OHSAS 18001 internal audit Audit number 2012.11 Audit date 21.11.12 and 22.11.12 Completed by Dale Town Auditee name/s Stuart Regan OHSAS Clause Manual Reference Clause description Objective evidence gathered Compliant? Y/N NCR/OBS/ OFI Ensure that sampling approach considers risk levels presented by activities and criticality of activities. Attach appropriate levels of objective evidence to your hard copy of this checklist. 4.1 OHSM 41 General Requirements 4.2 OHSM 42 Occupational Health and Safety Policy Does the OH&S policy comply with the requirements of clause 4.2 of OHSAS 18001? a) is appropriate to the nature and scale of the organization’s OH&S risks; b) Includes a commitment to prevention of injury and ill health and continual improvement in OH&S management and OH&S performance? c) Includes a commitment to at least comply with applicable legal requirements and with other requirements to which the organization subscribes that relate to its OH&S hazards? d) Provides the framework for setting and reviewing OH&S objectives? e) Is documented, implemented and maintained? TClarke North West Ltd Occupational Health and Safety Statement Date: 11th May 2012 and authorised by the MD Andy Smith. Evidence of policy statement compliance provided below TClarke North West Ltd provide electrical, instrumentation, mechanical and civil engineering contract work on client sites managed and coordinated from our office based at Accrington in Lancashire. Our health and safety policy statement is consistent with the nature and scale of our business activities. TClarke North West Ltd is fully committed to the prevention of injury and ill health and continual improvement of its OHSAS 18001 system and resulting OH&S performance. To this end, every reasonable effort, including: both physical and financial resources will be deployed to provide safe and healthy working conditions and to prevent dangerous occurrences, fire and any other damage. TClarke North West Ltd is fully committed to legal and other requirements compliance relating to the Health and Safety at work Act 1974 and other applicable regulatory requirements relating to its OH&S hazards. Occupational health and safety objectives are agreed at periodic management reviews. Objectives are monitored and adjusted at health and safety meetings forming the framework for objectives setting and OH&S performance review. Yes Full OHSAS Internal Audit Page 1 of 39 Issue 1 Dated:
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OHSAS 18001 internal auditAudit number 2012.11 Audit date 21.11.12 and
Ensure that sampling approach considers risk levels presented by activities and criticality of activities. Attach appropriate levels of objective evidence to your hard copy of this checklist.
4.1 OHSM 41 General Requirements4.2 OHSM 42 Occupational Health and Safety
Policy
Does the OH&S policy comply with the requirements of clause 4.2 of OHSAS 18001?
a) is appropriate to the nature and scale of the organization’s OH&S risks;
b) Includes a commitment to prevention of injury and ill health and continual improvement in OH&S management and OH&S performance?
c) Includes a commitment to at least comply with applicable legal requirements and with other requirements to which the organization subscribes that relate to its OH&S hazards?
d) Provides the framework for setting and reviewing OH&S objectives?
e) Is documented, implemented and maintained?
f) Is communicated to all persons working under the control of the organization with the intent that they are made aware of their individual OH&S obligations?
g) Available to interested parties?
h) Is reviewed periodically to ensure that it remains relevant and appropriate to the organization.
TClarke North West Ltd Occupational Health and Safety Statement Date: 11th May 2012 and authorised by the MD Andy Smith. Evidence of policy statement compliance provided below
TClarke North West Ltd provide electrical, instrumentation, mechanical and civil engineering contract work on client sites managed and coordinated from our office based at Accrington in Lancashire. Our health and safety policy statement is consistent with the nature and scale of our business activities.
TClarke North West Ltd is fully committed to the prevention of injury and ill health and continual improvement of its OHSAS 18001 system and resulting OH&S performance. To this end, every reasonable effort, including: both physical and financial resources will be deployed to provide safe and healthy working conditions and to prevent dangerous occurrences, fire and any other damage.
TClarke North West Ltd is fully committed to legal and other requirements compliance relating to the Health and Safety at work Act 1974 and other applicable regulatory requirements relating to its OH&S hazards.
Occupational health and safety objectives are agreed at periodic management reviews. Objectives are monitored and adjusted at health and safety meetings forming the framework for objectives setting and OH&S performance review.
The policy document forms an integral part of the company’s electronic management system. It is version controlled and posted at head office and at the company’s site offices.
The policy is communicated as part of the company’s induction process but also through posting as indicated above. The policy statement is also accessible to all employees via the company’s electronic management system.
Yes, if requested during pre-qualification exercises and during third party assessments conducted by ACS.
Review of policy content completed at periodic management reviews.
Yes
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Ensure that sampling approach considers risk levels presented by activities and criticality of activities. Attach appropriate levels of objective evidence to your hard copy of this checklist.4.3 OHSM 43 Planning4.3.1 OHSM 431 Hazard identification, risk assessment
and determining controls
The procedure(s) for hazard identification and risk assessment in place taking the following into account:
a) Routine and non-routine activities?
b) activities of all persons having access to the workplace (including contractors and visitors);
c) Human behaviour, capabilities and other human factors?
d) Identified hazards originating outside the workplace capable of adversely affecting the health and safety of persons under the control of the organization within the workplace?
e) hazards created in the vicinity of the workplace by work-relatedactivities under the control of the organization;
f) infrastructure, equipment and materials at the workplace, whether provided by the organization or others;
Ref: procedure SP 3.3.1 Dated 11.04.12 currently at Issue level F
Procedure references 5 Steps to Risk Assessment (INDG 163)Construction Site Safety (GE 700) OBS Validate that the team are using the up to date version of construction site safety GE 700
Covered under section 4 of the procedure ‘principles’
OBS Risk assessment procedure would benefit from referencing behaviour, capabilities and other human factors? i.e. Young persons, pregnant workers
OBS Clarity required in the risk assessment procedure relating to hazards originating outside the workplace capable of adversely affecting the health and safety of persons under T Clarke control
Covered under section 4 of the procedure ‘principles’
OBS Clarity required in the risk assessment procedure relating to infrastructure, equipment and materials at the workplace, whether provided by the T Clarke or contractors
NO NCRClustered observations
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g) changes or proposed changes in the organization, its activities, or materials;
h) modifications to the OH&S management system, includingtemporary changes, and their impacts on operations, processes,and activities;
i) Applicable legal obligations relating to risk assessment and implementation of necessary controls.
j) the design of work areas, processes, installations, machinery/equipment, operating procedures and work organization, including their adaptation to human capabilities.
Risk assessments
The organization’s methodology for hazard identification and riskassessment shall:
a) Is defined with respect to its scope, nature and timing to ensure it is proactive rather than reactive.
OBS Risk assessment procedure would benefit from covering changes or proposed changes to activities or materials used
OBS Risk assessment procedure would benefit from the covering temporary changes, their impacts on operations, processes and activities;
OBS The risk assessment procedure would benefit by making a reference relating applicable legal obligations and the implementation of associate controls.
OBS The risk assessment procedure would benefit by covering the design of work areas, processes, installations, machinery/equipment, operating procedures and work organization, including their adaptation to human capabilities.
Covered under section 4 of the procedure ‘principles’ relates to Project Engineer responsibilities.
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b) Provides for the identification, prioritization and documentation of risks, and the application of controls, as appropriate.
5x5 scoring mechanism provided in section 7 the procedure, see below
The following document formats referenced by procedure
NCR Eight clustered observations relating to risk assessment procedure content taken together re graded as a NCR. See observation details in audit 2012.10
4.3.2 OHSM 432 Legal and other requirements
Has the organization established, implemented and maintained a procedure(s) for identifying and accessing the legal and other OH&S requirements that are applicable to it?
Ensure that sampling approach considers risk levels presented by activities and criticality of activities. Attach appropriate levels of objective evidence to your hard copy of this checklist.
Does the organization ensure that applicable legal requirements and other requirements to which the organization subscribes are taken into account in establishing, implementing and maintaining its OH&S management system?
Does the organization keep legal and other requirements up-to-date?
See OBS relating to 4.3.1i Application of regs via risk assessment process!
7.1.Legislation Register SP3.3.2, see objective evidence on the next page of this audit
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Does the organization communicate relevant information on legal and other requirements to persons working under the control of the organization, and other relevant interested parties?
Evidence of the last legislative review evidenced above- dated 20.09.12
Ensure that sampling approach considers risk levels presented by activities and criticality of activities. Attach appropriate levels of objective evidence to your hard copy of this checklist.
Description of Work: THE REMOVAL AND MAKING GOOD OF THREE EXISTING PLANT ROOMS AND THE COOLING TOWER ON THE ROOFS OF A45/A47 OFFICES. THE EXISTING FLAT ROOF AREA IS BE RECOVERED WITH A LIQUID PLASTICS SYSTEM
4.3.3 OHSM 433 Objectives and programme
Has the organization established, implemented and maintained documented OH&S objectives, at relevant functions and levels within the organization?
Objectives currently recorded in the OHSAS manual
Objective Target and measure Responsibility
A reduction in reportable incidents per year, with the aim to be at least within the Construction LFS rate of 110.
Target is to be within the 2011, LFS rate. The measure is taken on an annual basis but will be logged monthly.
ALL TClarke North West Ltd OPERATIVES
SR to log and report details.
An increase in all NEAR MISS AND / OR YOU SEE YOU SAY REPORTS.
2011 showed 20 reports were forwarded.
TARGET 50 ALL TClarke North West Ltd OPERATIVES
A 10% increase in the amount of safety inspections that are carried out.
2011 figure 101. All TClarke North West Ltd Engineers.
Yes OBS
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Has the organization established, implemented and maintained a programme(s) for achieving its objectives based on the following minimum criteria;
Designation of responsibility and authority for achieving objectives at relevant functions and levels of the organization?
The means and time-frame by which the objectives are to be achieved?
Are programmes reviewed at regular and planned intervals?
Are programmes adjusted as necessary, to ensure that the objectives
2012 target 111. SR to log the stats. Numbers to be revealed monthly at H,S & E Meeting with Directors and Site Managers.
A 10% increase in the amount of Subcontractor Feedback Forms that are carried out.
2011 figure 145.
2012 target 160
All TClarke North West Ltd Engineers.
SR to log the stats. Numbers to be revealed monthly at H,S & E Meeting with Directors and Site Managers
TClarke NW drives improvement activity (programmes for achieving objectives) through monthly management meetings. See objective evidence provided below.
OHSAS manual, see objectives above and monthly management meetings
OHSAS manual, see objectives above and monthly management meetings
Monthly
OBS Safety inspections target surpassed, suggest target level is re adjusted
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Programme evidence = HEALTH, SAFETY & ENVIRONMENTAL REVIEW MEETING11th October 2012,10:00AM TClarke North West Ltd, Accrington Head Office, Conference Room
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Top management shall demonstrate its commitment to OH&S management.
Does the management team ensure the availability of resources essential to establish, implement, maintain and improve the OH&S management system?
Define roles, allocating responsibilities and accountabilities, and delegate authority to facilitate effective OH&S management?
Roles, responsibilities, accountabilities, and authorities documented and communicated?
Member(s) of top management with specific responsibility for OH&S, irrespective of other responsibilities and with defined roles and authority for:
a) Ensuring that the OH&S
Yes, IT resources, training budget, PPE in support of controls, management representative and consultancy support for the management system provided. Management Representative role often stretched partly through lack of direct admin support/volume of work. System essentials appear well supported by the MD.
OHSAS procedures specify, some improvement required to the RA procedures
OHSAS manual specifies key responsibilities
H&S Advisor – see org chart below
Yes
Full OHSAS Internal Audit Page 10 of 26Issue 1Dated:
Ensure that sampling approach considers risk levels presented by activities and criticality of activities. Attach appropriate levels of objective evidence to your hard copy of this checklist.management system is established,implemented and maintained in accordance with this OHSASStandard?
b) Ensuring that reports on the performance of the OH&S management system are presented to top management for review and used as a basis for improvement of the OH&S management system?
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Ensure that sampling approach considers risk levels presented by activities and criticality of activities. Attach appropriate levels of objective evidence to your hard copy of this checklist.4.4.2 OHSM 442 Competence, training and awareness
The organization identifies training needs associated with its OH&S risks and its OH&S management system and provides training or takes other action to meet OH&S needs?
Evaluates the effectiveness of the training or action taken, and retain associated records.
Evidence of training identification taken from the last health and safety review meeting dated 11th October 2012. Notes relate to CPCS and CSCS/ECS tests booked. Text evidenced is an extract taken from the most recent set of minutes.
Emergency preparedness procedure section 3.0 Training sample
Training reviews and competence levels relating to emergency preparedness are completed by the management team and documented our training records.
Open this link below to access our training records.
Indusys 2008.appref-ms
Yes
4.4.3 OHSM Communication, participation and YesFull OHSAS Internal Audit Page 13 of 26Issue 1Dated:
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With regard to its OH&S hazards and OH&S management system has the organization established, implemented and maintained a procedure(s) for:
a) Internal communication among the various levels and functions of the organization?
b) Communication with contractors and other visitors to the workplace?
c) Receiving, documenting and responding to relevant communications from external interested parties.
Ensure that sampling approach considers risk levels presented by activities and criticality of activities. Attach appropriate levels of objective evidence to your hard copy of this checklist.investigation?
Representation on OH&S matters?
The actions undertaken by the TClarke Project Team and site operatives was adequate and very proactive to ensure as little disruption to the client as possible. Discussions have been held with Paul Cryer’s on dust control. We have highlighted that we feel the dust became airborne not from the grinding process but from sweeping the dust left on the slab.
Our subcontractor will revise all future method statements to reflect cleaning only to be performed using sealed vacuums not brushing.
The incident has been reported to a TClarke Director who has been kept up to date with the incident.
The incident will be discussed with all the TClarke Directors and site managers at the Monthly Health, Safety and Environmental Review Meetings.
4.4.4 OHSM 444 Documentationa) The OH&S policy and objectives in place - YES SEE 4.2
b) Description of the scope of the OH&S management system in place? YES The design and project management of electrical, instrumentation, mechanical and civil engineering contract work.
c) Description of the main elements of the OH&S management system and their interaction, and reference to related documents in place? YES
Yes
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d) Documents, including records, required by this OHSAS Standard, YES, evidenced throughout this and previous internal and third party ACS audits
e) Documents, including records, determined by the organization to be necessary to ensure the effective planning, operation and control of processes that relate to the management of its OH&S risks in place? YES, numerous references to HSE related documents and internal document formats.
4.4.5 OHSM 445 Control of documents Management system documentaton evidenced this internal audit controlled in line with the following
QUENSH Procedure QP01Title: Control of Data and DocumentsISSUE No 1Dated: 02.09.11Authorised by: Chris Holmes
Yes
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Ensure that sampling approach considers risk levels presented by activities and criticality of activities. Attach appropriate levels of objective evidence to your hard copy of this checklist.4.4.6 OHSM 446 Operational Control
For those operations and activities does the organization implementand maintain:
SAMPLE
a) Operational controls, as applicable to the organization and its activities; the organization integrating those operational controls into its overall OH&S management system?
Yes
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Controls evidenced relates to incident report reference No. 12.11.04.G8927
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4.4.7 OHSM 447 Emergency preparedness and response
The organization maintains procedure(s):
a) To identify the potential for emergency situations?
b) To respond to such emergency situations?
EP03 Issue 1 dated: 13.10.11 in place combined 14001 and 18001 procedure
OFI The emergency preparedness procedure is currently under review – health and safety advisor to finalise improvements then amend the procedure.
Yes OFI
4.5 OHSM 45 Checking4.5.1 Performance measurement and monitoring
Procedure(s) in place to monitor and measure OH&S performance on a corrective action and preventive action analysis.
QUENSH QP04,Title: Non-conforming, Corrective and preventive actionISSUE No 1, Dated: 02.09.11 Authorised by: Andy Smith.
Compliance report (Safety and environmental standard assessment) dated October 17th 2012 evidenced below for BAE Warton
NO NCR
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4.5.2 Evaluation of compliance
4.5.2.1 – 4.5.2.2 Consistent with its commitment to compliance a procedure(s) for periodically evaluating compliance with applicable legal and other requirements in place?
NCR: Assessment report does not cross reference applicable regulations under the scoped works
Ensure that sampling approach considers risk levels presented by activities and criticality of activities. Attach appropriate levels of objective evidence to your hard copy of this checklist.order to:
See incident report reference No. 12.11.04.G8927.INC evidenced below
Recommendations for Corrective Action relating to the
Discussions have been held with Paul Cryer’s on dust control. We have highlighted that we feel the dust became airborne not from the grinding process but from sweeping the dust left on the slab.Our subcontractor will revise all future method statements to reflect cleaning only to be performed using sealed vacuums not brushing. The incident has been reported to a TClarke Director who has been kept up to date with the incident.The incident will be discussed with all the TClarke Directors and site managers at the Monthly Health, Safety and Environmental Review Meetings.
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a) Determine underlying OH&S deficiencies and other factors that might be causing or contributing to the occurrence of incidents?
b) Identify the need for corrective action?
c) Identify opportunities for preventive action?
d) Identify opportunities for continual improvement?
e) Communicate the results of such investigations?
f) Investigations performed in a timely manner?
Corrective action or opportunities for preventive action shall be dealt with in accordance with the relevant parts of 4.5.3.2?
Tool box talk to be produced between the TClarke Project Engineer and the TClarke Health & Safety department about the failures that led to the incident, this will be relayed to the TClarke Project Engineers for future learning’s.
SP 3.5.8 Dated: 03.04.12 principles – section 4 of the procedure
Yes, see action logs open for previous issues raised (audits and routine entries)
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OFI Procedure SP 3.5.8 Dated: 03.04.12 Issue D would benefit from a review aligning with the revised OHSAS system including action log records.
4.5.4 OHSM 454 Control or records
Records sampled during this audit legible, identifiable and traceable?
The following sampled records evidenced during this internal audit and retained in the management system in line with OHSAS records retention requirements.
Internal audits schedule – see 4.5.5 Management reviews – see 4.6 Site inspection reports – see 4.5.2.1 Action log – see 4.5.3 Legislation register – see 4.3.2
Yes
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4.5.5 OHSM 455 Internal audit
Internal audits of the OH&S management system conducted at planned intervals?
OHSAS audit schedule evidenced below
Three management system audits for OHSAS 18001 completed to date. Three audits at indicated remain at open status.
Yes
4.6 OHSM 46 Management Review Management review records on file compliant with clause 4.6 requirements
Next OHSAS management review scheduled for 22.11.12
Yes
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NCR Summary
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NCR = Non compliance OBS = ObservationOFI = Opportunity for improvement
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