Arthur D. Little Limited Science Park, Milton Road Cambridge CB4 0XL Telephone 01223 392090 Fax 01223 420021 Reference 20365
Table of Contents
Chapter Overview of Environmental, Health, and Safety Auditing Audit Approach Basic Steps in the Typical Audit Process Pre-Audit Activities On-site Opening Activities Understanding HSE Management Systems Effective Interviewing Preparing Working Papers Assessing Strengths and Weaknesses Gathering Audit Evidence Sampling Strategies Evaluating Audit Results Writing Audit Findings Post Audit Activities Appendix A Confirmation Letter Appendix B Roles and Responsibilities of the Audit Team Appendix C Guide to Acronyms Page No 5 12 23 25 42 55 75 105 135 161 189 220 242 260
List of Exercises
Exercise 1 2 3 4 5 6 Understanding HSE Management Systems Effective Interviewing - Difficult Interview Situations Effective Interviewing - Conducting Interviews Preparing Working Papers Assessing Strengths and Weaknesses Gathering Audit Evidence Developing Verification Strategies Sampling Strategies 1 Sampling Strategies 2 Evaluating Audit Results Specific Local vs Report Writing Audit Findings Critiquing Audit Findings Page No 69 88 93 126 152 177
7 8 9
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Provide assurance to corporate officers about the companys compliance status with HSE requirements and good industry practices. Assess potential HSE liabilities. Demonstrate effective management of HSE obligations to companies key stakeholders.
Audit Programme
Annual Report
Audit Report
Community Investors/Shareholders
An increasing number of companies are including status reports on their HSE audit programmes in their annual reports and/or annual environmental reports (e.g., Union Carbide, ARCO Chemical, NOVA, Deere & Company, WMX, DuPont, etc.).
Why Audit?
Overview of Health, Safety and Environmental Auditing What is Health, Safety and Environmental Auditing?
Environmental Protection
Hazard Management
Management Tool
Compliance Management
Overview of Health, Safety and Environmental Auditing Definition of Health, Safety and Environmental Auditing
Auditing has become recognised throughout the world by various organisations as a useful tool in managing HSE issues. Although a variety of definitions have been established for HSE auditing, they all share common elements and themes. For example, auditing has been defined as
A systematic, documented, periodic, and objective review by a regulated entity of facility operations and practices related to meeting environmental requirements. (U.S. EPA Policy Statement on Environmental Auditing, July 1986) Internal evaluations by companies and governmental agencies to verify their compliance with legal requirements as well as their own internal policies and standards. (Environment Canada, May 1988, Environmental Protection Act, Enforcement and Compliance Policy) A series of activities undertaken on the initiative of an organisations management to evaluate environmental performance. (International Chamber of Commerce) An activity directed at verifying a sites or organisations environmental, health, or safety status with respect to specific, predetermined criteria. (U.S. Environmental Auditing Roundtable)
Overview of Health, Safety and Environmental Auditing Definition of Health, Safety and Environmental Auditing
and the definition of auditing has broadened over the years to include the evaluation of management systems in determining a facilitys HSE performance status.
A systematic, documented verification process of objectively obtaining and evaluating evidence to determine whether specified environmental activities, events, conditions, management systems, or information about these matters, conform to audit criteria, and communicating the results of this process to the client. (International ISO 14000 Standard) A management tool comprising a systematic, documented, periodic, and objective evaluation of the performance of the organisation, management system, and processes designed to protect the environment with the aim of: facilitating management control of practices which may have impact on the environment; and assessing compliance with company environmental policies. (Eco-Management and Audit SchemeEuropean Union) A systematic evaluation to determine whether or not the environmental management system and the environmental performance it achieves conform to planned arrangements, and whether or not the system is implemented effectively, and is suitable to fulfill the organisations environmental policy and objectives. (ISO)
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Overview of Health, Safety and Environmental Auditing Standards Against Which to Audit
Since auditing has emerged as a systematic process intended to verify compliance with established standards and, in some cases, to review the effectiveness of management systems, it tends to be most effective for those HSE issues that are well defined by specific audit criteria.
Audit Criteria
Corporate/Division Policies and Procedures Facility Standard Operating Procedures (SOPs)
Management Systems
Increasingly, management system requirements are being incorporated into the scope of the audit in recognition that welldesigned and well-implemented management systems are an important vehicle for maintaining compliance over time.
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Audit Approach
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Audit Approach
Most companies engage in a three-phased audit process to fulfill the objectives of the audit programme.
Pre-Audit Activities
On-Site Activities
Post-Audit Activities
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Audit Approach
Pre-Audit Activities The pre-audit activities are designed to ensure that the audit team members and facility personnel understand the audit process, and their roles and responsibilities within that audit process, and are prepared to implement them.
Pre-Audit Activities
1. Initial planning activities 2. Document review Preparation of detailed plans 3. Audit plan preparation
Outcome
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Audit Approach
On-Site Activities Arthur D. Little has developed a well-defined and systematic fivestep process to provide organisation and structure to the on-site activities. This five-step process facilitates a review of how a facility manages its HSE obligations.
Basic Step On-Site Activities Opening meeting Tours Initial Interviews Document review Review of Step 1 information Team meetings Outcome Strong working knowledge of key systems on site Identification of key issues to review Develop verification strategies Reallocate team resources, if required Identify potential impacts and management system weaknesses Analyse site programs Develop evidence to substantiate findings Confirm status of compliance Prepare draft findings Confirm accuracy Identify potential root causes Early, clear, consistent communication Understand facility concerns Prepare preliminary draft report
Physical inspections Focused interviews Data and records examination Verification testing Review data collected Review factual accuracy of findings Analyse/integrate findings of team Daily debrief meetings Close-out meetings
In addition, the five-step process has been recognised by: Hundreds of companies Environmental Auditing Roundtable (EAR) Canadian Environmental Auditing Association (CEAA) International Chamber of Commerce in its Guide to Effective Environmental Auditing European Community in the Eco-Management and Audit Scheme (EMAS)
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Audit Approach
Two Components of HSE Auditing There are two important components in completing the five-step process: AssessmentProcess to develop an opinion (judgment) on the strengths and weaknesses of the activities under review. VerificationProcess to determine adherence to specific standards. Although assessment- and verification-based techniques play a key role in the audit process, they each provide the auditor with different information.
Principal Activities What you look for Deficiencies, problems, risks, conformance with good practice (performed during Steps 1, 2 and 4) Evidence of compliance with regulations, policies, and procedures (performed during Step 3) Output Professional opinion as to performance with regard to accepted practice and recommendations for improvement Statement of performance against standards with identification of shortcomings/areas for improvement
Assessment
Verification
Auditors need to use a mix of assessment and verification to complete the five-step process. Some skills are better suited toward assisting an auditor in the assessment stage while others suit the verification stage. Assessment is dependent upon the auditors knowledge of: Site operations Management systems (e.g., policies, procedures, etc.) HSE requirements Environmental technology Verification is dependent upon the auditors knowledge of: Auditing skills and techniques HSE regulations Internal standards
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Audit Approach
The balance between assessment and verification will vary depending on where you are in the five-step process. Five-Step Audit Process
Step 1: Understand Management Systems Step 2: Assess Strengths and Weaknesses of Management Systems
Assessment-related activities
Verification-related activities
Based on the information gathered, the auditor may move forward in the process or may need to reassess the information gathered in previous steps. For example, results obtained during gathering audit evidence (Step 3) or evaluating audit results (Step 4) can lead an auditor back to reassess his/her understanding of the management systems in place and/or the strengths and weaknesses of those management systems. The resulting finding may be one that identifies gaps in the facilitys management systems or the proximate or root cause of the finding.
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Audit Approach
Audit Skills, Techniques, and Tools In implementing the five-step audit process, there are some essential audit skills, techniques, and tools that can be utilised to increase on-site efficiency and effectiveness.
T oo udit
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Audit Approach
Post-Audit Activities The purpose of the post-audit activities is to ensure that: Audit results are communicated to the facility and appropriate levels of management. Audit findings are addressed.
Post-Audit Activities
1. Develop report
Outcome
Audit report (performance status)
2. Distribute report Corrective action plan 3. Develop and implement corrective actions 4. Track corrective actions Status reports
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Planning
Influencing issues/requirements Setting policy direction Establishing performance standards/guidance Obtaining needed permits/approvals
Implementing
Managing compliance Managing significant risks Preventing/reducing unwanted impacts Remediating past damages Responding to emergences Improving value to final customers
Reviewing
Measuring performance Assuring performance Communicating performance
Auditing
Supporting
Training & awareness Documenting / record keeping Managing information
Sound HSE management processes should include activities that address all four HSE management processes (assessing, planning, implementing, and reviewing) and incorporate the three key supporting activities (training and awareness, documenting/recordkeeping, and managing information). These same management processes are typically present at facilities in order to meet their HSE obligations.
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Planning
Developing entry procedures Establishing rescue procedures
Implementing
Issuing entry permits Monitoring confined spaces Using personal protective equipment
Reviewing
Reviewing cancelled permits Supervisor review of confined spaces
Supporting
Training & awareness - Training for entrants, attendants, & supervisor Documenting / record keeping - Permit retention - Training records - Written programme Managing information - Training database
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Utilising the teams collective experience and knowledge of the site operations, HSE standards, and auditing skills and techniques. Prioritising the topics to review in terms of importance/impact. Basing your prioritisation on a thorough review and assessment of management systems and controls. Developing verification strategies to gather data that will provide meaningful insights regarding compliance. Communicating, communicating, communicatingboth oral and written communications that occur within the team and externally with affected parties are essential factors influencing the success of auditing efforts.
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Pre-Audit Activities
On-Site Activities
Step 1: Understand Management Systems Conduct opening meeting Conduct orientation tour Review audit strategy Understand details of management systems
Post-Audit Activities
Prepare Draft Report Obtain Review Comments from Corporate HSE Law department Facility management
Step 2: Assess strengths & Weaknesses Consider potential impacts Evaluate management systems Set priorities for verification
Issue Final Report to Facility management Operations Corporate HSE Law department
Plan the Audit: Correspond with the facility Assemble & distribute background information Assign & communicate audit responsibilities Conduct pre-audit meeting
Step 3: Gather Audit Evidence Evaluate what needs to be done Determine depth & rigor of review Select types of evidence needed & methods to gather them Compare practices against requirements Document results
Develop Action Plan Develop proposed action(s) to address each finding Assign responsibility for corrective action Develop timetable
Step 4: Evaluate Audit Results Evaluate audit results Write audit findings
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Pre-Audit Activities
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Pre-Audit Activities
These are primarily the responsibility of the team leader, and have therefore been treated in detail later in this manual. It is important to remember that the team participates in the pre-audit preparation, by reviewing the background information to develop an initial understanding of the facilitys operations, modifying audit protocols as/if necessary, making their own travel arrangements, having liaised with the team leader on the time for the pre-audit team meeting, obtained and reviewed applicable regulations, and organising any materials or equipment necessary to perform the audit. Before the audit team arrives at the opening meeting, it should know enough about the site to be able to formulate some preliminary hypotheses about the major risks and HSE issues. There are several ways to accomplish this:
Auditors basic familiarity with company operations, policies, and procedures Pre-audit questionnaire Other background material provided by the facility Conversations between the team leader/members and plant personnel Review of applicable regulations
In our experience, it is not uncommon for team members to begin their pre-audit preparation only on the plane that is taking them to the site. Even if this were adequate for team members, it is definitely not sufficient for team leaders.
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Pre-Audit Activities
Pre-Audit Activities
On-Site Activities
Step 1: Understand Management Systems Conduct opening meeting Conduct orientation tour Review audit strategy Understand details of management systems
Post-Audit Activities
Prepare Draft Report Obtain Review Comments from Corporate HSE Law department Facility management
Step 2: Assess strengths & Weaknesses Consider potential impacts Evaluate management systems Set priorities for verification
Issue Final Report to Facility management Operations Corporate HSE Law department
Plan the Audit: Correspond with the facility Assemble & distribute background information Assign & communicate audit responsibilities Conduct pre-audit meeting
Step 3: Gather Audit Evidence Evaluate what needs to be done Determine depth & rigor of review Select types of evidence needed & methods to gather them Compare practices against requirements Document results
Develop Action Plan Develop proposed action(s) to address each finding Assign responsibility for corrective action Develop timetable
Step 4: Evaluate Audit Results Evaluate audit results Write audit findings
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Pre-Audit Activities
Planning
Assemble & review background information & applicable regulations Develop audit assignments & areas to focus on Review & discuss audit team responsibilities
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Pre-Audit Activities
The pre-audit activities provide the foundation upon which the team members build their understanding of the facilitys operations and establish an audit strategy. They also provide the facility with its first impressions of the audit programme and set the tone for audit team/facility interactions. The pre-audit activities should meet the following objectives:
Provide the audit team with sufficient plant information to enable the team members to develop a basic understanding of the facility, the processes, and the HSE management systems employed. For example, the audit team should understand:
The type of facility being audited (e.g., chemical manufacturing, injection molding, pulp and paper, distribution center, research laboratories, etc.). The employee population (e.g., 60-person plant or 1,000person plant, extent of contract employees and contractors used on site, business organisation). The general applicability of regulatory requirements to the facilitys operations (e.g., presence of wastewater treatment plant, hazardous waste generator status, number of permitted air sources, applicability of industrial hygiene programmes [e.g., respiratory protection, hearing conservation, bloodborne pathogens, etc.], presence of a fire brigade and/or spill response team, availability of routine and emergency medical personnel, etc.).
Inform the facility as to audit programme goals, objectives, and procedures. Typically, the more information facility personnel receive prior to the audit, the less anxious and more comfortable they will feel about the on-site portion of the audit.
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Pre-Audit Activities
Using the information obtained, allow the audit team to develop a basic audit strategy prior to arrival at the site. In developing an audit strategy, the audit team should consider the following: Audit objectives to be achieved, areas to receive emphasis, and a preliminary division of responsibility among the team members. Questions or issues that need to be resolved during the preliminary meetings and points to be clarified. A preliminary agenda and schedule to be used during the audit. To help facilitate the conduct of an efficient and thorough audit, the following pre-audit activities are frequently undertaken by the audit team leader and team members. 1. Corresponding With the Facility Within the designated time frame established by the audit programme, the team leader should contact the facility to confirm the exact dates of the planned audit and to address the following:
Audit process and activities Types of documents to be reviewed: Pre-audit information request Pre-audit questionnaire Planning/logistical details: Safety and security requirements Administrative/logistical details Initial interview schedule
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Pre-Audit Activities
Audit Process and Activities In general, the team leader should explain the audit process and the types of activities to be undertaken while on site. The audit programme objectives, purpose, and scope, and the types of interviews and tours that will be conducted, should be explained. In addition, the team leader typically requests that the facility prepare a short presentation describing the plant operations for the opening meeting. The facility should have a general understanding of how the audit will proceed and what type of time commitment will be required for the various levels of staff affected by the audit. Types of Documents to be Reviewed It is important to determine the background information to be requested and reviewed before arriving at the facility. A protocol represents a plan to be used by the auditors in conducting an audit. Protocols are produced in advance, for each of the issues to be audited, sometimes annotated with relevant regulatory standards references.The purpose is to provide the audit team with a step-by-step guide to collecting evidence about a facilitys programmes and practices included within the scope of the audit. In addition, the protocol identifies selected topics and requirements included in the audit and provides guidance regarding how the team may audit or review against those requirements. However, it typically does not include all applicable performance requirements that the team may need to review a facilitys compliance status. Typically, audit team members review applicable performance requirements prior to the audit to determine whether any other requirements are appropriate for indepth review and verification. Other purposes of an audit protocol include:
Pre-Audit Activities
Record for audit proceduresplanned and completed. Outline for working papers. Record of changes in audit scope, procedures, etc., and the rationale for any changes. Basis for reviewing/critiquing an individual audit.
be essential to have prior to the audit while other materials will only need to be looked at while on site. For some materials (e.g., training records, inspection logs, material safety data sheets, etc.), it is in the best interest of the audit team to see this material during the on-site visit. The team leader would be better advised to ask the plant to leave this information in existing files until the audit. As a result, the audit team will be able to see actual recordkeeping conditions and practices. The tables on the following pages list the types of information that are typically requested prior to the audit and information that should be available on site for review during the audit. The information listed in these tables serves only as an example. The type of documentation that should be requested will depend upon the staffing resources utilised (e.g., full-time corporate auditors, corporate or facility personnel with other full-time responsibilities, third-party auditors, etc.) and the time these resources realistically have for pre-audit preparation. When conducting pre-audit activities, it is important to keep in mind that the background materials should be requested early enough to ensure that there is enough time for:
The facility to assemble and send the information to the team leader. The team members to receive and review the materials prior to the audit.
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Pre-Audit Activities
Audit Information to be Sent in Advance Facility plot plan or map Directions to the facility Visitor safety requirements (e.g., personal protective equipment, orientation, specialised training, special clearances, etc.) Completed pre-audit questionnaire Description of the facilitys operations/processes Facility organisation chart, showing HSE responsibilities Local laws, regulations, and ordinances related to the scope of the audit List of current environmental licenses, certificates, and authorisations Copies of permits for wastewater discharges and example air emission permits Recent regulatory agency inspection/enforcement correspondence Recent internal and intra-company environmental, health, and safety audit reports Table of contents for facility-specific environmental, health, and safety policies and procedures
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Pre-Audit Activities
Audit Materials to be Reviewed Upon Arrival On Site Management objectives Copies of all current environmental licenses, certificates, registrations, authorisations, and applications for such (including air and wastewater discharges; hazardous waste treatment, storage, or disposal activities; underground storage tanks; drinking water supplies; etc.) Facility procedures and programme manuals (e.g., spill prevention plan, hazardous waste management contingency plan, respiratory protection plan, exposure control plan, hazard communication plan, etc.) Effluent and emission monitoring reports Training records Hazardous waste manifests Material safety data sheets (MSDSs) Inventory of chemicals, including oils, in use or stored on site Purchase orders for chemicals Annual PCB reports (for the five years preceding the audit) PCB transformers inspection records Monitoring instrument calibration records and maintenance logs Records of safety inspections, including reports of loss prevention surveys by insurance underwriters First aid/dispensary records Records of exposure monitoring and results, respirator fit testing, audiograms, etc.
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Pre-Audit Activities
Pre-audit questionnaire. In order to obtain a quick and concise
facility profile to provide the audit team members with a basic understanding of the facilitys operations, a pre-audit questionnaire is typically sent to be filled out and returned by the facility. The pre-audit questionnaire should be a tool that is easily processed by the facility and provides the auditors with basic information enabling them to begin planning for the audit. An example of a pre-audit questionnaire is provided in Appendix A of this manual. Although the pre-audit questionnaire may provide the audit team members with a basis to begin their understanding, the auditors should critically review the information and remember that the information provided may not be completely reflective of the facilitys operations. For example, the facility may indicate on the pre-audit questionnaire that it does not have underground storage tanks on site. However, the facility may be unaware that there are two abandoned underground storage tanks that were inadvertently omitted from the facilitys initial spill prevention plan and have long been forgotten. During the on-site phase, the auditor may need to change his/her original audit strategy (based on the pre-audit information) to ensure that the protocol areas assigned are properly addressed. Planning/Logistical Details During the team leaders communications with the facility contact, any planning details should be resolved, such as: Safety and security requirements Administrative/logistical details Initial interview schedule
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Pre-Audit Activities
Safety and security requirements. The team leader should clearly
understand the personal protective equipment requirements for visitors who will be touring and inspecting any and all site areas (e.g., safety glasses, hard hats, safety shoes, safety clothing, etc.). The team leader should also obtain information regarding whether:
Safety orientations and specialised training (e.g., hydrogen sulfide, respiratory protection, underground mine safety, etc.) are required to enter the general facility or regulated areas. The team leader should inquire as to the time needed to complete the necessary orientation or specialised training (e.g., 15 minutes, two hours, eight hours, etc.). Depending upon the training necessary, the team leader may need to adjust the audit schedule. Security clearances/passes are required for audit team members or vehicles to enter the facility or regulated areas. Restrictions apply to team members who are not citisens of the country where the facility is located. Escorts are required for team members touring and inspecting facility areas.
administrative and logistical details with the facility contact as early as possible in the pre-audit process. Administrative and logistical details that may need to be addressed include:
Requesting information regarding travel to the facility, as well as lodging in the vicinity of the site. Arranging for badges, clearances, car passes, safety orientation/ training, and escorts. Arranging for the audit team to stay after normal business hours and observe second or third shift operations, where applicable.
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Pre-Audit Activities
Scheduling the opening meeting and setting a tentative time for the closing meeting. Establishing a time during the day when the audit team can meet daily with the key HSE staff to discuss their preliminary findings and concerns. These meetings are typically referred to as daily debriefs. Arranging for meals (working breakfasts, lunches, or dinners). Requesting that the facility prepare a brief presentation on the facilitys operations for the opening meeting. Arranging for a meeting room to be available to the audit team during its visit. Informing facility personnel of any documentation/equipment (e.g., paper copy of the facilitys presentation, telephone directory, employee rosters, telephone, overhead projector, slide projector, printer, fax machine, photocopy capabilities, etc.) that needs to be made available for the audit team.
Initial interview schedule. The team leader may want to obtain the
names of facility contacts to begin scheduling interviews with key HSE staff for the first one or two days of the audit. The benefits associated with having the team leader and the facility put together an initial interview schedule with key HSE staff are twofold: 1) the facility is given an opportunity to feel a part of the audit process and to establish interviews at convenient times, lessening the impact on their day-to-day activities; and 2) the audit team will be able to begin their understanding of how the facility manages environmental, health, and safety areas immediately after the opening meeting and orientation tour.
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Pre-Audit Activities
Finally, after arrangements have been agreed upon, the team leader should send a letter to the facility contact confirming those arrangements along with an outline of the audit process and activities, and the audit objectives, purpose, and scope. In addition to the pre-audit questionnaire, a list of the materials that the audit team would like sent prior to the audit is typically sent as an attachment to the confirmation letter. An example confirmation letter is provided in Appendix B. 2. Assembling and Distributing Background Information Assembling Background Information Following the receipt of materials from the facility, the team leader should begin the task of assembling the available background information. This step, in general, will enable the team to develop an effective audit strategy tailored to an individual facility. This task typically involves: Reviewing facility information and responses to the pre-audit questionnaire and/or contacting the facility if background information has not been received within the specified time period. Contacting the facility to clarify any ambiguous or incomplete information received. Contacting the legal department, as appropriate, to ascertain whether the facility has any outstanding litigation or history of compliance problems. Obtaining relevant company policies and procedures and applicable federal/national, state/provincial, and local regulations. Identifying site-specific situations and requirements that may require modification of the standard audit protocols.
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Pre-Audit Activities
Assembling the appropriate audit protocols to be used for the audit, and assigning them to individual auditors according to their skills, experience and background. Distributing Background Information The background information collected by the team leader should be distributed in a timely fashion to allow the team members enough time to review the information prior to the audit. 3. Assigning and Communicating Audit Responsibilities As the necessary background information is gathered and reviewed, the team leader should make an initial allocation of the functional areas (e.g., air pollution control, hazardous waste management, industrial hygiene, employee safety, etc.). This task involves matching the talent and expertise of the team members with specific tasks or protocols, as well as taking into consideration the team members prior audit assignments. These assignments are typically made by the audit team leader with input from the individual auditors. If the audit team is not in one geographical location, a conference call or video conference can be set up to establish and communicate the audit responsibilities. In addition to the assignment of functional areas, the team leader should clearly communicate all pertinent information and audit team responsibilities during the pre-audit phase. For example, audit team members are typically responsible for:
Reviewing the background information supplied by the team leader to begin developing an initial understanding of the facilitys status with respect to each assigned functional area(s). Modifying the audit protocols, as appropriate, to incorporate state/provincial, local, or facility-specific requirements or special facility conditions, plans, procedures, etc.
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Pre-Audit Activities
Making travel/lodging plans. Obtaining and reviewing the applicable federal/national, state/ provincial, and local regulations. Bringing the necessary audit materials/equipment for the audit as directed by the team leader (e.g., personal protective equipment/ clothing, background information, audit protocols, working paper pads, regulations, computer, etc.).
4. Conducting Pre-Audit Meeting A pre-audit meeting may be the last step of the pre-audit planning phase. This meeting is typically held immediately before the audit (i.e., evening or early morning prior to the audit) if team members are not located in the same geographical area. The purpose of the pre-audit planning meeting is to clarify any details regarding the protocols and to develop an overall audit strategy. An audit strategy is essentially an outline of the tasks that may need to be done in order to complete the five-step onsite audit process, how each task is to be accomplished, and the time required to complete each step. Audit protocols serve as a basis for developing this strategy. During this meeting, team members also:
Discuss and evaluate background information received from the facility and determine if there are any overlapping areas (e.g., industrial hygiene and employee safety regarding personal protective equipment). Identify protocol steps and questions that have been modified to reflect special facility conditions or unique state/provincial or local regulatory requirements.
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Pre-Audit Activities
Confirm that they understand how much time to allocate during the on-site phase to complete the five-step audit process. Typically, each auditor should allocate his/her time on site as indicated below.
Allocation of Time On Site Percentage of Time 15 10 40 30 5 Activity Understand the management system for assigned topics Assess the apparent strengths and weaknesses of those management systems Gather audit evidence Re-assess strengths and weaknesses and evaluate audit results Formally report the audit findings to site management
In addition, some audit programmes find it beneficial, whenever possible, to conduct a pre-audit visit. During this pre-audit visit, the audit team leader will have a one-day meeting with facility personnel to review the audit programme objectives, scope, and approach; establish a preliminary interview schedule; and/or tour the facility to better understand the operations. The results from this pre-audit visit are shared with the audit team members prior to the audit to assist in the development of an audit strategy.
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Post-Audit Activities
Prepare Draft Report Obtain Review Comments from Corporate HSE Law department Facility management
Step 2: Assess strengths & Weaknesses Consider potential impacts Evaluate management systems Set priorities for verification
Issue Final Report to Facility management Operations Corporate HSE Law department
Plan the Audit: Correspond with the facility Assemble & distribute background information Assign & communicate audit responsibilities Conduct pre-audit meeting
Step 3: Gather Audit Evidence Evaluate what needs to be done Determine depth & rigor of review Select types of evidence needed & methods to gather them Compare practices against requirements Document results
Develop Action Plan Develop proposed action(s) to address each finding Assign responsibility for corrective action Develop timetable
Step 4: Evaluate Audit Results Evaluate audit results Write audit findings
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Wednesday Daily Debrief 8:00 - 8.30 Gather Audit Evidence 8:30 - 12.00
Thursday Daily Debrief 8:00 - 8.30 Continue to Gather Audit Evidence 8:30 - 12.00
Friday Meet with HSE Staff 8:00 - 8.30 Wrap Up Loose Ends 8:30 - 11.00 Conduct CloseOut Meeting 11:00 - 12.00
8:30 - 12.00
Lunch Assess Strengths and Weaknesses 1:00 - 2.00 Gather Audit Evidence 2:00 - 4.30
Lunch Continue to Gather Audit Evidence 12:30 - 2.00 Evaluate Audit Results 2:00 - 6.00??
Review Audit Plan 2:00 - 2.30 Understand Details of Systems 2:30 - 5.30
Team Meeting Team Meeting 4:30 - 5.30 Team Activities Individual Activities 4:00 - 5.30
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Document Review
Key plans, procedures, policies
Observation
Orientation tour
The on-site opening activities are intended to provide the audit team with a broad and general overview of facility operations and issues. The audit team members typically obtain this broad overview by:
Conducting an opening meeting with facility management upon arrival at the site to discuss overall facility operations and the organisational structure used to help facilitate the implementation of compliance activities. Conducting an orientation tour with key facility personnel to obtain a general orientation to the plant, including its layout and size, location of operations, and location of those activities pertaining to the audit scope. Reviewing the audit strategy as a team to ensure that the audit scope includes all the applicable audit topics and that resources are allocated appropriately, based upon the information gathered thus far, for each of the audit topics under review.
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Describe to facility personnel the overall objectives of the audit programme, and the purpose, scope, and approach of the audit. Gain an initial overview of the facilitys programmes and practices established to manage environmental, health, and safety issues relevant to the scope of the audit.
The opening meeting will, to a large extent, influence the overall outcome of the audit; therefore, it is important that this meeting be conducted in a professional manner which allows a comfortable exchange of information between the audit team and facility personnel.
The following table outlines the typical activities and topics included in the opening overviews of the:
Audit process presented by the team leader. Site operations, programmes, and procedures presented by a facility representative.
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Team Member
Team Member
Team Member
Team Member
Team Member
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Chemplant Opening Meeting Discussion Guide Audit Team: Lead Auditor: John Clarke Auditor: Peter Tillson Auditor: Paula Brown Local Address: Best East Inn Any road Anytown, Anyplace (222) 333-3333 NPC Contacts: Plant Manager: Jerry Osborne Safety and Health Supervisor: Pat Dawson Environmental Co-ordinator: Chris Carson Facility Address: 875 Willow Street Anytown, Anyplace (222) 222-2222
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Verify compliance with applicable national, regional (local, state etc.), and local environmental, health, and safety laws and standards Verify conformance with corporate, company, and facility environmental, health, and safety policies and procedures Determine whether activities are consistent with good environmental, health, and safety management practices and whether systems are in place and functioning
Scope This environmental, health, and safety audit will address the facilitys compliance and management systems in the following areas:
Water Pollution Control, including Spill Prevention and Control Air Pollution Control Solid and Hazardous Waste Management Employee Safety Industrial Hygiene Loss Prevention
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A physical survey of the facility Examination of a sample of environmental, health, and safety administrative, technical, and operating records available at the facility Interviews and discussions with key facility management and staff Verification procedures designed to examine the facilitys application of and adherence to environmental, health, and safety laws and regulations
Period of Review January 3, 2000 through the last day of the audit Reporting A hierarchical reporting scheme will be used: Who
Facility/HSE Supervision Facility Manager
What
All deficiencies noted All deficiencies noted
When
When noted Periodic, exit interview, final report
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Post-Audit Activities
Prepare Draft Report Obtain Review Comments from Corporate HSE Law department Facility management
Step 2: Assess strengths & Weaknesses Consider potential impacts Evaluate management systems Set priorities for verification
Issue Final Report to Facility management Operations Corporate HSE Law department
Plan the Audit: Correspond with the facility Assemble & distribute background information Assign & communicate audit responsibilities Conduct pre-audit meeting
Step 3: Gather Audit Evidence Evaluate what needs to be done Determine depth & rigor of review Select types of evidence needed & methods to gather them Compare practices against requirements Document results
Develop Action Plan Develop proposed action(s) to address each finding Assign responsibility for corrective action Develop timetable
Step 4: Evaluate Audit Results Evaluate audit results Write audit findings
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Gather information that will be used to help set priorities among the audit topics to review. Gain insights regarding how effectively and efficiently an EHS topic is being managed and, thus, establish a context for evaluating the audit results. Identify potential underlying causes that contribute to compliance-related deficiencies.
Other Driving Forces In addition, audit standardssuch as the ICC Charter for Sustainable Development, ISO 14000, EMAS, and BS7750 require a thoughtful review and evaluation of the facilitys systems for managing HSE obligations. Our approach to Step 1: Understand Management Systems will be to:
Explain what HSE management systems are and some of the specific activities involved. Describe how the auditor should go about understanding HSE management systems in Step 1 of the audit process.
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Source: Systemation, January 15, 1959, published by Systemation, Inc., Colorado Springs, Colorado.
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Supporting
Training and awareness Documenting/recordkeeping Managing information
Organisation
Resources
Foundation
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On-Site Activities Assessing is used by the facility for identifying conditions / aspects & materials on facility that have HSE implications, & for determining the applicability of regulations Planning is used by the facility for designing and establishing programs & systems for HSE compliance
Outcome Identify / evaluate HSE issues Identify on-site hazards Review HSE activities and projects Review applicable regulations Formulate HSE strategies & policies with clear objectives & targets that reflect the importance of the HSE issues applicable on site Develop HSE procedures for compliance & record keeping activities, as well as prevention plans with specific operating criteria Identify & design engineered controls & equipment Develop emergency response procedures; create procedures regarding critical HSE activities / issues or departures from established criteria Acquire permits Disseminate policies & procedures Assign & communicate roles & responsibilities Install, calibrate & maintain engineered controls Handle situations that deviate from an established standard Undertake activities in accordance with established schedules Conduct drills Conduct inspections / self-audits in accordance with documented procedures Review compliance data / performance Track continuous improvement Review the effectiveness of management systems Undertake corrective actions in response to identified directors from procedures or established criteria
Implementing is used by the facility for ensuring effective and consistent implementation of its HSE programs
Implementing Lets manage it
Reviewing is used by the facility for measuring & assuring HSE program effectiveness
Reviewing How are we doing?
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Documenting/ Recordkeeping
Managing Information
Organisation and resources should be aligned to support effective HSE management systems.
Clear assignments and understanding of HSE responsibilities and accountabilities among HSE and line management. Visible HSE commitment and support by management. Appropriate high-level HSE reporting. Sufficient number of qualified HSE staff. Adequate HSE staff/responsibilities to cover all business/organisation groups within the facility. Availability of needed financial and technological resources.
Organisation
Resources
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Understanding HSE Management Systems The Methodology for Understanding HSE Management Systems
There are three principal approaches used to understand HSE management systems within the context of an audit.
Talk to Key People
Warning Contains (or manufactured with, if applicable) (insert name of substance), a substance which har ms public health and environ ment b y destro ying ozone in the upper atmosphere
Warning Contains (or manufactured with, if applicable) (insert name of substance), a substance which har ms public health and environ ment b y destro ying ozone in the upper atmosphere
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Understanding HSE Management Systems The Methodology for Understanding HSE Management Systems
Technique Talk to Key People Activities Talk to several people (e.g., line management, HSE staff, operating personnel, maintenance personnel) to obtain a comprehensive understanding of the activities that are in place to manage compliance and to increase your sense of confidence in the information obtained. Summarise the information obtained from each interviewee to verify the completeness of your understanding. Probe to understand inconsistencies in the information obtained. Examples of what auditors should endeavor to understand during interviews include:
What is meant by the scope of the facilitys programmes? For example, when the facility says that, All employees receive hazard communication training, does this mean all employees, all employees who work in certain areas, or something even narrower? How does the facility handle seasonal, situational, or nonnormal activities? For example, how does a particular activity work on the off-shift, or when a key person is on vacation, etc.? How does the facility develop data for preparing compliancerelated reports, for determining compliance, or for identifying HSE-related problems? To understand this, the auditor may, for example, want facility personnel to describe or demonstrate how they reconcile the monthly inventory for an aboveground storage tank
Walk around the facility to understand the nature of the HSE issues that need to be managed and the types of engineered controls in place. (This is primarily accomplished during the orientation tour.) At this stage, auditors should focus on understanding the nature and rationale of the engineered controls used to manage HSE hazards.
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Understanding HSE Management Systems The Methodology for Understanding HSE Management Systems
Technique Review Key Programme Documents Activities Briefly review procedures, plans, etc., that explain how the facility manages HSE obligations. For example: Compliance-related programme documents Operational procedures Checklists or inspection forms Training programme description At this stage, auditors should focus on understanding: How the programme is supposed to work. Tools used by the facility for ensuring that the programme works as designed and is effective.
There are some key questions auditors should try to answer when understanding each stage of the management process.
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Understanding HSE Management Systems The Methodology for Understanding HSE Management Systems
Management Process Assessing
Things the Auditor Wants to Learn How are regulations tracked (i.e., identifying, tracking, interpreting, and communicating regulations)? How are HSE risks and effects assessed (e.g., waste stream inventory, air emissions inventory, natural resources consumed, likelihood and magnitude of unplanned events, potential exposure to hazardous substances, etc.)? How does the facility manage changes in procedures or facility design (e.g., HSE review and consideration for new products, processes, equipment, acquisitions and divestitures, maintenance modifications, etc.)? What type of basic compliance programmes (e.g., permitting, monitoring, training, recordkeeping, reporting, etc.) have been or are being established and do they include critical operating parameters and schedules? How does the facility prepare for emergencies (e.g., developing scenarios, response capability, response plans, etc.)? What type of issue-specific risk reduction programmes (e.g., groundwater monitoring, pollution prevention, waste management practices, spill containment programmes, ergonomics, engineered controls, etc.) are developed? What engineered controls or alarms are in place to help achieve desired results? What measures have been taken to reduce the likelihood of nonconformance with established criteria? What types of policy and related goals and objectives are established (e.g., vision statements, basic policies and guiding principles, specific goals and milestones, etc.)? What strategies are developed for managing HSE risks and effects?
Planning
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Understanding HSE Management Systems The Methodology for Understanding HSE Management Systems
Management Process Implementing
Things the Auditor Wants to Learn Has the facility fully implemented the various HSE programmes? How does the facility maintain operating equipment (e.g., preventive maintenance programmes, testing and monitoring, etc.)? How is nonconformance with established criteria handled? Are facility operations being inspected (e.g., routine walk-throughs, use of checklists, etc.)? How are HSE effects being measured? Does the facility analyse its performance (e.g., evaluate findings, lessons learned, trends, etc.)? Are programmes in place for developing, implementing, and tracking corrective actions? What formal training have key personnel had to assist them in performing their HSE tasks and functions? What training and awareness activities are conducted to provide an understanding of HSE obligations and responsibilities? What type of training programmes (e.g., compliancerelated training, emergency drills, on-the-job training, etc.) are available? What types of experience or background are required to perform HSE tasks? Are procedures and practices for both compliance and remediation generally written down? What records are routinely developed and retained in carrying out various tasks and functions? What exception reports are developed? What is the general nature or character of the documentation that is developed? How does the relative importance of HSE activities correspond to the nature and level of documentation that is developed? Where is information retained? How long is information retained?
Reviewing
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Understanding HSE Management Systems The Methodology for Understanding HSE Management Systems
Management Process Managing Information
Things the Auditor Wants to Learn How is important HSE information conveyed to personnel? Can the facility readily access HSE information? How does the facility ensure that reports are submitted in a timely manner and that essential records are retained? Are there procedures in place for responding to external requests for information? How are responsibilities and accountabilities defined, established, and communicated? How are assignments of responsibilities reinforced? Are any key responsibilities overlapping, shared, or conflicting? What potential exists for conflict of interest in accomplishing key HSE tasks and functions? How is authority granted to carry out assigned responsibilities? How have responsibilities for implementation been communicated to personnel who need to know? Are there sufficient resources to carry out the various HSE programmes? Who has the authority to waive adherence to, or conformance with, an established standard or requirement and are deviations recorded? Are there perfunctory approvalsauthorisations without understanding what is involved?
Organisation
Resources
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The facility has confined spaces, which are entered by facility personnel and contractors. The facility has a confined space entry programme along with permits. The facility is a chemical manufacturer that handles a variety of toxic and flammable substances.
Instructions Describe the steps you would take to understand the management systems used by the facility to implement the confined space entry programme. Include in your description:
Whom you would talk to. What questions you would ask. What documents and physical facilities you would want to look at. Any other activities you would conduct while completing Step 1 of the audit process for this topic.
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Other activities?
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Exercise 1A Potential Answers Understanding HSE Management Systems Confined Space Entry
Whom would you talk to? HSE Manager Maintenance Manager Maintenance Staff
What questions would you ask? What is the procedure for confined space entry? Where are they formalised (HSE manual)? To Maintenance Staff What do they do before and while entering confined space? Training PPEs? What documents and physical facilities would you look at? Permit to work Inventory of confined spaces
Other activities? Ask to go and see the confined spaces Ask to observe if any maintenance is scheduled during the audit
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Other activities?
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What questions would you ask? What is the procedure for spill control and countermeasure? Who is in charge? What training is carried out? Is external personnel (truck drivers) trained/supervised? What happens if a spill occurs on a Sunday night? What documents and physical facilities would you look at? Spill prevention control and counter measure plan (Accident/Incident/Near misses register) Loading/unloading, secondary containment Spill control kits Waste registers Hazard material inventory Quantities and storage locations Other activities? Observe loading/unloading
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Effective Interviewing
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Effective Interviewing
Interviewing is one of the primary techniques used in gathering audit information. Interviews provide auditors with:
A time-efficient way of gathering both broad general information and specific details from people who should know. A means to confirm hypotheses about site conditions, changes, needs, and opportunities. A current and credible source of facts and perceptions that complement written information and physical observations.
Thus, good interviewing skills are essential to the successful completion of the audit. While in one sense interviewing is a skill that comes naturally to most people, good interviewing techniques, which emphasise interaction between interviewer and interviewee, must be developed. By remembering some basic elements of good interviewing skills, the interviewer not only will be successful in gathering the information he/she desires, but will also find the interview process much more pleasant.
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Opening
Documenting
Conducting
Closing
1. Planning the Interview Prior to conducting the interview, the auditor should identify personnel to be interviewed, outline the objectives to be accomplished, and plan how to maximise the effectiveness of the interview. Key considerations include:
Iron out logisticsset a specific time and place for the interview. Define the desired outcomeidentify the types of information desired and/or areas to be addressed. The types of information gathered during interviews can be characterised as hard or soft.
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Soft
Quantitative data regarding emissions, exposure monitoring, etc. Records prepared for compliance purposes Historical information about a site Why did something (not) happen? How does the process/system work? How does the work really get done?
Most HSE audit interviews mix hard and soft information needs.
Organise your thoughtsdevelop a logical sequence of questions. Be preparedHSE interviews take place under all types of distracting conditions, so plan appropriately.
2. Opening the Discussion The quality of information gathered during an interview is closely related to the interviewees sense of comfort. The level of openness that develops during an interview, along with the interviewees confidence in the topic being discussed, depends a great deal on the rapport and atmosphere established during the initial contact.
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Cultivating a friendly, nonthreatening discussion. Attempting to respond to the interviewees social style. For example:
Social Style Analytical/ Thinker Driving/Doer Orientation Technicallyoriented Resultsoriented Example Interviewee Questions/Responses Whats your methodology? How will the results be used? What can I do for you in the next ten minutes? What is the outcome of all this time spent talking with auditors? How are you enjoying our plant/town? Why are we having this interview? Did you notice how effectively our waste management process operates? We believe weve made the most improvements in this area of anyone in the industry.
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Refraining from portraying a condescending, arrogant, knowit-all attitude. Acting in a supportive and nonjudgmental manner. Ensuring that the auditor and the interviewee are on equal ground.
3. Conducting the Interview Style, Flow, and Tone Once a comfortable interview setting and rapport have been established, the auditor should focus toward obtaining specific information from the interviewee. Some examples of specific items that an auditor should address include:
Request a brief overview of the interviewees job. Discuss the interviewees responsibilities in relation to the topic(s) being reviewed. Use language that the interviewee can understand. Start with some general questions, then gather more detailed information. Resolve ambiguities through constructive probing. Do not exceed the agreed-upon time limit without first obtaining the interviewees approval. Provide feedback as appropriate.
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Flow
Tone
Avoid interrogation Be empathetic Avoid defensiveness Be calm, objective, and non-partisan Be courteous, alert, and responsive Avoid disjointed transitions that damage rapport (e.g., cutting the interviewee off because you are trying to transition to a new topic) Use word association to change topic focus (e.g., if the interviewee mentions his/her training, use this opportunity to raise any training questions) Be genuine and take an interest in the interviewees responses Use a soft, friendly voice
Types of Interview Questions Appropriate questioning should be utilised to obtain the desired information. For example:
Type of Question Leading Typical Response Relative Value of Outcome Response Information to Auditor Of course you notify the Often state of a planned unintentionally discharge. lead the interviewee to the You do test the wells desired answer. every month, dont you? Do you have a spill Usually receive only response procedure? a yes or no answer. Have you conducted waste audits? What is your current Usually receive a production capacity? one-word answer. Example Questions
+ +
Yes/No
CloseEnded
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+++
Can provide the most insight into how things are actually managed.
+++
Active Listening Another important component to conducting successful interviews involves active listening. Active listening allows the interviewer to: Summarise information accurately. Test the interviewees understanding of the topic being discussed. Probe for confirmation. Facilitate the interview. Display empathy/establish greater rapport. All auditors should develop the following listening techniques:
Wait until the current question is answered before asking another question. Encourage the interviewee in a nonverbal manner (e.g., maintain eye contact, display attentiveness, etc.).
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Interrupt only if you sense avoidancepeople often feel more secure when given an opportunity to speak without being interrupted. Imagine the interviewees situation (i.e., put yourself in the interviewees job scenario). Listen for emotions and attitudes as well as facts.
In addition, the interviewer should remember to listen over 90 percent of the total interview time. Paraphrasing/Summarising Information Learned The technique of paraphrasing can aid the auditor in confirming or clarifying something said or implied by the interviewee. There are three levels of paraphrasing:
Level 1 Accomplishment Confirms or clarifies expressed thoughts and feelings Confirms or clarifies implied thoughts and feelings Surfaces core thoughts and feelings Example Paraphrase So there are three factors that determine the present situation... You would really like to change this situation... You are concerned that your companys engineering approach is outdated...
2 3
In using this technique, it is important to: Paraphrase completely. Match the levels of emotional intensity and factual content. Use levels 1 and 2 freely; treat level 3 with caution.
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Never try to hide the fact that you are taking notes. Rather, draw the interviewees attention to what you are doing by explaining the need to take notes and involving the interviewee in the process. If necessary, address the issue regarding the confidentiality of working papers. Offer the interviewee the opportunity to review the notes taken during your interview to put him/her at ease with the process, if necessary. Keep your working paper pad within easy reach, such as attached to a clipboard on a desk or table. Always make sure you have a pen handyand that it works.
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Take notes about facts that are relevant to the audit. Avoid listing points that do not relate to the audit topics of concern. For example: Record name, title, and job description of person with whom you spoke. Reference the appropriate protocol step(s) addressed in the interview. Note relevant interview information. Highlight key statements/observations. Put the interviewees words in quotation marks to distinguish them from your own comments. Spend time immediately following the interview summarising the key points obtained from the interview in your working papers
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Scenario A You are responsible for assessing the environmental training provided to site personnel during an environmental audit of the company Mining Samples. During an interview with the lab training co-ordinator , Jo Lopes, you ask Could you tell me what types of environmental training site employees receive? Mr. Lopes responds Sure. All site employees attend an initial eighthour environmental awareness course during their new employee orientation week. Employees also attend and must successfully pass a first aid/cardiopulmonary resuscitation course. You say, Getting back to the environmental awareness course, can you describe the types of information that are discussed in this training? Mr. Lopes replies, Sure. We train new site employees on environmental issues such as pollution prevention and air and water contamination. Our first aid courses instruct site employees on how to respond to health and safety emergencies that may occur here at Mining Samples. Let me get a copy of the training material for you.
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Establish and maintain mental and physical control of yourself. Vary your questioning pattern to obtain maximum information from the interviewee Make sure you are adequately prepared for the interview beforehand so you portray confidence and can maintain control of the interview Dont be afraid to openly acknowledge the difficulty, take a break, or ask if you can reschedule for a later time
If the interviewee becomes hostile and aggressive, remain calm and do not worsen the problem. Limit your questions to just the facts, and convey to the interviewee that the purpose of the interview is to uncover the truth If the interviewee cant stop talking, do not be afraid to politely interrupt in order to move on in the interview If the interviewee goes off course, sum up what the interviewee has said and either move onto the next question or return to the point where things went wrong in the interview
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We will break into groups (Observers, Auditors, and Plant Representatives in separate rooms). You will have 10 minutes to prepare for your role, 15 minutes to conduct the interview, and 5 minutes for feedback.
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Assume one of the following difficult interviewee stances for part of the review: Take control of the interview Become hostile and aggressive Give inadequate answers and/or become unresponsive Continue talking throughout the entire interview Go off course from the subject matter Insert a ten-second pause into the conversation. Give key information that should be recorded and one piece of superficial information that should not be recorded.
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Assume one of the following difficult interviewee stances for part of the interview: Take control of the interview Become hostile Give inadequate answers and/or become unresponsive Continue talking throughout the entire interview Go off course from the subject matter Insert a ten-second pause into the conversation Give key information that should be recorded and one piece of superficial information that should not be recorded.
If you are asked difficult questions for which not enough information has been provided to you, please feel free to make up information. Perhaps the next thing to do will be to imagine a facility with which you are familiar when creating your responses. Be imaginative and enjoy it!
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A description of the environmental, health, and safety management systems in place at the facility. A description of the specific actions taken to address each step of the protocol (tests conducted, sources(s) of information, evidence accumulated). A summary of the auditors findings and observations.
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Audit Planning
Working Papers
Audit Follow-Up
Audit Report
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Provide an organised method for ensuring that all audit steps have been addressed in a manner consistent with the objectives and established procedures of the audit programme. Supplement the protocols by providing audit planning details such as the time budgeted to individual audit tasks and the auditors evaluation of the management systems that may have influenced the conduct of the audit. Provide a record of tests conducted and evidence accumulated. Provide data that support the audit report and that may be useful in subsequent action-planning and follow-up activities. Provide information to assist in answering questions that may arise during subsequent action planning and follow-up. Provide a basis for quality assurance and aid in the planning, performance, and review of future audits.
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Until the final report and/or corrective actions are completed. Until the next audit of that facility. For a particular retention time based on corporate policy (e.g., five years).
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Write while conducting the audit. Notations that serve as reminders of key points are helpful in gaining a complete understanding of facility systems or activities. An auditor should avoid relying on his/her memory and putting off documenting items until he/she has more time. Start each new topic on a new page. Many times an auditor will obtain additional information even after he/she feels the particular topic has been completely documented. Any additional information or notes to clarify particular items can easily be inserted in existing text, and dated if the information was obtained on a different day from when the page was prepared, if each topic is entered on a new page. Also, crossreferences can be added to indicate where additional information on the topic can be found. Clearly label each working paper page. Initial, date, and sequentially number each page. Labelling each page with the protocol step makes it easier for both the auditor and the audit team leader to review the work performed and helps locate specific topics in the working papers. A single notation identifying the relevant protocol step is generally sufficient (e.g., Protocol Step 8b: Off-Site Shipment of Wastes). Keep entries factual. Each statement should be based on sound evidence, with unconfirmed data or information qualified, and speculation and generalities avoided. For example: Do not say, It appears that...; rather, state the facts that create the appearance. Avoid extreme language (e.g., terrible, dangerous, incompetent). Distinguish clearly between information obtained by wordof-mouth and information observed, verified, or concluded.
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Keep entries legible. Although no ones penmanship is perfect, working papers should be written in a legible hand. Avoid crowding, leave plenty of space, and write only on one side of the page. This practice will aid in the audit team leaders review of the working papers and will help the audit programme manager confirm that audit programme goals and objectives have been achieved. At a minimum, each auditor should be able to read his/her own notes. In the event of a mixed language team, the team leader will decide what the language to use in the working papers will be. Write clearly in an understandable style. An auditor should strive to write clearly, so that a person not involved in the audit can understand the steps taken and can reach the same conclusions. Avoid uncommon abbreviations. Include photocopies of selected documents. An auditor should sequentially number and reference selected facility documents as exhibits in his/her working papers (e.g., Exhibit A1). If any notations on any exhibit are made, they should be documented in the auditors working papers. For example: Exhibit G1 is a copy of the facilitys air pollution control permit. Page 3 of the permit contains notes that I used to confirm all emission sources. Maintain an exhibit list. To keep track of the exhibits, an auditor should develop and update an exhibit list as each new exhibit is identified and numbered.
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Highlight to do items and findings. Many auditors find it convenient to keep a running list of to do items (items that call for further investigation or additional information) during the audit. This can be done by either writing them on a separate page or in some way identifying them where they are noted. Any to do items should be indicated as complete and then cross-referenced when they have been finalised. Develop and use standard tick marks. To increase efficiency in developing useful working papers, many auditors develop standard tick marks, or legend codes (i.e., a personal type of shorthand) for many of the more common or cumbersome working paper notations.
Tick Mark Examples
Item needing further auditor attention Item where subsequent attention has been given and noted on page 15 in the working papers Potential report or exit interview exception/observation Exception/observation after reporting to team leader and/or facility
3
PCC-15
Exception confirmed by auditor (as item 3) on exit meeting discussion sheet Potential concern later determined by auditor not to be an exception (explanation on page 17 of the working papers)
PCC-17
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9. Initialed cross-outs
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MAC p1 of 675
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M DG 7 of 42
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Preparing Working Papers Example of Descriptions of Actions Taken and Tests Performed
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MDG - 85
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Sample Checklist to Review Working Papers Format Each working paper page is clearly labeled with the applicable protocol step. Sources of information are clearly identified. All exhibits are referenced in the working papers. Each page is sequentially numbered, initialed, and dated. Cross-outs are initialed; postscripts or afterthoughts are written in a manner that provides appropriate context. Content Each protocol step was addressed in accordance with the instructions provided. Any departures from the protocol are described and explained. A description of actions taken to complete each protocol step has been documented. An understanding of how the facility is managing the items under review has been documented. The conclusions reached as a result of testing have been documented. All audit findings have been clearly identified. All findings in the working papers have been included on the audit exit meeting discussion sheet.
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We will break into groups (Observers, Auditors, and Plant Representatives in separate rooms). You will have 10 minutes to prepare for your role, 15 minutes to conduct the interview, and 5 minutes for feedback.
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Department 901 has a safety committee (composed of yourself, two other management representatives) that meets twice per month to discuss safety issues of concern and to tour the department to conduct safety inspections. The pressure of production over the last two years have resulted in certain periods where the committee has failed both to meet and to conduct the inspections The result of each inspection are quickly reviewed by the committee; the two management representatives convey the results to specific work areas for corrective actions. No formal corrective action plans are developed but you believe things are getting addressed.
During the interview, you should project a friendly, accommodating demeanor. You are free to develop additional information in responding to the auditors questions, and should provide an abundance of information (all of which need not be relevant to the aforementioned topic). The purpose of your role in this exercise is to force the auditor and the observer to think before they write: rather than acting as stenographers who record every word, the auditor and the observer should ideally record only that information which is important and pertinent to the aforementioned topic.
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Absorbent pads, pillows, along with absorbent granule supplies are maintained in a central warehouse for distribution upon request. The spill team should receive monthly refresher training and conduct a mock spill event once every six months The spill team has its own meeting room and storage area for self-contained breathing apparatus, chemical resistant suits, etc. The spill teams mock spill conducted in August revealed that some of the newer members of the team were not familiar with procedure and did not know what action to take in the event of a facility spill. As spill team training has been patchy since August, follow-up on this shortcoming has not yet taken place.
During the interview you should project a friendly, accommodating demeanor. You are free to develop additional information in responding to the auditors questions, and should provide an abundance of information (all of which need not be relevant to the aforementioned topic). The purpose of your role in this exercise is to force the auditor and observer to think before they write; rather than acting as stenographers who record every word, the auditor and the observer should ideally record only that information which is important and pertinent to the aforementioned topic. Be imaginative in developing your description of the facilitys spill response programme and your responses to the auditors questions.
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Post-Audit Activities
Prepare Draft Report Obtain Review Comments from Corporate HSE Law department Facility management
Step 2: Assess strengths & Weaknesses Consider potential impacts Evaluate management systems Set priorities for verification
Issue Final Report to Facility management Operations Corporate HSE Law department
Plan the Audit: Correspond with the facility Assemble & distribute background information Assign & communicate audit responsibilities Conduct pre-audit meeting
Step 3: Gather Audit Evidence Evaluate what needs to be done Determine depth & rigor of review Select types of evidence needed & methods to gather them Compare practices against requirements Document results
Develop Action Plan Develop proposed action(s) to address each finding Assign responsibility for corrective action Develop timetable
Step 4: Evaluate Audit Results Evaluate audit results Write audit findings
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Assessing Strengths and Weaknesses Process for Assessing Strengths and Weaknesses
Determine the range of potential impacts if a particular HSE issue is not managed appropriately Evaluate the management systems to determine if they are designed soundly. That is, consider if the systems, coupled with the controls, are appropriate given the potential impacts Set priorities for verification so as to provide the optimum allocation of available team resources to ensure that issues representing high risk and weak management / control systems receive sufficient attention
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Assessing Strengths and Weaknesses General Approach for Considering Potential Impacts
Potential impacts refer to the range of potential consequences for the facility or company arising from an event or activity. In evaluating potential impacts, the auditor should ask: If a health, safety and environmental activity at the facility is not managed appropriately, what consequences could ensue? Potential impacts might include: Catastrophic events (e.g., explosion) Loss of life (e.g., confined space entry procedures) Injury or illness (e.g., levels of airborne pollutants in the workplace) Environmental damage (e.g., spills of hazardous materials to navigable waters or drinking water supplies) Legal or financial liability (e.g., air permit violations) Loss of operation and production Adverse publicity (e.g., release of visible hazardous toxic substance to air) Recordkeeping or reporting exceptions Occasional spills or releases to the environment Employee/community exposures to hazardous/toxic substances Loss of property (e.g., fire) The auditor should evaluate the potential impacts for each protocol topic based upon a high to low spectrum.
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Assessing Strengths and Weaknesses Assessing Health, Safety and Environmental Management Systems
Evaluating the soundness of a facilitys health, safety and environmental management of key programmes is inherently a subjective process. While regulations tend to stipulate explicit performance or technology requirements, explicit criteria/standards as to what constitutes an adequate management system are only beginning to emerge. In some instances, however, a corporation, division, or facility may have developed its own guidelines or policies as to how a particular activity or function is to be managed. In those situations where there are established management criteriabe they regulatory or internalthe auditor can look to the criteria for assistance in assessing the soundness of management systems. In all other instances, the guidance on the following pages provides a framework for assessing the strengths and weaknesses of the health, safety and environmental management systems.
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Assessing Strengths and Weaknesses General Principles for Assessing Management Systems
Given the absence of explicit criteria for assessing management systems, the following guidance may be helpful.
Management System Descriptors Assessing The facility has a process in place for: 1) identifying and evaluating conditions and/or materials on site that have regulatory implications, and 2) understanding the scope of applicable regulatory requirements. Assessments are performed to identify potential risks (e.g., leaking underground storage tanks or pipes, carcinogens in the workplace). Environmental, health, and safety evaluations are conducted for modified products, processes, and operating ventures and signed off by health, safety and environmental staff. Programmes are in place to keep abreast of regulatory changes, to interpret the applicability of those changes to facility operations, and to develop procedures to address those changes. The facility has developed procedures and systems for managing compliance (e.g., plans, procedures, policies). Appropriate procedures have been established to respond to unintended events, such as process shutdowns, as well as to notify appropriate groups within the corporation and in the community. Usable programme and procedure guidance exists to direct facility activities to achieve health, safety and environmental goals consistently. A system has been developed for recordkeeping which provides documentation of health, safety and environmental activities and compliance with governmental requirements and company policy.
Planning
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Assessing Strengths and Weaknesses General Principles for Assessing Management Systems
Management System Descriptors Implementing The facility has structures and/or equipment in place to manage or implement compliance (e.g., pH meters, approved vendor lists, methods to address nonconformance situations, etc.). Controls for equipment and storage areas are maintained in an operable manner. Systems are in place to address nonconformance situations (e.g., permit exceedances, internal alarms). The facility has developed a process for periodically reviewing and monitoring compliance programmes (e.g., selfinspections, audits, supervisory review of data to cross-verify reports). The functionality of the controls is periodically tested. Periodic and comprehensive inspection programmes are in place. Deficiencies identified during inspections are corrected in a timely manner. Clear roles and responsibilities have been established to manage compliance with applicable regulations. Roles and responsibilities are clearly understood with respect to health, safety and environmental functions. Health, safety and environmental staff have access to appropriate line management to discuss issues and concerns. Qualified and sufficient health, safety and environmental staff and/or line personnel are involved in compliance management. Staffing levels are appropriate to obtain environmental, health, and safety compliance management goals. Clear accountability exists for health, safety and environmental performance. Programmes are in place to familiarise staff with the nature and scope of compliance programmes. Health, safety and environmental staff have appropriate education, training, and experience to fulfill assigned duties. Information and education programmes are sufficient to enable employees to carry out health, safety and environmental functions.
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Reviewing
Organisation
Resources
Training
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Assessing Strengths and Weaknesses General Principles for Assessing Management Systems
Management System Descriptors Documentation/ Information Management The facility has an accessible and orderly recordkeeping system for compliance-related activities (e.g., training, monitoring, governmental correspondence) and mechanisms in place to communicate relevant information between the various levels and functions of the organisation (i.e., memoranda, weekly meetings). Records are accessible and managed in an orderly fashion. Sufficient information is reported to management and outside agencies, as appropriate.
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Assessing Strengths and Weaknesses General Principles for Assessing Management Systems
Based on the information gathered during Step 1: Understand Management Systems, the auditor should assess the strengths and weaknesses of the facilitys approach to managing each protocol topic. An example of such an assessment (to verify compliance with a wastewater permit) is illustrated below.
Management System Activity Assessing Strengths Weaknesses
Planning
Hired an outside Do not have formal procedure consultant five years ago to review capital projects for to review operations and wastewater impacts. identify wastewater issues. Do not keep P&IDs current. Have hard copies (2004) of regulations on site. Have not reviewed latest Corporate HSE provides stormwater regulations. monthly updates on changes. Do not have formal inspection Have formal inspection and PM programme for and preventive laboratory equipment. maintenance (PM) programme for Wastewater Treatment Do not have written pollution Plant equipment. prevention plan. Sampling and analysis manual Have site-specific wastewater sampling and does not address stormwater analysis manual based on sampling. procedures in 40 CFR 136. Plant managers secretary Have reduced total types final Discharge Monitoring Report for wastewater volume by 25% in past two years. signature, keeps file copies, and does any exceedance Lab chemist prepares draft reporting. HSE coordinator does not review final Discharge Monitoring Report. HSE coordinator documents. reviews report and raw Stormwater pollution data before sending to prevention plan is based on plant manager for typing and signature. draft general permit.
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Assessing Strengths and Weaknesses General Principles for Assessing Management Systems
Management System Activity Implementing Strengths Have continuous monitors for wastewater flow, temperature, and pH at outfall. Wastewater Treatment Plant operator is responsible for preventative measures. Inspected and calibrated weekly. Periodically have outside laboratory analyze split samples as quality control check. Weaknesses Do not do sampling and analysis of process-specific inputs to Wastewater Treatment Plant. Have not identified points for stormwater sampling. Process upsets cause slug flow to Wastewater Treatment Plant; no advance notice given.
Reviewing
Laboratory wastewater goes to Publicly owned treatment works, not Wastewater Treatment Plant. Reviewed and updated site Do not have formal selfpolicies and procedures in inspection programme. June 2000. HSE coordinator spends 50% of time out in plant; sees/hears about changes as they happen. Roles and responsibilities are defined in job descriptions for Wastewater Treatment Plant operator, lab chemist, HSE coordinator; well understood.
Organisation
Operations manager clearly considers wastewater compliance to be the responsibility of others (e.g., Wastewater Treatment Plant operator); end-of-pipe mentality.
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Assessing Strengths and Weaknesses General Principles for Assessing Management Systems
Management System Activity Resources Strengths Have sufficient number of qualified staff for Wastewater Treatment Plant and lab. Person who does sampling and analysis is trained chemist with >10 years experience. HSE coordinator has degree in environmental engineering. Chemist and HSE coordinator are encouraged to attend outside meetings/courses 2-3 times per year. Excellent laboratory recordkeeping. Issue weekly newsletter to all plant personnel that includes information on compliance with Wastewater Treatment Plant effluent limitations. Have automated system Do not have formal records for tracking training retention policy. requirements. Do not give notice to HSE HSE coordinator has coordinator when DMR is automated system to alert actually sent. him when Discharge Monitoring Report is due. Weaknesses
Training
Have not trained internal staff on stormwater issues. Have not provided operations personnel awareness training on wastewater issues.
Documentation
Information Management
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Assessing Strengths and Weaknesses Balancing Management Systems/Controls Strengths vs. Potential Impacts
Your overall judgment reflects, to a large extent, whether the facility has strong enough systems in place to minimise the potential impacts.
Balanced Approach Heavyweight System Lightweight System to Manage to Manage Low Potential Impacts High Potential Impacts
Pote n Imp tial acts s tem Sys d n a trols Con
Potential Impacts
Often strengths or weaknesses in the management systems are linked to the presence or absence of several of the activities. The key is to identify which are most relevant to achieve a balanced approach. For example, a redundant (belt plus suspenders) system may be appropriate for high-impact situations, while a more straightforward (strong leather belt) approach may suffice where impacts are not as significant. Poor or deficient management systems can lead to errors or omissions, (e.g., errorfailure to perform atmospheric testing prior to entry into a confined space; omissionfailure to reschedule new employees for training who missed the initial training) and there are some health, safety and environmental situations in which an error and/or omission could have a substantial impact. Strong controls also reduce the risk of either an error or omission.
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Management Systems
Potential Impacts
Low Low
High
Weak Weak
Strong
The process of gridding assists the auditor in setting the verification priorities. That is, the gridding helps auditors select an approach to data gathering that emphasises an in-depth review of areas where potential impacts are high and management systems are weak.
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If there are significant potential impacts associated with noncompliance with a particular topic, and the management systems associated with that topic are judged to be weak, the auditor should ensure that sufficient time is allocated to reviewing that topic. Conversely, if there are low potential impacts associated with noncompliance with a particular topic and the management systems associated with that topic are judged to be strong, the auditor need only spend a relatively small amount of time reviewing that topic.
By developing priorities for verification based on an assessment of the strengths and weaknesses of management systems, and potential impacts associated with noncompliance, the auditor helps ensure that the highest priority issues are covered in significant depth during the audit.
Verification Priorities
Level of Effort
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Assess the potential strengths and weaknesses of an HSE programme and the potential impacts if that particular issue is not managed appropriately. Prioritise the order in which the protocol elements should be completed based on your assessment of the management systems and the potential impacts.
Instructions You have been assigned the Hazardous Waste Management Audit Protocol. During Monday and Tuesday of the week that you are auditing the Woodmount Company, you have interviewed several key people who are involved in hazardous waste management. Attached is a summary of the information that you have compiled as you begin to understand the management systems surrounding hazardous waste management. Based on your understanding of the management systems and on your assessment of the risks involved, rank the following elements of your protocol:
Protocol Element Hazardous Waste Manifests Waste Accumulation and Storage Waste Classification Training Potential Impacts (low/high) Management Systems (weak/strong) Priority
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The work force is quite stable and most of the employees on site have been there for at least five years. The facility has a hazardous waste generator number which was obtained about ten years ago. The number is CAG 110 070 001. The facility generates hazardous wastes, including used solvents and oils generated in the process of maintaining and lubricating machinery, support equipment, and machine shop activities. Annually, production supervisors are required to review the waste profiles and initial the file copy to confirm that there have been no process changes that would alter the waste composition. Every five years, the facility hires a recognised consultant to review its waste characterisation programme. Hazardous wastes are stored in a locked shed adjacent to the main building. The only light in the shed comes from the indirect light through the window openings near the ceiling. Employees are instructed not to enter the shed after dark. Exterior spot lights are available in the event of a nighttime emergency. Floor drains lead to a small sump, which can be pumped out manually if necessary. You were told that the facility has an ample supply of sorbent materials, but have not seen it yet.
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The treatment, storage, and disposal facility (TSDF), which is also the transporter, prepares the manifests for the facility when it picks up a waste load. The TSDF comes whenever the facility calls. The TSDF leaves the generator copy of the manifest with the facility. Six different Woodmount employees have signed manifests in the last ten months. The receptionist keeps the facilitys manifests. During the previous year, 25 shipments of hazardous waste were sent off site to the TSDF. Whenever a signed TSDF copy of a manifest comes in the mail, the receptionist inserts it in the file with the original generator copy. (The receptionist noted that this usually occurs within a month of the shipment.) The current years manifests are kept in the receptionists files; older records are boxed and sent to a storage area in the manufacturing building. The sample manifest you pulled from the file was done on a 1984 form. The maintenance supervisor prepares the annual reports by recording the volume of waste per manifest and submits them to the regulatory agency every year by March 1.
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Facility hazardous waste training programmes are conducted once per year. They last approximately eight hours. The topics covered include HAZCOM, spill cleanup, and an overview of hazardous waste management rules, including waste characterisation. Training is provided by an outside consultant, who submits a contract every year describing the approach and scope of the services rendered. The contract includes a provision for back-up training of staff who are absent from the on-site session. An agenda is prepared to reflect the topics to be covered during the day-long session. Production, maintenance, and selected clerical staff and supervisors attend the yearly sessions. Attendees are required to sign in for both the morning and afternoon sessions. Copies of the attendance records are kept by the maintenance supervisor.
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Assess the potential strengths and weaknesses of an HSE programme and the potential impacts if that particular issue is not managed appropriately. Prioritise the order in which the protocol elements should be completed based on your assessment of the management systems and the potential impacts.
Introduction You have been assigned the Process Safety Management (PSM) Audit Protocol. During Monday and Tuesday of the week that you are auditing the Woodmount Company, you have interviewed several key people who are involved in process safety management. Woodmount is subject to the OSHA PSM Standard because it stores and uses more than 10,000 pounds of flammable materials, chlorine, and ammonia on site. The facility has three process areas that are covered by the standard. Two of the process areas use flammable materials only. The third process area uses chlorine and ammonia. Attached is a summary of the information that you have compiled as you begin to understand the management systems surrounding process safety management. Based on your understanding of the management systems and on your assessment of the risks involved, rank the following elements of your protocol:
Protocol Element Operating Procedures Mechanical Integrity Training Process Hazard Assessments/HAZOPs
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The work force is quite stable and most of the employees on site have been there for at least five years. The facility has an objective of keeping all operating procedures up to date. Every three years, the operating procedures are reviewed and updated as necessary. The facility has a standard for how to develop and write operating procedures. The supervisor for each department is responsible for maintaining operating procedures. The operations manager approves all operating procedures. The availability of operating procedures is verified during prestartup reviews. Operating procedures are updated by production engineers and are reviewed by a committee consisting of the safety manager and senior production operators. Changes to operating procedures are summarised in memos which are kept in a separate section of the operating procedures manual. The facility does not maintain documentation of maintenance performed on individual pressure relief devices. The facility has not completed an inventory of all pressure relief devices. Maintenance personnel have not yet received formal training in plant safety.
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Associated piping to and from raw material and product storage tanks is not included in the facilitys preventive maintenance (PM) programme. The facilitys computerised PM system has not been set up to archive the completion of the PMs, nor does the facility maintain a hard copy of this information. The facility has not yet implemented a periodic visual inspection and/or nondestructive testing programme for its critical equipment (e.g., storage tanks, piping, and process vessels). The facility maintains a matrix of all job titles and their applicable training requirements. The facility has developed training blocks in order to facilitate consistency. A refresher training programme has not yet been established to provide training every three years to operators. Most operators are due to receive refresher training within the next four to six months. The facilitys training programme concludes with a testing of the employees understanding of the material presented using a written exam and a practical. The facility has completed process hazard analyses (PHAs) for all three covered processes using the hazard and operability (HAZOP) methodology.
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The HAZOP studies included representatives from the following facility organisations: Operations Maintenance (instrumentation and process) Engineering HSE department, if deemed necessary by Engineering HAZOPs conducted included formal feedback from operators. Results of the HAZOPs are not consistently communicated to personnel.
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Protocol Element Hazardous Waste Manifests Waste Accumulation and Storage Waste Classification Training
Priority 3 1 2 4
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Post-Audit Activities
Prepare Draft Report Obtain Review Comments from Corporate HSE Law department Facility management
Step 2: Assess strengths & Weaknesses Consider potential impacts Evaluate management systems Set priorities for verification
Issue Final Report to Facility management Operations Corporate HSE Law department
Plan the Audit: Correspond with the facility Assemble & distribute background information Assign & communicate audit responsibilities Conduct pre-audit meeting
Step 3: Gather Audit Evidence Evaluate what needs to be done Determine depth & rigor of review Select types of evidence needed & methods to gather them Compare practices against requirements Document results
Develop Action Plan Develop proposed action(s) to address each finding Assign responsibility for corrective action Develop timetable
Step 4: Evaluate Audit Results Evaluate audit results Write audit findings
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The specific focus or goal of the data gathering; The types of data to be gathered and why; and The range of tests to be performed to confirm the validity of facility information.
This section of the manual explains the process by which (and the factors to consider) to develop a verification strategy that complements the priorities established in Step 2.
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Determine the specific objectives of the protocol steps for review and then prioritise them. Review the audit resources.
Determine the Specific Objectives of the Protocol Steps for Review and Then Prioritise Them As the auditor develops a verification strategy, he/she may still need to determine the specific objectives of the protocol steps for review and then prioritise them. This task builds on what the auditor has identified as priorities based on the assessment made in Step 2. The task of understanding and appreciating the objectives of the protocol steps can be more subtle than merely identifying a topic. For instance, suppose that an auditor has identified spill response training as an item that must be verified during the audit. In this situation, there could be two different aspects to verifying the training requirement. On the one hand, the auditor may only want to verify that all applicable employees have had training during the past year. Accordingly, the auditor will likely review training records and attendance sheets. Alternatively, if the auditor wanted to verify that training was adequate or appropriate to the level of the trainees, then he/she may take a different approach toward verification, such as talking with employees who were supposed to be trained and/or evaluating the content of the training manuals and comparing them to regulatory requirements and/or industry practices.
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Management Systems
Potential Impacts
Low Low
High
3
Weak Weak
Dig Less Deep
1
Dig Deepest
4
Strong
Dont Dig?
2
Dig Deep
After the auditor has determined how deep to dig, he/she is now in a position to select what types of information to gather and how.
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If the auditor is trying to confirm that a facility completely lacks a hazard communication programme, he/she should not expect to find any physical or documentary evidence because obviously there is no written document describing the nonexistent programme. Instead, the auditor will base this conclusion on the testimonial evidence. If the spill plan has not been updated in four years, then perhaps the auditor will need to focus efforts on gathering physical data to determine whether and how current activities compare against the elements of the plan.
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If a facility has different operations and/or different organisational structures at one location, then the auditor will want to ensure that any data-gathering activity is representative of each operation. For instance, if a facility has two different product lines, each of which is managed by a different division, then the auditor may need to go to two different sources to verify that employees received safety training. This factor should be taken into account when evaluating how much time is needed to complete a particular protocol step.
Select the Type(s) of Audit Evidence In general, there are four different types of evidence (also referred to as audit data or audit information) that can be gathered during an audit, and each can affect the quality and reliability of the audit results. Each type of evidence is associated with a particular method, and each has advantages and limitations. Physical evidence Documentary evidence Testimonial evidence Circumstantial evidence The auditor can strengthen the weight of the evidence by obtaining several different types and sources of evidence/information.
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Limitations
Documentary Evidence Definition Method Examples Advantages Something written down on paper or recorded electronically. Documentary evidence is obtained through the collection and ensuing review of something written or recorded. Facility HSE policies, standard operating procedures, reports, inspection sheets, etc. Documentary evidence allows the auditor to see the facilitys practices in a formal sense (i.e., the documentation) via a paper trail. As with physical data, the documentation itself is often a requirement for compliance. Furthermore, documentation of something makes a strong argument that an activity is indeed performed. Documentary evidence by itself does not tell the auditor that an activity actually took place. Also, its reliability can be questioned since documents can be generated or altered while preparing for the audit.
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Limitations
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Limitations
Circumstantial Evidence Definition Method Indirect evidence which conveys an overall impression. Circumstantial evidence is obtained through an auditors developing a general impression or intuitive feeling about something at the facility. The order and neatness of records and files, the attitudes of facility personnel, the apparent relevance of facility staffs background and experience to their HSE responsibilities. Circumstantial evidence can be useful in directing where potential deficiencies may lie within a facilitys HSE management systems. Circumstantial evidence is the most unreliable type of evidence and, thus, should never be used to verify compliance.
Examples
Advantages Limitations
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Testing in this context does not mean effluent or emissions sampling or chemical analysis.
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Recomputation
Retracing Data
Confirmation
An important part of the concept of testing is that auditors deliberately, independently, and systematically select the specific pieces of evidence they will look at. Examples of tests are provided below.
A test of the MSDS system might involve choosing a sample of chemicals from the facilitys master inventory, from purchasing or receiving records, or from chemicals observed during tours, and verifying that current and accurate MSDSs are on site for each chemical in the sample. (In contrast, simply noting whether there are books of MSDSs present in various locations during a tour would not constitute a test, but an observation).
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An auditor could start with personnel department or payroll records and develop a sample of employees who should have received particular types of training, then review training records to see whether all of these people had been trained.
Although testing is most commonly applied to documentary evidence, it can apply to testimonial or physical (but not circumstantial) evidence as well. For example, the auditor might test the effectiveness of spill response training by gathering testimonial evidenceasking a selected sample of employees to describe proper spill response procedures. Similarly, a sample of emergency eyewash stations might be selected and inspected by the auditor (gathering physical evidence) as a test to determine if they are in good working order and unobstructed. It is important to note that an auditor does not design a formal, rigorous test for every protocol step or topic. Conducting testing is likely to be appropriate for the protocol steps/topics associated with Dig Deepest and Dig Deep ratings (see p.167) resulting from the Step 2 assessment of strengths and weaknesses. For lower priority protocol steps, the auditor may decide to rely on inquiry and observation, rather than testing, in formulating a conclusion. Develop Sampling Strategies Even after developing a sound verification strategy, auditors can still find themselves with more data to review than time allows. When this happens, the auditor, as part of his/her verification strategy, needs to also develop a sampling strategy. Sampling is the tool the auditor utilises to look at a portion of a whole population of items. Like verification, there are strategies for effective sampling that serve to minimise bias and ensure that what the auditor looks at is representative of actual conditions at the audited facility. Indeed, the sampling strategy itself can affect the validity of the data gathered and, consequently, the validity of the conclusions reached. Sampling strategies will be discussed in detail in the next chapter of the manual.
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How to Do it Determine the specific objectives of the protocol steps for review and then prioritise them. Review the audit resources. Determine where you want to engage in a rigorous review of facility programmes and practices, based on your assessment of the following: High priorities Low priorities Where few or no systems exist Take into account what you learned in Step 1. Determine the types of audit information needed. Determine the most appropriate methods for collecting the audit data. Determine the areas where you need to design a test. Determine the most effective sampling strategy. Determine if you have enough data to evaluate whether systems are being implemented as designed. Explore selected deficiencies for underlying cause(s). Begin Step 4. Document what was looked at. Document what was not looked at and why. Summarise conclusions in working papers.
Select the types of evidence needed and the methods to gather them
What types of data will I gather and how can I collect them?
Document results
What information do I need to record to help me remember what I have learned and substantiate my conclusions?
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What evidence could you gather to address the protocol steps highlighted? Where or from whom could you gather the evidence? How could you design a test of the facilitys contractor safety programme with respect to the highlighted protocol steps? When you have decided what you could do, decide which of these data-gathering activities you would do to address the highlighted protocol steps.
3. Consider What Was Learned During Step 1 What factors learned in Step 1 drove your verification strategy?
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How would you design a test of the facilitys performance with respect to the highlighted protocol steps?
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Exercise 6B Gathering Audit Evidence Developing Verification Strategies: Hazardous Waste Manifests
Background It is now Tuesday afternoon of a one-week audit (the close-out meeting is scheduled for 10:00 a.m. Friday morning). After spending all day Monday and Tuesday morning learning how the facility manages its hazardous waste, you feel that you have a good understanding of the systems in place, and you are now ready to go out and verify. What You Understood from Step 1 About the Facilitys System for Managing Hazardous Waste Manifests
The facilitys is a large quantity generator of special (hazardous) wastes. The HSE coordinator and maintenance manager have been designated to fill out the waste manifests. Once the accumulation storage log indicates that wastes must be shipped off site because they are within two weeks of reaching an accumulation time of 90 days, the waste transporter is called and a pick-up is scheduled. The log must be periodically reviewed since there are no automatic systems to notify facility personnel that a shipment must be scheduled. Once the waste transporter picks up the hazardous waste, the facility copy of the waste manifests is retained by the Human Resources records clerk. The clerk is responsible for filing the waste manifests with the receipt copy once the signed receipt copy from the disposal facility is received.
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Exercise 6B Gathering Audit Evidence Developing Verification Strategies: Hazardous Waste Manifests
Protocol Steps Relating to Special Waste Manifests
Hazardous Waste Manifests 1. By reviewing a representative sample of Waste Manifests, verify that the facility has a program in place to accurately prepare these shipping documents and track waste loads from the point of generation to final disposition. In particular: a. Note whether or not signed Waste Manifests are returned to the producer from the disposal or treatment facility. For any that were not, document facility actions to locate the waste shipment. b. Compare the waste streams shipped off site to your list developed previously. For those materials not covered by Waste Manifests during the review period, interview staff in the operating area(s) where the waste is usually produced and determine if the waste was generated during the review period. If so, resolve how this stream was disposed of without being covered by Waste Manifests. c. Review the Waste Manifests and determine if each box or information entry has been filled out correctly.
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Exercise 6B Gathering Audit Evidence Developing Verification Strategies: Hazardous Waste Manifests
Instructions 1. Evaluate What Needs to Be Done Based on the information provided above, review the protocol steps highlighted and determine the specific objectives of those steps. 2. Select the Types of Evidence Needed and the Methods to Gather Them Identify the types of evidence that could be gathered to complete the highlighted protocol steps. In addition, identify the items or systems you will want to test, and how you will accomplish verification testing. In developing your verification strategies, consider the following:
What evidence could you gather to address the protocol steps highlighted? Where or from whom could you gather the evidence? How would you design a test of the facilitys hazardous waste consignment note programme with respect to the highlighted protocol steps? When you have decided what you could do, decide which of these data-gathering activities you would do to address the highlighted protocol steps.
3. Consider What Was Learned During Step 1 What factors learned in Step 1 drove your verification strategy?
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Exercise 6B Gathering Audit Evidence Developing Verification Strategies: Hazardous Waste Manifests
To assist in developing your verification strategy, use the worksheet provided below which will take you through the basic steps as described in this section.
Physical Evidence What evidence would you gather? Documentary Evidence Testimonial Evidence
How would you design a test of the facilitys performance with respect to the highlighted protocol steps?
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Documentary Evidence
Testimonial Evidence
Badge colours observed on site. Contractor activities on site against the facilitys safety rules.
Contractor training manual. Contractor training records. Facility contractor safety rules. Contractor sign-in log. Contract language. HSE coordinator. Site security. Contracting / Purchasing personnel.
How would you design a test of the facilitys performance with respect to the highlighted protocol steps?
Compare a sample of colour badges on contractors to the activity being conducted. Review contractor activities in comparison to the facilitys contractor safety rules.
Compare a sample of contractors on the sign-in log to the training records. Obtain a sample of contractor names and the colour badge observed and compare the colour badge to the level of training received through a records review.
Contractor understanding of the training materials and facility safety rules. Affected facility personnels understanding of the contractor safety programme and its implementation. HSE coordinator. Site security. Maintenance manager. Facility personnel who manage on-site contractors. On-site contractors (if practical). Survey a sample of contractors to test their understanding of the training provided. Survey affected facility personnels understanding of the contractor safety programme (e.g., badges).
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Documentary Evidence
Testimonial Evidence
Accumulation start dates on hazardous waste drums. Hazardous waste streams generated by the facility.
Hazardous waste accumulation storage logs. Filed Waste Manifests. Chemical purchasing or inventory lists. Annual hazardous waste reports. Purchase orders for waste disposal.
Hazardous waste accumulation storage area. Process areas where potential hazardous waste streams are generated.
Human resources records clerk. Facility personnel responsible for the accumulation area. Purchasing personnel.
HSE coordinators and maintenance managers understanding of Waste Manifests. Human resources records clerks understanding of consignment note record keeping. Affected facility personnels understanding of hazardous waste accumulation. HSE coordinator. Maintenance manager. Facility personnel responsible for the accumulation area. Human resources records clerk.
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Documentary Evidence
Testimonial Evidence
How would you test the facilitys management systems to address the highlighted protocol steps?
Compare the drums in the hazardous waste storage area to the information on the accumulation storage logs. Check the accumulation start dates on the hazardous waste drums to determine if drums are being stored over 90 days. Review facility processes to identify potential hazardous waste streams and compare to the facilitys identified waste streams.
Check consignment note signed copy from the waste disposal company, where applicable. Compare Waste Manifests versus the annual hazardous waste report. Compare Waste Manifests versus waste profiles and/or process information to verify correctness of waste classification. Compare lists versus Waste Manifests. Review purchasing / shipping records and verify that Waste Manifests are on file for a sample of shipments.
Ask the HSE coordinator / maintenance manager how they obtain the information regarding various wastes generated (i.e., waste characterisation, time generated etc.). Ask affected employees how they manage the hazardous waste accumulation area. Ask the records clerk how she/he manages the hazardous waste consignment note records (e.g., retention, signed copy from the waste disposal company etc.).
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Sampling Strategies
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Specify what you are trying to confirm. Consider the nature of the regulatory or internal standard to accurately identify the boundaries of the population under review.
Estimate size of population through: Review of selected documents. Observations made during initial understanding of health, safety and environmental management systems in place. Interviews with facility personnel. Pay attention to major subsets or key segments of the population that need to be included in the review. Define population before starting to sample.
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Sampling Methods
Judgmental
Probabilistic
Random Block Interval Stratification
3. Select Sampling Method Judgmental Sampling Judgmental sampling is used to gather examples of deficiencies or problems to support an auditors assessment of a weak or improper health, safety and environmental management system. Sampling is directed toward segments of the population where problems are likely to exist. Judgmental sampling cannot be used to draw compliance conclusions about an entire population because it focuses on only a portion or subset of that population. Judgmental sampling can be used as a first step to provide the auditor with an indication of whether to use a probabilistic sampling technique such as random, block, interval, or stratification sampling.
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Block. The objective is to analyze certain segments of records or areas of the facility. For example, if files were arranged alphabetically, in numerical order, or chronologically, one or more blocks (e.g., all the Es, records numbered 51 through 75, or January and June files) could be selected. While the block method is easy to use, it neglects entire segments of the population. Interval. The objective of interval sampling is to select samples at specific intervals (e.g., every nth segment of the population is analyzed) with the first item selected at random. Increased confidence is achieved where several intervals with different random starts are used. Stratification. The objective of stratification sampling is to arrange items by categories (e.g., high versus low effluent volumes; new versus experienced employees; regular versus weekend or off-shift transactions) based on the auditors judgment that the probability of finding an exception is different for different segments of the population and/or that there are categories within the population that represent higher inherent risks. Higher risk categories may, thus, receive greater review and testing. Once the population has been stratified, random, block, or interval sampling can be applied to select items within each segment.
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There are two ways to determine sample size: Statistically Auditors judgment In most HSE audit situations, it is both appropriate and adequate to develop sample sizes based upon professional judgment. The auditor must be sure that the sample size is large enough to be representative of the total population.
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Document rationale for selecting sample. Document how sample was selected. Include in working papers: Population under review How and why population was selected Type of sampling method employed Reasons sampling method was used Potential bias in sample Sample size and reasons for selecting sample size
Size of Population
(These percentages do not imply any specific confidence level but are intended as guidelines only.) A Suggested minimum sample size for a population(s) being reviewed which is considered to be extremely important in terms of verifying compliance with applicable requirements and/or is of critical concern to the organisation in terms of potential or actual impacts associated with noncompliance. Suggested minimum sample size for a population(s) being reviewed that will provide additional information to substantiate compliance or noncompliance and/or is of considerable importance to the organisation in terms of potential or actual impacts associated with noncompliance. Suggested minimum sample size for a population(s) being reviewed that will provide ancillary information in terms of verifying overall compliance with a requirement.
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Select items in entire population by chance (e.g. using a random Number table)
Block Sampling
Arrange items by certain segments or clusters and randomly select some clusters as your sample
Interval Sampling
Stratification Sampling Arrange items by important categories or subsets, then sample within the groups
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Use each sampling method (random, block, interval, and stratification) on a set of hazardous waste training records to determine if affected employees have received refresher training within the last year. Determine whether there are any advantages or disadvantages in using one sampling method versus another.
Background During your audit of the ACCO Chemical Company, you need to verify whether the site is complying with the corporate requirement that all employees who have responsibility for managing or handling hazardous waste have received annual refresher training and that the training is documented. You have learned that there are three categories of employees who are involved with hazardous waste management:
Within each production department, there are designated operators, who have routine, day-to-day responsibility for managing a variety of wastes that are generated as a result of frequent cleaning of reactors used for batch specialty chemical production. Other production employees, who might on occasion generate hazardous waste, know that they are not to handle it themselves but are to contact one of the designated operators. If the designated operators are not properly trained, the probability of waste mismanagement is high.
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Maintenance workers handle a much smaller number of relatively constant hazardous waste streams on an infrequent basis. The wastes most frequently handled are used oil and spent solvents from cleaning operations. Occasionally, maintenance workers encounter other wastes (when they service plant equipment (pumps, compressors), for example). Supervisors have virtually no hands-on responsibility for waste management. However, because they are ultimately responsible for the actions of the workers they supervise, it is company policy that all supervisors (not just those in production or maintenance) must receive annual training to maintain awareness.
Based on the above job descriptions and the employee roster, you have developed the list shown in Table 1, which indicates that there are 80 employees total who require annual hazardous waste refresher training according to company policy. The plant environmental coordinator has provided you with his list of employees who attended the two most recent refresher training sessions, both held within the past 12 months (see Table 2). Instructions Depending on the group to which you are assigned, you are to use one of the following methods to create a sample of approximately 25 percent of the 80-employee total (corresponding to the suggested minimum size of sample in column A using the table on page 9-10): Random Block Interval Stratification
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Job Category Maintenance Supervisor Supervisor Operator Operator Operator Supervisor Operator Supervisor Operator Maintenance Supervisor Operator Operator Operator Supervisor Operator Supervisor Operator Maintenance Supervisor Maintenance Operator Supervisor Supervisor
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B B
S S Y
I R B R B I S S
Y N N Y N
S R R R B B S I
Y Y N N
R R B R R B
I S S
Y Y N Y
I R
Y Y
S R I S
Y Y N
B B B I
N Y
I R
Y Y
I B R B B R I
Y Y
Y Y
R I S N
S R I S
Y Y N
S I
Y Y
B B B B I S
Y N Y Y
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Post-Audit Activities
Prepare Draft Report Obtain Review Comments from Corporate HSE Law department Facility management
Step 2: Assess strengths & Weaknesses Consider potential impacts Evaluate management systems Set priorities for verification
Issue Final Report to Facility management Operations Corporate HSE Law department
Plan the Audit: Correspond with the facility Assemble & distribute background information Assign & communicate audit responsibilities Conduct pre-audit meeting
Step 3: Gather Audit Evidence Evaluate what needs to be done Determine depth & rigor of review Select types of evidence needed & methods to gather them Compare practices against requirements Document results
Develop Action Plan Develop proposed action(s) to address each finding Assign responsibility for corrective action Develop timetable
Step 4: Evaluate Audit Results Evaluate audit results Write audit findings
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There is a problem
Everything is OK
Good Management Practice Observation An identified weakness with respect to general (industry) standards of good practice in health, safety and environmental management
Management Systems Observation An identified weakness with respect to the processes used by a facility to achieve and maintain conformance with established standards, including programs, policies, equipment, administrative controls etc.
Local Attention Item An isolated anomaly found in existing programs where regulatory or company standards of performance exist
In order to be sufficient to support the audit findings, audit evidence should be: Relevant Objective Persuasive The first two properties relate to the appropriateness of evidence. The last requirement, persuasiveness, refers to its strength.
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The auditors sampling strategy could introduce bias. For example, he/she might review all of the incident investigation reports in the Safety Coordinators files and conclude that they were being filled out correctly and comprehensively, without realising that there was a completely separate file in the Maintenance Supervisors office, which addressed all of the incidents relating to maintenance personnel.
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The auditor could be making some implicit assumptions, based on his/her prior knowledge and experience at other facilities, that are, in fact, not true for the facility being audited. This could introduce an inappropriate subjective element into the evaluation process. For example, an auditor might assume that all maintenance personnel handle hazardous waste and, therefore, require annual refresher training, when this might not be the case. Facility personnel could overstate their adherence to internal procedures if they feel a need to appear more confident and efficient than they really are.
Persuasiveness Evidence is persuasive when it forces a specific conclusion to be drawn and when another reasonable and knowledgeable person would not challenge the validity of the conclusion nor propose a conceptually different alternative. For example, the evidence that life does not exist on the planet Mercury is very persuasive, but the evidence that there is no extraterrestrial intelligence elsewhere in the universe is less so. In the HSE context, the evidence is persuasive that the facility has a fire extinguisher inspection programme when fire extinguishers are tagged with inspection stickers; the facility has records indicating that inspections are conducted; and the person in charge of the inspections knows when they were last done and when the next inspections are due. The table below indicates some examples of relevant, objective, and persuasive evidence to support particular hypotheses.
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Examples of Sufficient Evidence Written hazardous waste training programme has been prepared. Training records for personnel involved in hazardous waste management are on file. Training instructor has the necessary qualifications and expertise to teach the course. Written respiratory protection programme has been prepared. Fit testing and medical clearance have been performed. Periodic inspections of respirators are conducted. Personnel are trained in the use and maintenance of respirators.
Data Gathered
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Critically review the conclusions. It is essential in this step to critically analyse the rationale for those protocol topics where the team did not identify any findings. For example, if no problems were found with respect to the use of respiratory protection equipment, ask yourselves: Did we talk to the right people? Are we sure that we accurately identified the affected population? Could there be other plant areas or job tasks where respirators are used (e.g., in the laboratory, unloading rail cars, etc.)? Play devils advocate. Finally, pause for a moment to ask yourselves what you could have missed. Given what you have learned about the facilitys programmes, ask yourselves, what is the worst that could happen, and make sure the actions you took to address the protocol area were likely to catch the worst case, at least for your dig deepest and dig deep priorities.
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Ensure factual accuracy. Because the written findings provide the basis for the exit meeting with facility management, it is critical that each finding listed be factually accurate. Each team member, in reviewing the wording of the finding, should make sure he/she has the facts to substantiate each exception noted. Review with facility HSE coordinator. Prior to the exit meeting, the audit team should review the written findings with the facility individual who is responsible for day-to-day HSE compliance. He/she will want to know what the team is presenting to the boss before it is presented. Also, the coordinator may have some legitimate questions and comments on the findings that the team needs to clarify prior to the exit meeting.
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Isolated anomalies found in existing programmes where regulatory or company standards of performance exist (e.g., an occasional signature omission from documents requiring signatures; a single exit sign not lighted). Minor items that lack specific criteria (e.g., MSDSs available but not in each of several locations; responsibilities for responding to complaints or incidents not well coordinated). Items that are outside the audit scope (e.g., a safety deficiency observed during an environmental audit).
An item should never be for local attention if it is: An exception to a regulatory or company policy requirement and is associated with a flaw in the management system. A repeat of a finding from a previous audit. An immediate danger to health, safety, or the environment.
Example Local Attention Only Items The large alcohol tank in the tank farm does not have a drain plug in place to back up the spring-loaded valve. Two unlabelled 25-liter drums were observed on the concrete pad behind the fire water pump building. (Containers elsewhere at the site were labelled properly.) One wooden ladder being used outside the aerosol gas house was found to be unstable. Facility personnel removed and disposed of it immediately. (The team did not note any other defective ladders.)
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You may find that this opinion may change in the light of additional background information. For example the recommended answers for set 2 would be dependent on what the ventilation hood is used for, its toxicity and the frequency of exposure to employees.
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Identify common findings. Look for situations where two or more of the individual findings listed may relate to one basic problem, and may represent a system deficiency. Look for patterns or trends. In reviewing the findings, try to find whether any patterns emerge which suggest that several findings should be combined. Ask yourselves whether there are several findings that, when viewed as a group, may have greater significance. Be alert to systemic issues. Ask yourselves whether the symptoms observed (errors, omissions, etc.) are manifestations of a more fundamental systems weakness.
For example, the audit team may have several findings all related to the same general topic, such as training, and the findings themselves all point to the underlying management systems deficiency that there is no means to identify and track HSErelated training.
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Individual Individualfindings findingsrelated relatedto: to: Hazardous Hazardouswaste wastetraining training Spill Spillresponse responsetraining training Hazard Hazardcommunication communicationtraining training Respirator Respiratoruse usetraining training Confirmed Confirmedspaces spacesentry entrytraining training
The Themanagement managementsystem system deficiency: deficiency: No Nomeans meansto toidentify identifyand andtrack track HSE-related HSE-relatedtraining training
However, management systems observations are not always so easy to recognise during an audit. Thus, the team may want to relate the findings back to the management systems processes. In Step 1, the team gained a lot of insight into how HSE compliance is supposed to be managed at the facility. As the team verified conformance with the facilitys system, they most likely uncovered some gaps and breakdowns. As a means of discerning the management systems deficiencies, the team should try to relate individual findings to one or more of the management processes utilised by the facility to manage its HSE matters. The table on the following page describes how the individual findings can be categorised within the various management processes to assist in developing management system observations.
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The facility has not developed an air emissions inventory. The facility has not conducted a noise survey. The facility has not characterised 12 different waste streams. The facility has not conducted workplace monitoring for xyz chemicals. The facility has not conducted 7 of 12 monthly safety inspections. The facility does not document its fire extinguisher inspections. Respirators were observed stored out on shop floor.
There is no comprehensive system for HSE-related inspections. or Responsibility and accountability for the HSE inspection function have not been clearly defined.
2. Perform a Cause and Effect Analysis Another technique to develop a management systems observation is to identify the underlying causes associated with compliance and good management practice findings. The following examples illustrate this approach.
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Finding During the audit, the team observed that the employees hand could be pulled into the mobile pumping unit because the unit does not have a guard. Upon investigation, the team learned that the guard had been removed to make access to the equipment easier and a system is not in place to periodically verify that guards are in place where required. Incident/Effect The belt-driven pulley on mobile pumping unit 5123 does not have a guard. Possible Causes Training Inspection Lack of equipment
To make this technique truly useful, the cause-effect model begins at the incident, or effect, and proceeds backward by asking why until the appropriate management system conclusion is reached.
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Cause 2
Cause 1
Incident
Cause 3
Root cause
After the cause (i.e., the main point to communicate to management) is identified, the team is in a position to write a management systems observation.
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2. Distinguish Between Performance and Documentation Some regulatory or corporate requirements specify that a particular activity or programme be conducted, but do not specify that the completion of the activity or programme be documented. In other cases, regulatory or corporate requirements specify that the activity or programme be conducted, and that it be documented to verify that it was conducted.
Dont say... Weekly hazardous waste inspections are not conducted. Weekly ladder inspections are not conducted. If you mean... Weekly hazardous waste inspections are not documented. Weekly ladder inspections are not documented.
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4. Do Not Draw Legal Opinions Legal judgments, interpretations, and conclusions should be avoided when writing audit findings. Generally speaking, legal conclusions can be characterised by words such as in violation of, not in compliance with, as required by, etc.
244
5. Give Regulatory or Company Policy References Because the basis for a finding may not always be clear to the report recipient, particularly if the report recipient is an individual who is not involved with environmental, health, and safety issues on a daily basis, regulatory or company policy references should be included.
Poor Required annual hazardous waste training has not been conducted within the past 18 months. Required annual hearing conservation testing has not been conducted within the past 18 months. Improved Annual hazardous waste training has not been conducted within the past 18 months. (40 CFR 265.16 and XYZ Company Policy, HAZWASTE 3.2) Annual hearing conservation training has not been conducted within the past 18 months. (29 CFR 1910.95 and XYZ Company Policy, HEARCON 4.7)
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The lack of documented confined space entry procedures for the manufacturing operations may lead to an injury/accident.
7. Use Familiar Terminology Not all recipients of the report will be involved in health, safety and environmental activities on a daily basis and, thus, they may not be as familiar with the health, safety and environmental acronyms, abbreviations, and regulatory jargon as the auditors are.
Poor
The facility does not have pollution prevention equipment to prevent exceedances of TSS, BOD, and oil and grease in its discharges to the POTW.
Improved
The facility does not have pollution prevention equipment to prevent exceedances of total suspended solids (TSS), biochemical oxygen demand (BOD), and oil and grease in its discharges to the publicly owned treatment works (POTW). Four of 12 piping and instrumentation diagrams (P&IDs) were out of date.
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9. Avoid Contradictory Messages Activities or programmes presented in a positive light, when the ultimate message will involve pointing out deficiencies, may confuse the reader and obscure the real message being conveyed.
Poor Although the facility has a well-written waste analysis plan, it does not include parameters for each hazardous waste analyzed or the frequency of analysis. Improved The facilitys waste analysis plan does not include the following: a. Parameters for each hazardous waste analyzed. b. Frequency of analysis.
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10. Group Similar Findings Rather than state several individual findings, look for patterns or trends and group similar findings to more fully convey the message.
Individual Quarterly Discharge Report The analysis results for one of 13 samples of the wastewater discharged to the publicly owned treatment works (POTW) was not included in the quarterly discharge report. Reporting of Analytical Results Analytical results for samples taken at internal outfalls were not reported to the POTW. Grouped Reporting of Sample Events to POTW In reviewing quarterly monitoring reports and analytical data, the team noted the following: a. One of 13 samples taken and analyzed of the wastewater discharged to the publicly owned treatment works (POTW) was not included in the quarterly discharge report. b. Analytical results of samples taken at internal outfalls were not reported to the POTW.
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11. Write Management Systems Observations To be effective, management systems observations need to be: Crisp To the point (one point at a time) Clearly framed Expressed in terms meaningful to managers
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Uses 208 words Includes extraneous information on: The reorganisation itself The Safety department Greater emphasis on HSE issues Top management and supervisors job descriptions Unnecessarily muddles the basic accountability issue with the lesser question of who should sign HSE documents and correspondence.
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Twenty-nine words, or an 86 percent reduction in length. Crisp and to the point, which is that of joint accountability. Clearly framed as a management issue, that of clarifying accountabilities. Much more easily read, understood, and acted upon.
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12. Consider Using a Template Consider using a template to prepare a preliminary draft of your findings.
Template for Writing Findings Template The Statistical Finding Fifteen of a sample of 30 of the 52 employees who routinely enter confined spaces did not receive training during the last year The Have/Do Finding The facility does not have an air pollution permit to operate the three boilers in Powerhouse B on site Facility personnel do not conduct or document inspections of the hazardous waste accumulation area Finding [# of deficiencies] of a sample of [# in sample] of [# in universe] of what is wrong
Who or what / does not / do not have / what they do not have
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The team was told that what the team was told
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John Collins, Brenda Fields, Bob Taylor, Jane Smith Ralph Gold
MM/DD/YY
Prepared by
John Collins
# 1
Exception We could not verify that waste manifests were received from TSDFs (Treatment, Storage and Disposal Facility) within 45 days of shipment. Current storage of emergency response equipment may result in increased likelihood of failure. There is minimal on-site compliance with corporate or department contractor safety policy and procedures. Some of the air sources are being operated without proper permits and some are not adequately maintained. The facilitys central MSDS file is very neat and accessible to those employees who should see it. Not all materials used or stored by the facility have MSDSs (Material Safety Data Sheets) in the central file. Those MSDSs reviewed appeared complete and contained the appropriate information. There are no toe boards and missing hand rails. A discrepancy exists among the frequency of safety inspections.
Critique
6 7
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10
11
12
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John Collins, Brenda Fields, Bob Taylor, Jane Smith Ralph Gold
MM/DD/YY
Prepared by
John Collins
#
1
Exception
We could not verify that waste manifests were received from TSDFs within 45 days of shipment. properly
Critique Implies auditor has not done job Need to include citation What does TSDF stand for? Should not use ambiguous terms
(e.g. may, increased)
Current storage of emergency response equipment may result in increased likelihood of failure.
So what? Which equipment? Not specific Does not describe problem to help
site correct it
There is minimal on-site compliance with corporate or department contractor safety policy and procedures. Some of the air sources are being operated without proper permits and some are not adequately maintained.
The facilitys central MSDS file is very neat and accessible to those employees who should see it. Not all materials used or stored by the facility have MSDSs in the central file. Those MSDSs reviewed appeared complete and contained the appropriate information.
What does MSDS stand for? Combines good and bad findings Do not use not all or appeared
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Critique So what? How many? Where? What is the discrepancy? Needs clearer description Avoid using names
7 8
A discrepancy exists among the frequency of safety inspections. Ron Kline and Seth McGee were not familiar with the companys hazard communication programme or could identify where MSDSs were located. The facilitys computer monitoring programme for permit expiration was found to lack a procedure to make sure that all permits were entered into the computer system to begin with. No inspection and maintenance records were available to the audit team and no documented procedures for rail car loading / unloading. There is insufficient personnel to manage all HSE matters given the requirements put forth in the operating manuals which describe the gamut of environmental, health, and safety regulations.
10
11
12
The facility often goes through changes in operations which result in additional environmental impacts only to find notifications to permit conditions and variation in employee safety conditions. A management system should be addressed to fix this problem.
Bad English Whats the problem? Should the finding include a recommendation?
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Post-Audit Activities
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Post-Audit Activities
Pre-Audit Activities On-Site Activities
Step 1: Understand Management Systems Conduct opening meeting Conduct orientation tour Review audit strategy Understand details of management systems
Post-Audit Activities
Prepare Draft Report Obtain Review Comments from Corporate HSE Law department Facility management
Step 2: Assess strengths & Weaknesses Consider potential impacts Evaluate management systems Set priorities for verification
Issue Final Report to Facility management Operations Corporate HSE Law department
Plan the Audit: Correspond with the facility Assemble & distribute background information Assign & communicate audit responsibilities Conduct pre-audit meeting
Step 3: Gather Audit Evidence Evaluate what needs to be done Determine depth & rigor of review Select types of evidence needed & methods to gather them Compare practices against requirements Document results
Develop Action Plan Develop proposed action(s) to address each finding Assign responsibility for corrective action Develop timetable
Step 4: Evaluate Audit Results Evaluate audit results Write audit findings
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Responsibilities
To ensure that the audit results Meeting this objective is typically part are clearly communicated to the of the audit teams responsibility. This appropriate levels of management. is accomplished by means of a formal, written audit report, as described in this section of the manual. To ensure that all audit findings are addressed by management through the implementation of a formal corrective action process. Meeting this objective is typically the responsibility of line management, although the audit team may be asked to make recommendations, review proposed action plans, and/or track the implementation and closure of corrective action. Meeting these last two objectives is frequently among the responsibilities of the audit programme manager and team leader(s).
To evaluate the effectiveness of the audit and provide suggestions for improving future efforts. To share lessons learned during the audit, especially to similar facilities.
In this section of the manual, we discuss: Preparation of audit reports Protection of audit results Audit policy statements Quality assurance in the audit process
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To document the scope of the audit and the audit teams conclusions regarding the facilitys compliance status. To provide appropriate levels of management with information on the results of the auditinformation sufficient to meet the needs of the reports recipients and consistent with the overall objectives of the audit programme. To initiate corrective action so that once exceptions to applicable requirements have been identified, action steps are set in motion to correct the deficiencies found.
A strong linkage exists between the reports purpose and the overall audit programmes objective. For example, where the primary objective of the audit programme is to provide assurance to management, the purpose of the audit report is to provide top management with information on the more significant findings. Likewise, when the primary purpose of the audit programme is to provide plant management with information on the environmental, health, and safety status of the facility, the purpose of the audit report is to help facility managers.
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Most, but not all, programmes today require dissemination of audit reports to high levels of management. Increasingly, top corporate managers and/or boards of directors expect to be informed of audit results. There may, however, be some audit findings (local attention items) that do not require reporting beyond the facility manager level.
An example of a hierarchical reporting scheme is shown on the following page. Example of a Hierarchical Reporting Scheme
Who Facility HSE staff Facility manager Corporate HSE Affairs; Law Department; division or group management Corporate management How Daily communication Exit meeting; draft and final reports Draft and final reports What All deficiencies noted All deficiencies noted All deficiencies noted, except local attention items Significant matters; overall patterns and trends; general programme status Overall HSE performance; most significant matters
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Board of directors
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Audit results should be reported in a manner that is clear and easily understood by the recipient of the report. Audit findings need to be described in an appropriate managerial context, which takes into account the recipients extent of familiarity with the subject matter. They also need to be free of jargon and unfamiliar terminology. Audit reports should also be factual, unbiased, and free from distortion. Findings should be prepared without prejudice and expressed as pertinent statements of fact, which are supported by sufficient, valid, and documented evidence gathered during the audit. The focus of the audit report should be on the findings developed during the audit and, depending on the scope of the audit programme, recommendations where necessary.
NPC/20365/Mod6_158Audit_Skills_Training_Handbook.doc Copyright 2005 by Arthur D. Little Ltd. All rights reserved.
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On the basis of its review, the audit team believes that the environmental, health, and safety programmes and practices that were reviewed substantially meet governmental and internal requirements. On the basis of its review, the audit team believes that the environmental, health, and safety programmes and practices that were reviewed generally meet governmental and internal requirements, except as noted below. On the basis of its review, the audit team believes that the environmental, health, and safety programmes and practices that were reviewed require improvement to meet governmental and internal requirements. On the basis of its review, the audit team believes that the environmental, health, and safety programmes and practices that were reviewed require significant improvement to meet governmental and internal requirements.
The hazardous waste management programme is clearly understood by staff throughout the facility and is documented to demonstrate commitment to compliance. The bloodborne pathogens programme is well developed, organised, and tracked.
To avoid confusion, it is important that both the auditors and facility personnel have a common understanding of what is meant by a strength. A strength need not necessarily be a unique, world class, or extraordinary practice. On the other hand, the mere fact that a facility is in compliance with a regulatory requirement is not an example of a strength.
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Developing clearly stated and well-defined descriptions of roles and responsibilities for all HSE activities, and communicating those to facility staff. Establishing well-developed plans and written procedures, as appropriate, for undertaking compliance activities which are communicated and understood by all key HSE staff. Undertaking a facility programme to periodically review and monitor HSE compliance and to identify problems. Developing an active, formal training and awareness programme for key staff in all areas of HSE requirements.
Lastly, we believe the facility should continue in its efforts to identify and assess site contamination and to develop appropriate remedial plans.
NPC/20365/Mod6_158Audit_Skills_Training_Handbook.doc Copyright 2005 by Arthur D. Little Ltd. All rights reserved.
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Exception
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The person asserting the privilege is a client of the attorney to whom the information is entrusted. The communication is made to the attorney or someone working for the attorney (e.g., an audit team). The attorney is engaged in preparing a factual investigation or legal opinion for the client. The communication is kept confidential and the privilege is not breached voluntarily or inadvertently waived, i.e., information is not shared freely or recklessly.
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Audit Element 1 Technical Knowledge HSE science and technology Facility operations Regulatory requirements HSE management systems Audit procedures and techniques Interviewing Using the protocol Keeping working papers Writing findings Personal Attributes Clarity in oral communication Foreign language capability Diplomacy, tact, and listening skill Independence and objectivity Personal organisation and time management Ability to reach sound judgments based on objective evidence
Score* 2 3 4 5
Comments
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Re: Environmental, Health, and Safety Compliance Audit Dear __________: Confirming our telephone conversation of *[Date], we will conduct an environmental, health, and safety compliance audit of the *[Facility name] Plant the week of *[Date]. The audit will address air pollution control, water pollution control, spill control and emergency response planning, solid and hazardous waste management, underground storage tanks, soil and groundwater contamination, drinking water management, PCB management, employee safety, loss prevention, and industrial hygiene as well as company policies, guidelines, etc. The audit team will arrive on site on *[Date]. They would like to meet with you and other appropriate personnel on Monday morning to briefly describe the audit and to answer any questions. At that opening conference, it would be helpful if the team could receive a brief description of the current organisation and operations at the facility as well as an orientation tour. Those facility personnel involved with environmental, health, and safety activities will be needed on site for discussions during the audit week. At the conclusion of the audit, the audit team will again meet with you and other appropriate personnel to discuss the teams findings. This closing conference is a critical part of the audit, and it is very important that you be present.
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*[Name] *[Title] *[Company] The audit team will make its own lodging and transportation arrangements, including cars for use during the week. A dedicated meeting room (work area) is needed at the facility with one large conference table or several smaller tables to accommodate the team members and their working papers. Also, access to a telephone and a copier would be helpful. To assist us in our preparation, we would appreciate having the facility complete the enclosed pre-audit questionnaire (Attachment 1), and provide a copy of as many as possible of the applicable items listed in Attachment 2. The pre-audit documents should be sent to *[The Team Leader] s attention by *[Date]. Please do not hesitate to call me if you have any questions about this audit or the Environmental, Health, and Safety Audit Programme in general. Thank you for your assistance in these matters. Sincerely,
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General Information
1. Number of Employees on-site 2. 3. 4. 5. 6. 7. 8. 9. Number of Contractors (Firms) onsite Number of Contractors employees on-site (daily average) Number of Employees in Company Number of shifts worked (please specify times) Products Annual production volume Time company has operated at this site Nature of any previous industrial activities on this site 1. 2. 3.
10. Name(s) of Doctors and Occupational Nurses on-site and % time in attendance
1. 2. 3. 4.
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II Locality/Neighbourhood Description
1. Nature of facility location e.g., commercial, industrial, residential, agricultural, rural Are there any schools, hospitals, nursing homes, prisons, churches or other public buildings within two kilometres of the facility? Are there any nature reserves, national parks or sites of specific scientific interest within two kilometres of the facility? Distance to nearest industrial neighbour from the fence line Nature of neighbouring industrial activities Describe any major hazard installations within two kilometres of the facility and distance Distance to nearest residential property Approximate size of the population near this facility (see table below) 0-100 0-100 0-100 100-1000 100-5000 100-10,000 +1000 +5000 +10,000
2.
3.
4. 5. 6.
7. 8.
Number of complaints per year received from the local community related to HSE issues
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10. Nature of any local community activities in which the site participates
more than 1 kilometre 0.5-1 kilometre adjacent to facility boundary within facility
12. Is the facility affected by any natural hazards, e.g., earthquake, hurricane, flooding? 13. List any off-site facilities (warehouses, processing units)
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List site-specific written HSE policies and procedures below or attach an index if preferred
2.
Please provide an organisation chart showing HSE management structure and responsibilities Who is responsible for identifying training needs? Who is responsible for developing and implementing training programmes?
3.
4.
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5.
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Name: Title:
No No No No No No
Yes
No
N/A
3.
Yes
No
N/A
Yes
No
N/A
5.
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No No No No No
2.
Is there a preventative maintenance programme covering maintenance of Yes equipment and machinery, and associated protection? Are equipment inspections conducted to review the safe working condition(s) of the equipment/machinery? Are all lifting appliances examined and certified? Are all pressure vessels tested and certified? Does the facility have procedures for employees to report faults and for corrective action? Yes
No
N/A
3.
No
N/A
4. 5. 6.
No No No
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2.
Yes
No
N/A
3.
Yes
No
N/A
4.
Yes
No
N/A
5.
6. 7.
Yes Yes
No No
N/A N/A
8.
Yes
No
N/A
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11. Please complete the following table or supply copy of internal list:
Main Hazardous Materials, Goods and Substances used and stored on-site
Type of material e.g. Solvent Use Plant degreasing Approximate quantity used per year 1000 kg Maximum quantity stored on site 10 kg Type of storage4 AST Storage Area Description5 Covered concrete pad Spill6 containment type and capacity (m3) 15m with retention basin
Notes: 1 Indicate major hazardous materials used in operations or activities, and include potentially hazardous waste materials 2 Describe use of hazardous material listed, for example, boiler/furnace fuel, degreasing/metal cleaning chemical, wastewater treatment chemical, etc. 3 Indicate use per year in kilograms or litres 4 Please describe the type of container(s) the material is stored in using one of the following symbols : AST: Aboveground non-buried storage tank D200: 200 Litre drums UST: Buried underground storage tank D25: Approx. 25 litre or smaller O: Other (please specify) e.g., IBC/containers/piles 5 Briefly describe storage area (for example, inside, outside, covered, fenced, locked, restricted access, fireproofed etc.) 6 Indicate type of spill containment provided, if any (for example, retention basin, collection sump, oil/water separator, paved/sealed area, concrete pad, curbing, bunded area, etc,) and indicate by 'yes' or 'no' if the containment will retain firewater in the event of an emergency.
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2.
Yes
No
N/A
3.
Have any major modifications been made to processes over the past two Yes years? e.g. machinery replacements If so, what were they?
No
N/A
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E Hazardous Work
Who is responsible for hazardous work programmes at the facility? 1. Has the facility conducted formal risk assessments of hazardous work activities? (a) Hot work (b) Confined spaces (c) Energy isolation work (d) Working at height (e) Other (please specify) 2. Has the facility established documented procedures for hazardous activities, e.g. (a) Permit-to-Work/Approval procedures (b) Pre-use/activity inspections (c) Issue of personal locks (d) Buddy system ( for lone working) (e) Engineering controls, e.g guarding (f) Provision and use of personal protective equipment (g) Other (please specify) Name: Title:
No No No No
No No No No No No
296
3.
Are Work Permits/Approvals issued for: (a) Hot work (b) Confined spaces/Entry work (c) Electrical work (d) Working at heights (e) Contractor Control (f) Other (please specify)
No No No No No
4.
Is specific training provided or qualifications required for employees involved in hazardous activities? Yes (Please ensure training topics are included in your answer to section III, question 5.)
No
N/A
297
F Electrical Safety
Who is responsible for electrical safety programmes at the facility? 1. Has the facility conducted risk assessments for work on electrically energised equipment and electric circuits? What preventative and protective safety measures are in place, e.g. earthing, fuses and circuit breakers? Name: Title: Yes No N/A
2.
3.
Is a lock-out/tag-out programme in place at the facility for electrical and other energy isolation? Are regular inspections conducted to review the safe working condition(s) of the electrical equipment? Is specific training provided to/qualifications required for employees involved in electrical work? (Please ensure training topics are included in your answer to section III, question 5.)
Yes
No
N/A
4.
Yes
No
N/A
5.
Yes
No
N/A
298
G Work at Height
Who is responsible for working at height programmes at the facility? 1. Does the facility have personnel or contractors working at heights? (a) Routinely, as part of their work activities, e.g. Facilities engineer (b) Non-routinely 2. Has the facility conducted risk assessments on working at height activities? What controls are in place to reduce risks, e.g. (a) Permits-to-Work (b) Harnesses (c) Personal protective equipment (d) Buddy system (e) Others (Please specify) Yes Yes No No N/A N/A Name: Title:
Yes
No
N/A
3.
No No No No
4.
Does the facility have an inspection and maintenance programme for ladders and scaffolding? Does this include pre-use inspections, tagging and approvals?
Yes Yes
No No
N/A N/A
299
H Noise Control
Who is responsible for noise control programmes at the facility? 1. What are the main sources of noise at the facility? Internal Yes External Can be heard outside factory building Yes Name: Title:
No
2.
Are there any regulatory limits for noise at the facility? (a) environmental (b) occupational Yes Yes None Less than 5 5 - 10 More than 10 No No N/A N/A
3.
In the last three years, how many times has the facility received complaints from different neighbours relating to noise? (please tick)
300
4. 5.
Does the facility operate its own freight transport? Are there transport movements before 06.00 and after 22.00 hours? Are there any loading or unloading operations before 06.00 and after 22.00 hours?
Yes Yes
No No
N/A N/A
6.
Yes
No
N/A
301
1.
2.
3.
Does the facility have an approved list of PPE and/or an approved list of suppliers? Which PPE does the inspection and maintenance activities cover?
Yes
No
N/A
4.
5.
Is there a formalised inspection/maintenance programme? (a) Who inspects? (b) How often?
Yes
No
N/A
6.
Is training provided to employees involved requiring PPE? (Please ensure training topics are included in your answer to section III, question 5.)
Yes
No
N/A
302
Yes Yes
No No
N/A N/A
Yes
No
N/A
5.
Yes
No
N/A
303
Yes
No
N/A
4.
Who inspects and maintains first aid equipment regularly and how often?
Please attach a summary of accidents/incidents over the past 12 months (if easily available).
304
5.
Are medical examinations provided by the facility? (a) Pre-employment (b) Annual check-ups (c) Critical situations, e.g. exposure to hazardous substances pregnancy return to work after injury/illness persons under 18/over 60 terminal diseases other (please specify) Yes Yes Yes Yes Yes No No No No No N/A N/A N/A N/A N/A Yes Yes No No N/A N/A
6.
Which general welfare and wellness programmes are provided for employees?
305
Yes
No
N/A
Yes
No
N/A
3.
Yes
No
N/A
4.
5.
Yes
No
N/A
306
6.
Does the facility provide instruction, training, and testing of emergency plans? Please specify
Yes
No
N/A
7.
Date:
307
9.
Has the facility experienced any explosions or fires over the past: (a) ten years (b) five years (c) two years Yes Yes Yes No No No N/A N/A N/A
10. Has the facility experienced any near-misses involving explosions or fires over the past: (a) ten years (b) five years (c) two years 11. Of these, how many have been reportable to a government agency Yes Yes Yes No No No N/A N/A N/A
308
2.
Yes
No
N/A
3.
4.
Which air pollutants emitted from the facility are required to be monitored by a government agency? If none, state none Which types of air pollution control equipment are installed, e.g. scrubbers, dust filters? Does the plant operate planned maintenance procedures for its air pollution control equipment? State average number of public complaints for last three years attributed to air emissions from the facility, e.g. odour, dust, VOCs, smoke
5.
6.
Yes
No
N/A
7.
309
8.
How many cooling towers or static water tanks are located in the facility? Are 6-monthly chlorinations carried out on these to prevent growth of legionella pneumophilia? Yes No N/A
9.
Yes
No
N/A
310
Yes
No
N/A
2. 3. 4.
Yes
No No No
Does the facility conduct any effluent monitoring? Yes Does the facility make use of an onsite wastewater treatment system prior to effluent discharge? If the facility has own wastewater treatment plant, how is the sludge disposed of Is any process wastewater recycled? Yes Does any portion of the facilitys drinking water supply come from onsite wells or surface water sources? Yes
5.
6. 7.
No
N/A
Yes
No
N/A
311
O Waste Management
Who is responsible for waste management programmes at the facility? 1. Does the facility generate wastes that are defined as hazardous or special under government regulations? Please provide details in the Table below (question 6). Does the facility require/have a permit or license for its waste activities? Does waste treatment and/or disposal take place/ever taken place on-site? Please specify Name: Title:
Yes
No
N/A
2.
Yes
No
N/A
3.
Yes
No
N/A
4.
Are any waste materials separated and sent for recycling? Please provide details in the Table below (question 6). Does the facility monitor off-site disposal activities?
Yes
No
N/A
5.
Yes
No
N/A
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Notes : 1 Indicate which type of equipment or operation generates this waste stream. 2 Please enter one of the following letters as appropriate. If the disposal or treatment is on-site, please circle the letter. Re = Recycled externally S = Sold for further use (please specify) T = chemical or physical I = Incinerated Treatment Ri = Recycled Internally L = Landfill O = Other (please specify
313
Yes
No
N/A
2. 3.
Yes Yes
No No
N/A N/A
4.
Yes
No
N/A
5. 6.
Yes Yes
No No
N/A N/A
314
e.g 50m
In
35
none
Notes: 1 Indicate volume of tank in litres (I) or cubic metres (m) 2 Indicate whether tank is above ground - use letters AST, or below ground - use letters UST 3 Indicate whether the tank is equipped with leak detection measures, overfill protection, or corrosion protection 4 Indicate date of most recent leak test (including hydrostatic pressure testing, sampling and analysis of surrounding soil, etc.). If not tested, indicate None.
315
Q Product Stewardship
Who is responsible for product stewardship programmes at the facility? 1. Has the facility determined the environmental impacts of all its product and packaging materials, including transport packaging materials? Are environmental impacts formally considered during development and marketing of products? Do raw material specifications routinely include HSE requirements? Do manufacturing machinery specifications routinely include HSE requirements? Name: Title:
Yes
No
N/A
2.
Yes Yes
No No
N/A N/A
3. 4.
Yes
No
N/A
316
R Energy Conservation
Who is responsible for energy conservation programmes at the facility? 1. Has the facility carried out a systematic review of all its uses of energy, to identify major energy consuming equipment or activities? Name: Title:
Yes
No
N/A
2.
Have energy conservation objectives and targets been set? Yes Please specify
No
N/A
3.
Has the facility defined Energy Accountable Centres (i.e., discrete operating units within the site for which energy consumption figures are available)?
Yes
No
N/A
317
Facility plot plan or map Directions to the facility Visitor safety requirements (e.g., personal protective equipment, orientation, specialised training, special clearances, etc.) Completed pre-audit questionnaire Description of the facilitys operations/processes Facility organisation chart, showing HSE responsibilities Local laws, regulations, and ordinances related to the scope of the audit List of current environmental licenses, certificates, and authorisations Copies of permits for wastewater discharges and example air emission permits Recent regulatory agency inspection/enforcement correspondence Recent internal and intra-company environmental, health, and safety audit reports Table of contents for facility-specific environmental, health, and safety policies and procedures
318
319
Appendix B Roles and Responsibilities of the Audit Team Audit Team Leader Responsibilities
Pre-Audit Activities
Select team members and assign audit responsibilities. Gather and distribute background information. Identify applicable federal/national, state/provincial, and local regulations and company policies and procedures. Conduct advance visit to the facility (if necessary). Review and revise audit strategy and assigned duties as necessary. Determine and confirm arrangements with the team members and the facility: Travel arrangements Hotel/travel reservations Prepare items for audit (forms, supplies, protocols). Coordinate pre-audit team meeting(s).
On-Site Activities
Lead opening meeting presentation. Serve as liaison between team and facility personnel to ensure that all team members are appropriately scheduled to meet with facility personnel. Solicit feedback from each team member on the status of work accomplished throughout the audit. Perform audit duties as determined by the audit strategy.
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320
Appendix B Roles and Responsibilities of the Audit Team Audit Team Leader Responsibilities
Review assigned protocol steps with each auditor to ensure that all steps are covered appropriately. Document the rationale for changing the scope of the audit (if necessary). Understand the context for and meaning of each finding reported by the team. Provide periodic feedback to facility personnel on the status of the audit and the findings of the team. Prepare the exit meeting discussion sheets listing all findings as summarised by the team. Ensure that all exit meeting discussion sheets are reviewed by each team member. Review all findings with key facility personnel prior to the exit meeting to ensure the accuracy of all findings. Lead presentation of exit meeting discussion. Summarise reporting schedule and format.
Post-Audit Activities
Review all working papers to ensure that all topics were covered and that all findings are corroborated by working paper notes. Prepare draft report. Distribute draft report for comments. Incorporate comments where appropriate into the final report.
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Appendix B Roles and Responsibilities of the Audit Team Audit Team Member Responsibilities
Pre-Audit Activities
Make travel arrangements (if required). Attend pre-audit team meeting (if required). Prepare for the audit by reviewing appropriate federal/national, state/provincial, and local regulations, company policies and procedures, and available background information. Modify or annotate the protocol to reflect facility-specific requirements, state and local regulations, and information gained during review of background information.
On-Site Activities
Perform duties assigned by the team leader during the audit. Serve as a resource for other audit team members during the audit. Report on progress to the team leader throughout the audit, including any problems encountered. Share observations/concerns with other team members during the audit to ensure that each is addressed appropriately. Keep facility personnel apprised of findings as they are noted. Summarise all findings and report them to the team leader before the close-out meeting. Assist with preparing the exit meeting discussion sheets.
322
Appendix B Roles and Responsibilities of the Audit Team Audit Team Member Responsibilities
Ensure that all findings noted in your working papers are presented on the exit meeting discussion sheets and accurately reflect the facts as you understand them. Contribute during the exit meeting when questions are raised about your findings.
Post-Audit Activities
Review draft audit reports for: Wording changes Suggested changes in placement of findings within the report Provide input as necessary when findings in the draft report are challenged.
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324
FIFRA GEP HAZOP Hazwoper HCS HMTA HSWA IARC IDLH IH LAER LEPC LOTO MACT MSHA MSDS NAAQS NEPA NESHAP NIOSH NOAA NOx NRC NPDES
STS SWDA TCLP Title III TLV TPQ TSCA TSDF TSP TSS UST VHAP VOC WWTP Z List
Standard Threshold Shift Solid Waste Disposal Act Toxicity Characteristic Leaching Procedure (under RCRA) Emergency Planning and Community Right-to-Know Act Threshold Limit Values (for workplace exposure) Threshold Planning Quantity (for emergency planning Toxic Substances Control Act Treatment, Storage, and Disposal Facility Total Suspended Particulate (in air) Total Suspended Solids (in water) Underground Storage Tank Volatile Hazardous Air Pollutant Volatile Organic Compound Wastewater Treatment Plant OSHA list of hazardous chemicals (29 CFR 1910 Subpart Z, Worker Right-to-Know)
325