Teledyne Technologies Incorporated
Health and Safety Management System Manual

Edition: November 2019

© Teledyne Technologies Incorporated 2016, 2019

November 2019

Teledyne Technologies Incorporated
Health and Safety Management System Manual
EXECUTIVE SUMMARY
The purpose of the Health and Safety Management System (HSMS) Manual is to set forth the key
elements for incorporation into your facility’s written HSMS. The HSMS to be developed and implemented,
utilizing this Manual, is a set of written policies and procedures to guide the facility in providing a safe andhealthy work environment for all employees and to achieve and maintain regulatory compliance through its
health and safety management practices. Each Teledyne facility is required to have a written HSMS.
Note: Teledyne businesses and/or sites certified to OHSAS 18001, ISO 45001 or equivalent Health and
Safety Management System are considered to be in substantial compliance with the Teledyne HSMS Manual
requirements.
The HSMS is designed to be flexible to adapt to each facility. Prior versions of the facility’s HSMS
may be updated for incorporation into this written HSMS.
In general, the facility HMS is comprised of ten (10) key elements as outlined in Section 1 of thisManual. Policies, procedures and informational tools, as well as assessment of operations for hazards andpotential impacts to employee health and safety, will be required. To the extent not already done, the facility
and its management will also be required to:
•
•
•
•
•
•
•
•
•
•
•
•
•

Create a written organization plan for health and safety management (HSMS §5.2).
Assign and communicate specific accountability and responsibilities for the facility HSMS andcompliance therewith and evaluate performance based on HSMS and facility health and safetycompliance (HSMS §5.3).
Take disciplinary actions for health and safety violations (HSMS §5.3.2).
Identify health and safety requirements applicable to the facility and the ongoing process for assessing
operations to maintain continual compliance with applicable requirements (HSMS §5.4).
Implement management of change procedures and self-inspections procedures (HSMS §5.4.2).
Perform and document work place hazard assessments (risk assessments) (HSMS §5.4.3)
Implement procedures for health and safety incident response, investigation and correction. (HSMS,§5.5).
Implement awareness and training plan and record keeping requirements (HSMS §5.6).
Implement health and safety considerations in business planning (HSMS §5.7).
Integrate health and safety record keeping requirements (HSMS §5.8).
Perform annual HSMS compliance evaluations (HMS §5.9).
Perform compliance reviews and audits in conjunction with Teledyne’s health and safety complianceprogram (HSMS §5.9).
Certify annually to Senior Corporate Management that the Facility is in compliance with HSMS andapplicable laws (HSMS §5.9.3).

This Manual should be used in developing and implementing the facility HSMS. Feel free to call the
Corporate Environmental, Health and Safety Management Team with any questions. Team membership andcontact information is available on the Teledyne EHS Intranet page.
November 2019

Teledyne Technologies Incorporated
Health and Safety Management System Manual
Table of Contents______________________________________________________________________________
1.
2.
3.
4.
5.

PurposeScope
Applicability
Definitions
Health and Safety Management System (HSMS) Program Elements
5.1. Health and Safety Policy
5.1.1. Objectives
5.1.2. Policy Implementation
5.1.3. Policy Communication
5.2. Organization, Personnel and Oversight
5.2.1. HSMS Organization, Implementation and Maintenance5.2.2. Duties, Roles, Responsibility and Authority
5.2.3. Communications
5.3. Accountability and Responsibility
5.3.1. Accountability and Responsibility
5.3.2. Rewards and Penalties
5.4. Health and Safety Requirements, Assessment, Prevention and Control
5.4.1. Assessment of Regulatory Applicability
5.4.2. Maintenance of Compliance Mechanisms
5.4.3. Hazard Assessments
5.4.4. Hazard Prevention and Control
5.4.5. Ongoing Inspections
5.5. Health and Safety Incident Response, Investigation, and Correction
5.5.1. Reporting
5.5.2. Investigation and Corrective Action
5.5.3. Action Follow-up and Verification
5.5.4. Targets, Objectives and Action Plans
5.6. Health and Safety Training, Awareness and Competency
5.6.1. Specific Education and Training
5.6.2. Awareness5.6.3. Competency
5.7. Health and Safety Planning and Organization Decision-Making
5.7.1. Health and Safety Planning

November 2019i

5.8. Maintenance of Records and Documentation
5.8.1. Records
5.8.2. Data Management
5.8.3. Release of Information to Outside Parties
5.9. Continuing Program Evaluation and Improvement
5.9.1. Periodic HSMS Evaluations
5.9.2. Facility Compliance Evaluations
5.9.3. Certification of Compliance5.10. Public Involvement and Community Outreach
6. Appendices
Appendix A – Sample Job Hazard Assessment Procedure
Appendix B1 – IRIR Procedure
Appendix B2 – IRIR Form Instruction
Appendix B3 – IRIR Reporting FormAppendix C – Attorney Client Privilege and Attorney Client Work Product
Appendix D - Regulatory Inspection – Surprise or Scheduled
Appendix E – Management of Change
Appendix F – Annual Health and Safety Compliance Certification
Appendix G – Applicable Laws and Regulations
Appendix H – Worksite Inspection Forms
Appendix I – Corporate Environmental Management Team Contact List

November 2019

ii

Health and Safety Management System Manual

1. Purpose
The purpose of the Health and Safety Management System (“HSMS”) manual is toprovide Teledyne’s Operating Segments and their designated Facilities with a framework
to provide a safe and healthy work environment for all employees and to continue tomaintain and operate in compliance with applicable local, state and federal health andsafety laws, regulations, permits and corporate policies (the “HSMS requirement”).
This Manual sets forth guidelines for establishing and implementing a written HSMS for
those Facilities required to develop and implement the HSMS requirement (“Facility
HSMS”).
Each Facility General Manager has the primary responsibility to provide the appropriate
resources for developing and implementing the written HSMS consistent with thisManual.
At a minimum, each Facility's written HSMS must contain the following elements, each ofwhich is further explained herein:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Health and Safety Policy
Organization, Personnel, and Oversight
Accountability and Responsibility
Health and Safety Requirements Identification and Assessment, Prevention andControl
Health and Safety Incident and Noncompliance Investigations
Health and Safety Training, Awareness and Competency
Health and Safety Planning and Organization Decision-Making
Maintenance of Records and Documentation
Continuing Program Evaluation and Improvement
Public Involvement/Community Outreach

The policies contained in this Manual intentionally are general in nature in order to afford
the Operating Segments and their Facilities flexibility in developing a written HSMS thatwill work effectively. As long as the policies articulated in this Manual are met, Operating
Segments and their Facilities can develop a written HSMS uniquely suited to the health andsafety requirements applicable to the activities at each location. A Facility’s written HSMS
may be a combination of related policies, procedures and practices or a single document.
However, the connection between the management system elements must be clearly
explained. All applicable aspects of the HSMS must be in writing and must include an
explanation of how each element meets the policies contained in this Manual.

November 20191

Health and Safety Management System Manual

2. Scope
The HSMS applies to the full range of business activities that may impact employee healthor safety or that are subject to health and safety regulation.
3. Applicability
This Manual applies to all TDY operations that conduct operations or processes that
impact, or have the potential to impact, employee health and safety.
4. Definitions
Key terms used in this Manual and its Appendices have the following meanings:•

Compliance Mechanism – Procedure, practice, equipment, or operation
controlling an aspect of health and safety compliance.

•

Corporate Health and Safety Management Team - A multi-disciplined Team,
responsible for development and implementation of the HSMS, composed ofrepresentatives from the Operating Segments, and corporate environmental, legal,
auditing, engineering, and/or management. The Corporate Health and Safety
Management Team is also known as the Corporate Environmental Management
Team, the Teledyne Environmental Management Team, the Corporate
Environmental, Health and Safety Management Team, and the Teledyne
Environmental, Health and Safety Management Team.

•

Exposure – Employee complaints, or known conditions of, excessive noise levels;
high frequency sounds; radiation; vapors, fumes, mists, dusts; extreme heat or
extreme cold, indoor air pollution, poor air circulation, etc.

•

Health and Safety Incident – An injury, illness, near miss, property damage or
any other health or safety issue that a Health and Safety Manager or Facility
Health and Safety Management Team determines (with appropriate consultation
with a TDY attorney) may not be in accordance with corporate policy, applicable
procedures, federal, state, or local law or regulation in the health and safety area.
The characterization of an event as a Health and Safety Incident does notnecessarily mean a violation of law has occurred. For purposes of this definition,
any notification received from a regulatory agency such as a notice to comply,
notice of violation, etc., shall constitute a Health and Safety Incident.

•

Health and Safety Observation –An employee’s observation of a situation,
condition, or event which he or she believes may not be in accordance withcorporate policy, applicable procedures, or federal, state or local health and safety

November 20192

Health and Safety Management System Manual

law or regulations.
•

Facility – A physical structure (or structures) supervised by one General
Manager.

•

Facility Health and Safety Manager or Facility Health and Safety Management
Team - The person or person(s) assigned the primary responsibility for health andsafety issues at a Facility.

•

General Manager – The senior manager at a Facility.

•

Health Hazard- A hazard which may produce serious and immediate (acute)health effects or cause long-term (chronic) health problems. All or part of the
body may be affected.

•

Illness - A condition where the employee has symptoms, such as: skin or eye
irritation, dermatitis, headaches, dizziness and nausea, allergic reactions, aching
pain and numbness in the hands, etc.

•

Injury - A condition where the employee is suffering from bodily damage such as
wounds, cuts, scrapes, punctures, strains, sprains, breaks, etc.

•

MOC – Management of Change – See HSMS Manual Appendix E.

•

Near Miss - Situations where injury, illness, exposure or property damage could
have occurred, but did not.

•

On-Site Service Provider – A subcontractor providing a service that affects
Facility health and safety compliance.

•

Operating Segment – One or more Facilities of Teledyne set up as a separateorganization for purposes of management control.

•

Property Damage- Any form of injury or damage caused to the property, either
personal or real, due to negligence or intentionally by the person who is not theowner or that can happen naturally.

•

Safety Hazard- A safety hazard is anything that could endanger the immediate
safety of an employee, for example, a pinch point, an electrical connection, a hotpart, etc.

•

Senior Corporate Management – The principal executive officers of Teledyne
Technologies Incorporated, including its Chief Executive Officer, Chief Financial
Officer, Controller and General Counsel.

November 20193

Health and Safety Management System Manual•

TDY or Teledyne - Teledyne Technologies Incorporated and its consolidated
subsidiaries.

•

Workplace Assessment- A process used to identify, evaluate and control thehealth and safety hazards associated with the various tasks of a particular job. A
workplace assessment also provides a method for prioritizing health and safety
hazards.

5. HSMS Program Elements
5.1. HSMS Policy
It is the policy of Teledyne to provide a safe and healthy work environment for
all employees and to continue to maintain and operate our businesses in fullcompliance with applicable Health and Safety laws, regulations, permits andour corporate Health and Safety Management System. It is also our policy topromptly evaluate and resolve any suspected instances of unsafe or unhealthy
working conditions or non-compliance with applicable requirements.
Each employee has responsibility for maintaining a safe and healthy workplace.
The performance of all work assignments without incident is of utmost
importance. Employees must immediately report any suspect unsafe or
unhealthy condition, accident or near miss situation to their immediate
supervisor or the site Health and Safety Manager.
We shall take an active role in discovering and implementing new means toprevent harm to our employees by continuous improvement in our health andsafety performance. Teledyne is committed to providing adequate personnel
and other resources to maintain a safe and healthy workplace; comply withapplicable health and safety laws, regulations and permits; and implement,
maintain and improve our Health and Safety Management System.
5.1.1. Health and Safety Objectives
In the conduct of its business Teledyne’s Operating Segments and Facilities willseek to satisfy the following health and safety objectives:
5.1.1.1.

Comply with applicable health and safety laws and regulations.
Compliance is a minimum obligation, and, where economically andcommercially feasible, compliance with more stringent voluntarystandards should be achieved.

5.1.1.2.

Provide adequate control of the health and safety risks arising fromwork activities.

November 20194

Health and Safety Management System Manual

5.1.1.3.

Consult with employees on matters affecting health and safety.

5.1.1.4.

Provide and maintain safe and healthy working conditions and a safe
facility.

5.1.1.5.

Provide information, instruction and supervision to employees.

5.1.1.6.

Prevent accidents and work-related injury and illness

5.1.1.7.

Review and continuously improve the facility Health and Safety
program

5.1.1.8.

Make health and safety concerns (including staffing, budgets,recognition of liabilities, technological alternatives, etc) a part ofbusiness operating and planning decisions.

5.1.1.9.

Assign adequate personnel and other resources to health and safetycompliance.

5.1.1.10.

Provide information to interested parties on health and safety program
performance.

5.1.1.11.

Educate, train, and motivate our employees to conduct their activities
in a safe, healthy and responsible manner.

5.1.2. Policy Implementation.
Operating Segments/Facilities of Teledyne shall implement this policy throughadoption and application of written policies, programs, and procedures
developed for their particular circumstances.
5.1.3. Policy Communication.
Teledyne, with the assistance of its Operating Segments/Facilities, shallcommunicate the health and safety policy to all employees, as the efforts of all
employees are required to support the policy. Teledyne also is committed tocommunicate this policy publicly, via its website or otherwise.
5.2. Organization, Personnel and Oversight of the HSMS
5.2.1. HSMS Organization, Implementation and Maintenance
Overall responsibility for the maintenance of these guidelines, and formonitoring Corporate HSMS activities rests with the Corporate Health and
Safety Management Team. This team is under the direction of the Teledyne
General Counsel’s office.
November 20195

Health and Safety Management System Manual

Overall responsibility for implementation and compliance with a Facility HSMS
rests with the senior operating executive and the General Manager of the Facility.
At the Facility level, each Teledyne entity must have a written organization planfor health and safety management. Each Facility shall also prepare written
policies and procedures that implement the objectives and mandates set forth in
this Manual.
At a minimum, the health and safety organization plan must identify the Facility
Health and Safety Manager or Facility Health and Safety Management Team,and the Facility health and safety contacts. The relationship between individuals
with primary health and safety responsibilities to the overall management
structure at the Facility and Operating Segment must also be shown. The Healthand Safety Manager, or a member of the Facility Health and Safety Management
Team, must report directly to the Facility General Manager or have a clearly
defined means of effectively communicating health and safety issues to the Facility
General Manager.
The Corporate office will maintain an organization chart that defines the structure
and personnel of the Teledyne HSMS.
5.2.2. Duties, Roles, Responsibilities and Authority
Either a Facility Health and Safety Manager or a Facility Health and Safety
Management Team must directly or indirectly oversee the HSMS at each
Facility. The responsibility of the Facility Health and Safety Manager/Team is toadminister the HSMS Facility-wide. If a team approach is used, one member
must be designated as primarily accountable for team activities. The
individual(s) who have the major responsibility for administering the HSMS
should possess demonstrated communication skills and an understanding of theunderlying fundamentals of Health and Safety issues and technology. Though
the Facility Health and Safety Manager (or the Facility Health and Safety
Management Team) has overall responsibility for developing and implementing
the HSMS, such Manager or Team is not solely responsible for Health and
Safety compliance. The efforts of all employees are required in achieving andmaintaining Health and Safety compliance.
At minimum duties, roles, responsibilities, and authorities shall include thefollowing tasks:
5.2.2.1.

Corporate Health and Safety Management Team5.2.2.1.1.

November 2019

Develop, implement and maintain a written HSMS Manual.

6

Health and Safety Management System Manual

5.2.2.1.2.
5.2.2.1.3.
5.2.2.1.4.
5.2.2.1.5.
5.2.2.1.6.
5.2.2.1.7.

5.2.2.2.

Facility Health and Safety Manager or Health and Safety ManagementTeam

5.2.2.2.1.
5.2.2.2.2.
5.2.2.2.3.
5.2.2.2.4.
5.2.2.2.5.
5.2.2.2.6.
5.2.2.2.7.
5.2.2.2.8.

5.2.2.2.9.
5.2.2.3.

Administer the Facility HSMS.
Develop, review and/or approve Facility HSMS policies,
practices, and procedures.
Identify appropriate human and financial resources toimplement and maintain the HSMS.
Verify that the appropriate policies, practices, procedures andactivities are in place to achieve and maintain compliance.
Provide direction and technical support to Facility personnel
responsible for HSMS compliance.
Communicate HSMS related information to affected Facility
employees.
Stay abreast of Health and Safety regulations relevant to
Facility operations.
Work with Facility personnel to develop and implement
adequate and timely training programs for employees,
contractors, and other third party consultants whereappropriate.
Be accountable and responsible for the enforcement of HSMS
requirements.

All Employees

5.2.2.3.1.
5.2.2.3.2.

November 2019

Verify each Facility has identified and dedicated adequate
human and financial resources necessary for development,
implementation and maintenance of the Facility HSMS.
Verify each Facility has retained a competent individual(s) toact as the Facility Health and Safety Manager or Facility
Health and Safety Management Team.
Verify that Facilities have implemented the appropriate polices,
practices, procedures and activities to achieve and maintaincompliance with the HSMS.
Provide Health and Safety guidance to Facility personnel
responsible for HSMS compliance.
Report to Senior Corporate Management on Facility
compliance with HSMS policies and procedures.
Report to the Audit Committee of the Board of Directors ofTeledyne the results of audits conducted pursuant to Section
5.9.2.

Follow Facility HSMS policies, practices and procedures.
Report to the Facility Health and Safety Manager, Facility
Health and Safety Management Team or supervisor all unsafe

7

Health and Safety Management System Manual

5.2.2.3.3.
5.2.2.3.4.
5.2.2.3.5.

conditions, accidents, near misses and exceptions to known
HSMS requirements.
Perform job in a healthy, safe and compliant manner.
Be responsible and held accountable for compliance with
HSMS requirements applicable to job.
Suggest improvements in the HSMS and in Health and Safety
activities.

5.2.3. Communications
The Facility Health and Safety Manager or the Facility Health and Safety
Management Team shall develop a plan to, or define effective mechanisms,
that:
5.2.3.1.
5.2.3.2.
5.2.3.3.
5.2.3.4.
5.2.3.5.

Advise senior Facility management and the Corporate Health and
Safety Management Team of Health and Safety issues and problems.
Communicate specific instructions to employees with key HSMS
related responsibilities.
Disseminate Health and Safety information to specific departments or
the general employee population.
Communicate or flow down corporate Health and Safety requirements
to vendors, contractors, customers, or other third parties.
Facilitate feedback from Facility personnel and external parties related
to Health and Safety deficiencies or concerns, and to respond to thoseconcerns in a timely manner.

Mechanisms to accomplish these objectives may include, but are not limited
to, staff meeting presentations, safety committees, training sessions,newsletters, e-mails, desk instructions, standard disclosures and disclaimers,
and the like. Related guidance may be found in other elements of thisManual.
5.3. Accountability and Responsibility
5.3.1. Accountability and Responsibility
The Teledyne Chief Executive Officer is accountable and responsible fordirection and control of the Health and Safety performance of the corporation.
In turn, each Operating Segment Senior Operating Executive and each
General Manager is accountable and responsible for their operations. The
assigned Health and Safety Manager or Facility Health and Safety
Management Team is accountable and responsible for the operation of the
Facility HSMS. All employees are accountable and responsible for theiractions. On-site service providers and contractors are accountable andresponsible for their actions and compliance with the HSMS as it applies totheir respective contracted operations or services.

November 20198

Health and Safety Management System Manual

Specific accountability and responsibility must be assigned in the following
areas:
5.3.1.1.
5.3.1.2.
5.3.1.3.
5.3.1.4.

Developing Health and Safety Compliance Mechanisms;
Assuring that Compliance Mechanisms are properly operating;Appropriate reporting to regulatory agencies; andFollow-up on identified problems and corrective actions.

Assignments of accountability and responsibility should be documented.
Such documentation can include organizational charts, job descriptions, orfunctional descriptions in Facility operating procedures. These assignments
should also be communicated to all employees and on-site service providers
and contractors to ensure that they are clearly understood.
Accountability shall be part of annual performance evaluations of applicable
employees, including the Operating Segment senior operating executive, theGeneral Manager and the assigned Health and Safety Manager or Facility
Health and Safety Management Team.
5.3.2. Rewards and Penalties
Management and other employees with accountability and responsibility for a
Facility HSMS shall be evaluated, in part, for their Health and Safety
performance in their annual performance evaluations. Performance reviews
for these employees must consider the status of annual objectives related to
HSMS compliance. Management and other employees shall be subject todisciplinary actions (including termination of employment) if they violate
Health and Safety regulations and procedures. Each Facility shall develop a
disciplinary action plan. The plan shall identify categories of violations andthe associated disciplinary action. Facilities may integrate this plan into
existing disciplinary action plans or procedures.
Each on-site service provider and on-site contractor with accountability andresponsibility for HSMS compliance and Health and Safety performance shallbe evaluated for their Health and Safety performance. Substandard
performance will be grounds for dismissal or contract revocation.
Performance shall be reviewed as necessary but at least during contract orpurchase order renewal. Purchase Orders to service providers and contractors
must not relieve them of their accountability for their actions and theenforcement provisions of laws and regulations that apply to their services or
actions.
5.4. Health and Safety Requirements and Assessment, Prevention and Control
This section sets forth the steps to be taken by the Facility to identify (1) the
regulatory requirements that are applicable to each Facility, and (2) the process forassessing operations and maintaining continual compliance with applicable regulatory

November 20199

Health and Safety Management System Manual

requirements, including how to deal with changes to those operations and regulatory
requirements and (3) hazard assessment, prevention and control.
Steps in this process include:
5.4.1.

Assessment of Regulatory Applicability
5.4.1.1. Conduct an assessment of operations that includes a documented
inventory of the specific operations and work practices which occur at
the facility;

5.4.2.

5.4.1.2.

Identify the laws and regulations applicable to these processes
identified in 5.4.1.1 above. Appendix G contains a summary offederal health and safety statutes and regulations

5.4.1.3.

Identify licenses, registrations, permits and other authorizations
required for operation of the Facility;

5.4.1.4.

Determine whether the Facility complies with applicableregulations and permits. The method of compliance must be
identified.

5.4.1.5

Develop procedures that (i) assign responsibility andaccountability to appropriate Facility personnel for compliancewith applicable health and safety requirements and (ii)communicate applicable job responsibilities to Facility
personnel. Procedures should also ensure that contractors orservice providers who are identified as persons that are
responsible for compliance must enter into appropriate writtenagreements that define those responsibilities in accordance with
TDY’s health and safety policy and this Manual.

Maintenance of Compliance Mechanisms
Each facility shall develop procedures to ensure (i) operations are compliant,(ii) changes to operations are compliant, and (iii) Compliance Mechanisms areoperating as designed. These procedures include:
5.4.2.1.

Management of Change (MOC)
Implement a practice that evaluates the health and safety impacts
of proposed changes in the following change categories:••

November 2019

Raw Materials;
Products;
10

Health and Safety Management System Manual

•
•
•
•
•

Processes;
Facilities (including equipment and maintenance activities);
Personnel;
Corporate or Facility requirements; andFederal, state, and local regulations.

The objective of this element is the systematic and periodic
review of those changes that have a potential health and safety
impact. In the context of this HSMS, MOC applies to changes,
including temporary changes that occur at operating facilities. It
requires the development of procedures and practices, which
require appropriate evaluation of the health and safety impacts ofproposed changes prior to approving or implementing thosechanges. This objective should be accomplished by requiring healthand safety management review and written sign-off of all proposedchanges satisfying one or more criteria (i.e. triggers) as outlined inAppendix E of this Manual. For more efficient resource use, MOC
procedures should also address the discontinuation of processes,
relaxation of regulations, and other changes that might imply thatcertain controls are no longer necessary.
The requirement to monitor changes in applicable local, state orfederal regulations should be part of a general MOC overview
process, and should also be the responsibility of the Facility
Health and Safety Manager or Facility Health and Safety
Management Team. The manager or team shall identify sourcesof regulatory update information and periodically review thesesources for changes to applicable health and safety requirements.
Examples of regulatory update sources include, but are not limitedto:•Federal, state, and local web based services, mailing lists,
newsletters, etc.

•

Health and safety training/regulatory update seminars;•

3rd party regulatory update service providers; and•The Corporate Health and Safety Management Team.

Changes shall be made in the Facility HSMS and in supporting
procedures and Compliance Mechanisms if regulatory changes
affect the system. Changes shall be communicated to the
responsible person or team and to on-site contractors or service
providers that are affected.

November 201911

Health and Safety Management System Manual

5.4.3. Hazard Assessments
All Teledyne companies that conduct operations or processes that impact, or have thepotential to impact, employee health and/or safety are required to perform workplace
hazard assessments of their facility. Teledyne companies must institute and maintaina hazard assessment program that proactively assesses all jobs for hazards and key
personnel shall be trained in the process of carefully evaluating existing and potential
hazards at the worksite. Involvement at all levels, including management, is
important and will make both management and workers aware of hazards that may
not otherwise have been noticed until an incident occurred. The hazards
identification and assessment process will impact many other elements of the HSMS.
Hazard assessment data can also be used to develop other elements of the HSMS
including:•••Training and Orientation: use hazard assessment data to determine
training needs and to build the content of employee orientations andjob-specific training. See Section 5.6.
Worksite Inspections: use hazard assessment data as the basis forinspection checklists. See Section 5.4.5.
Incident Investigations: hazard assessment and control data can beused to help determine if a system failure was the cause of an incident.
See Section 5.5.

5.4.3.1.

Sources of Hazards:
There are many sources of hazards in a workplace, however, thethree most likely sources that should be considered are:
• People: Lack of training, poor communication, rushing, fatigue,poor housekeeping and other factors may cause risk behaviors.
• Equipment and Materials: Some equipment, tools and materials
used in the job process are inherently hazardous, and others
become hazardous over time due to inadequate maintenance,storage, or disposal method.
• Workplace Environment: Factors such as facility layout,
ventilation and lighting, walking surfaces, temperature and othervariables can all be sources of hazards.
The use of a Job Hazard Assessment (JHA aka risk assessment),
serves as the foundation of the employer’s health and safety
management system and involves the identification of all jobs andtasks performed by employees, the assessment of each task forhazards, and the prioritization of the hazards based on the level ofrisk. This process should be followed by the implementation ofcontrols for the identified hazards. JHA's should be reviewed on

November 201912

Health and Safety Management System Manuala regular basis. An example JHA Procedure and Form is provided
in Appendix A.
5.4.4.

5.4.5

Hazard Prevention and Control: a proactive approach to hazard prevention
and control is a necessity at Teledyne facilities. Hazards should becontrolled by one or more of the following:
5.4.4.1.

Engineering is the best method of hazard control, and involves
engineering out or substitution of the hazard. When possible,
engineering controls should always be the employer’s first option.
Examples include: Building a catwalk with handrails andreplacing a portable ladder with a permanent access ladder for
maintenance procedures, building a sound-dampening enclosurearound a piece of loud equipment to reduce workers' noise
exposure, and replacing a harmful chemical with a less hazardous
product.

5.4.4.2.

Administrative controls are the second most effective method ofhazard control, and involve the implementation of practices,
procedures and rules to reduce the amount of exposure a worker
has to the hazard. Examples include: Developing and enforcing theuse of practices and procedures for conducting a task safely,
providing emergency response training to workers and conducting
regular drills, job rotation, and posting signs to warn of high noise
areas.

5.4.4.3.

Personal Protective Equipment (PPE) is the method of last resort,and should always be used in combination with other control
methods. Personal protective equipment is often the easiest control
to implement, but is usually the least effective. Employers will
supply workers with the required PPE.. In all cases, formal training
in the care, use, and maintenance of all PPE should be provided by
the employer. Examples of Personal Protective Equipment include:
Safety glasses to protect the eyes from flying debris, hard hats toprotect the head from falling objects, and respiratory protective
equipment to protect the lungs from harmful dusts and chemical
vapors.

Ongoing Inspections
An ongoing system for conducting worksite inspections is another importantelement of a facility’s HSMS. Regular inspections will:•
Proactively identify potential hazards that may not have beenpreviously noted,•
Confirm the effectiveness of controls already in place, and•Demonstrate commitment to health and safety.

November 201913

Health and Safety Management System Manual

5.4.5.1.

Inspection Program
An inspection program should clearly outline which facility
processes/ equipment require inspection, who will be involved, thefrequency at which inspections should be conducted, and who is
responsible for corrective actions and follow-up. The results of theinspection program will provide information on whether thehazard assessment requires review, preventative maintenanceprograms are effective, and employer training programs areadequate.
When developing an inspection program each company shall:
•

•
•

•
•
•

Specifically identify which facility processes/ equipment require
inspection. The results of the formal hazard assessment andhazard control process can be used to determine what processes/
equipment will need to be inspected. Also check the relevant
health and safety standards to determine if there are specificinspection requirements relevant to the nature of your work.
Define a regular frequency for inspections. The frequency will
be determined by the nature of the facility’s operations, but it isrecommended that facilities be inspected at least annually.
Determine who will be assigned the responsibility to conduct
inspections. This will vary depending on what is being inspected.
In general, facility inspection tours will be performed by thefacility’s health and safety management team. Inspections ofspecific pieces of equipment can be done by an individual orcompetent worker. If there is a health and safety committee at thesite, they should be involved in the inspection process.
Provide training for those employees who are required toparticipate on inspection teams.
Make managers and supervisors responsible for ensuring regularinspection tours are completed, and that action is taken to correct
any issues identified.
Post the results of the inspections (both positive and negative
findings) for workers to see, and include the expected timelines
for follow-up action.

5.4.5.1.1. Inspection Forms
Developing a standard inspection form to suit the facility’s
specific needs can be a good way to gather consistent results,
allow for the easy maintenance of inspection records, andcollect data that can be analyzed later for trends. The format
can be as simple or complex as needed to inspect the specificNovember 201914

Health and Safety Management System Manual

work process or piece of equipment, but at minimum, allinspection forms should include:•

a checklist of items to be inspected•a description of the hazards to look for•space to list suggested actions required to remove orcontrol the hazard•

name of the person responsible to correct the problem•

date by which the action is expected.

The inspection form is not intended to generate a "to do" list
for the maintenance department. The person named as
responsible for inspection follow-up should be the supervisor
in control of the area where the hazard is found. The area
manager has overall responsibility for ensuring corrective
action has been taken, and should review and sign-off allinspections.
Management involvement in both follow-up and theinspections themselves will send the message to workers thatthe organization recognizes the importance of the Health and
Safety Management System (see the Appendix H for sample
Work Site Inspection Forms).
5.4.5.2. Types of Inspections
5.4.5.2.1. Formal Inspections
The team or employee conducting the formal inspections will
use a written inspection form to record items identified during
the inspection. The form will serve to prompt inspectors tocheck for specific items, and will create a consistent standard
for the gathering of information. The inspection team will belooking for:November 2019•

Unsafe Conditions: slippery floor, poor lighting,cluttered work area, slipping hazards, missing guards,
etc.

•

Unsafe Actions: improper use of machinery or
equipment, workers not wearing personal protective
equipment or following safe work procedures, etc.
15

Health and Safety Management System Manual•

Health Hazards: dangerous chemicals, dust exposure,noise, toxic waste, etc.

Once the formal inspection has been completed, an inspection
report will be written, and reviewed by the inspection team. The
items identified on the inspection report should be reported toresponsible person in order for corrective action plans to be
implemented.
5.4.5.2.2. Informal Inspections
Informal inspections are carried out by workers, supervisors, andmanagers, and may not involve a formal report or a specificschedule. Some examples of informal inspections include:•

A manager walking through the shop may take the opportunity
to verify that workers are following safe procedures, using
safety equipment, or following healthy work procedures, andprovide feedback on their safety performance.

•

A tradesperson conducts a routine check on their tools, looking
for defects and maintenance needs prior to starting work eachday.

Informal inspection information will only be recorded and reported
if the situation requires it. In most cases, the required action only
takes a few minutes. Regularly performed informal inspections canbe an effective health and safety tool. Both positive and negative
observations should be noted.

5.5 Health and Safety Incident Response, Investigation, and Correction
5.5.1 Reporting
Each Facility shall develop a procedure for identifying and reporting injuries,
illnesses, exposures, near misses, property damage, or any other potential unsafe
working conditions or employee health issues. Procedures should address bothinternal reporting and responsibilities related to any required disclosures to external
regulatory agencies. There must be a reporting system that is initiated by the firstobserver of an injury, illness, near miss, property damage or other potential issue andthat defines the chain of incident reporting, i.e. the sequence of whom to notify andback-up personnel to contact when primary contacts are not available. When in doubt,
contact the Corporate Legal Department. See Appendix I.

November 201916

Health and Safety Management System Manual

See Appendix B-1 for Sample “Health and Safety Incident Reporting Procedure”,
Appendix B-2 for “Supervisors Incident Investigation Report General Instructions”
and Appendix B-3 for “Supervisors Incident Report Form”.
Guidelines for notification of Operating Segment management or the Corporate Legal
Department representatives should also be incorporated in the procedures. The
guidelines set forth in Appendix C (Attorney-Client Privilege) must be consideredwhen developing notification procedures. The process must be integrated withemergency reporting procedures for incidents, which may require immediate response
and/or reporting. If an immediate external notification is required, notification shall be
made, and the Corporate Legal Department shall be promptly advised of thecircumstances underlying the notification.
Notifications or communications on potential noncompliance areas that do not require
immediate notification to a government agency, per regulatory requirements, shall be
communicated to the Facility Health and Safety Manager or Facility Health and Safety
Management Team and the Corporate Legal Department before contacting thegovernment agency.
5.5.2 Investigation and Corrective Action
Each Facility shall develop a procedure for investigating and promptly addressing
potential or actual regulatory violations related to health and safety requirements.
Potential violations may also be determined during Regulatory Agency inspections.
Facilities should follow Appendix D guidelines if Agency inspections occur.
Once a situation is identified a root-cause analysis technique shall be used ininvestigations to help assure that corrective actions are taken on the correct cause. The
practice may vary with the critical nature of the problem (i.e., from simple discussion
and agreement up to formal problem analysis reports and action plans). Corrective
actions must limit or prevent the future occurrence of the problem. Corrective action
target dates should reflect the criticality of the problem and be evaluated forappropriateness along with the proposed actions. See Appendix B-1 Reporting andInvestigating Incidents Procedure.
5.5.3 Action Follow-up and Verification
Each Facility shall implement a follow-up system that will be used to verify that
corrective and preventive actions were taken and were effective, and to ensure thatthe initiator of the finding is advised as to the disposition of the issue. Thisadvisement may range from a simple follow-up visit by the health and safety
representative at some stated period after the scheduled corrective action to formal
posting of investigation activities. Regardless of the system used, follow-up mustensure that delinquencies in the completion of corrective actions are identified,reported and addressed.

November 201917

Health and Safety Management System Manual

5.5.4 Targets, Objectives and Action Plans
In the event a Facility is in non-compliance with health and safety requirements, theFacility must establish targets, objectives, and action plans for achieving andmaintaining compliance with the subject requirement. The activities of on-site
service providers and contractors must be included when applicable. Action plans
must identify how progress towards targets and objectives are tracked and reported.
5.6. Health and Safety Training, Awareness and Competency
5.6.1 Specific Education and Training
Each Operating Segment or Facility shall implement a written training plan that
effectively provides basic health and safety education, and continuing training, toenable employees to understand and fulfill the health and safety responsibilities of
their position. Education and training is a critical element of a strong and effective
health and safety management system. The objective of the education and training isto provide employees with the level of knowledge necessary for them to properly
execute the health and safety responsibilities of their job positions or assignments.
The training plan must identify the type, amount, and current status of required
training for employees and/or categories of employees. Employees must receive alevel of health and safety training appropriate to their job responsibilities. Records ofcompleted training shall be maintained.
Examples of required training topics include, but are not limited to: Emergency
Response and Evacuation, Injury and Illness reporting, Hazard Communication
training for employees who work with or are exposed to hazardous materials; PersonalProtective Equipment Standard training for employees performing tasks which require
use of PPE; and Respiratory protection training for employees who require use of a
respirator to protect them from airborne contaminants.
5.6.2 Awareness
Each Facility shall develop a written plan that describes the process for ensuring
employees are aware of health and safety policies and procedures, applicable healthand safety requirements, and their roles and responsibilities within the HSMS. This
may include use of posters, supervisor discussions, meetings, written materials,
videos, etc.
The Facility HSMS should also address the process by which any employee canraise questions or concerns related to health and safety matters and/or their
responsibilities, without fear of retaliation, and the method by which health andsafety management will respond to each such question or concern. While it should
not be regarded as the first means by which an employee can raise questions orconcerns related to health and safety matters, or if anonymity is desired, employees
should feel free to contact and not be dissuaded from contacting the Corporate
Ethics Help Line (1-877-666-6968) with health and safety issues or concerns.
November 201918

Health and Safety Management System Manual

5.6.3 Competency
Each Facility shall develop a process for ensuring personnel responsible for meetingand maintaining compliance with health and safety requirements are competent.
Competency determinations shall be based on education, training and experience.
Competency determination may be performed by supervisor review andcertification, testing or other means.
5.7 Health and Safety Planning and Organization Decision-Making
5.7.1 Health and Safety Planning
In conjunction with Section 5.4.2. above on MOC procedures, the HSMS mustdescribe how health and safety planning is integrated into the organizational
decision making process for plans and programs such as: capital improvement
plans, new product plans, product and process improvement plans, new processdevelopment plans, training and maintenance programs, etc.
5.8 Maintenance of Records and Documentation
5.8.1 Records
The Facility HSMS shall identify the minimum requirements for records anddocumentation. These records and documents shall include those required byregulation, by provisions elsewhere in this HSMS, or those otherwise mandated byOperating Segment or Corporate Management.
5.8.2 Data Management
The Facility shall develop a written data management system that provides formaintenance of required records and documentation. This system shall define,among other things:•

The individuals or groups who "own" the document (i.e. those who have theresponsibility for maintenance and update)•

The requirements for keeping logs and tracking records up-to-date. This
includes, for example, the frequency with which OSHA logs should be updated.

•

The control requirements for procedure and other reference document
management. (A tie-in to other Facility document management or librarysystems should be considered.)•

Location of records and physical access controls.

•

Record retention requirements (as described by regulation or corporate
directive).

November 201919

Health and Safety Management System Manual

5.8.3

Release of Information to Outside Parties
The Facility shall have written procedures related to release of records. These
procedures should require that original records not be released outside of the controlof the responsible person unless directed in writing. Copies should be provided
instead of originals whenever possible. Neither copies nor originals shall be released
outside of the Facility without Corporate, Legal Department and General Manager
approval. Nothing in this requirement is intended to interfere with timely andcooperative disclosure of any data to governmental officials pursuant to a search
warrant, subpoena, or other legal enforcement mechanism. (Additional discussions
related to this topic are included at Appendix D regulatory inspections.)

5.9

Continuing Program Evaluation and Improvement

5.9.1

Periodic HSMS Evaluations
The Facility HSMS shall require, at least annually, an evaluation of the HSMS byappropriate personnel including the Facility Health and Safety Manager and/or
Facility Health and Safety Management Team. This evaluation shall look forprogram improvement opportunities. Viable program improvement opportunities
shall be incorporated into the Facility HSMS (subject, as necessary, to review andapproval by Operating Segment or Corporate senior management.) If needed,
action plans for the change(s) shall be developed. These changes to the HSMS shallbe disseminated as required by Section 4 above. Action plans shall also becoordinated with and disseminated to affected personnel, including employees, onsite contractors, vendors and suppliers.

5.9.2

Facility Compliance Evaluations for HSMS
Each Facility shall develop a program for periodic evaluation of Facility
compliance with health and safety requirements. Facilities may also consider using
an audit program conducted by Corporate or Operating Segment health and safety
personnel as a supplement to the internal evaluation. (Reviews conducted byoutside parties do not, however, eliminate the need for internal evaluations.)
Results of internal evaluations or of audits shall be reported to the General Manager
and the Operating Segment Health and Safety Manager/Corporate Health and
Safety Management Team who shall include the data in their report to upper
management. Required corrective actions should be established and monitored inaccordance with requirements outlined in Section 5.5 above.
Each Facility shall participate in health and safety compliance reviews and audits
conducted by the Corporate Health and Safety Management Team pursuant to suchscope and procedures set forth by Senior Corporate Management.

November 201920

Health and Safety Management System Manual

5.9.3.

Certification of Compliance
Within thirty (30) days of the end of each fiscal year, the General Manager andManager for each Facility subject to the HSMS shall certify to the best of theirknowledge, after due inquiry, that their Facility is in compliance with therequirements of HSMS and applicable laws. The form of certification to besubmitted to the Corporate Legal Department [attention General Counsel or
Designee] is attached as Appendix F to the HSMS Manual.
In 2002, Teledyne published the Teledyne Environmental Management System(HSMS) Manual which required, among other things, an annual certification ofcompliance with the EMS and applicable environmental laws. In 2019, theenvironmental and health and safety certifications were combined into a single
certification.

5.10

Public Involvement and Community Outreach
Each Facility HSMS shall consider fostering ongoing community education andinvolvement in the health and safety aspects of the Facility’s operations. Generally,
these efforts would be applicable to Facilities with operations that could have asignificant impact on employees and/or community members, or when required byregulation or as a legally mandated remedy pursuant to a Notice of Violation,
Citation, or other finding. Any such activities or programs must be coordinatedwith the Corporate Legal Department.

November 201921

Health and Safety Management System Manual

APPENDIX A
Sample Job Hazard Assessment Procedure
1

PURPOSE
1.1

2

3

REFERENCE
2.1

Code of Federal Regulations, Title 29 Part 1910, Subpart I (1910.132 1910.140), Appendix B - Non -mandatory Compliance Guidelines for Hazard
Assessment and Personal Protective Equipment Selection.

2.2

California Administrative Code, Title 8, Section 3203 - Injury and Illness
Prevention Plan.

ACTIVITIES AFFECTED
3.1

4This procedure is applicable to all applicable facility operations.

FORMS USED
4.1
4.2

5

The purpose of this procedure is to define the method for producing written“Job Hazard Analyses” for all applicable operations at the facility. The
process is intended to reduce risks of injury or illness through any
combination of the following: 1) removing hazards through engineering
controls; 2) reducing exposure through procedural controls (administrative);or 3) safeguarding employees by fitting them with personal protective
equipment controls.

Job Hazard Assessment Priority Worksheet
Job Hazard Assessment Worksheet

PROCEDURE
5.1

JHA Principles
5.1.1

Appendix A
November 2019

Each Facility shall have a working method for identifying andcontrolling hazards to ensure that employees can work safely.
A-1

Health and Safety Management System Manual

5.2

5.1.2

The purpose of JHA is to provide a comprehensive system forminimizing employee exposure to hazardous conditions.

5.1.3

The result of the JHA is a set of work rules for a specific process andor activity, many of which may be included in the Facility Code of
Safe Work Practices.

5.1.4

JHA data is collected and evaluated from a walk-through investigative
survey.

5.1.5

Each hazard identified on the JHA worksheet shall have acorresponding safe work condition, practice, or personal protection
measure.

5.1.6

JHA is dynamic and ongoing process that needs to keep pace with thechanges in process, equipment, and people in the workplace.

5.1.7

Safe work conditions must exist before employees are allowed toperform a job.

5.1.8

Safe work practices identify how the workplace should be maintainedor how a job should be performed. The safe work practice identifies anaction for the employee to take to ensure safety. Examples include:
requirements regarding how work areas should be maintained, howtooling should be placed and used, etc.

5.1.9

Personal protection measures shall always be reviewed and approvedby the Facility Safety Coordinator.

General Guidance
5.2.1

Establish a JHA Coordinator. This person should have a fairly goodunderstanding of the manufacturing process and work flow.

5.2.2

Form a JHA task force comprised of 4 to 6 members (including theCoordinator). Establish teams of 2 to perform JHA’s.
Note: Ideally, the committee should have supervisory or management
representation from Operations, Engineering, Quality, and Facilities.

5.2.3

Identify a schedule for the JHA task force to meet monthly for 30minutes. Meeting activity shall be as follows:
5.2.3.1

Appendix A
November 2019

Review completed JHA’s.

A-2

Health and Safety Management System Manual

5.3

5.2.3.2

Submit completed and approved JHA’s to the Coordinator.

5.2.3.3

Identify JHA assignment to be completed for next meeting.

5.2.4

Incorporate competed JHA’s into document control so that they aretraceable to specific job processes or activities.

5.2.5

Plan for each task force member to dedicate 1 to 2 hours per monthmaximum, including 30 minutes of meeting time.

5.2.6

Plan for the JHA task force to be an ongoing process.

Responsibility
5.3.1

5.3.2

Appendix A
November 2019

Senior Management
5.3.1.1

Holds ultimate responsibility for regulatory compliance andemployee health and Safety.

5.3.1.2

Ensures that an effective JHA program is in place inaccordance with the regulations and the needs of the
Facility.

5.3.1.3

Allocates resources for JHA activity.

JHA Coordinator5.3.2.1

Plan and coordinate monthly JHA meetings.

5.3.2.2

Produce minutes from the JHA meetings, and then distributeto management.

5.3.2.3

Channel completed JHA’s through a document control
system.

5.3.2.4

Ensure that JHA’s placed into a system where they aretracked, updated, and linked to mainstream activity (i.e. on
the job training).

5.3.2.5

Coordinate any necessary changes, trainings or other followon activity as result of the JHA.

5.3.2.6

Confer with Health and Safety to determine if any of the
JHA’s is regulated by a specific Corporate, Federal, State or
local standard.

A-3

Health and Safety Management System Manual

5.3.3

5.4

5.3.2.7

Forward completed JHA’s to Health and Safety staff forreview and distribution to other locations.

5.3.2.8

Forward any items in need of fixing, changing, etc., to theirrespective groups, with a copy to the Site Health and Safety
Coordinator for tracking and accountability.

5.3.2.9

Forward all items to be corrected to their respective
departments: for example safety issues to the Safety
Coordinator and process discrepancies to Quality Control,etc.

JHA Member.
5.3.3.1

Attend a JHA training session (2 hours).

5.3.3.2

Attend and participate in a monthly meeting (30 minutes).

5.3.3.3

Produce 1 JHA per month (with a partner).

5.3.3.4

Dedicate 1 to 2 hours per month for JHA activity.

JHA – How to Perform a JHA.
5.4.1

Select a specific process or activity from the JHA priority worksheet.
Those with greater exposures shall be selected first.

5.4.2

Observe the process or activity being performed.

5.4.3

Determine if the process or activity can be duly handled with one JHA.
Some processes may need to be handled in multiple JHA’s.

5.4.4

Review all written procedures or other guidance documentation.

5.4.5

Compare and evaluate all written instructions to the actual work being
performed.

5.4.6

Confer with area supervisor for input.

5.4.7

Complete the JHA worksheet as follows
5.4.7.1

Appendix A
November 2019

Document the first action in Column A of the JHA Priority
Worksheet.

A-4

Health and Safety Management System Manual

5.4.7.2

Identify sources of employee exposure to any of thefollowing Health and Safety Hazards:
5.4.7.2.1 Motion that could result in collision withpersonnel, (i.e. machinery, or processes where any
movement of tools, machine element or particles
could exist), or movement of personnel that could
result in collision with stationary objects.
5.4.7.2.2 High temperature that could result in burns or eye
injury to personnel or ignition of protective
equipment, etc.;
5.4.7.2.3 Chemical exposure (e.g. inhalation, eye and skincontact) see chemical group attachment for
guidance;
5.4.7.2.4 Harmful dust;
5.4.7.2.5 Light radiation, (i.e. welding, brazing, cutting,furnaces heat treating, high intensity lights, etc.);
5.4.7.2.6 Falling objects or potential for dropping objects;
5.4.7.2.7 Sharp objects which might pierce the feet or cut thehands;
5.4.7.2.8 Rolling or pinching objects which could crush
fingers, hands, arms, feet, etc.;
5.4.7.2.9 Poor workplace layout and location of co-workers
could cause collision;
5.4.7.2.10 Electrical hazards;
5.4.7.2.11 Trip and fall hazards;
5.4.7.2.12 Noise hazards;
5.4.7.2.13 Cumulative trauma or repetitive motion hazards.

Appendix A
November 2019

5.4.7.3

Identify and record a Safety and or Health Hazard for eachspecific action, then document in column B.

5.4.7.4

Review OSHA 300 Logs and Workers Compensation Loss
Runs to determine if there have been any injuries or
A-5

Health and Safety Management System Manual

illnesses resulting from the process or activity.

Appendix A
November 2019

5.4.7.5

Document a recommended or required safe work condition,
work practice, or personal protective equipment for eachspecific action if needed.

5.4.7.6

Submit all items for correction to the appropriate person.
Safety issues to be fixed shall not be included in the JHA.

A-6

Health and Safety Management System Manual

Description of Process /Activity

Appendix A
November 2019

Job Hazard Assessment Priority Worksheet
Safety or Health Hazard
Recommended Safe Work Condition,Work Practice or Personal Protective
Equipment

A-7

Health and Safety Management System Manual

JOB HAZARD ASSESSMENT WORKSHEET

Instructions:motion,movingparts

hightemperaturechemical
exposure

harmfuldust

lightradiation

falling
objects

sharp
objects

rolling or
pinching
objectspoor
workplacelayoutelectricalhazards

trip and fallhazards

Repetitive
motionhazards.

Refer to section 5.4.7.2 of this document for complete description of each source of exposure.
Circle “Y” for yes or “N” for no for those sources of exposure present.
Give higher priority on those items with more sources of exposure.
Give higher priority to those sources of exposure that can produce more severe injury or illness.
SOURCES OF EXPOSURE

activity orprocess

1.
2.
3.
4.

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Appendix A
November 2019

A-8

Health and Safety Management System Manual

APPENDIX B-1
Health and Safety Incident Reporting Procedure
Teledyne [company name]Category:
Classification:
Title:
Number:Revision Date:
Release Date:
Effective Date:
1.0

Health and Safety
Procedure
Incident Response, Investigation and Reporting
[TBD]
[TBD]
[TBD]
[TBD]

PurposeThis procedure describes the process for providing emergency medical response and investigating
and reporting work-related injuries, illnesses, and near miss incidents. The procedure also describes
a process for performing a root-cause analysis and identifying corrective and preventative
measures.

2.0

Scope
This procedure applies to all operations of Teledyne [company name]

3.0

PolicyIt is the policy of Teledyne [company name] to provide the most appropriate level of emergency
response and care to all occupationally injured or ill employees; to timely investigate and document
all occupational injuries, illnesses, and near miss incidents; to thoroughly evaluate such incidents sothat the root cause and contributing factors are clearly understood; and to implement the mostappropriate corrective and preventive measures to prevent recurrence.

4.0

References

Appendix B
November 2019

B-1

4.1

Health and Safety Management System Manual[Insert applicable state, provincial or federal occupational injury and illness reporting
regulatory citation, e.g. Title 29 Code of Federal Regulations Part 1904. Recording andReporting Occupational Injuries and Illness; Title 8 California Code of Regulations, §14000
et seq. Occupational Injury or Illness Reports and Records, etc.]

5.0

4.2

Supervisor’s Incident Investigation Report Instructions

4.3

Supervisor’s Incident Investigation Report

Definitions
5.1

Life Threatening: Any condition whereby delay in receiving medical attention may result infurther injury or death. Paramedics or other outside emergency services are typically notified.

5.2

Serious Injury or Illness: Any condition that requires medical evaluation, care, and/or
treatment beyond first aid, but is not life threatening.

5.3

Non-Serious Injury or Illness: Any condition that requires first aid or medical care but does
not reach the level of Serious Injury or Illness.

5.4

Incident: A generic term that is used to identify any of the following conditions: injury, illness,
exposure, and near miss events, that cause, or have to the potential to cause, bodily injury orillness.

5.5

Injury or Illness: An injury or illness is an abnormal condition or disorder. Injuries include
cases such as, but not limited to, a cut, fracture, sprain, strain or amputation. Illnesses
include both acute and chronic illnesses, such as, but not limited to, a skin disease,respiratory disorder, or poisoning.

5.6

First aid: First aid is defined at 29 CFR §1904 (b)(5)(ii) [or applicable state, provincial orfederal definition]

5.7

Near Miss: Incidents where no property was damaged and no personal injury sustained, butwhere, given a slight shift in time or position, damage and/or injury may have occurred.

6.0

General Guidelines and Principles
6.1

Emergency response and rescue, if applicable, shall be the first priority when an incident
occurs. The goal is to safely secure the incident area and protect affected individuals fromfurther harm.

6.2

Once an incident area is secure, the administration of first aid and medical care shall be thenext priority.

6.3
Appendix B
November 2019

Conditions deemed unsafe or unhealthy shall be safeguarded and corrected to prevent
B-2

recurrence.
6.4

Health and Safety Management System Manual

Required reporting and documentation shall be timely, complete and accurate as required bythis procedure and any applicable regulatory reporting requirements.

6.5

An incident investigation is intended to identify the root cause(s) of an accident or near miss
event so that appropriate corrective and preventative measures can be implemented toprevent recurrence.

6.6

All work-related injuries and illnesses must be reported to the appropriate facility personnel,e.g. Health and Safety Department (HS) and Human Resources Department (HR), and to theorganization’s workers’ compensation insurer, e.g. Zurich.

6.7

All serious injuries, illnesses and fatalities must be reported immediately to the Corporate
Legal, Risk Management and Human Resources Departments, and if required, to theapplicable state, provincial or federal Occupational Safety and Health Agency, e.g. State
OSHA, United States OSHA, United Kingdom Health and Safety Executive, CanadianCentre for Occupational Health and Safety, etc.

7.0

Responsibilities
7.1

Managers and Supervisors
7.1.1

Immediately report all incidents to the Health and Safety Department “HS” and the
Human Resources Department “HR”.
7.1.2 In the event of injury or illness, ensure proper action is taken to provide injured
employee with proper first aid or medical care.
7.1.3 In conjunction the HS and HR, complete a Supervisor Incident Investigation Reportin accordance with the form instructions, and provide a copy of the completed andsigned report to HS and HR no later than 24 hours from date/time of incident.
7.1.4 Collect and preserve all evidence that may be useful in an investigation.
7.1.5 Conduct interviews with the injured or ill employee (if possible) and witnesses.
7.1.6 Ensure all assigned corrective and preventative measures have been completed.
7.2

Employees
7.2.1
7.2.2
7.2.3

8.0

Immediately report all incidents, injuries and illnesses to area(supervisor/manager/HS/HR).
Assist as requested in all incident investigations.
Report all injuries and illnesses, hazardous conditions and near-miss incidents toyour supervisor.

Procedure
8.1

Appendix B
November 2019

Initial Response
B-38.1.1

Health and Safety Management System ManualLife threatening or Serious Injury or Illness

8.1.1.1 Assess the situation. Ensure that the employee(s) are safe from all conditions
that could cause harm or worsen their condition.
8.1.1.2 Notify public safety (i.e. call 911)
8.1.1.3 Notify HS, HR and Emergency Response Team for assistance. See Exhibit
B for contact information. Refer to company Emergency Response Plan.
8.1.1.4 If safe to do so, stay in the area and provide assistance if needed until
emergency services arrive and take control.
8.1.1.5 Control hazards, preserve the scene and secure equipment and materials that
may have caused or contributed to the incident.
8.1.1.6 HS shall notify the corporate legal department and government agencies as
required for serious injuries or illnesses. Refer to state or federal regulations
regarding the immediate reporting of fatalities and serious injuries.
8.1.2

Non-Serious Injury or Illness
8.1.2.1 Assess the situation. Ensure that the employee(s) are safe from all conditions
that could cause harm or worsen their condition.
8.1.2.2 Notify HS, HR and Emergency Response Team for assistance.
8.1.2.3 Control hazards, preserve the scene and secure equipment and materials that
may have caused or contributed to the incident.
8.1.2.4 During normal working hours (e.g., Monday through Friday 8 AM to 5 PM),the employee reporting the injury should contact HS and HR then proceed tothe appropriate offsite medical clinic as directed by management. See
Exhibit A for offsite medical clinic location map.
8.1.2.5 During other working hours, the employee reporting the injury should
contact the onsite shift supervisor then proceed to the appropriate offsite
medical clinic as directed by management.

8.1.3

Near Miss Events
8.1.3.1 All near miss events as defined in this procedure shall be reported to area
supervisor and HS.

8.2

Follow Up Investigation
8.2.1

8.2.2
Appendix B
November 2019

Upon employee notification or knowledge of an incident, the area supervisor, inconjunction with HS, HR, the Safety Committee and/or cognizant engineer(s), (i.e.
the “Incident Investigation Committee”) shall conduct an incident investigation anddocument findings in the Supervisor’s Incident Investigation Report. Instructions
for completing the report are provided in the Supervisor’s Incident Investigation
Report Instructions.
The Supervisor’s Incident Investigation Report shall identify all probable causes of,and factors that contributed to, the incident.
B-4

Health and Safety Management System Manual

8.2.3

Corrective and preventive measures shall be identified and implemented to prevent
incident recurrence.
8.2.4 Target dates shall be established for implementing corrective and preventive
measures.
8.2.5 Responsibility for implementation shall be assigned to the appropriate individual(s)8.3Verification of Corrective and Preventative Action
8.3.1

8.4

Return to Work
8.4.1

9.0

The area supervisor, HR and HS will review the report and confirm all required
information is recorded and that all corrective and preventive measures have been
implemented in a timely manner.

If an employee is on Workers’ Compensation because of a job related injury/illness andis temporarily unable to perform his or her regular duties because of a temporary
physical, mental or emotional impairment, the Company, consistent with its
obligation(s) under applicable law, will attempt to accommodate the employee’s work
restrictions, including, but not limited to, considering and/or assigning alternative duties
and responsibilities to encourage the employee back to work.

Recordkeeping
9.1

Copies of Supervisor’s Incident Investigation Reports shall be maintained by the HR
department.

10.0 Training/Information Distribution
10.1 All employees shall receive initial and recurrent training on their responsibilities under thisprocedure.
10.2 Recurrent training shall be conducted annually for managers, supervisors and other
employees who have Supervisor’s Incident Investigation Report preparation responsibilities.
10.3 Recurrent training on the requirements of Section 7.2 – Employee Responsibilities shall be
conducted annually for all other employees. Electronic or paper copy notifications toemployees concerning their responsibilities under Section 7.2 will satisfy the annual training
requirement.
11.0 Transportation
11.1 The supervisor, HS and/or HR shall make transportation arrangements for the injured or ill
employee and ensure that the employee receives prompt medical attention. Injured or ill
Appendix B
November 2019

B-5

Health and Safety Management System Manual

employees should be discouraged from self-transportation. Transportation arrangements
include, but are not limited to: ambulance, company or personal vehicle driven by someone
other than the injured or ill employee, e.g. supervisor, manager, HR, HS, on-site nurse, other
employee, etc., taxi, chauffer, etc.

Appendix B
November 2019

B-6

Health and Safety Management System Manual

EXHIBIT A[Insert facility map]
[Insert medical/MPN clinic map]

Appendix B
November 2019

B-7

Health and Safety Management System Manual

EXHIBIT B

HS Department Contact Information:
Name
Title
[insert HS contact][insert HS contact]

Phone

HR Department Contact Information:
Name
Title
[insert HR contact][insert HR contact]

Phone

Emergency Response Team (ERT) Contact Information:
Name
Title
[insert ERT contact][insert ERT contact]

Appendix B
November 2019

B-8

Phone

Health and Safety Management System Manual

APPENDIX B-2
Supervisors Incident Investigation Report General Instructions:•

The Supervisors Incident Investigation Report (the “Report”) requires the collection and documentation ofcertain incident information including: personal information (if other than a near miss), incident
classification, medical treatment (if other than a near miss), cause analysis and corrective and preventive
measure information. Certain information, e.g. personal and medical treatment information, should be kept
confidential.

•

The Report requires input from various personnel including, but not limited to, the injured employee, theSupervisor, the Human Resources Department (HR), the Health and Safety Department (HS), and if
applicable, the Safety Committee, cognizant engineer(s) and/or other personnel, e.g. incident witnesses.

•

The report is deemed complete only after it has been reviewed and approved by the Supervisor, HR and HS.

•

Questions 1 through 20 are to be completed by the area supervisor, with assistance if necessary, from the
HR and HS.

•

Questions 21 through 32 are to be completed by HR and follow-up must be completed within seven (7) daysof the incident.

•

Questions 33 through 38 are to be completed by the Incident Investigation Committee, e.g. supervisor, HR,HS, cognizant engineer(s), and/or safety committee, as applicable.

•

The Report shall be completed as soon as possible after the incident. The goal should be to complete thereport within 24 hours of the incident, however, additional time may be necessary to collect all relevant
information, perform a root-cause analysis and identify corrective and preventative measures.

•

Notify HR and HS if the report cannot be completed within 24 hours.

•

Contact HR or HS if you need assistance with the report.

•

Follow-up as necessary and confirm all corrective and preventative measures have been implemented.

Line Item Instructions:
Questions 1 through 20 (Personal and Incident Information) are to be completed by the supervisor.
1. State the employee's full name.
2. State the employee's gender.
Appendix B
November 2019

B-9

Health and Safety Management System Manual

3. Enter the time the employee started work on the day the incident occurred.

4. State the employee's ID number as it appears on his/her identification badge.
5. State the employee's job title.
6. List the employee's normal work hours. For example, 7 to 4 p.m.
7. State the employee's department name.
8. Indicate specific area/room number where the employee works.
9. List the employee's work telephone extension number.
10. Check the appropriate incident classification for this report. Use the following definitions as a guide:a. INJURY - A condition where the employee is suffering from bodily damage such as wounds, cuts,
scrapes, punctures, strains, sprains, breaks, etc.
b. ILLNESS - A condition where the employee has symptoms, such as: skin or eye irritation,dermatitis, headaches, dizziness and nausea, allergic reactions, aching pain and numbness in thehands, etc.
c. EXPOSURE - Complaints from the employee about the following: excessive noise levels, highfrequency sounds, radiation, vapors and fumes, extreme heat or extreme cold, indoor air pollution,
poor air circulation, etc.
d. NEAR MISS - Situations where injury, illness, or exposure could have occurred.
11. Based on your knowledge at the time, check if the incident is work related or not.
12. Record the incident date. If the exact incident date is not known, record the date given by the employee.
13. Record approximate time of the incident.
14. Record date the incident was reported. All incidents must be reported to HR & HS. If incident is reported
to carrier, indicate when it was reported.
15. Record who the incident was reported to initially (generally Supervisor/Management). All incidents must
be reported to HR & HS. If incident is reported to carrier, indicate who reported it to the carrier.
16. Record the exact location of the incident; include specific area or room number. Indicate if employee wasworking in a temporarily assigned work area.
17. Check the item that best describes the type/cause of injury or illness. Check "Other" and write-in your best
description if none of the items fit.
18. Check the item that best describes the nature of injury or illness. Check "Other" and write-in your best
description if none of the items fit.
19. Identify the object or substance that directly harmed the employee, e.g. concrete floor, chlorine gas, radialarm saw, knife blade, etc.
Appendix B
November 2019

B-10

Health and Safety Management System Manual

20. Be precise in identifying the body part affected by the injury or illness. A diagram is provided, however
you may sketch your own if appropriate. Fill in comments to assist in explanation of injury/illness.

Questions 21 through 32 (Treatment, Follow-up and OSHA Form 301) are to be completed by HR
21. Check the type of care or treatment received.
22. State the method of treatment administered.
23. Indicate whether lost time beyond the day of injury was incurred. Track the number of days away fromwork.
24. Indicate whether restrictions or modified duty was prescribed by treating physician.
25. Date employee was released by the treating physician to return to normal work schedule.
26. Enter the employee’s date of birth.
27. Enter the employee’s address.
28. Enter the date the employee was hired.
29. Was the employee treated in an emergency room? Enter yes or no.
30. Was the employee hospitalized overnight as an in-patient? Enter yes or no.
31. Enter the case number from the OSHA 300 log (OSHA Form 300)
32. If the employee died, enter the date of death.
Questions 33 through 38 are to be completed by the Incident Investigation Committee, e.g. supervisor,
HR, HS, cognizant engineer(s), and/or safety committee, as applicable.
33. Describe task/activity the employee was performing when the incident occurred.
34. To the best of your knowledge, describe in detail how the incident occurred.
35. Use the diagram or your own sketch and comments section to assist in explanation of incident details. Takephotographs, if appropriate, note photographs taken in comments section, and attach hard copies orelectronic files.
36. To the best of your knowledge, list and/or describe all direct and root causes of the incident. Include any
unsafe acts or conditions.
Examples of unsafe conditions include, but are not limited to: unguarded hazard, inadequate guard,
defective safety device, defective tool or equipment, hazardous workstation layout, inadequate lighting,inadequate ventilation, lack of personal protective equipment, inadequate or inappropriate tools, unsafe
clothing, no or insufficient training, etc.
Appendix B
November 2019

B-11

Health and Safety Management System Manual

Examples of unsafe acts include, but are not limited to: operating equipment or process without permission,
operation at unsafe speeds, servicing equipment that has not been properly de-energized and locked out,
making a safety device inoperative, using tools or equipment in an unapproved manner, improper lifting,taking an unsafe posture or position, distraction/teasing/horseplay, failure to wear personal protective
equipment, failure to use the correct tools, etc.
37. To the best of your knowledge, list and/or describe all indirect causes of the incident, e.g. factors that
contributed to the incident. Contributing factors are not direct causes, but an incident may have been
avoided or been less serious had these contributing factors not been in place. Include information on why anunsafe act or condition existed.
38. Describe measures that will be taken to correct any problems and prevent recurrence.
Examples of corrective and preventive measures include, but are not limited to: stopping the activity,
training the employee and other affected personnel, enforcing existing policy, develop and implement a newpolicy, design and install a guard, routinely inspect for the hazard, replace tools or equipment, redesign
work/task steps, redesign workstation/workplace, provide personal protective equipment, etc.
Corrective Action Plan:-

List corrective action items-

Enter target dates for each action items-

Assign the person who is responsible for each action item-

Enter the date each action item was completed

Review Signatures:-Enter the name, signature, title and date for reviewers.

-

Supervisor, HR & HS signatures are required.

Employee Statement (to be completed by injured employee)-

Detach form and give to injured employee-

Ask employee if they are comfortable filling the form out in English. If not, it is OK to fill out innative language.

-

Ask employee to complete and return statement within 24 hours.

-

Indicate if assistance (reading/writing/comprehension) was provided-

Indicate if translation assistance was provided-

Signatures are required

Witness Statement (to be completed by witness)
Appendix B
November 2019

B-12

Health and Safety Management System Manual-

Detach form and give to employee-

If more than one witness, then each witness must complete a separate form individually-

Ask witness if they are comfortable filling the form out in English. If not, it is OK to fill out innative language.

-

Ask witness to complete and return statement within 24 hours.

-

Indicate if assistance (reading/writing/comprehension) was provided-

Indicate if translation assistance was provided-

Signatures are required

APPENDIX B-3
Supervisors Incident Report Form
Personal Information (Completed by Supervisor)
1. Name:2. Gender:

3. Time employee began work:

4. Employee ID#:

5. Job Title:

6. Work Hours:

7. Department Name:

8. Work Area Area/Room#:

9. Work Ext:

Incident Information (Completed by Supervisor)
10. Incident Classification:
Death

InjuryIllness

11. Work Related:
No

Near Miss

Yes
Unknown

Other (describe)

If unknown provide comments:

12. Date of Incident:

13. Time of Incident:

14. Date Incident Reported:a. to Supervisor on dateb. to HR on datec. to HS on dated. to insurance carrier on date

15. Incident Reported:a. to Supervisor by nameb. to HR by namec. to HS by named. to insurance carrier by name

16. Incident Location:
17. Incident/Injury/Illness Type:
Slip/Trip
Exposure

Struck all

Falls all

Object in eye

Crush
Exposure

ImpactMotor vehicle

Other:___________________
18. Injury or Illness Nature:

Appendix B
November 2019

B-13

Step on/in
Repetitive motion

Caught all

Chemical
Hot/ColdHealth and Safety Management System Manual
Cut/Laceration

Avulsion

Amputation

Fracture

Sprain/ Strain

Dermatitis

Puncture

Abrasion

Irritation

Contusion

Numbness

StressOther:______________
19. Identify the object or substance that directly harmed the employee:

20. Specifically name the body part affected (e.g. rightelbow, left index finger, upper back, etc.):

Appendix B
November 2019

Comments:

B-14

Health and Safety Management System Manual

Treatment (completed by HR)
21. Type of Treatment:

NoneFirst Aid

22. Treatment administered by (Name of clinic):

MedicalOther

In house by
Onsite Nurse/Physician
Self explain
Emergency Response Team explain
Other explain

Off site by
Personal Doctor: name & contact info
Occupational Health Clinic (MPN): name & contact info

Follow Up(Must be completed by HR within seven (7) days of incident)
23. Was there lost-time beyond first day?

Yes

No

If so, track number of days away from work:
24. Did physician prescribe work restrictions?

Yes

No

If so, explain and track the number of days of job transfer or restricted work:
25. Date employee returned to normal work schedule:

OSHA Form 301 Required Information (completed by HR)
26. Employee date of birth:
27. Employee Address:
28. Date Employee Hired:
29. Was the employee treated in an emergency room?
30. Was the employee hospitalized overnight as an in-patient?
31. Case number from OSHA 300 log:
32. If the employee died, when did the death occur?

Appendix B
November 2019

B-15

Health and Safety Management System Manual

Incident and Cause Analysis (completed by incident investigation committee)
33. What specific activity was the employee performing when the incident occurred (e.g. welding, painting, loading, etc.)?

34. Describe in detail how the incident occurred:

35. Sketch or diagram if needed to add clarity:

Comments:*add photos if appropriate

36. List and describe incident cause(s); include any unsafe acts or conditions:37. List and describe contributing factors to the incident:

Appendix B
November 2019

B-16

Health and Safety Management System ManualCorrective and Preventative Measures(completed by incident investigation committee)
38. Describe measures that will be taken to correct any problems and prevent recurrence.
Corrective and Preventive Measure

Target Date

Responsible Person

DateCompleted

Title

Date

Review Signatures
Reviewed By:

Name

Signature

Supervisor:
HR Dept.
HS Dept.

Appendix B
November 2019

B-17

Health and Safety Management System Manual

Employee Statement (Detach and give to employee)

Describe what happened:

Comments:

Feel free to make any other sketches or diagrams to add
clarity:*add photos if appropriate

Do you have any suggestions on how this could be avoided in the future?

Review Signatures
Signature
Completed By: Employee name
Assisted By: Employee name
Translated By: Employee name
Received By: Employee nameAppendix B
November 2019

B-18

Title

Date

Health and Safety Management System Manual

Witness Statement (detach and give to witness)

Describe what happened:

Do you have any suggestions on how this could be avoided in the future?

Make any sketches or diagrams to add clarity:

Review Signatures
Signature
Completed By: Employee name
Assisted By: Employee name
Translated By: Employee name
Received By: Employee nameAppendix B
November 2019

B-19

Title

Date

Health and Safety Management System Manual

APPENDIX C
Attorney-Client Privilege
andAttorney Work Product Privilege
Confidentiality
The need for confidentiality when working in the health and safety area is paramount. Obviously,
there are many things, which must be written down in order to do your job. But, every effort should
be made to communicate information verbally where possible, and avoid committing to writing
unnecessary or sensitive information regarding your Facility and its operation. When you must
write information, limit your writing to facts. Avoid transmitting unnecessary or sensitive written
information to outside consultants. If, after consultation with the Corporate Legal Department, it isdetermined that such information must be transmitted to a consultant, oral communications with
consultants are preferable. In many health and safety matters, you will want to have counsel retain
outside consultants.
If you become aware of adverse information, do not discuss the information with personnel at your
Facility. Take any necessary emergency action to prevent harm to employees, the public, or theenvironment, then immediately call the Corporate Legal Department and discuss the information withan attorney. Your communication with counsel, if conducted properly, will protect thecommunication from disclosure in any adversarial situation. As discussed in greater detail below, theattorney-client privilege and the attorney work product doctrine are useful in protecting you and thepeople for whom or with whom you work.

AuditsAudits of your Facility or other health and safety investigations of your Facility need to be conductedin a highly confidential manner under the direction of counsel. If you wish to have a Facility audit orinvestigation to assess your level of compliance with health and safety requirements contact the
Corporate Legal Department in order to arrange for an audit.

What is a Privileged Communication?
Unlike other communications, a privileged communication is a communication between an
attorney and usually his or her client that is protected from disclosure in adversarial situations,
including litigation. In other words, the content of the communication will be kept confidential.

Appendix C
November 2019

C-1

Health and Safety Management System Manual

What Does the Attorney-Client Privilege Cover?
The attorney-client privilege covers confidential oral and written communications between
attorney and client, which relate to the legal advice being sought. Thus, any lawyer-client
communications that are outside the scope of legal advice are not protected.
Who Holds the Privilege – The Client or the Lawyer?
The privilege belongs to the client, who may refuse to reveal, or prevent another from revealing,
the confidential communication. Absent directions from the client to waive the privilege, anattorney generally must assert the privilege on behalf of the client. You should be aware that you
can intentionally or unintentionally waive the privilege by failing to observe the formalities ofmaintaining the privilege. One way to waive the privilege is if the client does not keep theircommunications confidential.
Why Was the Attorney-Client Privilege Created?
The privilege promotes full and open communication between lawyer and client without
apprehension that later disclosure can be compelled without the client’s consent. Without full
discussion with the client, the lawyer cannot give reliable or effective legal advice.
What Does the Attorney Work Product Doctrine Protect?
The attorney work product doctrine creates a qualified (i.e., not absolute) privilege for the work
papers, notes, memoranda, and reports gathered or prepared by or for counsel or their agents inanticipation of litigation.
What Does the Attorney Work Product Doctrine Not Protect?
Any material that is considered to be part of the underlying facts or evidence may not be deemed
work product. This material includes, for example, the identity or location of evidence, andmaterial objects that can be used as evidence.
Does the Attorney Work Product Doctrine Apply to Documents Prepared Before Litigation Is
Threatened?
Yes. If documents are prepared because of a concern about the potential for litigation, even if
they were prepared before litigation first was threatened, the privilege would apply. Thus, thework product doctrine can be a particularly effective tool in maintaining the confidentiality ofAppendix C
November 2019

C-2

Health and Safety Management System Manualinternal corporate investigatory reports. Documents and materials gathered in the course of aninternal corporate investigation, before litigation is actually threatened, may be considered tohave been prepared in anticipation of litigation.
Why Was the Attorney Work Product Doctrine Created?
Courts have recognized that an attorney’s or consultant’s preparation in anticipation of litigationor for trial should be protected to encourage pretrial investigation and analysis of facts without
fear that the information obtained or theories developed could be used to help an adversary’s
position.
Who Decides if the Privileges Apply in a Particular Case?
As a question of law, the court ultimately determines whether the privileges apply.
May the Attorney-Client and Attorney Work Product Privileges Be Waived?
Yes. The privileges may be waived through authorized or unintentional disclosure to certain third
parties either orally or through circulation of written materials. Unauthorized disclosure, such as
when documents are stolen or misappropriated, does not waive the privileges.
In the case of the attorney-client privilege, the essential element of confidentiality may be lost if
the communication occurs in the presence of third parties who have no legitimate reason forbeing there. Such third parties would not include your secretary or clerk, or a consultant retained
to assist the lawyer in advising his client, but would include parties copied on an otherwise
privileged communication with counsel.
May Communications With a Consultant Usually Be Protected From Disclosure?
Yes, generally not by the attorney-client privilege; instead, such communications may beprotected by the attorney work product doctrine.
The federal work product doctrine protects materials compiled, prepared or analyzed both bylawyers and non-lawyers, including consultants. It is not required that the documents be prepared
under the direction of an attorney in order to be privileged; however, if materials are prepared bya consultant who is not working under an attorney’s supervision, there is a risk that the
documents will be found to have been prepared in the ordinary course of business and not in
anticipation of litigation.
Does the Attorney Work Product Doctrine Apply If the Consultant Becomes a Witness?
No. Any consultant who is slated to testify at trial may be deposed and thus asked about any
opinions offered and the bases for those opinions. On the other hand, any facts known or
opinions held by a consultant who has been retained by a party in anticipation of litigation, but
who will not be called to testify at trial, constitute protected work product. Therefore, if it isAppendix C
November 2019

C-3

Health and Safety Management System Manual
anticipated that a consultant may be needed to testify as an expert witness, it may be desirable tohire two consultants: one to use generally and one for the limited purpose of expert testimony.
What Are the Rules For Maintaining the Attorney-Client Privilege?
Communicate information only to counsel. If communicated orally, other supervisory personnel
may be present. If communicated in writing (including via e-mail), NO OTHER PARTY MAY
BE COPIED.
If communicated in writing (including via e-mail), the following must appear on page one:
CONFIDENTIAL AND PRIVILEGED ATTORNEY-CLIENTCOMMUNICATION; or
CONFIDENTIAL; LEGALLY PRIVILEGED
The body of the writing should begin with substantially these words:"The following information is being provided to you in order to enable you torender legal advice in connection with this matter."Appendix C
November 2019

C-4

Health and Safety Management System Manual

Appendix D
Regulatory Inspection – Surprise or Scheduled
1. Introduction
When representatives of an health and safety regulatory agency arrive at your Facility to conduct anunanticipated inspection or audit of the Facility’s health and safety management practices or toinvestigate a death, serious injury, or serious health and/or safety mishap you need a responsive planof action. This Appendix sets forth a model response plan.
In general, most major federal health and safety laws specifically provide federal inspectors theauthority to enter facilities, review records and collect samples. State, county or city laws andregulations similarly authorize inspections by state and local inspectors.
The bywords in any inspection are "COOPERATION" and "BE POLITE." If Facility personnel
attempt to deny access to an inspector or allow a visit to become adversarial or antagonistic causing
the inspectors to leave the site, the inspection may continue later under authority of a search
warrant. If Facility personnel are adversarial or evasive, the inspectors’ curiosity will be aroused.
As a result, the inspectors may spend more time at the Facility, investigate Facility operations moreclosely, and be more likely to issue a violation for marginal non-compliance. A cooperative
working relationship between the inspectors and Facility personnel will simplify any investigationand contribute to development of a positive working relationship.
2. Death, Serious Injury or Serious Health and/ or Safety Mishap
It is important to note that, in the case of potential criminal liability, while maintaining acooperative attitude, you are not required to respond to questions without the advice of counsel.
Therefore, it is imperative that, IN THE CASE OF DEATH, SERIOUS INJURY OR SERIOUS
HEALTH AND/OR SAFETY MISHAP, you notify the Corporate Legal Department
immediately. You should request that counsel be present and Counsel should be present
during the inspection.
It is TDY’s policy to cooperate with regulatory and law enforcement authorities in the course ofinvestigations. However, in situations involving potential criminal liability, individuals have
Constitutional rights and TDY in no way intends for its cooperation to interfere with the rights of its
employees.
If an employee is contacted at home or at work by federal, state, provincial, local, etc. law
enforcement agents, (either domestic or international), the employee has the right (1) to choose
whether he or she wishes to be interviewed, (2) to request at any time that the interview be
Appendix D
November 2019

D-1

Health and Safety Management System Manual
terminated, (3) to request that the interview be held at a different time or location. The employee
also has the right to consult with either Corporate Legal Department attorney or his or her own
attorney before an interview and may insist that an attorney be present during any interview. In allcases, the agent must honor the employee’s request. If an employee is interviewed, the employee
must tell the truth to the best of his or her recollection.
If agents are seeking to execute a properly issued search warrant, the Facility and its employees
must furnish the materials requested in the search warrant. The Corporate Legal Department should
be contacted, and counsel should be present.
3. Model Response Plan for Regulatory Inspection
This section sets forth a model for a responsive plan of action. Note that this model approach works
equally well for scheduled or surprise inspections. The model can be customized for a Facility’s
individual circumstance. However, any customized response plan should be discussed with the
Corporate Legal Department prior to its implementation.
3.1

Inspection Response Team. Each Facility should designate an Inspection Response Team("IRT") to respond to surprise or scheduled inspections at the Facility. The IRT should
consist of at least two supervisory level employees familiar with the Facility’s production
processes and waste management practices. When responding to an inspection, the IRT
members should each have in their possession the following items:••••

A note pad;A hand-held tape recorder;
A camera with flash attachment; andA solid/liquid material sample collection kit.

3.2

Signing In. The Facility’s security guard or receptionist should have each regulatory agency
inspector present his or her credentials and sign the visitors’ log with his or her full name,title, date of arrival and time of arrival. In the event the Facility has national security
information, or is otherwise restricted or classified for security purposes, the investigatorshould be required to provide proof of appropriate security clearance before being allowed toenter restricted or classified areas. During the sign-in, the guard or receptionist should alert
the IRT. The guard or receptionist should advise the inspectors that appropriate Facility
representatives will meet them at the gate (or in the lobby) momentarily.

3.3

Meeting the Inspectors. The IRT should greet the inspectors at the gate (or in the lobby).
Upon greeting the inspectors, the IRT should politely ask:•

What the purpose of the inspection is;Appendix D
November 2019

D-2

Health and Safety Management System Manual
•
•
•
•
•
•
•

What the authority for the inspection is;
What the Facility’s rights are;
Whether the Facility or any employee at the Facility should have Corporate LegalCounsel present;
What portions of the Facility they would like to visit;
Whether they intend to take photographs, collect samples, copy documents and/orinterview employees;
Whether the IRT may have "splits" of any samples collected by the inspectors; andIN THE CASE OF DEATH, SERIOUS INJURY OR SERIOUS HEALTH AND/ OR
SAFETY MISHAP, whether they will delay the commencement of the inspection for areasonable time to allow for the arrival of the Facility’s Corporate or retained legal
counsel.

Preferably, the IRT will tape record these questions and answers. At a minimum, the IRT willtake extensive notes.
3.4

Press and Media Inquiries. The IRT will politely refuse access to any media representatives
who wish to accompany the inspectors and, at the first opportunity, should advise the
Corporate Media Contact of the situation. All requests for information from the media should
be referred to the Corporate Media Contact.

3.5

Keeping Together. As the inspection begins, the IRT will ask the inspectors to stay together.
If the inspectors do so, one member of the IRT will lead the inspectors through the requested
portions of the Facility, while the other IRT member notifies the Corporate Legal Department.
If the inspectors refuse to stay together, the IRT should temporarily delay notifying counsel
until additional properly equipped Facility personnel can be located to accompany eachindependent inspector or group of inspectors.

3.6. During The Inspection. During the course of the inspection, the IRT should ask to tape record
all conversations involving the inspectors – or, at a minimum, take extensive notes. Only themost innocuous questions should be answered on the spot. All other questions should be
deferred until the end of the inspection visit so that answers may be discussed in advance withan attorney in the TDY Legal Department. During the course of the inspection, the IRT
should:• Photograph everything photographed by the inspectors;• Duplicate sample everything sampled by the inspectors;• Duplicate copy every document copied by the inspectors; and• Make careful notes concerning those portions of the Facility seen by the inspectors
3.7

Documents. The IRT should number all documents reviewed by the inspectors. AttorneyClient privileged documents should never be produced under any circumstances. (SeeAppendix E for a discussion of the Attorney-Client Privilege.) The IRT should refuse to
produce any arguable privileged document to the inspectors until that document has first beenreviewed by counsel. In addition, trade secret documents should not be produced unless anduntil counsel has negotiated an appropriate protective agreement with the inspectors.

3.8

Employee Interviews. An IRT member should be present whenever an inspector interviews
any Facility employee. If, for any reason, this is not possible, an IRT member should de-brief
interviewed Facility employees immediately after completion of the inspection.

Appendix D
November 2019

D-3

Health and Safety Management System Manual
3.9

Signing Out. Upon the conclusion of the inspection, the IRT should accompany the inspector
to the gate or lobby where they entered the Facility. The IRT should ask the inspectors:
•
•
•
•
•
•
•

What they found during the inspection?
What significance they attach to their findings?
What plan of action they intend to pursue?
What laboratory they are taking any solid or liquid samples to for analysis?
Whether they would give the IRT a copy of their inspection notes?
Whether they would send the IRT a copy of the laboratory analysis report and/or their
final inspection report?
The IRT should then have the inspectors sign out at the visitors’ log.

3.10 After the Inspection. Following the inspection, the IRT should immediately review theinspection with counsel. The IRT should follow counsel’s advice concerning the separate
storage and preservation of the notes, photographs, samples and tapes generated during theinspection.
4. Checklist For Regulatory Inspections
4.1

Before the Inspection• Be polite at all times;• Have the inspectors present their credentials, and sign-in;• Ask what the authority for the inspection is;• Ask what the purpose of the inspection is; and• IN THE CASE OF DEATH, SERIOUS INJURY OR SERIOUS HEALTH AND/ OR
SAFETY MISHAP, notify the Corporate Legal Department immediately. In-house orretained counsel should be present during the visit.

4.2

During the Inspection•

The IRT should make every effort possible to have at least two people accompany theinspectors at all times – one to act as scribe-recording all questions asked and all responses.
If the inspectors are interviewing an employee, have an attorney or an Operating Segment
representative present. Alternatively, interview the employee after the government
inspector is done with the employee, including any people previously interviewed prior to
the inspections (e.g., at their homes after working hours);•

Check documents for attorney-client privileged communications and for trade
secrets/business confidentiality;•

Number every document the inspectors review;•

Be cooperative and polite but know that you do not have to say anything;•

If the inspectors ask you questions you can refer them to the relevant documents and ask
that they hold their questions until the end of the day;•

It is best not to answer any "why" questions:

Appendix D
November 2019

D-4

Health and Safety Management System Manual
•
•

4.3

4.4

Ask the inspectors to submit those in writing; orAsk them to save any "why" questions to be asked at the end of the inspections.
Record all "why" questions and discuss answers with counsel before responding, if
possible.

Before the Inspectors Leave•

Ask the inspectors for all split samples, photos, copies of notes and other materials
generated during the inspection;•

Ask for a copy of any reports they are preparing for internal or external use and a copy ofany data, lab results, etc.; and•Try to get as much information from them as possible to identify areas of potential
violation.
After the Inspectors Leave•

Immediately review the inspection with counsel.

•

Follow information retention guidelines given to you by counsel.

Appendix D
November 2019

D-5

Health and Safety Management System Manual

Appendix E
Management of Change (MOC) Triggers Guidelines
Examples of change criteria (i.e., MOC triggers) that trigger health and safety reviews include,
but are not limited to, the following.
1. Raw Materials
•
•
•
•
•

Request for a new material;
Request for a new use for an existing material;
Significant change in the quantity used of an existing material;
Materials that are purchased or received free as samples or for use on a trial basis, or usedby an outside contractor, or materials bought on one-time basis; orDeletion of a material from inventory.

2. Products••

The addition or deletion of a product line; or
A change in the customer’s end use of a product.

3. Processes••

Request for addition, deletion or change to an existing process including changes tooperating parameters (e.g. ranges of temperatures, pressure, hours of operation, etc.); or
Request for a new use of an existing material or an equipment.

4. Facilities (including equipment and maintenance activities)
Changes that will add, delete, relocate or modify any of the following:
•
•
•
•
•
•
•

Machinery or equipment;Interior walls;
Sidewalks/ employee walkways;
Recreational, cafeteria or break areas
Ventilation
Fire suppression systems
Electrical system

Appendix E
November 2019

E-1

Health and Safety Management System Manual

5.

Personnel••••

New hires;
Termination of an employee;
Significant change in number of hours worked by an employee; orTransfer of an employee from/to a different position.

6. Corporate or Operating Segment Requirements•

Issuance of a new policy or procedure; or•Deletion of an existing policy or procedure.

7. Federal, State, and Local Regulations•

Deletion, issuance, or changes to applicable federal, state, or local regulations.

8. Permits•

Application or receipt of any new or modified permit.
It is recommended that facilities identify existing change documents (e.g. engineeringchange orders and directives, purchase requisitions, bid decisions and proposals, design
documents, Facility work orders, maintenance requests, employee transfer requests,
new employee requisition forms, etc.,) and incorporate health and safety review into thechange approval process. For example, a Facility work order could have a check box toindicate that a health and safety review was performed and the requested work hasreceived the Facility Health and Safety Manager or Team’s approval.

Appendix E
November 2019

E-2

Health and Safety Management System Manual

Appendix F
Annual Health and Safety Compliance Certification

Refer to the Teledyne Environmental Management System Manual, Appendix H – Form ofCompliance Certification, November 2019 edition.

Appendix F
November 2019

F-1

Health and Safety Management System Manual

Appendix G
Summary of Major Federal Health and Safety Statutes and Regulations

United States
Description of Occupational Safety and Health Regulatory Framework
Workplace safety and health laws for the U.S.A are contained primarily in federal and statestatutes (federal laws and regulations/standards pre-empt state ones where they overlap or
contradict one another.) This database is concerned only with federal legislation.
The main law protecting the health and safety of workers is the Occupational and Safety HealthAct 1970, which covers commercial workplaces and, like other federal statues, is codified bysubject matter in the United States Code (U.S.C.) A number of regulations relate to the duty offederal agencies towards their employees. Federal regulations/standards contain both detailed
provisions and interpretations of provisions in the OSHA and other Acts. These final rules arecodified when added to the Code of Federal Regulations (CFR) and those relating to
occupational safety and health currently fill five volumes of the Code of Federal Regulations,which is revised annually on July 1.
The Occupational Safety and Health Administration (OSHA), is the agency of the Department ofLabor, which sets and enforces general workplace health and safety standards. However, otherfederal agencies also establish safety and health regulations relating to their own areas ofconcern.
Occupational Safety and Health Act
Statute: 29 U.S.C Sec 651 et seq. (1970)
Regulations: 29 Code of Federal Regulations
Administering Agency: Occupational Safety and Health Administration (OSHA)The Occupational Safety and Health Act (the “OSH Act”) was established to assure safe andhealthful working conditions for working men and women; by authorizing enforcement of thestandards developed under the Act; by assisting and encouraging the States in their efforts toassure safe and healthful working conditions; by providing for research, information, education,and training in the field of occupational safety and health; and for other purposes.

Appendix G
November 2019

G-1

Health and Safety Management System Manual

Regulations Applicable to General Industry and Construction
29 CFR PART 1904 -- Recording and Reporting Occupational Injuries and Illnesses
Subpart A -- Purpose
Subpart B -- Scope
Subpart C -- Recordkeeping Forms and Recording Criteria
Subpart D -- Other OSHA Injury and Illness Recordkeeping Requirements
Subpart E -- Reporting Fatality, Injury and Illness Information to the Government
Subpart F -- Transition From the Former Rule
Subpart G -- Definitions
29 CF PART 1910 -- OCCUPATIONAL SAFETY AND HEALTH STANDARDS
Subpart A -- General
Subpart B -- Adoption and Extension of Established Federal Standards
Subpart C -- [Removed and Reserved]
Subpart D -- Walking - Working Surfaces
Subpart E -- Exit Routes and Emergency Planning
Subpart F -- Powered Platforms, Manlifts, and Vehicle-Mounted Work Platforms
Subpart G -- Occupational Health and Environmental Control
Subpart H -- Hazardous Materials
Subpart I -- Personal Protective Equipment
Subpart J -- General Environmental Controls
Subpart K -- Medical and First Aid
Subpart L -- Fire Protection
Subpart M -- Compressed Gas and Compressed Air Equipment
Subpart N -- Materials Handling and Storage
Subpart O -- Machinery and Machine Guarding
Subpart P -- Hand and Portable Powered Tools and Other Hand-Held Equipment.
Subpart Q -- Welding, Cutting, and Brazing.
Subpart R -- Special Industries
Subpart S -- Electrical
Subpart T -- Commercial Diving Operations
Subparts U -- Y [Reserved]
Subpart Z -- Toxic and Hazardous Substances
29 CFR PART 1926 -- SAFETY AND HEALTH REGULATIONS FORCONSTRUCTION

Appendix G
November 2019

G-2

Health and Safety Management System Manual

Subpart A -- General
Subpart B -- General Interpretations
Subpart C -- General Safety and Health Provisions
Subpart D -- Occupational Health and Environmental Controls
Subpart E -- Personal Protective and Life Saving Equipment
Subpart F -- Fire Protection and Prevention
Subpart G -- Signs, Signals, and Barricades
Subpart H -- Materials Handling, Storage, Use, and Disposal
Subpart I -- Tools -- Hand and Power
Subpart J -- Welding and Cutting
Subpart K -- Electrical
Subpart L -- Scaffolds
Subpart M -- Fall Protection
Subpart N -- Cranes, Derricks, Hoists, Elevators, and Conveyors
Subpart O -- Motor Vehicles, Mechanized Equipment, and Marine Operations
Subpart P -- Excavations
Subpart Q -- Concrete and Masonry Construction
Subpart R -- Steel Erection
Subpart S -- Tunnels and Shafts, Caissons, Cofferdams, and Compressed Air
Subpart T -- Demolition
Subpart U -- Blasting and Use of Explosives
Subpart V -- Power Transmission and Distribution
Subpart W -- Rollover Protective Structures; Overhead Protection
Subpart X -- Stairways and Ladders
Subpart Y -- Commercial Diving Operations
Subpart Z -- Toxic and Hazardous Substances
Subpart AA-BB -- [RESERVED]
Subpart CC -- Cranes and Derricks in Construction
Subpart DD -- Cranes and Derricks Used in Demolition and Underground Construction
Link to United States’ Occupational Safety and Health laws and regulations:
http://www.ilo.org/dyn/legosh/en/f?p=14100:1100:0::NO:1100:P1100_ISO_CODE3,P1100_YE
AR:USA,2013:NO

Appendix G
November 2019

G-3

Health and Safety Management System Manual

Top 10 Most Frequently Cited Standards
by OSHA for Fiscal 2015
for Fiscal Year 2018 (Oct. 1, 2017, to Sept. 30, 2018).

The following is a list of the top 10 most frequently cited standards following inspections ofworksites by the United States Occupational Safety and Health Administration (OSHA). OSHA
publishes this list to alert employers about these commonly cited standards so they can take steps
to find and fix recognized hazards addressed in these and other standards before OSHA showsup.
1. Fall protection, construction (29 CFR 1926.501)
2. Hazard communication standard, general industry (29 CFR 1910.1200)
3. Scaffolding, general requirements, construction (29 CFR 1926.451)
4. Respiratory protection, general industry (29 CFR 1910.134)
5. Control of hazardous energy (lockout/tagout), general industry (29 CFR 1910.147)
6. Ladders, construction (29 CFR 1926.1053)
7. Powered industrial trucks, general industry (29 CFR 1910.178)
8. Fall Protection–Training Requirements (29 CFR 1926.503)
9. Machinery and Machine Guarding, general requirements
10. Eye and Face Protection (29 CFR 1926.102)

Appendix G
November 2019

G-4

Health and Safety Management System Manual

United Kingdom
Description of Occupational Safety and Health Regulatory Framework
The Health and Safety at Work Act 1974 (the HSWA) is the foundation law of the existing
system, but there are a number of other OSH-related acts and subsidiary regulations (more than
200 in all.)The HSWA reflects the principle that those who create risks for employees or others in thecourse of carrying out work activities are responsible for controlling those risks. It places
specific responsibilities on employers, the self-employed, employees, designers, manufacturers,
importers and suppliers. An overhaul of OSH legislation is underway to reduce/replace olderprescriptive regulations with legislation that expresses OSH management goals e.g. requiring‘adequate control’ or ‘reasonable’ steps.
An increasing amount of UK health and safety legislation is based on European directives,
including the important Management of Health and Safety at Work Regulations, which establish
broadly based obligations for employers to evaluate, avoid and reduce workplace risks. Note thatthe database only cites legislation which is either transposed into UK law or directly applicablein the UK. Some pieces of UK OSH legislation do not cover all of the UK and/or there can beoften small variations in detailed provisions in particular counties
Health and Safety at Work Act etc. 1974
The Health and Safety at Work etc. Act 1974 (also referred to as HSWA, the HSW Act, the 1974
Act or HASAWA) is the primary piece of legislation covering occupational health and safety inGreat Britain. The Health and Safety Executive, with local authorities (and other enforcing
authorities) is responsible for enforcing the Act and a number of other Acts and Statutory
Instruments relevant to the working environment.
The Management of Health and Safety at Work Regulations 1999:
The Management of Health and Safety at Work Regulations 1999 (the Management Regulations)generally make more explicit what employers are required to do to manage health and safety undthe Health and Safety at Work Act. Like the Act, they apply to every work activity.
Note: other regulations applicable to specific topics, e.g. noise, asbestos, fire protection,

Appendix G
November 2019

G-5

Health and Safety Management System Manual

hazardous substances are also in force. See link to Statutory Instruments owned and enforced by
HSE and local authorities: http://www.hse.gov.uk/legislation/statinstruments.htm

CanadaThere are fourteen jurisdictions in Canada - one federal, ten provincial and three territorial - eachhaving its own occupational health and safety legislation, outlining the general rights andresponsibilities of the employer, the supervisor and the worker. Federal legislation covers
employees of the federal government including Crown agencies and corporations across Canada.
•

Alberta
Laws governing health and safety in Alberta’s workplaces fall under the OHS Act,
Regulation and Code, and related legislation.
Link to Alberta OHS Act, OHS Regulations and OHS Codes:
http://work.alberta.ca/searchaarc/•

Ontario
The Occupational Health and Safety Act (OHSA) is Ontario's cornerstone legislation forworkplace health and safety. Other contributing legislation includes the Workplace
Safety and Insurance Act (WSIA), Part II of which deals with the prevention ofoccupational injury and disease and the Human Rights Code, which often has to beconsidered in dealing with OHS issues. Both OHSA and WSIA are available along withall of Ontario's other Acts and regulations at the e-Laws website.
Link to Ontario laws and regulations:
https://www.labour.gov.on.ca/english/hs/laws/index.php•

QuebecQuebec Occupational Health and Safety Acts and corresponding regulations
An Act respecting occupational health and safety (AOHS)(CQLR, c. S-2.1)
Passed in 1979, this Act deals first and foremost with the prevention of work-related
accidents and diseases. It created the CSST, now named CNESST, and entrusted thisorganization with its various mandates.

Appendix G
November 2019

G-6

Health and Safety Management System Manual

An Act respecting industrial accident and occupational diseases (AIAOD)(CQLR, c. A-3.001)
Having entered into force in 1985, this Act introduces a remedial system for injuries or
diseases caused by work. It provides for the payment of compensation when necessary,
the supply of health care and assistance with rehabilitation.
Workers’ Compensation Act (WCA) (CQLR, c. A-3)
This Act, passed in 1931, was replaced by An Act respecting industrial accidents andoccupational diseases on August 19, 1985, but is still in force for the accidents ordiseases having occurred prior to that date.
Link to Acts and corresponding regulations:
http://www.csst.qc.ca/en/Pages/en_legislation.aspx

MexicoDescription of Occupational Safety and Health Regulatory Framework
Article 123 of the Constitution of Mexico provides for standards and principles to be observed
within the employment relations, including duties of the employer in the field of occupationalsafety and health.
The Federal Regulation on Occupational Safety and Hygiene and the Working Environment
adopted in 1997 is the leading OSH legislation. It aims to set up the necessary measures toprevent accidents and diseases in addition to ensuring safe and healthy working conditions forworkers.
The Federal Labour Law, reformed in 2012 contains provisions on OSH. There are also a
number of Official Mexican Standards regulating particular OSH issues as the Standard on theConstitution, Composition, Organization and Operation of Safety and Health Committees.
Furthermore, the General Regulations on the Inspection and Application of Sanctions concerning
Labour Legislation Violations of 1998 contains OSH related provisions, and the Regulations of
the Secretariat of Labour and Social Welfare of 2008 provides for the duties of the General
Director of Safety and Health at Work
Link to Mexican law and regulations:
http://www.ilo.org/dyn/legosh/en/f?p=14100:1100:0::NO::P1100_ISO_CODE3,P1100_YEAR:
Appendix G
November 2019

G-7

Health and Safety Management System Manual

MEX,2013

Denmark
Description of Occupational Safety and Health Regulatory Framework
Documents of a legal nature include Acts, Executive Orders and WEA Guidelines.
Acts (Love):
The Danish Working Environment Act includes general provisions on the working environment.
The Work Environment Act is binding on citizens and any violation of the rules is therefore
subject to legal sanctions.
Executive Orders (Bekendtgørelser): The Work Environment Act is implemented throughExecutive Orders. Executive Orders are binding on citizens and any violation of the rules istherefore subject to legal sanctions.
WEA Guidelines (At-vejledninger): WEA Guidelines are based on Acts and Executive Orders.
They explain how the regulations are to be interpreted. WEA Guidelines describe, among otherthings, how enterprises, etc. can plan and carry out their work, so as to ensure that the health andsafety requirements are met. WEA Guidelines are not binding on the enterprises etc. but theDanish Working Environment Authority will take no further action if an enterprise has compliedwith the WEA Guidelines.
The Danish Working Environment Authority supervises whether Acts and rules in the field ofsafety and health at work are observed, inter alia through inspection visits and guidance of theenterprises and their safety organisations, with a view to making the enterprises capable ofsolving their own tasks in relation to the working environment. The different forms of sanctionsof the Danish Working Environment Authority, i.e. improvement notices, legal charges,
administrative fines and guidelines - will depend on both the enterprise’s actual working
environment standards and on its own efforts. As an executive authority, the Danish Working
Environment Authority focuses in particular on enterprises with poor safety and healthconditions and no serious policy in relation to working environment issues.
The Ministry of Employment is responsible for the framework and rules regarding employment
and working conditions, safety and health at work and industrial injuries, financial support andAppendix G
November 2019

G-8

Health and Safety Management System Manual

allowances to all persons with full or partial working capacity as well as placement services inrelation to enterprises and active employment measures
Link to Denmark’s occupational safety and health laws and regulations:
http://www.ilo.org/dyn/legosh/en/f?p=14100:1100:0::NO:1100:P1100_ISO_CODE3,P1100_YE
AR:DNK,2014:NO

The Netherlands
Description of Occupational Safety and Health Regulatory Framework
The Netherlands has adopted various laws and regulations applicable to occupational health andsafety.
Link to the Netherlands’ Occupational Safety and Health laws and regulations:
http://www.ilo.org/dyn/natlex/natlex4.listResults?p_lang=en&p_country=NLD&p_count=2273&p_classification=14&p_classcount=193

Belgium
Description of Occupational Safety and Health Regulatory Framework
Belgium has adopted various laws and regulations applicable to occupational health and safety.
Link to Belgium’s Occupational Safety and Health laws and regulations:
http://www.ilo.org/dyn/natlex/natlex4.listResults?p_lang=en&p_country=BEL&p_classification=14

Germany
Description of Occupational Safety and Health Regulatory Framework
Germany has adopted various laws and regulations applicable to occupational health and safety.
Link to Germany’s Occupational Safety and Health laws and regulations:
http://www.ilo.org/dyn/natlex/natlex4.listResults?p_lang=en&p_country=DEU&p_classification=14
Appendix G
November 2019

G-9

Health and Safety Management System Manual

China
Description of Occupational Safety and Health Regulatory Framework
The legislative structure of Occupational Safety and Health in China is based on theConstitution, and consists of laws, administrative regulations, local regulations, departmental
rules, local rules and OSH standards. The major OSH laws are Law on Work Safety, Law on
Prevention and Control of Occupational Diseases, Law on Safety in Mines, Labour Law, Labour
Contract Law, Fire Protection Law, Emergency Response Law and Criminal Law. The major
regulations are Regulations on Coal Mine Safety Inspection, Special Regulations of the StateCouncil on Preventing Coal Mine Accidents, Regulations on Safety Management in Construction
Projects, Regulations on the Safe Administration of Hazardous Chemicals, Regulations on
Fireworks and Firecracker Safety Management, Regulations on Work Safety Licenses,
Regulations on Civil Explosive Products Safety Management, Regulations on Special Equipment
Safety Inspection, Regulations on Safety Supervision and Management of Agricultural
Machinery, Regulations on Ascertaining Administrative Responsibility in Extraordinarily
Serious Safety Accidents, Regulations on Work Injury Insurance, and Regulations on Reporting,
Investigation and Handling of Work Safety Accidents
Link to China’s Occupational Safety and Health laws and regulations:
http://www.ilo.org/dyn/legosh/en/f?p=14100:1100:0::NO:1100:P1100_ISO_CODE3,P1100_YE
AR:CHN,2013:NO

Appendix G
November 2019

G-10

Health and Safety Management System Manual

APPENDIX H – SELF INSPECTION CHECKLISTS
Self-Inspection ScopeYour self-inspections should cover safety and health issues in the following areas:


















Processing, Receiving, Shipping and Storage - equipment, job planning, layout, heights, floorloads, projection of materials, material handling and storage methods, training for material handlingequipment.
Building and Grounds Conditions - floors, walls, ceilings, exits, stairs, walkways, ramps, platforms,
driveways, aisles.
Housekeeping Program - waste disposal, tools, objects, materials, leakage and spillage, cleaning
methods, schedules, work areas, remote areas, storage areas.
Electricity - equipment, switches, breakers, fuses, switch-boxes, junctions, special fixtures, circuits,
insulation, extensions, tools, motors, grounding, national electric code compliance.
Lighting - type, intensity, controls, conditions, diffusion, location, glare and shadow control.
Heating and Ventilation - type, effectiveness, temperature, humidity, controls, natural and artificial
ventilation and exhausting.
Machinery - points of operation, flywheels, gears, shafts, pulleys, key ways, belts, couplings,
sprockets, chains, frames, controls, lighting for tools and equipment, brakes, exhausting, feeding,oiling, adjusting, maintenance, lockout/tagout, grounding, work space, location, purchasing standards.
Personnel - training, including hazard identification training; experience; methods of checking
machines before use; type of clothing; PPE; use of guards; tool storage; work practices; methods forcleaning, oiling, or adjusting machinery.
Hand and Power Tools - purchasing standards, inspection, storage, repair, types, maintenance,
grounding, use and handling.
Chemicals - storage, handling, transportation, spills, disposals, amounts used, labeling, toxicity orother harmful effects, warning signs, supervision, training, protective clothing and equipment, hazard
communication requirements.
Fire Prevention - extinguishers, alarms, sprinklers, smoking rules, exits, personnel assigned,
separation of flammable materials and dangerous operations, explosion-proof fixtures in hazardous
locations, waste disposal and training of personnel.
Maintenance - provide regular and preventive maintenance on all equipment used at the worksite,
recording all work performed on the machinery and by training personnel on the proper care andservicing of the equipment.
PPE - type, size, maintenance, repair, age, storage, assignment of responsibility, purchasing methods,
standards observed, training in care and use, rules of use, method of assignment.
Transportation - motor vehicle safety, seat belts, vehicle maintenance, safe driver programs.
First Aid Program/Supplies - medical care facilities locations, posted emergency phone numbers,
accessible first aid kits.
Evacuation Plan - establish and practice procedures for an emergency evacuation, e.g., fire,chemical/biological incidents, bomb threat; include escape procedures and routes, critical plant
operations, employee accounting following an evacuation, rescue and medical duties and ways toreport emergencies.

Self-Inspection Checklists
These checklists are by no means all-inclusive. You should add to them or delete items that do not apply toyour business; however, carefully consider each item and then make your decision. You should refer to OSHA
standards for specific guidance that may apply to your work situation. (Note: These checklists are typical for
general industry but not for construction or maritime industries.)

Appendix I
November 2019

H-1

Health and Safety Management System Manual

EMPLOYER POSTING□ Is the required OSHA Job Safety and Health Protection Poster displayed in a prominent location where all
employees are likely to see it?
□ Are emergency telephone numbers posted where they can be readily found in case of emergency?
□ Where employees may be exposed to toxic substances or harmful physical agents, has appropriate
information concerning employee access to medical and exposure records and Material Safety Data
Sheets (MSDSs) been posted or otherwise made readily available to affected employees?
□ Are signs concerning exit routes, room capacities, floor loading, biohazards, exposures to x-ray,microwave, or other harmful radiation or substances posted where appropriate?
□ Is the Summary of Work-Related Injuries and Illnesses (OSHA Form 300A) posted during the months of
February, March and April?
RECORDKEEPING□ Are occupational injuries or illnesses, except minor injuries requiring only first aid, recorded as requiredon the OSHA 300 log?
□ Are employee medical records and records of employee exposure to hazardous substances or harmful
physical agents up-to-date and in compliance with current OSHA standards?
□ Are employee training records kept and accessible for review by employees, as required by OSHA
standards?
□ Have arrangements been made to retain records for the time period required for each specific type ofrecord? (Some records must be maintained for at least 40 years.)□ Are operating permits and records up-to-date for items such as elevators, air pressure tanks, liquefied
petroleum gas tanks, etc.?
SAFETY AND HEALTH PROGRAM□ Do you have an active safety and health program in operation that includes general safety and healthprogram elements as well as the management of hazards specific to your work-site?
□ Is one person clearly responsible for the safety and health program?
□ Do you have a safety committee or group made up of management and labor representatives that meetsregularly and reports in writing on its activities?
OSHA HANDBOOK FOR SMALL BUSINESSES□ Do you have a working procedure to handle in-house employee complaints regarding safety and health?
□ Are your employees advised of efforts and accomplishments of the safety and health program made toensure they will have a workplace that is safe and healthful?
□ Have you considered incentives for employees or workgroups who excel in reducing workplace
injury/illnesses?

Appendix I
November 2019

H-2

Health and Safety Management System Manual

MEDICAL SERVICES AND FIRST AID□ Is there a hospital, clinic, or infirmary for medical care near your workplace or is at least one employee
on each shift currently qualified to render first aid?
□ Have all employees who are expected to respond to medical emergencies as part of their job
responsibilities received first aid training; had hepatitis B vaccination made available to them; hadappropriate training on procedures to protect them from bloodborne pathogens, including universal
precautions; and have available and understand how to use appropriate PPE to protect against exposure
to bloodborne diseases?**Pursuant to an OSHA memorandum of July 1, 1992, employees who render first aid only as a collateral
duty do not have to be offered pre-exposure hepatitis B vaccine only if the employer includes andimplements the following requirements in his/her exposure control plan: (1) the employer must record all
first aid incidents involving the presence of blood or other potentially infectious materials before the end of
the work shift during which the first aid incident occurred; (2) the employer must comply with postexposure evaluation, prophylaxis and follow-up requirements of the Bloodborne Pathogens standard withrespect to "exposure incidents," as defined by the standard; (3) the employer must train designated first aid
providers about the reporting procedure; (4) the employer must offer to initiate the hepatitis B vaccination
series within 24 hours to all unvaccinated first aid providers who have rendered assistance in any situation
involving the presence of blood or other potentially infectious materials.
□ If employees have had an exposure incident involving bloodborne pathogens, was an immediate postexposure medical evaluation and follow-up provided?
□ Are medical personnel readily available for advice and consultation on matters of employees' health?
□ Are emergency phone numbers posted?
□ Are fully supplied first aid kits easily accessible to each work area, periodically inspected and replenishedas needed?
□ Have first aid kits and supplies been approved by a physician, indicating that they are adequate for aparticular area or operation?
□ Is there an eye-wash station or sink available for quick drenching or flushing of the eyes and body inareas where corrosive liquids or materials are handled?

Appendix I
November 2019

H-3

Health and Safety Management System Manual
FIRE PROTECTION□ Is your local fire department familiar with your facility, its location and specific hazards?
□ If you have a fire alarm system, is it certified as required and tested annually?
□ If you have interior standpipes and valves, are they inspected regularly?
□ If you have interior standpipes and valves, are they inspected regularly?
□ If you have outside private fire hydrants, are they flushed at least once a year and on a routine
preventive maintenance schedule?
□ Are fire doors and shutters in good operating condition?
□ Are fire doors and shutters unobstructed and protected against obstructions, including theircounterweights?
□ Are fire door and shutter fusible links in place?
□ Are automatic sprinkler system water control valves, air and water pressure checked periodically as
required?
□ Is the maintenance of automatic sprinkler systems assigned to responsible persons or to a sprinkler
contractor?
□ Are sprinkler heads protected by metal guards if exposed to potential physical damage?
□ Is proper clearance maintained below sprinkler heads?
□ Are portable fire extinguishers provided in adequate number and type and mounted in readily accessible
locations?
□ Are fire extinguishers recharged regularly with this noted on the inspection tag?
□ Are employees periodically instructed in the use of fire extinguishers and fire protection procedures?
PERSONAL PROTECTIVE EQUIPMENT AND CLOTHING□ Has the employer determined whether hazards that require the use of PPE (e.g., head, eye, face, hand,or foot protection) are present or are likely to be present?
□ If hazards or the likelihood of hazards are found, are employers selecting appropriate and properly fitted
PPE suitable for protection from these hazards and ensuring that affected employees use it?
□ Have both the employer and the employees been trained on PPE procedures, i.e., what PPE is necessary
for job tasks, when workers need it, and how to properly wear and adjust it?
□ Are protective goggles or face shields provided and worn where there is any danger of flying particles or
corrosive materials?
□ Are approved safety glasses required to be worn at all times in areas where there is a risk of eye injuries
such as punctures, abrasions, contusions, or burns?
□ Are employees who wear corrective lenses (glasses or contacts) in workplaces with harmful exposuresrequired to wear only approved safety glasses, protective goggles, or use other medically approved
precautionary procedures?
□ Are protective gloves, aprons, shields, or other means provided and required where employees could be
cut or where there is reasonably anticipated exposure to corrosive liquids, chemicals, blood, or otherpotentially infectious materials? See the OSHA Bloodborne Pathogens standard, 29 CFR 1910.1030(b), forthe definition of "other potentially infectious materials."□ Are hard hats required, provided and worn where danger of falling objects exists?

Appendix I
November 2019

H-4

Health and Safety Management System Manual□ Are hard hats periodically inspected for damage to the shell and suspension system?
□ Is appropriate foot protection required where there is the risk of foot injuries from hot, corrosive, or
poisonous substances, falling objects, crushing, or penetrating actions?
□ Are approved respirators provided when needed? (See 29 CFR 1910.134 for detailed information on
respirators or check OSHA's website).
□ Is all PPE maintained in a sanitary condition and ready for use?
□ Are food or beverages consumed only in areas where there is no exposure to toxic material, blood, orother potentially infectious materials?
□ Is protection against the effects of occupational noise provided when sound levels exceed those of the
OSHA Noise standard?
□ Are adequate work procedures, PPE and other equipment provided and used when cleaning up spilledhazardous materials?
□ Are appropriate procedures in place to dispose of or decontaminate PPE contaminated with, or
reasonably anticipated to be contaminated with, blood or other potentially infectious materials?
GENERAL WORK ENVIRONMENT□ Are all worksites clean, sanitary and orderly?
□ Are work surfaces kept dry and appropriate means taken to assure the surfaces are slip-resistant?
□ Are all spilled hazardous materials or liquids, including blood and other potentially infectious materials,
cleaned up immediately and according to proper procedures?
□ Is combustible scrap, debris and waste stored safely and removed from the worksite promptly?
□ Is all regulated waste, as defined in the OSHA Bloodborne Pathogens standard (29 CFR 1910.1030),
discarded according to Federal, state and local regulations?
□ Are accumulations of combustible dust routinely removed from elevated surfaces including the overhead
structure of buildings, etc.?
□ Is combustible dust cleaned up with a vacuum system to prevent suspension of dust particles in theenvironment?
□ Is metallic or conductive dust prevented from entering or accumulating on or around electrical enclosures
or equipment?
□ Are covered metal waste cans used for oily or paint-soaked waste?
□ Are all oil and gas-fired devices equipped with flame failure controls to prevent flow of fuel if pilots ormain burners are not working?
□ Are paint spray booths, dip tanks, etc., cleaned regularly?
□ Are the minimum number of toilets and washing facilities provided and maintained in a clean and sanitary
fashion?
□ Are all work areas adequately illuminated?
□ Are pits and floor openings covered or otherwise guarded?
□ Have all confined spaces been evaluated for compliance with 29 CFR 1910.146? (Permit required
confined spaces.)
WALKWAYS

Appendix I
November 2019

H-5

Health and Safety Management System Manual□ Are aisles and passageways kept clear and marked as appropriate?
□ Are wet surfaces covered with non-slip materials?
□ Are holes in the floor, sidewalk, or other walking surface repaired properly, covered, or otherwise madesafe?
□ Is there safe clearance for walking in aisles where motorized or mechanical handling equipment is
operating?
□ Are materials or equipment stored in such a way that sharp projections will not interfere with the
walkway?
□ Are spilled materials cleaned up immediately?
□ Are changes of direction or elevations readily identifiable?
□ Are aisles or walkways that pass near moving or operating machinery, welding operations, or similar
operations arranged so employees will not be subjected to potential hazards?
□ Is adequate headroom provided for the entire length of any aisle or walkway?
□ Are standard guardrails provided wherever aisle or walkway surfaces are elevated more than 30 inches(76.20 centimeters) above any adjacent floor or the ground?
□ Are bridges provided over conveyors and similar hazards?
FLOOR AND WALL OPENINGS□ Are floor openings guarded by a cover, a guardrail, or equivalent on all sides (except at stairways orladder entrances)?
□ Are toeboards installed around the edges of permanent floor openings where persons may pass below
the opening?
□ Are skylight screens able to withstand a load of at least 200 pounds (90.7 kilograms)?
□ Is the glass in windows, doors, glass walls, etc., subject to possible human impact, of sufficient thickness
and type for the condition of use?
□ Are grates or similar type covers over floor openings such as floor drains designed to allow unimpededfoot traffic or rolling equipment?
□ Are unused portions of service pits and pits not in use either covered or protected by guardrails or
equivalent?
□ Are manhole covers, trench covers and similar covers, and their supports designed to carry a truck rearaxle load of at least 20,000 pounds (9,072 kilograms) when located in roadways and subject to vehicle
traffic?
□ Are floor or wall openings in fire-resistant construction provided with doors or covers compatible with thefire rating of the structure and provided with a self-closing feature when appropriate?
STAIRS AND STAIRWAYS□ Do standard stair rails or handrails on all stairways have at least four risers?
□ Are all stairways at least 22 inches (55.88 centimeters) wide?
□ Do stairs have landing platforms not less than 30 inches (76.20 centimeters) in the direction of travel andextend 22 inches (55.88 centimeters) in width at every 12 feet (3.6576 meters) or less of vertical rise?
□ Do stairs angle no more than 50 and no less than 30 degrees?

Appendix I
November 2019

H-6

Health and Safety Management System Manual□ Are stairs of hollow-pan type treads and landings filled to the top edge of the pan with solid material?
□ Are step risers on stairs uniform from top to bottom?
□ Are steps slip-resistant?
□ Are stairway handrails located between 30 inches (76.20 centimeters) and 34 inches (86.36 centimeters)
above the leading edge of stair treads?
□ Do stairway handrails have at least 3 inches (7.62 centimeters) of clearance between the handrails andthe wall or surface they are mounted on?
□ Where doors or gates open directly on a stairway, is a platform provided so the swing of the door does
not reduce the width of the platform to less than 21 inches (53.34 centimeters)?
□ Are stairway handrails capable of withstanding a load of 200 pounds (90.7 kilograms), applied within 2
inches (5.08 centimeters) of the top edge in any downward or outward direction?
□ Where stairs or stairways exit directly into any area where vehicles may be operated, are adequate
barriers and warnings provided to prevent employees from stepping into the path of traffic?
□ Do stairway landings have a dimension measured in the direction of travel at least equal to the width of
the stairway?
□ Is the vertical distance between stairway landings limited to 12 feet (3.6576 meters) or less?
ELEVATED SURFACES□ Are signs posted, when appropriate, showing the elevated surface load capacity?
□ Are surfaces that are elevated more than 30 inches (76.20 centimeters) provided with standard
guardrails?
□ Are surfaces that are elevated more than 30 inches (76.20 centimeters) provided with standard
guardrails?
□ Are all elevated surfaces beneath which people or machinery could be exposed to falling objects provided
with standard 4-inch (10.16centimeter) toeboards?
□ Is a permanent means of access and egress provided to elevated storage and work surfaces?
□ Is required headroom provided where necessary?
□ Is material on elevated surfaces piled, stacked, or racked in a manner to prevent it from tipping, falling,collapsing, rolling, or spreading?
□ Are dock boards or bridge plates used when transferring materials between docks and trucks or railcars?
EXITING OR EGRESS - EVACUATION□ Are all exits marked with an exit sign and illuminated by a reliable light source?
□ Are the directions to exits, when not immediately apparent, marked with visible signs?
□ Are doors, passageways or stairways that are neither exits nor access to exits, but could be mistaken forexits, appropriately marked "NOT AN EXIT," "TO BASEMENT," "STOREROOM," etc.?
□ Are exit signs labeled with the word "EXIT" in lettering at least 5 inches (12.70 centimeters) high and thestroke of the lettering at least l/2inch (1.2700 centimeters) wide?
□ Are exit doors side-hinged?
□ Are all exits kept free of obstructions?

Appendix I
November 2019

H-7

Health and Safety Management System Manual□ Are at least two means of egress provided from elevated platforms, pits, or rooms where the absence ofa second exit would increase the risk of injury from hot, poisonous, corrosive, suffocating, flammable, or
explosive substances?
□ Are there sufficient exits to permit prompt escape in case of emergency?
□ Are special precautions taken to protect employees during construction and repair operations?
□ Is the number of exits from each floor of a building and the number of exits from the building itself
appropriate for the building occupancy load?
□ Are exit stairways that are required to be separated from other parts of a building enclosed by at least 2hour fire-resistive construction in buildings more than four stories in height, and not less than 1-hour fireresistive construction elsewhere?
□ Where ramps are used as part of required exiting from a building, is the ramp slope limited to 1 foot(0.3048 meter) vertical and 12 feet (3.6576 meters) horizontal?
□ Where exiting will be through frameless glass doors, glass exit doors, storm doors, etc., are the doors
fully tempered and meet the safety requirements for human impact?
EXIT DOORS□ Are doors that are required to serve as exits designed and constructed so that the path of exit travel isobvious and direct?
□ Are windows that could be mistaken for exit doors made inaccessible by means of barriers or railings?
□ Are exit doors able to be opened from the direction of exit travel without the use of a key or any special
knowledge or effort when the building is occupied?
□ Is a revolving, sliding, or overhead door prohibited from serving as a required exit door?
□ Where panic hardware is installed on a required exit door, will it allow the door to open by applying aforce of 15 pounds (6.80 kilograms) or less in the direction of the exit traffic?
□ Are doors on cold storage rooms provided with an inside release mechanism that will release the latch
and open the door even if the door is padlocked or otherwise locked on the outside?
□ Where exit doors open directly onto any street, alley, or other area where vehicles may be operated, areadequate barriers and warnings provided to prevent employees from stepping into the path of traffic?
□ Are doors that swing in both directions and are located between rooms where there is frequent traffic
provided with viewing panels in each door?
PORTABLE LADDERS□ Are all ladders maintained in good condition, joints between steps and side rails tight, all hardware andfittings securely attached, and moveable parts operating freely without binding or undue play?
□ Are non-slip safety feet provided on each metal or rung ladder, and are ladder rungs and steps free ofgrease and oil?
□ Are employees prohibited from placing a ladder in front of doors opening toward the ladder unless thedoor is blocked open, locked, or guarded?
□ Are employees prohibited from placing ladders on boxes, barrels, or other unstable bases to obtain
additional height?
□ Are employees required to face the ladder when ascending or descending?

Appendix I
November 2019

H-8

Health and Safety Management System Manual□ Are employees prohibited from using ladders that are broken, have missing steps, rungs, or cleats,
broken side rails, or other faulty equipment?
□ Are employees instructed not to use the top step of ordinary stepladders as a step?
□ When portable rung ladders are used to gain access to elevated platforms, roofs, etc., does the ladderalways extend at least 3 feet (0.9144 meters) above the elevated surface?
□ Are employees required to secure the base of a portable rung or cleat type ladder to prevent slipping, orotherwise lash or hold it in place?
□ Are portable metal ladders legibly marked with signs reading "CAUTION - Do Not Use Around Electrical
Equipment" or equivalent wording?
□ Are employees prohibited from using ladders as guys, braces, skids, gin poles, or for other than theirintended purposes?
□ Are employees instructed to only adjust extension ladders while standing at a base (not while standingon the ladder or from a position above the ladder)?
□ Are metal ladders inspected for damage?
□ Are the rungs of ladders uniformly spaced at 12 inches (30.48 centimeters) center to center?
HAND TOOLS AND EQUIPMENT□ Are all tools and equipment (both company and employee-owned) used at the workplace in goodcondition?
□ Are hand tools, such as chisels, punches, etc., which develop mushroomed heads during use,reconditioned or replaced as necessary?
□ Are broken or fractured handles on hammers, axes and similar equipment replaced promptly?
□ Are worn or bent wrenches replaced?
□ Are appropriate handles used on files and similar tools?
□ Are employees aware of hazards caused by faulty or improperly used hand tools?
□ Are appropriate safety glasses, face shields, etc., used while using hand tools or equipment that might
produce flying materials or be subject to breakage?
□ Are jacks checked periodically to ensure they are in good operating condition?
□ Are tool handles wedged tightly into the heads of all tools?
□ Are tool cutting edges kept sharp so the tool will move smoothly without binding or skipping?
□ Are tools stored in a dry, secure location where they cannot be tampered with?
□ Is eye and face protection used when driving hardened or tempered studs or nails?
PORTABLE (POWER OPERATED) TOOLS AND EQUIPMENT□ Are grinders, saws and similar equipment provided with appropriate safety guards?
□ Are power tools used with proper shields, guards, or attachments, as recommended by the
manufacturer?
□ Are portable circular saws equipped with guards above and below the base shoe?
□ Are circular saw guards checked to ensure that they are not wedged up, leaving the lower portion of theblade unguarded?

Appendix I
November 2019

H-9

Health and Safety Management System Manual□ Are rotating or moving parts of equipment guarded to prevent physical contact?
□ Are all cord-connected, electrically operated tools and equipment effectively grounded or of the approved
double insulated type?
□ Are effective guards in place over belts, pulleys, chains and sprockets on equipment such as concrete
mixers, air compressors, etc.?
□ Are portable fans provided with full guards or screens having openings 1/2 inch (1.2700 centimeters) or
less?
□ Is hoisting equipment available and used for lifting heavy objects, and are hoist ratings andcharacteristics appropriate for the task?
□ Are ground-fault circuit interrupters provided on all temporary electrical 15 and 20 ampere circuits usedduring periods of construction?
□ Are pneumatic and hydraulic hoses on powder-operated tools checked regularly for deterioration ordamage?
ABRASIVE WHEEL EQUIPMENT GRINDERS□ Is the work rest used and kept adjusted to within 1/8 inch (0.3175 centimeter) of the wheel?
□ Is the adjustable tongue on the top side of the grinder used and kept adjusted to within 1/4 inch (0.6350
centimeters) of the wheel?
□ Do side guards cover the spindle, nut and flange and 75 percent of the wheel diameter?
□ Are bench and pedestal grinders permanently mounted?
□ Are goggles or face shields always worn when grinding?
□ Is the maximum revolutions per minute (rpm) rating of each abrasive wheel compatible with the rpm
rating of the grinder motor?
□ Are fixed or permanently mounted grinders connected to their electrical supply system with metallic
conduit or other permanent wiring method?
□ Does each grinder have an individual on and off control switch?
□ Is each electrically operated grinder effectively grounded?
□ Are new abrasive wheels visually inspected and ring tested before they are mounted?
□ Are dust collectors and powered exhausts provided on grinders used in operations that produce large
amounts of dust?
□ Are splash guards mounted on grinders that use coolant to prevent the coolant from reaching
employees?
□ Is cleanliness maintained around grinders?
POWDER-ACTUATED TOOLS□ Are employees who operate powder-actuated tools trained in their use and required to carry a valid
operator's card?
□ Is each powder-actuated tool stored in its own locked container when not being used?
□ Is a sign at least 7 inches (17.78 centimeters) by 10 inches (25.40 centimeters) with bold face typereading "POWDER-ACTUATED TOOL IN USE" conspicuously posted when the tool is being used?
□ Are powder-actuated tools left unloaded until they are ready to be used?

Appendix I
November 2019

H-10

Health and Safety Management System Manual□ Are powder-actuated tools inspected for obstructions or defects each day before use?
□ Do powder-actuated tool operators have and use appropriate PPE such as hard hats, safety goggles,
safety shoes and ear protectors?
MACHINE GUARDING□ Is there a training program to instruct employees on safe methods of machine operation?
□ Is there adequate supervision to ensure that employees are following safe machine operatingprocedures?
□ Is there a regular program of safety inspection of machinery and equipment?
□ Is all machinery and equipment kept clean and properly maintained?
□ Is sufficient clearance provided around and between machines to allow for safe operations, set up andservicing, material handling and waste removal?
□ Is equipment and machinery securely placed and anchored to prevent tipping or other movement that
could result in personal injury?
□ Is there a power shut-off switch within reach of the operator's position at each machine?
□ Can electric power to each machine be locked out for maintenance, repair, or security?
□ Are the noncurrent-carrying metal parts of electrically operated machines bonded and grounded?
□ Are foot-operated switches guarded or arranged to prevent accidental actuation by personnel or falling
objects?
□ Are manually operated valves and switches controlling the operation of equipment and machines clearly
identified and readily accessible?
□ Are all emergency stop buttons colored red?
□ Are all pulleys and belts within 7 feet (2.1336 meters) of the floor or working level properly guarded?
□ Are all moving chains and gears properly guarded?
□ Are splash guards mounted on machines that use coolant to prevent the coolant from reaching
employees?
□ Are methods provided to protect the operator and other employees in the machine area from hazards
created at the point of operation, ingoing nip points, rotating parts, flying chips and sparks?
□ Are machine guards secure and arranged so they do not cause a hazard while in use?
□ If special hand tools are used for placing and removing material, do they protect the operator's hands?
□ Are revolving drums, barrels and containers guarded by an enclosure that is interlocked with the drive
mechanism so that revolution cannot occur unless the guard enclosure is in place?
□ Do arbors and mandrels have firm and secure bearings, and are they free from play?
□ Are provisions made to prevent machines from automatically starting when power is restored after a
power failure or shutdown?
□ Are machines constructed so as to be free from excessive vibration when the largest size tool is mounted
and run at full speed?
□ If machinery is cleaned with compressed air, is air pressure controlled and PPE or other safeguards
utilized to protect operators and other workers from eye and body injury?
□ Are fan blades protected with a guard having openings no larger than l/2 inch (1.2700 centimeters) when
operating within 7 feet (2.1336 meters) of the floor?

Appendix I
November 2019

H-11

Health and Safety Management System Manual□ Are saws used for ripping equipped with anti-kickback devices and spreaders?
□ Are radial arm saws so arranged that the cutting head will gently return to the back of the table whenreleased?
LOCKOUT/TAGOUT PROCEDURES□ Is all machinery or equipment capable of movement required to be de-energized or disengaged andblocked or locked out during cleaning, servicing, adjusting, or setting up operations?
□ If the power disconnect for equipment does not also disconnect the electrical control circuit, are theappropriate electrical enclosures identified and is a means provided to ensure that the control circuit canalso be disconnected and locked out?
□ Is the locking out of control circuits instead of locking out main power disconnects prohibited?
□ Are all equipment control valve handles provided with a means for locking out?
□ Does the lockout procedure require that stored energy (mechanical, hydraulic, air, etc.) be released or
blocked before equipment is locked out for repairs?
□ Are appropriate employees provided with individually keyed personal safety locks?
□ Are employees required to keep personal control of their key(s) while they have safety locks in use?
□ Is it required that only the employee exposed to the hazard can place or remove the safety lock?
□ Is it required that employees check the safety of the lockout by attempting a startup after making sureno one is exposed?
□ Are employees instructed to always push the control circuit stop button prior to re-energizing the main
power switch?
□ Is there a means provided to identify any or all employees who are working on locked-out equipment by
their locks or accompanying tags?
□ Are a sufficient number of accident prevention signs or tags and safety padlocks provided for any
reasonably foreseeable repair emergency?
□ When machine operations, configuration, or size require an operator to leave the control station and partof the machine could move if accidentally activated, is the part required to be separately locked out or
blocked?
□ If equipment or lines cannot be shut down, locked out and tagged, is a safe job procedure establishedand rigidly followed?
WELDING, CUTTING AND BRAZING□ Are only authorized and trained personnel permitted to use welding, cutting, or brazing equipment?
□ Does each operator have a copy of and follow the appropriate operating instructions?
□ Are compressed gas cylinders regularly examined for obvious signs of defects, deep rusting, or leakage?
□ Is care used in handling and storage of cylinders, safety valves, relief valves, etc., to prevent damage?
□ Are precautions taken to prevent the mixture of air or oxygen with flammable gases, except at a burner
or in a standard torch?
□ Are only approved apparatuses (torches, regulators, pressure reducing valves, acetylene generators,
manifolds) used?
□ Are cylinders kept away from sources of heat and elevators, stairs, or gangways?

Appendix I
November 2019

H-12

Health and Safety Management System Manual□ Is it prohibited to use cylinders as rollers or supports?
□ Are empty cylinders appropriately marked and their valves closed?
□ Are signs posted reading "DANGER, NO SMOKING, MATCHES, OR OPEN LIGHTS," or the equivalent?
□ Are cylinders, cylinder valves, couplings, regulators, hoses and apparatuses kept free of oily or greasy
substances?
□ Is care taken not to drop or strike cylinders?
□ Are regulators removed and valve-protection caps put in place before moving cylinders, unless they are
secured on special trucks?
□ Do cylinders without fixed wheels have keys, handles, or non-adjustable wrenches on stem valves whenin service?
□ Are liquefied gases stored and shipped valve-end up with valve covers in place?
□ Are employees trained never to crack a fuel gas cylinder valve near sources of ignition?
□ Before a regulator is removed, is the valve closed and gas released?
□ Is red used to identify the acetylene (and other fuel-gas) hose, green for the oxygen hose and black forinert gas and air hoses?
□ Are pressure-reducing regulators used only for the gas and pressures for which they are intended?
□ Is open circuit (no-load) voltage of arc welding and cutting machines as low as possible and not in excessof the recommended limits?
□ Under wet conditions, are automatic controls for reducing no-load voltage used?
□ Is grounding of the machine frame and safety ground connections of portable machines checked
periodically?
□ Are electrodes removed from the holders when not in use?
□ Is it required that electric power to the welder be shut off when no one is in attendance?
□ Is suitable fire extinguishing equipment available for immediate use?
□ Is the welder forbidden to coil or loop welding electrode cable around his body?
□ Are wet machines thoroughly dried and tested before use?
□ Are work and electrode lead cables frequently inspected for wear and damage, and replaced whenneeded?
□ Are cable connectors adequately insulated?
□ When the object to be welded cannot be moved and fire hazards cannot be removed, are shields used toconfine heat, sparks and slag?
□ Are fire watchers assigned when welding or cutting is performed in locations where a serious fire mightdevelop?
□ Are combustible floors kept wet, covered with damp sand, or protected by fire-resistant shields?
□ Are personnel protected from possible electrical shock when floors are wet?
□ Are precautions taken to protect combustibles on the other side of metal walls when welding isunderway?
□ Are used drums, barrels, tanks and other containers thoroughly cleaned of substances that could
explode, ignite, or produce toxic vapors before hot work begins?
□ Do eye protection, helmets, hand shields and goggles meet appropriate standards?

Appendix I
November 2019

H-13

Health and Safety Management System Manual□ Are employees exposed to the hazards created by welding, cutting, or brazing operations protected with
PPE and clothing?
□ Is a check made for adequate ventilation in and where welding or cutting is performed?
□ When working in confined places, are environmental monitoring tests done and means provided for quick
removal of welders in case of an emergency?
COMPRESSORS AND COMPRESSED AIR□ Are compressors equipped with pressure relief valves and pressure gauges?
□ Are compressor air intakes installed and equipped so as to ensure that only clean, uncontaminated air
enters the compressor?
□ Are air filters installed on the compressor intake?
□ Are compressors operated and lubricated in accordance with the manufacturer's recommendations?
□ Are safety devices on compressed air systems checked frequently?
□ Before a compressor's pressure system is repaired, is the pressure bled off and the system locked out?
□ Are signs posted to warn of the automatic starting feature of the compressors?
□ Is the belt drive system totally enclosed to provide protection for the front, back, top and sides?
□ Are employees strictly prohibited from directing compressed air towards a person?
□ Are employees prohibited from using highly compressed air for cleaning purposes?
□ When compressed air is used to clean clothing, are employees trained to reduce the pressure to less than
10 pounds per square inch (psi)?
□ When using compressed air for cleaning, do employees wear protective chip guarding and PPE?
□ Are safety chains or other suitable locking devices used at couplings of high-pressure hose lines where aconnection failure would create a hazard?
□ Before compressed air is used to empty containers of liquid, is the safe working pressure of the container
checked?
□ When compressed air is used with abrasive blast cleaning equipment, is the operating valve a type thatmust be held open manually?
□ When compressed air is used to inflate auto tires, are a clip-on chuck and an inline regulator preset to 40
psi required?
□ Are employees prohibited from using compressed air to clean up or move combustible dust if such action
could cause the dust to be suspended in the air and cause a fire or explosion hazard?
COMPRESSORS/AIR RECEIVERS□ Is every receiver equipped with a pressure gauge and one or more automatic, spring-loaded safetyvalves?
□ Is the total relieving capacity of the safety valve able to prevent pressure in the receiver from exceeding
the maximum allowable working pressure of the receiver by more than 10 percent?
□ Is every air receiver provided with a drain pipe and valve at the lowest point for the removal ofaccumulated oil and water?
□ Are compressed air receivers periodically drained of moisture and oil?

Appendix I
November 2019

H-14

Health and Safety Management System Manual□ Are all safety valves tested at regular intervals to determine whether they are in good operating
condition?
□ Is there a current operating permit?
□ Is the inlet of air receivers and piping systems kept free of accumulated oil and carbonaceous materials?
COMPRESSED GAS CYLINDERS□ Are cylinders with a water weight capacity over 30 pounds (13.6 kilograms) equipped with a means toconnect a valve protector device, or with a collar or recess to protect the valve?
□ Are cylinders legibly marked to clearly identify the type of gas?
□ Are compressed gas cylinders stored in areas protected from external heat sources such as flame
impingement, intense radiant heat, electric arcs, or high-temperature lines?
□ Are cylinders located or stored in areas where they will not be damaged by passing or falling objects or
subject to tampering by unauthorized persons?
□ Are cylinders stored or transported in a manner to prevent them from creating a hazard by tipping,falling, or rolling?
□ Are cylinders containing liquefied fuel gas stored or transported in a position so that the safety relief
device is always in direct contact with the vapor space in the cylinder?
□ Are valve protectors always placed on cylinders when the cylinders are not in use or connected for use?
□ Are all valves closed off before a cylinder is moved, when the cylinder is empty and at the completion ofeach job?
□ Are low-pressure fuel gas cylinders checked periodically for corrosion, general distortion, cracks, or any
other defect that might indicate a weakness or render them unfit for service?
□ Does the periodic check of low-pressure fuel gas cylinders include a close inspection of the cylinders'bottoms?
HOIST AND AUXILIARY EQUIPMENT□ Is each overhead electric hoist equipped with a limit device to stop the hook at its highest and lowest
point of safe travel?
□ Will each hoist automatically stop and hold any load up to 125 percent of its rated load if its actuating
force is removed?
□ Is the rated load of each hoist legibly marked and visible to the operator?
□ Are stops provided at the safe limits of travel for trolley hoists?
□ Are the controls of hoists plainly marked to indicate the direction of travel or motion?
□ Is each cage-controlled hoist equipped with an effective warning device?
□ Are close-fitting guards or other suitable devices installed on each hoist to ensure that hoist ropes will bemaintained in the sheave grooves?
□ Are all hoist chains or ropes long enough to handle the full range of movement of the application while
maintaining two full wraps around the drum at all times?
□ Are guards provided for nip points or contact points between hoist ropes and sheaves permanently
located within 7 feet (2.1336 meters) of the floor, ground, or working platform?

Appendix I
November 2019

H-15

Health and Safety Management System Manual□ Are employees prohibited from using chains or rope slings that are kinked or twisted and prohibited fromusing the hoist rope or chain wrapped around the load as a substitute for a sling?
□ Is the operator instructed to avoid carrying loads above people?
INDUSTRIAL TRUCKS - FORKLIFTS□ Are employees properly trained in the use of the type of industrial truck they operate?
□ Are only trained personnel allowed to operate industrial trucks?
□ Is substantial overhead protective equipment provided on high lift rider equipment?
□ Are the required lift truck operating rules posted and enforced?
□ Is directional lighting provided on each industrial truck that operates in an area with less than 2 footcandles per square foot of general lighting?
□ Does each industrial truck have a warning horn, whistle, gong, or other device that can be clearly heard
above normal noise in the areas where it is operated?
□ Are the brakes on each industrial truck capable of bringing the vehicle to a complete and safe stop when
fully loaded?
□ Does the parking brake of the industrial truck prevent the vehicle from moving when unattended?
□ Are industrial trucks that operate where flammable gases, vapors, combustible dust, or ignitable fibers
may be present approved for such locations?
□ Are motorized hand and hand/rider trucks designed so that the brakes are applied and power to the drive
motor shuts off when the operator releases his or her grip on the device that controls the truck's travel?
□ Are industrial trucks with internal combustion engines that are operated in buildings or enclosed areas
carefully checked to ensure that such operations do not cause harmful concentrations of dangerous gases
or fumes?
□ Are safe distances maintained from the edges of elevated ramps and platforms?
□ Are employees prohibited from standing or passing under elevated portions of trucks, whether loaded or
empty?
□ Are unauthorized employees prohibited from riding on trucks?
□ Are operators prohibited from driving up to anyone standing in front of a fixed object?
□ Are arms and legs kept inside the running lines of the truck?
□ Are loads handled only within the rated capacity of the truck?
□ Are trucks in need of repair removed from service immediately?
SPRAYING OPERATIONS□ Is adequate ventilation provided before spraying operations are started?
□ Is mechanical ventilation provided when spraying operations are performed in enclosed areas?
□ When mechanical ventilation is provided during spraying operations, is it so arranged that it will not
circulate the contaminated air?
□ Is the spray area free of hot surfaces and at least 20 feet (6.096 meters) from flames, sparks, operating
electrical motors and other ignition sources?
□ Are portable lamps used to illuminate spray areas suitable for use in a hazardous location?

Appendix I
November 2019

H-16

Health and Safety Management System Manual□ Is approved respiratory equipment provided and used when appropriate during spraying operations?
□ Do solvents used for cleaning have a flash point to 100 degrees Fahrenheit (deg. F) or more?
□ Are fire control sprinkler heads kept clean?
□ Are "NO SMOKING" signs posted in spray areas, paint rooms, paint booths and paint storage areas?
□ Is the spray area kept clean of combustible residue?
□ Are spray booths constructed of metal, masonry, or other substantial noncombustible material?
□ Are spray booth floors and baffles noncombustible and easily cleaned?
□ Is infrared drying apparatus kept out of the spray area during spraying operations and is the spray boothcompletely ventilated before using the drying apparatus?
□ Is the electric drying apparatus properly grounded?
□ Are lighting fixtures for spray booths located outside the booth with the interior lighted through sealed
clear panels?
□ Are the electric motors for exhaust fans placed outside booths or ducts?
□ Are belts and pulleys inside the booth fully enclosed?
□ Do ducts have access doors to allow cleaning?
□ Do all drying spaces have adequate ventilation?
ENTERING CONFINED SPACES□ Are confined spaces thoroughly emptied of any corrosive or hazardous substances, such as acids orcaustics, before entry?
□ Are all lines to a confined space that contain inert, toxic, flammable, or corrosive materials valved off andblanked or disconnected and separated before entry?
□ Are all impellers, agitators, or other moving parts and equipment inside confined spaces locked out ifthey present a hazard?
□ Is either natural or mechanical ventilation provided prior to confined space entry?
□ Are appropriate atmospheric tests performed to check for oxygen deficiency, toxic substances andexplosive concentrations in the confined space before entry?
□ Is adequate illumination provided for the work to be performed in the confined space?
□ Is the atmosphere inside the confined space frequently tested or continuously monitored during work?
□ Is there a trained and equipped standby employee positioned outside the confined space, whose sole
responsibility is to watch the work in progress, sound an alarm if necessary and render assistance?
□ Is the standby employee appropriately trained and equipped to handle an emergency?
□ Are employees prohibited from entering the confined space without lifelines and respiratory equipment if
there is any question as to the cause of an emergency?
□ Is approved respiratory equipment required if the atmosphere inside the confined space cannot be madeacceptable?
□ Is all portable electrical equipment used inside confined spaces either grounded and insulated or
equipped with ground fault protection?
□ Are compressed gas bottles forbidden inside the confined space?

Appendix I
November 2019

H-17

Health and Safety Management System Manual□ Before gas welding or burning is started in a confined space, are hoses checked for leaks, torches lighted
only outside the confined area and the confined area tested for an explosive atmosphere each time
before a lighted torch is taken into the confined space?
□ If employees will be using oxygen-consuming equipment such as salamanders, torches, furnaces, etc., ina confined space, is sufficient air provided to assure combustion without reducing the oxygen
concentration of the atmosphere below 19.5 percent by volume?
□ Whenever combustion-type equipment is used in a confined space, are provisions made to ensure theexhaust gases are vented outside of the enclosure?
□ Is each confined space checked for decaying vegetation or animal matter which may produce methane?
□ Is the confined space checked for possible industrial waste which could contain toxic properties?
□ If the confined space is below ground and near areas where motor vehicles will be operating, is it
possible for vehicle exhaust or carbon monoxide to enter the space?
ENVIRONMENTAL CONTROLS□ Are all work areas properly illuminated?
□ Are employees instructed in proper first aid and other emergency procedures?
□ Are hazardous substances, blood and other potentially infectious materials, which may cause harm byinhalation, ingestion, or skin absorption or contact, identified?
□ Are employees aware of the hazards involved with the various chemicals they may be exposed to in theirwork environment, such as ammonia, chlorine, epoxies, caustics, etc.?
□ Is employee exposure to chemicals in the workplace kept within acceptable levels?
□ Can a less harmful method or product be used?
□ Is the work area ventilation system appropriate for the work performed?
□ Are spray painting operations performed in spray rooms or booths equipped with an appropriate exhaustsystem?
□ Is employee exposure to welding fumes controlled by ventilation, use of respirators, exposure time limits,
or other means?
□ Are welders and other nearby workers provided with flash shields during welding operations?
□ If forklifts and other vehicles are used in buildings or other enclosed areas, are the carbon monoxidelevels kept below maximum acceptable concentration?
□ Has there been a determination that noise levels in the facilities are within acceptable levels?
□ Are steps being taken to use engineering controls to reduce excessive noise levels?
□ Are proper precautions being taken when handling asbestos and other fibrous materials?
□ Are caution labels and signs used to warn of hazardous substances (e.g., asbestos) and biohazards (e.g.,
bloodborne pathogens)?
□ Are wet methods used, when practicable, to prevent the emission of airborne asbestos fibers, silica dust
and similar hazardous materials?
□ Are engineering controls examined and maintained or replaced on a scheduled basis?
□ Is vacuuming with appropriate equipment used whenever possible rather than blowing or sweeping dust?
□ Are grinders, saws and other machines that produce respirable dusts vented to an industrial collector or
central exhaust system?

Appendix I
November 2019

H-18

Health and Safety Management System Manual□ Are all local exhaust ventilation systems designed to provide sufficient air flow and volume for theapplication, and are ducts not plugged and belts not slipping?
□ Is PPE provided, used and maintained wherever required?
□ Are there written standard operating procedures for the selection and use of respirators where needed?
□ Are restrooms and washrooms kept clean and sanitary?
□ Is all water provided for drinking, washing and cooking potable?
□ Are all outlets for water that is not suitable for drinking clearly identified?
□ Are employees' physical capacities assessed before they are assigned to jobs requiring heavy work?
□ Are employees instructed in the proper manner for lifting heavy objects?
□ Where heat is a problem, have all fixed work areas been provided with spot cooling or air conditioning?
□ Are employees screened before assignment to areas of high heat to determine if their health might makethem more susceptible to having an adverse reaction?
□ Are employees working on streets and roadways who are exposed to the hazards of traffic required towear bright colored (traffic orange) warning vests?
□ Are exhaust stacks and air intakes located so that nearby contaminated air will not be recirculated within
a building or other enclosed area?
□ Is equipment producing ultraviolet radiation properly shielded?
□ Are universal precautions observed where occupational exposure to blood or other potentially infectious
materials can occur and in all instances where differentiation of types of body fluids or potentially
infectious materials is difficult or impossible?
FLAMMABLE AND COMBUSTIBLE MATERIALS□ Are combustible scrap, debris and waste materials (oily rags, etc.) stored in covered metal receptacles
and promptly removed from the worksite?
□ Is proper storage practiced to minimize the risk of fire, including spontaneous combustion?
□ Are approved containers and tanks used to store and handle flammable and combustible liquids?
□ Are all connections on drums and combustible liquid piping, vapor and liquid tight?
□ Are all flammable liquids kept in closed containers when not in use (e.g., parts cleaning tanks, pans,etc.)?
□ Are bulk drums of flammable liquids grounded and bonded to containers during dispensing?
□ Do storage rooms for flammable and combustible liquids have explosion-proof lights and mechanical or
gravity ventilation?
□ Is liquefied petroleum gas stored, handled and used in accordance with safe practices and standards?
□ Are "NO SMOKING" signs posted on liquefied petroleum gas tanks and in areas where flammable or
combustible materials are used or stored?
□ Are liquefied petroleum storage tanks guarded to prevent damage from vehicles?
□ Are all solvent wastes and flammable liquids kept in fire-resistant, covered containers until they are
removed from the worksite?
□ Is vacuuming used whenever possible rather than blowing or sweeping combustible dust?
□ Are firm separators placed between containers of combustibles or flammables that are stacked one uponanother to ensure their support and stability?

Appendix I
November 2019

H-19

Health and Safety Management System Manual□ Are fuel gas cylinders and oxygen cylinders separated by distance and fire-resistant barriers while instorage?
□ Are fire extinguishers selected and provided for the types of materials in the areas where they are to be
used?
□ Class A - Ordinary combustible material fires.
□ Class B - Flammable liquid, gas or grease fires.
□ Class C - Energized-electrical equipment fires.
□ Are appropriate fire extinguishers mounted within 75 feet (22.86 meters) of outside areas containing
flammable liquids and within 10 feet (3.048 meters) of any inside storage area for such materials?
□ Are extinguishers free from obstructions or blockage?
□ Are all extinguishers serviced, maintained and tagged at intervals not to exceed one year?
□ Are all extinguishers fully charged and in their designated places?
□ Where sprinkler systems are permanently installed, are the nozzle heads so directed or arranged thatwater will not be sprayed into operating electrical switchboards and equipment?
□ Are safety cans used for dispensing flammable or combustible liquids at the point of use?
□ Are all spills of flammable or combustible liquids cleaned up promptly?
□ Are storage tanks adequately vented to prevent the development of excessive vacuum or pressure as aresult of filling, emptying, or atmosphere temperature changes?
□ Are storage tanks equipped with emergency venting that will relieve excessive internal pressure causedby fire exposure?
□ Are rules enforced in areas involving storage and use of hazardous materials?
HAZARDOUS CHEMICAL EXPOSURE□ Are employees aware of the potential hazards and trained in safe handling practices for situations
involving various chemicals stored or used in the workplace such as acids, bases, caustics, epoxies,
phenols, etc.?
□ Is employee exposure to chemicals kept within acceptable levels?
□ Are eye-wash fountains and safety showers provided in areas where corrosive chemicals are handled?
□ Are all containers, such as vats, storage tanks, etc., labeled as to their contents, e.g., "CAUSTICS"?
□ Are all employees required to use personal protective clothing and equipment when handling chemicals(gloves, eye protection, respirators, etc.)?
□ Are flammable or toxic chemicals kept in closed containers when not in use?
□ Are chemical piping systems clearly marked as to their content?
□ Where corrosive liquids are frequently handled in open containers or drawn from storage vessels or
pipelines, are adequate means readily available for neutralizing or disposing of spills or overflows andperformed properly and safely?
□ Are standard operating procedures established and are they being followed when cleaning up chemical
spills?
□ Are respirators stored in a convenient, clean and sanitary location, and are they adequate for
emergencies?
□ Are employees prohibited from eating in areas where hazardous chemicals are present?

Appendix I
November 2019

H-20

Health and Safety Management System Manual□ Is PPE used and maintained whenever necessary?
□ Are there written standard operating procedures for the selection and use of respirators where needed?
□ If you have a respirator protection program, are your employees instructed on the correct usage andlimitations of the respirators?
□ Are the respirators National Institute for Occupational Safety and Health (NIOSH) approved for thisparticular application?
□ Are they regularly inspected, cleaned, sanitized and maintained?
□ If hazardous substances are used in your processes, do you have a medical or biological monitoring
system in operation?
□ Are you familiar with the threshold limit values or permissible exposure limits of airborne contaminants
and physical agents used in your workplace?
□ Have appropriate control procedures been instituted for hazardous materials, including safe handlingpractices and the use of respirators and ventilation systems?
□ Whenever possible, are hazardous substances handled in properly designed and exhausted booths orsimilar locations?
□ Do you use general dilution or local exhaust ventilation systems to control dusts, vapors, gases, fumes,
smoke, solvents, or mists that may be generated in your workplace?
□ Is operational ventilation equipment provided for removal of contaminants from production grinding,buffing, spray painting, and/or vapor degreasing?
□ Do employees complain about dizziness, headaches, nausea, irritation, or other factors of discomfort
when they use solvents or other chemicals?
□ Is there a dermatitis problem? Do employees complain about dryness, irritation, or sensitization of theskin?
□ Have you considered having an industrial hygienist or environmental health specialist evaluate youroperation?
□ If internal combustion engines are used, is carbon monoxide kept within acceptable levels?
□ Is vacuuming used rather than blowing or sweeping dust whenever possible for cleanup?
□ Are materials that give off toxic, asphyxiant, suffocating, or anesthetic fumes stored in remote or isolated
locations when not in use?
HAZARDOUS SUBSTANCES COMMUNICATION□ Is there a list of hazardous substances used in your workplace and an MSDS readily available for eachhazardous substance used?
□ Is there a current written exposure control plan for occupational exposure to bloodborne pathogens andother potentially infectious materials, where applicable?
□ Is there a written hazard communication program dealing with MSDSs, labeling and employee training?
□ Is each container for a hazardous substance (i.e., vats, bottles, storage tanks, etc.) labeled with productidentity and a hazard warning (communication of the specific health hazards and physical hazards)?
□ Is there an employee training program for hazardous substances that includes:

an explanation of what an MSDS is and how to use and obtain one;MSDS contents for each hazardous substance or class of substances;
explanation of "A Right to Know";

Appendix I
November 2019

H-21

Health and Safety Management System Manual

identification of where an employee can see the written hazard communication program;location of physical and health hazards in particular work areas and the specific protective
measures to be used; anddetails of the hazard communication program, including how to use the labeling system andMSDSs.

□ Does the employee training program on the bloodborne pathogens standard contain the following
elements:















an accessible copy of the standard and an explanation of its contents;
a general explanation of the epidemiology and symptoms of bloodborne diseases;
an explanation of the modes of transmission of Bloodborne Pathogens;an explanation of the employer's exposure control plan and the means by which employees canobtain a copy of the written plan;an explanation of the appropriate methods for recognizing tasks and the other activities that may
involve exposure to blood and other potentially infectious materials;
an explanation of the use and limitations of methods that will prevent or reduce exposure,including appropriate engineering controls, work practices and PPE;
information on the types, proper use, location, removal, handling, decontamination and disposalof PPE;an explanation of the basis for selection of PPE;
information on the hepatitis B vaccine;
information on the appropriate actions to take and persons to contact in an emergency involving
blood or other potentially infectious materials;
an explanation of the procedure to follow if an exposure incident occurs, including the methodsof reporting the incident and the medical follow-up that will be made available;
information on post-exposure evaluations and follow-up; andan explanation of signs, labels and color coding.

□ Are employees trained in:






how to recognize tasks that might result in occupational exposure;
how to use work practice, engineering controls and PPE, and their limitations;
how to obtain information on the types, selection, proper use, location, removal, handling,
decontamination and disposal of PPE; andwho to contact and what to do in an emergency.

ELECTRICAL□ Do you require compliance with OSHA standards for all contract electrical work?
□ Are all employees required to report any obvious hazard to life or property in connection with electricalequipment or lines as soon as possible?
□ Are employees instructed to make preliminary inspections and/or appropriate tests to determine
conditions before starting work on electrical equipment or lines?
□ When electrical equipment or lines are to be serviced, maintained, or adjusted, are necessary switches
opened, locked out or tagged, whenever possible?
□ Are portable electrical tools and equipment grounded or of the double insulated type?
□ Are electrical appliances such as vacuum cleaners, polishers, vending machines, etc., grounded?

Appendix I
November 2019

H-22

Health and Safety Management System Manual□ Do extension cords have a grounding conductor?
□ Are multiple plug adaptors prohibited?
□ Are ground-fault circuit interrupters installed on each temporary 15 or 20 ampere, 120 volt alternating
current (AC) circuit at locations where construction, demolition, modifications, alterations, or excavations
are being performed?
□ Are all temporary circuits protected by suitable disconnecting switches or plug connectors at the junction
with permanent wiring?
□ Do you have electrical installations in hazardous dust or vapor areas? If so, do they meet the National
Electrical Code (NEC) for hazardous locations?
□ Are exposed wiring and cords with frayed or deteriorated insulation repaired or replaced promptly?
□ Are flexible cords and cables free of splices or taps?
□ Are clamps or other securing means provided on flexible cords or cables at plugs, receptacles, tools,
equipment, etc., and is the cord jacket securely held in place?
□ Are all cord, cable and raceway connections intact and secure?
□ In wet or damp locations, are electrical tools and equipment appropriate for the use or location orotherwise protected?
□ Is the location of electrical power lines and cables (overhead, underground, under floor, other side ofwalls, etc.) determined before digging, drilling, or similar work is begun?
□ Are metal measuring tapes, ropes, hand-lines or similar devices with metallic thread woven into the fabricprohibited where they could come in contact with energized parts of equipment or circuit conductors?
□ Is the use of metal ladders prohibited where the ladder or the person using the ladder could come incontact with energized parts of equipment, fixtures, or circuit conductors?
□ Are all disconnecting switches and circuit breakers labeled to indicate their use or equipment served?
□ Are disconnecting means always opened before fuses are replaced?
□ Do all interior wiring systems include provisions for grounding metal parts of electrical raceways,
equipment and enclosures?
□ Are all electrical raceways and enclosures securely fastened in place?
□ Are all energized parts of electrical circuits and equipment guarded against accidental contact byapproved cabinets or enclosures?
□ Is sufficient access and working space provided and maintained around all electrical equipment to permit
ready and safe operations and maintenance?
□ Are all unused openings (including conduit knockouts) in electrical enclosures and fittings closed withappropriate covers, plugs, or plates?
□ Are electrical enclosures such as switches, receptacles, junction boxes, etc., provided with tight-fitting
covers or plates?
□ Are disconnecting switches for electrical motors in excess of two horsepower able to open the circuit
when the motor is stalled without exploding? (Switches must be horsepower rated equal to or in excessof the motor rating.)□ Is low voltage protection provided in the control device of motors driving machines or equipment that
could cause injury from inadvertent starting?
□ Is each motor disconnecting switch or circuit breaker located within sight of the motor control device?
□ Is each motor located within sight of its controller or is the controller disconnecting means able to belocked open or is a separate disconnecting means installed in the circuit within sight of the motor?

Appendix I
November 2019

H-23

Health and Safety Management System Manual□ Is the controller for each motor that exceeds two horsepower rated equal to or above the rating of the
motor it serves?
□ Are employees who regularly work on or around energized electrical equipment or lines instructed in
cardiopulmonary resuscitation (CPR)?
□ Are employees prohibited from working alone on energized lines or equipment over 600 volts?
NOISE□ Are there areas in the workplace where continuous noise levels exceed 85 decibels?
□ Is there an ongoing preventive health program to educate employees in safe levels of noise, exposures,
effects of noise on their health and the use of personal protection?
□ Have work areas where noise levels make voice communication between employees difficult been
identified and posted?
□ Are noise levels measured with a sound level meter or an octave band analyzer and are records being
kept?
□ Have engineering controls been used to reduce excessive noise levels? Where engineering controls are
determined to be infeasible, are administrative controls (i.e., worker rotation) being used to minimize
individual employee exposure to noise?
□ Is approved hearing protective equipment (noise attenuating devices) available to every employee
working in noisy areas?
□ Have you tried isolating noisy machinery from the rest of your operation?
□ If you use ear protectors, are employees properly fitted and instructed in their use?
□ Are employees in high noise areas given periodic audiometric testing to ensure that you have an effective
hearing protection system?
FUELING□ Are employees prohibited from fueling an internal combustion engine with a flammable liquid while theengine is running?
□ Are fueling operations performed to minimize spillage?
□ When spillage occurs during fueling operations, is the spilled fuel washed away completely, evaporated,or are other measures taken to control vapors before restarting the engine?
□ Are fuel tank caps replaced and secured before starting the engine?
□ In fueling operations, is there always metal contact between the container and the fuel tank?
□ Are fueling hoses designed to handle the specific type of fuel?
□ Are employees prohibited from handling or transferring gasoline in open containers?
□ Are open lights, open flames, sparking, or arcing equipment prohibited near fueling or transfer of fueloperations?
□ Is smoking prohibited in the vicinity of fueling operations?
□ Are fueling operations prohibited in buildings or other enclosed areas that are not specifically ventilated
for this purpose?
□ Where fueling or transfer of fuel is done through a gravity flow system, are the nozzles self-closing?

Appendix I
November 2019

H-24

Health and Safety Management System Manual

IDENTIFICATION OF PIPING SYSTEMS□ When nonpotable water is piped through a facility, are outlets or taps posted to alert employees that thewater is unsafe and not to be used for drinking, washing, or other personal use?
□ When hazardous substances are transported through above-ground piping, is each pipeline identified atpoints where confusion could introduce hazards to employees?
□ When pipelines are identified by color painted bands or tapes, are the bands or tapes located atreasonable intervals and at each outlet, valve, or connection, and are all visible parts of the line so
identified?
□ When pipelines are identified by color, is the color code posted at all locations where confusion could
introduce hazards to employees?
□ When the contents of pipelines are identified by name or name abbreviation, is the information readily
visible on the pipe near each valve or outlet?
□ When pipelines carrying hazardous substances are identified by tags, are the tags constructed of durable
materials, the message printed clearly and permanently, and are tags installed at each valve or outlet?
□ When pipelines are heated by electricity, steam, or other external source, are suitable warning signs ortags placed at unions, valves, or other serviceable parts of the system?
MATERIALS HANDLING□ Is there safe clearance for equipment through aisles and doorways?
□ Are aisleways permanently marked and kept clear to allow unhindered passage?
□ Are motorized vehicles and mechanized equipment inspected daily or prior to use?
□ Are vehicles shut off and brakes set prior to loading or unloading?
□ Are containers of liquid combustibles or flammables, when stacked while being moved, always protectedby dunnage (packing material) sufficient to provide stability?
□ Are dock boards (bridge plates) used when loading or unloading operations are taking place between
vehicles and docks?
□ Are trucks and trailers secured from movement during loading and unloading operations?
□ Are dock plates and loading ramps constructed and maintained with sufficient strength to support
imposed loading?
□ Are hand trucks maintained in safe operating condition?
□ Are chutes equipped with sideboards of sufficient height to prevent the materials being handled fromfalling off?
□ Are chutes and gravity roller sections firmly placed or secured to prevent displacement?
□ Are provisions made to brake the movement of the handled materials at the delivery end of rollers orchutes?
□ Are pallets usually inspected before being loaded or moved?
□ Are safety latches and other devices being used to prevent slippage of materials off of hoisting hooks?
□ Are securing chains, ropes, chockers, or slings adequate for the job?
□ Are provisions made to ensure that no one is below when hoisting material or equipment?
□ Are MSDSs available to employees handling hazardous substances?

Appendix I
November 2019

H-25

Health and Safety Management System Manual

TRANSPORTING EMPLOYEES AND MATERIALS□ Do employees who operate vehicles on public thoroughfares have valid operator's licenses?
□ When seven or more employees are regularly transported in a van, bus, or truck, is the operator's license
appropriate for the class of vehicle being driven and are there enough seats?
□ Are vehicles used to transport employees equipped with lamps, brakes, horns, mirrors, windshields andturn signals, and are they in good repair?
□ Are transport vehicles provided with handrails, steps, stirrups, or similar devices, placed and arranged toallow employees to safely mount or dismount?
□ Are employee transport vehicles equipped at all times with at least two reflective-type flares?
□ Is a fully charged fire extinguisher, in good condition, with at least a 4 B:C rating maintained in each
employee transport vehicle?
□ When cutting tools or tools with sharp edges are carried in passenger compartments of employeetransport vehicles, are they placed in closed boxes or containers that are secured in place?
□ Are employees prohibited from riding on top of any load that could shift, topple, or otherwise become
unstable?
CONTROL OF HARMFUL SUBSTANCES BY VENTILATION□ Is the volume and velocity of air in each exhaust system sufficient to gather the dusts, fumes, mists,
vapors, or gases to be controlled, and to convey them to a suitable point of disposal?
□ Are exhaust inlets, ducts and plenums designed, constructed and supported to prevent collapse or failureof any part of the system?
□ Are clean-out ports or doors provided at intervals not to exceed 12 feet (3.6576 meters) in all horizontal
runs of exhaust ducts?
□ Where two or more different operations are being controlled through the same exhaust system, could the
combination of substances involved create a fire, explosion, or chemical reaction hazard in the duct?
□ Is adequate makeup air provided to areas where exhaust systems are operating?
□ Is the source point for makeup air located so that only clean, fresh air, free of contaminants will enter thework environment?
□ Where two or more ventilation systems serve a work area, is their operation such that one will not offset
the functions of the other?
SANITIZING EQUIPMENT AND CLOTHING□ Is required personal protective clothing or equipment able to be cleaned and disinfected easily?
□ Are employees prohibited from interchanging personal protective clothing or equipment, unless it has
been properly cleaned?
□ Are machines and equipment that process, handle, or apply materials that could injure employees
cleaned and/or decontaminated before being overhauled or placed in storage?
□ Are employees prohibited from smoking or eating in any area where contaminants are present that could
be injurious if ingested?
□ When employees are required to change from street clothing into protective clothing, is a clean changeroom with a separate storage facility for street and protective clothing provided?

Appendix I
November 2019

H-26

Health and Safety Management System Manual□ Are employees required to shower and wash their hair as soon as possible after a known contact with a
carcinogen has occurred?
□ When equipment, materials, or other items are taken into or removed from a carcinogen-regulated area,
is it done in a manner that will not contaminate non-regulated areas or the external environment?
TIRE INFLATION□ Where tires are mounted and/or inflated on drop center wheels or on wheels with split rims and/or
retainer rings, is a safe practice procedure posted and enforced?
□ Does each tire inflation hose have a clip-on chuck with at least 2.54 inches (6.45 centimeters) of hose
between the chuck and an in-line hand valve and gauge?
□ Does the tire inflation control valve automatically shut off the air flow when the valve is released?
□ Is a tire restraining device such as a cage, rack, or other effective means used while inflating tires
mounted on split rims or rims using retainer rings?
□ Are employees prohibited from standing directly over or in front of a tire while it is being inflated?

Appendix I
November 2019

H-27

Health and Safety Management System Manual

Appendix I – Corporate Environmental Management Team Contact List

Contact information for Corporate Environmental, Health and Safety Management Team members isposted to the Teledyne EHS Intranet site (employee access only):-END-

Appendix I
November 2019

I-1