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Development of an Audit Program

  


When developing, or continuing, an environmental compliance auditing program there are numerous questions that need to be asked and answered to ensure facilities are being audited in a manner that promotes effective environmental management and multi-media compliance. The following are examples of the types of questions to ask not only at the start of an auditing program, but throughout the ongoing implementation of the program.

Why?

Each agency needs to answer the question "Why are we performing environmental compliance audits?. The short answer is to identify noncompliance. But more can be gained from environmental auditing processes than just identifying noncompliance. Additional gains can include:

    • promotion of an environmental ethic by training personnel through and as a part of the audit process
    • identification of agency-wide policy issues and the development of policy to respond to those issues
    • development of out-year budgets
    • identification of noncompliance root cause rather than symptomatic relief of noncompliance.
Unless this question is answered an auditing entity will not gain the full benefit of its program and will often become disillusioned with the auditing process and the program will lapse into disarray.

Who?

Who is going to perform your audits is a reflection of why you are performing environmental compliance audits.  Typical scenarios include teams consisting of:

    1. personnel from outside the agency (i.e., contractors)
    2. personnel from agency headquarters
    3. personnel from regional headquarters
    4. combination of outside personnel and agency personnel
    5. combination of headquarters and facility personnel.

Each approach results in a different slant and result in the audit process.  Scenario 1 tends to develop an investigative flavor and, depending on how agency-smart your contractor is, can result in identification of surface noncompliance.  But, if the contractor selection process has been done carefully, and remains competitive, it usually results in fewer mis-identified issues of noncompliance. Scenarios 2, 3, and 5 brings agency knowledge to the process but it is a commitment to time and training to develop teams with the broad ranging regulatory knowledge needed to for accurate environmental compliance audits. Scenarios 2, 3, 5, do have the benefit of getting agency people in the field that often have not recently been in the field performing day to day operations.  Scenario 4 provides a combination of existing regulatory expertise and agency knowledge and results in a cross training of both entities.

It is highly recommended to not use one contractor for all your compliance audits.  The most cost effective and audit accurate use of contractors seems to be by developing a team across two or three corporations with the agency establishing the baseline.

Regardless of who performs your environmental compliance audits it important to remember this is not a process that runs itself.  Periodic quality assurance checkups by and outside organization provide invaluable ground-truthing of the process and encourages a consistent level of excellence.

Where?

The primary question to be answered is "Where are our facilities?  This question typically results in realizing there is no common definition for the term "facility" within an agency.  This term must be defined so that there is a commonality of understanding when developing your process and vision.   Typical definitions have included:

    • a set of buildings and operations identified under one name, regardless of whether they are contiguous or not,
    • a set of contiguous buildings and operations identified under one name,
    • a set of buildings and operations sharing a property identification number, regardless of name,
    • all the buildings and operations in a given geographic area (typically a state).

This definition will impact the implementation of environmental compliance audits.

What?

The first question is "What subject areas do I want to audit?  This question again relates back to why you are performing audits and it also relates to the type of operations your agency performs. Subject already covered in some existing agency auditing programs include:

    • Air Emissions Management
    • Cultural Resources Management
    • Hazardous Materials Management
    • Hazardous Waste Management
    • Natural Resources Management
    • NEPA
    • Cleanup sites
    • Environmental Noise
    • Pollution Prevention
    • Program Management
    • Pesticides Management
    • Petroleum, Oil, and Lubricants Management
    • Solid Waste Management
    • Storage Tank Management
    • PCBs
    • Asbestos
    • Radon
    • Lead Based Paint
    • Wastewater
    • Water Quality (everything from drinking water to swimming pools and beaches)
    • OSHA

Several DoD and non-DoD agencies have already developed checklists which they are willing to cost-share the ongoing maintenance costs with other agencies.  Examples include The Environmental Assessment and Management (TEAM) Guide used by more than 20 Federal agencies.

The second question is "What tools do I need/want to perform environmental compliance audits?"  The following list is a starting point which, depending your agency's vision of why you are performing environmental compliance audits, can enable you to determine which of these tools you want.

• Standardized checklists reflecting Federal, state, and Agency requirements.  It is a necessity for facilities across the US to be audited against a consistent standard.  Depending on the type of checklist selected, they can also be used as reference tools by the facility and serve as prompts to the audit team. Standardized checklists also facilitate the tracking of noncompliance.
• A Finding sheet.  What information do you want recorded when you identify an issue of noncompliance?  If you use previously developed software this decision is usually made for you.
• Report writing and tracking software.  This can be as simple as a program to enter noncompliance data and track the closure of findings or it can be as complex as a environmental management system (EMS). Several DoD and non-DoD agencies have already developed software which they are willing to cost-share the ongoing maintenance costs with other agencies.  Examples include the FWS, USPS, and the Army National Guard
• Style guide.  This is a helpful tool in establishing the standards for audit performance. It should cover everything from whether stormwater is one word or two to how do I deal with suspected noncompliance which cannot be confirmed.
• Root cause codes.  These are a set of codes used to identify the reason behind noncompliance.  The concept evolved when during the second round of environmental compliance auditing in many agencies the same findings were repeating themselves.  This meant that there was an underlying issue which was not addressed when rectifying the noncompliance identified in the first round. There are as many root cause code matrices as there are auditing agencies and it is a matter of selecting or developing one that fits with your Agencies operations and goals.
• Pre-audit Guidance. The agency needs to identify preparatory expectations to the facility and to the audit team.  This might include a pre-audit package that is sent to the facility telling them what documents to have ready for review, a copy of the checklist to be used, and a pre-audit questionnaire to be sent to the audit team so they can prepare prior to arrival.
• Scoring System.  This is defined in as many different way as there are audit programs.  It is used to serve as a measure of severity of noncompliance.   Common systems include:
• Significant, Major, Minor
• Red, Amber, Green
• a numeric scoring matrix.

How?

How encompasses programmatic decisions including external versus internal audits, number of days spent at a facility, size of the audit team, training of the audit team, resolution of noncompliance, program implementation, and assuring process quality.

External audits are defined as those conducted by a team consisting primarily of individuals from outside the facility.  Internal audits are those conducted by a team consisting primarily of individuals at the facility.   The purpose of an external is to identify those issues which facility personnel either did not know were problems, or did not see because familiarity does breed blindness. The purpose of an internal is two-fold, one is to perform a checkup in between externals and measure progress on resolving noncompliance identified during the external,  two is to train facility personnel on what compliance involves and forces them to look with fresh perspective at themselves.   External audits are usually performed by an onsite visit of a team for a designated period of time and result in the creation of a formal report.   Internal audits are done in a  variety of ways varying from a process that mirrors the external to a limited yes/no checklist.

The number of days and the size of the audit team are directly related to the complexity of the operations at the facility and the extent of the audit.    At many smaller sites  two person team to be sufficient as long as the team members experience and knowledge encompass the topics to be audited.

Currently, the favored method of training agency personnel how to perform environmental audits is a mixture of attending a class and on-the-job training by being paired with an experienced auditor.  Classroom training typically covers software usage, agency audit policies and expectations, highlights of the subject areas to be audited with typical findings for a given agency, and a field exercise.

Resolution of noncompliance is one of the most overlooked areas in audit program development.  The facility being audited must develop a plan on how they are going to resolve the identified noncompliance.  While the process of resolving noncompliance is ongoing, findings of noncompliance are typically classified as:

    • open (nothing has been done),
    • pending (a work order request has been submitted, funding requested), or
    • closed (the condition of noncompliance no longer exists).
Successful audit programs develop a timeline within which the facility must make decisions on how noncompliance will be corrected and the final audit report documents both the noncompliance and the corrective actions.

How the program will be implemented is specific to an agencies culture.  Some agencies are top down culture where others are regionalized.  Regardless of the agency culture, if there is no buy-in at the policy and funding levels it is impossible to implement an effective environmental audit program.  Additionally if your agency is regionalized and there is no one entity tasked with the responsibility for ensuring program consistency and efficiency experience dictates that regional authorities will change the programs such that eventually there will be little commonality across regions.  This is not to say that it is not important to tailor a program to regional needs.  It is, but it is equally important that there be an Agency standard and set of core principles that are the same across all of an Agency.

Ensuring consistent quality in the audit process is not an easy task.  If the same set of people are constantly auditing the same types of facilities it is easy to become complaisant and write the same old findings over and over and not look for anything new.  Also, like any other process, when we are in the middle of the process and/or the author of the process we often cannot see the possibilities for improvement in the process.  Therefore it is strongly recommended that QA/QC be built into your audit program.  QA/QC can occur at a number of levels:

    • review of reports
    • accompanying the audit team on an audit
    • onsite review and report review
    • review of agency auditing policies and how they are implemented.
QA/QC can be done by anyone who is familiar with the basics of your program, is an experienced auditor, and is not vested financially, politically, or emotionally in maintaining the status quo.

When?

When encompasses decisions on the frequency of the audit cycle.   This is usually determined by the following factors:

    • types of operations at a facility
    • total number of facilities in the Agency
    • cost

Conclusion

Environmental auditing is a tool that, when used effectively, can aid you in program development and in the avoidance of enforcement actions, fines, and penalties.  But in order for it to be effective thought must be given to all the issues discussed here and decisions must be made that allow for growth and evolution of a program that involves identification, correction, and proactive action.

Terminator
 
Last Updated: July 18, 2016