Task No.

2 – Legal and Other Requirements

Student:

John Alejandro Quintero Artunduaga

Code: [Link]

Tutor:
Maria Marcela Rodriguez

National Open and Distance University

School of Agricultural, Livestock and Environmental Sciences

Diploma in Integrated Management Systems in Safety, Health, Environment and Quality HSEQ

Environmental Engineering

September 12, 2021

 Legal Requirements Matrix

Matrix of legal requirements Transport Company

Theme
Regulatory Classification Year Article Requirement Process Responsible for Evidence of
applicable specific process Process
 INSTRUMENT
O I Case of
Study

DIPLOMA IN SECURITY, HEALTH AT WORK. ENVIRONMENT AND

QUALITY
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CASE OF
STUDY
Synopsis: This case illustrates a hypothetical situation that will provide you with data.
to carry out the course tasks. Each of the elements of this case is
designed to be analyzed and to provide in their training as auditors the
skills to observe, take notes, detect findings, write them down and
determine its correlation with the standards to audit.

It is essential in this process to use the strategy 'as if', that is, 'to act as if'
if you were the process auditor. Therefore, we recommend using the format
FIELD NOTES that will be filled out personally. This will allow you
take notes and write observations that will help you develop the exercise
throughout the entire Diploma. Consequently, this format is personal, only
it will be evaluated if specifically requested.
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Case Analysis The adoption of management systems in Safety, Health in the
work, environmental and quality (HSEQ) is a strategic decision
for the organization that allows it to improve overall performance and
provide a solid foundation for the initiatives of the
sustainability of the organization.
The following case allows students to be prepared in the exercise.
of the preparation of the HSEQ SG according to the guidelines
established in the ISO 9001:2015, ISO 14001:2015 and ISO
45001:2018, as well as conducting a systematic review of each one.
of the studied norms.

Companies, like people, are located in

a geographic region in which it is necessary to comply with a
Context of current legislation, have practices for compliance
of contracts agreed with clients, with workers,
the Company
suppliers and contractors, among others.

For this reason, the first thing you must understand is that
context, that is, the legal framework applicable to a company and that
it allows you to define the criteria for the implementation of
system
HSEQ.

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 Solidarily, the client company must ensure that the services are provided.
services contracted in accordance with the law or may also result in
this case the client sanctioned by the regulatory entities of the
status in case of non-compliance and if any complaint is filed, or
demand.

The company provides special passenger transport services to

national level in the different economic sectors, for the past 5
years. They own the facilities where they manage the areas
operational and administrative. They have hiring operators
directly and allies for the provision of services. The vehicles
(vans and light vehicles) are 50% owned by the company
and 50% of the allies.

They have a vehicle monitoring center to maintain

control over location and speeds. The clients that this manages
companies are found nationwide and are companies that
they require the transportation of their employees or individuals for
special transportation services to other cities outside of Bogotá.

The auditor in the preparation phase of the audit makes a

Review preliminary documentary review in the company in its initial phase, which is
Document
is considered necessary for the preparation of the audit plan.
to the

The auditor in this phase reviews the identification and definition of the
existing relationships between processes of the management system

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integrated to identify the structure of the processes that
carry out the company and the mode of organization in relation to it
to the areas that are going to be integrated. In this case, a
strategic planning report which includes the policy,
objectives and guidelines that are desired to be achieved, but
contemplates the analysis of the effectiveness of actions
proposals in the HSEQ System.

Upon reviewing the policy, it is found that it does not include the

commitment to compliance with legal requirements nor with

the identification of hazards, assessment, valuation of the
risks and determination of controls.

The objectives are associated with reducing accidents of

work and occupational diseases, reduce water consumption and
energy and meet the needs of their customers in the
services rendered.

For the management of the HSEQ system, it has a

professional in business administration with
diploma in ISO quality management system
9001:2014 certified as an internal auditor by an entity
nationally recognized certifier.

In the process map presented by the person in charge of

the HSEQ system does not show that they have included the processes
support related to leadership and managerial commitment.

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Observation:

In the preparation phase of the audit, observations are made of the company and/or the professional.

in business management, considering that they did not include, the commitment to the

compliance with legal requirements nor with the identification of hazards, assessment, valuation of

the risks and determination of controls.

Audit
Documentary in The auditor conducts after sending the audit plan with 8
site
days in advance, establish prior communication with the
company to clarify doubts about the process that takes place there
to finalize and schedule the field visit that will take place
agreement with the list of ongoing projects sent by the
company where the activities carried out are defined in
each
number of people exposed and execution percentage of
project. This will allow you to review the requested scope for
the certification in ISO 9001:2015, 14001:2015 and ISO
45001:2018

Additionally, it informs that according to the audit plan

sent the system review starts with the documentation phase
from SG HSEQy that during the second and third day of
the audit will take place during the field visit verifying the
activities carried out to verify compliance of
the
requested SIG regulations.

The auditor arrives at the company's facilities giving

compliance with the previous recommendations made by the
person in charge of the system in the company, before starting the meeting

they inform you about the protocol that the company follows to act

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in case of emergencies, the opening meeting begins at
 which informs among other aspects the objectives of the audit,
audit time, types of findings, methodology of the
evaluation, topics to consider in the audit of agreement
with the established regulations to be certified, schedules and date
on the delivery of the report with possible findings that may
to be determined in the evaluation process.

It additionally informs that the documentation process

It will be verified throughout the evaluation in a cross-cutting manner.
Only the representative participates in the opening meeting.
of the system that is the operations director, the coordinator
HSE and the HSE assistant, and they inform that the general manager and

the legal representative is out of the country and that the

people in charge of the processes do not need to be
in the opening meeting since the HSEQ system is managed in
his entirety the HSEQ coordinator from his computer and to
through the company's intranet.
Observation:

The pertinent observations are made for the people who are not present during the
diligence and to review the documentation.

The auditor, upon concluding the opening meeting, and in accordance with
the audit plan consults with who will carry out the
Evaluation of the elements of Leadership, Planning and
Support the manager and legal representative is not present.
that he will be informed by the HSEQ coordinator who
he has knowledge of the topics discussed since it is he who
manages the HSEQ system.

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The coordinator places it on the computer screen to his.
position, the minutes of managerial meetings held each
four months in which the aspects of are not taken into account
SG HSEQ systematically nor follow-up on the
commitments made and the management review minutes
where only the satisfaction indices were analyzed
the clients and that it was carried out a year before the execution of
the current audit taking into account the cut-off periods. It
it informs additionally that the results were
communications to the workers at the time and it was given
response to the PQR. The auditor requests the records of
disclosure of five previously selected workers and
find that the format used is not filled out
all the required and established data by the company
and additionally, it is an old format according to the
HSEQ coordinator information.

The auditor requests the HSEQ coordinator to analyze their

organizational context as defined by the regulations
international, the identification of the stakeholders and
prioritization of these based on the analysis
completed what are the needs and actions to continue with it
the coordinator reports that it has not been carried out.

For the review of compliance with the policy

HSEQ coordinator informs that it was disclosed some time ago

week, presents the records of the workers in the area

administrative and informs that the drivers are
carrying out activities with the clients and that he did not get to them
the new policy. Upon reviewing it again in the office, it did not

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found signed.

For the review of compliance with HSEQ objectives, the

HSEQ coordinator shows a compliance matrix of
objectives for which he is responsible for compliance
all the objectives that are monitored every six
months to verify compliance, these only
presents compliance results at 100%. The auditor
It informs that these results are verified during the process of
evaluation considering all aspects of the SG
HSEQ.

To review the resource allocation, the HSEQ coordinator.

informs that it does not have an assigned budget since
the management decision allocates resources according to
their needs and that in this they are very broad, they always provide
money for whatever is needed in order to prevent them from generating

PQR's.

When reviewing the legal requirements matrix

defined by the organization, it is evident that they are identified
client requirements without considering the mechanism of
compliance, nor the identification of the requirements of
safety, health at work, and environmental.

The auditor requests the procedure for the investigation

of incidents (accidents and near accidents) at work,
environmental and occupational diseases:

The HSEQ Coordinator presents a document called

Step by Step for conducting research on
Work Accidents PR-HSE-19 version 1 of 1
January 2018, specifying the methodology to be used

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for the research, identifying that they are not considered
criteria for incident investigation (accidents and near misses)
environmental accidents nor work-related diseases and
likewise has not conducted the investigation of the serious accident
that was presented to him two months before the audit and that was
reported to the ARL two weeks ago. This information is
find in the accident certificate issued by the
 ARL with the date of the last day of the previous month.

When requesting the statistical records of accidents

HSEQ coordinator reports that it only has records from the year
previously that in the course of this year has not had
time to make the records or investigate the events
due to being involved with many projects and not having
with enough staff to implement the controls.
Observation:

The finding is made considering that during the visit and the reviewed documents not
they meet the requirements and commitments stated, but the update is not carried out
periodic information.
.

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 The auditor, when reviewing the risk matrix previously,
risk assessment and determination of controls
it is found that the priority risk has not been identified
according to the company's activity, requests the Coordinator
HSEQ evidence of training records and
driver competencies whoever informs that until the
6 out of 10 workers still need to be updated.
documentation, which also carry out the activities due to the
importance of customers, presenting the certificates of the
four other workers, as well as the job profiles,
assignment of roles and responsibilities and the
training program according to the
requirements for each position in its evaluation
reports 100% coverage and 100% effectiveness.
Observation:

The finding and observation are made, taking into account that during the verification of the
The matrix does not show the priority risk, as well as its outdatedness.

Considering that there are workers carrying out

driving activities and that additionally do not have
with the training required by law, the auditor requests the
procedure for conducting medical evaluations
and the profesiogram, the coordinator reports that not yet
they have handed him the professional profile that he requested from the ARL and

that therefore the medical exams were carried out

requesting the IPS exams with specifications for
drivers, the respective fitness certificates are requested

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of the 10 selected workers and it is found that 3
they have medical recommendations that have not been
 follow-up has been carried out but which are the oldest in the
company that has always done it and that until now has not
nothing happened.

The coordinator informs the auditor that measures have been established

controls for endemic diseases and have

carried out campaigns that involve the families of the
workers related to vaccinations for tetanus, fever
yellow, prostate cancer and uterine cancer control for
the company's workers and oral hygiene campaigns for
the children of these. Shows the photographic records of all
the activities and the matrix of endemic diseases
present in the regions where they carry out activities.

The diagnosis of health conditions was delivered.

by the IPS the Friday before the audit and they are found
recommendations related to the continuity of
Epidemiological Surveillance Programs (PVE)
visual, auditory, and DME. The coordinator expresses that has

established PVE for disease control of

cardiovascular origin and effects due to DME that affect the
date has been evaluated with compliance indicators and expresses
what does it have qualified as an occupational disease due to loss of
auditory capacity in a 36-year-old worker, which the
auditor verifies the certificate issued by the ARL and the letter
sent to the company where they inform him about the loss of capacity
worker's hearing.

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Observation:
The observation is carried out in order to monitor the worker to verify that
The company has made a decision for the next visit.

The auditor requests the HSE coordinator the procedure.

administration for contractors and suppliers
PR-HSE- 015 version 2 of January 30, 2015 according
with the document control procedure sent to
auditor prior to what the coordinator informs that this
the procedure had changed version a week ago
but did not update the document control matrix.

The procedure shows the criteria of

selection, evaluation, monitoring and follow-up for
contractors and suppliers in accordance with the
services and risky those exposed, to validate
the auditor selects the EPS SANATE for its implementation.
temporary welding contractor SOLDAR SAS, Transport
LOAD and to the waste disposer ECO LTDA., the
the coordinator informs that the purchasing department is the
in charge of these services.

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 The auditor requests evidence from the purchasing representatives.
from the records, highlighting that when conducting the evaluation of
performance does not inform the contractors
selected suppliers the results of the
evaluation and that its monitoring will be carried out in the period

next that is in six months despite the fact that they know
the procedure in which it is established that they must establish
action plans according to the results.
Observation:

The observation is made in order to monitor the update of the matrix.

to carry out the follow-up regarding the performance evaluation of the
selected contractors-suppliers the results of the evaluation.

The company delivers hazardous waste

which generates for the company ECO LTDA., evidence that
It has permission for collection, transportation, and final disposal of

waste by the Secretary of the Environment of Bogotá. The

the company makes the delivery of the waste but has a
record of waste generated and disposed of
in accordance with the provisions of current legislation.

The management program you are handling is for reduction

of water and energy when reviewing the evaluation of the indicators
proposed to reduce water and energy by 20% per capita,
the analysis conducted is related to the number of
activities carried out during the period.

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At the end of the afternoon, the auditor requests the HSEQ coordinator to
Allows you to review the inspection program PR-HSE-020
version 5 of April 6, 2016, in which the is defined
carrying out inspections of PPE, machines and equipment, premises,
emergency teams, environmental aspects, vehicles, but the
The coordinator informs that they have not had time to carry out.

inspections this year and that the inspections it has are from the year
2019

When requesting vehicle maintenance records,

washing, vehicle cleaning and hygiene program, the
HSEQ coordinator informs that the vehicles are inspected at
neighborhood workshops where each partner driver takes the
vehicle and there is no control over the disposal of the
drainages, tire and oil changes. For the
own vehicles maintenance is established
same at the trusted diagnostic center and where the
they have been attended to for years so they have not requested any
documentation regarding this.

Review the internal audit process later.

request the PR-HSE-021 audit procedure
version 7 of April 12, 2016 where it is evident the
audit program, the competencies of the internal auditor.
Upon reviewing the planning of the internal audit, it is evident that
there was no participation from the COPASST, the internal auditor is the

coordinator

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 HSE and the report does not show any deviations from the system.
SSTA.

Review the corrective actions procedure and

preventive PR-HSE 022 version 3 of August 7
2013 where it establishes causal analysis methodology for
give treatment to the AC/AP which according to the
informed by the HSE coordinator it has not been implemented yet
that since he arrived at the company a year ago, he has been having a

analysis matrix where follow-up is done on the

deviations.

When reviewing the accidents to define the trend...

evidence has been presented in the year 2014 0 at, 2015 3 at
incompatibles with 45 days of incapacity, 2016 5 at with 345

days of incapacity, 2017 1 at fatal, 3 at with 90 days of

incapacity, 2018 2 with 30 days of incapacity. This
information is provided in the accident certificate
from the ARL issued 30 days before the audit date. In
Every year it is evident that they have no records of almost
accidents nor statistical records of accidents of
contractors.
Observation:

The observation is made in order to follow up on the responsibility of

coordinator regarding the fact that inspections have not been carried out this year, just as they have not
keep a record of waste generated and disposed of in accordance with what is established in the
current legislation, there is no control over the inspection of vehicles, not machinery.

Audit of
Field in
execution of
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According to the audit plan, the auditor taking into account
the recommendations made by the HSEQ coordinator for the
activities
carrying out the field audit, they move to where
find the nearest drivers located at the client
MAUROS PIZZA where transportation services are provided
personal at the different branches. The drivers are located
in the parking lot assigned by the company located half a block away
from this, the criteria to address the auditor are informed
emergencies and the risks one is exposed to during their visit, as well.
same proposed controls.

The workers of the audited company are already

performing their duties since 6 am, which is by call of
agreement with the needs and shifts of the workers. The auditor
request the procedure for passenger transfer PR-
HSE- 017 version 1 of December 1, 2012 and the
the coordinator is looking for him in the team he has been with since the office and

informs that it is not printed since the workers

they know, when verifying the information with the workers it
evidence that they do not conduct inspections of the belts
safety, tire levels, oil level, nor do they carry out ATS of
agreement with what is defined in the procedure.

The interview with the workers continues, and when asking how
they apply the comprehensive policy informing that by not carrying out the

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equipment inspections could not comply with the
defined in it. They are unaware of the proposed objectives
for the management of the HSEQ system and inform that the results
They were never informed about the performance evaluation.

It also shows that they have no knowledge of the

functioning of the COPASST they participated in the
election of the same despite having four years with the
organization.

The auditor is complying with the audit plan being the

11:30 am decide to move towards the company to give
continuation of the process and at around 2pm, when it arrives

evidence that the workers had requested permission and only

find the vehicle control operator to whom he
question about the calibration certificates of the equipment and
this informs that they do not have them on site, they had to deliver them
I sent it to the manager last week for his review and he hasn't
returned, informs the auditor that he delivers the waste
and that for the arrangement all take you to the same place without
separate those that are contaminated. Upon performing a
inspection in the waste storage room
find that in the area there is an adequate arrangement of
waste as defined in current legislation.

The auditor concludes their observation according to the plan of

audit to start the preparation of the preliminary report of
findings

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Screenshot contribution Discussion Forum Qualifiable