Annexure-14 INTERNAL AUDIT REPORT Format No: Department Effective Date: Sample 01.04.2021 Date of Audit Auditees’ Names Reference Audit Standard Sr. No. ISO 9001: 2015 QMS, ISO 14001: 2015 EMS and ISO 45001: 2018 OHSMS Requirements Ref. Clause No. Auditors’ Names Compliance Yes No Observation and Comments N/A Review No: 01 Review Dated: 01/04/2020 Review No: 01 Review Dated: 01/04/2021 Risk --Issues: High Batch Time Cycle 1. Has the department determined internal & External issues and risk & opportunity related to the IMS with systematic approach? Describe context issues and risk opportunity…. Risk: Production Loss/ Late Delivery 4.1/ 6.1.1 Yes -- -- Control: SCADA, Competent person / Production procedure, Evaluation and monitoring in Log sheet verification / Batch tracking sheet Risk Score:6 – Not Acceptable Risk Action Plan: Replacement of Under Capacity Equipments/ Batch cycle time to be monitored on daily basis and minimize the deviation for findings. Opportunity --Issue: High Batch Time Cycle Opportunity: Replacement of Under Capacity Equipments Action Plan: Action plan for Replacement of Under Capacity Equipments Page 1 of 6 Annexure-14 INTERNAL AUDIT REPORT Format No: Effective Date: 01.04.2021 Review frequency – Six Monthly Verified and found satisfactory P/PRD/NIRO Review No: 01 Review Dated: 01/04/2021 2. Has the department determined needs & expectations of interested parties and risk & opportunity related to the IMS with systematic approach? External Interested Party: Customer Needs/ Expectations: Material Received as Per Specification, No Variation in Weight 4.2/ 6.1.1 Yes -- -- Describe needs, expectations and risk opportunity…. Internal Interested Party: QA Needs/ Expectations: Proper sample with intimation slip, Batch details for batch record analysis Risk: Customer Complaints 3. Has the people are aware of organization IMS Policy. How it is communicated in the department up to bottom level? 5.2 Yes -- -- Has documented organization chart for department? 4. 5. Page 2 of 6 Verify Responsibility & Authorities of employees at different levels. What happens in absence? Trained to work at higher level? Is consultation of workers for as below: needs and expectations of interested parties establishing the IMS policy Review frequency – Six Monthly Verified and found satisfactory Annexure: 05 – Quality & EHS Policy Interview Person Name: XXX Awareness found regarding Quality and EHS Policy 5.3 Yes -- -- P/PRD/RRA Designation: Shift In-charge Verified and found documented. 5.4 Yes -- -- Procedure SMPL/SOP.EHS/018 - Participation and Consultation Near-miss report –Reporting for Participation of workers to identity the hazards. Annexure-14 INTERNAL AUDIT REPORT Format No: Effective Date: 6. assigning organizational roles, responsibilities and authorities fulfil legal requirements and other requirements establishing OH&S objectives and targets controls for outsourcing, procurement and contractors Is consultation of workers for as below: identifying hazards and assessing risks and opportunities determining actions to eliminate hazards and reduce OH&S risks determining competence requirements, training needs, training and evaluating training investigating incidents and nonconformities and determining corrective actions Evident verified and found satisfactory. 5.4 Yes -- -- 7. Has the department determined environmental aspect impact? 6.1.2 Yes -- -- 8. Dose retaining information of identified environmental aspect and updated periodically? 6.1.2 Yes -- -- Page 3 of 6 01.04.2021 Verified and found Ok. P/PRD/EIA Review No. Dated: 01.04.2021 Document prepared as per the requirements. Aspect Impact ref. SMPL/PRD/EIA Ref. Review No: 01 Review Dated: 01.04.2021 Activity: Atmospheric distillation Aspect: Vent loss Impact: 1. Discomfort / Nuisance to people. 2. Air pollution.3.Depletion of resources. Condition: Normal/ Direct Control: Mechanical seal is provided to Agitator to avoid leakage through gland Annexure-14 INTERNAL AUDIT REPORT Format No: Effective Date: 01.04.2021 Score: 08 – Non Significant Environment Aspect however cutoff score is 25. Action Plan/ OCP: SOP/PD/06 Verified and found satisfactory 9. 10. Dose the department has prepared action plan to significant environmental aspect? Is product life cycle perspective determined and considering in the aspect impact assessment? Describe product lift cycle perspective…. 6.1.2 Yes -- -- Verified and evidence is maintained effectively. 6.1.2/ 8.1 Yes -- -- Found Satisfactory. Hazard Identification & Risk Assessment ref. P/PRD/HIRA Review No: 01 Review Dated: 01.04.2021 11. Has the department determined hazards and assess the risk (HIRA)? 6.1.2.1 Yes -- -- Activity: Acetylation Hazard: Reactor may get pressurized during (AC2O+H2SO4) addition Risk: Skin contact with material, Vapour exposure Condition: Direct/ Routine/ Emergency Control: Engineering, SOP, Administrative, Visual and PPE controls are available. Action Plan/ OCP: SOP/PD/02 Verified and found satisfactory 12. 13. 14. 15. Page 4 of 6 Dose retaining information of identified Hazards & risk and updated periodically? Dose the department has prepared action plan to not acceptable OHS risk? Is relevant applicable requirement are identified and retained? Does the department establish objectives at relevant management system? 6.1.2.1 Yes -- -- Verified and found satisfactory 6.1.2.1 Yes -- -- Verified and found satisfactory 6.1.3 Yes -- -- P/PRD/LR -Legal register verified and updated as on dated 01.07.2021, found ok. 6.2.1 Yes -- -- Objective Monitoring Sheet: P/PRD/OBJ Annexure-14 INTERNAL AUDIT REPORT Format No: Effective Date: Are the IMS objectives as “SMART”? 01.04.2021 Objective: Improvement in through output of Technical from 560 to 583 Kg/Hr MS: QMS Base Value: 560 Kg/Hr Target Value: 583 Kg/Hr JUN’21: 581 is less then target and reason is 1) Big mixer motor tripping problem 2) Frequent MSEB power failure(10 Times for total 57 Hrs). Verified and found updated. 16. Do they retain documented information on the IMS objectives? 6.2.1 Yes -- -- Yes retained records effectively. Management Program Ref. P/PRD/MP Dose the department has prepared action plan to achieve the objective target. 17. Is any retaining documented information on the action plant to achieve the objectives and targets? 6.2.2 Yes -- -- MP No: PD-MP-02 Date: 01/01/2019 Objective: Through output of Technical from 560 to 583 Kg/Hr Action Plan is prepared and reviewed effectively. 18. 19. Verify the work environment condition. (Clean, noise free, sitting arrangement etc.) Is training related to IMS provided? - Training records are maintained? 7.1.4/ 8.1 Yes -- -- Yes, effective work environment observed, found satisfactory. 7.2 Yes -- -- Training Subject: External HAZOP Study for Critical processes, Dated: 10-12 Apr 2021, By Mr. Patel (External), Participations No. 11 Verified and found satisfactory. 8.1 -- No -- OHS Operation control not effective. – Minor NC - Bare cable (Without Plug) found inserted into socket. - Rubber mat found missing in front of panel. Is effective operational controls are verified, and maintained for OHS? 20. Page 5 of 6 i.e: Obstacle materials, Leak/ Spill Control, Process Parameter Control, PPE’s compliance, Visual identifications, etc) Annexure-14 INTERNAL AUDIT REPORT Format No: 21. Effective Date: Is effective operation of process as per defined parameters? - Give any Process batch sheet…. - Described Batch Process Paraments…. 8.5.1 Yes -- -- 01.04.2021 Batch production record –Technical Batch No: LT28151 Start Batch: 30/01/2021 Completion Batch: 01/02/2021 Data Checked & verified found ok. Observations Summary (Including Physical Operational Control): Minor NC 1. OHS Operation control not effective. – Minor NC i.e. Bare cable (Without Plug) found inserted into socket. Rubber mat found missing in front of panel. Audit Findings Category Number Auditor Auditee Signature Signature Conformity: Non-Conformity Observations: Page 6 of 6
