11.9. Maine DOT Environmental and Safety Auditing Policy and Procedure

11.9. Maine DOT Environmental and Safety Auditing Policy and Procedure

Example 23: Maine DOT Environmental and Safety Auditing Policy and Procedure

OBJECTIVE

This policy establishes a procedure to implement an effective environmental auditing program in the Bureau of Maintenance & Operations (M&O), including an auditing plan, auditing program, and auditor training. M&O’s goal is to maintain a safe workplace, protect the environment, and have no violations in conducting regulated activities. M&O’s objective is to close all non-conformances within time limits set by management at the time audit findings are reviewed. Other important benefits of auditing are cross-training, increased awareness of environmental requirements among its staff, and continuous improvement.

M&O recognizes that environmental and safety auditing is necessary to reduce the risk of noncompliance, and to provide assurance that regulations, Department requirements, policies and procedures are being followed. M&O’s environmental auditing program will focus on prioritizing compliance issues, managing environmental risks, improving operations, reducing costs, and verifying the effectiveness of management systems that will ensure compliance. M&O will identify and prioritize audit issues, develop annual audit plans, and develop standard audit protocols or methods.

APPLICABILITY

This policy is applicable to all Maine DOT maintenance divisions, including Highway Maintenance, Motor Transport Services (MTS), Bridge Maintenance and Traffic Engineering.

TARGET AUDIENCE

This policy will be distributed to M&O supervisory personnel in Highway, MTS, Bridge, and Traffic Engineering, and other affected units of Maine DOT, including but not limited to: Director, Bureau of Maintenance and Operations; Director, Motor Transport Services; Maine DOT Division Managers/Engineers; Assistant Division Engineers; Safety Coordinators; Superintendents, Managers, and Supervisors. This policy will also be distributed to: Director, Environmental Office (ENV); Manager, Water Resources and Hazardous Waste, OES.

RESPONSIBILITY

• It is the responsibility of the Division Manager/Engineer to implement actions that will ensure compliance with laws and regulations and Maine DOT’s environmental policies and procedures.
• The M&O Director will charter a standing Environmental Management Committee to oversee the implementation of the audit program. The Environmental Management Committee’s responsibilities will include, but not be limited to the following:
• Approve an annual environmental auditing plan for M&O
• Approve (and revise as needed) environmental audit procedures for M&O
• Receive reports of audit findings and communicate specific findings to appropriate levels of management
• Monitor implementation of corrective actions from audits
• Annually evaluate the audit program (and develop evaluation criteria and methodology)
• Recommend resolution of any appeals of Corrective Action Reports to the Bureau Director

It is the M&O Director’s responsibility to prepare the annual audit plan and to manage the implementation of the audit plan in accordance with this procedure, including the appointment and training of qualified auditors to serve on audit teams. It is the responsibility of the M&O Director to follow up with Division Managers to ensure that all corrective actions are completed or resolved in a timely manner.

It is the responsibility of all employees to be familiar with the Department’s environmental policies and procedures that affect their work, as documented in Maine DOT’s Environmental Policy and Procedures Manual.

It is the responsibility of the audit team leaders to plan and schedule audits according to the predefined scopes and purpose in conjunction with Division Managers/Engineers.

REQUIREMENTS

Audit Team. Auditors will be qualified by training and experience, and will follow generally accepted guidelines as described in ISO 14010, 14011 and 14012. Auditors must be approved by the M&O Director based on experience, training, and education. M&O will conduct its auditing program with advice as necessary from Legal Services, and will employ a team approach including members of ENV, M&O management, and M&O staff. M&O will use internal Department staff to perform audits when possible, provided that the auditors’ duties and responsibilities are independent of the area and activities being audited and that auditors have proper training and experience. Outside auditors will be used when necessary to ensure independence, and when specific expertise and experience are required.

Audit Preparation/Planning. The Director of M&O, with advice from ENV and Legal Service, will define a “regulatory framework” of laws and regulations that apply to M&O. This framework will be used to prioritize risks, and to develop the annual audit plan. The Director of M&O will prepare annually a two or three year audit plan which will include, at a minimum, the following elements: 1) Identification of high priority environmental compliance risks; 2) Areas and activities to be audited, including; compliance with regulations and internal policies and procedures, the required frequency of the audits, and the expected dates during the upcoming cycle; 3) Audit team to conduct each audit, including the team leader; and 4) Information about the planned scope and general methodology of each audit.

Audit Execution

• The Division Manager/Engineer of the area to be audited should be notified of the audit at least 45 days prior to the audit. The notification will include a definition of the audit scope, topics, and protocols, as well as a pre-audit questionnaire (if appropriate).
• At least two weeks prior to the audit, the audit team leader will provide to the Division Manager/Engineer a proposed schedule for the audit, which will include meeting times and a list of personnel who will be interviewed or otherwise must be present for the audit. At this time, certain documents may be requested by the audit team leader to help prepare for the audit. One week prior to the audit, a final audit schedule will be agreed upon between the audit team leader and the Division Manager/Engineer.
• The audit team will prepare, in advance, the audit methodology to be used, including checklists, worksheets, interview questions, and protocols.
• The audit team will conduct an Opening Meeting with the Division Manager/Engineer and local management employees from the area being audited. The purpose of this meeting will be to review the audit scope, methods, logistics, reporting requirements, Corrective Action Request forms, and follow-up requirements, including an appeals process.
• The audit team will use accepted methods (e.g., ISO or ASQ) to collect objective, verifiable evidence pertaining to the environmental aspects that are the subject of the audit. This evidence will include, but not be limited to observation, measurement, photographs, document review, interviews, testing, or inspection.
• Audit findings, including any non-conformances, will be recorded in writing, and may be entered into an audit tracking software program. Corrective Action Request (CAR) forms (example attached) will be completed prior to the closing meeting by the audit team member. Each CAR will be signed by a local management representative, who will be given a copy.
• The audit team may hold interim meetings daily with local management to address questions or issues that arise during the audit, or to revise the schedule as needed.
• The audit team will conduct a Closing Meeting with local management at the completion of the audit to review a summary of the findings before departing the area being audited. This meeting will include a discussion of each CAR, and the requirements for Corrective Action plans, including any appeals of CARs.

Audit Reporting and Corrective Action Follow-up

• A written audit report will be prepared by the audit team within two weeks of the audit. Copies of the audit report will be forwarded to the M&O Director and the Division Manager/Engineer of the area that was audited. Report distribution will be limited to individuals specified by the M&O Director.
• Within two weeks of receiving the audit report, the Division Manager/Engineer will submit to the M&O Bureau Director, a Corrective Action Plan, which will identify specific corrective actions, resources required, persons responsible for completion, any CAR appeals, and target completion dates.
• Completion of the corrective actions in the Corrective Action Plan will be monitored by the Environmental Management Committee on a bimonthly basis. Completed actions will be deleted from the Corrective Action Plan when evidence of completion is provided.
• If necessary, the audit team may be asked by the Environmental Management Committee to conduct a follow-up review of corrective actions to ensure effective implementation.
• Any environmental policies or procedures that are revised as a result of the auditing process will be done so according to the Environmental Procedure Development procedure.

COMMUNICATION AND TRAINING

All environmental auditors, including outside contractors, will be trained on the contents of this procedure and Environmental Management Systems auditing standards ( e.g., ISO 14010, 14011, and 14012) prior to conducting any audits.

The M&O Director will communicate to all M&O employees a general statement regarding the scope and purpose of environmental auditing at M&O, either in environmental awareness training or through other written or verbal communication, such as by memorandum or in Department or M&O newsletters.

EVALUATION

The Environmental Management Committee will conduct an annual evaluation of M&O’s environmental audit program. A written report will be provided to the Chief Engineer summarizing the findings of the environmental audit program evaluation.

Table 20: Mass Highway Compliance Tracking Roles and Responsibilities

Role / Responsibility
Deputy Chief Engineer Environmental / Assumes ultimate responsibility to ensure proper tracking of compliance matters at the facilities.
DMEs / Responsible for ensuring that compliance matters are properly identified and corrected by District Personnel.
Supervisor of HazMat/HazWaste Unit / Responsible for ensuring those out-of-compliance matters are addressed as quickly as possible and that issues that cannot be corrected within 14 calendar days are properly reported to the Clean State Database. Requests compliance tracking data from the District HazMat Coordinators and the Audit Program Coordinator.
DHCs / Perform regular inspections that ensure the compliance matters are properly addressed at the facilities. Ensure proper review of weekly inspection reports submitted by the CSIII/Area Supervisors and or the CSII/Facility Foreman.
Audit Program Coordinator / Maintains a record of all Self-audits including the Corrective Action Reports and the Clean State Matters Reports. Upon request by the Supervisor of the HazMat/HazWaste Unit will produce a record of all compliance issues identified by the Self —Audit Program.