AUDIT MANAGEMENT PROCEDURE

Document Control Details

Page 1 of 17 Date of Issue: 25-07-2019 IMS-PRO-003-VER-00

Document Control Details

Document
Document Issue Issue Date * Compiled By Approved by
Manager
Members of Chairman, Rules &
Rules & Procedures Sub- Chairman, Rules
0 25-07-2019 Procedures Committee & Procedures
Sub- Sub-Committee
Committee
Document Standard/Procedure Document
Revision Date
Revision No. No.
0 25-07-2019 IMS-PRO-003-VER-00

User Notes: - Chairman of R&P Committee is the custodian of this document.

Controlled copy of the current version of this document is held at DLF Connect Portal.
Any printed / electronic copy of this document is uncontrolled. It is recommended that
users verify that they are using the latest version of the document at all time.

This document contains proprietary and confidential information of DLF Rentco and is
intended solely for the internal use of authorized Personnel. It should be treated as
BUSINESS CONFIDENTIAL and its external use or disclosure, unless specifically
authorized is strictly prohibited.

* Standard / Procedure compiled by –

Sl. No. Team Members Agency

1 Suresh Babu V DLF

2 Vikram Choube DLF
3 Ramesh Chandra Joshi DLF
4 Jitesh Nichani DLF
5 Satish Gupta DLF
6 Kapil Shandilya DLF
DLF
7 Anil Yadav
DLF
8 Rajesh Hooda
DLF
9 Subodh Gupta

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 10 Manoj Chaudhary JLL
11 Sandeep Dhyani C&W
12 Deepak Rawat C&W
13 Jatindra Mohan JLL
14 Rajesh Kumar C&W
15 Amit Kumar C&W

Table of Contents

1. Purpose 04

2. Objective 04

3. Scope and field of application 04

4. Abbreviations / Acronyms 04

5. Responsibility & Accountability 05

6. References 06

7. Definitions 07

8. Type of Audits & Audit Process Flow

8.1 Second Party Audit on Critical Safety Standard(s) 07

8.2 Second Party – SPAD Audit 07
8.3 Third Party – Fire and Electrical Safety Audit 09
8.4 Third Party – Food and Beverage Fire Safety Audit 10
8.5 Third Party – DuPont Audit 10
8.6 Third Party – Safety Management System Audit 11

9. Frequency & Scheduling of audits 12

10. Level of Findings 14

11. Audit Document Retention Period 14

12. Procedure Renewal Process 14

13. Deviation Process 14

14. Audit Metrics 14

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Purpose

The purpose of this procedure is to have a detailed process for measuring / monitoring
the level of implementation of Safety Management System (SMS) through audits and
to take corrective & preventive actions for continual improvement.

2. Objective

The objective of the procedure is to ensure that all the audits are scheduled,
conducted, recorded and corrective / preventive measures are carried out in a
systematic way.

3. Scope and field of application

The scope of this procedure is to identify the areas of non-conformity within Safety
Management System (SMS) that covers Legal & Statutory requirements, Safety
Standards, Standard Operating Procedures, Engineering Guidelines and extends to all
Rentco facilities.
This procedure does not apply to other internal & external audit programs which are
run by functions/departments (e.g. Finance, Information Technology, Human
Resources, Security, Procurement Audit etc.).

4. Abbreviations /Acronyms:

SMS: Safety Management System

SPAD: System Process and Audits Department
BM: Building Manager
DOE : Director of Engineering
CE: Chief Engineer
MoM : Mall Operations Manager
MR : Management Representative

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5. Responsibility & Accountability

This section presents the Responsible-Accountable-Consulted-Informed (RACI) matrix

to implement the Auditing procedure (as per Annexure A). The Facility Incharge of FM
across DLF Rentco has the responsibility to implement this procedure (For the Lodhi,
Chief Engineer shall be responsible).

Auditor:
Auditors shall be responsible for:
a) Conduct audit as per schedule.
b) Conduct audits as per approved checklist and carry out efficient audit with
integrity. Also, verify the previous audit findings closure.
c) Discuss the audit findings with facility incharge in closure meeting.
d) Complete the audit process and submit the audit report as mutually agreed with
facility incharge.

Auditee:
Auditee shall be responsible for:
a) Coordinating with the auditor in conducting audit as per schedule.
b) Provide all relevant resources and assign support team.
c) Participate in the audit process and ensure all the documents, equipments are
available for audit.
d) Participate in the audit closure meeting alongwith his team members.
e) Discuss the audit report with his team members and assign responsibility for
addressing the findings/gaps in the audit report.
f) Provide all necessary resources to his team members in addressing the findings /
gaps observed.
g) Verifying the audit observations for completion alongwith his team members and
submit the audit closure report status on weekly basis till completion of findings.

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 The responsibility matrix is defined below for audit process (Table - A):

Type List of Audits Scheduling By Audited By : Closure Reviewed By :

Second Critical Safety Central Fire & Trainer certified BM/ CE FM SPOC /
Party Standards** Safety Team by DuPont DOE
System Process SPAD Head SPAD Auditors BM/CE FM SPOC
Audits (SPAD) /DOE
Third Party Fire & Electrical FM Fire Safety Reputed BM/CE FM SPOC /
Safety Audit Head Auditing DOE/ MoM
(Common Area) Agencies
Fire & Electrical FM Fire Safety Reputed CRM /CE GCRM
Safety Audit (Tenant Head Auditing / MoM
Area) Agencies
Food & Beverage Central Fire & Fire CRM /CE GCRM / DOE
Fire Safety Audit Safety Team Consultants
(F&B)
High Risk Activity Central Fire & DuPont BM/CE FM SPOC /
Audit (Common Safety Team DOE/MoM
Area)
Safety Management Central Fire & British Safety BM/CE CGCRM /
System Audit Safety Team Council GCRM / OH/
GM

** Critical safety standards – PTW, WAH, ESMS, LOTO, CSE, HW standard.

Note: The various audits observations closure status shall be reviewed in the site
operational head review committee meeting also.

6. References

• Applicable statutory and legal requirements to Rentco facilities

• DLF Safety standards
• DLF Standard operating procedures
• DLF Occupational health and safety procedures
• DLF Engineering guidelines and management guidelines

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7. Definitions

Audit: Audit is a systematic & independent process for evaluating and recording the
compliance with applicable standard, procedure, system/process. This comprises of
field inspection, equipment testing, personal interactions and document verification.

8. Types of Audits & Audit Process Flow

8.1 SECOND PARTY - Audit on Critical Safety Standard(s)

• Yearly plan shall be prepared by Central Safety Team to conduct the audit on DLF safety
standard and recorded.
• Monthly schedule shall be circulated by Central Safety Team to all the buildings.
• DuPont certified trainers on various Critical Safety standards shall conduct the audit.
• Audit report shall be shared to the facility incharge (FM)/ BM / CE for closure of
observation.
• Closure status shall be submitted to Central Fire and Safety team and records shall be
maintained.

8.2 SECOND PARTY - SPAD Audit:

• The audit shall be conducted as per the SPAD audit checklist.
• The SPAD audit checklist have two categories – A & B based on severity. The
timelines for closure of observations under these two categories are given below:
a) The A category to be closed within 72 hours (in case due to specific reason it
is not feasible to close the observations within 72 hours immediate risk
mitigation measures to be adopted).

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 b) The B category to be closed within 15 days (immediate mitigation measures
shall be adopted to control the risk).
• There shall be a plan to conduct audit by SPAD.
• SPAD head shall prepare annual audit plan and the same shall be intimated to
concerned person.
• An opening meeting is conducted with facility team by SPAD which shall also cover
deviations points if any.
• The audit shall be conducted as per the schedule & the observations / findings
shall be noted.
• Key audit findings shall be discussed with the facility team during closing meeting
and after discussion the final report shall be prepared.
• The audit report shall be sent to the facility incharge for implementation and
compliance. The facility incharge shall ensure closure and report status to SPAD
Head.
• FMSPOC shall monitor the closure of audit findings and follow-up to ensure
closure.
• SPAD team shall prepare consolidated status of closure and monitor the progress.
• The senior management shall review the closer status of audit observations.

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8.3 THIRD PARTY - Fire & Electrical Safety Audit:
• External Third-Party fire and electrical safety audit team shall conduct the audit as per
agreed schedule and the schedule shall be intimated by the auditing agency to the facility
management team / building team.
• The audit team shall conduct the audit as per schedule and the observations and
findings shall be recorded and communicated.
• The audit report shall be sent to the concerned for obtaining compliance.

• Senior level management shall monitor the progress of the closer of audit report.
• Central Fire & safety team shall monitor the compliance of the audit findings &
maintain the records.

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 8.4 Food & Beverage (including Kitchen) Fire Safety Audit
• Central Fire Safety Team shall prepare audit schedule and the same shall be intimated.

• The fire consultant team shall conduct the audit as per schedule and the
observations and findings shall be recorded and communicated.
• The audit report shall be sent to the concerned facility for obtaining the compliance.
• Central Fire Safety Team shall monitor the progress of the closer audit report and maintain
the records.

8.5 Third Party - DuPont Audit:

• The high-risk activity surprise audit shall be coordinated by central fire safety team
and is conducted by Dupont Safety Consultant.
• The audit report is shared by Central Fire Safety team to respective facility
incharge and the action status plan tracker is prepared for tracking the audit
observations for closure.
• The closure status shall be shared after review by FM Safety Heads / FMSPOC
once the facility incharge has ensured the closure.
• The records shall be maintained by the facility incharge.

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8.6 THIRD PARTY - Safety Management System (SMS) Audit:
• SMS audit shall be conducted by British Safety Council on Annual basis as per
current audit specifications.
• Audit schedule shall be released by Central Fire and Safety team.
• Report of audit shall be send by / issued by British Safety Council to Central Fire
and Safety Team.
• The Central Fire and Safety Team shall share the audit report to Operation
team.
• Building team shall take actions on the audit observations, monitor and review
the progress and share audit closure status to the central fire and safety team.
• Review of the audit closure status shall be carried out in Operation Head review
meeting.

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9. Frequency & Scheduling of audit:
The frequency and scheduling of various audits are categorized as below :
Type List of Audits Frequency Audit Scheduling By: Audit Conducted By:
Critical Safety Standards
Permit to Work Half Yearly
Lockout and Tagout Quarterly Central Fire & Safety Trainers certified by
Electrical Safety Half Yearly Team DuPont on critical
Confined Space Entry Half Yearly safety standards
Work at Height Half Yearly
Hot Work Yearly
System & Process Audits
Second
(SPAD) *
Party
Fire & Safety Half Yearly
Electromechanical Half Yearly
Sewage Treatment Plant Half Yearly SPAD Head
SPAD Auditors
Lifts & Escalators Half Yearly
Façade Half Yearly
Housekeeping Half Yearly
Legal & Statutory
Requirements Half Yearly
FM Fire Safety Head Reputed auditing
Fire & Electrical Safety Audit Annually agencies (e.g. Marsh,
Chola etc)
Food & Beverage Fire Safety FM Fire Safety Head
Third Annually Fire Consultants
Audit
Party
Central Fire & Safety
High Risk Activity Audit ** Annually DuPont
Team
Safety Management System Central Fire & Safety
Annually British Safety Council
Audit Team
*One Surprise and One Planned for SPAD
** Six monthly for outstations and annually for NCR .
10. Level of Findings :
The level of findings are provided as follows:

Level of findings Description of Finding Level

A Any non-adherence w.r.t fire safety and statutory compliance

requirements which has direct impact on building operations

B Any non-adherence of operational requirement other than

category A which are not directly impacting building operations

High Observations having high severity potential for injury

Medium Observations having medium severity potential for injury

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 Level of findings Description of Finding Level

Low Observations having low severity potential for injury

P1 • A non-compliance which can result in immediate danger to the

facility, fire, electrical and life safety.
• A non-compliance to the applicable statutory requirements
including CNOC/NOC

P2 • Not meeting relevant Indian standards which does not pose

danger to facility fire, electrical and life safety.
• Any deviation from DLF safety standards / procedure
guidelines.
• Any isolated failure to comply with the requirement.

P3 • Those NBC requirements which were not applicable for the

projects at the time of their approval.
• Good Engineering practices adopted nationally and
internationally.

C Observations which has potential for conformity to the standard

NC Observations which has potential for non-conformity to the

standard

SR Observations pertaining to Safety Standard

AOI Observations pertaining to Area of Improvement

Types of Audits Description Level of Findings

SPAD Audit A&B

Second Party
Critical Safety Standard Audit High, Med & Low

Fire & Electrical Safety Audit P1, P2 & P3

Fire & Electrical Safety Audit P1, P2 & P3

Third Party Food & Beverage Fire Safety Audit (F&B) C and NC

High Risk Activity Audit (Common Area) SR, AOI

Safety Management System Audit High, Med & Low

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11. Audit Documents Retention Period
Each site/facility shall maintain the appropriate records to document its compliance
with this procedure. This document shall include and retain the following documents
for a period of minimum three years:
• Final audit reports
• Audit closure status reports
• Audit schedules

12. Procedure Renewal Process:

The procedure shall be reviewed and revised as necessary and at a minimum, not
later than 3 years from the date of last review.

13. Deviation Process: Deviations from this procedure must be authorized by the
Rules & Procedure Sub Committee using the management of change process.
Deviations must be documented, and documentation must include the relevant
facts supporting the deviation decision. Deviations shall have a stated expiry date
not to exceed one years. Any extensions must be re-authorized.

14. Audit Metrics:

The following are measurement criteria / standard for measurement for the various
audits as mentioned in this procedure.
I) Critical Safety Standards Audit:
Table A - % of closure achieved in critical safety standard audit
High Medium Low
Critical Safety Standards
Total Closed % Total Closed % Total Closed %
Permit to Work
Work at Height
Confined Space Entry
Lockout and Tagout
Electrical Safety
Hot Work

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 II) SPAD Audit Metrics:
Table A - % closure of category A & B in SPAD audit
Category A Category B
SPAD Audit Categories
Total Closed Open % Total Closed Open %
Fire & Safety
Electromechanical
STP
Housekeeping
Façade
Lifts and Escalators
Legal & Statutory
Total

Table A - % closure within time limit for category A & B in SPAD audit
Category A Category B
SPAD Audit Categories Closed within Closed within
Total % Total %
time limit time limit
Fire & Safety
Electromechanical
STP
Housekeeping
Façade
Lifts and Escalators
Legal & Statutory

III) Dupont Audit:

Standard Related Area of Improvement

DuPont Audit
Total Closed % Total Closed %
Permit to Work
Work at Height
Confined Space Entry
Lockout and Tagout
Electrical Safety
Hot Work
Others

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 DuPont Action Tracking Report
Total Completed Pending Compliance
Building Name Employee Total task Pending
Task in target beyond target %
Name completed (nos.)
Assigned time time (nos.)

V) Fire & Electrical Safety - Common Area:

Audit Observations Closure Status – Common Area

Fire Safety Audit Electrical Safety Audit

% of % of
S Total Closed Closed
Loca Pri Pri Closed Pri Pri Total Closed
N Clo Clo Observ Observ Clo Clo Observ
tions orit orit Observ orit orit Observations Observ
sed sed ations ations sed sed ations
y 1 y 2 ations y 1 y 2 ations

VI) Fire & Electrical Safety - Client Area:

Audit Observations Closure Status - Clients Area

Fire Safety Audit Electrical Safety Audit

% of % of
S Total Closed Total Closed
Locat Prio Prio Closed Prio Prio Closed
N Clo Clo Observ Observ Clo Clo Observ Observ
ions rity rity Observ rity rity Observ
sed sed ations ations sed sed ations ations
1 2 ations 1 2 ations

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VII) Food and Beverage Fire Safety Audit:

Name of Food & Beverage Food and Beverage Fire Safety Audit Status
Company Total Closed % of audit observations closed

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