Professional Documents
Culture Documents
PSM 10 - Audits & Observations - Level 2 Document
PSM 10 - Audits & Observations - Level 2 Document
Page 1 of 34
Revision: 02 Revision Date: October 2016
Authorizations:
Change Record:
All changes have been made Bold, Italic and Highlighted in Grey
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 2 of 34
Revision: 02 Revision Date: October 2016
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 3 of 34
Revision: 02 Revision Date: October 2016
SECTION-2 BASIS
2.1 Purpose
The purpose of this document is to discuss importance of effective auditing in site safety
management and provide guidelines for conducting and evaluating safety audits.
EPCL believes that audits are important tools in the establishment, measurement,
Maintenance and continuous improvement of process safety performance. Audits compare
Performance vs. established standards and evaluate effectiveness of systems in
accomplishing their intended purpose. Proper auditing provides a process that nourishes
and reinforces correct systems, behavior and work practices while identifying opportunities
for improvement.
2.2 Summary
Auditing is an important aspect of safety management. Used properly and tactfully, audits
bring various good results, e.g.
Maintain standards by ensuring that everyone follows the rules and procedures.
Highlights areas where rules and procedures are insufficient.
Measures the effect of safety training and reveals weaknesses.
Motivates supervisors/ workers by giving results of their safety efforts.
A documented audit program should be in place which also provides guidelines for
conducting and evaluating results of safety audits by line managers and safety personnel.
Necessary training should be provided to all relevant personnel on auditing techniques.
Audit program/ results should be stewarded by line managers/ MHSE. The audits should be
used to determine necessary changes in management of safety. This procedure covers the
requirements, guidelines on how to conduct audits, compile report and steward
recommendations for following types of audits: 1st Party PSM Audits (Internal Audit); 2nd
Party PSM Audits; 3rd Party Audit (External PSM Audits); Hazardous Substances Survey; Safety
Critical System Audit.
The intent is to comply with the requirements of OSHA regulation 29 CFR 1910.119 and EPA
regulation 40 CFR Part 68.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 4 of 34
Revision: 02 Revision Date: October 2016
3.1 Audit
Area Audit:
The auditor or audit team focuses on the condition of a geographic area within the site. The
strength of area audits is that all areas of the site can be covered in one to three months.
Focused Audits:
A focused audit concentrates on a single aspect of a HSE management system e.g. single
element of PSM program. The bulk of the audit period is devoted to this focused subject.
e.g. audits of LOTO, confined space, work permits etc.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 5 of 34
Revision: 02 Revision Date: October 2016
from an independent viewpoint, which can help in identifying area of improvement that may
be overlooked during internal audits.
3.7 Hazard
An inherent property or characteristic of a material, system or process, that has the potential
for causing serious injury to people and/or property or environmental damage.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 6 of 34
Revision: 02 Revision Date: October 2016
minimum, preferred) and the consequences of deviation (i.e., above maximum condition or
below minimum condition).
3.15 Recommendations
Proposed modifications to equipment, facilities, operating procedures, engineering controls,
or administrative controls deemed necessary by a process hazards analysis study team or
audit team to reduce risk and permit safe operation.
3.16 Risk
The product of the expected frequency (events/unit time) and the consequences
(effects/event) of a single hazardous event or group of hazardous events. Typically it is used
as a measure of potential economic loss or human injury in terms of the probability of the
loss or injury occurring and the magnitude of the loss or injury if it occurs.
3.17 Site
The entire area within a geographical boundary, which houses one or more facilities, under
the jurisdiction of a common management structure.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 7 of 34
Revision: 02 Revision Date: October 2016
3.18 Standard
A set of either mandatory requirements or optional guidelines based upon corporate policy,
Government regulations, or consensus industry experience / practice.
3.19 Abbreviations
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 8 of 34
Revision: 02 Revision Date: October 2016
Safety auditing involves sampling the site’s safety program as a whole; it is not an in-depth
inspection of every aspect of the program. The safety management auditor should be
looking at the broad spectrum of safety programs to see if they are effective, if they are
being followed, and, ultimately, if they are getting results. Part of a safety audit is what is
usually called a safety inspection but with the major emphasis on observing people working
at their normal jobs; particular attention is paid every now and then to special situations.
Increase of safety awareness is the most important result of regular auditing since unsafe
actions result from a lack of safety awareness. A procedure cannot be provided to cover all
the actions of workers; therefore, we must rely on increasing their safety awareness which
would result in reducing the unsafe acts.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 9 of 34
Revision: 02 Revision Date: October 2016
When conducting audits, managers must do more than simply observe employees,
equipment, and the work environment. A good safety management auditor talks safety with
employees during the audit. These conversations can help the auditor answer questions such
as:
When audit results reveal gaps that require the authorization of other area resources, these
resources must be requested without delay. Simply requesting the resources to solve a
problem, however, does not relieve the manager of responsibility for operating a safe
workplace. If necessary, equipment must be shut down or the area roped off or barricaded
until the problem is actually resolved.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 10 of 34
Revision: 02 Revision Date: October 2016
made during the day and his impressions of the site. A formal audit report shall be
submitted to HSE department via online MSA application. Focus of the audit should be to
establish a safety contact with down the line employees. Additionally, all observations made
should be concurred with the respective interface before filing a formal MSA report.
5.3 Quality
A Manager should ensure that the audits conducted in his area are:
1. Effective
2. Of a consistent standard
To ensure the quality they should frequently match the results with his observations. This
comparison will show the Manager whether the line supervisors need further training in
conducting audits and what else you need to do to ensure a common standard of auditing
throughout the department or facility.
5.4 Frequency
1. VP Manufacturing and GM Operations should audit at least 30 minutes on once a month
of assigned areas as per MSA schedule issued by HSE.
2. Departmental Managers, Unit Manager/ Section Heads should also audit their areas for
at least 30 minutes twice a month of assigned areas as per MSA schedule issued by HSE.
3. Senior Engineer till E-2 (except Production Individuals) should also audit their areas for at
least 30 minutes twice a month of assigned areas as per MSA schedule issued by HSE.
4. All production Site Coordinator/ Shift In charge/ Shift Supervisors should audit their areas
weekly and formally record observations on online MSA application
5.5 Results
A site wide or area-wide auditing program results should be analyzed to observe trends in
safety performance.
To enable to see site wide or area-wide trends and problems, two basic conditions must be
met:
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 11 of 34
Revision: 02 Revision Date: October 2016
Each point on the graph is determined by the total number of audit defects recorded during
the month, divided by the number of man-hours spent auditing that month. For instance,
two people auditing for three hours is equivalent to one person auditing for six hours.
The site wide audit trend should be comparison of the area audits & the audits by Safety
Department in a given period. Different category can be plotted.
Such plotting helps to measure effectiveness at improving any particular aspect of safety
which can be decided is important site wide or in given areas. Breaking down the overall
audit results into categories can also show you where you need to focus your attention.
This sort of index works well in operations that are not labor intensive, like Process Plants,
where you might not see many workers when you audit. There, you will be looking for
indications of unsafe acts that occurred before you got there; for example, a forklift sitting
idle with its forks raised.
If the frequency of unsafe acts rises again, it may be symptomatic of an underlying problem
you need to tackle. A strategy for tackling problems could include:
1. Publicity.
2. Safety discussions.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 12 of 34
Revision: 02 Revision Date: October 2016
3. Close Monitoring.
4. New procedures.
You can use any or all of these methods. The Important point is that you cover all
employees.
After spotting any of these factors, you can take actions where appropriate (such as a
reviewing auditing technique or advice supervisors of the need for action (as in the case of
safety emphasis for an area with many audit defects).
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 13 of 34
Revision: 02 Revision Date: October 2016
6.1 Introduction
One-on-one safety contact audit is an essential feature of the Management audit program. It
is a formally scheduled audit conducted by auditors. The specific objective being that one-
on-one contact is established between supervisory level & employees to focus on safety.
These audits are to be conducted by all level of management employees from Plant VP
Manufacturing to Shift In charge.
Safety and housekeeping in your area reflect the standards you are willing to accept; they
will improve as soon as you communicate convincingly that you want them to improve. The
intent of this guide is to help you improve safety and housekeeping by establishing a
personal safety audit system.
6.2 Audit
You must get out into your area(s) of responsibility every week with one of your direct
subordinates to make a safety audit. You do not have to devote a lot of time to the audit,
and you do not have to conduct a complete tour of an area. If you have several locations
that you know are trouble spots, concentrate on them first. Sample one or more portions of
an area where you can audit employee work practices and conditions quickly and effectively.
Conduct an audit at least once a week, spending 30 minutes and make at least 03 contacts. It
is crucial that you do not try to combine a safety audit with other visits to the area. Your
safety audit to an area must be specifically designed to evaluate safety. Learn to take notes
of the things you see.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 14 of 34
Revision: 02 Revision Date: October 2016
Specifically, each time you audit an area, building, work site, room, or other facility, you must
ask yourself a question and make a decision: “Are all aspects of safety acceptable?”
Whenever the answer is “no,” you should record your reaction and comments about how the
facility deviates from your standards. Your standards will not be static; they will change with
time and as you develop more skill in auditing.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 15 of 34
Revision: 02 Revision Date: October 2016
In order for the contact to be productive, your subordinate must understand that:
1. You audited his area.
2. You are pleased (or displeased) with what you saw because of. . . . (Discuss your
observations.)
3. You expect him to react to your comments, and more importantly, to improve the quality
and effectiveness of his own audit system so that permanent improvements are made.
4. You will audit the area again in a specified number of days.
You and your subordinate must understand the implications of these points. If you expect
your subordinate to address certain situations, be sure he has the necessary authority to
obtain the resources to appropriately react to your comments.
6.5 Follow-up
Follow-up is the magic step for achieving results. You have now spent time auditing,
reacting, and communicating. If you fail to set up an effective reminder or tickler system to
enable you to follow up personally and demonstrate that you mean what you say; your
efforts may be wasted. Failure to follow up will give your subordinates the perception that
you do not care and those high standards of safety are not one of your important priorities
You must clearly communicate your assessment of the obtained results to your subordinates.
By doing this in an effective, timely manner, you will help them learn to manage safety more
effectively in their area of responsibility.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 16 of 34
Revision: 02 Revision Date: October 2016
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 17 of 34
Revision: 02 Revision Date: October 2016
Here are some specific questions you can ask about each category.
1. Are employees using the required protective equipment? Does it provide adequate
protection against employees’ exposure to harmful substances?
2. Are they using the equipment properly?
3. If not, why not? Is it inconvenient to get out or hampering?
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 18 of 34
Revision: 02 Revision Date: October 2016
8.2.4 Procedures
1. Are they adequate? Do they prevent all unnecessary risks?
2. Are they followed?
8.2.5 Orderliness
1. Is the workplace neat?
2. Are things put away properly?
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 19 of 34
Revision: 02 Revision Date: October 2016
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 20 of 34
Revision: 02 Revision Date: October 2016
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 21 of 34
Revision: 02 Revision Date: October 2016
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 22 of 34
Revision: 02 Revision Date: October 2016
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 23 of 34
Revision: 02 Revision Date: October 2016
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 24 of 34
Revision: 02 Revision Date: October 2016
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 25 of 34
Revision: 02 Revision Date: October 2016
13.3.4 Training
The team leader should brief the team on audit protocol and minimum requirements for the
audit. Moreover, Safety Section resources can be used for training purposes. Adequate
preparations must be done to ensure a high quality audit. Team members should receive
overview training using the Audit Checklists.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 26 of 34
Revision: 02 Revision Date: October 2016
5. The Safety Section will be responsible for follow up on all the recommendations and “Tracking”
them to closure in a timely manner. Actions / steps taken to address recommendations are also
to be documented.
6. “Highlights” of the audits and the overall “Plant Composite” score on each set of audits will be
presented to PSM Sub Committee and Manufacturing HSE.
7. Copies of audits and the documentation on the disposition of their recommendations should be
maintained for at least six (6) years in the Safety Section files per the requirements of 29 CFR
1910.119.
8. Manufacturing HSE is responsible for providing adequate and appropriate training of the audit
teams on the audit process and questions, both initially and on an ongoing basis. This should
include review of exactly what is to be done during each audit, in-depth discussion of the audit
questions and their intent, review of the scoring criteria, regular monitoring of audits, etc.
9. If an alternate approach acceptable to the team, is raised in the meeting, it should be added to
the report as an addendum.
13.4.1 Presentation
1. The audit team should present the findings and recommendations to the Manufacturing HSE.
2. If the recommendation is rejected, then a document prepared by the management, recording the
basis for rejection must be placed in the file.
13.5 Recommendations
The Safety Advisor would prepare an action plan on the audit recommendations with the
concurrence of Department Managers.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 27 of 34
Revision: 02 Revision Date: October 2016
Note: The audit report should be presented in Sub Committee PSM and/or Manufacturing
HSE. Protocol for audit report presentation, action plan, tracking and close out of
recommendations and waiver requirements as described above for internal audits will be
applicable.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 28 of 34
Revision: 02 Revision Date: October 2016
1. The area Unit Manager should ensure that audit of PSMs relevant to his area is
conducted thru line organization.
2. The audit frequency should be at least once a year.
3. Team must include personnel who are knowledgeable in the process and may include
members from site’s Sub-HSE committee (PSM).
4. The audit recommendations should be addressed within the assigned target date to
ensure safe operations and better score in site’s internal / external PSM audit.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 29 of 34
Revision: 02 Revision Date: October 2016
EPCL is committed to the safe operation of its facilities. This commitment requires that all
potential safety hazards are systematically identified and the risks from these hazards are
managed in such a way that the employees, the public, and the environment are protected.
16.1 Objective
The primary objective of the survey is a realistic appraisal of activities and conditions related
to handling and storage etc. of hazardous substances and pointing out areas for
improvement. Auditors should be carefully chosen with expertise to know what to look for
and to recognize deficiencies when they exist. The audit is conducted using a checklist
approved by Sub-HSE committee (Environment and Industrial Hygiene) and available as
Level-3 document.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 30 of 34
Revision: 02 Revision Date: October 2016
16.4.4 Training
1. Team members should receive overview training using the Guidelines and the Checklist.
2. The Hazardous Substances Survey leader should train the team using this guideline, checklist and
based on his experience in a previous Hazardous Substances Survey.
3. Adequate training of the survey team must be done to ensure a high quality audit. Training is
most effective when provided shortly before the beginning of the study.
4. Team training requirements typically include a team resource, or the leader, with in-depth
knowledge of the Hazardous Substances Survey methodology and experience in applying the
method.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 31 of 34
Revision: 02 Revision Date: October 2016
16.6 Recommendations
Recommendations are made to reduce an existing risk when it is at an unacceptably high
level. The following facts should be considered before giving a recommendation:
Clearly addressing a deficiency against a clause of the checklist.
All recommendations should be based on a good sample size.
Degree of risk.
Do ability.
1. When the team considers a non-compliance and concludes that a recommendation is
appropriate, the recommendation should be specific and doable.
2. In general, the team should not make recommendations to “study”, “consider” or “investigate” a
situation.
3. In documenting recommendations in the Hazardous Substances Report, each recommendation
should be listed against the relevant clause.
4. Recommendations from the survey should be categorized as given below. The category assigned
to a recommendation will be based on team’s judgment.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 32 of 34
Revision: 02 Revision Date: October 2016
16.6.1 Procedural
All the safe guards which can be achieved by providing an approved procedure, standing
order or instruction fall under this category.
16.6.6 Approval
Recommendations from a hazardous substances survey must be reviewed and approved by
the Manufacturing HSE. The action plan should be developed after getting concurrence from
all the relevant interfaces and stewarded in Manufacturing HSE.
Some of the reasons for rejecting a recommendation are as follows:
1. The analysis upon which the recommendation is based contains factual material errors.
2. An alternative measure would provide a sufficient level of protection.
3. The recommendation is not feasible.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 33 of 34
Revision: 02 Revision Date: October 2016
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed
Document # HSE / PSM / Level-II / 10 Date Prepared: December 2008
Page 34 of 34
Revision: 02 Revision Date: October 2016
2. Deficiencies shall be noted down and shall be used for reporting and must be tracked till
completion.
3. All Managers, Unit Managers and Section Heads will ensure that the deficiencies are
removed in a reasonable time and communicate the status of completion.
4. Record of safety critical system audit shall be kept for sufficient duration to analyze safety
critical system recurring deficiencies. Respective Operation Manager will keep such
records with him; audits can also be kept on HSE Portal.
Prepared By; Ammar Hussain Reviewed By: SMF/ FIQ/ RT Approved By: Jahangir Waheed