1. EPA Regions 9 & 10 and The Federal Network for Sustainability 2005
THE EMS AUDIT PROCESS
EPA Regions 9 & 10
and
The Federal Network for Sustainability
2005

2. Preparing the Audit Audits typically include:
Document review,
Site reconnaissance,
Interviews,
Records review.
In any type of audit, the auditor will compare evidence to criteria, and develop findings.

3. Key EMS Written Information
Policy
Objectives & Targets
EMS Procedures
Operating Procedures
Environmental Records

4. Working Documents Forms for documenting audit evidence and findings
Procedures and checklists for evaluating EMS elements
Checklist should
provide focus
act as a memory jogger
be auditor specific
Checklist should NOT
have exact questions
suggest yes/no inquiries
be totally generic

5. Conducting the Audit

6. Opening Meeting Introduce members of the audit team
Review scope, objectives and audit plan
Discuss which personnel will be involved
Agree on timetable
Provide summary of methods to be used
Establish communication links between audit team and auditee

7. Opening Meeting (cont.)
Confirm that resources and facilities needed by the audit team are available
Discuss date and time of closing meeting
Promote active participation by auditee
Review relevant safety and emergency procedures

8. Collecting Audit Evidence
Ask pertinent questions
Listen to the responses
Pursue vague answers
Take complete notes
Look for objective evidence
- “show me”
Consult with your team leader

9. Specific Evidence to Look For
Consistency between identified aspects and observed aspects,
How activities match procedures,
Employee awareness of relevant EMS elements,
Addressing non-conformances through the corrective action process,
Whether the system is effective and adequate,
Top management commitment to the EMS.

10. Conducting Interviews

11. How to Interview Attitude of the auditor, Purpose of the interview,
Types of questions; open, closed, leading, antagonistic, vague.

12. Typical Questions of any Employee:
What does the environmental policy mean to you?
What is the EMS?
What do you do if someone is not following procedures?
What do you do in case of a emergency?
What kind of environmental training have you received?
How do you communicate environmental concerns or ideas?
What do you do if someone from outside asks you environmentally-related questions?

13. Typical Questions of Critical Operations
What significant aspects and impacts apply to your job?
How do you know what to do? (Ask for procedures and operating criteria).
What specific training have you received?
What are the objectives and targets associated with your job?
Do you have any responsibility for monitoring and measurement ?
What records do you keep?

14. Categories of Interviewees:
Plant management
Management representatives
Department managers
Document control and record departments
Research and development
Engineering
Operations employees (plant, administration)
Human resources and training
Contractor management and purchasing
Security

15. Exercise #2 Teams Conduct interview of other Teams.
Focus questions on EMS awareness
Document findings in CAR/non conformance forms.

16. Examining Documents and Records

17. Documents and Records Say what you do - procedures Do what you say,
“Record” it (paper or electronic records)
Must be:
relevant to EMS (link to aspects),
Usable and appropriate,
Controlled,
Reviewed and revised as “continual improvement”.

18. What to Look for in Documentation
Does the documented system conform with the standard?
Do the procedures describe what’s happening?
Is the documentation controlled?
Are all employees informed?
Are relevant procedures followed, by everyone, all the time?
Is there objective evidence that the procedures are being followed?

19. Documentation Hierarchy
Level I = Upper Level “Road Map”- Policy
Level II = EMS Procedures
Level III = Work Instructions, Reference documents, Regulations, etc. Records - Verify the system (not “controlled”)

20. Typical Documents and Records to Review (by EMS Element)
Aspects Procedures
Aspects list
Significance determination information
Significant aspects/impacts list
Legal and Other Requirements
Listings of applicable legal and other requirements
Appropriate instructions for compliance
Permits, manifests, etc.

21. Typical Documents and Records to Review (by EMS Element)
Objectives and Targets and Environmental Management Programs
Minutes/notes of objective and target development
List of objectives and targets
Related action plans
Structure and Responsibility
Job descriptions
Organizational charts

22. Typical Documents and Records to Review (by EMS Element)
Training Awareness and Competence
Training needs listings/matrix
Manuals, course materials
Sign-in sheets
Test records, certificate copies, etc.
Communication
Specific work instructions
Records of communication and correspondence

23. Typical Documents and Records to Review (by EMS Element)
Document Control
Documents, procedures, and manuals
Operational Control
Critical operations/aspects listing/matrix
Specific work instructions
Environmental issues within work instructions
Contractor policies, work orders, etc.
Supplier requirements

24. Typical Documents and Records to Review (by EMS Element)
Emergency Preparedness and Response
Emergency plans and protocols
Practice and drill results
Monitoring and Measurement
Objectives and target action plans
Specific procedures and work instructions
Records of monitoring and measurement data

25. Typical Documents and Records to Review (by EMS Element)
Nonconformance, Corrective and Preventive Action
Corrective action reports
Evidence of discussion and follow-up (meeting notes, etc.)
Records
Monitoring records
Permits
Manifests
Correspondence

26. Typical Documents and Records to Review (by EMS Element)
EMS Audit
Specific audit procedures, checklists, forms
EMS audit notes and working documents
EMS audit reports
Management Review
Meeting agendas and attendance
Meeting minutes and action items
Evidence of follow-up actions, reports, etc.

27. Exercise #3 Whole Class participates in Question & Answers to Group.
Senarios to Group.
Walkaround Discussion to Group.
Teams document observations on the CAR/non conformance form.

28. Audit Findings
Review all audit evidence to determine where EMS does not conform to EMS audit criteria (nonconformance).

29. Non-Conformance vs. Non-Compliance
A deficiency in the EMS is a non-conformance
A non-compliance is a problem with respect to regulatory requirements
An EMS may have regulatory non-compliance but no system non-conformance, and vice versa.

30. Types of EMS Nonconformance
Major –EMS does not conform to requirements, may jeopardize certification
Minor – deficiency in implementation of the EMS that should be corrected by next audit cycle, continued deficiency may jeopardize certification
Observation – suggested, optional improvement, no risk to certification

31. What to do about a nonconformance
Explain the nonconformance immediately
Record details in a clear, concise manner
objective, factual, thorough, reproducible
Support with audit evidence
Consult with audit team leader

32. Exercise #4
Summarizing audit findings using all of your Teams observations from the interview process and the Group discussions in exercise 3.
Fill out Summary Table of Findings

33. Closing Meeting

34. Potential Topics for Closing Meeting
Acknowledgment of support,
Thanks for cooperation
Recap of audit scope, objectives, and plan,
Review of findings,
Any special issues or circumstances,
Initial discussion of next visit.

35. Presentation of Findings
Present audit findings to the auditee to achieve
a clear understanding of findings
acknowledgement of the factual basis of findings
Resolve disagreements where possible

36. Audit Report and Next Steps

37. Preparation of Audit Report
Prepared under the direction of lead auditor
Distributed to parties as agreed with client
Addresses topics in audit plan
Changes should be agreed upon by all parties

38. Content
Report should
contain the audit findings and/or a summary of the findings with references to supporting evidence
contain additional materials as agreed upon by the lead auditor and the client
be reviewed and dated by the lead auditor

39. Possible Contents of Audit Report
Audit-related information that may be included in the audit report:
The identification of the organization audited and the client,
The agreed objectives and scope of the audit,
The agreed criteria against which the audit was conducted.
The period covered by the audit and the date(s) the audit was conducted,

40. Possible Contents of Audit Report
Identification of the auditee’s representatives participating in the audit,
Identification of the audit team members,
A statement of the confidential nature of the contents,
The distribution list for the audit report,
A summary of the audit process including any obstacles encountered,
Audit findings and conclusion.

41. Document Retention
All working documents and draft and final reports pertaining to the audit should be retained by agreement between client, lead auditor and auditee and in accordance with any applicable requirements.

42. The Next Steps Role of EMS Auditors in Corrective Action
EMS auditors are not required to provide assistance in corrective action unless requested,
Should do so only if qualified; in other words ability to audit does not equate with ability to fix the problems,
EMS auditors should review corrective actions in subsequent audits,
EMS Auditors must look for continual improvement.

43. Exercise #5
Teams present a summary of findings to the Group at the Closing briefing.