DNV entity

Issue Date Category of Description of Finding (Requirement, non-conformity and evidence) Process/Area/
Finding Department

2/21/2023 CAT2 Requirement: IMS

(Minor) The organisation shall plan, establish and maintain an audit program management
taking into consideration the imprortance of processes, organisation
changes, previous audit results.
Nonconformance:
Internal Audit of Leadership/ Senior Management influencing Risks &
Opportunites and Strategic direction is not evident and not found
included in Internal Audit Plan of 2022-23 showing two half yearly
audits.
Evidence:
Internal Audit Plan of 2022-23 showing Audit of MR/ Head Technical
in two half yearly audits.

2/21/2023 CAT2 Requirement: QC

(Minor) The organization shall retain documented information on the release
of products and services which shall include:
a) evidence of conformity with the acceptance criteria;
b) traceability to the person(s) authorising the release.
Nonconformity:
Traceability to the person(s) authorising the release is not clearly
demonstrated in Test Report No. TC-QC-S-2023-88 as only Signature
of HOD QC is evident,however Name & Designation is not evident.
Evidence:
Test Certificate for OPC/ 53 Grade Test and Compliance Dispatch dt
02.02.2023 in Format NMGD- Ultratech 53
2/21/2023 CAT2 Requirement IMS
(Minor) Organisation shall identify Risk & Opportunities and evaluate the management
Effectiveness of Action Plan to Mitigate Risks & Opportunities.
Nonconformity
1. In R & O Review in Feb 2023, Risk Status has not been revised-
Reduced Residual Risk of last year has not been considered as
Current Risk. 2. New Risk due to Increased Clinker Requirement due
to growing Market demand for Cement for High Speed Rail Project in
coming 3 years, Scarecity of Fly Ash, Increased Parking Space for RM
Trucks has not been included.
Evidence
Risk Assesssment Doc. No.NCMW-MGMT-RA-01 reviewed on
02.02.2023.

2/21/2023 Observation Inadequecies observed in Controls of Recordsfor Logic Modification & Production
PLC/ DCS Temporary Signal Bypass: CCR/
1. Logs with continuity Sr. No demonstrting Date wise Start and End Instrumentation
time of Bypass/ Logic Modification and Authorization is not
systematicaly maintained.
2.Approved hard copies are stored/filed at multiple locations(CCR
and Instrumentation Dept) without continuity Sr No, thus
completeness of Activity/Records cannot be verified.

2/21/2023 Observation Changes in Roles & Responsibilites of Management/Engineer level is HR

frequently observed in view of Internal Transfer/New Joinees.
Following inadequecies observed:
1. Latest Organisation Chart does not show Name of Personnel,
though Position/Designation and reporting status is evident.
2. Internal circular for Joining of Mr Suresh in Mechanical
Maintenance due to Interplant transfer does not show to whom he
would be reporting.

2/20/2023 Observation It was noticed during dite visits that the access to he fire IMS
extinguishers at some of the locations was blocked, which may management
impact effectiveness in response to fire emergency situations.
2/20/2023 Observation 1. IMS Objective Variance in Target Compliance is not recorded as % Packing &
of Target to demonstrate Gap and trigger Improvent Action. Variance Dispatch
is recorded in Unit of Measurement, some time in Lacs.
2. Objective statement does not clearly mention about the
assumptions in Target selection. E.g. objective for power
comsumption has been set as 0.75 Kwh/ tonne of cement produced,
as against LY baseline of 0.71 Kwh/tonne. It was seen through the
discussions, that the target is set higher than LY, because of expected
increase in number of packer segment production TY. The
assumption has not be clearly mentioned, which may impact
effectiveness in objectives setting & monitoring process.

2/20/2023 Observation TPH of packer no. 3 as of Jan 23 was noted as 89 per month as Packing &
against target of 90. The action plan has been documented towards Dispatch
bridging the gap. Howver, analysis with regards to the cases of
packers nozzles blocked & changeover cases in cse of trade & non
trade products has not been available in structured manner, though
these were mentioned as contributing factors, as per discussions
withe the concerned persons.

2/20/2023 Observation A/I register needs to be reviewed & updated. E.g. applicable legal Packing &
requirements for dust generation, which is Air Act & generaion & Dispatch
disposal of pp bags used for packing, which Plastic rules, have not
been captured clearly.

2/21/2023 Observation MTTR for Jan 23 was noted as 4.83 hrs as against the target of 1.80 Mechanical
hrs. It has been noted that the tripping of lube pump has caused maintenance
tripping of the coal mill 1, leading to breakdown & RCA assigned was
delay in identifying the issue due to inadequate awareness of new
team & oil contaminated with cement. Though the actions having
been taken to address the RCA, the corrective actions have not been
documented for all root causes in structured manner.

2/21/2023 Observation 1. Working at Jetty is not in found included in Identified Emergency Jetty
Secenarios reffered for making yearly Mock Drill calender. maintenance
2. Mock drill for medical emergency at Jetty was carried out on
16.10.20 & reports maintained. However, the report needs to
capture the reponsibility & time frame for planned actions , reported
out of observations like injured person head was kept in opposite
direction ambulance near the door & rescue stretcher not available
near jetty
2/21/2023 Observation Specification of Dust mask in HIRA/ PPE matrix should be updated & Mechanical
monitoring of wearing them in Cement plant area by concerned maintenance
persons should be ensured in structured manner.

Positive indicators
1. No Customer Complaints during Last 2 years.
2. Supply of 30,000 MT/ month OPC to High Speed Rail Project,
planned to increase to 40,00 MT/month after installation of Roller
Press.
3. 1 MW Solar Power plant installed in 2021 March. 5.5MW
Renewalble Energy sourced from Rajkot since Aug 2022.
4. Cost saving of 4.7 lacs INR by locally repairing of Jetty unloader
conveyor wheels. 1.1 lacs INR savings /year achieved by modifying
discharge belt conveyor.

Focus Area: Improvement in Safety Performance

Positive indicators
1. No LTI during last 2 years. CMO's 60 Sec Safety Awareness
checklist introduced for Contract Workers since May 2022.
2. Engineering controls incorporated like Installation of bag stopper
by providing clitted belt conveyor & rotory valve modification
through Design improvement.
3. Provision of shock absorbers at the end of rope of safety harness
provided in loading of Bulk cement in vehicles.
 Fields marked with Amber text are manda
Standard and DNV Correction to Eliminate the Non-conformity*
Clause Auditor
Name

ISO Soumya Henceforth we will schedule a separate half yearly

9001:2015 Chatterjee internal audit of the Top management.
9.2

ISO Soumya As this format is provided from the central core

9001:2015 Chatterjee team of UTCL, we have communicated the matter to
8.6 the central core team. Awaiting for the revised
format
ISO Soumya We have updated and consider last year risk is
45001:2018 Chatterjee current year risk. New risks is also updated in the R
8.2 & O document

ISO Soumya 1.Register to be provided seperatly and kept in CCR.

90015:2018 Chatterjee 2.Sr. No & date wise Bypass/ Logic Modification
8.5.1 activities will be noted in the register

ISO Soumya 1. Name of the personnel is being updated in the

90015:2018 Chatterjee organisation chart and the same is monitored
8.5.1 regularly.
2. Reporting manager is now mention in the format
of internal circular of new joining

ISO Subhash Access is clearing to approching the fire

45001:2018 Rege extinguisher. This awarness is also given to Fire
8.2 Team to carryout regular monitoring
ISO Subhash Timely review and update the objective with
14001:2015 Rege baseline of last year with reason
6.2.1

ISO Subhash Analysis done and recorded

9001:2015 Rege
9.1.3

ISO Subhash We have reviewed and updated the A/I register

14001:2015 Rege
9.1.1

ISO Subhash Why why analysis is reviewed and updated

9001:2015 Rege
10.2

ISO Subhash 1. Jetty emergency scenerio to be included in Mock

45001:2015 Rege drill schedule
10.2 2. Action plan will be prepared and monitored for
compliance of observation
ISO Specification is already in place but properly used of
45001:2015 specified mask will be ensure through SO and if
8.1 further violation obswrved PCM will be apply
 Fields marked with Amber text are mandatory
Analysis of root cause of Non-conformity, Corrective action to Eliminate root cause of non-
Distribution of Responsibility within Organization* conformity(For actions not implemented after 90
days a committed date for implementation must be
stated)*

Due to lack of understanding, we were doing In the next year FY 23-24 of Internal audit plan, we
internal internal audit of MR dept along with the have included the half yearly audit for Top
Top management (TM) and not seperatly. management department seperatly.

Due to not mentioned in the across UTCL format, as Authorised signatory name will be mention after the
we are following central core team format of UTCL. approval of UTCL central core team by 30.04.2023
Less awareness in the system clause of R & O R & O register is updated with the new risk on
register 25.02.2023

Completed

Organisation chart is updated and

Reporting manager is being mentioned in the
internal circular joining format

Completed
 We have updated the objective & target register
with the appropriate reason.

Analysis done and record on 25.02.2023

Compeleted on 25.02.2023

During the analysis it is oversighted Completed on 27.02.2023

Missing in theyearly mock drill calender Updated in mock drill schedule and action plan
prepared
Due to negligence Regular monitoring at entry gate and permanent
locations
Date Response Name of DNV Auditor Comments Name of
Accepted Auditor Verifying Auditor
Response Closing NC
Date for
closure of
Non-
conformity

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Issue Date Audit Type Finding No Status Category of Finding Title

2021/05/15 RC SOCH-0001-368392 Closed CAT2 (Minor) Incident Investigation-

Worker Participation &
CA effectiveness
2021/05/16 RC SOCH-0002-368392 Closed CAT2 (Minor) EHS Legal compliance
Monitoring

2021/05/16 RC SOCH-0003-368392 Closed CAT2 (Minor) Effectiveness of Action

taken to Mitigate Risk &
Opportunites
2021/05/16 RC SOCH-0004-368392 Closed CAT2 (Minor) Safety Committee

2021/05/16 RC SOCH-0005-368392 Closed Observation Incoming Material Testing

2021/05/16 RC SOCH-0006-368392 Closed Observation Objective Monitoring

2021/05/16 RC SOCH-0007-368392 Closed Observation Training Effectiveness

monitoring

2021/05/16 RC SOCH-0008-368392 Closed Observation Supplier Performance

Evaluation
2021/05/16 RC SOCH-0009-368392 Closed Observation Mitigating actions

2021/05/16 RC SOCH-0010-368392 Closed Observation Mock Drill Reporting

Description of Finding (Requirement, non- Site Name
conformity and evidence)

"Requirement - 1. The organization shall emphasize UltraTech Cement

the participation of non managerial workers in Limited - (Unit Narmada
investigating incidents and non conformities and Cement Magdalla Works)
determining Corrective Actions as per clause 5.4 e7. Magdalla Port, Dumas
Incident Investigation Procedure Road,Surat - 395007,
ABG/CB/SAE/2013.20. Gujarat, India
2. Organisation shall review the effectiveness of
corrective action taken as per clause 10.2 f .
Failure & Evidence -
1. Participation of Non Managerial Workers are not
evident in Investigation team in Incident
Investigation Report in MySetu related to Near
Miss/ Equipment Failure, Investigation Team
Members does not include workmen. Workers
interviewed as Witness.
2. Provision and evidence of Verification of
effectiveness of Corrective Action as per
Recommendation derived after Why-Why analysis is
not found. "
"NonConformity & Evidence: UltraTech Cement
Following in adequecies observed in EHS Legal Limited - (Unit Narmada
compliance Monitoring: Cement Magdalla Works)
1. In Food Handlers Medical test Records validity of Magdalla Port, Dumas
Typhoid Vaccine ""Vac Typh"" ( One year/Two Road,Surat - 395007,
years) is not mentioned. Gujarat, India
2. Status of absence of E Coli & Residual Chlorine is
not recorded in Potable Water Testing Report as per
IS 10500:2012 of Royal Env Auditing dt 31.12. 2020.
3. Lux level monitoring report dated 10.12.2020
following are noted, (1) Lux meter Calibration
details is not found, (2) Improvement action is not
evident after getting low reading value of 15 against
requirement of 20 lux at Clinker Shed Silo , (3) IS
Standard reffered for Lux level not evident in the
report.
4.In Employee wise Yearly Health Monitoring
Record, though Weight is recorded, BMI is not
calculated and left blank."

"""Nonconformity & Evidence - UltraTech Cement

1. Effectiveness of Actions to address Risk & Limited - (Unit Narmada
Opportunites are not demonstrated with reference Cement Magdalla Works)
to Reduction of Risk Weightage of last years Risk Magdalla Port, Dumas
Assesment reviewed this year. Road,Surat - 395007,
2. In Risk Assesment carried out in Dec 2020, Gujarat, India
Descripency observed:
2.1, Delay in IA Audits- Compliance is 50% instead of
100% recorded as 1 out od 2 IA planned was
executed.
2.2 Compliance to Covid Guidelines is 85% instead
of 100% as 15% employees are under home
isolation.
2.3 Risk due non availability of Fly Ash, Clinker and
Cement demand in Market due to Covid are not
found included."
Nonconformity & Evidence: UltraTech Cement
In MOM of Quarterly Safety Committee Meetings Limited - (Unit Narmada
held on 18th Dec 2020 and 24th March 2021, Cement Magdalla Works)
though department specific issues related to Unsafe Magdalla Port, Dumas
Acts & Condition/Improvement areas were Road,Surat - 395007,
discussed, Following issues were not found Gujarat, India
discussed:
1. Overall Trend of Safety Performance Indicators of
the Plant.
2. Emergency Preparedness and Mock Drills
conducted
3. Status Of Health Monitoring
4. Communication of relevant OHS IA Findings/MRM
Outputs.
5. EHS TRaining & Status of First Aiders/ Fire
Fighters."

Quality control UltraTech Cement

Even though the results found within the limit of Limited - (Unit Narmada
standard specification. mismatch observed in the Cement Magdalla Works)
specification limits mentioned in documents. Magdalla Port, Dumas
1) Refer Monitoring Sheet Form No 4 & 5 (Clinker Road,Surat - 395007,
chemical composition) , Few of the specification are Gujarat, India
not correctly addressed, e.g. LOI - Min. 1.5 %, SO3 -
Min. 2.7 %, IR - Min. 1.0 % , As per BIS this limits are
Maximum, however all results found withing the
limit of BIS requirement.
2) objective is taken to maintain the C3S in clinker >
46 and results also found within the limits, however
in monitoring sheet it is mentioned as > 35 required.

3) For Chemical Gypsum, additonal parameters

P205 and SO3 is being carried out and accetable
limits/frequency are mentioned in monitoring
sheet, however the Quality plan (QA/QC07 dated
01.04.2018) is not addressing the required
specification and sampling for this parameter.
Packing and Dispatch UltraTech Cement
1) Objective of Turn Around Time (Plant) is being Limited - (Unit Narmada
monitored overall average for the month of Cement Magdalla Works)
March'21 found 1.38 hrs./month against target of < Magdalla Port, Dumas
1.40 hrs/month, however total 7 cases where found Road,Surat - 395007,
having TAT of > 2.00 hrs. / month, and few cases > Gujarat, India
1.5 hrs./month, eventhough the communication of
reasons is evident thru e-mails and SAP System, the
same is not systamatically summarized.
2) Actual specific power consumption for packing
plant is varying due to % loading of Bulk and Bagging
(which is also noted in monthly analysis), As of now
combined power is being monitored, seperate
monitoring of bulk and bagging power is not carried
out "

Though evaluation for effectiveness of Training is UltraTech Cement

carried out regularly however the same has not Limited - (Unit Narmada
been captured for few participants in Training Plan Cement Magdalla Works)
compliance Tracking system. Magdalla Port, Dumas
Road,Surat - 395007,
Gujarat, India

"1. Though the criteria for supplier performance UltraTech Cement

evaluation is evident in SOP - IMS/SOP/MATL/01, Limited - (Unit Narmada
Rev 02, however how the suppliers are categorized Cement Magdalla Works)
based on performance in different categories - A, B, Magdalla Port, Dumas
C, D and what actions to be taken for different Road,Surat - 395007,
rating is not found clearly discussed in the Gujarat, India
procedure.
2. Though Letters sent to suppliers about their
performance does not include weightage of low
rating parameters which can be highligted to guide
supplier for improvement. eg:- Quality, delivery,
HSE, Service parameter"
Risk of Non availability of low LOI & high Blaine fly UltraTech Cement
ash has been determined as medium risk. However, Limited - (Unit Narmada
the mitigating actions to reduce the risk are not well Cement Magdalla Works)
defined and documented for ensuring effective Magdalla Port, Dumas
implenetation ,though some of the actions like Road,Surat - 395007,
formation of task force team and exploring more Gujarat, India
sources of fly ash have been taken as seen from the
discussions with the concerned persons.

Mock drill has been conducted on 17/1/20 for UltraTech Cement

emergency related to confined space in Ball mill Limited - (Unit Narmada
area. The observations have been noted as Cement Magdalla Works)
Ambulance siren was not working, stretcher was Magdalla Port, Dumas
not used ,non availability of first aider in the area. Road,Surat - 395007,
Though actions have been taken in terms of Gujarat, India
responsibilty ,timeframe & monitoring method,
however details of the same has not been not
clearly mentioned in the report.
Focus Area Process/Area/Department

Improvement in EHS Operational Control Safety

Improvement in EHS Operational Control Safety

Management
Improvement in EHS Operational Control Safety

QC
Packing & Dispatch

Training

Purchase
 Management

Improvement in EHS Operational Control Safety

Standard and Clause DNV Correction to Eliminate the Non-conformity*
Auditor
Name

ISO 45001:2018 5.4 Soumya Changes in Mysetu for Provision of Involvement of

ISO 45001:2018 10.2 Chatterjee Non managerial worker & effectivenesss
measurement of Corrective actions completed.
ISO 45001:2018 9.1.2 Soumya """"1.0 Obtained the Certificate from Our Doctor for
Chatterjee Validity for Typhoid Vaccine.
2.0 Water sample given to analyse water as per IS
10500:2012 and report received.
3.1 Meter sent for calibration.Lux Level meter
calibration will be done.
3.2- Faulty lights being replaced with new lights to
improve the Lux level. IS levels will be mentioned in
Lux level monitoring report.""""

ISO 9001:2015 6.1 Soumya 1.0 Effectiveness of risk register is revised and
Chatterjee updated as per current year situation.
2.1 & 2.2 Regarding IA and COVID situation,
compliance updated in risk register.
2.3 Risk of fly ash and cement market demand due
to COVID is included in Risk & Opportunity
register""""
ISO 45001:2018 9.1.2 Soumya Detail agenda prepared for Safety Committee
Chatterjee Meeting including all the mentioned issues. Next
Safety Committee Meeting will be conducted as per
detail agenda by 30.06.2021.

ISO 9001:2015 8.4 Soumya All quality related points has been reviewed and
Chatterjee updated in monitoring sheet as per BIS guide line for
cement quality standard.
ISO 9001:2015 6.2.1 Soumya 1. Reviewed and Prepared action plan to reduce the
Chatterjee TAT with consultation of logistics and tech head.
2. Communicated to the logistic team to give
dispatch planing for bag and bulk on daily basis.""""

ISO 9001:2015 7.2 Soumya """"Training effectiveness evaluation tracking sheet

Chatterjee reviewed and updated for every training.
Created an excel sheet for tracking system with red
mark on the due date and green for the
completed.""""

ISO 9001:2015 8.4.3 Soumya """"1. Criteria for catagorisation of Vendor

Chatterjee perfromance rating in SOP - IMS/SOP/MATL/01, Rev
02, in different categories - A, B, C, D and same has
been upadted in SOP accordingly.
2. Discussed with SAP team to include relevant
details in Auto generated letter from SAP for better
infromation to vendor""""
ISO 9001:2015 6.1 Soumya Both Material and technical function action plan for
Chatterjee good quality fly ash availability has been aligned and
included in agenda for discussion on monthly basis
in production meeting.

ISO 45001:2018 8.2 Soumya All the observation/findings have been reviewed
Chatterjee and necessary actions taken to avoid repetition in
future. During SPSA audit a mock drill was
conducted all these observation have been taken
care properly and same has been mitigated.
Analysis of root cause of Non-conformity, Corrective action to Eliminate root cause of non-
Distribution of Responsibility within Organization* conformity(For actions not implemented after 90
days a committed date for implementation must be
stated)*

No provision in System for recording the Awareness given to all concerned for involvement of
involvement of non mangerial worker in Mysetu. non mangerial worker in Incident investigation and
register in Mysetu.
""""1.0 On the basis of oral statement of our doctor 1.0 In future will ensure that the certificate from
that vaccination is valid for two year. We had not doctor mentions -Validity for Typhoid Vaccine
taken a written letter / Certificate. """"""""Vac Typh"""""""" is Two years. Certificate is
2.0 All 28 parameters of water sample as per IS in 2nd attachment
10500 was not ensured in report submitted. 2.0 Total analysis of water is started and
3.0 Ecoil ,residual chlorine test report include in
1- Calibration not done within due date due to Covid quaterly .report will be documented in water
pandemic. analysis record.
2- Lights were under procurement 3.0 Awareness to be given about IS levels for Lux
3 - Not fully aware about the procedure"""" monitoring. Target Date:15.05.2021""""

Significance of all these points on effect on Unit All required compliance point are now included in
business was not analysed in depth. managment document and will be analysed in depth
in each review.
Safety Committee Agenda did not specifically
mention the agenda points, hence some ofthe
agenda points were not recorded even though they
were discussed in presentation. Reference of
Presentation was not recorded.
Awareness will be provided about the structured
Safety Committee agenda and its significance.
Compliance to agenda in Safety Committee MOM
will be monitored by Safety Head.
Date Response Name of Auditor Comments Name of Date for
Accepted DNV Auditor closure of
Auditor Closing NC Non-
Verifying conformity
Response

Soumya Correction accepted for involvement of non Soumya 2022/03/10

Chatterjee mangerial worker in Incident investigation and Chatterjee
register in Mysetu. Verified in PA1 Audit on 10th
March 2021, Evident in MGD/21-22/11 dt 11.6.21
for Near Miss Incident reported in portal. 1 Contract
Worker and 3 Company Employee evident in
Incident Investigation Team in Mysetu Portal. CA
effectiveness verified.
Soumya Correction accepted related to CA plan reviewed Soumya 2022/03/18
Chatterjee and accepted in PA1 Audit, CA effectiveness Chatterjee
verified:
1.0 Food Handlers Medical Certificate from doctor
mentions -Validity for Typhoid Vaccine """"""""Vac
Typh"""""""" as Two years.
2.0 Total analysis of water is started and
Ecoil ,residual chlorine test report include in
quaterly .report is documented in water analysis
record.
3.0 Awareness given about IS levels for Lux
monitoring May 2021 .

Soumya Correction accepted for review and updating Risk & Soumya 2022/03/18
Chatterjee Opportunities and action plan effectiveness , CA Chatterjee
plan verified for effectiveness in PA1 audit and
accepted.
Soumya In PA1 Audit Reviewed and verified -Quarterly Soumya 2022/03/10
Chatterjee Safety Committee Meetings of Dec21, CA accepted, Chatterjee
CA effectiveness verified satisfactorily- Safety
Performance, Training Data, LTFIR Trend, Red
Cornered Notice evident in Safety Committee
minutes.

Soumya In PA1 Audit- CA reviewed, verified and accepted Soumya 2022/03/10

Chatterjee for effectiveness -1) Monitoring Sheet Form No 4 & Chatterjee
5 (Clinker chemical composition) has been reviewed
and revised as per Max allowable limits of BIS
Standard 2) Objective reated to Clinker C3S is
taken as > 35 in Objectives Monitoring Sheet
dated 02/02/2022. 3) Quality Plan for Chemical
Gypsum modified to include P205 and SO3.
Soumya Correction accepted, CA plan verified for Soumya 2022/03/18
Chatterjee effectiveness and accepted in PA1 Audit. Real time Chatterjee
Logistics Tower dash board installed.

Soumya In PA1 audit verified Training effectiveness Soumya 2022/03/11

Chatterjee monitoring records satisfactorily. Chatterjee

Soumya In PA1 Audit,Correction verified satisfactorily for Soumya 2022/03/11

Chatterjee Supplier Performance Evaluation in SOP Chatterjee
IMS/SOP/MATL/01 Rev 03 dt 15 Feb 2022: A-9 -100 ,
B- 75-90 , C-60-74 D- >60% .Verified that Auto
generated mails are being sent to suppliers through
SAP.
Soumya In PA1 Audit- Verified mitigation plan in Risk Soumya 2022/03/10
Chatterjee Register- good quality fly ash availability is included Chatterjee
in agenda for discussion on monthly basis in
production meeting.

Soumya In PA1 Audit- Evidence of completion of CA plan is Soumya 2022/03/10

Chatterjee found verified with sign of Safety Head in Mock Drill Chatterjee
Report.