1. Introduction to Auditing
2012 Safety Groups – Advantage Program
Tom Welton
March 30, 2012

2. Overview Objective The Basics Audit Process Management Case Study
Principles of Auditing
Audit Process
Preparation & Initiation
Document Review
Evidence
Findings
Management
Management Review
Action Plan
Case Study
2012
Safety Groups
Introduction
To Auditing

3. Objective
To provide you an introduction to the basic process of conducting an audit of your Health and Safety Management System. 3

4. What is a HSMS? Health and Safety Management System (HSMS)
The Basics
What is a HSMS?
Health and Safety Management System (HSMS)
The documented process that fully incorporates effective risk management principles into a health and safety program.

5. The Basics
What is auditing?
The systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled

6. Other Audits Workwell Audits
The Basics
Other Audits
Workwell Audits
Compliance Audits (against legal requirements)
Combined Audits (for example, H&S and Environment)
Risk Audits/Risk Assessments
Workplace Inspections
Pre-start-up Inspections
Subject Specific – for example:
RTW Self-Assessment
Confined Space Audit/Assessment
Emergency Preparedness & Response Audit
Second party audits (for example, customers or suppliers) 6

7. The Basics
Why audit?
To provide Owner/Senior Management with objective information on which they can react to improve their health and safety activities

8. Definitions Conformity
The Basics
Definitions
Conformity
Conformity is the fulfillment of the audit criteria which includes requirements of an audit standard, the workplace’s health and safety policies, practices, procedures and related documentation.
Nonconformity
Nonconformity is the non-fulfillment of, or deviation from, the requirements. It is categorized as Major and Minor. 8

9. 5 Steps to Managing Health & Safety
The Basics
5 Steps to Managing Health & Safety
The 5 steps apply to the Advantage Program requirements
The 5 steps apply to each element of the HSMS Review and must be documented/recorded for each

10. Principles of Auditing
The Basics
Principles of Auditing
Audit Scope
Extent and boundaries of an audit
Note: The audit scope generally includes a description of the physical locations, organizational units, activities and processes, as well as the time period covered.
Audit Criteria
Audit criteria are used as a reference against which audit evidence is measured. In the WSIB Advantage Program the criteria includes; the requirements documented in the HSMS Review Form and the firm’s health and safety program, policies, procedures and related documents. 10

11. Principles of Auditing (cont’d)
The Basics
Principles of Auditing (cont’d)
Audit Evidence
Records, statements of fact or other information, which are relevant to the audit criteria and verifiable. (minimum two different sources of evidence).
Audit Findings/Conclusions
Results of the evaluation of the collected audit evidence against audit criteria.
Note: The audit findings can indicate either conformity or nonconformity with audit criteria.
Auditing relies on these principles to make it effective and reliable. 11

12. Key Concepts What is Auditing
The Basics
Key Concepts
What is Auditing
The systematic, independent and documented process for obtaining audit evidence and evaluating it objectively against established audit criteria
Why Audit
To provide Owner/Senior Management with information on which they can react to improve their health and safety activities 12

13. Key Concepts Auditing Principles
The Basics
Key Concepts
Auditing Principles
Scope – extend and boundaries of an audit
Criteria – a set of established requirements the audit evidence is evaluated against. The criteria for Advantage firms is - HSMS Review Form and the firm’s H&S program, policies, procedures and other related documents.
Evidence – records, statements of fact or other information, which are relevant to the audit criteria and verifiable (minimum two sources of information)
Findings – evidence compared to criteria 13

14. Audit Process
Key Concepts
An audit is conducted in a systematic manner and requires preparation
Document Review collects information to help determine if the audit criteria are being met by the firm 14

15. Audit Process
Key Concepts
There are multiple sources of evidence: documents, records, interviews and observations
Auditor(s) need sufficient information before it is considered evidence
Recorded evidence is evaluated against established audit criteria to determine objective audit findings
Finding of conformity or nonconformity (major or minor)
Nonconformities are situations where a requirement clearly has not been fulfilled with evidence based on objective facts 15

16. Key Concepts The audit report can be recorded on the HSMS Review Form
Management
Key Concepts
The audit report can be recorded on the HSMS Review Form
Other styles of audit reports can be used, as long as they include all nonconformities found and relate it to the criteria requirements
Report any commendable HSMS findings
Management Review can be formal or informal
Owner/Senior Management must understand and agree to the audit findings/conclusions. Any diverging opinions are recorded if not resolved. 16

17. Management
Key Concepts
All nonconformities are included and initiated in the action plan
Conformities can be included in the action plan for continual improvement
Resolving nonconformities and verifying they are resolved are done after audit activities 17

18. The Audit Process The Basics Document Review Evidence Findings
INITIATING
CONDUCT THE AUDIT
AUDIT REPORT
MANAGEMENT REVIEW
ACTION PLAN
Document
Review
Evidence
Findings

19. Initiate and Prepare Management assigns the qualified auditor(s)
Audit Process: Initiate
Initiate and Prepare
Management assigns the qualified auditor(s)
Develop an audit plan which includes:
Objectives, Scope, Criteria, Schedule
Resources:
Time
Audit support (team)
Health and Safety Equipment (PPE)
Floor Plan, Equipment List, Work room
Audit working documents (audit notes/sketches/interview notes etc.)
Communicate the audit activity to appropriate workplace parties 19

20. Document Review Documents and Records
Audit Process: Conduct the Audit
Document Review
Documents and Records
A document may be a policy, a procedure, a work instruction, a form, or other written information, that generally gives direction.
A document is current, active and changeable.
A record is dated, historical, and unchangeable. (An obsolete document may become a record). 20

21. Document Review First step in Conducting the Audit
Audit Process: Conduct the Audit
Document Review
First step in Conducting the Audit
Establishes initial conformity to the audit criteria
Determines other types of evidence the auditor(s) will sample 21

22. Forms, checklists, templates, & other “data collection” documents
Audit Process: Conduct the Audit
Document Review
Policy
System Procedures
Operating Procedures
Work Instructions
Forms, checklists, templates, & other “data collection” documents
RECORDS
Level 1 Docs What? (some why?)
H&S Policy Statement
H&S Policy Manual (optional)
Level 2 Docs 5W’s & H of system
Typically addresses each WSIB HSMS Requirement “Big Picture” (may be organized by “processes”)
Level 3 Docs - more details of 5W’s & H
Typically organized by department
Level 4 Docs detailed How
Task Specific Instructions

23. Audit Process: Conduct the Audit
Audit Evidence
Auditor(s) look for evidence that demonstrates requirements have been met.
The sources of information gathered are grouped into these categories:
Documents verify relevant, clear and complete procedures, work instructions, guidelines, etc., are readily accessible
Records: verify appropriate records have been kept to demonstrate that requirements of procedures and the standard have been met
Observations: verify activities, workplace conditions, controls are in place
Interviews: verify health and safety system/program understanding. 23

24. Audit Process: Conduct the Audit
Audit Evidence
If all available sources of information (minimum 2) are consistent then the information may be considered evidence of conformity. Inconsistent information is evidence of nonconformity.
Evidence is measured against the audit criteria to determine conformity or nonconformity 24

25. Audit Evidence Collecting and Verifying Information:
Audit Process: Conduct the Audit
Audit Evidence
Collecting and Verifying Information:
Review Documents and Records
Note details of documents and records reviewed
Observations while at the facility and throughout the audit
Note relevant observations that demonstrate conformity and nonconformity
Interviews during the facility tour and throughout the audit
Conduct interviews appropriate to the situation and the person
Interview people from appropriate levels and functions
Make notes of evidence of conformity and nonconformity
Summarize the results of the interview with the person 25

26. Audit Evidence Collecting and Verifying Information:
Audit Process: Conduct the Audit
Audit Evidence
Collecting and Verifying Information:
How much is enough?
Sufficient to demonstrate a consistent pattern of conformance
One piece might be enough, for example:
maybe only one incident occurred so there will be only one investigation report
observed one failure to use confined space procedure;
only one work instruction
Perhaps 10 to 50 pieces may be appropriate, for example:
monthly workplace inspections
pre-shift forklift inspections 26

27. Audit Findings Generating Audit Findings/Conclusions:
Audit Process: Findings
Audit Findings
Generating Audit Findings/Conclusions:
Evaluate all audit evidence against audit criteria
During the audit, evidence must be presented that the criteria are in place for conformity. If any requirement is not met, a nonconformity is noted.
Audit findings/conclusions indicate conformity or nonconformity to criteria
Note: Any corrective actions to a nonconformity does not change the audit finding/conclusion. 27

28. Audit Conclusion Conformity
Audit Process: Findings
Audit Conclusion
Conformity
Conformity is the fulfillment of the audit criteria which includes requirements of an audit standard, the workplace’s health and safety policies, practices, procedures and related documentation.
Nonconformity
Nonconformity is the non-fulfillment of, or deviation from, the requirements. It is categorized as Major and Minor. 28

29. Audit Conclusions MAJOR nonconformities: MINOR nonconformities:
Audit Process: Findings
Audit Conclusions
MAJOR nonconformities:
the issue will continue to occur because of how the HSMS and health and safety program are structured
there is unacceptable risk to a worker’s health or safety
there are serious legal implications, or
there is an accumulation of related minor nonconformities.
MINOR nonconformities:
the HSMS and the health and safety program structures are valid, but there was minor deviation (e.g. human error)
there is no unacceptable risk to the worker
there are no significant legal implications, and
there is not an accumulation of related minor nonconformities. 29

30. Management: Audit Report
The report must reference the requirement (i.e. A.2), and the evidence that supports the findings/conclusions of conformity and nonconformity
Indicate any situations encountered that may decrease the reliability of the audit conclusion
Diverging opinions about findings and conclusions should be discussed, resolved if possible, and recorded if not resolved
The report must include the date(s) of the audit, report date, auditor(s) name
Auditor(s) prepare to present or discuss the audit with the Owner/Senior Management
Note – For Advantage the completed HSMS Review Form can be the report submitted for Management Review. 30

31. Management Review Owner/Senior Management reviews the audit report
Ensure the Owner/Senior Management agrees with and understands the audit conclusions
A record of the Owner/Senior Management review
Establish a timeframe for the employer’s continual improvement plan 31

32. Action Plan As a result of the audit findings/conclusions:
Management: Action Plan
Action Plan
As a result of the audit findings/conclusions:
An action plan is developed for all nonconformities
The action plan outlines how nonconformities will be corrected, responsibilities assigned and timelines established.
The action plan is developed or reviewed, approved, resourced and initiated by the Owner/Senior Management.
The employer’s auditor(s) may conduct follow-ups to ensure the element is progressing to conformity
Note – for the Advantage Program the continual improvement plan is the action plan. 32

33. Action Plan An action plan can also be used for continual improvement
Management: Action Plan
Action Plan
An action plan can also be used for continual improvement
When a criteria requirement is met, but may deteriorate into a nonconformity, the audit may indicate an opportunity to improve.
Continual Improvement
The process of enhancing the HSMS to achieve ongoing improvement in overall health and safety performance.
Improved performance on its own IS NOT continual improvement, it is an outcome – you must improve the way you manage. 33

34. Year-End Submission 34

35. Case Study