PAS 99 Internal Auditing

INTEGRATED MANAGEMENT SYSTEMISO 9001 + ISO 14001 + OHSAS 18001SHERQ Management Framework

Risk based Integrated Management System of:ISO 9001:2008ISO 14001:2004 &OHSAS 18001:2007

Implementing PAS 99

General Requirements (PAS 99)

1.0 General requirements

1.1 The organization shall document the scope of the management

system and the management system standards/specifications to which

it subscribes (ISO 9001/ISO 14001/OHSAS 18001).

1.2 The organization shall establish, document, implement, maintain

and continually improve the management system in accordance with

the requirements of this integrated management system

standards/specifications to which it subscribes. (ISO 9001/ISO

14001/OHSAS 18001)

General Requirements (SHERQ)

1.3 In order to meet its declared policies and objectives, the organization shall:

a) Determine the processes needed for the implementation, operation and

maintenance

b) Determine the sequence and interaction of these processes

c) Determine methods needed to ensure that both the operation and control of

these processes are effective;

d) ensure the availability of resources and information necessary

e) monitor, measure and analyse these processes, and implement actions

necessary to achieve planned results and continual improvement of the

organization’s overall performance.

POLICY REQUIREMENTS POLICY REQUIREMENTS

Policy Requirements (PAS 99)

Demonstrates formal commitment of top management towards good QHSE MS.

Basis for establishing and reviewing objectives Commitment to comply with

- Customer requirements- applicable legal requirements- Prevention of pollution- Prevention of injuries and ill health- Continual improvement

Communication to all interested parties and Reviewed periodically

Planning02

Hazard Identification and Risk AssessmentIdentification of Environmental AspectsObjectives & Targets Management Programs

Hazard Identification & Risk Assessment

Hazard Identification: process of recognizing that a hazard exists

and defining its characteristicsRisk Assessment:process of evaluating the risk(s) arising

from a hazard(s), taking into account the adequacy of any existing controls, and deciding whether or not the risk(s) is acceptable

Environmental Aspect and ImpactAspect Identification: process of recognizing element of an

organization's activities or products or services that can interact with the environment

Impact Assessment:process of evaluating change to the

environment, whether adverse or beneficial, wholly or partially resulting from an organization's environmental aspects, and deciding whether it is significant or not

Failure Mode Effect Analysis

Failure Modes: process of recognizing potential failure modes

of an organization's activities or products or services against the Product or Process characteristics

Effect Assessment:process of evaluating the defect arising on the

product or process due to failure, and deciding whether it is fit for use or not

RISKRISKRISKRISK

CONSEQUENCECONSEQUENCE(Consequence Analysis)(Consequence Analysis)CONSEQUENCECONSEQUENCE(Consequence Analysis)(Consequence Analysis)

FREQUENCYFREQUENCY(Frequency Analysis)(Frequency Analysis)FREQUENCYFREQUENCY(Frequency Analysis)(Frequency Analysis)

PROBABILITYPROBABILITYPROBABILITYPROBABILITYEXPOSUREEXPOSUREEXPOSUREEXPOSURE

Risk Based Approach

OBJECTIVES & TARGETS OBJECTIVES & TARGETS

OBJECTIVES & TARGETS

Objectives are goals in terms of QHSE performance that an organisation set itself to achieve.

Objectives are long term and more generic than targets

Target is a detailed QHSE performance requirement derived from objectives and are used to achieve these objectives.

Targets are intermediate steps and work done to achieve objectives

The IMPs are the “Action Plans” or

“Programs” for achieving the objectives &

targets

Including:

Personnel responsible for action

Time frames and target dates

Management Programs

IMPs - Example

Aspect / Risks

Objective Target Performance Indicator

Progress Responsibility

Time Frame

Gas/ Diesel Usage

Reduce Consumption of Fuel

10% Reduction in Fuel Consumption by 2010

Fuel Consumption Reports

Determine Usage of Diesel Gas for first 6 months of 2010

ABC July 2010

Plot study of Usage Patterns XYZ Aug 2010

Actions for Vehicle Usage Optimization

ASD Oct 2010

Formal Action for improving efficiency

ASD Dec 2010

Develop, Document and Train on Operating Procedure from Action Plan

XYZ Jan 2011

Tracking of Fuel Consumption after Action Plan implementation

ABC July 2011

Legal Requirements, Resources

03

Legal RequirementsIdentification of ResourcesRoles and Responsibilities

Legal & Other RequirementsIdentify all (Hazardous) processes and

environmental aspects in your work area Determine applicable legislation and specification

requirements applicable to your processes and make a legal register

(Evaluate current compliance – auditDo a gap analysis – What do we have, what do we

need.Involve legal advisors to assist with compliance

assessments.)Revise current procedures to include requirements.Review the requirements at defined frequency

RESOURCE MANAGEMENTRESOURCE MANAGEMENT

Resource Management

Determine required resources based on the requirements

Determine availability of required resources

Develop procedures for implementing, maintaining and improving current resources.

Make a preventive maintenance plan Generate a training needs analysis on

current human resources

ROLES, RESPONSIBILITIES, AUTHORITY AND

ACCOUNTABILITIES

ROLES, RESPONSIBILITIES, AUTHORITY AND

ACCOUNTABILITIES

Roles, Responsibilities, Accountability and Authorities

Roles, Responsibilities, Authority and Accountability shall be defined, documented and communicated in order to facilitate QHSE management system

Top management shall appoint in writing, persons (Management Representative) responsible for ensuring that EMS, OH&S and Quality systems are established and will also be responsible for communicating back to top management on the performance of these systems

Roles, Responsibilities, Accountability and Authorities – example (MR)

1. Coordinate with TM for Management reviews. GM, All DH Preparation of minutes

2. Establishing, implementing, & maintaining structure of QHSE management systems.

GM, All Change structure of OH&S management systems

3. Document control. GM, All Verify all documents in

4. Plan and implement Internal Audit. GM, All Conduct Internal audit

5. Corrective actions on system non-conformities. GM, All Follow-up of corrective action

6. Control of Records. GM, All Verify all records.

7. Liaison with Certification body / external body. GM, Certification body Co-ordinate

8. To identify training needs and Implement & verify training effectiveness.

GM, All DH Decide on training needs and provide

9. Identify Preventive Action. All Initiate preventive action

10. Monitoring of QHSE process performance. GM, All DH Reporting to GM about status

11. Internal Communication System. GM, All DH Establish and Monitor

12. Promotion of awareness of interested party requirements throughout the organization.

GM, All DH Conduct training programmes

13. I MS Planning. GM, All DH To assist GM

14. Control of applicable laws. GM To control

Sr. No

ROLES & RESPONSIBILITIES &ACCOUNTABILITY Interface With Authority

Communication & Training04

CommunicationConsultation & ParticipationTraining

Communication

As per standard Top management shall ensure that the : QHSE policy is communicated and understood within

the organization Roles, responsibilities, authorities & accountability Communication of OH&S Hazards, Significant aspects

and applicable Legal Requirements to Employees, Contractors, Visitors & interested parties with training on handling safely.

Customer Communication Communication of Purchasing information to the

Supplier. Communicating Work Instructions to Employees. Setting up Internal & External Communication

systems.

Participation & Consultation

The organization shall establish, implement and maintain a procedure(s) for:

the participation of workers by their: Consultation with contractors where there are

changes that affect their OH&S. The organization shall ensure that, when appropriate,

where relevant external interested parties are consulted about pertinent OH&S matters.

Appropriate involvement in hazard identification, risk assessments and determination of controls;

Appropriate involvement in incident investigation; Involvement in the development and review of OH&S

policies and objectives; Representation on OH&S matters.

Participation & Consultation

Employee Direct participation & consultation:

Daily Department meetings

QHSE Committee meeting

Suggestion schemes

Incident investigation

COMPETENCE, TRAINING AND AWARENESS

Every Employee can have a potential impacts on the QHSE

Competence of Every Employee is required for implementation of the QHSE Management System

Any Employee can have good ideas about how to improve QHSE management system for which the required Awareness is necessary.

Training is important for all the Employees for awareness regarding QHSE Management System and his roles and responsibilities and activities making significant impact.

Training is just one element in establishing competence, which is typically based on combination of education, experience, skills and training

COMPETENCE, TRAINING AND AWARENESS

Developing a Training Program

1. Assess training needs and requirements

2. Define training objectives

3. Select suitable methods and materials

4. Prepare training plan (who, what, when, where, how)

5. Conduct training

6. Track training (and maintain records)

7. Evaluate training effectiveness

8. Improve training program as needed

Documentation05

DocumentationControl of Documents

HIERARCHY OF DOCUMENTS

Level I

Level II

Level III

Level IV

DOCUMENTATION APPROACH

Q H S E

Documentation Approach

Documenting Work Procedure - for example machine

maintenance:

OH&S: Wear your PPE, Use the permit to work, isolate the machine

Product: Ensure machine is cleaned, set up for quality critical to quality parameters

Environmental: Don’t throw the oil down the drain etc.

Goal: One stop shop document for each process and task.

CONTROLLED DOCUMENT

A Document that is subjected to processes that provide for the positive control elements of content,

revision,

publication,

distribution,

availability and

retention.

Operational Control & Emergency

06

Operational ControlEmergency Preparedness and Response

OPERATIONAL CONTROLS

Means by which the organization prevents

product conformity, harmful events and

pollution and manage OH&S risks from

operations is known as OPERATIONAL

CONTROLS

OPERATIONAL CONTROL

The organization shall identify and plan those operations that are associated with

1.The identified significant environmental aspects consistent with its environmental policy, objectives and targets,

2.The identified hazard(s) where the implementation of controls is necessary to manage the OH&S risk(s)

3.quality objectives and requirements for the product realization;

4.controls related to purchased goods, equipment and services;

5.controls related to contractors and other visitors to the workplace;

OPERATIONAL CONTROL

In order to ensure that operational controls, as applicable to the activities;

• stipulating the operating criteria to control all the operations (monitoring and measurement, controls and maintenance)

• establishing, implementing and maintaining a documented procedure(s) to control situations where their absence could lead to deviations from the QHSE policy, objectives and targets,

• communicating applicable procedures and requirements to suppliers, contractors and visitors

OPERATIONAL CONTROLS

SUPPLIER / CONTRACTOR MANAGEMENT

Purchase and transfer of goods and services and use of

external resources

Approval to purchase or transfer hazardous chemicals,

material and substances

Availability of documentation for safe handling of machinery,

equipments, materials, or chemicals at time of purchase, or the

need to obtain such documentation

Evaluation, and periodic re-evaluation of the

performance/competence of Supplier

Approval of the design for any new plant or equipment

EMERGENCY PREPAREDNESS AND

RESPONSE

EMERGENCY PREPAREDNESS AND

RESPONSE

DEFINITION OF AN EMERGENCY

An emergency is an abnormal situation, which arises as a result of or during the course of working operations and demands a high level of activity to normalise the situation and control the loss severity.

ACTIONS TO TAKE DURING AN EMERGENCY

Raise the alarm. Stay calm. Assess the situation. Follow instructions. Ensure your fellow workers are also aware of the

emergency. Proceed to a place of safety, which could be a

predetermined assembly point, or if underground, a refuge bay.

Help fellow workers in need. Ensure the supervisor or an official is aware of the

situation. Don’t simply go home. Await roll call. Render whatever help and assistance you can if required

or instructed.

Goal: To reduce losses due to emergency by quicker response

TYPES OF EMERGENCY TEAMS

Fire and rescue teams First Aid Team Search and rescue teams HAZMAT Team Security teams Communication Team

Monitoring & Measurement

Monitoring and Measurement1. Identify key characteristics and develop

process for tracking to show Process performance and operational controls.

2. Develop method for monitoring conformance with operational controls.

3. Develop method for tracking progress towards achievement of objectives and targets.

4. Develop method for Calibration and Maintenance

NON-CONFORMANCE CORRECTIVE AND

PREVENTIVE ACTION

NON-CONFORMANCE CORRECTIVE AND

PREVENTIVE ACTION

Non conformance

Non Conformance: Non-fulfilment of a requirement

NOTE A nonconformity can be any deviation from:

relevant work standards, practices, procedures, legal requirements, etc.

QHSE management system requirements.

47

Non-Conformance

Identify Non-conformance through routine inspection, monitoring, audit findings, trend analysis, complaint, employee comments, experience

48

A deficiency that seriously impairs the effectiveness of the IMS

Examples:An element of IMS not implementedProcedures not developed or not implementedFailure to take corrective or preventive actionSeveral minor non-conformances

What is major Non-conformance ?

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What is a Minor Non-Conformance?

A minor deficiency that does not seriously impair the effectiveness

of the IMS

Examples: One or a few individuals (out of many) do

not use a procedure correctly Procedure needs minor changes to be

effective One or a few records incomplete

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Non-Conformance Investigation

Use the investigation procedure to investigate the cause of the problem.

The goal of the analysis is to determine the root as well as contributing causes.

This process involves: Collecting relevant data. Investigating all possible causes, and Using the information available to

determine the cause of the problem.

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What are Correctiveand Preventive Actions?

Corrective action fixes action to eliminate the causes of nonconformities in order to prevent recurrence. (e.g., repair a leaking valve)

Preventive action is designed to eliminate the causes of potential nonconformities in order to prevent their occurrence. (e.g., improved maintenance procedures)

Effective corrective and preventive actions are a key to CONTINUAL CONTINUAL IMPROVEMENTIMPROVEMENT

Audit & Management Review

08

Internal AuditManagement Review

Audit:A systematic, independent and documented process for obtaining objective evidence and evaluating it to determine the extent to which audit criteria are fulfilled.

Audit Evidence: Records, statements of fact or other information, relevant to the audit criteria and which are verifiable.

Audit Criteria: Set of policies, procedures or requirements used as a reference.

Audit Scope: Extent and boundaries of an audit.

Audit Findings: Result(s) of the evaluation of the collected audit evidence against audit findings.

Internal Audit

What to Check?

SHERQ management Methods & techniques

• Policy, Objectives and Management Programs

• Legal compliance

• Hazard identification techniques & Methodologies for risk

assessment

• Technologies for reduction and elimination of risk

• Process performance evaluation

• Monitoring & measurement techniques

• Communication, participation & consultation methods

• Monitoring of Ill-health and toxicological data

Internal Audit

Documentation:

Documented Procedure for Internal Audit

List of certified internal auditor

Internal OH&S MS Audit Plan

Internal Audit notice

Internal Audit schedule

Internal Audit Report

Checklist

Internal Audit NCRs

Internal Audit

MANAGEMENT REVIEW MANAGEMENT REVIEW

4.6 MANAGEMENT REVIEWMINUTES OF MANAGEMENT REVIEW MEETING

MRM No.:

Date:

ATTENDEES Venue:

AGENDA INPUT Point of Discussions Action Plan Responsibility Target Date

Follow-up actions from previous management reviews;

Results of Internal Audits & evaluations of Compliance with legal & other requirements, Responsible care etc.

Results of participation and consultation

Communication from interested external parties including complaints.

Customer feedback (including customer satisfaction measurement data and customer complaints);

Environmental, OH&S & QMS performance of the organization

Process performance and product conformity;

The extent to which the objectives and targets have been met

Status of incident investigations, corrective and preventive actions;

Changing circumstances, including developments in legal and other requirements related to its environmental aspects and OH&S.

Changes that would affect the Quality management systems.

Evaluation of suitability of EHS policy and need for changes if any with respect to: -Changes in the legal and other E, OH&S requirements - Investigation reports on OH&S incident - Changes in statutory requirements - Any external communication received including complaints

Recommendations for improvements

Successful approach to the audit

• Establish suitable climate

• Put auditee at ease

• Use proper questioning technique

• Use open questions and sparingly closed questions

• Ask clarifying questions

• Avoid leading questions

• Don’t ask antagonizing questions

• Use body language

• Be friendly & diplomatic

Responsibility of auditor

• Collecting and analyzing evidence necessary to assess the compliance of the QHSE management system to the audit criteria.

• Recording the audit observations.

• Remaining alert to all situations where assessing compliance requires further investigation.

• Reporting the results of the audit observations both orally & in writing.

• Verifying the effectiveness of corrective actions taken as a result of the audit , if required to do so by the auditee.

THE ENDWHEN YOU ARE SERIOUS ABOUT MANAGING RISK