Compliance Mapping… an eye opener for many managers and supervisors

Last week I wrote about keeping safety simple by building upon the safety foundation that OSHA has provided and as I expected there were some that were insulted by my position on behavior based safety. Some thought I was some kind of “big government” person, which for those that know me are chuckling right now. I am in NO WAY anti-Behavior Based Safety; in fact I think it is the icing on the cake when it comes to safety. I just believe that it is truly the icing on the cake which means it is the LAST thing we do. I want to continue down this path of using OSHA Compliance as our foundation and introduce an exercise I have done many times with HUGE success. This exercise does NOT have a direct impact on worker safety, but I have come to consider it ESSENTIAL in helping management understand ALL THAT WE MUST DO, the FREQUENCY it MUST BE DONE AT, and WHO MUST BE INVOLVED for us to have a FULLY FUNCTIONING Safety Management System. This exercise has been a real eye-opener for many managers who thought they understood “safety” and it allows MANAGEMENT to keep the full 360 degree view of just what has to be done to achieve the “Lowest Safety Denominator”; some of you may even be surprised at what you have been accomplishing all these years! Here’s how it goes…

1) Using 29 CFR 1910 standards, conduct an applicability assessment of which standards apply to the business.

THIS IS AN ABSOLUTE CRITICAL STEP and must be carried out by someone knowledgable in BOTH the activities within the business and the applicability of the OSHA standards. Missing an OSHA standard that is applicable may leave a gapping hole in our safety management system and on the other hand incorrectly applying a standard may waste resources that could be better utilized in a more critical function. In this article I will use the Respirator Program again as my working example. If there is a respirator on your property we either will have a program OR we get rid of the respirator and have a POLICY STATEMENT that no respirators will be allowed on site without a review by the Safety Leader and Management. This includes “filtering face pieces”! Too often we find businesses that claim they do not have a respirator program as all of the “filtering face pieces” are worn on a “voluntary basis” only to find it is stated as “required PPE” in some Operating and Maintenance procedures – meaning it is NOT voluntary when the employer requires them in an SOP! But this OSHA standard has many twist and turns for someone who has not worked with respirators. There are a lot of small businesses that fall under PSM/RMP and although their workers in their normal duties do not use respirators (and I question this position) these businesses have an “emergency response team” that is trained to respond to uncontrolled releases which by default will put the business in the “respirator program” needed column!

2) Once we have defined what standards are applicable then we have to map out all that is required under EACH of the applicable standards.  Now some of these standards will require NOTHING MORE than identifying deficiencies and CORRECT these deficiencies, such as 1910.23 – Guarding floor and wall openings and holes. Now don’t get too excited thinking “finally a break” from all this structured approach – next week I will write about the “supplemental systems” that SUPPORT our safety management system in a VERY BIG way. One such system is what I have grown to call my “EHS Action List” which is the system used to manage ALL of my action items involving EHS matters. So in a nut shell, we identify a working surface that is over 4’ high and it needs a railing system for fall protection, this platform with its needed railing will be added to the EHS Action List with a manager assigned to the item and a due date assigned. Pretty simple, but I will explain this in more detail in my next article.

Some of these standards will require a MULTITUDE of activities and documents, all of which play a critical role in their effectiveness. Lets look at the Respirator Program again as our working example…

1. Written Program
2. Medical Clearance
3. Fit testing
4. Training
5. Evaluation/Auditing
6. Exposure Data to support the choice of respirator for the task

Who is responsible for EACH once of these basic requirements for an effective respirator program? Well the first one, the written program, OSHA did us a favor in 1998 when they revised the standard and REQUIRED that someone be appointed as the “Program Administrator” to oversee the implementation and management of the respirator program. The “administrator” is the one RESPONSIBLE for the contents of the written program and for assisting managers who have workers in the program be successful in managing the program as it applies to the workers they are responsible for. We have seen it time and time again – the program administrator getting beat up over workers missing their medical evaluations, fit testing, training, etc. How do we expect the program administrator to be responsible for activities they have ZERO control over. Their function is to ensure the requirements of 1910.134 are properly covered in the written program and then to inform each manager of their responsibilities under the program. Not all managers will have employees in this program, but if they do then they MUST be responsible for ensuring they comply with the program. More on this later. But all too often we find management teams that are not aware of their level of responsibility as no one has sat down with them and explained how the respirator program works. In this mapping exercise we will have it ALL LAID OUT for them to visually see.

3) Once we have all the written programs, activities, and documentation mapped out for EACH applicable standard we then move to DEFINING each management positions role in each activity. In other words… WHO, HOW and WHEN! Who has to be involved in each program? How are they involved? and How often/long is their involvement. This stage of the mapping process is when most managers will get the shock of their lives, as they have never actually fully understood just how much safety activity is REQUIRED at this very early stage of building a safety process. At this stage of the mapping process managers are now getting a first hand look at their role in the safety program. They begin to see that this management system is going to call out their “lip service” to safety as they begin to see what the expectations of their role actually is in a functioning safety process. It is in this stage they learn how many of their employees participate in the respirator program and just what this entails. However, once the shock wears off, they actually see the value in the mapping exercise as they can now BETTER PLAN for the safety requirements they will be MEASURED against. I have actually seen managers who begin to EVALUATE “safety” within their department. For example, a department manager who learns that his/her employees are using respirators VOLUNTARILY still has some obligations under the respirator program will actually begin to weigh the benefits of these “voluntary uses”. Before they were handing these air-purifying respirators out like candy as they had no “responsibility” (it was “safety’s job”). Now they get to see what has to be in place for a worker to even wear these APR’s on a voluntary basis. It is at this time when the manager is getting his/her first hand look of ALL their safety activities that MUST be accomplished annually and they are looking to REDUCE those unnecessary burdens that provide very little actual safety. Keep in mind that a manager over a department that has Permit Required Confined Spaces, Authorized and Affected employees in the LOTO program, uses a multitude of PPE, does hotwork, has qualified electrical workers, etc. is now starting to see the level of their RESPONSIBILITY in the execution of safety within their department. And this simple step in the mapping process WILL MAKE MANAGEMENT SIT UP and take notice of their “readiness” for a behavior based safety process. In other words, they will recognize all the fundamental gaps in their safety program that they WILL begin to question the efforts put forth to run the behavior based safety observation process instead of tending to the “Lowest Safety Denominator”!

4) Training obligations. The last element of this mapping excise is to map out the training obligations for each program and each department, including any emergency response team training. This mapping will be down to the minute detail including how long each session will last, who must attend, and when (i.e. month) the training will occur in. This can be simple, but keep in mind that some workers will need “affected LOTO training” and some will need “Authorized Training” and most everyone else on the plant site will need “other employees” training. Breaking this down into these three (3) groups will allow us to CLEARLY define who is authorized, who are affected and who falls into the “other employees” – then we can begin to understand the “other requirements” related to LOTO such as training, annual inspections, etc.

OSHA has a very nice document titled Training Requirements in OSHA Standards and Training Guidelines that lays out the training requirements for each standard; very helpful tool.

This mapping exercise is NOT meant to be quick and easy and if it is done correctly it will take about 1-2 days minimum for those facilities with fewer OSHA standards that are applicable to their activities and may take up to 4-5 days for those larger more complex facilities that fall under standards such as PSM or one of the Chemical Specific standards such as 1910.1048 – Formaldehyde. But one way we should look at this is that the higher the risk the facility has the more standards will be applicable to control these hazards.

Let me end by attempting to walk us through a standard mapping exercise for a respirator program.

1. Written Program and procedures for: (Program Administrator)
   1. selecting respirators
   2. medical evaluations
   3. fit testing procedures 
   4. proper use of respirators in routine and reasonably foreseeable emergency situations
   5. schedules for 
      1. cleaning and disinfecting
      2. storing
      3. inspecting
      4. repairing, discarding, and otherwise maintaining respirators
   6. ensure adequate air quality, quantity, and flow of breathing air for atmosphere-supplying respirators
   7. Training in the respiratory hazards to which they are potentially exposed during routine and emergency situation
   8. Training in the proper use of respirators, including putting on and removing them, any limitations on their use, and their maintenance
   9. regularly evaluating the effectiveness of the program
2. Medical Clearance (defined in written program)
   1. Department A
      1. Operators (15)
      2. Supervisors (4)
   2. Department B
      1. Operators (10)
      2. Supervisors (4)
   3. Department C
      1. Operators (20)
      2. Supervisors (4)
   4. Maintenance
      1. Mechanics (15)
      2. I&E Techs (10)
      3. Pipefitters (8)
   5. Support and ERT
      1. Engineers (6)
      2. ERT Members from Management (13)
3. Fit testing
   1. Qualitative
      1. Department A
         1. Operators (5)
         2. Supervisors (0)
      2. Department B
         1. Operators (0)
         2. Supervisors (0)
      3. Department C
         1. Operators (3)
         2. Supervisors (0)
      4. Maintenance
         1. Mechanics (0)
         2. I&E Techs (0)
         3. Pipefitters (0)
      5. Support and ERT
         1. Engineers (0)
         2. ERT Members from Management (0)
   2. Quantitative
      1. Department A
         1. Operators (10)
         2. Supervisors (4)
      2. Department B
         1. Operators (10)
         2. Supervisors (4)
      3. Department C
         1. Operators (21)
         2. Supervisors (4)
      4. Maintenance
         1. Mechanics (15)
         2. I&E Techs (10)
         3. Pipefitters (8)
      5. Support and ERT
         1. Engineers (6)
         2. ERT Members from Management (13)
4. Training
   1. Filtering Face Pieces (30 Minutes)
      1. Department A
         1. Operators (15)
         2. Supervisors (4)
      2. Department B
         1. Operators (10)
         2. Supervisors (4)
      3. Department C
         1. Operators (20)
         2. Supervisors (4)
      4. Maintenance
         1. Mechanics (15)
         2. I&E Techs (10)
         3. Pipefitters (8)
      5. Support and ERT
         1. Engineers (0)
         2. ERT Members from Management (0)
   2. Air Purifying (2 Hours)
      1. Department A
         1. Operators (5)
         2. Supervisors (4)
      2. Department B
         1. Operators (2)
         2. Supervisors (4)
      3. Department C
         1. Operators (2)
         2. Supervisors (4)
      4. Maintenance
         1. Mechanics (0)
         2. I&E Techs (0)
         3. Pipefitters (0)
      5. Support and ERT
         1. Engineers (6)
         2. ERT Members from Management (13)
   3. Supplied Air (2 hours; does NOT include emergency use that is covered in ERT training)
      1. Department A
         1. Operators (10)
         2. Supervisors (4)
      2. Department B
         1. Operators (10)
         2. Supervisors (4)
      3. Department C
         1. Operators (21)
         2. Supervisors (4)
      4. Maintenance
         1. Mechanics (15)
         2. I&E Techs (10)
         3. Pipefitters (8)
      5. Support and ERT
         1. Engineers (6)
         2. ERT Members from Management (13)
5. Annual evaluation of the effectiveness of the program
   1. Safety Manager quarterly audits and annual safety audit by 3rd party
   2. Department Supervisors (16) conduct monthly audits
6. Exposure Data to support the choice of respirator for the task
   1. Refer to the IH Sampling Plan managed by Safety Manager