External Audit Compliance Report

Compliance Copy of External HSE Report – 22 nd & 23rd February, 2024
Third-Party External HSE Audit Compliance Report - PNCPL

Project, Part – C, Mangaldoi and Tezpur, Assam
Introduction:
This report presents the findings of a third-party external Health, Safety, and Environment (HSE) audit compliance
assessment conducted by Sustineri Advisory Services Pvt. Ltd. at PNCPL Project, Part C, located in Mangaldoi, Tezpur,
Assam. The audit focused on evaluating the project's adherence to internationally recognized standards:
● ISO 14001:2015: This standard outlines the requirements for an effective Environmental Management System
(EMS) that helps organizations improve their environmental performance and operate sustainably.
● ISO 45001:2018: This standard provides a framework for improving an organization's Occupational Health & Safety
(OH&S) Management System to prevent work-related injury and illness.
The primary objective of this audit was to assess PNCPL Project, Part C's compliance with the aforementioned standards
and identify any areas for improvement within their HSE management system. This report details the audit observations,
evaluates the project's conformance to the standards, and provides recommendations for corrective actions where
necessary.
By utilizing this information, PNCPL Project, Part C can strive to maintain a robust and effective HSE management system.
This translates to a safer and healthier work environment for employees, along with minimized environmental impact
from project activities
Safety Implementation is a continuous process

AUDIT OBSERVATIONS AND RECOMMENDATIONS

PART-1 GENERAL REQUIREMENT
Claus Ques Audit Audit Evidence Opportunities for Complia Fig. No. Rem
e No. tion Findings Improvement nce arks
Audit
No. (OFI)
Question (Conformant,
OFI, Minor
NC, Major NC)
4.1 1 Has the organization Conformant The organisation has

established, established and
documented, maintained H&S system
implemented and in accordance with the
maintained and corporate guidelines.
continually improved an Reporting is done to the
H&S management corporate for
system in accordance performance evaluation
with the requirements? and scope of further
improvement.
2 Has the organization OFI
determined how it will
The organisation
fulfil these
initiates and fulfils the
requirements?
requirement as per
corporate directives. It

also fulfils H&S issues
generated
due to local conditions.
3 Has the organization Confrant The organisation

determined defined and implemented the
documented the scope corporate defined scope
of its H&S for its H&S
management system?
management system.
Client(EIL) Safety
Scope is aligned with
safety management
system and
implemented to fulfil
the
tender requirement.

4 Has the organization Confrant
established an
The organisation has an
appropriate health and
established Health &
safety policy?
Safety Policy well-
defined by its Top
management
4.5 5 Has the organization Minor NC HIRA prepared for all HIRA may be
identified the health and considered for
routine activities related
safety
to work site for site
hazards arising from its specific risk
project scope and duly
past, existing or planned
before starting of
approved by client.
activities, products and work in
services, in order to
particular sections
determine
the health and safety

risks of significance?
6 Has the organization Minor NC HIRA may be

Identified applicable considered for
legal requirements and work site for site
other requirements to specific risk
which it subscribes? before starting of
work in particular
sections.

7 Has the organization OFI The organisation
identified priorities and implements the H&S
set appropriate health objectives and
and safety objectives
targets as per
and targets?
corporateguidelines and
directives, based on its
monthly performance
report and
other associated factors
8 Has the organization OFI The organisation has
established a structure established a policy and
and program(s) to structure to meet day to
implement the policy day targets. Plans and
and achieve objectives programs are mostly
and meet targets? based on trainings,
awareness and involving
staffs in various
functions programs, and
communicated
to Client(EIL).
9 Has the organization OFI The organisation has a MOM covering
facilitated planning, system of reviewing all the agendas
control, monitoring previous corrective should be
preventive and actions as outcome of prepared and
corrective actions, internal and external circulated
auditing and review audits. Detail reporting amongst the
activities to ensure both is done to Client (EIL) concerned.

that the policy is and Record should be
complied with and that maintained.
Principal Employer
the H&S management
(GAIL).
system remains
appropriate?
10 Is the organization OFI The corporate Site specific
capable of adapting to guidelines are followed; documented
changes in procedure for change in guideline should
circumstances? local issues and be prepared.
circumstances is MOC procedure
controlled may be
formulated.
by local management.
PART-2 HEALTH AND SAFETY POLICY

11 Is the health and safety Confrant The organisation has its
policy documented and Corporate Health &
authorized by top Safety Policy, properly
management? documented and
authorised by top
management, duly
signed by
Managing Director
12 Is the policy is Confrant The policy covers all its
appropriate to the
health and safety risks
nature and the scale of
and other requirements.
the organization’s
health and safety risks?

13 Does the policy include Confrant The policy covers the
a commitment to aspect of continual
continual improvement.
improvement?
14 Does the policy include Confrant Yes. The safety
a commitment to committee should
comply with applicable look after the
legislation and other compliance to
requirements to which applicable law.
the organization
subscribes?
15 Confrant Yes. Implemented Strengthening on
through corporate drive. legal aspects on
ground is required
to drive safety
16 Is the policy effectively Minor NC Yes, by means of The policy should
communicated in the display at office only. be translated in
organization and local language
employees are aware of and displayed at
their H&S obligations? all locations.
17 Is the policy made OFI It is only displayed at
available to all office
interested parties?
and circulated to client
and owner.
18 Is the policy Confrant The policy is reviewed
periodically reviewed

for suitability? periodically by
corporate safety leaders.
19 Is a procedure for the Confrant Yes
identification of
hazards and assessment
of risks established and
is the methodology
defined?
20 Do risk assessment Minor NC It covers all the routine Site hazard to be
procedures cover activities through JSA. captured. All
routine-non routine However, site risk is not leftover activities
activities; personnel addressed. Fatality to be covered in
having access to the could occur due to HIRA.
workplace (visitors, failure in mitigating the
subcontractors)? risk, associated with site
and those activities
not addressed.
21 Does the methodology Confrant Yes.
provide for the
classification of risks
and identification of
those that are to be
eliminated or
controlled?
22 Does the methodology Minor NC Yes, Methodology is A training need
provide input into the incorporated in HIRA analysis is to be
determination of the SOP. However, a prepared and

facility requirements, training need is not updated
identification of identified and carried accordingly.
training needs and out. Outcome may be
development of recorded in
operational controls? HIRA.
23 Do risk assessment Minor NC Refer 4.3.1(Q-20) Additionally,
results demonstrate that Vehicle/
all the activities and Transport,
facilities were covered Dormitory and
and risks were Worker’s Canteen
evaluated? risk may
be assessed.
24 Does the process link Minor NC Corporate wise done for OCPs should be
to operational control all routine construction customised
procedures? (See activities
covering local
4.4.6.)
and site specific
risk.
25 Are results of hazard OFI Yes, Limited to
identification and risk corporate scope
assessments considered
while setting health and
safety
objectives?
26 Is a procedure Minor NC No clear guideline for
established for legal register
identifying and

accessing legal
requirements?
27 Are requirements other Major NC All other requirements May consider
than legal requirements are met and maintained construction of
identified? by the concerned some bio toilets
departments. as per the
prescribed scale.
However, welfare for
the workers and staff
and requirement of the
basic
facilities e.g. Toilet,
Wash Room is not
provided.
28 Is the information OFI Information is kept up- Consolidation of
concerning applicable to date. However Legal legal
legislation and other related HR is requirements is
requirements kept up- maintained by the suggested.
to-date? concerned dept.
29 Is relevant information OFI Communication to all
on legal and other level is not observed.
requirements
is communicated to
employees and other
interested parties?
30 Are documented health Confrant H&S objectives for each
and safety objectives relevant function are

established for each established as per
relevant function? corporate guidelines.
31 Are the results of Minor NC HIRA is considered Not aligned to site
hazard identification while setting H&S
and risk objectives.
assessments are
considered while
setting health and
safety objectives? (See
4.3.1.)
32 Are H&S objectives Confrant Yes.
established and they
consistent with the
commitment to
continual
improvement?
33 Are programmes for Confrant Yes.
achieving health and
safety objectives are
established?
34 Are responsibilities, OFI Documentation is Monitoring of
means and timeframe inadequate. objective
for achieving achievement
objectives are should be evident
documented?
35 Are health and safety Major NC Time to time by Revision of

management corporate. Site safety management
programmes are dept. does not have any program should
reviewed at regular and idea. be done at regular
planned intervals? interval, at
management
meetings, to
verify the
implement status
and to decide
further course of
action.
36 Are health and safety Minor NC Not evidenced As Above.
management
programmes are
amended to address
changing
circumstances?
37 Are roles, Confrant Yes, as per corporate
responsibilities and directives.
authorities are defined
and documented?
38 Is a member of top OFI Yes, as per corporate
management appointed directives. RCM is
to ensure that the health responsible.
and safety management
system is
implemented?

39 Are health and safety Confrant Yes, as per corporate
performance reports directives, and to Client
presented to top (EIL) and to Principal
management for review
Employer (GAIL).
and as a basis of
improvement of the
H&S management
system?
40 Do those with Confrant Yes, as per corporate
management directives.
responsibility
demonstrate their
commitment to
continual improvement
of the health and safety
performance?
41 Are competence Confrant Yes, as per corporate
requirements are directives.
defined?
42 Are employees are building up competence Various training
aware of the in high hazard area and programs should
importance of the work be organised by
requirements of the in-
e.g. storage of material
H&S management
at open yard, welding house competent
system?
and gas cutting, metal trainers
cutting and grinding etc. andexternal
experts to
improve safety

performance of its
work force in
high hazard areas
and activities.
Strong emphasis
is given to hot
work, electrical
and
material handling.
43 Are employees are OFI Documented Consequence
aware of the H&S consequence management
consequences of their management system system should be
work activities, benefits evidenced. established with
of improved personal corporate
Principal contractor
performance, and approval.
(EIL) procedure
consequences of
followed.
departing from
procedures?
44 Are employees are Confrant Yes, as per corporate
aware of their roles and directives.
responsibilities in
achieving conformance
to the H&S
management system?
45 Do training procedures Minor NC No such procedure is Documented
take into account evident. Training procedure and
differing levels of schedule is prepared, detail training

responsibility, ability, mostly covering site records should be
literacy and risk? activities of the workers. maintained, for all
level of
employees and
contract
workers.
46 Are training needs are Minor NC Identification of training Training needs
identified and trainings needs not evidenced. for all level of
are provided to satisfy employees should
competence needs? be identified
according to its
competence.
47 Are training records are Confrant Training records are
maintained? maintained.
48 Is there employee OFI Though corporate Any change in
involvement in the guidelines are activity, may
development and established, employee’s affect H&S
review of policies and involvement could not scenario, should
procedures to manage be evidenced, other than be communicated
risks is documented? Tool Box talk. to employee
through trainings,
safety committee
meetings etc.
49 Is there employee OFI Not evidenced. Done at
involvement in the corporate level
development and

review of policies and
procedures to manage
risks is documented?
50 Is there a procedure to Confrant Yes, various meetings,
ensure that health and toolbox talk, celebration
safety information is of
communicated to and
safety week, Fire safety
from employees and
day etc.
other interested parties?
51 Are employees are OFI Representation workers Participation and
represented on health in safety management maintaining of
and safety matters, and system is done through document should
informed as to who is formation of be adequate.
their employee health
safety committee.
and safety
representative(s) and
management
appointee?
52 Are the core elements OFI Some document is
of the health and safety established as per
management system corporate standard
are documented? requirement and EIL
requirement.
53 Does the information OFI Need adequacy As above
provide direction to the
related documentation?

54 Is there a procedure for Confrant Yes, as per corporate
document control directives.
established?
55 Are documents are Confrant Yes, as per corporate
periodically reviewed,
directives and Client
revised as necessary
requirements.
and approved by
authorized personnel?
56 Are current versions Confrant Yes
available at all relevant
locations?
57 Are obsolete docs OFI Identification of All obsolete
protected against obsolete documents is documents to be
unintended use; inadequate
replaced by
retained ones
updated one,
identified?
stamped or
marked as
58 Are operations and OFI Identification of hazard All control
activities associated and risk assessment, measures from
with risks where covering all routine the outcome of
control measures need activities associated is HIRA should be
to be applied are done. However, all implemented.
identified? (Also see Control measures are
clause 4.3.1.) not
implemented.

59 Do operational control OFI Not adequate As above
requirements cover all
activities and facilities?
(See guidance to
operational control)
60 Do documented OFI Yes, SOP maintained
procedures exist where and approved by
their absence could client(EIL).
lead to deviations from
the policy and the
objectives?
61 Are operating criteria OFI Yes to some extent All SOPs should
stipulated in the be reviewed
procedures? according to
HIRA and other
factors.
62 Has the organization Confrant Yes, prepared as per
established, corporate and Client
implemented and policy & guideline
maintained a
procedure(s) to identify
potential emergency
situations and potential
accidents that can have
an impact(s) and how it
will respond to them?

63 Does the organization Minor NC Yes, a procedure Post Mock drill
respond to actual developed. necessary
emergency situations preventive and
and accidents, and corrective action
prevent or mitigate should be
associated adverse initiated.
risks?
64 Does the organization Minor NC Yes, as per corporate, All Response
periodically review main vendor and Team members
and, where necessary, statutory authority should be trained
revise its emergency directives. accordingly.
preparedness and
However, related
response procedures, in
training
particular, after the
occurrence of accidents records for the various
or emergency teams are not evidenced.
situations?
65 Does the organization Major NC Mock drill is not Refer clause
also periodically test scheduled. 4.4.7(Q-74)
such procedures where
practicable?
66 In developing its Yes, various conditions
procedures, has the are taken into account
organization considered e.g. Fire, explosion,
the nature of on-site natural calamities etc.
hazards, e.g., flammable
liquids, storage tanks
and compressed gases,

and measures to be taken
in the event of spillages
or accidental releases?
67 In developing its No, emergency like Safety dept. to
procedures, has the electric shock, toppling of identify situations
organization considered vehicle etc. are not which are relevant
the most likely type and considered. to work and site
scale of an emergency specific.
situation or accident?
68 In developing its First identification then
procedures, has the comes response to
organization considered situation.
the most appropriate
method(s) for
responding to an
accident or emergency
situation?
69 In developing its Internal communication
procedures, has the plan is visible, however,
organization considered external communication
internal and external could not be
communication plans?
seen
70 In developing its Minimization of
procedures, has the environmental damaged
organization considered is addressed in the EMP.
the action(s) required to
minimize environmental

damage?
71 In developing its Yes
procedures, has the
organization considered
the mitigation and
response action(s) to be
taken for different types
of accident or emergency
situation?
72 In developing its Performance observation Organisation
procedures, has the is done. However, should also
organization considered improvement evaluate its own
the need for a process for methodology is not performance.
post-accident evaluation evidenced.
to establish and
implement corrective
and preventive actions?
73 In developing its Organisation
procedures, has the should also
organization considered consider other
the periodic testing of Yes, conditions,
emergency response pertaining to
procedure(s)? present day
scenario.
74 In developing its Yes, A routine mock
procedures, has the drill may be
However, mock drill not
organization considered scheduled once in

the training of carried out. three month and
emergency response carried out as per
personnel? R-36 of BOCW
Assam Rules
-2007 and EIL
HSE Standard
Specification 6-82-
0001/3.1.8
75 In developing its Yes, evidenced in the
procedures, has the plan.
a list of key personnel
and aid agencies,
including contact details
(e.g. fire department,
spillage clean-up
services)?
76 In developing its Yes, displayed at
procedures, has the locations.
evacuation routes and
assembly points?
77 In developing its Yes.
procedures, has the
the potential for an
emergency situation(s)

or accident(s) at a nearby
facility (e.g. plant, road,
railway line)?
78 In developing its Mutual-aid with nearby
procedures, has the industry is not applicable
organization considered to this project.
the possibility of mutual
It is collective activity
assistance from
with
neighbouring
organizations? the Client (EIL) and
Principal Employer
(GAIL).
79 Has the organization Significant risk has been
established and identified. However,
implemented a periodic monitoring other
procedure to regularly than IA not observed.
monitor and measure the
key characteristics of its
operations that have a
significant risk?
80 Does the procedure Inspection checklist are
include documenting followed
information to monitor
performance, applicable
operational controls and
conformity with the
health and safety

objectives and targets?
81 Does the organization
ensure that calibrated or
verified monitoring and Yes
measurement equipment
is used and maintained?
82 Yes, records for IA,
Does the organization MRM,
retain associated MOM and calibration
records? records of equipment are
maintained
83 Has the organization Significant risk has been
established and identified. However,
implemented a periodic monitoring other
procedure to regularly than IA not observed.
monitor and measure the
key characteristics of its
operations that have a
significant risk?
84 When necessary to Not evidenced
ensure valid results, is
measuring equipment
calibrated or verified
with measurement
standards traceable to
international/national

measurement standards?
85 If no such standards Not evidenced
exist, is the basis used
for calibration recorded?
86 Has the organization Legal compliance is
established and verified during IA and
implemented a third party audit.
procedure to periodically
Inspection and Test
evaluate how well your
certificate of Lifting
organization complies
tackles
with legal requirements?
not evidenced.
87 Are there records of the HR related compliance is Up-to-date record
results of your maintained by the of legal
organization's legal corporate office, taking compliance status
compliance feedback from site office.
should be
evaluations? consolidated and
All other site related
maintained. It
compliance is maintained
should be made
by
available for any
Safety dept. inspection /audit.
88 Has the organization Has the organization

established and established and
implemented a implemented a procedure
procedure to periodically to periodically evaluate
evaluate how well your how well your
organization complies organization complies

with non-legal (other) with non-legal (other)
requirements? requirements?
89 Are there records of the Are there records of the
results of your results of your
organization's non-legal organization's non-legal
(other) compliance (other) compliance
evaluations? evaluations?
90 Is the responsibility and Is the responsibility and
authority for handling authority for handling
and investigating and investigating
accidents, incidents, accidents, incidents,
nonconformities; taking nonconformities; taking
action to mitigate their action to mitigate their
consequences; initiation consequences; initiation
of corrective and of corrective and
preventive actions preventive actions
established? established?
91 Are the causes of Are the causes of
nonconformities are nonconformities are
investigated and results investigated and results
documented? documented?
92 Are appropriate Are appropriate HIRA should be
corrective actions corrective actions updated
developed to eliminate developed to eliminate accordingly.
the causes of the causes of
nonconformities? nonconformities?

93 Are proposed corrective Are proposed corrective
and preventive actions and preventive actions
are reviewed through are reviewed through risk
risk assessment? assessment?
94
95 Record keeping is done

Are health and safety as per corporate and
records identified? client
requirements.
96 Do records show Yes, as per corporate and List of files and
effective operation of the client requirements. documents should
health and safety be documented
management system and and maintained.
conformance to Retention period
requirements?
is to be declared.
97 Are health and safety Though related records
records are readily are maintained, retention
retrievable and retention time is not mentioned.
times recorded?
98 Are audit programmes Quarterly in house audit
and procedures for is done. Third party audit
periodic system audits also
are established?
conducted twice a year.
99 Do internal audits Qualified auditor does the
determine whether or not audit, to meet the

the H&S system requirement of OHSAS.
conforms to planned
arrangements including
the requirements of
OHSAS 18001?
100 Is the audit programme is Yes
based on the results of
risk assessment and
previous audits?
Do audit procedures
cover the scope,
frequency,
methodologies, Qualified auditor does
101
competencies and that
responsibilities and
requirements for
conducting audits?
102 Is the competence, Yes, third party service

experience, training and
independence of internal
auditors determined?
103 Is the effectiveness of Yes.

audit findings including
reports and records?
104 Does top management Yes.

follow-up on the
timeliness and
effectiveness of the

corrective actions?
105 Do internal audits Yes.

provide information to
management?
106 Has top management

reviewed the
organization’s health and
safety management
Yes, as per corporate
system at planned
directives.
intervals, to ensure its
continuing suitability,
adequacy, and
effectiveness?
107 Have top management Not evidenced

reviews included
assessing opportunities
for improvement and the
need for changes to the
management system,
including the policy,
objectives and targets?
108 Have records of the Not evidenced

management reviews
been retained?
109 Does input to Yes, All inputs are taken

management reviews into consideration during
include results of internal review.
audits and evaluations of

compliance with legal
requirements and with
other requirements to
which the organization
subscribes?
Does input to
management reviews
include
110 communication(s) from Yes.
external interested
parties, including
complaints?
111 Does input to Yes.

management reviews
include the health and
safety performance of
the organization?
Does input to
management reviews
112 include the extent to Not evidenced
which objectives and
targets have been met?
113 Does input to Yes.

management reviews
include status of
corrective and preventive
actions?

114 Does input to Not evidenced
management reviews
include follow-up actions
from previous
management reviews?
115 Does input to Not evidenced

management reviews
include changing
circumstances, including
developments in legal
and other requirements
related to its health and
safety hazards aspects?
116 Does input to Yes

management reviews
include
recommendations for
improvement?
117 Do the outputs from Theoretically yes.

management reviews
include any decisions and
actions related to
possible changes to the
policy, objectives, targets
and other elements of
the management system,
consistent with the
commitment to continual

improvement?

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Compliance Copy of External HSE Report – 22 nd & 23rd February, 2024

Third-Party External HSE Audit Compliance Report - PNCPL

Safety Implementation is a continuous process

AUDIT OBSERVATIONS AND RECOMMENDATIONS

4.1 1 Has the organization Conformant The organisation has

Safety Implementation is a continuous process

3 Has the organization Confrant The organisation

Safety Implementation is a continuous process

the health and safety

6 Has the organization Minor NC HIRA may be

Safety Implementation is a continuous process

Safety Implementation is a continuous process

PART-2 HEALTH AND SAFETY POLICY

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

Safety Implementation is a continuous process

88 Has the organization Has the organization

Safety Implementation is a continuous process

Safety Implementation is a continuous process

95 Record keeping is done

Safety Implementation is a continuous process

102 Is the competence, Yes, third party service

103 Is the effectiveness of Yes.

104 Does top management Yes.

Safety Implementation is a continuous process

105 Do internal audits Yes.

106 Has top management

107 Have top management Not evidenced

108 Have records of the Not evidenced

109 Does input to Yes, All inputs are taken

Safety Implementation is a continuous process

111 Does input to Yes.

113 Does input to Yes.

Safety Implementation is a continuous process

115 Does input to Not evidenced

116 Does input to Yes

117 Do the outputs from Theoretically yes.

Safety Implementation is a continuous process

Safety Implementation is a continuous process

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