EMS 92/193.5200.

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Environmental Management System

Internal Audit Report

U.S. EPA Region 7

Kansas City, Kansas

Conducted
August 22-24, 2011

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TABLE OF CONTENTS

1.0 INTRODUCTION Page 3

2.0 SITE TOURS AND INTERVIEWS Page 3

3.0 AUDIT OBSERVATIONS / FINDINGS Page 5

APPENDICIES

Attachment 1 Internal Audit Schedule Page 11

Attachment 2 Audit Opening Meeting Agenda Page 14

Attachment 3 Audit Team Notes Page 15

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1.0 INTRODUCTION
The internal audit was conducted on August 22-24, 2011 with the stated purpose of:
• Determining whether the Region’s EMS conforms to the core foundations of ISO-14001,
the requirements of EPA’s EMS Audit Protocol, and current Region 7 internal
performance objectives;
• Determining if the EMS has been properly implemented and maintained; and
• Providing relevant information on the suitability, adequacy, and sufficiency of the EMS
to the Region’s Senior Management.
The internal audit followed the schedule provided in Attachment 1. The initial schedule was
prepared by Chris Taylor, the EMS Coordinator, and was reviewed by Ruben McCullers, the
Lead Auditor. Minor schedule changes were made along the way to accommodate the needs of
Region 7 personnel and the Audit Team. An opening meeting, attended by Ruben McCullers;
Jennifer Boggess, Audit Team member; Diane Harris, Audit Team member; Chris Taylor, EMS
Coordinator; Luetta Flournoy, Acting Assistant Regional Administrator; and Janet Schwarz,
Acting Safety, Infrastructure, and Information Management Branch Chief, was held at the
beginning of the on-site activities to review the audit plan. A copy of the agenda for the opening
meeting can be found at Attachment 2. The closing meeting was held on August 24 at which the
time the Audit Team presented the preliminary findings of the internal audit. This meeting was
attended by Ruben McCullers, Jennifer Boggess, Diane Harris, Chris Taylor, Dale Bates
(Associate EMS Coordinator), and Luetta Flournoy. Senior staff and members of the EMS
Sustainment Team were invited to both the opening and closing meetings.
The EMS Internal Audit Team was led by Ruben McCullers of the Region’s Air and Waste
Management Division. Ruben has completed the ANSI-RAB Lead EMS Auditor Course, and
has participated as both a lead auditor and audit team member on numerous internal and external
EMS audits. He was assisted in the audit by Jennifer Boggess and Diane Harris; they are both
members of the Environmental Services Division, have completed an ANSI-RAB EMS auditor
course, and were members of the Region 7 Internal EMS Audit Team in 2009.
The criteria used for this internal audit is based on the ISO 14001 standard and is contained as an
attachment to EMS Operating Procedure 007.7210.13, Internal EMS Conformance Audits.
Observations and findings from the internal audit are found below in Section 3.0. All findings
are based on objective evidence that was gathered from reviews of EMS documents and records,
interviews with Region 7 employees, and direct observations made during site tours. Areas
listed in the criteria, but not listed as findings in Section 3.2, are considered to be in
conformance. Copies of notes created by the Audit Team during the course of the audit can be
found at Attachment 3.

2.0 SITE TOURS AND INTERVIEWS

2.1 Science and Technology Center
Jennifer Boggess and Diane Harris, Audit Team members, toured and met with staff at the
Science and Technology Center (STC) on August 23 and met specifically with the following
STC staff:
• Mike Davis, Chemical Analysis and Response Branch Manager

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Additionally, Jennifer and Diane randomly selected other staff members regarding their
knowledge of the EMS, e.g., compliance with regulatory requirements, continual improvement,
pollution prevention, and communication. All (100%) of the individuals interviewed
demonstrated a sufficient awareness of the EMS and their responsibilities under the EMS.
The management and staff at the STC have taken ownership of the EMS in terms of how their
activities at the facility relate to and impact the Region’s EMS. There is a clear commitment to
the EMS and they are proactive in working with the EMS Coordinator. Staff interviewed at
random were familiar with the EMS, could define what they saw as their role in the system, and
they were all aware of and had taken EMS training.
2.2 COOP/Warehouse Facility
Jennifer Boggess and Diane Harris toured and met with staff at the COOP/Warehouse Facility on
August 23 and met specifically with the following staff:
• Joe Ricard, Warehouse Manager
Additionally Jennifer and Diane randomly selected other staff members regarding their
knowledge of the EMS, e.g., compliance with regulatory requirements, continual improvement,
pollution prevention, and communication. All (100%) of the individuals interviewed had a full
awareness of the EMS and their responsibilities under the EMS.
There is a strong commitment to the EMS at the TLC and their efforts to incorporate EMS as a
natural part of their daily work is evident. Staff interviewed at random were familiar with the
EMS, could define what they saw as their role in the system, and they were all aware of and had
taken EMS training.
2.3 Regional Office
Ruben McCullers interviewed members of Senior Staff and others with EMS roles and
responsibilities. The following individuals were interviewed:
• Karl Brooks, Regional Administrator
• Mark Hague, Acting Deputy Regional Administrator
• Luetta Flournoy, Acting Assistant Regional Administrator
• Hattie Thomas, Deputy Director Office of Public Affairs
Each understood their roles and responsibilities but there was some lack of knowledge of the
EMS Policy.
The Audit Team also met with each of the Environmental and Sustainability Management
Program Leads: Chris Taylor, Michael Boeglin, Jennifer Dwani, Janet Schwarz, Mark Lesher,
John Begley, Mike Davis, and Joe Cothern. The results of these interviews are summarized in
Section 3.1, Observations, while specific issues in terms of recommendations are identified in the
table in Section 3.2, Audit Findings.
Additionally, Mr. McCullers randomly selected and interviewed other staff members regarding
their knowledge of the EMS, e.g., compliance with regulatory requirements, continual
improvement, pollution prevention, and communication. All (100%) those interviewed had a
full awareness of the EMS and their responsibilities under the EMS but there was some lack of

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knowledge of the EMS Policy.

3.0 AUDIT OBSERVATIONS / FINDINGS

3.1 Observations
Region 7 senior management and employees demonstrated an interest and commitment to
continually improving their environmental performance and reducing the Region’s footprint.
Observations included:
- EMP and SMP Leads were knowledgeable about their programs, how the review and
updating process works, how to address changes as they occur. They had all received some
form of training specific to their program.
- The EMS Coordinator was successful in training approximately 99% of employees on the
Region’s EMS.
- Staff interviewed at random were familiar with the EMS, could define what they saw as

their role in the system, and they were all aware of and had taken EMS training.

- In addition to the activities listed, the Pesticide Program SMP Lead includes walk-thru
inspections periodically to compare what is actually happening against what was identified
during the program review meeting; he receives and acts upon complaints from EPA staff;
and periodically reviews pesticides stored in the facilities (e.g. for controlling algae in the
chillers).
- Some interviewees identified ideas they had for improving the system and were planning
on following thru with them in the near future.
- It is clear that EMS activities are documented through EMS documents and/or EMS

records.

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3.2 Audit Findings

Finding Type

ISO 14001-2004(E) Minor Nonconformance – I Requirement Evidence of Nonconformity

Section Major Nonconformance – M
Opportunity for Improvement – O

4.1 General
Meets Standard
Requirements (Scope)

4.2 Policy Meets Standard

4.3.1 Environmental
Meets Standard
Aspects

4.3.2 The organization The Environmental Policy refers to Executive Orders

shall…determine those requirements and Agency Directives but the OP says it is Region
that apply to its environmental aspects. 7’s policy to not view Federal statutes, Executive
4.3.2 Legal and Other
Recommendation Orders, and other similar policies as a legal or other
Requirements
requirement. The relationship of legal and other
requirements to Executive Orders and Agency
Directives is not clear.
4.3.2 The organization The Pesticide Program SMP targets refer to ensuring
4.3.2 Legal and Other shall…determine those requirements continued compliance with all relevant legal and other
Recommendation
Requirements that apply to its environmental aspects. requirements but the section on legal and other
requirements (4.) says there are none.
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Finding Type

ISO 14001-2004(E) Minor Nonconformance – I Requirement Evidence of Nonconformity

Section Major Nonconformance – M
Opportunity for Improvement – O

4.3.3 The Objectives and Targets shall SMP # 006.2500.18D has imprecise targets:
4.3.3 Objectives, targets
be measureable… T1.a not correct: clarify target date
and environmental Recommendation
programs
SMP # 006.2500.18D has imprecise targets
4.3.3 Objectives, targets
T1.d cannot meet goal; reset goal
and environmental Recommendation
programs
OP EMS 006.7210.05F Page 7 of 8. In The legal and other requirements on the Hazardous
Field 4 list the specific legal and other Materials, Hazardous Waste and Wastewater EMPs
requirements applicable to the do not match the legal and other requirements on the
4.3.3 Objectives, targets
significant environmental aspect that Master List:
and environmental Recommendation
must be maintained and accounted for - 4.c. on Haz Mat EMP
programs
in the EMP. - 4.g. on Haz Waste EMP
- 4.b. on WW EMP

Roles and Responsibilities EMS Program Leads need more autonomy to carry out their
4.4.1 Resources, roles,
007.9500.01H assignments.
responsibility, and Recommendation
authority
Roles and Responsibilities EMS The document states that semiannual Program
4.4.1 Resources, roles, 007.9500.01H Management Reviews are required but only annual
responsibility, and Recommendation reviews are done.
authority - This is a semantics issue. Word was changed
from semiannual to periodic.

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Finding Type

ISO 14001-2004(E) Minor Nonconformance – I Requirement Evidence of Nonconformity

Section Major Nonconformance – M
Opportunity for Improvement – O

Roles and Responsibilities EMS The document states senior staff responsibilities
4.4.1 Resources, roles, 007.9500.01H include approval of the significant aspects; however,
responsibility, and Recommendation OP EMS 006.7210.01G only refers to validation of
authority the significant aspects by the EMS Sustainment Team
with no mention of the step of senior staff approval.
Persons working for an organization or Many individuals were unsure what if any
on its behalf shall be aware of the consequences there may be for departure from
4.4.2 Competence,
Recommendation potential consequences of departure specified procedures. STC staff was aware of
training, and awareness
from specified procedures. consequences from noncompliance but thru RCRA
rather than thru the EMS.

4.4.3 Communications Meets Standard

4.4.4 Documentation Meets Standard

4.4.5 Current versions of relevant Have online versions be current within a month.
documents are available at all locations
where operations essential to the
4.4.5 Document Control Recommendation effective functioning of the system are
performed, obsolete documents are
promptly removed from all points of
issue and points of use.

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Finding Type

ISO 14001-2004(E) Minor Nonconformance – I Requirement Evidence of Nonconformity

Section Major Nonconformance – M
Opportunity for Improvement – O

Operational Controls that only include lease or

procedures should be examined and clarification
4.4.6 Operational
Recommendation should be provided on where within the leases the
Control
OCs exist. If the leases do not provide OCs by
themselves, this should be corrected.
4.4.7 Emergency
Preparedness & Meets Standard
Response

4.5.1 Monitoring and

Meets Standard
Measuring

4.5.2 Evaluation of
Meets Standard
Compliance

4.5.3 Nonconformity,
Corrective Action, and Not examined
Preventive Action

4.5.4 Control of
Meets Standard
Records

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Finding Type

ISO 14001-2004(E) Minor Nonconformance – I Requirement Evidence of Nonconformity

Section Major Nonconformance – M
Opportunity for Improvement – O

OP EMS 006.7210.13F C.4. Training This training did not occur and no EMS document
will be provided to the Audit Team generated for the 2011 internal audit. It was noted the
members on auditing techniques and audit team include the same two members as in FY09
4.5.5 Internal Audit Recommendation
the procedures included in this OP. A and they were training on auditing techniques and the
copy of this training will be retained as procedures included in the OP at that time.
an EMS document…
OP EMS 006.7210.13F These duties Work was performed by EMS Coordinator when the
may be performed by the EMS Lead Auditor was a member of the Region 7 staff.
4.5.5 Internal Audit Recommendation Coordinator with the concurrence of
the Lead Auditor, if the Lead Auditor,
is not a member of the Region 7 staff.

4.6 Management
Meets Standard
Review

R7 EMS Suggestion
Meets Standard
Program

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Attachment 1

Audit Schedule

EPA Region 7
Internal EMS Audit Agenda
August 22-24, 2011
Monday; August 22, 2011
Time Activity Location EPA Participant
1:00-1:30 Audit Opening Meeting RO ARA ARA, EMS Coordinator,
Conference EMS Mgmt
Room Representative, Alternate
EMS Coordinator, EMS
Sustainment Team (as
available)
1:30-4:00 Review EMS Documents RO 4145 EMS Coordinator,
Associate EMS
-Scope and Policy Coordinator
-Roles and Responsibilities
-Significant Aspects
-Legal and Other Requirements
-Objectives and Targets
-EMPs/SMPs
-EMS Training
-Internal and External Communication
- Document Control/Records
Management
- Operational Controls
- Emergency Response
- Monitoring and Measuring
- Management Review
4:00-4:30 Audit Team Meeting RO 4145 None
4:30-5:00 Day 1 Review RO 4145 EMS Coordinator,
Associate EMS
Coordinator
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Tuesday; August 23, 2011

Time Activity Location EPA Participant
8:15-8:30 Audit Schedule Day 2 RO 4230 EMS Coordinator,
Associate EMS
Coordinator
8:30-10:00 Review EMS Documents (continued) RO 4230 EMS Coordinator,
Associate EMS
Coordinator

9:00-9:30 Interview with RA/DRA RA’s Office Karl Brooks/Mark Hague

10:00-12:00 - Interview AFV Management Program TBD Michael Boeglin
- Interview Alternate Transportation Chris Taylor
Mgmt Program
- Interview Reduce, Reuse, Recycling Jennifer Dawani
Mgmt Program
- Interview Sustainable Facilities Mgmt Chris Taylor
Program
- Interview Green Purchasing Mgmt Janet Schwarz
Program
- Interview Pesticides Mgmt Program Mark Lesher
- Interview Air Mgmt Program and John Begley
Wastewater Mgmt Program
12:00-1:00 LUNCH
1:00-1:30 Interview with ARA ARA Office Luetta Flournoy
1:30-3:30 - Interview Hazardous Material Mgmt STC Mike Davis & others with
Program and Hazardous Waste Mgmt responsibility as necessary
Program

- Interview EPA employees on awareness STC/RO/TLC TBD

- Interview Office of Public Affairs RO TBD

communications representative and
additional Senior Staff members as
necessary
3:30-4:15 Audit Team Meeting RO 4230 None
4:15-4:45 Day 2 Review RO 4230 EMS Coordinator,
Alternate EMS
Coordinator
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Wednesday, August 24, 2011

Time Activity Location EPA Participant
8:00-8:15 Audit Schedule Day 3 RO 5217 EMS Coordinator,
Associate EMS Coordinator
8:15-10:30 Complete any remaining interviews or RO/STC EMS Coordinator,
document reviews Associate EMS
Coordinator, others as
Audit Report Preparation necessary

10:30-11:00 Audit Pre-Brief RO 5127 EMS Coordinator,

Alternate EMS Coordinator
11:00-11:30 Audit Closing Meeting RO ARA Acting ARA, EMS
Conference Coordinator, Associate
Room EMS Coordinator, EMS
Sustainment Team (as
available)
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Attachment 2

Audit Opening Meeting Agenda

I) Introduction of Audit Team

II) Audit Scope

III) Audit Objectives and Criteria

IV) Schedule/Agenda

V) Communication
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Attachment 3

Audit Team Notes