client information note - ohsas 18001

MSBSR41604 of 5 Revision 2.3, 07 April 2014

Assessment process - OHSAS 18001

OverviewThis Client information note explains the main stagesof our process for OHSAS 18001 Occupational Health& Safety (OHS) Management System assessment andcertification.

The assessment process normally includes two visits toyour site before we can recommend approval. Wecall these two visits:

• Stage 1 (document review and planning visit),and

• Stage 2 (initial assessment).

Once we have issued your approval certificate, wewill carry out surveillance visits to maintain yourapproval.At each visit, our assessors will be open and helpful,and will follow a practical approach. In this way webelieve that we add value to the assessment process.Before we visit, we will discuss and agree with youthe visit dates, start and finish times, the assessmentteam members, how long the visit will last, and whichparts of your business we will visit. Visits will becarried out and reported in your national languageunless otherwise agreed.

Stage 1 - Document review and planning visitPurpose of the visitWe do this visit to:

• find out whether the management systemprocesses and documents required by thestandard are in place and put into practice so thata meaningful Stage 2 assessment can take place• assess the risk identification, assessment andtreatment process and the methods required toensure effective risk management and effectiveimplementation of the applicable controls• collect information about your company'sorganisation, processes and activities so that wecan develop a plan for the Stage 2 assessment• confirm the scope, assessment teamrequirements, and timing for the Stage 2assessment• answer any questions you may have about ourservice.

Our main focus is on the planning elements. Thisincludes:

• how effective your system is in identifyinghazards• the way you have assessed the associated risks,and


• how you plan the necessary control measures andimprovement objectives together with theassociated management programmes.

The visit will identify any weaknesses or omissions inyour system that may need to be put right before theStage 2 assessment.

Carrying out the visitThe visit (which usually lasts for two days), starts withan opening meeting. The assessor will explain toyour management team how we carry outassessments, and you will be able to introduce yourcompany. The assessor will agree a plan for the visitwith you.

The assessor will then:• review the design and documentation of thesystem against the assessment criteria and theproposed assessment scope

• conduct a site tour, where appropriate• produce a detailed visit plan for the Stage 2initial assessment visit• produce a focused report which describes bothpositive findings and any issues requiring yourattention before the Stage 2 visit takes place.The report will identify the grading of theseissues as if they were findings outstanding at theend of the Stage 2 visit.

The assessor will usually need to review your:• Occupational Health and Safety policy

• hazard identification, risk assessment and riskcontrol records

• access to applicable legislation and regulations• objectives and OHS management programmes• OHS performance measures and reporting• internal audit programme and reports

• procedures to manage and control the identifiedOHS risks

• emergency response plans


• management of the system - including correctiveand preventive action and management review• site activities - to observe site layout andconditions, and operations and activities inprogress; to confirm potential hazards and risks;to identify current control measures and OHSperformance measures and indicators; and asfamiliarisation for the Stage 2 assessment.

The visit ends with a closing meeting to present theStage 1 report and agree the next stage of theassessment process, including any health and safety,security and administrative issues.If your organisation controls significant maintenanceactivity, involving either your own staff, orcontractors and your staff, the Stage 2 visit may bearranged to coincide with a major shutdown formaintenance. This will be based on the assessors'assessment of the hazard content and the complexityof the applied controls likely to be assessable.The documentation reviewed during the Stage 1 visitwill be used at future visits as a baseline. However,you should continue to amend system documents as aresult of internal improvement activities. At eachvisit we will need to identify the changes betweenthe latest issue and the baseline.

Stage 2 - Initial assessment

Purpose of the visitDuring this visit the assessor will focus on how yourmanagement system has been put into practice. TheStage 2 visit aims to confirm that:

• your policies, objectives, programmes andprocedures are effectively put into practice• there is a planned and systematic approach toimprovement• you are effectively managing the identified OHSrisks in the management system• the management system meets all requirementsof the assessment standard.

Carrying out the visitThe assessment, which may have been arranged tocoincide with a major shutdown for maintenance,follows the plan prepared during the Stage 1 visit.Members of the assessment team will visit areas withguides who can witness the findings and help theaudit. The Stage 2 assessment usually includes ameeting with the representative of seniormanagement with overall responsibility for themanagement system.

Our assessment team will report, as a minimum, anyfindings related to:• follow-up of findings from the Stage 1 visit

• activities, products and services identified in theagreed scope for the assessment• how effective the management system is atachieving your organisation's policy includinglegal compliance, continual improvement andcontrol of risks to health and safety• putting into practice the arrangements tomanage OHS risks


• progress to achieve objectives throughmanagement programmes• putting into practice the systems needed by themanagement system and maintainingappropriate records• putting into practice monitoring andmeasurement arrangements to assess how themanagement system performs and whetherobjectives are achieved• how involved in, and committed to, themanagement system the senior management are,and• how effective the internal audit, corrective andpreventive action, and management reviewprocesses are.

The assessment team will hold review meetings withyou each day to discuss any findings. Appropriatestaff should be present to confirm that you acceptthese findings. Please see below in the 'Reporting'section how we define findings. We finalise thegrade of findings at the end of the visit.The visit ends with a closing meeting to present asummary of the findings, and to agree the next stageof the assessment process. The assessor will give acomplete report to your management representative.If we have not reported any Major Nonconformities,and you have informed the assessor of your proposedcorrective action for any Minor Nonconformities, theassessor will recommend approval to the assessmentstandard (although this depends on an independenttechnical review by our office). However, if anyMajor Nonconformities have been reported, we willdelay approval and carry out a follow up assessmentto review corrective actions. Our team leader willagree with you the arrangements for this visit.

Surveillance visits

Purpose of the visitOnce we have certified your management system, wewill begin a programme of surveillance visits, (whichnormally take place every six months). However, ifyou undertake major periods of shutdownmaintenance (either by your own staff or usingcontractors), and your Stage 2 visit did not coincidewith such a period, then we may arrange asurveillance visit to correspond with this activity bymoving one of the visits from the six-month cycle.


Surveillance visits aim to confirm that your approvedmanagement system continues to:

• be maintained• be in operation, and• deliver continual improvements.

We also consider the implications of changes to thesystem. Such changes may have been carried out as aresult of changes in your activities, products orservices.We will then consider whether you continue to meetcertification requirements.

Carrying out the visitThemes for surveillance visits will normally have beenagreed with you at your previous visit. We willconfirm the details with you at an opening meeting.

Themes chosen will allow us to review:• internal audit and management review processes

• how management programmes are operatingand their progress in meeting OHS objectives• corrective and preventive action processesincluding customer complaints• changes to the system and the effectiveness oftheir implementation• how you manage changes relating toresponsibilities and authorities of main staff.

We will also review any outstanding findings andhow you use and accreditation logos.

If we report any Minor Nonconformities during avisit, and the next visit is within six months, we willnormally follow them up during our next visit to you,otherwise we will make arrangements with you forthe follow up.If we report a Major Nonconformity during asurveillance visit, we will arrange a specialsurveillance visit to follow up the necessary correctiveaction (normally within three months). This is thefirst phase of our suspension and withdrawal ofapproval process.At the closing meeting, our assessor will report onthe current visit and agree with you the theme forthe next visit. If any Major Nonconformities havebeen reported, the assessor will also agreearrangements for follow up of actions you will take.

Certificate renewal

Planning for the certificate renewalWe conduct certificate renewals on a three-yearlybasis, planned at the previous surveillance visit andagreed with you.The certificate renewal planning process containsthree steps: Review, Preview and Planning.

ReviewThis step includes the review of past performancesuch as:

• trend information on complaints and otherperformance indicators

• system documentation improvements• Improvement Log projects


• lessons learned from audits• trends in our findings.

Based on this review of past performance, ourassessor will identify any potential risks in the presentmanagement system regarding successfulimplementation of the strategies and objectives.

PreviewThe aim of the preview is to align our assessmentactivities with your strategy and objectives. Theassessor will use the conversation with seniormanagement to understand your longer termexpectations, for example, strategy issues such asbusiness and operational risks, competitive issues,changes to internal and external environment, etc.Our assessor will establish, through the interview,whether these expectations, objectives and strategieswill impact your management system or thestakeholders of your organisation.The preview stage will be used to identify furtherthemes that can be used in the coming certificaterenewal visit and for the next three-year cycle.

PlanningThe next step in the visit is planning the certificaterenewal. In this part of the visit our assessor will:

• identify any aspects of the system that have notbeen appropriately addressed during thesurveillance cycle, and plan how to review these• use the information gained during the reviewand preview stages to support the planningprocess• if appropriate, consider how best to giveattention to any themes identified (including theimprovement tracking log)• identify the areas, departments, processes andactivities to be assessed• agree with you sensible durations for each ofthese, commensurate with risk• try to identify the best use of resources, andavoid duplication• add appropriate time for reporting, consolidatingand presenting reports• consolidate the information into a sensible visitplan.


Our assessor will allow time for discussion with allrelevant managers and for a review of records for allrelevant departments.

Conducting certificate renewal visitsWe conduct the certificate renewal visit similarly to aStage 2 assessment. In addition, we include a reviewof your system documentation to ensure that it:• continues to suit your company, and

• complies with the certification requirements andthe scope of certification, including continualimprovement.

Changes to your approvalFor any increase or decrease in your certificate ofapproval, please submit a formal request for thechange. will review the request to consider:

• additions or changes to competencyrequirements for the visit team(s)• additions or reductions in visit durationrequirements

and you will be notified of any changes by anamended contract.

If the change requested has meant a major change oraddition to your documented system, we willundertake a separate document review visit (Stage 1).We will conduct the change to approval visit in linewith our process for Stage 2 assessment visits,although we do not normally produce a formal visitplan. If we did not need to conduct a documentreview (Stage 1), we will allow time during the visitfor the team leader to review relevantdocumentation and to agree a plan for the visit.Change to Approval visits may be performed asseparate visits or may be combined with a scheduled(Surveillance or Certificate Renewal) visit. will issue an amended certificate(s), using thesame expiry date as on the current certificate.

ReportingThe reporting process for all our visits is similar. Wefill in visit reports to record assessment findings,progress against the assessment plan, positivecomments, and also points of clarification orinterpretation. We record assessment findings in anAssessment Findings Log, and identify them as MajorNonconformity or Minor Nonconformity. We definethese findings as follows:Major Nonconformity: The absence of, or the failureto implement and maintain, one or moremanagement system elements, or a situation whichwould, on the basis of the available objectiveevidence, raise significant doubt of the managementto achieve:

• the policy, objectives or public commitments ofthe organisation• compliance with the applicable regulatoryrequirements• conformance to applicable customerrequirements

• conformance with the audit criteria deliverables.Generally, a major nonconformity will be a system


failure that:• is already affecting system effectiveness ordeliverables• puts at risk the capability of the managementsystem

• requires immediate containment• requires immediate root cause analysis andcorrective action.

Our team leader will make arrangements with youfor follow up.Minor Nonconformity: A finding indicative of aweakness in the implemented and maintainedsystem, which has not significantly impacted on thecapability of the management system or put at riskthe system deliverables, but needs to be addressed toassure the future capability of the system.Generally, a minor nonconformity will be a weaknessin an internal facing process or procedure; or afinding where any further deterioration of controlcould reasonably be considered likely to result in thesystem becoming ineffective. Requires root causeinvestigation and corrective action.If raised at a visit that results in a certificate beingissued, then the assessor will ask you to indicate thecorrective action you will take. This corrective actionplan will form part of the independent review by ouroffice before your certificate is issued. If raised at asurveillance visit, although you need to takecorrective action within an appropriate time after thevisit, you do not normally need to provide us withdetails of the action until we next visit you.In both cases, at the next visit the assessor will reviewthe action you have taken and fill in the correctiveaction review section in the findings logPlease keep copies of all our visit reports for threeyears. In exceptional circumstances, we may ask youto provide copies of previous reports.If we identify any isolated issues that you shouldaddress to avoid us raising a nonconformity at asubsequent visit, we will record them in the relevantpart of the report.


Suggestions for improvements that could be made toa compliant management system that would improvethe efficiency of the processes undertaken we willrecord in either:

• the executive summary, for strategicimprovement suggestions, or• the body of the report, for improvementsuggestions that relate to a particular area.

SamplingIt is important to remember that even though aproblem may not have been identified in an area ofactivity, it does not necessarily mean that there areno problems. As assessment work is based onsampling techniques, statistically there is always apossibility that issues will not be identified during anassessment. Please consider this when you audit yourown management system.

Care is taken to ensure that all information provided is accurate and up to date. However, 's Register accepts no responsibility forinaccuracies in, or changes to, information. 's Register and variants of it are trading names of 's Register Group Limited, its subsidiaries andaffiliates.

Copyright © 's Register Quality Assurance Limited, 2014. A member of the 's Register group.

client information note - ohsas 18001

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