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This document is intended to provide a guide for: auditors in performing HSE audits; HSE management in administration of the HSE audit program; and organizations being audited to enhance their understanding of the auditing process and their role in it.
Fishbone Safety Solutions Audit Guidance Document
Summary This document is intended to provide a guide for: auditors in performing HSE audits; HSE management in administration of the HSE audit program; and organizations being audited to enhance their understanding of the auditing process and their role in it.
Contents (Use for Level 2 procedures only)
1. Purpose
2
2. Audit Program Overview
2
3. Audit Program Management
3
3.1. Audit Location Selection
3
3.2. Audit Criteria Identification
3
3.3. Auditor Selection and Training
4
3.4. Staffing Audits
4
3.5. Scheduling Audits
4
3.6. Tracking and Reporting HSES Audit Results
4
4. The Audit Process
5
4.1. Initiation
5
4.1.1. Audit Date
5
4.1.2. Scope
5
4.1.3. Audit Conformation Memo
5
4.2. Preparation
6
4.2.4. Preliminary Agenda
6
4.2.5. Audit Team Preparation
6
4.2.6. Audited Organization Preparation
7
4.3. On-Location Evaluation
7
4.3.7. Opening Meeting
7
4.3.8. Tour
7
4.3.9. Evaluation - Interviews
8
4.3.10. Evaluation Tours
8
4.3.11. Evaluation Records
8
4.3.12. On-going Communication with the Business
8
4.4. Reporting 8
4.4.13. Audit Findings
8
4.4.14. Closing Conference Report
9
4.4.15. Closing Conference 9
4.5. Corrective Action
9
4.5.16. Lead Auditor 9
4.5.17. Business Management
9
4.5.18. Summary Report
10
1. Purpose
Maintaining evaluation criteria and assessment tools that enable organizations to understand and determine the effectiveness and suitability of their HSE system, including conformance to Regulatory standards.
Provide business and management with objective information that enables them to conclude whether or not HSE standards and expectations are being met.
Identify deficiencies and opportunities for improvement in the HSE system, enabling continual improvement and sharing best management practices.
2. Audit Program
Overview
Administered by the Fishbone Safety Solutions
Collaboration with local HSE and business leaders
Annual schedule, based on HSE objectives, organization risks and performance
HSE auditors are trained professionals able to conduct audits
Audits comprise of five distinct phases: initiation, preparation, on-location evaluation, reporting, and corrective action.
Audits are conducted in accordance with the following principles:
1. Every audit is a joint and cooperative effort between the audited organization and the audit team
2. Every audit has the implicit objective of fostering improvement
Audit results are reported to the business organization senior management. The audited organizations management is expected to prepare a formal management response documenting strategies, owners and timing for addressing findings made by the audit team.
3. Audit Program Management
3.1. Audit Location Selection
The following can be used as a general guide to select locations or businesses to be included in the audit.
Site Characteristics
3 points
2 points
1 point
0 points
Score
Size and Type Major Mfg. or Significant Safety Issues Medium Manufacturing Minor manufacturing or engineering Warehouses, Real Estate, Admin. Bldgs.
Number of Employees at facility
>500 100 to 499 25 to 99 > 25
Employee Safety Did not meet safety goals last or this year YTD Did not meet last years safety goals but is meeting this years goal Meet safety goals last year and this year YTD Zero incident rates
Significance to Safety Performance
> 10 recordables/year 4 to10
recordables/year 3 or fewer
recordables/year 0 recordables
Radioactive Materials Program Yes triggers a bi- annual audit by the Radiation Safety Officer
Air Emissions Title V Permit (US operations only) Significant permit requirements No sources require air permits (minor source if any) No air emission sources
Toxic Chemical Use
Has 3 or more §313 chemicals Has 1 or 2 §313 chemicals Has no §313 chemicals. Has no §313 chemicals.
Hazardous Waste Consistently generates more than 1000kg/m Generates between 1000kg and 100kg/mn Consistently generates less than 100kg/mn No hazardous waste produced
Wastewater Discharges treated, direct discharge to water body Wastewater to sewer Discharges only sanitary wastewater no discharges
Prior Visit by HSE Professional None Zurich in last two years By Corporate in last two years By Corporate in last year
Professional Support No HSE coordinator Part time HSE coordinator Full time HSE coordinator Full time HSE professional
AVERAGE RISK VALUE
3.2. Audit Criteria Identification
Regulatory Standards
Fishbone Safety Core Process
Customer Procedures
Local requirements applicable to the audited organization
External HSE commitments subscribed to by the audited organization
Audit criteria to be used for each audit are identified during the development of the audit scope.
3.3. Auditor Selection and Training
HSE professionals from Fishbone Safety Solutions, but may include qualified individuals from the business and outside out consultants. All lead auditors must complete fundamental training in auditing methodology.
3.4. Staffing Audits
Fish Safety is responsible for selecting and staffing the audit team for their audit. Audit teams may compress of 2 to 4 individuals. The following may be used in determining size/composition of the audit team:
1. Audit scope
2. Size, type, risk and complexity of the operation
3. History of HSE performance
4. Audit team experience
3.5. Scheduling Audits
Audits are based on their relative level of HSE risk and demonstrated record of effectively address and managing HSE risk. .
The audit team leader and organization HSE representative work together to select the specific dates for the audit visit.
Once the date is scheduled the audit team leader coordinates the preparation, on-location visit, and follow-up processes.
3.6. Tracking and Reporting HSES Audit Results
Fishbone Safety Solutions Event Tracking shall be used to record all corrective actions. Each business is responsible for developing and assigning corrective action methods. The lead auditor is responsible for entering finding in to Fishbone Safety Solutions Tracking System.
4. The Audit Process
4.1. Initiation
4.1.1. Audit Date
The lead auditor and applicable business schedule and confirm a specific audit date.
The lead auditor should communicate with the business/organization 1month prior to the target audit date to allow proper preparation.
4.1.2. Scope
The lead auditor is responsible for working with the business to develop a customized scope document for the audit. The scope must include:
1. Location/sites and business included in the audit
2. Audit objectives
3. Audit criteria
4. Audit methodology and strategy
5. Results to be delivered by the audit team
6. Distribution list for the audit report
7. Responsibilities of the audited organization
The audit scope must be agreed to by the organization, documented by the team leader and distributed to the audit team.
4.1.3. Audit Conformation Memo
The lead auditor shall prepare and send a memo confirming the agreement on the audit date and scope. The memo also contains references and information to assist the business in their preparations. The confirmation letter should be sent 2 weeks before the audit.
Information sent with the confirmation memo should include:
1. Audit scope
2. HSE standards (web link)
The lead audit may also request information in memo such as:
1. Description of the business
2. HSE risk profile, aspects/hazards
3. Organization charts
4. Site plan
4.2. Preparation
4.2.4. Preliminary Agenda
Based on audit scope and communication with the business, the audit team leader validates the number of audit days.
The lead auditor six weeks prior along with the organization business representative prepare a list of key people and schedule:
1. Opening conference
2. Interviews (management and focal points)
3. Closing conference
4.2.5. Audit Team Preparation
The lead auditor shall select: HSE standards and operational issues (significant aspects/hazards) for each auditor to investigate.
The audit team conducts pre-audit review to gain a working understanding of the business to help in the planning of the detailed agenda.
The lead auditor shall establish a detailed audit agenda based on scope, HSE standards, samples, implementation and effectiveness. Audit time must be distributed to reflect the importance of the area being audited.
Each auditor is responsible for travel arrangements, computer, PPE, as required.
To improve efficiency, auditors should consider:
1. personal to be interviews
2. locations to visit
3. key questions
4. records to review
5. type and size of samples
6. estimated time requirements
4.2.6. Audited Organization Preparation
The audit team relies on the business to:
1. Confirm audit dates
2. Submit required information
3. Provide information on travel logistics
4. Participate in pre-audit documentation reviews
5. Prepare employees to participate in audit
6. Make arrangements with individuals to be interviewed
7. Arrange tour guides
8. Coordinate opening and closing meetings
9. Provide on-location support (workroom, computer access)
4.3. On-Location Evaluation
4.3.7. Opening Meeting
The lead auditor should meet with the business representative prior to the opening to address any last-minute issues.
The opening meeting should be attended by applicable business leaders, HSE staff, and others who may benefit from the presentation and coordinated by the lead auditor and the business.
The business should present a summary of operational issues, business climate, business structure, HSE goals, performance, and any other information which could be of interest to the auditors.
The lead auditor provides a summary of the audit scope, agenda and process and any other items request by business.
4.3.8. Tour
An orientation tour should take place after the opening meeting. The tour allows the auditors to observe general conditions, and identify and prioritize area and aspects/hazards.
Following the tour the lead auditor should identify areas warranting detailed tours and follow-up interviews/records and check team assignments match business/site profile.
4.3.9. Evaluation - Interviews
Interviews are the primary method used by the audit team. Interviews are also used to share company wide HSE developments and best management practices.
Employees and contractors should also be selected randomly and used to gauge HSE awareness.
Audit team should share findings, perceptions and observations with interviewees and key managers.
4.3.10. Evaluation Tours
Detailed tours verify that necessary controls systems, equipment ort other items (example labels, locks) are in place. Detailed tours are performed by the audit team member who is assigned the applicable risk.
4.3.11. Evaluation Records
Review of documents and records is required to gauge the effectiveness of process and programs. Sample sizes are based upon the needs and judgment of the audit team member.
4.3.12. On-going Communication with the Business
Audit team should meet frequently throughout the audit to exchange information and gauge the audit progress. Audit findings are summarized and discussed daily with the organizations business representatives (daily debrief)
4.4. Reporting
4.4.13. Audit Findings
The lead auditor and team shall ensure audit findings are:
1. Justifiable
2. Reflective of the HSE risk
3. Focused on the most important issues
4. Based on performance, or trends
5. Consistent among team members
6. Presented in a way to motivate improvements
Extra focus shall be highlighted for finds that could result in:
1. Employee illness or injury
2. Regulatory exposure
3. Business disruption
4. Negative stakeholder engagement
5. Jeopardizes HSE system implementation and effectiveness
4.4.14. Closing Conference Report
Prior to the end of the audit the team meets to complete their analysis of the audit findings, significant HSE risks, deficiencies and discrepancies to determine where they best fit and which items require management action. The results of the this meeting is documented and shared in the closing report, which contains:
1. An executive summary noting items for management action
2. A list of findings categorized by HSE standard
3. Rational related to the findings
4.4.15. Closing Conference
A closing conference shall be held at the end of the audit and attended by the participants from the opening conference. During the closing conference the lead auditor reviews the executive summary and presents the findings, the lead auditor should also present positive elements/controls identified during the audit as well.
4.5. Corrective Action
4.5.16. Lead Auditor
The lead auditor shall enter all findings into Fishbone Safety Solutions Event Tracking system within 10 days of the audit closing meeting.
4.5.17. Business Management
Business management is responsible to review each corrective finding update the system with responsible owners, corrective action descriptions and estimated closure timelines.
The business management representative shall monitor corrective action closure and update the system as required.
Business Leaders and local HSE coordinators shall assisted in monitoring and closing corrective actions as required.
4.5.18. Summary Report
The lead audit shall report back to Business Leader and applicable Regional Leader summary of the audit that includes:
1. Audit summary
2. Number of findings
3. Issues/concerns developed during the audit
4. Recommendations for future audits
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