talk to
Senior Managers.”
This study provided an opportunity to demonstrate the circumstances

where the application of the Safe Place, Safe Person, Safe Systems
framework would be problematic. Although there was merit in performing
the risk ranking exercises and preparing the report, it was apparent that
without adequate resourcing and support, there would be difficulty
translating the results into an active improvement plan. The value of this
Safe Place, Safe Person, Safe Systems assessment to initiate increased
OHS dialogue should not be discounted.
Although this was the only case study that did not attempt stage two, the
exercise had provided some valuable insights including:
appropriate methods for communicating the study’s results;
the problems associated with differences in risk perception and the

need to maintain objectivity and balanced perspectives;
281
the value of organisations reflecting on their own internal process, as
opposed to the quality of the services provided to others; and
the capacity for long term exposure to low/moderate risks to erode

confidence in support networks and commitment levels.
282
9.8 Case Study 8
Case study 8 was conducted on a small business unit that managed three
remote sites and an extensive supply network for a utility organisation in
rural New South Wales, in March 2008. The smaller office formed part of a
larger organisation however the scope of the exercise was limited to the
activities of the smaller division.
There were 15 employees in total; this included one operations manager,

one project engineer, two administration/support staff and two team
leaders that managed the remote sites. A small workshop was attached to
each of the local offices. Although the office areas were small, the supply
networks managed were hundreds of kilometres in length and passed
through rugged and sometimes mountainous terrain. The operations
manager and team leaders were on call 24 hours/seven days per week.
The offices and workshops were operated between approximately 7.00 am
and 4.00 pm. Regular overtime was worked on the weekends. The
organisation was in the midst of a restructuring period. Two separate OHS
MS were in use: the corporate system and the old system that was in use
prior to the take over. The organisation was classified as a strategic
planner according to the categories offered in Table 19.

element details. A results summary follows: Table 29, and Figures: 51-55.

Total 60
283
Electrical
Modifications
Plant/ Equipment
Disposal
Radiation
Biohazards
Access/Egress
Receipt/Despatch
Housekeeping
Noise
0 1 2 3 4
Risk Ranking Scores

0 1 2 3 4
Health Surveillance
Conflict Resolution
Networking etc
Stress Awareness
Equal Opportunity
Job Descriptions
Work Organisation
Feedback Programs
Health Promotion
Training
Selection Criteria
Inductions
Workers' Comp/Rehab
0 1 2 3 4
284
Elements
Incident Management
Consultation
System Rewiew
Audits
Procedural Updates
Legislative Updates
Goal Setting
Self-Assessment
Accountability
Communication
OHS Policy
0 1 2 3
Risk Ranking Scores

0 1 2 3 4

Legend

285
80
70
60
Risk Ranking
50
40
30
20
10
0
Without Intervention With Intervention
substances (asbestos register), job descriptions and incident
management. The actual questions developed for the monthly self
assessments can be found in Appendix 23.
The smaller division was very proud of the organisation’s achievements

and its standing in the local community. Employment opportunities were
limited in this rural setting and positions within the organisation were highly
valued. However, there was clearly some resistance to accepting the
systems and frameworks that the corporate entity was trying to
superimpose on the smaller business unit. The previous organisation
already had in place an OHS MS, which had many exemplary aspects
such as the OHS policy (see Appendix 26 on sharing good practice). As
the previous OHS MS had been well researched, many of the old
practices were still in place and what was observed was a hybrid between
the old and the new systems. For the purpose of the study, however, the
risk rankings scores allocated were based on the actual practices
286
observed during the time of the assessments, regardless of the point of
origin.
A corporate restructuring was under consideration during the time of the

assessments, and a number of the local staff members appeared to be
concerned about the long term security of their positions. Hence there was
a noted level of unsettledness during the course of the case study. The
organisation was providing an essential service to the surrounding
community, however, staffing levels were minimal and individuals were
being stretched to full capacity with very little slack having been built into
the system. Without any buffer and individuals being on call, 24 hours per
day, seven days per week, the distraction and concern of the restructuring
process had the potential to interfere with the safety of the operation by
becoming a preoccupation that would detract from the staff’s “mindfulness”
of OHS issues. This reinforces the points made by Weick and Roberts
regarding the need for “loose couplings” in high reliability organisations,
especially where complicated systems are in place and problems in one
area may cause many other negative interactions elsewhere.108, 396
Although a major injury had not yet occurred, a serious near miss had
been handled at the local level without the details being shared with the
corporate body. In this example, a contractor had nearly been accidentally
shot by game shooter whilst carrying out repair work on a utility line. The
incident had been reported to the local police; however regulations had
recently changed to allow recreational shooting in the national parks.
Failure to report this information at a corporate level had resulted in a lost
learning exercise for the organisation. The organisation had also been
denied the opportunity to put in place preventive measures to avoid the
recurrence of a potential fatality. The use of the Safe Place, Safe Person,
Safe Systems framework had enabled these important issues to be
highlighted, and incident management was targeted for improvement in
phase two of the study.
Poor contractor control was becoming a recurring theme in many of the

studies and the need to verify that contractors were implementing safe
287
systems of work was an area of clear difficulty. The cost advantages
derived from the use of contractors where work loads were of a sporadic
and fluctuating nature may be perceived to be lost if permanent staff have
to spend time to verify and audit the contractor’s safety systems. In this
case study, this was particularly problematic due to the large distances
that were involved, as the physical hardware and assets managed by the
local organisation covered hundreds of kilometers. Therefore the travelling
time required to perform these exercises was considered to be excessive
and a poor use of scarce resources in the short term. However, the
consequences of not auditing these activities had significant long term
implications for the risk and reliability of the service provided.
The Safe Place, Safe Person, Safe Systems framework was able to
demonstrate how poorly executed risk assessments were being used to
rationalize decisions to ignore OHS issues. Risk assessments were being
conducted by those without the necessary expertise and knowledge of
available solutions. This occurred in a number of instances in this
particular study, but was of most concern with regards to a decision not to
have emergency plans in place for the main local office. Emergency plans
for the management of the assets were available, but did not include the
evacuation of the small office or workshop. Other decisions based on poor
risk assessments were the lack of local exhaust ventilation for welding
activities, as the current arrangements would have drawn the fumes past
the faces of those conducting the welding. In another example, the hazard
of working at heights had been addressed through the use of harnesses.
However, these were stored in a location that had become nesting area for
pigeons. The equipment had been contaminated with droppings and the
potential for respiratory problems associated with these poor hygiene
conditions had been overlooked.
The use of the Safe Place, Safe Person, Safe Systems framework also
drew attention to the variable “place” component. Much of the work and
checking activities occurred at remote sites, therefore a large proportion of
the hazards were of an unpredictable, non-routine nature. This suggested
that the use of dynamic risk assessments would be more appropriate. This
288
would involve referencing the use of dynamic risk assessments in a
generic risk assessment document; stipulation of the precise
circumstances when activities should cease; and clear requirements for
the training and competency of those able to apply dynamic risk
assessments in the field.
One noticeable issue with the local operation was a desire to resist
documenting and registering all the plant and equipment. Whilst it was
certainly a cumbersome task with the current staffing levels and resources,
there also appeared to be some cultural factors operating and a rejection
of the new corporate infrastructure. Documentation was perceived as a
loss of bargaining power as this information was tied to the years of
experience these operators had with the organisation. Passing this
knowledge on was perceived as a threat to long term job security. It would
have taken an enormous amount of documentation to capture the vast
amount of experience held by these operators and years of mentoring to
replicate the competence levels displayed in the current operation.
Options for growing existing positions and developing succession plans
may have been more fruitful in securing co-operation to document work
practices and the current status of equipment, as the need to document
hardware was crucial to the provision of a safe and reliable service. A
program to obtain accurate descriptions of current job activities was
targeted for improvement in stage two of the study.
The organisation was very customer service orientated and handled this
aspect very well. However, other areas such as chemical safety and the
long term future health of employees were also in need of attention. This
was addressed in stage two of the study with a plan to update the
asbestos register. Once again, the lack of focus on OHS issues with long
term consequences was becoming a common theme throughout the
study.
All of the 60 elements were applicable to this case study. The organisation
had addressed approximately half of the elements formally and 23
elements informally. For such an essential service, this level of informality
289
could have increased the exposure of the corporate organisation in the
event of litigation. The four elements that were not addressed included:
health promotion; health surveillance, audits and system review. Once
again, these were issues that were of long term benefit.
The Preliminary Report was accepted after discussion with the local
operations manager and some minor amendments. Stage two of the study
was commenced after the results had been presented to senior
management in the corporate head office. Resources were available to
assist the local organisation and stage two of the study was launched
without any significant delays and the monthly results returned promptly.
This highlighted how the study could be very successful with an influential
internal advocate for the program and genuine commitment from upper
management to secure resources to complete the exercise.
The feedback from the evaluation survey was very positive and this case
study was able to demonstrate the conditions under which the application
of the Safe Place, Safe Person, Safe Systems OHS management
framework might flourish. As illustrated by the excerpt below in response
to whether this study was of benefit to the organisation:
“The study has already been of immediate benefit to us. I would imagine, now that
it has been reviewed by management that it will be of ongoing benefit for quite
some time to come … Would I recommend it, unquestionably.”
Feedback on some of the most valuable components of the exercise

(provided in full in Appendix 24) included:
“The report risk ranking of data, including the ‘with intervention and without
intervention table’ has and will make it very easy to focus on areas of concern
which in itself makes it a very valuable tool/report.”
290
The most unique feature of this study was its ability to illustrate the
concept put forward by the Safe Place, Safe Person, Safe Systems
framework that management practices can, in certain circumstances,
become one of the hazards in the workplace. In this particular instance,
the local operations manager was making decisions that were exposing
the larger corporation to potential litigation Decisions were also being
made to ignore corporate requirements in the belief that they were either
unnecessary or not covered by the State OHS regulation.
This case study demonstrated the necessary conditions for the successful
application of the Safe Place, Safe Person, Safe Systems framework - a
high level of energy and motivation from inside the organisation combined
with full management support. Furthermore, the existing OHS systems
were still in their infancy and there was not an excessive level of
bureaucracy associated with their current systems. This made it much
easier to implement the recommendations of the study without fear of
duplicating activities. Also, the questions selected had been carefully
thought through so that the outputs were clear and meaningful.
291
10. COMPARISON OF CROSS CASE RESULTS
In the analysis that follows, trend charts are used to compare results
across the eight case studies to explore any common threads of similarity.
Prior to reviewing these results, a summary of the characteristics of each
of the case studies is presented in Table 30 to assist the interpretation of
data.
Table 30: Summary of Case Study Characteristics
Case Organisation Scope Ownership Sector Industry

Study Size
1 Small/ Entire Private/ Manufacturing Paint

Medium Organisation Family
Business
2 Large Medium Private/ Manufacturing Foam

Division Corporate Recycling
3 Small Manufacturing Private/ Manufacturing Event

Family and Assembly Management/
Business Chemicals and
Dangerous
Goods
4 Large Small Division Public Service Media
5 Micro Entire Private/ Retail Pharmacy

Organisation Family
Business
6 Large Medium Private/ Manufacturing Chemical

Division Corporate Processing
and
Dangerous
Goods
Storage
7 Medium Regional Public Service Crisis

Office Management
8 Large Small Division Public Service Utility
As can be seen from the summary characteristics table above, the case
studies spanned a variety of business types, from micro businesses to
large international organisations and covered a range of sectors including
292
manufacturing, service organisations and retail. Two public sector
organisations were included – case studies 7 and 8.
For each of the safe place, safe person and safe systems elements across
each of the eight case studies:
Charts 8-10 explore trends in the existing level of OHS MS

infrastructure and present the number of elements assessed as being
handled formally (as denoted by having documented procedures in
place);
Charts 11-13 present the number of occasions individual elements

have not been addressed; and
Charts 14-16 present the number of occasions individual elements

have been assessed as high; Charts 17-19; 20-22; 23-25; and 26-28
perform the same analysis for medium-high, medium, low and well
done final ratings respectively.
Chart 29 presents a comparison of the total accumulated risk scores

separately for each of the safe place, safe person, safe systems areas for
each case study without interventions in place. Chart 30 presents the
same comparison for each case study with interventions in place.
Chart 31 provides a comparison of the total accumulated risk scores for

each individual case study, with and without interventions in place. This is
followed by Table 30 which shows the total risk reduction factors for each
case study, where the risk reduction factor is defined as the total risk score
(with interventions applied) divided by the total risk score (without
interventions applied).
Chart 32 examines the overall risk ranking scores, with and without
interventions applied, for each of the three areas - safe place, safe person
and safe systems with overall risk reduction factors provided.
Finally Chart 33 illustrates the perceived importance of individual elements

as assessed by the participants. This chart provides a summary of the
293
results from question 4 of the Follow Up Evaluations recorded in Appendix
24, that explored what five elements where considered to be the most
important for an OHS MS. As this question was interpreted to mean any
aspects of OHS MS, not the just the elements from the suggested
framework, the number of mentions of the individual items in the
responses was shown, regardless of their ranking in the survey response.
294
10.1 Comparison of the Existing Level of OHS MS Infrastructure across the Eight Case
Studies
Chart 8: Total Number of Safe Place Elements Addressed Formally Across the Eight Case Studies

Receipt/Despatch
Biohazards
Housekeeping
Noise
Radiation
Access/Egress
Disposal
Plant/ Equipment
Electrical
Modifications
0 1 2 3 4 5 6 7 8
Total Addressed Formally by the Organisations
295
Chart 9: Total Number of Safe Person Elements Addressed Formally Across the Eight Case Studies
Training
Job Descriptions -Task Structure
First Aid/Reporting
Conflict Resolution
Workers' Comp./Rehabilitation
Work Organisation - Fatigue
Equal Opportunity/Anti-Harrassment
Health Surveillance
Health Promotion
Inductions-Including Visitors/Contractors
Selection Criteria
Stress Awareness
Feedback Programs
Networking,etc
0 1 2 3 4 5 6 7 8
296
Chart 10: Total Number of Safe Systems Elements Addressed Formally Across the Eight Case Studies
Incident Management
OHS Policy
Consultation
Goal Setting
Customer Service
Accountability
Legislative Updates
Communication
System Rewiew
Audits
Self-Assessment
Procedural Updates
0 1 2 3 4 5 6 7 8
297
Chart 11: Total Number of Safe Place Elements Not Addressed Across the Eight Case Studies

Modifications
Installations/Demolitions
Radiation
Noise
Access/Egress
Inspections/Monitoring
Housekeeping
Security - Site /Personal
Preventive Maintenance/Repairs
Disposal
Biohazards
Electrical
Receipt/Despatch
Plant/Equipment
0 1 2 3 4 5 6 7 8
Total Not Addressed by the Organisations
298
Chart 12: Total Number of Safe Person Elements Not Addressed Across the Eight Case Studies
Health Surveillance
Feedback Programs
Health Promotion
Stress Awareness
Inductions - Including Visitors/Contractors
First Aid/Reporting
Conflict Resolution
Networking,etc
Training
Selection Criteria
0 1 2 3 4 5 6 7 8
Total Not Addressed by the Organisations
299
Chart 13: Total Number of Safe Systems Elements Not Addressed Across the Eight Case Studies
System Rewiew
Self-Assessment
Audits
Goal Setting
Procedural Updates
OHS Policy
Incident Management
Customer Service
Legislative Updates
Consultation
Communication
Resource Allocation/Administration
Accountability
0 1 Total
2 Not Addressed
3 4by the Organisations
5 6 7 8
300
10.2 Comparison of the Distribution of Final Scores after Interventions Applied across
the Eight Case Studies
Chart 14: The Number of “High” Risk Rankings Allocated, After Interventions Applied, for Each Safe Place Element
Electrical
Plant/Equipment
Receipt/Despatch
Access/Egress
Housekeeping
Security - Site/Personal
Modifications
Disposal
Radiation
Biohazards
Noise
0 1 2 3 4 5 6 7 8
Number of Rankings Across the Eight Case Studies
301
Chart 15: The Number of “High” Risk Rankings Allocated, After Interventions Applied, for Each Safe Person Element
Health Surveillance
Stress Awareness
Feedback Programs
First Aid/Reporting
Conflict Resolution
Networking,etc
Health Promotion
Training
Selection Criteria
0 1 2 3 4 5 6 7 8
302
Chart 16: The Number of “High” Risk Rankings Allocated, After Interventions Applied, for Each Safe Systems
Element
Incident Management
Consultation
Accountability
System Rewiew
Audits
Self-Assessment
Customer Service
Procedural Updates
Legislative Updates
Communication
Goal Setting
OHS Policy
0 1 2 3 4 5 6 7 8
303
Chart 17: The Number of “Medium - High” Risk Rankings Allocated, After Interventions Applied, for Each Safe Place
Element
Receipt/Despatch
Housekeeping
Noise
Plant/Equipment
Modifications
Disposal
Radiation
Biohazards
Electrical
Access/Egress
0 1 2 3 4 5 6 7 8
304
Chart 18: The Number of “Medium - High” Risk Rankings Allocated, After Interventions Applied, for Each Safe Person
Element
Feedback Programs
Health Surveillance
Stress Awareness
Selection Criteria
Conflict Resolution
Health Promotion
Networking,etc
Training
First Aid/Reporting
Job Descriptions - Task Structure
0 1 2 3 4 5 6 7 8
305
Chart 19: The Number of “Medium - High” Risk Rankings Allocated, After Interventions Applied, for Each Safe
Systems Element
System Rewiew
Incident Management
Self-Assessment
Procedural Updates
Consultation
Audits
OHS Policy
Communication
Goal Setting
Legislative Updates
Customer Service
Accountability
0 1 2 3 4 5 6 7 8
306
Chart 20: The Number of “Medium” Risk Rankings Allocated, After Interventions Applied, for Each Safe Place
Element
Modifications
Access/Egress
Housekeeping
Radiation
Biohazards
Electrical
Disposal
Plant/Equipment
Noise
Receipt/Despatch
0 1 2 3 4 5 6 7 8
307
Chart 21: The Number of “Medium” Risk Rankings Allocated, After Interventions Applied, for Each Safe Person
Element

First Aid/Reporting
Networking,etc
Health Promotion
Feedback Programs
Training
Conflict Resolution
Stress Awareness
Selection Criteria
Health Surveillance
0 1 2 3 4 5 6 7 8
308
Chart 22: The Number of “Medium” Risk Rankings Allocated, After Interventions Applied, for Each Safe Systems
Element
Legislative Updates
Goal Setting
Audits
Self-Assessment
System Rewiew
Accountability
Incident Management
Procedural Updates
Consultation
OHS Policy
Customer Service
Communication
0 1 2 3 4 5 6 7 8
309
Chart 23: The Number of “Low” Risk Rankings Allocated, After Interventions Applied, for Each Safe Place Element
Disposal
Biohazards
Noise
Receipt/Despatch
Housekeeping
Radiation
Electrical
Modifications
Plant/Equipment
Access/Egress
0 1 2 3 4 5 6 7 8
310
Chart 24: The Number of “Low” Risk Rankings Allocated, After Interventions Applied, for Each Safe Person Element
Conflict Resolution
Selection Criteria
Training
Feedback Programs
Health Surveillance
Networking,etc
Stress Awareness
First Aid/Reporting
Health Promotion
0 1 2 3 4 5 6 7 8
311
Chart 25: The Number of “Low” Risk Rankings Allocated, After Interventions Applied, for Each Safe Systems Element

Customer Service
Procedural Updates
Accountability
Communication
System Rewiew
Audits
Self-Assessment
Incident Management
Legislative Updates
Consultation
Goal Setting
OHS Policy
0 1 2 3 4 5 6 7 8
312
Chart 26: The Number of “Well Done” Rankings Allocated, After Interventions Applied, for Each Safe Place Element
Radiation
Access/Egress
Housekeeping
Modifications
Disposal
Biohazards
Noise
Electrical
Receipt/Despatch
Plant/Equipment
0 1 2 3 4 5 6 7 8
313
Chart 27: The Number of “Well Done” Rankings Allocated, After Interventions Applied, for Each Safe Person Element
First Aid/Reporting
Health Surveillance
Health Promotion
Training
Feedback Programs
Conflict Resolution
Networking,etc
Stress Awareness
Selection Criteria
0 1 2 3 4 5 6 7 8
314
Chart 28: The Number of “Well Done” Rankings Allocated, After Interventions Applied, for Each Safe Systems
Element
Customer Service
Communication
OHS Policy
Consultation
Accountability
System Rewiew
Audits
Self-Assessment
Incident Management
Procedural Updates
Legislative Updates
Goal Setting
0 1 2 3 4 5 6 7 8
315
10.3 Comparison of Total Risk Scores
Chart 29: Comparison of Accumulated Risk Scores for Each Case Study for Safe Place, Safe Person and Safe
Systems Elements, Without Interventions Applied
90
80
70
60
50
40
30
Accumulated Risk Scores

20
10
0
1 2 3 4 5 6 7 8
Case Study
Safe Systems Safe Person Safe Place
316
Chart 30: Comparison of Accumulated Risk Scores for Each Case Study for Safe Place, Safe Person and Safe
Systems Elements, With Interventions Applied
90
80
70
60
50
40
30
Accumulated Risk Scores

20
10
0
1 2 3 4 5 6 7 8
Case Study
317
Chart 31: Comparison of Total Accumulated Risk Scores for Each Case Study With and Without Interventions Applied
250
225
200
175
150
Total Risk Score 125
100
75
50
25
0
1 2 3 4 5 6 7 8
Case Study
Without Interventions With Interventions
Table 31: Total Risk Reduction Factors for each Case Study Showing Individual Risk Reduction Factors for Safe
Place, Safe Person and Safe Systems Components
Case Study 1 2 3 4 5 6 7 8
Total Risk Reduction * 0.5 0.6 0.7 0.7 0.7 0.6 0.7 0.6
Safe Place Risk Reduction 0.46 0.55 0.65 0.68 0.65 0.72 0.77 0.71
Safe Person Risk Reduction 0.59 0.45 0.76 0.69 0.92 0.51 0.54 0.64
Safe Systems Risk Reduction 0.58 0.56 0.69 0.68 0.50 0.58 0.65 0.54
*Where Risk Reduction = Score “With Interventions” applied / Score “Without Interventions” Applied
318
Chart 32: Total Accumulated Risk Scores, With and Without Interventions, Across the Eight Case Studies
600
500
400
300
200
Overall Risk Ranking Scores

100
0
Overall Risk Reduction Factors Safe Place Safe Person Safe Systems
0.65 0.63 0.60
319
10.4 Perceptions of Important Elements for an OHS MS
Chart 33: Perceptions of the Most Important Elements of an OHS MS from the Follow-Up Evaluation
Training
Incident Management
Communication
Accountablity
Consultation
Measurement
Measurable Goals
Developing Strategies
Reporting
Simplicity
Alignment of Goals and Values
Continuous Review
Clarity
Consistency
Due Diligence
Resource Allocation
Leadership
Plant and Equipment
0 1 2 3 4 5 6
Number of Mentions in Survey
320
Part 5: Discussion
321
11. DISCUSSION
11.1 Discussion of Results across the Eight Case

Studies
The following discussion compares the results across the eight case
studies and explores threads of similarity that were evident with respect to
the level of formality invoked; the frequency of ratings; and finally the
distribution of risk across the three areas - safe place, safe person, safe
systems, both before and after interventions were applied.
Training was the only element that had been addressed formally by all the
case studies, as shown in Charts 8-10. The importance of this element
was also reinforced in the responses given in the Follow-Up Evaluation,
see Chart 33. This feature is of particular interest because of the size and
variety of organisations that were examined, which ranged from a very
small micro business to large multi-national organisations and covered the
retail, manufacturing and service sectors.
The formality applied to the implementation of safe place elements was

examined in Chart 8. This showed that more than half of the organisations
sampled had dealt with Emergency Preparedness;
Installations/Demolitions; Hazardous Substances; Noise; Electrical; and
Baseline Risk Assessment on a formal basis. In four of the case studies,
Hazardous Substances also received a “high” final rating (after
interventions were applied), and Emergency Preparedness; Electrical; and
Plant/Equipment scored two “high” final ratings (see Chart 14). These
were areas that were substantially covered by State OHS regulations. In
these instances, the formality with which the elements were handled did
not necessarily equate with more effective risk management.
It was frequently observed across the study that attempts were made to
comply with the documentation required by relevant OHS regulations,
however, the point of the regulations had been misinterpreted or was
poorly understood. An example of this occurred in case study 3 where the
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information provided on the Material Safety Data Sheets (MSDS) was
minimal, but quickly rectified once the “spirit of the law” had been
explained.
In the safe person area, elements addressed formally spanned a wide

variety of functions. For more than half of the case study participants this
included Training; Job Descriptions - Task Structure; First Aid/Reporting;
Conflict Resolution; Performance Appraisals; Workers’ Compensation and
Rehabilitation; Employee Assistance Programs; Work Organisation -
Fatigue; and Equal Opportunity/Anti-Harassment. This reinforced the
necessity of being able to deal competently with a wide spectrum of
workplace scenarios and it was pleasing that access to employee
assistance programs and policies on equal opportunity and anti-
harassment were available. Interestingly, the elements of Health
Surveillance and Behaviour Modification were not addressed by half of the
case studies (see Chart 12).
In cases where a reluctance to conduct health surveillance was observed,

exploring the reasons for this may be an area for further investigation.
Whilst health surveillance is not preventive as such and should not be
relied upon solely as a means of control, it does provide a final cross-
check to determine whether or not current prevention and control
strategies have been effective and may provide reassurance for potentially
exposed workers. Whether this lack of uptake is associated with a fear of
potential litigation is worthy of deeper examination in future research.
The element of Behaviour Modification was also one where there was a
perceived reluctance to engage in overt behavioural change techniques.
The strategic use of rewards (such as praise and recognition) to influence
behaviour and break unsafe work habits was not widely appreciated by the
case study participants and in some cases, undesirable work practices
were being inadvertently rewarded. For example, in case study 6, targets
had been set to complete significant numbers of “Take 5” forms each
month to document the use of dynamic risk assessments. Some operators
explained how they had found a way around this requirement by having a
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number of hazards that they would routinely identify to ensure that they
would meet the monthly targets. Ironically, this would promote the
operators going into “automatic mode” rather than thinking through the
unique circumstances of the events presenting and considering a variety
of solutions, which was the exact opposite of what the application of the
“Take 5” program was trying to achieve. Based on reward theory, a fixed
reward schedule should have been in place whilst the technique was
being mastered. Then, once this was in place, a variable reward schedule
could have been implemented. Hale and Glendon point to the variable
timings of payouts in poker machines to illustrate the effectiveness of
variable reward schedules in preventing habits from being extinguished.304
This example illustrates how a preoccupation with written documents to
demonstrate proof that a procedure has been followed can be very
counterproductive when this results in the intended safety strategy being
by-passed altogether.
Excessive documentation, whether in an electronic or written format, may

also project the image that the purpose of OHS MS infrastructure is for
use as defensive documents to limit senior management’s personal
liability. This perception could significantly damage workplace
relationships, and was highlighted in the response to the Follow-Up
Evaluation from case study 6 which reinforced Deming’s suggestion to
“drive out fear”.41 Achieving OHS compliance through education and
understanding of the short and long term benefits may result in more
enduring changes and useful practical improvements.
Three of the eight case studies had not addressed the element of Auditing
(see Chart 13). In some cases there was a strong resistance to creating
more paperwork, especially in situations where they were already
overwhelmed with OHS actions. This aspect of being inundated with OHS
actions was further reinforced in a number of the responses to the Follow-
Up Evaluation. This links to a number of other elements such as Resource
Allocation and Accountability, and the need for responsibility to be
commensurate with authority. Also the need for a planned and targeted
approach was highlighted. This was the rationale behind the use of the
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monthly self assessments and focusing on only three elements for
improvement at the one time. This was found to be more successful in
organisations that were strongly motivated for improvement despite having
less well established OHS MS infrastructure, as in case studies 1, 3 and 8.
Another factor that contributed to the greater success with monthly self
assessments was the allocation of a specific person that had obvious
support and encouragement from senior management to follow through
actions from the programs of work developed.
The element of Stress Awareness was typically handled on an informal

basis and to good effect, often linked to the personal skills of particular line
managers (see Charts 9 and 12). It is suggested that there may be some
elements that are more appropriately handled in an informal manner
without excessive documentation, especially in situations where matters of
a personal nature are concerned and confidentiality is paramount to
maintain trust. The efficacy of informal systems was an area that
appeared to be underreported in the literature. Again this may provide
another area for greater exploration in future research.
Another example of an element that may be better handled informally was

that of Feedback. The value of “face to face” communications was
reinforced by the high impact of the personal presentation of the
Preliminary Report in case study 7 (see the Follow-up Evaluation in
Appendix 24). This also supports the work of Weick where the richness of
“face to face” communications is advocated to build trust.108
A due diligence program was absent in half of the case study

assessments, (see Chart 13). In some cases there was clearly more
emphasis on implementing a risk assessment approach, and this was
interpreted as an effort to comply with local OHS regulations. However,
the benefits of using a due diligence program were not well appreciated,
and in case study 5, such a document was thought to be a liability.
Perhaps the current emphasis on risk assessments needs to be tempered
against the practical benefits offered by a clear program of improvements.
The point made by Petersen to remind managers to ask three simple
325
questions: “Where am I going, how shall I get there and how will I know
when I’ve arrived?” is very basic, yet this process of understanding the
current position, having a goal to move towards, and regularly monitoring
and reviewing progress against those goals essentially underpins the
intentions behind a well managed OHS MS.265
In the safe systems area, more than half of the case studies had formally
addressed Incident Management; Supply with OHS Consideration; OHS
Policy; Consultation; Safe Working Procedures; Competent Supervision
and Goal Setting (see Chart 10).
Incident Management had been addressed formally by all but one case
study. Again, this did not necessarily correspond to a reduced final risk
ranking with this element receiving a “medium - high” final rating in four of
the case studies and a final “high” rating once. In case study 2, it was
observed that the paperwork for incident investigations was being used,
but in effect a “paper treadmill” was in place. On a number of occasions,
the paper work had been short circuited by reporting the outcome of the
investigation as simply: “the problem was not identified in the original risk
assessment”. In this example, the need for better root cause analysis was
clearly evident.
Narrowly focused risk assessments were encouraged by the prompts used

in the forms driving the incident management programs in three of the
eight case studies. It was also observed that there was a significant
amount of stress associated with the need to complete the paperwork on
time, especially for monthly reports. The value of this paperwork is
therefore questionable, especially where this does not translate into
meaningful improvements. Furthermore, the need to screen incidents in
order to prioritise the use of available resources was suggested. In the
pilot study, identifying two incidents per month for more thorough
investigation was found to be a manageable starting point.
The most OHS MS infrastructure was found to be associated with safe

place elements, followed by OHS MS infrastructure relating to the safe
326
systems area, and then finally the safe person area (see Charts 11, 12
and 13). In all cases, the elements least likely to be addressed related to
those that had long term benefits such as Health Surveillance or were
more strategic by nature such as Operational Risk Review and System
Review. This suggested that attention tends to be primarily focused on
managing day-to-day activities rather than future planning in OHS areas.
Discerning trends across the distribution of final risk ranking scores for the
eight case studies was more difficult and reinforced the concept that each
organisation had its own unique hazard profile, and hence the need for a
more customised approach to OHS management. Chart 29 illustrated this
concept well by showing the different hazard profiles across the three
areas for each of the case studies. This also supported the previous work
of Gallagher and the finding that “one size did not fit all”.10
It was originally thought that the number of applicable elements from the
Safe Place, Safe Person, Safe Systems framework would be able to be
customised for the individual organisations. However, after the case
studies were completed it was found that in the majority of situations all
the elements were found to apply. The aspect that was in most need of
customisation was how these elements applied to the individual
organisations and specifically, how they were most appropriately
addressed.
A review of OHS MS documentation in case study 8 demonstrated that a

straightforward OHS plan could be assembled quite effectively by
describing in a few simple paragraphs how each element applied to the
organisation, and the strategies invoked to manage the risk presented.
This could even form the basis of a streamlined OHS MS provided that
critical information was captured and links were available to direct the
reader to further information as necessary.
Ergonomic evaluations received a “medium - high” risk ranking after

interventions were applied in six of the eight case studies, see Chart 17. It
was apparent from the study that access to resources and expertise was
327
needed in this area. This aspect was particularly frustrating for case study
5, where standing for long hours in a retail environment was
uncomfortable, and there was little cash flow available to address the
issue by modifying the physical workplace. In case study 4, difficult
ergonomic issues were accepted as part of the job and strong competition
for positions tended to discourage complaints. Many of the workers in this
instance were being hired on a contract basis. The tentative nature of the
work agreement was considered to exacerbate the problem as these
workers had less permanent job security, which may have weakened their
leverage in negotiations.
The need for improved security was highlighted in Chart 17. Personal
security was a major issue for two of the eight case studies. In case study
5, the concern for personal security had dominated the hazards perceived
for the organisation and restricted cash flow limited the number of
solutions that were available. The end result was that the owner operated
with a very high level of residual risk. The importance of these issues
supports the growing volume of literature that examines the threat of
workplace violence, for example by authors such as Mayhew.190
In case study 4, a media organisation, the threat of personal security was

related to travelling and obtaining footage in potentially hostile
environments. However, whilst there was a mechanism in place to prevent
these situations from occurring, it was rarely invoked by the personnel. In
this instance, the organisation had been rewarding excessive risk taking
behaviour through opportunities to work on more prestigious assignments.
Hence there was a clear need for management within the organisations to
examine whether their actions were indirectly exposing their employees,
contractors and casual staff to high risk situations, and to consider the
ethics of these decisions. Whilst ever some of these individuals were
prepared to take on excessive risk exposure; others were also being put at
risk through peer pressure. In effect, it was a return to the days of “danger
money”, a concept which was rebuked almost three decades ago in the
Williams Report; yet is still clearly in existence today.21
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The elements of Stress Awareness and Inductions-Including
Visitors/Contractors received “high” ratings after interventions were applied
in case studies 5 and 7. In both of these situations, there was very little in
the way of existing formal OHS MS infrastructure and both were in the
early stages of the OHS improvement process. In these cases, the stress
levels appeared to be associated with a clear lack of available resources.
Safe systems elements received far fewer final “high” ratings than for safe
place and safe person elements, see Chart 16. This may suggest that
these elements may be inherently easier to address at a basic level. The
profiles of organisations that perform particularly well in this area may
provide a field of interesting research in the future.
It was observed during the course of the assessments that the elements of
Record Keeping/Archives; Legislative Updates; and Review of Personnel
Turnover most commonly incurred a “medium” final rating. This may be
explained by the perceived impact of these elements being less direct than
for some of the other elements. This supports Reason’s hypothesis that
organisational factors provide “latent pathways” for incidents.152 In
practice, management may even create some of the holes in the “Swiss
cheese” model by ignoring the insidious cumulative effect of multiple lower
grade risks.
Charts 23 - 25 found that in half of the case studies Safe Working

Procedures; Inspections/Monitoring; Preventive Maintenance/Repairs;
Conflict Resolution and Selection Criteria received “low” final ratings. The
element of Safe Working Procedures was generally handled more
effectively than Job Descriptions/Task Structure, and whilst this element
was handled formally in the majority of cases, this did not translate into
very usable documents. In case study 4, formal job descriptions were
available but did not accurately reflect daily activities, even for those who
were in pivotal roles. The element of Selection Criteria received a “low”
final rating in half of the assessments and in many cases it was observed
that process of natural selection was taking place, with either the role
attracting certain types of personnel or those personnel that were
329
unsuitable choosing to leave of their own accord. This was more obvious
as the roles became more specialised.
Safe systems and safe person elements received a “well done” final rating
on 22 and 20 occasions respectively. In sharp contrast to this, safe place
elements received only five “well done” final ratings suggesting once again
the difficulty in addressing OHS issues related to the physical work
environment. Workers’ Compensation/Rehabilitation and Competent
Supervision were the two elements that most frequently scored a “well
done” rating, with each element achieving this on five occasions. This
result may also have alluded to the nature of those who chose to
participate in the study.
In general, there were comparatively few “well done” ratings allocated.

This may have been explained in part by those participating in the study
doing so in order to seek assistance in OHS areas.
The unique nature of individual hazard profiles and how these were
distributed across the three areas was emphasised by Charts 29-30. In all
but one of the case studies, the highest level of inherent hazards was
related to the physical work environment and this was also the area of
highest residual risk in the majority of cases.
The total risk reduction factors for each of the eight case studies in Chart
31 showed case study 1 to have the highest level of overall risk reduction.
This case study was also one of the most satisfied with the application of
the safe place, safe person, safe systems framework and self assessment
exercise. The proposed methodology provided by the study was thought to
be particularly successful due to a combination of factors including:
a highly motivated managing director who engaged an enthusiastic

administrator to champion the project;
the fact that the existing OHS MS was very immature and there was
great scope for improvement;
330
the strong technical and personal skills of the managing director that
promoted strong leadership;
the small/medium size of the organisation that encouraged open

communication channels and fast decision making processes;
the clear availability of resources for OHS matters; and
the close relationships amongst the workers and a caring family

atmosphere that enabled high level risks to be handled responsibly.
Furthermore, safety was a clear organisational value and the benefits

bestowed to the organisation by this aspect supports the research of Silva
et al.397
Case studies 2, 6 and 8 had the next greatest level of overall risk
reduction. All these studies involved assessments of smaller divisions of
large corporate organisations with access to higher levels of resources
and existing OHS MS infrastructure. In relation to the aims of the study
and whether or not the use of a systematic approach to OHS was
connected with better performance, it was found to be very useful in
overall risk reduction for organisations that involved a significant
proportion of assets invested in the physical hardware and operating
environment, for example in multi-national manufacturers or utility
organisations.
Case studies 3, 4, 5 and 7 had the lowest overall risk reduction factors.
Case studies 3, 5 and 7 had very little existing OHS MS infrastructure. In
case study 4, OHS MS infrastructure was available, however there were
other significant factors contributing to the lower overall level of risk
reduction. These related to internal restructuring, the methodology
promoted within the existing OHS MS and the format in which OHS
information was being disseminated.
The overall risk reduction factors given by Chart 32 ranged from 0.60 -
0.65, illustrating that there is still a significant level of residual risk in
contemporary workplaces, and much scope for improvement. This also
331
implied that there is a strong need to provide assistance to enable
employers to address common OHS issues.
In Chart 33, the method used by Vassie and Cox was utilised to assess
391
which elements of an OHS MS were perceived to be most important.
The following ten items were most frequently recorded in the responses to
the Follow-Up Evaluation survey, and are presented below in ranked order
starting from the most important:
Training;
Baseline Risk Assessments;
Incident Management;
Communication;
Accountability;
Consultation;
Measurement;
Measureable Goals;
Emergency Preparedness; and
Hazardous Substances.
These could be considered as the “big ten” elements and whilst

measurement was not in itself an element there were a number of
elements that involved measuring such as Audits; Inspection and
Monitoring; Self Assessment and First Aid/Reporting. When the question
was posed to the participants regarding what would be an appropriate
measurement to determine whether the actions described in the self
assessment had been successfully completed, many declined to follow
this through. This implied that measuring performance is still problematic,
and this supports the recent findings of Simpson.371
332
In summary, the comparison of results across the eight case studies
reinforced the unique nature of each organisations hazard profile and
highlighted a number of typical problem areas such as:
hazardous substances management;
the lack of health surveillance;
the need for more ergonomic evaluations; and
contractor control.
Those participants involved in the study that were involved in line

management were found to be very competent in the supervision of their
workplaces and many had outsourced very proficient workers’
compensation and rehabilitation providers. In this study, addressing safe
place elements formally was not found to correspond with an improved
risk rating after interventions were applied, and in many cases these
elements were handled poorly. This may also suggest the formality may
provide a false sense of confidence and assurance, masking areas where
the practicalities of the requirements may have been ignored.
The Safe Place, Safe Person, Safe Systems framework was found to be
very effective in uncovering the problems associated with token
implementation of procedures. Furthermore, by using the Safe Place, Safe
Person, Safe Systems framework to assess informal systems, this OHS
management tool was able to highlight areas of strength that may not
have emerged if more traditional auditing techniques had been applied.
11.2 Cross Case Synthesis - Emergent Themes
In the cross-case synthesis that follows a number of themes emerged,

developed from the observations made during the eight case studies. In
some instances, these were based on common themes that linked a
number of case studies, whilst in others, one case study would crystallise
333
a particular point of interest. The benefits of a qualitative multiple case
study design are exemplified here as the opportunity for observation and
triangulation of data allowed areas where alignment was not found to be
explored in more depth. It was in this examination of the reasons
underpinning the observed practices, especially where these deviated
from the documented methods, that the evidence was found to test these
concepts; and negative cases, where these perceptions did not hold,
demonstrated limiting factors or constraints to the themes presented.
(i) The Inappropriate Use of Risk Assessment Methodology

Misconceptions relating to the appropriate use of risk assessments had
the effect of creating a “paper treadmill” instead of translating the
outcomes of risk management exercises into practical and visible
workplace improvements. Organisations need to be mindful of warning
indicators that may suggest that the risk management process is not
working as intended. Examples include: when checks on documentation
cannot be verified in the operational environment; when the clearance rate
of OHS actions is slow; and when there are high repeat rates for similar
incidents or injuries. This theme was illustrated particularly by case studies
2, 5 and 8.
(ii) Misconceptions Regarding OHS Responsibilities Owed to

Contractors
Induction programs must ensure that the appropriate information is being
provided where necessary to protect contractors from undisclosed
hazards. Identifying the different categories of contractors or site visitors
and tailoring inductions to cater for these differences may make the
induction program less arduous and more relevant. These themes were
particularly relevant in case studies 1, 2, 3, 6 and 8.
(iii) Lack of Focus on Long Term Health Issues

Where high level risks to the physical work environment are present, the
need to also consider long term health issues may require specialist input.
One of the major strengths of the Safe Place, Safe Person, Safe Systems
framework was the ability to put these issues into perspective and to force
334
a more thorough examination of the full context of workplace hazards. This
theme was mainly prevalent in those cases arising from the manufacturing
sector, such as case studies 1, 2, 3 and 6.
(iv) The Need for Periodic Review

The need for periodic review was overlooked in many instances, and
appears to underpin the reasons why many systematic improvements
appear to fail. Again this relates to a preoccupation with day to day
activities and less focus on the long term view. Without periodic review,
much of the effort invested may be wasted, especially if the strategies
invoked have not targeted all the root causes underlying the problems
identified.
This theme was evident in many cases that were only at the early stages
of the improvement process, such as case studies 1, 3, 4, 7 and 8. In case
study 2 which had a highly evolved OHS MS in existence, a pre-
occupation with performing risk assessments had the overall effect of
congesting the OHS MS to the point where the organisation was at a
standstill, unable to progress or respond in a timely manner to important
OHS issues. This suggests that one of the main benefits of performing a
system review is to ensure that a balanced approach has been applied
and that there is a healthy blend of proactive and reactive strategies in
place. This also reinforces the previous work of Redinger.13
(v) Resistance to the Use of Behavioural Change Techniques

The extinguishing of unsafe workplace habits is difficult without the
provision of appropriate and consistent feedback. The strategic use of
reward schedules to assist these techniques was also not widely
appreciated.304 Whilst behavioural techniques should not be the first or
only strategy invoked, especially where changes are needed in the
physical workplace, they are very useful as a back-up or a contingency
method, especially in circumstances where more enduring changes are
being planned for, but have not yet been implemented. Other
circumstances where behavioural change programs may be useful are in
335
the cases of lone workers and call out work to variable locations with
unpredictable hazards.
A particularly useful application of behavioural change programs is where

they are used to prevent people from rushing into a job without first
considering all the potential hazards and evaluating potential control
options. This was exemplified by case study 7 that used the “Take 5”
campaign, reinforcing the concept of taking five minutes to stop and
consider responses. In contrast to this, case study 6 had a similar program
that was less effective because constraints on “stop work” situations were
not uniformly enforced and the pre-occupation with monthly targets for
associated paperwork had thwarted the initial enthusiasm.
(vi) The Need to Allocate a Person to Facilitate OHS Projects

Whilst the concept of OHS activities being naturally integrated into every
day work processes is the ideal situation, it appears to be very difficult in
reality. Genuine application of the consultative process in a manner that
ensures transparency is likely to extend the time requirements of various
stages of a project. However, the increased quality of the final outcome
and the longer term benefits afforded should also be taken into
consideration, and these may be more clearly identified when a person
has been specifically allocated to follow up on these issues.
The difficulty in getting OHS projects initiated without a person with clear
OHS responsibilities was highlighted by case study 2, when the safety,
health, environment and quality (SHEQ) incumbent was transferred to
another division of the organisation. The initial enthusiasm provided by the
original SHEQ officer was lost and stage two of the study came to all but a
practical halt. In sharp contrast to this, in case studies 1, 3, and 8 that had
a person specifically allocated to drive OHS projects, the rate of progress
in stage two of the study was remarkably greater.
336
(vii) The Tendency to Overlook the Cumulative Effect of Multiple Low
Grade Hazards
The subtle yet sinister effects of multiple low grade hazards was
commonly overlooked, especially in cases where there were other more
obvious OHS risks to be considered. An example of this was in case study
7, where the main purpose of the organisation was to manage volunteers
to handle crisis situations. The risk presenting to the volunteers did appear
on first consideration to be far greater than the risk exposure of the
support staff that managed the process. However, the technique for
conducting dynamic risk assessments that the volunteers had been
trained on was not being applied by support staff in the less dramatic
scenarios of the supply stores which had many ergonomic issues to deal
with. High stress levels experienced by support staff, often linked to
instances where responsibility was not commensurate with authority, were
tolerated and accepted as part of the job. The impact of these cumulative,
low grade hazards was observed as deterioration in the experience of well
being and the potential for negative impacts on relationships outside the
workplace. Case Study 4 also reinforced these findings and again, it was a
situation where support staff were considered to be at much less risk than
those on the field. In fact, the stress levels of the support staff were
observed to be much higher than those in the field, possibly because the
potential for high stress situations when out in the field was openly
acknowledged. Interestingly, it was observed in both case studies 4 and 7
that those providing OHS assistance for others were less likely to ask for
help themselves. The importance of looking after oneself so they can then
be of better assistance to others, and the need to be on lookout for
symptoms of burnout, were points that may need further reinforcing.398
(viii) The Customisation Aspect of OHS MS is more related to how the

Elements Apply and are Suitably Addressed Rather than their Actual
Absence or Presence
The Safe Place, Safe Person, Safe Systems framework was originally
thought to provide a level of customisation to individual organisations by
eliminating elements that were not considered relevant. However, this was
337
not observed in the case studies examined. From the experiences
encountered, it is suggested that this level of customisation would only be
applicable in the smallest organisations, for example, sole traders.
The customisation factor was relevant to appreciating how each element

applied to the individual organisation, and more importantly, how these
unique hazards may be handled effectively. The importance of
customising information is an important message for organisations as “off
the shelf” OHS MS may provide an illusion of action, and whilst less
expensive to purchase, may still represent a waste of resources that could
be better utilised on understanding local hazards.
(ix) The False Sense of Confidence Bestowed in Overly Bureaucratic

OHS MS infrastructure.
Case studies 2 and 6 that had the most highly developed OHS MS
infrastructure also had extremely high levels of residual risk associated
with the physical workplace. In both these cases plans for treating the risk
at the root cause by replacing obsolete equipment or processes were in
hand, but dates for implementation of the improvement projects were often
significantly delayed or indefinitely “on hold”.
The seriousness of having processes known to be dangerous operating

for extended periods has the potential to place personnel at unreasonably
high levels of risk exposure and jeopardise their future health. The ethics
of such decisions should be carefully scrutinized, especially where
unnecessary delays are being encountered or a lack of commitment to the
improvement process is observed.
(x) The Importance on Providing OHS Management Feedback

The Safe Place, Safe Person, Safe Systems framework was particularly
valuable as a source of feedback to organisations. This enabled a number
of cases to reconsider current strategies and focus their limited resources
on more critical OHS issues, as identified by the framework charts
provided that showed final risk rankings scores after interventions were
applied.
338
The significance of providing feedback was best illustrated by the pilot
study where the increase in focus and attention resulted in a decrease in
the number of reported incidents (see Appendix 23 for Pilot Study Monthly
Self Assessment Results).
The Safe Place, Safe Person, Safe Systems framework was also
instrumental in providing opportunities for increased OHS dialogue. This
may serve as an opportunity to raise matters of concern before they
escalate to the point where they are impacting on interwork relationships.
This was illustrated by case studies 6, 7, and 8 where the results from the
Preliminary Report were presented and provided the basis for raising OHS
problems of concern and opening up discussions. In case study 4, the
results of the application of the framework resulted in the encouragement
of more open, informal discussions of OHS concerns, the more frequent
exchange of ideas and a better appreciation of the perspectives of others
involved. This was preferred to more formal approaches, reinforcing the
notion that formality is not always necessary or desirable. The benefits of
a more subtle approach and the advantages these may offer for
maintaining and establishing trust are concepts that may have been
previously underestimated.
(xi) Commitment to OHS Values Exemplified by Provision of

Sufficient Resources and High Rates of Organisational
Responsiveness
Organisations that encountered difficulties in proceeding to stage two of
the study were often under resourced or overwhelmed with current
outstanding OHS actions. Furthermore, in case studies 1, 3 and 8, the
visible support from senior management appeared to enhance the ease
with which their OHS duties were able to be discharged. This may be
explained by these incumbents having more perceived authority which
allowed them to be more effective in imparting change.
339
(xii) The Ability of Smaller Work/Organisational Groups to Handle
High Level Risks Effectively.
One unexpected finding of the study was how the strategic application of
small work group size was very effective in responsibly managing high
level risks. Small groups were able to communicate more efficiently
amongst themselves and with line managers. In these situations, line
management also appeared to be more aware of any factors that may be
affecting the performance of group members and so were more able
respond accordingly. Trust and respect also seemed to play important
roles as this reduced the potential for duplication of work processes and
minimised the distraction of workplace conflict. This was particularly
noticeable in case studies 1 and 3 that were family businesses. This
application of small workgroup size as a control strategy in itself was not
identified at the start of the study or in the body of literature associated
with OHS MS. It is suggested that this may be incorporated into the
element of Communication in future studies.
Hence, there were a number of emergent themes that ranged from the
effective use of smaller size as a means of handling high risk activities, the
need to provide more focus on long term health effects and the prevalence
of common misconceptions regarding the application of risk management
techniques and duties owed to contractors.
The ability to analyse these themes was enhanced by the use of the Safe
Place, Safe Person, Safe Systems framework as it provided a systematic
and consistent means of examining work practices related to OHS and
verifying whether or not the current interventions were being effective in
reducing the level of residual risk presenting to exposed workers.
The availability of the Safe Place, Safe Person, Safe Systems framework
to provide a guided, systematic approach to addressing OHS
responsibilities may also overcome a number of potential barriers
confronting small and medium enterprises that have difficulties interpreting
340
local OHS regulations or are distracted by pressing financial issues that
focus their attention on short term business survival. 399
11.3 Answering the Research Questions
How do contemporary employers go about fulfilling their OHS

obligations?
It was generally observed within the case studies that the requirements of
the local OHS regulations were the guiding mechanism and most had a
copy of these regulations available for reference. Interpretation of the
requirements was more difficult. In larger organisations that covered a
number of jurisdictions, conformance with relevant Australian/New
Zealand standards was targeted although many organisations in this
category had corporate standards that were used as an interface so that
the requirements were more relevant to the particular organisation.
Workers’ Compensation and Rehabilitation Providers were often the
driving forces in the very large, more bureaucratic organisations. On the
other extreme, small to medium sized family businesses that had high
level risks were observed to employ personnel to focus on these areas,
although these personnel were not formally trained in this field.
How can a systematic approach to OHS be identified?

A systematic approach to OHS was more about understanding obligations
and duties and being organised to address gaps and shortcomings, than
about a connection with formal systems and the use of electronic media.
A systematic approach to safety can be identified by having in place a

clear program to respond to recognised OHS hazards in the workplace
and the desire for the pursuit of increased knowledge and understanding
regarding techniques and preventive strategies for protecting employees
and others in the workplace, wherever that may be.
A systematic approach may also be described as a mental discipline

promoted by management that ensures that there is a high level of
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situational awareness and dynamic responsiveness to urgent OHS issues,
and a view to consider and guard against long term health risks.
Organisations employing a systematic approach to OHS may be

characterised by the provision of adequate authority and resources to
empower those with OHS responsibilities to respond in a timely manner to
OHS concerns and be mindful of the potential for OHS impacts of new
ventures or changes to current work practices.
The availability of formal procedures was found not to guarantee a

systematic approach to safety, but merely the knowledge of compliance
factors in local OHS regulations. Formal procedures were also considered
to be connected with a desire to demonstrate a due diligence defence in
the event of OHS litigation.
Those organisations utilising a systematic approach were also found to

have improved scores for risk reduction in the safe systems areas.
What are the barriers to the uptake of a systematic approach to

safety?
The greatest barriers to the uptake of a systematic approach to safety
were observed as follows:
lack of understanding of the intent of local OHS regulations;
insufficient allocation of resources to OHS matters, including the time

to focus on solutions;
perceived inconsistency between OHS policies and actions rewarded

and recognised by senior management;
lack of knowledge of available methods for dealing with significant

risks in environments that were potentially hostile or unpredictable;
mistrust in management’s motives behind the collection of data and

the perception that this may be a threat to the long term job security
of experienced personnel;
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the use of high volumes of contracting and casual staff;
lack of follow through on agreed activities to address OHS concerns;
lack of actual workplace inspections to check the effectiveness of

solutions implemented, and if they have in fact been implemented as
agreed; and
lack of understanding by senior management of actual OHS

difficulties experienced by operational staff and an inability to
empathise with the frustration these problems may evoke.
What questions may be used to promote a systematic examination of

the entire context of workplace hazards?
The questions in the Safe Place, Safe Person, Safe Systems framework
that considered the requirements in terms of the potential consequences if
the 60 elements were not addressed was found to be a good starting point
for such an exercise. This reconfiguring of the questions to examine the
risk presenting to the organisation if the essence of the elements was
ignored was found to be more fruitful than structuring the questions in an
alternative format that included what an experienced OHS practitioner may
expect to find. This may make the exercise more relevant to the
organisation and avoid responses designed to please the assessor.
What indicators are available on an operational level that may

suggest the existence of particular workplace hazards?
The indicators are likely to be specific for the particular industry or
organisation and the development of indicators is a task that would
generally benefit from a balanced peer review. However, there were some
indicators that may be used on a more generic level that suggest that OHS
activities are being carried out on a superficial level such as:
OHS minutes where one person is nominated for the majority of

actions;
review plans that are constantly amended to have later completion

dates;
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where overwhelmingly long actions lists are found that do not show
signs of progress;
where improvement plans to improve outdated processes with known

health risk factors are referred to constantly but there has been no
actual spending on project components;
where spot checks of actions are discouraged;
where there is emphasis on numerical targets for monthly reports

without checks on outcomes that would suggest actual
improvements;
where solutions point to the use of behavioural techniques without a

desire to address the root cause of the problem, especially if this
involves changes to the physical workplace;
where there is inconsistency between the OHS efforts made for

customers and those applied to internal staff;
where emergency plans exist but are not practiced regularly or

reviewed;
where appointments for OHS meetings are constantly rearranged;
where senior management do not participate in OHS committee

meetings and delegates are sent in place;
where OHS personnel appear distressed at the lack of progress or

resources available and signs of burn out are evident; and
audit reports that are completed without any observations or

comments.
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What strategies are typically invoked to prevent and control
particular workplace hazards on the following three levels: the
physical environment and infrastructure; the individual; and at a
managerial level?
Strategies used to address OHS issues in the physical workplace, where
this was represented by a fixed location, were typically handled using a
risk assessment approach. Networking to understand best practice was
common in specialist areas and outside expertise was often used to
minimise hazards of an electrical nature.
Where the work location was variable, contractors were often involved with
permanent staff in a more supervisory role.
On an individual level, hazards associated with the complexity of human

nature were handled most effectively by managers with highly developed
social skills. Those managers with the ability to manage the “big picture”
were particularly adept at also picking up subtle changes in morale and
attitudes. The managers that were able to direct people onto help when
necessary, use a team approach and were keen to keep staff informed
handled this area particularly well.
The use of outside health professionals to handle workers’ compensation

and rehabilitation was common and in many instances these services
were highly regarded. Health surveillance was mainly observed in larger
organisations with long standing OHS MS infrastructure.
Training was handled well in all occasions and seen as fundamental to the
establishment of a safe workplace, except on two occasions. In the first
instance, the format of the training was not well received by the target
audience (case study 4) and in the second instance, training was the
service provided to volunteers so training of support staff received much
less focus (case study 7). In both cases, in-house training for support staff
was perceived to be less vital and there was a large differential between
the hazards encountered by those in the field and those in support roles.
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At a managerial level, audit systems are typically invoked in larger
organisations with sophisticated infrastructure and are managed typically
with electronic databases that feed into corporate OHS compliance
operations.
In smaller organisations, systems may be applied on a more ad hoc basis.

As for example, there may be procedures for investigating incidents, and
there may be policies available, but much of the linking data is missing
and triggers are not in place to ensure that methods are applied uniformly.
Also commonly encountered in smaller organisations was the use of
laminated flow charts placed on walls at the point of use to remind staff of
the appropriate methods. Safety checks on suppliers were not enforced
regularly; however they were generally very aware of OHS provisions for
customers.
What are the most suitable measurement indicators to gauge the

effectiveness of the particular prevention and control strategies
invoked?
Organisational responsiveness is probably one of the most promising
indicators to gauge the effectiveness of OHS programs, as the length of
time required to get important OHS actions implemented was generally
indicative of the level of enthusiasm and support of senior managers for
OHS activities.
The level of satisfaction of personnel with responses to OHS concerns

may also be another useful gauge as this would be observed to reflect the
level of consultation that had been applied to the process.
The appropriate application of measurement indicators for OHS

performance is still a cause for concern for many organisations.
Organisations with the least effective OHS MS infrastructures were very
focused on crude measurements related to workers’ compensation and
claims data.
In corporations with extensive OHS MS infrastructure, a high level of

attention was observed to be focused on monthly numerical targets, and
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there appeared to be less concern whether these indicators are genuinely
representative of enduring improvements. In some instances, the need for
fulfilling monthly quotas of actions defeated the purpose of the actions
being measured.
Most measurements focused on outcomes that would reduce injuries but

had little impact on long term health or general well being. Whilst the
adage “what get’s measured, gets done” may be true, it may be more
pertinent to ask whether what is being done, is actually being done well.
Which prevention and control strategies are considered essential on

a broad level, and which strategies are industry specific?
All of the elements were found to be applicable on a broad level, except in
intermediate processing manufacturers where the element of Customer
Service - Recall/Hotlines did not apply.
This was unexpected, however, had more very small businesses been
studied, this may not have been the case.
Of all these elements, some were much more uniformly acknowledged as

being important and based on the researcher’s observations, these
included:
Training;
Risk Assessment;
Incident Management;
Inductions- Including Visitors/ Contractors;
Personal Protective Equipment;
First Aid/ Reporting;
Emergency Preparedness;
Workers’ Compensation/ Rehabilitation;
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Safe Working Procedures; and
Security – Site/Personal.
How does the nature of the organisation influence the type of

prevention and control strategies selected?
The use of small size and family relationships to handle very high level
risks was generally observed. Further to this, members of family
businesses appeared to accept much higher levels of residual risk than
personnel from corporate organisations.
Organisations that were experiencing cash flow difficulties were more

likely to use safe person and safe systems strategies as a means of
compensating for non-ideal work environments, especially where the
capital involved to make the appropriate changes was considered
significant.
Organisations that had obvious high risk activities relied more heavily on
close circles of trusted contractors/suppliers that generally had long term
working relationships with the organisation. These organisations often
employed workers through word of mouth, or personal recommendations
from trusted individuals.
Highly structured and bureaucratic organisations were observed to rely

more heavily on OHS committees to direct OHS activities and were found
to have many policies available. However, the presence of a policy did not
necessarily mean that this area had been addressed, and high stress
levels and suggestions of bullying were more commonly observed where
anti-harassment policies were available.
Larger organisations examined were found to be very focused on being

able to demonstrate compliance activities, but the effectiveness of these
actions was not often pursued. In these types of organisations, high levels
of responsibility were often passed onto those that did not have the
necessary authority, and many had to rely on their personal influencing
skills.
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The micro business observed was unable to finance many of the actions
necessary to achieve OHS compliance, so reliance was predominantly on
safe person and safe system strategies.
In the utility organisation studied, the application of safe systems

strategies was considered to be vital to the provision of a safe and reliable
essential service to the surrounding community.
What is the order of implementation of these prevention and control

strategies that leads to the development of a clear pathway to OHS
improvements?
Based on the case studies examined, it would be inappropriate to
generalise that safe place strategies were more important than safe
systems strategies or safe person strategies. All of the strategies were
important and it really was more dependent on whether the organisation
had to deal with existing infrastructure or was in a planning phase, and
whether the organisation was more capital intensive or labour intensive.
For example, if the organisation was small and operated over a small,
fixed location, it could manage with less safe systems strategies than if it
was larger and was managed remotely by more senior executives.
The most important starting point for an organisation that would lead to a
clear improvement path would be the acknowledgement and honoring of
OHS values by senior management, as witnessed by the provision of
necessary resources and authority; and an alignment of goals by support
staff.
The ability to concisely explain how the requirements of the 60 elements

were addressed by the organisation would be another useful exercise that
could lead to the development of a clear improvement path. Recognising
that a problem exists is ultimately the first step towards its final
rectification. Without knowledge of long term health consequences and
situations that might lead to increased incidents of injuries and illnesses,
organisations may be able to remain uninformed.
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Having policies in place was not perceived as efficient in sending OHS
messages as small OHS slogans that were easily remembered and
embodied the attitude of management. For example, many informants to
the study knew that a policy existed, but did not know what the essence of
the policy stated.
The need to review actions and check effectiveness of decisions was not
widely embraced and possibly offered an explanation for the often
observed dissatisfaction with current practices. Obviously, systems applied
and strategies invoked need to be given a period of time to settle in before
evaluation exercises are useful. Provisions for such activities should be
made at the onset to ensure time and resources have been set aside for
the review.
11.4 Potential Applications of the “Safe Place, Safe

Person, Safe Systems” Framework
The case studies were very useful in illustrating potential applications of

the Safe Place, Safe Person, Safe Systems framework, which ranged from
benchmarking exercises to the foundation of improvement programs.
These, and the circumstances which would be most favorable to the
successful application of Safe Place, Safe Person, Safe Systems
framework, are discussed below so that resources associated with any
future work may be utilised efficiently and benefit from the range of
experiences encountered during the eight case studies.
(i) Smaller Divisions with Little Existing OHS MS Infrastructure:

The Safe Place, Safe Person, Safe Systems framework was found to be
most helpful in organisations that had little existing OHS MS infrastructure
in place and in smaller divisions where the hazard profile was more
genuinely representative of the activities being undertaken. Attempting to
superimpose this framework where there were already high levels of
bureaucracy in place was found to be more problematic, especially if there
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were overwhelming levels of outstanding OHS actions. In these situations
it is suggested that all outstanding OHS actions be reviewed and the
remaining workload carefully prioritised. In some circumstances where
elements interact, addressing medium-high risk areas first may place the
organisation in a better position to respond to elements of even higher
risk.
(ii) To Triangulate Data from other Specialist Audits

In a number of instances, particularly with the larger corporate
organisations, the application of the Safe Place, Safe Person, Safe
Systems framework was used to triangulate data from other specialist
audits. This occurred in case studies 6 and 8. In these instances the Safe
Place, Safe Person, Safe Systems framework was found not only to
reinforce previous findings, but also to provide additional data and assist
management’s understanding of the finer details of local work practices.
(iii) Checking the Relevance and Practicality of Existing OHS MS

Infrastructure
In case study 8, the application of the Safe Place, Safe Person, Safe
Systems framework was found to help distinguish between the useful
elements of two different OHS MS that were co-existing, due to a change
in ownership. This resulted in the current senior management committing
resources to a new project that would merge the two systems together,
extracting the best elements from each.
(iv) Increasing the “Mindfulness” of OHS Activities

The Safe Place, Safe Person, Safe Systems framework was useful in
enhancing the “mindfulness” of safety activities as advocated by Weick.395
This was illustrated in case study 3 where employees no longer needed to
be reminded to complete incident reports (see 9.3.2 Discussion of Main
Findings for Case Study 3).
(v) Bringing Potential Long Term Health Issues into Focus

The use of this framework had an educative role by promoting the
handling of hazardous substances in a manner that catered for differences
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amongst individuals to workplace reagents. This is illustrated by the
following response from case study 6 in the Follow-Up Evaluation in
Appendix 24 which demonstrated how their attitude changed towards the
treatment of exposure limits for hazardous substances. This also impacted
on their approach to the type of PPE that was selected.
“… we need to reduce chemical exposure to the point that the most sensitive employee
has no adverse impact rather than ensuring we are below the maximum exposure
standards listed in the MSDS.”
(vi) Benchmarking Exercises

Case study 6 considered that the Safe Place, Safe Person, Safe Systems
framework would be useful for benchmarking exercises and as a
demonstration of due diligence. This exercise may be used across
different divisions in larger organisations and may be able to cater better
for local differences by being based on the level of risk reduction as
opposed to outright scores.
(vii) For Use in OHS Committees

The Preliminary Report delivered high impact information for OHS
committee members in case study 7 (see Follow-Up Evaluation in
Appendix 24). This may also assist with the transparency of OHS
improvement programs. As the report was written with neutral language
avoiding blame, and in a manner that preserved the confidentiality of
informants, it also made it easier to circulate the assessment without
creating a defensive environment.
(viii) To assist in the Procurement of OHS Funding

A number of case study participants found that the Safe Place, Safe
Person, Safe Systems framework was useful in the procurement of
funding for OHS activities. The assessment process was found to give
their arguments extra validity as it had come from an outside, objective
source (see Follow-Up Evaluation comments for case studies 4, 7 and 8).
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In all these cases, the Safe Place, Safe Person, Safe Systems framework
was a starting point for increased dialogue and communications.
(ix) Customising the Safe Place, Safe Person, Safe Systems

Framework Assessment Tool for Individual Organisations
There would be an opportunity to customise the prompts used in the Safe
Place, Safe Person, Safe Systems OHS management assessment tool to
cater for the needs of individual organisations. This would increase the
speed and efficiency with which the tool may be applied, and would open
up the prospects for the use of multiple assessors.
(x) To Indicate whether there is a need for Dynamic Risk

Assessments
As risk assessment methodology underpins many local OHS regulations,
this could be applied with better effect if there was a clearer understanding
of the circumstances and context that would be more suitable for the use
of dynamic risk assessments. The examination of local practices and the
focus on safe person strategies offered by the new framework allows a
multitude of techniques to be considered, especially in situations where
there are lone workers, or when there is call out work to variable locations
with unpredictable combinations of hazards and/or hostile environments.
In summary, the Safe Place, Safe Person, Safe Systems framework has a
wide variety of potential applications and its use in the eight case studies
has illustrated the versatility of the model and the number of benefits it
may provide. Not only may the Safe Place, Safe Person, Safe Systems
framework provide a catalyst for change and increased OHS dialogue, but
its use as an educational tool to increase understanding of OHS
responsibilities has the potential to generate benefits that are enduring,
practical and add value to the workplace environment.
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11.5 Limitations of the Study
Every attempt was made to ensure that the intellectual rigor of the study
was preserved, and that the validity of the study had been appropriately
addressed on all levels. However, there were a number of limitations that
were difficult to overcome either due to the resources available, the nature
of this particular field of research, or the time frame allowable.
One of the greatest limitations to the study was the difficulty in recruiting
participants. This impacted on another significant area - the sample size.
As the study involved two parts, one with the assessment using the Safe
Place, Safe Person, Safe Systems framework and the other, applying an
intervention over four months to target improvements in three elements,
the time frame for completion of individual case studies was expected to
span at least six months. Actual on site time by the researcher was
estimated to be equivalent to four full days and the remainder of the
communications were able to be conducted by telephone or email. Hence,
when participants were being recruited, these time frames had to be made
known and for some of the interested parties, these were too long or there
were concerns regarding how much time would be consumed by internal
resources with the study.
A total of 12 organisations originally showed interest in participating. In

one case, this was just a brief enquiry over the telephone in response to
the advertisement. In the other three cases that did not go ahead, this was
after one or two visits with representatives from the organisation. In all
cases, the reasons given for not pursuing the study were either:
the length of time necessary; or
declined approval by a more senior manager.
To recruit a participant usually involved at least two visits to the

organisation. One visit was usually to explain the purpose of the study to
the person that had become aware of the research being conducted. The
second visit would often involve either presenting this information again to
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more senior managers that had the authority to permit the study to go
ahead or to inform those that would be involved during the actual
assessment exercise. This recruitment stage was time consuming and did
add significantly to the time frames for completion of the study.
The sample size was small when compared with quantitative research
methods. However for a qualitative, multiple case study design, the use of
eight studies was a relatively large number given the substantial depth and
breadth of the research in each case. The sample size was obviously too
small for statistical analysis, however, this was not the purpose of the
research. Extrapolation of the findings to wider settings was not the
objective of this study, as already emphasised in the Methodology section,
see Chapter 7. Generalisations made from the particular findings of
individual case studies would depend on whether the contexts presenting
were similar. As noted in Section 7.2.3, external validity in this particular
research design was more related to the concepts of “fittingness” and
“transferability” than those of representativeness.
Although a purposeful random sampling strategy was aimed for, in some

cases the sampling strategy was based more on “convenience”. An
example of this was where a respondent had a number of sites to choose
from, as in case studies 7 and 8. In other instances “opportunistic” factors
were dominant with a number of organisations wanting an objective third
party to provide a risk assessment, for example in cases 5 and 6. There
was also some potential for bias of participants as those who decided to
show interest in the study were likely to be more highly motivated to seek
OHS improvements than those who were not interested. However, they
may also have been in more need for OHS assistance. These two factors
would be likely to counterbalance each other to some extent. Another
balancing factor was that the case studies came from such a wide variety
of organisations, spanning differences in size from very small to large
corporate organisations; and also the various sectors from retail,
manufacturing and service industries.
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Finally, the findings of the study must be viewed with the
acknowledgement that the researcher had significant industrial experience
(over fifteen years) in a wide variety of organisations in areas involving
Safety, Health and Environment as well as Quality Management. In
addition there was a technical background in chemical engineering which
was particularly useful in some of the studies involving the manufacturing
sector. Had the Safe Place, Safe Person, Safe Systems framework been
applied by a candidate with different industrial experience or technical
expertise, this may have impacted on the interpretation of the findings
within individual case studies. It is suggested that the findings of this study
must be interpreted with the knowledge that one researcher conducted the
entire eight case studies, and any researcher would bring to the study their
depth and range of personal and industrial experiences. For the purposes
of the study, to test the application of the Safe Place, Safe Person, Safe
Systems framework, having multiple researchers use the assessment tool
would have introduced another variable. This would have made the
findings more difficult to interpret and also reduced the level of consistency
of the findings, which would have impacted on the internal validity of the
study.
The fact that all the case study participants were drawn from New South
Wales was another potential limitation of the study. Extending the study to
different localities would have increased the breadth, richness and
transferability of the findings. This may be an area for future research
development.
Case study 7 was the only case that did not complete stage two of the
study. This had the potential to bias the results due to the small sample
size, however, it did serve very well as a “negative” case and exploring the
reasons behind this anomaly was very useful when looking for emergent
themes across the study as a whole.
In summary, there were a number of limitations that needed to be

appreciated when interpreting the findings of the study, and these related
to the difficulty in attracting participants which impacted on the sample
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size, the potential for the case study participants to be more motivated
towards improvements than what would be represented by larger sample
sizes with different sampling strategies; the fact that the study was
conducted by a single researcher; and finally that the research was
conducted across a single state. All these limitations do, however, present
areas for expansion and refinement in future research.
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Part 6: Recommendations and
Conclusion
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12. RECOMMENDATIONS AND CONCLUSION
12.1 Recommendations
The depth and breadth of OHS issues that this research was able to
explore through the multiple case study design has lead to a number of
recommendations that are intended to assist the promotion of OHS values
in the workplace. These are presented below to facilitate more sustainable
OHS improvements that enable the managers of organisations to grow in
their understanding and ability to successfully manage OHS issues.
; It was evident from the research that there are a number of

misconceptions regarding the correct application of risk management
methodology. Given the importance of risk management techniques
and its emphasis in many local OHS regulations, there needs to be
more widespread education on how a risk assessment is performed
so that the outcomes are valid and the information has been
generated by those with appropriate knowledge and in an
atmosphere of consultation and transparency. Factors that suggest
the need for a more dynamic approach must be well understood so
that the methodology is not by-passed altogether. Organisations that
have achieved high levels of success in this area without creating
excessive documentation should be held up as examples for other
organisations to learn from.
; The business community needs to be more informed of alternative

means for demonstrating due diligence without relying so heavily on
written communication. More visual techniques should be promoted
and more practical means of assessing competency, other than
through written assessments, should be encouraged. The need for
continual improvement so that work methods more accurately reflect
changes and challenges as they present must be provided for at the
onset. Responses to OHS issues need to be more dynamic to more
accurately reflect the typical nature of OHS issues encountered in the
modern workplace.
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; There needs to be a wider level of understanding and education on
the responsibilities owed by organisations to contractors. The
benefits of streamlining the number of contractors utilised also needs
to be emphasised.
; The strategic use of organisational size and structure can affect the
nature of workplace relationships, and the use of closer relationships
resulting from smaller size to ameliorate high level OHS risks should
be promoted. The benefits derived from the speed of
communications; the ability to be more “in tune” with co-workers; and
the opportunity to foster and build trust should be more widely
appreciated.
; There is a lack of focus on long term health issues which may result
in continuing and increased future burdens on the public health
system. The organisations observed were clearly preoccupied with
day to day issues and to some extent were in “survival mode”. Means
of making long term health issues more relevant need to be explored.
This may take the form of finding high impact consequences that are
meaningful and easy to relate to, similar to the anti-smoking
campaigns; or by increasing awareness of “nuisance effects”, so
these are acted upon before more irreversible damage occurs.
; The insidious effect of the accumulation of multiple low grade

hazards should be highlighted. Means of obtaining a better grasp on
the relationship between the cumulative effects of some common low
grade hazards and the impact these have on future injuries, for
example of a muscular-skeletal nature or even on emotional well-
being, should be more greatly explored. Where possible, any means
of quantifying the impact in terms of cost to the community should be
pursued.
; There appeared to be great inequalities between large and small

organisations in terms of the difficulty of enforcing OHS requirements
on suppliers and contractors. Additional assistance for smaller
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organisations is needed, so they have some level of protection from
the larger organisations using OHS as a means of manipulation for
tenders or as a way of abdicating corporate OHS responsibility.
There appears to be very high levels of risks being taken on by small
family businesses who may not have sufficient access to resources to
treat risks in a more permanent manner and rely heavily on personal
expertise and experience. Whilst this may be effective in the majority
of circumstances, it is still subject to the complexities of human
nature, and the potential for stress, fatigue and “burn out” must be
emphasised. The potential for OHS impacts on the general quality of
life must be more broadly communicated, and where this leads to a
deterioration of well being, this should be more widely perceived as
unacceptable.
; There should be more protection for workers in known high stress

environments so they have more leverage to demand higher OHS
standards without the threat of jeopardizing their careers. This is
particularly the case where these workers are in looser workplace
arrangements such as being hired on a contract basis or as casuals.
The management of organisations needs to be mindful that they are
not indirectly exposing their workers to excessive risk by taking
advantage of those with very caring natures who are more likely to
put the safety of others before themselves; or workers in places
where job opportunities are limited, for example in rural areas.
; It is recommended that all workers develop a clear image of what

they will accept and where the boundaries exist, so that the drive for
safer workplaces comes collectively from the individuals that are
potentially exposed to OHS risks. Support systems to reinforce these
high standards must be dependable, and most of all consistent,
applying to all workers regardless of education levels, social
demographics, gender or ethnicity.
; There needs to be more widespread education on how addressing all

the elements in the Safe Place, Safe Person, Safe Systems
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framework can be used to understand OHS responsibilities and help
achieve due diligence without excessive paper work. Success stories
need to be promoted, especially where this has lead to improved
work environments and greater levels of contentment within the
workplace. The workforce needs good role models in a variety of
industry sectors and organisational sizes.
Hence there are many opportunities to move forward with OHS. The
challenge is for regulatory authorities and educational institutions to
increase the understanding of techniques and strategies available for
managing OHS issues, and to increase the collective OHS consciousness
so that all workers are mindful of OHS values and understand how the
responsibility for OHS relies on a concerted approach with open dialogue,
transparency and continual feedback. It is envisaged that the promotion of
the Safe Place, Safe Person, Safe Systems framework will propel OHS
management into a new era of greater responsiveness built upon
foundations of increased understanding of OHS responsibilities, and a
deeper knowledge of options available for dealing with a wide variety of
potential OHS impacts.
12.2 Future Directions
Directions for future research building upon the themes already explored
in this study include:
investigating the structure of parallel “hierarchy of controls” that relate

more specifically to the three areas: safe place, safe person, safe
systems;
exploring the connection between the need for documentation and

levels of trust between co-workers;
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exploring more fully those elements of an OHS MS that are handled
better with informal techniques, and those that are suited to more
formal methods;
exploring the relationship between the level of OHS dialogue and

stress claims;
comparing the rates of organisational responsiveness in small and

large organisations;
investigating whether there is a need to identify high risk industries

with older technology and outdated processes with known potential
for long term health risks, and whether they should be given set time
frames to change over to inherently safer processes.
identifying and characterising the nature of the interactions between

the elements of the Safe Place, Safe Person, Safe Systems
framework;
indentifying how the current Safe Place, Safe Person, Safe Systems
assessment tool for OHS management can be adapted for use by
multiple assessors to achieve consistency in ratings; and
applying the Safe Place, Safe Person, Safe Systems framework to

identify threads of similarity between organisations with higher and
lower levels of risk reduction.
It can be seen that the Safe Place, Safe Person, Safe Systems framework
has the capacity to open up a whole new area of research with the
potential to uncover the heart of many important OHS issues that have
impeded progress in OHS matters in the past. It is hoped that this
foundation work will be used to enhance the mindfulness of OHS in the
workplace, whether it is in a fixed or variable location, and that this will
ultimately result in not only safer places, safer people and safer systems,
but also safer communities as a whole.
363
12.3. Conclusion
The Safe Place, Safe Person, Safe Systems framework was able to
illustrate a number of barriers to the effective implementation of OHS
management. These included:
organisations that were characterised by excessive bureaucracy and

the pursuit of targets that did not capture the root cause(s) of OHS
problems;
complex structuring within large organisations that resulted in long

time lags for responses to urgent OHS issues;
organisations that did not equip personnel allocated to address OHS

issues with sufficient authority or resources; and
where high volumes of contracting personnel were used in lieu of

permanent staff and this affected the full disclosure of workplace
hazards and increased the difficulty in enforcing designated
prevention and controls.
The use of the Safe Place, Safe Person, Safe Systems framework and the
accompanying Preliminary Report was able to present this information in a
manner that avoided blame and offered practical guidance for a workable
OHS improvement program.
The strong emphasis on the visual representation of data provided high

impact material for managers and a balanced representation of pertinent
OHS issues. The acknowledgement of OHS situations that were handled
well and the potential frustrations that may be encountered whilst
attempting to fulfill health and safety responsibilities served as a catalyst
for increased OHS dialogue. This in itself was a very powerful outcome of
the assessment process and the study as a whole.
The Safe Place, Safe Person, Safe Systems framework was particularly
useful in illuminating OHS concerns that had long term health implications
such as the inappropriate handling and storage of hazardous substances,
364
and the lack of health promotion and health surveillance. The reluctance
observed to confront these issues may have significant long term
implications for the community as a whole, and the public health system.
Unsurprisingly, ergonomic issues featured as areas of high risk exposure

in the study. However, areas of OHS concern related to personal security
also emerged as a significant issue. This supports current research that
has brought attention to the potential for workplace violence and reinforces
the need for improved strategies to deal with the increased use of lone
workers in highly mobile and transient work environments.
The prevalence of high stress work scenarios with unpredictable

combinations of OHS hazards and pressing time constraints has
suggested the more widespread use of dynamic risk assessments. The
Safe Place, Safe Person, Safe Systems framework illustrated this point
well as the hazard profiles for situations of fixed and variable work places
were very different.
The Safe Place, Safe Person, Safe Systems framework was unique in its
assessment of hazards both before and after interventions had been
applied. This had the advantage of pinpointing areas of potential
vulnerability, such as the OHS implications arising from changes in
personnel with long term experience and good situational awareness. The
new framework also drew attention to OHS issues relating to work
organisation and the popular use of longer shifts. The compounding effect
this may have on exposure to hazards such as noise and volatile organic
compounds was highlighted, as was the insidious nature of chronic
exposure to hazards perceived to be of low impact.
The triangulation of the different perspectives offered by operations, the

individual worker and management assisted in the ability to check for
follow through and the perceived effectiveness of actions. This was able to
distinguish very well between those actions that were of token value and
those that were of practical significance.
365
The need to scope the assessments to small areas of homogenous work
activities greatly improved the ease with which the new framework could
be applied. This extended the potential application of the Safe Place, Safe
Person, Safe Systems framework, provided this constraint was observed.
Scoping the assessments to smaller divisions of larger organisations also
served to provide a “test case” for those organisations involved, allowing
them to share lessons learnt with other business units that had similar
contexts and also to pilot improved work practices.
A systematic approach to OHS management was found to be more

connected with a desire to understand OHS responsibilities and address
gaps by searching for the root causes of OHS issues, than the presence
or absence of sophisticated documentation or electronic media. OHS MS
infrastructures that contained intentions that had not been translated into
actual outcomes and were not supported by the provision of sufficient
resources were observed to be mistrusted by workers or simply ignored. In
contrast to this, employees were observed to hold organisations and their
managers in higher regard where the accountability for OHS decisions
was openly embraced by senior management and personnel empowered
to move forward with OHS actions identified. Furthermore, OHS risks were
found to be addressed more successfully where there was a higher level
of trust in the competence of fellow workers and managers.
The Safe Place, Safe Person, Safe Systems framework was therefore
able to demystify OHS responsibilities and obligations and provided a
simplified approach to understanding areas of exposure to OHS hazards
whether they pertain to the physical work environment, the people
involved or management practices. This more holistic approach offers
opportunities to improve the relevance of OHS issues, to acknowledge the
value of people’s experience and open up channels for OHS dialogue so
that higher standards for occupational health and safety can form part of
the community’s collective consciousness.
[[[[[[[[[[
366
Part 7: References
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Part 8: Appendices
393
14. APPENDICES
Appendix 1: Definition of OHS MS Framework

Elements
Safe Place Strategies: Elements and Definition Criteria
Safe Place Element Definition Criteria

Baseline Risk Assessment A general broad based risk assessment has been performed at
some critical point in time from which improvement or decline in
overarching OHS risk presenting to the business may be
measured. It is assumed that all key areas of significant risk have
been considered. Areas requiring specialist expertise (internal or
external) should be identified.
Ergonomic Assessments A specialist risk assessment that examines those issues related
to fitting the task to the human and may be a very broad
category. However, in the context of “safe place strategies” it is
defined here as focusing on the layout of the workstation, manual
handling and examination of repetitive tasks. Such assessments
should be performed by person(s) with the appropriate
qualifications and competencies to do so.
Access/Egress This considers any threats to the quick and efficient entrance or
departure of personnel from the physical workplace. This
includes emergency exit signage, walkways, handrails, stairways
and fire doors. This is particularly important in the case of
emergency situations.
Plant/Equipment This requires that the safety aspects for all existing equipment or
plant have been fully considered. Where this requires specialist
knowledge this must be pursued with the supplier or designer,
and end users and others affected must be consulted and their
opinions duly considered. The hazards of rotating machinery,
pinch points, and crush injuries should be included here, as well
as the safe use of vehicles (including forklifts) and working from
heights. Confined or dangerous spaces should also be identified.
Storage/Handling/ This includes the safe storage, handling and disposal of all
Disposal materials used with the potential to cause harm. This information
may be provided from material safety data sheets or instructions
from the supplier. Specialist advice may be necessary to ensure
any special precautions required with certain materials have
been taken. Safe disposal should form part of a “cradle to the
grave” approach for safety and is sometimes referred to as
product stewardship.
Amenities/Environment This includes consideration of private, hygienic facilities for
personal use such as showers, toilets and change rooms;
provision of drinking water; heating; cooling; refrigerator/
microwave for mealtimes; and infant feeding where the need
exists. Heat stress may also be exacerbated by humidity levels.
Exposure to heat, cold and UV radiation may be particularly
important considerations for outdoor workers. Lighting within the
workplace and exposure to glare should also be considered here,
as should climate control; indoor air quality or the possibility of
working at high or low pressure (for example at high altitude or
underwater).
394
Electrical This considers the potential for electrical hazards including
electric shock from failure to isolate; static electricity; stored
electrical energy, access to high voltage equipment and sparks in
flammable/explosive atmospheres. Where live testing is
necessary, only appropriately trained and qualified personnel
should do so.
Noise Noise levels or noise maps have been documented where the
potential for harm exists, for example if a raised voice is
necessary to hear a conversation. In some cases baseline
audiometry testing will be necessary. Specialist advice should be
sought and attempts to remove the source of the problem should
be the first line of defence. Local regulatory requirements should
be known. Comparison with regulatory limits should take into
account the length of exposure especially if shifts longer than 8
hours are used.
Hazardous Substances All hazardous substances (toxic, irritant) and dangerous goods
(those which are flammable, combustible, corrosive or explosive)
should be identified and a register kept. In some cases this will
be dependent on the quantities or volumes stored. Material
safety data sheets should be available and accessible to all
personnel and language and literacy barriers taken into
consideration at the time this information is disseminated. All
hazardous goods and dangerous substances should be clearly
labelled. Special requirements for transportation, handling and
storage should be observed.
Biohazards Biological hazards include exposure to infection, contagious

diseases, bodily fluids (including blood) or other sources of
protein that may cause an allergic response – for example dust
mites. The source may include food; contact with animals;
plants/pollens; humans; insects; mites; sewerage; fungi or bird
droppings cooling water reservoirs and air conditioning systems
that may contain legionella organisms.
Radiation Sources of radiation may include ionising radiation such as x-

rays and radioactivity; non-ionising radiation such as ultraviolet
rays which may affect the skin or eyes; near infra-red radiation
affecting the eyes; LASER’s; the heating effect from microwaves
and mobile phone towers; and other extremely low frequency
radiation with associated magnetic field exposure such as
powerlines.
Installation/Demolition This includes planning for the safe installation of new buildings or
warehouses as well as the demolition of these structures. The
protection of pedestrians and others in the workplace is crucial
here. Also included is the safe connection or disconnection of
services such as gas, electricity, and telecommunications;
protection from noise, debris or other projectiles; and the
possibility of falling into excavated areas.
Preventive Maintenance/ Programmes exist for the regular maintenance of equipment that
Repairs is essential for the safe running of the operation so that
unplanned breakdowns are avoided. This includes the ordering
of parts and spares to enable the operation to keep in service.
Repair work is carried out in a timely fashion by those that are
qualified and competent to do so.
395
Modifications – Peer This involves the consideration of changes to existing

Review/Commissioning infrastructure and plant/equipment and the impact that this may
have on existing users and others affected. Modifications may be
minor or major, and should be peer reviewed by others with the
appropriate skills and knowledge. Commissioning involves
checking that implemented modifications achieve their aims and
that all safety impacts have in fact been considered before the
project is handed over to the regular users.
Security - Site/Personal Site security ensures that those persons entering the workplace
are authorised to do so and have been informed of any site rules
that are applicable. Personal security involves ensuring that
persons working alone are able to contact help in case of an
emergency (medical or otherwise) and that precautionary
measures have been put in place to reduce threats of bodily
harm. Provisions should also available for removing unauthorised
persons or unwelcome visitors.
Emergency Preparedness Emergency preparedness involves the preparation of

contingency plans to deal with situations such as fire, natural
disasters, explosions, bomb threats, and hostage situations;
vapour clouds, sabotage, medical emergencies and other
unwelcome events. Not only should these potential situations be
identified, but the required actions documented and practiced at
regular intervals. Debriefing sessions should be held after the
drills to identify areas in need of improvement. Emergency
equipment such as fire extinguishers should be regularly checked
and maintained in good working order.
Housekeeping The workplace should be kept in a clean and tidy state to avoid
trips, slips and falls; ensure clear access and egress and to avoid
fire hazards.
Plant Inspections/ Plant and equipment should be inspected regularly to detect as

Monitoring early as possible any malfunctions and monitored to ensure that
the process is operating as it should be within safe limits.
Risk Review A broad based risk assessment that compares the current
situation against a baseline assessment to indicate whether
strategies implemented for risk reduction have been effective.
396
Safe Person Strategies: Elements and Definition Criteria
Safe Person Element Definition Criteria
Equal Opportunity/ Anti- Policies are in place to ensure that all employees and others are
Harassment treated with respect and dignity. There is zero tolerance towards
bullying and diversity is accepted in the workplace. Awareness
programs have ensured that the intention of these policies have
been made clear to employees and management, as well as
educating management on the forms that discrimination or
harassment may take - including more subtle manifestations such
as holding back pay or entitlements; undue delays for provision of
resources; spreading malicious gossip; social exclusion; role
ambiguity; and career stagnation or uncertainty.
Training Needs Analysis The current level of skills and competencies in the workplace has
been assessed to ensure all personnel have the appropriate skills
to fulfil their roles safely and competently. Provisions have been
made to provide employees with new skills as their positions grow
and provide refresher training to their keep skills current.
Inductions- All visitors and contractors to the workplace are made aware of
Contractors/Visitors any hazards that they are likely to encounter and understand how
to take the necessary precautions to avoid any adverse effects.
Information regarding the times of their presence at the workplace
is recorded to allow accounting for all persons should an
emergency situation arise. Entry on site is subject to acceptance
of site safety rules.
Skill Acquisition – (criteria A list of the necessary skills, competencies and traits has been
screening) compiled that are considered necessary to discharge the duties of
the position competently and effectively. Any pre-existing
conditions that may be exacerbated by the role have been
identified to ensure that vulnerable persons are not at risk by
taking the position.
Work Organisation- Fatigue/ The individual arrangement of job tasks that constitute the role
Stress Awareness have been considered to ensure that the work load does not
induce undue fatigue or stress, and the required level of vigilance
is able to be maintained over the work period. Work breaks,
pauses or other rotation of duties have been introduced where
fatigue or stress inducing conditions have been identified. Fatigue
may be of a physical or mental nature.
Accommodating Diversity The workplace promotes an acceptance of diversity whether this

relates to cultural differences such as traditions, religious beliefs,
lifestyle choices, or physical or mental disabilities to eliminate the
potential for causes of psychological harm. Access for disabled
persons and appropriate work environments have been provided,
as well as special provisions in case of an emergency situation.
The special needs of young workers, pregnant or nursing
mothers, and older workers are taken into consideration. Where
workers are known to have a pre-existing psychological condition,
employers take care not to aggravate the condition by placing
such employees into situations where they are at increased
vulnerability.
397
Job Descriptions-Task Job descriptions and daily tasks have been documented so that
Structure the incumbent has a clear idea of the expectations of the role and
whether they are able to fulfil all their obligations. Where a
difference between work expectations and ability to fulfil these
exist, channels should be available to enable fair and equitable
negotiation on behalf of both parties. Skills and authority levels
commensurate with responsibilities allocated.
Training All employees and others affected have been made aware of local
procedures and protocols. Refresher training is provided at
appropriate intervals to maintain skills and provide ongoing
protection from workplace hazards. Competency training has
been scheduled according to the training needs analysis. All
persons conducting training are appropriately qualified to do so.
Training records are maintained. Evidence of competencies is
available.
Behaviour Modification Workplace behaviours are documented to positively reinforce safe

(PPI’s Observation Program) working practices and to discourage unsafe behaviours that may
have become habitual. This may take the form of informal
inspections, unsafe act observation programs or even “mystery
observers”. Each person should be encouraged to recognise
hazards and take suitable precautions - including the
acknowledgement of situations that they are not sufficiently skilled
to deal with whilst also watching out for the safety of their
colleagues.
Health Promotion Healthy lifestyle choices are promoted and an awareness program
exists to educate personnel on these issues. Topics may include
good nutrition, exercise, work-life balance, symptoms of
substance addiction, quit campaigns and home or off-site safety
tips.
Networking, Mentoring, Channels for networking have been established to assist

Further Education performance in positions, especially where there is little on site
help available. On site mentoring or buddy programs have been
established where more experienced personnel are available to
assist new employees adjust to their role and provide ongoing
support. Pursuit of higher order skills and professional
development are encouraged to grow job positions and increase
workplace satisfaction.
Conflict Resolution Mediation channels are available and/or supervisors have

received special training to deal with differences of opinion,
relationship breakdowns or personality clashes before the
situation reaches the point where workplace performance has
been impaired and is noticeable by other colleagues.
Employee Assistance Persons experiencing problems of a personal nature such as the

Programs breakdown of significant relationships, grief, substance abuse, or
other emotional problems may access help in a confidential
environment and receive the necessary support to enable them to
continue their work duties without compromising the safety or
health of others in the workplace.
398
First Aid/Reporting Provisions for first aid are available that meet local regulations
including the numbers of suitably qualified first aiders and
sufficient quantities of first aid materials. Qualifications are kept
current and first aid stocks regularly replenished. A register of
workplace injuries is kept that meets local OHS regulations and
notification of incidents to statutory authorities is observed as
required.
Rehabilitation Provisions are made to assist injured or ill employees returning

back to work without exacerbating their current condition.
Attempts are made to allow them to continue with meaningful
employment where such opportunities exist according to the
following hierarchy – same job/same workplace; modified
job/same workplace; different position/same workplace; similar or
modified position/different workplace; different position/ different
workplace. Return to work programmes exist and a co-ordinator
has been appointed either internally or externally to meet local
OHS regulations. All parties are kept informed of progress and
developments.
Health Surveillance Pre-employment medicals have been undertaken to provide

baseline information on the employee’s current state of health
from which the effectiveness of current control strategies may be
evaluated. Examinations may include lung function tests, blood or
urine samples for biological monitoring, chest x-rays and
audiometric testing. Where known hazardous substances are
present in the workplace, this surveillance may be subject to
compliance with local OHS regulations.
Performance Appraisals Performance appraisals include criteria for safe work practices
and observation of site safety rules, housekeeping, and the
display of safe working attitude. OHS responsibilities should be
commensurate with the level of responsibility and authority
bestowed. Setting good examples for workplace safety should be
encouraged and valued.
Feedback Programs Feedback may take the form of suggestion boxes, perception
surveys (questionnaires to gauge employee attitudes, morale,
and/or perceived effectiveness of safety campaigns), or reward
programs. Consideration is given to the use of variable,
unpredictable reward schedules so that the benefits are
maintained when the reward is removed. Rewards may include
praise, recognition or increased status.
Review of Personnel Turn over rates are reviewed to uncover the root cause for any
Turnover abnormally high levels, such as problems with leadership,
personality conflicts, excessive workloads, unreasonable
deadlines, unpleasant physical working environment and/or work
conditions. Exit interviews are conducted to gather feedback for
improvement where such opportunities present.
399
Safe Systems Strategies: Elements and Definition Criteria
Safe Systems Element Definition Criteria
OHS Policy An OHS policy is in place that conveys management’s intention

and attitude towards safety. It is one expression of
management’s will which may be used to motivate all
employees to behave in a certain way and uphold certain
attitudes. The credibility of the policy is witnessed by the
consistency of management’s actions and responses to daily
situations.
Goal Setting Goals and milestones should be set with sufficient detail to
determine whether OHS issues are improving, unchanged or in
decline. These goals should be consistent with the
organisation’s OHS policy and the goals should be reviewed at
regular intervals. Care should be taken to ensure that goals are
realistic and achievable; specific; measurable; and have been
adequately resourced.
Accountability Accountability for OHS issues has been allocated and there is
sufficient follow through and consequences in place if these are
not met to ensure that these responsibilities are taken seriously.
The accountability should be commensurate with the position,
and the sharing of accountabilities avoided to prevent
responsibility from being diffused.
Due Diligence Review/ A list of projects has been identified that would bring the
Gap Analysis organisation into regulatory compliance, with responsibilities
allocated and time frames for completion identified. The list is
reviewed on a regular basis and demonstrable progress is
evident.
Resource Sufficient resources have been allocated to OHS issues to

Allocation/Administration demonstrate that commitment is real and goals are achievable.
Funds are protected from “reallocation”. Time is available and
sufficient to address OHS issues, and has been budgeted for in
projects and tenders.
Procurement with OHS All new plant, equipment and services have been purchased
Criteria with OHS criteria taken into consideration. End users have been
included in the decision making process. Safety instructions are
available and training on new equipment, plant or services is
provided where necessary for safe operation. Technical or
specialist expertise has been acquired where written
instructions are insufficient or unavailable. There is clear
delineation of the point where new equipment or services have
been accepted and OHS issues resolved.
Supply with OHS All products and services supplied are provided in a safe state
Consideration with OHS criteria taken into consideration to ensure that the
client/customer is not exposed to harm when the products or
services are used according to the suppliers instructions with all
due warnings being heeded.
Competent Supervision Persons that are placed in a position of authority have the
talent/ technical ability, social skills and experience necessary to
do so.
400
Safe Working Procedures Sufficient procedures are in place to enable duties to be

conducted consistently and to document precautions necessary
to perform the job safely. Consideration is given to the level of
detail incorporated so that there is a balance between providing
sufficient information and allowing workers to use their
judgement and experience as necessary, for example where too
stringent or restrictive rules may encourage violations. The
procedures should be regularly reviewed to incorporate
improvements as these become available, and the level of
compliance assessed.
Communication Communication channels are available to facilitate the efficient

flow of information to perform workplace duties in a manner that
is safe and does not induce stress. This may include sufficient
contact with supervisors or colleagues, the provision of
communication equipment such as telephones, internet access,
or radios, access to noticeboards or newsletter, meetings and
other forums for exchange whether they be formal or informal.
Consultation The opinions of employees will be considered and valued with

respect to changes that may affect their health, safety or well-
being. Local OHS regulations regarding the formation of safety
committees are being observed, and the committee chairperson
has undergone appropriate training to fulfil their tasks and
duties. Meetings are conducted on a regular basis with
participation of a management representative with sufficient
authority to take action on items identified as being in need of
corrective action. The minutes of the meetings will be kept in a
secure location and made available to all employees, for
example by being displayed on a noticeboard in a prominent
location. Attempts are made to resolve disputes in-house before
outside authorities are brought in.
Legislative Updates A list of relevant OHS legislation has been complied and access
to these documents has been made available so the
organisation knows what legal obligations exist and has
supporting information such as standards or codes of practice
available for reference. A system is in place to ensure that
updates are received so that the information being acted upon is
always current.
Procedural Updates Procedures are kept current to incorporate lessons learnt and
other improvements as these become available. A means of
removing out of date information is in place so that there is
confidence that only the most current procedures are in use.
Any obsolete information that is kept for archival purposes is
clearly identifiable as being superseded. Training on updated
methods and procedures is provided where the changes are
considered to be significant.
Record Keeping/Archives Records are kept in a safe and secure location, protected from
deterioration and damage by water or fire. The duration for
which the records are kept is in accordance with local OHS
regulations and the confidentiality of health records is enforced
and respected. Regular back ups of electronic data are made
where their loss would have an impact upon the safety and
health of employees.
401
Customer Service – Information is made available to end users to address any

Recall/Hotlines health or safety concerns encountered during the use of the
organisation’s products or services. Procedures are in place to
recall goods or services in a timely manner where a danger or
threat may place end users at risk after purchase.
Incident Management A system is in place to capture information regarding incidents

that have occurred to avoid similar incidents from recurring.
Attempts are made to address underlying causes, whilst also
putting in place actions to enable a quick recovery from the
situation. Root causes are pursued to the point where they are
within the organisations control or influence. Reporting of
incidents is encouraged with a view to improve rather than to
blame. Near miss/ hits are also reported and decisions to
investigate based on likelihood or potential for more serious
consequences. Investigations are carried out by persons with
the appropriate range of knowledge and skills.
Self Assessment Tool A list of questions has been compiled to ensure that outcomes
are being achieved on a regular basis and the key requirements
of OHS procedures are being adhered to. The purpose is to
determine the level of compliance; whether the requirements
are suitable and reasonable; and to ensure that any practical
problems with the daily working of procedures are uncovered
whilst the situation is still recoverable. Self - assessments are
conducted on a frequent basis, for example monthly, and items
are independently spot checked to improve the reliability of the
results.
Audits Formal reviews of measures implemented to ensure that the

prime intention of the procedures is being met and that specific
criterion such as compliance with a regulation, standard or
organisational OHS requirement are addressed. Objective
evidence is available to support the findings. Specialist audits
may be necessary to determine risks in particular areas. The
frequency of audits will depend on the length of time that the
OHS systems have been in place, as established systems will
need less frequent audits than systems that are just being
introduced. The frequency may range from a yearly basis to
once every 3-5 years for specialist audits. Auditors utilised are
suitably qualified and experienced.
System Review A review of all the OHS systems in place to enable the
organisation to fulfil its duty of care to employees and others
affected by its business undertakings. Here the system as a
whole is examined to ensure that it has been set up correctly
and remains suitable in light of any organisational changes or
business acquisitions. Conducted typically on an annual basis.
402
Appendix 2: Study Advertisement
403
Appendix 3: Study Brochure (Tri-fold Pamphlet Side 1)
404
(Tri-fold Pamphlet Side 2)
405
Appendix 4: The Nominal Group Technique
Guidelines as per Delbeqc
The purpose of the nominal group technique (NGT) is to engage in a

creative process that facilitates decision making in situations where there
is a “lack of agreement or incomplete state of knowledge concerning either
the nature of the problem or the components which much be included in
the successful solution.” 384
The NGT takes the format of a structured meeting adhering to the

following guidelines:384
Number of participants: Seven to ten.
Materials needed: Each participant requires writing material.
Group facilitator: Flip chart or whiteboard that prints out information

recorded and a set of five blank cards for each of the participants.
Meeting start: Participants are given information after which there is a

period of silent time allowed for the generation of a private list of ideas.
Round Robin: Each idea is shared, one at a time, and recorded in a

round robin fashion until participants have no further ideas to share. Each
idea is clarified at the time of recording.
Output from meeting: List of ideas - eighteen to twenty-five.
Voting stage: Individuals vote on the five most important ideas. The
participants write down the item number on the upper left hand corner then
write an identifying phrase on the card. Then the facilitator asks the
participants to spread their cards in front of them and identify the most
important one by writing the number 5 in the lower right hand corner,
underlining the number three times. The participants must then turn that
card over and select from the cards remaining and select the one that is
least important and write a number one in the lower right hand corner and
406
underline that three times. The leader then proceeds to ask the group to
select the most important of the next three cards and to give it a ranking
of four; then to select the least important of the remaining two and rank it
as two, and finally to write three on the last remaining card. The facilitator
then collects the all cards, shuffles them and records the results on the flip
chart. A participant can read the results out.
Final outcome: Results are then mathematically pooled. The results may
be discussed if so desired and re-voting may take place if desired.
The essential function of the NGT is to provide a means of unbiased peer

review to enhance the internal validity of the study in terms of its credibility
and trustworthiness. The selection of participants is vital as they must
bring to the process depth of knowledge, and the composition should
reflect sufficient breadth and balance to cover the topic(s) in question.
Advantages over the Delphi technique include the reduced calendar time
to achieve resolution as the Delphi method is an iterative process involving
sending out questionnaires to individual participants. This may cause
significant time lags if there are delays in having the questionnaires
returned. NGT also has the advantage of providing the stimulus of other
ideas to enhance the “brainstorming“ period.
407
Appendix 5: Case Study Protocol
Organisations expressing interest in the study will be contacted and an

appointment time made to discuss with them the details of the project. A
study brochure will be sent out to interested organisations either by mail or
email as ppropriate. All expressions of interest will be responded to.
Those studies being conducted outside the Sydney metropolitan area will
need to bear the costs of travel and accommodation for the period of the
study. Such studies will be conducted over four consecutive days.
During the introductory meeting to determine whether or not the

organisation is still interested in becoming involved, a sample report from
the pilot study will be used to illustrate the process used and what they
may expect to receive. Background material in the front of the report will
be used to explain the concepts behind the study and what the project is
hoping to achieve. An indication of likely amounts of time required for
assessing the hazard profile and effectiveness of current prevention and
control strategies will be given, which will be a minimum of two hours for
each of the three areas – safe place, safe person, safe systems. A similar
period of time will be needed upon arrival so the researcher can become
familiarised with the site and understand the context of the operation. It is
preferable that these assessments are conducted on different days for
short periods to create as little disruption to the organisation as possible.
All efforts will be made to demonstrate flexibility and co-operation with the
organisations as they have been generous enough to offer their time for
the purposes of the study.
All appointment times will be confirmed prior to the day by email or

telephone. Checks to ensure personnel will be available for escorting the
researcher whilst on site will be confirmed.
Prior to commencement of the actual study a brief informal risk

assessment will be made by the researcher to evaluate ;the need for
special precautions to be taken whilst on the site, for example whether
408
there are requirements for personal protective equipment, long sleeved
cotton shirts, safety boots and safety glasses. Also the possibility of
odours, fumes or other potential respiratory irritants will be explored.
Whilst on site, the researcher shall respect any customs and be sensitive
to concerns over confidentiality. The privacy and confidentiality of the
informant shall be respected at all times. No information will be exchanged
about other participants in the study that could give away their identity or
put them at a disadvantage from having participated in this research.
Commercial information obtained from participants for explaining the
operational context will not be used in any reports or other publications
resulting from the research.
Reports will be peer reviewed by the supervisor of the project prior to

review by members of the organisation. Feedback from the review process
will be valued. Final drafts of reports will only be issued once approval
from the organisation has been obtained. The circulation of reports will be
up to the individual organisations.
Where requested, presentation of the study findings to the management of

the organisation or OHS committee will be provided as part of the study.
Any further presentations will be conducted at the organisation’s expense.
There will be no exchange of money or payments in kind for the work

undertaken within the realms of the study. No offers for additional
consulting work will be accepted during the course of the study to ensure
that there is no conflict of interest. Recommendations for assistance with
problems identified will not be made that could be considered a conflict of
interest or that would compromise the neutrality and objectivity of the
researcher.
Participants in the study will be thanked for their co-operation and time at
the end of each meeting. All exchanges of information will be promptly
acknowledged as a matter of courtesy.
409
Areas where best practice was observed will be highlighted to the
participants to provide positive feedback. Permission to share these
experiences in a manner that does not disclose their identity will be
requested. Permission for the use of any verbatim information will be
requested and purposes for which the information will be used shall be
fully disclosed.
The work undertaken in the study will remain as the intellectual property of
the researcher, supervisor and the University of New South Wales.
410
Appendix 6: Hazard Profiling Questionnaire - Without Interventions in Place
Safe Place Risk Factors Observations Overall
Building Block Element Rating
Baseline Risk No Generalised Risk Assessment/ Audit Formally Conducted
Assessment
Significant Risks Not Identified
No Baseline for Improvement Established
Ergonomic Workstations Generate Fatigue / Strain

Assessment
Lifting of Heavy Loads
Repetitive Movements
Twisting/ Bending
Standing/ Sitting for Prolonged Periods
History of Sprains/ Strains/ Back Injury
Access/ Egress Exits Not Identified
No Emergency Lighting for Exit Signs
Access to Fire Doors Restricted
Handrails on Stairways/Walkways Absent
Stairways/ Walkways not Inspected for Clear Access
Minimum Width for Walkways not Observed
Minimum Height for Rails not Observed
411
Plant/Equipment Explosive Powered Tools in Use
Pinch Points Present
Exposed Rotating Parts
Potential for Entrapment
Cranes and Hoists
Working at Heights
Work on Roofs
Confined Spaces
Lifts/ Elevators/ Travelators
Scaffolding
Spray Painting
Grinding Wheels
High Pressure Equipment
Loading Bays
Forklifts
Heavy Transport
412
Storage/Handling/ Dangerous Goods
Disposal
Sharps
Perishable Goods
Goods Unstable when Exposed to Weather
Use of Pallets
Trade Waste Generated
Solid Waste Products Generated
Gaseous Waste
Particulate Waste
413
Amenities/ Exposure to Heat/ Humidity
Environment
Exposure to Cold/Wind
Exposure to UV
Disabled Persons on Site
Pregnant Women/ Nursing Mothers on Site
Poor Lighting/ Glare
Light Spill
Poor Ventilation
Overcrowding
Distractions
Pedestrian Access to Plant Necessary
Roadways on Site
On Site Canteen
Electrical Electrical Equipment/Goods in Use
Repairs to Electrical Equipment Necessary
High Voltage Equipment In Use
Static Electricity Generated
Noise Difficulty in Hearing – Need to Raise Voice to Communicate
Use of Vibrating Equipment
Compressors or other noisy machinery
414
Hazardous Identification of
Substances
Irritants
Dusts
Toxic
Corrosive
Flammables
Combustibles
Asbestos
Biohazards Infectious Diseases
Exposure to Bodily Fluids- Blood/ Urine/ Sewerage
Animals
Parasites
Avian Flu
Allergens
Moulds
Radiation X-Rays
Infra Red
LASERS
Transmitter towers
Radioactivity
415
Installation/ New Equipment Being Purchased, Not Previously Used.
Demolition
New Facilities being Built
Removal of Existing Infrastructure
Preventive Mechanical Integrity/Reliability Critical to Safe Functioning

Maintenance/Repairs
Modifications – Peer Minor or Major Changes Being Made to Existing
Review
Equipment
Commissioning
Facilities
Services
Security - Site/ Lone Workers

Personal
Dangerous Areas if Public were to Gain Access
Valuables/ Cash on Site
Highly Confidential Material
Emergency Potential for Fire

Preparedness
Potential for Explosion
Potential for Bomb Treat
Potential for Hostage Situations/ Kidnapping
Potential for Terrorism
Potential for Flood
Potential for Earthquake
Potential for Storm/Tempest
416
Housekeeping Untidy Premises
Slip/ Trip Hazards
Unlabelled Containers
Unidentified Files/Boxes
Clutter
Spills
Leaks
Equipment Not Returned to Correct Location
Plant Inspections/ No Raw Material Input Measures

Monitoring
No Labour Measures
No Equipment Measures
No Output Measures
Risk Review No Comparison Data
No Measurement of Progress Against Goals
No Plans for Improvement
417
Safe Person Risk Factors Observations Overall
Equal Opportunity/ Presence of Minority Groups
Anti Harassment
Young Workers
Senior Workers
Pregnant Women
Mothers with Babies/ Young Children
Workers with Disabilities
Training Needs Specific Skills are Necessary to Conduct Role Competently and Safely
Analysis
Specific Skills are Necessary but Required Infrequently
Job Stagnation Likely Without Skill Upgrade
Working With Children
Site Specific or Organisation Specific Requirements are Necessary to

Conduct the Role Competently
Inductions – Accompanied Visitor on Site

Contractors/Visitors
Unaccompanied Visitors/ Inspectors from Regulatory Authorities/ Service
Providers on Site
Unaccompanied Contractors On Site
Performers/ Displays or Promotional Activities on Site
Work Experience Students
Public Access
418
Skill Acquisition Job Requirements Could Endanger Vulnerable Persons
(Criteria Screening)
Job Requirements Could Exacerbate Pre-Existing Conditions
Specific Qualifications are Necessary to Perform Role Competently and

Safely
Work Organisation – Shift Work

Fatigue /Stress
Awareness Night Shifts
Long Shifts
Routine Work – Little Variation
Heavy Work Loads
High Level of Responsibility
Frequent Critical Deadlines
Accommodating Workers Cannot Read/Write in National Language

Diversity
Workers Cannot Speak Fluently in National Language
Communication in other Languages Necessary
Presence of Minority Groups
Presence of Special Interest Groups
Job Descriptions – Undocumented Task Requirements

Task Structure
Unclear or Vague Job Expectations
High Frequency of Wilful Violations
Expected Outcomes Not Achieved in General
Expected Outcomes Not Achieved in Specific Areas
419
Training Inexperience
Changed Methods/Protocols
New Job Tasks or Requirements
Behaviour Unsafe Job Habits

Modification
Programs (PPI’s) Little/ No Capital Available for Repairs or Safety Improvements
High Repeat Rates for Sprains/Strains
High Repeat Rate for Slips/Trips
Long Time Lags for Completion of Investigations or Maintenance Jobs
Health Promotion Low Morale
High Absenteeism
Frequent Illness on Site
High Incidence of Working Back/ After Hours
Networking, Isolation from Others in Similar Industry

Mentoring, Further
Education Unaware of Latest Trends/ Best Practice
Significant Length of Time Since Qualifications Obtained
Major Changes in Work Practices Since Qualifications Obtained
Current Role no Longer Challenging
420
Conflict Resolution Personality Clashes
Inflexible Attitudes
Reluctance to Delegate
Rejection of Advice or Guidance
Micromanagement
No Mechanism for Feedback
No Mediation Facilities Available
Employee Assistance High Stress Environment

Programs
Experience of Recent Grief/ Loss
Evidence of Substance Abuse
Single Parent Families
Lack of Support Network
Financial Difficulties
Serious Health Concerns
First Aid/ Reporting Local Regulatory Requirements for First Aid Provision Unknown
Local Legal OHS Reporting Obligations Unknown
Rehabilitation Local Regulatory Requirements for Workers Compensation and Rehabilitation

Program Programmes
Inability to Provide Rehabilitation within Organisation
Micromanagement
Lack of Local Medical Expertise
421
Health Surveillance Use of Substances Identified by Local OHS Regulations for Health
Surveillance
Potential for Hearing Loss
Effectiveness of Current Controls for Known Hazardous Substances

Unestablished
Information on Long Term Health Effects of other Substances in use

Unestablished or Regulated in Other Regions
Performance Lack of Consistency Between Actions and Desired Safety Values

Appraisals
Poor Modelling of Safe Behaviours
Token Compliance with Safety Requirements
Feedback Programs Poor Workplace Morale
Job Dissatisfaction
High Turnover Rates
High Level of Disputes
Work to Rule/ Going Slow
Review of Personnel High Turn Over Rates

Turn Over
Frequent Requests for Transfers
High Stress Environment - Potential for Burn Out
High Level of Litigation
422
Safe System Risk Factors Observations Overall
OHS Policy Multiple Sites
Remote/ Off Site Management
Large Organisation
Lack of Focus/ Direction in OHS
Uncertain Pathway to OHS Improvement
OHS Viewed as an Impediment to Progress
Goal Setting Large OHS Improvements Needed - Potentially Overwhelming
Scarce Resources to Address OHS Issues
Widespread Cynicism Between Workers and Management/

Executive Staff
Accountability Fear of Personal Liability
Persons in Positions of Authority Inexperienced with Finer Details

of the Roles
Insufficient Resources of Capital, Time, or Technical

Competence
Rejection of Safety Vision/ Values
Strong Desire to Transfer Responsibility for OHS Elsewhere
Due Diligence Pathway to Legal Compliance Unknown

Review/ Gap
Analysis Lack of Specialist Expertise
Unwillingness to Become Informed
423
Resource Allocation/ Pending Sale/Transfer of Business
Administration
Regrouping of Business Units
Potential for Safety Funding to be Transferred Elsewhere
Failure to Appreciate Realistic Time/ Resource Needs
Procurement with OHS Criteria Associated with Large Increase in Procurement

OHS Criteria Costs
Isolation or Lack of Communication Between End Users and

those that Process Purchasing Orders
Insufficient Time Lag Allowed to Understand and Take OHS

Criteria into Account for eg. “Urgent Requests”
Supply with OHS Inability to Foresee All End User Applications

Criteria
Potential for Misappropriate Use of Final Product/Service
Competitors Undercutting by not Meeting OHS Criteria
Supply without Knowledge of End User Application
Competent Supervisor Inexperienced or Functioning “Out of Area” of

Supervision Expertise
On the Job Training Versus Formal Qualifications
Supervisor Under-Resourced
Supervisor Over-Loaded
424
Safe Working Methods Passed On, Not Documented
Procedures
Recent Experience of Injury/ Illness During Process
Perceptions of Weakness Associated with Known Safe Practices
Conflict of Interests-Production Pressure to Increase

Rates/Volume of Throughput
Lack of Enforcement
Communication Isolated Work Environments
Noisy Environments
Lack of IT Facilities
Time for Communication Activities not Factored into Daily

Workload
Highly Confidential Material/ Potential for Security Breaches
Disinterest
Consultation Autocratic/ Dictatorial Management Style
Inflexible Plans - Reluctance to Accommodate Changes
Decisions Made Remotely and Expected to Filter Down
Repercussions Expected (Direct or Indirect) for Questioning

Management Decisions or Policy
No Safety Committee on Site
425
Legislative Updates Lack of Funding to Update Reference Material
No Large Corporate Infrastructure to Pool Resources
Strained Relationships with Local OHS Authority
Lack of Knowledge of Available Resources
Procedural Updates Mechanics for Updating are Perceived as Tedious
Numerous Copies in Circulation – not Web-Based.
Superseded Information not Removed From Circulation
Inability to Identify Latest Update – No Date/Revision Number on

Documents
Responsibility for Updating Procedures not Allocated
Record Keeping/ Storage Facilities Not Allocated

Archives
Storage Facilities Not Fire/ Weather Proof
Legal Requirements for Record Keeping Unknown
Responsibility for Record Keeping not Allocated
Recent Moves/ Transfers of Premises
426
Customer Service- History of Customer Complaints
Recall/Hotlines
Extreme Difficulty in Logistics of Recalling Product – Small Time
Lags Between Purchase and Consumption of Goods/Service
No Recall Procedure in Place
No Information Hotline/ Number Available
No Expertise to Handle Queries
High Threat to Reputation/ Public Image if a Recall Occurred
Repercussions Expected (Direct or Indirect) if Recall

Occurred
Incident Management High Repeat Rate for Particular Injury/ Illness Types
“Knee Jerk” Reactions to Individual Incidents
Responses to Previous have been Known to Create Problems

Elsewhere
Reluctance to Report Incidents – Lack of Perceived Value
Personal Repercussions Expected (Direct or Indirect) for

Reporting of Negative Events
Tedious Paperwork Requirements
427
Self Assessment Key Outputs of Current Control/Prevention Strategies Not
Tool Identified
High Level of Non-Compliance with Local Procedures/Protocols
Impractical or Unrealistic Requirements
New Procedures/ Protocols in Place
Potential for Prevention/ Control Strategies to go “Off-Track”

Without Close Monitoring
Areas of Weakness Suspected
Audits OHS MS in “Set-Up” phase
Ability of Current System to Meet Requirements of Standards/

Legal Duties in Question
Adequacy of Current OHS MS to Reflect Local Changes in

Practices/ Structures In Question
System Weakness Suspected
Failure to Deliver Expected Outcomes or Sufficient Levels of

Improvement
System Stagnation
System Review Effectiveness of Current Prevention/ Control Strategies Unknown

or in Question
Use of Outdated Prevention/ Control Methods
Insufficient Resources Currently Allocated for OHS Needs
428
Appendix 7: Assessment of Current Controls against Proposed Safe Place, Safe Person,
Safe Systems Framework
Safe Place Prevention and Control Strategies Observations Overall
Baseline Risk Generalised Risk Assessment Conducted
Assessment
Significant Risks Identified
Priorities for Improvement Established
Ergonomic End User Input Sought

Assessment
User Friendly Workstations
Lifting Devices in Use
Analysis of Work Movements
Specialist Advice Sought where Necessary
Access/Egress Emergency Exits Clear
Fire Doors Clear
Stairways/Walkways/Rails Compliant with Local Regulations
Independent Emergency Exit Lighting
429
Plant/Equipment Restrictions on Use of Specialist or High Pressure Equipment
Machine Guarding
Maintenance Registers for Cranes/ Hoists
Restrictions and Planned Maintenance for Use of Lifts/ Elevators/ Travelators
Training/ Competency Requirements for the use Scaffolding/ Scissor Lifts/

Cherry Pickers/ Fall Arrestors
Restrictions for Access to Roofs
Restrictions on the Use of Ladders
Restricted Access and Identification of Confined Spaces
Spray Painting Booths
Procedures for Use of Grinding Wheels
Vehicle and Driver Checks
Loading Platforms
Transfer Hose/Coupling Checks for Maintenance
Earthing Facilities
Competency Requirements for Forklift Drivers
Speed Limits Enforced
Restricted Pedestrian Access
430
Storage/Handling/ Suitable Dangerous Goods Storage – Segregation, Housing and
Disposal Mass/Volume Restrictions Observed
Sharp Disposal Facilities
Stable Stacking Arrangements
Compliant Trade Waste Connection
EPA Complaint Vents/Flares
Dust Collection/ Removal Devices
Waste Removal Contracts in Place
431
Amenities/ Climate Control
Environment
Protection from Cold/Wind
Sun Protection
Work/Rest Schedules
Disabled Access
Indoor Air Quality Checks
Directional Lighting
Fluorescent Light Diffuser Covers
Even/Smooth Walking Surfaces
Hygienic Areas for Eating/ Food Preparation and Storage
Professional Catering Services
Hygienic Washroom Facilities
Provisions for Nursing Mothers
Privacy-Mail/ Personal Effects
Provision of Recreation/Social Areas
432
Electrical Isolation Procedures
Use of Authorised/ Qualified Repairers
Lead/Cable Checks
Circuit Breakers
Use of Residual Current Detectors
High Voltage Procedures
Static Electricity – Use of Earthing Devices or Non-Conducting Materials
Lightning Protection
Noise Noise Maps Established
Sound Insulation
Use of Sound Absorbing Materials on Walls/Floors
Strategic Layout of Noisy Equipment to Avoid Amplification
Soft Mountings for Vibrating Equipment
Regular Maintenance of Noise Producing Equipment
Use of Hearing Protection
Hazardous Environmental Monitoring

Substances
Personal Monitoring
Biological Monitoring
Hazardous Substances Register/ Inventory
Updated MSDS Available
Application of Hierarchy of Controls
433
Biohazards Vaccination Programs
Universal Precautions
Barrier Methods
Pest Control
Damp Control
Quarantine/ Isolation Procedures
Travel Restrictions
Allergen Awareness –Contingency Plans for Unexpected Exposures
Decontamination Procedures
Radiation Restricted Access
Warnings
Barriers/ Isolation Procedures
Installation/ Specifications Agreed

Demolition
Restricted Access/ Pedestrian Safety
Commissioning Period Defined
Formal Acceptance After Testing/ Suitability Determined
Preventive Planned Maintenance Schedule In Place

Maintenance/Repairs
Qualified/Suitable Repairers
Reporting of Malfunctions
Critical Spare Parts on Site
434
Modifications – Peer Peer Review
Review
Commissioning Commissioning Period
Formal Handover of Changed Equipment/Facilities
Security –Site/ Site Security Checks

Personal
Secure Premises
Communication Equipment Available - Mobile Phones/Pagers
Duress Switches Used
Restricted Access – Intercoms and/or Use of Physical Barriers
Lone Worker Procedures/ Communication Protocols
Emergency Emergency Plans

Preparedness
Plans Regularly Updated
Emergency Assembly Areas Identified
Ready Access to Critical Contacts/ Phone Numbers
Emergency Drills
Debriefing Sessions
Housekeeping Regular Inspections
Checklists/Prompts Available
Reporting Mechanism
435
Plant Inspections/ Key Inputs (Raw Materials) to Process Identified
Monitoring
Key Labour Inputs Identified
Key Equipment Settings/ Identified
Output Measures Identified
Risk Review Comparisons Made Against Baseline Data
Level of Progress Assessed
Areas for Future Improvements Identified
436
Safe Person Prevention and Control Strategies Observations Overall
Equal Opportunity/ Commitment to Equal Opportunity
Anti Harassment Anti-Harassment Policy
Anti -Discrimination Policy
Zero Tolerance of Work Place Bullying
Family Friendly Work Arrangements
Training Needs Skills Inventory Exists

Analysis Job Growth/ Succession Plans in Place and Necessary Skills Identified
Gap Analysis Carried Out Between Skills Required and Skills Present
Provisions Made for the Following:
Awareness Training for Site Specific/ Organisation Specific Procedures
Refresher Training where Updating Skills is Important
Child/Student Protection Training
Skills to Facilitate Succession Plans / Promotions
437
Inductions – Visitor Log
Contractors/Visitors Inductions Available for Visitors
Inductions for Contactors
Site Safety Rules Available
Staff Identification
Contractor Identification
Visitor Identification
Reference/ Record Checks
Clear Directions/ Signage for Visitors and Contractors
Skill Acquisition Pre-employment Selection Criteria Set

(Criteria Screening) Disclosure Required of Pre-Existing Conditions that may be Exacerbated by the
Role
Competency Testing
Aptitude/ Psychology Testing
Reference Checking
Work Organisation – Careful Shift Pattern Selection

Fatigue /Stress Introduction of Work/ Rest Pauses
Awareness
Job Rotation/ Enrichment
Bright Lighting/ Good Air Circulation During Night Shift
Meal Breaks at Regular Times
Authority Commensurate with Responsibility
Opportunities for Employees to Negotiate their Workload
438
Accommodating Literacy Testing (Direct or Indirect)
Diversity Translations Available of Critical Information
Interpreter Facilities
Use of Visual Training Material
Open/ Accepting Workplace Attitude
Respect of Customs/ Traditions
Job Descriptions – Key Tasks Documented

Task Structure Realistic Goals/ Expectations Documented
Regular Feedback on Expectations Obtained from Encumbents
Analyse Role/ Tasks by Breaking it Down into Discrete Steps to Ensure that it
Incorporates OHS Criteria
Training On the Job Training Offered
Training In New Procedures
Training in Changes to Procedures
Qualified Training Personal
Assessment of Learning Outcomes
Evaluation of Training Undertaken
Training Documented/ Recorded
439
Behaviour Safe Workplace Behaviours Identified
Modification Observation Programs in Place
Programs (PPI’s)
Feedback of Results Available
Positive Reinforcement of Desirable Work Practices
Checks to Ensure that Unsafe Behaviours are not being Inadvertently Reinforced
Health Promotion Healthy Lifestyle/ Choices Information Available
Life/ Work Balance Promoted
Off-Site/ Safety at Home Promoted
Guidance to Accessing Specialist Health Services Offered
Recreation Facilities Available
Networking, Opportunities to Network Promoted

Mentoring, Further Opportunities to Attend Conferences Available
Education
Opportunities to Update Qualifications Promoted
Mentors Allocated/ Available
Conflict Resolution Opportunities to Express Concern Available
Opportunities Available to Reconcile Differences
Independent Checking of Work Practices
Grievance Procedures
Appropriate Blend of Personality Types/ Managerial Styles
440
Employee Assistance Provision of Professional and Confidential Employee Assistance
Programs Counselling Skills in-House or Access to Off-Site Counselling
Direction to Specialist Programs Where Necessary
First Aid/ Reporting Compliant First Aid Facilities
Correct Number of Appropriately Qualified First Aiders on Site
Restocking of First Aid Materials Consumed
Sufficiently Detailed and Compliant Records Available
Rehabilitation Rehabilitation Provider Allocated

Program Return To Work Co-ordinator Allocated and Appropriately Trained
Return to Work Policy/ Program
Health Surveillance Baseline and Ongoing Surveillance for the Following as Appropriate:
Personal Monitoring
Environmental Monitoring
Audiometric Testing
Medical Checks/ Screening
Documentation and Record Keeping of Health Surveillance Records
Analysis of Health Surveillance Results and Action Levels Set
441
Performance Safe Working Criteria Included as Part of Job Description
Appraisals Objective Evidence of Safe Work Attitudes
Objective Evidence of Safe Work Practices
Responsibility/Accountability Designated as Appropriate
Feedback Programs Suggestion Boxes
Evaluation Material
Perception Surveys
Notice Boards
News Letters/ E-Letters
Review of Personnel Exit Interviews Conducted

Turn Over Reasons for Turn-Over Identified
Opportunities to Reduce Turn-Over Considered
442
Safe Systems Prevention and Control Strategies Observations Overall
OHS Policy OHS Policy or OHS Values and Vision Statement
Evidence of OHS Policy in Practice Available
Communication of OHS Policy to Interested Parties
Review of OHS Policy to Reflect Current Issues
Consistency Between Management Actions and Policy Statement
Goal Setting Breakdown of Larger Goals into Manageable Proportions

Use of “SMART” Criteria –Specific, Measurable, Achievable, Realistic
and Timely
Regular Review of Progress Against Set Targets
Communication of Results
Accountability Accountability Allocated to those with the Competence, Authority and

Resources to Manage Roles Effectively
Selection of Accountable Personnel Willing and Confident to Take on
Responsibility
Team Spirit – Everyone is Responsible for Safety in Some Way
Co-Operation Between Business Units, OHS Responsibility Not Isolated,
but Integrated
Due Diligence Review/ Due Diligence Plan Completed

Gap Analysis Projects Resourced and Resources Secure
Time Lines Agreed Upon
Progress Regularly Reviewed
443
Resource Allocation/ Management Commitment to OHS Projects and Ongoing OHS Needs
Administration
Protection of Funds Allocated to OHS Causes
Provision of Sufficient Time to Fulfil OHS Requirements
Provision of Necessary Expertise (In-house or External)
Regular Review of OHS Expenditure
Resources Allocated to Cover Critical Absences
Procurement with OHS General OHS Criteria Incorporated into Purchases

Criteria
Specific OHS Criteria Considered Prior to Selection of Purchased
Goods/ Services After End User Consultation
Consideration of OHS Criteria Included in Capital Expenditure Approvals
Supply with OHS Criteria Goods /Services Supplied with OHS Criteria Taken into Consideration
Instructions Supplied for Safe Use Where Applicable
MSDS Sheets Supplied for Hazardous Materials
Competent Supervision Supervisors with Appropriate Experience and Competence Allocated
Supervisors Allocated Realistic Numbers to Supervise – Able to Give

Adequate Attention
Authentic Leadership by Example/ Consistency
Safe Working Documented Safe Working Procedures with Sufficient Detail to Perform
Procedures the Task Safely
Training on Safe Working Procedures
Method for Alerting of Changes to Procedures
Education/ Awareness of Hierarchy of Controls
444
Communication Use of Newsletters, E-Letters, Noticeboards, Posters
Access to IT Equipment/ Telecommunications
Awareness/ Motivation Campaigns
Security Measures for Access to Confidential Material
Up to Date Phone and/or Email Directories
Meetings one on one with teams
Consultation Site Safety Committee
Valuing of Employee Opinions
Forum Established to Make Pending Changes Known Before

Implementation
Period of Time Set to Consider Comment or Feedback on Proposed

Changes
Transparent Decision Making Process
Legislative Updates Access to Update Alerts
Subscription to Updating Service
Mechanism to Distribute Updates
Removal of Superseded Information
Impact of Changes Assessed and Necessary Actions Implemented
Procedural Updates Mechanism to Trigger Updating from Procedure Authors
Mechanism to Distribute Updates
Removal of Superseded Information
Training on Procedural Changes Implemented/ Recorded
445
Record Keeping/ Secure, Fireproof, Weatherproof Storage Facilities
Archives
Time Periods for Keeping Documents Identified and Recorded
Confidentiality Procedures in Place
Regular Back Up/ Archiving
Records Maintained
Compliance with Identified Time Periods for Archiving Records
Customer Service- Recall Procedure in Place

Recall/Hotlines
Hotline/ Customer Service Number Established
Appropriate Technical Expertise Available to Handle Queries
Quarantine Facilities Available if Appropriate
Official Communications Channels Established
Debriefing Mechanism Established
446
Incident Management Injury/ Illness Recording
Legislative Compliance
Near Miss/ Hit / Unusual Incident Recording
Incident Screening
Quick Recovery - Stop Gap Measures
Root Cause Analysis
Corrective Action Against Root Cause(s)
Evaluation of Effectiveness of Measures
De - identified Reporting
Database for Records
Trend Analysis
Critical Incident Plan
Self Assessment Tool Self Assessment Questionnaire Compiled
Areas Requiring Special Attention Targeted
Regular Interval Set for Use
Independent Spot Checking of Results
Feedback and Evaluation of Results
447
Audits Competent Auditors Selected Qualified and Experienced
Auditing Guidelines/ Questionnaire/ Standards Identified
Purpose of Audit Clear – System Validation or Verification
Objective Evidence Recorded
Reports Circulated within Reasonable Timeframe
Recommendations Evaluated
and Decisions to Accept or Reject Suggestions Recorded
Progress Against Agreed Actions Monitored
System Review Collation of Broad Range of OHS Measures including Monitoring

Information; Results of Medical Surveillance; Perception Surveys; Injury
and Illness Statistics; Self Assessments; and Audits Reports
Analysis of Data/ Results
Suitability of Current System Evaluated
Recommendations Formulated & Documented
Actions/ Pathways/ Best Practice Considered
Improvements/ New Directions Implemented
448
Appendix 8: Performance Measurement Indicator Guidelines
Measurement Strengths Limitations Links with Suggested Building Blocks
Baseline risk assessment
LTI’s Links to Workers’ Compensation Subject to manipulation
Ergonomic assessments
premiums may provide a financial
May encourage under-reporting Access/Egress
incentive to embark on OHS programs
Plant/Equipment
Site comparisons may cause “sibling Storage Handling Disposal
High rates indicate serious problems –
rivalry” Electrical
necessary information on outcomes
Easy to become emotionally detached Noise
May be used for benchmarking Hazardous Substances
from figures
purposes over business units and Biohazards
multiple sites Radiation
Modifications/ Peer Review
Housekeeping
Plant inspections/ Monitoring
Security Site/Personal
Risk Review
Inductions-Contractors/ Visitors
Work Organisation- fatigue and stress
Skill Acquisition -Criteria Screening
Job Descriptions –Task Structure
Training
Rehabilitation
Health Surveillance
Procedural Updates
Communication
Consultation
Incident Management
449
MTI’s/ First Aid Injuries Numbers are meaningful May be subject to manipulation/ under- As for LTI’s
reporting if linked to reward schemes
Trends and patterns may be analysed
Negative, high numbers may lower morale
Provides information for investigation
and problem solving
Realistic – necessary information
Outcome indicators allow progress to
be evaluated
Near Misses/Hits Provides data for preventive action and Decisions to report may be subject to As for LTI’s as well as:
opportunities for learning politics and safety culture
Behaviour Modification (PPI’S/
Indicates good intentions and the Reluctance to report may lead to Observation Programmes)
desire for improved performance inconsistencies if comparisons are used
Feedback Programs
May “overload” the system
Record Keeping / Archives
Due Diligence Plan/ Provides critical information Time lines for actions may be continually OHS Policy
Gap Analysis extended
Demonstrates due diligence and good Goal Setting
corporate citizenship Responsibility for action items must be
Accountability
clear
Due Diligence/Gap Analysis
Legislative Updates
Audits
System Review
450
Unsafe/ Safe Act Focuses attention on critical safe May be seen as “blaming the worker” or Baseline Risk Assessments
Observations behaviours an abdication of employer responsibility if
used inappropriately
Encourages awareness and
Plant/ Equipment
responsibility of own actions May break down trust if co-workers report
on each other and anonymity is not Storage Handling Disposal
Fosters an attitude of care for
respected
colleagues Amenities/ Environment
Could be exploited to divert funding from
May teach workers how to “read” their Housekeeping
projects to improve the physical
environment
environment and infrastructure Job Descriptions/ Task Structure
Behavioural Modification (PPI’s
Observation Programs)
Networking, Mentoring, Further education
Control Charts Focuses attention Plotting is more complicated Plant/Equipment

Provides information about system May become lost in the numbers if the Plant Inspections/ Monitoring
capability strategic purpose is downplayed
Trends may be used to initiate changes
Positive Performance Provides information about the May be subject to manipulation Job descriptions/ Task Structure
Indicators (PPI’s) processes that are used to achieve
Too many become onerous Behavioural Modification (PPI’s
targets
/Observation Programs)
Impact may wear off over time, may need
“Tin openers “ may be used
to be rotated Feedback Programs
strategically to target areas that are in
need of improvement Only useful if the results lead to action Performance Appraisals
Offers the opportunity to have small Communication
victories – may boost morale
Consultation
Audit
451
Perception Surveys Spotlights areas of concern Individual results generally do lend not Equal Opportunity/ Anti-harassment
themselves to wider extrapolation
Informal surveys are easy to construct Training Needs Analysis
Generally “self reports” may be biased
Rich source of information not captured Job descriptions/ Task Structure
towards providing desirable answers
by other methods about the particular
unless anonymity is protected Training
site/organisation surveyed
May generate cynicism if surveys do not Skill Acquisition (criteria screening)
May be useful for meta - analysis of
result in action
common themes Accommodating Diversity
Demonstrates employees feedback is Health Promotion
valued
Networking, Mentoring, Further Education
Conflict Resolution
Rehabilitation
Review of Absenteeism/ Turn Over
OHS Policy
Goal Setting
Accountability
Legislative Updates
Procedural Updates
Communication
Consultation
Audits
System Review
452
Audits Highlights strengths and weaknesses Audit tool must accurately reflect the Baseline Risk Assessment
of the system hazard profile to avoid giving a false
sense of security
Attracts management’s attention
Plant/Equipment
Auditors may lack of local process
Encourages system users to learn
knowledge necessary to detect flaws Storage Handling Disposal
requirements and become aware of
responsibilities Recommendations may not be accepted Electrical
and actioned
Preparation for audits provides an Noise
opportunity to tidy up loose ends and May be used for political purposes
bring documentation up to date Hazardous Substances
Expensive and time consuming
Objectivity when independent auditors Biohazards
Fear of self-incrimination if
used Radiation
recommendations are not actioned
Excellent for determining system faults Installation/Demolition
Infrequent – potential for systems to off
or whether system incorporates system
track if there are large time lags between Preventive Maintenance Repairs
changes if audited against the
audits
appropriate criteria Modifications- Peer Review
Vigorous Emergency Preparedness
Documented Housekeeping
Follow through demonstrates due Plant Inspections/ Monitoring
diligence
Risk Review
OHS Policy
Goal Setting
Accountability
Due Diligence Reviews/Gap Analysis
Self Assessment Tools
Audits
System Review
453
Controlled Self Assessments When performed on a regular basis Lack of objectivity if independent spot Baseline Risk Assessment
ensures that documentation is updated checks not conducted Ergonomic Assessment
consistently
Requires follow through Electrical
Forms good habits
Value depends on quality and reliability of Noise
Higher frequency of checks – less parameters used Hazardous Substances
likelihood of system going off track
Biohazards
Good for monitoring compliance – poor
compliance may indicate weaknesses Radiation
in system construction Installations/Demolitions
Performed in-house, more incentive for Preventive Maintenance/ Repairs
full and frank disclosure Modifications/ Peer Review
Instils process ownership and clears up Storage Handling Disposal
lines of responsibility Housekeeping
Opens communication channels with Emergency Preparedness
upper management
Plant inspections/ Monitoring
Risk Review
Equal Opportunity/ Anti Harassment
Inductions – Contractors/ Visitors
Behaviour Modification (PPI’s Observation
Programs)
OHS Policy
Goal Setting
Accountability
Due Diligence Reviews/Gap Analysis
Performance Appraisal
Self Assessment Tools
Audits
System Review
454
Turn Over Rates Subtle Confounding factors may overstate or Amenities/ Environment
misrepresent information
May indicate psycho-social or work- Equal Opportunity/ Anti-Harassment
organisation hazards
Skill Acquisition – Criteria screening
May provide a source of financial
incentive for program improvements
Health Promotion
Conflict Resolution
Feedback Programs
OHS Policy
Accountability
Communication
Consultation
Customer Service – Recall/Hotlines
455
Helpful to draw attention to Descriptors may be negative and cynical Amenities/ Environment
Maturity Grid/ Models
organisational safety culture and safety – potentially discouraging and may “stick” Emergency Preparedness
values Equal Opportunity/ Anti-Harassment
Vagueness - descriptors need to be
May promote changes in attitudes customised for individual applications so Health Promotion
towards problem solving the actual pathway to improvement is Conflict Resolution
evident
May encourage strategic thinking Employee Assistance Programs
Subjectivity of measurement – difficult for Feedback Programs
On an organisational level, descriptors
cross comparisons
may be used to reflect visions and OHS Policy
stepwise improvements The scope of application of the descriptor
Accountability
should be defined to prevent unfair
May be useful in aligning goals and Resource Allocation/ Administration
generalisations being made.
working towards a common purpose
Supply with OHS Criteria
Communication
Consultation
Customer Service Recall/ Hotlines
Incident Management
Audits
System Reviews
456
Appendix 9: Guidelines for the Targeted Selection
of Three Building Blocks for Improvement
Using the Hazard Profiling Questionnaire in Appendix 5, tick selected

prompts as applicable. In the Observations column include any evidence
that may suggest that the particular building block element presents a
hazard to the organisation. These entries may be based on interviewing
personnel, viewing documentation or witnessing practices. Where possible
the evidence should be as objective as possible, with supporting
documentation or verification provided. “Hearsay” should be excluded.
Finally a rating for the risk presented by the particular OHS Building Block
Element (without the controls in place) should be allocated.
Using the Questionnaire for the Assessment of Current Controls against

Building Block Model in Appendix 6, tick the prompts as appropriate in the
column for prevention and control strategies. Where suggested strategies
are not applicable, these should be struck out. Where other controls or
prevention techniques have been used to minimise the risk, these should
be recorded in the observations column. Again, this should be based on
interviewing personnel, viewing documentation or witnessing practices.
Where possible the evidence should be as objective as possible, with
supporting documentation or verification provided. An action rating of high,
medium high, medium, low, non-applicable or area of excellence for the
effectiveness of prevention and control strategies should be allocated
based upon the presence of individual risk factors identified in Appendix 5.
Guidelines for the allocation of rating should be based upon the principles
given in the CCH email article: New approaches to OHS risk assessments:
Expanding traditional models for better managing OHS risks by Chris
Winder and Anne-Marie Makin (10/10/2006).
After the two questionnaires have been completed, the results for the
overall ratings have the allocated, the results should be reviewed for
comment by the organisation and their response recorded. Areas of
457
disagreement should be resolved before the results are made available
more broadly.
Based on the results, the organisation should be requested to pick three

areas that could benefit from improvement of the current prevention and
control strategies. The organisation then needs to decide what additional
prevention and control measures they wish to employ. Based on the
guidelines offered in Appendix 7 on Performance Measurement Indicator
Guidelines, the organisation will also need to decide how they will
measure whether their additional prevention/control measures have been
effective. The selected building block elements and corresponding
performance measurement indicators will be recorded.
Finally, the organisation will be asked to create a controlled self

assessment that will be used once a month, for four months, based on
expected outcomes or outputs from the three areas of improved
prevention and control strategies. The assessment will require that three
statements are made about each of these areas. These statements should
be phrased so that the desirable outcome is answered by yes; the
undesirable outcome is answered by no. Where a no response has been
entered, a comment should be entered to explain why.
At the end of the four month period, the Follow - Up Evaluation

(Appendix 10) should be completed by the organisation to assess whether
the techniques used in the study where considered beneficial and to
provide feedback and suggestions for improvements in future studies.
458
Appendix 10: Example of the Pro-Forma for the Customised Self -Assessment Tool
Item Item
Controlled Self-Assessment Answer Comments
No. Owner
1 JB Example Statement: Yes Instructions: Where no has been selected please include an explanation
Minutes of the last SHE Committee meeting have No

been circulated and displayed in a prominent location.
2 MJ Example Statement: Yes
All injuries have been recorded and investigated for No

the month
3 AN Example Statement: Yes
Housekeeping inspections have taken place and No

problems have been recorded and rectified.
4 MB Example Statement: Yes
All new employees have received induction training No

within a month of start-up.
459
Appendix 11:Follow-Up Evaluation
Question 1: What was the most valuable component of the exercise?
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Question 2: What component of the exercise did you like the least?
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Question 3: Was this study of benefit to your organisation? Would you recommend this
type of study to another organisation and why or why not?
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Question 4: What do you think are the 5 most important elements of an OHS Management
System? Please give your answer rankings from 1 to 5 with 1 being the most important.
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Question 5: Will this study change any local customs or practices in the future?
…………………………………………………………………………………………………………
………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Thank you for your valuable time and effort in participating in this
study
Appendix 12: Pilot Case Study Report
461
Summary
A framework of 57 OHS related elements was developed to assess the
safe person, safe place and safe systems components of organisational
OHS systems. The framework was used at your company to assess its
OHS management system.
A pilot study trialling the application of this framework was conducted at

your company (a flexible film manufacturer) between March and April
2007. This study found:
; of the 57 elements in the framework, 56 were applicable to your site;
; of these 56 elements applicable, your company had addressed 5 with

formal systems and another 36 elements informally. The informal
approach implies less documentation, is working well in most cases,
but may present difficulties should any litigation, claims or disputes
arise or should there be a change of key personnel.
; the hazard profile of your company suggests that your most

significant risks are with the hardware and operating environment
area, followed by management strategies and methodology. These
suggest the need for more specialised risk assessments and the
allocation of greater capital investment. Provision of sufficient time to
address these issues is crucial.
; the preferred prevention and controls strategies in your company

involve safe person methods. These rely heavily on personal
expertise, skills and judgement. These can be vulnerable to changes
in key personnel.
Your company has very successfully addressed the elements of

Inductions for visitors and contractors; Employee Assistance Programs;
First Aid/Reporting; and Consultation. Elements that are still in need of
attention include: Emergency Preparedness; Noise and Hazardous
Substances. Your current prevention and control methods have made a
significant impact on your overall risk ranking, so you are strongly
encouraged to continue your improvement efforts.
462
Background
Traditionally there are four methods for dealing with organisational risks:
eliminate the risk,
retain and manage the risk,
transfer the risk, which may involve outsourcing, contracting or the
like, or
minimising the financial impact through insurance or compensation.
Risks that have been eliminated are relatively easy to handle, providing
that elimination has really occurred. Risks that are transferred are also
operationally easy, provided that suitable safeguards check the nature,
suitability and viability of the transfer option. Difficulties are most
commonly encountered when there has been a decision to retain and
manage the risk in-house. Typically this has been managed through the
application of the traditional hierarchy of controls, involving:
elimination
substitution
isolation
engineering controls
administrative controls, and finally
personal protective equipment.
While this model has become formalised by most OHS authorities, it does
not deal effectively with the entire range of hazards and risks that currently
confront employers. After years of focusing on establishing a safe place
(which is certainly not without merit), other psychosocial and
organisational hazards are emerging as formidable issues to be
contended with. The current risk assessment and control model is
problematic for such risks. Expanded tools are becoming necessary to
accommodate the changing landscape of workplace hazards and risks.
The strategies in Table 1 are suggested to provide a greater range of risk
control options.
Table 1: Guidance on Risk Reduction Strategies
Descriptor Description Examples
Designing out with peer review and end user input,

At the facility
Safe place substitution, engineering controls — isolation and barriers,
and hardware
strategies ergonomic interventions, signage, inspections and
level
monitoring.
Equal opportunity/anti-harassment policies, employee

selection criteria, training needs analysis, education and
Safe person At the training, behaviour modification, employee assistance
strategies individual level programs, health promotion, health surveillance, PPE,
rehabilitation, perception surveys and feedback programs,
performance appraisal.
Clear lines of responsibility, due diligence reviews,

Safe resource allocation, defining OHS requirements up front,
At the
systems consultation and communication, competent supervision,
managerial and
strategies methods to ensure access to latest information regarding
operational
both legislation and local procedures, measurements and
level
monitoring in place, self assessment, internal audit and
system reviews.
Although it is generally considered that hazards of the physical working

environment should be addressed first, this may not be appropriate for
organisations where the workplace is not fixed (for example when
employees work off-site) or for cases where high levels of skill are
necessary (for example where advice is offered such as engineering
design work) and the duty of care extends mostly to “others” affected by
the business undertakings rather than direct employees. In these cases,
having the appropriate skills is crucial. If not conducted competently, the
potential for harm generated by employee activities may be greater than
the possibility of harm arising from within their physical working
environment.
Similarly, on an organisational level it is better to identify OHS criteria for

any planned acquisitions or undertakings, new developments or workplace
modifications rather than to deal with the consequences of any
subsequent harm caused. The use of consultative mechanisms should be
acknowledged as a primary preventive strategy for ameliorating
managerial hazards. Genuine management commitment to OHS values
464
and sincere equal opportunity and anti-harassment policies may be just as
effective on a psychosocial and managerial level as “designing out”
hazards of the physical environment.
As a general guideline, risk control strategies dealing with the conceptual,

design, or planning conceptual stages should always be considered as a
higher order control activities. The order of preference within each of these
three areas depends on whether they are planning, implementation,
measurement or review activities, as for the classic management (or
Deming) “Plan Do Check Improve” cycle. Planning activities represent
higher order strategies than implementation activities, and these in turn
rate higher than measurement or monitoring activities. Contingency
measures that address hazards when risk control plans have failed are
also necessary, even if the need to invoke these actions is undesirable.
It can be seen that many of the possible risk control options form part of
the building blocks of occupational health and safety management
systems (OHS MS), such as operational controls, emergency response or
injury management.
The strategic application of OHS MS building blocks may form a

comprehensive OHS risk defense system, the ultimate objective of the risk
management process. The safe organisation of the future will therefore
assume a more holistic, integrated approach to safety and health,
ensuring the effective coverage of physical, psychosocial and managerial
hazards.
This integrated approach may unfold by default, simply by considering a

wider context of potential hazards. This, combined with other
developments, such as making risk assessments accessible and visible
documents, training on problem solving skills and educating employers on
the use of long term strategies such as safe design and supply, will
resurrect the practical application of the risk management process and
ensure its ongoing value to OHS management in modern organisations.
465
Summary Results
Framework charts
Framework Chart 1: Final Control and Prevention Strategies in Place

Equal Opportunity/ Anti-
Harassment
Access/ Egress Accountability
Visitors
Due Diligence Review/ Gap
Plant/ Equipment Selection Criteria
Analysis
Amenities/ Environment Accommodating Diversity
Criteria
Electrical
Hazardous Substances (PPI’s Observation Safe Working Procedures
Programs)
Further Education
Installations/ Demolition Conflict Resolution Legislative Updates
Preventive Maintenance/ Employee Assistance

Procedural Updates
Repairs Programs
First Aid/ Reporting Record Keeping/ Archives
Commissioning
Customer Service –
Security – Site /Personal Rehabilitation
Recall/Hotlines
Plant Inspections/
Feedback Programs Audits
monitoring
Review of Personnel
Turnover
Priority Key for Effectiveness of Prevention and Control Strategies
High Risk Medium Risk Not Applicable
Medium-High Risk Low Risk Well done
466
Framework Chart 2: Initial Hazard Profile (No Interventions/Strategies)

Harassment
Visitors
Analysis
Amenities/ Environment Accommodating Diversity
Criteria
Electrical
(PPI’s Observation
P )
Further Education

Procedural Updates
Repairs Programs
Commissioning
Recall/Hotlines
Plant Inspections/
monitoring
Review of Personnel
Turnover
Priority Key for Hazard Profile Without Controls in Place
467
Framework Chart 3: Initial Profile (Interventions/Strategies in Place)

Harassment
Visitors
Analysis
Amenities/ Environment Accommodating Diversity Procurement with OHS Criteria

Electrical Supply with OHS consideration
Structure
(PPI’s and Observation
Further Education

Procedural Updates
Repairs Programs
Modifications – Peer
Review/ Commissioning
Recall/Hotlines
Plant Inspections/
monitoring
Review of Personnel
Turnover
Key for Formal (Documented) and Informal (ad hoc) Control Strategies
Formal Not Applicable
Informal Not Present at all l done
468
Analysis of Initial and Final Scores
Figures 1-3 show results of assessment of Safe People, Safe Place and
Safe Systems, scores, both before and after control strategies and
interventions hade been implemented. Where the differential between
before and after is large, the controls have made a significant impact.
Figure 1: Initial and Final Scores- Safe Place
Noise
Risk Review
Modifications - Peer Review/ Commissioning
Housekeeping
.
Storage/ Handling /Disposal
Plant/ Equipment
Access/Egress
Radiation
Biohazards
Electrical
0 1 2 3 4
Before
After
Risk Ranking Scores

4 3 2 1 0
Medium-High
High Risk Medium Risk Low Risk Well done
Risk
469
Figure 2: Initial and Final Scores- Safe Person
Training
Inductions
Feedback Programs
Health Surveillance
Rehabilitation
Job Descriptions-Task Structure
Accomodating Diversity
Work Organisation
Selection Criteria
Conflict Resolution
Equal Opportunity
Networking,etc
Health Promotion
0 1 2 3 4
After Before
Risk Ranking Scores

4 3 2 1 0
Medium-High
Risk
470
Figure 3: Initial and Final Scores – Safe Systems
Self-Assessment Tool
Incident Management
Consultation
System Rewiew
Audits
Legislative Updates
Communication
Accountability
Goal Setting
OHS Policy
Procedural Updates
0 1 2 3 4
Before
After
Risk Ranking Scores

4 3 2 1 0
Medium-High
Risk
471
Analysis of Hazard Profile Ratings
Figure 4 illustrates the hazard profile of the organisation before prevention
and control strategies are applied by taking the original hazard profile
assessment, allocating a weighting of 4 = high; 3 = medium high; 2 =
medium; 1 = low; 0 = well done; and distributing the total score across the
three main areas where hazards may arise. In this case, it may be seen
that the physical hardware and operating environment contain the majority
of hazards, closely followed by the lack of systems applied by
management.
Figure 4: Hazard Profile Rating - No Interventions and Strategies
Systems Place
People
Figure 5 demonstrates how safe person strategies have been used in

preference to risk assessment and systems management to reduce the
overall risk rating of the operation.
Figure 5: Hazard Profile Rating – No Interventions and Strategies
Systems Place
People
472
Pilot Study Main Findings - Element by Element
Safe Place Element Definition Criteria, Critical Risks and Actions Required
Baseline Risk A general broad based risk assessment has been performed at some critical point in time from which improvement or decline in
Assessment overall OHS risk presenting to the organisation may be measured. It is assumed that all key areas of significant risk have been
documented. Areas requiring specialist expertise (internal or external) should be identified.
The risk is that the organisation does not know what OHS issues need to be addressed or how urgent they are so resources can not
be allocated effectively according to priorities, and the response will be reactive only.
Documentation is needed in this area. Results need to be communicated to those with the authority and means to make
the necessary changes.
Ergonomic Assessments A specialised risk assessment that is concerned with fitting the task to the human and may cover a very broad range of issues
including manual handling, work organisation, task or job design, human error and problems with information processing as well as
industrial hygiene. However, in the context of “safe place strategies” the scope is limited here to focusing on the layout of the
workstation, manual handling and examination of repetitive tasks. Such assessments should be performed by person(s) with the
appropriate qualifications and competencies to do so.
The risk is that an employee will sustain a strain/sprain injury or cumulative trauma. Whilst the injury may not be fatal, it may be very
debilitating and result in significant periods of lost time, increased workers’ compensation costs and the injured worker may not be
able to return to the same type of employment.
Manual handling assessments needed in this area. Results need to be communicated to those with the authority and
means to make the necessary changes.
473
Access/ Egress This considers the quick and efficient entrance or departure of personnel to and from the physical workplace. This includes
emergency exit signage, walkways, handrails, stairways, fire doors and alternate exits. This is particularly important in the case of
emergency situations.
The risk is that someone may be unable to escape in an emergency situation or may be injured whilst trying to access or depart
from their workplace.
A higher level of vigilance would improve this result.

Plant/ Equipment This requires that all existing equipment or plant operates without causing harm. Where this requires specialist knowledge this must
be pursued with the supplier or designer, and end users and others affected must be consulted and their opinions duly considered.
The hazards of rotating machinery, pinch points, and crush injuries should be included here, as well as the safe use of vehicles
(including forklifts) and working from heights. Confined or dangerous spaces should also be identified.
The risk is that someone could be crushed, cut, impaled, hit or entrapped by the machinery.
Capital injection and some engineering solutions required. Once the necessary information is collected it needs to be
communicated and acted upon.
Storage/ Handling / All materials should be stored, handled and disposed in a manner that does not cause harm – whether this is of an immediate
Disposal nature or in the long term as a result of occupationally induced illness. Material safety data sheets or instructions from the supplier
will provide key inputs necessary to achieve safe outcomes and additional specialist advice may be necessary. Responsibility for
safe disposal should form part of a “cradle to the grave” approach and is sometimes referred to as product stewardship.
The critical risk is that inappropriate handling/storage/disposal causes a fire/explosion/injury or occupationally induced illness.
Directions on MSDS’s need to be communicated, adhered to and readily available at the point of use.
474
Amenities/ Environment Pertaining to a comfortable work environment this includes private, hygienic facilities such as toilets and change rooms; provision of
drinking water; heating; cooling; refrigerator/ microwave for mealtimes; and infant feeding facilities and showers where the need
exists. Heat stress may also be exacerbated by humidity levels. Exposure to heat and cold may be particularly important
considerations for outdoor workers. (See radiation for UV exposure). The special needs for divers or air cabin crew should also be
considered where applicable. Lighting within the workplace and exposure to glare should also be considered here, as should climate
control and indoor air quality. Smoking is banned from the workplace, and there are designated, outdoor areas with good natural
ventilation and away from fire hazards, for those who have a habit.
The risk is that an uncomfortable work environment will affect their judgement or well-being which may place them at greater risk of
other injuries or illnesses or impair their performance and put others at risk.
Hot working conditions in summer are likely to induce fatigue; Cold winter conditions are likely to increase the risk of
sprain/strain injuries. Outdoor smokers need to consider the flammability issues associated with solvents and drains.
Better lighting may also reduce fatigue during later shifts and allow greater attention to fine details.
Electrical All electrical equipment should be handled appropriately by those who are suitably qualified and kept in good working order. Other
electrical hazards include electric shock; static electricity; stored electrical energy, the increased dangers of high voltage equipment
and the potential for sparks in flammable/explosive atmospheres. Where live testing is necessary, only appropriately trained and
qualified personnel should do so.
The risk is that someone may be fatally electrocuted or cause a fire/explosion by creating sparks in a flammable or explosive
atmosphere.
High inherent risk but well controlled by high level of expertise. Better documentation would improve this result.
Noise Noise levels or noise maps have been documented where the potential for harm exists, for example if a raised voice is necessary to
hear a conversation. In some cases baseline audiometry testing will be necessary. Specialist advice should be sought and attempts
to remove the source of the problem should be the first line of defence. Local regulatory requirements should be known. Comparison
with regulatory limits should take into account the length of exposure especially if shifts longer than 8 hours are used.
The risk is that workers will suffer ear drum damage, tinnitus (ringing in the ears) or industrially induced permanent hearing loss.
Noise levels are high and this may induce stress and fatigue. Documentation is urgently needed in this area to ascertain
exact noise levels and the level of attenuation required by selected control measures.
475
Hazardous Substances All hazardous substances (toxic, irritant) should be identified and a register kept. In some cases this will be dependent on the
quantities or volumes stored. Material safety data sheets should be available and accessible to all personnel and language and
literacy barriers taken into consideration at the time this information is disseminated. All hazardous goods and dangerous
substances should be clearly labelled and the potential hazards made known to all those who may be exposed. Training for the
precautions necessary during handling and storage should given to those at risk.
The risk is that someone may become ill from exposure to a hazardous substance whether it is immediate or long term.
Solvent odours are apparent on site. Urgent attention is needed to reduce all sources of emissions. Where this option is
not available, engineering controls will be necessary and should be implemented as a matter of priority.
Biohazards Biological hazards include exposure to infection, contagious diseases, bodily fluids (including blood) or other sources of protein that
may cause an allergic response – for example mould or dust mites. The source may include infectious people; contaminated food;
contact with animals; plants/pollens; insects; mites; sewerage; fungi or bird droppings cooling water reservoirs and air conditioning
systems that may contain legionella organisms.
The risk is that someone may contract a fatal infection, become ill from an infectious disease, have an allergic reaction or develop
long term flu/asthma-like symptoms.
Greater awareness of potential biohazards and prevention strategies, including risks for travellers, would improve this
result.
Radiation Sources of radiation may include ionising radiation such as x-rays and radioactivity; non-ionising radiation such as ultraviolet rays
which may affect the skin or eyes; near infra-red radiation affecting the eyes (welding, furnaces, molten metals); LASER’s; the
heating effect from microwaves and mobile phone towers; and other extremely low frequency radiation with associated magnetic
field exposure such as powerlines.
The risk is that someone could get radiation poisoning or damage their eyes or skin or develop skin cancer.
High inherent risk but stringent controls in place.
476
Installations/ Demolition Planning for the safe installation of new buildings or warehouses as well as the demolition of these structures to ensure the
protection of pedestrians and others in the workplace. Also included is the safe connection or disconnection of services such as gas,
electricity, and telecommunications; protection from noise, debris or other projectiles; and the possibility of falling into excavated
areas.
The risk is that someone could be injured as a result of proximity to installation/demolition activities or as a result of unintentionally
breaking into service lines.
This area is inactive currently but corporate procedures are available for risk assessment should this become active.
The quality of the risk assessments undertaken will have the greatest impact on future results.
Preventive Maintenance/ Regular maintenance of equipment essential for safe operation is planned and critical spares are readily available to keep
Repairs production running without compromising safety. Repair work is carried out in a timely fashion by those that are qualified and
competent to do so.
The risk is that an equipment failure results in an injury.
An injection of capital is needed here to carry critical spares and increase maintenance labour availability.
Modifications – Peer Changes to existing infrastructure and plant/equipment are carefully controlled to minimise the impact that this may have on existing
Review /Commissioning users and others affected. Modifications may be minor or major, and should be peer reviewed by others with the appropriate skills
and knowledge. New plant or equipment is commissioned to ensure that all safety impacts have in fact been considered before the
project is handed over to the regular users.
The risk is that the modifications result in an injury because the full impact of the changes was not thought through prior to
implementation.
The risk assessment must focus on the local context. Documentation is lacking in this area. A database of drawings and
issues considered would greatly assist in the solving of any technical difficulties that may be experienced with modified
equipment at some future date.
477
Security – Site/Personal Only authorised persons who have been informed of relevant site rules enter the workplace. Persons working alone should be able
to contact help in case of an emergency (medical or otherwise) and precautionary measures have been put in place to reduce
threats of bodily harm. Provisions exist for removing unauthorised persons or unwelcome visitors.
The risk is that the personal and physical safety of employees is compromised by the entry of unauthorised persons onto the site or
because they are isolated from emergency assistance.
Security is weak during the time that the front gate is left open. Controls rely heavily on local knowledge and the ability
of workers to identify unknown persons. Signage is available but does not protect from unwelcome visitors.
Emergency Preparedness Contingency plans are available to deal with situations such as fire, natural disasters, explosions, bomb threats, and hostage
situations; vapour clouds, sabotage, medical emergencies and other unwelcome events. Not only should these potential situations
be identified, but the required actions documented and practiced at regular intervals. Debriefing sessions are held after the drills to
identify areas in need of improvement. Emergency equipment such as fire extinguishers are regularly checked and maintained in
good working order.
The risk is that in the event of an emergency situation people will be unable to evacuate safely which may lead to increased
casualties, panic and trauma.
Emergency drills involving all staff are urgently needed in this area. Updating of emergency contact information is also
required as a matter of priority.
Housekeeping The workplace should be kept in a clean and tidy state to avoid trips, slips and falls. Spillages should be cleaned up immediately.
The risk is that someone may trip/slip or fall or that there is increased potential for a fire.
This result in this area could be greatly enhanced by a higher level of focus.
478
Plant Inspections/ Plant and equipment should be inspected regularly to detect at the earliest opportunity any malfunctions and monitored to ensure
Monitoring that the process is operating within safe limits.
The risk is that the process operates outside of designated safe limits which may lead to injury or other ill effects.
The inherent risk is high but under strong control due to the impact this would have on production quality.
Risk Review A broad based risk assessment that compares the current situation against a baseline assessment to indicate whether strategies
implemented for risk reduction have been effective or otherwise.
The risk is that the effectiveness of current prevention and control strategies is unknown, so efforts and resources may have been
wasted.
Once a baseline has been established, this element will need to receive high priority to ensure resources have been
used wisely.
479
Safe Person Element Definition Criteria, Critical Risks and Actions Required
Equal Opportunity/ Anti- Policies are in place to ensure that all employees and others are treated with respect and dignity. There is zero tolerance towards
Harassment bullying and diversity is accepted in the workplace. Awareness programs have ensured that the intention of these policies have
been made clear to employees and management, as well as educating management on the forms that discrimination or
harassment may take - including more subtle manifestations such as holding back pay or entitlements; undue delays for provision
of resources; spreading malicious gossip; social exclusion; hiding belongings; role ambiguity; and career stagnation or uncertainty.
The risk is of long or short term psychological harm. This may indirectly place them at greater risk of physical harm by affecting their
performance or judgement or putting them at risk of workplace violence.
Awareness training on requirements and management expectations is necessary. Documentation in this area and
visual evidence to reinforce and support these expectations would greatly improve the result in this area.
Training Needs Analysis The current level of skills and competencies in the workplace has been assessed to ensure all personnel have the appropriate skills
to fulfil their roles safely and competently. Provisions have been made to provide employees with new skills as their positions grow
and provide refresher training to their keep skills current.
The risk is that management will not know what skills are necessary for employees to perform their roles safely and competently or
whether their skills are still current.
Documentation is needed in this area for management/ sales/ administration staff.
Inductions- All visitors and contractors to the workplace are made aware of any hazards that they are likely to encounter and understand how to
Contractors/Visitors take the necessary precautions to avoid any adverse effects. Information regarding the times of their presence at the workplace is
recorded to allow accounting for all persons should an emergency situation arise. Entry on site is subject to acceptance of site
safety rules where this is applicable.
The risk is that people unfamiliar with the site may be injured because they were unaware of potential hazards.
Procedures for contractors and visitors are working well.
480
Selection Criteria A list of the skills, competencies and traits considered necessary to discharge the duties of the position competently and effectively
has been documented and forms part of the selection criteria. Any pre-existing conditions that may be exacerbated by the role have
been identified to ensure that vulnerable persons are not at risk by taking the position.
The risk is that vulnerable persons may be placed in a position which they would be prone to injury or illness.
Documentation is needed in this area to assist the recruitment process and medical evaluations.
Work Organisation- Fatigue/ The individual arrangement of job tasks that constitute the role have been considered to ensure that the work load does not induce
Stress Awareness undue fatigue or stress, and the required level of vigilance is able to be maintained over the work period. Work breaks, pauses or
other rotation of duties have been introduced where fatigue or stress inducing conditions have been identified. Fatigue may be of a
physical or mental nature.
The risk is that the particular sequencing, timing or arrangement of job tasks will predispose employees to injury or illness.
12 hour shifts indirectly exacerbate issues related to manual handling, noise and hazardous substances. Analysis is
required to determine the severity of this impact, and to ensure threshold limits corrected for 12 hour shifts have been
used.
Accommodating Diversity The workplace promotes an acceptance of diversity. Access for disabled persons has been provided, and special provisions exist
for their safe evacuation in case of an emergency. The special needs of young workers, pregnant or nursing mothers, and older
workers are taken into consideration. Where workers are known to have a pre-existing psychological condition, employers take care
not to place such employees into situations where they are at increased vulnerability. Translations or other means of
communication are available for those that have language barriers.
The risk is that people with special needs are not catered for and so are more prone to injury or illness.
Although the inherent risk is high, the literacy is required for safe working practices and so the potential issue of
language barriers has been limited at the recruitment stage.
481
Job Descriptions -Task Job descriptions and daily tasks have been documented so that the incumbent has a clear idea of the expectations of the role and
Structure whether they are able to fulfil all their obligations. Where a difference between work expectations and ability to fulfil these exist,
channels should be available to enable fair and equitable negotiation on behalf of both parties. Skills and authority levels are
The risk is that people will not have the direction, skills or authority necessary to conduct their role competently, effectively and
safely.
Job descriptions are available but evidence of available channels to negotiate the requirements or assess how realistic
they are in view of current resourcing levels was unavailable at the time of the assessment.
Training All employees and others affected have been made aware of local procedures and protocols. Refresher training is provided at
appropriate intervals to maintain skills and provide ongoing protection from workplace hazards. Competency training has been
scheduled according to the training needs analysis. All persons conducting training are appropriately qualified to do so. Training
records are maintained. Evidence of competencies is available.
The risk is that people will not have the skills necessary to perform their roles competently and safely.
Training is performed well; however documentation in this area would greatly improve this result.
Behaviour Modification Safe working practices are positively reinforced and unsafe behaviours discouraged. This may take the form of informal
(PPI’s Observation inspections, unsafe act or observation programs. Observations may be overt or discreet. Employees are encouraged to recognise
Program) hazards and take suitable precautions - including the acknowledgement of situations that they are not sufficiently skilled to deal with
whilst also watching out for the safety of their colleagues.
The risk is that unsafe work habits will lead to an increase in injuries or illnesses.
Targeted campaigns to break unsafe working habits and positively reinforce desirable work practices would be of
assistance here.
482
Health Promotion Healthy lifestyle choices are promoted and an awareness program exists to educate personnel on these issues. Topics may include
good nutrition, exercise, work-life balance, symptoms of substance addition, quit campaigns and home or off-site safety tips.
The risk is that employees will suffer poor health or a lowered state of well-being which may predispose them to injuries or illnesses
in the workplace.
Information to promote healthy lifestyle choices and improve general well-being would assist lifting workplace morale
and reinforce management commitment to safety and health.
Networking, Mentoring , Channels for networking have been established to assist performance in positions, especially where there is little on site help
Further Education available. On site mentoring or buddy programs have been established where more experienced personnel are available to assist
new employees adjust to their role and provide ongoing support. Pursuit of higher order skills and professional development are
encouraged to grow job positions and increase workplace satisfaction.
The risk is that employees will lose motivation or become apathetic which may place themselves or others at increased likelihood of
injury or illness.
Investigating means of breaking into existing networks and finding out what courses available for currently available
for further education opportunities would improve this result.
Conflict Resolution Mediation channels are available and/or supervisors have received special training to deal with differences of opinion, relationship
breakdowns or personality clashes before the situation reaches the point where workplace performance has been impaired and/or
is noticeable by other colleagues.
The risk is that employees are unable to work as part of a team and this may affect their ability to carry out their roles competently
and safely.
The inherent risk is high but is well controlled by having an open atmosphere and approachable line management.
483
Employee Assistance Persons experiencing problems of a personal nature such as the breakdown of significant relationships, grief, substance abuse, or
Programs other emotional problems may access help in a confidential environment and receive the necessary support to enable them to
continue their work duties without compromising the safety or health of others in the workplace.
The risk is that employee’s personal problems interfere with their ability to conduct their roles competently and safely.
This is conducted with confidentiality and specialist input. This element demonstrates that operational managers are
actively involved with staff and able to provide guidance and direction for assistance when needed.
First Aid/ Reporting Provisions for first aid are available that meet local regulations including the numbers of suitably qualified first aiders and sufficient
quantities of first aid materials. Qualifications are kept current and first aid stocks regularly replenished. A register of workplace
injuries is kept that meets local OHS regulations and notification of incidents to statutory authorities is observed as required.
The risk is that the adverse effects and trauma associated with injuries will be greater and take longer time to heal, and OHS
regulations will be breached.
Records are diligently kept, and first aid facilities are readily available.
Rehabilitation Provisions are made to assist injured or ill employees returning back to work without exacerbating their current condition. Attempts
are made to allow them to continue with meaningful employment where such opportunities exist according to the following hierarchy
– same job/ same workplace; modified job/ same workplace; different position same workplace; similar or modified position/
different workplace; different position/ different workplace. Return to work programmes exist and a co-ordinator has been appointed
either internally or externally to meet local OHS regulations. All parties are kept informed of progress and developments.
The risk is that injuries will be exacerbated, that time away from the workplace will be increased and that the psychological effects
of the injury and loss of confidence will be heightened.
Requirements for local OHS regulations were strictly observed at the time of the assessment. NOTE: The result for this
area may be subject to change in the near future due to loss of experienced personnel and resourcing issues.
484
Health Surveillance Pre-employment medicals have been undertaken to provide baseline information on the employee’s current state of health from
which the effectiveness of current control strategies may be evaluated. Examinations may include lung function tests, blood or urine
samples for biological monitoring, chest x-rays and audiometric testing. Where known hazardous substances are present in the
workplace, this surveillance may be subject to compliance with local OHS regulations.
The risk is that the effectiveness of current control measures will be not be known, that employees health will be endangered, a
baseline for claims purposes will not exist and that local OHS regulations may be breached.
Health surveillance is carried out for phthalates and audiometry. However, this information is not being used
proactively to improve operational practices.
Performance Appraisals Performance appraisals include criteria for safe work practices and observation of site safety rules, housekeeping, and the display
of safe working attitude. OHS responsibilities should be commensurate with the level of responsibility and authority bestowed.
Setting good examples for workplace safety should be encouraged and valued.
The risk is that desirable OHS work behaviours and attitudes will not be reinforced, and that inappropriate OHS attitudes or actions
may be encouraged with employees believing that such behaviour or actions are acceptable.
Performance reviews are carried out but OHS issues are not embedded into the assessment, nor are their
consequences for undesirable OHS attitudes or practices. Checks and feedback to ensure that responsibility is
commensurate with authority were not available at the time of the assessment.
Feedback Programs Feedback may take the form of suggestion boxes, perception surveys (questionnaires to gauge employee attitudes, morale, and/or
perceived effectiveness of safety campaigns), or reward programs. Consideration is given to the use of variable, unpredictable
reward schedules so that the benefits are maintained when the reward is removed. Rewards may include praise, recognition or
increased status.
The risk is that opportunities for improvement are lost and the effectiveness of current strategies is unknown, and poor morale or
other workplace issues continue unresolved.
Opportunities for feedback are needed to provide management with more information about the effectiveness of
current OHS controls and to ensure that any problems are quickly brought to management’s attention.
485
Review of Personnel Turn over rates are reviewed to uncover the root cause for any abnormally high levels, such as problems with leadership,
Turnover personality conflicts, excessive workloads, unreasonable deadlines, unpleasant physical working environment and/or work
conditions. Exit interviews are conducted to gather feedback for improvement where such opportunities present.
The risk is that valuable experience is lost which may indirectly impact on the ability of the organisation to conduct its activities
safely, and the opportunity to correct problems or other underlying issues is lost.
Analysis of information obtained at exit interviews is not acted upon, so the opportunities for improvements are lost.
486
Safe System Strategies
Safe System Element Definition Criteria, Critical Risks and Actions Required
Accountability Accountability for OHS issues has been allocated and there is sufficient follow through and consequences in place if these are
not met to ensure that these responsibilities are taken seriously. The accountability should be commensurate with the authority
of the position, and sharing of accountabilities avoided to prevent responsibility from being diffused.
The risk is that no one will take responsibility for OHS actions and so OHS duties will be ignored.
Assignment of a single person to take ownership for specific OHS actions would demonstrate that responsibility for
OHS improvement depends on everyone playing their part. Shared responsibility for specific actions should be
discouraged and where difficulties are foreseen responsibility should be reallocated, commensurate with authority, at
the earliest available opportunity.
Audits Formal reviews of measures implemented to ensure that the prime intention of the procedures is being met and that specific
criterion such as compliance with a regulation, standard or organisational OHS requirement are addressed. Objective evidence
is available to support the findings. Specialist audits may be necessary to determine risks in particular areas. The frequency of
audits will depend on the length of time that the OHS systems have been in place, as established systems will need less
frequent audits than systems that are just being introduced. The frequency may range from a yearly basis to once every 3-5
years for specialist audits. Auditors utilised are suitably qualified and experienced.
The risk is that predetermined requirements for good OHS will not be met, and the actions necessary to achieve the desired
OHS outcomes are unknown.
No specific audits were made available at the time of assessment. High priority but down rated until more pressing
items addressed.
487
Communication Communication channels are available to facilitate the efficient flow of information to perform workplace duties in a manner that
is safe and does not induce stress. This may include sufficient contact with supervisors or colleagues, the provision of
communication equipment such as telephones, internet access, or radios, access to noticeboards or newsletter, meetings and
other forums for exchange whether they be formal or informal.
The risk is that critical information necessary to create a safe working environment is lost or unavailable.
Increased means of two-way communication on OHS matters to all employees would improve this result.
Competent Supervision Persons that are placed in a position of authority and supervision have the talent/ technical ability, social skills and experience
necessary to do so.
The risk is that employees may be exposed to injury or illness because the people supervising them did have the skills
necessary to know how to protect them from OHS issues.
There is a high level of experience amongst line managers, however this result could change if there were losses of
key staff members.
Consultation Employees’ opinions are considered and valued with respect to changes that may affect their health, safety or well-being. Local
OHS regulations on the formation safety committees are observed, and the committee chairperson has undergone appropriate
training to fulfil their tasks and duties. Meetings are conducted on a regular basis with participation of a management
representative with sufficient authority to take action on items identified as being in need of corrective action. The minutes of the
meetings are kept in a secure location and made available to all employees. Attempts are made to resolve disputes in-house
before outside authorities are brought in.
The risk is that the safety, health and well-being of employees and others at the workplace may be jeopardised because they
were uniformed of changes before the changes actually took place, were not updated about existing OHS issues, or because
they were uniformed about OHS information relevant to their employment.
Spot checks of documentation illustrated that this area is working well.
488
Customer Service – Information is made available to end users to address any health or safety concerns encountered during the use of the
Recall/Hotlines organisation’s products or services. Procedures are in place to recall goods or services in a timely manner where a danger or
threat may place end users at risk after purchase.
The risk is that the safety and health of a customer, client or consumer is threatened because they were unable to access
critical information in a timely manner regarding the organisations goods or services.
N/A Product is a non hazardous intermediate.
Due Diligence Review/ Gap A list of projects has been identified that would bring the organisation into regulatory compliance, with responsibilities allocated
Analysis and time frames for completion identified. The list is reviewed on a regular basis and demonstrable progress is evident.
The risk is that legal compliance with OHS duties will be ignored with the potential for fines, penalties or litigation as a result of
breaches.
A recent due diligence plan is urgently required to fulfil the organisation’s duty of care. A gap analysis that has
undergone regular review with demonstrable improvements will also assist in demonstrating goodwill and good
corporate citizenship should a penalty or breach occur.
Goal Setting Goals and milestones should be set with sufficient detail to determine whether OHS issues are improving, unchanged or in
decline. These goals should be consistent the organisation’s OHS policy and the goals should be reviewed at regular intervals.
Care should be taken to ensure that goals are realistic and achievable; specific; measurable; and have been adequately
resourced.
The risk is that OHS issues may appear too overwhelming to address systematically and that lack of feedback on recent efforts
may lead to apathy.
Goals were not available at the time of the audit. Specific, Measurable, Achievable, Realistic and Timely (SMART)
goals would enable to improvement task to be broken down into a manageable portions and provide some
encouragement when targets are met.
489
Incident Management A system is in place to capture information regarding incidents that have occurred to avoid similar incidents from recurring in the
future. Attempts are made to address underlying causes, whilst also putting in place actions to enable a quick recovery from the
situation. Root causes are pursued to the point where they are within the organisations control or influence. Reporting of
incidents is encouraged with a view to improve rather than to blame. Near miss/ hits are also reported and decisions to
investigate based on likelihood or potential for more serious consequences. Investigations are carried out by persons with the
appropriate range of knowledge and skills.
The risk is that information that could prevent incidents from recurring is lost and employees and others at the workplace
continue to contract illnesses or be injured.
This is used more as a database for reporting rather than as a problem solving tool. Selective application of root
cause analysis, corrective action and evaluation may yield significant improvements in this area.
Legislative Updates A list of relevant OHS legislation has been complied and access to these documents has been made available so the
organisation knows what legal obligations exist and has supporting information such as standards or codes of practice available
for reference. A system is in place to ensure that updates are received so that the information being acted upon is always
current.
The risk is that out-of-date or incorrect or incomplete information is used for actioning OHS issues, so inappropriate actions or
ill-informed decisions are made.
A more systematic approach that incorporates a trigger to alert management of legislative changes is required.
OHS Policy An OHS policy is in place that conveys management’s intention and attitude towards safety. It is one expression of
management’s will which may be used to motivate all employees to behave in a certain way and uphold certain attitudes. The
credibility of the policy is witnessed by the consistency of management’s actions and responses to daily situations.
The risk is that there will be no direction on OHS issues and employees will not know the organisation’s attitude towards OHS,
or what is expected from them.
Corporate expectations are not publicised or documented and visual evidence of management expectations is not
readily available.
490
Procedural Updates Procedures are kept current to incorporate lessons learnt and other improvements as these become available. A means of
removing out of date information is in place so that there is confidence that only the most current procedures are in use. Any
obsolete information that is kept for archival purposes is clearly identifiable as being superseded. Training on updated methods
and procedures is provided where the changes are considered to be significant.
The risk is that out-of-date procedures are used that do not include the latest information on how to avoid unsafe working
conditions.
A more systematic and dependable means of ensuring that changes are passed on and superseded information
removed would improve this result.
Procurement with OHS All new plant, equipment and services have been purchased with OHS criteria taken into consideration. End users have been
Criteria included in the decision making process. Safety instructions are available and training on new equipment, plant or services is
provided where necessary for safe operation. Technical or specialist expertise has been acquired where written instructions are
insufficient or unavailable. There is clear delineation of the point where new equipment or services have been accepted and
OHS issues resolved.
The risk is that new plant, equipment or services will be the cause of OHS problems and that it be very expensive to rectify the
OHS issues retrospectively.
A more formalised approach that takes into account the local context would improve this result.
Record Keeping/ Archives Records are kept in a safe and secure location, protected from deterioration and damage by water or fire. The duration for
which the records are kept is in accordance with local OHS regulations and the confidentiality of health records is enforced and
respected. Regular back ups of electronic data are made where their loss would have an impact upon the safety and health of
employees.
The risk is that critical records of employees’ health and safety will be unavailable in the event of litigation or for purposes
related to improving or resolving OHS issues.
Action to improve record collection systems would improve the results in this area.
491
Resource Sufficient resources have been allocated to OHS issues to demonstrate that commitment is real and goals are achievable.
Allocation/Administration Funds are protected from “reallocation”. Time is available and sufficient to address OHS issues, and has been budgeted for in
The risk is that there will be insufficient funding to rectify OHS issues identified.
Allocation of capital for OHS projects is urgently required in the operations and maintenance areas. Preservation of
funds for OHS projects once allocated must be assured.
Safe Working Procedures Sufficient procedures are in place to enable duties to be conducted consistently and to document precautions necessary to
perform the job safely. Consideration is given to the level of detail incorporated so that there is a balance between providing
sufficient information and allowing workers to use their judgement and experience as necessary, for example where too
stringent or restrictive rules may encourage violations. The procedures should be regularly reviewed to incorporate
improvements as these become available, and the level of compliance assessed.
The risk is that employees will not know how to perform their job tasks safely.
Procedures are available at the point of application. This result could be improved by extending the documentation
to areas outside of production and awareness, training and application of the hierarchy of controls.
Self Assessment Tools A list of questions has been compiled to ensure that outcomes are being achieved on a regular basis and the key requirements
of OHS procedures are being adhered to. The purpose is to determine the level of compliance; whether the requirements are
suitable and reasonable; and to ensure that any practical problems with the daily working of procedures are uncovered whilst
the situation is still recoverable. Self - assessments are conducted on a frequent basis, for example monthly, and items are
independently spot checked to improve the reliability of the results.
The risk is that the reasonableness and practicality of agreed OHS actions are not tested and OHS goes off track and is difficult
to get back on track.
No specific self-assessment tools were made available at the time of assessment. This result would be greatly
improved by consideration of actions that have the greatest impact on safe working and would be useful to ensure that
prevention and control strategies applied remain on track.
492
Supply with OHS Criteria All products and services supplied are provided in a safe state with OHS criteria taken into consideration to ensure that the
client/customer is not exposed to harm when the products or services are used according to the suppliers instructions with all
due warnings being heeded.
The risk is that products or services supplied are the cause of injury or illness as well as potentially exposing the organisation to
litigation for breaches of OHS duties.
Handling of the rolls may need further consideration here.
System Review A review of all the OHS systems in place to enable the organisation to fulfil its duty of care to employees and others affected by
its business undertakings. Here the system as a whole is examined to ensure that it has been set up correctly and remains
suitable in light of any organisational changes or business acquisitions. Conducted typically on an annual basis.
The risk is that the effectiveness of the entire combination of existing OHS prevention and control strategies remains unknown,
and there is no input for future directions in OHS.
No specific system reviews were made available at the time of assessment. High priority but down rated until more
pressing items addressed.
493
Appendix 13: Project Field Kit
Executive Summary
The purpose of this study is to explore whether a systematic OHS management

is linked to improved OHS performance. To guide and focus the research efforts
the following questions have been developed:
11) What are the barriers to the uptake of a systematic approach to safety?
12) What questions may be used to promote a systematic examination of the

entire context of workplace hazards?
13) What indicators are available on an operational level that may suggest the
existence of particular workplace hazards?
14) What strategies are typically invoked to control particular workplace

hazards on the following three levels: the physical environment and
infrastructure; the individual; and at a managerial level?
15) What are the most suitable measurement indicators to gauge the
effectiveness of particular control strategies invoked?
16) Which control strategies are considered essential on a universal level, and
which strategies are industry specific; and
17) How does the nature of the organisation influence the type of control
strategies selected; and is there a typical order of implementation that may
assist in the development of a pathway to OHS improvements?
There are no right or wrong answers to this study. The aim is to gain a better
understanding of what is involved in implementing a successful occupational
health and safety management system (OHS MS), and ultimately to simplify the
process so that the benefits of systematic management may be more widely
available.
In order to do this, the elements of an OHS MS have been separated into three
distinct areas – safe place, safe person and safe systems. Not all businesses will
need to invoke all these elements; the idea is to select the elements that are
appropriate and relevant for the individual organisation. It is hoped that by
viewing an OHS MS as simply a collection of prevention and control strategies,
the function of each element may be more evident and so add more value. The
prevention and control strategies have been sorted according to their location on
the Deming “plan/ do/ check/ act” cycle to give an indication as to the most
appropriate timing of each element. The building blocks of an OHS MS are
illustrated on the following page.
It is hoped that this study will of benefit to your organisation. The results of the
study will de-identified to preserve the confidentiality of the organisation.
495
Harassment
Access/ Egress Selection Criteria Accountability
Inductions-Including Due Diligence Review/

Plant/ Equipment
Visitors/Contractors Gap Analysis
Administration
Receipt/Despatch Work Organisation - Fatigue Contractor Management

Criteria
Noise
Hazardous
Behaviour Modification Competent Supervision
Substances/Dangerous
G d
Networking/Mentoring/
Further Education
Employee Assistance
Installations/ Demolition Legislative Updates
Programs
Preventive Maintenance/ Personal Protection
Procedural Updates
Repairs Equipment
Commissioning
Inspections/ Monitoring Feedback Programs Audits
Review of Personnel
Operational Review System Review
Turnover
Key
Progressive Routine
496
Hazards in the Workplace
External
People Environment

Operating Strategies and
Control Strategies for Complex

Hazards
External
Safe Environment
Person
OHS MS
Safe Safe
Place Systems
497
Strengths of Safe Place Strategies
¨ Underpinned by the risk management
process
¨ Involves the application of the hierarchy of
controls up to the point where alterations
are made to the existing environment
¨ Most effective when hazards are
predictable
¨ Includes provision for abnormal
conditions
¨ Flexible and adaptable
A.M. Makin and C. Winder March 2007
Limitations of Safe Place Strategies

¨ The risk management process is lengthy and
intense
¨ Need to know when to get outside expertise
¨ Varying perceptions of what constitutes an
“acceptable risk” and problems of
complacency or lack of situational
awareness
¨ May involve high level of capital expenditure
¨ Safety funds may be reallocated elsewhere
498
¨ Selection/ Screening of competent and
suitable employees
¨ Awareness training and inductions

¨ Competency training and further education
¨ Includes behaviour modification
¨ Health promotion/ employee assistance
programs
¨ Recovery and monitoring of the person
after an injury or illness experience – either
physical or psychological
Strengths and Limitations of

¨ Very useful when the workplace is not “fixed”,
example for call-out work
¨ High level skills suit hazards of an irregular

and complex nature, for example non-routine
and specialist work
¨ Often strategies are time consuming
¨ Vulnerability lies in the complexity of human

nature – breakdown of focused attention,
effects of stress, fatigue and compliance
499
¨ Leadership – policies, provision of
resources both time and capital
¨ Safe procedures are in place
¨ Consultation, updates
¨ Competent supervision
¨ Root causes of incidents are investigated
¨ Regular review and monitoring of the
system against set criteria
Strengths and Limitations of

¨ Logical, allows for safety to be built in at the
concept stage.
¨ Solutions are more cost effective when
preventive rather than retrospective
¨ Requires consultation, trust and transparency
¨ Corrective actions that constantly change the
procedures may create too much flux in the
system.
¨ Care not to “over specify” the system
500
“Plain English” Definition of Building Block Elements
Safe Place Elements Definition Criteria , Scope and Key Risks

Baseline Risk Assessment A general broad based risk assessment has been performed at some
critical point in time from which improvement or decline in overall
OHS risk presenting to the organisation may be measured. This
assessment must be recorded. It is assumed that all key areas of
significant risk have been considered. Areas requiring specialist
expertise (internal or external) should be identified.
The risk is that the organisation does not know what OHS issues
need to be addressed or how urgent they are so resources can not
be allocated effectively according to priorities, and the response will
be reactive only.
Ergonomic Evaluations A specialised risk assessment that is concerned with fitting the task
to the human and may cover a very broad range of issues including
manual handling, overuse injury, work organisation, human error and
problems with information processing. However, in the context of
“safe place strategies” the scope is limited here to focusing on the
layout of the workstation, manual handling, task design and
examination of repetitive tasks. Such assessments should be
performed by person(s) with the appropriate qualifications and
competencies to do so.
The risk is that an employee will sustain a strain/sprain injury or
cumulative trauma. Whilst the injury may not be fatal, it may be very
debilitating and result in significant periods of lost time, and the
injured workers may not be able to return to the same type of
employment.
Access/ Egress This considers the quick and efficient entrance or departure of
personnel to and from the physical workplace, including those with
special needs such as disabled employees. Emergency exit signage,
walkways, handrails, stairways and fire doors should be in
accordance with local building regulations, and escape routes clear.
This is particularly important in the case of emergency situations.
The risk is that someone may be unable to escape in an emergency
situation or may be injured whilst trying to access or depart from their
workplace.
Plant/ Equipment This requires that all existing equipment or plant operates without
causing harm. Where this requires specialist knowledge this must be
pursued with the supplier or designer, and end users and others
affected must be consulted and their opinions duly considered. The
hazards of rotating machinery, pinch points, and crush injuries should
be included here, as well as the safe use of vehicles (including
forklifts) and working from heights. Confined or dangerous spaces
should also be identified. Refer to individual elements for noise
and/or electrical for the potential of plant/equipment to cause noise,
vibration and electrical hazards.
The risk is that someone could be crushed, cut, impaled, hit or
entrapped by the machinery
501
Amenities/ Environment Amenities such as private, hygienic toilets and change rooms;
provision of drinking water and a refrigerator/ microwave for
mealtimes; infant feeding facilities and showers where the need
exists. The working environment for indoor workers should be
comfortable and meet relevant standards and codes for indoor air
quality, ventilation and lighting. The potential for heat stress should
be considered, which may be exacerbated by humidity levels.
Exposure to heat and cold may be particularly important
considerations for outdoor workers (see radiation for UV exposure).
The special needs for divers or air cabin crew should also be
considered where applicable.
The risk is that an uncomfortable work environment will affect their
judgement or well-being which may place them at greater risk of
other injuries or illnesses or impair their performance and put others
at risk.
Receipt/ Despatch Receipt of supplies and raw materials is conducted so that any
impacts on health and safety have been considered prior to
ordering/purchase; Safe despatch ensures that loading of finished
goods does not result in harm, including any earthing requirements
where applicable and the product is transported safely. Plans for
dealing with emergency situations in transit have been developed,
necessary information and contacts are available and training has
been conducted for affected parties.
The risk is that employees or others may be harmed during receipt of
materials being delivered, or handling, receipt, despatch and
transport of supplies and finished goods.
Electrical All electrical equipment should be handled appropriately by those
who are suitably qualified and kept in good working order. Other
electrical hazards include electric shock; static electricity; stored
electrical energy, the increased dangers of high voltage equipment
and the potential for sparks in flammable/explosive atmospheres.
Where live testing is necessary, only appropriately trained and
qualified personnel should do so in compliance with relevant
legislation and codes.
The risk is that someone may be injured or fatally electrocuted or
cause a fire/explosion by creating sparks in a flammable or explosive
atmosphere.
Noise Noise levels or noise maps have been documented where the
potential for harm exists, for example if a raised voice is necessary to
hear a conversation. In some cases baseline audiometry testing will
be necessary. Specialist advice should be sought and attempts to
remove the source of the problem should be the first line of defence.
Local regulatory requirements should be known. Comparison with
regulatory limits should take into account the length of exposure
especially if shifts longer than 8 hours are used. Sources of vibration
that impact on workers should be identified, including power tools,
seats on mobile plant equipment.
The risk is that workers will suffer ear drum damage, tinnitus (ringing
in the ears) or industrially induced permanent hearing loss; vibration
may cause disturbed blood circulation to the hands and tingling or
back pain when associated with seats.
502
Hazardous Substances/ All hazardous substances and dangerous goods (explosives,
Dangerous Goods pressurised chemicals, corrosives, oxidants, toxic chemicals, and
irritants) should be identified, listed and labelled and a register kept
containing all MSDS. Where the use of a chemical does not require
specific controls this is noted in the register. Where specific controls
are necessary, a reference to comply with the MSDS is noted, and
where this is inadequate a risk assessment has been prepared; these
requirements are made known to all those who may be exposed, In
some cases this will be dependent on the quantities or volumes
stored. Storage arrangements and inventory of dangerous goods
should comply with local OHS and DG legislation. Training for the
precautions necessary during use, handling and storage should given
to those at risk.
The risk is that someone may become ill from exposure to a
hazardous substance whether it is immediate or long term, or harmed
by fire or explosion due to inadequate storage and inventory
arrangements.
Biohazards Biological hazards include exposure to infectious agents, contagious
diseases, bodily fluids (including blood) or other sources of protein
that may cause an allergic response – for example mould or dust
mites. The source may include micro-organisms, infectious people;
contaminated food; contact with animals; rodents; plants/pollens;
insects; mites; lice; sewerage; fungi or bird droppings cooling water
reservoirs and air conditioning systems that may contain legionella
organisms.
The risk is that someone may contract a fatal infection, become ill
from an infectious disease, have an allergic reaction or develop long
term flu/asthma-like symptoms.
Radiation Sources of radiation may include ionising radiation such as x-rays
and radioactivity; non-ionising radiation such as ultraviolet rays which
may affect the skin or eyes; near infra-red radiation affecting the eyes
(welding, furnaces, molten metals); LASER’s; the heating effect from
microwaves and mobile phone towers; and other extremely low
frequency radiation with associated magnetic field exposure such as
powerlines.
The risk is that someone could get radiation poisoning or damage
their eyes or skin or develop skin burns or skin cancer.
Disposal All materials and waste products, including their containers, should
be disposed of in a manner that complies with local regulations and
that does not cause harm either through immediate contact or as a
result of transferring the substances / materials for disposal or
dispersal elsewhere. All those in contact with the waste materials are
aware of hazards and precautions necessary to minimise the risks
(see hazardous materials/ dangerous goods). Also included here are
the risks associated with hygiene and the handling of sharps.
The risk is that someone could be injured or get ill from contact with
or exposure to waste chemicals or materials.
Installations/ Demolition Planning for the safe installation of new buildings or warehouses as
well as the demolition of these structures to ensure the protection of
pedestrians and others in the workplace. Included here are the
presence of asbestos in demolished structures; the safe connection
or disconnection of services such as gas, electricity, and
telecommunications; protection from noise, debris or other projectiles;
and the possibility of falling into excavated areas.
The risk is that someone could be injured as a result of proximity to
installation/demolition activities or as a result of unintentionally
503
Preventive Maintenance/ Regular maintenance of equipment essential for safe operation is
Repairs planned and critical spares are readily available to keep production
running without compromising safety. Repair work is carried out on
failed equipment in a timely fashion by those that are qualified and
competent to do so.
Modifications – Peer Review Changes to existing infrastructure and plant/equipment are carefully
/Commissioning controlled to minimise the impact that this may have on existing users
and others affected. Modifications may be minor or major, and should
be peer reviewed by others with the appropriate skills and
knowledge. New plant or equipment is commissioned to ensure that
all safety impacts have been considered before the project is handed
over to the regular users.
The risk is that the modifications result in an injury because the full
impact of the changes was no thought through prior to
implementation.
Emergency Preparedness Contingency plans are available to deal with situations such as fire,
natural disasters, explosions, bomb threats, and hostage situations;
vapour clouds, sabotage, medical emergencies and other unwelcome
events. Not only should these potential situations be identified, but
the required actions documented and practiced at regular intervals.
Debriefing sessions are held after the drills to identify areas in need
of improvement. Critical emergency equipment, such as alarms,
smoke detectors, fire sprinklers, the correct type of extinguishers,
back up generators (where applicable) are provided and maintained.
The risk is that in the event of an emergency situation people will be
unable to react appropriately (for example, evacuate safely or
respond effectively, which may lead to increased casualties, panic
and trauma.
Security – Site/Personal Only authorised persons who have been informed of relevant site
rules enter the workplace. Persons working alone should be able to
contact help in case of an emergency (medical or otherwise) and
precautionary measures have been put in place to reduce threats of
bodily harm. Provisions exist for removing unauthorised persons or
unwelcome visitors.
The risk is that the personal and physical safety of employees is
compromised by the entry of unauthorised persons onto the site or
Housekeeping The workplace should be kept in a clean and tidy state to avoid trips,
slips and falls. Walkways should not be blocked. Spillages should be
cleaned up immediately. Fire extinguishers should be checked and
maintained. Hoses should be returned and empty containers and
pallets stored in appropriate locations. Unwanted materials should be
sorted and put into storage or disposed of.
The risk is that someone may trip/slip or fall or that there is increased
potential for a fire.
Inspections and Monitoring Processes should be monitored and inspected regularly to ensure
that equipment and facilities are being used and applied in the
manner that was intended and for which safety provisions have been
considered and implemented. The processes are monitored to
ensure that they are operating within safe limits. Causes of abnormal
operations are investigated and rectified.
The risk is that the process operates outside of designated safe limits
which may lead to injury or other ill effects, or that equipment is used
inappropriately leading to damage to property, loss of production or
other unwelcome events.
504
Operational Review A periodic review is conducted that compares the current situation
against a baseline assessment to indicate whether strategies
implemented for risk reduction have been effective or otherwise, and
whether there have been any changes to plant, the organisation or
legislation that may impact on the risk presented by the operation.
Any adverse findings are dealt with.
The risk is that the effectiveness of current prevention and control
strategies is unknown, so efforts and resources may have been
wasted, and the impact of changes on the operations.
505
Safe Person Elements Definition Criteria , Scope and Key Risks

Equal Opportunity/ Policies are in place to ensure that all employees and others are
Anti-Harassment treated with respect and dignity. There is zero tolerance towards
bullying and diversity is accepted in the workplace. Awareness
programs have ensured that the intention of these policies have
been made clear to employees and management, as well as
educating management on the forms that discrimination or
harassment may take - including more subtle manifestations
such as holding back pay or entitlements; undue delays for
provision of resources; spreading malicious gossip; social
exclusion; hiding belongings; role ambiguity; and career
stagnation or uncertainty.
The risk is of long or short term psychological harm. This may
indirectly place them at greater risk of physical harm by affecting
their performance or judgement or putting them at risk of
workplace violence.
Accommodating Diversity The workplace promotes an acceptance of diversity. Access for
disabled persons has been provided, and special provisions exist
for their safe evacuation in case of an emergency. The special
needs of young workers, pregnant or nursing mothers, and older
workers are taken into consideration. Where workers are known
to have a pre-existing psychological condition, employers take
care not to place such employees into situations where they are
at increased vulnerability. Translations or other means of
communication are available for those that have language
barriers.
The risk is that people with special needs are not catered for and
so are more prone to injury or illness.
Selection Criteria A list of the skills, competencies and traits considered necessary
to discharge the duties of a position competently and effectively
has been documented and forms part of the selection criteria (for
example in position descriptions). Any pre-existing conditions
that may be exacerbated by the role have been identified to
ensure that vulnerable persons are not at risk by taking the
position.
The risk is that employees may not be capable of doing the jobs
they are selected for, and vulnerable persons may be placed in a
position which they would be prone to injury or illness.
Inductions- All visitors and contractors to the workplace are made aware of
Contractors/Visitors any hazards that they are likely to encounter and understand
how to take the necessary precautions to avoid any adverse
effects. Information regarding the times of their presence at the
workplace is recorded to allow accounting for all persons should
an emergency situation arise. Entry on site is subject to
acceptance of site safety rules where this is applicable. Also,
specific contacts/hosts are designated to ensure compliance with
local rules.
The risk is that people unfamiliar with the site may be injured
because they were unaware of potential hazards.
506
Training A training needs analysis has been conducted to determine what
skills employees have and what skills are needed to perform their
roles safely and competently. Arrangements are in place to
address any gaps that may exist. All employees and others
affected have been made aware of local procedures and
protocols. Refresher training is provided at appropriate intervals
to maintain skills and provide ongoing protection from workplace
hazards. Competency training has been scheduled according to
the training needs analysis. All persons conducting training are
appropriately qualified to do so. Training records are maintained.
Evidence of competencies is available.
The risk is that people will not have the skills necessary to
perform their roles competently and safely.
Work Organisation- Fatigue The individual arrangement of job tasks that constitute the role
have been considered to ensure that the work load does not
induce unnecessary manual handling, overuse, undue fatigue or
stress, and the required level of vigilance is able to be
maintained over the work period. Work breaks, pauses or other
rotation of duties have been introduced where fatigue inducing
conditions have been identified. Fatigue may be of a physical or
mental nature.
The risk is that the particular sequencing, timing or arrangement
of job tasks will predispose employees to injury or illness.
Stress Awareness Personal skills, personality, family arrangements, coverage of
critical absences, resourcing levels and opportunities for
employees to have some control over work load are factored into
ongoing work arrangements so as not to induce conditions that
may be considered by that particular employee as stressful.
Plans are available for dealing with excessive emails and
unwelcome contacts.
The risk is that the employee becomes overwhelmed by the
particular work arrangements, and is unable to perform
competently or safely due to the particular circumstances.
Job Descriptions -Task Job descriptions and daily tasks have been documented so that
Structure the employee has a clear idea of the expectations of the role and
whether they are able to fulfil all their obligations. Where a
difference between work expectations and ability to fulfil these
exist, channels should be available to enable fair and equitable
negotiation on behalf of both parties. Skills and authority levels
are commensurate with responsibilities allocated.
The risk is that people will not have the direction, skills or
authority necessary to conduct their role competently, effectively
and safely.
Behaviour Modification Critical safe working practices are positively reinforced and
unsafe behaviours discouraged. This may take the form of
informal inspections, unsafe act or observation programs,
followed by suitable feedback. Observations may be overt or
discreet. Employees are encouraged to recognise hazards and
take suitable precautions - including the acknowledgement of
situations that they are not sufficiently skilled to deal with whilst
also watching out for the safety of their colleagues. Where
reward programs are used for positive reinforcement of safe
behaviours, consideration is given to the use of variable,
unpredictable reward schedules so that the benefits are
maintained when the reward is removed. Rewards may include
praise, recognition or increased status.
The risk is that unsafe work habits will lead to an increase in
injuries or illnesses.
507
Health Promotion Healthy lifestyle choices are promoted and an awareness
program exists to educate personnel on these issues. Topics
may include good nutrition, exercise, work-life balance,
symptoms of substance addiction, quit campaigns, medical
checks (prostate, bowel, breast, cervical) and home or off-site
safety tips.
The risk is that employees will suffer poor health or a lowered
state of well-being which may predispose them to injuries or
illnesses in the workplace.
Networking, Mentoring, Channels for networking have been established to assist
Further Education performance in positions, especially where there is little on site
help available. On site mentoring or buddy programs have been
established where more experienced personnel are available to
assist new employees adjust to their role and provide ongoing
support. Pursuit of higher order skills and professional
development are encouraged to grow job positions and increase
workplace satisfaction.
The risk is that employees will lose motivation or become
apathetic which may place themselves or others at increased
likelihood of injury or illness.
Conflict Resolution Mediation channels are available and/or supervisors have
received special training to deal with differences of opinion,
relationship breakdowns or personality clashes before the
situation reaches the point where workplace performance has
been impaired and/or is noticeable by other colleagues.
The risk is that employees are unable to work as part of a team
and this may affect their ability to carry out their roles
competently and safely.
Employee Assistance Persons experiencing problems of a personal nature such as the
Programs breakdown of significant relationships, grief, substance abuse, or
other emotional problems may access help in a confidential
environment and receive the necessary support to enable them
to continue their work duties without compromising the safety or
health of others in the workplace.
The risk is that employee’s personal problems interfere with their
ability to conduct their roles competently and safely.
Personal Protective Personal Protective Equipment (PPE) is used where other
Equipment options to minimise the risk are unavailable or inadequate. All
PPE supplied has been carefully selected to ensure that it meets
any standards applicable, is fit for purpose and is fitted correctly.
The potential for creating other hazards by the application of the
PPE selected has been carefully considered and the potential for
such impacts minimised.
The risk is that PPE selected will not provide the protection
expected (because of poor selection, poor training, poor fit or
poor maintenance) or may even be the cause of additional
workplace hazards.
First Aid/ Reporting Provisions for first aid are available that meet local regulations
including the numbers of suitably qualified first aiders and
sufficient quantities of first aid materials. Qualifications are kept
current and first aid stocks regularly replenished. A register of
workplace injuries is kept that meets local OHS regulations and
notification of incidents to statutory authorities is observed as
required.
The risk is that the adverse effects and trauma associated with
injuries and poor injury management will be greater and take
longer time to heal, and OHS regulations will be breached.
508
Workers’ Compensation / Provisions are made to compensate injured workers for lost time
Rehabilitation and medical/related expenses. Assistance is provided for
returning injured or ill employees back to the workplace in an
agreed timeframe without exacerbating their current condition
and to offer meaningful employment where such opportunities
exist according to the following hierarchy – same job/ same
workplace; modified job/ same workplace; different position same
workplace; similar or modified position/ different workplace;
different position/ different workplace. A return to work co-
ordinator has been appointed either internally or externally to
meet local OHS regulations. All parties are kept informed of
progress and developments. Systems are in place to ensure that
injured workers are not returned to the unaltered workplace that
injured them.
The risk is that injuries will be exacerbated, that time away from
the workplace will be increased and that the psychological effects
Health Surveillance Pre-employment medicals have been undertaken to provide
baseline information on the employee’s current state of health.
Examinations may include lung function tests, blood or urine
samples for biological monitoring, chest x-rays and audiometric
testing. Where known hazardous substances are present in the
workplace, this surveillance may be subject to compliance with
local OHS regulations. Health surveillance is conducted from
which the health of workers exposed to specific risks can be
monitored (including biological monitoring) and the effectiveness
of current control strategies may be evaluated
The risk is that (i) employees may be placed in situations where
their health may be damaged; and (ii) the effectiveness of current
control measures will be not be known, that employees health
will be endangered, a baseline for claims purposes will not exist
and that local OHS regulations may be breached.
Performance Appraisals Performance appraisals include criteria for safe work practices
and observation of site safety rules, housekeeping, and the
display of safe working attitude. OHS responsibilities should be
commensurate with the level of responsibility and authority
bestowed. Employees and management setting good examples
for workplace safety should be encouraged and valued.
The risk is that desirable OHS work behaviours and attitudes will
not be reinforced, and that inappropriate OHS attitudes or actions
may be encouraged with employees believing that such
behaviour or actions are acceptable.
Feedback Programs Feedback may take the form of suggestion boxes, perception
surveys (questionnaires to gauge employee attitudes, morale,
and/or perceived effectiveness of safety campaigns). Reward
programs may be used to encourage participation in feedback
activities.
The risk is that opportunities for improvement are lost and the
effectiveness of current strategies is unknown, and poor morale
or other workplace issues continue unresolved.
509
Review of Personnel Turnover Personnel turn over rates are reviewed to uncover the root cause
for any abnormally high levels, such as problems with leadership,
personality conflicts, excessive workloads, unreasonable
deadlines, unpleasant physical working environment and/or work
conditions. Exit interviews are conducted to gather feedback for
improvement where such opportunities present. Succession
plans are in place to provide a safe and sufficient level of
experience as others move on and continuity of safe working
arrangements.
The risk is that valuable experience is lost which may indirectly
impact on the ability of the organisation to conduct its activities
safely, and the opportunity to correct problems or other
underlying issues is lost.
510
Safe System Elements Definition Criteria , Scope and Key Risks

OHS Policy An OHS policy is in place that conveys management’s intention
and attitude towards safety. It is one expression of
management’s will which may be used to motivate all
employees to behave in a certain way and uphold certain
attitudes. The credibility of the policy is witnessed by the
consistency of management’s actions and responses to daily
situations.
The risk is that there will be no direction on OHS issues and
employees will not know the organisation’s attitude towards
OHS, or what is expected from them.
Goal Setting Goals and milestones should be set with sufficient detail to
determine whether OHS issues are improving, unchanged or in
decline. These goals should be consistent the organisation’s
OHS policy and the goals should be reviewed at regular
intervals. Care should be taken to ensure that goals are realistic
and achievable; specific; measurable; have been adequately
resourced and undergo periodic review. Performance measures
are aligned with goals and policies.
The risk is that OHS issues may appear too overwhelming to
address systematically and that lack of feedback on recent
efforts may lead to apathy.
Accountability Accountability for OHS issues has been allocated and there is
sufficient follow through and consequences in place if these are
not met to ensure that these responsibilities are taken seriously.
The accountability should be commensurate with the authority
of the position, and sharing of accountabilities avoided to
prevent responsibility from being diffused.
The risk is that no one will take responsibility for OHS actions
and so OHS duties will be ignored.
Due Diligence Review/ Gap A list of projects has been identified that would bring the
Analysis organisation into regulatory compliance, with responsibilities
allocated and time frames for completion identified. The list is
reviewed on a regular basis and demonstrable progress is
evident.
The risk is that legal compliance with OHS duties will be ignored
with the potential for fines, penalties or litigation as a result of
breaches.
Resource Allocation/ Sufficient resources have been allocated to OHS issues to
Administration demonstrate that commitment is real and goals are achievable.
Funds are protected from “reallocation”. Time is available and
sufficient to address OHS issues, and has been budgeted for in
The risk is that there will be insufficient funding to rectify OHS
issues identified.
Contractor Management Contracts are reviewed for suitability to the OHS program and
contractors are managed in such a way that their presence does
not create additional workplace hazards due to lack of familiarity
and local knowledge; and all those persons who may be
impacted by their activities are informed and aware of any
potential hazards that may arise. Areas of control and
responsibility are clearly delineated.
The risk is that contractors may injure or harm employees or
others at the work place as a result of their business
undertakings.
511
Procurement with OHS All new plant, equipment, materials, and services have been
Criteria purchased with OHS criteria taken into consideration. Provisions
are made to ensure that hazardous materials are reviewed prior
to purchase (see Hazardous Substances and Dangerous
Goods). Provisions for plant and equipment are installed safely
(see modifications). End users have been included in the
decision making process. Safety instructions are available and
training on new equipment, plant or services is provided where
necessary for safe operation. Technical or specialist expertise
has been acquired where written instructions are insufficient or
unavailable. There is clear delineation of the point where new
equipment or services have been accepted and OHS issues
resolved.
The risk is that new plant, equipment, materials or services will
be the cause of OHS problems and that it can be very
expensive to rectify the OHS issues retrospectively.
Supply with OHS Criteria All products supplied are provided in a safe state with OHS
criteria taken into consideration to ensure that the
client/customer is not exposed to harm when the products or
services are used according to the suppliers instructions with all
due warnings being heeded. All services are supplied in such a
way that safety has been considered and meets organisational
standards.
The risk is that unchecked or unreviewed products or services
supplied are the cause of injury or illness as well as potentially
exposing the organisation to litigation for breaches of OHS
duties.
Competent Supervision Persons that are placed in a position of authority and
supervision have the responsibility, talent/ technical ability,
social skills and experience necessary to do so.
The risk is that employees may be exposed to injury or illness
because the people supervising them did have the skills
Safe Working Procedures Sufficient safe working procedures are in place to enable duties
to be conducted consistently and to document controls and
preventive measures necessary to perform the job safely.
Consideration is given to the level of detail incorporated so that
there is a balance between providing sufficient information and
allowing workers to use their judgement and experience as
necessary, for example where too stringent or restrictive rules
may encourage violations. The procedures should be regularly
reviewed to incorporate improvements as these become
available, and the level of compliance assessed.
The risk is that employees will not know how to perform their job
tasks safely.
Communication Communication channels are available to facilitate the efficient
flow of information to perform workplace duties in a manner that
is safe and does not induce stress. This may include sufficient
contact with supervisors or colleagues, the provision of
communication equipment such as telephones, internet access,
local intranets, radios, access to noticeboards or newsletter,
meetings and other forums for exchange whether they be formal
or informal.
The risk is that critical information necessary to create a safe
working environment is available, but may be lost or
unavailable.
512
Consultation Employees’ opinions are considered and valued with respect to
changes that may affect their health, safety or well-being. Local
OHS regulations on the formation safety committees are
observed, and the committee chairperson has undergone
appropriate training to fulfil their tasks and duties. Meetings are
conducted on a regular basis with participation of a
management representative with sufficient authority to take
action on items identified as being in need of corrective action.
The minutes of the meetings are kept in a secure location and
made accessible to all employees. Attempts are made to
resolve disputes in-house before outside authorities are brought
in.
The risk is that the safety, health and well-being of employees
and others at the workplace may be jeopardised because they
were uniformed of changes before the changes actually took
place, were not updated about existing OHS issues, or because
they were uniformed about OHS information relevant to their
employment.
Legislative Updates A list of relevant OHS legislation and supporting codes and
standards has been complied and access to these documents
has been made available so the organisation knows what legal
obligations exist and has supporting information such as
standards or codes of practice available for reference. A system
is in place to ensure that updates are received so that the
information being acted upon is always current.
The risk is that out-of-date or incorrect or incomplete information
is used for actioning OHS issues, so inappropriate actions or ill-
informed decisions are made.
Procedural Updates Procedures are kept current to incorporate lessons learnt and
other improvements as these become available. A means of
removing out of date information is in place so that there is
confidence that only the most current procedures are in use.
Any obsolete information that is kept for archival purposes is
clearly identifiable as being superseded. Training on updated
methods and procedures is provided where the changes are
considered to be significant.
The risk is that out-of-date procedures are used that do not
include the latest information on how to avoid unsafe working
conditions.
Record Keeping/ Archives Records are archived in a safe and secure location, protected
from deterioration and damage by water or fire. The duration for
which the records are kept is in accordance with local OHS and
Privacy legislation and the confidentiality of health records is
enforced and respected. Regular back ups of electronic data are
made where their loss would have an impact upon the safety
and health of employees.
The risk is that critical records of employees’ health and safety
will be unavailable in the event of litigation or for purposes
513
Customer Service – Information is made available to end users to address any
Recall/Hotlines health or safety concerns encountered during the use of the
organisation’s products or services. Procedures are in place to
recall goods or services in a timely manner where a danger or
threat may place end users at risk after purchase. A document
trail is available to record the decision making process that
preceded the recall.
The risk is that the safety and health of a customer, client or
consumer is threatened because they were unable to access
critical information in a timely manner regarding the
organisations goods or services.
Incident Management A system is in place to capture information regarding incidents
that have occurred to avoid similar incidents from recurring in
the future. Attempts are made to address underlying causes,
whilst also putting in place actions to enable a quick recovery
from the situation. Root causes are pursued to the point where
they are within the organisation’s control or influence. Reporting
of incidents is encouraged with a view to improve rather than to
blame. Near miss/hits are also reported and decisions to
investigate based on likelihood or potential for more serious
consequences. Investigations are carried out by persons with
the appropriate range of knowledge and skills. A protocol for
reporting to external authorities notifiable events has been
established, and communicated.
The risk is that information that could prevent incidents from
recurring is lost and employees and others at the workplace
Self Assessment A list of questions has been compiled to ensure that outcomes
are being achieved on a regular basis and the key requirements
of OHS procedures are being adhered to in house. The purpose
is to determine the level of compliance; whether the
requirements are suitable and reasonable; and to ensure that
any practical problems with the daily working of procedures are
uncovered whilst the situation is still recoverable. Self-
assessments targeting particular areas where improvement is
sought are conducted on a frequent basis, for example monthly,
and items are independently spot checked to improve the
reliability of the results.
The risk is that the reasonableness and practicality of agreed
OHS actions are not tested and OHS goes off track and is
difficult to get back on track.
Audits A range of formal reviews of measures implemented to ensure
that the prime intention of the procedures is being met and that
specific criterion such as compliance with a regulation, standard
or organisational OHS requirement are addressed. Objective
evidence is available to support the findings. Specialist audits
may be necessary to determine risks in particular areas. The
frequency of audits will depend on the length of time that the
OHS systems have been in place, as established systems will
need less frequent audits than systems that are just being
introduced. The frequency may range from a yearly basis to
once every 3-5 years for specialist audits. Auditors utilised are
suitably qualified and experienced.
The risk is that predetermined requirements for good OHS will
not be met, and the actions necessary to achieve the desired
514
System Review A review of all the OHS systems in place to enable the
organisation to fulfil its duty of care to employees and others
affected by its business undertakings. Here the system as a
whole is examined to ensure that it has been set up correctly
and remains suitable in light of any organisational changes or
business acquisitions. Conducted typically on an annual basis.
The risk is that the effectiveness of the entire combination of
existing OHS prevention and control strategies remains
unknown, and there is no input for future directions in OHS.
515
Classification for Case Studies
Profile Operational Characteristics
Work processes are either simplistic or they may be

Routine
complex but “mastered” and performed automatically with
skill and precision. There is little scope for unplanned
events. The process outputs are known and unlikely to
change. Outcomes are predictable.
Examples: simple component manufacturing, assembly,

postal service, bakery, corner store, small businesses for
cleaning or lawn mowing, grocery store or newsagent.
Complex activities are undertaken, there is a high level of

Specialised
individual skill involved for which substantial training
(either academic or on the job) has been received and the
focus of business activities is narrow. There is the distinct
possibility of unforeseen events occurring, for which on
the job experience is necessary. A variety of related but
different process outputs are possible. Individual
outcomes are unique.
Examples: Health practitioner- doctors’ surgery; dentist;

educational institution; anaesthetist; artist, engineering,
designer, interior decorator, financial planner, hair stylists,
landscape gardening or executive chef.
Attempts are being made to gain an understanding of the

Progressive
processes with a view to improve. There is widespread
application of monitoring and the use of feedback. Both
upstream and downstream indicators are in use.
Outcomes are predictable but improvement is expected.
Examples: food or chemical manufacturers using batch

processes, software manufacturers, new businesses or
any business seeking to improve its basic operation.
Substantial understanding of internal processes has

Strategic Planners
already taken place, sub-processes are considered to be
“mastered” and the organisation is therefore in a technical
and financial position to look at newer methods and
consider the use of best practice. The organisation is
open to the possibility of change.
Examples: Multinational companies including

petrochemical giants with continuous manufacturing
operations, food or car manufacturers or airlines; national
government enterprises; property giants that build and
lease space such as shopping centres; international
technical specialists, service providers and fast food
chains.
516
3: Site Description
Question 1: What industry sector does this organisation fall into?
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Question 2: How many employees are there? How many executives are on site? How
many Administration/ Support Staff?
…………………………………………………………………………………………………………
………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Question 3: How large is the site? What is it surrounded by?
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Question 4: How would you describe the main business function?

…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Question 5: What system profile best describes this business?

………………………………………………………………………………………
517
Ranking Criteria
Ranking Criteria: Severity
Safety Health Environment Production Financial

Nuisance Nuisance Poor Housekeeping Minor Delay Petty Loss
No injuries. Annoyance. No injuries. No impact on environment. Minor delays in Up to $9,999.†
resumption of work.
Discomfort Discomfort Minor Loss of Containment Minor Disruption Minor Loss
First aid required. Short term medical treatment Spill/toxic gas release Delays in resuming work From $10,000 to
Short – term distress required. contained within work area. of at least one shift. $49,999.†
Short term distress No impact on environment.
Temporary Injury Reversible Illness/ Disease Moderate Loss of Containment Moderate Disruption Moderate Loss
Medical treatment required. Health problems that resolve Spill/toxic gas release Delays in resuming work From $50,000 to
Impact extends to family but is within six months. Impact on contained within work area. of more than one shift. $99,999.†
resolvable. Longer term family. Controlled with or without
distress. assistance of emergency
services. Small/transient
impact on environment.
Permanent Injury Permanent Illness/ Disease Major Loss of Containment Major disruption Major Loss
Extensive or multiple injuries. Permanent long term and Spill/gas release spreads Long term delays in From $100,000 to
At least one in patient severe health effects. outside work area. Controlled resuming production $199,999.†
hospitalisation. Trauma. with assistance of emergency
services. Minimal or temporary
impact on environment.
Life Threatening Terminal illness/ disease Critical Loss of Containment Business Continuity Critical Loss
Threat
Death of one or more people. Death of one or more people. Spill/gas release outside work Possible loss of business Above $200,000.†
Tragedy. area. Major impact on through inability to
environment. restart production
† The sums listed here are nominal and based on 2008 figures. Financial loss includes direct and indirect costs, for example, impact of loss of
reputation.
518
Ranking Criteria: Likelihood
Descriptor Examples of description

Highly The consequence is not likely to occur. Known history of occurrence in other organisations. Low probability
Unlikely of loss or harm
The consequence could occur at some time, but is not expected. History of at least one occurrence in the
Possible
organisation or similar setting. Moderate to low probability of loss or harm.
The consequence will probably occur in most circumstances. Known history of occurrences in organisation or
Likely
similar setting. High probability of loss or harm.
Almost The consequence is expected to occur in most circumstances. Common or repetitive occurrence in
certain organisation. Very high probability of loss or harm.
Overall Ranking Matrix
Likelihood
Severity
Almost certain Likely Possible Highly unlikely
Life Threatening OR Terminal Illness High High High Medium-High
Permanent Injury OR Long Term Illness High High Medium-High Medium
Temporary Injury OR Short Term Illness Medium-High Medium-High Medium Low
Discomfort Medium-High Medium Low Low
Nuisance Medium Medium Low Low
519
Appendix 14: The “Safe Place, Safe Person, Safe
Systems” OHS Management Assessment Tool
520
Safe Place Element

A general broad based risk assessment has been performed at some critical point in time from which improvement or decline in overall OHS risk
presenting to the organisation may be measured. This assessment must be recorded. It is assumed that all key areas of significant risk have
been considered. Areas requiring specialist expertise (internal or external) should be identified.
The risk is that the organisation does not know what OHS issues need to be addressed or how urgent they are so resources can not be allocated
effectively according to priorities, and the response will be reactive only.
Potential Risk Factors Possible Prevention and Control Strategies
No Generalised Risk Assessment/ Audit Formally Conducted Generalised Risk Assessment Conducted
Assessment Conducted but not Documented A Series of Assessments Conducted

Baseline Assessment Documented
No Baseline for Improvement Established
Significant Risks Identified
Significant Risks Not Identified
Priorities for Improvement Established
Limited Assessment Conducted – Narrow Scope
"
521
Safe Place Element
A specialised risk assessment that is concerned with fitting the task to the human and may cover a very broad range of issues including manual
handling, overuse injury, work organisation, human error and problems with information processing. However, in the context of “safe place
strategies” the scope is limited here to focusing on the layout of the workstation, manual handling, task design and examination of repetitive
tasks. Such assessments should be performed by person(s) with the appropriate qualifications and competencies to do so.
The risk is that an employee will sustain a strain/sprain injury or cumulative trauma. Whilst the injury may not be fatal, it may be very debilitating
and result in significant periods of lost time, and the injured workers may not be able to return to the same type of employment.
Possible Risk Factors Possible Prevention and Control Strategies
Workstations Generate Fatigue / Strain/ Eye Strain Lifting End User Input Sought User Friendly Workstations
of Heavy Loads Lifting Devices in Use Analysis of Work Movements
Repetitive Movements Twisting/ Bending Specialist Advice Sought where Necessary
Reaching
Standing/ Sitting for Prolonged Periods History
of Sprains/ Strains/ Back Injury
"
522
Safe Place Element
Access/Egress
This considers the quick and efficient entrance or departure of personnel to and from the physical workplace, including those with special needs
such as disabled employees. Emergency exit signage, walkways, handrails, stairways and fire doors should be in accordance with local building
regulations, and escape routes clear. This is particularly important in the case of emergency situations.
The risk is that someone may be unable to escape in an emergency situation or may be injured whilst trying to access or depart from their
workplace.
Exits Not Identified No Emergency Lighting for Emergency Exits Clear
Exit Signs Fire Doors Clear
Access to Fire Doors Restricted Handrails on
Walkways Unobstructed
Stairways/Walkways Absent
Stairways/Walkways/Rails Compliant with Local Regulations
Stairways/ Walkways not Inspected for Clear Access
Independent Emergency Exit Lighting
Minimum Width for Walkways not Observed
Disabled Access/ Egress Provided
Minimum Height for Rails not Observed
Presence of Disabled Persons
"
523
Safe Place Element
Plant/Equipment
This requires that all existing equipment or plant operates without causing harm. Where this requires specialist knowledge this must be pursued
with the supplier or designer, and end users and others affected must be consulted and their opinions duly considered. The hazards of rotating
machinery, pinch points, and crush injuries should be included here, as well as the safe use of vehicles (including forklifts) and working from
heights. Confined or dangerous spaces should also be identified. Refer to individual elements for noise and/or electrical for the potential of
plant/equipment to cause noise, vibration and electrical hazards.
The risk is that someone could be crushed, cut, impaled, hit or entrapped by the machinery
Confined Spaces Pits Restrictions on Use of Specialist or High Pressure Equipment
Work on Roofs Potential for Entrapment Machine Guarding
Cranes and Hoists Working at Heights Restrictions and Planned Maintenance for Use of Lifts/ Elevators/ Travelators
Exposed Rotating Parts Lifts/ Elevators/ Travelators Competency Requirements for the use Scaffolding/ Scissor Lifts/ Cherry Pickers/ Fall
Scaffolding Arrestors
Pinch Points Present Spray Painting Restrictions for Access to Roofs
Grinding Wheels Maintenance Registers for Cranes/ Hoists
High Pressure Equipment Restrictions on the Use of Ladders
Mobile Plant Forklifts Restricted Access and Identification of Confined Spaces
Welding Explosive Powered Tools in Use Spray Painting Booths

Procedures for Use of Grinding Wheels
Vehicle and Driver Checks
Requirements for Forklift Drivers
Competency Speed Limits Enforced Restricted Pedestrian Access
"
524
Safe Place Element
Amenities such as private, hygienic toilets and change rooms; provision of drinking water and a refrigerator/ microwave for mealtimes; infant
feeding facilities and showers where the need exists. The working environment for indoor workers should be comfortable and meet relevant
standards and codes for indoor air quality, ventilation and lighting. The potential for heat stress should be considered, which may be
exacerbated by humidity levels. Exposure to heat and cold may be particularly important considerations for outdoor workers (see radiation for
UV exposure). The special needs for divers or air cabin crew should also be considered where applicable.
The risk is that an uncomfortable work environment will affect their judgement or well-being which may place them at greater risk of other
injuries or illnesses or impair their performance and put others at risk.
Exposure to Heat/ Humidity (Heat Stress) Exposure to UV Air-conditioning Protection for Outdoor Workers
Exposure to Cold/Wind Poor Indoor Air Indoor Air Quality Checks Sun Protection - Shade
Quality
Protection from Cold/Wind Work/Rest Schedules
Poor Lighting/ Glare Poor Ventilation
Provision of Heaters/ Fans Directional Lighting
Light Spill On Site Canteen Even/Smooth Walking Surfaces Fluorescent Light Diffuser Covers
Overcrowding Distractions
Hygienic Meal Areas /Kitchen Catering Services
Pedestrian Access to Plant Necessary Roadways on Site
Hygienic Washroom Facilities/ Provisions for Nursing Mothers/ Disabled
Pregnant Women/ Nursing Mothers on Site Privacy-Mail/ Personal Effects Provision of Recreation/Social Areas
Disabled Persons on Site
Private Locker Area
Private Work Area / Reduced Distractions
"
525
Safe Place Element
Receipt/ Despatch
Receipt of supplies and raw materials is conducted so that any impacts on health and safety have been considered prior to ordering/purchase;
Safe despatch ensures that loading of finished goods does not result in harm, including any earthing requirements where applicable and the
product is transported safely. Plans for dealing with emergency situations in transit have been developed, necessary information and contacts
are available and training has been conducted for affected parties.
The risk is that employees or others may be harmed during receipt of materials being delivered, or handling, receipt, despatch and transport of
supplies and finished goods.
Loading Bays Heavy Loads Use of Forklifts/ Lifting Devices Earthing Facilities
Use of Heavy Transport Dangerous Goods Use of Specialist Contractors Universal Precautions
Loading Bays Hazardous Substances Transfer Hose/Coupling Checks for Maintenance
Worn Hoses Biohazards MSDS Available and Precautions Observed
Unloading/Loading Generates Static Safe Loading Platforms
Compliant Dangerous Good Storage Facilities
Plans for Emergencies in Transit Developed and Trailed
"
526
Safe Place Element
Electrical
All electrical equipment should be handled appropriately by those who are suitably qualified and kept in good working order. Other electrical
hazards include electric shock; static electricity; stored electrical energy, the increased dangers of high voltage equipment and the potential for
sparks in flammable/explosive atmospheres. Where live testing is necessary, only appropriately trained and qualified personnel should do so in
compliance with relevant legislation and codes.
The risk is that someone may be injured or fatally electrocuted or cause a fire/explosion by creating sparks in a flammable or explosive
atmosphere.
Electrical Equipment/Goods in Use Worn Cables Isolation Procedures Use of Authorised/ Qualified Repairers
High Voltage Equipment In Use Overloaded Lead/Cable Checks Circuit Breakers
Power Points Use of Residual Current Detectors High Voltage Procedures
Messy Power Leads Static Electricity Static Electricity – Use of Earthing Devices or Non-Conducting Materials
Generated
Lightning Protection
Use of Unqualified Personnel for Electrical Work
Live Testing Necessary
Breakdowns out of Normal Business Hours Difficulty in
Isolating Circuits
"
527
Safe Place Element
Noise
Noise levels or noise maps have been documented where the potential for harm exists, for example if a raised voice is necessary to hear a
conversation. In some cases baseline audiometry testing will be necessary. Specialist advice should be sought and attempts to remove the
source of the problem should be the first line of defence. Local regulatory requirements should be known. Comparison with regulatory limits
should take into account the length of exposure especially if shifts longer than 8 hours are used. Sources of vibration that impact on workers
should be identified, including power tools, seats on mobile plant equipment.
The risk is that workers will suffer ear drum damage, tinnitus (ringing in the ears) or industrially induced permanent hearing loss; vibration may
cause disturbed blood circulation to the hands and tingling or back pain when associated with seats.
Difficulty in Hearing – Need to Raise Voice to Communicate Noise Maps Established
Use of Power Tools/ Jack Hammers/ Chain Saws / Lawn Mowers Sound Insulation
Compressors or Other Noisy Machinery Worn Bearings Use of Sound Absorbing Materials on Walls/Floors
Sources of Vibration Riveting Use of Hearing Protection
Seats on Mobile Equipment/ Vehicles Drills Regular Maintenance of Noise Producing Equipment
Audiometry Testing
Strategic Layout of Noisy Equipment to Avoid Amplification
Use of Gloves for Power Tools
Soft Mountings for Vibrating Equipment/ Foam Cushioning
Use of Hearing Protection
"
528
Safe Place Element
Hazardous Chemicals
All hazardous substances and dangerous goods (explosives, pressurised chemicals, corrosives, oxidants, toxic chemicals, and irritants) should
be identified, listed and labelled and a register kept containing all MSDS. Where the use of a chemical does not require specific controls this is
noted in the register. Where specific controls are necessary, a reference to comply with the MSDS is noted, and where this is inadequate a risk
assessment has been prepared; these requirements are made known to all those who may be exposed, In some cases this will be dependent on
the quantities or volumes stored. Storage arrangements and inventory of dangerous goods should comply with local OHS and DG legislation.
Training for the precautions necessary during use, handling and storage should given to those at risk.
The risk is that someone may become ill from exposure to a hazardous substance whether it is immediate or long term, or harmed by fire or
explosion due to inadequate storage and inventory arrangements.
Identification of (for example) Environmental Monitoring Personal Monitoring
Irritants Dusts Toxics Biological Monitoring Clear Labelling
Corrosives Flammables Combustibles Hazardous Substances Register/ Inventory and Accessible
Oxidisers Asbestos MSDS Regularly Updated Application of Hierarchy of Controls
Hazards Associated with Substances Understood – Notation in Register or Risk
Assessment
Fume Cupboards/ Local Ventilation Exhausts
Compliant DG Facilities/Licence
"
529
Safe Place Element
Biohazards
Biological hazards include exposure to infectious agents, contagious diseases, bodily fluids (including blood) or other sources of protein that
may cause an allergic response – for example mould or dust mites. The source may include micro-organisms, infectious people; contaminated
food; contact with animals; rodents; plants/pollens; insects; mites; lice; sewerage; fungi or bird droppings; cooling water reservoirs and air
conditioning systems that may contain legionella organisms.
The risk is that someone may contract a fatal infection, become ill from an infectious disease, have an allergic reaction or develop long term
flu/asthma-like symptoms.
Identification of (for example) Vaccination Programs Universal Precautions
Infectious Diseases Exposure to Bodily Fluids- Blood/ Urine/ Barrier Methods Pest Control
Sewerage Damp Control Quarantine/ Isolation Procedures
Animals/ Insects Micro-organisms Travel Restrictions
Parasites/ Lice Avian Flu Allergens Allergen Awareness – Contingency Plans
Moulds Cooling Towers Rodents Legionella Testing Decontamination Procedures
"
530
Safe Place Element
Radiation
Sources of radiation may include ionising radiation such as x-rays and radioactivity; non-ionising radiation such as ultraviolet rays which may
affect the skin or eyes; near infra-red radiation affecting the eyes (welding, furnaces, molten metals); Lasers; the heating effect from microwaves
and mobile phone towers; and other extremely low frequency radiation with associated magnetic field exposure such as powerlines.
The risk is that someone could get radiation poisoning or damage their eyes or skin or develop skin burns or skin cancer.
X-Rays Lasers Restricted Access Warnings
Transmitter towers Welding Barriers/ Isolation Procedures
Radioactivity Infra Red/Ultraviolet Thermal Insulation
Sources of Radiant Heat- Furnaces/ Hot Glass / Molten Metal Welding Glasses/ Screens
Accredited Calibration/Maintenance Programs
Thickness Gauges
"
531
Safe Place Element
Disposal
All materials and waste products, including their containers, should be disposed of in a manner that complies with local regulations and that
does not cause harm either through immediate contact or as a result of transferring the substances elsewhere for disposal or dispersal. All
those in contact with the waste materials are made aware of hazards and precautions necessary to minimise the risks (see hazardous material/
dangerous goods). Also included here are the risks associated with hygiene and the handling of sharps.
The risk is that someone could be injured or get ill from contact with or exposure to waste chemicals or materials.
Asbestos Hazardous Chemicals MSDS/Risk Assessment Available
Industrial Wastes Biological Wastes Use of PPE or Other Precautions as Necessary
Sharps Unmarked Containers Use of Licensed Contractors
Use of Authorised Disposal Centre
Documentation Records Kept
"
532
Safe Place Element
Planning for the safe installation of new buildings or warehouses as well as the demolition of these structures to ensure the protection of
pedestrians and others in the workplace. Included here are the presence of asbestos in demolished structures; the safe connection or
disconnection of services such as gas, electricity, and telecommunications; protection from noise, debris or other projectiles; and the
possibility of falling into excavated areas.
The risk is that someone could be injured as a result of proximity to installation/demolition activities or as a result of unintentionally breaking
into service lines.
New Equipment Being Purchased, Not Previously Used. Specifications Agreed
New Facilities being Built Restricted Access/ Pedestrian Safety
Removal of Existing Infrastructure Commissioning Period Defined
Building Built prior to 1970 (Asbestos Use) Handover
Insulation Materials/ Fibro Asbestos Register and Plan / Use of Licensed Removalists
Service Diagrams Unavailable Dial Before You Dig/ Services Checks
"
533
Safe Place Element
Regular maintenance of equipment essential for safe operation is planned and critical spares are readily available to keep production running
without compromising safety. Repair work is carried out on failed equipment in a timely fashion by those that are qualified and competent to do
so.
Mechanical Integrity/Reliability Critical to Safe Functioning Planned Maintenance Schedule In Place
Lack of Funds Sound Cash Flow Management
After-Hours Operation Qualified/Suitable Repairers Critical Spare Parts on Site
Use of Unqualified Repairers Reporting of Malfunctions Preferred Suppliers
No Reporting System
Unreliable Suppliers
"
534
Safe Place Element
Modifications – Peer Review/Commissioning

Changes to existing infrastructure and plant/equipment are carefully controlled to minimise the impact that this may have on existing users and
others affected. Modifications may be minor or major, and should be peer reviewed by others with the appropriate skills and knowledge. New
plant or equipment is commissioned to ensure that all safety impacts have been considered before the project is handed over to the regular
users.
The risk is that the modifications result in an injury because the full impact of the changes was not thought through prior to implementation.
Modified Equipment Modified Facilities Peer Review Commissioning Period
Modified Services No Modifications Procedure – Modifications Procedure Links with Purchasing Established
Minor/ Major Formal Handover of Changed Equipment/Facilities
Prompt/ Check Sheets No links with Purchasing
"
535
Safe Place Element
Contingency plans are available to deal with situations such as fire, natural disasters, explosions, bomb threats, and hostage situations; vapour
clouds, sabotage, medical emergencies and other unwelcome events. Not only should these potential situations be identified, but the required
actions documented and practiced at regular intervals. Debriefing sessions are held after the drills to identify areas in need of improvement.
Critical emergency equipment, such as alarms, smoke detectors, fire sprinklers, the correct type of extinguishers, back up generators (where
applicable) are provided and maintained.
The risk is that in the event of an emergency situation people will be unable to react appropriately (for example, evacuate safely or respond
effectively, which may lead to increased casualties, panic and trauma.
Possible Risk Factors Potential for Explosion Possible Prevention and Control Strategies
Potential for Bomb Treat Potential for Hostage Emergency Plans
Situations/ Kidnapping
Emergency Assembly Areas Identified
Potential for Terrorism Potential for Natural
Disaster Ready Access to Critical Contacts/ Phone Numbers
No Smoke Detectors Emergency Drills - All Persons Involved
No Emergency Back-up Generators Plans Regularly Updated
No Sprinklers No Warning Systems Debriefing Sessions/ Lessons Learnt
No/ Insufficient Fire Extinguishers

No Documentation/ Contact Lists
"
536
Safe Place Element
Security – Site/Personal
Only authorised persons who have been informed of relevant site rules enter the workplace. Persons working alone should be able to contact
help in case of an emergency (medical or otherwise) and precautionary measures have been put in place to reduce threats of bodily harm.
Provisions exist for removing unauthorised persons or unwelcome visitors.
The risk is that the personal and physical safety of employees is compromised by the entry of unauthorised persons onto the site or because
they are isolated from emergency assistance.
Lone Workers Valuables/ Cash on Site Site Security Checks Secure Premises
Dangerous Areas (from Public access) Young Workers Communication Equipment Available - Mobile Phones/Pagers
on Site Duress Switches Used
Contact Angry/Distressed Customers/Clients Potential for Child
Restricted Access – Intercoms and/or Use of Physical Barriers
Custody Disputes
Lone Worker Procedures/ Communication Protocols
Contact with Mentally Disturbed Patients
Contact with Persons Under the Influence of Substance Abuse
"
537
Safe Place Element
Housekeeping
The workplace should be kept in a clean and tidy state to avoid trips, slips and falls. Walkways should not be blocked. Spillages should be
cleaned up immediately. Fire extinguishers should be checked and maintained. Hoses should be returned and empty containers and pallets
stored in appropriate locations. Unwanted materials should be sorted and put into storage or disposed of.
Untidy Premises Slip/ Trip Hazards Regular Inspections Checklists/Prompts Available
Unlabelled Containers Unidentified Files/Boxes Reporting Mechanism Spill Kits/ Signage Available
Clutter Spills/ Leaks Regular Waste Removal Smoke Alarms Checked
Equipment Not Returned to Correct Location Independent Observers
"
538
Safe Place Element
Inspections and Monitoring

Processes should be monitored and inspected regularly to ensure that equipment and facilities are being used and applied in the manner that
was intended and for which safety provisions have been considered and implemented. The processes are monitored to ensure that they are
operating within safe limits. Causes of abnormal operations are investigated and rectified.
The risk is that the process operates outside of designated safe limits which may lead to injury or other ill effects, or that equipment is used
inappropriately leading to damage to property, loss of production or other unwelcome events.
No Raw Material Input Measures No Output Measures Key Inputs (Raw Materials) to Process Identified
No Equipment Measures Processes not Well Output Measures Identified
Understood Key Equipment Settings/ Identified
No Checks to Ensure Correct Application
Experienced Operators
Inexperience
Method Checks
New Area – Experimental/ Pilot
Cross Referencing Available
Access to Networks/Best Practice Limited
Best Practice Knowledge/ Networking
Independent Checks
"
539
Safe Place Element
Operational Review
A periodic review is conducted that compares the current situation against a baseline assessment to indicate whether strategies implemented
for risk reduction have been effective or otherwise, and whether there have been any changes to plant, the organisation or legislation that may
impact on the risk presented by the operation. Any adverse findings are dealt with.
The risk is that the effectiveness of current prevention and control strategies is unknown, so efforts and resources may have been wasted, and
the impact of changes on the operations.
No Periodic Reassessments Conducted Off-Site Comparisons Made Against Baseline Data
Management Ready Access to Legislative Changes
No Improvement Plans
Level of Progress Assessed
No Checks for Effectiveness of Solutions Applied
Changes/ Plans Developed with Consultation
No Checks for Legislative Changes
Areas for Future Improvements Identified
No Consultation in Planning Phase for Changes
Management in Communication with Operations
"
540
Safe Person Element
Equal Opportunity/Anti-Harassment
Policies are in place to ensure that all employees and others are treated with respect and dignity. There is zero tolerance towards bullying
and diversity is accepted in the workplace. Awareness programs have ensured that the intention of these policies have been made clear to
employees and management, as well as educating management on the forms that discrimination or harassment may take - including more
subtle manifestations such as holding back pay or entitlements; undue delays for provision of resources; spreading malicious gossip;
social exclusion; hiding belongings; role ambiguity; and career stagnation or uncertainty.
Presence of Minority Groups Young Workers Commitment to Equal Opportunity Anti-Harassment Policy
Senior Workers Pregnant Women Anti -Discrimination Policy Zero Tolerance of Work Place Bullying
Mothers with Babies/ Young Children Workers with Disabilities Family Friendly Work Arrangements
"
541
Safe Person Element
Accomodating Diversity
The workplace promotes an acceptance of diversity. Access for disabled persons has been provided, and special provisions exist for their
safe evacuation in case of an emergency. The special needs of young workers, pregnant or nursing mothers, and older workers are taken
into consideration. Where workers are known to have a pre-existing psychological condition, employers take care not to place such
employees into situations where they are at increased vulnerability. Translations or other means of communication are available for those
that have language barriers.
Language Barriers Ethnic Diversity Literacy Testing (Direct or Indirect) Interpreter Facilities
Multiple Languages in Use Workers with Mental/ Use of Visual Training Material Opportunity for Expression Available
Physical Disabilities Open/ Accepting Workplace Attitude
Presence of Minority Groups Presence of Special Interest
Comprehension Checks
Groups
"
542
Safe Person Element
Selection Criteria
A list of the skills, competencies and traits considered necessary to discharge the duties of a position competently and effectively has been
documented and forms part of the selection criteria (for example in position descriptions). Any pre-existing conditions that may be
exacerbated by the role have been identified to ensure that vulnerable persons are not at risk by taking the position.
The risk is that employees may not be capable of doing the jobs they are selected for, and vulnerable persons may be placed in a position
which they would be prone to injury or illness.
Job Requirements Could Endanger Vulnerable Persons Pre-employment Selection Criteria Set
Job Requirements Could Exacerbate Pre-Existing Conditions Aptitude/ Psychology Testing
Specific Qualifications are Necessary to Perform Role Competently Disclosure Required of Pre-Existing Conditions that may be Exacerbated by the
and Safely Role
Competency Testing
Reference Checking
"
543
Safe Person Element
Inductions - Contactors/Visitors
All visitors and contractors to the workplace are made aware of any hazards that they are likely to encounter and understand how to take the
necessary precautions to avoid any adverse effects. Information regarding the times of their presence at the workplace is recorded to allow
accounting for all persons should an emergency situation arise. Entry on site is subject to acceptance of site safety rules where this is
applicable. Also, specific contacts/hosts are designated to ensure compliance with local rules.
Accompanied Visitors on Site Visitor Log Inductions Available for Visitors
Unaccompanied Contractors on Site Inductions for Contactors Site Safety Rules Available
Unaccompanied Visitors/ Inspectors from Regulatory Authorities/ Staff Identification Contractor Identification
Service Providers on Site Visitor Identification Reference/ Record Checks
Performers/ Displays or Promotional Activities on Site Clear Directions/ Signage for Visitors and Contractors
Work Experience Students Public Access
No Reception Area No Visitor/ Contractor Log
"
544
Safe Person Element
Training
A training needs analysis has been conducted to determine what skills employees have and what skills are needed to perform their roles
safely and competently. Arrangements are in place to address any gaps that may exist. All employees and others affected have been made
aware of local procedures and protocols. Refresher training is provided at appropriate intervals to maintain skills and provide ongoing
protection from workplace hazards. Competency training has been scheduled according to the training needs analysis. All persons
conducting training are appropriately qualified to do so. Training records are maintained. Evidence of competencies is available.
Specific Skills are Necessary to Conduct Role Competently and Skills Inventory Exists – Training Needs Analysis Conducted
Safely Gap Analysis Carried Out Between Skills Required and Skills Present
Specific Skills are Necessary but Required Infrequently
Awareness Training for Site Specific/ Organisation Specific Procedures
Organisation/Site Specific Requirements
Refresher Training where Updating Skills is Important
Working With Children
Child/Student Protection Training
New Job Tasks or Requirements
Qualified Training Personnel Used
Working With Students
Training In New Procedures/Changes
Inexperienced Personnel
Evaluation of Training Undertaken
Changed Methods/Protocols
Training Documented/ Recorded
Unqualified Trainers Used
Job Growth/ Succession Plans
No Records
Job Stagnation Likely Without Skill Upgrade
No Skills Records/Inventory
"
545
Safe Person Element
Work Organisation: Fatigue

The individual arrangement of job tasks that constitute the role have been considered to ensure that the work load does not induce
unnecessary manual handling, overuse, undue fatigue or stress, and the required level of vigilance is able to be maintained over the work
period. Work breaks, pauses or other rotation of duties have been introduced where fatigue inducing conditions have been identified.
Fatigue may be of a physical or mental nature.
Shift Work Careful Shift Pattern Selection
Night Shifts Introduction of Work/ Rest Pauses
Long Shifts Job Rotation/ Enrichment
Routine Work – Little Variation Meal Breaks at Regular Times
Heavy Work Loads Bright Lighting/ Good Air Circulation During Night Shift
Production Pressure Analysis of Injury Data Patterns
"
546
Safe Person Element
Stress Awareness
Personal skills, personality, family arrangements, coverage of critical absences, resourcing levels and opportunities for employees to have
some control over work load are factored into ongoing work arrangements so as not to induce conditions that may be considered by that
particular employee as stressful. Plans are available for dealing with excessive emails and unwelcome contacts.
The risk is that the employee becomes overwhelmed by the particular work arrangements, and is unable to perform competently or safely
due to the particular circumstances.
Shift Work Training in Necessary Skills Prior to Promotion/ Transfer/ Increased Responsibilities
Night Shifts Consultation Before Changes Made
Long Shifts Plans to Cover Critical Absences
High Level of Responsibility Authority Commensurate with Responsibility Access to Necessary Resources
Frequent Critical Deadlines Consideration of Individual Family Circumstances
Young Families Adequate Staffing Levels
No Control Over Work Load Authority Commensurate with Responsibility
No Consultation Prior to Changes Negotiated Workloads
Lack of Necessary Skills
Covering of Absences/ Unforseen Staff Shortages
"
547
Safe Person Element
Job Descriptions – Task Structure

Job descriptions and daily tasks have been documented so that the employee has a clear idea of the expectations of the role and whether
they are able to fulfil all their obligations. Where a difference between work expectations and ability to fulfil these exist, channels should be
available to enable fair and equitable negotiation on behalf of both parties. Skills and authority levels are commensurate with
responsibilities allocated.
The risk is that people will not have the direction, skills or authority necessary to conduct their role competently, effectively and safely.
Undocumented Task Requirements Key Tasks Documented
Unclear or Vague Job Expectations Realistic Goals/ Expectations Documented
High Frequency of Wilful Violations Regular Feedback
Unique Situations/ Non-Routine Work Consultative Approach Prior to Changes
Expected Outcomes Often Not Achieved OHS Criteria Worked into Task Steps
Unrealistic Expectations Critical Steps Identified
Complex Task – Judgement/Experience Necessary Use of Judgement/Experience Acknowledged
No Opportunity for Feedback Procedures Not Over-Specified
"
548
Safe Person Element
Critical safe working practices are positively reinforced and unsafe behaviours discouraged. This may take the form of informal inspections,
unsafe act or observation programs, followed by suitable feedback. Observations may be overt or discreet. Employees are encouraged to
recognise hazards and take suitable precautions - including the acknowledgement of situations that they are not sufficiently skilled to deal
with whilst also watching out for the safety of their colleagues. Where reward programs are used for positive reinforcement of safe
behaviours, consideration is given to the use of variable, unpredictable reward schedules so that the benefits are maintained when the
reward is removed. Rewards may include praise, recognition or increased status.
Unsafe Job Habits Critical Safe Workplace Behaviours Identified
Little/ No Capital Available for Repairs or Safety Improvements Observation Programs in Place
High Repeat Rate for Slips / Trips/ Sprains/ Strains Positive Reinforcement of Desirable Work Practices
Production Pressures Feedback of Results Available
Checks to Ensure that Unsafe Behaviours are not being Inadvertently Reinforced
Careful Use of Rewards/ Recognition
"
549
Safe Person Element
Health Promotion
Healthy lifestyle choices are promoted and an awareness program exists to educate personnel on these issues. Topics may include good
nutrition, exercise, work-life balance, symptoms of substance addiction, quit campaigns, medical checks (prostate, bowel, breast, cervical)
and home or off-site safety tips.
The risk is that employees will suffer poor health or a lowered state of well-being which may predispose them to injuries or illnesses in the
workplace.
Low Morale Healthy Lifestyle/ Choices Information Available
Frequent Illness on Site Life/ Work Balance Promoted
High Incidence of Working Back After Hours Off-Site/ Safety at Home Promoted
Unaware of Healthy Lifestyle Choices Recreation Facilities Available
Unaware of Risk Factors for Disease/Illness Guidance to Accessing Specialist Health Services Offered
Safety Not Practiced in Home Environment
"
550
Safe Person Element
Networking, Mentoring , Further Education

Channels for networking have been established to assist performance in positions, especially where there is little on site help available. On
site mentoring or buddy programs have been established where more experienced personnel are available to assist new employees adjust
to their role and provide ongoing support. Pursuit of higher order skills and professional development are encouraged to grow job positions
and increase workplace satisfaction.
The risk is that employees will lose motivation or become apathetic which may place themselves or others at increased likelihood of injury
or illness.
Isolation from Others in Similar Industry Opportunities to Network Promoted
Significant Length of Time Since Qualifications Obtained Opportunities to Attend Conferences Available
Major Changes in Work Practices Since Qualifications Obtained Opportunities to Update Qualifications Promoted
Current Role no Longer Challenging Mentors Trained, Allocated/ Available
Unaware of Latest Trends/ Best Practice Literature/ Journals Available
"
551
Safe Person Element
Conflict Resolution
Mediation channels are available and/or supervisors have received special training to deal with differences of opinion, relationship
breakdowns or personality clashes before the situation reaches the point where workplace performance has been impaired and/or is
noticeable by other colleagues.
The risk is that employees are unable to work as part of a team and this may affect their ability to carry out their roles competently and
safely.
Personality Clashes Opportunities to Express Concern Available
Inflexible Attitudes Mutual Respect
Rejection of Advice or Guidance Opportunities Available to Reconcile Differences
Micromanagement Consultative Approach
No Mechanism for Feedback Independent Checking of Work Practices
No Mediation Facilities Available Grievance Procedures Available
Reluctance to Delegate Appropriate Matching of Personality Types/ Managerial Styles
No Consultation Prior to Changes
"
552
Safe Person Element

Persons experiencing problems of a personal nature such as the breakdown of significant relationships, grief, substance abuse, or other
emotional problems may access help in a confidential environment and receive the necessary support to enable them to continue their work
duties without compromising the safety or health of others in the workplace.
High Stress Environment Experience of Recent Grief/ Provision of Professional and Confidential Employee Assistance
Loss
Counselling Skills in-House or Access to Off-Site Counselling
Evidence of Substance Abuse Single Parent Families
Direction to Specialist Programs Where Necessary
Lack of Support Network Financial Pressures
Serious Health Concerns
"
553
Safe Person Element

Personal Protective Equipment (PPE) is used where other options to minimise the risk are unavailable or inadequate. All PPE supplied has
been carefully selected to ensure that it meets any standards applicable, is fit for purpose and is fitted correctly. The potential for creating
other hazards by the application of the PPE selected has been carefully considered and the potential for such impacts minimised.
The risk is that PPE selected will not provide the protection expected (because of poor selection, poor training, poor fit or poor
maintenance) or may even be the cause of additional workplace hazards.
No Attempt to Address the Root Cause of the Hazard Applicable Standards/Codes Consulted Prior to Purchase
Specialist Advice Not Sought Training on Correct Use Provided Knowledge of Best Practice
Relevant Standards/Codes Unknown Specialist Advice Sought PPE Maintained/Stored Correctly
PPE not Fitted Fit Testing Records of Maintained of Training and Supply
Effectiveness of PPE Used Unknown
PPE not Used Correctly
PPE not Maintained Correctly
PPE not Stored
"
554
Safe Person Element
Provisions for first aid are available that meet local regulations including the numbers of suitably qualified first aiders and sufficient
quantities of first aid materials. Qualifications are kept current and first aid stocks regularly replenished. A register of workplace injuries is
kept that meets local OHS regulations and notification of incidents to statutory authorities is observed as required.
The risk is that the adverse effects and trauma associated with injuries and poor injury management will be greater and take longer time to
heal, and OHS regulations will be breached.
Local Regulatory Requirements for First Aid Provision Unknown Compliant First Aid Facilities
Local Legal OHS Reporting Obligations Unknown Correct Number of Appropriately Qualified First Aiders on Site/ Refresher Training
No /Insufficient First Aid Supplies and Equipment Provided
No/ Insufficient Numbers of Currently Qualified First Aiders Restocking of First Aid Materials Consumed
Sufficiently Detailed and Compliant Records Available
"
555
Safe Person Element
Workers Compensation/Rehabilitation
Provisions are made to compensate injured workers for lost time and medical/related expenses. Assistance is provided for returning injured
or ill employees back to the workplace in an agreed timeframe without exacerbating their current condition and to offer meaningful
employment where such opportunities exist according to the following hierarchy – same job/ same workplace; modified job/ same
workplace; different position same workplace; similar or modified position/ different workplace; different position/ different workplace. A
return to work co-ordinator has been appointed either internally or externally to meet local OHS regulations. All parties are kept informed of
progress and developments. Systems are in place to ensure that injured workers are not returned to the unaltered workplace that injured
them.
The risk is that injuries will be exacerbated, that time away from the workplace will be increased and that the psychological effects of the
injury and loss of confidence will be heightened.
Local Regulatory Requirements for Workers Compensation Rehabilitation Provider Allocated
Unknown
Rehabilitation Expertise Outsourced
Inability to Provide Rehabilitation within Organisation
Return To Work Co-ordinator Allocated and Trained
No Liaison Between Parties
Transparent Communication
Lack of Local Medical Expertise
Alternate Duties Program Available
Limited Alternative Opportunities
Return to Work Policy/ Program
"
556
Safe Person Element
Health Surveillance
Pre-employment medicals have been undertaken to provide baseline information on the employee’s current state of health. Examinations
may include lung function tests, blood or urine samples for biological monitoring, chest x-rays and audiometric testing. Where known
hazardous substances are present in the workplace, this surveillance may be subject to compliance with local OHS regulations. Health
surveillance is conducted from which the health of workers exposed to specific risks can be monitored (including biological monitoring) and
the effectiveness of current control strategies may be evaluated
The risk is that (i) employees may be placed in situations where their health may be damaged; and (ii) the effectiveness of current control
measures will be not be known, that employees health will be endangered, a baseline for claims purposes will not exist and that local OHS
regulations may be breached.
Use of Agents Identified by Local OHS Regulations for Health Baseline and Ongoing Surveillance for the Following as Appropriate
Surveillance Personal Monitoring
Use of other Hazardous Chemicals
Potential for Hearing Loss
Environmental Monitoring
Exposure Standards Unknown/ Action Levels Not Set
Audiometric Testing
Effectiveness of Engineering/Administrative Controls Measures Not
Medical Checks/ Screening
Established
Documentation and Record Keeping of Health Surveillance Records
No Records
Analysis of Health Surveillance Results and Action Levels Set
"
557
Safe Person Element
Performance appraisals include criteria for safe work practices and observation of site safety rules, housekeeping, and the display of safe
working attitude. OHS responsibilities should be commensurate with the level of responsibility and authority bestowed. Employees and
management setting good examples for workplace safety should be encouraged and valued.
The risk is that desirable OHS work behaviours and attitudes will not be reinforced, and that inappropriate OHS attitudes or actions may be
encouraged with employees believing that such behaviour or actions are acceptable.
Lack of Consistency Between Actions and Desired Safety Values Safe Working Criteria Included as Part of Job Description
Poor Modelling of Safe Behaviours Evidence of Genuine Safe Work Attitudes and Caring for Fellow Workers’ Safety
Token Compliance with Safety Requirements
Use of Injury Rates Linked with Performance Bonus Responsibility/Accountability Designated as Appropriate
Participation in Safety Meetings/ Training/ Inspections
"
558
Safe Person Element
Feedback Programs
Feedback may take the form of suggestion boxes, perception surveys (questionnaires to gauge employee attitudes, morale, and/or
perceived effectiveness of safety campaigns). Reward programs may be used to encourage participation in feedback activities.
The risk is that opportunities for improvement are lost and the effectiveness of current strategies is unknown, and poor morale or other
workplace issues continue unresolved.
Poor Workplace Morale Job Dissatisfaction Suggestion Boxes Evaluation Material
High Turnover Rates High Level of Disputes Perception Surveys Notice Boards
Work to Rule/ Going Slow News Letters/ E-Letters
Intention to Leave Use of Incentives to Encourage Feedback
"
559
Safe Person Element

Personnel turn over rates are reviewed to uncover the root cause for any abnormally high levels, such as problems with leadership,
personality conflicts, excessive workloads, unreasonable deadlines, unpleasant physical working environment and/or work conditions. Exit
interviews are conducted to gather feedback for improvement where such opportunities present. Succession plans are in place to provide a
safe and sufficient level of experience as others move on and continuity of safe working arrangements.
The risk is that valuable experience is lost which may indirectly impact on the ability of the organisation to conduct its activities safely, and
the opportunity to correct problems or other underlying issues is lost.
High Turn Over Rates Exit Interviews Conducted
Frequent Requests for Transfers Resource Levels Reviewed
High Stress Environment - Potential for Burn Out Reasons for Turn-Over/ Intention to Leave Identified
High Level of Litigation Feedback Used Constructively
Inadequate Resource Levels/ Financial Pressure Opportunities to Reduce Turn-Over Considered
Downsizing Succession Planning
"
560
Safe Systems Element
OHS Policy
An OHS policy is in place that conveys management’s intention and attitude towards safety. It is one expression of management’s will which
may be used to motivate all employees to behave in a certain way and uphold certain attitudes. The credibility of the policy is witnessed by the
consistency of management’s actions and responses to daily situations.
The risk is that there will be no direction on OHS issues and employees will not know the organisation’s attitude towards OHS, or what is
expected from them.
Multiple Sites Remote/ Off Site Management OHS Policy or OHS Values and Vision Statement
Large Organisation Lack of Focus/ Direction in OHS Evidence of OHS Policy in Practice Available
Uncertain Pathway to OHS Improvement Communication of OHS Policy to Interested Parties
OHS Viewed as an Impediment to Progress Review of OHS Policy to Reflect Current Issues
Consistency Between Management Actions and Policy Statement
"
561
Goal Setting
Goals and milestones should be set with sufficient detail to determine whether OHS issues are improving, unchanged or in decline. These
goals should be consistent the organisation’s OHS policy and the goals should be reviewed at regular intervals. Care should be taken to
ensure that goals are realistic and achievable; specific; measurable; and have been adequately resourced.
The risk is that OHS issues may appear too overwhelming to address systematically and that lack of feedback on recent efforts may lead to
apathy.
Large OHS Improvements Needed - Potentially Overwhelming Breakdown of Larger Goals into Manageable Proportions that Support
Policies and Values
Performance Measures not Aligned with Policies and Values
Scarce Resources to Address OHS Issues Use of “SMART” Criteria –Specific, Measurable, Achievable, Realistic
and Timely
Problems Areas Not Being Addressed
Regular Review of Progress and Setting of Carefully Targeted Positive
Performance Indicators
Communication of Results
"
562
Accountability
Accountability for OHS issues has been allocated and there is sufficient follow through and consequences in place if these are not met to
ensure that these responsibilities are taken seriously. The accountability should be commensurate with the authority of the position, and
sharing of accountabilities avoided to prevent responsibility from being diffused.
Fear of Personal Liability Accountability Allocated to those with the Competence, Authority and
Resources to Manage Roles Effectively
Rejection of Safety Vision/ Values
Selection of Accountable Personnel Willing and Confident to Take on
Insufficient Resources of Capital, Time, or Technical Competence
Responsibility
Persons in Positions of Authority Inexperienced with Finer Details of the Roles
Team Spirit- Everyone is Responsible for Safety in Some Way
Strong Desire to Transfer Responsibility for OHS Elsewhere
Co-Operation Between Business Units, OHS Responsibility Not Isolated,
but Integrated
"
563

A list of projects has been identified that would bring the organisation into regulatory compliance, with responsibilities allocated and time
frames for completion identified. The list is reviewed on a regular basis and demonstrable progress is evident.
The risk is that legal compliance with OHS duties will be ignored with the potential for fines, penalties or litigation as a result of breaches.
Pathway to Legal Compliance Unknown Due Diligence Plan Completed Projects Resourced and
Resources Secure
Lack of Specialist Expertise
Time Lines Agreed Upon Progress Regularly Reviewed
Lack of Access to Current Legislation and Supporting Codes and Regulations
Supportive Management
Lack of Support from Top Management
Unwillingness to be Informed
"
564
Sufficient resources have been allocated to OHS issues to demonstrate that commitment is real and goals are achievable. Funds are protected
from “reallocation”. Time is available and sufficient to address OHS issues, and has been budgeted for in projects and tenders.
Pending Sale/Transfer of Business Management Commitment to OHS Projects and Ongoing OHS Needs
Regrouping of Business Units Protection of Funds Allocated to OHS Causes
Potential for Safety Funding to be Transferred Elsewhere Provision of Sufficient Time to Fulfil OHS Requirements
Failure to Appreciate Realistic Time/ Resource Needs Provision of Necessary Expertise (In-house or External)
Lack of Communication with Other Business Units Regular Review of OHS Expenditure
Lack of Planning for Business Growth Resources Allocated to Cover Critical Absences
"
565
Contracts are reviewed for suitability to the OHS program and contractors are managed in such a way that their presence does not create
additional workplace hazards due to lack of familiarity and local knowledge; and all those persons who may be impacted by their activities are
informed and aware of any potential hazards that may arise. Areas of control and responsibility are clearly delineated.
The risk is that contractors may injure or harm employees or others at the work place as a result of their business undertakings.

Unclear Requirements Unclear Responsibilities Pre-Start Meeting/ Checklist Qualification/ Credential Check
Lack of Local Knowledge/ Protocols No Contractor Identification Those Impacted by Work Processes/Activities Informed Prior to Arrival
Undefined Work Scope No Risk Assessments Contractor Identification Induction Program – Hazard
No Safe Work Methods/ Safety Plan Lack of Credentials/ Qualifications Awareness
Unsafe Equipment/Tools Areas of Responsibility Delineated Liaison Person Appointed

Provision of Safe Work Methods/ Risk Assessments
Auditing Program to Ensure Compliance with Safe Working
methods/Risk Assessments an
"
566

All new plant, equipment, materials, and services have been purchased with OHS criteria taken into consideration. Provisions are made to
ensure that hazardous materials are reviewed prior to purchase (see Hazardous Substances and Dangerous Goods). Provisions are made to
ensure that plant and equipment are installed safely (see modifications). End users have been included in the decision making process. Safety
instructions are available and training on new equipment, plant or services is provided where necessary for safe operation. Technical or
specialist expertise has been acquired where written instructions are insufficient or unavailable. There is clear delineation of the point where
new equipment or services have been accepted and OHS issues resolved.
The risk is that new plant, equipment, materials or services will be the cause of OHS problems and that it can be very expensive to rectify the
OHS issues retrospectively.
OHS Criteria Associated with Large Increase in Procurement Costs General OHS Criteria Incorporated into Purchases
Isolation or Lack of Communication Between Users and Purchasing Officers Specific OHS Criteria Considered Prior to Selection of Purchased
Insufficient Time Lag Allowed to Understand and Take OHS Criteria into Account Goods/ Services After End User Consultation
for eg. “Urgent Requests” Consideration of OHS Criteria Included in Capital Expenditure Approvals
"
567
Supply with OHS Criteria

All products supplied are provided in a safe state with OHS criteria taken into consideration to ensure that the client/customer is not exposed
to harm when the products or services are used according to the suppliers instructions with all due warnings being heeded. All services are
supplied in such a way that safety has been considered and meets organisational standards.
The risk is that unchecked or unreviewed products or services supplied are the cause of injury or illness as well as potentially exposing the
organisation to litigation for breaches of OHS duties.
Inability to Foresee All End User Applications Goods /Services Supplied with OHS Criteria Taken into Consideration
Potential for Misappropriate Use of Final Product/Service Instructions Supplied for Safe Use Where Applicable
Competitors Undercutting by not Meeting OHS Criteria MSDS Sheets Supplied for Hazardous Materials
Supply without Knowledge of End User Application
"
568
Persons that are placed in a position of authority and supervision have the responsibility, talent/ technical ability, social skills and experience
necessary to do so.
The risk is that employees may be exposed to injury or illness because the people supervising them did have the skills necessary to know
how to protect them from OHS issues.
Supervisor Inexperienced or Functioning “Out of Area” of Expertise Supervisors with Appropriate Experience and Competence Allocated
On the Job Training Versus Formal Qualifications Supervisors Allocated Realistic Numbers to Supervise – Able to Give
Adequate Attention
Supervisor Under-Resourced
Authentic Leadership by Example/ Consistency
Supervisor Over-Loaded
"
569

Sufficient safe working procedures are in place to enable duties to be conducted consistently and to document controls and preventive
measures necessary to perform the job safely. Consideration is given to the level of detail incorporated so that there is a balance between
providing sufficient information and allowing workers to use their judgement and experience as necessary, for example where too stringent or
restrictive rules may encourage violations. The procedures should be regularly reviewed to incorporate improvements as these become
available, and the level of compliance assessed.
Methods Passed On, Not Documented Documented Safe Working Procedures with Sufficient Detail to Perform
Lack of Enforcement the Task Safely
Training on Safe Working Procedures
Recent Experience of Injury/ Illness During Process
Use of Safe Working Procedures Enforced
Perceptions of Weakness Associated with Known Safe Practices
Method for Alerting of Changes to Procedures
Conflict of Interests-Production Pressure to Increase Rates/Volume of
Throughput Education/ Awareness of Hierarchy of Controls
"
570
Communication
Communication channels are available to facilitate the efficient flow of information to perform workplace duties in a manner that is safe and
does not induce stress. This may include sufficient contact with supervisors or colleagues, the provision of communication equipment such
as telephones, internet access, local intranets, radios, access to noticeboards or newsletters, meetings and other forums for exchange
whether they be formal or informal.
The risk is that critical information necessary to create a safe working environment is available, but may be lost or unavailable.
Isolated Work Environments Use of Newsletters, E-Letters, Noticeboards, Posters
Noisy Environments Access to IT Equipment/ Telecommunications
Lack of IT Facilities Awareness/ Motivation Campaigns
Disinterest Security Measures for Access to Confidential Material
Time for Communication Activities not Factored into Daily Workload Up to Date Phone and/or Email Directories
Highly Confidential Material/ Potential for Security Breaches Meetings One on One with Teams
"
571
Consultation
Employees’ opinions are considered and valued with respect to changes that may affect their health, safety or well-being. Local OHS
regulations on the formation of safety committees are observed, and the committee chairperson has undergone appropriate training to fulfil
their tasks and duties. Meetings are conducted on a regular basis with participation of a management representative with sufficient authority
to take action on items identified as being in need of corrective action. The minutes of the meetings are kept in a secure location and made
accessible to all employees. Attempts are made to resolve disputes in-house before outside authorities are brought in.
The risk is that the safety, health and well-being of employees and others at the workplace may be jeopardised because they were uniformed
of changes before the changes actually took place, were not updated about existing OHS issues, or because they were uniformed about OHS
information relevant to their employment.
Autocratic/ Dictatorial Management Style Site Safety Committee
No Safety Committee on Site Valuing of Employee Opinions
Inflexible Plans - Reluctance to Accommodate Changes Forum Established to Make Pending Changes Known Before
Decisions Made Remotely and Expected to Filter Down Implementation
Period of Time Set to Consider Comment or Feedback on Proposed
Repercussions Expected (Direct or Indirect) for Questioning Management
Changes
Decisions or Policy
Transparent Decision Making Process
"
572
Legislative Updates
A list of relevant OHS legislation and supporting codes and standards has been complied and access to these documents has been made
available so the organisation knows what legal obligations exist and has supporting information such as standards or codes of practice
available for reference. A system is in place to ensure that updates are received so that the information being acted upon is always current.
The risk is that out-of-date or incorrect or incomplete information is used for actioning OHS issues, so inappropriate actions or ill-informed
decisions are made.
Lack of Funding to Update Reference Material Access to Update Alerts/ Subscription to Updating Service
No Large Corporate Infrastructure to Pool Resources Mechanism to Distribute Updates
Strained Relationships with Local OHS Authority Impact of Changes Assessed and Necessary Actions Implemented
Lack of Knowledge of Available Resources Removal of Superseded Information
"
573
Procedural Updates
Procedures are kept current to incorporate lessons learnt and other improvements as these become available. A means of removing out of
date information is in place so that there is confidence that only the most current procedures are in use. Any obsolete information that is kept
for archival purposes is clearly identifiable as being superseded. Training on updated methods and procedures is provided where the changes
are considered to be significant.
The risk is that out-of-date procedures are used that do not include the latest information on how to avoid unsafe working conditions.
Mechanics for Updating are Perceived as Tedious Mechanism to Trigger Updating from Procedure Authors
Numerous Copies in Circulation – not Web-Based Mechanism to Distribute Updates
Superseded Information not Removed From Circulation Training on Procedural Changes Implemented/ Recorded
Inability to Identify Latest Update – No Date/Revision Number on Documents Removal of Superseded Information
Responsibility for Updating Procedures not Allocated
"
574

Records are archived in a safe and secure location, protected from deterioration and damage by water or fire. The duration for which the
records are kept is in accordance with local OHS and Privacy legislation and the confidentiality of health records is enforced and respected.
Regular back ups of electronic data are made where their loss would have an impact upon the safety and health of employees.
The risk is that critical records of employees’ health and safety will be unavailable in the event of litigation or for purposes related to
improving or resolving OHS issues.
Storage Facilities Not Allocated Secure, Fireproof, Weatherproof Storage Facilities
Legal Requirements for Record Keeping Unknown Time Periods for Keeping Documents Identified and Recorded
Storage Facilities Not Fire/ Weather Proof Confidentiality Procedures in Place
Responsibility for Record Keeping not Allocated Records Maintained
Recent Moves/ Transfers of Premises Records Maintained and Kept for Time Periods Required by Legislation
"
575
Customer Service – Recall/Hotlines

Information is made available to end users to address any health or safety concerns encountered during the use of the organisation’s
products or services. Procedures are in place to recall goods or services in a timely manner where a danger or threat may place end users at
risk after purchase. A document trail is available to record the decision making process that preceded the recall.
The risk is that the safety and health of a customer, client or consumer is threatened because they were unable to access critical information
in a timely manner regarding the organisations’ goods or services.
History of Customer Complaints Recall Procedure in Place
No Recall Procedure in Place Hotline/ Customer Service Number Established
No Information Hotline/ Number Available Appropriate Technical Expertise Available to Handle Queries
No Expertise to Handle Queries Quarantine Facilities Available if Appropriate
Extreme Difficulty in Logistics of Recalling Product – Small Time Lags Between Official Communications Channels Established
Purchase and Consumption of Goods/Service Debriefing Mechanism Established
High Threat to Reputation/ Public Image if a Recall Occurred
Repercussions Expected (Direct or Indirect) if Recall Occurred
"
576
Incident Management
A system is in place to capture information regarding incidents that have occurred to avoid similar incidents from recurring in the future.
Attempts are made to address underlying causes, whilst also putting in place actions to enable a quick recovery from the situation. Root
causes are pursued to the point where they are within the organisation’s control or influence. Reporting of incidents is encouraged with a
view to improve rather than to blame. Near miss/hits are also reported and decisions to investigate based on likelihood or potential for more
serious consequences. Investigations are carried out by persons with the appropriate range of knowledge and skills. A protocol for reporting
to external authorities notifiable events has been established, and communicated.
The risk is that information that could prevent incidents from recurring is lost and employees and others at the workplace continue to contract
illnesses or be injured.
High Repeat Rate for Particular Injury/ Illness Types Injury/ Illness Recording
“Knee Jerk” Reactions to Individual Incidents Notification Meets Legislative Requirements
Tedious Paperwork Requirements Near Miss/ Hit / Unusual Incident Recording
Responses to Previous Incidents have been known to Create Problems Incident Screening
Elsewhere Quick Recovery - Stop Gap Measures
Reluctance to Report Incidents – Lack of Perceived Value
Root Cause Analysis
Personal Repercussions Expected (Direct or Indirect) for Reporting of Negative
Corrective Action Against Root Cause(s)
Events
Evaluation of Effectiveness of Measures
De - identified Reporting
Database for Records
Trend Analysis
Critical Incident Plan
"
577
Self Assessment
A list of questions has been compiled to ensure that outcomes are being achieved on a regular basis and the key requirements of OHS
procedures are being adhered to in house. The purpose is to determine the level of compliance; whether the requirements are suitable and
reasonable; and to ensure that any practical problems with the daily working of procedures are uncovered whilst the situation is still
recoverable. Self-assessments targeting particular areas where improvement is sought are conducted on a frequent basis, for example
monthly, and items are independently spot checked to improve the reliability of the results.
The risk is that the reasonableness and practicality of agreed OHS actions are not tested and OHS goes off track and is difficult to recover.
Key Outputs of Current Control/Prevention Strategies Not Identified Self Assessment Questionnaire Compiled
High Level of Non-Compliance with Local Procedures/Protocols Regular Interval Set for Use
Impractical or Unrealistic Requirements Areas Requiring Special Attention Targeted
New Procedures/ Protocols in Place Independent Spot Checking of Results
Areas of Weakness Suspected Feedback and Evaluation of Results
"
578
Audits
A range of formal reviews of measures implemented to ensure that the prime intention of the procedures is being met and that specific
criterion such as compliance with a regulation, standard or organisational OHS requirement are addressed. Objective evidence is available to
support the findings. Specialist audits may be necessary to determine risks in particular areas. The frequency of audits will depend on the
length of time that the OHS systems have been in place, as established systems will need less frequent audits than systems that are just
being introduced. The frequency may range from a yearly basis to once every 3-5 years for specialist audits. Auditors utilised are suitably
qualified and experienced.
The risk is that predetermined requirements for good OHS will not be met, and the actions necessary to achieve the desired OHS outcomes
are unknown.
OHS MS in “Set-Up” phase Competent Auditors Selected Qualified and Experienced
System Weakness Suspected Auditing Guidelines/ Questionnaire/ Standards Identified
Ability of Current System to Meet Requirements of Standards/ Legal Duties in Purpose of Audit Clear – System Validation or Verification
Question Reports Circulated within Reasonable Timeframe
Adequacy of Current OHS MS to Reflect Local Changes in Practices/ Structures
Recommendations Evaluated and Decisions to Accept or Reject
In Question
Suggestions Recorded
Failure to Deliver Expected Outcomes or Sufficient Levels of Improvement Progress Against Agreed Actions Monitored
System Stagnation
"
579
System Review
A review of all the OHS systems in place to enable the organisation to fulfil its duty of care to employees and others affected by its business
undertakings. Here the system as a whole is examined to ensure that it has been set up correctly and remains suitable in light of any
organisational changes or business acquisitions. Conducted typically on an annual basis.
The risk is that the effectiveness of the entire combination of existing OHS prevention and control strategies remains unknown, and there is
no input for future directions in OHS.
Effectiveness of Current Prevention/ Control Strategies Unknown or in Question Collation of Broad Range of OHS Measures including Monitoring
Information; Results of Medical Surveillance; Perception Surveys; Injury
Use of Outdated Prevention/ Control Methods
and Illness Statistics; Self Assessments; and Audits Reports
Insufficient Resources Currently Allocated for OHS Needs
Analysis of Data/ Results
No Data Collection
Suitability of Current System Evaluated
Separate Parts of System not Aligned
Recommendations Formulated & Documented
System Considered Bureaucratic
Improvements/ New Directions Implemented
"
580
Appendix 15: Case Study 1 Preliminary Results
Report
Summary
A framework of 60 OHS related elements has been developed to assess

the safe place, safe person and safe systems aspects of OHS
management within organisations. The framework was used at your
company for the purposes of assessing its management of OHS issues
and identifying areas for improvement. The results are based on evidence
made available at the time of the assessments.
The application of this framework was conducted at your company (a paint

manufacturer) between October and November 2007. This study found:
; Of the 60 elements in the framework, all were applicable to your site;
; Of these 60 elements applicable, your company had addressed 11

with formal systems and another 39 elements informally. The
predominantly informal approach implies less documentation and is
working well in most cases, but may present difficulties should any
litigation, claims or disputes arise in the future.
; The hazard profile of the company suggests that the most significant
risks are within the hardware and operating environment area,
followed by those hazards associated with people and the complexity
of human nature. This suggests that a high level of vigilance will
always be necessary to ensure safe operations; however this could
be greatly assisted by a more systematic approach, especially if the
operation wishes to expand.
; The preferred prevention and controls strategies in the company

involve safe place methods. These rely heavily on outside expertise,
skills and judgement. These can be vulnerable to differences in risk
perception, and may be influenced by the view of the particular
expert used, and their field of specialty. It is crucial that the entire
context of the operation is considered, and due consideration given
to the risks presenting from hazards that are not immediately
obvious, such as health effects. Also, it would be an investment to
582
develop some of this specialist expertise “in-house” amongst existing
personnel.
The organisation has very successfully addressed the elements of

Access/Egress; Amenities/Environment; Radiation (due to UV); Work
Organisation-Fatigue; Employee Assistance Programs; Accountability;
Resource Allocation/ Administration; and Customer Service-
Recall/Hotlines. Elements that are still in need of attention include: Health
Surveillance; Emergency Preparedness; Hazardous Substances and a
Due Diligence Review. current prevention and control methods have made
a significant impact on your overall risk ranking, so you are strongly
encouraged to continue your improvement efforts.
The results show that being a smaller organisation, that management are
very in tune with the operation and OHS matters are addressed in a timely
fashion. This provides the organisation with a number of distinct
advantages as far as communication and funding is involved. However,
there is less access to methods that are widely established to handle
organisational risks, so networking and establishing contacts with those
with such knowledge would be desirable and should be encouraged.
Furthermore, keeping up to date with legislative changes is most
important.
Where a high level of expertise is used to control inherently dangerous

operations there is also the risk that people may become desensitised to
the actual level of risk if they have not experienced a recent injury.
Management need to be aware that this may occur, and seek to ensure
that all safety measures provided continue to be used as intended.
Management should be commended for the level of risk reduction that has
already been applied, their clear dedication to the welfare of their staff and
their ability to appoint committed personnel in key areas of responsibility.
583
Background
Traditionally there are four methods for dealing with organisational risks:
eliminate the risk,
retain and manage the risk,
transfer the risk, which may involve outsourcing, contracting or the
like, or
minimising the financial impact through insurance or compensation.
Risks that have been eliminated are relatively easy to handle, providing
that elimination has really occurred. Risks that are transferred are also
operationally easy, provided that suitable safeguards check the nature,
suitability and viability of the transfer option. Difficulties are most
commonly encountered when there has been a decision to retain and
manage the risk in-house. Typically this has been managed through the
application of the traditional hierarchy of controls, involving:
elimination
substitution
isolation
engineering controls
administrative controls, and finally
personal protective equipment.
While this model has become formalised by most OHS authorities, it does
not deal effectively with the entire range of hazards and risks that currently
confront employers. After years of focusing on establishing a safe place
(which is certainly not without merit), other psychosocial and
organisational hazards are emerging as formidable issues to be
contended with. The current risk assessment and control model is
problematic for such risks. Expanded tools are becoming necessary to
accommodate the changing landscape of workplace hazards and risks.
The strategies in Table 1 are suggested to provide a greater range of risk
control options.
584
Table 1: Guidance on risk reduction strategies
Descriptor Description Examples
Designing out with peer review and end user input,

At the facility
Safe place substitution, engineering controls — isolation and barriers,
and hardware
strategies ergonomic interventions, signage, inspections and
level
monitoring.
Equal opportunity/anti-harassment policies, employee

selection criteria, training needs analysis, education and
Safe person At the training, behaviour modification, employee assistance
strategies individual level programs, health promotion, health surveillance, PPE,
rehabilitation, perception surveys and feedback programs,
performance appraisal.
Clear lines of responsibility, due diligence reviews,

Safe resource allocation, defining OHS requirements up front,
At the
systems consultation and communication, competent supervision,
managerial and
strategies methods to ensure access to latest information regarding
operational
both legislation and local procedures, measurements and
level
monitoring in place, self assessment, internal audit and
system reviews.
Although it is generally considered that hazards of the physical working

environment should be addressed first, this may not be appropriate for
organisations where the workplace is not fixed (for example when
employees work off-site) or for cases where high levels of skill are
necessary (for example where advice is offered such as engineering
design work) and the duty of care extends mostly to “others” affected by
the business undertakings rather than direct employees. In these cases,
having the appropriate skills is crucial. If not conducted competently, the
potential for harm generated by employee activities may be greater than
the possibility of harm arising from within their physical working
environment.
Similarly, on an organisational level it is better to identify OHS criteria for

any planned acquisitions or undertakings, new developments or workplace
modifications rather than to deal with the consequences of any
subsequent harm caused. The use of consultative mechanisms should be
acknowledged as a primary preventive strategy for ameliorating
managerial hazards. Genuine management commitment to OHS values
and sincere equal opportunity and anti-harassment policies may be just as
585
effective on a psychosocial and managerial level as “designing out”
hazards of the physical environment.
As a general guideline, risk control strategies dealing with the conceptual,

design, or planning conceptual stages should always be considered as a
higher order control activities. The order of preference within each of these
three areas depends on whether they are planning, implementation,
measurement or review activities, as for the classic management (or
Deming) “Plan Do Check Improve” cycle. Planning activities represent
higher order strategies than implementation activities, and these in turn
rate higher than measurement or monitoring activities. Contingency
measures that address hazards when risk control plans have failed are
also necessary, even if the need to invoke these actions is undesirable.
It can be seen that many of the possible risk control options form part of
the building blocks of occupational health and safety management
systems (OHS MS), such as operational controls, emergency response or
injury management.
The strategic application of OHS MS building blocks may form a

comprehensive OHS risk defense system, the ultimate objective of the risk
management process. The safe organisation of the future will therefore
assume a more holistic, integrated approach to safety and health,
ensuring the effective coverage of physical, psychosocial and managerial
hazards.
This integrated approach may unfold by default, simply by considering a

wider context of potential hazards. This, combined with other
developments, such as making risk assessments accessible and visible
documents, training on problem solving skills and educating employers on
the use of long term strategies such as safe design and supply, will
resurrect the practical application of the risk management process and
ensure its ongoing value to OHS management in modern organisations.
586
Summary Results
Framework charts
Chart 4: Risk Profile With Interventions and Prevention Strategies in Place

Harassment
Inductions-Contractors/ Due Diligence Review/ Gap

Plant/ Equipment
Visitors Analysis
Administration
Receipt/Despatch Work Organisation-Fatigue Contractor Management

Criteria
Noise Job Descriptions Supply with OHS criteria
Hazardous Substances Behaviour Modification Communication
Biohazards Health Promotion Consultation
Radiation Competent Supervision
Further Education
Disposal Conflict Resolution Safe Working Procedures
Employee Assistance
Programs
Preventive Maintenance/ Personal Protective
Procedural Updates
Repairs Equipment
Commissioning
Inspections/ monitoring Feedback Programs Audits
Review of Personnel
Operational Risk Review System Review
Turnover
587
Chart 5: Risk Profile Without Interventions and Prevention Strategies in Place

Harassment

Plant/ Equipment
Visitors Analysis
Administration
Electrical Stress Awareness Procurement with OHS Criteria
Noise Job Descriptions Supply with OHS criteria
Networking, Mentoring and

Further Education
Employee Assistance
Programs
Procedural Updates
Repairs Equipment
Commissioning
Review of Personnel
Turnover
588
Chart 6: Level of Formality Applied and Gap Analysis

Harassment

Plant/ Equipment
Visitors Analysis
Administration

Criteria
Noise Supply with OHS Criteria
Structure
Further Education
Employee Assistance
Programs
Procedural Updates
Repairs Equipment
Commissioning
Review of Personnel
Turnover
Priority Key for Level of Formality and Gap Analysis
Formal Not There Not Applicable

Well done
Informal Low Risk
589
before and after is large, the controls have made a significant impact.
Figure 1: Initial and Final Scores - Safe Place
Receipt/Despatch
Modifications
Plant/ Equipment
Disposal
Electrical
Housekeeping
Noise
Biohazards
Radiation
Access/Egress
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium-High
Risk
590
Figure 2: Initial and Final Scores - Safe People
Health Surveillance
Selection Criteria
Workers' Comp/Rehab
Training
Inductions Visitors/Contractors
Job Descriptions
Feedback Programs

Networking, etc
Health Promotion

Stress Awareness
Conflict Resolution
Equal Opportunity

0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium-High
Risk
591
Figure 3: Initial and Final Scores - Safe Systems
Legislative Updates
Due Diligence/ Gap Analysis
Incident Management
Consultation
System Rewiew
Audits
Self-Assessment
Goal Setting
OHS Policy
Procedural Updates
Supply with OHS
Customer Service
Communication
Resource Alloc/ Admin
Accountability
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium-High
Risk
592
of hazards, closely followed by those associated with people and the
complexities of human nature. This is due to the inherent high risk
associated with the nature of the operation and the need to ensure that
processes are conducted with a high level of vigilance and expertise.
Personnel need to be fully alert to ensure that risks are well controlled.
Figure 4: Hazard Distribution– No Interventions and Strategies
Safe Systems
30%
Safe Place
37%
Safe Person
33%
Figure 5 demonstrates how safe place strategies have been used to

reduce the overall risk rating of the operation. However, an number of
significant risks still remain, especially relating to the “safe person” area.
Figure 5: Risk Distribution– with Interventions and Strategies in Place
Safe Systems Safe Place

32% 32%
Safe Person
36%
593
Figure 6: Risk Reduction after Interventions Applied
70
60
50
Risk Ranking
40
30
20
10
0
Legend Without Interventions With Interventions
Figure 6 illustrates the effectiveness of risk reduction strategies already

applied. It should be remembered that high reliance on safe person
strategies such as the use of PPE is limited by the complexities of human
nature – and the safe guards are only able to be effective if they are being
used correctly and for their intended purpose. A number of safeguards that
were supplied by management were not being used as required. This can
occur when people become desensitised to the level of risk because they
are using it every day without experiencing negative consequences. This
“normalisation” of danger can be minimised by refresher training; the
reporting of near misses; reinforcement of hazards in meetings and
informal talks; as well as the circulation of alerts of incidents in similar
industries.
Finally, a list of potential hazards on site needs to be available to inform

any visitors or contractors who may be visiting the site. Without this crucial
information, these people are unable to protect themselves. Whilst this
may be provided verbally, should an incident occur, the organisation would
be better able to demonstrate they had used due diligence if such
evidence was formalised.
594
Case Study 1 Main Findings - Element by Element
Assessment overall OHS risk presenting to the organisation may be measured. This assessment must be recorded. It is assumed that all key
areas of significant risk have been considered. Areas requiring specialist expertise (internal or external) should be identified.
There is documentation in this area regarding the safety and environmental aspects of the operation. However, more
information is needed on the potential health impacts. Furthermore, the information that is available could be used to
greater effect to inform necessary parties of potential hazards on site.
Ergonomic Evaluations A specialised risk assessment that is concerned with fitting the task to the human and may cover a very broad range of issues
Manual handling assessments have taken place informally and key needs have been addressed. However, these rely on
the operators using the provisions as recommended. Refresher training in this area would further improve this score.
595
Access/Egress This considers the quick and efficient entrance or departure of personnel to and from the physical workplace, including those with
special needs such as disabled employees. Emergency exit signage, walkways, handrails, stairways and fire doors should be in
accordance with local building regulations, and escape routes clear. This is particularly important in the case of emergency situations.
The risk is that someone may be unable to escape in an emergency situation or may be injured whilst trying to access or depart from
their workplace.
This has been handled well and the natural layout of the operation facilitates this.
Plant/Equipment This requires that all existing equipment or plant operates without causing harm. Where this requires specialist knowledge this must
(including forklifts) and working from heights. Confined or dangerous spaces should also be identified. Refer to individual elements for
noise and/or electrical for the potential of plant/equipment to cause noise, vibration and electrical hazards.
The key necessary hazards have been addressed well and have been assisted by specialist advice. Some remaining
issues to be dealt with including the speed of forklifts and improved ventilation in some areas.
Amenities/ Amenities such as private, hygienic toilets and change rooms; provision of drinking water and a refrigerator/ microwave for mealtimes;
Environment infant feeding facilities and showers where the need exists. The working environment for indoor workers should be comfortable and
meet relevant standards and codes for indoor air quality, ventilation and lighting. The potential for heat stress should be considered,
which may be exacerbated by humidity levels. Exposure to heat and cold may be particularly important considerations for outdoor
workers (see radiation for UV exposure). The special needs for divers or air cabin crew should also be considered where applicable.
This has been handled extremely well.
596
Receipt/Despatch Receipt of supplies and raw materials is conducted so that any impacts on health and safety have been considered prior to
ordering/purchase; Safe despatch ensures that loading of finished goods does not result in harm, including any earthing requirements
where applicable and the product is transported safely. Plans for dealing with emergency situations in transit have been developed,
necessary information and contacts are available and training has been conducted for affected parties.
The risk is that employees or others may be harmed during receipt of materials being delivered, or handling, receipt, despatch and
Due to the complex nature of the language of the chemicals involved, errors may easily arise due to subtle differences in spelling.
Some further means of cross-checking would assist in improving this score.
qualified personnel should do so in compliance with relevant legislation and codes.
The risk is that someone may be injured or fatally electrocuted or cause a fire/explosion by creating sparks in a flammable or
explosive atmosphere.
High inherent risk due to static but well controlled by high level of expertise. Documentation of key electrical
requirements for the site and a hazardous zone classification diagram that covered all areas would further improve this
result.
with regulatory limits should take into account the length of exposure especially if shifts longer than 8 hours are used. Sources of
vibration that impact on workers should be identified, including power tools, seats on mobile plant equipment.
The risk is that workers will suffer ear drum damage, tinnitus (ringing in the ears) or industrially induced permanent hearing loss;
vibration may cause disturbed blood circulation to the hands and tingling or back pain when associated with seats.
Noise levels are not a major cause of concern, however in the areas where hearing protection is required compliance
must be monitored..
597
Hazardous Substances All hazardous substances and dangerous goods (explosives, pressurised chemicals, corrosives, oxidants, toxic chemicals, and
irritants) should be identified, listed and labelled and a register kept containing all MSDS. Where the use of a chemical does not
require specific controls this is noted in the register. Where specific controls are necessary, a reference to comply with the MSDS is
noted, and where this is inadequate a risk assessment has been prepared; these requirements are made known to all those who may
be exposed, In some cases this will be dependent on the quantities or volumes stored. Storage arrangements and inventory of
dangerous goods should comply with local OHS and DG legislation. Training for the precautions necessary during use, handling and
storage should given to those at risk.
The risk is that someone may become ill from exposure to a hazardous substance whether it is immediate or long term, or harmed by
fire or explosion due to inadequate storage and inventory arrangements.
A large variety of solvents are used on site and these are generally handled well. However handling of powdered
substances could be improved and attention should be drawn to hazardous materials of construction to ensure compliance
with local regulations.
Biohazards Biological hazards include exposure to infectious agents, contagious diseases, bodily fluids (including blood) or other sources of
protein that may cause an allergic response – for example mould or dust mites. The source may include micro-organisms, infectious
people; contaminated food; contact with animals; rodents; plants/pollens; insects; mites; lice; sewerage; fungi or bird droppings
cooling water reservoirs and air conditioning systems that may contain legionella organisms.
Greater awareness of potential biohazards and prevention strategies, including risks for travellers, would improve this
result.
598
which may affect the skin or eyes; near infra-red radiation affecting the eyes (welding, furnaces, molten metals); LASER’s; the heating
effect from microwaves and mobile phone towers; and other extremely low frequency radiation with associated magnetic field
exposure such as powerlines.
High inherent risk due to UV radiation and outdoor activities but this hazard has been well addressed by engineering
design solutions.
Disposal All materials and waste products, including their containers, should be disposed of in a manner that complies with local regulations
and that does not cause harm either through immediate contact or as a result of transferring the substances / materials for disposal or
dispersal elsewhere. All those in contact with the waste materials are aware of hazards and precautions necessary to minimise the
risks (see hazardous materials/ dangerous goods). Also included here are the risks associated with hygiene and the handling of
sharps.
This is an area of high inherent risk but is well controlled via contractors.
Installations/ Planning for the safe installation of new buildings or warehouses as well as the demolition of these structures to ensure the protection
of pedestrians and others in the workplace. Included here are the presence of asbestos in demolished structures; the safe connection
Demolition
or disconnection of services such as gas, electricity, and telecommunications; protection from noise, debris or other projectiles; and
the possibility of falling into excavated areas.
breaking into service lines
This is an area where documentation and registers would be useful. Capital provisions may be necessary in this area for
safe demolition of older buildings in the future.
599
Preventive Regular maintenance of equipment essential for safe operation is planned and critical spares are readily available to keep production
running without compromising safety. Repair work is carried out on failed equipment in a timely fashion by those that are qualified and
Maintenance/ Repairs
competent to do so.
An area of high inherent risk but currently handled well by contractors.
users and others affected. Modifications may be minor or major, and should be peer reviewed by others with the appropriate skills
Review
and knowledge. New plant or equipment is commissioned to ensure that all safety impacts have been considered before the project is
/Commissioning handed over to the regular users.
The risk is that the modifications result in an injury because the full impact of the changes were not thought through.
The inherent risk in this area is high due to the static hazard. Documentation of internal requirements and some means of
cross-checking for all modifications to the factory would improve this result.
Emergency Contingency plans are available to deal with situations such as fire, natural disasters, explosions, bomb threats, and hostage
situations; vapour clouds, sabotage, medical emergencies and other unwelcome events. Not only should these potential situations be
Preparedeness
identified, but the required actions documented and practiced at regular intervals. Debriefing sessions are held after the drills to
identify areas in need of improvement. Critical emergency equipment, such as alarms, smoke detectors, fire sprinklers, the correct
type of extinguishers, back up generators (where applicable) are provided and maintained.
The risk is that in the event of an emergency situation people will be unable to react appropriately (for example, evacuate safely or
respond effectively, which may lead to increased casualties, panic and trauma.
This area is currently under improvement and a recent evacuation drill was conducted. However, the documentation
needs to be in place, and a systematic means of updating is required. Formal debriefs after drills should also be conducted
so lessons from evacuation exercises are captured, and techniques improved.
600
Security – Only authorised persons who have been informed of relevant site rules enter the workplace. Persons working alone should be able to
contact help in case of an emergency (medical or otherwise) and precautionary measures have been put in place to reduce threats of
Site/Personal
bodily harm. Provisions exist for removing unauthorised persons or unwelcome visitors.
There is high inherent risk here due to the nature of the operations, but the layout allows for good visual observation and
strangers would easily be recognised. However, if someone did want to enter the premises, there are no physical barriers to
prevent them.
Housekeeping The workplace should be kept in a clean and tidy state to avoid trips, slips and falls. Walkways should not be blocked. Spillages
should be cleaned up immediately. Fire extinguishers should be checked and maintained. Hoses should be returned and empty
containers and pallets stored in appropriate locations. Unwanted materials should be sorted and put into storage or disposed of.
The management are very particular in this area. There is some accumulation towards the back of the site, but the
production area is kept very well.
Inspections/ Processes should be monitored and inspected regularly to ensure that equipment and facilities are being used and applied in the
manner that was intended and for which safety provisions have been considered and implemented. The processes are monitored to
Monitoring
ensure that they are operating within safe limits. Causes of abnormal operations are investigated and rectified.
The risk is that the process operates outside of designated safe limits which may lead to injury or other ill effects, or that equipment is
used inappropriately leading to damage to property, loss of production or other unwelcome events.
601
Operational Risk A periodic review is conducted that compares the current situation against a baseline assessment to indicate whether strategies
implemented for risk reduction have been effective or otherwise, and whether there have been any changes to plant, the organisation
Review
or legislation that may impact on the risk presented by the operation. Any adverse findings are dealt with.
This is an area for consideration in light of upcoming changes in legislation requiring the elimination of certain
ingredients and changes in hazardous substances regulations.
602
bullying and diversity is accepted in the workplace. Awareness programs have ensured that the intention of these policies have
Harassment
The risk is of long or short term psychological harm. This may indirectly place them at greater risk of physical harm by affecting
their performance or judgement or putting them at risk of workplace violence.
To the smaller nature of the operation and the attitude of management, this does not pose a significant concern.
However, ensuring these same attitudes are reflected by personnel is a point that could be promoted.
Accommodating The workplace promotes an acceptance of diversity. Access for disabled persons has been provided, and special provisions exist
Diversity
workers are taken into consideration. Where workers are known to have a pre-existing psychological condition, employers take
care not to place such employees into situations where they are at increased vulnerability. Translations or other means of
Attention should be given to a number of young workers on site. These younger workers may be especially prone to
certain injuries such as sprains and strains; open wounds; fractures; bruising and crushing, and burns.
603
Selection Criteria A list of the skills, competencies and traits considered necessary to discharge the duties of a position competently and effectively
has been documented and forms part of the selection criteria (for example in position descriptions). Any pre-existing conditions
that may be exacerbated by the role have been identified to ensure that vulnerable persons are not at risk by taking the position.
The risk is that employees may not be capable of doing the jobs they are selected for, and vulnerable persons may be placed in a
Due to the hazardous nature of the operation and solvents in use, defining clear selection criteria would be valuable
for protecting potentially vulnerable persons and possible reducing any potential for litigation.
Inductions-Including All visitors and contractors to the workplace are made aware of any hazards that they are likely to encounter and understand how
to take the necessary precautions to avoid any adverse effects. Information regarding the times of their presence at the workplace
is recorded to allow accounting for all persons should an emergency situation arise. Entry on site is subject to acceptance of site
safety rules where this is applicable. Also, specific contacts/hosts are designated to ensure compliance with local rules.
This area has been addressed informally but would benefit from a more formal approach. This result could be
improved by a number of simple additions to the current methods, and some printed bookwork/ handouts.
Training A training needs analysis has been conducted to determine what skills employees have and what skills are needed to perform
their roles safely and competently. Arrangements are in place to address any gaps that may exist. All employees and others
affected have been made aware of local procedures and protocols. Refresher training is provided at appropriate intervals to
maintain skills and provide ongoing protection from workplace hazards. Competency training has been scheduled according to the
training needs analysis. All persons conducting training are appropriately qualified to do so. Training records are maintained.
On the job training is handled fairly well. Refresher training for manual handling and dealing with the dangers of static
would be useful. Consideration should be given to compiling a skills database so that is clear when people are due for
refresher training (for example First Aid) and also for future planning to increase the range of skills on site.
604
Work Organisation - The individual arrangement of job tasks that constitute the role have been considered to ensure that the work load does not
induce unnecessary manual handling, overuse, undue fatigue or stress, and the required level of vigilance is able to be
Fatigue
maintained over the work period. Work breaks, pauses or other rotation of duties have been introduced where fatigue inducing
conditions have been identified. Fatigue may be of a physical or mental nature.
This is handled well and the short shift arrangement reduces the potential for work-induced fatigue.
Stress Awareness Personal skills, personality, family arrangements, coverage of critical absences, resourcing levels and opportunities for employees
to have some control over work load are factored into ongoing work arrangements so as not to induce conditions that may be
considered by that particular employee as stressful. Plans are available for dealing with excessive emails and unwelcome
contacts.
The risk is that the employee becomes overwhelmed by the particular work arrangements, and is unable to perform competently
or safely due to the particular circumstances.
This is managed well for the majority of staff by management and the close, friendly atmosphere. However,
management need also to be aware of their own stress levels.
Job Descriptions -Task Job descriptions and daily tasks have been documented so that the employee has a clear idea of the expectations of the role and
whether they are able to fulfil all their obligations. Where a difference between work expectations and ability to fulfil these exist,
Structure
safely.
Job descriptions are available for operating staff, but not for key management staff. Further documentation in this area
to capture key requirements would improve this result.
605
Behaviour Modification Critical safe working practices are positively reinforced and unsafe behaviours discouraged. This may take the form of informal
inspections, unsafe act or observation programs, followed by suitable feedback. Observations may be overt or discreet.
Employees are encouraged to recognise hazards and take suitable precautions - including the acknowledgement of situations that
they are not sufficiently skilled to deal with whilst also watching out for the safety of their colleagues. Where reward programs are
used for positive reinforcement of safe behaviours, consideration is given to the use of variable, unpredictable reward schedules
so that the benefits are maintained when the reward is removed. Rewards may include praise, recognition or increased status.
Targeted campaigns to break unsafe working habits (such as failing to safety equipment provided) and to positively
reinforce desirable work practices would be of assistance here.
Health Promotion Healthy lifestyle choices are promoted and an awareness program exists to educate personnel on these issues. Topics may
include good nutrition, exercise, work-life balance, symptoms of substance addiction, quit campaigns, medical checks (prostate,
bowel, breast, cervical) and home or off-site safety tips.
The risk is that employees will suffer poor health or a lowered state of well-being which may predispose them to injuries or
Information to promote healthy lifestyle choices, diet and improve general well-being would be of assistance here due
to the number chemicals in use with health effects that are still under speculation.
Networking, Mentoring, Channels for networking have been established to assist performance in positions, especially where there is little on site help
available. On site mentoring or buddy programs have been established where more experienced personnel are available to assist
Further Education
The risk is that employees will lose motivation or become apathetic which may place themselves or others at increased likelihood
of injury or illness.
Investigating means of breaking into existing networks and finding out what courses available for further education
opportunities would improve this result. Also consider career path planning.
606
and safely.
The risk is substantially reduced by having an open atmosphere and reasonable management.
other emotional problems may access help in a confidential environment and receive the necessary support to enable them to
Programs
This is conducted with confidentiality and compassion. This element demonstrates that management are actively
involved with staff and able to provide guidance and direction for assistance when needed.
Personal Protective Personal Protective Equipment (PPE) is used where other options to minimise the risk are unavailable or inadequate. All PPE
supplied has been carefully selected to ensure that it meets any standards applicable, is fit for purpose and is fitted correctly. The
Equipment
potential for creating other hazards by the application of the PPE selected has been carefully considered and the potential for
There are quite a number of PPE requirements. Evidence that training had been conducted on the correct use of PPE
provided would improve this result.
607
First Aid/Reporting Provisions for first aid are available that meet local regulations including the numbers of suitably qualified first aiders and sufficient
The risk is that the adverse effects and trauma associated with injuries and poor injury management will be greater and take
This area could benefit from more detailed reporting to capture more information, although essential criteria are
covered.
Workers’ Compensation/ Provisions are made to compensate injured workers for lost time and medical/related expenses. Assistance is provided for
returning injured or ill employees back to the workplace in an agreed timeframe without exacerbating their current condition and to
Rehabilitation
offer meaningful employment where such opportunities exist according to the following hierarchy – same job/ same workplace;
modified job/ same workplace; different position same workplace; similar or modified position/ different workplace; different
position/ different workplace. A return to work co-ordinator has been appointed either internally or externally to meet local OHS
regulations. All parties are kept informed of progress and developments. Systems are in place to ensure that injured workers are
not returned to the unaltered workplace that injured them.
This area needs to be developed so that should a rehabilitation case arise, the systems will already be in place and
relationships with off-site expertise have already been established so the process goes smoothly.
608
Health Surveillance Pre-employment medicals have been undertaken to provide baseline information on the employee’s current state of health.
Examinations may include lung function tests, blood or urine samples for biological monitoring, chest x-rays and audiometric
testing. Where known hazardous substances are present in the workplace, this surveillance may be subject to compliance with
local OHS regulations. Health surveillance is conducted from which the health of workers exposed to specific risks can be
monitored (including biological monitoring) and the effectiveness of current control strategies may be evaluated
The risk is that (i) employees may be placed in situations where their health may be damaged; and (ii) the effectiveness of current
control measures will be not be known, that employees health will be endangered, a baseline for claims purposes will not exist
This is an area that should receive specialist input. Documentation is required here to assure legislative requirements
are met and also to demonstrate that the organisation has undertaken its duty of care.
Employees and management setting good examples for workplace safety should be encouraged and valued.
The risk is that desirable OHS work behaviours and attitudes will not be reinforced, and that inappropriate OHS attitudes or
actions may be encouraged with employees believing that such behaviour or actions are acceptable.
This needs to be extended to include staff other than Sales. Performance reviews should ensure that OHS issues are
not embedded into the assessment, and there are clear consequences for undesirable OHS attitudes or practices.
Feedback Programs Feedback may take the form of suggestion boxes, perception surveys (questionnaires to gauge employee attitudes, morale,
and/or perceived effectiveness of safety campaigns). Reward programs may be used to encourage participation in feedback
activities.
Opportunities for feedback could provide management with more information about the effectiveness of current OHS
controls and to ensure that any problems are quickly brought to management’s attention.
609
Review of Personnel Personnel turn over rates are reviewed to uncover the root cause for any abnormally high levels, such as problems with
leadership, personality conflicts, excessive workloads, unreasonable deadlines, unpleasant physical working environment and/or
Turnover
work conditions. Exit interviews are conducted to gather feedback for improvement where such opportunities present. Succession
plans are in place to provide a safe and sufficient level of experience as others move on and continuity of safe working
arrangements.
Analysis of information obtained at exit interviews would provide opportunities for improvements.
610
Safe Systems Element Definition Criteria, Critical Risks and Actions Required
Policy An OHS policy is in place that conveys management’s intention and attitude towards safety. It is one expression of
Generally, the attitude by management is witnessed by their willingness to address safety issues and their obvious
intention to take care of their staff. Consideration should be given to an OHS policy or motto on display at reception.
This would send a good message to clients and contractors.
Care should be taken to ensure that goals are realistic and achievable; specific; measurable; have been adequately resourced
and undergo periodic review. Performance measures are aligned with goals and policies.
may lead to apathy.
Goals were not available at the time of the audit. Specific, Measurable, Achievable, Realistic and Timely (SMART)
goals would enable to improvement task to be broken down into a manageable portions and provide some
encouragement when targets are met.
This was not an issue at this operation as the top manager clearly took full responsibility for all OHS matters.
611
and time frames for completion identified. The list is reviewed on a regular basis and demonstrable progress is evident.
Analysis
breaches.
A due diligence plan is required as a matter of priority to fulfil the organisation’s duty of care. A gap analysis that
has undergone regular review with demonstrable improvements will also assist in demonstrating goodwill and good
corporate citizenship should a penalty or breach occur.
Resource Sufficient resources have been allocated to OHS issues to demonstrate that commitment is real and goals are achievable.
Funds are protected from “reallocation”. Time is available and sufficient to address OHS issues, and has been budgeted for in
Allocation/Administration
Funding was readily available for OHS matters, and resources were distributed as necessary.
Contractor Management Contracts are reviewed for suitability to the OHS program and contractors are managed in such a way that their presence does
not create additional workplace hazards due to lack of familiarity and local knowledge; and all those persons who may be
impacted by their activities are informed and aware of any potential hazards that may arise. Areas of control and responsibility
are clearly delineated.
This rating is based on a lack of detail surrounding service agreements and contracts, although the contractors in
use were clearly reliable and provided good service.
612
Procurement with OHS All new plant, equipment, materials, and services have been purchased with OHS criteria taken into consideration. Provisions
are made to ensure that hazardous materials are reviewed prior to purchase (see Hazardous Substances and Dangerous
Criteria
Goods). Provisions are made to ensure that plant and equipment are installed safely (see modifications). End users have been
included in the decision making process. Safety instructions are available and training on new equipment, plant or services is
The risk is that new plant, equipment, materials or services will be the cause of OHS problems and that it can be very expensive
to rectify the OHS issues retrospectively.
A more formalised approach to cover potential liability would improve this result.
Supply with OHS Criteria All products supplied are provided in a safe state with OHS criteria taken into consideration to ensure that the client/customer is
not exposed to harm when the products or services are used according to the suppliers instructions with all due warnings being
heeded. All services are supplied in such a way that safety has been considered and meets organisational standards.
The risk is that unchecked or unreviewed products or services supplied are the cause of injury or illness as well as potentially
exposing the organisation to litigation for breaches of OHS duties.
There is evidence that OHS criteria are well considered and readily available. Documentation that this has been
taken into consideration for all aspects of supply-such as the size of despatch lots, would further improve this result.
communication equipment such as telephones, internet access, local intranets, radios, access to noticeboards or newsletter,
meetings and other forums for exchange whether they be formal or informal.
This result was facilitated by the small nature of the operation and the “hands on” approach of management.
613
OHS regulations on the formation of safety committees are observed, and the committee chairperson has undergone
appropriate training to fulfil their tasks and duties. Meetings are conducted on a regular basis with participation of a
management representative with sufficient authority to take action on items identified as being in need of corrective action. The
minutes of the meetings are kept in a secure location and made accessible to all employees. Attempts are made to resolve
disputes in-house before outside authorities are brought in.
Spot checks of documentation illustrated that this area is working well. Just a number of small areas that could be
fine tuned to improve this result. This area is steered by a very committed staff member.
Competent Supervision Persons that are placed in a position of authority and supervision have the responsibility, talent/ technical ability, social skills
and experience necessary to do so.
There is a high level of experience amongst line managers; however this result could change if there were losses of
key staff members.
Safe Working Procedures Sufficient safe working procedures are in place to enable duties to be conducted consistently and to document controls and
preventive measures necessary to perform the job safely. Consideration is given to the level of detail incorporated so that there
is a balance between providing sufficient information and allowing workers to use their judgement and experience as necessary,
for example where too stringent or restrictive rules may encourage violations. The procedures should be regularly reviewed to
incorporate improvements as these become available, and the level of compliance assessed.
Procedures are available where necessary and are user friendly. This result could be improved by a system to track
documents.
614
Legislative Updates A list of relevant OHS legislation and supporting codes and standards has been complied and access to these documents has
been made available so the organisation knows what legal obligations exist and has supporting information such as standards
or codes of practice available for reference. A system is in place to ensure that updates are received so that the information
being acted upon is always current.
A more systematic approach that incorporates a trigger to alert management of legislative changes is required.
conditions.
Once a central tracking system has been established, updating of procedures will be easier to manage.
Record Keeping/Archives Records are archived in a safe and secure location, protected from deterioration and damage by water or fire. The duration for
which the records are kept is in accordance with local OHS and Privacy legislation and the confidentiality of health records is
enforced and respected. Regular back ups of electronic data are made where their loss would have an impact upon the safety
and health of employees
Action to formalise record collection systems, and ensure that all legal obligations are fulfilled would improve the
results in this area.
615
organisation’s products or services. Procedures are in place to recall goods or services in a timely manner where a danger or
Recall/Hotlines
threat may place end users at risk after purchase. A document trail is available to record the decision making process that
The organisation is very customer oriented and this is handled well.
situation. Root causes are pursued to the point where they are within the organisation’s control or influence. Reporting of
incidents is encouraged with a view to improve rather than to blame. Near miss/hits are also reported and decisions to
appropriate range of knowledge and skills. A protocol for reporting to external authorities notifiable events has been established,
and communicated.
This area could be developed in terms of incidents captured and information extracted. Analysis of the root cause
would greatly assist in the prevention of injuries recurring and would provide opportunities for learning.
616
Self Assessment A list of questions has been compiled to ensure that outcomes are being achieved on a regular basis and the key requirements
of OHS procedures are being adhered to in house. The purpose is to determine the level of compliance; whether the
requirements are suitable and reasonable; and to ensure that any practical problems with the daily working of procedures are
uncovered whilst the situation is still recoverable. Self-assessments targeting particular areas where improvement is sought are
conducted on a frequent basis, for example monthly, and items are independently spot checked to improve the reliability of the
results.
No specific self-assessment tools were made available at the time of assessment. This result would be greatly
improved by consideration of actions that have the greatest impact on safe working and would be useful to ensure that
prevention and control strategies applied remain on track.
Audits A range of formal reviews of measures implemented to ensure that the prime intention of the procedures is being met and that
specific criterion such as compliance with a regulation, standard or organisational OHS requirement are addressed. Objective
evidence is available to support the findings. Specialist audits may be necessary to determine risks in particular areas. The
frequency of audits will depend on the length of time that the OHS systems have been in place, as established systems will
need less frequent audits than systems that are just being introduced. The frequency may range from a yearly basis to once
every 3-5 years for specialist audits. Auditors utilised are suitably qualified and experienced.
No specific audits were made available at the time of assessment. Consultants are used to handle key risk areas,
however and internal system may be of use and extend the local knowledge base.
617
No specific system reviews were made available at the time of assessment. This is important due to the hazardous
nature of the operation, but other items must be addressed before this element will provide value.
618
Report
619
Summary

organisation for the purposes of assessing its management of OHS issues
The application of this framework was conducted at your company (a foam

recycling operation) during October and November 2007. This study
found:
; Of the 60 elements in the framework, 59 were applicable to your site;

(75%) with formal systems and another 12 elements informally. The
predominantly formal approach implies a higher level of
documentation. However, care should be taken not to overload the
system with too many requirements. A more targeted approach to
address the root causes of problems should receive priority.
risks are within the hardware and operating environment area,
followed by those hazards associated with people and the complexity
of human nature. This suggests that a high level of vigilance will
always be necessary to ensure safe operations; however, in this
instance there is no better way to reduce the inherent risks than to
engineer out the problems or review the actual process used and
hazardous chemicals involved.

involve safe person methods. These rely heavily on personal
expertise, skills and judgement. These can be vulnerable to changes
in key personnel. Care needs to taken that documentation of such
strategies exists, such a complete training records, in order to
620
demonstrate due diligence should a litigation situation arise. This
type of documentation is very useful.
; The organisation needs to be aware of the problems of

overcomplicated and over specified systems. In your organisation
there are large numbers of risk assessments specified, and dealing
with so many assessments may be overwhelming. Streamlining of
information captured and eliminating any replication should be further
investigated. The time necessary to comply with all the requirements
specified would provide an interesting analysis.
; The organisation also needs to be aware of problems with narrowly

focused risk assessments and should ensure that risk assessments
are conducted by a group of people that have the range and balance
of necessary skills to cover all the relevant perspectives to enable a
complete picture of the situation to be understood prior to
investigation.
; With respect to the use of contractors, their approach to on-site

hazards may be influenced by the view of the particular expert used,
whether or not they are accustomed to a high level of risk, and their
range of previous experiences. It is crucial that the entire context of
the local operation is considered, and due consideration given to the
risks presenting from hazards that are not immediately obvious, such
as the possibility of volatile organic compounds being present in the
atmosphere within the plant. Also, it would be an investment to
develop some of this specialist expertise “in-house” amongst existing
personnel.
; A careful balance needs to be achieved between the level of energy

directed into front end risk assessments, the quality of assessments
conducted and the clearance rate of actions arising. All three aspects
are of great importance, and one should not be sacrificed at the
expense of the others.
621
; The organisation has very successfully addressed the elements of
Employee Assistance Programs; Health Surveillance; Emergency
Preparedness; Baseline Risk Assessment; Communication,
Consultation and Competent Supervision. Your current prevention
and control methods have made a significant impact on the overall
risk ranking, so you are strongly encouraged to continue your
improvement efforts.
The results show that management are very in tune with the operation and
OHS matters are addressed in a timely fashion. Due to the larger
corporate infrastructure there is sufficient funding available for OHS
matters and the opportunity to attend training courses as necessary. There
are also career opportunities available so the organisation is able to attract
high calibre staff, and this was evident in the assessment process.
Management should be commended for the level of risk reduction that has
already been applied, their clear dedication to the welfare of their staff and
their ability to appoint committed personnel in key areas of responsibility.
622
Summary Results
Framework Charts
Safe Place Safe Person Safe System

Equal Opportunity/
Anti-Harassment
Ergonomic Evaluations Accommodating Diversity Goal Setting
Inductions – Contractors/ Due Diligence Review/

Plant/ Equipment
Visitors Gap Analysis
Amenities/ Environment Training
Administration
Receipt/ Despatch Work Organisation – Fatigue Contractor Management
Job Descriptions-Task Supply with OHS

Noise Structure Consideration
Hazardous Substances/
Dangerous Goods
Networking, Mentoring, Further

Education
Employee Assistance
Installations/ Demolitions Legislative Updates
Programs
Personal Protective Equipment Procedural Updates
Repairs
First Aid/ Reporting Record Keeping/Archives
Commissioning
Workers Compensation/ Customer Service – Recall/
Emergency Preparedness Rehabilitation Hotlines
Security – Site/ Personal Health Surveillance Incident Management
Housekeeping Feedback Programs Self Assessment
Inspections/ Monitoring Performance Appraisals Audits
Operational Review Review of Personnel Turnover System Review
Medium-High Risk Low Risk Well Done
623

Equal Opportunity/
Anti-Harassment

Plant/ Equipment
Administration

Criteria
Noise
Dangerous Goods
Further Education
Consultation
Disposal Conflict Resolution
Employee Assistance
Programs
Repairs Equipment Procedural Updates
Modifications – Peer Review/ First Aid/ Reporting Record Keeping/ Archives

Commissioning
Workers Compensation/ Customer Service – Recall
Emergency Preparedness Rehabilitation /Hotlines
624

Equal Opportunity/ OHS Policy
Baseline Risk Assessment Equal Opportunity/
Anti-Harassment
Anti-Harassment
Access/ Egress
Inductions – Contractors/ Due Diligence

Review/ Gap
Plant/
Plant/Equipment
Equipment
Analysis
Administration
Receipt/ Despatch
Receipt/Despatch Work Organisation – Fatigue Contractor Management
Fatigue/Stress
Stress Awareness Procurement with OHS
Electrical
Criteria
Noise
Hazardous
Substances/ Behaviour Modification
Dangerous Competent Supervision
Dangerous Goods
Goods
Biohazards
Communication
Further Education

Consultations
Employee Assistance Legislative Updates

Programs
Preventive Maintenance/ Personal Protective Procedural Updates
Maintenance/Repairs Procedural Updates
Repairs Equipment
Modifications
Modifications –– Peer
Peer Review
Review First Aid/
Aid/Reporting
Reporting Record Keeping/ Archives
/Commissioning
/Commissioning
Rehabilitation /Hotlines
Recall/Hotlines
Security
Security––Site/ Personal
Site/Personal Health Surveillance Incident Management
Inspections/
Monitoring Performance Appraisals Audits
Not Addressed by the

Formal Organisation
Informal
625
with and without intervention is large, the controls have made a significant
impact.
Electrical
Plant/ Equipment
Noise
Receipt/Despatch
Housekeeping
Modifications
Disposal
Radiation
Biohazards
Access/Egress
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium-High
Risk
626
Inductions
Selection Criteria
Feedback Programs
Stress Awareness
Work Organisation
Training
Networking etc
Job Descriptions
Conflict Resolution
Equal Opportunity
Health Surveillance
Workers' Comp/Rehab
Health Promotion
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium-High
Risk
627
Due Diligence / Gap Analysis
Audits
Procedural Updates
Legislative Updates
Accountability
Goal Setting
OHS Policy
Incident Management
System Rewiew
Self-Assessment
Consultation
Resources
Communication
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium-High
Risk
628
of hazards, closely followed by those associated with people and the
complexities of human nature. This is due to the inherent high risk
associated with the nature of the operation and the need to ensure that
Safe Systems
Safe Place
30%
37.3%
Safe Person
33.3%
Figure 5 demonstrates how safe person strategies have been used to

reduce the overall risk rating of the operation. However, a number of
significant risks still remain, especially relating to the “safe place” area.
Figure 5: Risk Distribution– with Interventions and Strategies in

Place

32% 39%
Safe Person
29%
629
80
70
60
Risk Ranking
50
40
30
20
10
0
Legend Without With

Intervention Intervention

strategies such as the use of PPE is limited by the complexities of human
nature – and the safe guards are only able to be effective if they are being
used correctly and for their intended purpose.
The higher level of residual risk in the safe place area suggests that there
is a need to address the root cause(s) of problems through engineering
and design methods. There is scope to eliminate some inherent hazards
through alternative supply of certain chemicals used in the binding process
and greater insulation of noisy areas. Other hazards such as mobile plant
may be addressed through some targeted campaigns to eliminate some
unsafe habits that have developed over time.
Finally, a list of specific, detailed potential hazards on site needs to be

available to inform any visitors or contractors to the site. Whilst this may be
630
provided in general terms it needs to be specific enough to enable
vulnerable persons to take the necessary actions to protect themselves
and to ensure that a sufficient and accurate exchange of information has
taken place to demonstrate due diligence.
631
There is sufficient evidence to demonstrate that this element is handled particularly well. In general, the organisation is
very risk management oriented.
There is a high degree of exposure to manual handling; however observations indicated that movements were smooth
and well considered. The exposure to cuts and lacerations is very high and this is an area that needs further investigation
and improvement.
632
their workplace.
The site is well marked and access/egress has been well considered. However, care needs to be taken to ensure vehicles/
mobile plant do not inadvertently stop in areas that may block access/egress pathways.
The particular operation involves a number of high risk operations – involving exposed blades, and heavy use of forklifts.
Key areas of exposure need further consideration to reduce the residual risk to a more acceptable level. The speed of
forklifts needs to be reduced to prevent the likelihood of a serious incident. No registers were available for the use of hoists
etc.
Amenities/Environment Amenities such as private, hygienic toilets and change rooms; provision of drinking water and a refrigerator/ microwave for mealtimes;
infant feeding facilities and showers where the need exists. The working environment for indoor workers should be comfortable and
Amenities are in good condition and a pleasant meal area is available. The main operations area would be difficult to keep
cool in summer and the potential for heat stress needs to be considered more fully.
633
Receipt of bulk liquid raw materials is handled very well. However, handling of scrap raw materials involves untying metal
fasteners, which may be hazardous. Safe use of forklifts needs emphasis.
The result in this area is not due to the expertise of electrical contract work, which is valued by the operations staff, but
due to the lack of information provided by the organisation to define sufficiently the risks due to static and the potential for
volatile organic compounds in the atmosphere. A hazardous area classification diagram was not available for electrical
work, This would provide contractors with information to specify the appropriate ratings for the safe use of electrical
equipment, and specialist advice may be required here.
634
The levels of noise and vibration are relatively high, especially is certain areas. Solutions to reduce noise exposure by
means other than hearing protection need further investigation. The correct attenuation of hearing protection devices used
should be verified.
storage should be given to those at risk.
An assumption is made that the residual levels of the isocyanate solvents in use is negligible. This should be verified by
personal monitoring conducted by a qualified occupational hygienist. The possibility of volatile organic compounds coming
in with the scrap raw materials should also be investigated, Again, an occupational hygienist would be useful here.
635
cooling water reservoirs and air conditioning systems that may contain Legionella organisms.
Greater awareness of potential biohazards and prevention strategies, including allergens would improve this result.
Potential for dust mites in scrap materials should be further considered.
A thickness gauge is in use and although there is high inherent risk this hazard is well managed. There are a number of
outdoor workers in despatch. The degree of UV protection is dependent on user compliance with provisions available.
sharps.
This is an area of high inherent risk but is well controlled via contractors.
636
Demolition
This is an area where documentation and registers would be useful. This is not an area of current activity.
Maintenance/Repairs
competent to do so.
An area of high inherent risk but currently handled well by contractors and maintenance staff.
Review
The risk is that the modifications result in an injury because the full impact of the changes was not thought through.
The inherent risk in this area is high due to the potential static hazard and possibility of volatile organic compounds.
Documentation of internal requirements for electrical equipment and some means of cross-checking all modifications for
OHS considerations would improve this result.
637
Preparedness
This area is handled extremely well.
Site/Personal
Whilst there are no physical barriers to prevent access, visual recognition of strangers is enhanced by use of high
visibility vests. Lone worker issues have been considered. Security could be tightened due to the dangerous nature of
equipment and processes in use especially during weekends and hours outside normal operations.
The main production area is in a reasonably good state, however other areas are in need of attention.
638
Monitoring
Review
This is performed annually. Details of actions arising from such reviews would improve this result.
639
Harassment
There is an EEO policy and anecdotal evidence of flexible, family friendly work arrangements. There is an established
HR department which appears to be supportive. This result could be improved by greater evidence that these policies are
actively promoted and regularly discussed.
Diversity
workers are taken into consideration. Where workers are known to have a pre-existing psychological condition, employers take care
not to place such employees into situations where they are at increased vulnerability. Translations or other means of
Whilst English is widely spoken; some workers have difficulty in expressing themselves in writing. Whilst training
styles generally accommodate this, it makes written reporting problematic. Management needs to be aware of the
differences in perception when verbal information is given to a third party There is also a young worker on site. This
result could be improved by increasing awareness of the special needs of younger staff members and the types of injuries
they are more vulnerable to, such as sprains and strains; open wounds; fractures; bruising and crushing, and burns.
640
has been documented and forms part of the selection criteria (for example in position descriptions). Any pre-existing conditions that
may be exacerbated by the role have been identified to ensure that vulnerable persons are not at risk by taking the position.
Due to the hazardous nature of the operation and solvents in use, defining clear selection criteria would be valuable for
protecting potentially vulnerable persons and possible reducing any potential for litigation. The assumption that key
solvents are reduced to negligible levels in the work environment may need to be challenged, and the possibility of VOC’s
entering the environment via the scrap imports reconsidered. Even managerial positions require considerable contact
with the operation, and for some of these solvents the TLV’s are so low that even low levels of exposure may be
problematic.
Inductions-Including All visitors and contractors to the workplace are made aware of any hazards that they are likely to encounter and understand how to
take the necessary precautions to avoid any adverse effects. Information regarding the times of their presence at the workplace is
This has been handled formally, but the concern here is the lack of detail about specific hazards that is made available.
Informing contractors and visitors that there are hazardous chemicals on site is insufficient to allow a person with
respiratory sensitivities to take the necessary precautions before entering the site. The purpose of identifying hazards is
to make sure vulnerable people are able to protect themselves. Greater transparency is required here.
641
Training and Skills A training needs analysis has been conducted to determine what skills employees have and what skills are needed to perform their
roles safely and competently. Arrangements are in place to address any gaps that may exist. All employees and others affected
have been made aware of local procedures and protocols. Refresher training is provided at appropriate intervals to maintain skills
and provide ongoing protection from workplace hazards. Competency training has been scheduled according to the training needs
analysis. All persons conducting training are appropriately qualified to do so. Training records are maintained. Evidence of
competencies is available.
On the job training is handled fairly well. Where literacy skills are poor it may difficult to assess competency through
tests, so assessment methods need to be carefully considered. Records need to demonstrate that training is conducted
by people qualified to do so. Access to in house electrical and engineering expertise may need to be reconsidered. A
training needs matrix exists. The contents may need to be expanded to cover awareness training on potential allergens,
the use of volatile organic compounds in general and the dangers of static electricity.
Work Organisation - The individual arrangement of job tasks that constitute the role have been considered to ensure that the work load does not induce
unnecessary manual handling, overuse, undue fatigue or stress, and the required level of vigilance is able to be maintained over
Fatigue
the work period. Work breaks, pauses or other rotation of duties have been introduced where fatigue inducing conditions have been
identified. Fatigue may be of a physical or mental nature.
This is handled well and the short shift arrangement reduces the potential for work-induced fatigue. However, given the
noise levels and the amount of manual handling involved, any move towards regular use of overtime or extended shifts
(for example 12 hourly shifts) should be avoided.
642
considered by that particular employee as stressful. Plans are available for dealing with excessive emails and unwelcome contacts.
The risk is that the employee becomes overwhelmed by the particular work arrangements, and is unable to perform competently or
safely due to the particular circumstances.
This is managed reasonably well for the majority of staff by management and the close, friendly atmosphere. However,
management need also to be aware of their own stress levels. One employee did appear particularly agitated during the
assessments. The underlying cause of this needs to be investigated so the issue is managed and does not affect others.
Structure
safely.
Job descriptions are available. Some jobs however seem to broader than the titles reflect. A review of current job
descriptions would improve this result.
inspections, unsafe act or observation programs, followed by suitable feedback. Observations may be overt or discreet. Employees
are encouraged to recognise hazards and take suitable precautions - including the acknowledgement of situations that they are not
sufficiently skilled to deal with whilst also watching out for the safety of their colleagues. Where reward programs are used for
positive reinforcement of safe behaviours, consideration is given to the use of variable, unpredictable reward schedules so that the
benefits are maintained when the reward is removed. Rewards may include praise, recognition or increased status.
Targeted campaigns to break unsafe working habits (such as the unsafe use of forklifts) and to positively reinforce
desirable work practices would be of assistance here. Any progress in this area should start out small, perhaps handling
one issue at a time.
643
Health Promotion Healthy lifestyle choices are promoted and an awareness program exists to educate personnel on these issues. Topics may include
good nutrition, exercise, work-life balance, symptoms of substance addiction, quit campaigns, medical checks (prostate, bowel,
breast, cervical) and home or off-site safety tips.
in the workplace.
This element is handled particularly well and there is a great assortment of information available in the meal room.
Further Education
injury or illness.
and safely.
The potential for conflict appears evident due to the large organisational structure and the possibility of edicts being
handed down from off-site locations or corporate. This result could be improved by having more opportunities to express
opinions in an open forum and greater interchange of experiences to improve understanding of the various positions.
644
Programs
There is anecdotal evidence that this is conducted with confidentiality and compassion. This element demonstrates that
management are actively involved with staff and able to provide guidance and direction for assistance when needed.
Equipment
potential for creating other hazards by the application of the PPE selected has been carefully considered and the potential for such
impacts minimised.
There are quite a number of PPE requirements and this area is well controlled. This result could be improved if more
information was available to demonstrate that the PPE selected represented best practice, and documented evidence of
training on correct fit and usage was available
The risk is that the adverse effects and trauma associated with injuries and poor injury management will be greater and take longer
time to heal, and OHS regulations will be breached.
This area is handled very well, a first aid room is available with designated First Aiders. Evidence was available to
indicate that reporting was part of the culture and that the requirements were well understood.
645
Workers’ Compensation/ Provisions are made to compensate injured workers for lost time and medical/related expenses. Assistance is provided for returning
injured or ill employees back to the workplace in an agreed timeframe without exacerbating their current condition and to offer
Rehabilitation
meaningful employment where such opportunities exist according to the following hierarchy – same job/ same workplace; modified
job/ same workplace; different position same workplace; similar or modified position/ different workplace; different position/ different
workplace. A return to work co-ordinator has been appointed either internally or externally to meet local OHS regulations. All parties
are kept informed of progress and developments. Systems are in place to ensure that injured workers are not returned to the
unaltered workplace that injured them.
This area is handled very well, key legislative requirements are understood and there is evidence of compliance.
control measures will be not be known, that employees health will be endangered, a baseline for claims purposes will not exist and
that local OHS regulations may be breached.
This is sourced independently and is conducted to meet legislative requirements. There is confidence in the service
provider.
646
activities.
Opportunities for feedback could provide management with more information about the effectiveness of current OHS
controls and to ensure that any problems are quickly brought to management’s attention. A level of frustration and a
need to provide feedback to explain managements’ response to certain situations was observed during the assessments.
This is an area for further investigation.
Safety forms an important part of the appraisal process. Regular review of these requirements and increased
opportunities to embed these values within all work processes would improve this result.
Review of Personnel Personnel turn over rates are reviewed to uncover the root cause for any abnormally high levels, such as problems with leadership,
conditions. Exit interviews are conducted to gather feedback for improvement where such opportunities present. Succession plans
are in place to provide a safe and sufficient level of experience as others move on and continuity of safe working arrangements.
647
The risk is that there will be no direction on OHS issues and employees will not know the organisation’s attitude towards OHS, or
what is expected from them.
Consideration should be given to an OHS motto on display at reception. This would send a good message to clients
and contractors. The existence of an OHS policy is known, but the contents are not.
may lead to apathy.
Goals are dominated by the existence of an overwhelming number of risk assessments. Focus and strategic planning
would improve this result.
not met to ensure that these responsibilities are taken seriously. The accountability should be commensurate with the authority of
the position, and sharing of accountabilities avoided to prevent responsibility from being diffused.
The site manager clearly took full responsibility for all OHS matters. However, the concept that everyone is
responsible in some way for safety could be promoted.
648
Due Diligence Review/ A list of projects has been identified that would bring the organisation into regulatory compliance, with responsibilities allocated
Gap Analysis
breaches.
A due diligence plan is required as a matter of priority to fulfil the organisation’s duty of care. This is different from
the risk assessments as it identifies areas of legislative non-compliance. This will also assist in demonstrating goodwill
and good corporate citizenship should a penalty or breach occur.
Resource Sufficient resources have been allocated to OHS issues to demonstrate that commitment is real and goals are achievable. Funds
are protected from “reallocation”. Time is available and sufficient to address OHS issues, and has been budgeted for in projects
and tenders.
Funding was readily available for OHS matters, and resources were distributed as necessary. Higher order solutions
addressing the root cause of problems should receive priority in funding.
This rating is based on a lack of detail surrounding the information provided in service agreements and contracts that
identified the potential hazards on site. However, it appears that many of the contractors in use were clearly reliable and
provided good service.
649
Procurement with OHS All new plant, equipment, materials, and services have been purchased with OHS criteria taken into consideration. Provisions are
made to ensure that hazardous materials are reviewed prior to purchase (see Hazardous Substances and Dangerous Goods).
Criteria
Provisions are made to ensure that plant and equipment are installed safely (see modifications). End users have been included in
the decision making process. Safety instructions are available and training on new equipment, plant or services is provided where
necessary for safe operation. Technical or specialist expertise has been acquired where written instructions are insufficient or
unavailable. There is clear delineation of the point where new equipment or services have been accepted and OHS issues
resolved.
Investigation into the scraps imported would improve this result. There are a number of issues mentioned previously
including the means of untying the bails and the odour levels.
There is visual evidence that OHS criteria of product supplied is well considered. Documentation that this has been
taken into consideration would further improve this result.
Communication Communication channels are available to facilitate the efficient flow of information to perform workplace duties in a manner that is
safe and does not induce stress. This may include sufficient contact with supervisors or colleagues, the provision of
Management are very open and there is a high level of transparency for which they are to be commended.
650
OHS regulations on the formation of safety committees are observed, and the committee chairperson has undergone appropriate
meetings are kept in a secure location and made accessible to all employees. Attempts are made to resolve disputes in-house
Spot checks of documentation illustrated that this area is working well. This area is steered by a very committed staff
member. The level of dedication to this process by all senior staff is to be commended.
Competent Supervision Persons that are placed in a position of authority and supervision have the responsibility, talent/ technical ability, social skills and
experience necessary to do so.
The risk is that employees may be exposed to injury or illness because the people supervising them did have the skills necessary
to know how to protect them from OHS issues.
The areas of the process that are under control of the local staff are managed very well.
preventive measures necessary to perform the job safely. Consideration is given to the level of detail incorporated so that there is
a balance between providing sufficient information and allowing workers to use their judgement and experience as necessary, for
example where too stringent or restrictive rules may encourage violations. The procedures should be regularly reviewed to
Procedures are available where necessary and are user friendly. Photographs are used to good effect. This result
could be improved by seeking out best practice available to disseminate the information provided.
651
been made available so the organisation knows what legal obligations exist and has supporting information such as standards or
codes of practice available for reference. A system is in place to ensure that updates are received so that the information being
acted upon is always current.
The risk is that out-of-date or incorrect or incomplete information is used for actioning OHS issues, so inappropriate actions or ill-
A legislative matrix exists. A systematic means of tracking changes would simplify the updating process. Consider
using a legislative alert system.
conditions.
This may be easier to manage if the procedures where available to all users including operators on-line. If this is not
possible, consider managing this in “blocks”, and issuing updates in quarterly or six monthly waves, where the change
is not urgent.
652
The risk is that critical records of employees’ health and safety will be unavailable in the event of litigation or for purposes related
to improving or resolving OHS issues.
result in this area.
Recall/Hotlines
The risk is that the safety and health of a customer, client or consumer is threatened because they were unable to access critical
information in a timely manner regarding the organisations goods or services.
This element is not applicable and is handled via the quality stream offsite.
653
incidents is encouraged with a view to improve rather than to blame. Near miss/hits are also reported and decisions to investigate
based on likelihood or potential for more serious consequences. Investigations are carried out by persons with the appropriate
range of knowledge and skills. A protocol for reporting to external authorities notifiable events has been established, and
communicated.
The risk is that information that could prevent incidents from recurring is lost and employees and others at the workplace continue
to contract illnesses or be injured.
This area could be developed in two key areas (i) root cause analysis and (ii) awareness of varying perspectives
during the write up of investigations. Allowance for multiple root causes should be factored in from the start and care
taken not to favour “typical” responses through the formwork used. Also, awareness that operations, the factory floor
and management will all have different explanations for why incidents occur, and how this may influence the
“published” outcomes should be recognised. Crucial information may be lost if certain perspectives are ignored.
Self Assessment A list of questions has been compiled to ensure that outcomes are being achieved on a regular basis and the key requirements of
OHS procedures are being adhered to in house. The purpose is to determine the level of compliance; whether the requirements
are suitable and reasonable; and to ensure that any practical problems with the daily working of procedures are uncovered whilst
the situation is still recoverable. Self-assessments targeting particular areas where improvement is sought are conducted on a
frequent basis, for example monthly, and items are independently spot checked to improve the reliability of the results.
No regular self-assessment tools were made available at the time of assessment. There are a lot of requirements to be
fulfilled for corporate purposes. Focusing on key outcomes would be helpful here.
654
frequency of audits will depend on the length of time that the OHS systems have been in place, as established systems will need
less frequent audits than systems that are just being introduced. The frequency may range from a yearly basis to once every 3-5
The risk is that predetermined requirements for good OHS will not be met, and the actions necessary to achieve the desired OHS
outcomes are unknown.
The operation has a very strong risk assessment focus; however this is potentially overloading the system at the
expense of other areas. Some audits in specialist areas may still be needed for due diligence purposes, and more clarity
regarding ranking criteria and level of urgency to be addressed would be helpful here.
This area is believed to be covered, however it is apparent that the nature of the review could be more strategic and
cover more areas without necessarily being so driven by the existing risk assessments. Narrowly focused risk
assessments and presumptions about existing conditions should be open for challenge. Data from health surveillance
could be used to better effect. Consider what information demonstrates that engineering controls are working as
expected, and what action levels could be set to ensure that the information received is being used for prevention rather
than cure.
655
Report
656
Summary

The application of this framework was conducted at your company (a

manufacturing operation for event management/ entertainment industry)
during November 2007. This study found:

with formal systems and another 36 elements informally. The
predominantly informal approach implies less documentation and
suits the smaller nature of the business; however this may present
difficulties should any litigation, claims or disputes arise in the future.
risks are clearly within the hardware and operating environment area.
This tends to dominate the current thinking, however other areas
such as chemical safety and future health must be considered as
well. These areas are in need of attention.

involve safe place methods. These rely heavily on outside expertise,
skills and judgement. These can be vulnerable to differences in risk
perception, and may be influenced by the view of the particular
expert used, and their field of specialty.
; The organisation also needs to be aware of problems with narrowly

focused risk assessments and should ensure that risk assessments
are conducted by a group of people that have the range and balance
of necessary skills to cover all the relevant perspectives to enable a
657
complete picture of the situation to be understood prior to
investigation.
; A careful balance needs to be achieved between the level of energy

directed into front end risk assessments, the quality of assessments
conducted and the clearance rate of actions arising. All three aspects
are of great importance, and one should not be sacrificed at the
expense of the others.
; Caution is advised against the use of paperwork that does not

produce meaningful output. Consider how the document is adding
value, and what does it actually want to achieve from the onset.
There are also alternatives methods available for delivering the
information and the pursuit of more visual techniques are to be
encouraged.
; The organisation is making good progress in the areas of competent

supervision, performance appraisals and accountability. Attention is
required in the areas of hazardous substances, health surveillance,
contractor management, receipt and despatch and emergency
preparedness.
The results show that management are very in tune with the operation and
resources are available to address OHS matters in a timely fashion.
However, there is a need to reconsider the overriding strategies used to
guide management’s distribution of resources.
Management should be commended for the skill displayed in handling

such a high risk operation and their understanding of the critical safety
issues. The small size and family ownership are key factors in the current
level of risk reduction. Whilst the OHS systems in place are still in their
infancy, there are many lessons to be shared with other organisations
such as the importance of trust and the development of high levels of
expertise and personal judgement to manage high risk situations.
658
Summary Results
Framework Charts

Equal Opportunity/
Anti-Harassment

Plant/ Equipment
Administration

Dangerous Goods

Education
Employee Assistance
Programs
Repairs
Commissioning
Rehabilitation Hotlines
659

Equal Opportunity/
Anti-Harassment

Plant/ Equipment
Administration

Criteria
Noise
Dangerous Goods
Biohazards
Health Promotion Safe Working Procedures
Further Education
Employee Assistance
Programs

Commissioning
660

Baseline Risk Assessment Equal Opportunity/ OHS Policy
Anti-Harassment
Anti-Harassment
Access/
Access/Egress
Egress Selection Criteria Accountability
Plant/ Equipment Inductions –– Contractors/

Inductions Contractors/ Due Diligence
Review/ Gap
Plant/Equipment
Visitors Analysis
Administration
Receipt/ Despatch Work Organisation –

Fatigue/Stress
Criteria
Noise
Hazardous
Substances/ Behaviour Modification
Dangerous Competent Supervision
Dangerous Goods
Goods
Biohazards
Communication
Further Education

Consultations
Employee Assistance
Programs
Preventive Maintenance/ Programs
Personal Protective Procedural Updates
Repairs Equipment
Modifications
Peer Review
Review First Aid/
Aid/Reporting
/Commissioning
/Commissioning
Workers Compensation/
Recall/Hotlines
Rehabilitation
Security
Inspections/Monitoring Performance Appraisals Audits

Formal Organisation
Informal
661
with and without intervention is large, the controls have made a significant
impact.
Receipt/Despatch
Housekeeping
Disposal
Biohazards
Plant/ Equipment
Modifications
Electrical
Access/Egress
Radiation
Noise
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium-High
Risk
662
Figure 2: Initial and Final Scores - Safe Person
Health Surveillance
Workers' Comp/Rehab
Stress Awareness
Training
Inductions
Selection Criteria
Feedback Programs
Equal Opportunity

Work Organisation
Conflict Resolution
Job Descriptions

Networking etc
Health Promotion
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium-High
Risk
663
Incident Management
Consultation
Self-Assessment
OHS Policy
Communication
Audits
Procedural Updates
Legislative Updates
Goal Setting
System Rewiew
Accountability
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium-High
Risk
664
of hazards, then followed by those hazards associated with people and the
complexity of human nature, and finally those hazards associated with the
need for a systematic approach. There is an extremely high inherent risk
associated with the nature of the operation and a need to ensure that
Safe
Safe Place
Systems
37%
32%
Safe Person
31%
Figure 5 demonstrates how safe place strategies have been used to

reduce the overall risk rating of the operation. However, a number of
significant risks still remain, especially relating to the “safe person” area.

32% 34%
Safe Person
34%
665
80
70
60
Risk Ranking
50
40
30
20
10
0
Without
Legend Interventi With Intervention
on

applied.
There is a very high overall level of residual risk all three areas - safe
place, safe person and safe systems. There is scope to eliminate some
inherent system hazards through careful planning and tightening of
contracts, improved emergency and fire fighting facilities, simple
documentation of key business policies and target setting, and improved
incident management. Other significant hazards to do with chemical safety
and health may require specialist input to better meet legislative
requirements. Reduction of further safe place issues will require
substantial capital injection.
Finally, a list of specific, detailed potential hazards on site needs to be

available to inform any visitors or contractors to the site. Whilst this may be
666
provided in general terms it needs to be specific enough to enable
vulnerable persons to take the necessary actions to protect themselves
and to ensure that a sufficient and accurate exchange of information has
taken place to demonstrate due diligence.
667
Clearly a number of risk assessments have taken place, and there is evidence that the static issue is dealt with
particularly well. These assessments need to be broadened to include health issues and chemical safety.
There is a high degree of manual handling and further need to take into account human factors. Stacking arrangements
in the warehouse area need revisiting.
668
their workplace.
The site is well arranged for easy access/ egress. However the distances in between buildings could create a critical time
lag in an emergency situation. Consider ease of access for emergency vehicles, ease of locating individual buildings and
alternative “safe areas” .
An inherently high risk operation that should only be undertaken by experts. Capital injection would improve this result,
however it is clear that the physical risks are well understood..
The amenities/ environment would not be very comfortable in hot weather, during the organisation’s busy season.
Consider improved climate control in work stations or working at times to avoid the greatest heat. Be aware that cold
weather exposure can increase the risk of sprains and strains.
669
Roadways need to be fit for transport used. In need of further investigation..

Clearly well executed, and the contractor used is covering this area well. However, this result relies of compliance with
precautions provided and is difficult to make inherently safe. Constance vigilance will always be necessary.
For the manufacturing operation examined, the exposure is very high but for short periods. The operators are well aware
of the risk and exclusion zones are observed. Be aware that the correct attenuation must provided by the hearing
protection used. This should be verified.
670
Specialist advice is necessary here to provide the correct information for MSDS’s and risk assessments provided to
clients. This information should be delivered with a view to help ease confusion in abnormal situations, and provide critical
information quickly. There is a DG licence that covers materials handled.
Whilst there is good evidence that control measures are in place, the particular allergen on site is quite troublesome and
difficult to remove. Ensure that this is brought to the attention of all those going outside, and relief is available for those
affected.
671
The degree of UV protection is dependent on user compliance with provisions available. Ensure that caps and sunscreen
are used outdoors.
sharps.
This result could be improved if evidence demonstrated that there was no contamination of water or soil.
Demolition
This is not an area of current activity for the operation considered by the assessment. Clearly all installations/demolitions
would need to undergo thorough planning to take into account the inherent risks on site.
672
Maintenance/Repairs
competent to do so.
An area of high inherent risk but currently handled well by contractors and staff.
Review
The inherent risk in this area is high due to the potential static hazard. Documentation of internal requirements for
electrical equipment and some means of cross-checking all modifications for OHS considerations would improve this
result.
Preparedness
Too much time has passed since the last fully emergency drill.
673
Site/Personal
Whilst there are no physical barriers to prevent access, visual recognition of strangers could be enhanced. Lone worker
issues have been considered and the risks balanced.. Security could be tightened due to the dangerous nature of the
operation and processes in use especially during weekends and hours outside normal operations.
The operation requires meticulous housekeeping. This could be improved in certain areas.
Monitoring
The inherent risk is high but under reasonable control due to the impact this would have on the final product.
674
Review
This is evident in an informal way. A more formalised approach would be of benefit.
675
Harassment
of resources; spreading malicious gossip; social exclusion; hiding belongings; role ambiguity; and career stagnation or
uncertainty.
There is some level of exclusion and tightly formed groups. A more open approach would be of benefit.
Diversity
There is ethnic diversity but literacy levels are good. Instructions are easy to read and there is a high level of
mentoring. The special needs of younger workers should be considered, especially including their propensity to certain
types of injuries such a s burns and sprains.
676
The risk is that employees may not be capable of doing the jobs they are selected for, and vulnerable persons may be placed in
a position which they would be prone to injury or illness.
Due to the hazardous nature of the operation and chemicals in use, defining clear selection criteria would be valuable
for protecting potentially vulnerable persons and possible reducing any potential for litigation..
to take the necessary precautions to avoid any adverse effects. Information regarding the times of their presence at the
workplace is recorded to allow accounting for all persons should an emergency situation arise. Entry on site is subject to
acceptance of site safety rules where this is applicable. Also, specific contacts/hosts are designated to ensure compliance with
local rules.
The concern here is the lack of detail about specific hazards that is made available. The purpose of identifying
hazards is to make sure vulnerable people are able to protect themselves. Greater transparency is required here.
Consider “no-go areas” for particular categories of visitors/contractors.
Training and Skills A training needs analysis has been conducted to determine what skills employees have and what skills are needed to perform
maintain skills and provide ongoing protection from workplace hazards. Competency training has been scheduled according to
the training needs analysis. All persons conducting training are appropriately qualified to do so. Training records are maintained.
On the job training is handled fairly well, however care needs to be taken that this is well documented. The contents
may need to be expanded to cover awareness training on potential allergens, the use of certain chemical compounds
and the dangers of working alone.
677
Fatigue
There are some peak times, and other slower periods. Whilst these may even out, the dangers of fatigue should be
emphasised, and work breaks factored in as necessary.
Stress Awareness Personal skills, personality, family arrangements, coverage of critical absences, resourcing levels and opportunities for
employees to have some control over work load are factored into ongoing work arrangements so as not to induce conditions that
may be considered by that particular employee as stressful. Plans are available for dealing with excessive emails and unwelcome
contacts.
There are some indicators of high stress levels on site. These should be investigated, and attempts made to address
the root cause of the problem(s)..
Structure
safely.
Job descriptions are available. Some jobs however seem to broader than the titles reflect. A review of current job
descriptions would improve this result.
678
Employees are encouraged to recognise hazards and take suitable precautions - including the acknowledgement of situations
that they are not sufficiently skilled to deal with whilst also watching out for the safety of their colleagues. Where reward programs
are used for positive reinforcement of safe behaviours, consideration is given to the use of variable, unpredictable reward
schedules so that the benefits are maintained when the reward is removed. Rewards may include praise, recognition or
increased status.
Targeted campaigns to break unsafe working habits and to positively reinforce desirable work practices would be of
assistance here. Any progress in this area should start out small, perhaps handling one issue at a time. Time must be
allowed for bad habits to be broken.
This element would help improve stress levels. Consider “quit smoking” campaigns and assistance in doing this.
Further Education
679
Conflict Resolution Mediation channels are available and/or supervisors have received special training to deal with differences of opinion,
relationship breakdowns or personality clashes before the situation reaches the point where workplace performance has been
impaired and/or is noticeable by other colleagues.
The risk is that employees are unable to work as part of a team and this may affect their ability to carry out their roles
The potential for conflict appears evident. Appreciation of alternative perspectives would be helpful here..
Employee Assistance Persons experiencing problems of a personal nature such as the breakdown of significant relationships, grief, substance abuse,
or other emotional problems may access help in a confidential environment and receive the necessary support to enable them to
Programs
This element could be addressed by making a few inquiries into local resources available. A key list of contacts could
improve this result..
Equipment
PPE is used as necessary in most instances. Those not complying with requirements need to be mindful of the
message this sends to other workers.
680
First Aid/Reporting Provisions for first aid are available that meet local regulations including the numbers of suitably qualified first aiders and
sufficient quantities of first aid materials. Qualifications are kept current and first aid stocks regularly replenished. A register of
workplace injuries is kept that meets local OHS regulations and notification of incidents to statutory authorities is observed as
required.
This is available, but there is scope for more detailed reports and improved facilities.
returning injured or ill employees back to the workplace in an agreed timeframe without exacerbating their current condition and
Rehabilitation
to offer meaningful employment where such opportunities exist according to the following hierarchy – same job/ same workplace;
The risk is that injuries will be exacerbated, that time away from the workplace will be increased and that the psychological
effects of the injury and loss of confidence will be heightened.
This area needs attention so that if an incident was to occur, systems would already be in place and the process
could be managed smoothly. Details of local practices and preferred medical centres etc, should be collected and ready
for use.
681
The risk is that (i) employees may be placed in situations where their health may be damaged; and (ii) the effectiveness of
current control measures will be not be known, that employees health will be endangered, a baseline for claims purposes will not
exist and that local OHS regulations may be breached.
In need of specialist help to bring into line with local regulatory requirements.
activities.
This would be a good way to open up any groups that have formed and provide management with valuable
information.
Performance Appraisals Performance appraisals include criteria for safe work practices and observation of site safety rules, housekeeping, and the
display of safe working attitude. OHS responsibilities should be commensurate with the level of responsibility and authority
bestowed. Employees and management setting good examples for workplace safety should be encouraged and valued.
This is poorly documented but clearly taking place on an informal basis and working relatively well,
682
Turnover
arrangements.
683
Consideration should be given to an OHS motto on display at reception. This would send a good message to clients
and contractors. Safety is critical in this particular operation.
may lead to apathy.
Goals are dominated by the existence of a number of risk assessments. Focus and strategic planning would improve
this result.
The creative director clearly took full responsibility for all OHS matters. However, the concept that everyone is
responsible in some way for safety could be promoted.
684
Analysis
breaches.
A due diligence plan is required as a matter of priority to fulfil the organisation’s duty of care. This is different from
the risk assessments as it identifies areas of legislative non-compliance. This will also assist in demonstrating goodwill
and good corporate citizenship should a penalty or breach occur.
and tenders.
Funding was readily available for OHS matters, and resources were distributed as necessary. Higher order solutions
addressing the root cause of problems should receive priority in funding.
This rating is based on a lack of detail surrounding the information provided in service agreement. However, it
appears that many of the contractors in use were clearly reliable and provided good service. The issue here is that a
contractor may injure someone on site, and if this occurred, evidence to support trust would be necessary. Whilst
contractors may be in short supply in certain areas, they still must comply with the latest requirements.
685
Criteria
resolved.
Information surrounding chemical supplies should be more detailed.
Information provided to clients should be more detailed and include health aspects.
It is a small business so communication is not a serious concern. Care to ensure that all workers are included in the
information should be noted.
686
An area for improvement and greater transparency. A more regular, formalised approach would be helpful.
The areas of the process that are under the control of the local staff are managed well and clearly there is a great deal
of experience available. A greater awareness of changes in local regulations would improve this result.
preventive measures necessary to perform the job safely. Consideration is given to the level of detail incorporated so that there is
a balance between providing sufficient information and allowing workers to use their judgement and experience as necessary, for
example where too stringent or restrictive rules may encourage violations. The procedures should be regularly reviewed to
Procedures are available where necessary and are user friendly. This result could be improved by seeking out best
practice available.
687
A systematic means of tracking changes would simplify the updating process. Consider using a legislative alert
system.
conditions.
This may be easier to manage if the procedures where available on line.
result in this area.
688
Recall/Hotlines
This element is critical in terms of safe handling and health effects. More information could be provided to clients.
communicated.
This area could be developed in two key areas (i) root cause analysis and (ii) awareness of varying perspectives
during the write up of investigations. A balanced perspective is always important, and emphasis on the underlying
cause is crucial to prevent incidents from recurring.
An area to expand in chemical safety. Also be aware of the need to focus on outputs.
689
A more formalised approach would be helpful here should litigation arise.
Consider what information demonstrates that engineering controls are working as expected, and what action levels
could be set to ensure that the information received is being used for prevention rather than cure. Also consider the
strategic direction the operation is heading in light of legislative changes.
690
Report
691
Summary
and identifying areas of strengths and vulnerabilities. The results are
based on evidence made available at the time of the assessments.
The application of this framework was conducted at your company (a large

media organisation), focusing specifically on one department during
December 2007 and early January 2008. This study found:
; Of the 60 elements in the framework, all were applicable to your

operations;

(68%) with formal systems and another 14 elements (23%)
informally. This predominantly formal approach also suggests that the
organisation has a high level of bureaucracy. The problem this poses
is that this can impede the time frames for action on serious OHS
matters.
; 5 of the 60 suggested elements were not addressed by your

organisation-these included: Operational Review; Behaviour
Modification; Health Surveillance; Self Assessment and System
Review.
; The systems used to manage the safe operation of the facility are
very focused on workers’ compensation and rehabilitation, and hinge
upon the use of risk assessments to continue to reduce the level of
exposure of workers to potential OHS hazards. However, more
emphasis is needed on problem solving skills to get to the root
cause(s) of the OHS issues.
risks are clearly within the hardware and operating environment area,
which in this particular case is a variable setting.
692
; Due to the unpredictable nature of the operating environments
where workers may be assigned, it is imperative that training for
dealing with various scenarios forms the cornerstone of the strategies
utilised to reduce the level of worker exposure. Training must be
delivered in a format which is compatible with the learning styles of
those at risk. Given that this is an organisation that is dealing with a
highly visual and aural medium, it is suggested that the training
packages are in a similar format. The key here is to deliver critical
information concisely and in a format that is interesting. Retention of
information should be verified by some form of competency testing,
possibly on an ongoing basis. It is clear that the current control
mechanism involving a two tiered risk assessment for reducing
exposure to potential hazards when on assignments is not working.
Other options are available.
; Whilst the systems being used are highly sophisticated, this may
create a false sense of confidence, and the systems are only helpful
if the documentation is actually translating into real actions that
demonstrate visible improvements.
; Manual handling of equipment for lone workers is an area that needs

to be reassessed. It was observed that there is such a high level of
pride of workmanship that workers are willing to take unnecessary
risks to ensure the quality of the final product. Management is
cautioned not to take advantage of this, and consider the absolute
duty of care that is owed.
; The organisation has achieved a high level of success in the areas of

equal opportunity/anti-harassment, accommodating diversity,
workers’ compensation and rehabilitation, safe working procedures
and competent supervision. Attention is required particularly in the
areas of ergonomic evaluations, work organisation – stress/fatigue,
accountability, due diligence reviews, resource
allocation/administration and consultation.
; The process of consultation is not working as intended. It is

suggested that there be greater use of informal forums and more
693
opportunities created to help understand the different perspectives of
those supplying a service and those requiring the assistance. This
would allow issues to be addressed at an early stage before they
escalate and damage workplace relations.
Management should be commended for the high level of people skills

displayed by those supervising potentially volatile situations. Furthermore,
the pride of workmanship and the flexibility displayed by all those involved
is to be highly commended. It is clear there is a strong desire to fulfil OHS
obligations and that there is a high level of motivation to move forward in a
constructive and meaningful way.
694
Summary Results
Framework Charts

Equal Opportunity/
Anti-Harassment

Plant/ Equipment
Amenities/ Environment Training and Skills
Administration
Receipt/ Despatch Contractor Management
Fatigue/Stress

Dangerous Goods

Radiation Education Communication
Employee Assistance
Installations/ Demolitions Programs Legislative Updates
Preventive Personal Protective Equipment


Commissioning First Aid/Reporting Record Keeping/Archives
Workers Compensation/ Customer Service –

Emergency Preparedness Rehabilitation Recall/Hotlines
Security – Site/Personal Health Surveillance Incident Management
695

Equal Opportunity/
Anti-Harassment

Plant/ Equipment
Administration
Fatigue/Stress
Electrical Stress Awareness Criteria
Dangerous Goods
Radiation Further Education Communication
Employee Assistance
Preventive Personal Protective

Maintenance/Repairs Equipment Procedural Updates

Commissioning First Aid/ Reporting Record Keeping/Archives

696

Policy
Baseline Risk Assessment Equal Opportunity/ OHS
Anti-Harassment
Anti-Harassment
Goal Setting
Access/ Egress
Accountability
Plant/ Equipment
Plant/Equipment
Amenities/
Environment Training and Skills
Training Administration
Receipt/Despatch
Receipt/Despatch Contractor Management
Fatigue/Stress
Criteria
Noise
Hazardous
Substances/ Behaviour Modification Competent Supervision
Supervision
Dangerous Competent
Dangerous Goods
Goods
Communication
Further Education
Disposal Conflict Resolution

Conflict Resolution Consultation
Consultations

Programs
Repairs
Equipment
Modifications
Peer Review/
Review First Aid/Reporting Record Keeping/ Archives
Commissioning
/Commissioning
Security––Site/
Personal Health Surveillance Incident Management
Inspections/

Formal
Organisation
Informal
697
Figures 1, 2 and 3 show results of assessment of Safe People, Safe Place

and Safe Systems scores, both before and after control strategies and
interventions have been implemented. Where the differential between with
and without intervention is large, the controls have made a significant
impact.
Figure1: Initial and Final Scores - Safe Place
Radiation
Noise
Access/Egress
Modifications
Biohazards
Electrical
Plant/ Equipment
Disposal
Housekeeping
Receipt/Despatch
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium- Medium
High Risk Low Risk Well done
High Risk Risk
698
Stress Awareness
Work Organisation
Inductions
Health Surveillance
Conflict Resolution
Training and Skills
Job Descriptions
Selection Criteria
Feedback Programs
Networking etc
Health Promotion
Workers' Comp/Rehab
Equal Opportunity
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium- Medium
High Risk Risk
699
Accountability
Communication
OHS Policy
System Rewiew
Goal Setting
Incident Management
Self-Assessment
Legislative Updates
Audits
Procedural Updates
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium- Medium
High Risk Risk
700
of hazards, and as the place where workers are sent on assignment is
variable, these hazards will be difficult to control due to the element of
unpredictability involved. This is followed by hazards associated with the
need for a systematic approach, and finally the balance comprises of
those hazards 0associated with people and the complexity of human
nature. The high inherent risk associated with the nature of the activities
requires a high level of vigilance, sound judgment and expertise to help
control the risks. Paradoxically, the systems that are in place for their
protection may be contributing to the current problems.

34% 36%
Safe Person
30%
Figure 5 demonstrates how the residual risk is distributed across the three
main areas. There are still significant risks associated with the physical
work environment and there is a need for reliable systems that are well
supported and easy to navigate.

34% 35%
Safe Person
31%
701
80
70
60
Risk Ranking
50
40
30
20
10
0

applied, with a risk reduction factor of 0.7 being achieved across all three
areas. This implies that there is still 70% of the risk initially assessed
without prevention and control strategies in place is still remaining. This
relatively high residual risk across all three areas - safe place, safe person
and safe systems reflects the fluctuating nature of the work loads, and the
need to travel out to different locations often with unpredictable hazard
profiles. However, this is inherent in this field so the risks must be
managed with alternative strategies. Reliance on time consuming risk
assessments from first principles for each assignment is simply an
unworkable option given the urgency and speed required to conduct tasks
in a highly competitive environment. More investment is needed in building
relationships with those in a supplier/customer relationship within the
organisation so that each side can understand the others’ perspective and
work together safely. Overly bureaucratic systems will encourage staff to
work around the system and lose the protection the system was designed
to offer. There is also a strong need to streamline and customise critical
information so that it is context specific and deliver it in a format which
caters for the personality and learning styles of those it is trying to protect.
702
A baseline risk assessment needs to be available that has been customised to the specific department. This should form
the basis for the safety plans that are necessary to meet the organisation’s internal OHS management system as discussed
under roles and responsibilities for managers and supervisors. Care needs to be taken that the risk assessment process
implemented uncovers the root cause of the potentially hazardous situation so the controls identified can be more effective.
Consider augmenting this with the use of dynamic risk assessments in the field and training sessions on the application of
this technique with likely scenarios.
There are a number of critical issues associated with manual handling, especially for those working essentially alone.
There was a perceived reluctance to reduce loads handled as this could adversely affect the quality of the final product,
which there was much pride in.
703
Access/ Egress This considers the quick and efficient entrance or departure of personnel to and from the physical workplace, including those with
accordance with local building regulations, and escape routes clear. This is particularly important in the case of emergency
situations.
their workplace.
Whilst this is available for the office setting, those workers travelling out to various locations need to be aware of the
means of emergency egress for each assignment.
(including forklifts) and working from heights. Confined or dangerous spaces should also be identified. Refer to individual elements
for noise and/or electrical for the potential of plant/equipment to cause noise, vibration and electrical hazards.
There are numerous procedures to cover this area and the integrity of equipment is essential to the quality of the final
product, so by necessity this is managed fairly well. There are still some issues that need to be addressed which the users
are well aware of.
Whilst there is training for hostile environments, contractors and employees are still at risk on an ongoing basis from
threats of violence and unpleasant conditions such as heat and lack of facilities which have been tolerated as part of the
job. These situations could be handled more effectively if there was greater pre-planning and buffer capacity in the
scheduling system.
704
This is a relatively low risk activity based on the observations during the time of the assessment.
There is a great deal of portable electrical equipment in use. There are clear requirements for tag and testing and use of
RCD’s. Common sense is used to handle these situations and those using the equipment are careful not o put themselves
at risk. Location of power outlets on location can be a limiting factor and can create difficulties with safe arrangements of
leads.
There is plenty of good information available within the organisation’s internal OHS management system – see the
Headphones/ Headsets rule. Managers are required to do a noise assessment although specialist assistance would be
necessary to perform this task adequately. There are no baseline audiometry checks performed on new starters. This area
needs greater focus to prevent the potential for future hearing loss.
705
This is handled on an ad hoc basis. There is protective equipment supplied, but the issue is in anticipating exposures and
the inherent difficulty with this. Greater consistency of approach is needed here and more preventive strategies required.
The organisation is well aware of the potential for biohazards and this is covered adequately by internal procedures. This
result could be improved if the requirements were implemented on a more regular basis.
The organisation’s internal OHS management system discusses at length the risks associated with hazards related to
Radio Frequency Radiation. There are also rules covering the use of microwaves and lasers. However the risks of UV
radiation are somewhat ignored and no sunscreen was provided for outdoor workers.
706
sharps.
Disposal of plant is referred to in the Guide to Managing Plant and Equipment. Batteries and Stanley knife blades are
managed on an “as needs” basis informally. The result could be improved if these areas were better documented and any
other areas identified.
Demolition of pedestrians and others in the workplace. Included here are the presence of asbestos in demolished structures; the safe
connection or disconnection of services such as gas, electricity, and telecommunications; protection from noise, debris or other
projectiles; and the possibility of falling into excavated areas.
There is a rule regarding derelict buildings and a checklist for installation of plant and equipment. Compliance with these
requirements may be an issue.
Maintenance/Repairs running without compromising safety. Repair work is carried out on failed equipment in a timely fashion by those that are qualified
and competent to do so.
The technical repairs are handled by an internal division of the organisation and this system seems to be working well.
707
Review users and others affected. Modifications may be minor or major, and should be peer reviewed by others with the appropriate skills
/Commissioning and knowledge. New plant or equipment is commissioned to ensure that all safety impacts have been considered before the project
is handed over to the regular users.
These are handled via an internal division of the organisation and examples includes modifications to handsets in
vehicles. This is handled informally and appears to be working well, although more rigorous documentation to track
changes would be of assistance to confirm end user consultation prior to the changes being made.
Preparedness situations; vapour clouds, sabotage, medical emergencies and other unwelcome events. Not only should these potential situations
There are emergency plans for the office environment, but there needs to be a protocol for workers on location. This
should be built into the induction program.
Security – Only authorised persons who have been informed of relevant site rules enter the workplace. Persons working alone should be able
Site/Personal to contact help in case of an emergency (medical or otherwise) and precautionary measures have been put in place to reduce threats
of bodily harm. Provisions exist for removing unauthorised persons or unwelcome visitors.
Threats to personal safety are a real risk and this is clearly tied to the issues surrounding lone workers. This matter needs
reconsideration to ensure duty of care obligations are fulfilled. Requirements for risk assessments to be carried out prior to
assignments are unworkable and the matter needs to be handled by an alternative mechanism.
708
The level of housekeeping appeared to be a function of current workloads. As work loads lighten, these matters are likely
to be addressed. This element could be improved by a greater level of ongoing consistency to ensure that incidents that are
clearly avoidable remain that way.
Monitoring manner that was intended and for which safety provisions have been considered and implemented. The processes are monitored to
This element is closely tied to the quality of the final product as such is under a reasonable level of control. Whilst this is
handled informally, a higher level of documentation would allow ongoing nuisance issues to be brought to management’s
attention.
Review implemented for risk reduction have been effective or otherwise, and whether there have been any changes to plant, the organisation
This element is not addressed currently by the organisation on a departmental level. The purpose of this is to ensure the
ongoing viability of the operations whilst fulfilling OHS duty of care obligations. A careful balance between operational
viability and exposure of workers to undue risks must be considered. Plans on how ongoing risks will be addressed to
minimise worker exposure should be documented.
709
Equal Opportunity/ Policies are in place to ensure that all employees and others are treated with respect and dignity. There is zero tolerance towards
Anti-Harassment bullying and diversity is accepted in the workplace. Awareness programs have ensured that the intention of these policies have
This element is handled well by the organisation.
Diversity for their safe evacuation in case of an emergency. The special needs of young workers, pregnant or nursing mothers, and older
Again, this area is handled well and there are policies in place to promote awareness of management’s attitude towards
these issues.
The department is clear about desirable traits in prospective workers and the natural selection processes appear to be
working well. However, the heavy use of casual and contract labour may be placing vulnerable persons at risk due to the
less vigorous screening procedures invoked in those circumstances.
710
Inductions-Including All visitors and contractors to the workplace are made aware of any hazards that they are likely to encounter and understand how to
Contractors/ Visitors take the necessary precautions to avoid any adverse effects. Information regarding the times of their presence at the workplace is
Inductions for contractors and casuals should be tightened up as these represent a high proportion of labour in use. A
short, department specific induction video that extracts the most critical and relevant information from the existing OHS
management system and presents it in a format that is most suitable for the target audience should be considered as a
matter of priority.
Much time, effort and resources have been invested in this area and significant progress has been made. The challenge
now is to translate this into a more user friendly system that is geared towards delivering critical information as quickly as
possible to those who need it urgently. The system covers a very broad range of topics so navigation within the system
can be difficult for those who are highly familiar with the system content.
Fatigue unnecessary manual handling, overuse, undue fatigue or stress, and the required level of vigilance is able to be maintained over
the work period. Work breaks, pauses or other rotation of duties have been introduced where fatigue inducing conditions have
been identified. Fatigue may be of a physical or mental nature.
The nature of the particular industry being examined suggests that this element is often outside the organisation’s
sphere of influence. As such there is little time available when work loads peak to take the necessary precautions that
would be reduce residual risk levels to a more acceptable level. An alternative mechanism needs to be investigated to
overcome the problems of short notice for assignments, and the admirable pride of workmanship and the influence this
has on the willingness to accept high level risks.
711
The potential for stressful situations originating from outside the organisation from the public is well understood.
However there is a high level of stress generated from within the organisation that is not being dealt with adequately. This
includes workplace relationships on the customer/ supplier interface; lack of control over workloads; and instances where
responsibility is not commensurate with authority.
safely.
These exist for staff members, however many of those employed are not technically staff. Whilst this may provide some
level of flexibility, this will be traded off against the ability to plan and anticipate problems as well as some loss of
consistency.
used for positive reinforcement of safe behaviours, consideration is given to the use of variable, unpredictable reward schedules so
that the benefits are maintained when the reward is removed. Rewards may include praise, recognition or increased status.
Whilst this element is not addressed specifically by the organisation on a departmental level, there is an opportunity
here to develop some strategies to address some unsafe work habits that have become accepted practice, and also to
encourage workers to feel confident about declining assignments that are clearly high risk situations.
712
in the workplace.
The organisation was placed as a finalist for an award for work/ life balance There is observational evidence that those
within the department are health conscious and physically fit. More emphasis could be placed on psychological well-
being.
injury or illness.
There is a natural pathway for career progression within the department that is well understood. It is highly competitive
and difficult to break into. Opportunities for mentoring should be identified, especially for those who are new to the
organisation.
and safely.
Management is very careful not create volatile situations. However, whilst this indirect approach may ease everyday
functioning the risk is that problems will escalate instead of being caught at an early stage when the options for
addressing the situation are simpler and more likely to be contained.
713
There is ample evidence that this service is available. Whether or not this service is utilised as well as it could be is
worthy of consideration. It appears that there are a number of coping mechanisms in place to deal with the high stress
environment, including mateship and a sub culture of humour.
Equipment supplied has been carefully selected to ensure that it meets any standards applicable, is fit for purpose and is fitted correctly. The
impacts minimised.
A variety of PPE is available for use. However, this forms the weakest level of control as its effectiveness is highly
related to user compliance and correct selection and fitting.
First aid facilities are available. Whether all first aid kits are complete may need to be examined. Reporting mechanisms
are available and in use.
714
Rehabilitation returning injured or ill employees back to the workplace in an agreed timeframe without exacerbating their current condition and to
modified job/ same workplace; different position same workplace; similar or modified position/ different workplace; different position/
different workplace. A return to work co-ordinator has been appointed either internally or externally to meet local OHS regulations.
All parties are kept informed of progress and developments. Systems are in place to ensure that injured workers are not returned
to the unaltered workplace that injured them.
This receives a high level of attention and appears to be managed very well.
Health surveillance is not in use and it is suggested that this be utilised to verify if current control measures are
working effectively and to establish baseline information for individual workers so that the causes of any changes may be
investigated.
Whilst email and informal phone calls appear to be the preferred means of communication, there are few opportunities
to exchange perspectives in a collective manner. Use of informal forums to liaise with those in other departments and mix
in an atmosphere that is non threatening and independent of existing hierarchical frameworks should be encouraged.
715
This is not undertaken for casual staff; hence the opportunity to reinforce the importance of the organisation’s
commitment to OHS values is lost.
The opportunity to extract information which could be used to improve existing scenarios is not being utilised
effectively, and it is unlikely that there would be much incentive to pursue this path due to the high level of competition in
the jobmarket.
716
The current OHS Policy relies heavily on the use of safe systems and employees, managers and supervisors sharing
the responsibility to ensure a safe work environment. However, responsibility must be commensurate with authority
and those with authority need to be provided with sufficient resources to fulfil their responsibilities. Systems provided
need to be shown to be effective and workable.
may lead to apathy.
There are lots of goals set for the reduction of workplace injuries. However, there is a lack of goal setting on a
departmental level to support these overall goals. Goals should be aligned with overall policy, and be translated into a
realistic set of tasks that could result in meaningful changes on a more local level. .
Responsibility is not commensurate with authority. On a daily basis, staff are trying to manage as best they can with
the resources available and conditions that are not always within their control. Urgent attention is needed here to allow
the situation to move forward.
717
breaches.
There is an urgent need for department specific OHS plans that are realistic and sufficiently funded. It is suggested
that this process by started by focusing on what are perceived to be the most important issues by those with the
highest level of exposure. There is also a need for some early victories to restore confidence in the process.
Resource Allocation/ Sufficient resources have been allocated to OHS issues to demonstrate that commitment is real and goals are achievable.
Administration Funds are protected from “reallocation”. Time is available and sufficient to address OHS issues, and has been budgeted for in
It appears that many of the current problems are related to past decisions that traded off safety for increased pay.
Whilst those who may have benefited from those decisions in the past may no longer be there, there is a level of
frustration evident amongst those left to deal with the situation as it currently stands. The existing strategies to reduce
the risk of injury to workers – both physical and psychological, are clearly unworkable.
There is a large volume of documentation to regulate the use of contractors. These procedures would consume a
considerable amount of what are clearly already stretched resources to implement. It would be a worthwhile exercise to
see what the existing level of compliance is with these procedures, and what mechanisms are utilised to work around
them. If procedures are not being invoked then they should be re-examined.
718
Criteria are made to ensure that hazardous materials are reviewed prior to purchase (see Hazardous Substances and Dangerous
Procurement planning is covered under the guide for managing plant and equipment risks. The level of
implementation of this policy should be examined.
In this particular case the greatest OHS impact is to do with the potential for trauma and psychological harm due to
the content of the finished product, and in the process of creating the final product. The process of natural selection for
those in these roles and the careful use of warnings has resulted in the current risk ranking, although this could easily
revert to a higher ranking if the warnings were not in place or if other persons were exposed to footage during the
editing process were not accustomed to the type of material being processed.
The level of competence displayed was high and there was clear commitment to core OHS values.
719
This area has been handled particularly well.
This could be significantly improved if an informal forum was available where co-workers could meet to exchange
perceptions and ideas and get to know each other on a more personal level.
This process is in place but is not working as intended by the spirit of the legislation. Consultation is currently
operating at too high a level and not involving enough of those persons actually exposed to workplace OHS risks. This
process could be far better utilised to address more practical issues and the development of departmental OHS plans.
Outcomes should be visible, responsibility for actions made clear and unambiguous, and progress reviewed.
720
This is handled at a corporate level. This result could be improved by greater awareness of local requirements.
conditions.
The organisation’s OHS management system is fairly well maintained. This result could be improved if awareness of
the corresponding changes was more widespread. .
There are a number of rules for record keeping. The question here is whether the right information is being captured
to move the organisation forward in OHS matters.
721
The organisation is very conscious of its public image so sufficient resources are available to handle this element
adequately. This result could be improved if the organisation was more preventive in its responses.
and communicated.
There is an elaborate incident management system in place and this is used as a means of last resort to gain
management attention on issues that are causing local frustration. This tactic will possibly have a paradoxical effect by
increasing the residence time of items in the system, as the system appears to work better for major incidents.
Furthermore, the problem solving section of the framework should be revisited as it emphasises the controls without
ensuring that the root cause of the incident has in fact been uncovered.
722
Focus in this area could deliver some quick improvements to the to help move the organisation forward, especially if
just a few areas were targeted.
These occur on an ad hoc basis and there are no internal auditing schedules. Before this element can be of good use,
there needs to be more emphasis on extracting information relevant to the specific department and delivering it to end
users in a format that is more readily retained.
This area is simply not addressed by the organisation on a departmental level. The organisation needs to have a
better grasp of how the existing strategies are working or not working together so the effectiveness of the current
pathways can be assessed.
723
Report
724
Summary
organisation company for the purposes of assessing its management of
OHS issues and identifying areas for improvement. The results are based
on evidence made available at the time of the assessments.

suburban pharmacy) during January 2008. This study found:
; Of the 60 elements in the framework, 60 were applicable to your

business;

(13%) with formal systems and another 37 elements informally. The
remaining elements were not specifically addressed by your
organisation. The predominantly informal approach implies less
documentation, and in most cases this approach works well,
however, this may present difficulties should any claims or litigation
arise.
; The hazard profile of the company suggests that your the most
significant risks are to do with the physical work environment area
and lack of space. Hazards associated with people, the complexity of
human nature and the need to have a systematic approach are also
present but to a lesser extent. This suggests that a substantial
amount of capital may be needed to reconfigure the current work
space to make a significant reduction on the level of residual risk
presenting to the business. Where these funds are not available,
lower order controls will need to be invoked, and it is likely that these
strategies will require a high level of training and co-operation from
staff members to be successfully implemented.
; The dominant prevention and controls strategies in the company

involve both safe person and safe system techniques. These rely
heavily on personal expertise, skills, judgement and a logical,
725
systematic approach. These attributes were well observed during the
assessment.
; The organisation needs to be aware of the potential for the

normalisation of danger and risk habituation. With normalisation of
danger - when the same hazardous situation is experienced
routinely, there may be a tendency to accept the situation rather than
to find means of addressing the problem at the root cause.
Furthermore, the organisation needs to be open to the possibility of
treating the risk using alternative approaches.
; In such a small organisation, there may be a reluctance to delegate

duties resulting in some staff members being overloaded. The
potential for delegation of more duties may need to be reconsidered
in areas not governed by legislation and the handling of scheduled
pharmaceuticals.
; Your company has very successfully addressed the elements of

Access/Egress; Amenities/Environment; Radiation (due to UV); Work
Organisation-Fatigue; Hazardous Substances; Equal Opportunity/
Anti-Harassment; Training and Skills; OHS Policy; Supply with OHS
Consideration; Competent Supervision and Customer Service. The
prevention and control . Your strategies associated with these
elements have been effective, and you are strongly encouraged to
continue with your improvement efforts.
The results show that the manager is very in tune and committed to OHS
matters and has a very high level of work dedication. Despite space
restrictions, efforts have been made where ever possible to find alternative
means of working safely and demonstrating a duty of care. The manager
has applied a very practical, commonsense approach to dealing with OHS
issues.
Management should be commended for the success of their current
controls and the their clear dedication to the welfare of their staff and
customers.
726
Summary Results
Framework Charts

Equal Opportunity/
Anti-Harassment

Plant/ Equipment
Administration

Dangerous Goods

Education
Employee Assistance
Programs
Repairs
Commissioning
727

Equal Opportunity/
Anti-Harassment

Plant/ Equipment
Administration

Criteria
Noise
Dangerous Goods
Biohazards
Health Promotion Safe Working Procedures
Further Education
Employee Assistance
Programs

Commissioning
728

Anti-Harassment
Anti-Harassment
Access/ Egress
Inductions – Contractors/ Due Diligence

Diligence Review/
Review/ Gap
Plant/ Equipment
Plant/Equipment Due
Analysis
Administration
Receipt/ Despatch Work Organisation
Work Organisation –– Fatigue
Fatigue/Stress
Criteria
Noise
Hazardous
Substances/
Dangerous Behaviour Modification Competent Supervision
Dangerous Goods
Goods
Biohazards
Communication
Further Education
Consultations

Programs
Updates
Procedural
Maintenance/Repairs
Repairs Equipment
Modifications – Peer Review Aid/Reporting
/Commissioning
/Commissioning Workers Compensation/
Compensation/ Customer Service – Recall
Emergency Preparedness Workers
Recall/Hotlines
Rehabilitation
Security

Formal Organisation
Informal
729
interventions had been implemented. Where the differential between with
and without intervention before and after is large, the controls have made
a significant impact.
Access/Egress
Housekeeping
Receipt/Despatch
Disposal
Biohazards
Electrical
Plant/ Equipment
Modifications
Radiation
Noise
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium-High
Risk
730
Figure 2: Initial and Final Scores – Safe Person
Stress Awareness
Work Organisation

Workers' Comp/Rehab
Inductions
Health Promotion
Selection Criteria
Conflict Resolution
Networking etc
Job Descriptions
Feedback Programs
Health Surveillance
Training
Equal Opportunity
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium-High
Risk
731
Figure 3: Initial and Final Scores – Safe Systems
Accountability
Legislative Updates
System Rewiew
Audits
Self-Assessment
Procedural Updates
Goal Setting
Consultation
Communication
OHS Policy
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium-High
Risk
732
of hazards. This is due to the lack of physical space, security issues and
the need for staff to be on their feet for long hours.

34% 37%
Safe Person
29%
Figure 5 demonstrates how safe person and safe system strategies have
been used to reduce the overall risk rating of the operation. However, an
number of significant risks still remain, especially relating to the “safe
place” area.
Figure 5: Risk Distribution – with Interventions and Strategies in

Place
Safe Systems
Safe Place
30%
42%
Safe Person
28%
733
70
60
50
Risk Ranking
40
30
20
10
0
With
Without Inter
Legend
Intervention venti
on

strategies is limited by the complexities of human nature – and the
effectiveness of such controls may be diminished under conditions of
stress and fatigue.
The higher level of residual risk in the safe place area suggests that there
is a need to address the root cause(s) of problems through engineering
and design methods, and may involve an injection of capital.
Finally, main issues presenting to the business involve ergonomic factors,

security threats such as armed ups, access and egress as well as the
stress of dealing daily with customers who are often have serious health
issues and may be experiencing some level of personal frustration. Whilst
the business is very customer orientated, it is important that management
734
also consider their own welfare, which will enhance their ability to continue
to provide such valuable and caring customer service.
735
The risk is that the organisation does not know what OHS issues need to be addressed or how urgent they are so resources can
not be allocated effectively according to priorities, and the response will be reactive only.
There is documentation in this area regarding the safety and environmental aspects of the operation. However, more
information is needed on the potential health impacts. Furthermore, the information that is available could be used to
greater effect to inform necessary parties of potential hazards on site. Key risks have been assessed informally and
addressed in a practical manner. A more formalised approach may be useful should the business which to grow, and also
to ensure that all significant risks have received sufficient attention.
The risk is that an employee will sustain a strain/sprain injury or cumulative trauma. Whilst the injury may not be fatal, it may be
very debilitating and result in significant periods of lost time, increased workers’ compensation costs and the injured worker may not
be able to return to the same type of employment.
Manual handling assessments have taken place informally and key needs have been addressed. However, these rely on
the operators using the provisions as recommended. Refresher training in this area would further improve this score.This
area represents a concern due to the restricted physical area within which the business operates. Standing for long
hours, bending for organising shelf space and unpacking deliveries are key areas where problems may arise. The use of a
footstool to relieve pressure from standing in the one area is suggested although clearly this issue would be better
handled if the physical work area could be redesigned.
736
situations.
This has been handled well and the natural layout of the operation facilitates thisThis needs to be reconsidered to
ensure that local regulations are complied with and that there is quick access/egress should an emergency situation
occur. There is some justifiable concern about armed hold-ups, however, the two issues need to be carefully weighed up
so the risks arising from both situations may be addressed, and the risk not transferred elsewhere to another scenario.
There is minimal plant and/or equipment, however what is being used is of importance and is under reasonable control.
Amenities/ Pertaining to a comfortable work environment this includes private, hygienic facilities such as toilets and change rooms; provision of
Environment drinking water; heating; cooling; refrigerator/ microwave for mealtimes; and infant feeding facilities and showers where the need
exists. Heat stress may also be exacerbated by humidity levels. Exposure to heat and cold may be particularly important
considerations for outdoor workers. (See radiation for UV exposure). The special needs for divers or air cabin crew should also be
considered where applicable. Lighting within the workplace and exposure to glare should also be considered here, as should
climate control and indoor air quality. Smoking is banned from the workplace, and there are designated, outdoor areas with good
natural ventilation and away from fire hazards, for those who have a habit.
The rating in this area reflects the small workspace available. Redesign of the existing area to improve the efficiency of
the current storage space would be helpful and is suggested. Furthermore, any attempts to provide the illusion of space
may also enhance the ability to relax whilst on a break or during times when “time out” is needed.
737
ordering/purchase; Safe despatch ensures that loading of finished goods does not result in harm, including any earthing
requirements where applicable and the product is transported safely. Plans for dealing with emergency situations in transit have
been developed, necessary information and contacts are available and training has been conducted for affected parties.
There is the potential for robbery during receipt/despatch. Also there are issues with the space to unload deliveries, and
carrying awkward sized boxes. The layout and space issues need to be reconsidered so that access/egress is not
blocked, bending and twisting is minimised, heavy loads are handled safely and trip hazards are not created.
qualified personnel should do so.
The risk is that someone may be fatally electrocuted or cause a fire/explosion by creating sparks in a flammable or explosive
atmosphere.
A regular contractor is used and there are only a small number of electrical items. However, because the jobs are only
small, this may lead to delays whilst jobs accumulate to justify calling the electrician in. This has increased the risk rating
as the delay increases the exposure and may also create other hazards in the process.
Noise Noise levels or noise maps have been documented where the potential for harm exists, for example if a raised voice is necessary
to hear a conversation. In some cases baseline audiometry testing will be necessary. Specialist advice should be sought and
attempts to remove the source of the problem should be the first line of defence. Local regulatory requirements should be known.
Comparison with regulatory limits should take into account the length of exposure especially if shifts longer than 8 hours are used.
Sources of vibration that impact on workers should be identified, including power tools, seats on mobile plant equipment.
The noise levels are fairly low other than the door buzzer. This may be quite annoying, and the buzzer sound may need
to be reconsidered.
738
noted, and where this is inadequate a risk assessment has been prepared; these requirements are made known to all those who
may be exposed, In some cases this will be dependent on the quantities or volumes stored. Storage arrangements and inventory of
dangerous goods should comply with local OHS and DG legislation. Training for the precautions necessary during use, handling
and storage should given to those at risk.
The risk is that someone may become ill from exposure to a hazardous substance whether it is immediate or long term, or harmed
by fire or explosion due to inadequate storage and inventory arrangements.
A large variety of solvents are used on site and these are generally handled well. However handling of powdered
substances could be improved and attention should be drawn to hazardous materials of construction to ensure
compliance with local regulations.This is well controlled by the high level of staff expertise and professionalism applied.
Only minor documentation issues to be addressed.
protein that may cause an allergic response – for example mould or dust mites. The source may include micro-organisms,
infectious people; contaminated food; contact with animals; rodents; plants/pollens; insects; mites; lice; sewerage; fungi or bird
droppings cooling water reservoirs and air conditioning systems that may contain legionella organisms.
long term flu/asthma-like symptoms
Customers are a potential source of infection. Gloves are only used when blood is involved when treating cutomers.
This more personal approach is part of the customer service provided. Dust and the carpet may also contribute to
biohazards and this also needs to be considered.
739
There is minimal outdoor exposure to UV. Hence the risk here is low.
and that does not cause harm either through immediate contact or as a result of transferring the substances / materials for disposal
or dispersal elsewhere. All those in contact with the waste materials are aware of hazards and precautions necessary to minimise
the risks (see hazardous materials/ dangerous goods). Also included here are the risks associated with hygiene and the handling of
sharps.
There is a program for returning waste medicines which is under good control. However, dealing with a spill in the
pharmacy itself would be more problematic, due to the small area and carpet floors.
Installations/ Planning for the safe installation of new buildings or warehouses as well as the demolition of these structures to ensure the
protection of pedestrians and others in the workplace. Included here are the presence of asbestos in demolished structures; the
Demolition
safe connection or disconnection of services such as gas, electricity, and telecommunications; protection from noise, debris or
other projectiles; and the possibility of falling into excavated areas.
There is a need to know whether there any asbestos has been used in the construction material. Capital provisions
may be necessary in this area for safe demolition of older buildings in the future. There is no current activity in this area.
740
Preventive Regular maintenance of equipment essential for safe operation is planned and critical spares are readily available to keep
production running without compromising safety. Repair work is carried out on failed equipment in a timely fashion by those that are
Maintenance/Repairs
qualified and competent to do so.
Ongoing maintenance could be handled in a timelier manner- cash flow considerations may be exacerbating the issues.
Modifications – Peer Changes to existing infrastructure and plant/equipment are carefully controlled to minimise the impact that this may have on
existing users and others affected. Modifications may be minor or major, and should be peer reviewed by others with the
Review
appropriate skills and knowledge. New plant or equipment is commissioned to ensure that all safety impacts have been considered
/Commissioning before the project is handed over to the regular users.
The risk is that the modifications result in an injury because the full impact of the changes was not thought through prior to
implementation.
Ergonomic considerations need to be factored in from the start, and all end users should be involved.
to contact help in case of an emergency (medical or otherwise) and precautionary measures have been put in place to reduce
Site/Personal
Key areas of concern have been identified such as armed robbery, fire and general accidents including needle stick
injuries This area is currently under improvement and a recent evacuation drill was conducted. However, the
documentation needs to be in place, and a systematic means of updating is required. Formal debriefs after drills should
also be conducted so lessons from evacuation exercises are captured, and techniques improved. However, there are no
duress switches or CTV and no smoke detectors. Quick egress from the site and additional security measures should
receive further consideration.
741
identify areas in need of improvement. Emergency equipment such as fire extinguishers are regularly checked and maintained in
good working order.
The risk is that in the event of an emergency situation people will be unable to evacuate safely which may lead to increased
casualties, panic and trauma.
Emergency drills involving all staff are urgently needed in this area. Updating of emergency contact information is also
required as a matter of priority.
The workplace should be kept in a clean and tidy state to avoid trips, slips and falls. Spillages should be cleaned up immediately.
There were numerous boxes to be unpacked during the time of the assessments, and these took up a significant
amount of the limited space available. This needs to be addressed on an ongoing basis so thoroughfares are not
restricted. There is some accumulation towards the back of the site, but the production area is kept very well.
Inspections/Monitoring Processes should be monitored and inspected regularly to ensure that equipment and facilities are being used and applied in the
manner that was intended and for which safety provisions have been considered and implemented. The processes are monitored
to ensure that they are operating within safe limits. Causes of abnormal operations are investigated and rectified.
The risk is that the process operates outside of designated safe limits which may lead to injury or other ill effects, or that equipment
is used inappropriately leading to damage to property, loss of production or other unwelcome events.
There regular tests on the refrigerator temperature. Scripts are checked on an ongoing basis. These procedures are
routine and well executed, but are still be susceptible to human error.
742
implemented for risk reduction have been effective or otherwise, and whether there have been any changes to plant, the
Review
organisation or legislation that may impact on the risk presented by the operation. Any adverse findings are dealt with.
This is an area for consideration in light of upcoming changes in legislation requiring the elimination of certain
ingredients and changes in hazardous substances regulations. Details of actions arising from more formalised reviews
would improve this result.
743
Harassment
of resources; spreading malicious gossip; social exclusion; hiding belongings; role ambiguity; and career stagnation or
uncertainty.
To the smaller nature of the operation and the attitude of management, this does not pose a significant concern.
However, ensuring these same attitudes are reflected by personnel is a point that could be promoted A very good ant-
discrimination/ anti-harassment policy exists which has been well communicated and there is evidence that the
sentiments are practised.
Accommodating Diversity The workplace promotes an acceptance of diversity. Access for disabled persons has been provided, and special provisions exist
Whilst English and language problems are not so much of an issue, specific risks related to younger workers could
receive greater attention.
744
This is handled well on an informal basis, essentially relying on personal recommendations or through work
experience. Documentation here would assist mainly to identify vulnerable persons and help minimise the potential for
litigation or claims.
Inductions- All visitors and contractors to the workplace are made aware of any hazards that they are likely to encounter and understand how
to take the necessary precautions to avoid any adverse effects. Information regarding the times of their presence at the workplace
is recorded to allow accounting for all persons should an emergency situation arise. Entry on site is subject to acceptance of site
Here, contractors need to ensure that any work carried out does not endanger the public. This may be difficult due to
the space limitations. Visitors also need to be aware of restricted areas and not to handle any medications without the
pharmacist’s knowledge. This area has been addressed informally but would benefit from a more formal approach. This
result could be improved by a number of simple additions to the current methods, and some printed bookwork/
maintain skills and provide ongoing protection from workplace hazards. Competency training has been scheduled according to the
training needs analysis. All persons conducting training are appropriately qualified to do so. Training records are maintained.
Inductions for staff are handled very well; training and skills development is undertaken with great care.
745
Organisation -Fatigue The individual arrangement of job tasks that constitute the role have been considered to ensure that the work load does not
Fatigue due to standing for long hours is a matter for greater consideration. There is also the stress of dealing with
customers who are often in need of informal counselling. Delegation of more duties may need to be considered as well
as other means of unwinding on a regular basis.
considered by that particular employee as stressful. Plans are available for dealing with excessive emails and unwelcome
contacts.
Due to the small nature of the business and the responsibilities falling mainly on the owner, stress awareness is an
important issue. Sources of stress need to be examined and current coping mechanisms reconsidered.
Structure
safely
Some job descriptions are available for operating staff, but not for key management staff. . Further documentation in
this area to capture key requirements would Documentation of job descriptions for more senior staff may help with
delegation of duties and more effective time management.
746
used for positive reinforcement of safe behaviours, consideration is given to the use of variable, unpredictable reward schedules
so that the benefits are maintained when the reward is removed. Rewards may include praise, recognition or increased status.
Analysis of unsafe work habits could be explored, especially with regards to stacking shelves and unpacking
deliveries.
Information to promote healthy lifestyle choices, diet and improve general well-being would be of assistance here due
to the number chemicals in use with health effects that are still under speculation. Whilst health promotion is part of the
business function, it is applied to customers rather than to the staff themselves.
Further Education
There is a reasonable degree of networking and development of staff.
747
and safely.
There is an understanding and compassionate environment provided by the owner, and this would not be an issue
whilst the owner is present.
Programs
There are a good number of contacts available and the owner is very approachable and understanding when it comes
to handling any staff matters. However, identifying someone to support the senior staff is also important.
Equipment
Gloves are used for biological hazards as well as for washing up. Consideration should be given to stipulation on
correct footwear.
748
This area could benefit from more detailed reporting to capture more information, although essential criteria are
covered. A First Aid kit is available and the owner is First Aid trained. Although not a regulatory requirement due to the
small numbers of staff, it would be useful is there was someone who was First Aid trained always on duty..
returning injured or ill employees back to the workplace in an agreed timeframe without exacerbating their current condition and to
Rehabilitation
This area needs to be developed so that should a rehabilitation case arise, the systems will already be in place and
relationships with off-site expertise have already been established so the process goes smoothly. Whilst there has been
no need to date for claims or injury management, contingency plans should be put in place to ensure that all due care
may be exercised should the need arise.
749
control measures will be not be known, that employees health will be endangered, a baseline for claims purposes will not exist
This is an area that should receive specialist input. Documentation is required here to assure legislative requirements
are met and also to demonstrate that the organisation has undertaken its duty of care. Formal health surveillance for
exposure to hazardous substances is not an issue, however, informal surveillance for the potential for substance abuse
and the potential development of ergonomic complaints should not be discounted.
Setting good examples for workplace safety should be encouraged and valued.
This needs to be extended to include staff other than Sales. Performance reviews should ensure that OHS issues are
not embedded into the assessment, and there are clear consequences for undesirable OHS attitudes or practices.
activities.
Opportunities to communicate with staff are facilitated by the small size of the business. However, the large age
differential between senior and junior staff may discourage the younger assistants from speaking up.
750
This element may become more important as the business expands and other pharmacists become more involved in
ongoing management activities.
Turnover
arrangements.
Whilst there is a very low turn over rate, reasons for any staff departures should be examined and opportunities to
address any issues considered.
751
Generally, the attitude by management is witnessed by their willingness to address safety issues and their obvious
intention to take care of their staff. There is an OHS policy which is communicated, well written and the intentions are
followed.
may lead to apathy.
The setting of a small number of goals would help focus attention on desired improvements.
This was not an issue at this operation as The owner takes full responsibility for OHS matters, however when the
owner is not there, it is important that those covering the owner’s absence also accept this function. Other staff
members also need to understand their role and responsibilities in all OHS issues, commensurate with their authority.
752
Analysis
breaches.
Areas of non-compliance need to be identified and an action plan assembled to demonstrate due diligence.
and tenders.
Priorities for OHS issues need to be reconsidered. Planning for budgets to address these items should be
documented.
Consideration should be given to expanding the pool of trusted contractors.
753
Criteria
resolved.
A more formalised approach to cover potential liability would improve this result. A commonsense approach is used,
however a more formalised approach may help focus attention of ergonomic considerations.
This is handled extremely well with respect to products dispensed and merchandise sold.
Record Keeping/Archives Records are kept in a safe and secure location, protected from deterioration and damage by water or fire. The duration for which
the records are kept is in accordance with local OHS regulations and the confidentiality of health records is enforced and
respected. Regular back ups of electronic data are made where their loss would have an impact upon the safety and health of
employees.
Action to improve record collection systems would improve the results in this area.
754
This result was facilitated by the small nature of the operation and the “hands on” approach of The small business
size facilitates ease of communication within the store. Hand-over information between pharmacists could be improved.
This rating could be improved by greater consideration of the perspective of the junior staff.
This area is handled extremely well. There is a high level of experience amongst line managers; however this result
could change if there were losses of key staff members.
755
Safe Working Procedures .Sufficient procedures are in place to enable duties to be conducted consistently and to document precautions necessary to
perform the job safely. Consideration is given to the level of detail incorporated so that there is a balance between providing
sufficient information and allowing workers to use their judgement and experience as necessary, for example where too stringent
or restrictive rules may encourage violations. The procedures should be regularly reviewed to incorporate improvements as these
become available, and the level of compliance assessed.
Procedures are available where necessary and are user friendly. Most of the information is disseminated verbally.
Consider using a legislative alert system or other means of being in touch with the latest regulations. This should
include amendments to the Pharmacy Act 1964, Privacy and Personal Information Protection Act 199, Heath Care
Liability Act 2001, Pharmacy Practice Act 2006 as well as relevant state OHS regulations
conditions.
Once a central tracking system has been established, updating of procedures will be easier to manage. Ensure that
there is a means of identifying the date of issue on all information displayed and set regular time frames for revision.
756
Consideration needs to be given to the amount of information that could be lost in between back-ups and whether
the number of back ups is sufficient.
Recall/Hotlines
The organisation is very customer oriented and this is handled well. Customer service is handled extremely well.
communicated.
The incident register is used to record some information but its application could be extended to better capture in-
store OHS issues. When investigating an incident emphasis on identifying the root cause and understanding whether
the actions address the root cause and not just the symptoms of the problem would be helpful. Where the root cause(s)
cannot be dealt with, the reasons why should be explored.
757
No regular specific self-assessment tools were made available at the time of assessment. This result would be
greatly improved by consideration of actions that have the greatest impact on safe working and would be useful to
ensure that prevention and control strategies applied remain on track. However, this is an area that could be developed.
No specific audits were made available at the time of assessment. Consultants are used to handle key risk areas,
however and internal system may be of use and extend the local knowledge base No internal or external OHS audits
have been conducted. Periodic auditing of OHS issues by an objective outsider may be helpful in meeting OHS legal
obligations and providing alternative perspectives on issues that staff may have become desensitised to or accepting
of..
758
No specific system reviews were made available at the time of assessment. This is important due to the hazardous
nature of the operation, but other items must be addressed before this element will provide value.A system review will
become more important once key OHS issues have been prioritised, and an action plan has been documented. A
review will also help identify where extra funding is necessary and may assist in decisions regarding the future of the
business.
759
Report
760
Summary
based on evidence made available at the time of the assessments.

manufacturing operation and storage facility for dangerous goods) during
late January 2008. This study found:

(95%) with formal systems and another 3 elements (5%) informally.
The systems used to manage the safe operation of the facility
display a high level of sophistication.
risks are clearly within the hardware and operating environment
area. The obvious hazards associated with the handling of
dangerous goods tends to dominate the current thinking, however
other areas such as chemical safety and future health must be
considered as well. These areas are in need of attention.
; The organisation is well aware of hazards associated with mobile

plant, and the risks are well managed by internal auditing
processes.
; The high inherent risk associated with the nature of the operation is
managed primarily through a combination of safe person strategies
involving the application of people skills and expertise as well as a
safe systems approach. There is still a very high level of residual
risk associated with the current physical work environment and
manufacturing operation and it would take a significant amount of
761
capital investment to bring this residual risk down to a more
acceptable level.
; A careful balance needs to be achieved between the amount of

energy directed into supplying information for the electronic
systems that manage incidents, audits actions and alteration
authorities, and the energy directed towards actually following
through and implementing actions arising from such investigations.
Whilst the systems being used are highly sophisticated, this may
create a false sense of confidence, and the systems are only
helpful if the documentation is actually translating into real actions
observed on site on an ongoing basis.
; A balanced approach is necessary to ensure that the system prompts

are not narrowing the focus of the risk assessments conducted and
over steering the investigation process.
; The consultation process could be better utilised to ensure follow

through of actions. There could also be greater involvement of the
safety committee members in incident investigations.
; There is such a high level of bureaucracy and control over every day
operations that it is important to ensure that the basis for such
actions is actually appropriate and not transferring the hazards
elsewhere. An example of this is the use of PPE and the potential
for heat stress in outdoor worker.
; The organisation is has achieved a high level of success in the

areas of competent supervision, communication, health promotion,
employee assistance programs and workers’ compensation and
rehabilitation. Attention is required particularly in the areas of
hazardous substances (safe handling), plant and equipment (the
ability to perform safe isolations and obtain access for
maintenance), and personal protective equipment (appropriate
usage).
; There are a number of other areas that need to be addressed

including contractor management given the high volumes of
762
contractors used on site; UV radiation with respect to protection of
outdoor workers; site security; emergency preparedness and the
potential for toxic fumes; and receipt and despatch including the
management of heavy transport on site.

such a high risk operation and their understanding of the critical safety
issues. It was observed that all staff were well versed on the
organisations’ attitude towards safety and took this matter very seriously.
The crew were very co-operative with the study, and instilled a high level
of confidence in the ability to manage the operation competently.
763
Summary Results
Framework Charts

Equal Opportunity/
Anti-Harassment

Plant/ Equipment
Administration
Fatigue/Stress
Dangerous Goods

Disposal Conflict Resolution Consultations
Employee Assistance
Preventive Personal Protective Equipment


Commissioning First Aid/Reporting Record Keeping/Archives

764

Equal Opportunity/
Anti-Harassment

Plant/ Equipment
Administration
Fatigue/Stress
Electrical Stress Awareness Criteria
Dangerous Goods
Employee Assistance
Preventive Personal Protective

Maintenance/Repairs Equipment Procedural Updates
Modifications – Peer Review/ First Aid/Reporting Record Keeping/Archives

Commissioning
765

Anti-Harassment

Plant/Equipment
Training Resource Allocation/
Administration
Work Organisation – Contractor Management
Receipt/Despatch Fatigue/Stress
Stress Awareness Procurement with OHS
Electrical
Criteria
Noise
Hazardous Substances/ Behaviour Modification Competent Supervision
Dangerous Goods
Further Education

Programs
Preventive Personal Protective Procedural Updates
Maintenance/Repairs Equipment
Modifications – Peer Review First Aid/Reporting Record Keeping/ Archives
/Commissioning

Formal Organisation
Informal
766

and Safe Systems, scores, both before and after control strategies and
interventions hade been implemented. Where the differential between with
impact.
Plant/ Equipment
Modifications
Radiation
Electrical
Receipt/Despatch
Noise
Disposal
Access/Egress
Housekeeping
Biohazards
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium- Medium
High Risk Risk
767

Health Surveillance
Conflict Resolution
Stress Awareness
Work Organisation
Training
Inductions
Networking etc
Job Descriptions
Feedback Programs
Selection Criteria
Equal Opportunity
Workers' Comp/Rehab
Health Promotion
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium- Medium
High Risk Risk
768
System Rewiew
Procedural Updates
Audits
Incident Management
Legislative Updates
Accountability
OHS Policy
Self-Assessment
Goal Setting
Communication
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium- Medium
High Risk Risk
769
of hazards, closely followed by those hazards associated with the need for
a systematic approach, and finally the balance comprises of those hazards
associated with people and the complexity of human nature. There is an
extremely high inherent risk associated with the nature of the operation
and a need to ensure that processes are conducted with a high level of
vigilance and expertise. Personnel need to be fully alert to ensure that
risks are well controlled.

34% 37%
Safe Person
29%
Figure 5 demonstrates how safe person strategies have been used very
effectively to reduce the overall risk rating of the operation. However, a
place” aspect.

32% 41%
Safe Person
27%
770
80
70
60
Risk Ranking
50
40
30
20
10
0

applied.
There is a very high level of residual risk remaining in the hardware and
operating environment. There is scope to reduce some of these inherent
physical hazards through better chemical handling, and the provision of
sufficient time and resources to ensure follow through of corrective actions
identified. Difficulties with dealing with the constraints presented by the
existing hardware and infrastructure must not be accepted at the expense
of worker safety whether long or short term and caution is advised against
tolerance of such high residual risk. Reduction of further safe place issues
will require substantial capital injection.
Finally, greater transparency of potential hazards on site needs to be

made available to visitors or contractors. Whilst this may be provided in
general terms it needs to be specific enough to enable vulnerable persons
to take the necessary actions to protect themselves and to ensure that a
sufficient and accurate exchange of information has taken place to
demonstrate due diligence.
771
The risk is that the organisation does not know what OHS issues need to be addressed or how urgent they are so resources can
not be allocated effectively according to priorities, and the response will be reactive only.
There is ample evidence that baseline risk assessments have been conducted. Whether or not these have taken into
account sufficiently all the health issues with the various chemicals involved may need re-examining. The physical risks
associated with dealing with dangerous goods are clearly understood.
The risk is that an employee will sustain a strain/sprain injury or cumulative trauma. Whilst the injury may not be fatal, it may be
very debilitating and result in significant periods of lost time, increased workers’ compensation costs and the injured worker may not
be able to return to the same type of employment.
More emphasis is needed on fatigue management to ensure vigilance remains high. There are quite a number of minor
sprains, strains, and falls. These should be examined for threads of similarity and awareness of the potential for similar
incidents to re-occur highlighted. Where it is impracticable or unlikely that the root cause(s) of the incidents will be
eliminated, it is crucial that other strategies are in place to reduce the level of residual risk and exposure of operators and
contractors to potential harm.
situations.
The site is extensive and in a rural location. Access/egress for locals passing through the back gate is cumbersome as
it is locked for security purposes. In case of an emergency it may take some time to evacuate to a safe place, simply
because of the distances involved and consideration should be given to the use of alternative safe zones within the site.
Plant/Equipment This requires that all existing equipment or plant operates without causing harm. Where this requires specialist knowledge this
must be pursued with the supplier or designer, and end users and others affected must be consulted and their opinions duly
considered. The hazards of rotating machinery, pinch points, and crush injuries should be included here, as well as the safe use of
vehicles (including forklifts) and working from heights. Confined or dangerous spaces should also be identified. Refer to individual
elements for noise and/or electrical for the potential of plant/equipment to cause noise, vibration and electrical hazards.
This is clearly an inherently high risk operation. Capital injection would greatly improve this result. The age of the
plant, corrosion issues, plant layout and difficulty in isolating various pieces of equipment for maintenance and cleaning
all contribute to the high rating.
Amenities/ Amenities such as private, hygienic toilets and change rooms; provision of drinking water and a refrigerator/ microwave for
Environment mealtimes; infant feeding facilities and showers where the need exists. The working environment for indoor workers should be
comfortable and meet relevant standards and codes for indoor air quality, ventilation and lighting. The potential for heat stress
should be considered, which may be exacerbated by humidity levels. Exposure to heat and cold may be particularly important
considerations for outdoor workers (see radiation for UV exposure). The special needs for divers or air cabin crew should also be
considered where applicable.
The amenities/ environment are not be very comfortable in hot weather, and this is not helped by the PPE requirements
for long sleeves, boots and trousers or overalls. Consider improved climate control in work stations and the effect of
heat on the ability to concentrate and maintain vigilance. Be aware also that cold weather exposure for outdoor workers
can increase the risk of sprains and strains.
773
ordering/purchase; Safe despatch ensures that loading of finished goods does not result in harm, including any earthing
requirements where applicable and the product is transported safely. Plans for dealing with emergency situations in transit have
been developed, necessary information and contacts are available and training has been conducted for affected parties.
The roadways are not in good shape and there is high use of heavy road vehicles and tankers. A combination of poor
conditions, speed, poor visibility and dangerous goods puts this area as a matter for concern.
There is difficulty in performing sound electrical isolations due to the age of the facility and how it has grown. An
electrical contractor is used which appears to be working well although it is crucial that the contractor used has extensive
experience and site knowledge. There is the potential for this rating to be higher should there be a change in personnel
used to conduct and co-ordinate these activities.
Noise Noise levels or noise maps have been documented where the potential for harm exists, for example if a raised voice is necessary
to hear a conversation. In some cases baseline audiometry testing will be necessary. Specialist advice should be sought and
attempts to remove the source of the problem should be the first line of defence. Local regulatory requirements should be known.
Comparison with regulatory limits should take into account the length of exposure especially if shifts longer than 8 hours are used.
Sources of vibration that impact on workers should be identified, including power tools, seats on mobile plant equipment.
There is an annoying hum around the main operators’ station and no requirement for hearing protection on the plant.
Whilst the exposure may be insufficient to be over the statutory limit, the effect on concentration and fatigue should be
taken into account, as the effect on vigilance may be more significant than the potential for hearing loss.
774
require specific controls this is noted in the register. Where specific controls are necessary, a reference to comply with the MSDS
is noted, and where this is inadequate a risk assessment has been prepared; these requirements are made known to all those who
may be exposed, In some cases this will be dependent on the quantities or volumes stored. Storage arrangements and inventory
of dangerous goods should comply with local OHS and DG legislation. Training for the precautions necessary during use, handling
and storage should given to those at risk.
The risk is that someone may become ill from exposure to a hazardous substance whether it is immediate or long term, or harmed
by fire or explosion due to inadequate storage and inventory arrangements.
This is an area that needs to be seriously re-considered especially in light of the potential for long term health effects.
It is suggested that the current mode of handling and information be updated and actual exposure under worst case
conditions be re-assessed. The need for a practicable and workable solution that will be implemented on a daily basis is
crucial, and for this to occur the information delivered to exposed workers must be in a format that ensures that they are
making informed decisions.
protein that may cause an allergic response – for example mould or dust mites. The source may include micro-organisms,
infectious people; contaminated food; contact with animals; rodents; plants/pollens; insects; mites; lice; sewerage; fungi or bird
droppings cooling water reservoirs and air conditioning systems that may contain legionella organisms.
There are a number of biological hazards in a rural setting such as this – including spider bites. There seems to be a
high level of awareness of these issues and the risks are handled fairly well.
775
The degree of UV protection is dependent on user compliance with provisions available. Ensure that sunscreen is
available. There is a real risk of heat stress/ heat stroke in hot weather conditions, especially for those attending to the
lawns. Core body temperature should not exceed 38 degrees Celsius. High risk work should be scheduled during the
cooler periods of the day and the signs of heat stress or heat stroke well understood.
and that does not cause harm either through immediate contact or as a result of transferring the substances / materials for disposal
or dispersal elsewhere. All those in contact with the waste materials are aware of hazards and precautions necessary to minimise
the risks (see hazardous materials/ dangerous goods). Also included here are the risks associated with hygiene and the handling
of sharps.
This result could be improved if evidence demonstrated that all waste streams could be accounted for.
Installations/ Planning for the safe installation of new buildings or warehouses as well as the demolition of these structures to ensure the
Demolition protection of pedestrians and others in the workplace. Included here are the presence of asbestos in demolished structures; the
safe connection or disconnection of services such as gas, electricity, and telecommunications; protection from noise, debris or
other projectiles; and the possibility of falling into excavated areas.
There are plans for a new installation so this element will have greater significance in the near future. Whilst there is a
high degree of technical expertise applied to these plans, it is crucial that such decisions are not used to justify a
continued level of unacceptable risk to those workers exposed by the current operation.
776
Preventive Regular maintenance of equipment essential for safe operation is planned and critical spares are readily available to keep
Maintenance/Repairs production running without compromising safety. Repair work is carried out on failed equipment in a timely fashion by those that
are qualified and competent to do so.
In some areas access to equipment and pipe work is difficult due to the plant layout and the amount of lagging used.
There is a high degree of production pressure and there are no dedicated shutdown periods although the plant is
shutdown over the weekends. This time on weekends when there is not a full crew around and maintenance work is
being undertaken in a much less formal atmosphere may change the way that risks are perceived, encourage a higher
level of risk acceptance and tolerance of deviations from standard operating practice.
Modifications – Peer Changes to existing infrastructure and plant/equipment are carefully controlled to minimise the impact that this may have on
Review existing users and others affected. Modifications may be minor or major, and should be peer reviewed by others with the
/Commissioning appropriate skills and knowledge. New plant or equipment is commissioned to ensure that all safety impacts have been considered
before the project is handed over to the regular users.
There is a high level of sophistication with the systems that are applied to manage this process. However, there is too
much emphasis of the mechanisms of the system and not enough follow through to ensure that the resultant actions have
been implemented and documented as originally intended.
Emergency plans exist, updated and drills conducted. An emergency response team is available. However there is a
somewhat fatalistic attitude due to the nature of the operation, and more thought needs to be put into practically dealing
with the potential for toxic fumes.
777
Site/Personal to contact help in case of an emergency (medical or otherwise) and precautionary measures have been put in place to reduce
Security on site is a major concern due to the nature of the operation. However, the site is large and practically it is
difficult to implement physical controls. There is a gatehouse and the gate keepers do perform their checks whilst
applying a degree of leverage where the risk is perceived to be minimal. Transport drivers are also “lone workers” and
keen to have a higher level of controls in place including GPS. The key risk here is the potential for complacency and the
difficulty in maintaining high levels of vigilance for long periods.
The level of housekeeping varies from being extremely meticulous in some areas and in need of improvement in
others. This result could be improved by a greater level of consistency.
Monitoring manner that was intended and for which safety provisions have been considered and implemented. The processes are monitored
to ensure that they are operating within safe limits. Causes of abnormal operations are investigated and rectified.
The risk is that the process operates outside of designated safe limits which may lead to injury or other ill effects, or that equipment
is used inappropriately leading to damage to property, loss of production or other unwelcome events.
The inherent risk is high but under reasonable control due to the impact this would have on the final product.
778
Review implemented for risk reduction have been effective or otherwise, and whether there have been any changes to plant, the
organisation or legislation that may impact on the risk presented by the operation. Any adverse findings are dealt with.
This is performed in a formal manner and the operation is well understood. However the emphasis on the obvious
risks associated with the type of product manufactured appears to overshadow some very real risks associated with the
ability to isolate equipment both physically and electrically; heat stress and the long term health effects from handling of
hazardous substances.
779
Equal Opportunity/ Policies are in place to ensure that all employees and others are treated with respect and dignity. There is zero tolerance
Anti-Harassment towards bullying and diversity is accepted in the workplace. Awareness programs have ensured that the intention of these
policies have been made clear to employees and management, as well as educating management on the forms that
discrimination or harassment may take - including more subtle manifestations such as holding back pay or entitlements; undue
delays for provision of resources; spreading malicious gossip; social exclusion; hiding belongings; role ambiguity; and career
stagnation or uncertainty.
There are formal policies in place and anecdotal evidence that the basic principles are upheld. However, in such a
highly developed organisation harassment can take on more sophisticated and subtle forms and more widespread
awareness of the potential for this would improve this result.
Accommodating The workplace promotes an acceptance of diversity. Access for disabled persons has been provided, and special provisions
Diversity exist for their safe evacuation in case of an emergency. The special needs of young workers, pregnant or nursing mothers, and
older workers are taken into consideration. Where workers are known to have a pre-existing psychological condition, employers
take care not to place such employees into situations where they are at increased vulnerability. Translations or other means of
There are no literacy issues on this site and no workers under the age of 20. A combination of factors including the
nature of the operation; the high skill levels required; the rural setting and the natural selection processes have reduced
the level of diversity evident on this site. This low rating is due to the lack of diversity evident rather than the ability to
cope well with diversity when presented.
780
The risk is that employees may not be capable of doing the jobs they are selected for, and vulnerable persons may be placed in
a position which they would be prone to injury or illness.
Whilst the organisation appears to be clear about desired personality traits and necessary skills, more consideration
should be given to including health criteria that is relevant to the chemicals on site and ensures that those people who
may be more genetically vulnerable to particular health effects are protected from undue exposure.
Contractors/Visitors to take the necessary precautions to avoid any adverse effects. Information regarding the times of their presence at the
workplace is recorded to allow accounting for all persons should an emergency situation arise. Entry on site is subject to
acceptance of site safety rules where this is applicable. Also, specific contacts/hosts are designated to ensure compliance with
local rules.
There is insufficient detail about the health effects of specific chemicals used on site made available at the time of
inductions. The purpose of identifying hazards is to make sure vulnerable people are able to protect themselves.
Consider having different levels of inductions for casual visitors/contactors and others who are more exposed and
working in higher risk areas.
maintain skills and provide ongoing protection from workplace hazards. Competency training has been scheduled according to
the training needs analysis. All persons conducting training are appropriately qualified to do so. Training records are maintained.
On the job training is handled well and it was noted that staff observed took pride in their roles. Consideration should
be given to the means of assessing competencies so the skill levels can be accurately captured and documented.
Training material should be reviewed to ensure that it covers all necessary safety requirements, explains any changes
to standard procedures and reflects best practice. Skills for trainers providing training should not be overlooked.
781
Fatigue induce unnecessary manual handling, overuse, undue fatigue or stress, and the required level of vigilance is able to be
Given the inherently high risk associated with the nature of the operation, it is critical that every effort is made to
ensure work conditions are comfortable and vigilance is maintained. This could be improved by examining the factors
that may be inducing fatigue- including shift arrangements; overtime; heat; noise; PPE necessary as well as production
pressure.
Stress Awareness Personal skills, personality, family arrangements, coverage of critical absences, resourcing levels and opportunities for
employees to have some control over work load are factored into ongoing work arrangements so as not to induce conditions that
may be considered by that particular employee as stressful. Plans are available for dealing with excessive emails and
unwelcome contacts.
Stress levels on site appear to be normal for the type of operation and there is a good grasp of any personal issues
that may be affecting individual team members. There was a high level of expectation perceived to work safely and
meet production commitments. Care needs to be exercised that the high level of expectation is well supported by the
resources provided.
safely.
There are standard job descriptions available for all management positions within the group. At the operator level
this documentation did not appear to be as significant and consideration should be given to documenting key aspects
of these roles that are critical for consistency and safety.
782
Employees are encouraged to recognise hazards and take suitable precautions - including the acknowledgement of situations
that they are not sufficiently skilled to deal with whilst also watching out for the safety of their colleagues. Where reward
programs are used for positive reinforcement of safe behaviours, consideration is given to the use of variable, unpredictable
reward schedules so that the benefits are maintained when the reward is removed. Rewards may include praise, recognition or
increased status.
There is a lot of emphasis on slowing down and thinking decisions through which is admirable. However, this is not
the only behaviour that needs modification, as it is apparent that some current practices are inappropriate and may
have developed out of convenience, lack of perceived benefits of alternative practices or simply by habits being passed
down. It is suggested that emphasis is placed on identifying and reinforcing the correct safe behaviours.
This element is handled extremely well and there is a high level of satisfaction with the current service level.
Further Education available. On site mentoring or buddy programs have been established where more experienced personnel are available to
assist new employees adjust to their role and provide ongoing support. Pursuit of higher order skills and professional
development are encouraged to grow job positions and increase workplace satisfaction.
There was anecdotal evidence that a higher level of mentoring for less experienced staff would be welcomed. This
would be of great benefit to newer staff, especially if the information could be captured for further training. Enhanced
knowledge of the intricacies of the particular work process would increase confidence and boost morale.
783
Conflict Resolution Mediation channels are available and/or supervisors have received special training to deal with differences of opinion,
relationship breakdowns or personality clashes before the situation reaches the point where workplace performance has been
impaired and/or is noticeable by other colleagues.
The risk is that employees are unable to work as part of a team and this may affect their ability to carry out their roles
The management style here is firm with a lot of emphasis on the worker taking responsibility for their actions and
understanding the consequences involved. Provided that the information they are acting on is accurate and
incorporates a balance of perspectives, this technique can work well. Where workers are empowered to provide
solutions to problems identified, caution is advised to ensure that they are also given sufficient time and access to
resources to complete these tasks.
Employee Assistance Persons experiencing problems of a personal nature such as the breakdown of significant relationships, grief, substance abuse,
Programs or other emotional problems may access help in a confidential environment and receive the necessary support to enable them to
This element is handled very well, and again there is a high degree of satisfaction with the current mechanism in
place.
Equipment supplied has been carefully selected to ensure that it meets any standards applicable, is fit for purpose and is fitted correctly.
The potential for creating other hazards by the application of the PPE selected has been carefully considered and the potential
for such impacts minimised.
The requirements for PPE need to be re-examined to ensure that workers exposed to hazardous conditions are
protected and that the organisation is fulfilling its duty of care. Arrangements for PPE need to be arrived at in full
consultation with end users to ensure that all practical considerations and worker comfort have been taken into
account, and users are trained and educated about the correct usage and the reasons for its application. Where the
need for PPE can be eliminated by alternative arrangements this should be pursued, and care taken not to generate new
hazards through the use of PPE selected.
784
First Aid/Reporting Provisions for first aid are available that meet local regulations including the numbers of suitably qualified first aiders and
sufficient quantities of first aid materials. Qualifications are kept current and first aid stocks regularly replenished. A register of
workplace injuries is kept that meets local OHS regulations and notification of incidents to statutory authorities is observed as
required.
There is a high degree of reporting and first aid facilities are available. There is a lot of energy dedicated into the
reporting system and capturing information about events that have occurred. Whilst this generates awareness, it is
also important that there is follow through to prevent these incidents from recurring.
Rehabilitation returning injured or ill employees back to the workplace in an agreed timeframe without exacerbating their current condition and
to offer meaningful employment where such opportunities exist according to the following hierarchy – same job/ same workplace;
The risk is that injuries will be exacerbated, that time away from the workplace will be increased and that the psychological
effects of the injury and loss of confidence will be heightened.
This is under a high level of control and appears to be managed very sensibly.
The risk is that (i) employees may be placed in situations where their health may be damaged; and (ii) the effectiveness of
current control measures will be not be known, that employees health will be endangered, a baseline for claims purposes will not
exist and that local OHS regulations may be breached.
This may be need to be reconsidered to deal with the health effects of some of the hazardous chemicals used on site,
and to provide a higher level of assurance to both management and exposed workers that control measures are being
effective.
785
activities.
Surveys are used and management appear to be in tune with what is desired, although the ability to act on the
feedback is limited by the bureaucracy of the organisation.
Performance Appraisals Performance appraisals include criteria for safe work practices and observation of site safety rules, housekeeping, and the
display of safe working attitude. OHS responsibilities should be commensurate with the level of responsibility and authority
bestowed. Employees and management setting good examples for workplace safety should be encouraged and valued.
There appears to be a clear understanding on site that safety is a key parameter in performance measurement and it
is taken very seriously due to the nature of the operation. At higher levels, performance bonuses are available for
safety performance although they only represent a small percentage of the total salary package. The pros and cons of
this approach should be re-examined, especially if targets appear unattainable or are linked to areas outside the sites
immediate sphere of influence.
Turnover leadership, personality conflicts, excessive workloads, unreasonable deadlines, unpleasant physical working environment and/or
work conditions. Exit interviews are conducted to gather feedback for improvement where such opportunities present.
Succession plans are in place to provide a safe and sufficient level of experience as others move on and continuity of safe
working arrangements.
Analysis of information obtained at exit interviews would provide opportunities for improvements. This could be
used to greater effect in the future.
786
The policy is well understood and the key sentiments are well known across the site. The slogan itself places
perhaps too much emphasis on injuries and not enough on health issues. The ability to prevent incidents from
recurring is not always straightforward, especially in situations where human factors are involved, resources are
stretched and production pressure is high.
may lead to apathy.
The organisation is very goal driven and these are set at very high ambitious levels for desired final outcomes.
These goals need to be broken down into actions that are more direct and related to daily activities with more visible
outputs.
Responsibility is not always commensurate with authority. On a daily basis, staff are trying to manage as best they
can with the resources available and conditions that are not always within their control.
787
breaches.
There are an abundance of plans available. However, long term plans for the site have affected the way in which the
plant is maintained and operated. This could be exposing workers to more potential hazards for extended periods of
time.
There are sufficient resources to address ongoing peripheral safety expenses such as PPE, but funding is tight for
items requiring larger allocations. Technical resources are located off site.
There are a large number of contractors in use. Areas suggested for review include the exposure of contractors to
heat stress and maintenance work conducted on weekends, especially if hot work is involved. Where the same
contractor has been in use for long periods of time and is well acquainted with the site and the hazards involved, the
risk is less pronounced, but those contractors performing small jobs on an infrequent basis are of much higher
concern.
788
This is performed well for the majority of procurement activities when large volumes are involved. This result could
be improved if examples were provided where this is demonstrated for smaller acquisitions.
Again, this is performed well for larger scale activities. This result could be improved if examples were provided for
the safe supply of smaller scale, non routine orders.
There is a high level of competence demonstrated by all staff in supervisory positions, and a high level of confidence
in the safe operation of the site.
789
This area could be improved with respect to the level of documentation available.
The operation is conducted by a small, close knit crew and the atmosphere is conducive to good communication
networks.
This is scheduled to coincide with production meetings and as a result less time is being dedicated to this function.
Whilst the difficulty in getting everyone together for these meetings is appreciated, this does not detract from the
importance of this mechanism. Minutes of the meeting should have actions pertaining to health and safety allocated to
a person responsible for follow up and a date nominated for the action to be completed which should be reviewed at the
next meeting. Actions arising from incidents investigated should also be discussed.
790
This is handled at a corporate level. This result could be improved by greater awareness of local requirements.
conditions.
This rating reflects the lack of documentation surrounding everyday operations.
This could be more secure with respect to hard copies of local records.
791
Most of the customers are internal so this represents an area of low risk due to the ease of accessing information
and communication channels available.
and communicated.
This area is managed through a highly developed electronic system, with great emphasis on information capturing
and data analysis. The issue here is the amount of follow-through and the ability to actually see the changes discussed
transformed into visible actions on site.
With so much emphasis on risk assessments and planning, there is less focus on upstream activities that are
involved in getting to the final desired outputs. A change in tactics may provide more tangible evidence of the ability to
remain on track, whilst providing a number of small victories along the way.
792
The system is overburdened with actions arising from audits and the high level of bureaucracy. There is too much
confidence in the security provided by the electronic systems in place, and these are not translating into meaningful
actions on site.
Given the information overload with actions arising from incidents and audits, it is crucial that a succinct summary of
the overall effectiveness of actions and control measures is reviewed on a regular basis, not for the purposes of
indemnifying liability, but for the objective of understanding whether the strategies in place are well aligned, supporting
co-existing risk reduction measures and are in fact, as a whole, are able to achieve ultimate occupational health and
safety goals.
793
Report
Summary
based on observations, interviews and documented evidence made
available at the time of the assessments.
The application of this framework was conducted at your organisation (an

emergency services organisation whose prime business function was the
management of a large pool of volunteers) during late February/ early
March 2008. The scope of the study was limited to the direct staff within
the organisation because of the very large numbers of volunteers involved
and the difference in the nature of the activities performed by staff and
volunteers. The volunteer work was very high risk, at unpredictable times
and in variable locations. This study found:

organisation;
; Of these 60 elements applicable, your organisation had addressed

26 (43%) with formal systems and another 28 elements (47%)
informally. Six (10%) of the elements suggested by the framework
were not addressed by your organisation. These elements not
addressed were: Inductions for Contractors/ Visitors; Modifications;
Operational Review; Self Assessment; Audits; and System Review.
Almost half of the elements of the framework are handled informally
and this includes safe working procedures. A formal, documented
OHS Management System is still in the planning phase.
; The hazard profile for the staff members of the organisation suggests
that the risks lie mainly with the need for a systematic approach,
followed fairly closely by the risks associated with people, skills and
the complexity of human nature. Finally the risks associated with
795
the physical operating environment – a head office and regional
head quarters with attached stores, make up the balance of the
risks. This reflects the core business function which is to do with the
management of a large pool of volunteers through a group that is
relatively small compared with the numbers being managed.
; The prime risks associated with the nature of the operation are
managed predominantly through a combination of safe person
strategies involving the application of people skills and expertise as
well as a safe systems approach.
; The application of a safe person approach has been very successful

and achieved a high level of risk reduction. This reflects an
organisation that is very people and service oriented.
; The risks associated with the physical hardware and operating

environment for staff members has not received the same degree of
attention as for the volunteer function, and so there is still a
significant level of residual risk associated with this area. The
emphasis on risk assessments conducted by the volunteers needs
to be translated into the local environment for staff members. It is
possible that the obviously higher inherent risks associated with the
volunteer operation may make the risks perceived with the
management of the support operation appear less significant.
; The staff support operation would benefit greatly from a more

formalised and documented approach to help reduce hazards in
their physical work environment.
; Management of incidents within the staff operation would be greatly

assisted by a greater awareness of problem solving techniques and
root cause analysis.
; The consultation process could be better utilised to ensure follow

through of actions and take on a more strategic focus. This may
require a higher allocation of resources to fund these processes.
; Whilst there is great emphasis on managing the stress associated

with the volunteer operation, stress levels amongst staff members
796
should not be ignored and the reasons for this should be
investigated and addressed.
; The organisation is has achieved a high level of success in the

areas of accommodating diversity; OHS policy; employee
assistance programs; first aid and reporting; workers’
compensation/rehabilitation; supply with OHS consideration; and
customer service. Attention is required particularly in the areas of
hazardous substances (asbestos register), inductions for
contractors and visitors (not currently performed); stress awareness
and incident management (for staff incidents).
; There are a number of other areas that need to be addressed

including receipt and despatch relating to hazards with the store
and the use of forklifts and pallet jacks; the need for a more
documented approach to safe work methods; contractor control and
the need to document risk assessments for the staff operation
including the stores. Issues relating to the allocation of resources
and responsibility being commensurate with authority are also in
need of attention.

such a highly dynamic operation with the large number of volunteers
involved, their understanding of the dynamic risk assessment process and
the high quality of their training packages and critical incident support
programs.
Translation and application of the knowledge used for the management of

volunteers to the OHS management of the support staff in combination
with the realisation of their plans for a formal OHS Management System
will go a long way towards reducing the residual risk levels for this
important organisation that provides a most valuable service to the wider
community.
The organisation is very fortunate to have a team of such highly dedicated

staff.
797
Summary Results
Framework Charts

Equal Opportunity/
Anti-Harassment

Plant/ Equipment
Administration

Dangerous Goods

Employee Assistance
Repairs
Modifications – Peer Review/ First Aid/ Reporting Record Keeping/Archives
Commissioning
798

Equal Opportunity/
Anti-Harassment

Plant/ Equipment
Administration

Criteria
Dangerous Goods
Employee Assistance


Commissioning
799

Baseline Risk Assessment Equal Opportunity/
Anti-Harassment
Anti-Harassment
Access/
Access/Egress
Egress Selection Criteria Accountability

Plant/
Plant/Equipment
Equipment
Training and Skills Resource Allocation/
Amenities/
Environment
Administration
Receipt/ Despatch
Fatigue/Stress
Stress Awareness Procurement with

OHS
Electrical
Criteria
Job Descriptions-Task Criteria
Supply with
with OHS
OHS
Noise Supply
Hazardous Consideration
Dangerous
Dangerous Goods
Goods
Communication
Further Education

Consultations

Legislative Updates
Programs
Updates
Procedural
Maintenance/Repairs
Repairs Equipment
Modifications
Peer Review
Review First Aid/Reporting Record Keeping/ Archives
/Commissioning
Recall/Hotlines
Security
Inspections/

Formal Organisation
Informal
800

impact.
Plant/ Equipment
Receipt/Despatch
Electrical
Access/Egress
Housekeeping
Modifications
Radiation
Noise
Disposal
Biohazards
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium- Medium
High Risk Risk
801
Stress Awareness
Inductions
Health Surveillance
Health Promotion
Work Organisation
Networking etc
Job Descriptions
Feedback Programs
Equal Opportunity
Training
Conflict Resolution
Selection Criteria
Workers' Comp/Rehab
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium- Medium
High Risk Risk
802
Incident Management
Communication
System Rewiew
Audits
Self-Assessment
Procedural Updates
Consultation
Legislative Updates
Accountability
Goal Setting
OHS Policy
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium- Medium
High Risk Risk
803
that the need for a systematic approach and the need for safe person
strategies are where the majority of the risks lie, followed lastly by the risks
of the physical hardware and operating environment. This hazard profile
relates to the activities conducted by support staff and does not include
those activities conducted by the volunteers on the field.

35% 32%
Safe Person
33%
Figure 5 demonstrates how safe person strategies have been used very
effectively to reduce the overall risk rating of the operation. However, a
place” aspect.

Place

35% 38%
Safe Person
27%
804
70
60
50
Risk Ranking
40
30
20
10
0
Without
Legend With Intervention
Intervention

applied.
The significant level of residual risk remaining in the hardware and

operating environment is perhaps related to the differences in perceived
risk of the activities carried out by support staff when compared with the
very high risks associated with the volunteer operation. There is scope to
reduce some of the hazards inherent to the support staff operation through
a more documented approach and the use of generic risk assessments for
store activities; the initiation of an incident management system for
support specifically for staff, the provision of sufficient time and resources
to ensure follow through of OHS actions identified, and greater awareness
of stress levels amongst direct employees.
It is clear that the strong focus on looking after the OHS needs of the
volunteers has helped the organisation to provide a very worthwhile
service, however the organisation needs also to be mindful of looking after
their direct employees so they can continue to provide such a high level of
service.
805
Whilst this is handled very well for the volunteers that are managed, the same process that has been applied to volunteers
needs to be performed for the direct employees. A series of generic risk assessments for staff activities including the stores
needs to be developed and documented.
Whilst the need for ergonomic evaluations including manual handling assessments has been identified, these need to be
conducted formally and documented. Once these have been formalised, a series of actions should be developed, with
persons responsible identified and completion dates set. This list should be reviewed on a regular basis and progress
against set tasks noted.
806
Access/ Egress This considers the quick and efficient entrance or departure of personnel to and from the physical workplace, including those with
situations.
their workplace.
The current work arrangements for staff make clear provision for good access/ egress. This rating would be improved if
inspections to ensure all critical exits were not blocked where being undertaken on a regular basis.
Whilst the plant and equipment being used by staff may not appear as high risk as that used by the volunteers, correct
use of forklifts and pallet jacks by staff in stores is still very important and the store areas still need to be assessed. This
should be conducted formally to ensure all activities are performed safely and corrective actions are identified and
implemented as necessary.
The amenities and work environment provided for staff are pleasant and well maintained. This result could be improved
by a more formalised approach to the set work environment, climate control and facilities provided.
807
The store areas are in need of evaluation and controls in these areas for safe working conditions could be tightened. See
also the comment for plant and equipment.
The risks arising from electrical hazards and portable electrical equipment are well understood. This result could be
improved by more rigorous documentation and review.
For staff, noise presents less of a hazard as they are typically in an office or store environment. Whist noise levels are
unlikely to exceed prescribed levels; nuisance background noise levels may interfere with concentration and induce fatigue.
808
Whilst there are not large volumes of hazardous chemicals being handled, there is still a need for an accurate asbestos
register and this matter should be given due attention.
For staff in an office environment and in the stores this is not an area of major concern, although this would be different
for the volunteers who operate predominantly outdoors. .
As for biohazards, for staff this is a much lower risk, although there is some outdoors work for those conducting training
in the field. The need for sun protection has been reinforced, however its effectiveness relies on user compliance.
809
sharps.
This is under fairly good control and the procedures for disposal are formalised.
A readily available asbestos register would be of use here, and this rating would be lower if such a register was available.
Preventive maintenance and repair work is critical for equipment supplied to volunteers. A more heavily documented and
systematic approach is needed to ensure control of this element.
The risk is that the modifications result in an injury because the full impact of the changes were thought through.
This element could be given more focus for any changes made to store arrangements.
810
An evacuation plan is available, training has been conducted and floor and area wardens identified. Attention should be
given to clarifying the circumstances under which an alarm is raised to ensure that someone is always readily available to
carry out this first critical step.
Security – Site/ Only authorised persons who have been informed of relevant site rules enter the workplace. Persons working alone should be able
Personal to contact help in case of an emergency (medical or otherwise) and precautionary measures have been put in place to reduce threats
Arrangements in the regional headquarters could be tightened to ensure that workers feel safe when they are on the
premised by themselves. Staff are often required to travel alone on country roads and the areas managed are quite vast.
Attention is needed to ensure that employee safety can be guaranteed whilst travelling alone in remote areas.
Housekeeping in the store areas could be improved. Safe stacking arrangements should be agreed upon and followed.
811
Agreement on what activities should be monitored on a regular basis that pertain to staff functions would assist in the
smooth management of the volunteer operation.
The risks relating directly to staff need to be identified and separated from those risks presenting to volunteers that are
clearly understood and well managed. These should be reviewed on a regular basis.
812
There are formal policies in place such as EEO and anti-bullying as a result of the large corporate framework that this
smaller organisation is part of.
There are no reported literacy issues on this site. This element is handled particularly well and provisions for disabled
persons and those with mobility issues have been incorporated into the emergency plans.
Selection criteria is handled very formally and the blend of staff in place suggest that this is working well.
813
Inductions-Contractors/ All visitors and contractors to the workplace are made aware of any hazards that they are likely to encounter and understand how to
Visitors take the necessary precautions to avoid any adverse effects. Information regarding the times of their presence at the workplace is
Arrangements to induct contractors and visitors are not in place, and this area should receive attention.
The core function of the organisation is the safe management of volunteers and as such they have become particularly
good at training, and just needs to ensure that routine staff activities also receive the same level of attention.
A flexible attitude to work arrangements was noted. There is still the potential for stress levels to induce fatigue and
this should be given consideration.
814
The organisation seemed to be very aware of the potential for stress and post traumatic syndrome to develop in the
volunteers, yet the existence of stress within its own staff members is not given the same level of attention. This may be
in part to due to the culture related to dealing with emergency situations, the need to be calm under pressure and
appearing to be in control at all times. Responsibility that is not commensurate with authority, minimal resources and lack
of control over workloads can all contribute to high stress levels amongst staff. The causes of this should be investigated
and measures to address this situation acted upon as a matter of priority.
safely.
These are available for staff in key roles and should be extended to cover all staff with the level of detail commensurate
with the roles.
The use of “Take Five” for the purpose of conducting dynamic risk assessments is well promoted. This targets
correcting the behaviour where people may rush into a task without thinking it through. This is very well done, and this
technique of targeting change could be applied more widely to correct any bad habits that have developed over time or
been passed down during on the job training.
815
in the workplace.
Promotion of healthy lifestyle choices and means of relaxation to reduce stress would be of assistance here.
injury or illness.
There is evidence of networking available. This could be extended further to obtain even greater benefits.
and safely.
There are formal mechanisms for dealing with conflict and the operation works well as a team.
The organisation has a very good employee assistance program available.
816
impacts minimised.
The organisation is very good at identifying PPE necessary as part of its role in managing volunteers. Again, activities
conducted by staff that appear less hazardous still need to receive attention.
First Aid/ Reporting Provisions for first aid are available that meet local regulations including the numbers of suitably qualified first aiders and sufficient
This element is handled particularly well.
A high degree of satisfaction was reported with this function.
817
The need for health surveillance will be clearer once the asbestos register is available.
The use of feedback programs may assist with understanding causes of stress within the staff work environment.
Performance reviews should ensure that OHS issues are embedded into the assessment for all staff members.
818
The OHS policy is very well worded.
may lead to apathy.
The goals stated in the corporate plan are focused around the management of the volunteers, and as their main
business function, this is performed extremely well. However a key goal for OHS pertaining to staff was the
development of a formalised OHS Management System. This is a very big task which would be of great benefit to staff.
This goal would benefit from being broken down into smaller activities that can be reviewed and tracked more easily.
Goals analysed and ranked in order of priority.
Accountability for OHS matters is well accepted at all levels of line management. However, it appears that authority
is not always commensurate the high levels of responsibility expected.
819
breaches.
A due diligence plan needs to be compiled as a central document to address areas where full compliance with OHS
regulations and codes of practice has not been achieved.
Resource allocation appears to be an area of concern and a possible contributor to work place stress.
A more formal, controlled approach to contractor management would be of benefit.
This task could be improved through the use of an OHS checklist for purchasing activities.
820
This is performed particularly well. The management of the volunteers is very well supported by a strong training
program and critical incident support team.
Competent Supervision Persons that are placed in a position of authority and supervision have the responsibility, talent/ technical ability, social skills
and experience necessary to do so.
Competence levels are high in key support roles.
Work methods for tasks undertaken by staff are handled on a completely informal basis. Capturing this information
would ensure consistency and assist in business continuity planning. Safe work procedures should include reference
to a generic risk assessment for the particular task and any need to perform ongoing dynamic risk assessments where
relevant.
Ongoing communications and updating within the staff environment could be improved.
821
OHS regulations on the formation of safety committees are observed, and the committee chairperson has undergone
appropriate training to fulfil their tasks and duties. Meetings are conducted on a regular basis with participation of a
management representative with sufficient authority to take action on items identified as being in need of corrective action. The
minutes of the meetings are kept in a secure location and made accessible to all employees. Attempts are made to resolve
disputes in-house before outside authorities are brought in.
There is a safety committee and regular meetings are conducted according to their constitution. However actions
appear to fall mainly onto one person and are not evenly distributed. Also, the focus could be more strategic.
been made available so the organisation knows what legal obligations exist and has supporting information such as standards
or codes of practice available for reference. A system is in place to ensure that updates are received so that the information
being acted upon is always current.
There is clear understanding of relevant regulations and code. These should be listed and collated to facilitate the
updating process.
conditions.
This will be able to be addressed once safe work methods for staff are documented and formalised.
822
Whilst handled informally, this should be more secure and rigorous.
Customer Service – Recall/ Information is made available to end users to address any health or safety concerns encountered during the use of the
Hotlines organisation’s products or services. Procedures are in place to recall goods or services in a timely manner where a danger or
The organisation is very customer service focused and people oriented.
future. Attempts are made to address underlying causes, whilst also putting in place actions to enable a quick recovery from
the situation. Root causes are pursued to the point where they are within the organisation’s control or influence. Reporting of
appropriate range of knowledge and skills. A protocol for reporting to external authorities notifiable events has been
established, and communicated.
A formalised system for investigating incidents related to staff should be initiated. Whilst there is much emphasis on
risk assessment and controls for volunteers in the field, information needs to be captured within the staff setting and
problem solving skills reinforced. This will assist in preventing incidents from recurring by not only making sure that
controls are in place, but that the controls or actions identified are actually addressing the root cause of the situation
and not just the symptoms.
823
Self Assessment A list of questions has been compiled to ensure that outcomes are being achieved on a regular basis and the key requirements
of OHS procedures are being adhered to in house. The purpose is to determine the level of compliance; whether the
requirements are suitable and reasonable; and to ensure that any practical problems with the daily working of procedures are
uncovered whilst the situation is still recoverable. Self-assessments targeting particular areas where improvement is sought are
conducted on a frequent basis, for example monthly, and items are independently spot checked to improve the reliability of the
results.
Once larger goals are broken down into smaller tasks, the use of a regular self assessment tool will help keep
projects identified on track. See the element for goal setting. A targeted, prioritised approach would be of great use
here.
frequency of audits will depend on the length of time that the OHS systems have been in place, as established systems will
need less frequent audits than systems that are just being introduced. The frequency may range from a yearly basis to once
every 3-5 years for specialist audits. Auditors utilised are suitably qualified and experienced.
Before this element can work smoothly, a formally documented OHS Management System is necessary and ideally
should be in place for a period of at least six months. The current set up is not ready to implement this yet as most of
the current arrangements are informal.
The management of OHS issues related to specifically to staff would benefit from a regular overview. Separating
staff activities from volunteer activities will be necessary to provide the focus needed.
824
Report
825
Summary
based on observations, interviews and documented evidence made
available at the time of the assessments.
The application of this framework was conducted at your organisation (a

rural utility operation with a small office, a few remote service sites and
extensive supply networks) during early March 2008. The background to
the context of this assessment was that of a relatively small, close knit
enterprise that had become part of a much larger corporation. This study
found:

operation;

(55%) with formal systems and another 23 elements (38%)
informally.
; The mix of systems and work practices in place were a hybrid

between the remnants of the smaller organisation and the customs
and culture of the larger corporation. The assessment focused on
actual work methods observed, regardless of where the practice
originated.
; There was a level of unsettledness noted, which may be due to the

merging of the two cultures or concern with future job security.
Management of this situation and any transitionary phase should
receive consideration as it could have impacts of an OHS nature.
; Whilst most of the obvious potential hazards are related to the

physical work environment and plant, the local organisation is
providing an essential service to the surrounding community, so
826
ensuring reliability through a systematic approach, sound
management decisions and safe work methods is essential.
; A significant proportion of the physical hazards are of an

unpredictable, non-routine nature. The management of these
requires a very high level of skill and expertise that has taken many
years to develop and this knowledge is crucial to the continued safe
running of the local organisation.
; It would take a vast amount of documentation to capture the local

knowledge that exists and years of mentoring of newer staff to even
attempt to replicate the current level of expertise currently
demonstrated. This needs to be appreciated and valued by the
larger corporation.
; The organisation is very customer service oriented, however other

areas such as chemical safety and future health must be
considered as well. These areas are in need of attention.
; The hardware managed by the local organisation covers a very large

physical area. This can create difficulties in supervising contractors.
; The local organisation would strongly benefit from the use of a

dynamic risk assessment program with reference of its use
embedded into the generic risk assessments due to the amount of
work required at variable locations with unique conditions.
; In cases where there were some non-compliances with local OHS

regulations, this may have been related to a misinterpretation of the
exact requirements. Local management made it clear that it was
their intention to be in compliance wherever reasonably practicable.
; When conducting a risk assessment where the outcomes affect

others in the workplace, those affected need to be consulted. The
risk assessment should not be performed in isolation or without
review.
; The organisation has achieved a high level of success in the areas of

competent supervision; communication; workers’ compensation/
827
rehabilitation; inductions for contractors and visitors; and OHS
Policy. Attention is required particularly in the areas of hazardous
substances, health surveillance, emergency preparedness (for the
local office and workshop) and formalising contingency
arrangements for electrical failures impacting dosing equipment.

such an intricate operation. It was observed that the larger organisations’
attitude towards safety was well promoted and staff understood that safety
was taken very seriously. Whilst more emphasis may be needed in the
area of health, the crew instilled a high level of confidence in their ability to
manage the operation competently.
828
Summary Results
Framework charts

Equal Opportunity/
Anti-Harassment

Plant/ Equipment
Administration

Dangerous Goods

Education
Employee Assistance
Programs
Repairs Personal Protective Equipment Procedural Updates

Commissioning First Aid/ Reporting Record Keeping/Archives

829

Equal Opportunity/
Anti-Harassment

Plant/ Equipment
Administration

Criteria
Dangerous Goods
Employee Assistance
Programs

Commissioning
830

Equal Opportunity/
Anti-Harassment
Anti-Harassment
Access/ Egress
Inductions – Contractors/ Due Diligence Review/ Gap

Plant/
Plant/Equipment
Equipment
Visitors Analysis
Gap Analysis
Amenities/ Environment Training Resource Allocation/
Administration
Receipt/ Despatch Work Organisation
Work Organisation –– Fatigue
Fatigue/Stress
Criteria
Noise Job Descriptions-Task Supply with OHS

Hazardous
Dangerous
Dangerous Goods
Goods
Biohazards
Communication
Further Education
Consultations

Programs
Repairs Equipment
Modifications
Peer Review
Review First Aid/
Aid/Reporting
/Commissioning
/Commissioning
Recall/Hotlines
Security
Inspections/

Formal Organisation
Informal
831

impact.
Electrical
Modifications
Plant/ Equipment
Disposal
Radiation
Biohazards
Access/Egress
Receipt/Despatch
Housekeeping
Noise
0 1 2 3 4
0Risk Ranking Scores

4 3 2 1 0
Medium- Medium
High Risk Risk
832
Health Surveillance
Conflict Resolution
Networking etc
Stress Awareness
Equal Opportunity
Job Descriptions
Work Organisation
Feedback Programs
Health Promotion
Training
Selection Criteria
Inductions
Workers' Comp/Rehab
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium- Medium
High Risk Risk
833
Incident Management
Consultation
System Rewiew
Audits
Procedural Updates
Legislative Updates
Goal Setting
Self-Assessment
Accountability
Communication
OHS Policy
0 1 2 3 4
Risk Ranking Scores

4 3 2 1 0
Medium- Medium
High Risk Risk
834

of hazards, closely followed by those hazards associated with the need for
a systematic approach, and finally the balance comprises of those hazards
associated with people and the complexity of human nature.

34% 36%
Safe Person
30%
Figure 5 demonstrates how safe person and safe system strategies have
been used to reduce the overall risk rating of the operation. However, a
place” aspect and this is a function of the extensive amount of physical
hardware that is being managed.

Place

29% 40%
Safe Person
31%
835
80
70
60
Risk Ranking
50
40
30
20
10
0

applied.
The options available for reducing the level of residual risk remaining in
the hardware and operating environment are likely to be constrained by
the large amounts of capital that would be involved in the replacement of
the works and a practical need to manage the existing infrastructure.
There is potential to increase the risk reduction even further in the safe
person and safe system areas by gaining a greater appreciation of health
issues and not just the need to avoid injuries; by encouraging a higher
level of documentation and formalised, systematic reporting; through the
promotion of problem solving skills so that the organisation can learn from
past incidents and put in place measures to prevent their recurrence in the
future; and finally by using the mechanism of consultation to promote a
greater atmosphere of transparency and participation in all decisions that
affect the safety, health and well-being of staff and others affected by the
business undertakings.
836
A number of baseline line risk assessments have been conducted at various stages. However key points from these
various sources needs to be brought together into a central document to enable the risks to be reviewed with greater ease
and to ensure all areas of significant risk have been addressed should the business grow or its functions change. Generic
risk assessments should reference the use of dynamic risk assessments in the field, the competencies of those performing
the dynamic risk assessments and the situations when work should be stopped or other specialist assistance sought.
The ergonomics of the office environment are well considered and a checklist is available for review. However on various
sites the tasks are much more varied and there is a high degree of manual handling and physically taxing work in day to day
activities. These would benefit from a more detailed ergonomic evaluation to identify any opportunities to remove the
potential for sprain, strain or back injuries.
837
situations.
their workplace.
Whilst the organisation consists of a number of small sites with small numbers of staff, the areas managed by these
employees are very extensive and in rural locations. Personnel involved often have a long history with the organisation and
there is a great deal of local knowledge which goes towards reducing the risks. Pick up points and access ways for
emergency vehicles should be agreed upon, especially in the more remote locations, and the decisions documented.
There are a variety of plant and equipment in use, ranging from typical equipment in workshops to process plants.
Critical items such as hoists and cranes would benefit from being on a register. Harnesses and ropes or lanyards for
working at heights need to be regularly inspected. Given the remote nature of some of the work locations a register of
confined spaces or dangerous spaces may make the safe management of these areas more consistent and reliable. Risk
assessments records related to confined spaces need to be kept for 5 years after the date of preparation. Consideration
should be given to whether there are sufficient personnel and/or time resources available to manage these tasks.
838
The office environments are very pleasant and comfortable. The workshops would be very hot in summer, cold in winter
and are of the WW2 vintage, with concrete floors and metal spanning an arch to form the roof and side walls. Local exhaust
ventilation needs to be available for welding activities. Here it is critical that fumes are not drawn past the face. The use of
large pedestal fans blowing past towards the outside of the building may be used as a contingency measure and care must
be taken where the fumes are being directed. This should be checked in all workshop areas.
No receipt/ despatch activities where being undertaken during the time of the assessment although this is reported to be
under a reasonable level of control. There were no records of injuries associated with these tasks, but the nature of the
operations suggests that a high degree of manual handling would be involved at some stage, especially on the more remote
sites. These activities should be further examined on a site by site basis to exclude the potential for sprain/strains and back
injuries. The reviews should be documented.
839
An electrical contractor is in use and this appears to be working well. The high rating is due to the need to formalise and
document contingency arrangements where a loss of power affects dosing equipment on remote sites. The impact of these
scenarios must be thought through and the use of an analysis tool such as HAZOP is suggested.
There are some individual items that generate high noise levels such as compressors and grinders. Exposure to these
items is considered to be for short periods only and in the case of the workshop equipment, hearing protection is required.
As this is the lowest means of protection according to the hierarchy of controls, the effectiveness of this control strategy
will depend on user compliance. This will also be the case for maintenance work around compressors etc. The seats on all
excavation equipment such as backhoes should be checked to ensure that they are in good condition and are not
transferring high levels of vibration to prevent back problems.
840
Not all hazardous substances in use appear on the hazardous substances register, although there are a number of
chemicals listed with MSDS and it is clear that efforts have been made in this area and management has intended to comply
with this requirement. For example, molten lead is used is some repair work, and this is not listed. An inspection of the
chemicals in the workshops on all sites would be a valuable exercise that could be undertaken by a safety committee
representative. In some cases, the difficulty with compliance may be due to a misunderstanding of what is actually
categorised as a hazardous substance. There is an opportunity here to tie this requirement in with procurement activities,
and given that many of the sites use the same chemicals, replication could be avoided if information was available on the
organisation’s intranet. In general, better control to exposure of hazardous chemicals is needed.
There are a number of biological hazards in a rural setting such as this – including spider and snake bites. There seems
to be a high level of awareness of these issues and the risks are handled fairly well. Bird droppings can also cause
respiratory problems in sensitive individuals, and this is also a matter of good hygiene. This result could be improved by
bird-proofing the necessary areas, especially where ongoing access is required.
841
The degree of UV protection is dependent on user compliance with provisions available. Ensure that sunscreen is
available. Core body temperature should not exceed 38 degrees Celsius to avoid heat stroke/stress. It appears that staff are
very familiar and used to the sometimes extreme weather conditions, and clearly understand the need to keep up water and
this factor has substantially reduced the risk rating. However, if personnel were to change or a contractor was used who
was not a local and not familiar with the heat there would be the potential for heat stroke/ stress so this point must be
emphasised in induction material.
sharps.
This result could be improved if evidence demonstrated that all waste could be accounted for, including broken AC
piping.
A readily available asbestos register would be of use here. This risk ranking would be higher if any new installations or
demolition work was being planned although this was not apparent during the time of the assessment.
842
The nature of the operations suggest that much of the repair work may be non-routine and highly specialised. It would be
a useful exercise to differentiate between those tasks that are routine and preventive and to have a more systematic
approach to their management. This information would also create better understanding of the sheer volume of equipment
that was being managed by the local organisation, and how difficult this might be with the existing staffing levels. Clearly
those involved in the tasks have a very high level of the competence to have managed as well as they have to date with
such good injury records.
The risk is that the modifications result in an injury because the full impact of the changes were thought through.
Completing this task with full end user input and consultation may be difficult under the current staffing levels.
Emergency plans are specific for the local office. Agreement on local alert/ and or evacuation signals should receive
high priority. Consider the use of a simple flowchart to assist the documentation process and training exercises. Plans need
to comply with local regulations and codes of practice.
843
Security – Site/ Only authorised persons who have been informed of relevant site rules enter the workplace. Persons working alone should be able
Personal to contact help in case of an emergency (medical or otherwise) and precautionary measures have been put in place to reduce threats
The area managed by the local organisation is quite vast and practically it is difficult to implement physical controls.
Many of the staff operate as lone workers at some time. In the office a duress switch was installed and consideration should
be given to whether or not this could be applied in other work areas. Radios are in use and the small numbers of staff
appear to be happy with the communication arrangements. Ensure that lone workers report to someone at regular intervals
to minimise the time that would elapse in case of a medical emergency.
There are a number of “graveyards” on the sites which could be cleared up and the contents disposed of appropriately.
Due to the impact this would have on customer service this is under a fairly tight level of control. This result could be
improved with a higher level of documentation and record keeping.
844
This has been performed in a formal manner and the operation is well understood by the local organisation. An
operational review checklist exists. However, more emphasis is needed on chemical safety and the identified projects need
to be broken down into smaller, more achievable tasks.
845
There are formal policies in place such as EEO and anti-bullying as a result of the large corporate framework that this
local organisation has become part of. Anti-harassment , and the various forms this can take, still needs attention.
Consider inclusion of this information in the induction material to visitors/ contractors.
There are no reported literacy issues on this site. Diversity was observed across the various sites. The organisation
needs to be mindful of the special needs of younger workers such as their susceptibility to sprains, strains, cuts and
burns when taking on new staff.
846
Whilst the local organisation appears to be clear about the desirable skills and traits they are seeking and a cautious
approach is taken to the hiring of new staff through a probation system, more consideration should be given to the
inclusion of health criteria, given the nature of some of the chemicals used on the various sites. The organisation should
give consideration to the use of pre-employment medicals.
Inductions-Contractors/ All visitors and contractors to the workplace are made aware of any hazards that they are likely to encounter and understand how to
Visitors take the necessary precautions to avoid any adverse effects. Information regarding the times of their presence at the workplace is
This was conducted particularly well during the assessment and it should be noted that personnel on one of the remote
sites went to great lengths to make sure that any physical hazards that were present at that time were identified and
precautions taken.
On the job training is handled well and it was noted that staff observed took great pride in their roles. A training
register was kept and updated. Some thought should be given to documenting the range of skills necessary in some more
detail and how competencies could be assessed on an ongoing basis to improve this result.
847
Some of the leading roles on the remote sites and in the main operations role require being on standby 24hrs/ 7 days a
week. This could be a source of ongoing stress and consideration should be given to ensuring that back-ups are available
to cover these periods on a regular basis to provide some relief from this need to be on constant alert.
A high level of stress was observed across the local organisation, possibly due to uncertainty of the future direction of
the business and the potential for staff reductions. This appeared to be the cause of some concern and should be
addressed in a more formal manner so that those under the impression that they may be affected know with some
authority the larger corporations intentions.
safely.
There are standard job descriptions available for all senior positions within the group, and all other staff have some
form of job description even if it is very broadly stated. It is suggested that some time is invested in capturing with more
detail the specifics of the key roles to ensure business continuity and to assist with training of back ups to cover critical
absences.
848
Consideration should be given to the use of dynamic risk assessment strategies that emphasise the need to stop and
think before rushing into a high risk situations, given the variable nature of the work and the range of situations
encountered on a daily basis.
in the workplace.
This element is considered to be addressed by the local organisation. Attention in this area may help promote morale
in light of the unsettled atmosphere observed.
injury or illness.
There is a need to establish networks that are seen to be helpful and encouraging. This may assist in breaking down
some barriers between the larger corporation and the local division. Networking should be conducted in an atmosphere of
equality and mutual respect.
849
and safely.
There are formal mechanisms for dealing with conflicts but in practice it is more about managing these issues on an
informal basis. The local organisation has lost leverage due to the low staffing levels and intricacies of the roles that are
passed on by word of mouth and not documented. A more formal recognition of the high level of competency that
currently exists may help ease some of the tension noted.
This element is handled by the larger corporation, and is completely confidential. There may be some reluctance to
utilise this service, so greater awareness of its availability and reinforcement of the confidential nature of the service may
be necessary.
impacts minimised.
PPE is available for use, but it needs to be emphasised that this is a weak level of control and the effectiveness of this
strategy will depend on user compliance. This may be harder to reinforce when workers are on jobs alone, so it is crucial
that all workers using PPE understand the consequences of any decisions not to use it. It is important that they are in a
position to make a well informed decision, so refresher training sessions may be necessary.
850
A higher level of formalised reporting is needed. This could be assisted by having more reporting forms/booklets
available in prominent locations. Where there is a low level of injuries being experienced, consider the use of a formalised
near miss reporting system.
A high degree of satisfaction was reported with this function on a local level.
851
Health surveillance to cover the use of molten lead may be necessary to comply with local OHS regulations; however
this will depend on individual exposure levels. Whether or not this is necessary should be determined and the results
documented stating the conditions that were in existence at the time the decision was made. The decision should be
regularly reviewed, especially if exposure levels or techniques used for heating were to change. The organisation should
also give consideration to audiometric testing and surveillance for maintenance workers any personnel exposed to noisy
equipment on an ongoing basis. Audiometric testing for new employees would provide an important baseline for future
comparison. Any workers involved with AC piping should be identified and the possibility of ongoing surveillance
established with specialist input.
Employee satisfaction surveys are conducted on a corporate level but it is suggested that more local feedback might be
useful given the level of unsettledness.
These are conducted at more senior levels. Performance reviews should ensure that OHS issues are embedded into the
assessment, and there are clear consequences for undesirable OHS attitudes or practices.
852
Turnover levels are reviewed on a corporate level. Analysis of information obtained at exit interviews would provide
opportunities for improvements. This could be used to greater effect in the future.
853
The local OHS policy is an example of best practice and very well worded.
may lead to apathy.
The larger corporation is very goal driven and these are documented in the corporate plan. These goals need to be
broken down into small sized projects or ongoing activities with more visible outputs on a local level.
Accountability for OHS matters is well accepted at all levels of line management. However, it appears that authority is
not always commensurate with the high levels of responsibility expected.
854
breaches.
Due diligence exercises have been conducted in the past. These should be captured in one central document and
translated into a program of OHS projects to cover gaps identified. For each project or activity, a responsible person
should be allocated and a review date for completion specified.
There are sufficient resources to address small to medium sized OHS issues as they arise. However, staffing levels
may not be adequate to achieve a higher strategic level of OHS compliance and this should receive due consideration.
There are five major contractor organisations in use and this small number is useful in controlling the risk associated
with lack of local knowledge. The key concern here is monitoring of contractor activities when they are being used on
remote locations and being able to verify if they are operating according to their own OHS procedures. Consider the use
of an OHS booklet for contractors.
855
This task could be improved through the use of an OHS checklist on purchasing activities.
This is performed well for the main business function, however supply involves the use of materials and property
that are accessible by the public. The large distances and areas involved make this practically quite difficult to regularly
inspect with the current staffing levels.
There is a high level of competence demonstrated, especially by those in key roles.
856
There are some very comprehensive safe working procedures available for major tasks.
The operation is conducted by a small, close knit crew and the atmosphere is conducive to good communication
networks.
There is a safety committee but it is not operating at a strategic level. There is a duty to consult on all changes that
may affect health, safety and welfare including changes to the systems or methods of work or to the plant or
substances used for work and on any decisions made about the adequacy of facilities for the welfare of employees.
857
Much of the groundwork for this has already been done, it is just a matter of collating the various references and
supporting codes and using an alert system that will notify of changes to the legislation and codes that are of interest.
conditions.
Some safe working procedures have not been reviewed for ten years.
This could be more secure with respect to hard copies of local records.
858
Customer Service – Recall/ Information is made available to end users to address any health or safety concerns encountered during the use of the
Hotlines organisation’s products or services. Procedures are in place to recall goods or services in a timely manner where a danger or
The local organisation is very customer service focused.
and communicated.
As only injuries of a serious nature are reported and these are few and far between there is little opportunity for
organisational learning. In these situations reporting of minor injuries and near misses should be encouraged and
promoted. Problem solving skills need to be further developed so that investigations of reports can be used to improve
the local conditions.
Currently there are a number of bimonthly reports and OHS is an agenda item for reporting to the executive. The
nature of the self assessment activities could be stretched to include more risk reduction exercises. .
859
There was no program for internal OHS audits at the time of the assessment. The organisation should consider
developing a program to implement this.
The larger corporation needs to determine whether it is possible to support the broader OHS goals stated in the
corporate plan with the current combination of OHS activities in place.
860
Appendix 23: Monthly Self Assessments
Note: Where information was received that may have inadvertently disclosed the identity of the participating organisation either
directly or indirectly, “XXX” was inserted to remove such references.
861
Pilot Study
862
1st Month’s Results
Item Item
No. Owner
1 DCV WORK ORGANISATION Yes Instructions: Where no has been selected please include an explanation
Purchase Noise monitoring equipment and measure No Yes - Purchased sound level meter
noise Level across Plant.
2 DCV WORK ORGANISATION Yes PDF drawing of site available but test points yet to be finalised
Establish Plant monitoring points (Noise Map – No

Static points) and measure monthly.
3 DJC WORK ORGANISATION Yes No
Analysis of incidents in relation to time of Shift or No

time of Day.
4 DJC INCIDENT MANAGEMENT Yes ??No
Fully review two incidents per month, using 5 STEP No

PROCESS (rear of Incident form).
6 DJC INCIDENT MANAGEMENT Yes Instructions: Where no has been selected please include an explanation
Ensure that actions from Incident Reviews are No ??No

carried out.
7 DCV ACCESS/EGRESS Yes Yes – schedule drawn up to cover plant machines, admin and general site. Inspection
checklists are currently being reviewed
Develop Plan for Department & Machine inspection. No
863
Item Item
No. Owner
8 DCV ACCESS/EGRESS Yes No
Inspect Plant / Departments via above plan. No
9 GRB ACCESS/EGRESS Yes Not yet
Ensure that actions from Safety Audits are carried No

out.
864
2nd Month’s Results
Item Item
No. Owner
1 DCV WORK ORGANISATION Yes Yes - Purchased sound level meter
Purchase Noise monitoring equipment and measure No

2 DCV WORK ORGANISATION Yes No - PDF drawing of site available but test points yet to be finalised – Finalised in
Extrusion, but waiting on confirmation from OH&S chairman as to points in PLC
Establish Plant monitoring points (Noise Map – Static No
points) and measure monthly.
3 DJC WORK ORGANISATION Yes No – DV instigating new data collection vis PC in First Aid room, but experiencing
problems with IT dept in firstly installing PC and secondly getting network access
Analysis of incidents in relation to time of Shift or time No (useless)
of Day.
4 DJC INCIDENT MANAGEMENT Yes Yes

5 DJC INCIDENT MANAGEMENT Yes No – last meeting not held due to poor attendance, but finds available.
Communicate findings from each at OHS&E meetings No

and at Monthly Shift meetings.
6 DJC INCIDENT MANAGEMENT Yes Yes – maintenance dockets to be raised for any modifications required from incident
reports and outstanding issues to be reviewed during OH&S committee meetings
Ensure that actions from Incident Reviews are carried No
out.
865
Item Item
No. Owner
checklists are currently being reviewed
8 DCV ACCESS/EGRESS Yes Yes – Audit checklist handed out as per schedule
9 GRB ACCESS/EGRESS Yes No – Waiting for completed checklists
Ensure that actions from Safety Audits are carried out. No
866
3rd Month’s Results
Item Item
No. Owner

2 DCV WORK ORGANISATION Yes Yes – Site map created and fixed points now finalised and first audit carried out

3 DJC WORK ORGANISATION Yes No – DV instigating new data collection vis PC in First Aid room, but experiencing problems
with IT dept in firstly installing PC and secondly getting network access (useless).
Analysis of incidents in relation to time of Shift or time No
PC data collection went live from the 1/10/07
of Day.
4 DJC INCIDENT MANAGEMENT Yes Yes

5 DJC INCIDENT MANAGEMENT Yes No – we are currently reviewing the structure of the OHS&E committee and it is planned to
review the findings of accident investigation during the meeting.
867
Item Item
No. Owner
6 DJC INCIDENT MANAGEMENT Yes Yes – maintenance dockets to be raised for any modifications required from incident reports
and outstanding issues to be reviewed during OH&S committee meetings
Ensure that actions from Incident Reviews are carried No
out.
checklists complete for PL&C but are currently being reviewed for Extrusion
8 DCV ACCESS/EGRESS Yes Yes – Audit checklist handed out as per schedule for PL&C but problems with the audits
being carried out.
868
4th Month’s Results
Item Item
No. Owner

2 DCV WORK ORGANISATION Yes Yes – Site map created and fixed points now finalised and first audit carried out

3 DJC WORK ORGANISATION Yes No – PC data collection went live from the 1/10/07. Need to delay analysis until a minimum
of 6 months data is available
Analysis of incidents in relation to time of Shift or time No
of Day.
4 DJC INCIDENT MANAGEMENT Yes Yes – ongoing.

5 DJC INCIDENT MANAGEMENT Yes No – incident investigation requirements being reviewed to reflect current structure. Then
monthly SH&E meetings.
869
Item Item
No. Owner
6 DJC INCIDENT MANAGEMENT Yes Yes – maintenance dockets to be raised for any modifications required from incident
reports. Safety incidents are recorded in daily production meetings data base and
Ensure that actions from Incident Reviews are carried No outstanding “Safety” dockets are to be presented in monthly S&HE meetings
out.
checklists being reviewed by area supervisors with a view to commence 1/12/07
8 DCV ACCESS/EGRESS Yes No – as above
870
Injury and Incident Statistics Over the Pilot Study Period
14
12
10
Jun Jul Aug Sep Oct Nov Dec Jan
LTI's Medical treatments First Aid treatments Reports Near miss
871
Case Study 1
872
1st Months Results
Item Item
No. Owner
1) A storage rack containing separate bins

1 KS X No J, K and M held discussion on best design for storage area. Needs to be
to be installed in Manufacturing Area to hold
practical and accessible. K has asked XX to come in and design a storage rack.
the powders used in production. To be done
by end February.
KS 2) Bins are to be clearly labelled by powder
name.
3) Operators to be trained on how to use bin
TK system and keep it tidy. Completion by end
of February.
Has rack been installed, bins labelled
and training provided to operators?
1) Asbestos registers to be compiled,
2 MK X No Mi will investigate legal requirements then discuss with J the most appropriate
recording location of any asbestos identified
method of completing register
on site.
2) Asbestos type and condition to be clearly
identified by signage.
3) Timetable implemented to make regular
quarterly inspections of asbestos and
condition recorded. Completion by end
March 2008
Has asbestos register been compiled,
asbestos identified and labelled and
inspection timetable implemented?
873
Item Item
No. Owner
3 MK Prepare an emergency contact list for all X No An ‘Information Update Form’ was issued to all employees on 23/01/08. All
employees showing next of kin and employees completed the form, eg. Name, Address, Emergency Contact Details
emergency contact numbers. Must be and from these, MYOB employee card files were updated. The information was
accessible and updated regularly. then used to make a convenient Emergency Contact List on one A4 page.
Complete by end January.
We have asked employees to notify us of any changes to personal details, so
Has emergency contact list been that we may update the list as required.
completed?
4 MK 1) Finalise Emergency Plan in accordance X No Commenced Emergency Plan previously but still requires a good deal of
with NSW Fire Brigade Guidelines structure and information to complete. Keep J updated on progress.
2) Implement Emergency Drill timetable for

quarterly fire drills. Evacuation times and X No
any hesitancy or confusion to be recorded
and training given to address. Complete by
end Feb 08
Has emergency plan been finalised and

emergency drill timetable been
completed?
874
Item Item
No. Owner
5 MK 1) Select a local GP with Occupational X No Visit local Medical Centres in January/February to select suitable GP
Health expertise to work with the company
and employees in case of injury.
2) Develop package for employees to take

to GP showing location of Medical
Centre/Emergency Room, include letter
from Company and any forms required.
Complete by end March 08
Has a GP been selected to work with us

in case of employee injury and a
package put together for employees to
take to GP?
6 MK 1) Source a Rehabilitation Provider to X No Once GP is selected they may recommend a Rehab Provider they already work
ensure injured employees receive with
assistance and guidance, enabling them to
return to work.
2) Nominate a Rehabilitation Co-ordinator

from the workplace, to consult with Treating
Doctor and Rehabilitation Provider.
Has a Rehabilitation Provider and
Rehabilitation Co-ordinator been
selected?
875
Item Item
No. Owner
Worker Health Surveillance
7 MK Select two employees from the Factory area X No Once local GP with Occupational Health experience is selected as our doctor, I
to undergo complete health checks. will arrange for 2 employees to have complete health checks.
Occupational health GP may be able to
conduct health checks.
Have two employees been selected and
undergone health checks
Preventative OHS
1) Monthly workplace audits to be

8 MK conducted by 2 employees each month. X No Have to decide best method of recording audit – checklist or audit form? Look
Prepare checklist or audit form to record for ideas best suited to our workplace. Hopefully commence audit in Feb 08
unsafe situations.
2) Analyse findings and implement
procedure to reduce or eliminate hazards.
Implement by end Feb 08
Have monthly workplace audits
commenced and checklist or audit form
prepared?
876
Item Item
No. Owner
9 MK Prepare Contractors agreement to be X No M will prepare Contractors Agreement on return from leave late January, early
signed by contractor when they come on Feb 08
site. To include a list of hazards eg:
Solvents, Asbestos. Rules – No lighters,
matches, mobile phones. Contractor’s name
at top and signature panel for them to sign
acknowledging their awareness of risks and
agreeing to comply with our OHS policy.
Complete Feb 08
Has Contractors agreement been drawn

up?
877
Item Item
No. Owner
1) A storage rack containing separate bins

1 KS X No K has had discussions XX requesting them to design a suitable
to be installed in Manufacturing Area to hold
storage rack for manufacturing area. Due to XX current workload, they
the powders used in production. To be done
have advised us it will be toward the end of March before they can
by end February.
begin this job.
KS 2) Bins are to be clearly labelled by powder
name.
3) Operators to be trained on how to use
TK bin system and keep it tidy. Completion by
end of February.
1) Asbestos registers to be compiled,
2 MK X No M will investigate legal requirements then discuss the most appropriate
recording location of any asbestos identified
method of completing register
on site.
March 2008

878
Item Item
No. Owner
3 MK Prepare an emergency contact list for all Yes An ‘Information Update Form’ was issued to all employees on
employees showing next of kin and 23/01/08. All employees completed the form, eg. Name, Address,
emergency contact numbers. Must be Emergency Contact Details and from these, MYOB employee card files
accessible and updated regularly. were updated. The information was then used to make a convenient
Complete by end January. Emergency Contact List on one A4 page.
Has emergency contact list been We have asked employees to notify us of any changes to personal
completed? details, so that we may update the list as required.
4 MK 1) Finalise Emergency Plan in accordance X No Commenced Emergency Plan previously but still requires a good deal
with NSW Fire Brigade Guidelines. of structure and information to complete. Keep J updated on progress.

end Feb 08

completed?
879
Item Item
No. Owner
5 MK 1) Select a local GP with Occupational X No M has phoned approx ten local medical centres and GP practices and
Health expertise to work with the company spoken with the receptionists as the doctors are too busy to take
and employees in case of injury. phone calls. I have received no enthusiasm whatsoever and in fact,
sensed a reluctance to become involved. I decided to contact a
2) Develop package for employees to take Rehabilitation Provider instead, hoping for better response. (see
to GP showing location of Medical below)

take to GP?
7 MK Select two employees from the Factory area X No Once local GP with Occupational Health experience is selected as our
to undergo complete health checks. Doctor, I will arrange for 2 employees to have complete health checks.
880
Item Item
No. Owner
Preventative OHS
8 MK 1) Monthly workplace audits to be X No Monthly audits will commence on Tuesday 11th March, 2008. As
conducted by 2 employees each month. discussed at our OHS meeting, two employees from the factory will be
Prepare checklist or audit form to record chosen to conduct the audit, with guidance if required. An audit form
unsafe situations. has been selected, but may evolve if required.

Implement by end Feb 08
Have monthly workplace audits
prepared?
9 MK Prepare Contractors agreement to be Yes A CONTRACTOR/VISITOR AGREEMENT has been drawn up to fit
signed by contractor when they come on behind our Visitors Pass. This will be signed by all contractors and
site. To include a list of hazards eg: visitors (we will also continue to use the visitor’s register) These will
Solvents, Asbestos. Rules – No lighters, then be filed by month.
matches, mobile phones. Contractor’s
name at top and signature panel for them to We commenced using this agreement on 22/2/08,
sign acknowledging their awareness of risks
and agreeing to comply with our OHS
policy. Complete Feb 08
up?
881
Item Item
No. Owner
1 KS 1) A storage rack containing separate bins X No K has had discussions with XX requesting them to design a suitable
to be installed in Manufacturing Area to hold storage rack for manufacturing area. Due to GSR current workload,
the powders used in production. To be done they have advised us it will be toward the end of May before they can
by end February. begin this job.
KS 2) Bins are to be clearly labelled by powder In the meantime, we have installed an old locker unit (minus the doors)
name. TRIAL as a temporary measure, to see if it is practical, and improves the
tidiness of the area and easy access to the powders. Early trials have
TK 3) Operators to be trained on how to use bin the employees in Manufacturing complaining and saying it’s a
system and keep it tidy. Completion by end hindrance. Time may change their opinion. The area certainly looks
of February. more organised.

882
Item Item
No. Owner
1) Asbestos register to be compiled, Yes An asbestos register has been prepared and will be further discussed
2 MK
recording location of any asbestos identified over the next few months
on site.
March 2008
883
Item Item
No. Owner
completed? details, so that we may update the list as required.
4 MK 1) Finalise Emergency Plan in accordance X No Commenced Emergency Plan previously but still requires a good deal
with NSW Fire Brigade Guidelines. of structure and information to complete. Keep J updated on progress.

end Feb 08

completed?
884
Item Item
No. Owner
5 MK 1) Select a local GP with Occupational Yes In case of injury, employees are entitled to attend their own GP.
Health expertise to work with the company Where there is no preference, we have nominated to attend a Medical
and employees in case of injury. Centre. They offer a wide range of services and are local.
2) Develop package for employees to take X No Working on package for employees to take to GP.
to GP showing location of Medical

take to GP?
6 MK 1) Source a Rehabilitation Provider to Yes We have selected XX as the Rehabilitation Provider we will use if
ensure injured employees receive necessary.
return to work.


selected?
885
Item Item
No. Owner
7 MK Select two employees from the Factory area X No Once local GP with Occupational Health experience is selected as our
to undergo complete health checks. Doctor, I will arrange for 2 employees to have complete health checks.

Preventative OHS
8 MK 1) Monthly workplace audits to be X No Monthly audits will commence on Friday 13th June, 2008. As
conducted by 2 employees each month. discussed at our OHS meeting, two employees will be chosen to
Prepare checklist or audit form to record conduct the audit, with guidance if required. There are five separate
unsafe situations. areas to be audited and each area will have its own checklist.

procedure to reduce or eliminate hazards. 1.Production–Manufacturing Area,
Implement by end Feb 08 2.Production–Filling Area,
3.Despatch,
4.Laboratories,
Have monthly workplace audits 5. Administration.
prepared?
886
Item Item
No. Owner
9 MK Prepare Contractors agreement to be Yes A CONTRACTOR / VISITOR AGREEMENT has been drawn up to fit
name at top and signature panel for them to We commenced using this agreement on 22/2/08.

up?
887
Item Item
No. Owner
1 KS 1) A storage rack containing separate bins X No K has had discussions with XX requesting them to design a suitable
to be installed in Manufacturing Area to hold storage rack for manufacturing area. Due to XX current workload, they
the powders used in production. have advised us it will be toward the end of May before they can begin
To be done by end February. this job.
KS 2) Bins are to be clearly labelled by powder In the meantime, we have installed an old locker unit (minus the doors)
name. TRIAL as a temporary measure, to see if it is practical, and improves the
tidiness of the area and easy access to the powders. Early trials have
3) Operators to be trained on how to use the employees in Manufacturing complaining and saying it’s a
TK bin system and keep it tidy. Completion by hindrance. Time may change their opinion. The area certainly looks
end of February. more organised.

888
Item Item
No. Owner
2 MK 1) Asbestos register to be compiled, Yes An asbestos register has been prepared and will be further discussed
recording location of any asbestos identified over the next few months.
on site.


March 2008

889
Item Item
No. Owner
details, so that we may update the list as required.
completed?
4 MK 1) Finalise Emergency Plan in accordance X No Continuing to work on Emergency Plan. Already have lots of
with NSW Fire Brigade Guidelines. information; just have to put it together in an organised manner.
2) Implement Emergency Drill timetable for Yes Emergency Drill timetable has been implemented
quarterly fire drills. Evacuation times and
end Feb 08

completed?
890
Item Item
No. Owner
5 MK 1) Select a local GP with Occupational Yes In case of injury, employees are entitled to attend their own GP.
Health expertise to work with the company Where there is no preference, XX have nominated to attend a Medical
and employees in case of injury. Centre. They offer a wide range of services and are local.
2) Develop package for employees to take
to GP showing location of Medical Working on package for employees to take to GP is underway and will
Centre/Emergency Room, include letter be completed July 08.

take to GP?
6 MK 1) Source a Rehabilitation Provider to Yes We have selected XX as the Rehabilitation Provider we will use if
ensure injured employees receive necessary.
return to work.


selected?
891
Item Item
No. Owner
7 MK Select two employees from the Factory area X No Two employees have been selected to undergo health checks, one
to undergo complete health checks from the factory and one from the laboratory. This will be done July or
Occupational health GP may be able to August.

undergone health checks?
Preventative OHS
8 MK 1) Monthly workplace audits to be Yes Monthly audits commenced on Tuesday 24th June. Two employees
conducted by 2 employees each month. were selected to check the five areas of our workplace using
Prepare checklist or audit form to record Housekeeping checklists (one for each area). This was done
unsafe situations. enthusiastically and thoroughly by the two employees and highlighted
a number of concerns which are now registered to be rectified.
Implement by end Feb 08. 1.Production–Manufacturing Area
2.Production–Filling Area
3.Despatch & Labelling
Have monthly workplace audits 4.Laboratories
commenced and checklist or audit form 5.Administration
prepared?
892
Item Item
No. Owner
9 MK Prepare Contractors agreement to be Yes A CONTRACTOR/VISITOR AGREEMENT has been drawn up to fit
name at top and signature panel for them to We commenced using this agreement on 22/2/08.

up?
893
Case Study 2
894
1st Months Results
Item Item
No. Owner
1 OHS Hazardous Substances Yes
Does XXX store or handle hazardous substances?
2 OHS Hazardous Substances Yes
Does XXX meet all regulatory requirements to hold

and handle hazardous substances?
3 OHS Hazardous Substances Yes Next Step
Trials will continue until the process until the process is perfected.
Has XXX looked at a replacement chemical non-
hazardous chemicals?
895
Item Item
No. Owner
1 OHS Noise: Yes Most current Noise survey shows the XXX to be the highest contributor to overall noise.
Has the main source of noise been identified and

documented.
2 OHS Noise: Yes Administrative controls in place
Does the business have interim controls to protect

employees working in the area?
3 OHS Noise: X No No formal noise reduction plan in place. Consideration to noise given when making process
improvements.
Does the business have a noise reduction plan witch
Next Step
focuses on of reducing noise in the high risk area
first? Formalise a noise reduction plan in consultation with engineers and noise hygienists
896
Item Item
No. Owner
1 OHS Contractor management Yes

Have contractors been identified as a risk to XXX
2 OHS Contractor management Yes XXX contractor management in place

Is there a formal contractor management process in
place that determines contractor suitability to carryout
work?
3 OHS Contractor management X No Corporate contractors are not captured as part of site contractor management process.
Do all contractors that work on site meet the minimum
Next Step
criteria to perform work? i.e. Licenses, insurances,
training of staff, before been given consent to work? Formalise areas of responsibility with corporate representatives to ensure all areas requirement
are met prior to contractor being given consent to work
897
Item Item
No. Owner
3.1 OHS Hazardous Substances X No Set specific timelines for the completion of XXXI conversion. Include;
Have timeline for trials on XXXI been set? Trial dates with specific areas of research.
Completion dates for process and engineering changes.
Training of employees on all changes and modifications.
Final product tests and introduction into the market.
3.2 OHS Hazardous Substances X No Nil to report at present.

Has the trial been conducted as per the schedule/
program?
3.3 OHS Hazardous Substances X No Nil to report at present.

Has information from the trial been acted upon and
documented, and a new trial date been set to move
closer to a solution?
898
Item Item
No. Owner
3.1 OHS Noise: X No Contract a suitably qualified engineer to assist with formulating and implementing a noise
reduction plan.
Have the noise engineers and /or hygienists been
identified to assist in formulating the noise
reduction plan?
3.2 OHS Noise: X No A noise management plan exits that will need to be upgraded to an a noise improvement plan
Has the noise reduction plan been formulated?
3.3 OHS Noise: X No Nil to report
Have actions relating to one item on the noise

reduction been implemented?
899
Item Item
No. Owner
3.1 OHS Contractor management X No XXX to seek clarification from XXX OHSE Manger with relation to corporate contracts.
Points of clarification are;
Have areas of responsibility with corporate
representatives been formalised?
Do the corporate contract managers understand the requirements under XXX contractor
managing procedure
Does the contractor meet minimum criteria to work for XXX company?
Will the minimum requirements be reviewed by corporate and what internals?
Can the site have input into the tendering process?
3.2 OHS Contractor management X No Only for site engaged and ongoing contractors?
Have requirements for contractors, including
identification of all hazards they may encounter,
been formally documented?
3.3 OHS Contractor management X No Corporate contractors are not captured as part of site contractor management process.
Do corporate representatives understand
contractor control requirements and is there means
of ensuring the process is being followed?
900
Case Study 3
901
1st Months Results
Item
Item N. Controlled Self-Assessment Answer Comments
Owner
HAZARDOUS SUBSTANCES
1 Has a list of unwanted hazardous substances been X No Contractor sourced.

TG compiled and a suitable contractor been found and
utilised to dispose of the unwanted stock?
2 Are all the hazardous substances in the workplace X No Templates ready for labels; bulk storage area to be organised; intermediates storage
area complete.
appropriately labelled and stored?
JC
3 Has a complete list of all hazardous substances on X No Not completed, but progress made on updating and improving MSDS’s
site been compiled, have any risk assessments
JC
been undertaken and are all the MSDS’s up to
date?
Question 1 Question 2 Question 3

¾ Obtain full list of hazardous ¾ Determine labeling requirements for ¾ Prepare full list of all hazardous
substances each substance substances that are kept on site
¾ Liaise with employees on unwanted ¾ Research proper storage ¾ Source MSDS for each substance
product requirements for all hazardous ¾ Undertake risk assessment to determine
¾ Determine safe handling and safe substances safe handling requirements for each
disposal requirements ¾ Produce labels for hazardous ¾ Compile all information into a database/
¾ Find contractor for waste disposal substances management system that is easy to use
¾ Remove stock from storage ¾ Ensure all hazardous substances in and can be accessed by all employees
¾ Transport unwanted hazardous the workplace are labeled
substances to waste disposal facility
902
Item
Item No. Controlled Self-Assessment Answer Comments
Owner
EMERGENCY PREPAREDNESS
4 Has the list of fire extinguishers and fire blankets Yes Complete
JH been updated to suit locations and are all
extinguishers tested according to standard and
functioning?
5 TG/ GW Has an emergency evacuation drill and fire X No Date set for drill next month.
training session been conducted in the past 6
months?
6 TG Has an evacuation alarm and testing siren been X No Not yet

installed and have all employees been trained in
the use and awareness of this equipment?

¾ Check all extinguisher locations and update list ¾ Update emergency evacuation ¾ Contact alarm contractor to determine
¾ Test all extinguishers in accordance with procedure document and fire training different types of sirens
standard syllabus ¾ Decide upon a method of installation
¾ Send any extinguishers away for repair if ¾ Contact trainer to organise training (PABX or wireless)
required session ¾ Install system and conduct
¾ File testing report and update procedure ¾ Conduct training session familiarization with all employees
¾ Follow up evaluations need to be ¾ Update all procedures with new system
carried out to test the skills taught
903
Item Item
No. Owner
INDUCTIONS – INCLUDING CONTRACTORS/ VISITORS
7 Has the induction procedure been updated to suit Yes Completed

TG the different types of inductions that are
conducted at the manufacturing site?
8 TG/ PW Has signage been put in place to inform all X No Quotes organised. Funds being arranged.
contractors/ visitors of the site rules and the areas
they are allowed to access?
9 Has a list of contractors/ suppliers been X No Not yet. Being scoped.

developed that contains all details including
VF
induction dates and frequency of work?

¾ Split induction procedure into 3 areas ¾ Decide upon the signage that needs to ¾ Re design current contractors/
(contractors, escorted visitors, be displayed and the most prominent suppliers database to include the
unescorted visitors) place to put them details of OH&S requirements
¾ Update the procedure to ensure that the ¾ Liaise with sign writer to produce ¾ Divide the database into
new induction process is in place artwork contractors and suppliers for
¾ Rearrange filing system to be in line with ¾ Print signs and install in workplace ease of finding information
the new procedure ¾ Develop procedure to update the
list of contractors/ suppliers and
the OH&S requirements
904
Item
Item N. Controlled Self-Assessment Answer Comments
Owner
1 Has a list of unwanted hazardous substances X No Contractor sourced.

TG been compiled and a suitable contractor been
found and utilised to dispose of the unwanted
stock?
2 Are all the hazardous substances in the X No Templates ready for labels; bulk storage area to be organised; intermediates storage area
complete.
workplace appropriately labelled and stored?
JC
3 Has a complete list of all hazardous X No Not completed, but progress made on updating and improving MSDS’s
substances on site been compiled, have any
JC
risk assessments been undertaken and are all
the MSDS’s up to date?
905
Item
Item
Owne Controlled Self-Assessment Answer Comments
No.
r
4 Has the list of fire extinguishers and fire blankets Yes Complete
functioning?
5 TG/ Has an emergency evacuation drill and fire X No Date set for drill next month.
GW training session been conducted in the past 6
months?
6 TG Has an evacuation alarm and testing siren been X No Not yet

906
Item Item
No. Owner
7 Has the induction procedure been updated to Yes Completed

TG suit the different types of inductions that are
8 TG/ Has signage been put in place to inform all X No Quotes organised. Funds being arranged.
PW contractors/ visitors of the site rules and the
areas they are allowed to access?
9 Has a list of contractors/ suppliers been X No Not yet. Being scoped.

VF
907
Item Item
No. Owner
1 Has a list of unwanted hazardous substances Yes Completed

TG been compiled and a suitable contractor been
found and utilised to dispose of the unwanted
stock?
2 Are all the hazardous substances in the X No Templates ready for labels; bulk storage area to be organised; intermediates storage area
complete.
JC
In progress
3 Has a complete list of all hazardous substances X No Not completed, some MSDS’s have been revised and improved. No further progress this month.
on site been compiled, have any risk
JC
assessments been undertaken and are all the
MSDS’s up to date?
908
Item Item
No. Owner
4 Has the list of fire extinguishers and fire blankets Yes Completed
functioning?
5 TG/ Has an emergency evacuation drill and fire Yes Completed

GW training session been conducted in the past 6
months?
6 TG Has an evacuation alarm and testing siren been X No No further progress this month.
909
Item
Item
Own Controlled Self-Assessment Answer Comments
No.
er
7 Has the induction procedure been updated to Yes Completed

TG suit the different types of inductions that are
8 TG/ Has signage been put in place to inform all X No No further progress.
PW contractors/ visitors of the site rules and the
areas they are allowed to access?
9 Has a list of contractors/ suppliers been X No Not yet,

VF
910
Item
Item No. Controlled Self-Assessment Answer Comments
Owner
1 Has a list of unwanted hazardous substances Yes List of hazardous substances has been compiled
TG been compiled and a suitable contractor been Partial Suitable contractor has been sourced (cost to be determined)
found and utilised to dispose of the unwanted All unwanted hazardous substances have been separated from normal storage
stock?
2 Are all the hazardous substances in the Yes All intermediate storage completed. Bulk storage been transferred to new site and
labelled and stored correctly according to the standard and code of practice.
JC
3 Has a complete list of all hazardous Yes Complete list and stocktake has been compiled
substances on site been compiled, have any Partial New signage on buildings to indicate level of hazard and minimum PPE required (see
JC
attachment)
risk assessments been undertaken and are all
Risk assessments still need to be updated
the MSDS’s up to date?

¾ Determine safe handling and safe ¾ Undertake risk assessment to
disposal requirements determine safe handling
¾ Find contractor for waste disposal requirements for each
¾ Remove stock from storage ¾ Compile all information into a
¾ Transport unwanted hazardous database/ management system
substances to waste disposal facility that is easy to use and can be
accessed by all employees
911
Item Item
No. Owner
4 Has the list of fire extinguishers and fire blankets YES For both complete
JH been updated to suit locations and are all New signage installed in the areas that needed it. All buildings up to date
functioning?
5 TG/ Has an emergency evacuation drill and fire training YES All staff have been involved and it is up to date
GW session been conducted in the past 6 months?
6 TG Has an evacuation alarm and testing siren been NO ($400 for siren)
installed and have all employees been trained in the Car alarm an alternative. Noise is loud enough and cost effective. Need to source testing
siren
use and awareness of this equipment?
(two tone siren needed to suit needs)
¾ Decide upon a method of
installation (PABX or
wireless)
¾ Install system and conduct
familiarization with all
employees
¾ Update all procedures with
new system
912
Item Item
No. Owner
7 Has the induction procedure been updated to suit the YES 5 main types of induction and they have been collated into 1 procedure. FIP-007
inductions
TG different types of inductions that are conducted at the
manufacturing site?
8 TG/ Has signage been put in place to inform all YES - photo of site has not been approved (too low resolution image, blurred) need a
better photo
PW contractors/ visitors of the site rules and the areas
- visual warning signage has been approved and delivery expected by late June
they are allowed to access?
2008
9 Has a list of contractors/ suppliers been developed NO Started but still being amended
that contains all details including induction dates and
VF
frequency of work?
¾ Print signs and install in workplace ¾ Re design current contractors/
suppliers database to include the
details of OH&S requirements
¾ Divide the database into
contractors and suppliers for ease
of finding information
¾ Develop procedure to update the
list of contractors/ suppliers and
the OH&S requirements
913
Case Study 4
914
1st Months Results
Item Item
No. Owner
Base line risk assessment
Yes
1 DG Have field crews been informed/contributed to the Instructions: Where no has been selected please include an explanation
idea of creating OH&S material No
Yes
Have experienced crew been identified to assist in
this process? No
Yes
Has appropriate footage been gathered and/or
No
created for compiling into video?
Inductions, training and awareness;
Yes
2 DG Have typical scenarios been identified and compiled
No
Has video been approved for training sessions Yes

No
Yes
Have crews and programs viewed the OH&S video
No
915
Item Item
No. Owner
Feedback and consultation
3 AN Has a forum been established? Yes
No
Have field crews discussed material?

Yes
No
Have crews identified and discussed further incidents Yes

(1-2 /month)
No
Have crews considered other OH&S issues Yes
No
916
Item
Item
No.
r
Yes
1 DG Have field crews been informed/contributed to the
idea of creating OH&S material
Staff have been identified to gather footage from video archives. Footage in video archives is
Yes
Have experienced crew been identified to assist in yet to be researched. This is due to current disruptions in News Field. New equipment role
this process? out, and crew room relocation. Time has been set aside for week 26 for this task.
Has appropriate footage been gathered and/or X No

2 DG Have typical scenarios been identified and X No Typical Scenarios have been identified but not compiled.
compiled
Has video been approved for training sessions

X No
Have crews and programs viewed the OH&S video X No
917
Item
Item
No.
r
3 AN Has a forum been established? Forum is yet to be formalised. All staff are aware of the discussions but no staff have been
X No
selected to coordinate discussions/ actions/feedback.
Have field crews discussed material? Yes
Have crews identified and discussed further Yes
incidents (1-2 /month)
918
Item Item
No. Owner
1 DG Have field crews been informed/contributed to the

idea of creating OH&S material Yes
Have experienced crew been identified to assist in

this process? Yes Selected staff will gather new footage in the field. This will be used to demonstrate correct
and incorrect method of SPC Field News gathering.
Has appropriate footage been gathered and/or
Yes Archive footage has been identified and is currently being compiled.
2 DG Have typical scenarios been identified and

Yes
compiled
Has video been approved for training sessions X No

Typical Scenarios have been identified and are being compiled.
Video package has not been completed

Have crews and programs viewed the OH&S video X No
919
Item Item
No. Owner
3 AN Has a forum been established? X No We are all aware of SPC issues. Discussions happen on a very regular basis; the forum is in
a loose configuration where staff discuss topical issues as they are able … rather than calling
staff to a venue at a specific time.
Have field crews discussed material? Yes
Have crews identified and discussed further

Yes
incidents (1-2 /month)
920
Case Study 5
921
1st Months Results
Item Item
No. Owner
1 Access/Egress: Yes Instructions: Where no has been selected please include an explanation
No
AC Arrangements changed so that back door can be
a.
opened by anyone in an emergency.
Yes
No
AC Practice drill conducted once per month
b.
Yes
AC Time to get out the back door documented. No
c
2 Ergonomics:
Yes
No
AC Fatigue mat placed behind counter
Yes
AC Foot stool acquired for prescriptions area No
Days with sore legs noted and monitored Yes

AC
No
Security:
3 Yes
AC Days with potential for trouble per month noted No
Ideas for increased security during winter months Yes
AC
discussed No
Yes
AC Increased security measures implemented
No
922
Item Item
No. Owner
1 Access/Egress:
a AC Arrangements changed so that back door can be Yes

Yes
Practice drill conducted once every 3 months
b. AC Time in future to be documented in minutes
Time to get out the back door documented. No

AC
c
2 Ergonomics:
AC Fatigue mat placed behind counter Yes
AC Foot stool acquired for prescriptions area Yes
AC
3 Security:
AC Extend front bench area to limit access to dispensary Yes
Ideas for increased security during winter months Yes
AC
discussed
AC Increased security measures implemented Yes
923
Item Item
No. Owner
1 Access/Egress:
a AC Arrangements changed so that back door can be Yes

Yes
Practice drill conducted once every 3 months
b. AC Documented in minutes
AC Time to get out the back door documented.

c Yes
2 Ergonomics: Fatigue mat placed back in the dispensary since an increase in days with sore legs was noticed.
Other staff also felt there was a difference.
AC Fatigue mat placed behind counter No
AC Foot stool acquired for prescriptions area Yes
AC
3 Security: Yes
AC Extend front bench area to limit access to dispensary
Ideas for increased security during winter months
AC Yes
discussed
Yes
AC Increased security measures implemented
924
Case Study 6
925
1st Months Results
Item Item
No. Owner
1 Operating Instructions Up to date. Yes
Process description complete. Work instruction No

complete. JSERA complete. Competency assessment
complete.
2 Hazardous Substance Review Complete: Yes
Substance risk reviewed within last 12 months (review No

of PPE, handling exposures, health risks). Review
communicated to team as tool box talk.
3 Contractor passports implemented: Yes
All contractors who have been on site for more than No

16hrs in a month have completed a contractor
induction.
926
Item Item
No. Owner
1 Workplace Ergonomics:
Supervisor
Has an ergonomic assessment taken place of
your work station?
No
.
Supervisor
Have the top three items that cause concern
been prioritised and identified after end user
input into the discussion? No
Supervisor
Has an implementation program been
developed with time lines and persons
No
responsible identified, and resources secured?
927
Item
Item Owner Controlled Self-Assessment Answer Comments
No.
1 Workplace Behaviour Modification Significant improvement in volume 2x last month at 65.

Supervisor
Have Take 5 assessments been performed No Target will be 300
– one per person per day?
2 Workplace Behaviour Modification Not reviewed at meeting. Shift tool box talks not
Supervisor
Have they been reviewed at tool box talks No Yet recorded.
and new information communicated?
3 Workplace Behaviour Modification Not reviewed at meeting

Supervisor
Has the team agreed to any changes to No
current work practices as a result of
discussions at tool box talks:
928
Item
No.
1 Workplace Hazardous Substances Last completed Nov 05. No new chemicals on site
Supervisor
Has a current hazardous substances No
assessment been conducted in your work
area?
2 Workplace Hazardous Substances No We believe this is so but it requires the review of 3

Supervisor
Have workable controls been identified and Training has been completed for key chemicals
training conducted for chemicals of concern?
3 Workplace Hazardous Substances Requires review of current practise

Supervisor
Has implementation of controls been validated No
so that controls are being applied as intended?
929
Item Item
No. Owner
1 Workplace Ergonomics: No
Supervisor
your work station?
Supervisor
Have the top three items that cause concern No
input into the discussion?
Supervisor
Has an implementation program been No
developed with time lines and persons
responsible identified, and resources secured?
930
Item
No.
1 Workplace Behaviour Modification Less Take 5 (35) but more actions (80)
Supervisor
Have Take 5 assessments been performed No Target will be 300
– one per person per day?
2 Workplace Behaviour Modification Not completed at every tool box talk

Supervisor
Have they been reviewed at tool box talks No
and new information communicated?
3 Workplace Behaviour Modification Nothing specifically from tool box talks

Supervisor
931
Item
No.
Supervisor
area?

Supervisor

Supervisor
932
Item Item
No. Owner
Supervisor
your work station?
No
.
Supervisor
Have the top three items that cause concern
input into the discussion? No
3 Workplace Ergonomics: Completed Generic JSRA for unloading of XXX at customer sites. Plan in place to audit all sites to
customise risk assessment. Will involve customer and operators.
Supervisor
Has an implementation program been developed
with time lines and persons responsible
No
identified, and resources secured?
933
Item
No.
1 Workplace Behaviour Modification Dropped away in July to 29

Supervisor
Have Take 5 assessments been performed – No
one per person per day?
2 Workplace Behaviour Modification Shift tool box talks not yet recorded.
Supervisor
Have they been reviewed at tool box talks and No
new information communicated?
3 Workplace Behaviour Modification Changed hose coupling procedures to reduce leakage and remove need to use shims on camlock
arms.
Supervisor
934
Item
No.
Supervisor
area?

Supervisor

Supervisor
935
Case Study 7
936
No Results Returned
This page has been left intentionally blank.
937
Case Study 8
938
1st Months Results
Asbestos Register
Item Item
No. Owner
4.1.13 ET An asbestos register has been developed? Yes ET: Develop an asbestos register.
No
4.1.13 ET Training in Asbestos contained material has been Yes ET: Develop and co-ordinate the asbestos identification and testing training.
provided?
No
4.1.13 XXX Identify and register all incidence of asbestos contained Yes XXX: To continually investigate and/or test for ACM and establish and update the
Asbestos Register.
material (ACM) at all XXX owned or controlled sites.
No
4.1.13 XXX ACM available to interested parties. Yes XXX: Develop a system to review projects to ensure the ACM Register is provided to
all project planners/designers employees and contractors.
No
939
Job Description & Training/Skills Register
Item Item
No. Owner
4.2.05 & XXX Gaps identify in the job descriptions and/or task Yes XXX: Identify the gaps in the standard job descriptions or task specifications.
4.2.08 ET
specifications.
No
4.2.05 & XXX Job or task descriptions and minimum competencies Yes Part A:XXX: Where gaps have been identified, prioritise in the job and task from a
4.2.08 developed for all standard jobs or tasks. health and safety hazard perspective. Job and task descriptions developed where a
No gap has been identified.
Yes Part A:XXX: Job and task descriptions, minimum competencies developed where a gap
has been identified.
No
4.2.05 & XXX Measurable job competencies developed and Yes XXX/ET: Investigate job competencies and develop competency assessment tool.
4.2.08 documented. Job competency assessment tool developed.
No
4.2.05 & XXX Training Register current with employee training Yes XXX/ET: Training register updated with all standard job or task competency
4.2.08 assessment details.
competencies.
No
940
Incident Management
Item Item
No. Owner
4.3.17 XXX All health or safety incidents (or near misses) are reported. Yes ET: Reaffirm the XXX(& NSW OHS Regulations) requirement to report minor
injuries and near misses.
No
4.3.17 ET Selected supervisor & managers trained in incident and Yes ET: Develop and co-ordinate incident and accident investigation training.
accident investigation.
No
4.3.17 XXX Management and Employees have adopted the XXX Yes XXX Management: To review and direct XXX employees and management to
adopt the established XXX Hazard, Incident, Near-Miss and Injury reporting forms
Hazard, Incident, Near-Miss and Injury reporting forms and
No and corrective action sign-off record management flow chart and systems.
corrective action sign-off records management flow chart
and systems. .
941
Asbestos Register
Item Item
No. Owner
Asbestos Register now available kept under central control with input from managers
and team leaders
provided?
Organised training for employee to undertake Asbestos awareness training in July
2008
4.1.13 XXX Identify and register all incidence of asbestos contained No XXX: To continually investigate and/or test for ACM and establish and update the
Asbestos Register.
942
Item Item
No. Owner
4.2.05 & XXX/E Gaps identify in the job descriptions and/or task No XXX: Identify the gaps in the standard job descriptions or task specifications.
4.2.08 T
specifications.
4.2.05 & XXX Job or task descriptions and minimum competencies No Part A:XXX: Where gaps have been identified, prioritise in the job and task from a
gap has been identified.
Yes Part A:XXX: Job and task descriptions, minimum competencies developed where a
No
The position descriptions for XXX are being re-developed as part of XXX new
arrangements.
4.2.05 & XXX Measurable job competencies developed and No XXX/ET: Investigate job competencies and develop competency assessment tool.
In development as part of XXX new arrangements
competencies.
Training register implemented, however current training competencies still to confirm
943
Incident Management
Item Item
No. Owner
4.3.17 XXX All health or safety incidents (or near misses) are No ET: Reaffirm the XXX(& NSW OHS Regulations) requirement to report minor injuries and near
misses.
reported.
No near misses or hazards reported for May
4.3.17 ET Selected supervisor & managers trained in incident No ET: Develop and co-ordinate incident and accident investigation training.
and accident investigation.
No yet attempted
4.3.17 XXX Management and Employees have adopted the No XXX Management: To review and direct XXX employees and management to adopt the
established XXX Hazard, Incident, Near-Miss and Injury reporting forms and corrective action
XXX Hazard, Incident, Near-Miss and Injury
sign-off record management flow chart and systems.
reporting forms and corrective action sign-off
Incidents are not being reported within the time frame required and hazards and incidents are
records management flow chart and systems. .
kept in house
944
Asbestos Register
Item Item
No. Owner
Asbestos Register sent to all sites with a 54% received to 30 June 2008
provided?
Training road show for Asbestos awareness and identification training now well
under way with 5 out of 11 completed
Asbestos Register.
Asbestos register on central file with OHS Coordinator 54% response rate to 30
June 2008
4.1.13 XXX ACM available to interested parties. Yes XXX Develop a system to review projects to ensure the ACM Register is provided
to all project planners/designers employees and contractors.
945
Item Item
No. Owner
4.2.05 & XXX/E Gaps identify in the job descriptions and/or task No XXX: Identify the gaps in the standard job descriptions or task specifications.
4.2.08 T
specifications.
4.2.05 & XXX Job or task descriptions and minimum competencies No Part A: XXX: Where gaps have been identified, prioritise in the job and task from a
Yes Part A: XXX: Job and task descriptions, minimum competencies developed where a
No
The positions Descriptions for XXX are being re-developed as part of XXX’s new
arrangements.
4.2.05 & XXX Measurable job competencies developed and No XXX/ET: Investigate job competencies and develop competency assessment tool.
In development as part of XXX’ new arrangements
competencies.
Training register implemented, however current training competencies still to confirm
946
Incident Management - Customised Self -Assessment Tool
Item Item
No. Owner
4.3.17 XXX All health or safety incidents (or near misses) are Yes ET: Reaffirm the XXX (& NSW OHS Regulations) requirement to report minor injuries and near
misses.
reported.
One near misses or hazards reported for June involving potential injury to hand
No yet attempted
4.3.17 XXX Management and Employees have adopted the Yes XXX Management: To review and direct XXX to employees and management to adopt the
established XXX Hazard, Incident, Near-Miss and Injury reporting forms and corrective action
sign-off record management flow chart and systems.
Incidents are now being reported within the time frame required and incidents are being
forwarded to OHS Coordinator
947
Asbestos Register
Item Item
No. Owner
Asbestos Register sent to all sites with a 80% received to 30 July 2008
provided?
Training road show for Asbestos awareness and identification training now well under
way with 9 out of 11 completed
Asbestos Register.
Asbestos register on central file with OHS Coordinator 80% response rate to 30 June
2008
948
Item Item
No. Owner
4.2.05 & XXX Gaps identify in the job descriptions and/or task Yes XXX: Identify the gaps in the standard job descriptions or task specifications.
4.2.08 /ET
specifications.
Job descriptions updated to reflect the future direction of XXX. Last update
22/7/08
4.2.05 & XXX Job or task descriptions and minimum competencies No Part A: XXX: Where gaps have been identified, prioritise in the job and task from a
4.2.08 developed for all standard jobs or tasks. health and safety hazard perspective. Job and task descriptions developed where
a gap has been identified.
Yes Part A: XXX: Job and task descriptions, minimum competencies developed where
a gap has been identified.
Position Descriptions now completed under new arrangements for XXX.
4.2.05 & XXX Measurable job competencies developed and No XXX ET: Investigate job competencies and develop competency assessment tool.
Position Descriptions now completed under new arrangements for XXX.
XXX/ET: Training register updated with all standard job or task competency
4.2.05 & XXX Training Register current with employee training Yes
assessment details.
4.2.08
competencies.
Training register implemented, however current training competencies still to
confirm
949
Incident Management - Customised Self -Assessment Tool
Item Item
No. Owner
4.3.17 XXX All health or safety incidents (or near misses) are Yes ET: Reaffirm the XXX (& NSW OHS Regulations) requirement to report minor injuries
and near misses.
reported.
One near misses or hazards reported for June involving potential injury to hand
No yet attempted
4.3.17 XXX Management and Employees have adopted the Yes XXX Management: To review and direct XXX to employees and management to adopt
the established XXX Hazard, Incident, Near-Miss and Injury reporting forms and
corrective action sign-off record management flow chart and systems.
Incidents are now being reported within the time frame required and incidents are being
forwarded to OHS Coordinator
950
Appendix 24: Follow-Up Evaluation Surveys
Note: Where information was received that may have inadvertently

disclosed the identity of the participating organisation either directly or
indirectly, “XXX” was inserted to remove such references.
951
Follow Up Evaluation - Pilot Study
Reviewing our concepts of safety systems against the approach provided by Pilot
assessment method.
The magnitude of the total task, considering the resources available.
type of study to another organisation and why or why not?
Yes, would recommend as we believe it simplified the process down to Person, Place and
Systems. It supplied a simple self evaluation process and simple definition criteria for each
element.
x Base line Risk Assessment (Current Situation)
x Resource Allocation
x Hazardous Substances (know what you have within the business)
x Emergency Preparedness (Know what to do)
x Communications
x Training
Yes, however see response for question two.
study
952
Follow-Up Evaluation Case Study 1
Implementing the “Self Assessment Tool”, as it encourages you to look at the overall
picture (Building Blocks) of your OHS Systems and methodically select elements in need of
improvement from the Framework Charts.
Recognising the mammoth task of formalising all systems, procedures and policies.
type of study to another organization and why or why not?
Yes, the study was definitely of benefit to our organisation and I would recommend it to
others. The Management Assessment Tool is easy to follow covering three areas Safe
Place, Safe Person and Safe System. Each area has a list of elements which have a
simple definition criteria. Using the Self Assessment Tool, you can methodically improve
or implement OHS systems and procedures allocating responsibility and time frames for
completion.
1. Baseline Risk Assessment (identify what risks you have and how serious they are)
2. Systems and Procedures (control the risk)
3. Hazardous Substances (labelled, stored and used correctly)
4. Emergency Preparedness (what to do)
5. Training & Communication (knowledge)
Yes, we will continue to use the “Self Assessment Tool” and methodically increase safety
awareness and culture.
study
953
We found the 60 safety elements component to be a comprehensive tool for identifying

gaps, it provides greater scope and flexibility than the one currently being used by XXX.
XXX’s Risk Profile is base on “Safe Place” only.
We found the self assessment tool difficult to implement into our current system. XXX is
driven by risk score and control and its prescriptive nature does not allow for action to be
implemented with out a risk assessment to qualify/quantify. We chose to stay within the
confines of XXX.
I did not find the study a benefit for XXX purely because we have a “mature” OHMS on site
and proper implementation would have meant doubling up on work. I would however
recommend this study to other companies because I found it to be comprehensive and
detailed.
Risk Assessment
Training
Consultation
Objectives and Targets
Measurement and Evaluation
Element by element findings have given me feedback to act upon. Risk assessments on
findings will have to be completed to ensure XXX requirements are met. I can recommend
to our SHEQ “people” through our coordinator elements that I found useful and practical. It
is their decision change entrenched costumes.
954
955
Follow-Up Evaluation - Case Study 4
x Simplifying the way for a supervisor to look at the OHS “mumbo jumbo”. Charts /
Colours etc made it more understandable and useable. It led to control solutions
being commenced / developed to address highlighted issues of concern.
x Formal external evaluation and feedback across a range of audit elements from a
reputable organization and its representatives.
x Staff realized that we (including their local supervisor and his managers) were
more actively pursuing solutions to issues that have been around for a long time.
x Having to think about the results, particularly the (poor) ones you don’t like and
which pertain to regular parts of the work.
x Getting the attention of managers and supervisors to address the issues.
Our own lack of time to in a busy work environment linked to news / story deadlines to
complete the exercise properly.
x Yes. We used it to focus on a long-term problematic operational area

(newsgathering) with a mobile workforce of both permanents and contractors in
non-fixed work locations and environments. They attend a variety of work locations
to gather the news every day.
x Yes. All auditing is a complex mix of measurement and views of the systems /
operations in place. This system is an attempt to simplify the process and the
reporting and is also highly visible in terms of report colours etc. It led to easier
engagement of the supervisors and managers.
956
System? Please give your answer rankings from 1 to 5 with 1being the most important.
x Leadership / Visible Commitment / Organizational values – Values based OHS/

Integration into mainstream activities and appropriate Resourcing to match.
x Defined responsibilities and accountabilities, particularly for safety critical roles.
x Training – particularly risk management training (using the hierarch of controls) so

that everyone sings from the same page. In this case dynamic risk assessment
and supervisor training in risk assessment.
x Incident and hazard reporting, investigation and appropriate control responses.
x Measurement against targets – both lag indicators and Positive Performance

Indicators.
x Yes but not necessarily on its own. We have been “lucky” that the internal
environment (changes in personnel, particularly a new manager and a willing
supervisor). This made it a bit easier than before to attempt to measure and
address some long-standing issues in this area. Management commitment to the
process has been felt and more incident reporting encouraged.
x Induction – we will develop, through consultation, induction / refresher materials to

address domestic in-the-field safety hazards and hazardous operations. Our
responses to the study will help speed up the induction process.
x The involvement of the crews themselves means that they help develop the video
and safety ideas to be used in the induction and other ‘field dynamic risk
management’ training that we will develop. They are using their own craft skills
(video) to identify problems and possible solutions.
x Using the video footage of the crews themselves will help personalize and
internalize their responses to safer operation. Consequences and near misses are
highly visible and available to remind crews of the field safety issues. It gets buy-
957
in. They become part of the solution – creating safe work practices. They are
creating / developing more responsibility for their own actions.
study
958
959
Follow-Up Evaluation - Case Study 6
Having an external party review the process with a fresh perspective
Getting more actions to manage. May not be a problem for all participants but I am
currently overwhelmed by actions from various sources.
Yes it was of benefit, if only to get an external perspective. My business is very inward
looking and this often blinds us to issues. I would recommend this process to a company
as a useful benchmarking tool or as a demonstration of duty of care.
System? Please give your answer rankings from 1 to 5 with 1being the most important.
2 Consistency. Most system fail because as businesses we fail to walk the talk and allow
too many exceptions to occur. The standard should apply to all, always and everywhere.
4 Clarity. We have often built in conflicting priorities within the business (ie profitability vs
speed) All personnel need 1 set of priorities that cant be misinterpreted.
3 Simplicity. If you have to explain it – it is too complex. Systems need to be easy to read
– focused to the reader and provide a consistent message (ie the same question gets the
same answer – whoever you ask)
5 Continuous review. Most documented processes fail due to their inability to keep pace
with change in the operational world – usually linked to being overly complex.
1 Alignment. All processes must be aligned with the business vision and values. Safety
cannot be seen as a functional add on – it is part of risk management which is what doing
business is about.
960
As a general statement most of the OHS system is focused on being a defensive
document (ie being able to prove your not to blame) rather than being a process to
continually improve safety. For me there are 2 main components to a safe operation: the
safety you can build into a process (ie Layers of protection) and the safe behaviours we
bring to the operation. In the XXX business we focus heavily on the individual
responsibility as we have variable uncontrolled environments with low levels of supervision,
whereas a major chemical plant is focused more on process safety. The ideal system
would be a balance of both of these philosophies.
Yes, we need to reduce chemical exposure to the point that the most sensitive employee
has no adverse impact rather than ensuring we are below the maximum exposure
standards listed in the MSDS.
study
961
Follow Up Evaluation – Case Study 7
The ability to look at a new system and evaluate our current practice against it.
The monthly assessments as they proved time consuming, however this was
due to internal resourcing issues within our organisation.
The study has been very beneficial not just only the system itself, the risk assessments but
also the presentation which was given to our OHS committee which has driven our OHS
program for the coming 2 years. Yes I would recommend this type of study to other
organisations as it requires minimal involvement from the organisation but provides high
impact results which can be used to talk to Senior Managers.
1 Risk Assessment
2 - Reporting
3 - Corrective Actions
4 - Authority and Accountability
5 - Consultation and Communication
Yes it will and already has in particular with regard to stress management and awareness.
study
962
Follow-Up Evaluation – Case Study 8
x A third party assessment of our OH&S management system.
x The assessment used a comprehensive, 60 element assessment tool which had

application to all areas of our “field” activities.
x We were very fortunate (and such a coincidence) to have the assessment

conducted by someone who understood the very specialised (and some seldom
used) techniques that are still currently used (eg XXX ).
x The report risk ranking of data, including “with intervention and without intervention”,
table has and will make it very easy to focus of areas of concern which in itself
makes it a very valuable tool/report.
x As above the Element by Element triangulated assessment and such

comprehensive findings give my ongoing argument greater impact with gaining XXX
and/or resources approval and for relevant improvements, suggestions or corrective
actions.
There was not a component of the assessment that we “liked the least”. The assessment
was conducted by someone (Anne-Marie Makin) who by a fortunate coincidence had
knowledge and a working background in many of our specialised activities. I found the sixty
element preliminary results and summary (Case Study #8) a little overwhelming but that is
more a compliment than a “liked least”.
The study has already been of immediate benefit to us. I would imagine, now that it has
been reviewed by management, that it will be an ongoing benefit for quite some time to
come.
963
Would I recommend it, unquestionably.
Are we recommending the OH&S Management Assessment study, yes, and selling it’s
praises at every opportunity.
1. Developing strategies, guidelines, procedures and inspection/audit tools that

ensure XXXs activities are safe, user friendly, easily understood and have a
practical application irrespective of current legislation.
2. Ensuring the above corporate documents meet the minimum legislative

requirements.
3. Focuses on hazard identification and risk assessment in a consultative manner

that includes all level of employees.
4. Identifies minimum skill levels to ensure all activities are carried out safely and
includes a system to evaluate and identify training.
5. The management system is measurable and includes a system to inspect, audit

and recommend improvements and identify non-conformances.
Absolutely, the comprehensive nature of the Definition Criteria, Critical Risks and Actions
Required will add weight to pro safety employee focus on continually enhancing all safety
aspects of our OH&S Management System. The study will subtly assist the same pro
safety employees win the battle over the “we’ve been doing this, this way for 30 years why
should we change” brigade.
study
964
Appendix 25: Sharing Good Practice
965
Case Study 1
Figure 1: PPE poster for use with multiple chemicals and language
barriers
966
Case Study 3
Figure 1: Ground Testing Station Figure 2: Conductive Flooring
Figure 3: Intrinsically Safe Lighting Figure 4: PPE to Reduce Static
967
Case Study 6: -Management Style
Quote from Participant
“Good team management is about the following:
1. Select the right personnel - check they have aligned values
2. Provide them with the skill and knowledge they require before they
need it. Constantly grow the ability of the team.
3. Support them with adequate resources and clear direction.
4. Provide them with feedback, positive and negative to help align with
the business goals. This should constant, consistent and 2 way.”
Case Study 7 - Training:

A DVD was specially produced for training purposes. This was on the use
of dynamic risk assessments. The DVD was made for their own use, and
features members of their own organisation.
968
Case Study 8
Occupational Health Safety and Rehabilitation Policy
XXX accepts the responsibility to develop and maintain a working

environment that is safe and without risk to the health of all employees,
contractors and visitors.
All Managers, Supervisors, Employees and Contractors are required to

observe and work within the following standards;
Managers and Team Leaders will be responsible at all times to ensure that
all persons within the area of their control, work in a safe manner and
ensure compliance with XXX OHS&R policies and procedures.
All employees will be involved in positive programs to minimise risks, and

be accountable for the correct use and maintenance of tools, plant and
safety equipment.
Plant, equipment and processes will be designed, purchased, installed,

monitored and maintained to ensure high standards of health and safety
are provided.
All persons working on XXX contracts / projects shall receive appropriate

and adequate training to enable them to carry out the work safely and
efficiently.
Decisions and changes being made which may affect the health and
safety of employees will be discussed during staff meetings. Staff
meetings will provide opportunities for discussion between employees and
management with regard to occupational health and safety.
969
Each supervisor and manager is responsible for ensuring there is
opportunity for subordinates to directly discuss health and safety issues.
In the event of an accident / incident occurring, the circumstances must

and will be thoroughly investigated and recorded by the Operations
Manager or Team Leader in charge of the area, and the appropriate
corrective measures taken to prevent any recurrences.
Effective health and rehabilitation services shall and will be provided.
All operations within the XXX shall comply with both the letter and spirit of
the 2000 Occupational Health and Safety Act and Regulations, Guides,
Codes of Practice and XXX own policies and procedures.
Commitment and involvement by everyone is required to ensure the

success of this policy and sufficient resources will be allocated where
required to assist in this commitment.
Operations Manager:
Date:___/___/___ Review Date: ___/___/___
970

Applying The Safe Place Safe Person Safe System Framework To Improve OHS Management Makin 2009

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Applying The Safe Place Safe Person Safe System Framework To Improve OHS Management Makin 2009

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Applying the “safe place, safe person,

safe systems” framework to improve

A thesis submitted for completion

Submitted November 2008

0.2 Copyright Statement

I also authorise University Microfilms to use the 350 word abstract of my

I have either used no substantial portions of copyright material in my

Dr Carlo Caponecchecia, Dr Anne Wyatt; Dr Christian Khalil; Dr Shahnaz

Many thanks to you all. This journey was a team effort.

not everything that counts can be counted.”

2. STRATEGIES TO IMPROVE OCCUPATIONAL HEALTH AND SAFETY _________40

3. DEVELOPMENT OF THE OHS MS MODEL FRAMEWORK ______________107

4. MEASURING & EVALUATING SAFETY PERFORMANCE ________________138

5. PREVIOUS STUDIES AND GAP ANALYSIS _________________________159

6. RESEARCH PROJECT AIMS, RESEARCH QUESTIONS AND OBJECTIVES____184

8. PILOT STUDY RESULTS _____________________________________204

9. INDIVIDUAL CASE STUDY RESULTS -SUMMARY AND DISCUSSION _______223

10. COMPARISON OF CROSS CASE RESULTS _______________________292

11. DISCUSSION ____________________________________________322

12. RECOMMENDATIONS AND CONCLUSION _______________________359

13. REFERENCES __________________________________________368

14. APPENDICES ___________________________________________394

Peer Reviewed Papers

x Makin, A.-M., Winder, C. (2009) Managing hazards in the workplace

x Makin, A.-M., Winder, C. (2009) Development of an assessment tool

x Makin, A.-M., Winder, C. (2008) A new conceptual framework to

x Makin, A.-M., Winder, C. (2007) Emergent trends in safety

x Makin, A.-M., Winder, C. (2007) Measuring and evaluating safety

x Makin, A.-M., Winder, C. (2006) Do self-assessment tools assist the

x Makin, A-M., Winder, C. (2008) Dynamic risk assessments: When

x Makin, A-M., Winder, C. (2007) Systematic OHS management: What

x Winder, C., Makin, A.-M. (2006) Hierarchy of controls: inflexible

The definitions of Occupational Health and Safety Management Systems

An OHS MS is a framework that facilitates the management of health and safety

 allocation of responsibility and accountability,

 a repertoire of strategies for dealing with work related hazards/risks,

 cues for the timing and co-ordination of key system elements,

 contingency plans for handling situations where preventive measures

 tools for enhancing the understanding of the system and to provide

 a means of identifying system strengths and vulnerabilities.

The presence of an OHS MS serves as a catalyst for improvement and

 implement changes that are planned, proactive and preventive,

 learn from past experiences both internal and external to the

 maintain and improve upon practices found to be conducive to

None of this, of course, can be achieved without genuine commitment and

Working with the statement of an OHS MS presented for the purposes of

In the past, employees sometimes traded personal safety for danger

Whether or not an organisation will take on the responsibility for actions

Alternatively, this responsibility can be denied or ignored. In these cases

The purpose of this thesis is to provide a means of avoiding the above

 those that focus on people and human factors, including behavioural-

 those that focus on the system including leadership, culture and

Hence, the planned assessment tool, based on a three-part model

With the perspective that safety is an individual as well as a collective

1.2.1 Historical Legal Developments in Britain Leading to the

The framework of Australian legislation has largely followed developments

 1850 Hutchinson v. York, Newcastle and Berwick Railway Co.:

 1858 William v. Clough: Duty on employers to provide safe

 1862 Clarke v. Holmes: Duty on employers to provide a safe system

 1915 Toronto Power Co. v. Paskwan: Duty on employers to provide

These and other common law precedents made contributions to what is

Whilst this established a fundamental duty of care in common law, and

The passing of the various Factories Acts had opened up another

allocation of responsibility and accountability,

a repertoire of strategies for dealing with work related hazards/risks,

cues for the timing and co-ordination of key system elements,

contingency plans for handling situations where preventive measures

tools for enhancing the understanding of the system and to provide

a means of identifying system strengths and vulnerabilities.

implement changes that are planned, proactive and preventive,

learn from past experiences both internal and external to the

maintain and improve upon practices found to be conducive to

those that focus on people and human factors, including behavioural-

those that focus on the system including leadership, culture and

1850 Hutchinson v. York, Newcastle and Berwick Railway Co.:

1858 William v. Clough: Duty on employers to provide safe

1862 Clarke v. Holmes: Duty on employers to provide a safe system

1915 Toronto Power Co. v. Paskwan: Duty on employers to provide

the provision of systematic, structured guidelines for improving OHS

emphasis on management leadership and commitment; employee

references to the relevant OHS legislation to assist employers

tiering systems to package the potentially overwhelming amount of

incentive schemes for workers’ compensation premium discounts

the total quality management (TQM) movement and implementation

a high proportion of a relatively stable work force involved in the off-

an atmosphere of strong but co-operative union involvement,

the governing inspectorate having a strong presence, and

regulatory authorities that supported the trade unions.

the pitfalls of becoming lost in the mechanism of the system, such as

difficulties for small firms trying to comply and if unable to do so,

Are alternative models available, other than strictly prescriptive or

Do these alternatives generate worse problems?

prosecutions focused on the events immediately leading up to the

there was little incentive to do more than meet minimum standards

trivial or inadequate penalties being imposed did not provide a

failure to accommodate the trend towards a more fluid labour force

Jensen describes the phenomenon of “sidecar” learning based on

The mistaken belief that a plea of ignorance might mitigate a penalty

sufficient funding of regulatory bodies to enable greater application of

the formation of strong links between regulatory authorities and

dissemination of legal precedents that encourage organisations to

the existence of an appropriate safety culture in organisations that

access to trade union support where necessary; and

management and line supervisors that are seen to be accountable for

fear of loss of credibility and reputation;

fear of business interruption and the resulting loss of consumer/

desire to reduce compensation costs; and

a perceived moral/ethical duty to comply with OHS regulations.