Documenting Safety Program Requirements

In both general industry and construction, the Occupational Safety and Health Administration (OSHA) regulates development and maintenance of company health and safety programs


In both general industry and construction, the Occupational Safety and Health Administration (OSHA) regulates development and maintenance of company health and safety programs. Accordingly, two basic divisions in a documented safety and health program might well comprise OSHA requirements and company-specific protocol.

Many companies distinguish policies and procedures within safety programs, or treat them separately, though such terms commonly are used interchangeably. To further complicate the issue, some progressive companies Û trying (admirably) to incorporate safety procedures within work routines Û may create greater confusion, as steps articulated in cumbersome, regulatory-compliance language are woven into the work process. Regulatory requirements are so lengthy that developing concise, safe work procedures for everyday use becomes difficult. Necessary documentation, involving extensive regulatory jargon, discourages most plant personnel from even the attempt.

Among worthy policies and programs that are not OSHA-driven and may serve as a basis for documented requirements are Department of Transportation fleet-safety guidelines targeting driver selection, as well as drug and alcohol testing. Additionally, the Americans with Disabilities Act stipulates employment mechanisms to ensure accommodation of physical needs. Moreover, essential nonsafety-related procedures, incorporated via overall safety program, an environmental plan, or other administrative arrangement, include Environmental Protection Agency programs, such as the Community Right to Know, storm water management, and certified spill-control/prevention plans. Introducing quality procedures in written work protocols can further complicate documentation.

To clarify confusion, separate sections can be designated within a company manual to distinguish (I) Compliance Programs, maintained separately from (II) Company Programs. Whether referred to as policies, procedures, programs, or processes, while respecting the particular meaning of each term, company guidelines can be documented with regulatory requirements in a single binder or binder series, using a tab system or other designation for separation. Such a division facilitates writing a company program by simply referencing applicable safety regulations.

A secondary advantage of the division is that the regulatory-compliance section or manual can be audited separately by a third party. Thus, it can be presented to the OSHA inspector without providing access to additional company documents that could trigger unnecessary faultfinding.

OSHA safety requirements ultimately reduce employer flexibility in designing unique, experimental, or otherwise revolutionary work systems to improve safety and minimize incidents. At the base of incident causation is a complicated tangle of management commitment (stated versus actual), plant safety culture, supervisory styles, budgetary restrictions, seasonal and cyclical production fluctuations, personality traits, availability of qualified workers, hiring procedures, training effectiveness, employees’ personal matters, work environment, vindication and fraud, employee ownership, behavioral systems, plant design/process flow, and physical equipment. Since regulated safety programs fail to address the plethora of problems, they are not likely to resolve the incident-rate dilemma. Government regulation simply cannot force resolution of all such issues.

Nevertheless, OSHA attempts to make the industry care and do the right thing, even though Îthe right thing to doÌ is unclear in view of incident-reduction results. In the Federal Register of January 26, 1989, OSHA issued Safety and Health Program Management Guidelines; Issuance of Voluntary Guidelines; Notice. Subsequently, in a 1996 notice of OSHA’s Proposed Safety and Health Program Standard, voluntary guidelines Û though never actually passed Û were revised to include the following provisions (see sidebar below):

Another set of OSHA guidelines, detailed in the OSHA Voluntary Protection Program (VPP) and mandatory for companies enrolling in the program, include slightly different criteria than those referenced earlier. Companies intending to implement VPP are subject to OSHA review before VPP status can be approved.

Focusing on mandatory compliance programs would require consideration first of OSHA 29 CFR 1910 general industry and/or 29 CFR 1926 construction guidelines, as appropriate. While some of these programs do not specifically require a written record, the lack of appropriate documentation may lead to an employer’s citation for noncompliance. These programs typically include the following:

  • Management commitment or policy statement
  • Hazards assessment (periodic physical and health hazards evaluations) and company safety inspections
  • Provisions for medical care and access to medical records
  • Training programs including orientation, safety meetings, and specific topics
  • Hearing conservation
  • Confined space entry
  • Fall protection (construction)
  • Lockout/tagout
  • First aid and treatment for blood-borne pathogens
  • Emergency and fire-prevention plans
  • Personal protective equipment (per hazards assessment)
  • Hazard communication
  • Machine safeguarding
  • Site safety plan (construction)
  • Other topics frequently covered in compliance manuals, though not specifically required in written form, include special-emphasis programs, compressed gas use, welding and cutting, material handling, and use of electrical equipment, ladders, scaffolds, and forklifts.

Depending on the employer’s operations, additional subjects may be appropriate for the company safety manual in a section (or binder) separate from compliance documents. Such topics include hiring practices, behavioral programs, employee participation, safety-incentive bonus programs and promotions, reference documents, incident reporting and worker’s compensation procedures, document retention guidelines, work practices or procedures, OSHA inspections policy, handling of fatal or major incidents, press relations, ISO standards, bulletin boards and posters, and company program of the day.

Special-emphasis programs identified in the preceding list often are ascertained by the employer through osmosis or monitoring of the OSHA website, since they may not be announced as specific regulations. They are pseudo-regulatory, although enforcement can be effected via the general duty clause. Typically, such special-emphasis programs will embellish an existing regulation: one example is the silicosis program, occasionally spotlighted at OSHA regional offices for enforcement via industrial hygiene dust monitoring. OSHA also may ask to see a training program, though training is not specifically required in any single regulation; however, specific training is required for regulated areas such as HazCom, confined space entry, and lockout/tagout.


Management leadership

  • Clearly defined responsibilities for health, safety
  • Provisions for supervisors and employee authority, access to relevant information, training and other resources
  • Designation of at least one management person to receive reports about work-site safety and health conditions needing attention

Employee participation

  • Ongoing, effective communications with employees regarding occupational safety and health matters
  • Employee participation in assessing and controlling hazards, investigating incidents, developing safe and healthful work practices, training, and evaluating the safety and health program
  • A mechanism for employees to report injuries, illnesses, and hazards, as well as submit recommendations regarding hazards, plus provisions for prompt employer responses to these reports and recommendations
  • Provisions to prevent employer discrimination or reprisals against employees for participation

Hazard assessment

  • Implement a system to identify OSHA-regulated and other hazards, which would include inspections, review of safety and health information, accident and incident investigations, and a process to evaluate the seriousness of non-OSHA-regulated hazards
  • Conduct work-site hazard assessments

Hazard control

Control identified hazards

Information and training

Provide prescribed employee safety training, which would include training prior to beginning work, frequent training, and training for newly identified hazards, plus similar training or certifications for existing employees.


Not yet clearly defined Û may be left up to the employer

Multi-employer work sites

  • Provisions for host employer responsibilities via contract
  • Provisions for contract-employer responsibilities

Program evaluation

Employers must periodically evaluate their work-site safety and health plans to assure appropriateness, compliance with the standard, and its effectiveness