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This document provides guidance for entities in Abu Dhabi on developing an Environmental, Health and Safety Management System (EHSMS) in accordance with the Abu Dhabi EHSMS Regulatory Framework. It outlines the key steps to develop an EHSMS, including: 1) gaining management commitment through establishing an EHS committee and developing an EHS policy; 2) planning activities such as identifying risks, legal requirements, targets and an EHS management program; 3) implementing and operating the EHSMS through roles, training, procedures and emergency management; 4) checking performance through monitoring, auditing, and corrective actions; and 5) conducting management reviews. Entities with existing international certifications also need to integrate E
Originalbeschreibung:
EHSMS
Originaltitel
AD EHSMS Guideline - Entity Guideline to Assist With Development of EHSMS Latest
This document provides guidance for entities in Abu Dhabi on developing an Environmental, Health and Safety Management System (EHSMS) in accordance with the Abu Dhabi EHSMS Regulatory Framework. It outlines the key steps to develop an EHSMS, including: 1) gaining management commitment through establishing an EHS committee and developing an EHS policy; 2) planning activities such as identifying risks, legal requirements, targets and an EHS management program; 3) implementing and operating the EHSMS through roles, training, procedures and emergency management; 4) checking performance through monitoring, auditing, and corrective actions; and 5) conducting management reviews. Entities with existing international certifications also need to integrate E
This document provides guidance for entities in Abu Dhabi on developing an Environmental, Health and Safety Management System (EHSMS) in accordance with the Abu Dhabi EHSMS Regulatory Framework. It outlines the key steps to develop an EHSMS, including: 1) gaining management commitment through establishing an EHS committee and developing an EHS policy; 2) planning activities such as identifying risks, legal requirements, targets and an EHS management program; 3) implementing and operating the EHSMS through roles, training, procedures and emergency management; 4) checking performance through monitoring, auditing, and corrective actions; and 5) conducting management reviews. Entities with existing international certifications also need to integrate E
System Regulatory Framework (EHSMS) Guidance Documents Entity Guideline to Assist with Development of EHSMS July 2009 Contents 1. Introduction 1 1.1 Background 1 1.2 Purpose of Guideline 1 1.3 Entities with International Certification 2 2. Management Commitment 4 2.1 Establishment of an EHS Management Committee 4 2.2 Development of Policy 4 3. Planning 5 3.1 Identify EHS Risks 5 3.2 Identify Legal Requirements 5 3.3 Develop EHSMS Targets and Key Performance Indicators 6 3.4 Developing an EHS Management Program 7 4. Implementation and Operations 9 4.1 Identify Roles and Responsibilities 9 4.2 Identify Training Needs 11 4.3 Develop EHS Policies and Procedures 12 4.4 Develop Document Control Procedures 12 4.5 Emergency Management 13 4.6 Communicate to Staff 14 5. Check and Corrective Action 15 5.1 Monitor, Measure, and Report 15 5.2 External Reporting 15 5.3 Internal EHSMS Auditing 16 5.4 External EHSMS Auditing 16 5.5 Non-Conformance and Corrective and Preventative Action 17 5.6 Records Management 19 6. Management Review 20 7. Approval of EHSMS 21 8. Special Provisions for Entities with Established Systems 22 Table Index Table 1 Federal and Abu Dhabi Emirate Legal Requirements 5 Figure Index Figure 1 Roadmap for Successful Environmental Health and Safety Management System Implementation 3 Figure 2 Non-Conformance and Corrective Action Plan Decision Making Tool 18 1 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System 1. Introduction 1.1 Background On 6 th December 2006, the Executive Council issued a Decree (Committee Decree 2- Session 31/2006) approving "Abu Dhabi Emirate EHS policy" and nominated the Environment AgencyAbu Dhabi (EAD) as the Authority responsible for supervising the implementation of the EHS Management System (EHSMS) at Abu Dhabi Emirate level in cooperation and coordination with all concerned parties. The objective of the policy is to achieve excellence in the management and protection of the environment, health, and safety through partnership between all government and private sectors to ensure activities within Abu Dhabi Emirate are undertaken in a responsible, safe, and sustainable manner. To follow up the development and implementation of the Abu Dhabi Emirate EHSMS Framework, the Executive Council established the "EHS Higher Committee" by a Decree issued on 11 th J une 2007. 1.2 Purpose of Gui deline This report is a guideline that provides an overview of the steps that need to be undertaken by an entity to develop its own EHSMS. A full training program has also been developed within Abu Dhabi Emirate EHSMS framework to help entities establish their 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; and 5. Management review and approval. This report assumes that entities using this guideline have not previously developed a management system based on international standards such as ISO 14001, ISO 9000 or, OHSAS 18001. Thus, the report provides a step-by-step breakdown of the key tasks that need to be completed to develop and implement an EHSMS. This report outlines the steps that can be undertaken by entities to develop and implement an entity-specific EHSMS. The Emirate EHSMS Framework Codes of Practice (CoPs) provide clear guidance on how entities can develop their own systems within the required EHSMS framework. Figure 1 outlines the necessary steps which will be explained in more detail in the report. These steps are based on the International Standards Organisation (ISO) standards while also outlining Abu Dhabi Emirate EHSMS specific requirements. 2 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System In addition to these steps, the Abu Dhabi Emirate EHSMS has the following requirements: All entities are required to register their EHSMS or their intent to develop an EHSMS to their Sector Regulatory Authority; Once the systems have been integrated and an EHSMS established, this must be submitted to the Sector Regulatory Authority for approval; Entities whose EHSMS have been approved must report quarterly or annually to their Sector Regulatory Authority. This will likely form a condition of a licence to operate; and Entities with established EHSMS must conduct ongoing audit and inspections which is an essential part of the self-regulation framework established by the Emirate EHSMS. 1.3 Entities with International Certification If an entity has an existing system certified under ISO 14001, OHSAS 18001, or ISO 9000, then many of the requirements outlined in this report will have been met although 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 work will be required to update the procedures to integrate environment and health and safety. A separate report (Abu Dhabi Emirate EHSMS Guidance Documents Comparison with International Management Systems Standards) describes the relationship between the elements of the international standards and the requirements of Abu Dhabi Emirate EHSMS Framework. Entities with existing certified systems should refer to the Comparison report and Section 8 of this report for further guidance. 3 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System Figure 1 Roadmap for Successful Environmental Health and Safety Management System Implementation Key: Step 1: Management commitment Step 2: Planning Step 3: Implementation and operations Step 4: Checking and corrective action Step 5: Management review Monitor, measure & report Management Commitment to EHSMS Develop EHSMS Policy Establish EHSMS Committee Identify EHSMS Risks Review Legal Requirements Identify EHSMS targets and KPIs Establish procedure to access current and future legal requirements Establish procedure to identify EHSMS risks Goals and Policies Continual Improvement Compliance Implementation Schedule Document EHSMS Policy Develop EHS Management Program Document objectives and targets Website Identify Roles and Responsibilities Identify training needs Train staff in operations with significant impacts Document roles and responsibilities Establish document control procedures Emergency management Communicate to staff Meetings Emails Posters Newsletters Bulletin boards EHSMS awareness training Document findings Establish procedures for managing non-conformance Document all decisions and actions Return To Top For Continual Improvement Cycle EHSMS Auditing Management Review Sector Regul atory Authority Approval - 4 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System 2. Management Commitment 2.1 Establishment of an EHS Management Committee Establishing an EHS Management Committee is an important first step when introducing an EHSMS into an entity. The role of the Committee will be to facilitate implementation of the EHSMS, provide direction for the development of policies and procedures, act on behalf of management, and report to management. The EHS Committee usually includes representatives from staff, management, environment officers, and health and safety officers. For organisations with less than 50 employees the committee may comprise only the CEO (or a senior manager) and an EHS Officer. 2.2 Development of Policy One of the first steps that are to be undertaken in the development of an EHSMS is the development of a Policy. The development and endorsement of an EHS Policy by management is an important way of demonstrating management commitment to the development and implementation of an EHSMS. The policy should be short and concise. It can be supplemented with an explanatory booklet for personnel to enhance 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 using EHSMS 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 management 4. 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 safety stewardship; 7. Statement extending responsibility of implementation of EHSMS to contractors; 8. Provision of education opportunities in EHS; 9. Monitoring EHSMS performance; and 10. Provision for continuous improvement. - 5 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System 3. Planning 3.1 Identify EHS Risks The development of an entity-specific EHSMS begins with identifying key environmental and health and safety risks. The risks should relate to impacts from the entitys activities in the day-to-day operations of the entity and reputation risk. One of the guiding principles in the EHS policy is to integrate economic, social, and environmental considerations into decisions to ensure that the measures adopted are cost-effective and in proportion to the significance of the issues being addressed. Therefore, to fully understand the cost and effort required for 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 to gain 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 the likelihood of that incident occurring. Identification of an entitys EHS risks is part of developing an EHS aspects register. 3.2 Identify Legal Requirements Part of managing EHS risks is to identify the legal requirements that apply to environment, health, and safety. As a guide, the current relevant UAE Federal and Abu Dhabi Emirate legislation is outlined in Table 1. It is recommended that all entities undertake their own internal review of legislation. Table 1 Federal and Abu Dhabi Emirate Legal Requi rements Environmental Legislation Health and Safety Legislation Federal Law No. 24, 1999 - This law outlines ways to achieve sound environmental management and sustainability through the establishment and enhancement of suitable management, legal, and technical instruments to protect, develop, and conserve the environment in the Emirate of Abu Dhabi. Federal Law No. 8 (1980) - Chapter 5 - Occupational Safety, Preventive, Health, and Social Care. Local Law No. 16 2005 This law outlines the requirements to assess environmental impacts of sewage, air emissions, hazardous waste management, impacts to current and future developments, and urban planning. Local Law No. 16 (2005) - Article 14 - Establishment or individual is prohibited from practising any work or conducting any activity adversely affecting the health of man and safety of environment without obtaining licence from the Authority. Local Law No. 21 2005 (Waste Management) requires the EAD as the competent authority to assume responsibility for the enhancement of Federal Law No. 1 (2002) -Article 9 - Regulation and Control of the Use of Radioactive Sources and Protection against its Hazards. - 6 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System Environmental Legislation Health and Safety Legislation waste management through reduction of generated waste, recycling and reuse, and by providing solutions for the treatment of waste. Ministerial Order No. 32 (1982) - Determination of Preventive Methods and Measures for the Protection of workers from the risks of work. Issued by Ministry of Labour. Ministerial Decree(s) 55/2004 Regarding the Basic Regulations for Protection Against Ionizing Radiation; 56/2004 Regarding the Regulations for Safe Transport of Radioactive Materials; 57/2004 Regarding the Regulations for Radioactive Waste Management. Regulation Concerning Environmental Impact Assessment of Projects. Ministerial Order -No 32 1982 Article 1 Every employer shall provide the appropriate preventative measures for the protection of workers from risks of injuries or occupational diseases which may occur during working hours. Regulation Concerning Protection of the Marine Environment. Regulation Concerning Handling of Hazardous Substances, Hazardous Wastes, and Medical Wastes. Regulation Concerning Agricultural Pesticides, Agricultural Conditioners, and Fertilisers. Regulation Concerning Environmental Impact Assessment of Projects. 3.3 Develop EHSMS Targets and Key Performance Indicators 3.3.1 Developing Key Performance Indicators The development of an EHSMS should include targets and key performance indicators (KPIs). KPIs are a way to measure success of an entity and are an important way of assessing and tracking implementation of the EHSMS. KPIs are quantifiable measurements, agreed to beforehand, that reflect the critical success factors of an entity. They should be entity-specific, reflect the entitys goals, and be related to the success of specific policies, procedures, and initiatives. - 7 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System Entities developing KPIs need to ensure that the entity-specific KPIs are linked to and reflect KPIs developed at the Emirate level. To allow for tracking, KPIs should be quantifiable, measurable, and achievable, however, they should also 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 in number and essential to the entitys 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; and Targets, i.e., each indicator should have specific targets. 3.3.2 Developing Targets Each indicator should have a target or a series of target that help monitor progress towards meeting the KPI. Like KPIs, targets should be measurable and defined. Entity targets should contribute to reaching long-term goals set by sectors which again will align with government 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; and Increase 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; and Comply with all relevant UAE and Abu Dhabi Emirate EHS regulations. 3.4 Developing an EHS Management Program Once the entity has determined the EHS risks and has developed targets it is vital to develop a management 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 program needs to identify all key tasks that need to be undertaken to commence development and implementation of an EHSMS including key actions, personnel requirements, budget requirements, and timeframes. - 8 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System Once completed, the EHSMS Management Committee should approve the program for implementation within the entity. The EHS Management Program will form part of the annual review to identify tasks completed and those outstanding. - 9 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System 4. Implementation and Operations 4.1 Identify Roles and Responsibil ities Everyone has a role to play in the development and implementation of an EHSMS. Within an entity it is important to clearly identify these roles. The Abu Dhabi EHSMS framework identifies the roles and responsibilities 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 Dhabi EHSMS Manual. 4.1.1 Emi rate Level Competent Authority The Competent Authority will assume a coordinating and overseeing role in the implementation of the Emirate 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, and Partner with sectors to understand and assist with compliance issues. Sectors Initial focus will be to assist the eight (8) major sectors in developing and implementing an EHSMS. The Major Sectors are: Building and Construction Transportation Health Energy Waste Tourism Oil and Gas - 10 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System Industry Each sector will have a Sector Regulatory Authority. These authorities will be able to provide support and guidance 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 the Sector Guidelines and to report to the Competent Authority, as required. Community By instigating development and implementation of an EHSMS throughout Abu Dhabi Emirate, a process of community engagement and education is commenced. The role of the community is to work towards minimising their environmental impacts, improve safety in the Emirate, and work towards continuous improvement. A Framework Code of Practice has been developed to assist in identifying key roles and responsibilities in an entity AD EHSMS CoP 02 - Roles and Responsibilities. 4.1.2 Enti ty Level Though the organisation structure of each entity may differ, there are commonalities in relation to management structures that can assist in identifying the roles and responsibilities within an entity. This section outlines these roles and responsibilities which have been adapted from Abu Dhabi Emirate EHSMS Guidance Documents Guideline for EHSMS Organisational Structure in Sectors/Entities. EHS Department and EHS Manager The role of an EHS Manager is to develop an entity EHS Policy and oversee the development of EHS policies and procedures. The core responsibility for EHS rests with the EHS Department managed by the EHS Manager. The EHS Department may comprise of one or several officers depending on the size of the entity. The EHS department and Manager functions may be implemented in different forms depending on the nature and size of the entity, in other words, the EHS Manager position may not be a full time role. EHS Management Committee The EHS Manager is usually assisted by a Management Committee that is responsible for monitoring the progress of the establishment, development, and implementation of an entity EHSMS. The EHS Management Committee develops a timetable for internal auditing and reporting. This is an important part of the Abu Dhabi Emirate EHSMS. The EHS Management Committee is required to report via the EHS Manager/EHS department to the EHS 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 of management 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 finalised policies. - 11 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System For smaller entities, the role of this committee is delegated to the General Manager or to a high-ranking management committee. 4.2 Identify Training Needs Ensuring staff are trained in all aspects of environment, health, and safety can ensure staff uptake of the EHSMS and minimising environmental incidents and health and safety risks. The provision of adequate staff training will be a Key Performance Indicator that must be reported by the entity to the Competent Authority under Abu Dhabis EHSMS. The specific training needs of an entity will differ depending on works undertaken by the entity, however, the following general rules apply: Give participants an understanding of the EHS Policy, EHS impacts, procedures, and responsibilities; Be ongoing with regular refresher courses; Cover all aspects or operations related to environmental, health, and safety; Provide knowledge of management systems; and Address implementation issues. There are national and international training providers that provide EHS training. It is also important to note that the Competent Authority has developed a series of training modules that can be provided to a specific entity. The process of identifying key risks will help identify opportunities for further experience and training for staff. EHSMS training must include all aspects of the EHSMS (environment, health, and safety). Some examples of training include: Site induction; Housekeeping; Building site safety; About the companys 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; - 12 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System 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; and Natural Resources Permitting and Compliance issues. 4.3 Develop EHS Policies and Procedures Once the entity has adopted an EHS Policy and established targets and benchmark and a management program, it is important to develop the EHSMS policies and procedures. The policies and procedures developed 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 and the 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; and Any definitions. Policies and procedures must be kept in the entity-specific EHSMS Manual. 4.4 Develop Document Control Procedures When developing EHSMS policies and procedures a standard format helps in the document management 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; and Technical information or EHS requirements. - 13 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System The control of EHSMS documents is an important issue in preventing unauthorised amendments and ensuring that the latest version is being implemented. To effectively control documents only the EHSMS Officer 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 from construction 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; and Next 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 service involved; Ensure that EHS records are stored and maintained such that they are readily retrievable and protected against damage, deterioration, or loss; Ensured that the retention times of these EHS records have been established and recorded. 4.5 Emergency Management In the case of an environmental and/or health and safety emergency that occurs as a result of activities being 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 these risks occurring. The entity needs to ensure there are emergency management procedures that address each 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; and How to prevent re-occurrence. - 14 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System The AD EHSMS CoP 06 - Emergency Management in the Abu Dhabi EHSMS Manual provides more guidance on ways to identify a hazard and the requirements of an emergency management plan. 4.6 Communicate to Staff Once an entity commences development of an EHSMS, communicating this to staff is advisable. There are many ways to communicate the entitys EHSMS commitments and requirements and staff roles and responsibilities 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 for contractors 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 must sign; Regular training; EHS on intranet; Regular newsletters; and Prizes, awards and other promotional activities. - 15 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System 5. Check and Corrective Action 5.1 Monitor, Measure, and Report Measurement of EHSMS KPIs and continual monitoring plays a significant role in continuous improvement and is a very important aspect of the EHSMS. Without some form of monitoring and measurement it is difficult to know whether EHSMS controls are effective or whether improvements have been 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; and Hazardous substances management. Monitoring may require different forms of data collection from physical measurement to regular inspections to regular data collection. Where possible, data monitoring should take the form of quantitative measurement. The Abu Dhabi Emirate Environment Health and Safety Protection Policies (EEPPs) contain monitoring and reporting requirements. Monitoring and reporting will form an important component of the self- regulation procedure developed for the EHSMS. There are two forms of reporting required by the EHSMS. First, the entity will need to establish procedures for internal reporting. This will assist management in tracking progress towards meeting the targets 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 Reporting In 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 of the status of the implementation of the EHSMS, data on emissions, any reported environmental or health and 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 outlines monitoring and reporting requirements. The AD EHSMS CoP 03 - Self-Regulation in the Abu Dhabi EHSMS Manual provides the requirements that need to be met to allow for self-regulation under Abu Dhabi EHSMS. - 16 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System 5.3 Internal EHSMS Auditing Internal and entity self-auditing is important in the continuous improvement cycle. A self-audit can be defined 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 conducted by 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 audit plan: 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; and Development 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; and Audit Program Evaluation. Audits can be conducted a number of ways including interviews, review of records, and physical inspections. 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 a breach is found and corrective action taken then no enforcement may be necessary. The AD EHSMS CoP 08 - Audit and Inspection in the Abu Dhabi EHSMS Manual outlines self-auditing procedures and developing audit plans. 5.4 External EHSMS Auditing All entities implementing the Abu Dhabi EHSMS framework will be required to allow external audits of their EHSMS. (refer AD EHSMS CoP 03 Self-Regulation). External audits should be undertaken at least annually as part of the entitys commitment to demonstrating self-regulation and results of the audit should be reported to the Sector Regulatory Authority. - 17 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System The AD EHSMS CoP 08 Audit and Inspection details the scope and requirements to be met by the audit and also describes the responsibilities of the external auditor. To demonstrate compliance with the Abu Dhabi EHSMS framework, the entity EHSMS must include a commitment to allow external audits and a procedure that details the process to be followed when an external audit is to be undertaken. The external audit can be requested both by the entity or the sector regulatory authority and the entity must make available all documents relevant to the EHSMS to the auditor regardless of who requested the audit. 5.5 Non-Conformance and Corrective and Preventative Action If the audit finds an example of non-conformance, then corrective action must take place and preventive action, to ensure the non-conformance doesnt re-occur. Figure 2 provides an overview of procedures that may be followed by an entity. - 18 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System Figure 2 Non-Conformance and Corrective Action Plan Decision Making Tool Once a non-conformance is identified and the appropriate actions taken, the root cause of the non- conformance needs to be identified. Non-conformance observed from: Internal EHS Audit Monitoring Competent Authority Inspection Internal/ External Non- Conformance Issued Corrective action initiated, schedule follow up and timeframe. Responsibility assigned to Area Manager EHS compliance officer or designee follows up on corrective action to ensure compliance to schedule All changes to procedures resulting from a corrective and/or corrective action are documented Steering Committee and Management review corrective/ preventative actions and follows up to ensure effectiveness All records are filed Management andEHS Director regularly review compliance issues. Steering Committee tracks use of EHSMS objective and targets. - 19 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System 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; and Corrective 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 the effectiveness of these measures assessed. 5.6 Records Management Management of records is important in preventing unauthorised amendments and ensuring the latest versions 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 from construction 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; and Next 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 or service involved; Ensure that EHSMS records are stored and maintained such that they are readily retrievable and protected against damage, deterioration, or loss; and Ensured that the retention times of these EHSMS records have been established and recorded. - 20 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System 6. Management Review The management review periodically reviews the EHSMS to ensure it is meeting the objectives of the EHSMS, legal requirements, and the developed performance indicators. Management reviews are a necessary part of due diligence and self-regulation. The management review ensures that the EHSMS continues to be effective and continues to improve. The outcome of the management review should be a statement on the performance of EHS within the entity based on the targets and goals set by the entity. Where non-conformance or improvement is required, the statement should clearly and concisely indicate how the entity is addressing each particular issue. 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; and Any 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 management committee and who needs to sign off on procedures. This is important as it will establish the hierarchy for reporting; Frequency of meeting How often management is expected to meet to review the EHSMS and documentation needs to be stated in the procedure; Agenda items The procedure should outline what the key agenda items will be for every meeting. This will be made up of some key points that must be discussed in every meeting and will relate to the environment, health, and safety performance indicators, audit results, and legal requirements; Roles and responsibilities Issues such as who will conduct meetings and who is responsible for maintaining meeting minutes and records should be outlined in the procedure; and The annual review should take place before reporting to the Regulatory Authority. - 21 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System 7. Approval of EHSMS When an entity has developed an EHSMS, it is required to seek approval of the management system from the Sector Regulatory Authority. This is best achieved by contracting a third-party accredited consultant who specialises in EHS management systems to review and approve the system. Once the consultant is satisfied that the requirements of the EHSMS framework have been met then he/she will prepare a statement to that effect. This statement can then be submitted to the Sector Regulatory Authority who should approve the entity EHSMS. - 22 - 76/10169/10/5953 Implementation of Abu Dhabi EHSMS Entity Guideline to Assist with Development of EHS Management System 8. Special Provisions for Entities with Established Systems This report outlines the steps that must be followed by entities that have not previously developed a management system. The steps outlined in the report are similar to the establishment of a management system under ISO standards. For entities that already have an established management system, whether an Environmental Management System (ISO 14001), Occupational Health and Safety Management System (OHSAS 18000), or a Quality Management System (ISO 9000), then it is important that the entity undertake steps to 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; and Develop a new code of practice (or similar) describing the process for external reporting of compliance 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 and documents to include health and safety If the entity has an OHSAS 18001 Certified system then the entity will also need to update all procedures and documents to include environment If the entity has an ISO 9000 Certified system then the entity will also need to develop a new EHS management system that is supported by the quality system Further details on similarities and differences between the ISO standards and the Abu Dhabi EHSMS are outlined in the report Abu Dhabi Emirate EHSMS Guidance Documents Comparison with International Management Systems Standards.