Presentation on theme: "EPA Regions 9 & 10 and The Federal Network for Sustainability 2005"— Presentation transcript:
1EPA Regions 9 & 10 and The Federal Network for Sustainability 2005 THE EMS AUDIT PROCESSEPA Regions 9 & 10andThe Federal Network for Sustainability2005
2Preparing 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.
3Key EMS Written Information PolicyObjectives & TargetsEMS ProceduresOperating ProceduresEnvironmental Records
4Working Documents Forms for documenting audit evidence and findings Procedures and checklists for evaluating EMS elementsChecklist shouldprovide focusact as a memory joggerbe auditor specificChecklist should NOThave exact questionssuggest yes/no inquiriesbe totally generic
6Opening Meeting Introduce members of the audit team Review scope, objectives and audit planDiscuss which personnel will be involvedAgree on timetableProvide summary of methods to be usedEstablish communication links between audit team and auditee
7Opening Meeting (cont.) Confirm that resources and facilities needed by the audit team are availableDiscuss date and time of closing meetingPromote active participation by auditeeReview relevant safety and emergency procedures
8Collecting Audit Evidence Ask pertinent questionsListen to the responsesPursue vague answersTake complete notesLook for objective evidence- “show me”Consult with your team leader
9Specific 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.
11How to Interview Attitude of the auditor, Purpose of the interview, Types of questions; open, closed, leading, antagonistic, vague.
12Typical 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?
13Typical 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?
14Categories of Interviewees: Plant managementManagement representativesDepartment managersDocument control and record departmentsResearch and developmentEngineeringOperations employees (plant, administration)Human resources and trainingContractor management and purchasingSecurity
15Exercise #2 Teams Conduct interview of other Teams. Focus questions on EMS awarenessDocument findings in CAR/non conformance forms.
17Documents 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”.
18What 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?
19Documentation Hierarchy Level I = Upper Level “Road Map”- PolicyLevel II = EMS ProceduresLevel III = Work Instructions, Reference documents, Regulations, etc. Records - Verify the system (not “controlled”)
20Typical Documents and Records to Review (by EMS Element) Aspects ProceduresAspects listSignificance determination informationSignificant aspects/impacts listLegal and Other RequirementsListings of applicable legal and other requirementsAppropriate instructions for compliancePermits, manifests, etc.
21Typical Documents and Records to Review (by EMS Element) Objectives and Targets and Environmental Management ProgramsMinutes/notes of objective and target developmentList of objectives and targetsRelated action plansStructure and ResponsibilityJob descriptionsOrganizational charts
22Typical Documents and Records to Review (by EMS Element) Training Awareness and CompetenceTraining needs listings/matrixManuals, course materialsSign-in sheetsTest records, certificate copies, etc.CommunicationSpecific work instructionsRecords of communication and correspondence
23Typical Documents and Records to Review (by EMS Element) Document ControlDocuments, procedures, and manualsOperational ControlCritical operations/aspects listing/matrixSpecific work instructionsEnvironmental issues within work instructionsContractor policies, work orders, etc.Supplier requirements
24Typical Documents and Records to Review (by EMS Element) Emergency Preparedness and ResponseEmergency plans and protocolsPractice and drill resultsMonitoring and MeasurementObjectives and target action plansSpecific procedures and work instructionsRecords of monitoring and measurement data
25Typical Documents and Records to Review (by EMS Element) Nonconformance, Corrective and Preventive ActionCorrective action reportsEvidence of discussion and follow-up (meeting notes, etc.)RecordsMonitoring recordsPermitsManifestsCorrespondence
26Typical Documents and Records to Review (by EMS Element) EMS AuditSpecific audit procedures, checklists, formsEMS audit notes and working documentsEMS audit reportsManagement ReviewMeeting agendas and attendanceMeeting minutes and action itemsEvidence of follow-up actions, reports, etc.
27Exercise #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.
28Audit FindingsReview all audit evidence to determine where EMS does not conform to EMS audit criteria (nonconformance).
29Non-Conformance vs. Non-Compliance A deficiency in the EMS is a non-conformanceA non-compliance is a problem with respect to regulatory requirementsAn EMS may have regulatory non-compliance but no system non-conformance, and vice versa.
30Types of EMS Nonconformance Major –EMS does not conform to requirements, may jeopardize certificationMinor – deficiency in implementation of the EMS that should be corrected by next audit cycle, continued deficiency may jeopardize certificationObservation – suggested, optional improvement, no risk to certification
31What to do about a nonconformance Explain the nonconformance immediatelyRecord details in a clear, concise mannerobjective, factual, thorough, reproducibleSupport with audit evidenceConsult with audit team leader
32Exercise #4Summarizing 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
34Potential Topics for Closing Meeting Acknowledgment of support,Thanks for cooperationRecap of audit scope, objectives, and plan,Review of findings,Any special issues or circumstances,Initial discussion of next visit.
35Presentation of Findings Present audit findings to the auditee to achievea clear understanding of findingsacknowledgement of the factual basis of findingsResolve disagreements where possible
37Preparation of Audit Report Prepared under the direction of lead auditorDistributed to parties as agreed with clientAddresses topics in audit planChanges should be agreed upon by all parties
38ContentReport shouldcontain the audit findings and/or a summary of the findings with references to supporting evidencecontain additional materials as agreed upon by the lead auditor and the clientbe reviewed and dated by the lead auditor
39Possible 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,
40Possible 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.
41Document RetentionAll 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.
42The 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.
43Exercise #5Teams present a summary of findings to the Group at the Closing briefing.