10. Improvement
10.1 General
Improvement is a continuous obligation, not a phase. The organisation actively looks for ways to make the OH&S system work better — drawing on incidents, audits, monitoring data, worker input and emerging best practice — and converts those findings into specific actions with owners and deadlines.
Sources of Improvement Opportunities:
- Incident Investigations: Learning from incidents, near-misses and unsafe conditions
- Worker Suggestions: Ideas and feedback from workers on safety improvements
- Audit Findings: Internal audit recommendations and external certification audit findings
- Risk Assessments: Identifying better controls during risk assessment reviews
- Performance Analysis: Trends and patterns in OH&S performance data
- Benchmarking: Comparing with industry best practices and leading performers
- Technology Advances: New safety technologies and equipment
- Management Review: Strategic improvement decisions from management review
- Legal Changes: New regulatory requirements driving improvements
- Customer Requirements: Client expectations for OH&S performance
Improvement is everyone's job:
The system can't improve only when management decides to run a project. The workforce needs visible, low-friction routes to suggest changes — and they need to see those suggestions acted on. Where improvement only flows top-down, the system stagnates between audits.
The system can't improve only when management decides to run a project. The workforce needs visible, low-friction routes to suggest changes — and they need to see those suggestions acted on. Where improvement only flows top-down, the system stagnates between audits.
Areas for OH&S Improvement:
- Enhancing hazard elimination and risk reduction
- Improving worker competence and awareness
- Strengthening operational controls
- Increasing worker participation and engagement
- Improving emergency preparedness and response
- Enhancing OH&S communication effectiveness
- Reducing incident and injury rates
- Improving compliance with legal requirements
- Integrating OH&S into business processes
- Enhancing OH&S culture and behaviors
10.2 Incident, Nonconformity and Corrective Action
A defined process for handling incidents and nonconformities — reporting, investigating, correcting, learning. The aim is twofold: deal with the immediate event, and stop it happening again here or anywhere else in the operation.
Incident Response Requirements
The response sequence:
a
React quickly:
- Contain and correct the immediate situation
- Manage the consequences — medical care, regulator notification, family contact
b
Decide whether deeper action is needed to remove the cause:
- Investigate the event or examine the nonconformity
- Identify the cause — not just what failed, but why the system allowed it
- Check whether similar events have already happened or could happen elsewhere
c
Revisit the relevant risk assessments and update where the event has changed the risk picture
d
Implement corrective action through the controls hierarchy and the MOC process — not bolt-on fixes
e
Assess any new or changed hazards introduced by the corrective action itself before applying it
f
Verify the action worked — close-out is a check, not a tickbox
g
Update the OH&S management system where the event has exposed a system-level gap
Incident Definition and Types
Incident Categories:
- Fatality: Work-related death
- Lost Time Injury (LTI): Injury resulting in time away from work beyond the day of injury
- Medical Treatment Injury (MTI): Injury requiring professional medical treatment beyond first aid
- Restricted Work Injury (RWI): Injury where worker can return but with limitations
- First Aid Injury: Minor injury requiring only first aid treatment
- Near-Miss: Event that could have resulted in injury or ill health but did not
- Dangerous Occurrence: Event with potential for serious harm (e.g., structural collapse, major release)
- Occupational Illness: Work-related disease or health condition
- Property Damage: Incidents causing damage to equipment, facilities or materials
Near misses are early warnings:
A high-energy near miss is the same event as a fatality with one variable changed. Treating near misses as nuisance reports — or pretending they didn't happen — closes off the most useful early-warning signal the system has. The reporting culture has to make raising them easier than hiding them.
A high-energy near miss is the same event as a fatality with one variable changed. Treating near misses as nuisance reports — or pretending they didn't happen — closes off the most useful early-warning signal the system has. The reporting culture has to make raising them easier than hiding them.
Incident Reporting Process
Effective Incident Reporting:
1Provide multiple, easy-to-use reporting channels (forms, phone, email, app)
2Ensure workers know how and when to report incidents
3Encourage reporting without fear of blame or reprisal
4Require immediate reporting of serious incidents
5Capture essential information: who, what, when, where, how
6Acknowledge and respond to reports promptly
7Provide feedback on actions taken
Incident Investigation
Investigation Objectives:
- Understand what happened and how it happened
- Identify the root causes (not just immediate causes)
- Determine effective corrective actions to prevent recurrence
- Share lessons learned across the organization
- Meet legal reporting and investigation requirements
- Not to assign blame or punish individuals
Investigation Process:
1Immediate Response: Ensure scene is safe, provide first aid, secure the scene
2Notification: Notify management, emergency services, regulatory authorities as required
3Investigation Team: Assign competent investigators (include worker representatives)
4Gather Evidence: Photos, measurements, witness interviews, documents, physical evidence
5Analyze Information: Reconstruct the incident sequence of events
6Identify Causes: Use root cause analysis techniques (5 Whys, Fishbone, etc.)
7Develop Recommendations: Identify corrective actions using hierarchy of controls
8Report Findings: Document investigation and recommendations
9Implement Actions: Assign responsibilities and deadlines for corrective actions
10Verify Effectiveness: Follow up to ensure actions are effective
11Share Lessons: Communicate findings to prevent similar incidents
Root Cause Analysis:
Look beyond the obvious immediate causes to identify underlying root causes:
- Immediate Causes: Unsafe acts (what the person did) and unsafe conditions (physical hazards)
- Basic Causes: Personal factors (lack of knowledge, improper motivation) and job factors (inadequate procedures, poor design)
- Root Causes: Management system failures (lack of standards, inadequate training, poor enforcement)
Worker representatives sit on the investigation:
The investigation team includes a worker representative. They bring direct knowledge of how the work actually happens and they keep the investigation honest about systemic factors versus individual blame. Investigations run without worker input tend to land on "the operator did it wrong" — which is rarely the full story.
The investigation team includes a worker representative. They bring direct knowledge of how the work actually happens and they keep the investigation honest about systemic factors versus individual blame. Investigations run without worker input tend to land on "the operator did it wrong" — which is rarely the full story.
Corrective Actions
Action proportional to the event — a fatality and a paper-cut don't get the same response
Action targets root causes, not the surface symptom
Controls selected through the hierarchy — elimination first, PPE last
Look across the operation for the same hazard pattern; one event often points to many
Action implemented to a defined timeframe, with overdue actions escalated
Effectiveness verified after a defined period — did the corrective action actually hold
Examples of Corrective Actions:
- Engineering: Install machine guards, improve ventilation, redesign work process
- Procedures: Develop or revise safe work procedures, update risk assessments
- Training: Provide additional training or competency verification
- Supervision: Increase supervision, implement permit-to-work systems
- Equipment: Replace or upgrade equipment, improve maintenance
- System Changes: Modify management systems, improve communication
Nonconformity Management
Types of Nonconformities:
- Failure to comply with legal requirements
- Failure to meet ISO 45001 requirements
- Failure to follow organizational OH&S procedures
- Ineffective implementation of controls
- Non-achievement of OH&S objectives
- Audit findings requiring correction
What gets recorded:
Records that capture:
- The nature of each incident or nonconformity and what was done about it
- The results of corrective action and verification of effectiveness
Relevant findings shared with workers and other interested parties — not held as internal management information
Legal Reporting Requirements
Regulator notification — South African context:
Section 24 of the OHS Act requires notification of fatalities, serious injuries and dangerous occurrences to the provincial Department of Employment and Labour. The Mine Health and Safety Act has its own notification regime through the DMRE, including section 11(5) reportables. COIDA reporting deadlines run separately. Know which regime applies to the operation, who notifies whom, and inside what timeframe.
Section 24 of the OHS Act requires notification of fatalities, serious injuries and dangerous occurrences to the provincial Department of Employment and Labour. The Mine Health and Safety Act has its own notification regime through the DMRE, including section 11(5) reportables. COIDA reporting deadlines run separately. Know which regime applies to the operation, who notifies whom, and inside what timeframe.
10.3 Continual Improvement
Continual improvement targets three properties of the OH&S system at once: suitability (still right for this organisation), adequacy (still complete enough), and effectiveness (still delivering outcomes). Improvement actions are pulled from across the system and tracked through to completion.
Continual Improvement Requirements
a
Drive measurable improvement in OH&S performance
b
Build and protect the safety culture that supports the system
c
Get workers actively involved in implementing improvements — not just suggesting them
d
Communicate improvement outcomes to workers and their representatives
e
Keep records that show the improvement cycle is running, not just claimed
Continual Improvement Focus Areas:
Suitability: Is the OH&S management system appropriate for the organization?
- Aligned with organizational context, purpose and strategic direction
- Appropriate for the size, complexity and nature of OH&S risks
- Meets the needs of interested parties, especially workers
Adequacy: Is the system sufficient and complete?
- All ISO 45001 requirements are addressed
- All significant hazards and risks are covered
- Resources are adequate for effective implementation
- Processes are comprehensive and cover all necessary elements
Effectiveness: Is the system achieving its intended outcomes?
- Preventing work-related injury and ill health
- Providing safe and healthy workplaces
- Meeting OH&S objectives
- Eliminating hazards and reducing OH&S risks
- Ensuring legal compliance
- Continually improving OH&S performance
Continual Improvement Methods
Improvement Approaches:
- Plan-Do-Check-Act (PDCA): Systematic approach to problem-solving and improvement
- Kaizen: Small, incremental continuous improvements by all workers
- Breakthrough Improvements: Major projects targeting significant OH&S enhancements
- Best Practice Adoption: Learning from and implementing proven practices from other organizations
- Innovation: Developing new approaches, technologies or methods for OH&S
- Benchmarking: Comparing performance with industry leaders and striving to match or exceed
- Lean Principles: Eliminating waste and inefficiency in OH&S processes
Continual Improvement Cycle:
1Identify: Recognize improvement opportunities from various sources
2Prioritize: Select improvements based on risk reduction potential and feasibility
3Plan: Develop improvement plans with objectives, actions, responsibilities, resources
4Implement: Execute improvement actions with worker participation
5Verify: Monitor and measure results to confirm improvement achieved
6Standardize: If successful, make the improvement standard practice
7Share: Communicate lessons learned and replicate across organization
8Repeat: Continue the cycle, always looking for further improvements
Promoting a Culture of Improvement
Building an Improvement Culture:
- Leadership Commitment: Leaders champion improvement and allocate resources
- Worker Empowerment: Workers have authority and support to improve their work
- Learning Environment: Mistakes are learning opportunities, not reasons for punishment
- Recognition: Acknowledge and reward improvement contributions
- Communication: Share improvement successes and lessons learned
- Resources: Provide time, training and tools for improvement activities
- Measurement: Track and celebrate improvement achievements
- Innovation Encouraged: Support creative thinking and new ideas
Workers lead improvement, not just feed it:
The most durable improvements come from the people closest to the work — they know which control is being worked around, which procedure is unworkable on shift, and where the system is quietly failing. Improvement mechanisms have to give workers room to suggest, participate in and run improvement initiatives, with management backing and visible follow-through.
The most durable improvements come from the people closest to the work — they know which control is being worked around, which procedure is unworkable on shift, and where the system is quietly failing. Improvement mechanisms have to give workers room to suggest, participate in and run improvement initiatives, with management backing and visible follow-through.
Measuring Improvement:
Track improvement through:
- Reduction in injury and illness rates over time
- Increased leading indicator performance (inspections, training, hazard reports)
- Achievement of continual improvement objectives
- Number and quality of improvement suggestions implemented
- Enhanced worker engagement in OH&S
- Improved audit scores and reduced nonconformities
- Better compliance performance
- Positive trends in safety culture assessments
Documentation of Continual Improvement:
Improvement plans and objectives
Actions taken and results achieved
Before and after performance comparisons
Lessons learned and best practices identified
Communication to workers on improvements made
Recognition of improvement contributions
The point of all of it:
Continual improvement is the mechanism by which the OH&S system stays alive after certification. Risk profiles change, processes change, people change — and the system has to evolve with them. The measure isn't whether the operation reached perfection; it's whether year-on-year fewer people get hurt, fewer near misses go unreported, and fewer corrective actions stay open past their due date.
Continual improvement is the mechanism by which the OH&S system stays alive after certification. Risk profiles change, processes change, people change — and the system has to evolve with them. The measure isn't whether the operation reached perfection; it's whether year-on-year fewer people get hurt, fewer near misses go unreported, and fewer corrective actions stay open past their due date.