NCCOS Internal Audits
NCCOS Self-declaration Audits
NCCOS EMS Self-Declaration Statement
Current
Fiscal Year Audit Plan-Audit Date Revised to 9/10-14/07
Audit Program Templates
The following documents should be used for the Internal audit:
i. Audit
Plan Template
ii. Audit
Criteria
1. Audit Program Purpose
The NCCOS EMS Audit Program is implemented to ensure the
organization allocates resources, provides qualified auditors,
plans the execution of audits and otherwise arranges for
the efficient and effective conduct of internal EMS audits
in support of the EMS. Internal EMS audits support the EMS
and provide a periodic check of its status so that management
can make decisions regarding its continuing suitability,
adequacy and effectiveness. Internal EMS audits also assess
conformance to the NOAA audit protocol based on the requirements
of the ISO-14001 standard and are used either to check compliance
status or to verify that the organization periodically does
such checks. The NCCOS Audit Program is based on the ISO-19011
standard.
For additional detail regarding the EMS Internal Audit, refer
to NOAA EMS Standard:
EMS.013 Regulatory Compliance And EMS Audits And Self-Assessments
Audit Program Chart: International Organization for Standardization.
(Final Draft 2002). ISO-19011: Guidelines for quality and/or
environmental management systems auditing. ISO/FBIS 19011:
2002(E).
2. Definitions
a. Internal EMS Audit - A periodic audit of the EMS to verify
that it is properly implemented and that it continues to
conform to planned arrangements for environmental management.
It is an audit of the system and findings are expressed as
non-conformities. Audit conclusions are based on the findings
and focus on the root causes that led to the non-conformities.
It is appropriate to seek the root causes of known compliance
findings during an EMS audit, since these may reflect EMS
deficiencies.
b.
Compliance Audit - A periodic audit of compliance with
regulatory and other requirements that are imposed on the
organization. Findings are expressed as non-compliances.
The search for root causes in a typical compliance audit
may not be as intense as it should be during an EMS audit.
c.
Non-conformity - Any deviations from established procedures,
programs and other elements of the EMS. They may include
non-compliance with regulations, but not all instances of
non-compliance are necessarily non-conformities of the EMS.
d. Correction: The totality of immediate and long-term steps
taken to mitigate the consequences of a nonconformity (e.g.,
cleanup of spilled hazardous material; remediation of groundwater;
natural habitat restoration). The correction does not by
itself remove the underlying cause of the nonconformity,
e. Corrective Action - Action to address the underlying cause
of an actual event that has been identified as a non-conformity
through an audit.
f. Preventive Action - Action to prevent potential problems
before they occur at other areas or functions of the organization
that may have similar vulnerabilities to that which caused
the original non-conformity.
g. Verification – A follow-up visit by the audit team
to ascertain that corrections, and corrective and preventive
actions have been appropriately completed. The decision to
do this is based upon the frequency, severity, and/or risk
of continued nonconformity, as well as on whether the finding
was either a major or critical audit finding.
3. Approach Audit
Program Manager Responsibilities - The Management
Representative may also act as the EMS Audit Program Manager
and has the following responsibilities:
a. Ensures adequate resources have been budgeted or allocated
for the conduct of planned internal EMS audits.
b. At the beginning of each fiscal year, plans the audit
strategy (e.g., functions to be audited, elements to be audited,
schedule of audits, team members for each audit, lead auditor
for each audit, etc.).
c. Ensures sufficient auditors will be available and that
they remain competent through annual training or other means
of maintaining competency.
d. Stores and manages all documentation from previous audits
(e.g., audit reports, corrective action requests, records
of corrective actions, etc.)
e. Maintains audit templates and checklists of criteria
for use by the audit teams.
f. Evaluates auditors and makes decisions on qualifying
additional individuals as competent internal auditors.
g. Works with the lead auditor assigned to a given audit
to establish the objectives for that audit and to ensure
that the proper resources and information are available to
conduct the audit.
h. Ensures that the audit team conducts and completes the
audit.
Additional
EMS Audit Procedures for NCCOS
4. Frequency of EMS Audits Internal EMS audits shall be scheduled on the basis of need
as reflected by the importance of activities or the results
of previous audits, but not less than annually, in order
to verify that the system is implemented and functioning
as expected. An individual audit may be limited to a sampling
of EMS elements or areas and can be both random and/or focused
on certain activities based on their importance and/or results
of previous audits. The audit program manager will decide
on the strategy to be pursued in the audit at the beginning
of each fiscal year.
5. Scope of EMS Audits
On an annual basis, internal EMS audits assess all operations
and facilities described within the scope of the EMS to
determine conformance for these operations and facilities
against the requirements of ISO-14001, and the organization’s
internal performance objectives. Depending on the results
of previous audits, the organization may opt to conduct
one yearly audit or a series of audits that focus only
on specific elements
6. Selection of Audit Team The audit team shall be selected by the audit program manager
and shall consist of NCCOS EMS team or other NOAA EHS staff
that have received internal EMS auditor training and/or are
deemed competent to conduct such audits. He or she is also
responsible for selecting the lead auditor for a given audit.
The designated lead auditor is responsible to ensure that
the audit team conducts and completes the audit as planned.
Every four years the organization shall bring in an outside
contracted audit team to get a fresh perspective and overview
if its EMS regarding meeting established goals and functionality.
The audit program manager will not be a member of the audit
team.
7. Internal Audit Procedure
The internal audit will be conducted in accordance with
NOAA EMS Standard: EMS.013 Regulatory Compliance And EMS
Audits And Self-Assessments. EMS internal audits shall be
conducted against NOAA Audit Criteria, which can be tailored
to suit the specific needs and goals of the organization
based on input from the Management Representative and the
lead auditor.
Audit
criteria shall consist of questions based upon the specified
arrangements
for the EMS, and shall be designed
to elicit evidence of conformity with the organization’s
EMS requirements. The focus of the EMS audit is to ascertain
whether the EMS has been effectively implemented and is functioning
in accordance with established arrangements.
Audit findings must be based on objective evidence that
is properly corroborated and authenticated. (Auditors should
avoid reaching conclusions on the basis of hearsay or opinion.)
7. Compliance Status
The EMS audit may also be used to record the status of regulatory
compliance. This status may be based on the results of a
recent compliance audit that may have occurred, or it may
be based on the data generated in the EMS to track the achievement
of objectives and targets. Since the organization has objectives
and targets for compliance, the degree to which those have
been accomplished should give an accurate reading of the
compliance posture. If this method is not reliable, then
the organization will rely on compliance audits to ascertain
compliance status.
Alternatively, the internal EMS auditor will ascertain that
the organization has previously conducted periodic compliance
checks as required by the ISO-14001 standard. In this case,
the auditor establishes that the checks did occur and that
they were done in a manner that would produce reliable results.
8. Corrective Action
As part of the audit procedure, corrective actions will
be requested by the audit team by use of the Corrective Actions
Request form. This will be made available along with the
Internal Audit Report to Management Representatives, the
EMS Team, the Management Representative and the supervisor(s)
of the area(s) audited.
After conferring with the Management Representative, the
appropriate area or functional manager will address findings
within a specified number of days by developing corrective
actions which will be included in the summary response to
the corrective action request.
If a nonconformity relates to the EMS itself, the Management
Representative will have the primary responsibility to apply
the corrective and preventive actions. In this instance,
the audit team ensures that the corrective and preventive
actions have been completed when the next scheduled audit
is conducted.
For more detailed information, refer to NOAA Standard EMS.014
Corrective Action To Regulatory Compliance Audits And EMS
Non-Conformances Corrective And Preventive Actions.
9. Preventive Action
Preventive action is undertaken to avoid repetition of the
non-conformity in other areas or functions of the organization
that may have similar vulnerabilities that caused the original
non-conformity. It is the responsibility of the Management
Representative to initiate preventive actions as specified
in the EMS procedure for Non-Conformance, Corrective and
Preventive Actions. The execution of preventive actions may
be recorded in the Corrective Action Request report or it
may be documented separately.
For more detailed information, refer to NOAA Standard EMS.014
Corrective Action To Regulatory
Compliance Audits And EMS Non-Conformances Corrective And
Preventive Actions.
10. Verification
At the conclusion of the audit, the audit team will determine
whether any findings require verification after the corrective
and preventive actions are applied. This will be based upon
the frequency, severity, and/or risk of continued or potential
nonconformities, as well as on whether the finding was either
a major or critical audit finding.
11. Closing the Audit
EMS audits are closed when the audit team leader establishes
that the corrective and preventive actions have been completed.
12. Input to Management Review and to Next EMS Audit
The Audit Report and actions taken to address findings will
be inputs to the Management Review. For more detailed information
on the purpose and content of the Management Review, please
refer to the Management Review Procedure. (The audit report,
corrective action requests and records of corrective and
preventive actions will also be available to auditors preparing
the next scheduled audit.)
13. Audit Resources
The organization should be able to demonstrate that it has
committed to provide the resources necessary to support the
continual improvement of its EMS by providing the budget
and staff resources necessary to maintain this EMS Audit
Program. In addition, it should be able to show that auditor
training will be provided for the audit team as necessary
and that contracted resources may also be utilized, as necessary,
to perform internal and external audits.
14. Audit Process Documentation
Documentation that result from the conduct of an EMS audit
may include the items listed below. The audit program manager
provides proper templates for these items to the audit teams
for their use on audits:
i. Audit Plan
ii. Audit Criteria
iii. Internal Audit Report
iv. Completed corrective action requests showing actions
that were taken
v. Statement on compliance status
Page
Last Updated
February 12, 2008
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