NIS Doc No:

Rev:
HSE/SOP-53
01
DESCON DESCON HEALTH SAFTEY & ENVIRONMENT MANAGEMENT SYSTEM Date of Rev: June 22, 2016
Page: 1 of 23

Policy Element: 12
HSE Auditing
Audits and Review

Rev
Date Originator Reviewed By Endorsed By Approved By
No.

Name Signature Name Signature Name Signature Name Signature

MJM
111.i MKK 144,3kii NH Ar
. ) ,
AMW , 1-- AAM kl""•-"'""v\-kii..--
:,
;>...&",-.44.-
AB AD
-)

AUH

MZ

MJM = Muhammad Junaid Mubashar, MKK = Muhammad Khawar Khan, AMW = Ahmad Mubeen Awan, NH = Nasir Hameed,
AAM = Ahmad Abbas Mirza, AB = Adnan Bakhtiar, AUH = Anwar ul Haq, MZ = Masood Zafar, ARD = Abdul Razak Dawood

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 Doc No: HSE/SOP-53
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Page: 2 of 23

Document Revision/Review History

REVISION REVIEW Reviewed by

No. Date Description No. Date

Development of Procedure
00 22-06-2016 as per requirement of
HSEMS Revamping Project C

01
C

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 Doc No: HSE/SOP-53
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Table of Contents

1.  OBJECTIVES ......................................................................................................... 4 

2.  SCOPE ................................................................................................................... 4 

3.  RESPONSIBILITIES .............................................................................................. 4 

4.  ABBREVIATIONS / DEFINITIONS ......................................................................... 4 

5.  PROCEDURE ........................................................................................................ 7 

5.1  HSE audits .......................................................................................................... 7 

5.2  Audit Levels ........................................................................................................ 7 

5.3  Synopsis of HSE audit Positions ........................................................................ 8 

5.4  HSE Audit Planning .......................................................................................... 12 

5.5  Preparation for audits ....................................................................................... 13 

5.6  Conducting the Audit ........................................................................................ 16 

5.7  Preparing the audit Report................................................................................ 19 

5.8  Audit Follow-Up ................................................................................................ 21 

6.  RELATED DOCUMENTS ..................................................................................... 22 

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 Doc No: HSE/SOP-53
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1. OBJECTIVES

The purpose of this document is to establish the methodology for Planning, execution
and follow up of HSE audits to assess the compliance and suitability of Company’s
Health Safety and Environment management system to achieve the stated HSE goals
and objectives at various levels.

2. SCOPE

This procedure shall be applicable on various levels of HSE audits conducted within the
company on Divisions / Units or at projects / facilities levels.

3. RESPONSIBILITIES

Chief Executive Officer

 Shall be owner of this document and overview the compliance of
guidelines and fulfillment of all the expectations outlined in this procedure.

Divisional Presidents / Head Business Units / Project Managers / Site

Managers
 Shall be responsible for the implementation of all the details given in this
procedure wherever they are applicable in their respective areas of
influence.
 Shall ensure availability of all resources required for the compliance of the
details given in this document and shall participate in compliance audits.
 Business Unit Head shall be responsible for providing authorization for
the exemption against the fulfillment of any of the requirement of this
document for a specific period of time under particular conditions giving
details of controls put in place for that period in consultation with HSE
Manager on Exemption format.

Division Head HSE/ HSE Manager Business Unit / Site HSE Manager or
In-charge
 Shall be responsible for adequate communication, trainings and
compliance audits along with advising to fill the gaps identified in
implementation of the requirements as details given in this procedure.
 Shall be responsible for review of this procedure as per set frequency or
on need basis.

Chief Risk & Compliance Officer

 Shall coordinate for the revision of this document as per set frequency or
as and when needed.

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 Shall be responsible for conducting the compliance audits of this

procedure.

4. ABBREVIATIONS / DEFINITIONS

HSE Health, Safety & Environment

COMPANY Descon Engineering (Pvt.) Limited
SM Site Manager
RM Resident Manager
CAR Corrective Action Request
Shall Mandatory
Should Recommended
SOP Standard Operating Procedure
TOR Terms of reference

Systematic, independent and documented process for

Audit
obtaining audit evidence and evaluating it objectively to
determine the extent to which audit criteria are fulfilled.

Auditee Party/organization/department being audited.

Accreditation Audits to verify that state of compliance of HSE

Audits management system warrants initial or continued
accreditation. Accreditation Audits are conducted by
person(s) appointed by the accreditation organization
(e.g. ISO 9000/14000, OHSAS 18001: 2007).

Auditor Person with the competence to conduct an audit.

Policies, procedures or requirements used as a

Audit Criteria
reference to conduct an audit.

Result of evaluation and observations noted during the

Audit
physical or documentation reviews against per agreed
findings
audit criteria.

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Action to eliminate the root cause of detected non

Corrective
conformity.
Action

The ability to perform a particular job in compliance with

Competency performance standards. Will usually require the
necessary blend of skills, training and experience.

Gap A Gap is a finding that an Expectation is not being met.

Health, Safety, Environmental Management System being

HSEMS the company structure, responsibilities, practices,
procedures, processes and resources for implementing
health, safety and environmental management.

Non- Any deviation from specified requirements or from pre-

Conformance defined written protocol, e.g. legal / standard / company
guidelines.

A finding, which does not have any clear objective

Observation evidence to prove it a non-conformance and need further
attention.

Preventive Action to reduce or eliminate the cause of potential non-

action conformity.

A documented series of steps to be carried out in a logical

Procedure order for a defined operation or in a given situation. A
prescribed set of rules, conditions or requirements.

Standard is an all-inclusive term denoting specifications,

Standard
Recommended practices, procedures, guidelines,
philosophies and handbooks.

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System A management tool for meeting an established objective

made up of four steps: plan, implement,
measure/evaluate and adjust.

HSE HSE inspections as opposed to audits are usually unplanned

Inspections and sometimes may be planned/scheduled activities used to
verify the health check of HSE System, HSE equipment, and
Safe working practices. These inspections may base on pre-
defined checklist for gauging system compliance and
ensuring fit for job equipment.

Management walk around is the activity which management/

steering committee undertake as per plan to gauge overall
Management
HSE compliance with respect to working conditions and safe
Walk Around
behaviors of personnel at any site / location. The findings of
management walk-around should be tracked like HSE
inspections and audits.

5. PROCEDURE

5.1 HSE AUDITS

HSE Audit is a Systematic, independent and documented process for obtaining audit
evidence and evaluating it objectively against verifiable evidence to determine the extent
to which audit criteria is fulfilled.
It is a documented process of objectively obtaining and evaluating to determine that HSE
controls:
 Are complete and consistent,
 Are efficient,
 Safeguard the company’s resources and promote their effective use,
 Provide, and protect the integrity of, required records and information,
 Allow for compliance with policies, chosen standards, laws and regulations.

5.2 Audit Levels

5.2.1 Level-1 Audit

Company Level-1 audit involves the immediate and 1st party audit conducted by the
team that is directly related to the job/project including project HSE team and execution
team, it also covers project contractors, vendors, suppliers HSE audits. These types of
audits are planned, executed and recorded at project sites and all the follow ups and
close outs records are stored at project site.

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5.2.2 Level-2 Audit

These audits involve any company parallel Business divisions, Business units, sister
companies and 2nd party audit shall be conducted by the team that is not directly
related to the job/project including business divisions and business units, corporate
HSE and execution team, it shall also cover HSE audits of pre-qualified contractors,
vendors, suppliers. These types of audits are planned, executed and recorded at
Business divisions, business units and corporate level. All the follow ups and close outs
records are stored at business division, business units or corporate HSE level.

5.2.3 Level-3 Audit

Level-3 audit comprises of 3rd party audit like accreditation audits for example ISO
14001: 2007, OHSAS 18001: 2015, standard compliance certification surveillance
audits, regulatory and government agencies compliance audits, These audits are
planned, executed and recorded at project sites, business divisions and Corporate
levels.

5.3 SYNOPSIS OF HSE AUDIT POSITIONS

5.3.1 Roles & Responsibilities

The key responsibilities in the HSE Auditing System are as follows:

1. HSE Audit Coordinator.

2. HSE Audit Leader.
3. HSE Auditors, member/s of audit team
4. Principal Auditee, line function manager as per scope of audit / company HSE
staff for 3rd part audit.
.
The effectiveness of the HSE Audit plan preparation depends entirely on the resources
provided to the above parties, and their commitment to fully assume their auditing
responsibilities.

HSE Audit Coordinator

The Audit Coordinator is responsible for:

1. Developing Audit Plan, and for selection of projects/facilities to be audited.

2. Coordinating Audit Leaders and Auditors as per specific scope of audit.
3. Providing training to Audit Leaders and Auditors, including those business
divisions, BU and project site staff selected to participate in HSE audits.
4. Ensuring that Lead Auditors have appropriate tools, e.g. up-to-date procedures
and current checklists.

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5. Facilitate for the timely preparation and processing HSE audits reports by Audit
Leaders.
6. Coordinating assistance to business divisions, BU and project audit team in
preparing and completing a corrective action plan for each audit.
7. Reviewing and monitoring HSE Auditing plans and providing feedback to
respective management regarding overall audit plan effectiveness

Audit Leader

Audit Leaders are responsible for:

1. Defining and agreement of Audit TOR with the Principal Auditee.
2. Prior to each audit, to review audit scope and complexity of project, facility or
HSE system to be audited to identify adequate qualification requirements for the
audit team members.
3. Develop audit TOR to determine applicability to the project, facility or HSE
system to be audited, and to prepare appropriate pre-audit questionnaires.
4. Determining special safety training or permit requirements for the audit team prior
to the site visit.
5. Contacting and briefing audit team.
6. Ensuring that the audit team have appropriate tools, such as current procedures
and checklists.
7. Distribution of audit tasks to audit team members, in accordance with their
expertise and experience.
8. Contacting and orienting business divisions, BU & project site management.
9. Coordinating the on-site audit, including logistics.
10. Developing the audit report, submitting it to the management.
11. Working with site management to develop the corrective action plan. When
conducting on-site audits with their teams, Audit Leaders must avoid undertaking
large portions of the audit workload. Instead, they must concentrate on
delegation and maintaining a good overview of progress, issues, gaps and
weaknesses. The key task of an Audit Leader is to develop a holistic view and
direct the team towards comprehensive auditing of the key HSE issues.

Throughout audit process, the Audit Leader must keep the Principal Auditee informed of
observed gaps, strengths, and weaknesses.

Auditors

Auditors may originate from various potential sources within or outside the business
divisions, BU and Project team.
For example: (a) Corporate; (b) specific or other related BUs (c) The project team
depending upon the nature of the projects; or (d) External consultancies with specific
specialist expertise in auditing.

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All auditors nominated for an HSE Audit must be approved in advance by the Audit
Leader and, once adopted, will be subject to the Audit Leader’s direction and control.
Each member of the audit team is responsible for:
1. Familiarizing themselves with relevant background of the project site or facility
prior to commencing the audit.
2. Thoroughly understanding the audit procedures, including:
 how to conduct the site walk-around, interviews and verification,
 what items to document,
 procedures to follow for potential incidents requiring immediate attention,
 gaining any required special safety training prior to site visit,
 conducting the audit in a confidential, tactful, efficient and impartial manner;
 Completing all items on the audit agenda.
3. Documenting each finding in a manner that allows an auditor with similar level of
expertise/experience level to confirm the conclusions without consulting other
resources.
4. Submitting their portion of the audit report to the Audit Leader within the agreed
time.
5. Returning Audit Checklists, notes and findings to the Audit Leader at the end of
the audit.

Principal Auditees, Site Managers and/or HSE Staff

These parties, as nominated by business divisions, BU or project Management, are

responsible for:
1. TOR Agreement
2. Assisting the audit team in the on-site review
3. Preparing a corrective action plan and advocating necessary measures
4. Implementing the corrective action plan

5.3.2 Competency Requirements for HSE Audit Positions

HSE Audit Coordinator

The Audit Coordinator must:

1. Be an experienced and competent with good planning, delegation,

communication (verbal and written) and presentation skills.
2. Be a good coordinator who has to act as a bridge between Audit Leaders and
principle auditee.
3. Be proficient on standard computer Microsoft software such as. Word, Excel and
PowerPoint.
4. Have a good overview of the project activities, business and HSE risks (including
overlaps/interfaces between company and Contracted services).

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5. Have considerable capacity to view issues holistically, and be capable of placing

observations and findings into management system context.
6. Have a broad and general knowledge of the HSE subjects to be audited and
familiarity with the company procedures.
7. Have participated in several real-time audits [e.g. conducted/led by other
accredited company Audit Leaders], or via short-term assignments with
established HSE Audit plans.

Audit Leader

The success and effectiveness of an audit team, and the HSE Audit Plan as a whole, are
linked to the competencies of Audit Leaders and the quality of the audit reports that they
deliver. Thus, Audit Leaders must:

1. Be experienced team leaders with good planning, delegation, communication

(verbal and written), and presentation skills.
2. Be proficient on standard computer Microsoft software such as. Word, Excel and
PowerPoint.
3. Have a broad and general knowledge of the HSE subjects to be audited, which
can be developed rapidly from reading applicable documentation e.g. HSE
procedures and safe working practices. Audit Leaders needed to be expert in all
subjects related to HSE management. Detailed HSE knowledge will invariably be
developed whilst conducting audits and from on-the-job communication with their
expert audit team members.
4. Have a capacity to quickly develop a project sites and HSE Management
overview.
5. Have considerable capacity to view issues holistically, and be capable of placing
observations and findings into management system context.
6. Be accredited auditors with formal audit training in. ISO14000 or OSHAS: 18001.
7. Have participated in several real-time audits [e.g. conducted/led by other
accredited company Audit Leaders,

Audit Leaders will be formally authorized in their respective capacities by the

management.

Auditors

Training and qualification requirements for the adopted audit team members (auditors)
will depend on specific scope of the audit. In general they must:

1. Be fully familiar with the HSE audit procedures.

2. Be technically competent to allow rapid understanding of the project sites, facility
or HSE systems to be audited, which includes a capacity to rapidly
understanding the project sites and facility specific HSE and HSEMS
documentation.

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3. Be familiar with those HSE laws and regulations, Company guidelines/

procedures that appertain to their specific tasks in covering the audit scope.
4. Be tactful and skilled in interviewing techniques.
5. Be sufficiently removed from management of the audited site to be objective in
their audit activities.

Prior audit experience is preferred but, provided that the above is adhered to, is not a
prerequisite. At the start of each audit, depending on the auditing skills observed within
his audit team, the Audit Coordinator and/or Audit Leader will conduct refresher training.

Auditor Training

The company HSE Audit coordinator will develop an audit training plan for BU and
projects sites respectively.

5.4 HSE AUDIT PLANNING

5.4.1 Contents and Timing

At pre-determined frequency of each year, the HSE Audit Coordinator will prepare a
HSE Audit Plan, which eventually should become an integral element of the HSEMS and
consists of the following.

1. 1st Quarter projects/facilities and HSE systems to be audited, Audit type, precise
audit scope, outline terms of reference and agreed timing/duration of audits
2. 2nd Quarter projects/facilities and HSE systems to be audited, Audit type, outline
audit scope and proposed timing (quarterly phasing).
3. 3rd Quarter projects/facilities and HSE systems to be audited and audit type.

5.4.2 Audit Scope

The exact scope and timing of individual HSE audits will be determined and prioritized
by the HSE Audit Coordinator, in consultation with business division, business unit HSE
Manager and project management, project HSE and the potential Principal Auditees.

5.4.3 Planning Coordination

In finalizing the plan, the HSE Audit Coordinator must ensure with the Principal Auditee
and/or other nominated persons (e.g. the Audit Manager and/or HSE Manager):
1. Best timing of the audits with regards to other activity planning, e.g., no conflicts
with major Project activities and/or shutdowns
2. That the audits do not duplicate the audit effort planned. Potentially significant
overlaps could occur if the HSE audit would closely follow a similar scope to the
Company-led audit or that of an external audit.
3. That business division, BU and project team deliver suitable personnel to
participate in the HSE audits.

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5.4.4 Resource Planning and Allocation

When preparing the HSE Audit Plan, it is imperative that the Audit Coordinator verifies
that adequate Audit Leaders are available to execute the Plan. This requires a thorough
understanding of the various key steps of a typical audit process, and the timeframes
required to initiate and conduct these audits.

5.5 PREPARATION FOR AUDITS

5.5.1 Terms of reference

The first and key activity for any audit will be for the Audit Leader to prepare the
detailed Terms of Reference (TOR). TOR preparation must commence at the earliest
possible time, as specific audit details (e.g. scope, technical complexity) may affect
resource requirements and dictate the mix of skills required within the audit team.
Thus, the Audit Leader must:
 Ensure that the TOR definition process commences in advance of the
planned audit start date.
 Agree the TOR with the Principal Auditee, preferably at least 2 weeks prior
to the planned start of the audit. If the TOR cannot be agreed prior to
commencing the audit, the audit must be deferred until agreement is
reached.
The TOR must provide applicable details on audit objectives, scope, standards, audit
methodology, reporting requirements, team members and Principal Auditee. The
finalized TOR must be agreed between the Audit Leader and the Principal Auditee,
specifically audit scope, timing and duration

5.5.2 Scope and General requirements

The scope of HSE audits should, in principle, be set to assess compliance with
applicable HSEMS of company, laws and regulations, policies, guidelines and
procedures/ instructions by the audited Company business division, BU/ project as a
whole or for pre-selected facilities or operations.

5.5.3 Review of Follow Up actions

A standard audit scope element of every HSE audit plan must to review of effective
follow-up to gaps and weaknesses identified during earlier HSE audits, assessments
and/or inspections. Preferably, this should also include follow-up to
recommendations resulting from near-miss reporting and incident/accident
investigations.
One of the principal aims of an audit is to obtain an overview of the general
Company ability to manage and implement improvement recommendations.

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Therefore, the review of follow-up should not be limited to issues with a ‘High’
potential risk.
Auditors should review a representative sample of all issues to avoid ‘Low’ and
‘Medium’ risk issues from developing into ‘High’ risk issues over time.

5.5.4 Standards

The compliance standards for all HSE audits should include, in priority order:

 Legal and obligatory requirements

 Standards to which company is accredited and certified
 Company standards and procedures, including HSEMS and standards to
which the company is accredited.
 Company HSE procedures as specified in guidelines and other
documentation.

Company HSE audits will be expected to comment on any shortfall in the above.

5.5.5 Principle Auditee

Nominating the Principal Auditee is a responsibility of business division, BU Head

Ops Manager of the audited organization. The Principal Auditee should be:
 An individual, preferably the business division, business unit head/ Head
operations, clearly identified by name and/or reference indicator.
 The person ultimately accountable (and responsible) for follow-up on the
audit findings.
 A senior member of staff at the appropriate organizational level. For example,
for an HSE audit of a project or facility the Principal Auditee should be the BU
head or project manager respectively.
Multiple Principal Auditees must be avoided by nominating a person at the higher
organization level with overall accountability for the entire audited projects/facilities
and HSE systems.

5.5.6 Team Selection and Composition and Sizing

As a minimum, every facility and Project audit team must consist of an Audit Leader
and one HSE Auditor. Both will coordinate with the HSE Audit Coordinator. The HSE
Audit Coordinator and/or Audit Leader will select the audit team from line function
and HSE staff in the Company business division, BU or Project depending upon the
nature of the audit.

Depending on audit scope, an optimum team size for any HSE Audit is 3-5 persons
(including the Audit Leader). This number will allow adequate flexibility when
distributing audit team tasks, allow for sufficient back-up during contingencies (e.g.
absence for compassionate of illness reasons). Also, it allows team meetings to be
effective and manageable.

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5.5.7 Methodology and Structure

All HSE audits will be conducted in accordance with methodology and auditing
procedures, as documented in this procedure.
As a common approach to all audits, audit team members are required to gather
information by observation, through interviews and by checks of hardware and
documentation. An essential element in the audit process is the diligent and impartial
verification of facts and findings leading to the identified gaps and weaknesses.
Where judgment is required, there should be consensus within the audit team and
the Audit Leader has overall responsibility for reaching a conclusion.
Where possible, Company HSE audits will attempt to identify root causes for the
observed deficiencies but, given the time constraints; this may not always be
possible.

5.5.8 Reporting

All HSE audits must deliver a management overview of the overall level of control in
relation to the HSE aspects and impacts of the projects/facilities and HSE systems.
The TOR must specify an opportunity for the audit results to be presented to the
Principal Auditee at the final day of an audit.
Preferably, this should be in the form of presentation to relevant members of
company, business division, BU or project senior management where the audit is
already been conducted.
The Auditee must be issued with a draft report at the end of the audit. Where there
are time constraints, this should be clearly identified as DRAFT, as later changes
and editing may occur.

5.5.9 Pre-audit preparation

At the start of an audit, Audit Teams require a considerable amount of information

appertaining to the audited projects/facilities and HSE systems.

At least one week prior to the on-site audit visit, the Audit Leader will notify the Audit
Coordinator to arrange a meeting with appropriate line and HSE management to
discuss:
 Audit objectives, scope, schedule and timing of the on-site portion of the
audit;
 Names of team members;
 Information to be collected at the site prior to the audit and to be made
available to the Audit Team e.g. procedures, work instructions.
 Interviews requirements and site support required
 Procedures for responding to the pre-audit questionnaire (if one is used).
 Any special issues to be considered.

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5.5.10 Audit Follow up

The TOR must highlight that translating audit findings into agreed actions assigned
to action parties is a post-audit activity and is entirely a Principal Auditee
responsibility.

5.6 CONDUCTING THE AUDIT

5.6.1 First meeting with Audit Team

Immediately upon commencing the 1st day of the on-site audit, the Audit Team
Leader must conduct his first meeting with his team. The Audit Leader must use this
meeting to verify the following:

1. Audit Terms of Reference (TOR):

 The finalized TOR must be agreed between the Audit Leader and the
Principal Auditee, specifically audit scope, timing and duration;
 The TOR must provide applicable details on audit objective, scope,
standards, audit methodology, reporting requirements, team members and
Principal Auditee;
 The TOR has been made available to and is understood by all members of
the Audit Team.

2. All members of the Audit Team have a good understanding of:

 the Audit Objectives i.e. the purpose(s) of the audit;

 the Audit Scope i.e. the boundaries of what will and will not be included in the
audit;
 Audit Standards i.e. against laws, policies, procedures, standards, etc. will
the audited organization /project sites be assessed; and
 Audit Methodology, Structure and Schedule i.e. the common roadmap
towards timely delivery of the final audit report.

3. All members of the Audit Team have a good understanding of their and other’s
specific roles/responsibilities in the Audit Team. This includes their thorough
understanding of requirements for teamwork and possibly long working hours.

All members have a good overview of the various HSE aspects as relating to the
audited projects/facilities and HSE systems including those that will and will not be
reviewed in detail as part of the audit.

If the Audit Leader perceives any gaps or shortfalls in the above, he must rectify
these prior to continuing with the on-site audit

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5.6.2 Distribution of team tasks

Immediately upon conducting the Initial Site Familiarization Tour, the Audit Leader
should have another meeting with his Audit Team to distribute the various audit tasks
to the Team members.
These tasks must be assigned to individuals in accordance with their particular skill
and experience. It is advisable to have the Team members volunteer for their
respective tasks, as opposed to being instructed.
The workload should be distributed equally, i.e. each team member should end-up
with approximately the same number of HSEMS objectives/Sub-elements.
Preferably, these should remain grouped per HSEMS Element and other tasks,
although some Sub-elements are suitable for assignment as separate items.

5.6.3 Data and documentation review

Prior to commencing the site visit(s) by individual Auditors or groups of Auditors, the
Audit Team should become familiar with Project site through the project HSE
orientation given in start of site arrival and study of available documentation. Then
audit team requires the review of pertinent laws, regulations, guidelines and
company HSE procedures, responses to the pre-audit questionnaire, and the results
of previous audits at the site.

Also, the Audit Leader may provide guidance to his team, specifically those with little
audit experience, to review selected parts of this document. This will allow the Audit
Team members to:
 Identify potentially significant issues in relation to HSE risk and thus prioritize
their Work prior to visiting the site.
 Better distribute the audit work amongst the Audit Team members.
 Develop focused interview schedules.

To facilitate such a structured review of data and documentation, each Team

member must carefully review those parts of the HSEMS Audit Checklist that relate
to the audit tasks delegated to him.

5.6.4 Interviews

The success and thoroughness of any audit will depend on interviews with business
division, BU and project management and site-personnel and project HSE team. It is
therefore essential that, prior to commencing an audit, the Audit Leader should make
it explicitly clear to the Principal Auditee (and his organization) that management and
personnel at various levels of the organization will be interviewed.
It is important that the Principal Auditee communicates to his management and
subordinates that they may be required to adjust their agendas at short notice to fit
the audit schedule.

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 Doc No: HSE/SOP-53
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Page: 18 of 23

5.6.5 Site Visits

The initial visit is for familiarization only and the Audit Leader must endeavor to limit
the duration to 1-2 hours. The visit should be conducted with the whole team,
accompanied by two senior site staff that are capable of explaining HSE issues and
project site developments.
Any areas or issues of potential impact, not previously anticipated, should be noted
for subsequent discussion with the team. Following the visit and prior to the Audit
Team commencing their individual objectives, the Team should meet to compare first
impressions. Depending on observations, the Audit Leader may have to modify the
audit focus and/or task distribution.
Subsequent visits can by conducted by Audit Team members on their own or in any
combination with the rest of the team.

5.6.6 Verification of facts

Interviews and observations during site visits will provide evidence of strengths,
weaknesses and gaps. It is imperative that, prior to documenting these findings in
the audit report, all issues are verified as being factual.
This should be done either via cross checks with other team members, other or
additional interviews, or cross-reference to existing documentation and procedures.
Two important rules must be rigorously applied:
 Rule 1: Every audit finding, irrespective of whether it is positive or negative needs
to be verified thoroughly.
 Rule 2: If in Doubt, Leave it out.

A single unverified issue that is reported formally, but is subsequently shown (by the
Auditee) as being non-factual, will affect the whole audit. It distracts the attention of
the Auditee from the remainder of factual and verified findings.

5.6.7 Closing Meeting

The Audit Leader should conduct a closing meeting with the entire Team. The aim of
the meeting is to review progress and to share major findings and conclusions.
During the meeting the team should develop consensus on the audit findings and on
the strengths and weaknesses observed during site visits, interviews and
documentation review.
The meetings should be used to analyze the findings and, where appropriate, to
address the underlying or root causes. This process will continue into the report
writing phase of the audit.
The Audit leader should be prepared to keep these meetings short, sharp and
focused and lasting no more than 60 minutes.

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 Doc No: HSE/SOP-53
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Page: 19 of 23

5.7 PREPARING THE AUDIT REPORT

5.7.1 Report Contents

The Audit Leader will compile the draft audit report with the findings and conclusions.
The report will comprise;

Executive summary: A concise and accurate summary of observations and findings by

the Audit Team members. The summary must be balanced and reflect both the
strengths and weaknesses. Under normal circumstances, no more than ½ A4 page
should be required, the summary must be concluded with the Audit Opinion.

Introduction: Information regarding the BU and Projects audited, the specific audit
dates (inclusive of those for preparation and post-audit activities), TOR (as an
attachment to the report), Company expectations regarding the audit follow-up

Principal positive findings: A summary of positive aspects as observed by the

auditors. It will also contain highlights of issues as observed, which may be
communicated to other Project sites as ‘Best Practice’.

Audit Findings: All audit findings, the listing will be inclusive of the codes relating to
potential risk level. This risk rating will be the equivalent of the priority for corrective
action

Note:
In order to limit the size of the Audit reports, these should not contain appendices such
as organograms, technical diagrams, extracts from manuals/procedures, etc. However, if
specifically required in the context of some of the audit findings, it suffices for the Audit
Report to refer to these documents. Under special circumstances, the Audit report may
include information on where the documents are located.

The audit report must reflect the contents of the Management Audit Presentation,
and vice versa if necessary.
If the audit report reflects a more negative picture than was presented initially, the
Principal Auditee may decide not to accept the report. In the longer term, a repeat of
such instances will affect the credibility of the Lead Auditor or even the audit process
as a whole.

5.7.2 Audit Findings

 For purposes of brevity, all audit findings will be named ‘Gap’ and must relate to
the gaps/weaknesses which have been identified for the Expectations, and must
provide the detail as required by the Principal Auditee to develop rectification
action plan.

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 Each audit finding should be stand-alone. The reader should be able to interpret
the recommendation without having to relate to the body of the audit report, the
audit Checklists or any other working papers.
Each audit finding will reflect the potential risk level of the gap, which, in turn
reflects the priority for corrective action i.e. H – High; H/M - High/Medium; M –
Medium; L - Low.
 The audit finding must not make any reference to possible methods for rectifying
the audit gap i.e. the Principal Auditee is responsible for determining the most
effective solutions and specific remedies to the reported gaps and must address
each of these in writing. He must propose an audit follow-up action plan, which
includes timing and resources. Alternatively he must demonstrate why the gap
exists and why the associated risk is acceptable.
 A unique numbering system will be used as to allow identification of each of the
audit findings in the context of the particular HSEMS Element, Sub-element and
Expectation.
 As a general rule, audit findings with (L) low risk rating will be omitted from the
report. Time permitting, and on specific request by the Principal Auditee, they
may be provided as a separate list.

5.7.3 Report approval and distribution

The Audit Leader will issue the draft report for review by HSE Audit Coordinator and
the Principal Auditee within one week of finishing the site audit. The purpose of this
review is to ensure that the report is factually correct. The Principal Auditee is
responsible for ensuring that appropriate management and site personnel in the
audited organization review the report.
Auditee comments should be returned within 14 days to the business division,
business unit and Project Audit Coordinator, who will review and consolidate these
prior to discussing these with the Audit Leader.
Upon receipt of the consolidated comments, the Audit leader will finalize the report.
As a general rule, finalized audit reports should be issued within 15 days of
completing the onsite audit activities.

The business division, business unit /Project HSE Audit Coordinator will distribute the
final report as follows:
 A full report, with attachments, to the Principal Auditee or any number of full
reports agreed between Principal Auditee and Audit Leader. The Principal
Auditee is responsible for distributing the report within his own organization.
 A full report, with attachments, to the Corporate, business division /business unit/
Project HSE depending upon the level of audit
 A full audit report of specified audit level shall be shared and presented to the
steering committee respective members if required.

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 Doc No: HSE/SOP-53
Rev: 01
HSE AUDITING Date of Rev: JUNE 22, 2016
Page: 21 of 23

5.8 AUDIT FOLLOW-UP

5.8.1 Corrective Action Plan

The Corrective Action Plan must relate to the documented audit findings of the
identified gaps/weakness. The findings must provide the detail as required by the
Principal Auditee to arrive at a Corrective Action Plan.

5.8.2 Preparing the Plan

The Principal Auditee is responsible for preparing the action plan to correct the audit
findings. Formulating the plan should be completed within 15 days of issuance of the
final audit report. The plan must address:
 SMART (Specific, Measurable, Achievable, Realistic and Time-based) actions to
correct each audit finding, in sufficient detail so that all steps are clearly
understood.
 Assignment of responsibility for each action to specific personnel or groups
 Provision for sufficient resources i.e. manpower and finance
 The estimated completion timing for each step
Audit Coordinator will assist in preparing the plan through clarification of the
documented audit findings and suggesting possible corrective actions.

5.8.3 Conflicts and Disagreements

All audit findings should preferably be agreed between the Audit Leader and the
Principal auditee prior to issue of the final audit report. Nevertheless, there may be
occasions when:
 The Principle Auditee disagrees with one or more audit finding(s).
 The Principal Auditee agrees with one or more finding(s), but concludes that no
corrective action is required i.e. the risk is acceptable and can be justified.
In these circumstances the Principal Auditee must provide documented reasons
for the disagreement or the rationale for not taking corrective action. The
documentation must include the case study/risk analysis and cost benefit
analysis. Also, this disagreement or risk acceptance must:
 Be approved by an appropriate level business division/ BU/Project management
of the audited business division/BU or project.
 Be documented in the corrective action plan
 Be copied to the business division/ BU/Project HSE Audit Coordinator.

5.8.4 Action Plan Follow-up Progress Reporting

The Principal Auditee is responsible for ensuring timely completion of the corrective
actions, and must provide status reports to the HSE Audit Coordinator of each
corrective action. If applicable, the status reports must provide suitable explanation
why scheduled completion dates are missed.

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 Doc No: HSE/SOP-53
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Page: 22 of 23

5.8.5 Audit Follow-up Tracking

Detailed tracking of audit follow-up and reporting to business division/ BU/Project

management is the responsibility of the HSE audit coordinator along with business
division/ BU/Project HSE.

5.8.6 Follow Up Reviews

The HSE Audit Coordinator and Audit Leaders must conduct periodic reviews of
actual follow-up to audits. To this effect, they will conduct on-site visits to previously
audited business divisions, BUs or projects to confirm factual completion of actions.
These reviews will be conducted for up to 25% of the audits conducted each year

Such reviews will generally consist of an on-site meeting with appropriate personnel,
a review of documentation and a brief site tour to review selected actions taken to
correct audit findings.
Persons conducting these reviews will provide formal feedback to business divisions/
BU/Project management on appropriateness and effectiveness of the corrective
actions.
The HSE Audit Coordinator will use the results of these reviews for improving the
audit and follow-up process and procedures.

5.8.7 Audit Close Out

Upon receipt of action follow up close out and CAR report by the Principal Auditee
that all corrective actions have been completed, the HSE Audit Coordinator will issue
a formal audit close-out memo, with distribution as follows:
 Business division/ BU/Project Principal Auditee
 Business division/ BU/Projects HSE Manager
 HSE steering Committee members from different business divisions, BUs if
applicable.
The issue of the formal audit close-out memo may be subject to a follow-up review.

6. REFERENCE & RELATED DOCUMENTS

 Yearly HSE Audit Plan HSE/FRM-25

 Audit Interview Schedule HSE/FRM-26

 HSE Action Item close Out Form HSE/FRM-27

 HSE Audit Report HSE/FRM-28

 HSE Audit Term of Reference Annex - A

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 Doc No: HSE/SOP-53
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Page: 23 of 23

 Descon HSE Management System Framework

 OHSAS 18001:2007 HSMS Standard

 EMS ISO 14001:2004

 Occupational Safety and Health Administration (OSHA) USA

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  Doc. No.: Annexure-A
HSE Audit TOR Rev.: 00
Date: June 22, 2016
Page 1 of 2 

 
 

Project (name of the Project) Project No.:

Audit Level: Proposed Dates:

Introduction: ________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Objective: ____________________________________________________________
______________________________________________________________________
______________________________________________________________________

Scope: _______________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Audit Methodology: ____________________________________________________

______________________________________________________________________
______________________________________________________________________

Reporting: ____________________________________________________________
______________________________________________________________________
______________________________________________________________________

Post Audit Follow Up: __________________________________________________

______________________________________________________________________
______________________________________________________________________
  Doc. No.: Annexure-A
HSE Audit TOR Rev.: 00
Date: June 22, 2016
Page 2 of 2 

Principal Audit Positions

Name BA/Project Function

Principal Auditee

Audit Coordinator

Auditors HSE Lead Auditor

HSE Auditor

HSE Auditor

Agreed by:

Principal Auditee Name:

Signature: Date:

Approved By: Signature:

HSE Audit coordinator Name Date:

 Doc. No.: HSE/FRM-25
Rev.: 00
Yearly HSE Audit Plan Date: June 22, 2016
Page 1 of 1

S.No. Project/Facility/System Project Monthly HSE Audit Schedule

1 1 2 3 4 5 6 7 8 9 10 11 12

Prepared by: Reviewed by: Approved by:

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Reserved.
 Doc. No.: HSE/FRM-26
Rev.: 00
Audit Interview Schedule Date: June 22, 2016

Page 1 of 1

Audit Team
Project Staff to be interviewed
Lead Auditor Auditor Audit Team member

Ref
Name Project/Position Name Name Name Name Name Name
#

1 Project Manager

2 Site Manager

3 CM Mechanical

4 CM Electrical

5 CM Civil

6 CM I&C

7 Area I/C Elec

8 Area I/C Mech

9 Area I/C Civil

10 E & P manager

11 Workers

12 Workers

13 Craftsman
14 Craftsman

Lead Auditor Principal Auditee

 Doc. No.: HSE/FRM-27
HSE Action Item Close Out Form Rev.: 00
Date: June 22, 2016
Page 1 of 1

Project/Facility/System Audit No:

Reference No : Audit Team:

Date/Time :
Principle Auditee :
Source of finding Type/Category
 Audit/Level of Audit  Major Non-Conformance
 Management Walk around  Minor Non-Conformance
 Near Miss (high Potential)  Observation
 Incident
 HSE Focused Inspection

Description of Finding _______________________________________________________

___________________________________________________________________________
___________________________________________________________________________

Action taken for Closure ______________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________

Closure Status
 HSE Action Open Closed By : _________________
 HSE Action Closed
Date: _________________

Verified By: ___________________________________________________________________

SM/PM/BU Head __________________ Date: __________________

HSE Representative Line Management Representative

 Doc. No.: HSE/FRM-28
Rev.: 00
Date: June 22, 2016
HSE AUDIT REPORT Page 1 of 2

Project/Faculty/System : Audit no.:

Project no.: Audit team: 1)
Area audited : 2)
Date of audit : 3)
TIME (24 Hrs) : 4)

FOLLOW UP STATUS
RECOMMENDED ACTION (Audit date & brief
description with new
Description Finding
SR TARGET REMARK target date if required)
of Category ACTION BY
NO. DATE S
Findings H/M/L Corrective Preventive
Action Action
NO.1 NO.2

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 Doc. No.: HSE/FRM-28
Rev.: 00
Date: June 22, 2016
HSE AUDIT REPORT Page 2 of 2

DISTRIBUTION:

1. __________________ 4. ________________
2. __________________ 5. ________________ INCHARGE SITE HSE PM/SM
3. __________________ 6. ________________

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