Swine Pilot EMS Audit Training

Suzanne W. Sessoms, PEPrincipal Consultant

Environmental Mgmt. Services(910) 520-3641

emsnc@yahoo.com

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

CheckAct

Plan

IMPROVE

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

Do What You Say- Implementation

Be Able to Prove It- EMS Audit

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

ISO 14001 Element

Pre-w

ork/Docum

ent Review

Farm O

wner

Environm

ental Mgr.

Farm M

anager

Farm E

mployees

Land Applicators

Training/HR

Farm A

uditors

Closing M

eeting

Report P

reparation

4.2 Policy Commitments x X Policy Devel./Review XPolicy Awareness x x x x

4.3.1 Aspects x X4.3.2 Legal x X4.3.3 Objectives/Targets x X4.3.4 Program x X

Change Management X4.4.1 Structure and Resp. X x x x4.4.2 Training Needs X X X X

Training Curriculum X XTraining Effectiveness/Competency X X X X

4.4.3 Communication X X x x4.4.4 Documentation X X 4.4.5 Document Control X X X X4.4.6 Operational Control x X X X

Supplier/Contract Mgmt. X 4.4.7 Emergency Response Plan X

Development X XUnderstanding/practice x x X x X

4.5.1 Monitor and Measure x X X X Calibration XCompliance Audits X X X

4.5.2 Corrective Action Procedure X x x XFollow-up x x xTrue Corrective Action X X

4.5.3 Records X X X X4.5.4 EMS Audit X X4.6 Management Review X X

Interview #/hours 2 1.5 1.5 1 2 3 1 1 2 4Interview Location A O O I I F O O O A

O=officeF=lagoon/sprayfieldsI=inside farmA=auditor's office

Audit Plan

• Use the audit planning matrix to develop a rough schedule– Key audit steps are noted– Key interviewees are

identified– Topics are prioritized– Audit trails identified to

optimize order of interviews

Documentation Review

Why do it?– familiarizes auditor with

organization’s EMS– identifies if an element

has been overlooked– allows for refining on-

site interview schedule– identifies audit trails

Documentation Review Summary

Clause Number

Clause Description Who does it?

How often?

How is it done?

What records are kept?

All shall statements are addressed

Some shall statements are not fully addressed.

Element is not addressed

4.2 Environmental Policy 4.3 Planning 4.3.1 Environmental Aspects 4.3.2 Legal and Other Requirements 4.3.3 Objectives and Targets 4.3.4 Environmental Mgmt. Program(s) 4.4 Implementation and Operation 4.4.1 Structure and Responsibility 4.4.2 Training, Awareness & Competence 4.4.3 Communication 4.4.4 Documentation 4.4.5 Document Control 4.4.6 Operational Control 4.4.7 Emergency Preparedness & Response 4.5 Checking and Corrective Action 4.5.1 Monitoring and Measurement 4.5.2 Non-conformance and Corr./Prev. Action 4.5.3 Records 4.5.4 EMS Audit 4.6 Management Review

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-1What is the history of the farm site? Any prior owners/operations? How old are the structures? Any retrofit work req'd?

4.2/ 4.5.2 Commitment to pollution prevention

FO-2What considerations did you make when choosing to raise pigs here? (acreage, location to receptors) 4.2 Commitment to pollution prevention

FO-3What, if any, close receptors did you have to consider? (neighbors, schools, churches, etc.) 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• Traceability

– audit– auditor– auditee– date/time/place

• Requirement– internal and/or external

• Objective Evidence– records– statement– observation

CORRECTIVE ACTION REQUEST (CAR)

Company/Location: Date: Auditor: Finding Number: Location of Finding: CAR Number: Escort: Previous CAR Number/Date: Discussed with: (if applicable) FINDING: (Requirement reference standard or policy number and clause): Finding: Company Representative: The finding has not been classified as a nonconformity. It classified as one of the following: Observation Opportunity for Improvement NONCONFORMITY: The finding has been determined to be a nonconformity. It is classfied as a Major Minor Standard Number and Clause: Statement of Nonconformity: Company Representative: Date: CORRECTIVE ACTION: The following action has been planned/taken to correct the item observed and to prevent recurrence. This can be in a separate report as long as the CAR number is referenced. Company Representative: Expected completion date: Date: REVIEW OF CORRECTIVE ACTION: Accepted Accepted/Need Verification Rejected Comments: Auditor: Date:

Audit Summary.

ISO 14001 Environmental Management Systems - Specification Yes No Comments

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

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.

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 CAWMPb) Technical specialist completed new CAWMPc) 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.

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) 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.

b) EMS coordinator issued a reminder to maintenance regarding the status of the work order.

Verifying Corrective/Preventive Actions

Nonconformance 3:

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 Finding

ISO14001/ 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

FarmManager

Observer

Auditor

• You have 30 minutes to complete the interview.

• Auditor should conduct a mini opening meeting

• 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 facility

• Allow 3-4 minutes for observer to provide feedback

Farm No.

Beg Date Meter Reading End Date Meter Reading Gallons UsedWeek 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 Period Water Usage:_______________ Total Days:_____ Gallons/ Day________ Current Operational Strategy is Appropriate for Lagoon Status

Current Operational Strategy is Inappropriate for Lagoon Status Sent Memo to Farm Leader and Production Team Leader to Nofify of Corrective Action No Report Received, Notified Production Team Leader

Water Usage Report

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

Day Time (Fill In) Lago

on at

Pro

per L

evels

Cross

over

Pipe Flowing

or ab

ove w

ater li

ne

No Bro

ken C

lean ou

ts

No Miss

ing or

Uns

ecure

d Clea

nout C

aps

No Wet

Soil A

roun

d Pits

, Pipes

or Lag

oon

No Exp

osed D

rain pipes

No Dam

age o

r Hole

s in L

agoo

n Line

r

No Sign

ifican

t Emban

kmen

t Ero

sion

No Sign

ifican

t Rode

nt Int

rusio

n

No W

halin

g of L

agoon

Liner

Recycle

Pum

p Ope

ratin

g Corr

ectly

Minimal

Debris

in Lag

oon o

r nea

r Rec

ycle P

ump

No Anc

hor T

renc

h Ero

sion

Mortali

ties p

laced

in du

mpster a

t the e

nd of

the d

ay

Corrective Actions Taken (if any) Initials 12

Daily Checklist

Round 2

FarmEmployee(s)

SupervisorPlays Host

Auditor

• You have 30 minutes to complete the interview.

• Auditors should introduce themselves and explain what 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 the farm manager interview

Round 3

FarmManager

Observer

Auditor

• You have 30 minutes to complete the interview.

• Auditor should conduct a mini opening meeting

• Use the questions from the audit tool to interview the nutrient applicator/OIC

• Feel free to ask about anything you noted on the 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 FO-5

b) includes a commitment to continual improvement and prevention of pollution

PR-1, FO-1,2

c) includes a commitment to comply with relevant environmental legislation and regulations and with other requirements to which the organization subscribes

PR-1

d) provides the framework for setting and reviewing environmental objectives and targets

EM-6

e) is documented, implemented and maintained and communicated to all employees

PR-1, FE-1, NA-1

f) is available to the public 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.

FO-7, EM-2

The organization shall keep this information up to date. EM-2 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-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

• Thank you• Participants• Scope/Methodology• Overall conclusions• Recap of findings

– Details in non-conformance reports

• Next steps– Corrective action– Follow-up audit

Utah 2002 EMS Audit Summary Report – November 1, 2002 Lead Auditor – Suzanne W. Sessoms, RAB-certified Lead Auditor Auditors – 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 user-friendly 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