EMS Workshop for SGI

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Performance-Based Auditing A Different Approach
to Enhancing Your EMS SESHA Hill Country Chapter
Meeting June 2, 2005 Jeanne Yturri,
Principal Zephyr Environmental Corporation
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EMS Implementation Focuses on Results

• Your EMS is not procedures!
• When well-defined, understood, and implemented,
  your EMS documents will support and achieve your
  organizations Environmental Policy. The
  effectiveness of your EMS is demonstrated through
  measurable results, not procedures on a shelf.

Documentation
Implementation Results
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Performance-Based Approach

• Focus on what is seen.
• Understand the underlying causes.

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Why Do An Audit?

• Traditional Reasons
• To identify the organizations compliance
  position
• To identify how to fix compliance gaps
• To be able to report on compliance position to
  others
• To support ISO14001 registration
• Better Reasons
• To identify environmental risks and potential for
  pollution.
• To determine opportunities for improvement.
• To assess conformance or compliance with
• Regulatory requirements
• Operating procedures
• International standards

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Auditors Must Have

• Knowledge of applicable regulatory requirements
  (current and emerging).
• An understanding of the processes and activities
  their auditing.
• Experience with operational controls (best
  practices) that support continual improvement.

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How is an EMS Best Audited?
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Performance-Based Audit Approach
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Audit Process
Pre-Audit Planning Records and document review.
Agree to logistics and schedule.
Opening Meeting Decision makers present.
Bottom-up Analysis How it is
Site Survey Physical observations (photos with
permission), employee interviews.
Causal Analysis Scheduled interviews with
managers.
EMS Analysis Environmental aspect/impact and
goals review.
Review Performance Improvement
Top-down AnalysisWhy it is
Business Review
Meeting with Senior Person
Closing Meeting
Audit Report
Audit
Corrective Action
Plan
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Audit Process Steps

• 1. Pre-Audit Planning
• 2. Opening Meeting
• 3. Site Survey
• 4. Causal Analysis
• 5. EMS Analysis
• 6. Review Performance Improvement
• 7. Business Review
• 8. Meeting with Senior Person
• 9. Closing Meeting
• 10. Audit Report

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Step 1 Pre-Audit Planning

• Get a sense of organizations activities,
  products and services.
• Obtain and review relevant records and documents.
• Understand applicable legal/regulatory
  requirements.
• Understand general structure of organization.
• Understand elements of the system to be audited.
• Agree to audit logistics and schedule.
• Provide advance notice of scope and agenda to
  management personnel that will be interviewed.

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Step 2 Opening Meeting

• Introduce audit team
• Present audit plan and schedule
• Discuss ground rules and logistics

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Step 3 Site Survey

• Walk the entire site to gain familiarity
  with operations.
• Observe the sites environmental performance.
• Identify evidence of nonconformance... focus on
  areas that have/could have
• environmental impact, including non-routine and
  emergency situations,
• environmental compliance concerns, and/or
• greater opportunities for improvement in
  compliance and performance.
• Take photos to document work practices and
  conditions.
• Interview personnel to understand and evaluate
  practices.
• Document evidence of nonconformance.
• Determine root cause through additional
  interviews, document review, and
  observations.

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Traditional Compliance Questions

• How do you track chemical use?
• How do you determine emission rates?
• How do you perform/document waste stream
  classification determinations?
• Have you conducted required PPE risk assessments?
• Have you had any wastewater permit limit
  exceedances?
• Can I look at your records?

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Traditional EMS Questions

• How do employees use the Environmental Policy in
  their work?
• How is the Policy communicated to outside
  stakeholders?
• What process did you follow to identify and rank
  your environmental aspects?
• How do you train employees about the EMS?

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Performance-Based Questions

• Understand what the employee understands and does
  about environmental performance.
• Watch behaviors, and determine if good behaviors
  are taught and encouraged.
• Look for training problems, resource problems,
  and/or management problems when observing
  behaviors and conditions, and asking
• What goes on in this area?
• What do you do with that? Why?
• What do you do if xyz?
• Is this normal? If not, why is it this way
  today?

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Step 4 Causal Analysis

• Is the situation (observed practice/condition)
  the result of
• Error/behavioral problems,
• Resource problems (e.g., improper tools,
  insufficient time, etc.),
• Training problems (e.g., never/poorly taught),
  and/or
• Management problems (e.g., not noticing poor
  behaviors, not enforcing policies, not holding
  employees accountable).

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Step 5 EMS Analysis

• Identify the degree of nonconformance a
  condition that is contrary to the EMS or an
  environmental requirement.
• Major A serious deficiency that could adversely
  affect the EMS or the environment. A systemic
  failure no system or a flawed system.
• Minor Temporary or isolated instance of failure
  to conform with EMS or environmental requirement.
  An isolated failure.
• Concern Undesirable situation that could result
  in a nonconformance in the future if not
  addressed. An opportunity for error or
  improvement.

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Examples of a Major Nonconformance

• A systemic failure no system or a flawed system.
• Evidence of negative environmental impact
• Evidence of unidentified risk and/or safety
  hazard
• Evidence of failure to adequately train personnel
• Compliance requirement not identified and/or not
  adequately addressed
• A required document does not exist
• A documented procedure exists but is not
  implemented
• Employees permitted to disregard work
  instructions without corrective action
• Required records not being maintained
• Obsolete procedures are being used

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Examples of a Minor Nonconformance

• An isolated failure.
• Evidence of potential negative environmental
  impact
• Safety or environmental hazard associated with
  poor housekeeping
• Occasional failure to follow documented procedure
• Documented procedure requires minor
  clarification/amplification

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Examples of a Concern

• An opportunity for error or improvement.
• Poor housekeeping
• Procedures are complicated and/or many pages
  long, making them hard to follow
• A key activity is dependent on one or two
  specific people, one of whom is near retirement
• A monitoring or measurement method is cumbersome
  or difficult to perform

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Step 6 Review Performance Improvement

• Look for evidence of the good stuff
• Reduction in environmental impact
• Reduction of liabilities for known issues and for
  others that may emerge
• Improving compliance with environmental
  regulations
• Stakeholder (community, customer, etc.)
  involvement
• Participation in community outreach
• Beyond compliance controls and programs

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Step 7 Business Review

• Interview management staff (operations, human
  resources, finance, etc.) to determine their
  knowledge of environmental aspects and
  involvement in EMS.
• Assess certain aspects of the EMS to see how they
  fit in with the organizations operational,
  financial, and other business systems.
• Discuss environmental objectives/targets and
  process for achieving those continuous
  improvement goals.

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Step 8 Meeting with Senior Person

• Interview senior person (top management) to
  determine his/her knowledge of environmental
  aspects and involvement in EMS.
• Assess how the EMS is considered compared to
  other business programs.
• Identify the extent of resource allocation for
  environmental performance and improvement.
• Understand how upcoming operational changes are
  evaluated for potential environmental issues.

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Step 9 Closing Meeting

• Show photos and discuss observations and
  findings.
• Provide organization with an opportunity to
  clarify or provide additional explanation.
• Facilitate discussion regarding
  corrective/preventive actions and closure dates.

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Step 10 Audit Report

• The report should document the following
• Dates at site
• Names of audit team and management personnel that
  were interviewed
• Positive observations
• Findings of nonconformance
• Root cause determinations
• Recommendations for corrective action

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A Different 80/20

• 80 of auditing should assess management and
  employee behaviors to drive environmental
  performance and improvement.
• 20 should be validating plans through document
  and records review.

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Collecting Evidence Observation

• Start from the fenceline and work in.
• Dont just rely on what you are told, see it for
  yourself.
• Dont be locked on a checklist keep your
  mind/eyes open for any and all issues.
• Watch for risks which cant be easily seen.
• Always look in forgotten corners and dont be
  led away.

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Collecting Evidence Interviewing

• Ask open-ended questions.
• Dont lead or consult.
• Question people at all levels.
• Focus on the people responsible, but get
  information from other relevant persons.
• Ask about low frequency activities which often
  lead to highest impact.
• Consider actual and potential emergency
  scenarios.

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Collecting Evidence Documents and Records

• Look for evidence of audit preparation.
• Review records to check that current situation is
  constantly maintained.
• Track through records sample according to
  significance and frequency of recordkeeping.
• Does a lack of recording mean a lack of action or
  just no supporting paperwork?
• Are procedures that should be documented (e.g.,
  high risk, low frequency activity, complicated
  activity, significant impact potential)

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Traditional Audit Example Waste Management

• Interview
• What waste is generated here? At what rate?
• How is it handled and by whom?
• Where is it stored? Where is it disposed? How
  often?
• What records are used during generation,
  handling, or storage?
• Review Documents and Records
• Waste management procedures
• Waste logs and inventory records
• Waste manifests/shipping documents
• Waste registrations/permits
• Transporter/disposer licenses
• Training records
• Observe
• Inspect waste containers labeling, conditions,
  etc.
• Look at accumulation/storage areas

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Performance-Based Audit Example Waste Management

• Start with Observation
• Look at the obvious waste containers, generation
  points, accumulation and storage areas, etc.
• Look at the big picture (context, quality,
  quantity, etc.)
• Understand the processes that generate waste
• Consider how waste is managed
• Address compliance and performance (minimization,
  pollution prevention, best management practices)
• Then Conduct Interviews
• Tell me about this who, what, when, where, how,
  why?
• Lastly, Review Documents and Records
• When you see something that doesnt look right
• To verify what someone said
• To see if behavior matches procedure

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Work from the Outside In

• Inspect the site to validate the environmental
  aspects are controlled.
• Recognize safety hazards, housekeeping problems,
  etc. as indicators of a nonconforming EMS.
• Do employees see and elevate opportunities to
  improve the operation or reduce cost?
• Track interview responses up the chain of
  command.
• Dig deep for evidence
• Inform vs. communicate?
• Correction vs. corrective action ?
• Ask probing questions
• Why are you doing things the way you are?
• Are there other or better ways to do that?
• What contingencies are you prepared for?

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Photo Show and Tell

• Look at the following photographs and
• Describe the situation you see.
• Recognize the environmental risk(s) and/or safety
  hazard(s).
• What questions could you ask to better understand
  the situation.
• What documents/records could you review to verify
  and or better understand the situation.
• Conduct causal analysis. What behavior,
  training, resource, or management problem(s) may
  have lead to the situation?
• Identify operational control(s) that would
  improve the situation.
• Determine potential regulatory issues triggered
  or affected by the situation.

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www.ZephyrEnv.com!