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SOUTH AFRICA REGION REFERENCE REVISION PAGE

SERVICES H&S 031 7 1 OF 16


HEALTH & SAFETY SYSTEM OPERATIONAL ORIGINATOR H&S MANAGER
PROCEDURE
INTERNAL AUDIT
DESIGNATION PRINT NAME SIGNATURE DATE

COMPILED BY H&S OFFICER S THERON Original Signed 2/08/2012

REVIEWED BY SNR H&S OFFICER JSD CRONJÉ Original Signed 2/08/2012

AUTHORISED BY H&S MANAGER J SODEN Original Signed 2/08/2012

TABLE OF CONTENTS PAGE ADDENDA PAGE


1. PURPOSE 2 ANNEXURE “X” – DEFINITIONS AND ABBREVIATIONS 10 – 14
2. SCOPE 2 ANNEXURE “XX” - REFERENCES 15
3. DEFINITIONS AND
2 RECORD OF AMENDMENTS 16
ABBREVIATIONS
4. REFERENCES 2
5. RESPONSIBILITY /
2
ACCOUNTABILITY
6. AUDIT REQUIREMENTS 3–5
7. PROCEDURE /
5–8
METHODOLOGY
8. RECORDS APPLICABLE TO
9
THIS PROCEDURE

REVISION DESCRIPTION OF REVISION DATE

7 CHANGES AS PER RECORD OF AMENDMENTS 2 AUG 2012

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1. PURPOSE

The purpose of this procedure is to define the process of planning and executing systematic,
independent, internal OHSAS audits in order to:

• Evaluate the effective development, implementation, maintenance and continual improvement of


the South Africa Region Services safety system in accordance with the requirements of OHSAS
18001. (This excludes Mine Services.)
• Evaluate the effective development, implementation, maintenance and continual improvement of
Radiation Protection within South Africa Region Services in accordance with the requirements of
the NNR.
• Manage risks within South Africa Region Services.

2. SCOPE

This procedure applies to the conducting of internal audits and the evaluation of compliance to the
South Africa Region Services safety system based on OHSAS 18001 as well as the compliance to
Radiation Protection Act based on NNR requirements, and the methodology for communicating,
reporting and recording audit findings and the implementation of action plans.

3. DEFINITIONS AND ABBREVIATIONS

Refer to Annexure “X”

4. REFERENCES

Refer to Annexure “XX”

5. RESPONSIBILITY / ACCOUNTABILITY

DESIGNATION RESPONSIBILITIES AND ACCOUNTABILITIES


HOD / Engineer • Authorise the internal South Africa Region Services audits as per the
audit programmes.
• Ensure the necessary resources (staff, documentation) are made
available for the audits.
• Review results of internal audits and evaluation of compliance findings
and provide recommendations for improvement, if required.
Health & Safety • Ensure that the organisations audit function is sufficient to permit
Manager objectivity, impartiality, and to ensure the accomplishment of its audit
responsibility.
• Ensure that the lead auditor has a registered qualification.
• Ensure the resources (within budget and organisational structure), to
implement audit action plans.
• Approve final audit report.
• Ensure that negative findings are actioned, allocated and scheduled to
ensure correction and improvement.
• Develop an audit programme for South Africa Region Services.
• Coordinate the South Africa Region Services audit programme.
• Coordinate the development, implementation, and progress of an audit
action plan.
• Provide relevant information on audit to top management for review.

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• Act as host during the independent internal audits and be available to
answer any queries that may arise from the audit team.
• Ensure that pertinent policies, procedures, standards, regulatory
requirements and previous audit reports are made available for review
to the internal auditor and audit team.
• Maintaining HS audit records, including a list of auditor records, audit
schedules and protocols, and audit reports.
H&S Officer • Maintaining HS audit records, including a list of auditor records, audit
(Systems) schedules and protocols, and audit reports.
Management • Ensure availability of resources to implement the OH&S programme
Representative • Ensure that analysis is made of information pertinent to OH&S
• Compare information with objectives, evaluate effectiveness of controls
and where targets are not met change controls to achieve desired
results
• Ensure information is distributed and communicated to employees
relevant to the work they perform
• Ensure that personnel are aware of applicable legal and other
requirements
• Ensure H&S Officer (Systems) keep and maintain records

Employee • To form part of the pre audit meeting and participate in the audit
Representative protocol.
Audit Manager • Form part of the internal audit team as and when required.
- AGA
Lead Auditor • Identify experienced and / all qualified auditors who will accompany
(Internal him/her on the audit.
Audits) • Orientate audit team, coordinate the audit process, and coordinate the
preparation of the audit report.
• Execute internal audits.
• Write audit reports.
• Develop audit protocols for internal audits.
• Communicate audit results and ensure availability of the audit report.

6. AUDIT REQUIREMENTS

Internal audit

The organisation shall ensure that internal audits of the South Africa Region Services safety system are
conducted at planned intervals to:

Determine whether OHSAS

• Conforms to plan arrangements for South Africa Region Services safety system including the
requirements of the International Standard, and specifications.
• It will be verified if it has been properly implemented and is maintained, and

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Provide information on the results of audits to management , employees and relevant parties
(Refer to H&S 029 – Communication, Participation & Consultation procedure)

Audit programme(s) shall be planned (see Annexure 1) whereby results of the baseline risk
assessment and results of previous audits will be considered, established, implemented and
maintained by South Africa Region Services, taking into consideration the Risk concerned and the
results of previous audits. (All risk assessment processes as per the South Africa Region Services
safety system should be considered.)

• The responsibilities and requirements for planning and conducting audits, reporting results
and retaining associated records.
• Audit process is planned - considering the status and importance of the procedures and areas
to be audited. Audit criteria, scope, frequency and method are then defined.
• Management to review audit schedule prior to the audit taking place as well as the monthly
results done for the evaluation of the South Africa Region Services safety system.
• Selection of auditors and conducting of audits shall ensure objectivity and the impartiality of
the audit process.
• Audits shall be conducted by the H&S officers and other identified employees who are
independent of those having direct responsibility. They will be trained in systems auditing
techniques and have adequate experience. Include interview techniques, verification
techniques, audit preparation, report writing, demeanour, and interpretation of criteria used in
the audit (CRA process form part of this Audit).
• Training sessions will be given to the Foremen, Supervisors to assist with the internal audit
where required.
• Ensure that internal audits of the Occupational Health and Safety management system are
conducted at planned intervals that conform to planned arrangements for Health and Safety
management including the requirements of the International Standard and specifications. It
will be verified if it has been properly implemented and is maintained, and provide information
on the results of audits to management.
• Audit results are discussed at the various management levels and MANCOM.
• Audit results will also be discussed at the relevant employee forums as per communication
procedure.
• The responsibilities and requirements for planning and conducting audits, reporting results
and retaining associated records – Health and Safety Manager. A post audit meeting is called
for where all affected supervisory staff is informed about the results and necessary corrective
measures.

This procedure also provides the methodology for communicating, reporting and recording audit
findings.

Annual Internal Audit

This is a planned annual audit that will be included in the SA Region audit programme. The OH&S
audit will be audited by an AGA auditor where after certification will be issued. Audit programme will
be communicated to all relevant parties.

a) Audits will take place once a year to determine whether the OH&S Management System:

1. conforms to planned arrangements for OH&S management, including the requirements of


this OHSAS Standard; and
2. has been properly implemented and is maintained; and
3. is effective in meeting the organisations policy and objectives;

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b) Provide information on the results of audits to management.

All audit results will be discussed at the relevant forums as per communication procedure.

Audit programme(s) shall be planned, established, implemented and maintained by the organisation,
based on the results of risk assessments of the organisation’s activities, and the results of previous
audits and include the following:

a) The responsibilities, competencies, and requirements for planning and conducting audits,
reporting results and retaining associated records (refer to H&S 023 Procedure); and
b) The determination of audit criteria, scope, frequency and methods.

Sufficient resources will be available to assist in the audit process. Selection of auditors and
conducting of audits shall ensure objectivity and the impartiality of the audit process.

External Audits

The AGA Audit Team will conduct independent audits to evaluate compliance to OHSAS 18001
requirements. A schedule will be drafted and made available on an annual basis.

The frequency of the audits will be determined by:

• The potential for the activity to impact O H & S risks


• Previous audit results; and
• The potential for losing certification (internal)
• Occurrence of previous incidents
• Changes to the organisation

Evaluation of Compliance

• According to Section 4.5.2 of OHSAS 18001 standards, the operations should periodically
evaluate the compliance to legal and other requirements. The evaluation of compliance will
be conducted on an annual basis and will form part of the O H & S audit programme.
Critical evaluations will be done on a monthly, quarterly and annual basis to reflect
compliance and continual improvement.

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7. PROCEDURE / METHODOLOGY

a. Internal Audits

AUDIT PROCESS PROCESS PHASES WHEN WHO


Prepare Audit Programme for annual internal Annually, H&S
7.1.1 Audit pre-work audits, which include the evaluation of as Manager
compliance. The Internal audit document will be scheduled & Audit
used. Manager

• The objectives of the audit, which direct the


planning and conduct of audit, are:
⇒ To meet the requirements of the OHSAS
18001 standard, in order to
obtain/maintain certification and ensure
continual improvement.
⇒ To verify conformance to legal and other
requirements.
⇒ To contribute to the improvement of the
South Africa Region Services safety
system
• The extent of an audit is influenced by audit
scope
PLANNING

Communicate the audit programme and obtain


authorisation.

A Lead Auditor will be appointed to conduct 2 Weeks Lead


7.1.2 Establish Audit internal audits and will be responsible for audits. before Auditor /
Team audit Health &
The Health & Safety Manager (Safety & Risk) at Safety
South Africa Region Services will form part of the Manager
audit team.

The Lead Auditor may assign to each audit team


member specific processes, procedures, sites or
activities to audit.

7.1.3 Finalise Audit Finalise the audit plan


Plan It must contain the following:
• Objective of the audit as defined and agreed
upon by the lead auditor and the Health &
Safety Manager.
Confirm the audit criteria e.g. inclusion or
exclusion of policies, procedures, standards,
legislation and other requirements.

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AUDIT PROCESS PROCESS PHASES WHEN WHO

7.1.4 Execute internal All audits will start with a brief Opening Meeting. Day of Lead
audit The Lead Auditor again goes through the Agenda audit Auditor
to emphasise the objective, criteria and audit plan.
An Attendance Register shall be completed

Audit:
• If any, establish whether previous audit findings Lead
were closed -out by the due date. Record Auditor/
findings. Team
• Establish if personnel are familiar with and
understand the policies, procedures against
which the audit is being conducted. Record
findings.

Check whether specified requirements, objectives,


specifications, and other performance indicators are
being achieved. Record findings.
AUDIT EXECUTION

7.1.5 Audit Findings For the Internal audit, three criteria will be evaluated Lead
and compliance will be evaluated: Auditor

A: Are documented procedures available


B: Do the procedures comply with the OHSAS
requirements
C Are the procedures implemented, verified, and
complied with?
Lead
The Lead Auditor or Audit Team will be allowed a Auditor /
minimum of 30 minutes to ensure the validity, top
accuracy, and completeness of the audit findings. manage
ment
Although some findings are to be discussed with
the Health & Safety Manager and other audited
representatives who accompany the Lead Auditor
or Audit team throughout the duration of the audit,
the closure meeting will be used to ensure and
emphasise the validity, accuracy, and
completeness of the audit findings. Audit
Team
Conclude the audit with a Closure Meeting
between the Lead Auditor and top management.
Lead
The Lead Auditor provides detail on the main non- 1 Week Auditor
conformances, strengths, weakness, after audit
improvements, and risks.

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AUDIT PROCESS PROCESS PHASES WHEN WHO
7.1.6 Audit Report The Audit Team members provide their audit Audit
findings to the Lead Auditor. Team

The Lead Auditor will compile an Audit Report, 1 Week Lead


within one week after the audit a hardcopy report after audit Auditor
will be provided

7.1.7 Summary Audit An audit summary report will be distributed by the Within 10 Lead
Report Lead Auditor, as per the distribution list. The audit days of Auditor
summary report will also summarise the audit audit
scope, restate the Lead Auditor or audit team,
observers and where possible state
recommendations.
AUDIT REPORTS

7.1.8 Audit Actions Should the audit findings be positive, the lead Lead
auditor will give the feedback to management and Auditor
comment on the positive findings, and a report will
be submitted?

However, if the findings of the audit indicate the H&S


need for corrective or preventative actions, the Manager
Health & Safety Manager shall ensure the
implementation of appropriate action plans, with
specified time frames and responsible persons for
Negative

ensuring the actions are taken. The action


Positive

manager must be used to record items requiring a


follow up

If required, the Lead Auditor, Audit team or, Health


End Action & Safety Manager can further assist with possible
Plan solutions pertaining to audit findings. This is
however not considered part of the audit.

7.1.9 Follow-up Audit To verify the completion and effectiveness of Lead


on effectiveness corrective and preventative actions, a next audit Auditor
can be scheduled as per the auditing process if
FOLLOW UP AUDIT

and when required.

Execute follow up audit This may not be an official internal audit but the
(Next audit cycle) H&S Officer could also do a follow-up investigation
if required.

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8. RECORDS APPLICABLE TO THIS PROCEDURE

RECORDS LOCATION

VR South Africa Region Services H&S


OHSAS 18001 Audit documents
Department

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Annexure X

DEFINITIONS AND ABBREVIATIONS

DEFINITIONS:

DOCUMENT
Information and its supporting medium (The medium can be paper, magnetic, electronic or optical computer
disc, photograph or master sample, or a combination thereof.)

RECORD
Document stating results achieved or providing evidence of activities performed

CONTROLLED DOCUMENT
Any document that needs to be controlled in terms of its distribution and use, such as the Policy and
documented procedures. These documents are either signed in original ink and/or signed for on a
distribution list. These documents will be signed off after evaluation has been done to determine that they
are adequate for purpose. The document will be signed off by the relevant members as depicted on the
distribution list.
Once copies are printed of the database, they are considered to be “uncontrolled”.

OBSOLETE DOCUMENTS
Documents that have been replaced by later revisions or those that is no longer relevant or valid, and has
been cancelled from the system. These documents will be identified either by crossing them out and writing
obsolete or rubber stamp obsolete document.

UNCONTROLLED DOCUMENTS
Any documents that have not been issued under the circumstances under “controlled documents” are
categorised as uncontrolled. This includes, but may not be limited to:
• Documents that do not need to be controlled such as the monthly safety topic.
• Documents not distributed by the authorised person as per the procedures “authority and
responsibility” table and signed for by the recipient.
• Documents printed from the electronic database. (Watermarked “uncontrolled document”)
• Documents duplicated or photocopied from controlled documents.
• Photocopies of the Occupational Health and Safety policy as issued to the public or other
Interested and Affected Parties

It is not possible to judge from an uncontrolled copy whether it is the latest version. It is the responsibility of
the person holding the documentation to ensure that (s) he has the latest version.

INJURY
Physical harm or damage

OCCUPATIONAL HEALTH AND SAFETY


Conditions and factors that affect, or could affect the health and safety of employees or other workers
(including temporary workers and contractor personnel), visitors, or any other person in the workplace
Occupational Health and Safety hazards, which include airborne pollutants, noise, illumination, vibration,
ergonomics, radiation, as well as thermal stress.

OH&S MANAGEMENT SYSTEM


Part of an organization’s management system used to develop and implement its OH&S policy and manage
its OH&S risks

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SEVERITY / CONSEQUENCE
Outcome of an event. There may be one or more consequences from an event. May be expressed
qualitatively or quantitatively may range from positive to negative (Speculative).

FREQUENCY
Occurrence per unit time, (May be expressed qualitatively or quantitatively).

EXPOSURE
How often and for how long employees are exposed to a hazard/s.

LIKELIHOOD
Means the chance of an event occurring.

DUE DILIGENCE
Taking reasonable care to protect the health and safety of all employees. Provide equipment, maintain the
equipment, use equipment as prescribed, provide information relating to the equipment, and provide
competent supervision.

INCIDENT
An undesired event which under slightly different circumstances could result in harm to people. Damage to
property or loss to process or an undesired event that could or does result in a loss.

RISK MATRIX
A Risk index can be determined by plotting likelihood and severity indices on the y and x-axis respectively
and then using them to obtain a risk ranking.

HIRA
Process of recognizing that a hazard exists and defining its characteristics
• H = HAZARD
Anything around us that we can see as well as those energy sources we cannot see e.g. Gas and
radiation that can cause harm
• I = IDENTIFICATION
Identify the significant hazards (Process and recognition)
• R = RISK
Risk imagining (Likelihood and consequence if risk materializes)
• A = ASSESSMENT
Determine the magnitude of the risk if materialized

ROUTINE ACTIVITY
An activity which is performed on a regular basis (day to day)

NON ROUTINE
An activity performed on an adhoc basis

ACCOUNTABILITY
Principle that, individuals, organizations, and the community are responsible for their actions and may be
required to explain them to others.

RESPONSIBLE
Liable to be called to respond to a person for issues to be done.

ILL HEALTH
Identifiable adverse physical or mental condition arising from and/or made worse by a work activity and/or
work-related situation.

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INTERESTED PARTIES
Person or group, inside or outside the workplace, concerned with or affected by the SARSSS performance.

NONCONFORMITY
Non-fulfilment of a requirement – can be any deviation from:
Relevant work standards, practices, procedures, legal requirements.

SARSSS OBJECTIVES
SARSSS goals, in terms of OHS performance, that SA Region Services sets itself to achieve. Objectives are
quantified wherever practical.

SARSSS PERFORMANCE
Measurable results of SA Region Services management of its risks.
Note: Performance measurement includes measurement the effectiveness of controls.

OHS POLICY
Overall intention and direction which will be followed for the management of health and safety.

RECORD
Document stating results achieved or providing evidence of activities performed

HAZARD
A condition or practice with the potential to cause harm, or exposure to danger. (Immediate Causes,
Substandard Act or Substandard Condition)

RISK ASSESSMENT
Process of evaluating the risk(s) arising from a hazard(s), taking into account the adequacy of any existing
controls, and deciding whether or not the risk(s) is acceptable

PREVENTATIVE ACTION
Action to eliminate the cause of a potential nonconformity or other undesirable potential situation.

CORRECTIVE ACTION
Action taken to rectify a non-conformance or deviation

CONTINUAL IMPROVEMENT
To constantly improve on current Health and Safety standards

PROCEDURE
Specified way to carry out an activity or a process.

RISK ASSESSMENT
Process of evaluating the risk arising from a hazard, taking into account the adequacy of any existing
controls, and deciding whether or not the risk is acceptable.

WORKPLACE
Any physical location in which work related activities are performed under the control of SA Region
Services.

AUDIT
Independent and documented process for obtaining “audit evidence” and evaluating it objectively to
determine the extent to which “audit criteria” are fulfilled.

SAFETY MONTH
Period from the 20th of a particular month up to the 19th of the following month.

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EFFORT BASED OBJECTIVES
Objectives set to improve program related issues

EFFECT BASED OBJECTIVES


Objectives set to improve severity or injury rates

MANCOM
Management Committee

EXCO
Executive Committee

SUPERVISOR
Within SA Region Services – One who supervise or has charge and direction of i.e. Foreman, Clerk of
works, Training Officer, Residence Manager, Security Officer etc.

EMPLOYEE
Person working under the control of the organisation and includes contractors.

MANAGEMENT REPRESENTATIVE
A Person appointed in writing ensuring that the OH&S management system is established, implemented
and maintained in accordance with this OHSAS Standard;
and ensuring that reports on the performance of the OH&S management system are presented to top
management for review and used as a basis for improvement of the OH&S management system.

VISITOR
Any person who enters the premises of the mine who is not a full time employee or Contractor paid by the
mine

CONTRACTOR
Any person who perform work for the mine and is paid for his/her service.

ACCEPTABLE RISK
Risk that has been reduced to a level that can be tolerated by the organization having regard to its legal
obligations and its own

HEALTH AND SAFETY COMMITTEE


A committee as required by law M H & S Act Section 25(2)

VERIFICATION
Verification is the act of reviewing, inspecting, testing, etc. to establish and document that a product, service,
or system meets the regulatory, standard, or specification requirements.

VALIDATION
Validation refers to meeting the needs of the intended end-user or customer to
prove the truth or to determine or test the accuracy. Also, validation is the process of checking if something
satisfies a certain criterion.

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ABBREVIATIONS:

M H & S Act - Mine Health & Safety Act


MA&R - Mineral Act & Regulations
OHASA - Occupational Health and Safety Act
DMR - Department of Mineral Resources
DOL - Department of Labour
SARS - South Africa Region Services
ESW - Engineering Services Workshops
WITW - Wellness in the Workplace
H&S - Health and Safety
LTIFPD - Loss Time Injury Free Production Days
IFPD - Injury Free Production Days
AGAH - AngloGold Ashanti Health
TMM - Trackless Mobile Machinery
COP - Code of Practice
ATDS - AngloGold Ashanti Training and Development Services
CRA - Continuous Risk Assessment
SARSSS - South Africa Region Services Safety System
NNR - National Nuclear Regulator

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Annexure XX

REFERENCES

• Roles and responsibilities are depicted in each system procedure and updated as and when
required in table format
• OHSAS 18001:2007 (Occupational Health and Assessment Series)
• The Mine Health and Safety Act 29 of 1996
• The Minerals Act 50 of 1991
• Occupational Health and Safety Act (Act 86 of 1993)
• COIDA
• AGA Strategic Objectives
• Implex Legal Register
• ATDS Training Matrix
• AGA RCAT
• Corporate Procedure Directive
• Health and Safety Agreement
• SAR/OESH/P/A/001.01 – AGA Incident reporting
• H&S 004 – Incident investigation
• H&S 006 – Emergency preparedness and response
• H&S 014 – Issue based risk assessment
• H&S 018 – Baseline risk assessment H&S 019 – Control of records
• H&S 023 – Control of documents
• H&S 027 – Competence, training and awareness
• H&S 028 – Continuous risk assessment
• H&S 029 – Communication, participation and consultation
• H&S 030 – Management review
• H&S 031 – Internal audit
• H&S 037 – Management of change
• H&S 055 – SA Region Services Scope
• H&S 058 – Legal and other requirements
• H&S 059 – Performance measurement and monitoring
• H&S 060 – Evaluation of compliance
• H&S 061 – Nonconformity, corrective and preventative action
• H&S 065 – Objectives and programme(s)
• H&S 067 – Resources, roles, responsibility, accountability and authority
• H&S 069 – Operational control
• H&S 070 – Documentation
• H&S 071 – H&S Policy
• MS SHE OP 151– Emergency Procedure

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RECORDS OF AMENDMENTS

PROCEDURE DATE OF
CHANGES TO PROCEDURE
REVISION NUMBER APPROVAL
Definitions and abbreviations, References,
Roles and responsibilities, Communication,
H&S 031 – Revision 3 Audit programme, Action plans, 4 June 2009

H&S 031 – Revision 4 Name Changes 2 Oct 2009


Changed SADS to SARS and added Mine
H&S 031 - Revision 5 Services 26 Oct 2010

H&S 031 – Revision 6 Excluded Mine Services 5 March 2012

H&S 031 – Revision 7 Included NNR requirements 2 August 2012

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