WSH Audit Report

COMPANY XXXX OPENING AND CLOSING ADDRESS MEETING ATTENDANCE 

Company XXXX Safety & Health Management System Audit Opening Meeting was held on Thursday , 20 July  2013 @ 0900 am at the  Company XXX  Board Room.

Opening address meeting attendees:

Name	Job Title	Signature	Date
Robert Tan Eng How	Operation Manager	ROBERT	20 July 2013
Richard Ong	Production Manager	ROng	20 July 2013
Bahrin Shah	Maintenance Manager	Shah	20 July 2013
Ng Say Thoong	Facility Manager	Ngg	20 July 2013
Victor Tan	Safety Manager	Vickie	20 July 2013

 Company XXXX Safety & Health Management System Audit Closing Meeting was held on Thursday , 21 July  2013 @ 1130 am at the  Company XXXX  Board Room.

Closing address meeting attendees:

Name	Job Title	Signature	Date
Robert Tan Eng How	Operation Manager	ROBERT	20 July 2013
Richard Ong	Production Manager	ROng	20 July 2013
Bahrin Shah	Maintenance Manager	Shah	20 July 2013
Ng Say Thoong	Facility Manager	Ngg	20 July 2013

 

  FINDINGS AND RECOMMENDATIONS

       

Element 1	Audit Criteria	Audit Findings		Recommendation
Safety Policy	Singapore Standard SS 506 Part 3 : 2006 Occupational safety and health (OSH) management system – Requirements for the chemical industry	Company XXXX SGP safety policy is adopted from its US parent company .Though Company XXXX Safety policy comply with Singapore Standard SS 506 Part 3 : 2006 Occupational safety and health (OSH) management system – Requirements for the chemical industry , it does not mean that the adopted safety policy is appropriate to the nature and scale of its Singapore operation in view of the country difference in which Company XXXX operates   Due to diverse business operations needs and different cultures between Singapore and US. There is a need for Company XXXX to establish its own identity and develop its own safety policy contingent and applicable to its own culture and manufacturing operations		Company XXXX SGP to establish their own safety policy taking into consideration both the internal and external factors that would affect it’s WSH policy.   Company XXXX senior management should immediately appoint one management representative , preferably the senior management level staff to over-see the development of the safety policy and prescribe the management representative with the responsibility to chair meeting and to report all progress and achievements on the development of the safety policy   Once the senior management staff has been appointed as the management representative, He/she should work with the safety department to establish realistic and achievable WSH goals, objectives and target at departmental level for those KPI with poor performance and to establish  & prescribe WSH roles and responsibility for worker, supervisor, engineer, manager and senior management  level staff
Element 2	Audit Criteria		Audit Findings	Recommendation
Safe Work Procedure	Singapore Standard SS 506 Part 3 : 2006 Occupational safety and health (OSH) management system – Requirements for the chemical industry		Sampled check on Company XXXX  high risk activities such as the two roll mill operations, hot works and steam boiler Preventive Maintenance as well as working on building roof top revealed each has an established safe work procedure and risk assessment.   To control the high risk activities and non routine activities undertaken by contractors, west has a Permit to work system to monitor and control the high risk activities as well as designating one west employee as the project coordinator over-seeing all activities until the project completed. Unfortunately , Company XXXX is still adopting the 3x3 risk assessment matrix which is not as effective as a 5x5 matrix in that the risk of the hazards cannot be interpreted representatively due to fewer risk options available for a 3x3 risk assessment matrix. In addition, the risk assessment for individual department were undertaken individually without cross functional collaborative efforts   In addition Company XXXX has established safety rules and regulations to enforce safe work behaviour in the workplace among its employees. However, the safety rules and regulations were established without taking into consideration the Current WSH behaviour of its employee, the WSH performance and changes in the WSH regulations and other related legal requirements	Company XXXX should establish a risk assessment team which is made up of cross functional employees with different background, knowledge and experience with the objective to ensure that no hazards from any aspect are left undetected   The risk assessment team shall be place under the care of  Company XXXX WSHO who will be the risk assessment leader.   Upon the establishment of the risk assessment team, west should undertake all risk assessment study using the 5x5 risk assessment matrix rather than sticking to a 3x3 matrix due to the fact that a 5x5 matrix provide the opportunity for tracking the implementation of the safety control measures, track the Responsible person who is following up on the action item and also tracking the effectiveness of the implemented control measure   On Company XXXX safety rules and regulations, Company XXXX  should rewrite their safety rules and regulations not least because they are outdated and the safety rules and regulations were established without taking into consideration the Current WSH behaviour of its employee, the WSH performance and changes in the WSH regulations and other related legal requirements
Element 3	Audit Criteria		Audit Findings	Recommendation
Safe Training	Singapore Standard SS 506 Part 3 : 2006 Occupational safety and health (OSH) management system – Requirements for the chemical industry		Company XXXX employee’s WSH competency fulfilled the Factory ( Safety Training Order) regulations as review on Company XXXX employee training record revealed that mandatory training of forklift training, mobile elevating platform, First Class Boiler Attendant and working at height for both worker and supervisor were all complied with   Company XXXX analysed its employees training needs at different levels of the organization which include workers, supervisor and managerial level. Unfortunately, Company XXXX failed to identify the training needs of departmental managers who are in fact the leaders of their department. And these managers would be the one driving the WSH performance of Company XXXX	Company XXXX has procedure to analyse the training needs of its employee from worker level, supervisor level to manager level.   Unfortunately little is done to analyse the training needs of the manager level employees.     Management training needs cannot be neglected as they are the leaders of their own department and are typically the one who drive the WSH performance of their own department   Company XXXX should consider the following training courses in the pipeline for their manager level employees which include   a)Safety and Health Management system audit b)Quantitative Risk Assessment c)Project Management d)Behaviour safety management  etc   Company XXXX should conduct survey with regards to the employee training needs and from the survey, tabulate the training needs of the workforce and match these training needs with the regulations requirement together with the safety department
Element 4	Audit Criteria		Audit Findings		Recommendation
Group Meeting	Singapore Standard SS 506 Part 3 : 2006 Occupational safety and health (OSH) management system – Requirements for the chemical industry		Company XXXX has established WSH safety committee team where the team members were made up of cross functional department representative.   The team met up once in a month to discuss issues relating to the organization safety and health   These members also assisted in communicating pertinent HSE information to both employees and contractor. Example is the display of the safety committee team for year 2013 to create awareness among employees   Typical communication mode involve the use of email and bulletin board. Or present during the production toolbox meeting To communicate the changes in the local WSH regulations   Review on the current safety inspection reports show it was authored by the WSH secretary who is a qualified WSHO with relevant qualification ,skills, knowledge and attitude.   Unfortunately sampling check on the WSH safety committee team WSH competency revealed none of the member were trained in the WSH ( Safety Committee team) regulations for their roles and responsibilities and the basic investigation skills		Company XXXX should review the WSH competency level of its WSH safety committee team members by undertaking training needs analysis of these group of people with the intention to send them out for external training to equip them with the knowledge,skills and attitude to assume their role as WSH safety committee team members helping west to proactively manage its workplace WSH.   Similarly, the WSH Safety committee team members should be replace yearly once the member one year terms is up with the objective to further spread the WSH knowledge and skills to more people within west organization as review on current WSH safety committee team revealed few members still in the team despite having served a 2 year term
Element 5	Audit Criteria		Audit Findings	Recommendation
Incident Investigation & Analysis	Singapore Standard SS 506 Part 3 : 2006 Occupational safety and health (OSH) management system – Requirements for the chemical industry		Company XXXX has an incident investigation & analysis procedure .   The procedure define the responsibility of employee ,supervisor ,WSH personnel , investigation team and  leveraging on external subject matter of experts should situation require.   Role of employee to report accident /incident upon its occurrence.   Role of supervisor (where the accident/incident is reported) to preserve scene & collect evidence at accident/incident scene and conduct preliminary investigation by putting up the accident/incident investigation report before handing over to the WSHO   Role of WSHO is to verify the information in the accident/incident report, initiate meeting with relevant stakeholders which may include cross functional department to leverage on their knowledge to establish the cause and effect analysis to understand the probable causes of the accident, before the 5 Why Analysis to establish the root cause of the accident   For complex cases, WSHO will enlist external subject matter of experts for their opinions   Upon established the root cause of the workplace accident/incident, the WSHO will seek consultation with the investigation team on the appropriate CAPA to recommend to ensure the CAPA effectiveness	Company XXXX  depends very much on their WSHO for all its workplace accidents/incidents reported within west Company XXXX  as document review had revealed the investigation team members did not received any formal training on investigation, the use of investigation tools to identify the probable causes and root cause of an workplace accident   To show the top management commitment to west WSH, specifically the top management commitment in the safety policy, the top management should set aside certain amount of budget for WSH training for its employees to increase their human capital and knowledge in proactively managing Company XXXX WSH performance   On the WSH accident statistics, west seem to have one workplace accident reported almost on every month and review on the accident/incident report revealed unsafe condition ad unsafe behaviour are the root cause of most workplace incidents.   Company XXXX workplace accident/incident can only be improved if the top management set WSH objectives, goals and target to stimulate improved WSH performance within the workforce and prescribed safety rules and regulations to control unsafe behaviour and implement a HSE reporting system for employees to report unsafe conditions in the workplace and to reward & recognise employee for their WSH contributions and commitments
Element 9	Audit Criteria		Audit Findings	Recommendation
Safety Inspection	Singapore Standard SS 506 Part 3 : 2006 Occupational safety and health (OSH) management system – Requirements for the chemical industry		Company XXXX documents its site monthly safety inspection in words documents.   The inspection report contain information on observations, photograph, inspection criteria, action item , responsible person and due date.   Every month the WSH safety committee team focus on different issue with last month the team focus on fire protection system in view of its upcoming fire insurance inspection   The WSH Safety committee team also established the frequency of inspection schedule for the statutory equipment which are required by the Singapore Ministry of Manpower to be regularly inspected and load tested by an authorised examiner   Review on the inspection team WSH competency revealed none of them received any formal training on audit and inspection and were not competent to assume their inspector role during the site monthly WSH safety committee team inspection	Company XXXX should immediately looks into the WSH competency of their WSH safety committee team members and to provide the require training to increase their knowledge ,skills and attitude making the team members competent to assume their WSH roles. When the WSH committee team members are equip with the knowledge and skills to make them competent , west can expect that it’s workplace WSH performance will improved over the years due to proactively management of the site WSH performance by these people
Element 11	Audit Criteria		Audit Findings	Recommendation
Hazard Analysis	Singapore Standard SS 506 Part 3 : 2006 Occupational safety and health (OSH) management system – Requirements for the chemical industry		Company XXXX use Qualitative Risk Assessment 3x3 matrix for hazard identification, and risk assessment and the implemented control measures are based on the hierarchy of control   Document review on west high risk activities such as the steam boiler ,hot works and 2 roll mills operations revealed that each have a risk assessment and the sampled activity with medium residual risk level , each were implemented with SWP   However documentation review on the risk assessment register of most department revealed that the risk assessment were undertaken by the individual department and there is no cross functional collaboration among departments to identify the hazards collectively and to ensure no hazards are being oversight nor left out	Company XXXX should relook into their risk assessment methodology in identifying the workplace hazards/risks associated with its manufacturing operations.   Pursuant to the WSH (Risk Management) Regulations, it is a legal requirement by law that west should formed a risk assessment team which comprises of employees of different background cross functionally.   The risk assessment team would be under the care of the risk assessment leader who is usually the site WSHO   Upon formation of the risk assessment team, Company XXXX should provide the necessary training to equip the team with the knowledge ,skills and attitude for them to better assume their WSH roles in particular as risk assessment team members   When Company XXXX has a team of capable and competent risk assessment team , west can expect reduction in their workplace accidents/incident over the years as the team would have tidy up the workplace operating procedures

 

PHYSICAL INSPECTION

Site physical walkabout inspection as per audit plan led by Company XXXX Audit Coordinator, Mr Daniel Phong together with the lead auditor and the team auditor was undertaken in Company XXXX external facility and the respective production shop floors on  20/7/2013 @ 1000 am.

The objective of the inspection is part of the audit schedule to provide an overview of Company XXXX facility to the auditors and also for the auditors to gather evidence on Company XXXX implementation of the Safety and health management system

Inspection checklist were used by the auditors to assess Company XXXX Safety and Health
Management  System based on the auditors observations and evidences gathered during
the inspection

During the inspection, many observations were recorded where some are good proactive
safety  measures which deserves to be complimented while others are identified as areas
that needs further improvement

To ensure that Company XXXX best work practices is not confined to just it’s organization, it will be made  mentioned in this audit report

GOOD SAFETY MEASURES OBSERVED IMPLEMENTED ON SITE 

The following are observations which are worthy to be mentioned in this audit report due to
the commitments of West Management in improving its WSH performance and also its
exemplary work practices in creating a safe and healthful work environment

Inspected Area	Observation	Photograph	Audit Findings
Dust Collector	A safe working platform was observed parked beside west pharmaceutical dust collectors  It was understood that the work platform is meant for safe access and egress of personnel  to and fro from the dust collectors  Even though it is just a work platform, west goes to the extra miles by making sure that the work platform comply with Singapore Standard CP 27 : 1999 Code of Practice for Factory Layout - Safety, Health and Welfare consideration                        specifically Safe means of access and safe place of employment  For every staircase in a building or affording a means of exit from a building, a substantial handrail shall be provided and maintained, which , if the staircase has an open side, shall be on that side, and , in the case of a staircase having two open side, such a handrail shall be provided on both sides. Any open side of a staircase shall also be guarded by the provision o a lower rail or other effective means	N.A	Company XXXX proactive WSH management is evidently seen on the design of the work platform for safe access and egress of personnel

Inspected Area	Observation	Photograph	Audit Findings
Toolshop /Maintenance Lifting equipment, gears, accessories and appliances	During the inspection in the tool shop and maintenance workshop, the inspection team observed West has in place a system to proactively managed the site WSH performance and this include:  Statutory equipment inspection monitoring chart – to monitor the statutory equipment inspection and testing requirement by authorized examiner   Monthly WSH Safety Committee Team Inspection Schedule   -to monitor the site progress especially for areas/facility which requires the WSH Safety Committee team inspection and also to ensure no areas/facility are left un- combed or left not-inspected		West commitment in proactive WSH management is evidently seen in how they managed their statutory equipment inspection and testing by authorised examiner as well as how it planned out its site WSH Safety Committee team inspection to ensure no areas are left un-combed  or left not-inspected

 

 

Statutory Equipment Inspection Monitoring Chart

S/N	Item Description	Frequency of inspection	Responsible person	WK1	WK 2	WK3	WK4	Remarks
1	Lifting Machines	Once in every 6 months	Authorized Examiner	Refer to Maintenance Preventive Maintenance Program Chart
2	Lifting Gears	Once in every 12 months	Authorized Examiner	-do-
3	Lifting Appliance	Once in every 12 months	Authorized Examiner	-do-
4	Hoist	Once in every 6 months	Authorized Examiner	-do-
5	Air Receiver	Once every 24 months	Authorized Examiner	Refer to Maintenance Preventive Maintenance Program Chart
6	Scaffold Inspection	Weekly After Stormy Weather	Scaffold Supervisor	-do-
7	Temporary Electrical Installation Check	Monthly	Licensed Electrical Worker ( LEW)	-do-
8	WSH Committee Inspection	Monthly	WSH Committee Members	-do-
9	Environmental Control	Fortnightly	ECO	-do-
10	Toxic Industrial Waste Weekly Inventory Register	Weekly	WSH Committee Members	-do-
11	Toxic Industrial Waste Annual Inventory Register ( to ensure waste qty generated is less than the schedule)	End 31 Dec	WSH Committee Members	Refer to Maintenance Preventive Maintenance Program Chart
12	Steam Boilers	Once every 2 years	Authorized examiner	Refer to Maintenance Preventive Program Chart
13	Steam Receivers	Once every 2 years	Authorized examiner	-do-
14	Abrasive Blasting machine	Once in every 7 days	Competent Person	-do-
15	Incident Reporting	Within 10 Days	Supervisor of injured worker	-do-

 

Monthly Site Safety Inspection Schedule

	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
		1	2	3	4	5	6
AM	Monthly inspection of fire extinguishers	Weekly inspection of Scaffold	Weekly inspection of lifting gears		Weekly inspection with WSH Committee	Monthly inspection of fire extinguishers
PM	Monthly inspection of lifting gears		Weekly inspection of work tools	Monthly inspection of First Aid Box		Monthly inspection of lifting gears
	7	8	9	10	11	12	13
AM	Weekly inspection of work tools		Weekly inspection of Scaffold		Weekly inspection with WSH Committee
PM	Weekly inspection of lifting gears	Bi weekly inspection of Electrical SOAs				Bi weekly inspection of Electrical SOAs
	14	15	16	17	18	19	20
AM			Weekly inspection of work tools		Weekly inspection with WSH committee	Weekly inspection of lifting gear
PM	Monthly inspection with Safety Committee		Weekly inspection of Scaffold				Monthly inspection with Safety Committee
	21	22	23	24	25	26	27
AM	Weekly inspection of lifting gear			Weekly inspection of work tools		Bi weekly inspection of Electrical SOAs
PM		Weekly inspection of Scaffold			Weekly inspection with WSH Committee
	28	29	30	31
AM	Weekly inspection of lifting gear		Weekly inspection of Scaffold	Weekly inspection of work tools
PM

 

 

 

 

 

 

 

Audit plan

INTRODUCTION

Company XXXX is a global manufacturer of polymeric medical grade components and systems for injectable drug delivery, including stoppers, seals for vials, and closures.In view of Company XXXX varying customer’s products dimensional and functional requirements, it’s facility stored and employed significant amount of hazardous and flammables chemicals for it’s manufacturing operations.

Similarly to power and fuel up it’s utility and manufacturing operations, Company XXXX house statutory equipment such as the steam boilers, pressure vessel ,  air compressor and cooling tower in its site located at XXXX.

Following two fatal accidents and numerous safety lapses reported in its manufacturing site prompted Company XXXX Director to formally invite the HSE Consultancy and Services Pte Ltd to conduct an audit on it’s Safety and Health Management System to identify the strengths and weaknesses of its Safety and Health Management System

OBJECTIVE

The purpose of the Safety Management System audit is to assess Company XXXX Safety Management System Manual based on the WSH Act and its subsidiary legislation as well as the Singapore Standard SS 506 Part 3 : 2006 Occupational safety and health (OSH) management system – Requirements for the chemical ,by gathering evidence on System Implementation through Sampling, Document Review, Interview of Personnel and Physical Inspection.

SCOPE

The scope of this audit was limited to assessing 7 Elements out of the 14 Elements of Company XXXX Safety and Health Management System

The Safety and Health Management System Elements Assessed are tabulated below

Element #	Element Description
Element 1	Safety Policy
Element 2	Safe Work Procedure
Element 3	Safety Training
Element 4	Group Meetings
Element 5	Incident Investigation and Analysis
Element 9	Safety Inspections
Element 11	Hazard Analysis

 

The Safety and Health Management System audit is undertaken in Company XXXX located at XXXX

The Auditee site comprised of the following utilities and facilities which will be inspected
on site during the scheduled audit from period 20 July 2013 to 21 July 2013

 

Utilities / Facilities located in Company XXXX

Steam Boiler

Air Compressor room

Autoclave

Toxic Industrial Waste Storage

Chemicals Storage

Flammable Chemical Storage

Steam Boiler

Air Compressor room

Cooling Tower

Dust Collector

 

AUDIT CRITERIA

The audit criteria strictly adhere to the Ministry of Manpower Guidelines on the Audits of Safety and Health Management System where the audit on the SHMS is conducted in accordance with the relevant WSH legislation and guidelines set out for each industry.

The audit on the SHMS is based on the WSH Act and its subsidiary legislation as well as the Singapore Standard SS 506 Part 3 : 2006 Occupational safety and health (OSH) management system – Requirements for the chemical industry

AUDIT PROTOCOL

The following on-site SHMS audit protocols are to be observed by the auditors. And the activities involve in each phase is tabulated under audit methodology

·         Pre-audit Activities

·         On-Site Audit Activities

·         Post Audit Activities

 

AUDIT METHODOLOGY/PROCESS

The conduct of the Safety and Health Management System in Company XXXX involve various phases, which include the pre-audit phase, audit phase and post audit phase activities

Tabulated below is the list of activities undertaken during the various audit phases

 

Audit Phase	Activities	Responsibility	Timeline
Pre-Audit Phase	Gathering of background information from audited organization using pre-audit questionnaires and obtain previous year audit report	Lead auditor email organization   Audited organization furnish the organization background information as per established questionnaire	2 weeks
	Developed audit plan and audit schedule upon received required information from the organization	Lead auditor	1 weeks
Pre-Audit meeting with Auditee	Pre-site visit by lead auditor to confirm the audit plan which include audit schedule ,audit sampling, audit methodology ,audit criteria	Lead auditor	1 weeks
	Notification of confirmation of audit date, audit agenda, audit plan, and audit schedule	Lead auditor	1 month
Audit Phase	Opening address -explain to auditee the audit objective, audit purpose, scope and audit methodology and identify personnel for interview	Lead auditor	-
	Familiarization tour by site audit coordinator to  provide an overall view of the site facility to the audit team	Site audit coordinator	-

 

Audit Phase	Activities	Responsibility	Timeline
Audit Phase	Documentation Review -assess site safety and health management system manual , -Safety Policy -Statutory equipment inspection schedule -WSH training records of workers, supervisors and managers -safe work procedures for high risk activities -safety committee inspection records -safety committee team meeting minutes -risk assessment of risk activities   Use of checklist to confirm findings from the assessment of the company SHMS during documentation review phase	Team Auditor	-
	Interview of Person   Interview of person which include contractors, workers, supervisors, engineers and managers for verification of information   Use of checklist to confirm findings from the assessment of the company SHMS during the interview of personnel phase	Lead Auditor	-
Audit Phase	Site Physical Inspection   Observe processes and procedures related to health and safety which include housekeeping, production processes, job task, machine, equipment function and the use of PPE etc to confirm findings gathered from the document review and interview of personnel   To ascertain actual physical system compliance in the factory   Obtain general impression of the state of the safety and health of the factory   Use of checklist to confirm findings from the assessment of the company SHMS during site physical inspection phase	Team Auditor	-
Audit Phase	Closing meeting   Closing address with site management presenting the audit findings, observations  and conclusion and allow clarification from site management   Timeline on receiving of official audit report   Timeline on the follow up of the identified action items	Lead Auditor	-
Post-Audit Activities	Preparation of draft SHMS Audit report for Company XXXX management team and give them 2 week grace period to review and comment   Issue the final SHMS Audit report 1 month from the date of actual audit   Develop Action Plan on identified audit findings by   ·         Proposed Action ·         Resolve differences ·         Establish Responsibility ·         Determine schedule for next follow up   Follow up to monitor progress of audit action progress, verification of audit action items and verification of effectiveness of action items

 

 

INTERVIEW PERSONNEL

During the interview of personnel, Company XXXX employees from different levels of the
organizational hierarchy which include company management, line management, workers,
OSH personnel and even subcontractors and suppliers are randomly selected and sampled.

The names of the interviewees were withheld and not disclosed nor published in this audit
 report for confidentiality reasons

Interview checklist developed for the purpose of assessing the SHMS Elements and designed for different levels of staffs within Company XXXX organizational hierarchy are used to assess Company XXXX SHSMS effectiveness

Company XXXX Audit Coordinator is responsible for over-seeing the coordination and the scheduling
of Company XXXX  employees for interview with the auditors.

AUDIT CLASSIFICATION

Audit Finding Classification

At the completion of the audit, the lead auditor will discuss with the team auditor to make an assessment about the findings taking into consideration both positive and negative aspects and classify the audit findings based on the following criteria

Major

An audit finding is Major if any of the following criteria apply, presenting a significant risk:

-an EHS Management System element is largely missing or its implementation is almost completely ineffective

-the site doesn’t comply with a legal obligation

-repeat findings have arisen for the same issue in consecutive audits

-a significant risk (to EHS) is present.

Minor

An audit finding is Minor if any of the following criteria apply, presenting a non-significant  risk:

-an effective but incomplete system element requires some improvements

-non-significant risk (to EHS) is present.

SUGGESTION

-A Suggestion will be made if the auditor is aware of situations which may benefit the site. This need not be limited to the scope of the audit.