OSHAD Audit Guidelines-1
OSHAD Audit Guidelines-1
OSHAD Audit Guidelines-1
OSHAD
AUDIT
GUIDELINE
First Issue
2016
Important Disclaimer:
The contents of this document are intended solely for the purpose of guidance and awareness.
Users shall refer to www.oshad.ae for the published version of the OSHAD-SF. If any conflict is
found between the requirements listed within this document and those within the OSHAD-SF, the
requirements within the OSHAD-SF shall prevail.
The aim of the guideline is to raise awareness on OSHAD SF requirements by sharing the following:
a) Positive points which are considered as good initiatives adapted by some entities. These points
are intended to encourage / inspire the entities on OSH initiatives.
b) Noncompliances (NCs) are considered gaps which require corrective action. These NCs are
listed which are the most commonly observed in the entities.
Contents:
1. Introduction 01
2. Purpose 01
7. Detailed Requirements 10
7.2
OSH Roles and Responsibilities 12
7.3
OSH Targets and Objectives 13
7.4
Legal Compliance 14
7.5
Risk Management 15
7.6
Management of Contractors 18
7.7
Emergency Management 20
7.8
Operational Procedures 23
7.9
Management of Change 25
7.10
Training and Competency 26
7.11
Incident Reports and Investigation 29
7.12
Communication and Consultation 31
7.13
Inspection and Audit 33
7.14
OSH Performance Monitoring 35
7.16
Management Review 38
8. References 39
1. Introduction:
In February 2010, Abu Dhabi Occupational Safety and Health Center (OSHAD)
was established to ensure the implementation of a comprehensive and integrated
management system for occupational safety and health (OSH) and to oversee all
OSH issues at Emirate level, to ensure reduction of incidents, injuries and illnesses
and provision of safe and healthy workplaces.
2. Purpose:
The guideline includes OSHAD Audit Process and selected findings of OSHAD
OSHMS Compliance Audits. The aim of providing examples from OSHAD audits
including positive points and noncompliance is to clarify compliance expectations
and ensure effective implementation of an OSHMS.
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4. OSHAD Audit Process:
This section presents OSHMS Compliance Audit Process. The objective of presenting
OSHAD Audit Process is to help the entities in understanding expectations on
establishing an OSHMS Audit Program.
Entities’ OSHMS Audit program shall comply with the OSHAD-SF requirements
including:
• OSHAD SF Elements
• OSHAD SF Technical Guidelines
The pre-audit phase includes preparation of the audit schedule, determining the
scope of the audit, formation of the audit team and developing the audit plan of
the entity to be audited.
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• Main activities
• Locations details
• High risk activities
• Audit focal point
• Any other information
The lead auditor develops the audit plan based on the information
provided by the entity and on OSHAD-SF criteria (Elements).
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4.2 Conducting the Audit:
OSHAD audit team conduct the audit according to the audit plan using audit
checklist and following the audit scope through the following steps:
• Risk registers
• Training matrix
• Emergency response plans
• Evacuation drill reports
• Inspection reports
• Internal audit reports
• Legal registers
• Targets and objectives programs
• Incident records
• Management review MoM,
• Other related documents and records.
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4.3 After the Audit
This phase includes issuance of the audit report and sending it to the entity
audited. Then the entity sets the corrective action plans to close non-
compliances identified in the reports. These plans are reviewed and approved by
the lead auditor.
• Positive
• Satisfactory
• Observation
• Minor Non-compliance
• Major Non-compliance
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Entities that will be audited by OSHAD shall ensure implementing the below
requirements before, during and after OSHAD audits:
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6. Audit Process Summary
1. Annual
OSHAD Audit
Schedule
9. Continual 2. Selecting
Improvement Audit Team
8. Verifying the
Implentation 3. Pre Audit Info
of Corrective
Actions
5. Conducting
6. Audit Report
the Audit
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7. Detailed Requirements:
This section presents three main subjects based on OSHAD Audits on Govt.
Entities OSHMS:
The three above subjects are explained for the following OSHAD SF elements:
1. OSH Policy
2. OSH Roles and Responsibilities
3. Targets and Objectives
4. Legal Compliance
5. Risk Management
6. Contractor Management
7. Emergency Management
8. Operational Controls
9. Management of Change
10. Training and Competency
11. Incident Notification and Reporting
12. Communication and Consultation
13. Inspection and Audit
14. OSH Performance Monitoring
15. Document Control and Record Retention
16. Management Review
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7.1 OSH Policy:
7.1.1 OSHAD-SF Requirements:
The entity’s OSH policy shall, at a minimum:
• demonstrate Occupational Safety and Health commitment;
• be authorized by Top Management;
• be appropriate to the nature and scale of the entity’s OSH risks;
• include commitment to:
a. prevention of injury and illness;
b. enhancement of employee health and wellbeing;
c. legal compliance;
d. setting, monitoring and reviewing OSH targets
and objectives;
e. provision of appropriate OSH resources; and
f. continual improvement.
7.1.2 Positive points observed, for example but not limited to:
• OSH Policy effectively communicated to employees, contractors and visitors through
distribution of the policy in the appropriate locations and intranet.
7.1.3 Points could lead to NC, for example but not limited to:
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7.2.2 Positive points observed, for example but not limited to:
• Auditee positive approach and openness towards the audit process.
• OSH Roles and Responsibilities are included in all employees’ job descriptions.
• Employees are aware of their OSH related roles and responsibilities.
• OSH roles and responsibilities undertaken signed by the entity’s employees.
7.2.3 Points could lead to NC, for example but not limited to:
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7.3 OSH Targets and Objectives:
7.3.1 OSHAD-SF Requirements:
The entity’s OSH policy shall, at a minimum:
• ensure documented and effectively communicated OSH targets and objectives;
• ensure targets and objectives, where practicable shall be measureable;
• incorporates requirements of:
a. the entity’s OSH policy;
b. legal requirements;
c. relevant Competent Authorities requirements;
d. OSHAD-SF mandatory key performance indicators, as
defined in OSHAD SF.
e. Sector specific targets and objectives, if applicable.
• set program(s) for achieving the targets and objectives,
including, the methods, timeframes, monitoring activities and
responsibilities; and
• ensure targets, objectives and procedure(s) are reviewed periodically to ensure they remain
relevant and appropriate.
7.3.2 Positive points observed, for example but not limited to:
• Well defined Objectives and KPI’s monitoring system.
• KPI’s are periodically monitored for on time completion. This information is also used as one
of the inputs for Directors performance appraisal.
• The Entity has implemented an automated KPI’s monitoring software.
• Well developed and detailed management programs.
• Significant reduction in Incident Rate.
• Detailed analysis of OSH KPI is done, which contributes towards improving the OSH perfor-
mance.
7.3.3 Points could lead to NC, for example but not limited to:
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7.4.2 Positive points observed, for example but not limited to:
• Legal Register is comprehensive and detailed.
• OSH Legal Register is being updated / reviewed regularly by Legal Dept.
7.4.3 Points could lead to NC, for example but not limited to:
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7.5 Risk Management:
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7.5.2 Positive points observed, for example but not limited to:
• Comprehensive risk assessment has been developed which covers all the activities
undertaken by the entity.
• Risk assessment and operational controls process being implemented and managed in all
activities projects.
• Expectant mother risk assessment done for all expectant mothers once they report the same.
This may lead to necessary changes in their work assignment.
7.5.3 Points could lead to NC, for example but not limited to:
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OSH Hierarchy of • There was no evidence to show that the legal Register has been
Control: communicated to the concerned/responsible persons.
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7.6.2 Positive points observed, for example but not limited to:
• Effective OSH pre-qualification and assessment during projects tendering and contractor
selection process.
• Health & safety requirements are incorporated in Project Document like “Instruction for
Technical Tender Document” which is used at the RFP stage.
• OSH review of the service providers / contractors is done at tender evaluation stage.
• OSH requirements comprehensively defined in “Project Contract” document.
• Safety and Health on the construction sites are effectively managed using Safety and Health
assessment, regular inspection and weekly site management meetings.
• Permit to Work (PTW) is being implemented for different types of contractors’ activities.
• Contractor monitoring includes process for issuance of OSH Violation Notices on non-
compliances to OSH requirements.
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7.6.3 Points could lead to NC, for example but not limited to:
Including the • OSH requirements are not included in the Contractor Management
requirements: documents
Evaluation and • OSH requirements are not evaluated during tender / contract
Selection: evaluation stage. Even though contract management program states
for evaluation of the same.
• A tender evaluation criterion doesn’t include OSH.
• Contractor Selection Process is not based on minimum acceptable
OSH rating, which is not defined. Bidders scoring high or low
scores can still be awarded the contract in spite of low OSH
rating. Contractor selection Process shall ensure that (a) minimum
acceptable OSH rating (score) is defined (b) only those bidders
can be awarded the contract whose OSH rating is higher than the
minimum acceptable score.
Contractor • OSH criteria / requirements are not defined within the contractor
Performance management process (monitoring of performance)
Monitoring: • OSH performance of contractors not monitored through the contract
life cycle. No evidence of OSH evaluation during tender, ongoing
operations and contract close out are observed. This includes OSH
inspections / audits of contractor activity as well.
• Site inspectors don’t review the control measures identified in the
risk register before performing inspection on the site. Inspectors
visiting hazardous environment (oxygen cylinders, forklift trucks etc.)
without proper preparations / awareness of the site conditions.
Control and • Lack of control and coordination from the entity to its contractors
Coordination: • Unsafe scaffold used by a contractor working at height
Contractors • Contractors are not evaluated against OSH requirements during all
Performance the stages of project life cycle.
Evaluation: • Contractor OSH assessment and evaluation not done after the close-
out of the contract.
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The entity’s Emergency Response and Management program / procedure(s) shall address, at a minimum:
• risk-based identification & response to potential emergency situations;
• specific emergency response & management roles, responsibilities and resources;
• appropriate risk-based emergency response and management plan(s), including:
a. threat-specific plan(s);
b. facility specific(s); and
c. appropriate support / functional plans.
• provision of appropriate resources (e.g. human, equipment, facilities, training, etc.);
• arrangements for external stakeholder communications;
• arrangement for communications with concerned SRA’s and emergency services,
if applicable;
• periodic emergency response and management tests and exercises; and
• monitoring and review of plans and procedures.
7.7.2 Positive points observed, for example but not limited to:
• Emergency Management Procedures and Emergency Response Plans in place with clear
safety signage and adequate emergency response equipment provided.
• Emergency evacuation chairs provided for disabled employees.
• Each work area has a displayed list of first aiders, fire wardens, emergency numbers and
graphical illustration of how to use fire extinguishers.
• The emergency plan is communicated to visitors by using simple tools like pocket cards, etc.
• Good response times following activation of emergency alarms.
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7.7.3 Points could lead to NC, for example but not limited to:
Evacuation Drill: • Emergency drill conducted but not analyzed (critiques) for any
desired improvement in the Emergency Response System.
• Emergency procedure does not specify the frequency for the
Emergency Drills / Exercises.
• Emergency drills not conducted.
• No records were available of the actual emergency evacuations
events that have taken place.
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First Aid Box: • The contents of First Aid boxes were expired and inadequate.
• First aid box not available or accessible
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7.8 Operational Procedures
7.8.1 OSHAD-SF Requirements:
The entity’s operational program(s) / procedure(s) shall address, at a minimum:
• Operations and activities that are associated with identified hazard(s) that require
implementation of control measure(s) to manage risk(s);
• Control measures related to supply chains (purchase of goods, equipment and services);
• Control measures related to contactors and other visitors to the workplace; and
• Stipulated operating criteria / instructions, maintenance instructions / integrity programs
where their absence could lead to an increase in OSH risk(s).
7.8.2 Positive points observed, for example but not limited to:
• Photocopy machines are kept in a confined and segregated space away from employees.
• Well defined operational controls incorporated into operational procedures (Division
Processes & Procedure Manual)
• Entity has comprehensively documented its operational controls.
• Project Manual includes detailed OSH processes related to all the stages of project life cycle.
• Robust process within licensing and permitting for inspection of facilities
• Pre travelling checklist developed and implemented for abroad missions.
7.8.3 Points could lead to NC, for example but not limited to:
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Unsafe Conditions • Cooking stove in kitchen placed on wooden top / shelves, which has
in Workers wood underneath. This is creating a fire hazard.
Accomodations (where
• Unsafe living conditions at the workers accommodation observed
applicable):
including fire hazards because of temporary kitchens made of plywood
walls and next to living quarters and improper welfare conditions.
High Risk Activities: • X-Ray equipment safety guideline does not include 2 hrs. max exposure
limit, while operating an x-ray machine, as practiced by employees.
• Standard Operation Procedures are developed; however, they are not
linked with the risk assessment associated with activity.
• Detailed operational controls are documented as Standard Operating
Procedures; however, not referenced, as applicable, within the control
measures column of the risk assessments.
• Manual handling is considered as a routine activity, yet the operational
control procedures do not include instructions for the safe operation
of this activity.
• Contractor staff while polishing the fire exit door was not wearing
appropriate PPE.
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7.9 Management of Change
7.9.2 Positive points observed, for example but not limited to:
• Corrective action to close the audit findings (NC’s) effectively implemented with the required
revision in entity’s OSHMS.
7.9.3 Points could lead to NC, for example but not limited to:
• No process developed by the entity for Management of Change (e.g. organization structure,
location, change of equipment, work shift, operating conditions, work procedures, etc.)
• No link between Training Procedure and Communication Procedure with Management of
Change Process.
• Management of change requirements for upgrading OSHMS in accordance with OSHAD SF
v2.0 requirement not implemented.
• No evidence for updating Risk Register, Emergency Response Plan etc. following changes in
regulations or incidents investigations.
• No clear process documented or implemented for managing OSH aspects upon
establishment of new division under the entity, e.g. performance reporting and risk
management. The entity OSHMS not updated to account this major change in organization.
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7.10.2 Positive points observed, for example but not limited to:
7.10.3 Points could lead to NC, for example but not limited to
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Inductions: • There was no OHS induction provided to the new employees and
visitors.
• The induction presentation for new employees does not cover the
Emergency Response Plan.
• No OSH Induction/training conducted to Contractors
• No OSH induction of ‘work placement’ students.
Training plan: • OSH Training Matrix was developed. However, training plan was not
developed to ensure the delivery of targeted trainings for the current year.
• Language barrier is not considered while delivering the OSH trainings
to different levels in the organization / contractors.
Refresher requirements: • Refresher training requirements not documented in the training matrix.
Review and update: • Training program not updated to add new training as per new activities
added.
Competency: • Competency measurement criteria do not consider all parameters such
as knowledge, experience, training, qualifications, etc.
• Competency requirement of OSH investigators / inspectors / internal
auditors not defined.
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7.11 Incident Reports and Investigation
7.11.1 OSHAD-SF Requirements:
The entity’s OSH Reporting Procedure(s) shall address, at a minimum:
• hierarchies, timetables and responsibilities for reporting;
• internal OSH performance and incident reporting requirements;
• external OSH performance and incident reporting requirements,
including:
a. OSH Incidents to the SRA / CA as required;
b. quarterly OSH performance to the SRA;
c. annual third party external compliance audit results to the SRA;
d. requirements of OSH Performance & Incident Reporting; and
e. other legal and regulatory reporting requirements.
• Requirements outlined in SRA / CA requirements / permits / licenses /
no objection certificates, or equivalent;
• requirements outlined in approved OSH Plans and Studies
• requirements outlined in relevant OSHAD SF Regulatory Instruments; and
• other requirements outlined by the entity’s approved OSHMS.
The entity’s OSH Incident Investigation Procedure(s) shall be compliant with OSHAD
SF and shall address, at a minimum:
• process of recording, investigating and analyzing OSH incidents;
• ensure investigations are performed by competent person(s) in consultation and
coordination with relevant stakeholders;
• ensure investigations are performed in a timely manner;
• process to determine the root causes of OSH incidents;
• identify opportunities for corrective and preventative control measures; and
• ensure effective communication of investigation outcomes to relevant stakeholders.
7.11.2 Positive points observed, for example but not limited to:
• Incident register is accurate and includes all information of OSH incidents from incident date
to completion of investigation and follow up and closure of corrective actions required.
• All the reported incidents are investigated thoroughly, and corrective actions implemented
and verified for effectiveness.
• Employees are encouraged to report Near Miss Reporting, which can prevent major incidents
in the future.
• A unified register exists for all OSH incidents that occurred in the entity (entity with multiple
locations).
• All serious incidents reported to OSHAD and included in the performance report.
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7.11.3 Points could lead to NC, for example but not limited to:
Incident Notification: • The Incident Reporting process is not available and employees were not
familiar on how to report incidents.
• Serious OSH incidents not reported to OSHAD.
Incident Reports: • Investigation reports were not identifying the root causes and the corrective
action plan and follow-up requirements.
• An incident was not reported using correct forms by the entity for closure.
Performance Report: • Performance Reporting submitted to OSHAD does not reflect the incident
statistics shown as evidenced during the audit.
Corrective Actions: • No evidence of corrective actions taken to prevent the reoccurrence of similar
incidents e.g. an incident where an electrical cable got burned and no action
taken to identify the root cause and check all other cables that could lead to
same incident.
• Incident corrective actions need to be included in the incident register for
follow up and ensuring close-out.
• Corrective Action identified in Incident Investigation has not been
i m p l e m e n te d .
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7.12 Communication and Consultation
7.12.1 OSHAD-SF Requirements:
The entity’s Communication Procedure(s) shall address, at a minimum:
• internal communication throughout the various levels of the entity;
• communication with contractors and other visitors to the workplace;
• relevant communication with external stakeholders; and
• development of an annual OSH performance report, to be used for internal communication
and management review purposes (external stakeholder communication / distribution is
optional).
7.12.2 Positive points observed, for example but not limited to:
• Some good initiatives in place including development of an OSH portal internally for the
department website and OSH E-awareness & training for their staff.
• Good OSH communication through Display screens and emails.
• Advance Document Management System for sharing OSHMS documents with all employees
• Safety instructions at the visited sites were displayed in multiple languages.
• A monthly OSH newsletter is issued to all employees which includes OSH.
• Safety and Health Cards provided to all employees visiting the sites (as part of the licensing
activities).
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7.12.3 Points could lead to NC, for example but not limited to:
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7.13 Inspection and Audit
7.13.1 OSHAD-SF Requirements:
The entity’s OSH audit and Inspection program / procedure(s), shall address, at a minimum:
• scope, criteria, and objectives of audits / inspections to be conducted;
• program responsibilities, competencies and resources;
• program planning and implementation processes, including:
a. criteria;
b. frequency and schedule;
c. methods of collecting and verifying information;
d. reporting results; and
e. program record keeping.
• program monitoring and review; and
• internal and external reporting requirements.
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7.13.3 Points could lead to NC, for example but not limited to:
Procedure: • Audit and Inspection Procedure not complying with OSHAD SF requirements.
OSH Audit and Inspection • No OSH Audit & Inspection plan was available
Plan: • Inspection plan is not suitable to adequately cover entity’s area and
facilities requiring large scale inspections.
• Audit scope needs to refer to OSHAD-SF as a requirement within the
audit procedure / report / plan etc.
Conducting Internal OSH • Internal OSHMS Compliance Audits were not conducted since approval.
Audit: Moreover, there is no plan in place for internal audit.
• Internal audits were conducted, however, the audit reports and non-
compliances reports template (as per the internal audit SoP) were
not used.
Conducting OSH • Inspection planned to be done at least once a month according to
Inspection:
Workplace Inspection Procedure. However, inspection reports were
not available.
Monitoring Corrective • Corrective actions of non-conformance raised during the internal audit
Actions: were not monitored for closure.
Third Party Audit: • The third party audit scope does not cover OSHAD SF requirements.
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7.14 OSH Performance Monitoring
7.14.1 OSHAD-SF Requirements:
The entity’s OSH Monitoring Procedure(s) shall address, at a minimum:
• monitoring of the entity’s OSH targets and objectives;
• monitoring the effectiveness of OSH programs and control measures;
• proactive and reactive measures of performance to monitor conformance with OSH
programs and control measures;
• monitoring compliance with applicable Federal Occupational Standards and OSHAD SF-
Standards and Guideline Values;
• relevant requirements outlined in relevant OSHAD SF Regulatory Instruments;
• requirements outlined in SRA / CA permits / licenses / no objection certificate / etc.;
• requirements outlined in approved OSH Plans and Studies;
• requirements outlined by relevant SRA / Competent Authority(s); and
• description of methodologies and instruments used to monitor, including, calibration
requirements and records.
The monitoring of occupational Safety and Health shall be risk based and include at a minimum:
• occupational noise, air and lighting;
• ergonomic and workplace design factors;
• wellness programs;
• waste management;
• hazardous substances;
• health surveillance;
• occupational illnesses; and
• OSH hazards, near-misses and incidents.
7.14.2 Positive points observed, for example but not limited to:
• Implementing programs for occupational health & safety to enhance employee awareness
and wellbeing e.g. (ergonomic program, Blood donation campaign, Heat Stress and Healthy
heart campaigns etc.).
• Conducting health campaign for employees like blood pressure campaign.
• Implementing programs for vaccination and health follow up for relevant employees in order
to protect them from animal infectious disease.
• Noise monitoring survey to assess indoor noise levels was conducted.
• Organizing annual OSH week including health campaigns and programs like blood pressure
and healthy diets, etc.
• Project OSH performance included in the entity performance reporting on monthly basis.
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7.14.3 Points could lead to NC, for example but not limited to:
Performance reports: • LTISR not defined in the OSHMS and neither monitored
through objectives.
• Quarterly report sent to OSHAD does not include OSH Performance
data for the operational activities within the scope of entity’s OSHMS.
• OSH Performance data (KPIs) reported to OSHAD does not include all
sites / locations.
Corrective actions: • No monitoring process of the proactive and reactive actions (e.g.
tracking register). A tracking register can help in recording the
identified actions in order to monitor and track them for closure.
• No corrective action taken on indoor air quality tests.
• OSH corrective actions were not tracked, monitored and closed.
Examples are:
a. Internal audit non conformities
b. Incident investigation corrective actions
c. Inspections reports corrective actions
d. Findings of risk management activities (controls)
Indoor air quality and • No indoor air quality monitoring conducted although identified in
noise monitoring: Risk Register.
• Indoor air quality monitoring not done in high risk areas.
• Air quality monitoring in the laboratory has not been conducted despite
warning of carcinogens being present within certain areas.
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7.15 Document Control and Record Retention
7.15.2 Positive points observed, for example but not limited to:
• OSHMS records are effectively managed with well-established logs.
• The entity OSHMS is very well structured and documented and updated as per latest version
of OSHAD-SF
• Management System processes effectively managed using software application.
7.15.3 Points could lead to NC, for example but not limited to:
Procedure: • Document Control and Record Retention Procedure not complying with OS-
HAD SF requirements.
Updated and • The OSHMS is not upgraded in compliance with OSHAD-SF latest version.
approving OSHMS: • There was no approval signature on all the OHS documents as required un-
der “Document Control & Record Retention Procedure”
Record retention: • Record Retention was not defined as minimum retention period of OSH
records for 5 years and employee medical / occupational health records for
employment duration plus 30 years
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7.16.2 Positive points observed, for example but not limited to:
• High level commitment from the Top Management with regards to OHS follow-up and
monitoring by involvement in the OSH committee and Top Management Committee.
• Weekly OSH action plan status update is sent to the management.
• High level commitment from the Top Management with regards to OHS follow-up and
monitoring to close all issues related to OSH.
7.16.3 Points could lead to NC, for example but not limited to:
Management review • Management review did not cover the minimum agenda as defined in
agenda: OSHAD-SF.
Management review • Management review was done; however actions recommended from the
recommendations: management review were not implemented.
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8. References:
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www.oshad.ae