ENVIRONMENTAL PROCEDURE MANUAL - ims.secsl.lkims.secsl.lk/ISODocuments/EMS/5.PROCEDURE MANUAL/EMS Proced… · Web view3.2 The list shall be prepared in record ELS 432 ... (quality

The State Engineering Corporation of Sri Lanka

ENVIRONMENTAL PROCEDURE MANUAL

COPY NO. MasterCOPY HOLDER Management RepresentativeCONTROLLED COPY √

Reviewed by – Asst.Manager ( QA ) Approved by– General Manager ( MR )

Issue No.1/2013-05-28 Environmental Procedure Manual

List of Environmental Procedures Page

Page 2 of 28

PROCEDURE NUMBER TITLE

EP/431 Procedure for determining environmental aspects

EP/432 Procedure for identification of legal and other requirements

EP/443 Procedure for Internal and External communication

EP/446 Procedure for operational control

EP/447 Procedure for emergency preparedness and response

EP/451 Procedure for monitoring, and measurement

EP/452 Procedure for evaluation of compliance

EP/453 Procedure for nonconformities, corrective and preventive actions

EQP/1 Procedure for Document Control [Common to QMS and EMS]

EQP/2 Procedure for Control of Records [Common to QMS and EMS]

EQP/3 Procedure for Internal Auditing [Common to QMS and EMS]



Amendment Record Sheet Page 3 of 28

Procedure No Amendment Issue No Issue Date Authorized by



Procedure for identification and evaluation of environmental aspects and related activities

EP/431

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1.0 Objective and Scope:

The objective of this procedure is to ensure implementation of an effective and consistent procedure for identification and evaluation of aspects in order to determine their significance. This procedure applies to all operational areas within the premises of SEC.

2.0 Responsibility : a) Overall Responsibility: General Manager

b) Functional responsibility: 1. DGMs

2. DEMR

3. Environmental action group (EAG)

3.0 Activities :

3.1 An Environmental action group (EAG) shall be formed by MR representing all divisions as far as feasible. The committee shall be chaired by General Manager OR in his absence member of Environmental Steering committee nominated by GM.

3.2 Identification and evaluation of environmental aspects in each department shall be carried

out by the Environmental Action Group (EAG)under the guidance of Section Head of the division.

3.3 Identification /Evaluation and review shall be done once every six months after the initial evaluation OR whenever a change in services, plant, equipment, facilities or procedures including new construction, modifications and changes in process/technology that could result in new environmental aspects/ impacts and/or change in existing aspects/impacts.

3.4 During the evaluation of environmental aspects the group should give due consideration to the provisions and / or requirements laid down in the following documents:

a) Environmental Protection License (EPL)

b) Factories Ordinance

c) National Environmental Act.

d) Any legal /statutory or other requirements identified in EP/432.



3.5 The EAG shall use record ERG/431 for the evaluation of aspects as follows:

3.5.1 Each activity in the department /section shall be carefully considered in filling (Columns 2 to 6)

3.5.2 Where relevant each activity identified in Column 4 shall be separately considered under Normal, Abnormal and Emergency operational situations (Column6)

3.5.3 If the aspect relates to a legal requirement that the company must comply with mark ‘yes (Y)’ and mark ‘no (N)’ if legal compliance is not required (Column 7)

3.5.4 If the impact is a known community issue (like release of a pollutant) mark ‘yes (Y)’ and ‘No (N)’ if the impact is not a known community issue (Column 8)

3.5.5 Environmental Risk Rating (ERR) {Column 9 to 13} is calculated as shown below

ERR = [Likelihood of occurrence (A) + Likelihood of Detection (B) +Continuity (C)] x

Severity of Consequences (D)

3.5.5.1 Likelihood of Occurrence, (A), (ERG 431, Column 9).

Points Rating Description

5 High It is almost certain to happen

4 Moderate It is likely to happen

3 Low It could happen

2 Very low It is unlikely to happen

1 Negligible It is very rare occurrence

3.5.5.2 Likelihood of Detection, (B), (ERG 431, Column 10).


1 Real time continuous Can be detected at the moment

2 Within 1 hour Can be detected every hour

3 Within 8 hour Can be detected in 8 hours time

4 Within 24 hour Can be detected in 24 hours time

5 More than 24 hour Will take more than 24 hours



EP/431

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EP/431

Page 6 of 28

3.5.5.3 Continuity, (C), (ERG 431, Column 11).


5 Continuous Impact is continuous and frequent

3 Non continuous Impact is moderately frequent

1 Once Impact is only at once

3.5.5.4 Severity of Consequences, (D), (ERG 431, Column 12).


5 High Catastrophic damage to local and global Environment

4 Moderate Extensive damage to local and global Environment

3 Low Damage to intermediate Environment

2 Very low Minor damage to Environment

1 Insignificant Almost no damage to Environment

3.5.6 Evaluation and Determination of Significant Aspects

a) If the aspect of activity bear the legal condition or subjected to the community issue it automatically become a significant activity.

b) Determine the Environmental Risk Rating Score as shown in (3.5.5).c) Activities that score thirty (30) or more points for Environmental Risk Rating is categorized as

activities with significant environmental aspect and are listed in ELS 431.d) Activities, which score below thirty (30) points but above 15 points, are also dealt with

Objectives/EMPs, if there is a potential for improvement.e) To satisfy certain conditions of the environment policy of SEC, additional Objectives/

Environment Management Programs (EMP) and Operation Control measures are developed.f) All significant Environment Aspects are recorded in (ELS 431)

References

ERG 431 Aspect Register

ELS 431 List of significant aspects



Procedure for identification of legal and other requirements

EP/432

Page 7 of 28

1.0 Objective and Scope: To ensure identification of legal and other requirements applicable to SEC and

keep this information updated and current with legal/statutory requirements.

2.0 Responsibility: a) Overall: General Manager


2. Legal officer

3.0 Procedure

3.1 Legal officer shall maintain a list of applicable legal and other requirements to which SEC subscribes. (S) he shall communicate with relevant national, provincial and local Government Institutions to collect this information.

3.2 The list shall be prepared in record ELS 432 and the relevant details under each column should be filled.

3.3 Copies of the relevant legal and other requirements to which SEC subscribes shall be kept in the custody of responsible person identified in ELS 432.

3.4 Sectional Heads shall take necessary action to make the relevant information available to the persons who need them.

3.5 Legal officer shall regularly , but not later than every six months , review the list of legal requirements by communicating with relevant authorities to identify any new regulations/ amendments to existing regulations or repealing the existing requirements and take suitable action to effect the changes to documents relating to legal and other requirements as applicable.

3.6 Whenever a new process/ technology or modification to existing process is introduced or change in any activity results in a change in aspects already identified, step 3.5 shall be followed irrespective of the time limit specified therein.

References

ELS 432 List of legal and other requirements





Procedure for Internal and external Communication

EP/443

Page 8 of 28

1.0 Objective and Scope: To stipulate a mechanism for the establishment of sound communication channels among internal staff interested parties and public authorities with regard to the matters relevant to EMS and significant aspects.

2.0 Responsibility: a) Overall: General Manager


2. Managers/ SPM/ /RPM/WM/RA

3. Procedure3.1. Internal Communication

3.1.1.Internal Communication relating to EMS and significant environmental aspects is maintained using numerous formal and informal channels

3.1.2.Formal communication is maintained through issue of EMS documentation to all users. 3.1.3.Web based document issue system has been introduced to ensure availability of system

documents to all identified users.3.1.3.1. Intranet is used for document issue to all sites where this facility is available. All

other sites are given facilities to access EMS documents through internet.3.1.3.2. In addition to document issue this facility is used to maintain two way

communication with all staff members about matters related to maintenance of EMS3.1.4.A hierarchy of committees [Figure 1] is formed in order to facilitate direct formal

communication3.1.4.1. Regular meetings of these committees are conducted and minutes of

Management Review and Steering committees are maintained.3.1.4.2. An action group has been formed with the participation of representatives from

all functional areas3.1.4.3. This group meets periodically to discuss and recommend solutions to any

matters relating to significant aspects and also recommend actions to Steering committee for effective maintenance and improvement of EMS.

3.1.4.4. The action group also undertakes studies into specific areas relating to Environmental Objectives and improvement of EMS.

3.1.4.5. Recommendations of Action Group are submitted to Steering Committee for action as appropriate



3.1.5.Internal communication is further facilitated through feedback received from incident registers (ERG/443/1) kept at all permanent and ongoing sites.

3.1.5.1. All employees are requested to record incidents affecting environment including those relating to significant aspects in this register.

3.1.5.2. The site in charge reviews the entries in the register periodically and takes action as detailed below

3.1.5.3. All matters that can be resolved by site in charge shall be implemented by him3.1.5.4. Any incident that requires attention of Steering committee shall be forwarded

to EMR for consideration at the Steering committee.3.1.5.5. Incidents which indicate non compliance with EMS requirements should be

raised as non conformities in format number F 073.1.5.6. All actions taken shall be recorded in the register with appropriate references

and pending issues should be communicated to EMR at the end of the month3.1.6.Communication during emergency situations are maintained as described in the

emergency response procedure [EP 447]3.2. External Communication

3.2.1.Environmental and quality policy of SEC is communicated to public via official website.3.2.2. The policy is also displayed prominently in all permanent and ongoing sites.3.2.3.Community complaints relating to activities of SEC are received by Site Managers or other

officer in charge of permanent or ongoing site and recorded in customer complaints register

3.2.3.1. Such complaints should be resolved by the site in charge if the actions involved are within the purview of him

3.2.3.2. Any matter requiring the attention of the EMR should be forwarded to EMR for action

3.2.3.3. Non Conformity report should be raised against all community complaints if such complaints are related to violation of EMS requirements

3.2.4.SEC has decided that it should not communicate externally regarding its environmental aspects.

References

EP 447 Procedure for emergency response

F07 Corrective action form



EP/443

Page 9 of 28


Figure 1


ems/awa/ho1m

Management Review Committee

Environmental Steering Committee

Environmental Action Group

Sub Committee

sEner

gywate

rSolid waste

Paper

H. Wast

e

Air Pollutio

n


EP/443

Page 10 of 28


Procedure for operational control EP/446

Page 11 of 28

1.0 Objective and Scope: To define criteria necessary for carrying out operations associated with significant environmental aspects in order to ensure that they are carried out under specified conditions.

2.0 Responsibility a) overall: MR

Functional: 1. DGMs

2. DEMR3. Designated persons in relevant operational control documents

3.0 Procedure

3.1 For each activity associated with significant environmental aspects operational criteria and control limits shall be established.

3.2 Where relevant, monitoring and measurement frequencies shall be identified.

3.3 Actions to be taken when control limits are exceeded shall be specified together with persons responsible.

3.4 The resources and facilities for the identified controls shall be provided for implementing the specified requirements.

3.5 The competence of the operational staff shall be determined and any training required for effective operation of activities need to be provided to them.

3.6 The procedures related to any activities associated with the significant aspect carried out by suppliers and contractors shall be established and communicated to the persons engaged in such activities.

3.7 The records related to operational controls applied shall be established and maintained.

References

F04 Master List of documents



Procedure for emergency preparedness and response

EP/447

Page 12 of 28

1.0 Objective and Scope:

To ensure implementation of an effective and consistent procedure for identification of potential emergency situations and accidents that can have adverse environmental impacts and lay down actions to be taken to avoid mitigate and/ or control their impacts.

2.0 Responsibility: a) Overall: MR

b) Functional: 1. Fire and Safety officer

2. Department Heads

3. All employees

3.0 Procedure:

3.1 The Environmental Steering committee shall ensure a list of potential emergency situations and an accidents including accident/incident classification is prepared and maintained.

3.2 The Environmental Steering committee shall also ensure an emergency response program in respect of each potential emergency situations accident identified. Format in EPL 447 shall be used for this purpose.

3.4 Based on emergency response programs developed the teams shall be appointed.

3.5 General and specialized training required for task team members and all employees shall be identified and presented to management review committee for inclusion in the annual training programme

3.6 Fire evacuation routes and assembly point shall be clearly displayed as appropriate.

3.7 Environmental Steering committee shall ensure a list of important telephone numbers are prepared and prominently displayed at appropriate locations.

3.8 Environmental Steering committee shall plan and conduct regular mock drills involving task teams and all staff where appropriate.

3.9 Emergency response programs and training to task team members and other employees shall be reviewed by Management Review Committee not more than six months interval.



Procedure for emergency preparedness and response

EP/447

Page 13 of 28

3.10 All documentation related to emergency preparedness and response including this procedure, emergency response programs and related documentation shall be reviewed by Management Review committee annually or after the occurrence of major accident / incident.

3.11 All Sectional heads shall ensure through regular checks that designated employees use PPE as detailed in instructions.

Reference:

ELS/447/1 List of emergency situation and accidents

ELS/447/2 Emergency telephone & contact numbers

EPL/447/1 Emergency response program

EPL/ 447/2 Evacuation plan



Procedure for Monitoring and measurement EP/451

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1.0 Objective and Scope: To ensure that SEC implements a consistent procedure to monitor& measure on a regular basis, the key characteristics of company operations that can have significant environmental impact.

2.0 Responsibility: a) Overall: MR

b) Functional: 1. Steering Committee

2. DEMR

3.0 Procedure

3.1 Environmental Steering committee shall determine Monitoring & measurement required to implement operational controls related to significant Environmental impacts and any monitoring and measurements required to achieve set objectives, targets or environmental programmes.

3.2 Key characteristics to be measured / monitored shall be identified in the formats EFO/451

3.3 Identified characteristics shall be monitored / measured by responsible person and any threshold values/limits provided should be used to compare the results obtained

3.4 Any non-compliance with the stipulated criteria shall be reported to ESC for initiation of action as laid down in EP/453.

3.5 Competence required for persons engaged in monitoring and measurement activities shall be maintained through training and/or any other measures.

3.6 Sectional Heads shall take action to calibrate any equipment used for the monitoring and measuring so that the results obtained using such equipment are traceable to national and international measurement standards.

3.7 Records of calibration shall be maintained by Sectional Heads.

References

EFO/451 Characteristics measured and monitored



Procedure for Evaluation of compliance EP/452

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1.0 Objective and Scope: To ensure that SEC implements a consistent procedure for evaluation of compliance on a regular basis, with applicable legal requirements and other requirements to which SEC subscribes.

2.0 Responsibility: a) Overall: EMR

b) Functional: 1. Steering Committee

2. DEMR

3.0 Procedure:

3.1 Environmental Steering committee shall identify evaluation necessary for maintaining legal and other compliance with the applicable requirements using ELS/432.

3.2 DEMR shall ensure that these evaluations are carried out at frequencies stipulated in EPL/452

3.3 The competence of staff engaged in the evaluations shall be maintained as appropriate through training and/or other means.

3.4 The records of the results of the periodic evaluations shall be maintained by DEMR

Reference:

ELS/431 List of Significant Environmental aspects

EPL/452 Program for evaluation of compliance



Procedure for Non- conformance corrective and preventive action

EP/453

Page 16 of 28

1.0 Objective: To ensure that a consistent procedure is followed for identification of actual and potential environmental non-conformities and taking action to mitigate their environmental impacts

2.0 Responsibility a) Overall: MR

b) Functional: 1) All Sectional Heads

2) DEMR

3) Designated employees

3.0 Procedure:

3.1 Any employee identifying actual or potential non-conforming situation shall bring it to the notice of Site in Charge/Sectional Head of the relevant division. The Site in charge/Sectional Head shall ensure such situations are recorded in the Incident register.

3.2 Site in charge/Sectional Head shall take corrective actions as appropriate for any nonconforming situations that can be rectified within his/her area of responsibility and record the actions in the Incident register and close the NC then and there.

3.3 If the non conforming situation cannot be rectified within his/her area of responsibility the Site in Charge/Sectional head shall raise nonconformity in Corrective Action form follow up as appropriate and/or forward the same to responsible DGM for appropriate action.

3.4 DGM shall ensure such NCs are followed up through Action group and reported to Environmental Steering committee for resolution of issues, if any.

3.6 The potential non-conformities for which preventive actions are required shall be recommended using Preventive Action form.

3.7 All nonconformities with identified root causes and recommendations for corrective action shall be reported to EMR. Expected dates of completion shall also be indicated on F07.



Procedure for Non- conformance corrective and preventive action

EP/453

Page 17 of 28

3.8 Environmental Steering committee shall take action to implement the corrective actions giving specific responsibilities for implementation of corrective action and verification of results.

3.9 DEMR shall recommend to EMR any document changes by the implementations of corrective actions.

3.10 DEMR shall report to Management Review Meeting the results of corrective actions taken including any outstanding issues.

Reference:

ERG/443/01 Incident register

F 07 Corrective action form

F10 Preventive action form



Procedure for Document and Data Control EQP/1

Page 18 of 28

Scope

This procedure covers controlling of all quality management system (QMS) & environmental management system (EMS) documents

Objective

To ensure the availability of correct version of the document at correct place

Responsibility

MR - Overall system documents

GM – Corporate level documents

DGM s- Divisional level documents

Legal officer – Statutory and regulatory documents

Sectional Heads – Sectional documents

Site in charge – Site/Project manuals and associated documents

Definitions

Corporate level Documents – SEC quality manual, six mandatory QMS procedures and associated formats, general documents (quality plans / check lists / forms/ work instructions / other procedures) , environmental manual, environmental procedures and other EMS documents

Functional level Documents – Divisional level documents, project manuals, specific (quality plans / check lists / work instructions / other procedures) and relevant EMS documents




Page 19 of 28

Procedure

Document identification

1. All documents in the QMS & EMS are uniquely identified. As the identity, the document title or a number or a combination or any user friendly mechanism authorised by MR is used.

2. All QMS & EMS documents carry indicator for status identification as issue number and date of issue, for EMS manual revision number and revision dates are additionally identified.

3. MR maintains the Master List of Documents indicates the status of corporate level QMS & EMS documents and set of corporate level formats file containing up to date corporate level record formats.

4. All DGMs maintain list of documents indicating the status of functional level QMS & EMS documents and set of functional level formats file containing up to date functional level record formats

Document approval and distribution

Corporate level document

1. The QMS Manual & EMS Manual are reviewed by GM and approved by the Chairman.

2. All other corporate level QMS & EMS documents are reviewed by DMR or (DMR and respective DGM/S) and finally approved by MR.

3. MR handles the distribution control as per the Master List of Documents that indicates the distribution of documents. MR maintains the original set of documents and controlled master format file.

4. All distributed paper versions of documents carry “Controlled Copy” seal in blue colour stamped by MR/DMR.




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5. Only MR is permitted to edit electronic versions of distributed documents. All other users are given read-only access.

Functional level documents

1. All functional level QMS documents are reviewed by sectional heads and approved by respective DGM.

2. DGM handles the distribution control as per the distribution list along with the Divisional list of documents. DGM also maintains the original set of documents and controlled Divisional master format file.

3. All distributed documents carry “Controlled Copy”/DGM (---*)” stamp [*respective DGM] in Blue colour.

4. All documents with respect to completed projects / sites are recalled by respective DGM and retained for knowledge, traceability and legal purposes with proper identification.

Amending of documents

Corporate level documents

1. Any amendment that exceeds more than two consecutive lines (01 – 25 words) of text in any one page is considered as a major amendment and the amendment status of that page shall be changed along with the amendment.

2. All proposals for document changes are communicated to MR appropriately. The MR reviews the proposal with the signatory for the review and approval of the document and with the relevant sectional head of the document.

3 .If the change is in technical nature, the matter is discussed by MR with the relevant sectional head and other parties involved and MR drafts the amended document.

4.When the change is accepted, MR reprints the document with new issue number and date and immediately recall all copies of old version of the document following the document approval and distribution control mechanism.




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5.The original of the obsolete documents are retained (if required) for legal / knowledge / traceability purposes & carry “obsolete” red color seal stamped by MR/DMR. All other copies of obsolete documents are destroyed.

6. The obsolete electronic version of the document is superseded by the new issue.

7. MR briefly records the details of amendment in the record register.

8. Any change in EMS manual is recorded in the manual itself as specified therein.

9. All changes are done in Italic letters.

Functional level documents

1. All proposals for document changes communicated to respective DGM. The DGM reviews with the sectional head that has reviewed the document and relevant Site in Charges and drafts the amended document.

2. If the change effects to the quality/environmental management system, the matter is discussed with MR and other relevant parties involved.

3. When the change is accepted, DGM reprints the document with new issue number and date and recall all copies of old version of the document following the document approval and distribution control mechanism.

4. The original of the obsolete documents are retained (if required) for legal / knowledge / traceability purposes & carry “obsolete” red colour seal stamped by. All other copies of obsolete document are destroyed.

5. DGM briefly records the details of amendment in the amendment record register.

Controlling of externally generated documents

1. GM maintains a file of all applicable external documents and at least the validity of those documents are reviewed annually. Access is provided to all for those documents.

2. Legal officer maintains the list of applicable statutory and regulatory requirements (e.g. Acts, Regulations, Licenses, etc) and updates at least annually.

3. All DGM s control externally originated documents regularly and obtains applicable updates and amendments.




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4. All externally originated documents carry “ Control copy “ green color seal stamped by MR/DMR

Safe keeping of documents

1. All documents are maintained in safer manner to prevent them deteriorating from various factors affecting their legibility.

2. Users are educated to keep all documents in an easily retrievable manner for easy reference.

3. All computers are provided with UPS units to protect the data from sudden power fluctuations and failures.

4. IT Unit takes routine backups from all electronically maintained documents and access is controlled by pass-word protection.

5. At least annually, MR and DGM s review the condition of all distributed documents and electronically maintained files, and if any adverse conditions observed, take appropriate action to rectify the situation.

References:


Original sets of documents Controlled Master Formats Files Amendment record registers Master list of document Externally Originated Document Files Site / Project Manuals


Procedure for control of records EQP/2

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Scope: This procedure covers the controlling of all records of quality & environmental management systems.

Objective: To ensure that all system records are properly maintained in order to provide management information effectively and efficiently.

Responsibility: Main – MRFunctional – GM, All DGM s, Sectional Heads (SH)

Procedure:



1. Ensure controlled formats are used to record data manually or electronically as practical as possible.

MR , GM, DGM, SH

2. All relevant formats are distributed referring to the master set of formats and controlling of them done following the procedure for document and data control.

MR , GM, DGM, SH

3. All record keepers are instructed to make records clearly and legibly. MR , GM, DGM, SH

4. All records (hard and soft copies) are kept in easily retrievable manner SH

4. When filing the record, appropriate indexing system (e.g. date order, numerical order, etc) is ensured.

SH

5. When filing a category of records, the file identifies the record category (e.g. purchase records, audit records, inspection records, ‘X’ project records, etc).

SH

6. Retention periods of all system records are identified in the List of Records. When identifying the retention periods of any records, actual need for keeping them is considered.

MR

7. All record maintained in the IT system including the e-mails are organized to retrieve them efficiently. They are also put into folders depending on the type of record.

8. All records kept in electronic form only need to be so identified in the master list of records. Such records shall be kept with proper access and change control measures as decided by Management Review committee.

SH


Procedure for control of records EQP/2

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9. Retention periods of sectional records are identified in the Sectional List of Records. When identifying the retention periods of any record, actual need for keeping them is considered

SH

10. Records are stored in safe locations/areas to prevent damages or loss during storage and due to working conditions.

SH

11. Uninterrupted power supply (UPS) are provided for computers as required and backups of records are taken in a regular manner to prevent unforeseen data losses.

SH

12. Records are kept during the retention period as identified in the list. SH



13. After the completion of retention period the records are disposed of as stated in the list.

All

14. Review the identified retention periods annually for its suitability and amend appropriately if required.

MR

Procedure for control of records EP/454

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References:

- Record Formats Master File- QAP 01Procedure for document and data control - List of Records- Sectional list of Records

Scope: This procedure covers the auditing of quality & Environmental management systems.

Objective: - To ensure that all planned arrangements are effectively implemented and to introduce ways and means of improving quality & Environmental management systems.

Responsibility: MR (Main) / DMR / Sectional Heads (SH) [Functional], Audit Team Members

Procedure:

1. At the year beginning the combined Annual Internal Quality Audit Schedule is prepared considering the followings.

MR

a. The audit frequency is six month.b. All areas of the management systems and the relevant

standard requirements of ISO 9001:2008 & ISO 14001:2004 (the criterion) to be covered six monthly.

c. Auditable areas to be decided based on the status and importance of the area


Procedure for Internal Auditing EQP/3

Page 26 of 28


d. Previous audit results. e. Audit matrixesf. Number of locations to be audited and the distanceg. Duration of the projects (If duration is less than six month one

audit is to be done in the project period)2. Annual schedule is sent to GM for the approval with the amendments if

required. DMR

3. Communicate the annual audit schedule to all sectional heads and verify its receipt.

DMR

4. One month prior to the scheduled audit, proposes a convenient date/s consulting sectional heads to carry out the audit.

DMR

Procedure for Internal Auditing EP/455

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5. Once the dates are confirmed, prepare the Audit Plan considering the followings Previous audit results Annual internal quality audit schedule Changes occurred in the system (New sites, completed sites etc) Audit matrixes (to determine processes, applicable standard

requirements and sections to be audited) Status and importance of the area (to determine time allocation) Independency of auditors (selected from the List of Trained Auditors)

DMR

6. Sending the Audit Plan to GM/MR for finalizing and approving with the necessary changes if required.

DMR

7. The approved audit plan is sent to the selected auditors (as audit team members) and all sectional heads one week prior to the date of audit and verifies the receipt.

DMR



8. Provide all required facilities to the audit team during the audit SHs

9. Conducting the audit as planned, getting acknowledgements for NC reports (if any) from the relevant SH and submitting NC reports to DMR.

Audit Team members

10. Give the fullest cooperation in auditing and acknowledge NC reports (if any) SHs

11. Distribute NC reports to relevant SH s within one week from the date of audit to record corrective actions (CAs), responsible person/s and time frames to complete the agreed action/s.

DMR

12. Record the CAs and time frame for the actions, sign for responsibility, making photocopies and send originals to MR within two weeks of the audit. Keeping the photocopies for own references.

SH

13. Obtain the duly completed audit NC forms from respective sectional heads within two weeks of the audit.

DMR

14. Inform the actions decided and the time plans to the audit team. DMR



15. Ascertain whether the corrective actions are taken and completed after the agreed time frame and decide whether the verification to be done immediately or at the next audit with the consultation of GM/MR.

DMR

16. If immediate verification is required, call the auditors to carry out verification audit.

DMR

17. Conducting verification audit to verify whether the action/s taken are effective or not. If the action/s taken is effective close the NC report with the note as verification records. If not effective keep the NC report open with the note as verification records. Send the completed NC form/s to DMR.

Audit Team members

18. The summery of audit result is submitted at the Management Review Meeting to discuss the status of C/A taken, possible P/A for other areas and effectiveness of the management system.

MR

19. Maintaining the List of raised NCs and the status (whether closed or open) in the CA/PA Log-Internal audit. Follow up actions to open NCs.

DMR

20. Maintaining the List of trained auditors and update annually DMR

21. Arranging special internal audits (completely or partially) as and when required. (As requested by certification body or the top management, considering the duration of projects etc.)

MR

Procedure for Internal Auditing EP/455

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References:

- Format-Annual internal quality audit schedule- Audit Matrixes- Annexure C of Quality manual- Format – Audit plan- Format- NC Forms- Audit record file- CA/PA Log –Internal audit- List of trained auditors


