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HSE Audit
HSE Audit
Rev:
HSE/SOP-53
01
DESCON DESCON HEALTH SAFTEY & ENVIRONMENT MANAGEMENT SYSTEM Date of Rev: June 22, 2016
Page: 1 of 23
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Policy Element: 12
HSE Auditing
Audits and Review
Rev
Date Originator Reviewed By Endorsed By Approved By
No.
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MJM = Muhammad Junaid Mubashar, MKK = Muhammad Khawar Khan, AMW = Ahmad Mubeen Awan, NH = Nasir Hameed,
AAM = Ahmad Abbas Mirza, AB = Adnan Bakhtiar, AUH = Anwar ul Haq, MZ = Masood Zafar, ARD = Abdul Razak Dawood
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Doc No: HSE/SOP-53
Rev: 01
HSE AUDITING Date of Rev: JUNE 22, 2016
Page: 2 of 23
Development of Procedure
00 22-06-2016 as per requirement of
HSEMS Revamping Project C
01
C
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Doc No: HSE/SOP-53
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Table of Contents
1. OBJECTIVES ......................................................................................................... 4
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2. SCOPE ................................................................................................................... 4
3. RESPONSIBILITIES .............................................................................................. 4
5. PROCEDURE ........................................................................................................ 7
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1. OBJECTIVES
The purpose of this document is to establish the methodology for Planning, execution
and follow up of HSE audits to assess the compliance and suitability of Company’s
Health Safety and Environment management system to achieve the stated HSE goals
and objectives at various levels.
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2. SCOPE
This procedure shall be applicable on various levels of HSE audits conducted within the
company on Divisions / Units or at projects / facilities levels.
3. RESPONSIBILITIES
Division Head HSE/ HSE Manager Business Unit / Site HSE Manager or
In-charge
Shall be responsible for adequate communication, trainings and
compliance audits along with advising to fill the gaps identified in
implementation of the requirements as details given in this procedure.
Shall be responsible for review of this procedure as per set frequency or
on need basis.
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4. ABBREVIATIONS / DEFINITIONS
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5. PROCEDURE
HSE Audit is a Systematic, independent and documented process for obtaining audit
evidence and evaluating it objectively against verifiable evidence to determine the extent
to which audit criteria is fulfilled.
It is a documented process of objectively obtaining and evaluating to determine that HSE
controls:
Are complete and consistent,
Are efficient,
Safeguard the company’s resources and promote their effective use,
Provide, and protect the integrity of, required records and information,
Allow for compliance with policies, chosen standards, laws and regulations.
Company Level-1 audit involves the immediate and 1st party audit conducted by the
team that is directly related to the job/project including project HSE team and execution
team, it also covers project contractors, vendors, suppliers HSE audits. These types of
audits are planned, executed and recorded at project sites and all the follow ups and
close outs records are stored at project site.
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These audits involve any company parallel Business divisions, Business units, sister
companies and 2nd party audit shall be conducted by the team that is not directly
related to the job/project including business divisions and business units, corporate
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HSE and execution team, it shall also cover HSE audits of pre-qualified contractors,
vendors, suppliers. These types of audits are planned, executed and recorded at
Business divisions, business units and corporate level. All the follow ups and close outs
records are stored at business division, business units or corporate HSE level.
Level-3 audit comprises of 3rd party audit like accreditation audits for example ISO
14001: 2007, OHSAS 18001: 2015, standard compliance certification surveillance
audits, regulatory and government agencies compliance audits, These audits are
planned, executed and recorded at project sites, business divisions and Corporate
levels.
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5. Facilitate for the timely preparation and processing HSE audits reports by Audit
Leaders.
6. Coordinating assistance to business divisions, BU and project audit team in
preparing and completing a corrective action plan for each audit.
7. Reviewing and monitoring HSE Auditing plans and providing feedback to
respective management regarding overall audit plan effectiveness
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Audit Leader
Throughout audit process, the Audit Leader must keep the Principal Auditee informed of
observed gaps, strengths, and weaknesses.
Auditors
Auditors may originate from various potential sources within or outside the business
divisions, BU and Project team.
For example: (a) Corporate; (b) specific or other related BUs (c) The project team
depending upon the nature of the projects; or (d) External consultancies with specific
specialist expertise in auditing.
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All auditors nominated for an HSE Audit must be approved in advance by the Audit
Leader and, once adopted, will be subject to the Audit Leader’s direction and control.
Each member of the audit team is responsible for:
1. Familiarizing themselves with relevant background of the project site or facility
prior to commencing the audit.
2. Thoroughly understanding the audit procedures, including:
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Audit Leader
The success and effectiveness of an audit team, and the HSE Audit Plan as a whole, are
linked to the competencies of Audit Leaders and the quality of the audit reports that they
deliver. Thus, Audit Leaders must:
Auditors
Training and qualification requirements for the adopted audit team members (auditors)
will depend on specific scope of the audit. In general they must:
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Prior audit experience is preferred but, provided that the above is adhered to, is not a
prerequisite. At the start of each audit, depending on the auditing skills observed within
his audit team, the Audit Coordinator and/or Audit Leader will conduct refresher training.
Auditor Training
The company HSE Audit coordinator will develop an audit training plan for BU and
projects sites respectively.
At pre-determined frequency of each year, the HSE Audit Coordinator will prepare a
HSE Audit Plan, which eventually should become an integral element of the HSEMS and
consists of the following.
1. 1st Quarter projects/facilities and HSE systems to be audited, Audit type, precise
audit scope, outline terms of reference and agreed timing/duration of audits
2. 2nd Quarter projects/facilities and HSE systems to be audited, Audit type, outline
audit scope and proposed timing (quarterly phasing).
3. 3rd Quarter projects/facilities and HSE systems to be audited and audit type.
The exact scope and timing of individual HSE audits will be determined and prioritized
by the HSE Audit Coordinator, in consultation with business division, business unit HSE
Manager and project management, project HSE and the potential Principal Auditees.
In finalizing the plan, the HSE Audit Coordinator must ensure with the Principal Auditee
and/or other nominated persons (e.g. the Audit Manager and/or HSE Manager):
1. Best timing of the audits with regards to other activity planning, e.g., no conflicts
with major Project activities and/or shutdowns
2. That the audits do not duplicate the audit effort planned. Potentially significant
overlaps could occur if the HSE audit would closely follow a similar scope to the
Company-led audit or that of an external audit.
3. That business division, BU and project team deliver suitable personnel to
participate in the HSE audits.
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When preparing the HSE Audit Plan, it is imperative that the Audit Coordinator verifies
that adequate Audit Leaders are available to execute the Plan. This requires a thorough
understanding of the various key steps of a typical audit process, and the timeframes
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The first and key activity for any audit will be for the Audit Leader to prepare the
detailed Terms of Reference (TOR). TOR preparation must commence at the earliest
possible time, as specific audit details (e.g. scope, technical complexity) may affect
resource requirements and dictate the mix of skills required within the audit team.
Thus, the Audit Leader must:
Ensure that the TOR definition process commences in advance of the
planned audit start date.
Agree the TOR with the Principal Auditee, preferably at least 2 weeks prior
to the planned start of the audit. If the TOR cannot be agreed prior to
commencing the audit, the audit must be deferred until agreement is
reached.
The TOR must provide applicable details on audit objectives, scope, standards, audit
methodology, reporting requirements, team members and Principal Auditee. The
finalized TOR must be agreed between the Audit Leader and the Principal Auditee,
specifically audit scope, timing and duration
The scope of HSE audits should, in principle, be set to assess compliance with
applicable HSEMS of company, laws and regulations, policies, guidelines and
procedures/ instructions by the audited Company business division, BU/ project as a
whole or for pre-selected facilities or operations.
A standard audit scope element of every HSE audit plan must to review of effective
follow-up to gaps and weaknesses identified during earlier HSE audits, assessments
and/or inspections. Preferably, this should also include follow-up to
recommendations resulting from near-miss reporting and incident/accident
investigations.
One of the principal aims of an audit is to obtain an overview of the general
Company ability to manage and implement improvement recommendations.
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Therefore, the review of follow-up should not be limited to issues with a ‘High’
potential risk.
Auditors should review a representative sample of all issues to avoid ‘Low’ and
‘Medium’ risk issues from developing into ‘High’ risk issues over time.
5.5.4 Standards
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The compliance standards for all HSE audits should include, in priority order:
Company HSE audits will be expected to comment on any shortfall in the above.
As a minimum, every facility and Project audit team must consist of an Audit Leader
and one HSE Auditor. Both will coordinate with the HSE Audit Coordinator. The HSE
Audit Coordinator and/or Audit Leader will select the audit team from line function
and HSE staff in the Company business division, BU or Project depending upon the
nature of the audit.
Depending on audit scope, an optimum team size for any HSE Audit is 3-5 persons
(including the Audit Leader). This number will allow adequate flexibility when
distributing audit team tasks, allow for sufficient back-up during contingencies (e.g.
absence for compassionate of illness reasons). Also, it allows team meetings to be
effective and manageable.
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All HSE audits will be conducted in accordance with methodology and auditing
procedures, as documented in this procedure.
As a common approach to all audits, audit team members are required to gather
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5.5.8 Reporting
All HSE audits must deliver a management overview of the overall level of control in
relation to the HSE aspects and impacts of the projects/facilities and HSE systems.
The TOR must specify an opportunity for the audit results to be presented to the
Principal Auditee at the final day of an audit.
Preferably, this should be in the form of presentation to relevant members of
company, business division, BU or project senior management where the audit is
already been conducted.
The Auditee must be issued with a draft report at the end of the audit. Where there
are time constraints, this should be clearly identified as DRAFT, as later changes
and editing may occur.
At least one week prior to the on-site audit visit, the Audit Leader will notify the Audit
Coordinator to arrange a meeting with appropriate line and HSE management to
discuss:
Audit objectives, scope, schedule and timing of the on-site portion of the
audit;
Names of team members;
Information to be collected at the site prior to the audit and to be made
available to the Audit Team e.g. procedures, work instructions.
Interviews requirements and site support required
Procedures for responding to the pre-audit questionnaire (if one is used).
Any special issues to be considered.
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The TOR must highlight that translating audit findings into agreed actions assigned
to action parties is a post-audit activity and is entirely a Principal Auditee
responsibility.
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Immediately upon commencing the 1st day of the on-site audit, the Audit Team
Leader must conduct his first meeting with his team. The Audit Leader must use this
meeting to verify the following:
The finalized TOR must be agreed between the Audit Leader and the
Principal Auditee, specifically audit scope, timing and duration;
The TOR must provide applicable details on audit objective, scope,
standards, audit methodology, reporting requirements, team members and
Principal Auditee;
The TOR has been made available to and is understood by all members of
the Audit Team.
3. All members of the Audit Team have a good understanding of their and other’s
specific roles/responsibilities in the Audit Team. This includes their thorough
understanding of requirements for teamwork and possibly long working hours.
All members have a good overview of the various HSE aspects as relating to the
audited projects/facilities and HSE systems including those that will and will not be
reviewed in detail as part of the audit.
If the Audit Leader perceives any gaps or shortfalls in the above, he must rectify
these prior to continuing with the on-site audit
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Immediately upon conducting the Initial Site Familiarization Tour, the Audit Leader
should have another meeting with his Audit Team to distribute the various audit tasks
to the Team members.
These tasks must be assigned to individuals in accordance with their particular skill
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and experience. It is advisable to have the Team members volunteer for their
respective tasks, as opposed to being instructed.
The workload should be distributed equally, i.e. each team member should end-up
with approximately the same number of HSEMS objectives/Sub-elements.
Preferably, these should remain grouped per HSEMS Element and other tasks,
although some Sub-elements are suitable for assignment as separate items.
Prior to commencing the site visit(s) by individual Auditors or groups of Auditors, the
Audit Team should become familiar with Project site through the project HSE
orientation given in start of site arrival and study of available documentation. Then
audit team requires the review of pertinent laws, regulations, guidelines and
company HSE procedures, responses to the pre-audit questionnaire, and the results
of previous audits at the site.
Also, the Audit Leader may provide guidance to his team, specifically those with little
audit experience, to review selected parts of this document. This will allow the Audit
Team members to:
Identify potentially significant issues in relation to HSE risk and thus prioritize
their Work prior to visiting the site.
Better distribute the audit work amongst the Audit Team members.
Develop focused interview schedules.
5.6.4 Interviews
The success and thoroughness of any audit will depend on interviews with business
division, BU and project management and site-personnel and project HSE team. It is
therefore essential that, prior to commencing an audit, the Audit Leader should make
it explicitly clear to the Principal Auditee (and his organization) that management and
personnel at various levels of the organization will be interviewed.
It is important that the Principal Auditee communicates to his management and
subordinates that they may be required to adjust their agendas at short notice to fit
the audit schedule.
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The initial visit is for familiarization only and the Audit Leader must endeavor to limit
the duration to 1-2 hours. The visit should be conducted with the whole team,
accompanied by two senior site staff that are capable of explaining HSE issues and
project site developments.
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Any areas or issues of potential impact, not previously anticipated, should be noted
for subsequent discussion with the team. Following the visit and prior to the Audit
Team commencing their individual objectives, the Team should meet to compare first
impressions. Depending on observations, the Audit Leader may have to modify the
audit focus and/or task distribution.
Subsequent visits can by conducted by Audit Team members on their own or in any
combination with the rest of the team.
Interviews and observations during site visits will provide evidence of strengths,
weaknesses and gaps. It is imperative that, prior to documenting these findings in
the audit report, all issues are verified as being factual.
This should be done either via cross checks with other team members, other or
additional interviews, or cross-reference to existing documentation and procedures.
Two important rules must be rigorously applied:
Rule 1: Every audit finding, irrespective of whether it is positive or negative needs
to be verified thoroughly.
Rule 2: If in Doubt, Leave it out.
A single unverified issue that is reported formally, but is subsequently shown (by the
Auditee) as being non-factual, will affect the whole audit. It distracts the attention of
the Auditee from the remainder of factual and verified findings.
The Audit Leader should conduct a closing meeting with the entire Team. The aim of
the meeting is to review progress and to share major findings and conclusions.
During the meeting the team should develop consensus on the audit findings and on
the strengths and weaknesses observed during site visits, interviews and
documentation review.
The meetings should be used to analyze the findings and, where appropriate, to
address the underlying or root causes. This process will continue into the report
writing phase of the audit.
The Audit leader should be prepared to keep these meetings short, sharp and
focused and lasting no more than 60 minutes.
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The Audit Leader will compile the draft audit report with the findings and conclusions.
The report will comprise;
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Introduction: Information regarding the BU and Projects audited, the specific audit
dates (inclusive of those for preparation and post-audit activities), TOR (as an
attachment to the report), Company expectations regarding the audit follow-up
Audit Findings: All audit findings, the listing will be inclusive of the codes relating to
potential risk level. This risk rating will be the equivalent of the priority for corrective
action
Note:
In order to limit the size of the Audit reports, these should not contain appendices such
as organograms, technical diagrams, extracts from manuals/procedures, etc. However, if
specifically required in the context of some of the audit findings, it suffices for the Audit
Report to refer to these documents. Under special circumstances, the Audit report may
include information on where the documents are located.
The audit report must reflect the contents of the Management Audit Presentation,
and vice versa if necessary.
If the audit report reflects a more negative picture than was presented initially, the
Principal Auditee may decide not to accept the report. In the longer term, a repeat of
such instances will affect the credibility of the Lead Auditor or even the audit process
as a whole.
For purposes of brevity, all audit findings will be named ‘Gap’ and must relate to
the gaps/weaknesses which have been identified for the Expectations, and must
provide the detail as required by the Principal Auditee to develop rectification
action plan.
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Each audit finding should be stand-alone. The reader should be able to interpret
the recommendation without having to relate to the body of the audit report, the
audit Checklists or any other working papers.
Each audit finding will reflect the potential risk level of the gap, which, in turn
reflects the priority for corrective action i.e. H – High; H/M - High/Medium; M –
Medium; L - Low.
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The audit finding must not make any reference to possible methods for rectifying
the audit gap i.e. the Principal Auditee is responsible for determining the most
effective solutions and specific remedies to the reported gaps and must address
each of these in writing. He must propose an audit follow-up action plan, which
includes timing and resources. Alternatively he must demonstrate why the gap
exists and why the associated risk is acceptable.
A unique numbering system will be used as to allow identification of each of the
audit findings in the context of the particular HSEMS Element, Sub-element and
Expectation.
As a general rule, audit findings with (L) low risk rating will be omitted from the
report. Time permitting, and on specific request by the Principal Auditee, they
may be provided as a separate list.
The Audit Leader will issue the draft report for review by HSE Audit Coordinator and
the Principal Auditee within one week of finishing the site audit. The purpose of this
review is to ensure that the report is factually correct. The Principal Auditee is
responsible for ensuring that appropriate management and site personnel in the
audited organization review the report.
Auditee comments should be returned within 14 days to the business division,
business unit and Project Audit Coordinator, who will review and consolidate these
prior to discussing these with the Audit Leader.
Upon receipt of the consolidated comments, the Audit leader will finalize the report.
As a general rule, finalized audit reports should be issued within 15 days of
completing the onsite audit activities.
The business division, business unit /Project HSE Audit Coordinator will distribute the
final report as follows:
A full report, with attachments, to the Principal Auditee or any number of full
reports agreed between Principal Auditee and Audit Leader. The Principal
Auditee is responsible for distributing the report within his own organization.
A full report, with attachments, to the Corporate, business division /business unit/
Project HSE depending upon the level of audit
A full audit report of specified audit level shall be shared and presented to the
steering committee respective members if required.
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The Corrective Action Plan must relate to the documented audit findings of the
identified gaps/weakness. The findings must provide the detail as required by the
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The Principal Auditee is responsible for preparing the action plan to correct the audit
findings. Formulating the plan should be completed within 15 days of issuance of the
final audit report. The plan must address:
SMART (Specific, Measurable, Achievable, Realistic and Time-based) actions to
correct each audit finding, in sufficient detail so that all steps are clearly
understood.
Assignment of responsibility for each action to specific personnel or groups
Provision for sufficient resources i.e. manpower and finance
The estimated completion timing for each step
Audit Coordinator will assist in preparing the plan through clarification of the
documented audit findings and suggesting possible corrective actions.
All audit findings should preferably be agreed between the Audit Leader and the
Principal auditee prior to issue of the final audit report. Nevertheless, there may be
occasions when:
The Principle Auditee disagrees with one or more audit finding(s).
The Principal Auditee agrees with one or more finding(s), but concludes that no
corrective action is required i.e. the risk is acceptable and can be justified.
In these circumstances the Principal Auditee must provide documented reasons
for the disagreement or the rationale for not taking corrective action. The
documentation must include the case study/risk analysis and cost benefit
analysis. Also, this disagreement or risk acceptance must:
Be approved by an appropriate level business division/ BU/Project management
of the audited business division/BU or project.
Be documented in the corrective action plan
Be copied to the business division/ BU/Project HSE Audit Coordinator.
The Principal Auditee is responsible for ensuring timely completion of the corrective
actions, and must provide status reports to the HSE Audit Coordinator of each
corrective action. If applicable, the status reports must provide suitable explanation
why scheduled completion dates are missed.
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The HSE Audit Coordinator and Audit Leaders must conduct periodic reviews of
actual follow-up to audits. To this effect, they will conduct on-site visits to previously
audited business divisions, BUs or projects to confirm factual completion of actions.
These reviews will be conducted for up to 25% of the audits conducted each year
Such reviews will generally consist of an on-site meeting with appropriate personnel,
a review of documentation and a brief site tour to review selected actions taken to
correct audit findings.
Persons conducting these reviews will provide formal feedback to business divisions/
BU/Project management on appropriateness and effectiveness of the corrective
actions.
The HSE Audit Coordinator will use the results of these reviews for improving the
audit and follow-up process and procedures.
Upon receipt of action follow up close out and CAR report by the Principal Auditee
that all corrective actions have been completed, the HSE Audit Coordinator will issue
a formal audit close-out memo, with distribution as follows:
Business division/ BU/Project Principal Auditee
Business division/ BU/Projects HSE Manager
HSE steering Committee members from different business divisions, BUs if
applicable.
The issue of the formal audit close-out memo may be subject to a follow-up review.
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Doc. No.: Annexure-A
HSE Audit TOR Rev.: 00
Date: June 22, 2016
Page 1 of 2
Introduction: ________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Objective: ____________________________________________________________
______________________________________________________________________
______________________________________________________________________
Scope: _______________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Reporting: ____________________________________________________________
______________________________________________________________________
______________________________________________________________________
Principal Auditee
Audit Coordinator
HSE Auditor
HSE Auditor
Agreed by:
Signature: Date:
1 1 2 3 4 5 6 7 8 9 10 11 12
This document is the Intellectual Property of Descon Integrated Projects (Private) Limited. Any unauthorized use, including the modification and reproduction of the content is strictly prohibited. © Copyrights Ordinance 2011, All Rights
Reserved.
Doc. No.: HSE/FRM-26
Rev.: 00
Audit Interview Schedule Date: June 22, 2016
Page 1 of 1
Audit Team
Project Staff to be interviewed
Lead Auditor Auditor Audit Team member
Ref
Name Project/Position Name Name Name Name Name Name
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1 Project Manager
2 Site Manager
3 CM Mechanical
4 CM Electrical
5 CM Civil
6 CM I&C
10 E & P manager
11 Workers
12 Workers
13 Craftsman
14 Craftsman
Date/Time :
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Principle Auditee :
Source of finding Type/Category
Audit/Level of Audit Major Non-Conformance
Management Walk around Minor Non-Conformance
Near Miss (high Potential) Observation
Incident
HSE Focused Inspection
Closure Status
HSE Action Open Closed By : _________________
HSE Action Closed
Date: _________________
FOLLOW UP STATUS
RECOMMENDED ACTION (Audit date & brief
description with new
Description Finding
SR TARGET REMARK target date if required)
of Category ACTION BY
NO. DATE S
Findings H/M/L Corrective Preventive
Action Action
NO.1 NO.2
This document is intellectual property of Descon Engineering. Any unauthorized use, including the modification and reproduction of the content is strictly prohibited.
© Copyrights Ordinance 2002, All Rights Reserved.
Doc. No.: HSE/FRM-28
Rev.: 00
Date: June 22, 2016
HSE AUDIT REPORT Page 2 of 2
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DISTRIBUTION:
1. __________________ 4. ________________
2. __________________ 5. ________________ INCHARGE SITE HSE PM/SM
3. __________________ 6. ________________
This document is intellectual property of Descon Engineering. Any unauthorized use, including the modification and reproduction of the content is strictly prohibited.
© Copyrights Ordinance 2002, All Rights Reserved.