FORT RUCKER Environmental Management System Title: Internal Auditing

Transcription

1 Approved By: Melissa Lowlavar 1.0 PURPOSE The purpose of this procedure is to ensure the effective and timely conduct of internal EMS and compliance audits by Fort Rucker personnel. Implementation of this EMS procedure will ensure the periodic review of the EMS for its continued conformance with the ISO standard, Army EMS Policy and Fort Rucker s EMS procedures, as well as compliance with all applicable legal requirements. Additionally, periodic internal audits will address the need for modifications to policy, objectives and targets, procedures, and other elements of Fort Rucker s ISO conforming EMS. 2.0 SCOPE The audits will cover key elements of the EMS and will include necessary and sufficient information for management to assess whether the installation is in conformance with all ISO requirements and internal procedures, in compliance with applicable legal requirements, and for making decisions or authorizing actions that need to be taken by Fort Rucker personnel to ensure the continual improvement of its environmental program. 3.0 DEFINITIONS Term Compliance Audit Corrective and Preventive Action (CA/PA) Corrective and Preventive Action Request (CAR or PAR) EMS Documentation Definition An audit to evaluate compliance with the legal and other requirements that apply to environmental aspects as part of the installation s commitment to compliance. The compliance audit can encompass single or multiple environmental program elements. Action taken to eradicate the cause of or prevent a nonconformance or noncompliance. A form used to initiate a request to address an existing or potential undesirable situation, nonconformance, noncompliance or other unsatisfactory condition. Any EMS related documentation that is pertinent to the area being audited, including but not limited to relevant EMS procedures and work instructions. Page 1 of 12

2 Term Environmental Performance Assessment and Assistance System (EPAAS) Internal Audit Internal EMS and Compliance Audit Team Lead Auditor Noncompliance Nonconformance Objective Evidence Observation Definition Army multi-media assessment program designed to identify noncompliance with environmental regulations (compliance audit) and non-conformance with the ISO environmental performance standard used by Army EMS (EMS audit). EPAAS is also used to provide suggestions for both immediate and longterm corrective actions and to indicate resources needed for implementation. A systematic, independent, and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which the environmental management system audit criteria set by the organization are fulfilled or to determine the regulatory compliance status of the facility. Personnel assigned to conduct internal EMS and compliance audits by the EMS Management Representative (EMSMR) that have successfully completed program-specific internal auditor training. The EMSMR may assign personnel to an audit team who have not completed internal auditor training as Auditors In Training. These personnel will be supervised during the audit and provided on the job training in lieu of classroom internal auditor training. Person who has successfully completed a lead auditor course and is approved by the EMSMR to conduct and lead internal audits. A non-fulfillment of a specified legal or regulatory requirement supported by objective evidence. A non-fulfillment of a specified requirement of the EMS standard or Fort Rucker procedure supported by objective evidence. Information which can be proven true, based on facts that are obtained through observation, measurement, test or other means. An undesirable practice that cannot be directly referenced as a requirement of the standard, Fort Rucker procedures, and/or regulatory requirements. If the practice is left unchecked, it could lead to a finding of nonconformance or noncompliance. Page 2 of 12

3 4.0 RESPONSIBILITIES Role Audit Coordinator Commanders, Directors, and/or Supervisors of the Activity Being Audited EMSMR Internal EMS and Compliance Audit Teams Lead Auditor Responsibilities Prepares and maintains a schedule for internal audits. Maintains internal audit results. Provides audit summary results and applicable CAR / PAR status information to the EMSMR for EMS management review as needed. Make applicable personnel and records available during the scheduled locations, dates, and times coordinated for the audit. Ensure the pertinent process owners take action on CARs/PARs assigned to them. Assigns and approves internal auditors. Ensures the periodic scheduling of internal auditor training to maintain an adequate roster of internal auditors. Reviews final audit report and communicates results to management review. As appropriate for the type of audit, coordinates with appropriate commanders, directors, or supervisors for development of the audit schedule. Performs pre-audit preparations. Conducts the audit and documents the findings. Conducts quarterly compliance inspections. Conducts program-specific inspections required for regulatory compliance (i.e., bulk oil storage container inspections, stormwater discharge inspections). Ensures the appropriate commanders, directors, or supervisors of the activities assigned are audited. Conducts a closing meeting upon completion of the audit to summarize findings and observations, both positive and negative. Page 3 of 12

4 Role Responsibilities DPW-ENRD Program Managers Installation Organizations Track findings resulting from program-specific inspections required for regulatory compliance. Conduct program-specific inspections of applicable activities. 5.0 PROCEDURE 5.1 Quarterly Compliance Inspections Audit Scope Fort Rucker conducts quarterly compliance audits for organizations with an Environmental Officer assigned in accordance with the Environmental Officer and EPOC Appointment and Training Plan. In general, any organization that has the potential to impact two or more of the significant aspects will require an Environmental Officer. Otherwise, the organization will be required to have an Environmental Point of Contact (EPOC). Organizations with only an EPOC are not included in the quarterly compliance inspections Audit Schedule The DPW-ENRD Quarterly Compliance Inspection Program Manager will determine the schedule for inspections each quarter. The program manager will communicate with the auditors regarding schedule development to ensure it will not conflict with other DPW-ENRD activities, such as training. The schedule will be documented and maintained by the Quarterly Compliance Inspection Program Manager. The schedule will be unannounced to the organizations being inspected Audit Team The quarterly compliance audit team is determined by the EMSMR. The team is usually composed of the Quarterly Compliance Inspection Program Manager and one contractor who supports DPW-ENRD. Additional government or contractor personnel may be assigned to assist with quarterly compliance audits as necessary to complete the audits. The audit team members will all be competent in conducting the audits. Page 4 of 12

5 5.1.4 Audit Checklist Quarterly compliance audits will be conducted using USAACE Form 2717, Environmental Compliance Inspection Checklist. This checklist will be reviewed at least annually to ensure continued applicability to installation operations Evaluation The quarterly compliance auditors will collect objective evidence through interviews, records review, and physical inspections at each location. The auditors will document inspection findings using the Compliance Inspection Database that includes the questions from USAACE Form 2717, Environmental Compliance Inspection Checklist Audit Results The audit team will submit completed inspections to the Audit Coordinator for technical review. The Audit Coordinator will verify the findings are correctly documented and will create at Summary Findings Report using the report function of the database. The Audit Coordinator will send the Summary Findings Report for review to the Quarterly Compliance Inspection Program Manager, the EMSMR, and other program managers with findings identified in their program areas. The program managers and EMSMR will submit comments or concurrence to the Audit Coordinator for each report. The Audit Coordinator will document comments in the database, incorporate comments in the report, and submit a revised report for concurrence. After receiving concurrence from all program managers and the EMSMR, the Audit Coordinator will finalize the report within the database. The Audit Coordinator will notify the Quarterly Compliance Inspection Program Manager that the report has been finalized and is ready for distribution to the subject organization. The database will generate a submittal letter for the report. The Quarterly Compliance Inspection Coordinator will route the report and cover letter through DPW-ENRD as appropriate then for signature to the Director of Public Works. The signed report will be sent to the inspected organization. Page 5 of 12

6 5.1.7 Corrective Action The inspected organization is responsible for conducting a root cause analysis and developing appropriate corrective actions for any identified findings as specified in EMS-P007, Nonconformity, Noncompliance, Corrective and Preventive Action. The organization will submit information regarding implemented corrective actions according to the date indicated on the report letter using USAACE Form 2742, Quarterly Inspection Corrective Actions. Verification of implementation of any corrective actions will be completed during the subsequent quarterly compliance inspection. 5.2 Internal EPAAS Audit Scope The internal EPAAS is an installation-wide assessment of compliance with environmental regulations and conformance with the EMS. Because it is impractical to observe every installation facility during the time frame allotted for this audit, the internal EPAAS locations that are assessed will be determined in a manner that gives a representative sample of the installation activities Develop Audit Schedule In accordance with Army Regulation 200-1, Section 16-1(c)(1), the internal EPAAS will be conducted annually unless an external EPAAS or external installation-wide agency inspection is conducted for that calendar year. The Audit Coordinator will develop a schedule for the internal EPAAS that includes a representative sample of all installation activities. The schedule will be distributed to all auditors and to installation organizations through the EMS Implementation Team Identify and Assemble Audit Team Each audit shall be performed by qualified personnel as selected by the EMSMR. To assure objectivity, the audit team will include personnel not directly responsible for the area(s) being audited Audit Checklist The EPAAS will utilize the TEAM guides and applicable supplements maintained by the Army Environmental Command. The auditors are Page 6 of 12

7 responsible for reviewing applicable checklists during the audit. As part of the assessment of the EMS, the audit team members will complete USAACE Form 2704, Internal Audit Interview Checklist, to assess overall installation awareness of the EMS. This checklist will be reviewed at least annually to ensure continued applicability to installation operations In Brief The Audit Coordinator will conduct an in brief and review the audit scope and schedule. The in brief will include a summary of findings from previous internal audits. The in brief will also include refresher internal auditor training information Evaluation The internal audit team will collect objective evidence through interviews, records review, and physical inspections. Annual installation-wide EPAAS findings will be documented on USAACE Form 2705, Internal Audit Findings. The auditors are responsible for determining a root cause for each negative finding from the list of possible choices in the findings form based on the conditions observed during the inspection. The internal audit team will document EMS interview results from all inspected activities on USAACE Form 2704, EMS Audit Interview Checklist. The summary results from the audit interviews will be incorporated in the EMS findings documented in USAACE Form 2705 as appropriate Audit Results The audit team will forward completed USAACE Form 2705, Internal Audit Findings, and USAACE Form 2704, EMS Audit Interview Checklist, to the Audit Coordinator for technical review. The Audit Coordinator will verify the findings are correctly documented and will create a consolidated spreadsheet of all findings that will become the CA/PA tracking spreadsheet. The Audit Coordinator will also summarize the data in the USAACE Form 2704, EMS Audit Interview Checklist. The Audit Coordinator will send the CA/PA tracking spreadsheet for review to the EMSMR and the Chief, DPW-ENRD. The reviewers will submit comments or concurrence to the Audit Coordinator for each finding. The Audit Coordinator will incorporate any comments and submit Page 7 of 12

8 a revised CA/PA tracking spreadsheet for concurrence. After receiving concurrence from all reviewers, the Audit Coordinator will divide the findings by organization and enter the information in the Compliance Inspection Database. The Audit Coordinator will forward the reports to the EMSMR for final review. The EMSMR or designee will then distribute the reports to the subject organization. If no findings are identified at one of the areas inspected that are also part of the quarterly compliance audit program, the Audit Coordinator will submit an inspection report indicating no negative findings were identified during the EPAAS audit to the EMSMR. The EMSMR or designee will route the submittal letter and the report for signature to the Director of Public Works. The signed report will be sent to the inspected organization Corrective Action The auditors will suggest a corrective action based on the root cause indicated in the findings form. The inspected organization is responsible for implementing an appropriate corrective action for any identified findings as specified in EMS-P007, Nonconformity, Noncompliance, Corrective and Preventive Action. The corrective action may differ from the suggested corrective action. The organization will submit information regarding implemented corrective actions within 30 days of receipt of the report using USAACE Form 2742, Quarterly Inspection Corrective Actions. The EMSMR will request periodic updates on the status of corrective actions and report the status to the EMS Implementation Team. Verification of implementation of any corrective actions will be completed during subsequent quarterly compliance inspections and/or internal EPAAS as appropriate Out Brief The EMSMR will conduct an out brief at the next EMS Implementation Team meeting and include finding information as part of the EMS Management Review. 5.3 Non-EPAAS Internal EMS Audit Audit Scope The non-epaas internal EMS audit is an assessment of conformance with the EMS during years when an external EPAAS or external agency Page 8 of 12

9 installation-wide audit is scheduled. Because the external EPAAS is an installation-wide assessment of compliance and EMS conformance, the non-epaas internal EMS audit will have a stronger focus on EMS conformance within DPW-ENRD and selected high priority activities Develop Audit Schedule In accordance with Army Regulation 200-1, Section 16-1(c)(1), the internal EPAAS will be conducted annually unless an external EPAAS is conducted for that calendar year. In years when an external EPAAS is scheduled, the Army still requires the installation to conduct an internal EMS audit. The Audit Coordinator will develop a schedule for the non- EPAAS internal EMS audit that includes a sample of priority installation activities. The schedule will be distributed to all auditors and to the EMS Implementation Team Identify and Assemble Audit Team Each audit shall be performed by qualified personnel as selected by the EMSMR. To assure objectivity, the audit team will include personnel not directly responsible for the area(s) being audited Audit Checklist The non-epaas internal EMS audit will utilize the TEAM guide and applicable supplements maintained by the Army Environmental Command that address the EMS. The auditors are responsible for reviewing applicable checklists during the audit In Brief The Audit Coordinator and EMSMR will review the audit scope and schedule with the Lead Auditor prior to initiation of the audit Evaluation The internal audit team will collect objective evidence through interviews, records review, and physical inspections. Findings will be documented on USAACE Form 2705, Internal Audit Findings. The auditors are responsible for determining a root cause for each negative finding from the list of possible choices in the findings form based on the conditions observed during the inspection. Page 9 of 12

10 5.3.7 Audit Results The audit team will forward findings forms (USAACE Form 2705) to the Audit Coordinator for technical review. The Audit Coordinator will verify the findings are correctly documented and will create a consolidated spreadsheet of all findings that will become the CA/PA tracking spreadsheet. The Audit Coordinator will send the CA/PA tracking spreadsheet for review to the EMSMR and the Chief, DPW-ENRD. The reviewers will submit comments or concurrence to the Audit Coordinator for each finding. The Audit Coordinator will incorporate any comments and submit a revised CA/PA tracking spreadsheet for concurrence. After receiving concurrence from all reviewers, the Audit Coordinator will divide the findings by organization and enter the information in the Compliance Inspection Database. The Audit Coordinator will forward the reports to the EMSMR for final review. The EMSMR or designee will then distribute the reports to the subject organization. The EMSMR or designee will route the submittal letter and the report through DPW-ENRD as appropriate then for signature to the Director of Public Works. The signed report will be sent to the inspected organization Corrective Action The auditors will suggest a corrective action based on the root cause indicated in the findings form. The inspected organization is responsible for implementing an appropriate corrective action for any identified findings as specified in EMS-P007, Nonconformity, Noncompliance, Corrective and Preventive Action. The corrective action may differ from the suggested corrective action. The organization will submit information regarding implemented corrective actions according to the date indicated on the report letter using USAACE Form 2742, Quarterly Inspection Corrective Actions. The EMSMR will request periodic updates on the status of corrective actions and report the status to the EMS Implementation Team. Verification of implementation of any corrective actions will be completed during the next internal EPAAS Out Brief The Lead Auditor will conduct an out brief and review the draft findings with the EMSMR. The findings will be briefed at the next EMS Page 10 of 12

11 Implementation Team meeting and as part of the EMS Management Review. 5.4 Program-Specific Regulatory Inspections Periodic program-specific inspections are required for regulatory compliance. Frequency of these inspections is based on regulatory requirements, which are tracked by program managers. Program-specific inspection findings will be documented in accordance with the regulatory requirements. Forms and records associated with these inspections are listed in Section 6.0. Any programmatic issues noted during the program-specific inspections will be presented periodically at EMS Implementation Team meetings. The results of these inspections may also be incorporated into the findings for the internal EPAAS audit if installation-wide issues are noted that need additional emphasis. Program Managers are responsible for tracking findings from program-specific inspections 5.5 Management Review The EMSMR will communicate all audit findings via the Management Review process, as defined in EMS-P005, Management Review. If any findings resulting from an EPAAS or non-epaas internal EMS audit have not been closed by the time of the management review, an action plan for closing the findings will be discussed and developed as an output from the management review. 5.6 Documentation The EMSMR will maintain copies of audit forms, findings, and reports for at least three years from the conclusion of the audit. 6.0 FORMS AND RECORDS ADEM Form 500 USAACE Form 2704, Internal Audit Interview Checklist USAACE Form 2705, Internal Audit Findings USAACE Form 2711, SPCC Plan Container Inspection Checklist USAACE Form 2712, Washrack Inspection Checklist USAACE Form 2717, Environmental Compliance Inspection Checklist USAACE Form 2725, HWSAP Inspection Checklist USAACE Form 2726, 90-HWAS Inspection Log Page 11 of 12

12 USAACE Form 2728, STI SP001 Annual AST Inspection Form USAACE Form 2731, STI SP001 AST Repairs USAACE Form 2737, Asbestos Physical Assessment USAACE Form 2738, Asbestos Abatement Compliance Checklist USAACE Form 2742, Quarterly Inspection Corrective Actions USAACE Form 2745, Stormwater Outfall Inspection Checklist Fort Rucker Form 128, Investigation of Noise/Damage Complaint EMS Management Review Minutes 7.0 REFERENCES EMS-P005, Management Review EMS-P007, Nonconformity, Noncompliance, Corrective and Preventive Action Army Regulation 200-1, Environmental Protection and Enhancement Page 12 of 12