INTRODUCTION TO

ENVIRONMENTAL, HEALTH
AND SAFETY AUDITING

Lucien Klejbuk, Manager, EHS Audits

7/30/2014

Course Outline
 Introduction to Salt River Project Audit program
 History of environmental, heath and safety audits
 EHS audit organizations, certification programs, and
references
 Important elements of a successful EHS audit program
 BREAK
 Examples of typical audit findings
 Vendor audit program
 Environmental Site Assessments
 Summary
2
 Salt River Project
 Oldest multipurpose federal
reclamation project in the United
States (1903)
 Integrated utility, providing
generation, transmission and
distribution services.
 One of the largest raw-water
suppliers in Arizona
 Manage a 13,000-square-mile
watershed and extensive system of
reservoirs, wells, canals and
irrigation laterals.

Mission of SRP EHS Audits

 Identify EHS non-compliance
 Promote and provide tools for EHS “Self Assessments”
 Assess corporate risk exposure
 Reduce costs associated with accidents, injuries, environmental
harm, losses, litigation, fines and penalties
 Establish defense under EPA & OSHA Policy and Sentencing
Guidelines and Arizona Revised Statutes

4
 History of EHS Auditing
 1970s
 Proliferation of regulatory statutes (EPA and OSHA)
 Allied Chemical indicted on pollution violations
 Occidental Petroleum lawsuit
 1980s
 Superfund
 Formation of Auditing Roundtable
 Union Carbide incident in Bhopal, India and Emergency Planning and
Community Right-to-Know
 Exxon Valdez oil spill and Oil Pollution Act
 First official EPA policy on auditing published
 Lead and hearing conservation standards
5

History of EHS Auditing

 1990s
 ISO 14000 Standards for Environmental Management Systems

 EPA Brownfield and Land Revitalization program

 EHS Auditor certifications through BEAC

 2000s
 OSHA Audit Policy

 Sarbanes-Oxley Act

 Global Harmonization System

 BP Refinery explosion in Texas City

 Arizona Environmental Audit Policy

6
 History of EHS Audits at SRP

 1980s – Focus on Superfund Liability, TSDFs, and used oil

recycling (“vendor audits”), and environmental site
assessments
 1990s – Started SRP facility audits. Added audits of solid
waste landfills and battery, scrap metal, tire, transformer,
and computer recyclers
 2000s – Included fire protection as part of facility audits.
Added audits of green waste, plastics, paper, and
refrigerant recycling vendors

Our Audits

Facilities and Waste and Recycling Environmental Site

Programs Vendors Assessments
Over 40 SRP Facilities and Over 85 vendors used for All appropriate inquiry on
programs waste disposal and recycling land
bought/sold/exchanged by
SRP/USBR

8
 Course Outline
 Introduction to Salt River Project Audit program
 History of environmental, heath and safety audits
 EHS audit organizations, certification programs, and
references
 Important elements of a successful EHS audit program
 BREAK
 Examples of typical audit findings
 Vendor audit program
 Environmental Site Assessments
 Summary
9

EHS Auditing Resources

 The Auditing Roundtable

 Board of Environmental, Health and
Safety Auditor Certifications (BEAC)
 Reference books / websites

10
 The Auditing Roundtable
The Auditing Roundtable’s mission:
 Use authoritative body of audit knowledge to be the voice
of the profession
 Advance best practices, principles and values of auditing
 Provide resources to enable and enhance professional
growth and learning
 Offer forums for the exchange of ideas and information

11

The Auditing Roundtable

 Founded in 1982; currently 600 members
 Code of Ethics (adopted in 1987)
 Auditing Standards (published in 1994)
 Meetings and conferences
 Skills Training
 EHS Audit Skills
 Environmental Compliance
 Health & Safety Compliance
 Process Safety Management
 Lead Auditor
12
 BEAC Organization

Board of
Environmental, Health & Safety
Auditor
Certifications

BEAC was created in 1997 as a joint venture

between The Institute of Internal Auditors and the
Auditing Roundtable

13

What does BEAC do?

 Certifies professional EHS auditors

 Issues Standards
 Recognizes training course
providers

14
 Other Audit References
 Books
 “Environmental, Health and Safety Audits”; Lawrence
Cahill and Raymond Kane (2011)
 “Environmental Audits”; Cliff Van Guilder (2014)

 “Environmental Auditing: Fundamentals and

Techniques”; Greeno, Hedstrom, DiBerto (1987)
 Websites
 EHS Journal – www.ehsjournal.org

 The Auditing Roundtable – www.auditing-

roundtable.org
 BEAC – www.beac.org

15

EHS Audits – Why Do It?

 General Driving Forces

 Increased Awareness Of EHS Issues
 Increase In Number Of Laws
 Increase In Complexity Of Requirements
 Increase In Enforcement

16
 What is Audit Defense?
 EPA Audit Policy (2000)
 100% mitigation for gravity-based penalties from violations of
federal environmental laws
 No recommendation for criminal prosecution
 Companies must meet nine criteria to take advantage of policy
 Systematic discovery of the violation through an audit program
 Voluntary discovery
 Prompt disclosure within 21 days
 Violations must be discovered independently from third-party audits
 Violations must be promptly corrected
 No repeat violations
 No imminent damage to environment
 Cooperation with the EPA
17

What is Audit Defense?

 OSHA Audit Policy (2000)
 Self-audits are an evidence of “good faith” of the employer
 25% reduction for of penalties from violations of federal health and
safety laws
 Arizona Audit Privilege (49-1401)
 Audit reports are not admissible as evidence or subject to discovery
 Audit reports must be noted as a “Compliance Report: Privileged
Document”
 Tracking system to correct past noncompliance
 Audit shall be completed within 6 months

18
 Audits as an Effective Risk
Management and Control Process
 Institute of Internal Auditors – “Three Lines of Defense”
 1st Line – Operational Management
 Own and manage risk
 2
nd Line – Risk Management and Compliance Functions
 Oversee risks
 Support, inform and alert management
 Monitor internal controls that are in place
 3rd Line – Internal Audit
 Independent assurance
 Governance in accordance with recognized standards
 Higher reporting level within organization
19

What Makes a Successful Audit

Program – Seven Steps
1. Have top management support for auditing
and commitment to follow-up on audit findings.
2. The auditing function is independent of audited
activities.
3. There is an adequate and well trained audit
team.
4. Explicit audit program objectives, scope,
resources and frequency.

20
 What Makes a Successful Audit
Program – Seven Steps

5. Have a process to collect, analyze, interpret

and document information to achieve audit
objectives.
6. Have a process to generate written reports of
audit findings and track corrective actions and
schedules for completion.
7. Have in place quality assurance procedures to
assure accuracy and thoroughness of audits.

21

Management Support

SRP “Key Management Principle”

Implement comprehensive compliance programs

and regularly perform in-depth self-assessments
and compliance audits of our facilities and
operations.

22
 Management Review Process
President Staff
and Board:
Annual summary
of audit
findings
GM Staff Meeting:
Semi-annual
presentation of
Sr. Director / AGM consolidated audit
Meeting: Present findings, trends and
audit findings of recommendations
operating groups
Audit Exit Meeting:
• Present audit
findings to facility
management
23

Independent Audit Process

Department in Which the EHS Auditing Function is

Located

5 2 Combined EHS
6
7 Environmental
Legal
10 Health and Safety
57 Other
11 Auditing
HR

24
 Trained Audit Team

 Professional Competence
 Knowledge
 Skills (verbal and written)
 Experience
 Objective
 Ethics and Standards of Conduct (BEAC)
 Lead Auditor role and roles of other team members
 Good communicator and decision maker

25

Size of ESH Audit Staff

6

5
Number of Companies

4
Small
3
Medium
Large
2

0
1 to 2 3 to 4 5 to 6 7 to 9

26
Staff Size
 Audit Scope, Resources, Objectives
and Frequency
Examples of Audit Scope
Environmental Health and Safety
Hazardous Waste Personal Protective Equipment
Air Quality Working Surfaces
Water Quality Electrical
Underground Storage Tanks Lock Out / Tag Out
Asbestos Medical Facilities
Drinking Water Hearing Conservation
Sewage Treatment Material Handling

27

Standards Used to Measure

Compliance During an Audit
 Environmental
 EPA 40 CFR
 State, County and Tribal regulations
 Health and Safety
 OSHA 29 CFR 1910 (General Industry) or 1926
(Construction)
 Fire Prevention
 OSHA; National Fire Prevention Association;
International Fire Code
 Department of Transportation
28
 Standards Used to Measure
Compliance During an Audit
 Management Systems
 Company Accident Prevention Manual

 Laboratory Chemical Hygiene Plan

 Hearing Conservation Plan

 Contractor Safety Programs

 Training Program

 Hazardous Communication Program

29

Objectives and Available

Resources
 How Audits will be used?
 Meet EPA/OSHA Audit Policy
 Compliance assurance only
 Performance evaluation
 Compliance versus management system audits
 Resources
 Audit team
 Audit documentation
 How to track corrective actions to completion
30
 Frequency of Audits - Assessment of
Risk
Risk Factors
 Regulatory Risk - “No fine or penalty” “Criminal penalty”

 Health and Safety Risk – “No injury” “Serious injury or death”

 Production Risk – “No impact to operations” “Potential shutdown”

 Environmental Risk – “No impact to environment” “Offsite release”

 Management System - “Procedures in places” “No procedures”

31

Annual SRP EHS Audit Production

7
6
Number of Audits

5
4 Program
3 Facility

2
1
0
FY09 FY10 FY11 FY12 FY13 FY14

32
 The Audit Process

 Pre-Audit Planning
 On-site Data Gathering

 Reporting

 Corrective Actions

 Follow-Up

 Management Briefing

33

Pre-Audit Planning
 Access Issues
 Activities planned during the audit

 PPE requirements-site data gathering

 Daily audit objectives

 Review past audit reports

 Develop scope of audit

 Identifiely site contacts

 Compile checklists (Yes/No versus Procedures)

 Audit tools (camera, tape measure)

34
 On-site Audit Activities

Interviews Document
Review

Observations

35

On-Site Activities
 Ensure All Findings Have Been Substantiated
 Work as a team to review and cross check

audit observations
 Develop complete list of exceptions/issues
and observations
 Did you talk to the right people?

 Are you clear that you identified all the

equipment, processes, etc.?
 Did you address all the regulatory areas?

36
 Audit Documentation

 Audit Report
 Findings

 Auditors’ Opinion

 Ratings

 Root Cause Analysis

 Corrective Action Plans
 Tracking of Findings and Follow-up

37

SRP Audit Reporting Approach

 Hybrid approach that uses external and internal
reporting databases
 External – Dakota Software
 Establish “Profiles” for each facility
 Generate regulatory checklists

 Add “Custom Questions’ for site-specific permits

 Regular updates to regulations

38
 SRP Audit Reporting Approach
Internal
 Record scope for each audit
 Document audit findings (regulatory basis, root cause,
citation, severity)
 Assign responsibilities for corrective actions
 Automate corrective action tracking
 Generate Word reports and PowerPoint presentations
 Search function for finding and corrective action type
 Compile statistics on audit types, risk-ranking by site
and finding

39

SRP Audit Database – Initial Setup

40
 SRP Audit Database – Scope

41

SRP Audit Database – Findings

42
 SRP Audit Database – Findings

43

SRP Audit Database – Corrective

Actions

44
 SRP Audit Database – Audit Notes

45

Course Outline
 Introduction to Salt River Project Audit program
 History of environmental, heath and safety audits
 EHS audit organizations, certification programs, and
references
 Important elements of a successful EHS audit program
 BREAK
 Examples of typical audit findings
 Vendor audit program
 Environmental Site Assessments
 Summary
46
 BREAK

47

Typical Audit Findings

 Health and Safety

 Annual list of highest enforcement items based on
OSHA
 Environmental
 Air Quality
 Waste Management

 Oil Storage/Water Quality

48
 Health and Safety Findings
(2013)

49

Walking and Working Surfaces

STAIRWAY RAILING AND HANDRAILS

50
 Walking and Working Surfaces

51

Walking and Working Surfaces

52
 Walking and Working Surfaces

53

Means of Egress

54
 Means of Egress

55

Means of Egress

56
 Personal Protective Equipment

57

Personnel Protective Equipment

58
 Personnel Protective Equipment

59

Medical First Aid

60
 Medical First Aid

61

Medical First Aid

62
 Material Handling and Storage

63

Material Handling and Storage

64
 Material Handling and Storage

65

General Electrical

66
 General Electrical

67

General Electrical

68
 General Electrical

69

General Electrical

70
 General Electrical

71

Hand & Portable Powered Tools

72
 Hand & Portable Powered Tools

73

Welding, Cutting & Brazing

74
 Welding, Cutting & Brazing

75

Machinery & Machine Guarding

76
 Machinery & Machine Guarding

77

Machinery & Machine Guarding

78
 Machinery & Machine Guarding

79

Fire Protection

80
 Fire Protection

81

Fire Protection

82
 Fire Protection

83

Toxic and Hazardous Substances

84
 Toxic and Hazardous Substances

85

Environmental Findings
Air Quality
Emission of hazardous air pollutants

Ozone-depleting air emissions

Water Quality

Effluent exceeedances

Incomplete storm water discharge reporting

Improper hazardous chemical release reporting

Waste Management

Storing hazardous waste without permit

Improper waste characterization

Poor management of universal waste

Poor container management

Incorrect container labeling

Failure to train employees for hazardous waste management

86
 Air Emissions

87

Oil Storage Management

88
 Waste Management

89

Waste Management

90
 Course Outline
 Introduction to Salt River Project Audit program
 History of environmental, heath and safety audits
 EHS auditor organizations, certification programs, and
references
 Important elements of a successful EHS audit program
 BREAK
 Examples of typical audit findings
 Vendor audit program
 Environmental Site Assessments
 Summary
91

SRP Waste and Recycled Material

Vendor Audit Program

92
 Recyclable Materials
 Ferrous and non ferrous  Plastics
metals
 Street lights
 E-waste
 Tires
 Used oil
 Antifreeze  Salvaged transformers
and other electrical
 Batteries equipment
 Paper / Cardboard  Used Tires
 Concrete
 Soil

93

Waste Disposal

 General refuse
 Construction and demolition debris
 Asbestos
 Mercury contaminated debris
 Hazardous waste
 PCB-contaminated and PCB waste

94
 Vendor Audits Annual Production

50
45
40
Number of Audits

35
30
25
20
15
10
5
0
FY09 FY10 FY11 FY12 FY13 FY14

95

FY14 Revenue - Investment Recovery

Department

 Scrap Aluminum $ 1,153,290

 Scrap Copper $ 817,688
 Scrap Steel $ 538,347
 Scrap Wire $ 61,538
 Recycled Meters $ 50,755
 Salvaged Transformers $ 741,351

TOTAL REVENUE $ 3,362,970

96
 Vendor Evaluation Criteria
 Necessary Permits  Community Relations
 Compliance Status  Other Large Customers
 Litigation Status  Operations
 Financial and Business  Site Conditions
Condition
 Insurance
 CERCLA and State
Superfund Status  Customer Service
 Location and Environmental  Closure and Post-Closure
setting  Env Management Systems
 Company Size and  Health and Safety
Experience  Emergency Preparedness
97

How We Evaluate

 Rating based on 17 elements:

 Minimal risk

 Moderate risk

 Unacceptable risk (not approved for use)

 “Conditionally Approved”
 Deficient in one or more elements that can be corrected

 Restrict material sent to a vendor

98
 Necessary Environmental Permits
 Spill Prevention Control
and Countermeasures
 General Storm Water
Plan
 Non-Title V Air Permit
(Dust Control Plan)
 EPA Waste ID
 Registered UST
 Registered Drywells
99

Compliance Status
 EHS Compliance
 Regulatory inspections
 Fines / Penalties / Notice
of Violations
 Regulatory Resources
 Arizona Department of
Environmental Quality
 Maricopa County Air
Quality Department
 EPA ECHO Database
100
 Litigation / Financial Condition /
Superfund
 Regulatory enforcement actions/ Consent Orders
 Current or pending criminal or relevant civil action
 Financials
 Public disclosures (10-k)
 Dunn and Bradstreet Ratings
 Altman Z”-Score
 Clear and stable market for recyclables
 Potential Responsible Party (PRP)

101

Altman Z” - Score for Non-

Manufacturers
 Z” - Score = 6.56T1 + 3.26T2 + 6.72T3 + 1.05T4
 T1 = (Current Assets – Current Liabilities) / Total Assets
 T2 = Retained Earnings / Total Assets
 T3 = Earnings before Interest and Taxes / Total Assets
 T4 = Market Value of Equity / Total Liabilities
 Zones of Discrimination
 Z” > 2.9 “Safe” Zone
 1.22 , Z” < 2.9 “Grey” Zone
 Z” < 1.22 “Distress” Zone

102
 Location and Environmental
Setting
 Floodplains/ Waterways
Water wells
 Facility surroundings
 Heavy vs. light industrial
 Agricultural
 Residential
 Sensitive Receptors
 Schools / nursing homes
 Environmentally sensitive
areas
103

Company Size & Experience /

Community Relations / Customers
 Number of employees and years in business
 Former business names
 Public perception
 Local/nationwide news feeds
 Facility tours
 Community support
 Impact to permit renewals
 Other customers that make up more than than 10% of
business
104
 Operations Status
 Activities performed at the
site
 Waste generation and
management
 Inspection of storage tanks
 Onsite laboratory
 Transportation facility
 Security

105

Site Conditions
 Housekeeping
 Visible air emissions and dust
control
 Storm water controls
 Noticeable spills
 Storage of waste
 Condition of tanks and
secondary containment
 Paved areas

106
 Customer Service / Insurance /
Closure Funding
 Customer service history
 Insurance
 General liability
 Environmental / Excess /
Umbrella / Pollution
Prevention
 Copy of insurance certificate
 Closure plan and funding
source

107

EMS / Health & Safety / Emergency

Preparedness
 Environmental Management System – Policies and Procedures
 Health and Safety Program
 Identification of hazardous
 Training of employees
 Visible use of correct PPE
 Posted OSHA 300 Log
 Emergency Preparedness
 Fire Prevention / Emergency Response plans
 Emergency response equipment onsite
 Training and drills
108
 SRP Vendor Information

109

Vendor Audit Observations

 The vendor should know their environmental

regulatory obligations
 Regulatory documents should be available and
in one place
 Have a documented Health & Safety Program

110
 Environmental Site Assessments
 Purpose of Phase I ESA to evaluate the potential for
recognized environmental conditions as defined in
ASTM E 1527-13
 Meets All Appropriate Inquiry and allows the user to
satisfy one of the requirements to qualify for the
innocent landowner, contiguous property owner, or bona
fide prospective purchaser limitations on CERCLA
liability

111

Environmental Site Assessments

 Scope  Purpose
 Property bought or  Minimize SRP
sold by SRP environmental liability
 USA/USBR for property transfers
exchanges and  Meet EPA requirements
abandonments for All Appropriate
Inquiry

112
 SRP Process for Environmental Site
Assessments
 Phase I ESAs are performed by qualified
environmental professional on-call consultants
 Only SRP can rely on consultant reports prepared for
SRP
 SRP must meet user responsibilities outlined in the
ASTM E 1527-13
 SRP Field Services performs sampling for Phase II
Environmental Site Assessments

113

Environmental Site Assessment

Production
70
60
50
Number of ESAs

40
30
20
10
0
FY09 FY10 FY11 FY12 FY13 FY14

114
 Environmental Site Assessments

 Phase I- Identifies Recognized Environmental

Conditions

115

Environmental Site Assessments

 Phase II ESA will be recommended based

on results of the Phase I

116
 Environmental Site Assessments
 USBR Exchange Parcels

117

Environmental Site Assessments

 SRP Projects

118
 Environmental Site Assessments

 Phase III ESA may be recommended if a

Phase II ESA positively identifies the
presence of contaminated material
 Remediation may follow the Phase III ESA

119

ASTM E 1527-13 Key Changes

 Revised/simplified definition of recognized
environmental condition
 Revised definition of historical recognized
environmental condition
 New definition for controlled recognized environmental
condition
 Clarified that vapor migration is part of a Phase I
ESA
 New language for agency file reviews
120
 Summary
 History of environmental, heath and safety
audits
 EHS audit organizations, certification
programs, and references
 Important elements of a successful EHS audit
program
 Examples of typical audit findings

 Vendor audit program

 Environmental Site Assessments

121

Future of EHS Auditing

 Pressure on EHS audits to expand scope

 Improve cost effectiveness
 Improve quality assurance and control
 Deliver on stakeholder value
 Increase corporate governance and assurance
 Increased third-party audits
 Consistent audit metrics

122
 Questions and Takeaways

123