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

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.

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

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

Conducting the Audit

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

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

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

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.

Conducting Interviews

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

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?

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?

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

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

Examining Documents and Records

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”.

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?

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”)

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.

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

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

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

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

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

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.

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.

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

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.

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

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

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

Closing Meeting

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.

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

Audit Report and Next Steps

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

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

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,

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.

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.

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.

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