SOP: Incident Investigation

1.0 GENERAL 
Scope:

• Compliance to clause  4.5.3.1 of OHSAS18001: Incident Investigation
• Subject for compliance to the following laws
• Occupational Safety And Health (Notification Of Accident,Dangerous Occurrence, Occupational Poisoning And Occupational Disease)Regulations 2004; Regulation 5. Notification and reporting of accident and dangerous occurrence or NADOPOD Regulation
• Guidelines on Safety and Health (Notification of Accident,Dangerous Occurrence, Occupational Poisoning and Occupational Disease)Regulations 2004 or NADOPOD Guidelines
• Occupational Safety and Health (Safety and Health Committee)Regulations 1996; Regulation 13. Investigation into any accident, etc.
• Applied to all activity and operational running at <name of organization>

2.0 DEFINITION 

• Ill health: identifiable, adverse physical or mental condition arising from and/or made worse by a work activity and/or work-related situation these (OHSAS 18001:2007, Clause 3.8
• incident: work-related event(s) in which an injury or ill health (3.8) (regardless of severity) or fatality occurred, or could have occurred (OHSAS 18001:2007, Clause 3.9)
• DOSH: Department of Occupational Safety and Health, Malaysia
• OHD: DOSH registered medical practitioner
• NADOPOD: Occupational Safety and Health (Notification of Accident, Dangerous Occurrence,, Occupational Poisoning and Occupational Disease) Regulation 2004
• Serious Injury: Serious bodily injury, as specified in First Schedule under NADOPOD Regulation, which prevents the person from following his normal occupation for more than four calendar days (As specified in Reg. 5, NADOPOD)
• Minor Injury: Whenever any accident arising out of or in connection with work which causes bodily injury to any person which prevents the person from following his normal occupation for more than four calendar days. (As specified in Reg. 5, NADOPOD)
• Poisonous: A suffer from one of the occupational poisonings or occupational diseases specified in column 1 of Third Schedule under NADOPOD Regulation and the work involves one of the activities specified in the corresponding entry in column 2 of that schedule. (As specified in Reg. 7, NADOPOD)
• Property Damage: where a dangerous occurrence, as specified in Second Schedule under NADOPOD Regulation. (As specified in Reg. 5, NADOPOD)
• First aid case: Whenever any accident arising out of or in connection with work which causes bodily injury to any person which prevents the person from following his normal occupation for not more than four calendar days.
• Property: A property of company with in the physical form of machinery, transporting and electronically lifting medium or any permitted, licensed and approved machine defined in section 3 of FMA or equivalent facility defined in OSHA 94.  

3.0 RESPONSIBILITY AND AUTHORITY

Safety Manager:

• Responsibility: <define the function>
• Accountability:<define the function>
• Authority: <define the function>

OSHMR:

• Responsibility: <define the function>
• Accountability: <define the function>
• Authority: <define the function>

SHO

• Responsibility <define the function>
• Accountability <define the function>
• Authority <define the function>

4.0 CONTROL PROCEDURE 

• Action for incident is depending on severity of the accident as following accident description and action necessary;
• Accident description: Death
• Action:
• Immediately to contact Ambulance or lodge a Police report or/and other necessary mitigation in obligatory of laws;
• Immediately notify DOSH
• Corrective measures ations per SOP: Nonconformity, corrective action and preventiveaction.
• Within 7 days send a report (JKKP 6) thereof in an approved form to DOSH
• Discuss and review the measures during safety meeting.
• Reported in JKKP 8 Form for annual submission to DOSH
• Accident description: Serious Injury
• Action:
• Immediately to contact Ambulance or send victim to hospital, lodge a Police report or/and other necessary mitigation in obligatory of laws;
• Immediately notify DOSH
• Corrective measures as per SOP: Nonconformity, corrective action and preventive action.
• Within 7 days send a report (JKKP 6) thereof in an approved form to DOSH
• Discuss and review the measures during safety meeting.
• Reported in JKKP 8 Form for annual submission to DOSH
• Accident description: Minor Injury
• Action:
• Immediately to contact Ambulance, or send victim to hospital or/and other necessary mitigation in obligatory of laws;
• Corrective measures as per SOP: Nonconformity, corrective action and preventive action.
• Within 7 days, send a report (JKKP 6) thereof in an approved form to the Department of Occupational Safety and Health office to DOSH
• Discuss and review the measures during safety meeting.
• Reported in JKKP 8 Form for annual submission to DOSH
• Accident description: Poisonous
• Action:
• Corrective measures as per SOP: Nonconformity, corrective actionand preventive action.
• Within 7 days send a report (JKKP 6) thereof in an approved form to DOSH - Notify OHD or medical officer and reporting to DOSH within 7 days.
• Discuss and review the measures during safety meeting.
• Reported in JKKP 8 Form for annual submission to DOSH
• Accident description: First Aid Case
• Action:
• Corrective measures as per SOP: Nonconformity, corrective action and preventive action.
• Discuss and review the measures during safety meeting
• Accident description: Near Miss
• Action:
• Corrective measures as per SOP: Nonconformity, corrective action and preventive action.
• Discuss and review the measures during safety meeting
• Accident description: Property Damage
• Action:
• Immediately notify DOSH
• Corrective measures as per SOP: Nonconformity, corrective actionand preventive action.
• Within 7 days send a report (JKKP 6) thereof in an approved form.;
• 
  

5.0 CROSSED REFERRENCE SECTION

• SOP: Nonconformity, Corrective Action and Preventive Action

6.0 RECORDS

• JKKP 6
• JKKP 8
• CAR

SOP: Control of Records

1.0 GENERAL
 

Scope:

• Compliance to clause  4.5.4 of OHSAS 18001: Control of Records
• Applied to all activity and operational running at <name of organization>

2.0 DEFINITION 

• Record: Document stating results achieved or providing evidence of activities performed (refer to section 3.20 of OHSAS 18001 Standard Requirement)

3.0 RESPONSIBILITY AND AUTHORITY

Safety Manager:

• Responsibility: <define the function>
• Accountability: <define the function>
• Authority: <define the function>

OSHMR:

• Responsibility: <define the function>
• Accountability <define the function>
• Authority: <define the function>

SHO

• Responsibility <define the function>
• Accountability <define the function>
• Authority <define the function>

4.0 CONTROL PROCEDURE 

• Identification and traceability
• All records shall be filed in sequence and/or dated to allow easy identification and retrieval.
• Unique identification is generated as described in SOP: Control of Documents
• MR shall be responsible to maintain the List of Records. If any changes to the list of their records, the list shall be updated accordingly.
• Records should be kept at the designated location to ensure the traceability and person in charge is defined.
• Storage, protection and retention
• All records shall be stored and maintained and retrievable by the respective department.
• Records shall be stored in hard copy and/or soft copy as appropriate. For non-critical records, storage in normal file cabinet is sufficient. For critical records, if any, the records shall be protected from potential fire, theft, unauthorized removal and other damage.
• Also, critical records on electronic media shall be secured from inadvertent deletion, computer viruses and corruption of files; hard copies shall be produced and kept at a different location / area.
• Records on soft copy shall be backed-up and back-up records shall be protected accordingly from damage or loss.
• All records shall be retained for a minimum period as specified in the List of Records. Each Head of Department shall be responsible to establish the retention period.
• Retrieval and Disposal
• All records shall be made available for inspection by management or as requested by the interested parties.
• The records shall be stored in such a way that they are readily retrievable for review. For any request for records by external parties.
• Records only can be disposed once obtained approval from MR.
• Records shall be disposed off by any suitable means.  Confidential records shall be disposed off by shredding
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5.0 CROSSED REFERRENCE SECTION

• SOP: Control of Documents

6.0 RECORDS

• List of Records

SOP: Control of Documents

1.0 GENERAL
 

Scope:

• Compliance to clause  4.4.5 of OHSAS 18001: Control of Document
• Applied to all activity and operational running at <name of organization>

2.0 DEFINITION 

• Document: information and its supporting medium (refer to section 3.5 of this standard)
• SOP: A Standard Operating Procedure. A document specified a way to carry out an activity or a process (refer to section 3.19 of this standard).
• WI: A Work Instruction. A document specified an extent requirement addressed in SOP: Operational Control. It is another way to carry out an activity or a process (refer to section 3.19 of this standard).
• DCN: Document used to propose a new creation of document or needs of document revision for controlled document.
• Controlled Document: All document listed in the Document Master List

3.0 RESPONSIBILITY AND AUTHORITY

Safety Manager:

• Responsibility: <define the function>
• Authority: <define the function>

OSHMR:

• Responsibility: <define the function>
• Authority: <define the function>

SHO

• Responsibility
• Authority

4.0 CONTROL PROCEDURE 

• New Document
• Any new document proposal must use DCN.
• It is however the use of DCN only applicable after the OHSMS has been fully implemented.
• Any new proposal of document other than OH&S Manual, Procedure and Work Instruction, no DCN issued but QMR need to state evidence of document being reviewed and approval. (Need to confirm the applicability)
• DCN after filled-in by initiator and submit to MR for review. MR has to review the DCN. Generate a unique reference number if the proposal is accepted.
• DCN to be forwarded to <MD> for approval.
• Issue to the respective section.
• Revision history is placed in the front page of Quality Manual and Procedures to track the changes record.
• Generation of document numbering.
• The Quality Manual is to be numbered as follows;  SM – 001.
• The OH&S System procedures are to be numbered as follows: - SOP  - Sequential Number (001-999).
• The Work Instruction are to be numbered as follows: WI  - Sequential Number (001-999).
• The form type code shall be as follows; FM – Sequential Number (001-999)
• The flow chart or flow process type code shall be as follows; FC – Sequential Number (001-999).
• The other type of document than above the code shall be as follows; DOC – Sequential Number (001-999)
• If there any document without the document number, the document is classified as an old document generated before the establishment of company QMS. The QMR will decide the generation of numbering depends on it impact to QMS implementation.
• Revise Document
• Any proposal of revision to the existing document must use DCN.
• Any proposal of changes the existing document other than Quality Manual and Procedure, no DCN issued but need to be reviewed and approved by the MR.
• The DCN need to be filled-up by issuer and submit to MR for review.
• MR has to review the DCN. Generate a revision number based from running order if the changes are accepted.
• DCN to be forwarded to <MD> for approval.
• If use of DCN is not applicable, old version of document need to be cleared first before use of revised document. Where applicable, MR has authorized to stop usage of old document if reflected to the document control conformity.
• Additional control required for revision of OH&S Manual and procedure;
• Changed item will over write the old version of document.
• Integrity of document
• Master Copy shall be in PDF file and stored in <web-based system>.
• Copy of document is allowed but shall obtain approval from MR before issuance.
• Original soft copy only kept by the MR for reference or to be used upon requires for changed.
• Maintenance of soft copy should be in appropriate manner and back-up system should be activated.
• If requires an extra hard copy, MR will justify the method of distribution and <DRL> will be update
• Distributed copies shall be indicated with CONTROLLED in red on the first page of Revision History. MASTER indication shall be remained but font to be set in black color.
• Distribution of document should be completed by filling the <DRL>.
• Any content printed onto hard copy format will be deemed 'uncontrolled' & will not maintained as part of the OH&S management system.
• Control of External Document
• External document can be described as any document originated by the external parties which may reflected to the product conformity and/or QMS implementation effectiveness.
• Following is the list of external document kept by company;
• Document A
• Document B
• Document C
• Document D
• Control of the external document shall be in accordance to Integrity of Document subject.
• Control of Obsolete Document
• After approval process of DCN is completed or any existing document is no longer to be used, the superseded document should be returned to <MR> to prevent unintended of use.
• No obsolete copy is applicable for Master Copy of OH&S Manual and SOP as changes being made is done through over-writing the valid document.
• Obsolete document should be crossed and can be used as a recycled paper.
• Master copy of obsolete document (if applicable) can be retained as for reference and indicated by OBSOLETE at each pages for identification.
• The soft copy of obsolete document must be kept by MR only, if necessary.
• Document should remain legible and readily identifiable.
• All documents must be readable and given the clear direction in meeting the intent of its establishment.
• No any duplication of document prior approval as procedure is described for new creation document and amendment of document as above.
• Any establishment or re-establishment of document which are not following with procedure for document creation or revision of document process, the document is consider invalid.
• If distributed document found damaged or unable to be read due to circumstances, <process owner> should ask <document controller > to provide new legible document. jihiuhui
• Maintenance of document
• MR shall ensure the controlled document shall be preserved though periodical backup process.  
  

5.0 CROSSED REFERRENCE SECTION

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6.0 RECORDS

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SOP: Legal and Other Requirements and Evaluation of Compliance

1.0 GENERAL
 

Scope:

• Compliance to clause  4.3.2 of OHSAS 18001: Legal and Other Requirement and 4.5.2 of OHSAS 18001: Evaluation of Compliance
• Applied to all activity and operational running at <name of organization>

2.0 DEFINITION 

• OSHA: Occupational Safety and Health Act 1994
• FMA: Factory and Machinery Act 1967
• UBBL: Uniform Building Bi-Law 1984
• FSA: Fire Service Act 1988
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3.0 RESPONSIBILITY AND AUTHORITY

Safety Manager:

• Responsibility: <define the function>
• Accountability: <define the function>
• Authority: <define the function>

OSHMR:

• Responsibility: <define the function>
• Accountability: <define the function>
• Authority: <define the function>

SHO

• Responsibility
• Accountability: <define the function>
• Authority

4.0 CONTROL PROCEDURE

• Identification and accessibility of applicable legal and other requirements related to occupational safety and health can be defined as following inputs;
• Name of Laws; OSHA, FMA, UBBL and FMA (Laws subject are inclusively covered Act and it regulations)
• Accessibility: JKKP website at http://www.dosh.gov.my/ (browse at legislation button) or any relevant Law Book, where the latest version is available.
• <Who> is responsible to ensure the all relevant applicable legal and other requirement to be logged in the Legal Register and Compliance Evaluation.
• Obtain OH&S-related licenses, permits and approval as required.
• <who> has to ensure to obtain OH&S-related licenses, approvals and permits for the respective facilities / assets.
• All document shall meet the condition of licenses, permits and approval including specification, expiry, limitation etc. Ensure timely renewal of licenses, permits and approval.
• Record all particular of licenses, permits and approval in the <name of document> for monitoring, control and traceability purpose.
• Monitoring of compliance process shall follow as per SOP: Performance Measurement and Monitoring
• Track changes to OH&S legal and other requirements.
• If there any change in OH&S Legal and other requirement, Legal Register and Compliance Evaluation will be updated accordingly.
• Any updates, information of changed shall communicate to all concerned as follow SOP: Communication, participation and consultation requirement.
• MR has to ensure that person in charge are aware on the requirement based from cross checking process as defined in the Communication Matrix.
• Identification of change also taking a consideration of OHSAS 18001 standard requirement.
• Revision of document process shall follow SOP: Control of Document.
• To ensure up-to-datedness, MR shall confirm the latest regulation/other requirement by half yearly basis or latest before evaluation of compliance process.
• Evaluation of compliance.
• Evaluation of compliance for legal and other requirement shall be conducted at least once a year to ensure fulfillment of requirement is maintained.
• Those requirements was justified as not-complied, action need to be taken and where appropriate, measures should follow SOP: Nonconformity, corrective action and preventive action.
• To keep the result of periodical evaluation of compliance in accordance to List of Record.
• Review the result of compliance evaluation to done during management review to ensure effectiveness of its implementation.

5.0 CROSSED REFERRENCE SECTION

• SOP: Control of Documents
• SOP: Communication, Participation and Consultation
• SOP: Nonconformity, Corrective and Preventive Action
• OH&S Manual: Management Review

6.0 RECORDS

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