Safety Management
GUIDE FOR MAJOR HAZARD FACILITIES: SAFETY MANAGEMENT SYSTEMS
Safe Work Australia is an Australian Government
statutory agency established in 2009. Safe Work Australia consists of
representatives of the Commonwealth, state and territory governments, the
Australian Council of Trade Unions, the Australian Chamber of Commerce and
Industry and the Australian Industry Group.
Safe Work Australia works with the Commonwealth,
state and territory governments to improve work health and safety and workers’
compensation arrangements. Safe Work Australia is a national policy body, not a
regulator of work health and safety. The Commonwealth, states and territories
have responsibility for regulating and enforcing work health and safety laws in
their jurisdiction.
1 . INTRODUCTION
Under the WHS Regulations, operators of major
hazard facilities (MHFs) must establish and implement a Safety Management
System (SMS) that must be used as the primary means of ensuring the safe
operation of the MHF.
A SMS is a comprehensive and integrated system
for managing health and safety risks at a major hazard facility.
This Guide provides an overview of what a SMS
must contain to comply with the requirements of the WHS Regulations. It is not
intended to provide detailed guidance on how to set up a SMS for the first
time.
This guidance has been prepared for the operator
of a MHF who is responsible for preparing the safety case and coordinating the
necessary work prior to applying for a MHF licence or renewal. Most facilities
applying for a MHF licence will already have an established SMS. If you are in
this position, this guidance will help you identify any gaps between the
current SMS at your facility and the WHS Regulations.
However, some facilities may not have a
comprehensive SMS in place at the time of applying for a MHF licence e.g. where
an operator is applying for a MHF licence for the first time. If you are in
this position, the information in this Guide should be supplemented by reading
more comprehensive material on the subject to assist you in establishing a
compliant SMS. See Appendix C for a recommended list.
This Guide forms part of a set of guidance material for MHFs that
includes information on:
•
Notification and Determination
•
Safety Assessment
•
Developing a Safety Case Outline
•
Preparation of a Safety Case
• Safety Case: Demonstrating the Adequacy of
Safety Management and Control Measures
• Information, Training and Instruction for
Workers and Others at the Facility
•
Providing Information to the Community
•
Emergency Plans.
1.1 What do the
Regulations require?
The operator of a determined MHF must establish and implement a SMS for
the operation of the
MHF. The SMS must:
• be
comprehensive and integrated with respect to adopted control measures in
relation to the occurrence and potential occurrence of major incidents at a MHF
• be
implemented, so far as is reasonably practicable, and used as the primary means
of ensuring the safe operation of a MHF
• have sufficient focus on major incident safety
which includes planning and operations
• comply
with all of the requirements prescribed in regulation 558 and Schedule 17,
including that the SMS must be documented and readily accessible to persons who
use it
•
cover the whole facility defined within the
Safety Case
• be continually reviewed and revised so that the
SMS remains current and effective.
The SMS should not be a pure paperwork system;
rather it should reflect the overall safety culture and practical operation of
the facility, and should be consistent with the assessment of risk gained from
the Safety Assessment.
All persons
involved in the operation of a MHF should have knowledge of the SMS prepared
for the facility.
Further details of the requirements under the
WHS Regulations are set out in Appendix A and definitions of terms used in this
Guide are set out in Appendix B.
1.2 Components of a Safety
Management System
The main components of Safety Management Systems
correspond with the structural elements of a generic management system
specified in AS/NZS 4804:2001 – Occupational
health and safety management systems (see
Figure 1). Key components include:
•
establishing the context
•
commitment and policy
•
planning and prioritising
•
implementation
•
measurement and evaluation
•
review and improvement
2 . CONSIDERATIONS FOR DEVELOPING
A NEW SMS
This section provides an overview of the issues that should be
considered by new MHF operators.
2.1 Planning
When establishing a SMS for a MHF where a SMS
does not exist, matters that should be considered include the:
• information
required e.g. background understanding and explanation of what is needed for
those who will be involved in developing and implementing the SMS
• people to
be involved e.g. a mix of people and roles for the various stages of system
development and implementation
• allocation
of time for the various tasks involved. These timeframes should not be
underestimated
•
technique(s) to be used
• documentation of the development process, such
as consultation
•
documentation of outcomes such as safe work
procedures and worker training materials.
2.2 Establishing the SMS
The SMS of a determined MHF must provide a
comprehensive and integrated system for the management of all aspects of
controlling the risk of major incidents at the facility.
Establishing a SMS involves developing and
implementing SMS procedures. For most MHFs, this stage will also involve
considerable consultation. It is recommended that operators in this position
seek assistance from someone familiar with what is involved (such as
consultants) due to the large amount of work required at this stage.
There are some off-the-shelf SMS packages
available that may assist in developing a SMS. However, since these are often
generic, a certain amount of work is still usually required to tailor the
package to suit the particular MHF’s operations.
The hazard identification, safety assessment and
risk management required by regulations 554– 556 provides operators with a
clear understanding of what controls are needed to prevent major incidents
occurring at a facility, while regulation 559(2) requires all implemented
control measures to be adequately supported by the SMS so that they will
function effectively each and every time they are needed. The operator
therefore needs to check that each control measure in relation to major
incidents is adequately supported by relevant systems within the SMS. In
practice this is generally not as daunting as it may sound, since most control
measures are supported by a few common SMS elements. For example:
• The
reliability of all safety instrumented systems (SIS) is assured by a
maintenance and inspection program or critical function testing (CFT).
• The
reliability of procedural control measures is assured by including them in a
competency based training and assessment program (CBTA).
Some means of ensuring that systems work
together and that links between systems are not broken should be provided when
setting up a new SMS. Some operators do this by regular programmed reviews of
all documents within the SMS. Some operators with electronic document systems
ensure that links between documents are always maintained by providing hot
links between them.
Once the SMS procedures have been developed,
they then need to be implemented by people who have the appropriate skills and
knowledge. Training packages should be developed to explain the SMS and
delivered to all workers involved in implementing the SMS. The time and effort
involved in fully implementing the SMS should not be underestimated and you
should avoid delaying the development of the SMS.
3 . CONSIDERATIONS FOR
FACILITIES THAT ALREADY HAVE A SMS
Most determined MHFs may already have some form
of SMS in place at the time they first provide notification of the facility. In
general, the task of establishing a SMS that complies with the WHS Regulations
is an easier task for these facilities than for those developing a SMS for the
first time, as the task is primarily one of conducting a gap analysis between
their current SMS and the regulatory requirements and then making the necessary
revisions or additions.
Particular attention should be paid to the
requirements in Schedule 17 of the Regulations. It is also advisable to check:
• that
systems are actually implemented in practice and before the regulator conducts
any verification
•
that all
engineering and procedural controls are covered by the usual support systems,
including CFT and CBTA
• whether
emergency plans cover all potential major incidents identified in the safety
assessment.
4 . ESTABLISHING THE
CONTEXT
The first step in preparing the SMS is to evaluate
and understand both the internal and external environment that the MHF operates
in, as this can significantly influence the design of the SMS.
Evaluating the MHF's external context may include:
• the social
and cultural, political, legal, regulatory, financial, technological, economic,
natural and competitive environment, whether international, national, regional
or local.
• key drivers and trends having an impact on the
objectives of the organisation
•
relationships with, and values of, external
stakeholders.
Evaluating the MHF's internal context may include:
• governance, organisational structure, roles and
accountabilities
• policies and objectives, and the strategies that
are in place to achieve them
• capabilities,
understood in terms of resources and knowledge (e.g. capital, time, people,
processes, systems and technologies)
• information
systems, information flows and decision-making processes (both formal and
informal)
•
relationships with, and values of, internal
stakeholders
•
the MHF's culture
•
standards, guidelines and models adopted by the
MHF
•
the form and extent of contractual
relationships.
4.1 Elements of the SMS
Establishing the context will lead to the SMS
including a number of elements that address the following:
• higher level system needs including policies, objectives and structures to
achieve those objectives
• day-to-day safe operation including operating procedures, work permitting
and maintenance management
• longer term safety of the facility including risk management,
emergency planning, asset integrity
management and management of change
•personnel-related systems including recruitment, worker induction and
training, consultation, contractor
selection, and management and training
•the effectiveness of the SMS including
performance monitoring, auditing, incident investigation and continuous
improvement
• administrative procedures such as
document control.
Different operators have different ways of
organising these elements. For example, asset integrity management is treated
by different operators as a part of the maintenance management system, an
aspect of the risk management system or a stand-alone system. Depending on the
complexity of the operations at a facility and the way elements are grouped, a
SMS may vary from 12 to 30 principal elements and may include an array of
underlying sub-systems, documents, procedures and forms.
Table 1 details a list of common elements that
are likely to be present at most MHFs. In many cases the structure of the SMS
is influenced by the practices of the broader organisation relevant to the MHF.
5 . COMMITMENT AND POLICY
The operator of a MHF should define its safety
policy and ensure commitment to its SMS. While often generic, the safety policy
and the organisational commitment to achieving it set out the framework for the
SMS and how it will be followed at the MHF.
5.1 Safety policy and
safety objectives
A health and safety policy that sets out a high
level statement detailing the operator’s broad aims for the safe operation of
the facility should be created. Policy statements, or Charters in some cases,
are usually expressed in general terms (see Example 1 below). The policy is
intended to inform all stakeholders, including workers and others, that safety
is an important part of all operations and should be reinforced through periodic
review and involvement of management.
The policy objectives should be as specific as
possible and quantified where possible, as it is easier to measure performance
against clear and quantified objectives.
5.2 Commitment
A MHF’s success at fulfilling its safety policy
and achieving its safety objectives is usually proportional to the organization’s
commitment to achieving those goals amidst all the other goals competing for
its attention, and hence the importance of clear commitment to those safety
objectives starting at senior management level.
Regular review of safety performance and
performance against the safety objectives at management level reinforces the
importance of safety to the organisation’s success. While management are
required to demonstrate commitment through their actions and involvement, all
workers need to be involved for the system to be fully functional and
integrated. Everyone at the facility should be aware of the influence that
their action or inaction may have on the effectiveness of the system.
5.3 Planning
The ‘planning’ stage of safety management is the
work performed to define the scope, boundaries and performance objectives of
specific SMS components. Many MHFs achieve this by setting standards for
various SMS elements. These standards are different to the performance
standards specified in Schedule 17. For example, one of the ways a MHF can achieve
its policy objective of “providing a safe
work place and safe systems of work” is to have an effective Work Permit
system.
System
standards are often specified by the parent business or undertaking of many MHF
operators. The local MHF operator then has the simpler task of developing a
specific local procedure or work instruction in some cases that meets the
requirements of the standard and the requirements of the WHS Regulations.
Some other aspects of the SMS that could be
considered during planning are:
• emergency planning, including the development of
pre-incident plans
• development
of engineering standards for application in particular services throughout the
facility and pre-emptive risk studies.
6 . IMPLEMENTATION
The implementation part of the SMS is the group
of elements directly involved in the day-to-day operation of the facility.
Examples include:
•
operating procedures
•
maintenance procedures
•
direct work management, including work permits
•
emergency exercise programs
•
asset integrity programs
•
contractor management and the CBTA systems.
For the purposes of this Guide, this section is
divided into the headings for sub-sections in Schedule 17.
6.1 Organisation and
personnel
The WHS Regulations require all SMSs to contain
systems that ensure the facility has people with appropriate responsibilities
and necessary skills to implement the procedures and other activities contained
in the SMS.
The SMS must also define the roles and
responsibilities of individuals to ensure the safe operation of the facility,
and the overall means of ensuring they have the necessary knowledge and skills
to enable them to perform their allocated tasks and discharge their allocated
responsibilities.
Typically these systems could include role
statements for all positions of responsibility, a system for defining the
skills necessary for all positions (e.g. skills matrix), a training management
system complete with specific training modules, and a record keeping system
that keeps track of skills gaps and the need for refresher training and
upgrades (see Example 3).
There are a number of other personnel and human
factor issues that could impact on safe operation. MHFs may decide to include
systems that address these factors as part of their SMS, for example:
•
management of knowledge
•
competency assurance
•
staff turnover
•
changes in skills or knowledge
•
clarity of command structures and
responsibilities
•
handling workloads
•
fatigue and shift work
•
communications
•
handling disputes.
6.2 Operational controls
The operational controls required by the WHS
Regulations include all processes and procedures impacting directly on safe
operation of plant. For most MHFs, this group of elements is likely to make up
the majority of the SMS.
Operational controls likely to be of particular
importance to MHFs are the processes and procedures for:
•
operating plant and equipment
•
maintaining the integrity of that equipment
•
permitting work
•
starting up plant or commissioning
•
shutting down plant or de-commissioning
•
achieving safe isolation of equipment
•
controlling abnormal conditions
• identifying, handling, and reducing or
eliminating human error, including procedural checks
•
error reporting
•
alarm handling procedures
• fault-tolerant procedures and processes for
improving compliance with procedures.
6.3 Duties of operators
The SMS must include a description of the
policies and procedures that the operator proposes to use to comply with the
WHS Act and the following:
• Division 3
of Part 9.3 of the WHS Regulations (Duties of operators of determined MHFs –
Management of risk)
• Part 9.4 of the WHS Regulations (Licensed MHFs –
Risk management)
• Part 9.5 of the WHS Regulations (Consultation
and Workers’ Safety role).
Although not specified in the regulations, MHFs
may also choose to extend the SMS component to check and ensure compliance with
other relevant obligations under the Regulations, such as Chapter 7 – Hazardous
Chemicals.
The documented procedures and other SMS
components that are relied upon to meet obligations under Chapter 9 of the
Regulations must be clearly identified with an annotation or cross-reference
identifying the specific provision being complied with.
6.4 Management of change
The SMS must contain formal procedures for
planning and managing ‘modifications’ (as defined in Appendix B) at the
facility. These are commonly referred to as ‘Management of Change’ (MoC)
process. This is an essential element of a robust and comprehensive SMS, as
changes can introduce new major hazards or potential major incidents and can
increase the risk arising from existing hazards. There should also be effective
management of all changes in the facility including operational,
organisational, procedural and equipment changes.
Regulations 559 and 569 require the safety
assessment, emergency plan and safety management system to be reviewed, and if
necessary revised. The MoC procedure should ensure that these reviews will
happen every time a relevant change is proposed.
The MoC process at most MHFs manages more than
the health and safety concerns of a proposed change.
The MoC system should at least:
• define the
type of change to which it applies. For many MHFs, the system applies to
anything other than ‘like for like’ replacement
• require
consultation with all workers or their representatives likely to be affected by
the change
• ensure
that the proposal for change is reviewed for all health and safety implications
by people sufficiently knowledgeable to make informed judgments in their areas
of expertise, such as operations or maintenance
• ensure that the proposal is reviewed and
approved before it is implemented
• ensure
that necessary follow-up activities arising from the change are completed in
time, for example updating drawings, equipment registers, procedures, training
modules, etc.
6.5 Design principles and
standards
The SMS must contain an element that documents
the design principles and engineering standards that the operator is relying on
to ensure safe operation of the facility. Since most standards change over
time, the system needs some means of ensuring that it is kept up-to-date.
‘Design principles’ can take many forms and may
include technical, engineering or management principles developed or applied by
the operator. Examples include:
•
principles for the management of human factors
• standards for development or implementation of
operating procedures
•
design principles for control rooms and alarm
systems
•
engineering design standards
•
fire protection standards
•
maintenance standards
•
‘layers of protection’
•
process control systems.
These are often captured in Basis of Design
documents for new facilities, but may be harder to collect and document for
older facilities. They should be consistent with the approach to risk reduction
and safety management in the facility’s Safety Case.
The specification of engineering standards
should be more detailed than a simple generic statement such as “Flammable
liquids storage facilities conform to AS 1940”. Many MHFs use corporate-wide
engineering standards which can include quite specific details, for example
what type of valves are permitted or preferred in certain services, when
certain types of level gauges are permitted, mandated or forbidden, and rules
for setting alarm set points for various services.
7 . MEASUREMENT AND
EVALUATION
The next SMS elements of the continuous
improvement cycle are those involved with measurement and evaluation. It is
through measurement and evaluation that the MHF operator knows what elements of
the SMS elements are effective.
The two main aspects of this element are:
• measuring or monitoring the performance of
specific aspects of the SMS
• evaluating
or judging if the performance is sufficient to achieve the function that the
system or control is intended to achieve.
Clause 7 of Schedule 17 of the WHS Regulations
makes mandatory a number of requirements for performance monitoring at a MHF.
Clause 8 of Schedule 17 also requires auditing of SMS performance against the
performance standards set by the operator.
7.1 Performance monitoring
The operator must have a system in place for
monitoring the performance of both SMS elements and control measures.
This involves developing:
• performance
standards that are sufficiently detailed for measuring the effectiveness of all
aspects of the SMS
• performance
indicators for measuring the effectiveness of control measures, including
indicators of the failure of any control measure.
In setting performance standards operators should consider the following
questions:
• How will I know that this particular SMS system
is working effectively?
• Alternatively, what will tell me that the system
is not working?
As an example, almost all MHFs have a formal
incident investigation system within their SMS. A common performance measure
for the system is the length of time taken to fully complete an investigation,
and may have a performance standard of ‘No outstanding incident investigations
> X days’, where X is based on some historical evidence of how long an
incident investigation should take. While this is a useful measure for showing
if the investigation system exists, it gives no indication of how good the
investigations are, or whether they are effective in achieving their purpose or
identifying direct and underlying causes of incidents so that action can be
taken to prevent similar occurrences in the future. A more meaningful
performance measure might result from an independent review of the
investigation and a rating given for causes being identified and relevant
follow-up action items being developed.
Similar thinking is required for developing
performance indicators for control measures with appropriate targets. Since
control measures tend to be more concrete when compared with SMS elements,
assigning performance indicators for control measures may be an easier task
than assigning performance standards. It is possible that indicators may be for
a group of controls rather than an individual control. However, it is also
possible that more than one may be required for a particular control.
Performance indicators should be defined for all
control measures, which enable the MHF operator to measure, monitor or test the
effectiveness or failure of each control measure. However, it is not necessary
to define a separate indicator for each and every control measure individually
i.e. it is possible to define an indicator for a group of control measures.
Pressure safety valves (PSVs) are an example of such a group (see Example 4).
It may also be necessary to define more than one indicator for a control
measure or group of control measures. The operator should also determine the
method for reporting performance against these indicators and corrective
actions to be taken in the event of failure of controls and in the event of the
indicators not meeting performance targets.
Performance
indicators should measure the performance of control measures and also how well
the management system is monitoring and maintaining them. Performance
indicators for control measures therefore overlap with the performance
standards required for the SMS. Some performance standards for engineered
control measures may be adopted from manufacturer's recommendations. However,
operators should determine if these are appropriate to the specific conditions
of their facility. Performance indicators take many forms and can be
quantitatively or qualitatively expressed. In practice, having an effective
maintenance system such as a system for testing critical functions is the only
practical way to monitor performance of individual control measures.
7.2 Audit
Auditing is the most commonly used means for
operators to check the performance of SMS elements against their performance
standards. The SMS of a MHF must include a system for managing these audits
(e.g. qualifying auditors, scheduling, documenting results and tracking
recommendations).
Auditing should look at both implementation and
functionality of the systems, that is:
• Does the MHF have a system that meets the
required standard?
• Does the MHF follow its own system procedures
and are they effective?
Persons unfamiliar with auditing should refer to
a recognised standard such as AS4801 or SafetyMAP (see reference section at
Appendix C).
8 . REVIEW AND IMPROVEMENT
The SMS should include some means for the
operator to formally review SMS performance and develop improvements based on
the results of the review. There are many different ways to review safety
performance, but it often consists of reviews by the management committee with
health and safety representatives and often assisted by technical specialists.
The review committee is likely to examine data
from the operator’s performance monitoring system on a regular basis. Some
performance indicators may be activity measures and some should be
effectiveness measures. The review should identify any gaps, consider what
factors might be causing or contributing to those gaps and assign follow-up
action items to close any gaps.
If an activity measure shows that a particular
system is not being used in the required situations, review by management
should consider why that would be happening. For example:
•
Are people unaware the system is required in
those situations?
•
Is the system too cumbersome?
•
Are human factors involved?
The actions needed to improve performance may be
quite different if effectiveness measures are found to be deficient. For
example, if the data showed that the system was being used but incorrectly or
that the safety matters that system was meant to manage were breaking down
despite personnel using the system as specified, the system may need to be
revised.
The safety review system may also include other
matters to generate improvements, including incidents at similar facilities in
Australia or overseas, or new and emerging issues that may be relevant to the
facility’s operation.
The system should also provide a means of prioritizing
action items and improvements, with higher priority being given to higher risk
issues. Progress on action items should be formally tracked.
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