Auditing in terms of a SMS function and Continuous Improvement

We have a long-time client for whom we have now completed OSH and/or PSM/RMP audits at all of their North American facilities over the past 8 years. And this last audit was a “deal breaker” for many clients, as they were fit to be tied after the audit. Seems the facility had run its Safety/PS programs through AI, asking for a compliance evaluation. Seems that the SAFTENG is better at this than AI! They made some high-level changes to their programs before our arrival, and we left them with 168 findings, several related to inadequate programs, ineffective/incorrect implementation, incorrect training content, etc. This organization is BIG on the SMS approach to managing their risks, and these programs were a major disappointment to the corporate S&H team that managed the audit.

Safety programs in 2026 MUST include the WHO-WHAT-WHEN-WHERE and, most importantly, the HOW the program functions. So I wonder whether AI could evaluate against the Compliance Directive rather than the standard, and whether that would yield a better evaluation. As this facility’s written programs were almost a cut-and-paste of the OSHA standard it was meant to comply with. The problem was that a manager responsible for compliance was NOT offered insights into what, when, or how they were actually to comply with the program. So AI was looking at a mirror of the OSHA standard, so of course, it’s going to give a passing grade on the written program. But AI can not evaluate how the program is functioning and if all the requirements are being done properly and on time.

For example, the Respiratory Protection Program (RP) met all OSHA requirements; yet employees were not receiving their medical evaluations BEFORE being fit-tested and provided a respirator. Emergency Response team members were receiving ONLY the RP medical eval and NOT the eval required under 1910.120(f). Additionally, ER team members expected to wear SCBAs were not receiving the required QNFT; everyone received a QLFT. (1910.134(f)(6) The fit testing records did not comply with 1910.134(m)(2); nor did the written program state what had to be on the Fit Testing records.

Just about every program had serious flaws in the content and implementation. But here is the catch, and how you know you’re working for a world-class organization…

In 2018, I was asked to speak at the company’s annual EHS conference regarding the audit program. In that presentation, I offered up the following advice…

Don’t wait for us to arrive at your facility; LEARN from the other facilities’ audits!

The VP of Global EHS followed up with a weeklong exercise in which the SAFTENG team reviewed all the audit findings from 20 facilities and explained WHERE these programs are required within the company. We then developed a ROADMAP for the company to implement corrective action plans (CAPs) across the company to make IMPROVEMENTS long before the facility’s actual audit. This was viewed as a “best practice” within the company; therefore, some divisions did not embrace this approach, and, yes, their facilities did not fare well in their audits. But this effort is what every single company should undertake within the auditing component of their SMS, whether it’s OSH or PSM/RMP.

LEARN from others’ mistakes! Take action to IMPROVE the SMS before you’re forced to via an ugly audit, or worse, an accident!

This last facility had since 2016, to correct all their issues as each of their findings had been identified in a previous audit. They were provided a Roadmap in 2019 on what their written programs and training content must include and who was impacted by the program. At that time, the management of the facility decided, based on a 2008 3rd-party audit, that they were solid and did not need to take any action. The new management that came in around 2024 asked EHS to use AI in their prep for their 2026 audit. And we know how that turned out.

Ironically, this facility was slated to go last based on its Injury Rates and the fact that it had undergone several OSHA inspections over the years. These OSHA inspections were mostly in response to complaints, and none resulted in a serious inspection of the facility. So be careful when using lagging indicators and OSHA inspections in your risk evaluations, particularly regarding who should be audited and in what order those audits should be carried out. The corporation walked away from this last audit understanding their flaws in their risk evaluations, and I am betting there will be a lot of discussion about this last facility’s Sub-1 injury rates, given a program that clearly cannot produce such results.

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