Internal Audit Report

Audit Identification: IA202614
Area: Corrective Actions
Audit Date: 7th May 2026
Auditor: Sean Ashton (HSQE Consultant, Onyx Operations)
Date Completed: 7th May 2026
Findings: 0 Non-conformities, 0 Observations
Scope: ISO 9001:2015 / 14001:2015 / 45001:2018 — Clause 10.2
Document Number: FORM_INTAR001 Rev 1 ID 01/09/2025
Builds on prior audit: IA202514 (02/10/2025) — 0 NC, 1 OBS

Audit cycle context

This audit is part of AMWS's rolling 2026 internal audit cycle conducted across 28/04-19/05/2026 by Sean Ashton (HSQE Consultant), ahead of the Achilles UVDB Verify Category B2 surveillance audit on 3-4 June 2026. Some documents reviewed during the cycle were revised within the cycle as part of the broader 2025-26 IMS rebuild — see the Post-audit IMS evolution block at the foot of this report for details of changes completed by 13/05/2026.

Executive Summary

This audit re-examined the Corrective Action workflow one year on from IA202514. The 2025 observation is closed:

• CAR-2025-019 (quarterly trend analysis to leadership) — closed. The standing weekly Director / HSQE compliance call provides routine NC / CAR visibility to leadership in real time, replacing the quarterly trend report concept. The audit-readiness Gap Closure tracker provides programme-level visibility against the 15 P1 items. The 5 CARs raised by IA202601–04 (28/04–01/05) plus the 2 from IA202605 / 13 are visible in real time.

No new observations. The corrective-action workflow is operating as designed: this very 2026 IA cycle is generating CARs on a planned basis, with named owners and target dates, all tracked through APP_21 and the gap-closure tracker.

Year-on-year follow-up — IA202514 outcomes

2025 ref	2025 finding (summary)	Status in 2026 audit
OBS-IA14-01 / CAR-2025-019	Trend analysis not formally reported outside MR	Closed. Standing weekly Director / HSQE compliance call provides routine real-time leadership visibility; gap-closure tracker provides programme-level view. Quarterly written report deemed unnecessary at AMWS scale.

Introduction

This audit examined the Corrective Action workflow (clause 10.2) — root-cause identification, effectiveness verification, prevention of recurrence — one year on from IA202514.

Aims & Objectives

1. Confirm closure of IA202514 OBS-IA14-01
2. Verify the corrective-action pathway from raise → root cause → action → close-out → effectiveness check operates for the 2026-cycle CARs raised so far
3. Sample CAR records for evidence of root-cause analysis and not just symptom treatment
4. Confirm CAR records are accessible (APP_21) and integrated with the wider improvement framework

Audit Method

• Document Review: SOP 7.1 Complaints / NCR / Corrective Action Rev 3 HTML, APP_21 NC Register Rev 3, gap-closure tracker, the 7 CARs raised in the 2026-IA cycle to date (CAR-2026-001 through 007).
• Interviews Conducted: Directors (Aaron + Leanne Mason — CAR owners), Site Supervisor (Jason May — CAR owner for some operational items), HSQE Consultant.
• Observations: Walkthrough of CAR-2026-001 (light-touch monthly context capture) and CAR-2026-005 (Q2 BCP desktop) from raise → action plan → expected close-out.
• Sampling: 7 × 2026-IA CARs against SOP 7.1 workflow; 6 of the 15 P1 gap-closure items closed in 2025–26 (#1, #3, #4, #7, #8, #9, #11, #12, #14, #15) reviewed for closure evidence quality.

Non-conformities

No non-conformities identified.

Observations

No observations identified.

Conclusions

The Corrective Action workflow is functioning as designed:

Areas Meeting Requirements (sustained from IA202514):

• APP_21 continues to operate as the canonical CAR register
• SOP 7.1 continues to define the workflow (now in rebuilt HTML format)
• Root-cause analysis continues to be evidenced in CAR records

New strengths since IA202514:

• 2026-IA CAR pipeline. Within 8 days of starting the 2026 IA cycle (28/04 to 06/05), 7 CARs raised, 7 owners named, 7 target dates set, all visible in the gap-closure tracker. The auditor can trace CAR-2026-005 in particular — Q2 BCP desktop — from observation through to scheduled close (28/05/2026).
• Programme-level CAR visibility through the gap-closure tracker — bridges between individual CARs and strategic risk.
• Closed gap-closure items demonstrate 10.2 close-out quality — 10 of 15 P1 items closed in the 2025–26 cycle each have a documented closure entry naming the artefact that closes them (e.g. #1 Suppliers → APP_19 Issue 7 HTML register; #4 TBT → TBT_PROG_01; #7 IT Security → POL_HSQE_30; #15 Recycling → recycling-initiatives.md). Effectiveness of the corrective action is therefore directly verifiable by inspection of the deliverable.

Position as at 13/05/2026: The findings above remain the formal record. The 12-13 May 2026 IMS consistency pass (see closure block below) does not alter any audit verdict; it strengthens the supporting evidence base going into the Achilles UVDB B2 surveillance audit (3-4 June 2026).

Recommendations

1. Continue using the standing weekly compliance call as the active CAR-review forum.
2. At the September 2026 MR, present the 2026-IA CAR set with status — close out the cycle visibly.
3. As the 2026 IA cycle continues (12 audits remaining IA202607–IA202616), expect more CARs to be raised — this is the system working, not a sign of regression.

Feedback & Acknowledgments

Full cooperation. The 2026 IA cycle has been deliberately structured to test the corrective-action workflow under load, and the system has handled the 7 CARs raised in 8 days without any backlog or bottleneck.

Post-audit IMS evolution (12-13 May 2026)

The findings above stand as a point-in-time record at audit date. Following the 2026 audit cycle, AMWS completed an IMS-wide consistency pass on 12-13 May 2026 that affects references in this report. The audit findings remain valid; the system updates strengthen rather than supersede them. Material changes the auditor should be aware of:

Appendix-level changes

• APP_01 Context & Interested Parties Log — Issue 3 / 01/06/2026; 10 → 12 interested parties (Ofwat [NEW 2026], ICO [NEW 2026]); 2 [NEW] + 3 [UPDATED] tags inline
• APP_02 ISO Clause Application Matrix — Issue 2; Standards Watch section added tracking ISO 14001:2026 / 9001:2026 / 45001:2027 transitions
• APP_02.1 Process Application Log — Issue 2; 8 → 9 processes (Information Security & Cyber [NEW 2026] added)
• APP_05 Risk & Opportunity Log — risks reorganised by category (R-01..R-21 in category order); opportunities now scored using the same A + B + (C × D) method as risks (8 opportunities O-01..O-08, O-09 dropped — Onyx Operations business, not AMWS); R-07 Supply chain controls reflect the APP_19 Issue 7 / 19-May-2026 HTML register migration (18 Active rated Excellent / 13 Inactive / 1 Merged following the IA cycle proportionality review)
• APP_06 Aspect Identification — Issue 3 / 01/06/2026; 12 → 14 environmental aspects (Aspect 13 Climate Adaptation [NEW 2026], Aspect 14 PFAS [NEW 2026])
• APP_07 Hazard Identification — Issue 4 / 01/06/2026; HO-18 Fatigue Management added 04/05/2026; named owners throughout (generic role labels retired); RA review dates aligned to 01/06/2027
• APP_08 OHS Hazard Assessments — Issue 2 (corrected from phantom Issue 3); RA_HO_18 added to register; compliance matrix expanded for 2026 legislation stack
• APP_11 HSQE Objectives & KPIs — B4 Cyber Resilience KPI added [NEW 2026] (Cyber Essentials by 31/12/2026; zero notifiable breaches per year); B2 KISS reframe; E3 Carbon baseline now live (288.7 tCO₂e Scope 1+2)
• APP_15 Lifecycle Analysis — 14 aspects in lifecycle matrix; Strategic Actions section added with KPI / SOP cross-references
• APP_16 Emergency Preparedness — 12-scenario Response Matrix added (ER-01..ER-12 including ER-11 Cyber [NEW 2026] and ER-12 Extreme Weather [UPDATED 2026]); 2026 YTD testing log populated; APPL_16 Excel master created
• APP_17 Disaster Recovery & BCP — Issue 4 / 13/05/2026; KISS testing cadence (annual desktop + real-incident reviews + continuous currency); two-tier interlink with APP_16 (Tier 1 incident response, Tier 2 business continuity) with shared scenario-mapping table
• APP_18 Emergency Equipment Log — Issue 3; 2026 YTD inspection history populated (20 rows Jan-May); APPL_18 Excel master created
• APP_19 Approved Suppliers — Issue 6 / 13/05/2026; explicit Performance Rating Criteria added (6 criteria × 3 bands: Excellent / Good / Do Not Use)
• APP_20 Internal Audits Programme — Issue 3; 16 × 2026 internal audits delivered (28/04-19/05/2026); CAR-2026-001..011 tracker; 2026-27 forward programme with ISO 14001:2026 transition + Cyber audit slots
• APP_21 NC Register — Issue 4 / 13/05/2026; dual-master pattern (audit-derived CARs portal-master; operational NCRs Leanne's live Excel)

Risk Assessments

• All 18 RAs (RA_HO_01..18) standardised to consistent layout: Document Information callout → Download this risk assessment callout with .docx download → page body → How this document is approved callout
• 4 × 4 matrix consistency applied across all 18 RAs (RA_HO_18 rescaled from 5×5 to match the rest)
• 18 × .docx companions generated and linked from each RA page
• APP_07 and APP_08 RA Coverage tables now have correct 04/07/2026 / 04/05/2027 review dates (was wrongly showing 01/06/2027) and clickable RA hyperlinks

Policies and procedures

• POL_HSQE_29 Mental Health Policy (issued 04/05/2026 — Issue 1) — in operation
• POL_HSQE_30 IT Security Policy (issued 04/05/2026 — Issue 1) — in operation
• POL_HSQE_29 and POL_HSQE_30 cross-referenced from new APP_11 B4 KPI, APP_16 ER-11 Cyber scenario, APP_17 §3.1 Technology Disruption

Carbon Baseline 2025

• Published 12/05/2026: 288.7 tCO₂e Scope 1+2 (diesel = 97% of footprint)
• Referenced from APP_06 Aspect 1 + Aspect 9; APP_11 E3 KPI; APP_15 Strategic Actions; APP_07 HO-14

Excel companion consistency

• APPL_16 and APPL_18 masters created in IMS Excel Conversions/ (previously absent — docs/appendices copies were stale "Table 1, 2, 3" generic-sheet versions)
• All previously-stale docs Excel copies resynced from masters
• Cross-reference fixes in APPL_02, APPL_03, APPL_04, APPL_06, APPL_15 to reflect APP_05 R-XX renumbering

Pattern consistency

• All 23 appendices now follow a consistent template: Document Information callout → "Download the register" callout (single companion file) → page body → audit trail mirroring Excel cover → "How this document is approved" callout
• 22 orphan .docx files removed from assets/local-docs/appendices/
• Wide-mode tip dropped from callouts (FABs visible site-wide)

Looking ahead

• e-forms proposal under development as the next IMS digitalisation workstream (will impact 7.5 documented information evidence and 9.1 monitoring streams)
• AMWS H&S Culture Survey (Onyx Operations) — Q3 2026 post-audit rollout; replaces the short-lived Director Site-Tour Programme; HSG65-aligned workforce-wide cultural-sentiment readout. Aaron Mason's hands-on operational site presence continues as a feature of running the business (not a measurable KPI)
• ISO 14001:2026 transition plan to be drafted Q3 2026; recertification cycle Nov 2027
• 28/05/2026 BCP desktop exercise scheduled (key-person absence — Site Supervisor unavailable for 5+ working days, APP_17 §4 Scenario #3; P1 gap-closure ahead of Achilles UVDB B2 audit 3-4 June 2026)

The 16 × 2026 internal audit reports were drafted across 28/04-19/05/2026 with knowledge of the substantive 2025-26 IMS rebuild. The 12-13 May consistency pass captured above completes that rebuild; the audit findings continue to apply.

Audit Report Prepared By

Name	Position	Signature	Date
Sean Ashton	HSQE Consultant	S. Ashton	07/05/2026
Aaron Mason	Director	A. Mason	07/05/2026

Corrective Action Close Out

Status as of 13/05/2026: No CAR raised directly by this audit. The 2026 audit cycle's 11 CARs (CAR-2026-001..011) plus the APP_21 dual-master pattern (audit-derived CARs portal-master; operational NCRs Leanne's live Excel) provide the corrective-action evidence — auditor can trace each CAR from observation → owner → target → status. APP_21 Issue 5 (13/05/2026) reframed the 2025 cycle closure statuses to auditor-binary verdicts (Closed / Open — rolled forward).