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GENERAL POLICY INTERPRETATION ON ENVIRONMENTAL AUDITING



Office of Environmental Policy and Compliance
U.S. Department of the Interior
1849 C Street, NW
Washington, DC 20240
April 1998

Table of Contents

Introduction

General Policy Interpretation on Environmental Auditing

2.1 Purpose

2.2 Scope

2.3 Reference

2.4 Policy

2.5 Program Criteria

2.5 A. Environmental Auditing Protocol

2.5 B. Qualifications of Environmental Auditing Personnel and Training

2.5. C. Baseline Environmental Audits

Environmental Auditing Finding and Corrective Actions

Responsibilities

Appendix

Introduction

The purpose of this "General Policy Interpretation" is to provide guidance on the interpretation of 515 DM 2 "Environmental Auditing," for the purposes of: (1) consistent Departmental use of terms and definitions; and (2) assisting Bureaus and Offices in developing or enhancing their own procedural guidance on environmental auditing.

Notes:
  1. The exact wording of 515 DM 2 is presented in the left column of this document and clarification/explanation language is presented immediately adjacent in the right column in the succeeding pages.

  2. The Appendix contains some suggestions for implementing a successful environmental auditing program.


Purpose

515 DM 2
Clarification of Explanation
This chapter
This is one of multiple chapters on Environmental Management.
Chapter 2 addresses Environmental Audition
Provides Departmental
This is Departmental policy so it applies to all Departmental units. It is the minimum policy. Bureaus and Offices may have more rigorous policies but they must meet the requirements of this policy.
Policy "Policy" refers to the highest level statement about the Department's position on environmental auditing. See section 2.4 Policy.
Responsibilities "Responsibilities" are further outlined in section 2.6 Responsibilities. There are additional responsibilities, some explicitly and some subtlety, embedded within the chapter such as:

  • Describing auditor responsibilities (Section 2.5 A)

  • Addressing imminent hazards (Section 2.5 D)

All responsibilities for successfully implementing an environmental auditing program are not addressed in this chapter. User's should carefully consider their needs and assign responsibility for designing, implementing, and closing on environmental audit program issues.
Functions "Functions" refers to specific environmental auditing objectives stated in Section 2.4 Policy.
Environmental Auditing
Environmental auditing is one means, but not necessarily the only way, to ensure compliance. Other compliance tools and techniques are allowable and/or encouraged to ensure compliance.
As a means to assure compliance
"Compliance" is the goal of auditing addressed by this policy.
with applicable Federal
Specific examples are listed in Section 2.3.
State Some states have parallel requirements to federal requirements while others are different or are absent. Users of this chapter are cautioned to explore the applicability of state-level requirements on a case-by case basis. See section 2.3 for further explanation.
and local environmental requirements
Some counties and municipalities may have additional requirements. See section 2.3 for further explanation
that affect Departmental lands, facilities,
Departmental lands and facilities are further defined in Section 2.2.
operations, Operations could mean any activity that results in environmental liability attributable to the Department. For example the Department could incur environmental compliance liability from the legal or illegal activity of contractors, visitors, concessionaires, tenants, and others, whether or not it occurs on Department lands. "Operations" connotes a regular activity or practice as opposed to one that is irregular. This makes sense because in order for operations to be auditable, they must be predicted.
and uses thereof.
Means any other activity, not previously described which may result in environmental compliance liability attributable to the Department. For example, environmental compliance liability may originate within contract terms, Memorandums of Understanding, Interagency Agreements, or other commitments of historic, current, or future standing.

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Scope

515 DM 2
Clarification or Explanation
 The responsibilities and requirements for the use of environmental auditing as specified in this chapter shall apply, where applicable, to all Department lands, facilities, and operations.
 "responsibilities" has been previously discussed (Section 2.1).

  • "requirements" refers to the details of Section 2.5 Program

  • Criteria

Departmental lands and facilities are defined as
Because of the emphasis on "lands and facilities" the scope of this chapter is largely based upon geography or tangible assets. However, environmental compliance liability may occur off Department lands and independently of its facilities because of "operations." For example, Department participation in polar research programs.
any Departmental site or area, The terms "site or area" connote ownership, administration, or management of geography or tangible assets.
including all agency lands contiguous to the site or area "Contiguous" means "related to" or "under the same management" not just adjacent or adjoining.
other appurtenances and improvements on lands "Appurtenances and improvements" are defined here as aspects of "lands."
including, but not limited to, The following are some of the most likely types of "appurtenances and improvements" but are not necessarily all there could be. These are just examples provided for illustration.
all buildings,
Means:

  • Office buildings, visitor centers, garages, laboratories, and others.

  • Entire or portions of buildings.

  • Permanent or temporary buildings.

  • Occupied or unoccupied buildings.

  • Complete or partial buildings.

  • Modern and historic buildings.

  • In-place, transported, or reconstructed buildings.

  • Mobile buildings.

  • Buildings as part of other appurtenances and improvements.

  • Owned, leased, rented, or otherwise used, intentionally or not, for Department business.

structures, Means identifiable natural or man-made landmarks which are classified similarly to buildings (see above). Examples include:

  • Radio towers

  • Dams

  • Bridges

  • Gazebos

installations, Means any temporary or permanent installed appurtenance or improvement which is not a building such as:

  • Airstrips

  • Roadways

  • Rest areas

  • Picnic grounds

  • Boat ramps

equipment,
Means any mechanical device, tool, implement, or other man-made object such as:

  • Aircraft and watercraft

  • Trucks and machinery

Equipment tends to be mobile while installations are not.
pipeline (including any pipe into a sewer or publicly owned treatment works)
Means temporary or permanent enclosed conveyance, used or not, for transporting water, oil, gas, chemicals, or mixtures.
well Means drilled, dug, bored, by hand or by equipment,

  • Permanent, temporary, exploratory, or abandoned

  • For water or natural resources (i.e. oil)

  • For withdrawal, recharge, or discharge

pit Means a man-made earth excavation for any purpose and of any size.
pond Means a natural entrapment of water or other liquid, smaller than a lake (i.e. 10 hectares), which may be temporary or permanent.
lagoon Means a man-made or natural semi-static entrapment of water or other liquid of any size which may be temporary or permanent.
impoundment Means a man-made entrapment of water typically held in place by a dam.
ditch Means a man-made unlined excavation for conveying water, or other liquid, by gravity
landfill Means a man-made earthern structure accumulation location for long-term storage of waste material.
and storage unit
Mean natural features or man-made equipment, structures, or installations that intentionally contain liquid, solid or gaseous material for future use

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References

515 DM 2
Clarification or Explanation
In terms of compliance with environmental requirements of the Department, the following
  • This section indicates specific environmental requirement areas that the Department is expected to maintain compliance with.

  • Consequently, an environmental compliance audit (i.e. baseline) should address these areas at a minimum.
statues,  Those listed are:

  • CERCLA

  • CAA

  • CWA

  • HMTA

  • OPA

  • AEA

  • HAZWOPER AND HAZCOM portions of OSHA

  • PPA

  • RCRA

  • SDWA

  • TSCA

  • EPCA

Executive Orders
Those listed are:

  • 12088

  • 12580

  • 12873

  • 12856

  • 12196

  • 13016

and Departmental Manual Chapters are referenced
Those listed are:

  • 518 DM 1

  • 518 DM 2

  • 602 DM 2

and include but are not limited to:
Acknowledges that there may be other statutes, Executive Orders, and Departmental Manual chapters.
(The list of acronyms above is not reproduced here as it is too long for the related comments.)
  • Need to address the uniqueness and applicability of State and local level requirements which may supersede those above (i.e. State NPDES permits) or address areas not related to those above (i.e. municipal sewer ordinances).

  • Need to address the importance of including voluntary consensus standards for determining compliance such as those from ANSI or NFPA.

  • Need to mention the importance of updating this list and the vital importance of understanding the applicability of new requirements.

Policy

515 DM 2
Clarification or Explanation
It is Department policy that each Bureau and Office shall
 This is the policy---the highest level statement on environmental auditing within the Department.

  • All Departmental Bureau and Office organizational units which manage lands, facilities, operations, and uses thereof.
develop Each of the above organizational units must develop its own program to reflect its unique mission.
implement The program must be implemented. See section 2.5 D on a schedule for completing baseline audits. To demonstrate a realistic implementation plan, information on the number of facilities, scope of compliance issues, source of auditors, and budget issues should be specified.
and document
The program must be documented. See section 2.5. A documented program means a written policy, guidance, plan, and protocols that would assure an outside reviewer of the program that it exists and is consistent with this chapter and that compliance could be measured.
an environmental auditing program
The environmental auditing program addresses the universe of auditable entities such as lands, facilities, and operations.
Environmental auditing programs shall be conducted in order to:
The specific objectives of an environmental auditing program are now specified. These should be defined in measurable terms.
A. Assure compliance with applicable Federal, State and local environmental requirements.
Traditional audits are "report cards" on compliance status. Because the Department insists that the program assure compliance, a much more difficult task, a "report card" system will not be good enough. This program will require (1) higher levels of competence in staff, (2) a tight feed-back information mechanism for tracking results and corrective actions, and (3) consistent follow-up..
B. Promote sound environmental practices
The audit program is expected to have non-compliance related environmental benefits. Sound environmental practices include compliance but are broader. These broader aspects should be sought by audited entities to reduce environmental risk as an intended by-product of the program.

  • One example is pollution prevention.
C. Monitor environmental compliance of the user's activities (e.g., contractors, concessionaires, etc.).
  • The policy is clear in requiring the Department to address the environmental compliance status of Department land, facilities, and operations users. "Users" defined here is a non-Departmental entity such as any other government or non-government organization or individual.

  • This means that the Department should (1) conduct audits of user activities or (2) request environmental compliance information from users, or (3) specify that users conduct environmental audits and submit results to the Department.

  • Receipt and disposition of information from audits should be handled in accordance with Departmental or Bureau and Office record keeping provisions.
D. Identify and assign environmental compliance responsibility
Through an audit program, responsibility for environmental compliance at each audited entity will be established. This means a specific individual(s). Responsibility for environmental compliance may be shared at each audited entity but there will always be one single lead person responsible for the entire entity. This is necessary for ensuring follow-up and completion of corrective action. It is also necessary for promoting sound environmental practices. Also, responsibility of the audited entity includes providing access to lands and facilities, cooperating during interviews, providing records in a timely manner, and responding to compliance issues.

Program Criteria

515 DM 2
Clarification or Explanation
A documented environmental auditing program must include the following:
Section 2.4 Policy specified that the program must be documented. This section explains exactly what, at a minimum, must be documented.
(1) periodic review of operations and development of a schedule for periodic audits;
  • "Periodic review" means that auditing is an ongoing process, not just a one time exercise.

  • "Operations" in this case means all auditable entities such as lands, facilities and operations as specified in the Policy (2.4) and Purpose (2.1).

  • A schedule specifying the frequency of audits must be established and documented. For example, a rolling schedule projection may be every 2-3 years for successive audits at a particular facility.

  • Scheduling should be according to the degree of environmental compliance risk. Priority and intensity should be directed towards those entities where a high degree of environmental compliance risk occurs. All entities need not be audited with the same frequency and scope, but a rationale needs to be supplied for differing frequency of audits.
(2) a protocol for environmental auditing procedures;  "Protocol" is addressed in section 2.5 A in detail. It is a procedure not a checklist, a concept which is often confused.
(3) verification of timely and effective actions on environmental audit findings; and
  • An information feed-back loop must exist to assure the Department (and Bureaus and Offices) that there are no open issues after an audit is completed. "Open" means not addressed or unscheduled.

  • Documentation must exist that shows all findings were addressed in a timely manner.

  • Legal issues associated with documentation of possible non-compliance situations should be addressed here.
(4) a mechanism for reporting environmental auditing program activities. Bureaus and offices must be capable of reporting on the status of their environmental auditing programs.
In addition to the above program criteria, each environmental auditing program must include the following:
  • The next four subsections describe required elements of an audit program. These are:
  1. Environmental Audit Protocol.

  2. Qualifications of Environmental Auditing Personnel and Training.

  3. Baseline Environmental Audits.

  4. Environmental Auditing Findings and Corrective Actions.
  • Each of these four areas are addressed separately in the following pages.

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Environmental Auditing Protocol

515 DM 2
Clarification or Explanation
 An environmental auditing protocol is a plan that systematically documents how and when an environmental audit will be conducted. The protocol is the plan for an individual audit.  Most protocols are organized into three parts:

  • Pre-visit

  • Site-visit

  • Post-visit

They are further organized by compliance functional area. 

ASTM, other standards, and EPA guidance documents, on environmental auditing are useful as guides.
In general, an environmental auditing protocol should include:
  • These are the minimum required elements of an acceptable protocol.

  • This list is based upon commonly accepted practices both within and outside of the Department.
(i) a description of the responsibilities of the auditor, Need to describe job functions for auditors, lead auditors, and audit team leader (see Section 2.5 C). The job functions should be spread out over the audit protocol to ensure all aspects are covered: Pre-visit, Site-visit, and Post-visit. Specific activities include updating regulatory information, collecting entity information, interviewing, reviewing records, compiling results, reporting, and offering assistance.
(ii) identification of the audited entity and other users,
  • This refers to " responsibilities" from above.

  • "Users" (third definition here) means a user of the audit information.
(iii) schedules
Means the audit schedule. For example, an audit may take about 40 hours of work and a site-visit may range anywhere from one to five days.
(iv) expectations for site-visit activities,
Site-visit activities must be arranged in advance to make the audit most productive. Touring, interviewing, record reviewing, and inspections can be disruptive to both the auditor(s) and the audited entity.
(v) auditor obligations regarding disclosure and release reporting, and

(vi) measures to ensure confidentiality issues with respect to the audit in accordance with applicable laws, regulations, and government policy.
In general, an auditor's preliminary "working papers" related to an environmental audit do not fall under public disclosure. However, final reports relating to an environmental audit may be subject to public disclosure. It is recommended that any specific issues relating to disclosure be discussed with the Office of the Solicitor.
Environmental auditing protocols may take a number of different formats.
Audit protocols may be "home-made," adaptations of others, or store-bought as long as they meet the requirements of this chapter (i.e. documented).
At a minimum, however, environmental auditing protocols should address the following areas: air pollution........and pollution prevention activities.
This minimum range of regulated areas is required for an environmental audit.
Bureaus and Offices may include additional areas within their environmental auditing protocols to support specific mission requirements.
  • Some Bureaus and Offices have included additional areas in their protocols.

  • In any case, Bureaus and Offices have some flexibility in designing their protocols, as long as the minimum range of regulated areas is covered.

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Quantification of Environmental Auditing Personnel and Training

515 DM 2
Clarification or Explanation
Bureaus and Offices shall establish
  • This section applies to all Departmental Bureau and Office organizational units which manage lands, facilities, operations, and uses thereof.

  • This is a mandatory requirement.

  • This requirement applies to internal (Bureau or Office) and external (contracted or other Department) auditors.
qualifications  Qualifications means:

  • Skills: such as communication, interpersonal, observational, and analytical.

  • Knowledge: such as of this policy, environmental requirements (i.e., laws and regulations), the types of facilities to be audited, audit standards, compliance assistance, pollution control technology.

  • Experience: such as years of experience in auditing as a lead auditor or audit team member.

  • Auditors are required to prove that they are "qualified" before providing auditing services.

  • Third party certification of auditors is permissible if the certification program ensures that its standard meets or exceeds the qualification requirements specified by the organizational unit.
and training requirements for environmental auditors
  • Bureaus and Offices should specify the level of training required for auditors to be "qualified."

  • Training may be internal or external.

  • Training may be through a formal training session or through a mentoring relationship (OJT) or a combination of both.

  • Training must be documented.

  • Training should not be a one-time event. Some type of "refresher training" should be implemented.
 
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Baseline Environmental Audits

515 DM 2
Clarification or Explanation
All bureaus and offices shall conduct baseline environmental audits
  •  All Departmental Bureau and Office organizational units which manage lands, facilities, operations, and uses thereof must conduct baseline environmental audits.

  • Baseline environmental audits must be defined. Typically a baseline audit is a first-time audit that addresses compliance aspects)
within five years of the issuance of this Departmental Manual Chapter.
  • "Issuance" means as a final approved document.

  • This means that, within five years, all baseline audit reports are complete and data is in a reporting system.

  • This does not mean only that all auditable sites have been visited.

  • Audits are done when paperwork is done.

  • Corrective actions do not have to be completed within the five year deadline, however they must be realistically scheduled for completion of corrective actions.
 The baseline environmental audit team leader, shall be independent from the facility being audited The definition of "independent" includes the following aspects:

  • Not affected by management at the audited entity.

  • Not eligible to benefit from corrective action or follow-on work.

  • "Facility" in this sentence refers to the audited entity which means "lands, facilities, and operations" as defined in Section 2.1.
as defined in the bureau and office environmental auditing program. Bureaus and Offices have the freedom to define "independent" for their own programs, but it must be consistent with the above aspects that are common to any definition.

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Environmental Auditing Finding and Corrective Actions

515 DM 2
Clarification or Explanation
 All environmental audit findings
  • Regardless of priority.

  • Regardless of whether they have been corrected during the site-visit or at any time during an audit.

  • "Can not determine" is a finding.

  • Good (notable) practices may also be recorded.
shall be documented
Must be reported (written copy preferred).
in accordance with bureau and office environmental auditing programs
Allows Bureaus and Offices to develop their own reporting formats, subject to their conformance with the above requirements for environmental audit findings.
Any conditions identified in an audit finding "Conditions" would include the following aspects:

  • First-hand observations.

  • Data from records.

  • "Reliable" testimony.

The auditor must have a sufficient body of evidence from all or any of the three aspects to create a reasonable belief.
which may pose an imminent
  • a condition about to occur
and substantial endangerment to the public health or welfare or to the environment
  • A condition which may result in death or serious injury or serious damage.
must be addressed immediately.
  • Organizational entities must promptly take measures to fix the problem.
Conditions identified in audit findings requiring response in accordance with applicable legal requirements should be addressed in a timely manner. If there are legal requirements for response actions, these should be met.

  • The requirements may be for time periods or for specific types of response.

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Responsibilities

The responsibilities of applicable Departmental Bureaus and Offices are defined in Section 2.6 (a-e) of 515 DM 2.
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APPENDIX

Suggestions for Implementing a Successful Environmental Auditing Program
  1. Commitment from the Head of the Bureau or Office in establishing the environmental auditing program with long and short-term goals and objectives.

  2. Provide a detailed description of the scope, goals, and objectives of the Bureau or Office environmental auditing program.

  3. Explain how the environmental auditing program will be administered and managed.

  4. Distribute a statement from the Head of the Bureau or Office that the program is intended to help facility managers improve compliance and reduce the potential for liabilities and is specifically not for the purpose of "checking on" facility managers.

  5. Budget for the environmental auditing program.

  6. Support the environmental auditing program through Bureau and Office actions.

  7. Determine the best way to communicate the goals, objectives, and results of the environmental auditing program to interested parties both within and outside of the Bureau or Office.
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