Since the early 1970’s, private industries have recognized the benefits of conducting environmental, health and safety audits at their regulated facilities. In general, the purpose of an environmental, health and safety audit is to ensure compliance with the myriad of environmental, health and safety regulations that have been promulgated by the Occupational Health and Safety Administration (OSHA), the Environmental Protection Agency (EPA), the Nuclear Regulatory Commission (NRC), and many other federal, state and local agencies. In addition, contemporary audits include the implementation of environmental health and safety management systems such as ISO 14001 and OHSAS 18001 and adherence to corporate standards or guidelines. In order for an environmental, health and safety audit to be successful, the author offers the following tips:
A lead auditor must be assigned. This person will have the primary responsibility for assembling the audit team, defining the scope of the audit, preparing the agenda and audit plan, reviewing the draft report, and following up with any required corrective actions upon completion of the audit.
A primary site contact will need to be assigned. In most cases, this contact will be an environmental, health and safety manager or a person with similar responsibilities. This person should have access to all important environmental, health and safety records and permits, and should have unimpeded access to every physical area of the facility. In addition, verify that the primary site contact communicates with the highest ranking member of management at the site about the audit and its schedule. Nothing causes more of an uproar than conducting an environmental, health and safety audit at a facility where the senior management team is unaware of its occurrence. Of course, if your company has a policy that “surprise audits” are acceptable then that’s a different story.
Pre-planning for an environmental, health and safety audit is as important as the audit itself. Much of the success of an environmental, health and safety audit program depends upon careful planning. At least two weeks prior to the on-site activities, the lead auditor should prepare and distribute an agenda to all involved personnel, including the site contact.
Provide a list of requested documents and programs to the site contact. Copies of these documents should be received by the audit team well in advance of the on-site activities. Important documents to be included on this list are regulatory permits such as air permits, wastewater permits, radioactive materials licenses, storm water permits, etc. Written programs and associated training materials for regulatory programs such as hazard communication, chemical hygiene, respiratory protection, bloodborne pathogens, and hazardous waste management. If you are uncertain if any of these programs apply to a given facility, go ahead and include it on the list and provide the respondent with the “not applicable” option. For larger facilities, having a site map may also be helpful.
Review written documents. The amount of time that you will have on-site will generally be limited to one week or less. For larger facilities you must use your on-site time wisely. To the extent possible, review as many of the written documenst prior to the on-site activities. Make notes of important items that you will want to verify during the on-site activities. Prior to the on-site activities, become reacquainted with important regulatory requirements, and review state and local requirements
Review publicly available databases for site regulatory information. Go on-line to the various regulatory databases maintained by OSHA, EPA, and state agencies to see historical information on regulatory inspections, air emissions, hazardous waste generation, etc. What you’re looking for is to determine the site’s regulatory history and any prior history of violations. If violations have occurred in the past, when on-site you will want verify that systems are in place to prevent repeat violations.
Refine the agenda. Based on the review of the documents, refine the agenda so that there is adequate time to review the items where there may be concerns or areas where there may be higher risk. Don’t waste your valuable on-site time on trivial issues.
Make sure that the primary site contact has dedicated adequate time. Nothing is more frustrating for an audit team than to have a primary site contact that is constantly leaving to go attend other meetings or perform other duties. In addition to dedicating adequate time for the audit team, the primary site contact should also reserve a conference room of adequate size, has internet access, and can be secured overnight. During an audit you will be working long hours and reviewing many sensitive documents. You don’t want to waste time having to pack up your materials at the end of each day.
Once on-site, conduct an opening conference. Persons that should be at this opening conference include the audit team members, the primary site contact, key operational personnel, and if available, the site manager. During the opening conference introductions should be made, the agenda review, the purpose of the audit review, key schedule items, and the timing of the closing conference. In addition, site personnel should indicate if any special activities are occurring that will prevent them from being available for questions.
After the opening conference, I generally like to take a brief tour of the facility. This tour should not be of any significant detail, but more of a tour to become familiar with the facility. Make notes of areas that you will want to return to for a more detailed examination.
Compare statements made in plans and programs with actual records and activities. Discrepancies between the two may be an indication of program gaps.
At the end of each day the audit team should meet with the primary site contact to review any unanswered questions. Provide the primary site contact with a list of potential findings or areas that need further investigation. In many cases, these items may be resolved simply by locating the correct records.
On the evening before the closing conference, plan on it being a long evening. You will want to prepare a draft list of audit findings. Audit findings should be written as precise as possible. Avoid subjective terms such as “all”, “many”, “poor”, or “inadequate.” Provide evidence to support the findings. If further investigation is necessary, state so.
Conduct the closing conference. On the final day of the audit, a closing conference should be conducted. It is preferable that the same attendees that were in the opening conference be present. During the closing conference the audit team should thank everyone for their time and cooperation, all draft audit findings should be reviewed, key concerns should be voiced, and a schedule and distribution list for the draft report should be indicated. It is important that every finding that will be in the draft report be presented. There should not be any surprise finding in the draft report.
Prepare and submit the draft report to the distribution list for review. Make sure that the distribution of the draft audit report is controlled. In some cases where there are significant regulatory findings, e-mail distributed of the draft report should be avoided. Hard copies of the draft report, sent via over night express delivery may be preferred. If there are significant regulatory findings, check with your company’s legal counsel prior to distributing.
After review and comment of the draft report, finalize the report and prepare a corrective action plan. This is the most important part of any audit. Now that deficiencies have been found, corrective actions must be performed. A process for tracking the completion of all findings, the priority, and the responsible person(s) is absolutely necessary. Failure to correct found deficiencies in a timely can represent a significant liability to the company. Simple and affordable corrective action software systems are available and should be considered a must have for any environmental, health and safety audit program.
Conducting an environmental, health and safety audit is a valuable tool for improving the EH&S performance at a given location. However, in order to be successful the audit team and site personnel must carefully plan the audit, and ensure that adequate follow-up is conducted on corrective actions to be performed.
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