PRINCIPLES OF SAFETY AUDITING
ALLEN CLARK
Audit. Just hearing that word can strike terror in the hearts and minds of many. What is an audit? Most people associate the term with the dreaded Internal Revenue Service audit. Yet, the majority have never experienced such an audit. An audit is an in-depth look at an item or a program using criteria established for that purpose. In this case, the audit is of a fire department`s health and safety program (HSP).
What function does the audit serve? Used properly, it can help to evaluate and target problem areas in the HSP. It is a requirement of NFPA (National Fire Protection Association) 1500, Fire Department Occupational Safety and Health Program–1997 (2.3.2). An audit is not to be used to belittle or demean the HSP, safety officer, chief, fire department, or members. Note: All department personnel are referred to as “members,” to cover all the categories of individuals covered by the HSP.
An audit differs from an inspection in that it is all-encompassing and has some degree of subjectivity. Most topics are judged as objectively as possible; however, some require the professional judgment of the auditor. To the best of my knowledge, there is no standardized form, procedure, or protocol for auditing fire departments. If this is the case, obviously there are no auditors specifically trained for the job. That is not to say that there aren`t individuals who could easily qualify for the job after a little familiarization with the process.
AUDIT COMPONENTS
An audit has three major components: the Member Perception Survey (MPS), the Safety Audit Checklist (SAC), and the Work Practices Observations (WPO). A fourth component–Maximum Credible Events/Priority Plan (MCE/PP)–is discussed here, but it should already be part of the department`s required risk management program. To use these components successfully, the audit team must understand management and its styles, priorities, practices, and expectations.
The first step in an audit is fact-finding; the MPS and the style, content, and philosophy of management philosophies are compared by way of a questionnaire. An audit is scheduled, as is a briefing with the audit team to discuss procedures with the management (union/member representation is included) team. The principal component of the audit consists of using the SAC to cover all aspects of the HSP. During or subsequent to this process, auditors use the WPO to ascertain that what is stated or implied is actually what is occurring. Finally, a summarization of findings is presented to the management team, with a formal report to follow.1
Member Perception Survey
The MPS is used to get a feeling for what the HSP actually does. The survey is designed to evaluate how members perceive safety aspects of everyday and emergency operations. As Kase and Wiese observe in Safety Auditing: A Program Management Tool, “It is a truism that it doesn`t really matter what I say or do to you; what matters is what you think I have said or done.”2 Members may not understand the department or management`s intent in policies, procedures, and directives. Their perception may even conflict with the intent. Discrepancies will become apparent in the survey. Cautious auditors will investigate any conflicting evidence to verify whether there is a misconception on the part of the respondent or a deficiency in the HSP.
The survey (see Figure 1) covers seven topics designed to check employee opinion of actual occurrences. The auditors can infer compatibility by contrasting and comparing these with stated policies, procedures, and directives. Survey statements are letter coded to match categorically to facilitate pinpointing a problem. The topics are Communications (C), Alcohol and Drugs (D), Equipment (E), Management (M), Priorities (P), Supervision (S), and Training (T). The codes are in parentheses at the end of the statement and are optional. There is no reason to believe that they create bias, and they do facilitate auditor analysis.
A larger percentage of member participation provides more reliable data for statistical analysis. It is desirable to obtain a minimum of 15 persons or 25 percent of membership, whichever is greater. Representation from all ranks is desirable; however, it is difficult in an anonymous survey. To be selective would skew the results.
The survey is scored by subtracting the total of the even-numbered responses from the total of the odd-numbered ones. This can also be applied intracategorically. The higher the score, the higher the correlation between actual and intended program content. It is preferable that one auditor have sole responsibility for scoring and investigating discrepancies. The MPS is an important tool, but it can be abused should labor/management or personal conflicts occur within a department. Any such problems need to be brought up during the initial briefing.
Safety Audit Checklist
The heart of the audit is the SAC (see Figure 2). (I am still fine-tuning this component of the audit.) The SAC provides a method of rating the HSP numerically and objectively. Other checklists are available, but none furnish a numeric rating, and they do not address some important items not covered in NFPA 1500.
“Checklists are often used to evaluate many of the safety features (or their lack) … . The person making the survey may add other items to be reviewed … ,”3 explains Willie Hammer in Occupational Safety Management and Engineer, 4th ed. The SAC was modeled after the International Safety Rating SystemT.4 Myriad possibilities exist for comparisons using this system. National, state, or regional ratings can be used to analyze HSPs and target improvement.
The SAC cover all facets of the HSP. Policies, procedures, records, systems, training, certifications, and subprograms–such as bloodborne pathogens–come under scrutiny. The examination of position qualifications, assignments, and composition of the Safety Committee is also part of the audit. Such an all-encompassing appraisal makes considerable knowledge of safety, standards, tactics, techniques, equipment, and apparatus requisite. Since most standards represent minimums, auditors with superior knowledge and experience in methodology to exceed them will be better equipped to judge HSP effectiveness, particularly in areas permitting subjectivity. The auditor`s professional opinion is vital where total objectivity is impossible or impractical. Quality auditors will ensure equity in the rating.
Work Practices Observations
The WPO (see Figure 3) is the inspection of the HSP in action. Just as the MPS looks for variances in the philosophical angles, the WPO checks for variances in the stated and physical performance of the HSP. These two, when used in conjunction with the SAC, give auditors the tools to produce a meaningful analysis the department can use to improve the HSP. Discrepancies indicate a lack of management`s efforts to educate members about the program or to enact or enforce the stated program. One of the most common problems is the failure of upper management to hold first-line supervisors accountable for safety. The safety officer is only the coordinator and facilitator; safety must be pres-ent from the bottom up.
Three fields of activity are studied–station, training, and incident operations. Station safety focuses on the facilities; housekeeping; and maintenance of buildings, grounds, and equipment. Personal protective equipment, facilities, equipment, instructors, and activities comprise training safety. Incident operations review the following: command, PPE, equipment, apparatus, tactics, communications, exposures, and reporting.
Workplace observations for productivity are routine. It is critical to coordinating the HSP. The inherent hazards of firefighting could make minor lapses critical. A comments section is provided for the auditor to record positive and negative specific observations. All particulars, along with the date, should be recorded. Smaller departments may require a much longer period for observation because of the sporadic nature of incident response.
Maximum Credible Events/Priority Plan
The MCE/PP (see Figure 4) is a brief example of prioritizing risks based on a hazard matrix. It is used to define problems that cause the most concern and present a system for addressing them effectively.5 Fatalities, debilitating injuries, long-term loss of member services, resource losses, and cost efficiency are common priorities for preventive measures. Workers` compensation cost reduction is a prime goal. All possible avenues of injury and loss are compared with the probability/severity matrix for prioritization and devising abatement methods.
These events evolve from a “listing of potential problems … a fairly wide variety of items, with … consequences ranging from trivial to … catastrophic. Not only the event and its consequences must be credible, but also must the circumstances, the precursor conditions under which it can happen, be credible.”6 Not only do they help establish a course to confront problems in a high-priority order, but they avoid oversights in regions considered routine or acceptable risks. The latter is often equally as or more important than the former, since so many of our injuries happen as a direct result of ignoring or becoming complacent about everyday operations.
TYPES OF AUDITS
There are two basic types of audits–internal and external. The internal audit is done by members of the department. This requires a commitment of time and money to train the audit team and the time needed to perform the audit, write the reports, and analyze the results. The advantages of the audit are the following: (1) It is a one-time investment if the department has personnel stability, (2) a team is available on a continual basis, and (3) those involved are more intimately familiar with the department`s philosophy and operations. Lack of credibility, potential larger ex-pense, and having auditors under the direction of those who are being audited are disadvantages.
External audits have the following advantages: (1) a contract specifies exactly what will be done and how much it will cost, (2) there is a reduced commitment of time but not necessarily money, (3) access to the perspectives of outside personnel who may have a wider range of experience and knowledge, (4) a higher level of confidence, and (5) a lack of control conflict. The external audit does not relieve the department of the responsibility to ensure that the contractor has the needed expertise and objectivity. This may not be a faster way to get an audit done be-cause safety is a comparatively new topic and there is a shortage of qualified auditors. In fact, the field is very open for those inclined to specialize. This may present a dilemma until departments accept the requirement under NFPA 1500.7 This may sound erratic, but it is common when new procedures are established. Beware of consultants touting credentials.
Perhaps a better way would be to select one or two members from each department in a regional cartel. Members do not audit their own department, but the team serves to examine all departments in the group, thus retaining many of the benefits of both. Major advantages are availability on a continual basis; lower costs; and an opportunity to observe a larger volume of experiences, especially vital in low-response areas.
CONDUCTING THE AUDIT
Preparation of the audit team is crucial to the credence of the audit regardless of whether it is internal or external. Knowledge of standards, regulations, hazards, and operations is requisite. Team members must comprehend management functions and philosophies. Auditors must ascertain clear lines of responsibility, authority, and accountability. The tone for the process is set by the selection of the audit team.
Understanding and ascertaining maintenance of schedules and records concerning all operations; inspecting equipment, facilities, and personnel performance for adherence to department or accepted standards; submitting reports to management; explaining deviations from norms; recommending corrective actions; and functioning independently of all audited duties encompass auditor responsibilities.8
All team members are expected to participate in pre- and post-audit briefing. Member interviews, inspections, and observations are preassigned to auditors. Final reports are formulated by coordinating findings.
A questionnaire is used to develop a department database that includes the names of contact persons, the names and addresses of the fire stations and key personnel, management`s expectations and philosophies, and the history of major incidents and losses. All nonconfidential information on programs and personnel is recorded.
Items to be audited include all test data, apparatus and equipment maintenance records, licenses or permits, certifications, and documents pertaining to the HSP. At least one copy of applicable standards, codes, and regulations should be available to auditors (memory is not to be relied on). Reports of previous audits, inspections, problems, and so on, assist in determining corrective actions. Portable computers are priceless in assimilating and coordinating information.
Findings must be documented. Oral reports give no assurance of remedial action. Managers` demands not to put the reports in writing should serve as a red flag for auditors. A list of those to receive the reports should be compiled before the audit. One point normally reserved for private industry is discovery protection. This covers trade secrets. A fire department might request such protection for any research and development it is doing; however, it would be rare. Within a reasonable time for compilation of data, a formal report is issued to the department and others listed in the contract.9
The entire process should be accomplished in seven to 10 days when enough personnel are assigned. The time can vary according to the size of the department. The WPO in small organizations can be done by a regional team that can respond on short notice to obtain sufficient observations for significant analysis.
AUDIT BENEFITS
Departments should determine how to use the audit to their best advantage. Compliance with NFPA 1500 should not be the department`s only impetus for an audit. Enhancement of the HSP should be the obvious priority. Liabilities and legal ramifications indicate the need to comply with rules, regulations, and standards. First-line supervisors, captains, and lieutenants who deal daily with operations and personnel should be made accountable for magnifying the HSP`s effectiveness and efficiency. Cost control is an often overlooked phase of a good HSP. Accident costs are seldom calculated. Economics is usually the driving force behind most decisions; therefore, the potential savings that can result from an improved HSP is an excellent selling point.
Incidents that do not result in dollar loss or injury are like pennies from heaven. Record and analyze them so that further occurrences that may have more serious outcomes can be prevented. If properly recorded, the auditors will pick them up and include them in the improvements component of the HSP.
The audit is a tool that should be used more often. As the concept catches on, more qualified auditors will be available to fire departments. This will also reduce the costs associated with such a complex exercise. In an occupation with so many inherent risks, we are obligated to do whatever we can to protect our most valuable investment–our members. The audit can help us meet this goal.
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Endnotes
1. Kase, Donald W. and Kay J. Wiese. Safety Auditing: A Program Management Tool. (Van Nostrand Reinhold, 1990), xiv-xvi.
2. Ibid., 143.
3. Hammer, Willie. Occupational Safety Management and Engineering, 4th ed. (Prentice Hall, 1989), 232.
4. International Loss Control Institute, International Safety Rating System (Institute Publishing, 1988) , 1-193.
5. Kase and Wiese, 75.
6. Ibid., 77.
7. NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, National Fire Protection Association, 1992, 10.
8. Reed, Jack. Class Handout, SA581, Indiana University of Pennsylvania, 1994.
9. Ibid.
ALLEN CLARK, a 24-year veteran of the fire service, is assistant chief and safety officer of the Bell Township (PA) Fire Department. A certified Firefighter III, Fire Instructor III, Fire Officer I, haz mat technician, and vehicle rescue technician, he is a contract instructor for the National Fire Academy, a senior field instructor at the Pennsylvania Fire Academy, and a consultant to fire departments and industry on safety and fire-related matters. He has an associate`s degree in fire science, a bachelor`s degree in fire administration, and a master`s degree in safety science.
