You are asked to conduct a gap analysis in relation to the organization you chose for your course project. When selecting your organization, you were asked to either select a company that was already utilizing a systems approach to management or an organization that was not. Since that point in time, you have been asked to make various observations about the company you selected.
In this assignment, you are asked to first review the CSA Z1000 checklist provided on pages 64-72, as it provides a detailed list of requirements. In order for you to focus on specific management system elements, use the list provided below when writing your gap analysis:
1. Policy and management commitment: What is the policy? Is it communicated and understood within the organization? Are responsibilities assigned?
2. QEHS manual (or other document which describes the MS): How is the MS documented within the organization?
3. Documentation and records: Is there control over documentation, including records?
4. Evaluation of risk: Has the organization identified key QEHS risks? Is there a method to evaluate new risks that may arise based on changes in the management system?
5. Objectives: Has the organization established measurable objectives related to risks identified? Are they periodically reviewed to determine if the organization is meeting them?
6. Identification of regulatory requirements: Has the organization evaluated regulatory requirements impacting the organization, is this review updated periodically?
7. Evaluation of regulatory requirements within the organization: Does the organization have an internal process to determine if it meets regulatory requirements (compliance audits)?
8. MS conformance evaluation (Internal Audit): Does the organization review its conformance with any MS standard?
9. Management review: Does top management periodically review the progress of the organization in terms of implementation of the MS and in continuing to improve?
10. Operational controls/equipment: Are there procedures to address the implementation of controls necessary to address QEHS risks? Is equipment maintained and is there a preventive maintenance program? MOS 5525, Integrated Safety Management Systems 5
11. Employee involvement: How are employees involved in the management system and what are their responsibilities?
12. Suppliers and contractors: Is there a supplier quality, and EHS program? How are they managed with respect to meeting the organization's QEHS requirements?
13. Measurement and monitoring: Does the organization measure its ability to meet requirements and parameters related to operational controls? Are the instruments used calibrated? Does the organization have a process to collect, store, and evaluate data related to its operational controls?
14. Deficiencies and process failures (corrective and preventive action): Does the organization have a documented process for addressing defects, process failures, accidents, and other unexpected events? Does the process include a method to determine root cause, prevent reoccurrence and to evaluate effectiveness of those actions? Does the organization have a process to evaluate potential problems before they occur?
15. QEHS improvement: Does the organization have a defined process for continuous improvement? How is it implemented within the organization?
16. Emergency planning: Does the organization understand the potential sources of emergencies (based on the location of the organization and its operations) which could impact the organization and have plans been developed on how to address those emergencies? Are the plans checked? Are there drills/checks to ensure that the plans work?
17. Training: Are training requirements identified and competency requirements determined? Is training conducted to meet the requirements and are records maintained to reflect the training completed?