Shell Confidential / EP 200_-0 ___
HSE MANAGEMENT SYSTEM AUDIT
Oil & Gas Ltd
EP_____200_.___
(December 200_)
Sponsor: ______
Team Members: ______
______
______Audit Team Leader
______
______
Approved by: ______
Date of issue: January 200__
ECCN number: Not subject to EAR-No US content
This document is Confidential. Distribution is restricted to the named individuals and organisations contained in the distribution list maintained by the copyright owners. Further distribution may only be made with the consent of the copyright owners and must be logged and recorded in the distribution list for this document. Neither the whole nor any part of this document may be disclosed to any third party without the prior written consent of the copyright owners.
Copyright 2000 SIEP B.V.
SHELL INTERNATIONAL EXPLORATION AND PRODUCTION B.V., THE HAGUE
Further copies can be obtained from the Global EP L ibrary, The Hague with permission from the author.
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EP200406364000/Tool EP2005-0180-TO-82, Version 1
EP 2000-0725 / - 1 - / Shell ConfidentialTable of Contents
1. Introduction
2. Executive Summary
2.1 Statement of Review Opinion
2.1 Assessment of HSE Management System Elements
3.Audit Findings and Recommendations
Table 3.1 Leadership and Commitment
Table: 3.2 Policy, Strategic Objectives and Sustainable Development
Table: 3.3 Organisation, Responsibilities, Resources, Standards and Documents
Table: 3.4 HEMP
Table: 3.5 Planning and Procedures
Table: 3.6 Implementation and Monitoring
Table: 3.7 Audit
Table: 3.8 Review
Appendix
A0.1.Definitions of Audit Opinions
A0.2.Classification of Findings
A0.3.Recommended Actions Ranked by Severity and Category
A0.4.Terms of Reference
A0.5.Glossary of Abbreviations
A0.6.HSE MS Assessment
A0.7.Distribution List
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EP 2000-0725 / - 1 - / Shell Confidential1. Introduction
This report presents the findings and recommendations of the audit of the ___ HSE Management System (HSE MS), carried out between ____.
The audit was conducted using EP Standard ‘ HSE Auditing’ .The Audit Terms of Reference (TOR) are included in Appendix 4.
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2. Executive Summary
2.1 Statement of Review Opinion
Using the methodology summarised in Appendix 1 the overall assessment of this HSE Management System Audit is ____, however, attention is required to correct ___ High and ___ Medium deficiencies noted.
In reaching this opinion, the team has taken into account both the seriousness and breadth of findings, details of which are presented in Chapter 3.
High Findings: ___ (classified as Few)
Medium Findings: ___
Low Findings: ___
A total of ____ recommendations (__ H, __ M, __ L) have been made to correct the gaps noted in the findings. These are listed in Appendix 3, ranked by severity and category of the associated findings.
Main Findings:
2.1 Assessment of HSE Management System Elements
Figure1: Distribution of Findings within the HSE Management System Elements
An assessment of the effectiveness of the HSE MS was made using the SIEP HSE MS Self-Assessment Questionnaire (SAQ). The main issues in each of the elements are highlighted below. See Appendix 6 for HSE MS Self Assessment details.
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3.Audit Findings and Recommendations
Note: Recorded in these tables are the Review Findings (deficiencies), together with their Significance and Recommendations as to how each deficiency might be rectified. Findings are classified as detailed in Appendix 1, and are listed in the appropriate HSE MS sub-element table.
Table 3.1 Leadership and Commitment
3.1.1Visibility
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.1.2Proactive in target setting
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.1.3Informed involvement
Reference / levl / sev / cat / ele / Finding / Significance / RecommendationTable: 3.2 Policy, Strategic Objectives and Sustainable Development
3.2.1Content
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.2.2Dissemination
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.2.3Strategic objectives and Sustainable Development
Reference / levl / sev / cat / ele / Finding / Significance / RecommendationTable: 3.3 Organisation, Responsibilities, Resources, Standards and Documents
3.3.1Roles and Responsibilities
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.3.2HSE Advisors
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.3.3Resourcing
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.3.4Competence assurance
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.3.5Contractors
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.3.6Communication
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.1.3.7Documentation – HSE MS Manual
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.1.3.8Documentation – HSE Cases
Reference / levl / sev / cat / ele / Finding / Significance / RecommendationTable: 3.4 HEMP
3.4.1Identification of Hazards and Effects (Identification)
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.4.2Evaluation (Assessment)
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.4.3Recording of Hazards and Effects (Recording)
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.4.4Objectives and Performance Criteria controls (Performance maintaining controls)
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.4.5Risk Reduction Measures (Controls and ownership)
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.4.6Risk Reduction Measures (Recovery)
Reference / levl / sev / cat / ele / Finding / Significance / RecommendationTable: 3.5 Planning and Procedures
3.5.1HSE Plan
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.5.2Asset Integrity
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.5.3Procedures and Work Instructions
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.5.4Management of Change (Change Controls)
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.5.5Contingency Planning and External Planning
Reference / levl / sev / cat / ele / Finding / Significance / RecommendationTable: 3.6 Implementation and Monitoring
3.6.1Performance Monitoring
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.6.2Records
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.6.3Non-Compliance and Corrective Action
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.6.4Incident Reporting Follow-Up
Reference / levl / sev / cat / ele / Finding / Significance / RecommendationTable: 3.7 Audit
3.7.1Audit Plan
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.7.2Competency
Reference / levl / sev / cat / ele / Finding / Significance / Recommendation3.7.3Contractor
Reference / levl / sev / cat / ele / Finding / Significance / RecommendationTable: 3.8 Review
3.8.1Review
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A0.1.Definitions of Audit Opinions
The possible audit opinions are as defined in EP Specification ‘Findings Assessment and Evaluation’.
Audit opinion / Level of concern / Inference for senior managementGood / Specific / There is no desire / need to take more or less risk, therefore no additional actions or resources are needed to alter the framework. Continue to maintain and adapt the current framework. No follow-up is required by the next level of management.
Fair / Overall scope for enhancement / Actions are needed to enhance the design and / or operation of the control framework, in order to adjust the level of risk exposure. The next level of management should be advised of and review the actions being taken to enhance the framework.
Unsatisfactory / Overall cause for concern / Actions are needed to improve key elements of the design and / or operation of the control framework. There is a significant gap between the current level of risk exposure and the ‘target’ level. The next level of management should monitor the implementation of agreed actions / improvements.
Unacceptable / Overall cause for grave concern / The next level of management should take urgent action to confront the situation and commit appropriate resources to immediate resolution of the weaknesses. Business or Group senior management should monitor the implementation of agreed actions/ improvements.
The most favourable audit opinion as defined in EP Specification ‘Findings Assessment and Evaluation’ is derived from the matrix below:
Finding Rating / Most favourable possible audit opinionSERIOUS / HIGH / MEDIUM / HIGH +
MEDIUM / GOOD / FAIR / UNSATIS- FACTORY / UNACCEPTABLE
NIL / NIL / FEW / - / X
NIL / NIL / MANY / X
NIL / FEW / FEW / X
NIL / FEW / MANY / X
1 or 2 / ANY / ANY / X
NIL / MANY / ANY / X
2 / ANY / ANY / X
The basic definitions to be used for “Few” and “Many” are:
- Few 20 findings;
- Many 40 findings.
It would be at the discretion of the Audit Leader to propose a variation to these definitions in the light of specific circumstances, such as: the audit scope, the distribution of findings within the MS elements and the degree to which clustering of findings may have distorted the numbers.
These numbers assume that each finding contains only one, discrete, weakness. The fact that one such finding gives rise to more than one recommendation has no influence upon the count.
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A0.2.Classification of Findings
Each finding in §3 is identified in the following manner, for example:
Reference / level / sev / cat / ele3.1.4.6 a / 3 / L / R / 20
The reference is the number of the section of the report in which the finding appears, together with a sequencing letter (a) to (z) where more than one finding has been identified. The first number, ‘3’ in above example, refers to the level in the Self-Assessment Questionnaire (SAQ). The following two letters, ‘L’ and ‘R’ in the above example, are in accordance with the Weakness Classification Matrix shown in Figure 1.
Note: The matrix to be used is the Group (YG) ‘Risk Assessment Matrix’ (RAM).
Figure 1: Weaknesses classification matrix
The first letter identifies the severity level as related to the potential consequences of the observed weakness or deficiency, as detailed in Table 2:
Severity level / DefinitionS - Serious / The finding is likely to cause a high undesirable effect on the achievement of the entity’s (HSE) objectives and / or is likely to have a notable impact on other Shell entities, therefore warranting immediate reporting to senior management (e.g. OpCo or Business level).
H - High / The finding is likely to cause a high undesirable effect on the achievement of one of the entity’s (HSE) objectives, warranting reporting to the Auditee’s management.
M - Medium / The finding is likely to cause a measurable undesirable effect on the achievement of one of the entity’s (HSE) objectives.
L - Low / The weakness is unlikely to have a measurable impact on the entity’s (HSE) objectives, but its correction would enhance the risk based control framework.
Table 2
The second letter identifies the category:
P - Peopleaffecting people via accidents and injuries.
A - Assetsaffecting costs and efficiency.
E - Environmentaffecting environmental concerns.
R - Reputationaffecting company reputation without direct link to the above categories.
The final digit of the code, ‘20’ in the above example, refers to the sub-element number (1-33) of the HSE MS with which the finding is most strongly associated.
As far as possible root causes for weaknesses have been identified. HSE audits/reviews identify potential long and short-term hazards to personnel, assets, the environment and reputation. It should be understood that auditing is a sampling process with the widest scope in the time available. In addition, not every aspect of a potential hazard may have been fully examined by the audit team. It is, therefore, essential that whilst in the process of closing out recommended action items presented in this report, the HSE MS for routine identification of new and existing hazards for all operations continue as normal.
Audit/review recommendations are made to indicate possible solutions. This should not be taken to imply that they are mandatory. Alternatives should be explored to find the optimum solution for each weakness or gap identified in the findings.
Audit/review follow-up is the Operating Company (OpCo)/NVO's responsibility. With reference to the guidance provided in the Group Internal Audit Guidelines, the OpCo/NVO's IAC should maintain a register of the recommendations resulting from this audit/review, in which the status of open actions are regularly updated.
OpCo/NVO approved justifications of variations or rejections of audit/review recommendations may be copied to the SIEP audit/review team leader to avoid misinterpretation of recommendations. There is no requirement to report routine follow-up details to EP-HSE or the SIEP audit/review leader.
Documentation of closed-out items should be retained by the OpCo/NVO for possible inspection during subsequent audits/reviews.
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A0.3.Recommended Actions Ranked by Severity and Category
High Risk – People
Reference / sev / cat / ele / Recommendation / Status / Action Party / Target DateMedium Risk – People
Reference / sev / cat / ele / Recommendation / Status / Action Party / Target DateMedium Risk - Environment
Reference / sev / cat / ele / Recommendation / Status / Action Party / Target DateMedium Risk - Reputation
Reference / sev / cat / ele / Recommendation / Status / Action Party / Target DateLow Risk - People
Reference / sev / cat / ele / Recommendation / Status / Action Party / Target DateLow Risk - Asset
Reference / sev / cat / ele / Recommendation / Status / Action Party / Target DateLow Risk - Environment
Reference / sev / cat / ele / Recommendation / Status / Action Party / Target DateLow Risk - Reputation
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A0.4.Terms of Reference
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A0.5.Glossary of Abbreviations
ALARPAs Low As Reasonably Practicable
CMCrisis Management
HAZOPHazard and Operability Study
HAZIDHazard Identification
HEMPHazard and Effect Management Process
HRAHealth Risk Assessment
HSE Health, Safety and Environment
HSE MSHealth, Safety and Environment Management System
ISOInternational Standards Organisation
JVJoint Venture
JV-NUOCJoint Ventures not under operational control
KPIKey Performance Indicator
LTILost Time Incident
LTIFLost Time Incident Frequency
OHOccupational Health
OpCoOperating Company
PPEPersonal Protection Equipment
PTWPermit To Work
RSIRepetitive Strain Illness
SAQSelf Assessment Questionnaire
SGSShell Global Solutions
SIEPShell International Exploration and Production B.V.
TORTerms of Reference
TRCFTotal Recordable Case Frequency
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A0.6.HSE MS Assessment
For details of the assessment methodology see the SIEP HSE-MS Self Assessment Questionnaire. The following assessment is based on the evidence reviewed by the review team during the review.
HSE Management System Element and Sub Elements / SAQlevel / Number of Findings
S / H / M / L / Total
1. Leadership and commitment
1Visibility
2Proactive in Target setting
3Informed involvement
2. Policy and strategic objectives
4Content
5Dissemination
6Strategic objectives (including SD)
3. Organisation, responsibilities, resources, standards and documents
7Roles and responsibilities
8HSE Advisers
9Resourcing
10Competence assurance
11Contractors
12Communication
13Documentation – HSE MS Manual
14Documentation – HSE Case
4.Hazards and Effects Management Process
15Identification
16Assessment
17Controls and Ownership
18Performance in maintaining controls
19Recovery
20Recording
5. Planning and procedures
21HSE Plan
22Asset integrity
23Procedures and work instructions
24Contingency and external planning
6. Implementation and monitoring
25Performance Monitoring
26Records
27Non-compliance and corrective action
28Incident Reporting and follow-up
29Change Control
7. Audit
30Audit plan
31Competency
32Contractor
8. Management review
33General
Overall average / total findings
A0.7.Distribution List
OpCo / Recipient / Ref.ind. / No. of copiesAuditee / 10
HSE Manager of OU / HSE Mgr / 1
Reg HSE Manager / EPM -S - HSE / 1
Reg Support Director / EPS - HSE / 1
T&OE Facilities Focal Point / EPT – OE / 1
SIEP Rijswijk Library / EPT – IT - EI / 1
Audit Team Member / 1
Audit Team Member / 1
Audit Team Member / 1
Audit Team Member / 1
Audit Team Member / 1
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