Introduction to Auditing

Safety Groups – Advantage Program

Tom Welton

■ Objective

■ The Basics

– Principles of Auditing

■ Audit Process

– Preparation & Initiation

– Document Review – Evidence – Findings ■ Management – Management Review – Action Plan ■ Case Study

■ To provide you an introduction to the basic process of conducting an audit of your Health and Safety Management System.

■ Health and Safety Management System (HSMS)

– The documented process that fully incorporates effective risk management principles into a health and safety program.

■ The systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled

■ Workwell Audits

■ Compliance Audits (against legal requirements)

■ Combined Audits (for example, H&S and Environment)

■ Risk Audits/Risk Assessments

■ Workplace Inspections

■ Pre-start-up Inspections

■ Subject Specific – for example:

– RTW Self-Assessment

– Confined Space Audit/Assessment

– Emergency Preparedness & Response Audit

■ To provide Owner/Senior Management with objective information on which they can react to improve their health and safety activities

■ Conformity

– Conformity is the fulfillment of the audit criteria which includes requirements of an audit standard, the

workplace’s health and safety policies, practices, procedures and related documentation.

■ Nonconformity

– Nonconformity is the non-fulfillment of, or deviation from, the requirements. It is categorized as Major and Minor.

5 Steps to Managing Health & Safety

■

The 5 steps apply to

the Advantage

Program

requirements

■

The 5 steps apply to

each element of the

HSMS Review and

must be

documented/recorded

for each

■ Audit Scope

– Extent and boundaries of an audit

Note: The audit scope generally includes a description of the physical locations, organizational units, activities and processes, as well as the time period covered.

■ Audit Criteria

– Audit criteria are used as a reference against which audit evidence is measured. In the WSIB Advantage Program the criteria includes; the requirements documented in the HSMS Review Form and the firm’s health and safety

program, policies, procedures and related documents.

■ Audit Evidence

– Records, statements of fact or other information,

which are relevant to the audit criteria and verifiable. (minimum two different sources of evidence).

■ Audit Findings/Conclusions

– Results of the evaluation of the collected audit evidence against audit criteria.

Note: The audit findings can indicate either conformity or nonconformity with audit criteria.

Auditing relies on these principles to make it effective and reliable.

Key Concepts

What is Auditing

■ The systematic, independent and documented process for obtaining audit evidence and evaluating it objectively against established audit criteria

Why Audit

■ To provide Owner/Senior Management with information on which they can react to improve their health and safety activities

Key Concepts

Auditing Principles

■ Scope – extend and boundaries of an audit

■ Criteria – a set of established requirements the audit evidence is evaluated against. The criteria for Advantage firms is - HSMS Review Form and the firm’s H&S program, policies, procedures and other related documents.

■ Evidence – records, statements of fact or other information, which are relevant to the audit criteria and verifiable (minimum two sources of information)

Key Concepts

■ An audit is conducted in a systematic manner and requires preparation

■ Document Review collects information to help determine if the audit criteria are being met by the firm

Key Concepts

■ There are multiple sources of evidence: documents, records, interviews and observations

– Auditor(s) need sufficient information before it is considered evidence

– Recorded evidence is evaluated against established audit criteria to determine objective audit findings

– Finding of conformity or nonconformity (major or minor)

■ Nonconformities are situations where a requirement clearly has not been fulfilled with evidence based on objective facts

Key Concepts

■ The audit report can be recorded on the HSMS Review Form

■ Other styles of audit reports can be used, as long as they include all nonconformities found and relate it to the criteria requirements

■ Report any commendable HSMS findings

■ Management Review can be formal or informal

■ Owner/Senior Management must understand and agree to the

Key Concepts

■ All nonconformities are included and initiated in the action plan

■ Conformities can be included in the action plan for continual improvement

■ Resolving nonconformities and verifying they are resolved are done after audit activities

The Audit Process

■ Management assigns the qualified auditor(s)

■ Develop an audit plan which includes:

– Objectives, Scope, Criteria, Schedule

■ Resources:

– Time

– Audit support (team)

– Health and Safety Equipment (PPE)

– Floor Plan, Equipment List, Work room

– Audit working documents (audit notes/sketches/interview notes etc.)

■ Communicate the audit activity to appropriate workplace

parties

Documents and Records

■ A document may be a policy, a procedure, a work instruction, a form, or other written information, that generally gives direction.

■ A document is current, active and changeable.

■ A record is dated, historical, and unchangeable. (An obsolete document may become a record).

■ First step in Conducting the Audit

■ Establishes initial conformity to the audit criteria

■ Determines other types of evidence the auditor(s) will sample

Policy System Procedures Operating Procedures Work Instructions Level 2 Docs

5W’s & H of system Typically addresses each WSIB HSMS Requirement “Big Picture” (may be

organized by “processes”)

Document Review

Level 1 Docs

What? (some why?)

H&S Policy Statement

H&S Policy Manual (optional)

Level 3 Docs - more details of 5W’s & H Level 4 Docs detailed How Typically organized by department Task Specific Instructions

■ Auditor(s) look for evidence that demonstrates requirements have been met.

The sources of information gathered are grouped into these categories:

– Documents verify relevant, clear and complete procedures, work instructions, guidelines, etc., are readily accessible

– Records: verify appropriate records have been kept to demonstrate that requirements of procedures and the standard have been met

– Observations: verify activities, workplace conditions, controls are in place

– Interviews: verify health and safety system/program understanding.

■ If all available sources of information (minimum 2) are

consistent then the information may be considered evidence of conformity. Inconsistent information is evidence of

nonconformity.

■ Evidence is measured against the audit criteria to determine

conformity or nonconformity

Collecting and Verifying Information:

■ Review Documents and Records

– Note details of documents and records reviewed

■ Observations while at the facility and throughout the audit

– Note relevant observations that demonstrate conformity

and nonconformity

■ Interviews during the facility tour and throughout the audit

– Conduct interviews appropriate to the situation and the person

– Interview people from appropriate levels and functions

– Make notes of evidence of conformity and nonconformity

– Summarize the results of the interview with the person

Collecting and Verifying Information:

■ How much is enough?

– Sufficient to demonstrate a consistent pattern of

conformance

– One piece might be enough, for example:

• maybe only one incident occurred so there will be only

one investigation report

• observed one failure to use confined space procedure;

• only one work instruction

– Perhaps 10 to 50 pieces may be appropriate, for example:

Generating Audit Findings/Conclusions:

■ Evaluate all audit evidence against audit criteria

■ During the audit, evidence must be presented that the criteria are in place for conformity. If any requirement is not met, a nonconformity is noted.

■ Audit findings/conclusions indicate conformity or nonconformity to criteria

Note: Any corrective actions to a nonconformity does not change the audit finding/conclusion.

Conformity

■ Conformity is the fulfillment of the audit criteria which includes requirements of an audit standard, the

workplace’s health and safety policies, practices, procedures and related documentation.

Nonconformity

■ Nonconformity is the non-fulfillment of, or deviation from, the requirements. It is categorized as Major and Minor.

MAJOR nonconformities:

■ the issue will continue to occur because of how the HSMS and health and safety program are structured

■ there is unacceptable risk to a worker’s health or safety

■ there are serious legal implications, or

■ there is an accumulation of related minor nonconformities.

MINOR nonconformities:

■ the HSMS and the health and safety program structures are valid, but there was minor deviation (e.g. human error)

■ there is no unacceptable risk to the worker

■ there are no significant legal implications, and

■

■ The report must reference the requirement (i.e. A.2), and the evidence that supports the findings/conclusions of conformity and nonconformity

■ Indicate any situations encountered that may decrease the

reliability of the audit conclusion

■ Diverging opinions about findings and conclusions should be

discussed, resolved if possible, and recorded if not resolved

■ The report must include the date(s) of the audit, report date, auditor(s) name

■ Auditor(s) prepare to present or discuss the audit with the Owner/Senior Management

■ Owner/Senior Management reviews the audit report

■ Ensure the Owner/Senior Management agrees with and understands the audit conclusions

■ A record of the Owner/Senior Management review

■ Establish a timeframe for the employer’s continual improvement plan

As a result of the audit findings/conclusions:

■ An action plan is developed for all nonconformities

■ The action plan outlines how nonconformities will be corrected, responsibilities assigned and timelines established.

■ The action plan is developed or reviewed, approved,

resourced and initiated by the Owner/Senior

Management.

■ The employer’s auditor(s) may conduct follow-ups to ensure the element is progressing to conformity

■ An action plan can also be used for continual improvement

■ When a criteria requirement is met, but may deteriorate into a nonconformity, the audit may indicate an opportunity to improve.

Continual Improvement

■ The process of enhancing the HSMS to achieve ongoing improvement in overall health and safety performance.

■ Improved performance on its own IS NOT continual improvement, it is an outcome – you must improve the way you manage.

Year-end Report Checklist:

*All Advantage firms submit the following documentation attached to the Checklist;

1 Written Standard 20%

2 Internal Auditor training record 20%

3 Completed an approved HSMS Review (internal audit) w/Senior Management sign-off

acknowledging their involvement 20%

4 Written Continual Improvement plan addressing HSMS Review w/Senior Management

sign-off acknowledging their involvement 20%

Case Study