CASE STUDY

BACKGROUND TO MONTGOMERY SCOTT FABRICATIONS LIMITED

This Case Study is part of an audit of Montgomery Scott Fabrications Limited which seeking
registration to ISO45001. The company is already certified to ISO 9001. The company’s
senior management has realised that they are trailing their competitors who already have
this certification and therefore need to maintain commercial par with them.

The assessment audit (Stage 2 Audit) is being conducted by a team of two Auditors, one
acting as Lead Auditor (LA) and the other as Auditor (A) against the Standard ISO 45001.
The LA has provided a detailed audit plan which identifies the departments and areas to be
reviewed and showed that he was going to complete an interview with ‘Top Management’,
conduct a tour of the facility and review the organisation’s processes and associated risks
and hazards. The LA had determined at the document review stage (Stage 1 Audit) that this
audit trail would enable him to review a significant proportion of the Occupational Health and
Safety (OHS) system.

The company manufactures pressure vessels and chemical reactors, and provides all of the
associated auxiliary equipment as a general package.

The audit covered:

 The Drawing Office

 Machining

 Fabrication

 The Plating Shop

 Purchasing Office

 Stores

 Packaging and Dispatch area

The personnel involved are:

 Managing Director

 Works Manager

 QHSE Manager

 OHS Manager

 Chief Designer

 Designer

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 Purchasing Clerk

 Chief Inspector

 Plating Shop Supervisor

 Storeman

 Packaging & Dispatch Supervisor

INTERVIEW WITH TOP MANAGEMENT

The audit team arrived at Montgomery Scott’s premises at 09.25 and were met in the foyer
by the QHSE Manager, who led them to the Conference Room where an Opening Meeting
was to be held at 09.30. There, they were introduced to the Managing Director, and the
Works Manager.

During the Opening Meeting, it was explained to the auditors that QHSE Manager and the
Works Manager both shared responsibility between them for the new IMS system. Although
the QHSE Manager’s role is primarily to co-ordinate and monitor the health and safety
elements of the system, given the Works Managers engineering background the Works
Manager concentrated more on the quality elements of the system.

The management consultant who had developed the OHS element of the IMS had not been
asked to attend the audit as the Managing Director decided that this would show a sign of
weakness and that the staff were competent to answer all of the Auditors’ questions on their
own.

The Managing Director explained that building was constructed in the 1920s but had been
renovated in 1957. Montgomery Scott Engineering bought the site in 1991 and renovated it
again in 1998. Not much had been done to the place since then. The Managing Director
explained that the staff consisted of a mixture of qualified designers, engineers, machinists,
metal workers, welders, storemen and office staff. In total there are 76 on site staff. The
company does not employ any staff who work off site except the lorry driver and two van
drivers. Over 90% of the company’s products are supplied to customers both nationally and
internationally.

The premises are in the middle of a large industrial estate and have direct access to the sea.
The premises contain a fixed crane in the yard and several mobile cranes and hoists to
manage handling inside the workshop and for loading purposes onto vehicles and boats.

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Machinery consists of hydraulic presses, drills, milling machines and pressure testing
equipment. The site is surrounded by a four metre high fence with access through an
electronic gate operated from the reception area. Staff also have electronic devices to
operate this gate.

The company operates a large articulated lorry and two small vans which it uses for local
deliveries. Other deliveries involve subcontract hauliers or customer vehicles.

Lead Auditor: “Great; thank you for giving me that introduction to your site and company
activities. Now could you tell me who are the external interested parties with whom your
organisation impacts such as the Central Government Health and Safety Executive, worker
representative unions, and how you plan meeting all of their various needs and expectations
including statutory requirements”?

MD: “Good question, we really don’t have a list of all of the interested parties affected by us
or interested in our activities and we certainly don’t have a list of all of their various needs
and expectations. Should we have? Each of the management team here deals with various
outside organisations affecting their jobs but really unless there is a real problem none of the
rest of us knows what they do or what records they keep of these communications”.

Lead Auditor: “Well if you don’t know what others expect of you then it is difficult to know
whether you are being a responsible employer and neighbour and if you are complying with
their wishes expressed or otherwise and in particular statutory legislation. As the
Management Director you have a legal responsibility for the activities and actions of this site
and all of the employees. I note that the scope of your OHS system is very simply stated as
‘The manufacturing of pressure vessels and chemical reactors’. Could you explain what you
believe that actually means in relation to health and safety during manufacture and
operation?”

MD: “The Consultant did all that for us after a meeting with myself, the Works Manager and
the QHSE Manager. We weren’t involved after that. I remember he said something like ‘Just
another standard manufacturing company then, I’ve done plenty of those and I have plenty
of sample policies which we can pick from’

Lead Auditor: “How can you show that you and your fellow Directors, as the persons
ultimately responsible for the OHS system, are fully committed to OHS and how you lead
from the front? How do you ensure that all staff have bought into the idea of being safety
conscious for themselves and their work colleagues and how the site’s OHS performance is
continually improving?”

MD: “45001 certification is very important to our business and without it we run the risk of
losing out on some critical contracts. So I have to admit it is primarily a financial thing. We
have always had safety committees and briefing sessions for staff. We have a quarterly OHS
Team meeting which I think is chaired by the QHSE Manager. There’s three or four on the
team and they come up with new ideas all the time.

Lead Auditor: “How do you communicate your OHS Policy to staff and outsiders?”

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MD: “It’s on the wall at reception and we email or post copies to contractors working on site
and any outsiders who want it – but that has never happened yet”

At the end of the meeting, the Managing Director left the auditors with the QHSE Manager
and the Works Manager advising them that he was rather busy that day, but would be
available if he was needed. The audit team asked to have a conducted tour of the works.
This took about one hour after which they returned to the Conference Room. The Audit Plan
divided the roles of each Auditor to audit various departments and areas separately and to
meet up briefly at lunch and then to split up again in the afternoon before meeting to write up
the Audit Report prior to the closing meeting with the management team.

SITE TOUR

The tour of the premises was conducted by the Works Manager and the QHSE Manager and
took about one hour.

The Lead Auditor confirmed the neat and tidy state of the buildings and grounds but noted
following during the short tour:-

 fire extinguishers were standing on the floor with no secure arrangements for fixing
them to wall brackets or similar;

 there were several oil spills in the despatch area;

 there were no indication of maximum load limits on racking;

 the file in the Purchasing Office for keeping the maintenance records for the fire alarm
and fire extinguishers had not been updated in three years and no one knew where
these might now be held;

 there were no emergency exit signs in the office complex;

 the Environmental Policy had been signed by the QHSE Manager;

 the Plating Shop Supervisor did not know anything about 45001, but said he
understood the safety needs for working in this area: he had been working there for 24
years;

 there were no records of forklift servicing and no-one could remember the last
maintenance on it;

 there were no signs in the plating area to warn of fumes from the cleaning baths
(Chromic Acid) and hot dips;

 the fume extraction system in the welding shop was not working;

 no noise level survey had been carried out in the factory;

 there were four barrels of unidentified chemicals in the area outside the Plating Shop.
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The Auditors finished the site tour and went to the QHSE Manager’s office before going with
Works Manager to his office. The Audit Plan detailed that the Lead Auditor would look at
Risk Assessments and Compliance Obligations and evaluation of OHS Objectives, overall
performance evaluation and the other Auditor would cover Support and Operation. They
agreed to break for lunch in one hour’s time and continue in the afternoon until
approximately 15.30 when they would meet up to compile their Audit Report. The closing
meeting was planned for 16.30 in the Managing Director’s office.

RISK ASSESSMENT

Lead Auditor: “Can you explain how you carried out your initial assessment of the risks on
this site and how you calculated the potential impacts of these?”

QHSE Manager: “That was fairly easy. Here this is the site’s Register of hazards and risks. I
have a cousin who is a Management Consultant and she gave me a copy of one she had
done for a manufacturing company; so I tweaked it for here – not rocket science is it? My
cousin gave me a standard formula to calculate the risk scores and I used those. So for most
manufacturing companies the main aspects are handling, breathing, equipment
maintenance, maintenance of the premises and then provision of clean welfare facilities.

Lead Auditor: “I notice that you have not considered the company’s suppliers and
contractors’ OHS arrangements.”

QHSE Manager: “What the suppliers do isn’t our concern. This company is run on a tight
budget – cost is important I’m afraid and we buy from the most economical sources.”

COMPLIANCE OBLIGATIONS AND EVALUATION

Lead Auditor: “Can you explain how you carried out your initial assessment of the OHS
legislation applicable to this site and how you were complying with each piece of
legislation?”

QHSE Manager: “Again that was fairly easy – my cousin again. Here this is the site’s
Register of Legislation and Compliance Checks. I tweaked the version she gave but it’s
pretty much the same as she explained that the same legislation applies to all manufacturers
– not much work involved in this element of the project – two minutes to change the name at
the front and the dates in the footer”.

Lead Auditor: “But you have included some oil storage legislation in the register which is not
relevant, and I notice that the current version of the ‘Working at Heights Regulations’ is the
previous one – there is no indication of any updates. I note also that there is no mention in
this register of noise, fumes and asbestos regulations”.

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QHSE Manager: “That cousin of mine – she said I wouldn’t have to make any changes; so I
never really checked it to be honest”.

Lead Auditor: “Did the MD have any involvement in finalising this legal register?”

QHSE Manager: “Sorry, no he just left that to me and the Works Manager. The whole legal
thing scares him – he even panics if he gets a parking ticket”

OHS OBJECTIVES AND TARGETS

Lead Auditor: “OK moving on to your OHS objectives and targets. I suppose you have an
objectives and targets plan for this site?”

Susan: “Well, not really. We are pretty good from a safety point of view. We don’t have many
lost time objectives or targets – as you know, the MD just usually tells staff to keep up the
good work during his speech at the Annual Staff party”

PERFORMANCE EVALUATION

Lead Auditor: “Can you tell me what the management team on site here is doing to monitor,
measure, analyse and evaluate the OHS performance of the company?”

QHSE Manager: “Oh dear, well I suppose our financial people in the office do all this. Yes I
think the Directors’ annual financial report to the management review has a section on the
OHS performance of the company in so far as costs of absence go. I quickly scanned
through these the other day and if my memory serves me right I don’t believe there were any
big differences between the last year and the previous three years. The main thing our
Directors are interested in is profit so I doubt if they read too much of this section of the
report either as long as there are no significant changes year on year”.

Lead Auditor: “Can I ask you both about internal audits of your OHS system?”

QHSE Manager: “The Works Manager and I carry out at least one audit of the site every
month”.

Lead Auditor: “OK but can you explain why my colleague and I noted about a dozen issues
during our site audit which could have potential impacts if not addressed somewhat
promptly? You were with us, so you know what I am talking about”.

QHSE Manager: “Well I have to admit the staff have let me down on this occasion. Anyway
as you know audits are all about sampling and being lucky or unlucky on the day. I obviously
didn’t cover those areas at my last audit”.

Lead Auditor: “But some of those issues like oil on the ground and lack of maintenance
records go back years; surely we should have picked those up before?

QHSE Manager: “Well, we can sort it now if you make a note”.

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Lead Auditor: “I need to ask a few more questions on your management review process and
your improvement activities”.

QHSE Manager: “I’ll try but I’m probably not the best person to be talking to – you should be
talking to the boss. The OHS Team had a meeting last week which I chaired – I suppose it
was a management review, but the boss said he was too busy to attend. I issued all the
attendants, well all three of us to be exact, with an agenda and we talked for about twenty
minutes. He made a few notes and then we had lunch in the canteen. I haven’t done the
minutes yet. As for improvement, do we need to improve do you think? We have never had
any major injuries recently and the boss thinks this is a well-run site”.

SUPPORT

The Auditor interviewed the Works Manager in his office.

A: “I will be asking you about how the company manages two areas of its business – support
for and operation of the OHS system. You have been one of the persons who has had most
input into setting up the OHS system for the company. Are there any other staff involved with
you now that the system has been established?”

Works Manager: “We have an OHS Team which consists of the QHSE Manager as the
Team Leader, myself and the Plating Shop Supervisor and the Stores Supervisor. We meet
on the last Friday of every third month and discuss any audit findings for that period. To be
honest he has never raised anything, so we assumed that we a squeaky clean”.

A: “Has any of your OHS team ever received any health and safety training?”

Works Manager: “Don’t think so. The QHSE Manager’s cousin who is a Management
Consultant did a short session at our first OHS Team meeting six months ago and we all got
a nice certificate from him for that – there’s mine framed on the wall behind me”.

A: “What about the other staff, are they aware of the OHS system?”

Works Manager: “No, none of the other staff knows anything about the OHS. There’s a
notice board in the two canteens which I control but there has never been anything put up
regarding the health and safety or this audit”.

A: “Do you personally deal with communications with outside third parties in relation to OHS
matters?”

Works Manager: “Like who, the council, the HSE do you mean? Well me and QHSE
Manager, I suppose, would deal with all those sort of correspondences in and out of the
business. But to be honest I can’t remember ever getting any to do with anything safety-
related”.

A: “I have examined your OHS manuals and procedures and it all looks very professional.
Can you explain how you review and make changes to these if need be?”

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Works Manager: “What you have in front of you is the only copy we have. The QHSE
Manager’s cousin has it on her computer I assume as we don’t have it on our server here.
She would make the changes for us and print them off, but everything is still at Issue 1 and
there have been no changes made to date as far as I am aware”.

OPERATION

A: “As you we had a brief tour of the site with yourself and the QHSE Manager before lunch
and there were quite a few issues which we noted and which we will have to address as
soon as possible. So can you explain how you and the others on the site management team
plan the operation of the OHS?”

Works Manager: “I haven’t a clue what you mean?”

A: “An effective OHS system is planned. Staff are allocated duties, and everyone knows
what their role in the operation of the OHS system is and what is expected of them, when,
how etc. For example who knows when the fire drill and equipment maintenance would be
due?”

Works Manager: “Me; but there is nothing formal or planned or written down and if I was run
over by a delivery truck in the morning, the place would fall apart”.

A: “You are being very honest. One last topic looking at your risk register, I note that the
main issues would be fire and manual handling. Who manages these risks and what
emergency preparedness and response procedures have you in place?”

Works Manager: “At last something I can answer. We have a Site Emergency Plan which
was drawn up for us by QHSE Manager’s cousin and which details all of the precautions,
checks and responses needed in the case of an accident. I ensure that the plan is reviewed
annually”.

A: “But what about all the precautions and checks – our site audit highlighted many issues
where these obviously were not being done as required”.

Works Manager: “I thought the plan only kicked in if there was an emergency. I just review
it”.

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