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HSE Procedures


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HSE Internal Audit Procedure

1.0 Purpose

The purpose of this procedure is to describe how internal HSE audits are managed, conducted and

2.0 Scope of application

This procedure covers the methodology for HSE Internal Audit applicable to all SUCO operations
at Cairo and the fields.

3.0 Responsibilities

Cairo HSE is responsible for producing an internal audit schedule for the Fields and Cairo areas
based on the HSE importance of the area involved. The schedule specifies quarterly audits
sufficient to cover the whole areas operations and activities within a yearly programme. Scopes for
each audit are defined in an individual audit timetable.

For each audit Field/Cairo HSE specify the scope based on the requirements of ISO 14001/OHSAS
18001, findings from previous audits, any organisational changes and the commitment to continual

Lead Auditor and auditors are also appointed for each audit. At this time the dates for the audit are
fixed and a unique audit identification number assigned by Cairo HSE.

The schedule and audit scopes are updated annually and approved at the Management Review
Meeting in November.

The Lead Auditor arranges logistics to ensure that the audit can go ahead.

The Lead Auditor prepares any checklists and arranges any forms or paperwork necessary to carry
out the audit.

The Lead Auditor conducts the audit and manages any auditors in the team.

The Lead Auditor completes the written report of the audit and returns this to the Field or Cairo
Division Manager. A copy is sent to the HSE General Manager who collates all findings in an audit

The Field or Division Manager proposes any corrective action plans and timescales and returns the
completed audit report to Field and Cairo HSE.

Field Managers and Cairo HSE prepare a status report on their audits and corrective actions every
two months for the HSE Committee Meeting.

Cairo HSE produces an analysis report of audit findings for discussion at the Management Review

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Cairo HSE maintains a list of approved auditors which is copied to the Fields.

The HSE General Manager in co-operation with the Administration General Manager arranges
provision of appropriate training courses for auditors.

Field/Cairo HSE is responsible for maintaining audit files to demonstrate that their corrective
actions are completed and audit non-conformities closed out.

4.0 Procedure

4.1 Audit Scheduling

Once a year, in October, the Cairo HSE reviews the HSE system to examine if any changes have
occurred in Legislation, organisation, activities or products that would influence the required audit
schedule. The Fields are advised about the changes in priority.

HSE also examines the significant risks and aspects and ensures that schedules and scopes are
constructed that balance the importance, the findings from previous audits, the logistics and the
available resources to carry out the audit.

The audit schedule includes sufficient scope to demonstrate that the system conforms to ISO 14001
and OHSAS 18001, whilst focusing more on performance issues.

Each audit is allocated a unique identification number.

Field Manager and HSE, or Cairo HSE for Cairo audits, assign a Lead Auditor and team for the

Once a year a comprehensive audit is held in each Field and Cairo, as part of confirmation of legal
compliance and conformance with ISO 14001 and OHSAS 18001. This audit is carried out by
auditors outside of the location.

All audit schedules are approved at the Management Review Meeting.

With the approval of the Managing Directors, the HSE General Manager may call an unscheduled
audit at any time if there is a need to examine HSE performance in any area.

4.2 Audit Preparation

Having prepared the schedule for the overall audit system, the scope for each individual audit is

Cairo HSE arranges a scope for each audit and discusses with the nominated Lead Auditor the
scope or any particular issues to be covered. In addition, the Lead Auditor confirms any NCN's that
need to be verified from previous audits.

The Lead Auditor then prepares an audit plan for conducting the audit and obtains any checklists or
documents needed. Then he makes contact with the auditees to discuss the scope and arrange in
advance who is likely to be needed for interview and potential documents and records to be

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4.3 Audit Conduct

On arrival at the audit location the Lead Auditor makes contact with the appropriate persons and
establishes a base office/room for the audit.

Then the Lead auditor carries out a short discussion of the programme with the auditee to establish
if the timetable needs to be amended. Where a team is carrying out the audit then the duties of each
auditor are allocated.

The auditors then carry out the audit involving interviews and observations and using the scope and
any checklists/forms necessary. Information is verified by examining documents and records

Each Field audit must include a visit to operational areas to examine performance objectively.

The Auditors prepare records or logs of their findings indicating the areas/items covered, records
examined and persons interviewed. These records must include these items even where no non-
conformities are identified, to demonstrate that good performance is recognised and that the audit
scope was adhered to. These notes are retained in the audit file.

Where any Non-conformities are identified these should be given a Reference Number and recorded
for discussion with the relevant Area Manager.

The Non-conformity record should collate evidence and support the decision that the system or
practice is non-conforming.

Categories of Non-conformities to be used are:

Category 1

A complete system breakdown or absence of a key element, or an accumulation of sufficient

Category 2 items.

Category 2

An isolated lapse or breakdown in performance of an element of the system.

The Lead Auditor must ensure that all forms used can be identified with the audit by using the audit
identification number, and all Non-conformities are given a unique identifier for follow-up.

Having identified any non-conformity, the Lead Auditor must agree the corrective action and
proposed completion dates with the Manager and include these in the non-conformity record.

At the end of the audit he Lead Auditor prepares an Audit Report covering findings and non-
conformity records.

4.4 Audit Reporting

To close the audit a short closing meeting is held with the relevant Manager to summarise the audit

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The original of any non-conformity record, along with all supporting notes and documents, is
retained by the relevant Field/Cairo HSE.

A draft copy of the audit report is sent by the Lead Auditor to Managers of the areas being audited
for identification of the proposed corrective actions and timescales. A copy of the draft report is
also sent to Cairo HSE.

Managers who have actions are required to respond to the report with the proposed actions and
timetable within one week of the audit.

Non-conformities are entered into the audit database by the HSE or follow-up co-ordinator.

When the proposed actions are received from the managers then the final report is issued by the
Lead Auditor.

The Final audit report contains the findings, the Non-conformity Notes and the summary of non-
conformities extracted from the database.

4.5 Corrective and Preventive Action and Follow-up

Corrective actions and timescales are proposed by the relevant Manager and agreed by HSE.

Cairo HSE also examines each audits findings to ensure that valid items are recorded and that
suggested corrective actions are appropriate to the nature and scale of the problem encountered.

Every two months Field and Department Managers update the status of audits and corrective
actions at the HSE Committee Meeting.

4.6 Analysis and Reporting of Findings and Audit Results

In addition to reporting bi-monthly the results of audits it is also necessary to examine underlying
trends and issues that may affect the system and performance.

Once a year, for the Management Review, the HSE General Manager prepares an analysis summary
for the Management Review Meeting describing key findings. This information is used to assess
the effectiveness of the audit system, develop future audit schedules and confirm that the
commitment to continual improvement is being implemented.

4.7 Verification of Corrective Actions

It is also necessary to verify that the corrective actions have been completed and that the solutions
proposed have been effective in resolving the non-conformity.

Verification of previous audit corrective actions is included in the scope of each audit. The Auditor
must examine the objective evidence that the actions have been done. If they are acceptable then
the audit non-conformity sheet can be signed off.

If some audit actions are not completed to plan then it is necessary to raise the matter in importance.

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For a single Non-conformity not meeting the plan where there are good reasons then the matter
must be discussed with the auditee and a new action plan agreed. Otherwise it should be re-raised
at Category 1 in a new NCN report.

If a substantial number are not completed then all the unresolved actions are collated into one Non-
conformity at Category 1 against ISO 14001/OHSAS 18001 Clause 4.5.2, Non-conformity,
Corrective and Preventive Action.

The new action plan on the form should include both correcting the original defects and a further
plan to correct the failure in the corrective action system. However, auditees have to present
significant documented evidence to demonstrate that the corrective action system has been
adequately followed.

5.0 Required Records

The Field and Cairo HSE hold a record file of each audit including all documents and reports
prepared during the audit. This remains open until all Corrective Actions have been satisfactorily

Records of audits and corrective actions are maintained by HSE on a database.

The HSE General Manager retains all summary and analysis reports.

A file of correspondence will be held centrally.

Staff who have been audited must also keep their own records of audit and any follow-up corrective

All audits done are also recorded against the auditors name as demonstration of audit competence.

6.0 Auditor Competence

Auditors are declared competent on the basis of attending a relevant internal auditing training
course. Then they should observe for one audit and audit under supervision for a further audit.
Alternatively auditors may be declared competent by observation of their performance during
training audits. Responding to third party audits also contributes to development of auditor

Lead Auditors are declared competent on the basis of at least one audit that they lead under
supervision of an Approved Lead Auditor.

To remain competent an auditor must carry out a minimum of one audit per year.

Once a year an additional day of update training is also required.

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Example Audit Programme

Time Activity Notes/Items to Check

08.00-10.00 Production Manager

Verify previous audit NCN's

hazards, risk assessments, environmental aspect identifications,

controls & monitoring. Handling & reporting of accidents and

Operating procedures

Emergency response and communication

HSE Policy, objectives, management reviews, legal requirements

10.00-12.00 Chemical Labs

Verify previous audit NCN's

Monitoring/measurements, analyses plans, calibration,

hazards/risks, aspects/impacts, chemicals storage and disposal,
MSDS, procedures.

Records - effluent water quality, potable water, etc.

Waste Management

12.00-13.00 Break
13.00-14.00 Administration

Verify previous audit NCN's

Training Needs
Training Records
Licenses and Permits

14.00-15.30 Site Visit Process/Waste Water/Tank Farm/Winning

Pump/Methanol Handling
15.30-17.15 Production Dept.

Work Permits
Planned General Inspections
Internal Audits
Document Control

17.15-17.45 Auditors alone to prepare audit findings

17.45-18.15 Closing Meeting and presentation of Findings

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Audit No: Example HSE Audit Report Date:

Department: Procedure: Standard: Focus Area:


Scope of Audit: Previous NCN's Raised and Current Status:


Number of NCN Cat 1: Number of NCN Cat 2:

Other Results:

Positive Points: Observations/Improvement Suggestions:

Auditor 1: Lead Auditor :

Auditor 2: Signature Date

Auditor 3:

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Audit No: EXAMPLE NON- Date:

Standard/Procedure: Location: NCN Number:

Clause: Department: Category:


Lead Auditor: Accepted by (Auditee):

AUDITEE RESPONSE (corrective / preventive actions proposed):

What are the Causes?

What are the Proposed Actions to eliminate the Deficiency?

Reference Action Responsibility Completion Date

Signature: Date:

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Example Audit Database and Findings Report

Category Process/
Audit Description and Investigation
Audit No. NCN No. of Area/ Standard Clause Auditor Action No. Corrective Responsibility Deadline
Date Consequence of Causes
Finding Department Action

OHSAS requires that the

organisation "shall establish
and maintain" emergency
plans. The Emergency Plan
states this should be reviewed Changes in Update and
annually. The HSE OHSAS staffing has Reissue the 14/12/200
20/09/2005 2005-02 2005-10 Document Control Procedure Minor HSE 4.4.7 P.Jarvis A2005-16 HSE
18001 allowed this Emergency 5
(Caireo HSE-P-01) states this item to slip Plan
should be a maximum of 2
years. The current versiuon
was issued in September
Determine and
Publish an
system for 14/12/200
A2005-17 HSE
timely updates 5
of critical
OHSAS requires that the
organisation establish and
maintain plans and The plans for
procedures to cover disabled
situations for "preventing and people have
Prepare a
mitigating the likely illness been
briefing Paper
and injury that may be OHSAS developed but 20/10/200
20/09/2005 2005-02 2005-11 Minor HSE 4.4.7 P.Jarvis A2005-18 with the range HSE
associated with..." emergency 18001 are not 5
of available
situations. SUCO is aware of documented
the need for special within the
arrangements to be made for emergency
disabled employees working plan.
in the office, but has taken no
action yet.

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