Abu Dhabi Environment, Health and Safety Management System ...

Abu Dhabi Environment,Health and Safety ManagementSystem Regulatory Framework(EHSMS)Guidance DocumentsEntity Guideline to Assist withDevelopment of EHSMSJuly 2009

Contents1. Introduction 11.1 Background 11.2 Purpose of Guideline 11.3 Entities with International Certification 22. Management Commitment 42.1 Establishment of an EHS Management Committee 42.2 Development of Policy 43. Planning 53.1 Identify EHS Risks 53.2 Identify Legal Requirements 53.3 Develop EHSMS Targets and Key Performance Indicators 63.4 Developing an EHS Management Program 74. Implementation and Operations 94.1 Identify Roles and Responsibilities 94.2 Identify Training Needs 114.3 Develop EHS Policies and Procedures 124.4 Develop Document Control Procedures 124.5 Emergency Management 134.6 Communicate to Staff 145. Check and Corrective Action 155.1 Monitor, Measure, and Report 155.2 External Reporting 155.3 Internal EHSMS Auditing 165.4 External EHSMS Auditing 165.5 Non-Conformance and Corrective and Preventative Action 175.6 Records Management 196. Management Review 207. Approval of EHSMS 218. Special Provisions for Entities with Established Systems 22

Table IndexTable 1Federal and Abu Dhabi Emirate LegalRequirements 5Figure IndexFigure 1Figure 2Roadmap for Successful Environmental Health andSafety Management System Implementation 3Non-Conformance and Corrective Action PlanDecision Making Tool 18

1. Introduction1.1 BackgroundOn 6 th December 2006, the Executive Council issued a Decree (Committee Decree 2-Session 31/2006) approving "Abu Dhabi Emirate EHS policy" and nominated theEnvironment Agency–Abu Dhabi (EAD) as the Authority responsible for supervising theimplementation of the EHS Management System (EHSMS) at Abu Dhabi Emirate levelin cooperation and coordination with all concerned parties.The objective of the policy is to achieve excellence in the management and protectionof the environment, health, and safety through partnership between all government andprivate sectors to ensure activities within Abu Dhabi Emirate are undertaken in aresponsible, safe, and sustainable manner.To follow up the development and implementation of the Abu Dhabi Emirate EHSMSFramework, the Executive Council established the "EHS Higher Committee" by aDecree issued on 11 th June 2007.1.2 Purpose of GuidelineThis report is a guideline that provides an overview of the steps that need to beundertaken by an entity to develop its own EHSMS. A full training program has alsobeen developed within Abu Dhabi Emirate EHSMS framework to help entities establishtheir own EHSMS. This guideline is a summary of that training program.Generally, the steps to develop an EHSMS fall into five main categories:1. Management commitment;2. Planning;3. Implementation and operations;4. Checking and corrective action; and5. Management review and approval.This report assumes that entities using this guideline have not previously developed amanagement system based on international standards such as ISO 14001, ISO 9000or, OHSAS 18001. Thus, the report provides a step-by-step breakdown of the keytasks that need to be completed to develop and implement an EHSMS.This report outlines the steps that can be undertaken by entities to develop andimplement an entity-specific EHSMS. The Emirate EHSMS Framework Codes ofPractice (CoPs) provide clear guidance on how entities can develop their own systemswithin the required EHSMS framework.Figure 1 outlines the necessary steps which will be explained in more detail in thereport. These steps are based on the International Standards Organisation (ISO)standards while also outlining Abu Dhabi Emirate EHSMS specific requirements.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System1

In addition to these steps, the Abu Dhabi Emirate EHSMS has the followingrequirements:All entities are required to register their EHSMS or their intent to develop anEHSMS to their Sector Regulatory Authority;Once the systems have been integrated and an EHSMS established, this mustbe submitted to the Sector Regulatory Authority for approval;Entities whose EHSMS have been approved must report quarterly or annuallyto their Sector Regulatory Authority. This will likely form a condition of a licenceto operate; and Entities with established EHSMS must conduct ongoing audit and inspectionswhich is an essential part of the self-regulation framework established by theEmirate EHSMS.1.3 Entities with International CertificationIf an entity has an existing system certified under ISO 14001, OHSAS 18001, or ISO9000, then many of the requirements outlined in this report will have been metalthough they will be specific to either environment, health and safety, or quality.If an entity has certification under any of these three international standards, then workwill be required to update the procedures to integrate environment and health andsafety.A separate report (Abu Dhabi Emirate EHSMS Guidance Documents– Comparisonwith International Management Systems Standards) describes the relationshipbetween the elements of the international standards and the requirements of AbuDhabi Emirate EHSMS Framework.Entities with existing certified systems should refer to the Comparison report andSection 8 of this report for further guidance.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System2

Figure 1Roadmap for Successful Environmental Health and Safety Management SystemImplementationContinualImprovementComplianceGoals andPoliciesEstablish EHSMS CommitteeManagement Commitment to EHSMSDevelop EHSMS PolicyDocument EHSMSPolicyEstablish procedure toidentify EHSMS risksImplementationScheduleIdentify EHSMS RisksReview Legal RequirementsEstablish procedure toaccess current andfuture legalrequirementsIdentify EHSMS targets and KPIsTrain staff in operations withsignificant impactsDevelop EHS Management ProgramIdentify Roles and ResponsibilitiesIdentify training needsEstablish document control proceduresDocument objectivesand targetsDocument roles andresponsibilitiesEHSMS awareness trainingWebsiteEmergency managementEmailsNewslettersCommunicate to staffBulletin boardsMeetingsMonitor, measure & reportPostersEHSMS –AuditingDocument findingsReturn To Top ForContinualImprovementCycleManagement ReviewSector Regulatory AuthorityApprovalEstablish procedures formanaging non-conformanceDocument alldecisions andactionsKey:Step 1: Management commitmentStep 2: PlanningStep 3: Implementation and operationsStep 4: Checking and corrective actionStep 5: Management review76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System3

2. Management Commitment2.1 Establishment of an EHS Management CommitteeEstablishing an EHS Management Committee is an important first step when introducing an EHSMS intoan entity.The role of the Committee will be to facilitate implementation of the EHSMS, provide direction for thedevelopment of policies and procedures, act on behalf of management, and report to management.The EHS Committee usually includes representatives from staff, management, environment officers, andhealth and safety officers.For organisations with less than 50 employees the committee may comprise only the CEO (or a seniormanager) and an EHS Officer.2.2 Development of PolicyOne of the first steps that are to be undertaken in the development of an EHSMS is the development of aPolicy. The development and endorsement of an EHS Policy by management is an important way ofdemonstrating management commitment to the development and implementation of an EHSMS. Thepolicy should be short and concise. It can be supplemented with an explanatory booklet for personnel toenhance their understanding.Generally, there are 10 components that should be included in an EHS Policy:1. Statement of commitment of the entity to protect environment and health and safety usingEHSMS and self-regulation;2. Roles and responsibilities of management and workers in EHS;3. Establishment of a set of guiding principles:- Based on the principles of self-regulation and continual improvement- Based on the principles of ecologically sustainable development (integrating social,economic, and environmental spheres of development)- Adopting the precautionary principle- Risk management4. Development of EHS goals and targets;5. Requirement to meet regulatory requirements;6. Statement regarding achievement of a high level of environmental and health and safetystewardship;7. Statement extending responsibility of implementation of EHSMS to contractors;8. Provision of education opportunities in EHS;9. Monitoring EHSMS performance; and10. Provision for continuous improvement.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 4 -

3. Planning3.1 Identify EHS RisksThe development of an entity-specific EHSMS begins with identifying key environmental and health andsafety risks. The risks should relate to impacts from the entity’s activities in the day-to-day operations ofthe entity and reputation risk.One of the guiding principles in the EHS policy is to integrate economic, social, and environmentalconsiderations into decisions to ensure that the measures adopted are cost-effective and in proportion tothe significance of the issues being addressed. Therefore, to fully understand the cost and effort requiredfor activities undertaken by an entity, a risk assessment must be completed.The Abu Dhabi EHSMS Manual includes a AD EHSMS CoP 05 - Risk Management. This can be used togain further understanding into ways to undertake a risk assessment.Once all risks have been identified, they need to be prioritised. This should be done by analysing thelikelihood of that incident occurring.Identification of an entity’s EHS risks is part of developing an EHS aspects register.3.2 Identify Legal RequirementsPart of managing EHS risks is to identify the legal requirements that apply to environment, health, andsafety. As a guide, the current relevant UAE Federal and Abu Dhabi Emirate legislation is outlined inTable 1.It is recommended that all entities undertake their own internal review of legislation.Table 1Federal and Abu Dhabi Emirate Legal RequirementsEnvironmental LegislationFederal Law No. 24, 1999 - This law outlinesways to achieve sound environmentalmanagement and sustainability through theestablishment and enhancement of suitablemanagement, legal, and technical instruments toprotect, develop, and conserve the environmentin the Emirate of Abu Dhabi.Local Law No. 16 2005 – This law outlines therequirements to assess environmental impacts ofsewage, air emissions, hazardous wastemanagement, impacts to current and futuredevelopments, and urban planning.Local Law No. 21 2005 (Waste Management)requires the EAD as the competent authority toassume responsibility for the enhancement ofHealth and Safety LegislationFederal Law No. 8 (1980) - Chapter 5 -Occupational Safety, Preventive, Health, andSocial Care.Local Law No. 16 (2005) - Article 14 -Establishment or individual is prohibited frompractising any work or conducting any activityadversely affecting the health of man and safetyof environment without obtaining licence from theAuthority.Federal Law No. 1 (2002) -Article 9 - Regulationand Control of the Use of Radioactive Sourcesand Protection against its Hazards.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 5 -

Environmental Legislationwaste management through reduction ofgenerated waste, recycling and reuse, and byproviding solutions for the treatment of waste.Health and Safety LegislationMinisterial Order No. 32 (1982) - Determination ofPreventive Methods and Measures for theProtection of workers from the risks of work.Issued by Ministry of Labour.Ministerial Decree(s)55/2004 – Regarding the Basic Regulations forProtection Against Ionizing Radiation;56/2004 – Regarding the Regulations for SafeTransport of Radioactive Materials;57/2004 – Regarding the Regulations forRadioactive Waste Management.Regulation Concerning Environmental ImpactAssessment of Projects.Ministerial Order -No 32 1982 Article 1 – Everyemployer shall provide the appropriatepreventative measures for the protection ofworkers from risks of injuries or occupationaldiseases which may occur during working hours.Regulation Concerning Protection of the MarineEnvironment.Regulation Concerning Handling of HazardousSubstances, Hazardous Wastes, and MedicalWastes.Regulation Concerning Agricultural Pesticides,Agricultural Conditioners, and Fertilisers.Regulation Concerning Environmental ImpactAssessment of Projects.3.3 Develop EHSMS Targets and Key Performance Indicators3.3.1 Developing Key Performance IndicatorsThe development of an EHSMS should include targets and key performance indicators (KPIs). KPIs area way to measure success of an entity and are an important way of assessing and trackingimplementation of the EHSMS.KPIs are quantifiable measurements, agreed to beforehand, that reflect the critical success factors of anentity. They should be entity-specific, reflect the entity’s goals, and be related to the success of specificpolicies, procedures, and initiatives.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 6 -

Entities developing KPIs need to ensure that the entity-specific KPIs are linked to and reflect KPIsdeveloped at the Emirate level.To allow for tracking, KPIs should be quantifiable, measurable, and achievable, however, they shouldalso drive an entity towards success, i.e, they should not be too easily achievable.In addition to considering how measurable an indicator is, it is also important for the KPI to be limited innumber and essential to the entity’s goals. A good KPI will have the following:Title of the KPI;Defined indicators, i.e., the time period, the department, or the volume or unit of measure;Measurable, i.e., they are able to be monitored and measured; andTargets, i.e., each indicator should have specific targets.3.3.2 Developing TargetsEach indicator should have a target or a series of target that help monitor progress towards meeting theKPI. Like KPIs, targets should be measurable and defined.Entity targets should contribute to reaching long-term goals set by sectors which again will align withgovernment goals.Some example targets include:Reduce energy use by 20% from 2007 levels;Reduce water use by 25% from 2007 levels;Reduce total CO 2 emissions by 15% from 2007 levels;Reduce waste generated by 10% from 2007 levels; andIncrease concrete recycling by 50% from 2007 levels.Non-numerical targets include:Develop programs to improve EHS performance of suppliers;Establish annual awards to promote EHS behaviours amongst workers;Establish program to promote EHS integration throughout company; andComply with all relevant UAE and Abu Dhabi Emirate EHS regulations.3.4 Developing an EHS Management ProgramOnce the entity has determined the EHS risks and has developed targets it is vital to develop amanagement program that helps the entity work towards those targets and goals.The Program can be a five-year program with details provided for the first few years. The programneeds to identify all key tasks that need to be undertaken to commence development andimplementation of an EHSMS including key actions, personnel requirements, budget requirements, andtimeframes.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 7 -

Once completed, the EHSMS Management Committee should approve the program for implementationwithin the entity.The EHS Management Program will form part of the annual review to identify tasks completed and thoseoutstanding.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 8 -

4. Implementation and Operations4.1 Identify Roles and ResponsibilitiesEveryone has a role to play in the development and implementation of an EHSMS. Within an entity it isimportant to clearly identify these roles. The Abu Dhabi EHSMS framework identifies the roles andresponsibilities of the Competent Authority, the Sector Regulatory Authorities, and the entities.Further details can be found in the AD EHSMS CoP 02 - Roles and Responsibilities in the Abu DhabiEHSMS Manual.4.1.1 Emirate LevelCompetent AuthorityThe Competent Authority will assume a coordinating and overseeing role in the implementation of theEmirate EHSMS.The Competent Authority will:Coordinate – encourage and guide sectors to develop an EHSMS;Communicate – advise sectors on government goals and targets;Monitor – check, review, and assist in an informal capacity;Audit – check and review in a formal capacity (where and if required);Approve – provide approval of sector EHSMS;Educate – provide and/or coordinate training for specific issues and sectors;Research – compile information and data, and to investigate new opportunities;Report – to government on status of EHS management within the Emirate, andPartner – with sectors to understand and assist with compliance issues.SectorsInitial focus will be to assist the eight (8) major sectors in developing and implementing an EHSMS.The Major Sectors are:Building and ConstructionTransportationHealthEnergyWasteTourismOil and Gas76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 9 -

IndustryEach sector will have a Sector Regulatory Authority. These authorities will be able to provide support andguidance for entities establishing EHSMS and will approve a completed entity EHSMS.The role of the sectors will be to develop and implement their EHSMS systems in accordance with theSector Guidelines and to report to the Competent Authority, as required.CommunityBy instigating development and implementation of an EHSMS throughout Abu Dhabi Emirate, a processof community engagement and education is commenced. The role of the community is to work towardsminimising their environmental impacts, improve safety in the Emirate, and work towards continuousimprovement.A Framework Code of Practice has been developed to assist in identifying key roles and responsibilitiesin an entity – AD EHSMS CoP 02 - Roles and Responsibilities.4.1.2 Entity LevelThough the organisation structure of each entity may differ, there are commonalities in relation tomanagement structures that can assist in identifying the roles and responsibilities within an entity. Thissection outlines these roles and responsibilities which have been adapted from Abu Dhabi EmirateEHSMS Guidance Documents –Guideline for EHSMS Organisational Structure in Sectors/Entities.EHS Department and EHS ManagerThe role of an EHS Manager is to develop an entity EHS Policy and oversee the development of EHSpolicies and procedures. The core responsibility for EHS rests with the EHS Department managed by theEHS Manager. The EHS Department may comprise of one or several officers depending on the size ofthe entity.The EHS department and Manager functions may be implemented in different forms depending on thenature and size of the entity, in other words, the EHS Manager position may not be a full time role.EHS Management CommitteeThe EHS Manager is usually assisted by a Management Committee that is responsible for monitoring theprogress of the establishment, development, and implementation of an entity EHSMS. The EHSManagement Committee develops a timetable for internal auditing and reporting. This is an importantpart of the Abu Dhabi Emirate EHSMS.The EHS Management Committee is required to report via the EHS Manager/EHS department to theEHS Steering Committee as explained in the following section.EHS Steering Committee (optional)For a very large organisation an EHSMS Steering Committee can be established to act on behalf ofmanagement and to direct the EHS Department and EHS Management Committee.The role of the committee is also to review EHSMS policies and procedures and sign off on finalisedpolicies.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 10 -

For smaller entities, the role of this committee is delegated to the General Manager or to a high-rankingmanagement committee.4.2 Identify Training NeedsEnsuring staff are trained in all aspects of environment, health, and safety can ensure staff uptake of theEHSMS and minimising environmental incidents and health and safety risks. The provision of adequatestaff training will be a Key Performance Indicator that must be reported by the entity to the CompetentAuthority under Abu Dhabi’s EHSMS. The specific training needs of an entity will differ depending onworks undertaken by the entity, however, the following general rules apply:Give participants an understanding of the EHS Policy, EHS impacts, procedures, andresponsibilities;Be ongoing with regular refresher courses;Cover all aspects or operations related to environmental, health, and safety;Provide knowledge of management systems; andAddress implementation issues.There are national and international training providers that provide EHS training. It is also important tonote that the Competent Authority has developed a series of training modules that can be provided to aspecific entity.The process of identifying key risks will help identify opportunities for further experience and training forstaff. EHSMS training must include all aspects of the EHSMS (environment, health, and safety). Someexamples of training include:Site induction;Housekeeping;Building site safety;About the company’s EHSMS;Fall Protection;Personal protective equipment;Back/ spinal safety;Stairways and ladder safety;Ergonomics;Emergency response;Lifting safety;Preventing heat stress;Fire protection;First aid;Hearing safety;76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 11 -

Environmental protection – dust control;Environmental protection – prevention of water pollution;Environmental protection – hazardous materials;Environmental protection – protecting site vegetation/ trees;Environmental protection – protecting wildlife;Transfer of flammable liquids to containers, equipment, and vehicles;HAZCOM Standard;Spills and Releases; andNatural Resources Permitting and Compliance issues.4.3 Develop EHS Policies and ProceduresOnce the entity has adopted an EHS Policy and established targets and benchmark and a managementprogram, it is important to develop the EHSMS policies and procedures. The policies and proceduresdeveloped will align with the EHS aspects register that identifies the entity EHS risks.The policies and procedures identify ways to mitigate the risks and prevent harm to the environment andthe health and safety of employees. At a minimum, policies and procedures need to state the following:The purpose of the policy;The scope of the policy, i.e., what the policy applies to;The approach to achieving the purpose of the policy;What records are needed;Review of records; andAny definitions.Policies and procedures must be kept in the entity-specific EHSMS Manual.4.4 Develop Document Control ProceduresWhen developing EHSMS policies and procedures a standard format helps in the documentmanagement system. Documents should have the following key components:Definitions which define any technical terms or any words with special meanings;Purpose of the document;Scope of the document;Type of document (whether a code of practice, standard operating procedure, form, or guideline);Any other related documents; andTechnical information or EHS requirements.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 12 -

The control of EHSMS documents is an important issue in preventing unauthorised amendments andensuring that the latest version is being implemented. To effectively control documents only the EHSMSOfficer or Coordinator will have editing rights and all documents should have:The EHS Procedure number – all EHS procedures must have a number;The document name, for example, ‘Code of Practice for the management of dust emissions fromconstruction projects’;The name of the person who prepared the document;The name of the person Who approved the document;The signature of the approval authority;The EHSMS requirement that the document meets, where relevant;Revision number;Revision date;Effective date; andNext review date.The record management procedures should include:Training records and the results of audits and reviews;Ensure that EHS records are legible, identifiable, and traceable to the activity, product or serviceinvolved;Ensure that EHS records are stored and maintained such that they are readily retrievable andprotected against damage, deterioration, or loss;Ensured that the retention times of these EHS records have been established and recorded.4.5 Emergency ManagementIn the case of an environmental and/or health and safety emergency that occurs as a result of activitiesbeing carried out by the entity (internal risk) or from events beyond the control of the entity (external risk),proper procedures need to be in place to manage and respond to these events.The risk assessment will identify key environmental, health, and safety risks and the likelihood of theserisks occurring. The entity needs to ensure there are emergency management procedures that addresseach of the high risks. Emergency management procedures should address the following key aspects:What constitutes an emergency;Communication protocols in case of an emergency;Reporting protocols in case of an emergency;Ways to respond to and manage the emergency; andHow to prevent re-occurrence.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 13 -

The AD EHSMS CoP 06 - Emergency Management in the Abu Dhabi EHSMS Manual provides moreguidance on ways to identify a hazard and the requirements of an emergency management plan.4.6 Communicate to StaffOnce an entity commences development of an EHSMS, communicating this to staff is advisable. Thereare many ways to communicate the entity’s EHSMS commitments and requirements and staff roles andresponsibilities including:Inclusion in position descriptions;Induction training;Supply chain management (by requiring suppliers to have an EHSMS);Management of contractors by inclusion on contractor selection briefs (requirement forcontractors to have an EHSMS);Incorporating into work instructions;Developing EHS KPIs in yearly job reviews;EHSMS roles and responsibilities in all contract documents;Having a code of conduct including EHSMS that all employees, contractors and, suppliers mustsign;Regular training;EHS on intranet;Regular newsletters; andPrizes, awards and other promotional activities.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 14 -

5. Check and Corrective Action5.1 Monitor, Measure, and ReportMeasurement of EHSMS KPIs and continual monitoring plays a significant role in continuousimprovement and is a very important aspect of the EHSMS. Without some form of monitoring andmeasurement it is difficult to know whether EHSMS controls are effective or whether improvements havebeen implemented.Monitoring and measurement requirements cover all aspects of EHS, for example:Water quality;Air quality;Noise levels;Waste generated and how it is managed and disposed;Plant and wildlife species on the site;OHS incidents and near misses;Land use and any potential contamination; andHazardous substances management.Monitoring may require different forms of data collection from physical measurement to regularinspections to regular data collection. Where possible, data monitoring should take the form ofquantitative measurement.The Abu Dhabi Emirate Environment Health and Safety Protection Policies (EEPPs) contain monitoringand reporting requirements. Monitoring and reporting will form an important component of the selfregulationprocedure developed for the EHSMS.There are two forms of reporting required by the EHSMS. First, the entity will need to establishprocedures for internal reporting. This will assist management in tracking progress towards meeting thetargets and KPIs as well as monitoring budgets and implementation of the EHS Management Plan.Second, the entity will need to establish procedures for external reporting as described below.5.2 External ReportingIn addition to internal monitoring, Abu Dhabi EHSMS requires reporting to the Competent Authority.External reporting is a central part of self-regulation. External reporting should provide an overview ofthe status of the implementation of the EHSMS, data on emissions, any reported environmental or healthand safety incidents and remedial actions, and progress towards targets and KPIs.The AD EHSMS CoP 09 - Monitoring and Reporting in the Abu Dhabi EMSHS Manual outlinesmonitoring and reporting requirements. The AD EHSMS CoP 03 - Self-Regulation in the Abu DhabiEHSMS Manual provides the requirements that need to be met to allow for self-regulation under AbuDhabi EHSMS.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 15 -

5.3 Internal EHSMS AuditingInternal and entity self-auditing is important in the continuous improvement cycle. A self-audit can bedefined as a systematic, objective, and documented system that is part of a planned effort to prevent,identify, and correct workplace environment and health and safety hazards. The audit may be conductedby qualified in-house personnel (competent employees or management officials) or third party auditors.Audit findings must be recorded and maintained by the employer.When developing an auditing procedure, the following considerations should be included in the auditplan:Specific areas, functions, procedures, and activities to be audited;Personnel qualified to perform the audits;Audit schedule and frequency;Audit processes and techniques;Method of recording and reporting audit findings; andDevelopment and implementation of corrective action to resolve cited audit discrepancies.The audit plan developed for the entity should include:Audit Team Identification;Pre-audit Review;Opening Meeting;Data Collection;Data Review and Analysis;Closing Meeting;Reporting; andAudit Program Evaluation.Audits can be conducted a number of ways including interviews, review of records, and physicalinspections. Audit reports must be made available to management and the rest of the audit team.It is important to note that audits must be open, transparent, and do not seek to apportion blame. If abreach is found and corrective action taken then no enforcement may be necessary. The AD EHSMSCoP 08 - Audit and Inspection in the Abu Dhabi EHSMS Manual outlines self-auditing procedures anddeveloping audit plans.5.4 External EHSMS AuditingAll entities implementing the Abu Dhabi EHSMS framework will be required to allow external audits oftheir EHSMS. (refer AD EHSMS CoP 03 – Self-Regulation).External audits should be undertaken at least annually as part of the entity’s commitment todemonstrating self-regulation and results of the audit should be reported to the Sector RegulatoryAuthority.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 16 -

The AD EHSMS CoP 08 – Audit and Inspection details the scope and requirements to be met by theaudit and also describes the responsibilities of the external auditor.To demonstrate compliance with the Abu Dhabi EHSMS framework, the entity EHSMS must include acommitment to allow external audits and a procedure that details the process to be followed when anexternal audit is to be undertaken.The external audit can be requested both by the entity or the sector regulatory authority and the entitymust make available all documents relevant to the EHSMS to the auditor regardless of who requestedthe audit.5.5 Non-Conformance and Corrective and Preventative ActionIf the audit finds an example of non-conformance, then corrective action must take place and preventiveaction, to ensure the non-conformance doesn’t re-occur.Figure 2 provides an overview of procedures that may be followed by an entity.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 17 -

Non-conformance observedfrom:Internal EHS AuditMonitoringCompetent AuthorityInspectionInternal/ External Non-Conformance IssuedCorrective action initiated, schedule follow up andtimeframe.Steering Committee tracksuse of EHSMS objectiveand targets.Responsibility assigned to Area ManagerEHS compliance officer or designee follows up oncorrective action to ensure compliance toscheduleAll changes to procedures resulting from acorrective and/or corrective action aredocumentedSteering Committee and Management reviewcorrective/ preventative actions and follows up toensure effectivenessManagement and EHSDirector – regularlyreview complianceissues.All records are filedFigure 2Non-Conformance and Corrective Action Plan Decision Making ToolOnce a non-conformance is identified and the appropriate actions taken, the root cause of the nonconformanceneeds to be identified.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 18 -

There are many reasons for non-conformance including:Poor communication;Faulty or missing procedures;Equipment malfunction or lack of maintenance;Lack of training;Lack of understanding of requirements;Failure to enforce rules; andCorrective actions fail to address root cause(s) of problems.Preventive actions need to be put in place to stop re-occurrence of non-conformances and theeffectiveness of these measures assessed.5.6 Records ManagementManagement of records is important in preventing unauthorised amendments and ensuring the latestversions of policies and procedures is being implemented.All EHSMS documentation must have the following:EHSMS Procedure number – all EHSMS procedures must have a number;Document name, for example, ‘Code of Practice for the management of dust emissions fromconstruction projects’;The name of the person who prepared the document;The name of the person who approved the document;The signature of the approval authority;The EHSMS requirement that it meets, where relevant;Revision number;Revision date;Effective date; andNext review date.The records management procedures should include:Training records and the results of audits and reviews;Ensure that EHSMS records are legible, identifiable, and traceable to the activity, product orservice involved;Ensure that EHSMS records are stored and maintained such that they are readily retrievable andprotected against damage, deterioration, or loss; andEnsured that the retention times of these EHSMS records have been established and recorded.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 19 -

6. Management ReviewThe management review periodically reviews the EHSMS to ensure it is meeting the objectives of theEHSMS, legal requirements, and the developed performance indicators. Management reviews are anecessary part of due diligence and self-regulation. The management review ensures that the EHSMScontinues to be effective and continues to improve.The outcome of the management review should be a statement on the performance of EHS within theentity based on the targets and goals set by the entity. Where non-conformance or improvement isrequired, the statement should clearly and concisely indicate how the entity is addressing each particularissue.The statement is to be made available to the Sector Regulatory Authority.The management review is usually annual and includes a review of:EHS Audit results;Results of monitoring and measurement of environmental indicators;Progress towards achievement of objectives and targets;Regulatory compliance status;History of corrective and preventive actions; andAny other relevant information on EHS.The management review process also allows for updating of policies and procedures, targets and KPIs,and improvements to the system.Management review procedures should address the following:Management Committee – The procedure needs to outline who will form the managementcommittee and who needs to sign off on procedures. This is important as it will establish thehierarchy for reporting;Frequency of meeting – How often management is expected to meet to review the EHSMS anddocumentation needs to be stated in the procedure;Agenda items – The procedure should outline what the key agenda items will be for everymeeting. This will be made up of some key points that must be discussed in every meeting andwill relate to the environment, health, and safety performance indicators, audit results, and legalrequirements;Roles and responsibilities – Issues such as who will conduct meetings and who is responsible formaintaining meeting minutes and records should be outlined in the procedure; andThe annual review should take place before reporting to the Regulatory Authority.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 20 -

7. Approval of EHSMSWhen an entity has developed an EHSMS, it is required to seek approval of the management systemfrom the Sector Regulatory Authority.This is best achieved by contracting a third-party accredited consultant who specialises in EHSmanagement systems to review and approve the system. Once the consultant is satisfied that therequirements of the EHSMS framework have been met then he/she will prepare a statement to thateffect.This statement can then be submitted to the Sector Regulatory Authority who should approve the entityEHSMS.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 21 -

8. Special Provisions for Entities with EstablishedSystemsThis report outlines the steps that must be followed by entities that have not previously developed amanagement system. The steps outlined in the report are similar to the establishment of a managementsystem under ISO standards.For entities that already have an established management system, whether an EnvironmentalManagement System (ISO 14001), Occupational Health and Safety Management System (OHSAS18000), or a Quality Management System (ISO 9000), then it is important that the entity undertake stepsto integrate or upgrade its management systems to form a compliant EHSMS.In general, all entities must complete the following to comply with the Abu Dhabi EHSMS requirements:Develop a policy that demonstrates the entity is committed to EHSMS and self-regulation;Develop a new code of practice (or similar) describing how the entity is to achieve self-regulation;andDevelop a new code of practice (or similar) describing the process for external reporting ofcompliance with the relevant environment, health, and safety law identified in the EHSMS.If the entity has an ISO 14001 Certified system then the entity will also need to update all procedures anddocuments to include health and safetyIf the entity has an OHSAS 18001 Certified system then the entity will also need to update all proceduresand documents to include environmentIf the entity has an ISO 9000 Certified system then the entity will also need to develop a new EHSmanagement system that is supported by the quality systemFurther details on similarities and differences between the ISO standards and the Abu Dhabi EHSMS areoutlined in the report “Abu Dhabi Emirate EHSMS Guidance Documents – Comparison with InternationalManagement Systems Standards”.76/10169/10/5953 Implementation of Abu Dhabi EHSMSEntity Guideline to Assist with Development of EHS Management System- 22 -