Is an accident an 'incident' or a 'nonconformance?

S

samsung

#11
OK guys, don't waste time debating this, that, I think, could be or any of that other dribble related stuff.....Look at the OHSAS Standard itself for the answer. Remember, once it is stated that it will be the method to manage OHS related risk and seek overall improvement in OHS performance it is:
1) Non-Negotiable
2) All inclusive...No exclusions

1st let's look at what an INCIDENT is as defined by OHSAS 18001:2007

3.9 incident
work-related event(s) in which an injury or ill health (3.8) (regardless of severity) or fatality occurred, or could have occurred

NOTE 1 An accident is an incident which has given rise to injury, ill health or fatality.

NOTE 2 An incident where no injury, ill health, or fatality occurs may also be referred to as a “near-miss”, “near-hit”, “close call” or “dangerous occurrence”.

NOTE 3 An emergency situation (see 4.4.7) is a particular type of
incident.


2nd lets look at what we have committed to in the OHS Policy

4.2 OH&S Policy
...b)...a commitment to prevention of injury and ill health...


Having an accident/incident/injury in the workplace is in fact a failure to meet a specified requirement and commitment in the policy and is a nonconformity ....failure to fulfill a requirement...

Now when it comes to INCIDENT INVESTIGATION in 4.5.3.1 we see among other things...

a) determine underlying OH&S deficiencies and other factors that might be causing or contributing to the occurrence of incidents;
b) identify the need for corrective action;


Except for an act of nature or God, depending upon how the organization likes to express this, incidents (accidents) occur by one of two reasons...

1) an unsafe condition (most of which are created by #2 below)
2) an unsafe act

Both #1 & #2 are situations that must be corrected if conformance to policy commitment of "...prevent..." has any hope of being achieved.

Remember guys...in the systems approach to management conformance to elements of the system requirements are necessary to help meet conformance to other elements (Input-Activity-Output)
:applause: Now I understand what you meant by 'special type of Nonconformance'
4.2 OH&S Policy
...b)...a commitment to prevention of injury and ill health...


Having an accident/incident/injury in the workplace is in fact a failure to meet a specified requirement and commitment in the policy and is a nonconformity ....failure to fulfill a requirement...
:agree1: And I do agree to everything you explained above but still there's a point of debate on the stated policy requirement - Prevention of injury and ill health. Question is - to what extent ? Should it be at ALARP levels ? In my opinion, the ALARP level is what one can practically achieve based on up-to date available information, technology, equipment and knowledge. And if something does fall beyond this level, it should be exempted from being a nonconformance

What's your opinion on this perspective ?

Meanwhile thanks for your valued support.
 
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Jen Kirley

Quality and Auditing Expert
Staff member
Admin
#12
:applause: Now I understand what you meant by 'special type of Nonconformance'


:agree1: And I do agree to everything you explained above but still there's a point of debate on the stated policy requirement - Prevention of injury and ill health. Question is - to what extent ? Should it be at ALARP levels ? In my opinion, the ALARP level is what one can practically achieve based on up-to date available information, technology, equipment and knowledge. And if something does fall beyond this level, it should be exempted from being a nonconformance

What's your opinion on this perspective ?

Meanwhile thanks for your valued support.
I looked up ALARP and came up with 30 different graphic representations. So, it seems fair to say there's no single rule set or definition for this. It seems to me the organization gets to set the bar for what nonconformance will (may) result in an incident or accident.

So in my mind, there it is: a system nonconformance can result in a consequential mishap or incident. Cause and effect. Just my opinion.
 
S

samsung

#13
I looked up ALARP and came up with 30 different graphic representations. So, it seems fair to say there's no single rule set or definition for this. It seems to me the organization gets to set the bar for what nonconformance will (may) result in an incident or accident.

So in my mind, there it is: a system nonconformance can result in a consequential mishap or incident. Cause and effect. Just my opinion.
Infact the acronym ALARP (as low as reasonably possible/ practicable) is synonymous to what OHSAS 18001 defines as 'Acceptable Risk Level' to be determined by the organization based on it's OHS policy commitments & legal obligations.

Now the question is - How to determine the 'ALARP' or 'Acceptable Risk levels' or how much risk an organization can tolerate ? In order to find a reasonable answer to what constitutes an Acceptable / ALARP level, we need to refer to the relevant H&S legislation which do prescribe not only the methods to perform a risk assessment but also the permissible exposure levels against various existing hazards & pollutants which are supposed to threaten the Health & Safety of the employees at workplace.

But here again the law does not require anyone to completely eliminate the hazards or to maintain a 'zero' injury or ill health status'. It only requires us to maintain the prescribed levels, also known as 'Acceptable levels'.

Let's see, what H&S legislation actually intends: (the following para has been taken from our national H&S legislation)

General duties of the occupier.
3*[7A. General duties of the occupier. (1) Every occupier shall
ensure, so far as is reasonably practicable, the health, safety and
welfare of all workers while they are at work in the factory.
(2) Without prejudice to the generality of the provisions of subsection
(1), the matters to which such duty extends, shall include-
(a) the provision and maintenance of plant and systems of work in the factory that are safe and without risks to health;
(b) the arrangements in the factory for ensuring safety and absence of risks to health in connection with the use, handling, storage and transport of articles and substances;
(c) the provision of such information, instruction, training and supervision as are necessary to ensure the health and safety of all workers at work;
(d) the maintenance of all places of work in the factory in a condition that is safe without risks to health and the provision and maintenance of such means of access to, and egress from, such places as are safe and without such risks;
Based on above explanation, one can reasonably ask for an exemption with respect to full compliance of the "Policy Commitment'; i.e.; 'prevention of injury and ill health (unless one has committed to achieve specific levels of OHS performance)
 
S

samsung

#14
4.2 OH&S Policy
...b)...a commitment to prevention of injury and ill health...


Having an accident/incident/injury in the workplace is in fact a failure to meet a specified requirement and commitment in the policy and is a nonconformity ....failure to fulfill a requirement...
IMHO, occurrence of an accident in the workplace should not be construed as 'non-fulfillment of a specified requirement' resulting in a nonconformance unless the management has committed to maintain a 'zero' accident status under any cost /circumstances.

If there are enough evidences of a system being in place

- to 'prevent' injury and ill health' of people at the workplace, and
- to analyze and investigate all accidents to determine the system deficiencies & taking actions to eliminate the root causes, why should an auditor raise a nonconformance for an issue which has already been investigated, reviewed & acted upon.

Secondly, unlike ISO 14001, OHSAS doesn't define the term 'prevention'. However, if it's taken to mean as 'avoidance' or 'an act of delaying', the intent of OHSAS is pretty clear:

This OHSAS Standard contains requirements that can be objectively audited; however it does not establish absolute requirements for OH&S performance beyond the commitments, in the OH&S policy, to comply with applicable legal requirements and with other requirements to which the organization subscribes, to the prevention of injury and ill health and to continual improvement. Thus, two organizations carrying out similar operations but having different OH&S performance can both conform to its requirements.
Nevertheless, I need to be guided if I have interpreted anything wrong in my posts, particularly in this thread.

Thanks,
 

Ajit Basrur

Staff member
Admin
#15
Nevertheless the accidents happen accidentally despite numerous controls and often the root causes are the ones that weren't either perceived beforehand or were beyond the control of the affected person and as such, it's very much difficult to establish the complete set of requirements against which the system could be evaluated.

Whether or not such events could be contentiously justified as nonconformances (per standard definition), the question is whether it is appropriate to equate accidents with other OHS nonconformances. If yes, how should I resolve the problem I'm currently confronted with ?
samsung,

The standards are written by people who brainstorm and think hard on the concepts; thus we blindly take it as a "shall". Therefore, much against your wish, it is a "standard" requirement that accidents are classified as non conformances and is thus equated and has to be done.

You raised another point on accidents happenning despite numerous controls - yes, these are the lessons learnt to prevent from happening in the future. IN NC, you should have adequate CA and PA. FMEA and other tools should be used as part of system designing to ensure accident-free environment.

From your posts, it looks like your organization is very averse to raising NC, is it ? If the standard mandates, it "shall" be done :)
 
S

samsung

#16
samsung,
Therefore, much against your wish, it is a "standard" requirement that accidents are classified as non conformances and is thus equated and has to be done.
Hi Ajit,

:nope: I respectfully propose to disagree to this statement since the current version of OHSAS:18001 neither prescribes such a 'requirement' nor does it indicate to have such an (implied) intention.

OHSAS doesn't establish any 'requirements' beyond

- the Policy commitments
- compliance with applicable Legal obligations &
- prevention of injury & ill health (only upto the extent of 'acceptable level', and how this level is determined, I have already explained in my previous post.

Ajit, only upto this point, if I have missed something, kindly point me to the relevant clause of OHSAS which says 'it has to be done'.

......CA and PA, FMEA and other tools should be used as part of system designing to ensure accident-free environment.
Yes, but 'as far as is reasonably practicable' (law says so, not me)

From your posts, it looks like your organization is very averse to raising NC, is it ?
No, we never think so. We always welcome the opportunity when valid NC's are raised and every time we request the CB team, during the opening meeting, to point to us as much issues as they can.

The reason why this issue got to surface was that our workers are of the opinion that 'incidents (accidents)' must be accorded a higher significance and one of the ways to attract the management's attention is to stop them being treated as mere NCs.
If the standard mandates, it "shall" be done.
Believe me, there's no other way provided the standard does so.
 
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S

samsung

#17
If you go with the definition of ISO, a Non Conformance is non-fulfillment of a requirement. In that context, for example, if a person handling the forklift in the warehouse doesnot follow the work instruction of stacking properly, accidents could not happen. In this case, this is a non fullfillment of requirement.
What if there are no Work Instructions ? There's no requirement that every activity has to have a Work instruction. My example - Someone plainly walks on the road inside the factory, suddenly feels giddiness, collides with another passerby, both fell down and sustain injuries. This is, by all means, an accident but I don't see, in order to justify a Nonconformance, a requirement that wasn't fulfilled. I just can't think of a 'work instruction' on how to walk on the road.

From your previous post:
I thought bad quality products arent planned either but we give NC to non conforming products, right In the same tone, all accidents, incidents and near misses are non conformances.
I request you to review the above analogy where it's not clear why and whom are you giving NC's ? Do you mean to say as an auditor you give NCs to someone who produces the bad product ? IMO, this is not the auditor's job to detect Nonconforming products. If he does that, who's going to audit the process ? It's the process owner who should be doing it and once a nonconforming product is detected, s/he needs to make sure that such a product is quarantined and Corrective Action is initiated to ensure that the problem doesn't recur.

The auditor, in case of NC products, has simply to determine whether a process exists to detect the Nonconfroming products and once detected, whether subsequent actions are taken as planned/ required /documented. In case s/he identifies any gaps, s/he has to recognize the problem as a Nonconfromance; not the NONCONFORMING PRODUCT per se.

Further, it's not reasonable to issue a nonconformance to a problem which has already been booked as a nonconformance. There was a long discussion sometimes back on the same point and, as I can remember, all the experts at the Cove were of the opinion that if a nonconformance is detected during, e.g., in an Internal Audit, the CB auditor, during the Surveillance/ registration audit, shouldn't issue a nonconformance to the same issue twice provided the previously detected problem is being acted upon as required.

I hope you get the point.
 
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Ajit Basrur

Staff member
Admin
#18
The giddiness has to be definitely investigated - if it is due to working environment, say a solvent plant with no proper ventilation or air handling unit, it shall be definitely categorized as an "accident".

You mentioned what if there are no Work Instructions - I mentioned it only because it became evident that your organization has a well defined quality and environemntal management system and would not have mentioned if it was not known to me.
 
S

samsung

#19
The giddiness has to be definitely investigated - if it is due to working environment, say a solvent plant with no proper ventilation or air handling unit, it shall be definitely categorized as an "accident".

You mentioned what if there are no Work Instructions - I mentioned it only because it became evident that your organization has a well defined quality and environemntal management system and would not have mentioned if it was not known to me.
Investigation of accidents is an altogether different issue and certainly this isn't what I questioned and discussed about. Investigations have to be done whether we call it an NC or an Incident or anything else. If an accident is not investigated, it is certainly a nonconformance but the question still is 'whether an accident, in itself, is a nonconformance' or should it be considered so ?.
 

Ajit Basrur

Staff member
Admin
#20
Investigation of accidents is an altogether different issue and certainly this isn't what I questioned and discussed about. Investigations have to be done whether we call it an NC or an Incident or anything else. If an accident is not investigated, it is certainly a nonconformance but the question still is 'whether an accident, in itself, is a nonconformance' or should it be considered so ?.
The reason why I wrote "investigated" was to find out if giddiness was caused by some illness "of his own", like low Blood Pressure and / or his personal illness or if it was caused improper working conditions due to lack of fresh air.

In this case, if it was due to improper working conditions (and going by all my previous replies on the related subject), I would say giddiness is an accident and is a non conformance as proper infrastructure was not being provided.

To summarize, I will categorize accidents as non conformance,
 
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