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Health and Safety,
Environment and
Quality Audits
Internal auditing is an essential tool for managing compliance and for initiating and
driving continual improvement in any organization’s systematic HSEQ performance.
Health and Safety, Environment and Quality Audits includes the latest health and
safety, environmental and quality management system standards—ISO 9001:2015, ISO
14001:2015, and ISO 45001:2018. It delivers a powerful and proven approach to risk-
based auditing of business-critical risk areas using ISO, or your organization’s own
management systems. It connects the ‘PDCA’ approach to implementing management
systems with auditing by focusing on the organization’s context and the needs and
expectations of its interested parties. The novel approach leads HSEQ professionals and
senior and line managers alike to concentrate on the most significant risks (Big Rocks
and Black Swans) to their objectives. It provides a step-by-step route through The Audit
AdventureTM to provide a high-level, future-focused audit opinion. The whole approach
is aligned to the international standard guidance for auditing management systems, ISO
19011:2018.
With thousands of copies now sold, this unique guide to HSEQ and operations
integrity auditing has become the standard work in the field over four editions, while
securing bestseller status in Australasia, Europe, North America, and South Africa. It is
essential reading for senior managers and auditors alike. It remains the ‘go-to’ title for
those who aspire to drive a prosperous and thriving organization based on world-class
HSEQ management and performance.
Dr Stephen Asbury is the author of seven books on safety, risk management, and
decision-making for Taylor & Francis. He is Chartered Fellow of the Institution of
Occupational Safety and Health (CFIOSH), an Emeritus Professional of the American
Society of Safety Professionals (ASSP), and a Fellow of the Institute of Environmental
Management and Assessment (FIEMA). He has almost 40 years’ experience from
assignments in over sixty countries on six continents.
Health and Safety,
Environment and
Quality Audits
A Risk-based Approach
Fourth Edition
Stephen Asbury
Designed cover image: © Shutterstock
Fourth edition published 2024
by CRC Press
2385 NW Executive Center Drive, Suite 320, Boca Raton, FL 33431
and by CRC Press
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
CRC Press is an imprint of Taylor & Francis Group, LLC
© 2024 Stephen Asbury
Third edition published by Routledge 2018
Second edition published by Routledge 2014
First edition published by Butterworth Heinemann 2006
Reasonable efforts have been made to publish reliable data and information, but the author and publisher
cannot assume responsibility for the validity of all materials or the consequences of their use. The
authors and publishers have attempted to trace the copyright holders of all material reproduced in
this publication and apologize to copyright holders if permission to publish in this form has not been
obtained. If any copyright material has not been acknowledged please write and let us know so we may
rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced,
transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or
hereafter invented, including photocopying, microfilming, and recording, or in any information storage
or retrieval system, without written permission from the publishers.
For permission to photocopy or use material electronically from this work, access www.copyright.com
or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-
750-8400. For works that are not available on CCC please contact [email protected]
Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used
only for identification and explanation without intent to infringe.
Library of Congress Cataloging‑in‑Publication Data
Names: Asbury, Stephen, author.
Title: Health and safety, environment and quality audits : a risk-based approach / Stephen Asbury.
Description: Fourth edition. | Boca Raton, FL : CRC Press, 2024. | Includes bibliographical references
and index.
Identifiers: LCCN 2023020594 (print) | LCCN 2023020595 (ebook) | ISBN 9781032429083 (hbk) |
ISBN 9781032427577 (pbk) | ISBN 9781003364849 (ebk) | ISBN 9781032583310 (ebook+)
Subjects: LCSH: Total quality management. | Organization. | Auditing. | MESH: Total Quality
Management—standards | Management Audit—standards | Organizational Culture | Safety
Management—standards
Classification: LCC HD62.15 .A845 2023 (print) | LCC HD62.15 (ebook) | DDC 658.5/62—dc23/
eng/20230707
LC record available at https://lccn.loc.gov/2023020594
LC ebook record available at https://lccn.loc.gov/2023020595
ISBN: 978-1-032-42908-3 (hbk)
ISBN: 978-1-032-42757-7 (pbk)
ISBN: 978-1-003-36484-9 (ebk)
ISBN: 978-1-032-58331-0 (eBook+)
DOI: 10.1201/9781003364849
Typeset in Times
by Apex CoVantage, LLC
For Faye Lillian (6 Sep 2021)
Contents
Introduction1
The Audit Adventure™ 2
A-factors5
Case Studies 6
Tips6
vii
viii Contents
xiii
xiv Figures
xvii
Case Studies
xix
xx Case Studies
xxi
Foreword
This fourth edition recognizes that we live in extraordinary times. Our organizations
operate in complex and dynamic risk landscapes where near-term operational resilience
is as important as reinventing business models, products, and services.
The good news is that a ‘robust’ business management system continues to
provide the machinery for organizations to deploy policy, mitigate risk, and improve
performance. A ‘living’ management system allows organizations to respond to
extraordinary times at pace, building resilience and de-risking reinvention.
Audit must act, not to defend the status quo or mark process owners’ homework, but
to help shine a light on risk and performance and to drive principled improvement.
In these extraordinary times the philosophy, principles, and approaches to audit in
Stephen’s book are more important than ever.
Vincent Desmond
Chief Executive Officer
The International Register of Certificated Auditors (IRCA)
and the Chartered Quality Institute (CQI)
London, UK
xxiii
Endorsements
In my Presidential year, Stephen Asbury worked closely with me to re-enforce the IOSH
CPD scheme, and together, we had considerable success. This success was by and large
due to the passion and tenacity of someone who, for many years, has remained a stalwart
volunteer for IOSH and other organisations, an advocate for the complete ethos and
understanding of the structure and control of HSEQ-MS.
Now in its fourth edition, Stephens’s thoughts on structure in control and auditing
of HSEQ-MS have been expressed through this book since 2007. It is inspiring and
wonderful that his approach continues to guide health and safety and other risk
practitioners on how to deliver meaningful business risk management, efficiency, and
continual improvement. In everything he does, Stephen remains true to PDCA roots,
easily seen through this wonderful fourth edition.
As chair of IOSH Professional Committee for more than twelve years, he led the
creation of the current IOSH membership structure, CPD, IPD, and the Code of Conduct.
This structure allowed IOSH to achieve its Royal Charter in 2003 and its permission to
grant an individual Charter to its competent members from 2005. A prolific IOSH m ember,
mentor, professional, and inspiring person, Dr Stephen will continue to assist through these
nuggets of experience in the narrative of his books, and this one is no exception.
It gives me great pleasure to endorse this new edition of how you can assist your
employer or client deliver exceptional HSEQ-MS success.
Jimmy Quinn CFIOSH
IOSH President, 2020–21
As a past General Manager for Royal Dutch Shell, my time spent doing HSE audits
provided some of the most rewarding experiences in my career. There is no better way
to learn about a business than by asking questions, seeking evidence, and prioritising the
xxv
xxvi Endorsements
findings against the risks. However, carrying out an audit brings with it the responsibility
to follow the process.
Stephen Asbury is probably the best instructor that I have come across, and he
certainly received the highest level of feedback for the courses that he delivered for the
PetroSkills oil and gas training alliance.
Stephen brings enthusiasm, ability to communicate, and an understanding of the
subject that comes through in his writing. If you have an opportunity to participate in an
audit, seize it, and enjoy.
Dr Adrian Hearle
former Shell Head of Distribution, and former Director HSE, PetroSkills
Health and safety management is an integral part of business risk management, with
auditing being an essential component for helping ensure efficacy and continual
improvement. Audits should not be dreaded or adversarial, but regarded as opportunities
for organizations to learn and for their auditors to share good practices. The international
adoption of ISO 45001 is a timely reminder of the value of structure in establishing
control of health and safety risks.
Stephen Asbury’s excellent book, now in its fourth edition, can assist employers
and prospective and practising auditors to better understand their respective roles and
also the potential value to the organization of a well-designed and conducted audit
undertaken by a competent auditor or audit team.
Rob Strange, OBE
Chief Executive (2001–2013) The Institution of Occupational
Safety and Health (IOSH) Leicester, UK
Stephen Asbury and I have been associated for over twenty-five years. Back then, he was
Royal Insurance’s risk engineer assigned to our account, and we conducted many audits
together in Europe and here in the US.
Audits have increasingly become an essential part of doing business and have not
only been embraced by our management but built into the educational structure of
McDonalds and our Hamburger University. Safety and the protection of our customers
and employees are the highest priority.
Risk-based audits play a major role in allowing us to provide that protection, and
I am pleased to endorse Stephen’s methodology presented within the fourth edition of
this extremely popular book.
Jim Marshall
Director, Insurance & Safety (retired)
McDonald’s Corporation, Oak Brook, Illinois, USA
Stephen is world renowned for his contribution to the field of health, safety and
environment assurance, and risk-based auditing. I was privileged to have worked with
him in South Africa, Europe, and many parts of Asia to sincerely share his strong
qualities of dedication, perseverance, and such fun to work with. He takes pain to
complete his tasks with aplomb, is a great team player, orchestrator yet an excellent
mastermind. His penchant for detail and customer satisfaction is worthy of emulation.
This book HSEQ Audits succinctly traces the logic of the effective risk-based audit
approach, with a culmination of years of continuous improvement in the art and science of
auditing. I recommend Stephen and his approaches to auditing to any organization wanting
to improve their risk management or health, safety, and environment management systems.
Dato Lokman Awang, DIMP, MBA(Fin), CMIIA, MICG, BAppSc (hons) (Mining)
Managing Director, Proactive Control Sdn Bhd. Kuala Lumpur, Malaysia
xxviii Endorsements
Maintaining control in a very large and complex organization of many divisions and
many sites such as ours requires thoughtful structure in control systems. Over the years,
we have learned to drive improvement into our systems by learning positively from our
experiences—actively and reactively. Our commitment to validate our competence and
continual improvement is driven by our senior management and satisfies our customers’
compliance requirements, so we have maintained SHE and Q systems for many years.
There is always a possible danger that some sites might try to do the bare minimum
(or less), ramping up their control only when an external audit draws close. And so,
this is where our internal audit programme fits. It is designed to regularly, reliably, and
thoroughly assess the performance of our management systems and controls to assure
and assist our divisions and sites to deliver against their business objectives.
Stephen Asbury has provided management systems training to all our senior,
division, and site managers. It was extremely well received. This book captures the
essence of the ‘Asbury live’ risk-based auditor training event, and I am pleased to
recommend it to you.
Ian Kempson
SHEQ Manager
Bunzl Catering & Hospitality Division
My greatest challenges have come from implementing HSE programmes in the emerging
markets of the Far East, Africa, Eastern Europe, and Eurasia, where Stephen Asbury
first provided the foundation of my assurance programmes.
In my experience, an HSE practitioner requires the skills to positively influence the top
management of a business from a position of strength, credibility, and neutrality. In turn,
management teams at all levels must be willing to use audit information “intelligently” for
sustainable change to occur. For audit results to be utilised effectively, it is my view that
they are best regarded in the same way as a business uses a profit and loss account.
In this fourth edition of this excellent book, Stephen has updated his comprehensive
insight into the effective tools needed to develop and sustain an effective assurance
programme delivering that elusive “value add” to any organization.
Fred Alderson CMIOSH
Present and past positions: HSE Manager, Belhaven Brewery (Greene King)
HSE Manager, The Scottish Salmon Company
HSE Manager, Britvic Soft Drinks
Vice President Global Operational Risk, Deutsche Post DHL
Head of Loss Control, Coca-Cola Hellenic
Counter-intelligence Operative, RAF
It is hard to believe that the fourth edition of this book is soon to be published. Having
read all three previous editions over the years and personally used many of the tools and
techniques provided, it is a given that the fourth will again provide us all with simply the
best audit advice and guidance available from a master practitioner.
Mike Hann
Health and Safety Manager
Mayflower Theatre, Southampton, UK
Abbreviations
xxix
xxx Abbreviations
Several historical indicators of global recessions are already flashing warnings. The
global economy is now in its steepest slowdown following a post-recession recovery
since 1970. Global consumer confidence has already suffered a much sharper decline
than in the run-up to previous global recessions . . .
—World Bank (2022)
Austerity, and Asylum. Brexit, and Bird flu. China (PRC and ROC). Cost of living,
Corruption, Climate, and CO2. Drugs, Debt, and Demographics. Energy prices, and
Electric vehicles. Food supply, Food banks, and Furlough. Gas, and George Floyd.
Homeworking, Hacking, Homelessness and Hatred. Inflation, and Interest rates. Jeff
(Bezos, Amazon; online sales vs High Street decline). Knife crime. Loss and Damage.
Mental health and Migration. NHS. Obesity. Population (8bn on 15 November 2022),
Pollution, Pandemic, and Partygate. Quantitative easing, and Qatar (FIFA World Cup).
Russia, Recession, and Racism. Strikes, and Slavery. Trussonomics, and Trump. Ukraine.
Vladimir (Putin). Wade v Roe, and Whataboutism. ftX (collapse of crypto). Youth
capacity (of 15–24s to make change in the world). Zaporizhzhia nuclear power station.
My A-Z picks out some features of the global chaos since the third edition,
published in October 2018. I heard someone had called this a period of VUCA (volatility,
uncertainty, complexity, ambiguity). Either way, a perfect storm in the macro environment.
Geopolitical and economic chaos in 120 words. So many events, so much change, in so
little time. The world is heading for recession (World Bank, 2022) as consumer confidence
falls, and central banks hike interest rates to combat the old enemy of inflation. The effects
of climate change ravage our planet as we seek to overcome a desperate inheritance for our
children—a test of international resolve to steer us all away from disaster. And an illegal
war in Europe has reignited the old east-west Cold War tensions. I could go on, but I know
you get the picture. Many organizations find themselves in a mess.
And so, against this depressing backdrop, health and safety, environment, and
quality management systems (HSEQ-MS) are fading away, dying in organizations, due
to more important, more pressing matters, right?
Err, no.
Every year, the International Organization for Standardization (ISO) conducts a survey
of certifications to its management system standards. The latest data available*, published in
September 2023 (ISO, 2023a), is for the year to 31 December 2022. It shows the following:
xxxi
xxxii Preface to the Fourth Edition
*New data is published in September each year for the preceding year, and
readers are encouraged to track the adoption of certifications in future years
on the ISO website www.iso.org
Me? I anticipate continued growth in certified (and non-certified) adoption, and we have
stable standards for the foreseeable future:
• ISO 9001:2015 was reviewed and confirmed in 2021 and remains the current
standard. It will not be reviewed again before 2026.
• ISO 14001:2015 was also reviewed and confirmed in 2021 and remains the
current standard. It will not be reviewed again before 2026.
• ISO 45001:2018 was reviewed and confirmed in 2022 and remains the current
standard. It will not be reviewed again before 2027.
I have prepared new illustrations which summarize ISO 9001:2015, ISO 14001:2015, and
ISO 45001:2018 as they are—see Figures P.1, P.2, and P.3.
In Chapter 2, I’ll also share a new illustration of an integrated HSEQ management
system model based upon this ‘holy trinity’ of management standards. My thanks to
Rocky Vega for her assistance with these illustrations.
Proper and meaningful implementation of HSEQ management system standards
(MSS)—whether they are ISO standards, your sector’s, your client’s, or your own
organization’s standards—require competent auditing if the benefits are to be
maximised. Clause 9.2 of all ISO MSS mandate an internal audit process. That’s where
this book has fitted in since its first edition in 2007. Back then, it intentionally aligned
with the first ISO guidance standard for management system auditing, ISO 19011:2002,
and it continues to align with the latest edition of that standard today.
ISO 19011:2018 (ISO, 2018b) is the current version, and this in the final stages of
a planned review commenced in 2022. At the time of writing, it was at international
harmonized stage code 90.60 Completion of Main Action/Close of Review (ISO, 2023).
The results of this review are expected shortly, and I anticipate nil or minimal changes. It
will not be reviewed again before 2028.
In the preface to the first edition (which you’ll find herein on pages xlvii–xlviii),
I asked why anybody might write a book about auditing. I answered saying that we live
in a world where enterprises of all types, sizes, and sectors must be able to prove to both
those inside and outside their organizations that they are being managed in a way which
is consistently acceptable to all of society. This remains true today.
Preface to the Fourth Edition
FIGURE P.1 Structure of ISO 9001:2015 (quality management systems).
xxxiii
xxxiv
Preface to the Fourth Edition
FIGURE P.2 Structure of ISO 14001:2015 (environmental management systems).
Preface to the Fourth Edition
FIGURE P.3 Structure of ISO 45001:2018 (occupational health and safety management systems).
xxxv
xxxvi Preface to the Fourth Edition
• support senior managers who are thinking (or should be thinking) about
setting up an internal audit function in their organization, or who may be
questioning the value of their existing audit function;
• shine a bright light onto a field-tested, practice-hardened approach to risk-
based auditing for those who may like to develop and deploy their skills as an
internal auditor in the future; and
• improve the effectiveness of seasoned HSEQ and other internal auditors, who
may already have management systems audit experience but are disillusioned
with the style, process, results, or reception of the findings of audits they are asked
to conduct. Or they may wish to improve, refresh, or top up their current skills—
this new edition includes learning assessments worth 30 hours of CPD credit.
My hope is that the first two groups will read this book from cover to cover (and watch
my MicrolearningTM presentations), and that the information and techniques they
learn will inspire them to create centres of excellence in their own internal auditing
departments. I want them to be able to initiate, prepare, conduct, and report on audits
which help their organizations to be the best they can be, and for their stakeholders to
truly esteem the assurance provided and the improvements triggered.
For the third group, my hope is that they will dip into the book to contrast with
and add to their practice. It has been written to allow such dipping, with Chapter 5
summarizing the whole process. For them, I hope, it will become a well-thumbed source,
with useful tips and challenging ideas to try out on their future auditing assignments.
Along our journey through The Audit Adventure™ described in this book, you will
have the opportunity to reflect on why so much activity called auditing is being done
today with so little benefit accruing in some organizations—either to the managers
Preface to the Fourth Edition xxxvii
of the entities being audited or to those people who expect every entity to be run by
superheroes and paragons of virtue.
I always look forward to building on these ideas and sharing new experiences in
future editions. I also try to support those interested in management systems and the
people I’ll call Audit Adventurers through the book’s companion website at https://
routledgetextbooks.com/textbooks/_author/asbury/
There, you’ll find a host of useful materials for your use, including the following:
* Many HSEQ and audit professional bodies require their members to participate in continuing
professional development (CPD) to show they are keeping their knowledge up to date and
developing new skills in a structured manner. These per-chapter learning assessments, presented
as ten multiple-choice tests, provide you with a recognized CPD opportunity. Successful
completion of each assessment will confer three hours of CPD—30 hours CPD for all ten of the
chapter assessments. This CPD opportunity is formally recognized by IEMA as follows:
IEMA is pleased to endorse the CPD learning content in this book and see it
as a valuable contribution to our members’ ongoing demonstration of their
personal development.
xxxviii
Preface to the Fourth Edition
FIGURE P.4 Timeline of example world events shown along the Dow Jones Industrial Average (DJIA) from
January 1983 to January 2023 (40 years). Graph data used with kind permission of Macrotrends LLC.
Preface to the Fourth Edition xxxix
A guide to all the eBook+ and other online content is provided in Appendix 4.
You can also keep up to date with risk management news, views, and solutions by
following me on X (Twitter) @Stephen_Asbury.
You’ll also find me easily on LinkedIn, and I’ll be pleased to accept your
connection request.
As three times previously, I remain keen to share the ideas and experiences of auditors
using the methodology presented in this book in future editions. Your comments, stories,
tips, and ideas are welcomed and can be sent to me at [email protected].
I promise to namecheck any that I use in future editions.
Global and national economic recovery will happen. It has before, as shown in
Figure P.4. The timeline is the 40 years from 1983 to date, approximately one working
lifetime. Recovery and growth will happen, and effective HSEQ/risk management, with
effective risk-based auditing, can only hasten and support this.
Together we can, and we will, win the battle against ineffective auditing!
Preface to the
Third Edition
Every 15 seconds, somewhere in the world, one worker dies and another 153 have a
work-related accident.
—ILO, 2016
In just ten years, this book has become the bestselling book in the world on risk-based
HSEQ-MS auditing. A good question might be why? It may be because over 15,000
people have attended the live Asbury auditing class and generally found the approach
it commends to be both interesting and helpful to their practice. However, there are
probably several other answers:
Firstly, it has kept up to date with the developments in management system
standards—particularly those related to HSEQ. It charts the evolution of management
system thinking from ancient China, through the work of Shewhart and Deming, and
US defence standard MIL-Q-9858 in the 1950s to the numbered standards we know
today—the trilogy of ISO 9001, ISO 14001, ISO 45001; and it considers other systems
based on or influenced by these. The book’s continued reference to the PDCA approach
was subsequently adopted in 2012 by the International Organisation for Standardization
(ISO) in its framework for management standards, Annex SL.
Secondly, it provides a straightforward, reliable, and repeatable approach for those
who wish to adopt a risk-based auditing process in their organizations (as many have).
The Audit AdventureTM method presented herein has tracked and mirrored the evolution
of the guidance for auditing management systems: ISO 19011. When that standard was
last published in 2011, there were eleven management system standards, but that number
has since grown significantly to thirty-nine, with twelve others presently in development.
Accordingly, a further revision to this standard is expected in mid-to-late 2018. This
latest revision has been written with that in mind.
Thirdly, the book is a very practical source of helpful information, with over 50 case
studies illustrating major points in the text, and dozens of tips learned from over 1000
HSEQ audits conducted by the author over the last 30 years.
Despite all the progress, we still kill people at work. The International Labour
Organization (ILO, 2016) says that every 15 seconds, somewhere in the world, one
worker dies, and another 153 have a work-related accident. In each of the two earlier
editions, I have provided a world map showing some examples of catastrophic HSEQ-
related losses since the last edition. I could have done the same again in this edition—
the Savar building collapse in Bangladesh in 2013 (1129 killed), the Lac Megantic
derailment in Canada in 2013 (47 killed and thirty buildings destroyed), the Soma mine
disaster in Turkey (301 miners killed), the Tianjin port explosions in China in 2015
xli
xlii Preface to the Third Edition
FIGURE P.5 Silos: How management systems are sometimes implemented and audited.
(173 killed), and the Gazipur boiler explosion in Bangladesh in 2016, which killed
twenty-three. And I could have added some of the newer types of loss, such as the data
breach at Equifax in 2017 (loss of personal information for 134 million customers) or
those relating to workers’ rights in the gig economy, for example Uber (2016). On a
different writing day, I could have selected a dozen different examples for you to think
about and, if you wished, to research further.
The bottom line remains that we must learn how to manage and audit HSEQ better.
Figure P.5 shows a major part of the challenge we are to overcome. I worry that too
many management systems seem to be more about creating paperwork than actually
doing anything to mitigate risks. Expressed simply, too many organizations prepare and
file job descriptions (and audit these job descriptions) or fill in and file risk assessment
forms (and audit these risk assessments) in a silo-type (vertical) approach, rather than
using management systems as they are intended through a (horizontal) continuity of
planning, doing, checking, and acting to improve (PDCA). You’ll be delighted to know
that this book provides you and your organization with a highly effective and highly
implementable solution.
This new edition of this book has been structured to be of interest to three broad sets
of readers:
1 Senior managers who are thinking (or should be thinking) about setting up an
internal audit function in their organization, or who may be questioning the
value of their existing internal audit function.
2 Those who might like to develop their skills as an internal auditor in the
future.
3 Seasoned HSEQ and other internal auditors who may already have risk-based
or management system auditing experience—perhaps they are disillusioned
with the style, process, and reception of the audits they are presently being
asked to do—and wish to improve, refresh, or top up their skills.
Preface to the
Second Edition
In the preface to the first edition of this book, back in 2007, I asked you to ponder why
anyone might wish to write a book about auditing. I believe the answer to this question
remains as straightforward now as it was back then. The expectation of internal and
external stakeholders is still that organizations should be able to demonstrate acceptable
standards of risk management. The pressure for this has, if anything, increased in the
last six years—we all expect and demand better performance.
Let’s be clear what we mean by better performance here. We expect organizations
that introduce hazards into our global and local societies, and that take risks in order
to be successful, to properly control them. The greater those risks, the more control we
reasonably expect. Lawmakers call this approach to risks ALARP—as low as reasonably
practicable. But we can express this more simply. We’re happy to pay a fair price for
the goods and services, and we don’t like it when organizations kill their workers, their
customers, or the public. We don’t want them to pollute our lungs or the environment.
Or lose our personal data. Or blow up the city. Employees expect to keep their jobs, get
paid, and build their skills and careers. Suppliers wish to prosper over the years with
their partners. And investors want their money back, with growth in their capital.
We expect senior managers to keep an all-seeing eye on their external environment,
set their business objectives in the context of that environment, and then deal with
the significant risks—the Big Rocks—that might impact on those objectives and the
requirements of society at large. And, for all of us to be assured of management’s
proper governance and probity, we expect them to initiate independent audits of the
management systems at agreed intervals, maintaining control where it works and taking
corrective or improvement actions where these are found to be necessary.
Taken together, we call this operations integrity (OI). Operations integrity addresses
all aspects of an organization’s business, including security, which can impact its safety,
health, or environmental performance. And, despite all the auditing done, there is a
critical failure somewhere in the world almost every day, almost every week. Some
examples are shown in Figure P.6, but this is by no means a definitive list. On a different
writing day, I could have selected a dozen different examples for you to think about and,
if you wished, to research further.
Facilities and assets that have sustained losses have invariably been audited. I have
noticed that one of the common conclusions of many disaster enquiries is that the
auditing of the management systems was defective. The problem with many audits is that
they tend to be conducted at too low a level, with low-level understanding of the business
and its context and low-level reporting of the findings—trivial matters unnecessarily
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escalated, or significant matters reported out of context or lost amongst trivia. Too
many audits are historically focused, on observed hazards, instead of future-focused,
on proper control of critical operations. It’s all too easy for an audit team to take the
low-hanging fruit of personal protective equipment not being worn or training records
being misfiled without focusing on what really matters to the organization and to society.
And it’s much easier for an audit team to report good news to management than bad.
And if a management team sees auditing only as a means of providing themselves with
assurance that things are as they should be, then this is what they are likely to be given.
As Hopkins (2009) says, leaders who want to pinpoint unrecognized problems that
may be lurking below the surface need to avoid any suggestion that they are asking for
assurance; they need to be suspicious of audit reports that suggest all is well.
When we asked senior management why they didn’t know about many of the failings
uncovered by the enquiry, one of them said, ‘I knew everything was alright because
I never got any reports of things being wrong’. In my experience, there is always news
on safety and some of it will be bad news. Continuous good news—you worry.
From a video lecture on the 1988 Piper Alpha disaster
"Ja rohkea! Hän on rohkein olento, mies tai nainen, jonka mikään
tuuli koskaan on tuonut Salomonille. Olisittepa nähnyt Punga-Pungan
sinä aamuna, jolloin me sinne saavuimme. Snider-kiväärejä
paukahteli rannalla ja mangrove-pensaikoissa, sotarummut rämisivät
viidakoissa, ja merkkitulien savuja näkyi joka suunnalta. 'Tämä
menee päin mäntyä', sanoi kapteeni Munster."
"Niin sanoin", myönsi kapteeni. "Oli aivan selvää, että kaikki oli
menossa päin mäntyä. Sen saattoi nähdä puolella silmällä ja kuulla
toisella korvalla."
Kadonnut lelu.
Sheldon huomasi yht'äkkiä, miten oikeassa Joan oli. Sen mitä hän
oli tehnyt, hän olisi tehnyt vaikkakaan ei olisi ollut hänen
yhtiökumppaninsa. Ja hän, Sheldon, ei ollut millään tavoin ottanut
osaa "Marthan" pelastamiseen. Omin avuin ja neuvoin, Guvutun
irvihampaitten naurun alaisena ja miesten sellaisten kuin Morganin ja
Raffin kanssa kilpaillen, hän oli antautunut seikkailuunsa ja
suoriutunut siitä kunnialla.
"Kun te puhutte noin, alkaa minusta tuntua siltä, kuin olisin paha
iso mies, joka on ottanut pieneltä lapselta hänen rakkaimman
lelunsa", sanoi Sheldon äkkiä katuvaisena.
"Mutta pieni lapsi ei enää itke", kuuli hän Joanin sanovan. "Tuo oli
viimeinen nyyhkytys. Tiedän, että ellei Kinross saata laivaa
perikatoon, niin te jonakin päivänä uskotte sen yhtiökumppaninne
huostaan. Ja nyt en enää aio nalkuttaa. Mutta toivoisin teidän
ymmärtävän, mitä minä tunnen. Minun tunteeni eivät ole vain kuin
'Marthan' ostajan tai rakentajan. Minä olen sen pelastanut. Minä
autoin sen karilta. Minä pelastin sen joutumasta meren hautaan,
vaikka pidettiin uhkarohkeana panna viisikymmentä puntaa alttiiksi
koko yritykseen. Se on minun omani, aivan erikoisesti minun omani.
Ilman minua sitä ei olisi olemassa. Tuo kova luoteismyrsky olisi
tehnyt siitä lopun, ennenkuin se olisi kolmeakaan tuntia puhaltanut.
Ja sitten minä olen purjehtinut sillä, ja se kulkee kuin noiduttu, aivan
kuin noiduttu. Esimerkiksi käännöksissä! 'Marthaa' teidän ei tarvitse
mairitella nostamalla etupurjetta, vähentämällä isoapurjetta ja
hiljentämällä vauhtia ruorilla. Ei, ruori alas vain, ja se kääntyy aivan
kuin ori, jolla on suitset suussa. Ja sen saa kulkemaan taapäin kuin
höyrylaivan. Tein sen Langa-Langassa karin ja rantahietikon välillä.
Se oli suurenmoista… Mutta te ette rakasta laivoja niinkuin minä, ja
minä tiedän, että teidän mielestänne olen naurettava. Mutta kyllä
minä vielä kerran taas purjehdin 'Marthalla'. Tiedän sen. Tiedän
sen."
Vastaukseksi Sheldon — ennakolta ensinkään harkitsematta
tekoaan ojensi kätensä ja laski sen Joanin kädelle, joka lepäsi
kaidepuulla. Mutta hän tiesi — eikä siitä ollut vähintäkään epäilystä
— että hän sai vastauksen kädenpuristukseensa pojalta, pojalta, joka
suri lelunsa menettämistä. Tuo ajatus jäähdytti häntä. Hän ei ollut
todellisuudessa koskaan ollut Joania lähempänä, mutta samalla tämä
ilmeisesti ei ollut koskaan ollut hänestä niin kaukana kuin nyt. Hän ei
varmaan ollut edes tietoinen siitä, että Sheldon oli koskettanut
hänen kättään. Hän oli suruissaan 'Marthan' lähdöstä, ja Sheldonin
käsi oli hänelle kuin kenen tahansa — parhaassa tapauksessa
ystävän — käsi.
"Pääsihän Noakin."
"Pannukakku tuli koko yrityksestä", sanoi hän, "ja nyt hän koettaa
uudestaan. Ja tuollainen mies saa ohjata 'Marthan' kaltaista
hurmaavaa alusta. No onhan tämä ainakin hyvä este avioliitolle
heidän kesken. Ei, en tahdo enää katsoa. Tulkaa sisään ja
pelatkaamme rauhallinen, vanhanaikainen peli biljardia. Ja sitten
minä satuloin hevosen ja lähden kyyhkysiä metsästämään. Tuletteko
mukaan?"
"Te ette voi mitään sille, että olette sellainen kuin olette. Te ette
voi mitään sille, että minun mielestäni olette hyvin viehättävä olento.
Te olette herättänyt minussa halun saada teidät omakseni. Te ette
tarkoittanut sitä, ette millään tavoin koettanut herättää rakkauttani,
mutta te olitte niin luotu, että sen piti tapahtua, siinä kaikki. Ja minä
olin niin luotu, että minun täytyi tuntea halua saada teidät
vaimokseni. Mutta minäkään en voi mitään sille, että olen se mikä
olen. En voi tahdonponnistuksella tappaa haluani saada teidät
omakseni, niinkuin tekään ette voi tehdä itseänne minulle
vastenmieliseksi, vaikka haluaisittekin."
"Tahdon kysyä teiltä, miksi näytätte siltä, kuin olisitte nainen. Miksi
teillä on naisen ruumis, naisen huulet, ihanat naisen hiukset. Ja minä
vastaan itse: siksi, että te olette nainen — vaikka nainen teissä
nukkuu. Mutta kerran hän herää."
Kiellettyä tavaraa.
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