EPA's Region 6 Office
Serving: Arkansas, Louisiana, New Mexico, Oklahoma, Texas, and 66 Tribal Nations
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Q. EMS Procedure for Conducting Internal EMS and Compliance Status Audits
The purpose of this procedure is to establish a process for periodically determining whether the EMS conforms to planned arrangements for environmental management. The EMS audit determines whether the EMS has been properly designed, implemented, maintained, and is functional.
Environmental Management System audits are not compliance audits. They are system audits to verify the workings of the management system. If compliance data is examined, it is for the purpose of verifying that the environmental programs are sufficient to achieve compliance with legal requirements.
Systems audits are used to ensure conformance to ISO 14001:1996 and to identify continual improvement opportunities. Two types of EMS audits are conducted at the Region 6 lab & field operations: internal and external third-party audits.
This procedure applies to all elements of the region 6 lab & field operations EMS. The region 6 lab & field operations EMS audit scope includes all activities, products, and services that are within the defined scope of the region 6 lab & field operations EMS. The U.S.EPA Region 6 lab & field operations Environmental Management System (EMS) is designed to manage the environmental impacts that result from the operations at the facility and, to a limited extent, off-site field activities. All of the operations conducted at the facility located at 10625 Fallstone Road, Houston, Texas 77099 are considered within the scope of the EMS. The activities of all of the occupants of the facility are subject to the policies and procedures described in this manual. The Region 6 lab & field operations EMS is designed to conform to the international standard ISO 14001 (1996), Environmental Management Systems - Specification With Guidance For Use. This procedure applies to all EPA and contractor personnel working at the Region 6 lab & field operations Region 6 facility.
Audit Team and Team Leader
As part of the EMS implementation, Houston Lab established an Internal EMS Audit Team. The internal EMS audits are led by the Audit Team Leader, who is recommended by the EMS Coordinator and is approved by the EMS Advisory Committee.
The Audit Team Leader is supported by a team of qualified personnel from various parts of the Region 6 lab & field operations. The Audit Team Leader is responsible for recruiting Audit Team members, who must then be approved by the EMS Advisory Committee. To assure objectivity, the Audit Team should include personnel not directly responsible for the area(s) being audited.
Audit Team members should have formal training in EMS auditing, or possess specific skills or knowledge of pertinent technical issues, regulations, management systems, and/or facility processes and products.
All personnel acting as Audit Team members should have received adequate training in the requirements of respective standard and internal auditing techniques prior to performing an audit. Auditor orientation and training should include, as a minimum, the following activities:
- Review of the relevant ISO 14001 standard and pertinent elements to be audited,
- Defining of the auditor(s) role, responsibilities, and auditing techniques,
- Determining the scope of the audit and review of relevant documents and procedures,
- The method of documenting the audit and nonconformance.
Training may be accomplished through either:
- The successful completion of an internal auditing course or lead auditor course by a recognized third party,
- Internal auditor training provided by personnel who have successfully completed an internal auditor or lead auditor training course.
The EMS Audit Team Leader, in consultation with the EMS Coordinator, EMS Team, EMS Advisory Committee, and top management determines the criteria to be used as the audit standard.
The EMS Audit Team, under direction of the Audit Team Leader, develops an overall audit plan for the Region 6 lab & field operations. The audit plan covers the following elements:
- The specific areas, functions, procedures, and activities to be audited,
- Personnel qualified to perform the audits,
- Audit schedule, duration, and frequency,
- Audit processes and techniques,
- Development and implementation of corrective action to resolve cited audit discrepancies.
Audit schedule and frequency
An audit schedule is developed and conveyed to the audit team via an audit plan prepared by the Audit Team Leader. The audit frequency is based on the status and importance of the system elements defined in the EMS manual, as determined by:
- Significant Environmental Aspects or risks and hazards,
- Concerns raised by interested parties,
- Results of third party and internal audits,
- Concerns raised during Management Reviews,
All applicable system elements shall be audited a minimum of once annually.
Audit frequency and scheduling includes auditing all areas of the Region 6 lab & field operations against all elements of the audit standard. Audit frequency and scope for the various areas of the Region 6 lab & field operations will be determined by the Audit Team Leader and communicated to the audit team.
For each audit, an Audit Team Leader is identified.The Audit Team Leader is responsible for
- Assigning audit responsibilities to the audit team members,
- Developing the audit plan,
- Conducting audit team meetings,
- Conducting opening and closing meetings with the auditee(s),
- Resolving differences of opinion among audit team members,
- Maintaining communications with the auditee(s) throughout the audit,
- Preparing the final audit report,
- Communicating the findings of the audit report to top management in association with R—Management Review.
The audit plan consists of requirements for the following elements:
- Audit team identification
- Pre-audit review
- Opening meeting
- Data collection
- Data review and analysis
- Closing meeting
- Audit program evaluation
Each section of the EMS Manual is considered a system of elements. Auditors normally review a minimum of three randomly chosen sets of supporting records and other supporting documentation for conformance with the EMS Manual section.The EMS audit is conducted primarily through the review of records, observations of operations, and interviews with personnel. EMS audits may involve sampling compliance data to ascertain whether compliance programs are achieving their intended objectives.
Interviews. Interviews are conducted in the employee’s normal work area, if possible, so that actual processes can be observed and any records or related data are available for review.
Records review. The records review is typically conducted prior to actual interviews, while physical inspections with follow up reviews are conducted following the findings of previous steps.
Physical inspection and observation. A physical inspection of the facility, process, or designated areas of the facility is conducted.
Information obtained from interviews, Record reviews, and physical inspection and observation is documented.
Upon completion of the audit, the audit team meets with relevant management representative(s) and departmental supervisors to advise them of the audit results.
- EMS audit findings are based on objective evidence that is properly corroborated and authenticated. Audit findings are not based on hearsay or opinions.
- Each audit team member is responsible for obtaining an objective review of his/her audit findings from another audit team member. The goal is to ascertain whether another independent auditor comes to the same conclusions when presented with the facts.
- All final findings must represent the consensus opinion of the entire Audit Team.
- At the conclusion of the audit, the Audit Team reviews their consensus findings verbally with the EMS Team during an exit briefing. This briefing is an opportunity for questions and clarifications between the Audit Team and the EMS Team.
The Internal EMS Audit Team submits completed audit documents to the Audit Team Leader, who prepares the Final Audit Report. The Final Audit Report includes the following sections:
- Introduction and scope, describing what was covered in the audit
- Description of areas reviewed and related activities
- Assessment date(s)
- Audit team members and areas of responsibility
- Individuals interviewed and respective areas of responsibility
- Audit findings
The final Audit Report is submitted by the EMS Coordinator to top management for appropriate action according to Management Review.
The responsibility for corrective action to address EMS internal audit findings lies with the EMS Coordinator. The EMS Coordinator may consult with the EMS Team, EMS Advisory Committee, or top management in Region 6 lab & field operations to develop corrective action recommendations. Corrective action implementation and follow-up will be as specified under Handling Nonconformance’s.
Staff of the Region 6 lab & field operations conducts internal audits. Internal auditors receive formal EMS audit training. The internal audit program is based on FDIS ISO 19011:2002. The EMS Coordinator is responsible for forming the internal audit group and ensuring the auditors receive training. An Audit Team Leader is identified. The Team Leader is responsible for drafting an audit plan and submitting it to the EMS Coordinator. The audit plan specifies the logistics, scope, objectives and criteria for the audit. The Audit Team conducts the audit and submits a written report to the EMS Team. The EMS Team reviews the report and constructs a corrective action response, which includes recommendations and resource estimates for corrective actions. The EMS Coordinator for consideration and implementation decisions presents the corrective action response to the Region 6 lab & field operations Administrative Team. It is the responsibility of the EMS Coordinator and the EMS Team to ensure that needed corrective actions are completed in a timely manner. All audit plans, audit reports and corrective action plans are retained as EMS records.Records: All relevant records for the Region 6 lab & field operations EMS can be located on the Region 6 shared directories, see records section in: S:\Environmental Management Systems\ “A. EMS Procedure for Identifying Significant Environmental Aspects”