Circular #7-HSE Management System Audit Procedure
Circular #7-HSE Management System Audit Procedure
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HSE MANAGEMENT SYSTEM AUDIT
PROCEDURE
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Title
KESC-SP-005 I 0 I I 1 of 9 HSE
Document No. I Version I Date of Version I Page Issuing department
1.0 PURPOSE:
This Procedure describes the processes to be followed for HSE Management Audits of the company
(Head Office, BUs / Departments), high risk contractors and outlines the procedure to be adopted
including planning, scheduling, execution, report preparation and submission.
2.0 SCOPE:
This procedure applies to all employees and third party contractual staff.
3.0 DISTRIBUTION:
Throughout all levels in the company and third party high risk contractors.
4.0 DEFINITIONS:
KESC-SP-005 Rev: 00
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KESC-SP-005 I 0 I I 2 of 9 HSE
Document No. I Version I Date of Version I PaQe Issuing department
Rev: 00
KESC-SP-005
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Title
KESC-SP-005 I 0 I I 30f9 HSE
Document No. I Version I Date of Version I Paqe Issuing department
Selection of auditors and conduct of audits shall ensure objectivity and the impartiality of the
audit process.
5.4 FACTORY ORDINANCE ACT 1934 (Chapter III, Section 11, 12)
6.0 RESPONSIBILITIES:
• Coordinate with Corporate HSE department for the success of audit and continual
improvement.
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KESC-SP-005 I 0 I I 4of9 HSE
Document No. I Version I Date of Version I Paae lssuinq department
• Ensure corrective actions are taken and provide root causes for the identified non-
conformances (Major, Minor, Observations) as agreed with Audit Team on priority
basis.
6.3 AUDITOR:
7.0 PROCEDURE:
Audit type
DIVISIONS I BUs Departments Frequency
Internal External
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KESC-SP-005 I 0 I I 5 of 9 HSE
Document No. I Version I Date of Version I Paqe . Issuing department
• MECHANICAL • ANNUALLY
• Electrical &
Instrumentation
• LOGISTICS
(Surface Mobile
Equipments)
Persons who take part in audits are to be nominated by the Director HSE in agreement with the audit
schedule as mentioned in Section 7.1. Departmental Heads (Auditee) will be responsible to nominate his
delegate to take part in the Audit.
Rev: 00
KESC-SP-005
HSE MANAGEMENT SYSTEM AUDIT
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Title
KESC-SP-005 I 0 I I 6 of 9 HSE
Document No. I Version I Date of Version I Paqe lssuinq department
• Audit initiation as per the audit schedule as mentioned in Section 7.1 or triggered by a high
HSE risk of issue that needs investigation.
• Contractor HSE Prequalification audit as and when required prior to contract award to
contractor involved in high risk activities (F-SP-005-04). To be ensure by procurement
department to carryout HSE Audit in conjunction with Corporate HSE Department after short
listing of vendors.
• Setting up major, minor non-conformance in the HSE Action Tracking Register (F-SP-005-
01 ).
The HSE Department shall be responsible for developing an audit schedule for the HSE Management
System processes. The audit schedule / frequency shall reflect a periodic schedule of auditing of selected
locations (Auditee) which is briefed in section 7.1. Change in the frequency will be determined in
consultation with the BUs Head and Director HSE by the significance of their effect on quality, HSE,
environmental, and financial results or shall be reviewed at the end of 12 months to see if any timing and
frequency need to be altered because of the audits being too brief or too long.
The Director HSE shall be responsible for ensuring that audits are performed in accordance with the audit
schedule.
The Director HSE shall assign an audit team to perform the audit, and shall appoint a Lead Auditor, as
per the audit schedule.
Auditors where possible shall be independent of the function they are to audit. As a minimum the Lead
Auditor shall have internal training as an auditor or have completed 5 audits with either KESC or other
multinational companies.
Audit scope shall be derived from Audit Schedule or by the Senior Management.
The lead auditor shall agree the audit schedule with the auditee and audit team member.
Rev: 00
KESC-SP-005
HSE MANAGEMENT SYSTEM AUDIT
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Title
KESC-SP-005 I 0 I I 7 of 9 HSE
Document No. I Version I Date of Version I Page Issuing department
• Evaluate the document control aspects of the document (eg. adequate referencing, form
numbering, sample inclusion, etc)
The Audit Coordinator (Auditee) shall conduct an entry meeting in order to run through any questions,
observations or technical concerns of either the audit team or the Auditee. The Audit Opening / Closeout
Register (F-SP-005-03) may be used as a basis for this meeting.
In the opening meeting, maximum attendance of relevant members is recommended, so that they are
informed about the purpose, scope and duration of the audit.
Audits shall be documented by either the Audit Checklist (F-SP-005-02) or a report layout provided by the
external auditors. However, audit checklist shall as a minimum contain the following information
The audit check lists shall not be a standard checklist but shall be formulated questions based on;
KESC-SP-005 Rev: 00
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Title
KESC-SP-005 I 0 I I 8 of 9 HSE
Document No. I Version I Date of Version I Page Issuing department
~-D-e-s-c-r-ip-t-io-n---------------------------------------------------
Comply Complies with work practice, work instruction or procedure
Note worthy Significant improvement or achievement which the auditor will like to mention in the
audit report
Opportunity for Suggestion from the auditor which can bring in improvement in the system, however
improvement the auditee may ignore or rate low in the actions list
Observation Auditor suggestion to improve system efficiency or observation that a procedure is
difficult to understand.
Minor An isolated incident of a non-compliance with a procedure or work instruction and
one which has no direct consequential effect on quality, HSE, environmental or
financial results.
Major An activity, which is in direct contravention of a procedure or work instruction. It also
applies when an element of the management standard or management manual is not
addressed or when an activity is in contravention of them.
The auditor shall inform the auditee as to whether a finding complies or does not comply with the
specified standards. However, the auditee shall be reminded that a "does not comply" shall not
automatically result in a System Non-compliance/Corrective Action Report being raised.
If during the course of an audit the auditor encounters untoward lack of cooperation or hostility from the
auditee the auditor shall cease auditing and report this matter to the Lead Auditor. The Lead Auditor
shall attempt to resolve the communication difficulty with the auditee but if this is not successful then the
problem shall be reported to the Director HSE & Departmental/BUs Head.
At the conclusion of the audit the audit team shall convene to review the findings. A list of the audit
observations shall be shown in the Audit Checklist (F-SP-005-02).
The non-compliances shall be reviewed as being major or minor by the audit team. In addition, the Lead
Auditor may group a number of minor non-compliances together into a major non-compliance if they stem
from the same deficiency. The Lead Auditor's has the final responsibility for the classification of non-
compliances as either major non-compliances or as minor non-compliances.
A hard copy of all non-compliances shall be printed for presentation at the close out meeting.
The audit close out meeting shall be a meeting between the audit team and relevant members of
Departmental/BUs (Audittee).
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KESC-SP-005 I 0 I I 90f9 HSE
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• Record those present at the meeting on the Audit Opening / Closeout Register (F-SP-005-
03).
The Lead Auditor shall be responsible for documenting the audit findings in the report using the Audit
Checklist (F-SP-005-02) or other reporting formats mentioned in section 7.6. This shall be completed
within two weeks of the conclusion of the audit. The Director HSE shall approve the report.
The following items shall be appended to the report:
• Audit Scope
• Attendance Register
The report shall be distributed to all concerned KESC Management Staff and audit team members for
further follow-up and continual improvements
8.0 APPLICABILITY:
HSE Dept.)
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(IR Dept.)
By 'I,;--H ~~!tJ_Lv.
JAHANGIR AZAR
DIRECTOR
(HUMA.~RESOURCE)
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HSE ACTION TRACKING REGISTER HSE
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Raised Action
Sr. Type of Target Closeout Comments I Close out
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Date by Non-Compliance (Noted) By Status remarks
Audit date date
whom Whom
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Audit Team:
Determine whether the HSE Management System (SMS, EMS) conforms to planned arrangements for occupational health,
Audit Scope: safety and environmental management including requirements of the national and international standards (NEPRA, Factory
Ordinance Act Pakistan, OHSAS, ISO), and whether the management system have been properly implemented and
maintained.
From: To:
Previous Audit Dates:
Distributio n:
Copies:
Date: (DD/MMIYY)
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'EVIDENCE'(COuldb~ .
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CHARACTERISTICS ; .. DOC#
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Has top management
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HSE Policy
organization? Is it:
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HEADING I
CHARACTERISTICS
CLAUSE
• ISO 14001 - 4.3.3 Are the objectives and targets consistent with HSE
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(Objectives, policy?
Targets and
Programs) Are objectives and targets quantified and with timescales
(Measurable)?
• Factory Ordinance
Act Chapter -111- Are the objectives reflected in the long-term plans?
12 (Written Policy
Are objectives made for "improvement, management &
Statement)
measurement?
• NEPRA GRID Are views of interested parties, such as shareholders,
CODE -?C 9,1 regulating bodies and public, considered when
(introduction, establishing the objectives and targets?
Objective & Scope),I-====.::..:.:::'....:.:..:-=----::2~~-=--=~....:..:.:~...:.:..--------+__----_+---------t_---------------1
-Distribution Code Do the objectives and targets indicate a commitment to
DOC 6,1 prevention of pollution?
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Is there tangible commitment from top management
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• NEPRA CODE
(SRO 45 (1)/2005-
OS 7 (Overall
Standard for
Performance)
-NEPRA
Distribution Code
DOC 6.2
(Procedures)
HEADltJG I
CI.,A,VS.E CHARACT~RISTics
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• NEPRA CODE
(SRO 45 (1)/2005-
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Standard for
Performance)
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Code DOC 6.2
(Procedures) & 6.2.2.2
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Are the occupational health surveys carried out for all the
sign ificant known hazards?llIuminations, Ventilation,
temperature, dust, fumes and artificial
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viDENCE (b2Jld;be.
verbal intervie\i(s)
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EVIDENCE (Couldbe
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COMMENTS
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• OHSAS 18001-
4.5.2 (Evaluation of
Compliance)
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• Factory Ordinance
Act Chapter -IV -
28,29,30
(Notification &
investigation of
accidents,
~~~~~~~~~s & IAre all results o~such investigation properly documented
occupational illness and maintained.
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COMMENTS
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Nonconformity, Is there a procedure for identifying potential nonconformity
Corrective and (hazardous Situation)?
Preventive Actions Are all nonconformities investigated to determine their
cause and avoid recurrence?
• OHSAS 18001- Are corrective actions recorded and communicated to all
4.5.3.2
within the organization?
• ISO 14001 -
4.5.3.2
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(Notification &
investigation of
accidents,
dangerous
occurrences &
occupational illness
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Is necessary information collected to allow the review!
eva luation?
• OHSAS18001-4,6r---------------------------------------~--------_+----------------+_--------------------------~
(Management Are the management reviews documented and records
Review retained?
~-------------------------------------+---------+----------------~--------------------------~
• ISO 14001 - 4.6 Does the review include assessing opportunities for
(Management improvement and the need for changes to the HSE
Review) management system, including the HSE policy and HSE
objectives, targets and other elements of the HSE
• Factory Ordinance Management System in the light of audit results,
Act Chapter-III changing circumstances and the commitment to continual
(Health and Safety) improvement?
• NEPRA CODE No. Does the management review also include:
F.9(46)/97-Legis. a) Results of internal audits and evaluations of
Chapter III (34) - compliance with legal requirements and with other
Performance
Standard .
req ulremen t SOW
t hiIC h th e organJza
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ib es
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Sr. No. Observation!Possible Non Compliance Root Cause Importance By when Comments
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1
2
3
4
5
6
7
8
* Major! Minor! Observation! Suggestion for improvemenU Note worthy improvement
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Aud it Details
,Audif Title/Scope
Leat! Auditor:
1.
2.
3.
4.
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• REPORTABLE INCIDENTS
10.2 DO YOU HAVE A PROCEDURE FOR THE
INVESTIGATION, REPORTING AND FOLLOW-
UP OF ACCIDENTS, DANGEROUS
OCCURRENCES OR OCCUPATIONAL
ILLNESSES?
IF SO, PLEASE PROVIDE DETAILS.
10.3 DO YOU COMMUNICATE THE RESULTS OF
INCIDENT INVESTIGATIONS TO YOUR
PERSONNEL?
IF SO, PLEASE PROVIDE DETAILS.
10.4 PLEASE PROVIDE EXAMPLES OF
INVESTIGATION REPORTS FOR THE LAST
TWELVE MONTHS.
10.5 PLEASE PROVIDE DETAILS OF ANY
SIGNIFICANT HSE ACHIEVEMENTS OR
AWARDS.
10.6 PLEASE PROVIDE DETAILS OF YOUR ANNUAL
SAFETY RECORDS FOR THE LAST THREE
YEARS (ON A YEAR BY YEAR BASIS)
COVERING THOSE DETAILED IN 10.1 ABOVE
107 PLEASE PROVIDE DETAILS OF MAJOR
SUBCONTRACTORS USED IN THE LAST
THREE YEARS AND TO ADVISE AS TO THEIR
SAFETY RELATED DATA IN ACCORDANCE
WITH 10.1 TO 10.6 ABOVE.
10.8 DO YOU HAVE ANY OBJECTION TO YOUR
CEO (OR NEAR EQUIVALENT) BEING
RESPONSIBLE TO COMPANY FOR CLOSEOUT
OF ALL HSE RELATED REPORTS AND
INCIDENCES?
11 EMPLOYEE ORIENTATION PROGRAM
11.1 DO YOU HAVE A WRITTEN ORIENTATION
PROGRAM?
IF SO, PLEASE PROVIDE A COPY.
11.2 HOW DO YOU MANAGE ORIENTATION OF
SUBCONTRACTOR'S PERSONNEL?
PLEASE PROVIDE DETAILS.
12 HEALTH
12.1 DO YOU HAVE A DRUG AND ALCOHOL
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-CONTRACTOR
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COMMENTS:
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