The Warehouse Near-Miss Spike After a Layout Change
A regional distribution centre (180 workers, two shifts) reorganised its picking area three months ago: racking was moved 2 metres closer to the loading bays to add 14 extra pallet positions. Since then, the OH&S manager has logged 9 near-misses involving forklifts and pedestrians in the shared aisle, up from 1 per quarter previously. No injury has occurred. The operations director argues that because there have been no incidents, no action is needed and the layout change was signed off by the site engineer. The OH&S manager wants to treat this as a formal nonconformity and escalate it. The organisation is certified to ISO 45001 and its OH&S policy commits to providing safe and healthy working conditions and to eliminating hazards.
1. Should the near-miss cluster be handled as a nonconformity under Clause 10.2, or as something else? Justify your answer by reference to the nature of near-misses and the concept of hazard identification.
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It is defensible, and generally correct, to treat this as a nonconformity - but the reasoning matters more than the label.
- A near-miss is evidence of a failed control, not an absence of a problem. ISO 45001 defines an incident as an occurrence arising out of, or in the course of, work that could or does result in injury and ill health. Near-misses fall within the 'could' side of that definition. A nine-fold increase in near-misses is objective evidence that the hierarchy of controls in the shared aisle is not effective.
- Clause 6.1.2 requires hazard identification to be ongoing and to consider changes. The layout change (racking moved closer to loading bays) is a change to the organisation, its activities and its work environment. If the change was implemented without re-assessing pedestrian/forklift interaction, that is a failure of the planning process - a nonconformity against 6.1.2 and/or 8.1.2 (management of change).
- The 'no injury' argument is not a valid defence. OH&S performance is measured by the effectiveness of controls, not only by lagging outcomes. Clause 9.1.1 requires monitoring and measurement of the extent to which OH&S objectives are met and of the effectiveness of operational controls.
- Corrective action under 10.2 should address the cause (the change process and the risk assessment), not just the symptom (add barriers or repaint lines). The model answer should insist on: contain the risk immediately (physical separation), investigate why the change bypassed risk assessment, update the hazard identification and risk assessment, and verify effectiveness over a defined period (e.g., near-miss rate over the next quarter).
A weaker answer simply says 'near-misses are not incidents so no action is needed' - that misreads the standard and the intent of Clause 10.2.
2. The operations director says the engineer 'signed off' the layout change, so the change was properly managed. Evaluate this claim against Clause 8.1.2.
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An engineering sign-off is not the same as management of change under 8.1.2.
Clause 8.1.2 requires the organisation to establish a process for the planned, controlled and documented management of changes that affect OH&S performance, including:
- New or modified hazards and risks - the change must trigger a re-assessment of OH&S risks (linking back to 6.1.2.2). An engineer's structural or layout sign-off does not assess pedestrian–vehicle interaction risk.
- Changes to the OH&S management system - the change may require updates to operational controls, training, signage, traffic management plans.
- Consequences, whether intended or unintended - the loss of 2 metres of aisle clearance is an unintended consequence that should have been evaluated.
- Consultation and participation of workers (5.4) - the people who work in the aisle should have been consulted before the change.
So the correct judgement is: the change was approved but not managed. The existence of a signature is evidence of authorisation, not evidence of control. The auditor/exam answer should distinguish between the authorisation step and the risk-assessment and consultation steps that 8.1.2 requires. This is a classic 'documented ≠ effective' trap.
3. Draft the essential elements the OH&S manager should include in the corrective action record, mapped to Clause 10.2 sub-requirements.
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A model corrective action record should show each 10.2 element explicitly:
| 10.2 requirement | What goes in the record |
|---|---|
| 10.2.1 a) react and control | Immediate containment: temporary barriers, revised traffic route, speed limit, briefing to both shifts - with date and responsible person |
| 10.2.1 b) evaluate need for action | Root cause analysis (e.g., 5-Whys or fishbone): why did the layout change bypass risk assessment? Findings recorded |
| 10.2.1 c) investigate the incident | Timeline of the 9 near-misses, witnesses, shift patterns, time of day |
| 10.2.1 d) review existing risk assessments | Reference to the pre-change risk assessment and what it missed |
| 10.2.1 e) determine and implement action | Physical separation (barriers), revised traffic management plan, updated risk assessment, retraining, change-control procedure update |
| 10.2.1 f) review effectiveness | Defined verification: near-miss count over the next quarter, walk-round audit, sign-off by OH&S manager |
| 10.2.1 g) update the OH&S MS | Update hazard register, risk assessment, operational controls, possibly objectives |
| 10.2.2 retain documented information | Record retained as evidence of the nature of the nonconformity, actions taken, and results |
The examiner is looking for cause, not symptom. An answer that lists only 'install barriers' misses the systemic cause (the change process) and would likely be marked incomplete.