This policy sets out our approach to Duty Holder Reviews, and our expectations of duty holders we work with on a Duty Holder Review.


How we do Duty Holder Reviews (PDF 315 KB)

What a Duty Holder Review is

A Duty Holder Review is a structured self-review that’s done voluntarily. We may ask a duty holder to carry one out after a near miss or serious harm event. It helps the duty holder learn:

  • what caused the near miss or serious harm event
  • what they can do to prevent another one happening
  • how they can encourage good practices that result in positive outcomes for workers.

This helps them build their capability so they can prevent harm and encourage good practices and positive outcomes for their workers. As the Duty Holder Review is voluntary it doesn’t attribute blame.

Duty Holder Reviews help us learn about:

  • the performance of the work health and safety
    system, and
  • what duty holders are doing to prevent harm, minimise risks and encourage good practices.

During a Duty Holder Review we may use a range of methods to engage with duty holders, victims, workers and unions. These include in writing, by phone, email, or kanohi ki te kanohi through a hui, site visit, marae hui, or wānanga.

How we decide when to do a Duty Holder Review

After we’ve become aware of a near-miss or serious harm event we start by applying When we intervene

This helps us decide whether we’ll intervene in some way or not.

Once we’ve decided to intervene, we’ll then decide what action to take.

We use Duty Holder Reviews sparingly and in limited circumstances. We make decisions to offer a Duty
Holder Review on a case-by-case basis.

We’re more likely to consider a Duty Holder Review when we:

  • think there are opportunities to work with the duty holder to prevent harm and encourage good
    practices, and
  • haven’t previously worked with them or offered to work with them on a Duty Holder Review, and
  • haven’t previously taken any other intervention.

We may conduct an inspection and a Duty Holder Review at the same time to maximise harm prevention outcomes.

What we’ll do if a duty holder chooses not to participate in a Duty Holder Review

If a duty holder decides not to participate then we’ll:

  • engage with them to better understand why they don’t want to participate, and answer any questions they have
  • consider whether to take another intervention
  • record their decision in our system, along with any other actions we’ve taken.

What happens during a Duty Holder Review

The three broad phases of a Duty Holder Review are planning, doing, and closing.

The planning phase

In the planning phase:

  • we’ll invite the duty holder to participate, explain the process, and what we would expect of them
  • if the duty holder decides to participate we’ll work with them to agree timeframes and how we’ll work together.

The doing phase

In the doing phase the duty holder will:

  • look into the incident or near-miss to:
    • find the underlying causes of it
    • identify areas where their system could be improved, and
    • identify where there are existing good systems and practices that could be built on
  • engage with workers so they can contribute their knowledge and experience. This includes victims where relevant, and health and safety representatives and unions where possible
  • contact us if they need information or guidance to support their self-review
  • develop a plan to prevent harm and build good practice to achieve positive outcomes for their workers.

The closing phase

In the closing phase:

  • the duty holder will engage with us, victims where relevant and workers where possible to share what they’ve done, what they’ve found, and what they plan to do. They can do this via a written report or email, or kanohi ki te kanohi at a marae, worksite, or another location
  • we’ll consider if the self-review and plan have been completed to our satisfaction, seek more information if needed, and provide feedback to the duty holder
  • we’ll consider if there are any other actions we need to take
  • we’ll tell the duty holder that the Duty Holder Review process is closed once we are satisfied
  • the duty holder will then start implementing the plan they’ve developed.

We may visit the site after the Duty Holder Review is closed to check that the duty holder’s delivering on their plan. We may take further action if we find that they’re not.

We may decide to stop a Duty Holder Review or take another intervention

We make our decision to do a Duty Holder Review based on the information we have to hand.

We may stop a Duty Holder Review, or take another intervention, if we:

  • get new information that changes our view
  • become aware of another event or near-miss
  • think the Duty Holder Review is not progressing as we’d have expected. This could include if it’s taking longer than planned, it’s not being done in good faith, or it isn’t likely to achieve what we want it to.

What we expect of duty holders

We expect duty holders to:

  • be open and honest, both in their Duty Holder Review and when they engage with us
  • engage willingly and openly with their workers, including victims where relevant, and health and safety representatives and unions where possible
  • do what they say they will in the timeframes we’ve agreed with them
  • show that they want to learn and have good systems and practices
  • apply what they learn from the Duty Holder Review to other applicable parts of their business. For example, if the duty holder has multiple, similar sites then we expect them to apply the lessons learnt and make improvements to all the sites.