HSE Auditors Training

HSE Auditing

by Adebiyi Adeleke Adeosun Paradigm Environmental System Consultants, Lagos.

Why is HSE Audit becoming popular? • Increasing corporate sensitivity to HSE problems • Increasing complexity of the regulatory programs

“Corporate managers wants to verify the quality and effectiveness of their firms HSE MS- processes and procedures”

Why is HSE Audit becoming popular? HSE Audits are defined as a systematic, documented, periodic and objective review of facility operations and practices related to meeting HSE requirements “they are different from regulatory agency inspections in that they are performed by or on behalf of the regulated entity, and deal with broader concerns than compliance with a single regulatory program

Audits can be modified to achieve following objectives • Identification of both regulated and unregulated risks to health and environment associated with processes and operations conducted on site • Identification and evaluation of opportunities for waste minimisation • Identification and planning and budgetary purpose, of those control investment necessary to meet anticipated regulatory developments • Identification and evaluation of risks and liabilities involved in past on site and offsite disposal practices

Audits can be modified to achieve following objectives contd. • Assessment of facilities emergency response capabilities • Identification and evaluation of regulatory requirement and potential liabilities associated with major modification to existing facilities • Compliance with regulatory requirement

Audit- a process which …. Collects, analyse, interprets and documents information sufficient to achieve objectives …..includes specific procedures to promptly prepare candid and appropriate written report on findings, corrective action, schedule and implementation ……quality assurance procedures to assure the accuracy and thoroughness through supervision, independent internal review and evaluation

 Two main criteria for effective audit

• First, audit should be designed to be as comprehensive as possible given the specific objectives in  – Identifying activities and  – Conditions Which could have adverse effect

• Second, it should not be seen as a one-time-only occurrence but as an integral part of the rational management process that includes evaluation of  any problem identified in terms of potential consequence

Given these two criteria, a good audit should be multidimensional •Compliance • risk evaluation

Essential Element of an Effective Audit •  Top management support and commitment to follow up on audit findings • Simple and manageable audit process • Utilisation of in-house personnel where possible • Appropriately trained staff  • A standardised approach • Specific audit program objectives, scope, resources and frequency

Contd. • Sensitivity to confidentiality • A process that obtains appropriate and sufficient information • Procedures for documentation of findings, follow up on corrective action of schedule for implementation • A process that includes quality assurance procedures to ensure the accuracy of audits

AUDIT TYPE MANAGEMENT

ITEMS CONSIDERED COMMITTMENT POLICIES

ORGANISATION AFFECTED Top Management

ORGANISATIONAL EFFECTIVENESS

RESOURCES REPORTING LINES

FUNCTIONAL

PROGRAMS AND PERMITS IN PLACE TRAINING PROCEDURES

Middle Management • Operations • Facility • HSE

QA/QC

PROCEDURAL PRACTICES RECORD KEEPING PRACTICES

INSPECTION

TRAINING /AWARENESS HOUSE KEEPING PHYSICAL COMPLIANCE OF FACILITY

Direct Labour  • Operations • Facilities

Pre Audit Activities • Select activity or activities to be audited • Ensure top management commitment • Select audited objectives • Define audit scope • Select audit team • Ensure independence and objectivity Plan • Define roles and responsibilities • Ensure top management commitment Prepare audit team • Understand activities and management system • Review previous audit/review • Prepare questionnaire • Review questionnaire Develop checklist

On site Activities • Discuss with personnel on site Carry out a SWOT Analysis • Determine standard Gather evidence • Inspect activities, processes • Review documents Evaluate findings • Determine performance • Check for non conformances Prepare audit findings and conclusions

Post Audit Activities

Prepare Audit Report Communicate to the company

Follow Up Audit follow up •Develop corrective action plan •Establish mechanism to ensure follow up

HSE Management System Aspects • Corporate Policy • Standard Operating Procedures • Organisational Assignment of  responsibilities/authority • Internal Inspection and evaluation system • Reporting system •  Training and continuing education • Planning

 Types of Audit • Regulatory Compliance Audit (RCA) • Process Safety Audit • Occupational Health Audit • Product Quality Audit • Liability Audit • Management System Audit

Assessing Strength and Weakness • Compile a list of issues from the questionnaires • Rank issues in terms of risk • Compare obtained response with  – Policy objectives  – Regulatory standards  – Self-set targets  – Industry best practices

Internal Audit Program • Definition

A relatively inexpensive proactive approach to staying on top of HSE regulatory onslaught, while keeping current with technological practices

HSE Audit …. is a means of measuring the performance of HSE activities or practices at a facility against some standards or commitment

Standards? “Standards” – generally written documents accepted by or imposed upon program management.  These documents then serve as yardsticks of measurement of  performance

Standard Standards could be anything from  –  –  –  –  –  –  –  –  –

Federal State Local Codes Regulations to be established from engineering specs Standard Operating Procedures (SOP) Good management practices Corporate or departmental policies or just plain “common sense”

Sufficient and reliable information • Factual • Adequate • Convincing • Consistent • Candid • Clear

 Through the use of appropriate techniques in  – Interviewing

Why Internal Audit “ If an appropriate effort is initiated by a facility for internal audit, then the facility should adequately be prepared for external audit. Audit is a tool.

Audit a tool? • Management Tool  – Appraisal of current compliance  – Improvement of corporate image  – Early warning device for impending problems

•  Training Tool (Dry run)  – Increasing overall level of awareness

Audit a tool? (contd.) • Risk Management Tool  – Improvement of risk management system by reducing HSE risks and liabilities

• Management accounting Tool  – Control of compliance cost

• Line Management Tool  – Improvement of overall performance at operating level

Audit a tool? (contd.) • Program-wide Tool  – Development of proactive management program for optimising resources

• Bottom-line Tool  – Reducing/elimination of non-compliance conditions and fines due to violation

Points to note! Do not execute an internal audit of a facility unless top management intends to correct all non-compliance conditions or provide a reasonable schedule for implementation of  corrective actions. Audit documents are tenable for criminal prosecution of individual as well as citation and fines against corporations

Once an audit of a facility is conducted and documented, the documentation can, under certain circumstances, be requested by regulators

Basic Audit Tools •  The S/H/E audit process is most commonly supported by some important tools: the audit protocol and the working papers.

Audit Protocols • Names for the various documents that guide the auditor while conducting the audit include audit protocols, audit work programs, review programs, checklists, and audit guides. • An audit protocol represents a plan of 

Audit Protocols…….. • An audit protocol also provides the basis for assigning specific tasks to individual members of the audit team, for comparing co mparing what was accomplished with what was planned, and for summarizing and recording the work accomplished. • A well-designed audit protocol can also be used to help train inexperienced auditors and reduce the amount of supervision required by the audit team leader. •  The audit protocol itself is a listing of  auditing procedures that are to be performed to gain evidence about abou t safety,

Who performs the audit ? Basic qualities/skills of any auditor  • Knowledge of auditing process • Knowledge of all applicable regulations and standards • An independent viewpoint • Familiarity with facility history and processes • Knowledge of corporate policy • An understanding of facility organisation • Knowledge of facilities management philosophy

Use of consultants Advantages • Experience in auditing process • Current expertise in multiple regulatory programs • Obtaining an impartial survey of facility • Quick turn around time • Minimal time spent and involvement by facility personnel

Review all materials obtained • All materials received must be  –  Thoroughly and critically reviewed

• Design and develop follow up question where necessary information is missing or poorly communicated • Identify  – Key players  – Key issues  –  Types of facilities  – Programme Strength and Weakness

Preparation of Working Papers • Prepare a pre-visit questionnaire a) List items to be provided provided to the team team for for review review which which may include •

Permit

•

Inspection/Training Inspection/Training records

•

Analytical data

•

Site inspection

b)

A list of the questions to be answered concerning

•

Organisational Organisational chart

•

Resource allocation

•

Assigned responsibilities responsibilities

•

Physical plant layout

Make responses simple – Yes or No or Not Applicable

Preparation of Working Papers

Lastly, send out pre-visit questions to the operations to be audited to be accompanied by an appropriate letter from the top management to announce the HSE audit • topic • issues • timing

List of departments that must be involved in the HSE Audit • • • • • • • • •

Management Operations Maintenance Legal Purchasing HSE Facility Support Engineering QA Emergency Response

Basic Structure of a well executed audit • Pre Audit • Field Visit • Post Audit • Follow-Up

Pre Audit Activities • Determination of goals and objectives • Selection of targets, subject and scope (Scoping meeting) • Plan and Schedule (Planning meeting) • Preparation (checklist, questionnaires) • Kick off (Pre visit exchange of information) • Review of materials recieved

Objectives Objectives are created by top management  They may be part of   – compliance order  – Consent decree  – Settlement agreement with regulatory agencies

Audit Objectives Determine conformance of the HSEMS with the audit criteria

udit Objectives

 To determine whether the HSEMS has been properly implemented and is being maintained

 To identify areas for potential improvement

Assessment of the internal management reviews process to ensure continuing suitability and effectiveness of the HSEMS

Objective Evidence Objective evidence “First hand” evidence, based on witnessed facts, not supposition, presumption, hearsay, rumour, conjecture etc

Examination of system documentatio Interview, demonstrating training, understanding and competence Observation of actual practice or physical evidence demonstrating compliance/control Records (data, lists, report) demonstrating compliance/ capability/ performance

Records… • OS&H Policy • Safety organization chart •  Training Records on safety, fire and first aid • Accident investigation reports • Accidents and dangerous occurrencesStatistics and analysis • Records of tests and examination of  equipment and structures • Safe operating procedures for various operations

Contd. • Record of work permits • Record of monitoring of flammable and explosives • Maintenance and testing records of fire detection and fire fighting equipment • Medical records of employees • Records of industrial hygiene surveys(noise, ventilation, illumination levels, airborne and toxic substances, explosive gases) • MSDS

Contd. • Onsite emergency plans and record of  mockdrills • Records of waste disposal • Records of effluent discharge to the environment • Housekeeping inspection records • Minutes of Safety committee meetings • Approval of layouts and other approvals from statutory authorities

Contd. • Records of any modifications carried out in plant and process • Maintenance procedure records • Calibration and testing records • Shutdown maintenance procedures • In service inspection manuals, records including that of material handling • Safety Budget • Statutory Records, Previous audit reports,  Transportation of Hazardous substances

Strategy  This is the guideline to accomplishing objectives It may be:  – Assess organisational effectiveness (management audit)  – Assess facility operational effectiveness (facility audit)  – Assess facility condition (physical inspection)

Frequency  This is dependent on 1. The The acti activit vity y type type or or indu indust stry ry 2. Inte Intern rnal al/E /Exte xtern rnal al pres pressur sure e 3. Prog Progra ram m con condi diti tion ons s

It may be a yearly (annual), two-or-three year cycle program or optionally 1st year – occupational health audit 2nd year – safety audit 3rd year – Behavioral safety audit

Scope (select Target, Subject,) •  Target  – Small aspect of a facility  – Entire facility

• Subject

 This may be regulatory or self  assessment program

Depth Once target and subject is set, a decision must be taken on the depth and breadth of  efforts A detailed look at all documents related to:  –Management strategy  –QA  –Maintenance system  –HSE records

could be undertaken

Plan and Schedule Good communication is critical here. • Inform auditees of   – Purpose  – Extent of involvement  – Schedule

• Plan and know  – Who is auditing what  – Who or what authorises the audit

Plan and Schedule Be sensitive of operational schedulesDo not waste people’s time Have an estimate of time needed to visit site and look over document, then double it. Finally, stick to your schedule.

Reporting Findings •  The report should follow the below format  – A brief introduction • Purpose • Authority • Strategy •  Terms of Refefence • Scope

 – Report of the site/facility inspection • • • •

Evaluation of records Non compliances/Conformance Areas for improvement Conclusion

Reporting Findings • Recommendations • Follow Up Action Plan

 The report should have an executive summary where a synopsis of the entire report is included

Post Audit Activities • Corrective Action Documentation of Action Close-Out  – Documentation Documentation of Action Plan  – Documentation

• Development of Critical Success Factor (CSF)  – Commitment  – Allocation of Resources  – Budget

Functional) • Follow Up and Verification (Cross Functional)

Evaluating Finding and Result • Rules  – Do not draw unsubstantiated conclusions  – State the exact nature of the problem  – Avoid generalisation  – Use familiar terminologies  – Communicate extent of the problems • Compliance • Non compliance

Evaluating Finding and Result • Follow the below steps  – Priorities the problems/impact  – Allocate responsibilities  – Develop an action plan  – Implementation of the plan  – Assess the effectiveness of the plan and recommend change where necessary  – Document and communicate

Conducting and audit (types of  information) Verbal Interviews

Physical

Site visit & Observations Reviews

Objective Evidence

Documentary Circumstantial Anecdotal

Collecting audit evidence: Document review Records of complaints and prosecution Procedures and work instruction

HSE Case/HSE MS

Documents to reviewed include

Previous audits and inspection reports

Process flow diagrams

Legal documentspermits, waivers

Site and plant layout plans and diagrams

EIA, EER report Incident records Monitoring data

Training records

Collecting audit evidence: Site visit Waste storage and disposal facilities

Chemicals and drum storage

Examples of areas to focus on during site visit Points of  discharge to surface water  General housekeeping

Accident & Emergency procedures and activities related to actual or potential hazards

Diesel storage area

Audit findings The audit team must review all of the audit evidence to determine whether  the HSEMS conforms to audit criteria c riteria

Audit finding s

Nonconformity issues are properly documented in a clear and concise c oncise way and are supported by objective audit evidence The audit findings needs to be reviewed with the auditees The audit findings should be agreed between the auditors and the auditees

Audit findings Major non-conformances

Audit finding s

Minor non-conformances

Observation

Legal Issues and Protection of Audit Document States: •  The attorney-client privilege •  The work-product privilege •  The self evaluation privilege

Gathering Audit EvidencesField visit Arrange a meeting or preferably informal session with each group  –Explain the purpose  –Authority  –Confidentiality agreements  –Facility to be audited  –Documents to be surveyed

Establish good rapport.

at er ng u t v enceReview program/documentations • Present previous findings • Interview with pre-designed questionnaires • Questions must be in three parts  – Management (policies/resources)  – Senior management (system)  – Technical questions (procedures, process, guidelines)

Out briefing  Two separate sessions  – Management must be briefed first  – All other key participants should be invited to a general facility outbriefing

Outbriefing should be brief normally (1530 mins) Review • •

Good highlights Bad highlights

Outbriefing Take note of areas for improvement and stress that they are general impressions and that more detailed comment will be produced in an indepth report.