Company Operational Manual COM 2.7 Measurement Analysis and Improvement	Doc No.: COM 2.7 Revision: 1 Date: 15 Oct 2024 Issued by: DPA Approved by: MD

1. APPLICATION

This document applies to all employees and contracted personnel in the Company.

2. PURPOSE

To provide a process whereby the fulfilment of Company Management System (CMS) policies, objectives, and targets may be measured and analyzed to improve performance.

3. GENERAL REQUIREMENTS

• Vessels and offices shall be periodically evaluated via internal/external audits, inspections, appraisal systems, collection of customer feedback, etc., to verify compliance with documented requirements in the CMS or identified legislation and regulations.
• All such activities shall be planned and documented.
• Internal audits shall be carried out by qualified personnel.
• Findings from the evaluations shall be:
  • Documented, categorized, and closed out within an agreed time frame.
  • Reported in DSM unless otherwise specified below.
  • Handled in DSM unless otherwise specified below.
  • Closed out in a manner that will prevent reoccurrence.
  • Analyzed to determine areas requiring additional focus, identify gaps, errors, or areas for improvement.
  • Reviewed to evaluate the effectiveness of implemented actions.
  • Lessons learned from findings shall be shared with relevant personnel.

4. PLANNING

4.1 Planning

• The Head of HSSEQ is responsible for verifying, reviewing, and evaluating compliance with CMS onboard and ashore.
• HSSEQ is responsible for developing annual audit plans for offices and appointing internal auditors.
• HSSEQ is also responsible for developing annual audit plans for vessels and appointing internal auditors.
• The audit plan shall be maintained for all offices and fully managed vessels.
• The details of the plan must be communicated to relevant stakeholders at defined intervals.
• Office audit plans shall be communicated in advance of the due date.
• The plan shall specify the due dates and types of audits to be scheduled.

5. VESSEL AUDITS (INTERNAL / EXTERNAL)

5.1 General

All fully managed vessels and offices/business units shall undergo internal and external audits as per regulatory/mandatory codes, conventions, and international standards, as applicable. These may include:

• ISM Code
• ISPS Code
• STCW Code
• MLC Convention
• ISO 9001
• ISO 14001
• ISO 45001

5.2 Internal Audits – Vessels

• At least one internal audit per year shall be carried out by qualified personnel.
• All internal audits must be completed before the due date.
• HSSEQ dept shall commence planning, in coordination with the fleet group and vessel, no later than 90 days before the due date.
• Auditors shall use the following:
  • COM 2.6 Vessel internal audit guidance
  • DSM for reporting or forms A1, A2, and A3
• Reports shall be submitted no later than 5 working days after completion of the audit.
• The Head of HSSEQ shall review the reporting times monthly and evaluate reasons for late submissions for improvement purposes.

5.2.1 Exemptions in Exceptional Circumstances

• The DPA may grant extensions to internal audits in consultation with the relevant flag state (where applicable) only in exceptional circumstances.
• The Head of HSSEQ is solely responsible for the appointment of external 3rd party auditors if internal resources are unavailable.

5.3 Environmental Compliance Audits (Internal)

• Audits shall be conducted to promote and evaluate environmental compliance onboard.
• Reference shall be made to EMS Procedures.
• The audit report shall be created within DSM by the auditors and must comply with the following guidelines:

Form	Name of Checklist/Report	Personnel trained to carry out the Audit
A1	DSM Vessel Internal Audit Checklist	HSSEQ Supt / MHSSEQ Supt / Vessel Manager / Environment Compliance Department Auditors

5.4 External Audits

• External audits are conducted by independent auditing organisations, such as regulators or those providing certification.
• The Tech Superintendent in charge of the vessel shall commence planning, in coordination with the vessel, for external auditor attendance within the audit window.
• Reports shall be entered into DSM as soon as possible once received from the external auditor. If for some reason the vessel is unable to use DSM, the report is to be submitted to HSSEQ dept.

6. SHORE AUDITS (INTERNAL/EXTERNAL)

6.1 Internal Shore Audits

• HSSEQ shall prepare an annual audit plan for the Company’s shore sites.
• The plan shall cover all business areas and support departments across the Group of Companies.
• HSSEQ shall appoint auditors for the execution of audits.
• Fleet groups shall be audited for technical, marine, and crewing compliance.
• Use the following checklist for reference:
  • A8 - Office Internal Audit Checklist
• Use DSM for reporting.
• Reports shall be entered into DSM no later than 10 working days after completion of the audit.

6.2 External Shore Audits

• Complete all external audits (Document of Compliance and ISO) before the due date.
• Planning shall commence no later than 90 days before the due date.
• HSSEQ shall coordinate with the relevant external auditing party to fix a date for the audit and coordinate with relevant departments internally.
• Enter reports into DSM as soon as possible once received from the external auditor.

7. OTHER AUDITS AND INSPECTIONS

7.1 Flag State Inspections (FSI)

• Vessels shall undergo FSI as required by the nominated flag state.
• Flag state inspections, also known as Annual Safety Inspections (ASI), are carried out by the flag state or an organization authorised by the flag state in accordance with its relevant rules and regulations.
• The Marine Superintendent forwards the requests for FSI from the responsible flag state to the Tech Superintendent.
• The Tech Superintendent shall coordinate with the nominated flag state inspector to ensure it is completed before the due date.

Note :

• More detailed information regarding the conduct and the frequency of the flag inspection will be available from the flag state rules on-board each vessel. These rules would dictate the frequency of such inspections; however, they are generally performed at least once a year.

7.2 Port State Control Inspections

• Vessels may be subject to Port State Control (PSC) inspections.
• PSC guidance will be provided to vessels as per the latest ongoing CICs and focus areas.

7.3 Vessel Periodical Inspections

• Fully managed vessels are scheduled for periodic inspections to ensure the vessels are maintained and operated as per the Company’s requirements.

Note :

• Refer to FOM 1.5 Periodic inspections.

Note :

• Refer to FOM 1.7 Shipboard Inspections for more information on handling and preparation for the abovementioned inspections.

8. COMMERCIAL AUDITS

8.1 Commercial Office Audits (TMSA / OVMSA / Owners)

8.1.1 General

• Business units (Vessel management) may be required to undergo TMSA / OVMSA / Owners audits as applicable.
• HSSEQ shall coordinate commercial office audits and notify all parties involved in the audit.
• HSSEQ shall coordinate preparation for the audits and work with all departments involved to verify that findings from previous audits have been closed out.
• Findings related to commercial office audits are handled outside of DSM.

8.2 Commercial Shipboard Inspections (SIRE / OVID / CDI / Right Ship)

8.2.1 General

• These are shipboard inspection regimes which allow commercial stakeholders such as Oil Majors, Right Ship, charterers to evaluate the condition and operation of the vessel.

8.2.2 SIRE Inspections (Tanker Vessels) & OVID Inspections (Offshore)

• Commissioned by oil companies that are members of the OCIMF.
• Reports of inspections are maintained on the OCIMF database for members to access, providing them with the most up-to-date inspection status of the vessel.

8.2.3 CDI (Chemical Distribution Institute) Inspections

• Inspection regime designed for chemical and gas tankers.
• The completed report provides a score for the inspected vessel.
• A higher score indicates a vessel compliant with industry standards.

8.2.4 Right Ship Inspection

• Inspection regime designed for Bulk carriers and General cargo vessels.

9. EXPERIENCE FEEDBACK AND INTERNAL AUDIT EVALUATION

9.1 Experience feedback can be obtained in several ways, such as:

• Client contact.
• Complaints.
• Audit findings and observation.
• Class and statutory reports (vessels).
• Through daily work and reporting of sharing of good practices, near misses, or accident reporting.
• Office & Shipboard inspections.

9.2 Internal Audits Evaluation

• The purpose of the internal audit evaluation is to evaluate the ship internal audits and the performance of the internal auditors.
• An internal audit evaluation shall be carried out as and when required by the HSSEQ for the ship’s annual internal audits.
• The request for evaluation shall be sent by the HSSEQ to the auditee or interested party audited within one week after the completion of the internal audit.
• An evaluation shall be carried out at least once a year for every internal auditor performing audits in the organization.
• The A30 - Internal Audit Evaluation shall be used for the evaluation purpose.
• The record of evaluation shall be filed and maintained by the company. The internal auditor will be evaluated on the following criteria:
• The audit planning.
• Execution and conduct of the audit.

Note :

• Refer to COM 2.5 handling of experience feedback.
  Refer to A30 auditor evaluation form.

10. SELECTION OF INTERNAL AUDITORS

Office Internal Auditor

• The individual should possess an internal auditor certificate.
• Carry out at least one audit under the supervision of the current auditor.

Third Party Auditor

• The individual should possess an internal auditor certificate.
• Have prior experience in carrying out internal audits and/or flag state inspections onboard.
• Have access and/or understanding of SMS before going onboard.

Note :

• Auditors shall hold certification covering the scope of the audit and this applies to all audits. The certificates include ISM, ISPS, MLC, ISO 9001:2015, ISO 14001:2015 and ISO 45001:2018

11. REPORTING OF INSPECTIONS AND AUDITS

• Audit and inspection reports shall normally be reported and handled in DSM.
• If DSM for some reason is unavailable, the report is to be submitted to the HSSEQ dept.

12. AUDIT AND INSPECTION FINDING

• Findings shall be closed out by preparing and submitting a corrective action plan (CAP) and a corrective action report (CAR).
• As a minimum, a root-cause analysis, corrective action, and preventive action shall be prepared.

Note :

• Refer to COM 2.4 Root cause analysis for further details.
• Reference shall be made to the table below regarding submission deadlines for each type of verification event.

Type of Verification	Time Limit for Submission of CAP or CAR	Submission of CAP or CAR to the relevant authority	Date due for closure of the NC	PIC for granting extension of CAP & CAR
Internal Audit	CAP to be submitted within thirty (30) days	NA	Maximum 90 Days	DPA
External Audits	CAP to be submitted within fifteen (15) days	CAP to be submitted as per the Class Surveyor but generally, three (3) weeks	As per the report or generally, minimum two (2) months and maximum three (3) months	DPA before requesting to external parties
Port State Control	CAP/CAR to be submitted as per the Codes in the report	CAR to be submitted as per the Codes in the report	As per the Codes given in the report	DPA before requesting to external parties
Flag State Inspection	CAP to be submitted within fifteen (15) days	CAR to be submitted within thirty (30) days	Within thirty (30) days	DPA before requesting to external parties

13. ISSUANCE OF NON-CONFORMITIES OUTSIDE OF AUDIT WINDOWS

• If a non-conformity is found outside of a scheduled audit, for any department within the organisation, DSM shall be used to document that finding.
• The form shall be submitted to the HSSEQ department together with objective evidence showing the non-compliance.
• The non-conformity shall be referenced against the CMS.
• The Head of Department, HSSEQ will, after review of the report and objective evidence, issue the NC to the affected department.
• The affected department shall then prepare a CAP/CAR in DSM.
• The completed CAP/CAR shall then be submitted for approval within the due date stipulated.

14. APPENDICES

• COM 2.4 - Root cause analysis / Corrective and preventive actions
• COM 2.5 - Experience feedback
• COM 2.6 - Vessel internal audit guidance