OPITO DESKTOP AUDIT & ONGOING APPROVAL GUIDANCE MATRIX For desktop/initial audits, the Guidance Matrix is to be submitted with the application form The purpose of this document is to enable an applicant to map their evidence of compliance against the OPITO requirements. Applicants who currently hold OPITO Approval status do not require to submit evidence for those sections marked with an asterisk (*), unless new systems/procedures have been developed in support of an application. If so, these must be included in the submission for the Desktop Audit. For multiple applications in a single desktop submission, evidence of compliance for section 1 (Management Systems) only needs to be submitted once. Note: All material submitted by the Applicant as evidence of compliance against the OPITO approval requirements must be in English. Upon close-out of the OPITO Desktop Audit, the Applicant must also ensure that the course delivery will be in English (without the use of an interpreter or translator) during the initial site audit. Following OPITO approval, all material must be updated and maintained in English. All supporting records (e.g. certifications of qualifications or inspections) which are not in English must also be appropriately translated. Kindly contact the relevant regional OPITO office for further clarifications on translation requirements. Columns in Guidance Matrix titled OPITO Requirement and Explanation of evidence required contains the OPITO approval and minimum amount of evidence required to meet the approval criteria, respectively. OPITO will audit against both the OPITO Requirement and Explanation of evidence required column during both initial and ongoing monitoring audits. Reference to sections indicating a formally documented procedure: is defined as being a written description of a prescribed course of action or process. To Be Completed By Applicant Applicant: Contact Point: Scope of Application (Title of OPITO Standard): Applicant currently holds OPITO Approval for the delivery of the following OPITO Standards: (complete if applicable) Title(s)...... For Office Use Only Date Received by OPITO: FORMOPITO004.01A Page 1 of 15 Rev 6 (17/10/2016)
OPITO DESKTOP AUDIT & ONGOING APPROVAL GUIDANCE MATRIX For desktop/initial audits, a procedure must be submitted for the items identified in bold text 1.Management Systems OPITO Requirement Explanation of minimum evidence required Management Systems are required to include the following: 1.1 An explicit policy demonstrating commitment by senior management to safely implement and maintain OPITO standards. (signed by Senior Management)* 1.2 A Customer Service Statement which clearly defines the standards of service which delegates can expect from the OPITO approved centre.* This document is to reflect the organisation s overall philosophy and commitment towards complying with OPITO s training and assessment requirements. It must be explicit to OPITO approval and be signed by senior management. This statement must be brought to the attention of delegates by inclusion in course materials and displayed in training areas. A pro forma statement is available at www.opito.com in the information for training providers section 1.3 Organisation chart, roles and responsibilities and authority for the management and delivery of the OPITO approved standard. The organisation chart must show roles and responsibilities as well as reporting authority for the management and delivery of the OPITO approved standard (training provider management and staff) and indicate the roles and responsibilities of any third parties related to the delivery of the OPITO standard e.g. facilities and equipment. FORMOPITO004.01A Page 2 of 15 Rev 6 (17/10/2016)
Explanation of minimum evidence required Formally documented procedures are required which: 1.4 Ensure frequent internal audits are conducted by appropriately trained personnel with no conflicting interest in the area(s) being audited (i.e. auditors must not audit their own work) of all system activities and procedures relative to the OPITO standard and Approval Criteria. 1.5 Ensure regular review by Senior Management of the organisation s effective and safe delivery of OPITO courses and compliance with OPITO approval requirements. This documented procedure will cover auditing of OPITO approval requirements. All the criteria of management systems, staff and physical resources must be subject to internal audit. This is in addition to actual delivery of training and/or assessment standards which also need to be audited. Evidence must include an indicative audit plan. The training provider must ensure that the internal audit plan captures all existing approved OPITO standards and include any new standard applications. Internal Audit frequency minimum annual frequency. This documented procedure will cover the process for Management review of the delivery of OPITO training. The management review will cover as a minimum the following fixed agenda: review of safe systems of work to ensure safety is being maintained, internal/external audit findings, customer/delegate feedback, assessment results, incident reports and statistics, Emergency Response drill reports, inspection and maintenance reports, competence matrix, complaints, appeals. Evidence will include management review meeting agenda covered within minutes of meetings. 1.6 Support delegate complaints.* A documented procedure which shows all steps in dealing with delegate complaints, the person(s) responsible, how delegates are made aware of the procedure, what records are kept etc. FORMOPITO004.01A Page 3 of 15 Rev 6 (17/10/2016)
1.7 Control the maintenance, updating and back-up of databases (IT and/or manual).* 1.8 Ensure accurate records of candidate assessment are maintained and securely stored.* 1.9 Ensure appropriate inspection maintenance activities for all facilities and equipment to be used during delivery of the OPITO Standard.* 1.10 Ensure effective liaison and communication between all sites where training and/or assessment is conducted.* 1.11 Ensure that OPITO administrative requirements are fulfilled. These are required to include the following: 1.11.1 Delegate registration and forwarding of delegate registration details to OPITO on a weekly basis Explanation of minimum evidence required This may be a single documented procedure which identifies relevant databases or controls may be included in other procedures e.g. maintenance, administration etc. The documented procedure requires to indicate how is this undertaken, how and where the records are stored, who is responsible for maintaining the records, what security provisions are in place, etc. This information may be included in the general assessment procedure(s). A documented procedure which shows that a system is in place for planned and unplanned maintenance of facilities and equipment. A documented procedure which applies only to centres having remote sites where training is conducted e.g. TEMPSC / fireground areas etc. Procedures are required to demonstrate that management systems accommodate these. E.g. administration, maintenance, document control procedures and emergency response procedures including communication etc. A formally documented procedure which shows the administration process from booking through to certification is required. Note for 1.11.1: OPITO will assist in putting an electronic registration system in place once approval has been granted. FORMOPITO004.01A Page 4 of 15 Rev 6 (17/10/2016)
1.11.2 Verification of delegate pre-requisites (where required) 1.11.3 Dispensation for expired certificates, including three month allowance window for delegates to retake not yet competent (NYC) outcomes (where applicable) 1.11.4 Certificate issue 1.11.5 Ensure verification of delegate identity by means of government issued photographic identification e.g. Passport, Driving Licence, etc. 1.11.6 To ask delegates for current contact information for next of kin and/or sponsor for delegates in case of an emergency. Explanation of minimum evidence required 1.12 Facilitate the identification of resources required by candidates with individual training and assessment requirements and ensure availability.* 1.13 Ensure all training is conducted safely and delegate well-being is maintained at all times. Procedures are required to include the following: 1.13.1 Safety Procedures A documented procedure is required. Examples of individual training and assessment requirements include: - English not first language - Literacy - Religious considerations - Disability Documented Safety Procedures relevant to the OPITO Standard(s) being delivered are required. Photographic evidence of delegate s wellbeing must include as a minimum: - Changing rooms, toilets, showers, washing facilities and canteen FORMOPITO004.01A Page 5 of 15 Rev 6 (17/10/2016)
1.13 Ensure all training is conducted safely and delegate well-being is maintained at all times. Procedures are required to include the following: 1.13.2 Emergency Procedures including external interfaces and exercises Explanation of minimum evidence required appropriate to training provided and the number of delegates - Emergency escape routes The Training Provider must demonstrate that they are capable of responding to an emergency within the expected timeframes, have sufficient competent medical emergency response staff, and necessary medical equipment and facilities. Refer to OPITO Medical Emergency Response Audit Criteria document for further guidance on the evidence required. 1.13 Ensure all training is conducted safely and delegate well-being is maintained at all times. Procedures are required to include the following: 1.13.3 Job Safety Analysis/Risk Assessments OPITO requires dynamic risk assessments, which will include tiered response appropriate to the level of risk, which includes appropriate mitigations to the risks associated with the type and location of the activity being conducted, this will enable the training provider to adequately prepare for and to take the appropriate action at the right time based on prevailing circumstances. Dynamic risk assessment will replace any historic generic static provision or blanket mitigations. As an example of a static mitigation a declaration that a Training Provider has x number of medically trained staff or y items of medical equipment is not sufficient mitigation. The requirement is to dynamically assess then associate specific mitigation against specific activity on the day with a defined set of prevailing conditions, for example the dynamic risk assessment would contain, scenario FORMOPITO004.01A Page 6 of 15 Rev 6 (17/10/2016)
1.13 Ensure all training is conducted safely and delegate well-being is maintained at all times. Procedures are required to include the following: 1.13.4 Medical Screening Procedures (where applicable) 1.13 Ensure all training is conducted safely and delegate well-being is maintained at all times. Procedures are required to include the following: 1.13.5 Accident/Incident Reporting and Investigation Procedure Explanation of minimum evidence required specific circumstances e.g. specific hazards for that exercise have been identified, specific equipment has been verified on location, equipment is operational, staff are available with appropriate qualifications (Advanced Cardiac Life Support (ACLS) or equivalent qualification) are in date (valid). The training provider must demonstrate fit for purpose Emergency Response capable of responding to the highest risk identified within section 1.13.3 i.e. within the tiered MER framework Documented Medical Screening Procedure relevant to the OPITO Standard(s) being delivered. Refer to OPITO Medical Emergency Response Audit Criteria document for further guidance (Appendix E) Documented Accident/Incident Reporting and Investigation Procedure. It is an OPITO requirement for training providers to keep records of all incidents. In the event of a Lost Time Incidents, an incident summary covering the event, type of injury, initial actions and initial incident findings, this information is required to be communicated with the relevant OPITO Regional Manager as soon as practical, but no later than 48 hours following the occurrence of the Lost Time Incident, this requirement is to be contained within the Accident /Incident reporting and investigation procedure. FORMOPITO004.01A Page 7 of 15 Rev 6 (17/10/2016)
1.13 Ensure all training is conducted safely and delegate well-being is maintained at all times. Procedures are required to include the following: 1.13.6 Toolbox Talks (prior to specific practical training) Explanation of minimum evidence required All incidents are to be recorded as defined using the OPITO Medical Emergency Response document Appendix F. Incident reports and investigation records are to be maintained and available at the time of audit and if requested by OPITO. The responsible course instructor has to ensure that all course participants for that particular unit attend the briefing session and a record of those present is to be maintained. The following must be covered and recorded as a minimum during the toolbox talk: a) Specific task description/practical exercises to be conducted, including the individual right of all those involved in the exercise to intervene and stop exercises if there are unsafe acts and conditions, including meaningful engagement to prevent reoccurrence and the right to raise the alarm with staff if someone is thought to be in distress b) Date and time c) Conditions at training area i.e. weather d) Identified and explained the exercise risks and corresponding emergency responses e) Medical provisions location of equipment and medical staff including emergency telephone numbers f) Verification and confirmation of Safety checks/inspections/pre-use checklists prior to task commencement FORMOPITO004.01A Page 8 of 15 Rev 6 (17/10/2016)
Explanation of evidence required Reference where Evidence Of Compliance can be 2.Physical Resources 2.1 Resource needs are identified in relation to the specific OPITO Standard and are available. 2.2 There are sufficient and appropriate inspection, maintenance and testing activities to ensure that all training and emergency response equipment and facilities are safe and fit for purpose. The system of maintenance must include: 2.2.1 A current and accurate inventory of all facilities and equipment used for the safe delivery of OPITO approved training and/or assessment plus facilities and equipment For all Facilities and Equipment where training is conducted, the resource needs are identified as per relevant sections of the OPITO Standard and associated safety and health risk assessments. Evidence of compliance with this criterion will be in the form of an accurate inventory of all facilities, equipment and personal protective equipment to be used for the safe delivery of the OPITO Standard. The actual numbers/quantities available require to be listed. All items listed in inventory must be supported by photographic evidence. Details of any & all media and reference documentation used during the delivery of the course will be included. The equipment and facilities necessary to effectively operate Emergency Response (including Medical) protocols will be determined in accordance with the health risk assessments, tiered response protocol, and time to nearest adequate emergency medical facility. Evidence will be demonstrated via: - Equipment/facilities checklists - Equipment inspection and maintenance plans/ schedules - Contingency plans are also required in the event of equipment breakdown/failure - Load test certificates FORMOPITO004.01A Page 9 of 15 Rev 6 (17/10/2016)
available to respond to emergency situations. (as per 2.1 above) 2.2.2 Facility and equipment inspection and maintenance plans/contingency plans (computer or paper- based). 2.2.3 Third party certification of facilities and equipment where appropriate (e.g. for lifting equipment, medical response equipment, etc). 2.2.4 Accurate recording of inspection and maintenance activities conducted on facilities and equipment used in the delivery of OPITO approved training and/or assessment plus facilities and equipment available to respond to emergency situations. FORMOPITO004.01A Page 10 of 15 Rev 6 (17/10/2016)
3.Staff Resources 3.1 There are sufficient staff with the appropriate qualifications and experience as defined within the OPITO Standard and Medical Emergency Response Document to deliver effective and safe training. 3.2 There are formal job descriptions/specifications for all job roles involved in the delivery and support of the OPITO Standard. 3.3 There are sufficient assessors and internal verifiers with the appropriate training and competencies to ensure quality and objective assessments of staff and delegate performance. Explanation of evidence required The relevant section of the OPITO Standard clearly indicates the required skills, experience and qualifications for training delivery and competency assessment. Evidence to be sufficient, valid and must include; CVs/Résumés, copies of certificates, staff training and competency records to cover the staff roles. A Competence Matrix for all staff involved in the delivery of the standard. Note: In situations where an OPITO standard requires staff to hold an OPITO certificate as evidence of competence, and this initially cannot be achieved; training providers could be approved to deliver the standard provided the relevant staff meet the evidence indicated in this section 3.1. Thereafter the relevant staff must achieve certification within a 12 month period. Job descriptions for all job roles specific to the delivery and support of OPITO Standards. To include instructors, assessors, support staff, medical and emergency response personnel, administrative staff, maintenance staff, etc. As for 3.1 FORMOPITO004.01A Page 11 of 15 Rev 6 (17/10/2016)
Formally documented procedures are required which: 3.4 Ensure that staff training and development needs are regularly reviewed and a programme is put in place to meet any requirements which are identified.* 3.5 Ensure that regular confirmation of staff competency is undertaken.* Explanation of evidence required This procedure relates to all staff involved in the training and/or assessment of OPITO Standards i.e. full-time, part-time, subcontracted, etc. This may be a stand alone procedure or be part of the training & development process/procedure. To include instructors, support staff, maintenance staff etc. 4.Training & Assessment 4.1 Course Joining Instructions containing information, advice and guidance on training, assessment and safety aspects will include course learning outcomes to ensure delegates have information about what they re required to know and do, and (where applicable) that the course is of a stressful and/or physical nature. This process would normally be included in administrative procedures. Additional documentation may include: - Course Information sent to delegates/delegates representatives - Sample of completion certificate - Link to course specific OPITO briefing video materials e.g. OPITO BOSIET DVD on the OPITO website or a TP website 4.2 Delegates are informed of OPITO s role within the oil & gas industry and contact points within OPITO. This may be achieved by a prominently displayed notice and inclusion in training materials. This will be achieved by a prominently displayed notice in the training centre. This is available from the OPITO website documents library at www.opito.com FORMOPITO004.01A Page 12 of 15 Rev 6 (17/10/2016)
4.3 There is documentary evidence to confirm that training and assessment is carried out as specified within the relevant OPITO Standard. This documentation must include: 4.3.1 Assessment checklists including assessment methods, clearly referenced against the relevant OPITO Standard. 4.3.2 Detailed lesson/exercise plans, clearly referenced against the relevant OPITO Standard (including toolbox talks, delivery methods (explanation/demonstration/practice), instructor/delegate ratios, resources to be used, time allocation, location of training, staff roles etc). Explanation of evidence required Assessment checklists referenced against the learning outcomes contained within the standard. Lesson plans (theory and practical) referenced against the training programme and learning outcomes contained within the standard, plans need to be sufficiently detailed to ensure that training is consistently delivered. The Theoretical lesson plan sets out what information is going to be delivered and the sequence of delivery to enable a competent instructor to deliver the lesson plan consistently and must cover all the elements of the OPITO Standard, as a minimum. The theoretical lesson plan must also contain facility and equipment required. The Practical Exercise Plan must contain: A description of the scenario and staff roles, with supporting drawings/plans so it is clear what the delegates will be expected to practice and demonstrate. A list of PPE required by the delegates Planned timing of exercises Facilities, equipment & props to be used Safety points, stress aspects and emergency response to be covered in tool box talk prior to commencing with the practical exercise Recommended points for preventive safety verification checks on course FORMOPITO004.01A Page 13 of 15 Rev 6 (17/10/2016)
4.4 A Timetable/Programme to cover course delivery and enable sufficient time for effective administration of the programme in line with the OPITO Standard. Explanation of evidence required participants and stop training intervention principles References which may include, e.g. supporting Instructor guidance, relevant operational procedures, JSAs, lift plans in the case of Rigger Training Examples of documentation which reflect the optimum time allocations set out in the OPITO Standards must include: - Course Programme Timetable - Administration and break times Formally documented procedures are required which: 4.5 Ensure candidate assessment is conducted in alignment with OPITO Standard requirements.* 4.6 Support candidate appeals against assessment decisions relating to treatment within the assessment process.* 4.7 Ensure consistency, quality and objectivity of assessments* A documented procedure which outlines all steps of the candidate assessment process, to include addressing the needs of delegates who are deemed not yet competent. This may be combined with the appeals procedure (4.6). A documented procedure which outlines the process involved in a candidate appealing against an assessment decision. This is a separate issue from a delegate who wishes to complain about service etc. A documented procedure which outlines all steps required for quality assurance of the assessment process. This may include: - Meetings with Assessors where support and advice to assessors is provided FORMOPITO004.01A Page 14 of 15 Rev 6 (17/10/2016)
Explanation of evidence required - Sampling of assessment evidence to verify assessor s decisions and assessment - Record keeping FORMOPITO004.01A Page 15 of 15 Rev 6 (17/10/2016)