Swine Pilot EMS Audit Training
Suzanne W. Sessoms, PE
Principal Consultant
Environmental Mgmt. Services
(910) 520-3641
[email protected]
Environmental
Management System
• An EMS is “the part of the
overall management
system that includes
organizational structure,
planning activities,
responsibilities, practices,
procedures, processes and
resources for developing,
implementing, achieving,
reviewing and maintaining
the environmental policy.”
Do
Plan
IMPROVE
Act
Check
Why does an EMS
require an audit?
•
•
•
•
•
•
To ensure EMS is fully implemented
To identify best practices
To identify potential problems
To promote continual improvement
To provide feedback to management on system
It’s the Check part of Plan-Do-Check-Act
Purpose of EMS Audit
To confirm conformance
NOT
To find non-conformances
EMS Audit
ISO14011 defines an EMS audit as:
“a systematic and documented verification process of
objectively obtaining and evaluating evidence to
determine whether an organization conforms to the
EMS audit criteria set by the organization, and for
communication of the results of this process to
management”
Audit Criteria
ISO14011 defines audit criteria as:
“policies, practices, procedures or requirements,
such as those covered by ISO14001 and, if
applicable, any additional EMS requirements
against which the auditor compares collected audit
evidence about the organization’s environmental
management system”
ISO14001 Section 4.5.4
Requires:
“Organization shall establish and maintain a
program and procedures for periodic EMS audits
to be carried out in order to
– a) determine whether or not the EMS
1) conforms to planned arrangements for environmental
management including the requirements of ISO14001
2) has been properly implemented and maintained; and
– b) provide information on the results of audits to
management
Section 4.5.4 Requires:
“The organization’s audit program, including any
schedule, shall be based on the environmental
importance of the activity concerned and the
results of previous audits.
In order to be comprehensive, the audit procedures
shall cover the audit scope, frequency, and
methodologies, as well as the responsibilities and
requirements for conducting audits and reporting
results.”
Audit Triangle
Say What You Do
- Documentation
Be Able to Prove It
- EMS Audit
Do What You Say
- Implementation
Food for thought
• Who can be EMS auditors?
– Farm owners?
– Consultants?
– Employees?
• How often is often enough?
– Every six months?
– Yearly?
– Every other year?
• How could one demonstrate that an
audit schedule is based on the
environmental importance of the
activities?
– Time spent on topic
– Sample size
Audit Process
•
•
•
•
Initiating/Planning the Audit
Evaluating the Evidence
Reporting the Findings
Continual Improvement
Initiating/Planning
the Audit
• Request the audit
• Define the audit scope and
timing
• Select auditors
• Schedule the audit
• Review documentation
• Prepare checklists
• Prepare interview schedule
Traits of a Good Auditor
• Knowledgeable of industry
and associated regulations
• Familiar with management
system approaches
• Unbiased opinion
• No direct responsibility for
EMS
• No direct authority over
auditees
Audit Plan
x
x
x
x
X
X
X
X
X
X
X
x
X
X
x
x
X
X
X
x
x
X
X
x
X
X
x
X
X
X
X
x
X
X
X
X
X
X
x
x
x
X
X
X
x
X
X
X
x
X
X
X
X
x
X
X
X
X
X
x
X
X
X
X
x
X
X
x
X
X
X
Report Preparation
4.5.3
4.5.4
4.6
x
X
X
Closing Meeting
4.5.2
x
Farm Auditors
4.5.1
Training/HR
4.4.7
Land Applicators
4.4.3
4.4.4
4.4.5
4.4.6
Farm Employees
4.4.1
4.4.2
Farm Manager
4.3.1
4.3.2
4.3.3
4.3.4
Policy Commitments
x
Policy Devel./Review
Policy Awareness
Aspects
Legal
Objectives/Targets
Program
Change Management
Structure and Resp.
Training Needs
Training Curriculum
Training Effectiveness/Competency
Communication
Documentation
X
Document Control
X
Operational Control
Supplier/Contract Mgmt.
Emergency Response Plan
Development
Understanding/practice
Monitor and Measure
Calibration
Compliance Audits
Corrective Action Procedure
Follow-up
True Corrective Action
Records
EMS Audit
Management Review
Environmental Mgr.
4.2
Farm Owner
– Key audit steps are noted
– Key interviewees are
identified
– Topics are prioritized
– Audit trails identified to
optimize order of
interviews
ISO 14001 Element
Pre-work/Document Review
• Use the audit planning
matrix to develop a
rough schedule
Documentation Review
Why do it?
– familiarizes auditor with
organization’s EMS
– identifies if an element
has been overlooked
– allows for refining onsite interview schedule
– identifies audit trails
Documentation Review
Summary
C lause
N um ber
C lause D escription
4.2
E n viron m en tal Policy
4.3
Plan n in g
4.3.1
E n viron m en tal A spects
4.3.2
Legal an d O th er Requirem en ts
4.3.3
O bjectives an d T argets
4.3.4
E n viron m en tal M gm t. Program (s)
4.4
Im plem en tation an d O peration
4.4.1
Structure an d Respon sibility
4.4.2
T rain in g, A w aren ess & C om peten ce
4.4.3
C om m un ication
4.4.4
D ocum en tation
4.4.5
D ocum en t C on trol
4.4.6
O peration al C on trol
4.4.7
E m ergen cy Preparedn ess & Respon se
4.5
C h eckin g an d C orrective A ction
4.5.1
M on itorin g an d M easurem en t
4.5.2
N on -con form an ce an d C orr./Prev. A ction
4.5.3
Records
4.5.4
E M S A udit
4.6
M an agem en t Review
W ho
does
it?
H ow
often ?
H ow is
it don e?
W h at
records
are kept?
A ll sh all statem en ts
are addressed
Som e sh all
statem en ts are n ot
fully addressed.
E lem en t is n ot
addressed
Workshop:
Review documentation
• Individually, review the
assigned sections of your
EMS manual and fill out
the associated rows on
the review form
• Spend about 15 minutes
• Prepare to discuss any
findings with the class
Checklist
Checklist questions are organized
by interviewee, not by element of
the standard.
Review the spreadsheet
worksheet format and a couple
sample questions
Farm Owner
FO-1
FO-2
FO-3
What is the history of the farm site? Any prior owners/operations? How old
are the structures? Any retrofit work req'd?
What considerations did you make when choosing to raise pigs here?
(acreage, location to receptors)
What, if any, close receptors did you have to consider? (neighbors, schools,
churches, etc.)
4.2/
4.5.2 Commitment to pollution prevention
4.2
Commitment to pollution prevention
4.3.2 Knowledge of legal requirements
Interview Questions
Farm Owner/Env. Mgr.
• Individually, read scripted
interview questions for the
farm owner and environmental
manager
• Do any of the questions seem
unusual or irrelevant.
• Discuss any concerns with
your table group
• Record any issues on flip chart
• Pick a spokesperson
• Spend about 20 minutes
Evaluating Evidence
• Conduct opening
meeting
• Interview employees
• Review documentation
– SOPs
– Records
• Observe activities
• Daily caucus
Opening Meeting
• Introductions
• Review logistics
– schedule
– lunch arrangements
– closing meeting
• Review methodology of audit
–
–
–
–
–
interviews
documentation/records
caucus/debriefings
communications
reports
Objective Evidence
• can be verified
• can be physical
(activity observed)
• can be documented
• can be stated
(watch out for hearsay)
• is based on facts not
opinion
Interview with
Farm Employee
• Each table team will ask
me a question related to a
specific ISO14001 reqmt.
– pick a question from
questionnaire or select one of
your own
• Based on my response,
develop an audit trail
– ask for objective evidence
• Determine conformance or
non-conformance to the
ISO14001 reqmt.
Nutrient Application
• Each table team will ask
me a question related to a
specific ISO14001 reqmt.
– pick a question from
questionnaire or select one of
your own
• Based on my response,
develop an audit trail
– ask for objective evidence
• Determine conformance or
non-conformance to the
ISO14001 reqmt.
Types of Evidence
• Conforming Evidence
• Non-conformance
– Minor Non-conformance
– Major Non-conformance
• Non-compliance
• Opportunities for improvement/Observations
Conforming Evidence
Non-conformance
• Objective evidence does
not agree with stated
program - pieces don’t fit
• Procedure says that
preventive maintenance is
performed annually;
however records show last
action over 18 months ago
Minor/Major
Non-conformances
• A minor non-conformance
is not systematic
– Isolated occurrence
– Low priority issue
• A major non-conformance
indicates a system
breakdown
– Failure to address a “shall”
statement
– Several issues regarding the
same element of the EMS
Non-compliance
• Objective evidence exists
which shows operation
in conflict with permit or
regulatory requirement
• May require immediate
attention
• May require regulatory
agency notification
• What is the auditor’s
role?
Observation
• Something that could pose
a problem in the future
• Something that could be
improved
• Not in conflict with
procedure or EMS
– could be a safety concern
– attitude issue
Reporting the Findings
• Report finding to interviewee
and escort during or upon
conclusion of interview
• Report finding to audit team
leader and EMR during daily
debriefing session
• Report finding to
management at closing
meeting and audit report
Non-conformance Report
C O R R E C T IV E A C T IO N R E Q U E S T (C A R )
C om p a n y/L oca tion :
D a te:
A u d itor :
F in d in g N u m ber :
L oca tion of F in d in g :
C A R N u m ber :
E scor t:
P r eviou s C A R N u m ber /D a te:
D iscu ssed w ith :
(if a p p lica ble)
• Traceability
–
–
–
–
F IN D IN G :
(R eq u ir em en t r efer en ce sta n d a r d or p olicy n u m ber a n d cla u se):
F in d in g :
C om p a n y R ep r esen ta tive:
T h e fin d in g h a s n ot been cla ssified a s a n on con for m ity. It cla ssified a s on e of th e follow in g :
O bser va tion
O p p or tu n ity for Im p r ovem en t
N O N C O N F O R M IT Y : T h e fin d in g h a s been d eter m in ed to be a n on con for m ity. It is cla ssfied a s a
M a jor
M in or
S ta n d a r d N u m ber a n d C la u se:
C om p a n y R ep r esen ta tive:
• Objective Evidence
D a te:
C O R R E C T IV E A C T IO N : T h e follow in g a ction h a s been p la n n ed /ta k en to cor r ect th e item obser ved a n d
to p r even t r ecu r r en ce. T h is ca n be in a sep a r a te r ep or t a s lon g a s th e C A R n u m ber is r efer en ced .
C om p a n y R ep r esen ta tive:
E x p ected com p letion d a te:
D a te:
A ccep ted
A ccep ted /N eed V er ifica tion
C om m en ts:
A u d itor :
• Requirement
– internal and/or external
S ta tem en t of N on con for m ity:
R E V IE W O F C O R R E C T IV E A C T IO N :
audit
auditor
auditee
date/time/place
D a te:
R ejected
– records
– statement
– observation
Audit Summary
.
IS O 1 4 0 0 1 E n v ir o n m e n t a l M a n a g e m e n t S ys t e m s - S p e c if ic a t io n
4 .1
Yes
No
C o m m e n ts
G ENERAL
T h e o rg a n iz a tio n sh a ll e sta b lish a n d m a in ta in a n e n v iro n m e n ta l m a n a g e m e n t sy ste m , th e re q u ire m e n ts o f w h ic h a re d e sc rib e d in th is
4 .2
E N V IR O N M E N T A L P O L IC Y
T o p m a n a g e m e n t sh a ll d e f in e th e o rg a n iz a tio n ’s e n v iro n m e n ta l p o lic y a n d e n su re th a t it:

a ) is a p p ro p ria te to th e n a tu re , sc a le , a n d e n v iro n m e n ta l im p a c ts o f its
a c tiv itie s, p ro d u c ts, o r se rv ic e s

b ) in c lu d e s a c o m m itm e n t to c o n tin u a l im p ro v e m e n t a n d p re v e n tio n o f
p o llu tio n

c ) in c lu d e s a c o m m itm e n t to c o m p ly w ith re le v a n t e n v iro n m e n ta l
le g isla tio n a n d re g u la tio n s a n d w ith o th e r re q u ire m e n ts to w h ic h th e
o rg a n iz a tio n su b sc rib e s

d ) p ro v id e s th e f ra m e w o rk f o r se ttin g a n d re v ie w in g e n v iro n m e n t a l
o b je c tiv e s a n d ta rg e ts

e ) is d o c u m e n te d , im p le m e n te d a n d m a in ta in e d a n d c o m m u n ic a te d to
a ll e m p lo y e e s

f ) is a v a ila b le to th e p u b lic
4 .3
P L A N N IN G
4 .3 .1

E n v iro n m e n ta l a s p e c ts
T h e o rg a n iz a tio n sh a ll e sta b lish a n d m a in ta in p ro c e d u re s to id e n tif y th e
e n v iro n m e n ta l a sp e c ts o f its a c tiv itie s, p ro d u c ts, o r se rv ic e s th a t it c a n
c o n tro l a n d o v e r w h ic h it c a n b e e x p e c te d to h a v e a n in f lu e n c e , in o rd e r
to d e te rm in e th o se w h ic h h a v e o r c a n h a v e sig n if ic a n t im p a c ts o n th e
e n v iro n m e n t. T h e o rg a n iz a tio n sh a ll e n su re th a t th e a sp e c ts re la te d to
th e se sig n if ic a n t im p a c ts a re c o n sid e re d in se ttin g its e n v iro n m e n ta l
o b je c tiv e s.

T h e o rg a n iz a tio n sh a ll k e e p th is in f o rm a tio n u p to d a te .
4 .3 .2 L e g a l a n d o th e r re q u ire m e n ts

T h e o rg a n iz a tio n sh a ll e sta b li sh a n d m a in ta in a p ro c e d u re to id e n tif y
a n d h a v e a c c e ss to le g a l re q u ire m e n ts a n d o th e r re q u ire m e n ts to w h ic h
th e o rg a n iz a tio n su b sc rib e s d ire c tly th a t a re a p p lic a b le to th e
e n v iro n m e n ta l a sp e c ts o f its a c tiv itie s, p ro d u c ts, a n d se rv ic e s.
se c tio n .
Closing Meeting
• Review findings
• Identify next steps
– corrective action plan
– follow-up visit
• Coordinate report
– timing
– distribution list
Auditor’s Role
In Corrective Action
• Identify need for corrective action
• Evaluate if true root cause analysis has been performed
• Verify that corrective actions have been taken and that
the problem does not reoccur
Verifying Corrective/Preventive Actions
Nonconformance 1:
Crop cover listed in CAWMP, dated 6/30/99 for Farm XX
field 3 is bermuda; however cows were seen grazing in the field
on 5/4/01.
Corrective Actions:
a)
Identified the root cause to be the failure of the technical
specialist to complete and approve a revised CAWMP
b)
Technical specialist completed new CAWMP
c)
Old CAWMP stamped obsolete
Verifying Corrective/Preventive Actions
Nonconformance 2:
Pager numbers and extensions for farm personnel have not
been updated on contact list.
Corrective Action:
a)
Farm manager called production manager and got new
numbers.
b)
New numbers were added to the list. Farm manager
dated and initialed the changes.
Verifying Corrective/Preventive Actions
Nonconformance 3:
Daily inspection form dated 4/15/01 stated there were cracks
in building 4’s foundation and that a maintenance request had
been placed. On 5/15/01 the cracks were still evident and stains
indicated potential leakage.
Corrective Action:
a)
b)
Farm manager was advised by EMS coordinator to repeat
observation if problem not resolved in a time frame
appropriate to the nature and potential environmental impacts.
EMS coordinator issued a reminder to maintenance regarding
the status of the work order.
Virtual Audit
• Logistics wouldn’t allow an on-site activity
• Let’s break into teams of three as shown on the
flipchart
• Each team will conduct their own audit using
actual EMS documentation as well as observations
from pictures taken from various farms
• As you conduct the audit, take notes on the
attached forms for reporting later
Summarize Findings
Interviewee
Description of ISO14001/
Finding
EMS Reqmt.
Type of
Finding
Prepare to Audit
• For each round there are three roles
– Auditor
– Auditee
– Observer
• Decide who will play the auditees and auditors in each scenario
– Farm Manager
– Farm Employee
– Nutrient Applicator/OIC
• Review your respective checklist questions
• Before conducting each round, add any new trails based on the
audit findings and observations thus far
• Observer will take notes and provide feedback to the auditor
following the interviews on the form provided
Observer Feedback Form
• At the conclusion of the scenario, the observer
will provide feedback to both the auditor and
auditee regarding how the session went
• If possible, let the auditor keep their review for
their personal reference
Round 1
Auditor
• You have 30 minutes to
complete the interview.
Farm • Auditor should conduct a mini
opening meeting
Manager
• Use the questions from the audit
tool to interview the farm
manager
• Feel free to ask about anything
you noted on the drive to the
Observer
facility
• Allow 3-4 minutes for observer
to provide feedback
Water Usage Report
Farm No.
Beg Date Meter Reading End Date Meter Reading Gallons Used
Week 1
Week 2
Week 3
Week 4
Week 5
Farm Weekly Target Water Usage Is:
gallons/week
CURRENT OPERATIONAL STRATEGY
Operating Near or at Target Water Usage
Still Trying to Cut Water Usage to Target
Adding Water to the System for Proper Lagoon Operation or in Startup Mode.
OPERATIONAL NOTES:
Engineering Section (Farms Do Not Fill Out)
Total
Current
Period
Operational
Water Usage:_______________
Strategy is Appropriate for Lagoon
Total Days:_____
Status
Gallons/Day________
Current Operational Strategy is Inappropriate for Lagoon Status
Sent Memo to Farm Leader and Production Team Leader to Nofify of Corrective Action
Day
1
2
Time (Fill In)
La
go
Cr on
a
Nooss t P
r
o
Br ve op
r
o
No k P er L
e
M n Cip e eve
i
No ssi le Flo ls
an w
W ng
in
No et or U outs g o
S
ra
Ex oil ns
bo
e
p
A
No o
ve
ro cur
s
D e d un ed
w
am D d
at
C
er
ag ra Pit lea
lin
No
e in s,
n
ou
e
or p ip P
Si
i
p
t
H
No gni
ol es es C a
es
or ps
Si fica
La
in
g
n
No nif t E
La
go
go
on
W ican mb
on
Re ha t
an
Li
cy lin Ro km
ne
g
d
M cle
of en ent
r
in
t
im Pum La Int Ero
g
No al
p oo ru s sio
D
O
n
i
A
e
p
L on n
M nch br is era in e
or or
in tin r
ta
lit Tre L a g C
ie
s nch goo orr
pl
e
ac Er n o ctl
ed o s r n y
in ion ear
du
R
ec
m
ps
yc
le
te
ra
Pu
tt
m
he
p
en
d
of
th
e
da
y
Daily Checklist
Farm Checklist for Waste Handling System
Farm:_____________
Month:______________
Instructions: Inspect the following items daily. Place a check in each box if the item is found to be satisfactory. If any problems are
identified during the inspection, call a representative from the Environmental Resources department immediately. If the
Corrective Actions Taken (if any)
Initials
Round 2
• You have 30 minutes to
complete the interview.
• Auditors should introduce
Farm
Auditor
themselves and explain what
Employee(s)
they are doing
• Use the questions from the
audit tool to interview the
farm employee(s)
• Feel free to ask about
anything you noted during
Supervisor
the farm manager interview
Plays Host
Round 3
Auditor
• You have 30 minutes to
complete the interview.
Farm • Auditor should conduct a
mini opening meeting
Manager
• Use the questions from the
audit tool to interview the
nutrient applicator/OIC
• Feel free to ask about
anything you noted on the
Observer
drive to the facility
Review of Findings
.
ISO 14001 Environmental Management Systems - Specification
Yes
Min
.
No
Comments/Questions
4.1 GENERAL
The organization shall establish and maintain an environmental management system, the requirements of which are described in this section.
4.2 ENVIRONMENTAL POLICY
Top management shall define the organization’s environmental policy and ensure that it:
 a) is appropriate to the nature, scale, and environmental impacts of its
activities, products, or services
 b) includes a commitment to continual improvement and prevention of
pollution
 c) includes a commitment to comply with relevant environmental
legislation and regulations and with other requirements to which the
organization subscribes
 d) provides the framework for setting and reviewing environmental
objectives and targets
 e) is documented, implemented and maintained and communicated to
all employees
 f) is available to the public
FO-5
PR-1, FO-1,2
PR-1
EM-6
PR-1, FE-1, NA-1
FO-10
4.3 PLANNING
4.3.1 Environmental aspects
 The organization shall establish and maintain procedures to identify the
environmental aspects of its activities, products, or services that it can
control and over which it can be expected to have an influence, in order
to determine those which have or can have significant impacts on the
environment. The organization shall ensure that the aspects related to
these significant impacts are considered in setting its environmental
objectives.
 The organization shall keep this information up to date.
4.3.2 Legal and other requirements
 The organization shall establish and maintain a procedure to identify
and have access to legal requirements and other requirements to which
the organization subscribes directly that are applicable to the
environmental aspects of its activities, products, and services.
FO-7, EM-2
EM-2
FO-3,4,7, FM-1, EM-3,4,5,5a
Non-conformance Report
• Any findings requiring corrective action will be
written up on a non-conformance or corrective
action request (CAR) form
• It is critical that complete information be given to
the auditee to ensure they can do a root cause
analysis and prevent recurrence.
• This record could be used
• Sometimes data is input into a database to watch
for recurring trends and to ensure timely closure
Summary Report
•
•
•
•
•
Utah 2002 EMS Audit Summary Report – November 1, 2002
Thank you
Participants
Scope/Methodology
Overall conclusions
Recap of findings
– Details in non-conformance
reports
• Next steps
– Corrective action
– Follow-up audit
Lead Auditor –
Auditors –
Suzanne W. Sessoms, RAB-certified Lead Auditor
Judy Schaub, EMS Coordinator
Al Witt, Corporate EMS Mgmt. Representative
Jim Webb, Utah Environmental Manager
Scope of Audit: The scope of the EMS audit included all swine production, nutrient storage, and
associated activities for Circle 4 (C4) Farms in Milford, UT. As noted in WO’s EMS manual, the
EMS audit requirements for ISO14001 are met by a combination of bi-annual farm audits and the
annual EMS audit. For details on what is covered by each audit, please refer to WO’s EMS
manual, section 4.5.4.
Audit Criteria: The audit criteria included ISO14001:1996 Environmental Management Systems –
Specification with guidance for use along with WO’s EMS policies, manuals, and procedures.
Audit Schedule: The audit included interviews with C4 Upper Management, Human Resources,
Public Relations, Environmental Management, and visits to 5 farms. See attached audit plan
matrix, schedule, and participants list for details of personnel interviewed and elements covered.
Good Practices:
The audit confirmed management’s true commitment to environmental
stewardship, regulatory compliance and continual improvement. The dedicated efforts of the
Environmental Manager and EMS coordinator are to be commended. The thorough, yet userfriendly documentation allow for efficient and value-added environmental monitoring. The
awareness training was successful in reaching a diverse, multi-lingual workforce.
The
housekeeping and audit preparation was evidenced by well-groomed yards, orderly office/break
areas, readily accessible records, available personnel and receptive atmosphere. For additional
details, see attached color-coded table – best practices are identified in green.
Findings: Follow-up is recommended in the following areas: 1) completion of farm and EMS
audit corrective actions, 2) clarification of MSDS procedure, 3) chemical labeling and 4)
clarification of inquiry tracking requirements. For details, see attached color-coded table, which
details objective evidence for conformance (in black) as well as non-conformance (in red). Some
suggestions for system optimization are also noted in the summary (in purple).
Next Steps: A corrective action plan should be developed to address all non-conformances (red
items). Internal decisions regarding the observations (purple items) are also recommended. The
Phase 1 audit is scheduled for early December and will focus on understanding WO’s EMS
Process – in-depth review of the EMS Manual, figures, tables, etc., review of aspects analysis and
regulatory requirements, and visits to farms to understand processes/technologies. The Phase 2
detailed audit schedule will then be developed. Completion of farm audits per schedule,
completion of corrective actions from this audit and participation in WO management review
should be sufficient preparation for the phase 2 registration audit in February 2003.
Closing Meeting
Closing Meeting Agenda
Month xx, 200x
Review Scope and Purpose
Review Schedule
Limits of Sampling
Review of Findings
Next Steps
Corrective Action Plan
Management System Implementation
Budget/Timing
Name
Title
Name
Title
Next Steps
• Finish Implementation
–
–
–
–
–
–
Implement SOPs
Train Employees
Keep Records
Audit Your System
Take Corrective Action
Conduct Mgmt. Review
• Consider Recognition
– Attestation
– Registration
– External Communication
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Swine Pilot EMS Auditor Training - infoHouse